Services and Supports Array Provider Network Natural Helpers Financing – Track 2

1. Services and Supports Array Provider Network Natural Helpers Financing – Track 2 Sheila A. Pires Human Service Collaborative sapires@aol.com Vickie Miene Northeast Iowa vickie-miene@uiowa.edu Matt Wojack Ingham County, Michigan wojack@ceicmh.org

2. State and Local Realities Growing evidence of effectiveness of home and community-based services & of system of care technologies – even for youth with most challenging issues, e.g. youth with sex offenses, fire starting behaviors, dual diagnoses + Potential cost savings to Medicaid, mental health, child welfare, education, juvenile justice in HCB and SOC + Lack of sufficient HCB service capacity + Dollars are finite Conclusion: Redirect spending from out of home placements with high costs and/or poor outcomes to home and community-based services and supports in a system of care 2 2 Pires, S. (2006). Primer Hands On . Washington, D.C.: Human Service Collaborative.

3. Redirection Where are you spending resources on high costs and/or poor outcomes? • Residential Treatment? • Group Homes? • Detention? • Hospital admissions/re-admissions? • Too long stays in therapeutic foster care? • Inappropriate psychotropic drug use? • “Cookie-cutter” psychiatric and psychological evaluations? 3

4. Wraparound Milwaukee – Example of Redirection and Pooled Funds • Mental Health • Crisis Billing • Block Grant • HMO Commercial • Insurance Child Welfare Funds thru Case Rate (Budget for Institutional Care for CHIPS Children) Juvenile Justice (Funds Budgeted for Residential Treatment for Delinquent Youth) Medicaid Capitation (1557 per Month per Enrollee 9.5M 8.5M 10M 2.0M Management Entity: Wraparound Milwaukee Management Service Organization (MSO) $30M Family Organization $300,000 Per Participant Case Rate Provider Network 240 Providers 85 Services Care Coordination Child and Family Teams Plans of Care Mgt. Entity: Co. BH Div. 4 Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

5. Example of Braided Funds DAWN Project - Indianapolis, IN How Dawn Project is Funded Dawn Project Cost Allocation CFT and Care Coordination Structure RAINBOWS (Family Organization) 5 2005 CHIOCES, Inc., Indianapolis, IN

6. Example of “Virtual” Pooled Funds Cuyahoga County (Cleveland) System of Care Oversight Committee County Administrative Services Organization FCFC $$ Fast/ABC $$ Residential Treatment Center $$$$ Therapeutic Foster Care $$$ “Unruly”/shelter care $ Tapestry $$ SCY $$ } State Early Intervention and Family Preservation } System of Care Grants Neighborhood Collaboratives & Lead Provider Agency Care Coordination Partnerships Child and Family Team Plan of Care Reinvestment of savings Community Providers and Natural Helping Networks 6 Pires, S. (2006). Primer Hands On . Washington, D.C.: Human Service Collaborative.

7. KEY QUESTIONS • Expenditure and Utilization Questions: • Which State agencies spend dollars on BH services for children and youth? • How much do they spend? • What types of dollars are spent (e.g., Fed’l., State)? • What services are financed? • How many children and youth use services? • What are the characteristics of these children and youth (e.g., by age, gender, race/ethnicity, diagnosis, region)? • What services do they use? • How much service do they use? 7

8. Financing Strategies and Structures to Support Improved Outcomes for Children, Youth and Families FIRST PRINCIPLE: System Design Drives Financing 8 Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

9. Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (1) 9 Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

10. Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (2) 10 Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

11. Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (3) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C. 11

12. Purchasing/Contracting Options Pre-Approved Provider Lists: + Flexibility for system of care + Choice for families - Could disadvantage small indigenous providers - Could create overload on some providers Risk-Based Contracts + Flexibility for providers + Individualized care for families - Potential for under-service - Potential for overpaying for services Fixed Price/Service Contracts + Predictability and stability for providers - Inflexible-families have to “fit” what is available 12 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

13. Capitation and Case Rate Distinctions Capitation: Pays MCOs or providers a fixed rate per eligible user Incentive: #1: Prevent eligible users from becoming actual users (e.g., make it difficult to access services; engage in prevention) #2: Control the type and volume of services used Case Rate: Pays MCOs or providers a fixed rate per actual user Incentive: #1: Control the type and volume of services used 13 Pires, S. Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

14. Risk-Based Contracting Arrangement State-Capped Out of Home Placement Allocation County Dept. of Human Services acts as Management Care Organization (contracting, monitoring, utilization review) BH Tx $$ matched by Medicaid. Capitation contract with BHO with risk-adjusted rates for child welfare-involved children Child Welfare $$ Case rate contract with CPA Joint treatment planning approved by Dept. of Human Services Child Placement Agencies (CPA) Responsible for full range of Child Welfare Services & ASFA (Adoption and Safe Families ACT) related outcomes Mental Health Assessment and Service Agency (BHO) Responsible (at risk) for full range of MH treatment services & clinical outcomes & ASO functions 14 Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.

15. Services/Supports Array, Provider Network, Natural Helpers and Financing Vickie MieneIowa

16. Iowa’s current system

17. Lessons Learned - Community Based Resources • Building on existing Community Based Services is: • Empowering to the agency providing the service • Better for youth and families (fewer out of town trips saves gas, energy, and time) • Creates better relationships with the service agencies and forces communication among providers and the SOC which results in less duplication of efforts. • SOC values and principals are taught and applied on a local level, creating a common thread between service entities

19. Family Team Meeting • Natural Supports identified • Agenda set by family/youth • Community supports Family Team Meeting Concept, (providers attend and provide input, they offer to host meetings at their location) • Families report feeling empowered and like they really had choices • Barriers discovered during family team meetings, are taken to advisory meetings for solution focused discussion.

20. Crisis Intervention Services • 1-800 number for over the phone crisis talk down • 1 hour face to face response with a crisis intervention worker • Cool down respite placement that can be utilized for 48 hours.

21. STEP-IN Crisis Services • 45 day program • Intensive Family Preservation Model • 1 hour response time • Prevent hospitalization • Utilize respite if needed

22. Service/Supports Array, Provider Network, Natural Helpers and Financing“2010 CHILD MENTAL HEALTH INITIATIVE NEW COMMUNITY TRAINING”(Issue Briefs #3, #5, #6) Matt Wojack Ingham County, Michigan

23. Any Effective System of Care for Children with Serious Emotional Disturbance is Built Upon an Outcome Oriented Home-Based Mental Health Program --Bob Friedman

24. Family Empowerment • How do We support Families in Using Voice • What Do Families Need • How are Supports Organized to Accommodate Such

25. Commitment to SOC Changes the World Shift in Values Shift in Practice Real Data Supports real Change

26. Bundle of Services • Home-Based Mental Health • Wraparound Facilitation • Family Advocacy Support

27. Cost Monitoring Supports the Long-Term Viability of the System “How Do you Want to Spend Your Money?” 1 Residential = 8 System of Care Broad Examination of Cost Savings >40% reduction in JJ; $1M saved by CPS

28. Case Rate Model • Up to One Year of Support • Three Components • Realigning Resources Sustaining a System of Care “We were headed in the right direction…” “There is no going back..”

29. Matt Wojack, Project Director Impact, Ingham County System of Care Initiative 517-346-8038 wojack@ceicmh.org www.impactsystemofcare.org