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Transcript of 1 Maximizing Opportunities to Increase Child and Family Well Being Through Innovative Funding...
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Maximizing Opportunities to Increase Child and Family Well Being Through
Innovative Funding Approaches
Sheila A. Pires
Human Service Collaborative
Washington, DC
Because Minds Matter: Collaborating to Strengthen Psychotropic Medication Management for Children and Youth in Foster Care
August 27-28, 2012Washington, DC
Effectiveness Research(Barbara Burns’ Research at Duke University)
• Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care
• Less evidence (because not much research done): Crisis services, respite, mentoring, family education and support
• Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.2
Examples of What You Don’t See Listed as Evidence-Based Practice
(though they may be standard practice)
• Traditional office-based “talk” therapy• Residential Treatment• Group Homes• Day Treatment_______________________________________________Examples of Potentially Harmful Programs and Effective Alternatives in Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer Influences in Intervention and Public Policy for Youth,” Social Policy Report, Vol. XX, No. 1, January 2006. Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7.
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C. 3
Broad, Flexible Service ArrayExample: Dawn Project Services & Supports
Behavioral Health•Behavior management•Crisis intervention•Day treatment•Evaluation•Family assessment•Family preservation•Family therapy•Group therapy•Individual therapy•Parenting/family skills training•Substance abuse therapy, individual and group•Special therapy
Placement•Acute hospitalization•Foster care•Therapeutic foster care•Group home care•Relative placement•Residential treatment•Shelter care•Crisis residential•Supported independent living
Psychiatric•Assessment•Medication follow-up/psychiatric review•Nursing services
Mentor•Community case management/case aide•Clinical mentor•Educational mentor•Life coach/independent living skills mentor•Parent and family mentor•Recreational/social mentor•Supported work environment•Tutor•Community supervision
Respite•Crisis respite•Planned respite•Residential respite
Service Coordination•Case management•Service coordination•Intensive case management
Other•Camp•Team meeting•Consultation with other professionals•Guardian ad litem•Transportation•Interpretive services
Discretionary•Activities•Automobile repair•Childcare/supervision•Clothing•Educational expenses•Furnishings/appliances•Housing (rent, security deposits)•Medical•Monitoring equipment•Paid roommate•Supplies/groceries•Utilities•Incentive money
2005 CHIOCES, Inc., Indianapolis, IN
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Types of Medicaid Services in Systems of Care
• Assessment and diagnosis
• Outpatient psychotherapy
• Medical management
• Home-based services
• Day treatment/partial hospitalization
• Crisis services – mobile & residential
• Behavioral aide services
• Behavioral management skills training
• Therapeutic foster care
• Therapeutic group homes
• Targeted Case Management
• Inpatient hospital services• Case management services• School-based services• Respite services• Wraparound • Family peer support/education• Youth peer support• Transportation• Mental health consultation• Early intervention and prevention services• Supported independent living• Residential treatment centers• Telehealth
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Examples of Sources of Funding for Children/ Youth
Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.
Medicaid• Medicaid Inpatient• Medicaid Outpatient• Medicaid
Rehabilitation Services Option
• Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT)
• Targeted Case Management
• Medicaid Waivers• TEFRA Option• ACA options
Substance Abuse• SA General Revenue• SA Medicaid Match• SA Block Grant
Juvenile Justice• JJ General Revenue• JJ Medicaid Match• JJ Federal Grants
Mental Health• MH General Revenue• MH Medicaid Match• MH Block Grant
Child Welfare• CW General Revenue• CW Medicaid Match• IV-E (Foster Care and
Adoption Assistance)• IV-B (Child Welfare
Services)• Family
Preservation/Family Support
Education• ED General Revenue• ED Medicaid Match• Student Services
Other• TANF• Children’s Medical
Services/Title V– Maternal and Child Health
• Mental Retardation/ Developmental Disabilities
• Title XXI-State Children’s Health Insurance Program (SCHIP)
• Vocational Rehabilitation
• Supplemental Security Income (SSI)
• Local Funds
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FIRST PRINCIPLE: System Design Drives Financing
Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.
REDIRECTIONUsing the money we already haveThe cost of doing nothingShifting funds from treatment to earlyintervention and preventionMoving across fiscal years
REFINANCINGGenerating new money by increasing federal claimsThe commitment to reinvest funds for families and childrenFoster Care and Adoption Assistance (Title IV-E)Medicaid (Title XIX)
RAISING OTHER REVENUE TO SUPPORT FAMILIES AND CHILDREN
DonationsSpecial taxes and taxing districts for childrenFees & third party collectionsTrust funds
FINANCING STRUCTURES THAT SUPPORT GOALS
Seamless services: Financial claiming invisible to families Funding pools: Breaking the lock of agency ownership of fundsFlexible Dollars: Removing the barriers to meeting the unique needs of familiesIncentives: Rewarding good practice
Financing Strategies and Structures
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Redirection
Where are you spending resources onhigh 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 psychologicalevaluations?
Implications for How RTCs are Utilized
• Movement away from “placement” orientation and long lengths of stay
• Residential as part of an integrated continuum, connected to community
• Shared decision making with families/youth and other providers and agencies
• Individualized treatment approaches through a child and family team process
• Trauma-informed care
For more information, go to Building Bridges Initiative:www.buildingbridges4youth.org
Data Trends #127, February 2006,University of South Florida. 9
The Cost of Doing Nothing
If Milwaukee County had done nothing: the $18m. spent by child welfare ten years ago would be $48m. today
Project Bloom “Cost of Failure Study” Early childhood services at an average cost per child of $987/year save $5,693/year in special education
If New Jersey had done nothing: it would have spent $30m more in inpatient psychiatric hospitalization over the last three years
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The Cost of Doing Nothing:Racial & Ethnic Disparities/Disproportionality
“…youths of color were less likely to receive outpatient therapy…..and more likely to receive residential services.” (1)
“The study finds greater use of residential treatmentcenters by black persons and Hispanic persons thatis attributable in part to (public sector) managed care” (2)
1. McMillen, J., Scott, L.et. al. Use of Mental Health Services Among Older Youths In Foster Care. 2004. Psychiatric Services 55:811-817. American Psychiatric Association
2. Snowden, L., Cuellar, E. & Libby, A. Minority Youth in Foster Care: Managed Care and Access to Mental Health Treatment. 2003. Med Care. 41(2): 264-74). University of California Berkley
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Strategic Financing Analysis
1. Identify state and local agencies that spend on youth/families at risk
How much? What kind of $?
2. Identify resources that are untapped or under-utilized (e.g., Medicaid)
3. Identify utilization patterns and expenditures
Consider high cost/poor outcome
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
4. Identify disparities and disproportionality in access to service/supports
What are the strategies to address?
5. Identify the funding structures that will best support the system design
Braided, blended, risk-based, purchasing collaborative???
6. Identify short and long term financing strategiesFederal revenue maximization; re-direction from
restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum
Strategic Financing Analysis
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System of Care
Child Welfare
Alternative to out-of-home care high costs/poor outcomes
Juvenile Justice
Alternative to detention-high cost/poor outcomes
Medicaid
Alternative to IP/ER/PRTF; multiple psychotropic meds
Education
Alternative to out-of-schoolplacements, high special ed costs
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
Aligning Incentives Across Agencies
UMDNJ Training & TA Institute
Department of Children and FamiliesDivision of Child Behavioral Health Services
Dept. of Human ServicesMedicaid Division
BH, CW, MA $$ - Single Payer
Provider Network
Contracted Systems Administrator- PerformCare
•1-800 number•Screening•Utilization management•Outcomes tracking
Any licensed DCF provider
Family peer support,education and advocacyYouth movement
Lead non profit agencies managing children with seriouschallenges, multi-system involvement
New Jersey
Care Management Organizations - CMOs
Family SupportOrganizations
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Louisiana
Children’s System of Care (CSoC) Governing Body
Medicaid, Behavioral Health and Child Welfare
dollars
1915 b and c waivers
Statewide Management
Organization (ASO)
Regional Care Management Organizations
Family Support Organizations
Provider Network
Magellan
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Care Management Entity FunctionsAt the Service Level: Child and family team facilitation using high quality
Wraparound practice model Screening, assessment, clinical oversight Intensive care coordination Care monitoring and review Peer support partners Access to mobile crisis supports
At the Administrative Level: Information management – real time data; web-based IT Provider network recruitment and management (including
natural supports) Utilization management Continuous quality improvement; outcomes monitoring Training Pires, S. 2010. Human Service Collaborative
Affordable Care Act Opportunities and Challenges
Medicaid Re-Design
Renewed interest in various waivers/options
• 1115, 1915b, 1915i, Money Follows thePerson, health homes
Renewed interest in managed care, includingfor populations with high use/cost (e.g., chronicconditions, foster care, SSI)
I. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk
Requirements for:
Incorporation of State and federal requirements for child welfarepopulation, e.g. PH and BH screens within certain timeframe,monitoring of psychotropic meds (requirement for all children)Risk-adjusted rate for children in child welfare and childrenwith serious behavioral health challengesSpecial liaison for child welfare-involved children,children enrolled in Care Management Entities, youth transitioningHire/contract with family and youth organizations to serve as family and youth advocates and peer supportsIncentives to require out-of-office careSpecific performance measures related to children in child welfare Reinvestment back into child home and community services
Pires, S. 2012.Washington DC: Human Service Collaborative
II. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk
Requirements for:
EPSDT inclusion of behavioral health screens and linkageto BH services when indicatedBroad BH benefit, inclusive of in-home, respite, family andyouth peer support, mobile response and stabilization, behavioralmanagement consultation, therapeutic foster care, telebehavioral healthProvider network requirements to include: providers trained in child welfare population issues, EBPs, trauma-informed care; racially/ethnically diverse providers; inclusion of families/youth asproviders/advocatesEnhanced rates for providers trained in EBPs and trauma-informed careTimely provider payments
Pires, S. 2012. Washington DC: Human Service Collaborative
III. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk
Requirements for:
No “fail first” policies regarding access to service type or psychotropic med typeSpecific “pass-through” case rate for Care Management Entityor wraparound team approach for children with most complexchallengesUse of standardized tools for screening, and determination ofservice intensity neededPrior authorization parameters that enable “ready access” toservices (e.g., first 12 visits do not require prior auth)Prior authorization parameters that allow wraparound plan ofcare to drive medical necessity (with outlier management)
Pires, S. 2012. Washington DC: Human Service Collaborative
IV. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk
Requirements for:
Quality review process that involves families and youthwith lived experience on quality review teams and requiresinput from child welfare systemData tracking requirements to include: service useand expenditures of children in foster care, including psychotropic meds – stratifiable by age, gender, race/ethnicity, aid category, region, diagnosis, service type, medication typeEngagement in quality improvement initiatives involvingchildren’s behavioral health and children in child welfareFocus groups and satisfaction surveys of youth and familiesinvolved in child welfare and of child welfare workers
Pires, S. 2012. Washington DC: Human Service Collaborative
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Summary of Financing Characteristicsof Systems of Care for Children/Youth and Families
in Child Welfare and At Risk
Maximize Medicaid (e.g., flexible Rehab Option)Blend, braid or intentionally coordinate funding streamsacross systemsRe-direct spending from high cost and/or poor outcomeservices to effective practicesManage dollars through managed care arrangements thatare tied to values and goalsRisk adjust payment for complex populations of children(e.g., risk-adjusted capitation rates to MCOs; case rates toproviders)Finance locus of accountability – e.g., care management entitiesfor most complex, cross-systemFinance family and youth partnerships at policy, managementand service levels Finance training, capacity building, quality and outcomes monitoring
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
For further information, contact:
Sheila A. PiresHuman Service [email protected]