1 THE SKILL BUILDING CURRICULUM Module 7 Service Array and Financing Developed by: Sheila A. Pires Human Service Collaborative Washington, D.C. In partnership

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THE SKILL BUILDING CURRICULUM

Module 7Service Array and Financing

Developed by:Sheila A. Pires

Human Service CollaborativeWashington, D.C.

In partnership with:Katherine J. Lazear

Research and Training Center for Children’s Mental HealthUniversity of South Florida, Tampa, FL

Lisa ConlanFederation of Families for Children’s Mental Health

Washington, D.C.

Primer Hands On-Child Welfare

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Medicaid is the primary source for health/mental health care for children in child welfare.

Most states (86%) are applying managed care approaches to their Medicaid programs.

Why Focus on Medicaid Managed Care?

Health Care Reform Tracking Project 2003 State Survey. Research and Training Center for Children’s Mental Health, University of South Florida, Tampa, FL

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Children in Child Welfare in MedicaidManaged Care

HMO Enrollment: 245,313

BHO Enrollment: 174,584________________________Total Enrollment: 419,897

Source: CMS/MSIS State Summary Data, FY 2003

53% - 72% of foster care population is enrolled in Medicaid managed care –

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

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State Coverage of Child Welfare Populationin Medicaid Managed Care

26 states include the child welfare population in Medicaid managed care –

• 22 with mandatory enrollment• 4 with voluntary enrollment

Source: Health Care Reform Tracking Project 2003 State Survey


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NRCOI Framework for a Full Service Array in Child Welfare

1. Assessment of Current Practices in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities.

2. Assessment of Current Leadership and Systemic Culture in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities.

3. Assessment of Current Services in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities.

4. Assessment of the Need for Other Services Not Currently Available in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities.

“Collaborative, strategic, population-focused process, guided by set of tools, to identify array of practices, services,

and supports needed in a SOC for child welfare populations”

Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource Center for Organizational Improvement

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Purposes of NRCOI Framework• Create a service directory• Prepare for the CFSR, the Statewide Assessment, and indeveloping the PIP re the service array• Meet CAPTA requirement to conduct annual inventory• Help define array of services needed in SOC whenspecific target population has been chosen• Identify gaps and strategies to improve service array• Can lead to better collaboration among providers and a better functioning community collaborative

ExamplesPulaski, Co., Virginia

Nebraska – 14-county rural area

Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource Center for Organizational Improvement

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PRIMER HANDS ON- CHILD WELFARE

HANDOUT 7.1

National Child Welfare Resource Center for Organizational Improvement:

Service Array Framework

www.nrcoi.org

Primer Hands On - Child Welfare (2007)

http://www.nrcoi.org/

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Dawn 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 therapyPlacement•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 servicesMentor•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 supervisionRespite•Crisis respite•Planned respite•Residential respiteService Coordination•Case management•Service coordination•Intensive case management

Other•Camp•Team meeting•Consultation with other professionals•Guardian ad litem•Transportation•Interpretive servicesDiscretionary•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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Programs Addressing Safety- Abuse-Focused Cognitive Behavioral Therapy (AF-CBT) - AMEND, Inc. (Abusive Men Exploring New

Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Project Connect - Child Parent Psychotherapy for Family Violence (CPP-FV) – Trauma Treatment Rated - Project

SafeCare - Domestic Abuse Intervention Project (DAIP) - Nurturing Parenting Programs - Project SUPPORT - Intensive Reunification Program (IRP) Motivational Interviewing (MI) - Nurturing Program for Families in

Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - Supported Housing Program (SHP) - The Community

Advocacy Project - Triple P – Positive Parenting ProgramPrograms Addressing Permanency

HOMEBUILDERS - Intensive Reunification Program (IRP) - Project CONNECT - Shared Family Care Programs Addressing Well-Being

1-2-3 Magic: Effective Discipline for Children 2-12 - Abuse-Focused Cognitive Behavioral Therapy -Alcoholics Anonymous (A.A.) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent

Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Child Parent Psychotherapy for Family Violence (CPP-FV): Trauma Treatment Rated - Community Reinforcement + Vouchers Approach

(CRA + Vouchers) - Community Reinforcement Approach - Domestic Abuse Intervention Project (DAIP) - Eye Movement Desensitization and Reprocessing (EMDR) - Intensive Reunification Program (IRP) -

Motivational Interviewing (MI)Nurturing Parenting Programs - Nurturing Program for Families in Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Parenting Wisely - Project

CONNECT - Project SUPPORT - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - STEP: Systematic Training for Effective Parenting - Supported Housing Program (SHP) - The Community

Advocacy Project - The Incredible Years – Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - Triple P – Positive Parenting Program

Examples of Evidence Based Practices Related to CFSR Outcomes

California Evidence-Based Clearinghouse at: http://www.cachildwelfareclearinghouse.org

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Examples of Other Services You’d Want to Provide Based on

Practice/Family Experience & Outcomes Data• Family Group Decision Making• Wraparound• Integration of natural helping networks• Intensive in-home services (not just MST)• Respite services • Mobile response and stabilization services • Independent living skills and supports• Family/youth education and peer support

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

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Examples of What You Don’t See Listed as Evidence-Based Practice

(though they may be standard practice)

• Residential Treatment

• Group Homes

• Day Treatment

• Traditional office-based “talk” therapy


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Examples from Hawaii’s List of Evidence Based PracticesProblem Area Best Support Good Support Moderate

Support

Anxious or Avoidant Behaviors

Cognitive Behavior Therapy (CBT); Exposure Modeling

CBT with Parents; Group CBT; CBT for Child & Parent; Educational Support

None

Depressive or Withdrawn Behaviors CBT

CBT with Parents; Inter-Personal Tx. (Manualized); Relaxation None

Disruptive & Oppositional Behaviors

Known Risks:Group Therapy

Parent & Teacher Training; Parent Child Interaction Therapy

Anger Coping Therapy; Assertiveness Training; Problem Solving Skills Training, Rational Emotive Therapy, AC-SIT, PATHS & FAST Track Programs

Social Relations Training; Project

Achieve

Juvenile Sex Offenders None None Multisystemic Therapy

Delinquency & Willful Misconduct BehaviorKnown Risks: Group Therapy

None Multisystemic Therapy; Functional Family Therapy

Multi-Dimensional

Treatment Foster Care;Wraparound

Foster Care

Substance UseKnown Risks:Group Therapy

CBT Behavior Therapy; Purdue Brief Family Therapy

None

HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd

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HANDOUT 7.2

Examples of Potentially Harmful Programs and Effective Alternatives

Source: 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. As published in Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7. www.youthtoday.org


http://www.youthtoday.org/

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Challenges to Financing and Implementing Evidence-Based/Promising Practices

Financing & Infrastructure needed for:

TrainingConsultation Coaching

Provider Capacity DevelopmentFidelity Monitoring

Outcomes Tracking

Pires, S. 2005. Human Service Collaborative. Washington, D.C.

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How to Finance/Implement Evidence-Based and Promising Practices

Adopt a Population Focus: Who are the populations of families and youth for whom you want to change practice/outcomes?

Adopt a Cross-Systems Approach: What other systems serve these children and families? Who controls potential or actual dollars? Which systems now spend a lot on restrictive levels of care with poor outcomes or on deficit-based assessments not linked to effective services - opportunities for re-direction?

Identify Incentives and Supports to finance/implement evidence based practices


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Examples of Incentives to Various Systems Serving Children and Families

Medicaid: slowing rate of growth in inpatient, emergency room, residential treatment and pharmacy costs

Child Welfare: meeting Adoptions and Safe Families Act outcomes; reducing out-of-home placements

Juvenile Justice: creating alternatives to incarceration

Mental Health: more effective delivery system

Education: reducing special education expenditures


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Examples of Cross-System Partnerships to Financeand Implement Evidence-Based and Promising Practices


District of Columbia Multi Systemic Therapy (MST), Mobile Response, In-Home

Medicaid Rehab Option to pay for MST, Intensive Home-Based Services (Ohio model), Mobile

Response and Stabilization Services (NJ model)Child Welfare provided match and paid for initial

training, coaching, provider

capacity development;

Mental health/child welfare to share costs of outcomes tracking

Juvenile Justice also to pay match, training costs as well

Medicaid HMO expressing interest in Mobile Crisis

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Service Array Focused on a Total Population

Family Support Services

Youth Development Program/Activities

Service Coordination Intensive Service

Management Wraparound Services

& Supports; Family Group Decision Making

Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative.

Core Services Prevention Early Intervention Intensive Services

Universal Targeted

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• Driven by family/youth-preferred choices;

• Understands the needs/help-seeking behaviors of youth/families;

• Embraces principles of equal access/non-discriminatory practices;

• Designs/implements services and supports that are tailored or matched to the unique needs of children, youth, families, organizations and communities served;

• Recognizes well-being crosses life domains;

• Understands that cultural competence must be defined and required for Evidence Based Practices (EBP), and that Practice Based Evidence (PBE) must be taken into consideration as a critical component of EBPs in communities of color.

Lazear, K. J Primer Hands On Human Service Collaborative, Washington, DC. 2006

Characteristics of a Culturally and Linguistically Competent Service Design & Practice

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Families and Youth Provide Valuable Services and Supports

As technical assistance providers & consultants

Training

Evaluation

Research

Support

Outreach

As direct service providers

Foster Parents

Mentors

Service Coordinators

Family Educators

Specific Program Managers (respite, etc)

Adapted from Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

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Family and Youth Roles in Building Evidence-Based Practice (EBP)

• Advocate for ethical, culturally sensitive research• Participate in the development and analysis of

research to support EBP• Assist in data collection to support EBP• Educate families, family leaders and youth about

EBP

Wells, C. & Pires, S. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

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Examples of Strategies to Address Lack of Home and Community-Based Services

• Support family and youth movements• Engage natural helpers and culturally diverse communities• Implement a meaningful Medicaid rehab option• Write child and family appropriate service definitions• Collapse out-of-home and home and community-based budget

structures• Re-direct dollars from out-of-home to home and community-

based• Implement flexible rate structures (e.g., bundled rates/case

rates)• Implement pilots or phase in system change


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• Implement capacity-building grants

• Implement performance-based contracts

• Develop practice and implementation guidelines

• Train providers, judges, families, etc. – use training resources across systems

• Implement quality and utilization management

• Apply for federal demonstration grants

• Collect data on child and family outcomes, family/youth satisfaction, and cost/benefits

• Educate key constituencies (e.g., legislators, Governor’s Office, State Insurance Commissioner)

Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.

Examples of Strategies to Address Lack of Home and Community-Based Services

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Examples of Sources of Funding for Children/Youth with Individualized Needs in the Public Sector

Pires, S. (1995). Examples of sources of funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

Medicaid• Medicaid In-Patient• Medicaid Outpatient• Medicaid Rehabilitation

Services Option• Medicaid Early Periodic

Screening, Diagnosis and Treatment (EPSDT)

• Targeted Case Management

• Medicaid Waivers• TEFRA Option

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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Major Child Welfare Funding Streams

• Child Welfare Services – Title IV-B • Foster Care & Adoption Assistance – Title IV-E • Social Services Block Grant• Temporary Assistance to Needy Families (TANF)• Medicaid – Title IX• State and local general revenue


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Type Advantages Drawbacks

IV-B

Flexible, includes family preservation and support $$

Capped allocation from federal government to states and represents a relatively small percentage of available $$

IV-E

Uncapped entitlement $$ Can be used only for room/board costs for eligible children in out-of-home placements and certain administrative and training costs

Medicaid

Important source of revenue for health and behavioral health services for children in or at risk for child welfare involvement

Medicaid agencies are concerned about increasing costs and assuming too much responsibility for “high-cost” populations;

Adult family members may not be eligible

TANF Important source of emergency funds for families

Capped

SS Block Grant Flexible Capped and shrinking

Advantages and Drawbacks of Specific Child Welfare Financing Streams


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Creating “Win-Win” Scenarios

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 Inpatient/Emergency Room-

high cost

Special Education

Alternative to out-of-schoolplacements – high cost


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Thinking Across Systems Serving Children, Youth and Families


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Financing Strategies to Support Improved Outcomes for Children, Youth and Families

FIRST PRINCIPLE: System Design Drives Financing

Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

REDEPLOYMENTUsing the money we already haveThe cost of doing nothingShifting funds from treatment to 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 collections including child supportTrust 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

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What Are the Pooled Funds?

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

CHILD WELFAREFunds thru Case Rate(Budget for Institutional

Care for CHIPS Children)

JUVENILE JUSTICE(Funds budgeted for

Residential Treatment forDelinquent Youth)

MEDICAID CAPITATION(1557 per month

per enrollee)

MENTAL HEALTH•Crisis Billing•Block Grant

•HMO Commercial Insurance

Wraparound MilwaukeeManagement Service Organization (MSO)

$30MPer Participant Case Rate

Care Coordination

Child and Family TeamProvider Network240 Providers85 Services

Plan of Care

9.5M 8.5M 10M 2.0M

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Example: Pooled Funds forNebraska’s Integrated Care Coordination Units

Child WelfareState General Revenue,

IV-E, IV-B

Juvenile JusticeState General Revenue

Federal Mental Health Block Grant

Case Rate

Integrated Care Coordination Unity

Services and supports for children in state custody

with complex needs

Families Care 8% of Case Rate

Pires, S. (2007) Primer Hands On - Child Welfare

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Financing – Cuyahoga County (Cleveland)

FCFC $$Fast/ABC $$Residential Treatment Center $$$$Therapeutic Foster Care $$$“Unruly”/shelter care $Tapestry $$SCY $$

County Administrative

Services Organization

Neighborhood Collaboratives &Lead Provider Agency

Partnerships

Community Providers and Natural Helping Networks

Reinvestment of savings


}

}

StateEarly Intervention and Family Preservation

System of Care Grants

System of Care Oversight Committee

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Youth who are at-risk of entering a RTC

The three sources of funding stream into the local management entity from the state and federal government. The local management entity is held accountable to the state. The three sources of funding are from Medicaid, Mental Hygiene, and a combination of DHR and DJS.

MedicaidFederal and State

(MHS Match Mental HygieneBlock Money

DHR and DJS

Example of Redirecting Funds

Adapted from State of Maryland, 2004

Treatment services (in patient (treatment facility) and out-patient (in-home) services)

Support services (respite, behavioral supports, nutrition, etc.)

Housing/Placement services

(foster care, group home, adoption, etc.)

Youth referred to a local management

entity

At risk pool is created for the local management entities

Local Management

Entity

Controls the management of

treatment services, support services, and housing/placements. Money form the three funding sources are streamlined into the local management

entity

$ $$

$

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Where to Look for Money and Other Types of Support

Pires, S. (1994). Where to look for money and other types of support. Washington, DC: Human Service Collaborative.

ee

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SOURCE SYSTEM DESCRIPTION

State Mental Health General fund, Medicaid (including FFS/managed care/waivers), federal mental health block grant, redirected institutional funds, and funds allocated as a result of court decrees

Child Welfare Title IV-B (family preservation), Title IV-B (foster care services), Title IV-E (adoption assistance, training, administration), and technical assistance and in-kind staff resources

Juvenile Justice Federal formula grant funds to states for juvenile justice prevention, state juvenile justice appropriations, and juvenile courts.

Education Special education, general education, training, technical assistance, and in-kind staff resources

Governor’s Office/Cabinet Special children’s initiatives, often including interagency blended funding

Social Services Title XX funds and realigned welfare funds (TANF)

Bureau of Children with Special Needs

Title V federal funds and state resources

Diversity of Federal Grant Sites Funding

Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

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CMHS GRANT SITES FUNDING DIVERSITYSOURCE SYSTEM DESCRIPTION

State Health Department State funds

Public Universities In-kind support, partner in activities

Department of Children In states where child mental health services are the responsibility of child agency, not mental health, sources of funds similar to above

Vocational Rehabilitation Federal- and state-supported employment funds

Housing Various sources

Local County, City, or Local Township

General fund

Juvenile Justice Locally controlled funds

Education Courts, probation department, and community corrections

County May levy tax for specific purposes (mental health)

Food Programs In-kind donations of time and food

Health Local health authority-controlled resources

Public Universities and Community Colleges

Substance Abuse In-kind support

Diversity of Federal Grant Sites Funding (continued)

Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s

mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

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Diversity of Federal Grant Sites Funding (continued)

SOURCE SYSTEM DESCRIPTION

Private Third Party Reimbursement Private insurance and family fees

Local Businesses Donations and in-kind support

Foundations Robert Wood Johnson, Annie E. Casey, Soros Foundation, and various local foundations

Charitable Lutheran Social Services, Catholic Charities, faith organizations, homeless programs, and food programs (in-kind)

Family Organizations In-kind Support

Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

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Example: Diversified Funding Sources & Approaches at the Parent Support Network, RI

Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.

CHILD WELFAREIVB FUNDS

STATE APPROPRIATION

FUNDSBEHAVIORAL

HEALTH

DEPARTMENT OF EDUCATION

DISCRETIONARYFUNDS

FEDERAL GRANTS&

PRIVATE DONATIONS

Administrative Infrastructure (4.0 FTE)

Executive Director, Assistant Director, Administrative Assistant, and Data and Technology Specialist

Peer Mentor Program (3.25 FTE)

Information & Referral

Child & Family Teams

Education Planning

Support Groups/ Youth Speaking Out

Training

Family & Youth Leadership Program (2.50 FTE)

System Reform Training & TA

Placement on Policy Boards

Focus Groups

Social Marketing/ Presentations

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Medicaid Option Advantages Issues Example

Rehabilitation Services Option

•Flexibility to cover a broad array of services and supports provided in different settings (e.g., home, school)

•Service definitions often adult-oriented

•Provider-service mismacth

•OH – developing new service definitions and case rates for intensive home-based services and Multisystemic Therapy

Managed Care Demos and Waivers - 1115 and 1915 (b)

•Accountability and management of cost through risk structuring/sharing

•Flexibility to cover wide range of services and populations

•Managed care not without risks/challenges

•Federal waiver process can be challenging

•Cost neutrality issues

•NM – covering Multisystemic Therapy

•AZ – covering family support and urgent response for child welfare

Home and Community-Based Waivers - 1915 (c)

•Flexibility, broader coverage, waiver of income limits and comparability

•Alternative to hospital-level of care but PRTF (i.e., residential tx.) may be issue

•Cost and management concerns/limited to small number

•KS, NY, VT, IN, WI – have HCBS Waivers

•AK, FL, GA, IN, KN, MD, MS, MT, SC, VA – have community alternatives to psychiatric residential treatment facilities demonstration grant

Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (1)


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Medicaid Option

Advantages Issues Example

Early and Periodic Screening, Diagnosis and Treatment - EPSDT

•Broadest entitlement

•Supports holistic assessments and services

•No waiver or state plan amendment requirements

•Management mechanism critical because of cost concerns

•Oriented more to physical health in practice

•RH

•PA

Targeted Case Management

•Can be targeted to high need populations, such as child welfare

•Supports small case load focus (e.g., 1-10)

•Not sufficient without other services

•Federal attention

•VT

•NY

Administrative Case Management

•Ability to cover basic case management services to support enrollment access

•Not sufficient without other services

•NJ – covering some activities of family-run organizations



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Medicaid Option

Advantages Issues Example

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

•Avenue to eligibility to community-based services for children who meet SSI disability criteria – allows disregard of family income

•SSI criteria not easy to meet for children with SED

•Does not expand types of covered services

•Cost issues, so generally small program

•MN

•WI

Medicaid as Part of a Blended or Braided Funding Approach (without a waiver)

•Holistic, integrated (across systems) financing, supports broad array of services, natural supports and individualized care

•Involves significant restructuring

•Milwaukee Wraparound

•DAWN Project

•Massachusetts Mental Health Services Program for Youth

•New Jersey Partnership



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Bottom Line

State Medicaid agencies are cobbling together a variety of Medicaid options in attempt to cover and contain community-based services for children and families - often without involvement of other systems serving children and families.

What is needed is a more integrated, strategicfinancing approach across systems.


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If you have answered the questions:

Financing For Whom? Financing for What?

Then You Are Ready To Talk About Financing!


I.E., Identified your population(s) of focus

Agreed on underlying values and intended outcomesIdentified services/supports and practice model to achieve outcomes

Identified how services/supports will be organized(so that all key stakeholders can draw the system design)

Identified the administrative/system infrastructure needed to support the delivery system

Costed out your system of care

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Strategic Financing Analysis1. Identify state and local agencies that spend dollars on the identified

population(s). (How much each agency is spending and types of dollars being spent, e.g., federal, state, local, tribal, non-governmental)

2. Identify resources that are untapped or under-utilized (e.g., Medicaid).

3. Identify utilization patterns and expenditures associated with high costs/poor outcomes, and strategies for re-direction.

4. Identify disparities and disproportionality in access to services/supports, and strategies to address.

5. Identify the funding structures that will best support the system design (e.g., blended or braided funding; risk-based financing; purchasing collaboratives).

6. Identify short and long term financing strategies (e.g., Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum, etc.).


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Example: Program Budget for a Neighborhood-Based System of CareCost

Categories

Proposed Total Costs

Neighbor-hood Governance

Family Leadership

Family Service/ Support

Removal of Barriers

Community Organizing

School Linkage

Tracking & Evaluating

Volunteers Partnership Building

Exec. Direction &Support

Salaries 446,000 21,000 29,000 190,000 21,000 26,000 35,000 15,000 30,000 18,000 63,000

Fringe 133,000 6,300 8,700 57,000 6,300 7,800 10,500 3,900 9,000 5,400 18,900

Building Occupancy

93,600 8,700 12,300 36,800 2,400 4,300 4,000 2,500 4,300 2,500 15,800

Professional Services

109,000 17,600 22,100 32,400 3,600 2,700 2,700 18.600 2,700 2,900 3,700

Travel 43,700 12,300 5,300 10,300 9,000 1,200 3,000 500 500 500 1,600

Equipment 6,000 600 600 600 600 600 600 600 600 600 600

Food Services

25,000 0 4,000 1,000 18,000 0 1,000 0 1,000 0 0

Subcontract 89,000 0 0 89,000 0 0 0 0 0 0 0

Operating Supplies & Expenses

21,500 1,800 700 8,600 200 1,300 2,100 500 1,500 4,100 4,100

Other (stipends, transport, child care)

84,000 0 40,000 9,000 35,000 0 0 0 0 0 0

Equipment Lease

25,000 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500

Property 25,000 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500

Insurance 13,500 2,700 1,200 1,200 1,200 1,200 1,200 1,200 1,200 1,200 1,200

GRAND TOTALS: 1,115,100 80,000 125,900 459,900 84,300 51,100 64,100 45,800 55,300 36,800 113,900

Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.

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Proposed Total Costs

Neighbor-hood Governance

Family Leadership

Family Service/ Support

Removal of Barriers

Community Organizing

School Linkage

Tracking & Evaluating

Volunteers Partnership Building

Exec. Direction&Support

Revenue Totals Across Sources

Foundation 217,100 40,000 30,000 25,000 28,300 24,000 0 22,800 12,000 15,000 20,000

State Mental Health & Substance Abuse

258,800 2,500 28,400 157,900 3,000 20,000 0 5,000 12,000 5,000 25,000

County- Child Welfare

124,900 20,000 30,000 30,000 10,000 5,000 0 3,000 12,000 2,000 12,900

Dept of Education

70,100 2,500 1,600 0 0 0 60,000 0 0 0 6,000

State Family Preservation Grant

373,400 5,000 20,000 230,000 35,000 0 0 12,000 18,000 14,000 39,400

In-Kind 29,300 0 10,000 10,000 5,000 1,000 0 0 800 0 2,500

Donations 21,300 5,000 900 5,000 1,000 100 2,100 3,000 500 800 5,000

Other Grants

20,200 5,000 900 5,000 1,000 100 2,100 3,000 0 0 3,100

GRAND TOTALS

1,115,100 80,000 125,900 459,900 84,300 51,100 64,100 45,800 55,300 36,800 113,900

Revenue Allocation By Program

Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.

Example: Program Budget for a Neighborhood-Based System of Care(continued)

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HANDOUT 7.3

The “Matrix” from OregonHow to Fund the Service Array and How to Process

Includes: Client Related ExpendituresResource PrioritiesPayment Documents
