Accessibility and Community Involvement and the Role of Residential in Systems of

Care

Bruce Kamradt

Cathy ConnollyJuly 19, 2007

Values That Guide Accessible Community-Based Care

Individualize the Provision of Services to Meet The Child’s and Family’s Unique Needs

Provide Access To A Comprehensive Array of Services and Supports

Strength-based approaches work best Services and Treatment are provided in the

community whenever possible Child and Family Team Guides Treatment and

Service Planning no matter where the child resides

Success determined thru Measurable Outcomes

What Is Wraparound Milwaukee-

I. Organized as a Unique Type of Public Care Management Organization--HMO

II. Defined Populations for Enrollment—children at immediate risk of Institutional placement—640 enrollees

III. Operates with Pooled Funds--$37 million—single payor of all services for SED youth Child Welfare Juvenile Justice Mental Health Medicaid

IV. No Formal Contracts -- Utilizes A Comprehensive Fee for Service Approach with Extensive Provider Network—Residential Treatment is a network service

V. Employs Care Coordinators who facilitate Child and Family Teams—one family and one plan

Continued

Wraparound Milwaukee - What Is It?

VI. Strong Mobile Crisis Services—24/7VII. Strong QA/QI and Single internet-based

Information System Serves All 230 Provider Agencies

VIII. Organized Family Advocacy and Support System Partners with Families

Continued

Daily Living Skills - TrainingIndependent Living Apt.Parent AideChild CareHousekeepingMentoringTutorLife Coach RecreationAfter School ProgrammingSpecialized CampsDiscretionary FundsSupported Work Environment

List of Available Servicesin Social / Mental Health Plan

Case ManagementReferral AssessmentMedication ManagementOutpatient

Individual/FamilyOutpatient - GroupOutpatient - AODA Psychiatric AssessmentPsychological EvaluationMental HealthAssessment/EvaluationInpatient Psychiatric Nursing

Assessment/ManagementConsultation with Other

Professionals

Group Home Care Respite Respite - Foster Care Respite - Residential Crisis Bed - RTC Crisis Home Foster Care Treatment Foster Care In-Home Treatment (Case

Aide) Day Treatment Residential Treatment Transportation Crisis 1:1 Stabilizers/Aides

Utilization of Residential Services Within Our System of Care

Average of 80 youth in Residential Treatment Centers and 75 youth in Group Homes-Out of Average Daily Enrollment of 640 youth

Average about $1800 per month per enrollee for above services or 45% of Service Costs

4 of our 9 Care Coordination Agencies are Residential or Group Home Providers

Overall Utilization of Residential Tx. has Decreased Over past 12 years from 375 Average RTC placements to 80 and Length of Stay from 12 months to 3.5 months

Best Practice Approaches for Residential Treatment In A System of Care

Residential Care should and can be Short-Term (30 – 90 Days)

Residential Care should be Pre-Authorized by the Purchaser

Integrate Residential Plan into Community Plan—Residential Care Is Part of A Strategy To Meet A Need

Involve and Engage Parents

High Risk Youth Need a Good Safety Plan

Best Practice Approaches for Residential Treatment …. continued

Outcomes should be Clear, Measurable and Time-Limited

Residential Staff should Participate with Community Professionals, Neighbors, Informal Supports on the Care Planning Team—The CFT Designs and Oversees The Care Plan Regardless of Where The Child Resides

Discharge should Occur When Immediate Needs are Met and Community Resources Put in Place to Meet longer Term Treatment Needs

Challenges For Purchasers And Providers

Political Support for Changing Role of Residential Care

Legal Support for Changing Role of Residential Care

Learning To Share The Same Values, Approaches and Goals

Expanding Array of Community Services Residential Centers Provide While Often Reducing The Physical Infrastructure

Training and Technical Assistance Required

Challenges For Purchasers And Providers…continued

Familiarizing Residential Centers and Other Agencies with Managed Care Techniques

– Participating in a Provider Network

– Fee-For-Service

– Prior Authorization

Establishing Outcomes for Youth in Residential Care—We May Each Be Evaluating Progress In Different Ways With Different Timelines

St. Charles: Brief History

Established in 1920 by Archdiocese as single service organization on 57-acre campus in Milwaukee, Wisconsin

Exclusively boys residence for 65+ years

Children were generally referred by family & others for “delinquency”

A Business Case for Change

Typical residential stay in 1960s-1970s was 3-4 years3-4 years in length

By 1980s, typical stay fell to 1 year1 year with ability to extend an additional year

Since Wraparound began, the initial commitment is generally 30 days30 days with average stay being 3-6 months3-6 months

Strategic Internal QuestionsSt. Charles had to question itself in the

face of change:

Who would we be if we were no longer defined by the facilities we had invested in over decades?

What would we do with all those facilities if multi-year residential stays were not going to return?

Elements of Immediate Change

MissionInternal “Self-Image”NameResidentially Focused StaffAbundance of Residential FacilitiesExcess Land

Change Forces New Vision

We would no longer be facilities-driven…we would serve youth & families wherever they might be

We would embrace the trend away from residential services, and transform ourselves to meet new market

As a result of strategic planning:

The Challenges of Change

1. DECISION-MAKING: From “experts” role exclusively making treatment decisions to “team members” providing input

The Challenges of Change

2. STRENGTH-BASED: From managing behavior to facilitating self-management

The Challenges of Change

3. PERFORMANCE: From individual definitions of performance and quality to standardized community-wide indicators

The Challenges of Change

4. RESIDENTIAL POPULATION: From nearly 500 area youth receiving residential services to only 50

The Challenges of Change

5. SERVICE DELIVERY: From on-site residential treatment to in-home and community-based service delivery

The Challenges of Change

6. WORKFORCE DIVERSITY: From emphasis on residential staff/staff training to seeking/training for more diverse skills sets

The Challenges of Change

7. FINANCIAL PRESSURE: From full beds and balanced budgets with 1+ year stays to greater financial uncertainty and need to diversify funding sources

The Results of Embracing Change

Agency grew from $3 million to $13 million in annual revenues

Staff grew from 25 to 300Most importantly, positive results for

youth & families

Much has improved as a result of embracing change:

The Results of Embracing Change

Wraparound Care Coordination

Safety ServicesMedical Day TreatmentAlternative EducationIntensive Family

Development Services

St. Charles transitioned from a single service to a wide range of programming, including:

The Results of Embracing Change

MentoringResidential TreatmentShelter CareFamily PreservationFirst Time Juvenile

Offender ProgramAlternatives to Incarceration

St. Charles transitioned from a single service to a wide range of programming, including:

St. Charles: Programming Today

JAC, 6%

Shea, 5%

K Ctr, 3%

MDT, 7%

BR, 2%

IDT, 4%

Day Ctr, 2%

Cty Shelter, 19%

State Shelter, 4%

Kiley, 5%

MAT, 2%

Other, 4%

IFDS, 3%

ESP, 2%

Kenosha, 4%

TFC, 2%

Mentor, 3%

Wrap, 4%

Ed Ctr, 12%

Level 2, 4%

Safety, 3%FTJOP, 2%

Today, St. Charles Youth & Family Services is a well diversified service provider with no more than 20% of revenues being received from a single source.