Customizing Care Coordination in Medicaid for Children with

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Georgetown University 2014 Training Institutes

Customizing Care Coordination in Medicaid Delivery Systems for Children with Serious Behavioral Health Challenges:

The Use of Care Management Entities and Wraparound Teams

PRESENTERS

Sheila A. PiresSenior Partner, Human Service Collaborative; Core Partner, Technical Assistance Network

Jody Levison‐JohnsonJody Levison‐JohnsonDeputy Assistant Secretary, Louisiana Office of Behavioral Health

Elizabeth ManleyDirector, System of Care Division, New Jersey Dept. of Children and Families

Jackie ShippDirector, Community Based Services, Oklahoma Dept. of Mental Health and Substance Abuse Services

Dayana SimonsSenior Program Officer, Center for Health Care Strategies, Inc.; Core Partner, Technical Assistance Network

Michelle ZabelUniversity of Maryland Baltimore, Institute for Innovation and Implementation; Lead Core Partner, Technical Assistance Network

Setting the Context

Why Children with Significant Behavioral HealthChallenges Need Customized Care Coordination

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Mental Health = Costliest Health Condition of Childhood

$8.90

$20.00

$25.00

$30.00

S of Dollars Mental Health

Disorders

3

$2.90

$3.10

$6.10

$8.00

$0.00

$5.00

$10.00

$15.00

BILLIONS

Asthma

Trauma Related ConditionsAcute BronchitisInfectious Diseases

Source: Soni, 2009 (AHRQ Research Brief #242)

Children in Medicaid: Behavioral Health Penetration and Total Expense

• Children in Medicaid using behavioral health (BH) care:• Under 10% of children enrolled in Medicaid, but • An estimated 38% of total Medicaid child expenditures ($19.3b)

• 9.6% of children in Medicaid used BH care• 6.7% used BH services (with or without psychotropic meds)• 5.8% used psychotropic medications (with or without BH services)

• 0.8% of Medicaid children used substance use disorder services

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Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid:Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

Children in Medicaid Using BH Care:A High‐Cost Population

• Mean Medicaid expenditures (PH and BH) = $8,520 per year • Nearly 5x higher than for Medicaid children in general ($1,729 per

year*)• TANF‐enrolled children – nearly 3x higher• Foster care – 7x higher• SSI/disabled – nearly 9x higher• SSI/disabled – nearly 9x higher

• Expenditures driven more by behavioral – rather, than physical – health service use, except for children on SSI/disability who have slightly higher physical health expense

• Children with top 10% of BH expense are 28x more expensive than Medicaid children in general

*As estimated in Center for Medicaid and State Operations: Statistical Report on Medical Care: Eligibles, Recipients, Payments, and Services (HCFA 2082), MSIS. 2008 Statistical Supplement.

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Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

Children in Foster Care Use More Restrictive, More Expensive Services in Medicaid

•More likely to use: •Inpatient psychiatric services•Residential treatment •Therapeutic group care •Emergency room services •Psychotropic medications

•One‐fifth the size of the TANF population, but use: •Nearly the same amount of dollars for residential, group care andER visits

•3.5 times more for therapeutic foster care

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

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2 - 5%

More complex needs Intensive

Services –60% of $$ Home &

community services Prevention

Prevalence/Utilization Triangle

15%

80%Less

complex needs

and supports;

early intervent’n–35% of $$

and Universal Health Promotion –5% of $$

Pires, S. 2006. Human Service Collaborative. Washington, D.C.

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Children and Youth with Serious Behavioral Health Conditions:Distinct Population from Adults with Serious and Persistent Mental Illness

• Do not have the same high rates of co‐morbid physical health conditions as adults with SPMI

• Have different mental health diagnoses from adults with SPMI (i.e. ADHD, Conduct Disorders, Anxiety); not as much Schizophrenia, Psychosis, Bipolar; and diagnoses change often

• Two‐thirds are typically involved with child welfare and/or juvenile justice systems, and b l d d b l l d60% may be in special education – systems governed by legal mandates

• Care coordinator’s time is primarily spent on coordination with other children’s systems (i.e. child welfare, juvenile justice, schools), behavioral health providers, family needs/concerns, not coordination with primary care

• To improve cost and quality of care, focus must be on child and family/caregiver(s) which takes time

Pires, S. March 2013 Customizing Health Homes for Children with Serious Behavioral Health Challenges .Human Service Collaborative

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Customized, Intensive Care CoordinationApproaches Are Needed

•Traditional case management and care coordination approaches for adults are not sufficient

•Need for:i•Lower case ratios

•Higher payment rates•Approach based on evidence of effectiveness

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Customized Care Coordination Approaches for Children with Serious Behavioral Health Challenges

• Care Management EntitiesOrganizations providing intensive care coordination at low

ratios (1:10) using high quality Wraparound* care planning approach

• High Quality Wraparound Teamsb dd d i ti i ti h CMHC FQHCembedded in supportive organization, such as CMHC, FQHC

or school‐based mental health center, providing intensive care coordination at low ratios

Pires, S. 2013. Washington DC: Human Service Collaborative

Growing number of states experiencing better outcomes, lower per capita costs. (MA, LA, NJ, WI, IL; PRTF Waiver Demo states; CHIPRA Care Management Entity Quality Collaborative states(MD, GA, WY); OK)

(*May 7, 2013 CMCS SAMHSA Joint Informational Bulletin)

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Important Points About Wraparound• Wraparound is:

– A defined, team‐based service planning and coordination process

– A structured approach to service planning and care coordination

• It is NOT a service per se• The Wraparound care planning process ensures that there is

one coordinated plan of care and one care coordinator• The ultimate goal is to improve:

– Outcomes – Family and youth experience with care– Per capita costs of care – health care’s triple aim

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What’s Different in Wraparound?• High quality teamwork

– Collaborative activity– Brainstorming options– Goal setting and progress monitoring

• The plan and the team process is driven by and “owned” by the family and youth

• Taking a strengths based approach• Taking a strengths based approach• The plan focuses on the priority needs as identified by the

youth and family• Focus on:

– Whole youth and family– Developing optimism and self‐efficacy– Developing enduring social supports

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In wraparound, a care coordinator coordinates the work of system partners and other natural helpers so there is one coordinated plan

BehavioralJuvenile J ti

Education Child

Care Coordinator(+ Peer Partner)

Health

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Behavioral Health

Justice welfare

YOUTH

FAMILY“Natural Supports”

•Extended family

•Neighbors

•Friends

“Community Supports”

•Neighborhood

•Civic

•Faith‐based

ONE PLAN Adapted from Laura Burger Lucas, ohana coaching, 2009

care

Wraparound is Increasingly Considered “Evidence‐Based”

• State of Oregon Inventory of Evidence‐Based Practices (EBPs)

• California Clearinghouse for Effective Child Welfare Practices

• Washington Institute for Public Policy: “Full fidelity wraparound” is a research‐based practice

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Costs and Residential Outcomes are Robust

CMS Psychiatric Residential Treatment Facility (PRTF) Waiver Demonstration (Urdapilleta et al., 2011)

• Average per capita saving by state ranged from $20,000 to $40,000

Los Angeles County Department of Social Services• Found 12‐month placement costs were $10,800 for Wraparound‐discharged youths compared to $27,400

for matched group of RTC youths

Wraparound Milwaukee• Reduction in placement disruption rate in child welfare from 65% to 30%• School attendance for child welfare‐involved children improved from 71% days attended to 86% days p y y

attended• 60% reduction in recidivism rates for delinquent youth from one year prior to enrollment to one year post

enrollment• Decrease in average daily pop. in residential treatment centers from 375 to 50• Reduction in psychiatric inpatient days from 5,000 days per year to <200 • Average monthly cost of $4,200 (compared to $7,200 for RTC, $6,000 for juvenile detention, $18,000 for

psychiatric hospitalization)

Maine• Experienced 30% net reductions in Medicaid spending, comprised of decreases in PRTF and inpatient

psychiatric with increases in targeted case management and home‐ and community‐based services

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Child and Youth Populations Typically Served by CMEs/High Quality Wraparound Teams

• Children and adolescents:• With serious emotional/behavioral challenges at risk of out‐

of‐home placement in residential treatment, group homes, and other institutional settings

• Returning from institutional placements in residential treatment, correctional facilities, or other out‐of‐home settingg

• At risk of or returning from psychiatric inpatient settings• in child welfare

• Youth at risk of incarceration or placement in juvenile correctional facilities

• Detention diversion and alternatives to formal court processing for juveniles

• Other populations (e.g., youth at risk for alternative school placements)

Pires, S. 2010. Human Service Collaborative16

Customization Strategies – Regardless of Medicaid System Design

Customized Care Coordination(May 7, 2013 CMCS and SAMHSA Informational Bulletin)

•Incorporate intensive care coordination using Wraparound approach for children with serious behavioral health challenges (growing number of states –MA, LA, NJ; PRTF Waiver Demo; CHIPRA Care Management Entity Quality Collaborative states)Collaborative states)

•Intensive care coordination rates for this population range from $780 pmpm to $1300 pmpm (CHCS Matrix)•In fidelity intensive care coordination/Wraparound approaches, all‐inclusive cost of care (e.g., admin, care coord, placements, clinical treatment, informal supports) averages $3700‐$4200 pmpm (about $2100 is Medicaid ) –compare to $9,000 pmpm in PRTFs, higher in psych inpatient

Pires, S. & Stroul, B. 2013. Making Medicaid Work for Children in Child Welfare. Hamilton, NJ: Center for Health Care Strategies17

Care Management Entity Functions

Service Level

• Child and family team facilitation using fidelity wraparound practice model

• Screening assessment

Administrative Level

• Information management –real time data; web‐based IT

• Provider network recruitment and management (including


• Screening, assessment, clinical oversight

• Intensive care coordination• Care monitoring and review• Peer support partners• Access to mobile crisis supports

and management (including natural supports)

• Utilization management• Continuous quality improvement; outcomes monitoring

• Training

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Variation in Types of CME Entities

•Public agency as CME – Wraparound Milwaukee

•New non profit organization with no other role – New Jersey Care Management Organizations

•Existing non profit organization with other direct service capability –Massachusetts Community Service AgenciesMassachusetts Community Service Agencies

•Hybrid – Non profit organization with other direct service capability in formal partnership with neighborhood organization – Cuyahoga County, OH Coordinated Care Partnerships

•Non profit HMO – Massachusetts Mental Health Services Program for Youth


Integration at the Systems/Medicaid Purchaser Level: Caveats

Research has shown that…

• When adult and child behavioral health dollars are integrated, there is a risk of child behavioral health dollars being absorbed by adult services

• When physical and behavioral health dollars are integrated there is• When physical and behavioral health dollars are integrated, there is a risk of behavioral health dollars being absorbed by physical health services

Especially in the absence of customization within the design for children with serious BH challenges, risk‐adjustment strategies, strong contractual performance measures and monitoring mechanisms

See publications and issue briefs published by the Health Care Reform Tracking Project at: http://www.fmhi.usf.edu/cfs/stateandlocal/hctrking/hctrkprod.htm20

Medical Homes vs. Health Homes

Medical Homes

All children

Health Homes

Children with chronichealth conditions, childrenwith serious behavioral health conditions

Coordination of medical care

Physician‐led primary carepractices

Coordination of physical,behavioral, and social supports

Specialty provider organizations,including behavioral health specialtyorganizations (e.g., not only medical)

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Analysis of Medical Home Services for Children with Behavioral Health Conditions

“All behavioral health conditions except ADHD are associated with difficulties accessing specialty care through a medical home”

“The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with theand youth with behavioral health conditions are not consistent with the medical home model has more to do with difficulty in accessing specialty care than with accessing quality primary care”.

There is a need for more customized, intensive care coordination approaches for children with significant behavioral health challenges.

Pires, S. 2013. Washington DC: Human Service Collaborative

Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb‐Mar 31 (2) 92‐9

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“Integration” with Primary Care in a Wraparound Approach

• Ensuring child has an identified primary care provider (PCP)

• Tracking of whether child receives EPSDT screens on schedule

• Ensuring child has at least an annual well‐child visitEnsuring child has at least an annual well child visit• Communicating with PCP opportunity to participate in child and family team and ensuring PCP has child’s plan of care and is informed of changes

• Ensuring PCP has information about child’s psychotropic medication and that PCP monitors for metabolic issues such as obesity and diabetes

Pires, S. 2013. Customizing Health Homes for Children with Serious Behavioral Health Challenges. Hamilton, NJ; Center for Health Care Strategies23

Accountable Care Organizations• “I believe, with some exceptions, ACOs will not succeed…it will be difficult for anything

but an organization that has been at it a long time to develop the team culture needed to be an ACO”

• “The reason that patient‐centered medical homes will not succeed is that health care follows the 80/20 rule ‐ 20% of patients generate 80% of the costs. Those 20% are the chronically ill, and I don’t see how primary care physicians serving those patients add value to their care.”

• “Focused factories of care – that is a term I use for provider organizations that deliver highly specialized care for a certain group of patients, such as those with diabetes…you need specialists for that. They are the opposite of ACOs that do everything for everyone.”

‐‐Regina Herzlinger, Harvard Business School, as quoted in Managed Care Magazine Online (http://www.managedcaremag.com)

REALITY: Care coordination ratios within Medicaid ACOs‐ for the highest need‐ run 1:50‐75.

Pires, S. 2013. Washington DC: Human Service Collaborative24

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Medicaid Vehicles to Support Customized IntensiveCare Coordination Using Fidelity Wraparound

• With population pmpm case rate or with care coordination pmpm rate

• 1915(a) – Wraparound Milwaukee, Children Come First (Dane Co WI)

• Targeted Case Management – NJ, MA• 2703 Health Home SPA OK (for SED) NJ (for subset of children• 2703 Health Home SPA – OK (for SED), NJ (for subset of children

with SED and co‐occurring medical or developmental conditions• 1915(b) or (c) – LA• 1915(i) – MD• Money Follows the Person (GA)• Balancing Incentive Program (GA)• CMMI Health Innovations Grant (CHCS and 4‐state application)

Pires, S. 2014. Human Service Collaborative: Washington DC25

State Examples

•Intensive Care Coordination/Wraparound•Structures•How Embedded within Medicaid Delivery System•Medicaid Vehicles Used•Populations Served

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Customizing Care CoordinationCustomizing Care CoordinationThe Louisiana ExperienceThe Louisiana ExperienceJuly 17 & 19, 2014July 17 & 19, 2014

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OVERVIEWOVERVIEW

Louisiana Coordinated System of CareThe Coordinated System of Care (CSoC) is an initiative to serve Louisiana’s youth with significant behavioral health challenges who are in highest need and at greatest risk. CSoC is a component of the Louisiana Behavioral Health Partnership.

CSoC is a philosophy and approach to service delivery that results in i d i i d di i h d i ff iimproved integration and coordination, enhanced service offerings and improved outcomes.

At full implementation the CSoC will serve 2400 youth.

Specific goals for the CSoC include decreasing the number of youth in residential/detention settings, reduction in the state's cost for providing services by leveraging Medicaid and other funding sources, and improving the overall outcomes for these children/youth and their caregivers.

Louisiana Department of Health and Hospitals – Office of Behavioral Health 30

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Winn

Grant

LaSalle Catahoula

Concordia

Caldwell

Natchitoches

Caddo

Bossier

RedRiverDeSoto

Sabine

Webster

Bienville

Claiborne

Lincoln

Jackson

Union Morehouse

Ouachita Richland

FranklinTensas

Madison

CarrollWest East

CSoC Implementing Regions Region 8 – Shreveport; WAA = ChoicesDavid Sikes, 318‐221‐1807, [email protected](Bienville, Bossier, Caddo, Claiborne, DeSoto, Jackson, Natchitoches, Red River, Sabine, Webster)

Region 9 – Monroe; WAA = Wraparound of Northeast LouisianaCurtis Eberts, 318‐654‐4245, [email protected](Caldwell, East Carroll, Franklin, Lincoln, Madison, Morehouse, Richland, Ouachita, Tensas, West Carroll)

Region 7 – Alexandria; WAA = EckerdJodie Roberts; 318‐443‐7900, [email protected] (Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, Winn)

Region 2 – Baton Rouge; WAA = National Child and Family Services (NHS)Carolina Jones, LCSW, 225‐456‐2006, cjones02@nhsonline(Ascension, East Baton Rouge, East Feliciana, Iberville, Livingston, Pt. Coupee. West Baton Rouge, West Feliciana)

Region 1 – Greater New Orleans; WAA = National Child and Family Services (NHS)Karen Davis, Ph.D., LPC, LMFT, 504‐266‐2576, [email protected](Jefferson Orleans Plaquemines St Bernard)

WestFeliciana

Washington

St. Tammany

Tangipahoa

St.Helena

Livingston

CoupeePt.

East

Avoyelles

Baton RougeW.

Iberville Orleans

JohnSt.

St.Charles

St. Bernard

Plaquemines

Jefferson

AscensionSt.James

sAssumption

LafourcheSt.Mary

Terrebonne

Beauregard Allen

Calcasieu

Cameron

JeffersonDavis

Evangeline

St. Landry

Acadia

Vermilion

Lafayette

St.Martin

Iberia

Vernon Rapides

East

(Jefferson, Orleans, Plaquemines, St. Bernard)

Statewide FSO: Ekhaya Youth ProjectDarrin Harris, [email protected], 504‐821‐2601 x577

3132

STRUCTURESSTRUCTURES

Intensive Care Coordination / Wraparound Structure in Louisiana

Department of Health & Hospitals

Office of Behavioral HealthMedicaid

Statewide Management Organization

(SMO)

Wraparound Agencies Family Support Organization Provider Network


Medicaid Vehicles in Louisiana

• CMS Authority:• 1915(b) Waiver allows for the use of Managed Care in the Medicaid Program

• 1915(c) Waiver allows for the provision of long1915(c) Waiver allows for the provision of long term care services in home and community based settings under the Medicaid Program

• Wraparound Agencies: administrative payment• Peer Support Services (Youth & Parent): Fee for service payment

34Louisiana Department of Health and Hospitals – Office of Behavioral Health

Population Served in Louisiana

• Age 21 or under• DSM diagnosis or exhibiting behaviors indicating a behavioral health diagnosis may exist

li i l li ibili h CA S• Meets clinical eligibility on the CANS Comprehensive

• Generally involved with multiple child‐serving systems

• In or at‐risk of out of home placement

35Louisiana Department of Health and Hospitals – Office of Behavioral Health36

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Keeping Families Strong Keeping Children Safe and Well Children’s System of Care

Presented byPresented by

Elizabeth Manley

Division Director

At HomeSuccessfully living with their families and reducing the need for out-of-home treatment settings.

Children’s System of Care ObjectivesTo help youth succeed…To help youth succeed…

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In School

In the Community

Successfully attending the least restrictive and most appropriate school setting close to home.

Successfully participating In the community and becoming independent, productive and law-abiding citizens.

Children’s System of Care Values and Principles

Child Centered & Family DrivenCommunity Based

Culturally Competent

Strength Based Family Involvement Individualized

Unconditional Care

Promoting

Independence

Collaborative

Cost Effective

Comprehensive

Home, School & Community Based

Team Based

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FinancingRehab OptionChild Welfare and Juvenile JusticeTargeted Case Management1915 like (i) or (c)1115 WaiverCHIP/SCHIPState Funds

EnvironmentPolitical

Perspectives of LeadersLaw Suits/Settlements

Crisis/TragedyMandates

Community WillEconomic

Priorities Structure

CSOC Values &

Final System of Care

iPrioritiesServe MoreEBPsCare ManagementSystem CoordinationReduce Institutional CareParticular Populations

StructureGovernment

State vs. CountyExisting Reality

Envisioned IdealMedicaid AgencyLocus of Control

Leadership Structure

Factors That impact Design

Principles

Design

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Key System Components

Contracted System Administrator • CSA is the single portal for access to care available 27/7/365

Care Management Organization

• Care Management Organization utilizing a wraparound model of care serving youth with complex and moderate and their families

Mobile Response & Stabilization Services • Crisis response and planning available 24/7/365

Family Support Organization • Family‐led support and advocacy for parents and caregivers and youth

Fle ible m lti p rpose in home/comm nit clinical s pport for parents/caregi ersIntensive In‐Community

• Flexible, multi‐purpose, in‐home/community clinical support for parents/caregivers and youth with behavioral and emotional disturbances who are receiving care management, MRSS, or out‐f‐home services

Out of Home • Full continuum of residential treatment / out of home care

DD‐Family Support Services• Supports, services, resources, and other assistance designed to maintain and enhance the quality of life of a young person with developmental disability and his or her family, including respite services and assistive technology

Substance Abuse Treatment Services • Out of home and outpatient substance abuse treatment services (limited)

Traditional Services • Partial Care, Partial Hospitalization, Inpatient and Outpatient services

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Role of Contracted Systems Administrator (CSA)

CSA creates pathways for youth and young adults by providing access to the right care at the right

time.

CSA authorizes services, based on the most recent clinical information that is submitted to them.

CSA does not provide direct services.

Anyone helping children and families may contact CSA on behalf of a youth in need of a referral. However, the parent/legal guardian of the youth must

give consent for services.

CSA has a dedicated child welfare unit

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The vision of CSOC is to create positive outcomes for children with emotional and behavioral needs and those with intellectual and developmental disabilities by:

The Role of Assessment within CSOC

Appropriate Services

AppropriateLength of Stay

PositiveOutcomes

• Identifying the child and family’s needs

• Determining the most appropriate Intensity of Service

Assessment Tools

Child and Family Needs

Appropriate Intensity of Service

ServicesIntensity of Service

• Delivering the most appropriate servicesfor the most appropriate length of time

• Using standard assessment tools --the foundation of the Children’s

System of Care.

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Intensities of Service (IOS)

Inpatient Treatment

Out of Home Treatment

Care Management Organization (CMO)

Mobile Response & Stabilization Services

Intensive In‐Community (IIC) & Behavioral Assistance (BA) Services

Outpatient Treatment

Assessment Services

Access / Triage and Information and Referral (PerformCare)

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Care ManagementCare Management Organizations (CMO’S)Utilize Child Family Teams (CFT’s) within Wraparound Model to facilitate a planning process to address the individualized needs of each youth.

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New Jersey Department of Children and Families

Commissioner

NJ Department of Children and Families

Division of Children’s System of

Care(formerly DCBHS)

Division of Child Protection &

Permanency (formerly DYFS)

Division of Family

& Community Partnerships

(formerly DPCP)

Office of Adolescent ServicesDivision on Women

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Oklahoma Systems of Care

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Children and Youth Served

• Children and youth*– Up to age 22– With SED or co‐occurring disorderAt risk of out of home or out of school placements– At risk of out of home or out of school placements

– With complex needs served by multiple agencies

*Up to age 26 at Healthy Transitions Sites

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Care Coordination

• Care coordination in the wraparound process is designed to facilitate a collaborative relationship among the child with SED, the family and all systems involved The Carefamily and all systems involved. The Care Coordinator ensures that the wraparound process is organized and integrated across all child‐serving systems to enable the child to remain in his/her own home community.

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Wraparound In Oklahoma

Wraparound teams (Care Coordinator and FSPs) are trained, coachedand credentialed through the well‐established process managed by theODMSHAS. Mandatory ODMHSAS sponsored/conducted trainingsinclude:• SOCWraparound 101 Training:

h d d f h l• This is an introductory two‐day training focusing on the principlesand values of Wraparound. It is an in depth look at the phases ofWraparound and teaches participants how to complete thenecessary components including Strengths, Needs, Culture,Discovery (SNCD) assessments, functional assessments, crisis/safetyplans, Wraparound plans, and other items.

• SOC Family Support Provider Training is required for FSPs.

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.

Rehab Option of State Plan Amendment

Role in Wraparound HCPC Code Rate Timeframe

Behavioral Health Aide H2019 $ 7.52 15 minutes

F il S t P id H2015 9 75 15 i tFamily Support Provider H2015 9.75 15 minutes

Care Coordinator (TCM) – bachelor’s T1017 16.21 15 minutes

Care Coordinator (TCM) – LBHP T1016 21.61 15 minutes

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Customizing Care Coordination in the Medicaid Delivery System for Children with Serious Behavioral

H l h Ch ll I h

www.chcs.org

Health Challenges In MassachusettsTargeted Institute #3

Georgetown Training Institutes

Dayana Simons, M.Ed. LMHC

July 2014

State Context: Massachusetts

• Services are delivered through statewide system (not county‐based)

• Direct services are delivered primarily by contracted agenciesg

• There is the greatest concentration of teaching hospitals in the U.S.

• Medicaid managed care state

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Adapted from Massachusetts Executive Office of Health and Human Services

System of Care/Wraparound Timeline

1980’s: Federal CASSP Grants

1998: RWJ Mental Health Services Program for Youth (MHSPY)

2003: WCC incorporated into to Coordinated Family-Focused Care (CFFC), which together with MHSPY, served ten cities and towns through Medicaid Waiver

1991: Parent/Professional Advocacy League (PPAL - state organization of the Federation of Families for Children’s Mental Health)

1999:SAMHSA SOC Grants to Worcester Communities of Care (WCC)

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The Massachusetts Catalyst: “Rosie D.”

• Federal Class Action Lawsuit (2001) on behalf of children and youth with serious emotional disturbance

• Final judgment issued July, 2007

• MassHealth, found to be out of compliance with “reasonable promptness” and “Early Periodic Screening Diagnosis and Treatment” (EPSDT)provisions of federal Medicaid law

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The Remedy

• Statewide Implementation of:

► Standardized BH screening in primary care

► Standardized scope of BH assessment using the Child and► Standardized scope of BH assessment, using the Child and Adolescent Needs and Strengths (CANS) tool

► New home‐ and community‐based BH services, including intensive care coordination with high quality wraparound

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MassHealth(Office of Medicaid)

MassHealth Managed Care Entities

Access to Services & Supports: Medicaid Managed Care in MA

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Primary Care Clinician (PCC) Plan (medical)/Massachusetts Behavioral

Health Partnership (MBHP)(behavioral health carve out)

Managed Care Program

Health New England Be Healthy

Massachusetts Behavioral Health Partnership (MBHP)

(behavioral health)

Neighborhood Health Plan

Boston Medical Center

HealthNet Plan

Beacon Health Strategies

(behavioral health)

Fallon Community Health Plan

Network Health (medical and

behavioral health)

Massachusetts1115 Waiver, State Plan (TCM)

MCO MCO MCO MCO

Standardized tools for screening and assessment by PCPs

State Medicaid Agency (MassHealth) – Purchaser

BHO

PCCM MCO

Community Services Agencies (CSA)Non Profit BH and Specialty Providers

(Locally‐Based Care Management Entities)

Standardized tools for screening and assessment by PCPsCANS

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Massachusetts Definition of Intensive Care Coordination (Targeted Case Management)

Includes:• Assessment• Development of an Individual Care Plan• Referral and related activities• Monitoring and follow‐up activities

All of which is done using a high quality wraparound care planning process

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Massachusetts Populations Served in Intensive Care Coordination

All children under the age of 21, and enrolled in MassHealth Standard or CommonHealth with:

• A diagnosis of SED as defined by SAMHSA OR The Individuals with Disabilities Education Act (IDEA)

And: • Needs or receives multiple services other than ICC from the same or multiple

provider(s) Or:• Needs or receives services from, state agencies, special education, or a

combination thereof; And:• Needs a care planning team to coordinate services the youth needs from

multiple providers or state agencies, special education, or a combination thereof

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Maryland’s ApproachMichelle Zabel, MSSDirector & Clinical Instructor,

The Institute for Innovation & ImplementationThe Institute for Innovation & Implementation

Director, The Technical Assistance Network for Children’s Behavioral Health (TA Network)

[email protected]://theinstitute.umaryland.edu

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The Institute for Innovation & Implementation 67

Maryland: 1115 Waiver & Behavioral Health Carve‐Out; 1915(i) SPA in submission process

Children’s Cabinet

Interagency


Interagency Administrative Administrative Individual

Agency Funds & F d l

Individual Agency Funds & F d l

Department of Human

Resources (child welfare)

Department of Human

Resources (child welfare)

Department of Juvenile Services

Department of Juvenile Services

Maryland State

Department of Education

Maryland State

Department of Education

Department of Health & Mental

Hygiene (including Medicaid)

Department of Health & Mental

Hygiene (including Medicaid)

1115 Waiver1115 Waiver

+ Governor’s Office for Children, Maryland

Department of Disabilities, Department of Budget &

Management

+ Governor’s Office for Children, Maryland

Department of Disabilities, Department of Budget &

Management


FundFund Service Organization

Service Organization

Managed Care OrganizationsManaged Care Organizations

& Federal Grant Funds& Federal

Grant Funds

Public Mental Health System (specialty)

Public Mental Health System (specialty)

Intensive Care Coordination using Wraparound Practice Model

Intensive Care Coordination using Wraparound Practice Model

***All children with Medicaid (Medicaid, CHIP, CHIP Premium, State Custody, Family of One) have an MCO and access to the full Public Mental Health System (access to those services for which they meet medical necessity criteria)

Standardized Assessment Tools: CANS is used throughout the system for care planning; CASII is used for eligibility for the 1915(i) & will be used for PRTF level of intensity determinations

Primary Mental Health Services (non‐

specialty)

Somatic Health Care,

incl. Oral Health

Pending 1915(i) SPA & TCM SPA

The Institute for Innovation & Implementation

68

Current/Proposed Funding MechanismsCME CCO (proposed)

Funder Governor’s Office for Children on behalf of the Children’s Cabinet

Medicaid through State Plan Amendments for Targeted CaseManagement (and 1915(i) re: population eligibility)

# youth Up to 370 at any time 200 first year; ultimately 500‐750

Populations Served

MD CARES & Rural CARES (SOC Grants)Stability Initiative

1915(i) State Plan AmendmentTargeted Case Management, Tier 3


Served Stability InitiativeSAFETY Initiative

Targeted Case Management, Tier 3

Functions and Responsibilities

• Intensive Care Coordination using a Wraparound service delivery model • Child and Family Team Facilitation• Utilize assessment tools (e.g., Child and Adolescent Needs and Strengths)• Connections and referrals to natural and professional supports, including peer

support• Management of the Plan of Care• Utilization of management information system• Continuous Quality Improvement, including participating in fidelity monitoring,

satisfaction, and evaluation activities• Provider network recruitment and management (CME only)

69

BREAK

State Examples

•Care Coordinator Requirements, Certification,Training, Rates, Case Ratios, Supervisory Structure

•Peer Partner RequirementsPeer Partner Requirements•Certification•Training•Rates•Case Ratios•Supervisory Structure

•Interface between Care Coordinators and Peer Partners72

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CARE COORDINATORSCARE COORDINATORSPEER PARTNERSPEER PARTNERS

Wraparound Agencies in Louisiana

• Wraparound Facilitators (Care Coordinators)– Engage family and team members– Facilitate Child and Family Team (CFT)– Monitor plan implementation– Prepare for transition– Document outcome data– Collaborate with Peer Partners

• Paid PMPM ($1035)• Case ratio: 1 to 10• Supervisory structure: 1 supervisor to 8 facilitators


Wraparound Agencies in Louisiana

• Training– Current contract with University of Maryland– Development of core competencies through prescribed training program for Facilitators andprescribed training program for Facilitators and Supervisors

– Creation of in‐state trainers/coaches for sustainability


Peer Partners in Louisiana• Parent/Youth Support Specialists

– Engage parent and youth– Provide education/support in wraparound process– Provide education on behavioral health issues and servicesOff kill b ildi i f d id tifi d b CFT– Offer skill building in areas of need identified by CFT

– Collaborate with Wraparound Facilitators• Paid Fee‐for‐Service ($40/hour, rate change pending)• Case ratio: 1 to 20• Supervisory structure: 1 supervisor to 4 PSS/YSS


Peer Partners in Louisiana• Training

– University of Maryland WAA training– University of Maryland Parent Partner training– Functional Behavioral Approach trainingpp g– Content specific training

• Use of self in relationship (boundaries)• Ethics• Confidentiality• Other

77Louisiana Department of Health and Hospitals – Office of Behavioral Health78

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Care Management• Care Managers are have a BA/BS or masters degree in social service.

• The CMO’s have established a certification process and different levels of certification.

• Care Managers’ are required to attend a series ofCare Managers are required to attend a series of trainings provided by CSOC.

• Family Support Partners are certified through Rutgers – UBHC. CSOC training partner.

• Care Managers are trained by Family Support Organizations

79

Care Management• Care management is provided for youth with both high and moderate needs

• NJ is moving toward a caseload size of 14 with a mixed caseload of high and moderate (currently in t iti )transition)

• Care Managers are supervised by a master’s prepared supervisor

• Supervisors have 6 Care Managers on their team

80

Behavioral Health HomeNJ is currently working on a pilot BHH. The goal of the BHH is to expand the Child Family Team. We are looking to add a nurse and wellness coach to all teams for youth identified with a chronic condition.

81 82

Contract Requirements

• Caseloads of 10• Child and Family Teams• Strengths Needs and Culture Discovery• Wraparound Care Plan• Ohio Scales• Staff attends all training and coaching required

83

Billing Wraparound

• Wraparound teams bill fee for service through the integrated MMIS system.

• Request prior authorization:– For Medicaid as payor source; andFor Medicaid as payor source; and– For ODMHSAS state funding as payor source.– CC is the highest level of targeted case management.

– Must submit letters of collaboration with all other providers billing MMIS system.

84

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85

Intensive Care Coordination:Massachusetts

• 1:10 average care coordinator to youth/family ratio• Average length of enrollment for youth who graduate from ICC is 11‐12 monthsg

• CANS is used as part of a comprehensive psychosocial assessment for ICC

• 1:8 average ICC supervisor to care coordinator ratio

86


• Care Coordinators: ► CANS certified► Skill‐ and competency‐based training in the delivery of ICC consistent with Systems of

Care philosophy and the wraparound planning process and have experience working with youth with SED and their families

► Weekly individual supervision with a behavioral health clinician licensed at the independent practice levelindependent practice level,

► Weekly individual, group, or dyad supervision with the senior care coordinator.► Master’s degree in a mental health field; or bachelor’s degree in a human services field

and one year of relevant experience working with families or youth. If the bachelor’s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree. Individuals with an associate’s degree or high school diploma must have a minimum of five years of experience working with the target population; experience in navigating any of the child/family‐serving systems; and experience advocating for family members who are involved with behavioral health systems.

87


• T1017‐HN Targeted Case Management, per 15 minutes (service provided by a Bachelor‐level care manager) :► $18.88 August 1, 2013 ‐ July 31, 2014 ► $19.07 August 1, 2014, and after

• T1017‐HO Targeted Case Management, per 15 minutes (service provided by a Master‐level care manager): ► $23.74 August 1, 2013 ‐ July 31, 2014 ► $23.98 August 1, 2014, and after

88

Family Support & Training (Family Partners):Massachusetts

•A Family Partner must have ► Experience as a caregiver of youth with special needs, preferably youth with mental health needs► Experience in navigating any of the youth‐and family‐serving systems► Either a bachelor's degree in a human services field from an accredited academic institution, or an associate’s degree in a human services field from an accredited academic institution and one year of experiencefrom an accredited academic institution and one year of experience working with children, adolescents, or transition‐age youth and families, or a high school diploma or equivalent and a minimum of two years of experience working with children, adolescents, or transition‐age youth and families. If the bachelor's or associate‘s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree.

•H0038 $15.60 per 15 minutes

89

Payment & Financing for All Remedy Services

• No data to build case rate

• Rate setting agency developed 15‐minute unit costs for each service

M d titi (MCE ) id th h dditi

Massachusetts Executive Office of Health and Human Services

90

• Managed care entities (MCEs) paid through addition to capitation rate, based on unit rates and assumed utilization

• MCEs not at risk for Remedy services initially –performed an annual reconciliation

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91

Training & Technical Assistance• The Institute for Innovation & Implementation at the University of Maryland

School of Social Work provides training, coaching, policy and finance support, fidelity and outcomes monitoring, and evaluation to support the CME and CCOs in Maryland.

• The Institute is a founding member of the National Wraparound Implementation Center (NWIC).

• Wraparound Practitioner Certification:– Online trainings– In‐person training– On‐Site Coaching– Team Observations– Document Review– Ongoing Certification

(For more information on the Wraparound Practitioner Certificate Program at the UM SSW, please contact Marlene Matarese at [email protected])


Staffing Requirements• CMEs in MD must employ:

– Executive Director– Chief of Finance– Provider Network Director– Clinical DirectorClinical Director– Care Coordinator Supervisors– Care Coordinators– Community Resource Specialists– Quality Assurance and Data Director

• CCOs have few required personnel (care coordinators, care coordinator supervisors, clinical director) in the proposed SPA; more delineation will occur in the individual RFPs.


Care Coordinator Requirements• Care Coordinators in MD must:

– Have a minimum of a bachelor’s Degree and be enrolled in or have completed the Wraparound Practitioner Certificate Program

OROR– Have a minimum of a high school diploma or equivalency,– Be at least 21 years old– Have been a participant of or are/were the direct caregiver of

an individual who received services from the public mental health system

– Have completed the Family Support Partner Certificate Program and are enrolled in or have completed the Wraparound Practitioner Certificate Program


Case and Supervisor Ratios• Staff‐family Ratio

– CME: 1:9 to 1:11– CCO: 1:8CCO: 1:8

• Supervisor‐care coordinator ratio (supervisors do not maintain a caseload)– CME: 1:6 to 1:8– CCO: 1:7


Care Coordinator Supervisor Requirements

• Care Coordinator Supervisors in MD must:– Have a Master’s Degree in a human services field and two years

of experience in a human services position– Have at least one year experience working in community‐based

service provisionservice provision– Have at least one year experience working with children, youth

and families– Possess an understanding of child and adolescent development– Have completed trainings on Wraparound, crisis planning,

system of care, and comprehensive screening and assessment tools

– Be enrolled in or have completed the Wraparound Practitioner certificate program or other equivalent training and certification


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Billing Rates• CME:

– The state funded rate as of July 1, 2014 will be a full year equivalent of $14,048.62 annual per child (approximately $1170.71 per child per month).

– This rate is inclusive of CC costs and CME operating expenses for the first year of the CME contract

• CCO: – Under the pending TCM SPA, billing units will be in 15‐minute

increments. – Proposed rate in 1915(i) SPA (version released for public comment, fall

2013): $24.06/15 minutes or $294.24/week (up to $15,003/year)– Proposed reduced rate while child is in a residential placement up to a

certain length of stay (40% of regular rate)


Provision of Family Peer Support• Family peer support is available to families enrolled in care coordination.

Family peer support specialists are employed through family support organizations.

• Family Support Specialists must meet the following requirements:– Be at least 21 years old– Receive supervision form an individual who is at least 21 years old and has at p y

least 3 years of experiencing providing peer support– Have current or prior experience as a caregiver of a child with a SED or young

adult with SMI– Be enrolled in the Wraparound Practitioner Certificate Program for Family

Support Partners• Under the 1915(i), family peer support will be reimbursed at $15.97 per 15

minute unit for face‐to‐face services or $7.98 per 15 minute unit for telephonic or non‐ face‐to‐face activities

• Youth enrolled in the CME can access peer support through discretionary funds


State Examples

•Access to Services and Supports•Provider network•Interface with MCOs/BHOs/ASOfor Service Authorizationfor Service Authorization

•Coordination with Primary Care, Courts,Schools

99 100

101

SERVICES & SUPPORTSSERVICES & SUPPORTS

Services & Supports in Louisiana• State Plan service array

– Inclusive of evidence‐based practices– Community‐based alternatives– Out of home placement optionsS i li d S i f th i CS C• Specialized Services for youth in CSoC– Parent Support & Training– Youth Support & Training– Crisis Stabilization– Independent Living/Skills Building– Short‐term Respite

• Natural supportsLouisiana Department of Health and Hospitals – Office of Behavioral Health 102

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Authorization Process in Louisiana

• Statewide Management Organization (SMO) receives and reviews plan of care created and authorized by the Child & Family Team (CFT).

• SMO approves authorization based on indications from CANS, Independent Behavioral Health Assessment and , pCFT recommendations.

• SMO builds and monitors authorization to ensure youth receive appropriate level, frequency and duration of care.


Coordination in Louisiana• State level

– Entire managed behavioral healthcare system is partnership of:

• Office of Behavioral Health• Medicaid• Department of Children and Family Services• Department of Education• Office of Juvenile Justice

– Established Governance Board through Executive Order

– Meetings: Judges, provider associations, etc.


Coordination in Louisiana

• Regional level– Community Teams– Child and Family TeamsRelationships– Relationships

• Judges• Schools• Informal/Natural supports


106

• Referral to Perform Care is not required for outpatient services, such outpatient counseling, psychiatric evaluations / medication monitoring, anger management, etc.

• NJ MentalHealthCares maintains a thorough

Outpatient Services

NJ MentalHealthCares maintains a thorough directory of services and can be accessed by visiting njmentalhealthcares.orgor calling 866‐202‐HELP

107

Intensive In-Community Services

Our in-community services are flexible therapy services that are provided at the home or other in-

community sites.

Intensive In Community ServicesIntensive In-Community Services –Psychotherapy services provided in the youth’s home.

Behavioral Assistance – Under a plan developed by an IIC therapist, the BA will work to modify specific behaviors of the youth.

IIC

BA

108

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Focuses on (re)engaging the family into community based services

(must have CMO or MRSS involvement)

Securing appointmentsPreparing for appointments

Processing through transition

What are IIC and BA Services?

Provided based on an evaluation of need

Address symptom reduction

Part of a comprehensive plan of care

Time limited

Provided in the community

Focused on skill strengthening

109

IIC is Not:

“In Home Therapy” delivered in the home only for the convenience of the family A long‐term service

BA is Not:

Mentoring

A way to get supervision for the youth / young adult to get him/her out of the

houseA long‐term service

A substitute for individual and/or family therapy

110

Out of Home Intensity of Service*

• Psych Community Homes (PCH)

• Specialty Beds (SPEC)

• Residential Treatment Centers (RTC)

• Group Homes (GH)

• Treatment Homes (TH)

111

* Intensity of Service (IOS): Levels of OOH treatment based on intensity, frequency, and duration of treatment.

CSOC SUBSTANCE ABUSE TREATMENT SERVICES

Available Services:• Assessment (SA Evaluation, Needs Bio Psychosocial‐BPS)• *Outpatient (OP)• *Intensive Outpatient (IOP)• *Partial Care (PC)• *Long‐Term Residential (LT‐RTC)Long‐Term Residential (LT‐RTC)• *Short‐Term Residential (ST‐RTC)• Detoxification

All service authorizations are based on clinical justification.

*Qualifies for enhancement services for co‐occurring youth

112

Access to Community Services

• In 2000, NJ Served Approximately 7000 Children In Community‐based Care Management, In‐Home and day treatment programs

• In 2013, NJ Served over 44,000 In Care Management, In‐Community and day treatment programs(∆+500%)

• In 2003, 40% of newly enrolled children were under 14 years old, in 2013 that percentage had grown to 65%

‐Tends to indicate system of care has become more preventative, families are seeking services sooner

113 114

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CHILDREN’S HEALTH HOME

Child & Family SOC Team

INTEGR

PCMH

Access to physicianConsultation with HHEPSDT screeningImmunization

LinkageAssessment

Specialty BH Services

Community Support

HousingTransportationFood

LinkageEngagementAdvocacySupports

Schools

WraparoundPsychiatrist

IDEATransitionsEducation

Specialty Healthcare

ATION

ImmunizationReferral to specialty care

Transition to/from hospital care

pp

Community Safetyplacement

OJATeam ApproachOne Care Plan

Team ApproachOne Care Plan

Support

OKDHSSafety

Placement(s) Permanency

PsychiatristMedication Management

TherapyFamily Support

Wellness Services & Services

115 116

Massachusetts CBHI/Remedy Services

• Intensive Care Coordination (Wraparound)

• Family Support & Training (Family Partners)

• In‐Home Therapy

• In Home Behavioral Services• In‐Home Behavioral Services

• Therapeutic Mentoring

• Mobile Crisis Intervention

• Crisis Stabilization *

117


Intensive Care Coordination(Wraparound)

•Clinical Assessment inc. CANS•SED determination for eligibility•Medical Necessity determination

•Care coordination

In-Home Therapy

•Clinical Assessment inc. CANS•Medical necessity determination

Families decide on

most appropriateinitial service

AdditionalServices

(accessedthrough

core clinicalservices)

I H

Access to Care Coordination


118

•Medical necessity determination•Care coordination available

Outpatient Therapy

•Clinical Assessment inc. CANS•Medical necessity determination

•Care coordination available

initial service

EmergencyServices

Mobile CrisisIntervention

•In-Home Behavioral

Services

•Family Partners

•TherapeuticMentoring

Massachusetts1115 Waiver, State Plan (TCM)

MCO MCO MCO MCO

Standardized tools for screening and assessment by PCPs

State Medicaid Agency (MassHealth) – Purchaser

BHO

PCCM MCO

*Locally‐Based Care Management Entities Non Profit BH and Specialty Providers(called Community Services Agencies)

Ensure Child & Family Team Plan of CareProvide Intensive Care Coordination

Provide peer supports and link to natural helpersManage utilization, quality and outcomes at service level

Standardized tools for screening and assessment by PCPsCANS

119

Managed Care Entity Authorization Parameters for Services

• INITIAL AUTHORIZATION PERIOD FOR ICC AND FS&T :

► Intensive Care Coordination (ICC) 1 unit = 15 minutes ► Family Support and Training (FS&T) 1 unit = 15 minutes ► 192 total units for ICC and FS&T combined, with no maximum units for either

• EVERY 90 DAYS FOLLOWING INITIAL AUTHORIZATION:

► Intensive Care Coordination (ICC) 208 units/90 days (13 weeks) 1 unit = 15 minutes

► Family Support and Training (FS&T) 208 units/90 days (13 weeks) 1 unit = 15 minutes*

120

Note: All authorization parameters are floors not ceilings. If a provider uses up the units authorized in a given time parameter prior to the end of the end date of the authorization, the provider can contact the MCE to request additional

units. Dayana Simons, Center for Health Care Strategies, 2014

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CBHI Coordination and Governance EOHHS

Secretary(17 Agencies)

CBHI Staff (4.5 FTE)

121

CBHI Executive Committee

Interagency Implementation

Team

Children’s BH Advisory Council

Office of Medicaid

Office of Behavioral Health (9 FTE)

MassHealthImplementation

TeamMCE Workgroup

Massachusetts Executive Office of Health and Human Services122

Maryland’s Public Behavioral Health System• Maryland has an 1115 Waiver, which creates the following

structures for Medicaid service delivery:– HealthChoice—MCOs for somatic health and dental– Behavioral Health Carve‐Out—Fee‐For‐Service

• Administrative Service Organization (ASO)—ValueOptions (new contract to be awarded in early 2015)

• Medicaid eligible youth can access the fee for service PBHS and 1915(i) eligible use will be able to access specialty services through the SPAthe SPA

• Discretionary Funds (CME Only) ‐ General funds allocated per youth per day to support components of the Plan of Care not otherwise funded. (All State‐only or grant funds)

• Residential Services– Medicaid funds inpatient or RTC stays (Medical Necessity)– Custodial agency funds group home or foster care placement, with some

Medicaid reimbursement through the Rehab Option• Behavioral Health Homes—Designed around the population of

adults with SPMI, although youth with SED can be served


Role of the ASO• Manage the Behavioral Health Carve‐Out, which will include CCOs

and providers of 1915(i) services• Deliverables related to the 1915(i) (per RFP) include:

– Designate a staff member to be the liaison with responsibility for oversight and problem resolution and to interface with CCOs

– Register providers of specialized servicesg p p– Review and authorize requests for specialized services– Jointly determine with local mental health authorities medical

eligibility for admission using needs‐based eligibility criteria– Assure that POCs for each participant reflect all behavioral health

services authorized and develop a mechanism to assure that participants are actively engaged in behavioral health treatment

– Conduct on‐site audits of providers


Simplified Version of Maryland’s Public Behavioral Health System Service Array for Youth

Family Peer

Intensive Care Coordination & 1915(i)

Inpatient Psychiatric

Hospitalization

Health Home PRP

General Care

Coordination

Mobile Treatment

Partial Hospitalization

Program

Moderate Care

Coordination

Mobile Crisis &

Residential Treatment

Outpatient Therapy

Respite Care

Support Services Stabilization

Treatment Center

Therapy Care

Least intensive Most intensive


Maryland has a traditional but robust PBHS for children and youth with Medicaid and MCHP

Other services and supports outside the Public Behavioral Health System include Multi‐Systemic Therapy, Functional Family Therapy, Parent‐Child Interaction Therapy, Treatment Foster Care, Peer Support, and Community‐Based and Natural Supports. Eligibility will depend on the funder and associated parameters for each individual service.

125

Proposed Services under the 1915(i)Maryland has a robust public mental health system; these services will fill gaps in the current home‐ and community‐based provider array:• Care Coordination (provided by CCO who is a TCM Provider)• Community‐Based Respite Care• Out‐of‐Home Respite• Family Peer SupportFamily Peer Support• Mobile Crisis Response and Stabilization• Intensive In‐Home Services (differentiated from Therapeutic Behavioral

Services and from Psychiatric Rehabilitation Programs)• Expressive & Experiential Behavioral Services (art, dance, drama, music,

equine, horticultural)• Mental Health Consultation to Health Care Professionals (only paid to the

consulting professional)• Customized Goods and Services


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Eligibility and Authorization Process for Care Coordination Services

• For populations served by the CME, eligibility screenings are performed by referral sources (DJS, DHR, CSA, LCT, LMB, public local school systems)– After the referral source gatekeeper has determined that a youth is

eligible and has referred the youth to the CME, the CME's Clinical Di t i th f l d th i ll tDirector reviews the referral and authorizes enrollment.

• For the 1915(i) SPA, eligibility screenings are performed by the CCO based on Certificate of Need (CON) documents (psychiatric/psychosocial assessments). The clinical information will be compared to the MD Medicaid medical necessity criteria (MNC) for this level of care. – the ASO, in a team decision process with the CSA, will review the CON

documents and complete a CASII assessment. When the CON is determined to meet the MNC, the ASO authorizes all of the medically appropriate behavioral health services.


Interagency Coordination• At the state level, the Children’s Cabinet (which funds the CME) is chaired

by the Executive Director of GOC and comprised of the Secretaries of the Departments of Budget and Management, Disabilities, Health and Mental Hygiene, Human Resource (child welfare), Juvenile Services, and the Superintendent of the Maryland State Department of Education

• At the practice level, the CME’s program plan must:D ib h it ill d l i iti l ti hi th l d– Describe how it will develop or improve upon positive relationships the lead agencies (e.g., DSS, DJS)

– Describe how it will enhance their current relationships with the direct services provider community to facilitate appropriate linkages and services to families

• CCOs and CMEs are required to commit to coordination with all agencies involved in the participant’s POC and work with the State and local child‐and family serving agencies to develop a network of clinical and natural supports in the community to address strengths and needs identified in each POC


State Examples

•Evaluation, Quality Monitoring anda uat o , Qua ty o to g a dOutcomes

129 130

131

EVALUATIONEVALUATIONQUALITY MONITORINGQUALITY MONITORING

OUTCOMESOUTCOMES

Quality Monitoring/Evaluationin Louisiana

• National Wraparound Initiative Tools • Wraparound Fidelity Index (WFI EZ):

• Office of Behavioral Health is currently conducting the WFI EZ with all five Wraparound Agencies

• Document Review Measure (DRM): • SMO will use the DRM to compliment the WFI EZ with all five Wraparound Agencies

• Planned evaluation activities with University of Washington Wraparound Evaluation & Research Team


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Tracking Outcomes in Louisiana

• Child and Adolescent Needs and Strengths Assessment (CANS) scores

• Out of Home placements• Psychiatric Emergency Department utilizationPsychiatric Emergency Department utilization• Inpatient Psychiatric utilization• Home and Community Based Service utilization• School suspensions and expulsions• Costs


CANS Scores

52

94

4850

60

70

80

90

100

2c ‐ CSoC

2d ‐ TGH

3 Nursing Facility

134

25

18

1113

39

11

00 0 0 0

24

13

86

48

18

20

10

20

30

40

Initial 180 Days 360 Days 540 Days

3 ‐ Nursing Facility

4 ‐ PRTF

5 ‐ Inpatient Psyc

Out of Home Placements(3/1/12 to 3/31/14)

Percent of CSoC children and youth who had restrictive placements prior to enrollment in WAA: 31.4%

Percent of CSoC children and youth place in restrictive placement after enrolling in WAA = 18.3%

135135

CSoC Children Inpatient Psychiatric Utilization

0100200300400500

Admits / 1000

0100020003000400050006000

Days / 1000

136

Total Admissions for all CSoC Inpatient Stays in Month /Number of CSoC Participants in Month * 1000

(Total Days for all CSoC Inpatient Stays Discharged in Month) / (Number of CSoC Participants in Month) * 1000

05

1015

Average Length of Stay

Total Days for all CSoC Inpatient Stays in Month /Total Admissions for all CSoC Inpatient Stays in Month

Home and Community‐Based Service Utilization

4000

5000

6000

7000

2012‐03

2012‐04

2012‐05

2012‐06

2012‐07

2012‐08

2012‐09

2012‐10

2012‐11

2012‐12

2013‐01

2013‐02

2013‐03

2013‐04

2013‐05

2013‐06

2013‐07

2013‐08

2013‐09

2013‐10

2013‐11

2013‐12

2014‐01

2014‐02

2014‐03

Services Utilized 401 952 16861978194622462218270323552245253120262215265328472491304639224103509851295759611457885882

0

1000

2000

3000

137

School Performance/Conduct(Suspensions and Expulsions)

20%

25%

30%

School Performance Measures

0%

5%

10%

15%

Period 1 Period 2 Period 3 Period 4

% Members with Missed Days

% Members with Suspensions

% Members with Expulsions

*based on quarterly data reported by CSoC Wraparound agencies

138

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24

CSoC Expenditures

$10,933,421

$8,000,000

$10,000,000

$12,000,000 Waiver Services and WAA Payments

$378,451

$5,940,505

$1,143,567

$0

$2,000,000

$4,000,000

$6,000,000

Waiver Services WAA Payments

Contract Yr 1Contract Yr 2


CSoC Expenditures

$5,522,977

$4 000 000

$5,000,000

$6,000,000

State Plan Services for CSoC Enrollees

$930,454

$1,784,486$2,173,438

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

Inpatient Outpatient

Contract Yr 1Contract Yr 2


141

What Have We Learned?

• The system of care model works– Less children in institutional care– Less children accessing inpatient treatment– Closure of state child psychiatric hospital and RTCs– Very few children in out‐of‐state facilitiesy– Children in out of home care have more intense needs than prior to

the system of care development– Wraparound works – Less youth in detention centers – many reasons, not necessarily

because of the system of care • Federal funding support under Title XIX

142

Evaluation Quality Monitoring• All providers certified on CANS Tool• Certification for BA and FSO• Credentialing for IIC/IIHUtili ti M t b CSA• Utilization Management by CSA

• Contracting monitoring by CSOC• Child Family Teams • WFI is used by CMO’s• Management by data

143

NJ Department of Children and FamiliesFiscal Year 2014 $1.65 BillionOverall Department Budget

144

Funds by State/Federal/Dedicated Funds by Division

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25

NJ Department of Children and FamiliesFiscal Year 2014 $498 Million

Children’s System of Care

145

Funds by State/Federal Funds by Service

A Continuum of Care: Mobile ResponseWorking hard to keep children & youth successfully at home & avoid hospitalization or

placement.

Did not stay in current living situation

4%

NJ DCF CHILDREN'S SYSTEM OF CARE (CSOC)Mobile Response Children Stabilized in Current Living Situation

4/1/2014 ‐ 4/30/2014( n = 1,532 )

Stayed in Current Living Situation96%

146

A Continuum of Care: Mobile Response

1,4981,585

1,278

1,443

1,760

1,610

1400

1600

1800

2000

MRSS Service Dispatch Data2011 ‐ April 2014

147

1,055

693 657

1,095 1,1211,296

0

200

400

600

800

1000

1200

Jan Feb Mar April May June July Aug Sept Oct Nov Dec

2011 2012 2013 2014

Out of Home TreatmentAuthorizations (which provide access to out of home care) is reduced due to more access and availability of

community resources

148

In April 200753% (157) of youth in Out of State programs were involved with child welfare system further complicating opportunities for family engagement

Today

327

299

229

200

250

300

350

NJ DCF CHILDREN'S SYSTEM OF CARE (CSOC)Authorized Out-of-State Placements

Number of youth in Out-of-State placements at the first of the month

There are 3 youth in Out of State behavioral health treatment programs, 1 youth is involved with child welfare

149

98

3620

6 4 30

50

100

150

Mar.2006

Apr.2007

Jan.2008

Jan.2009

Jan.2010

Jan.2011

Jan.2012

Jan.2013

Jan.2014

A Continuum of Care: Care Management Organization (CMO)Serving over 10,000 children, with a focus on the high need youth and their families

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A Continuum of Care: Out of Home TreatmentCurrently, most youth receiving out of home treatment are adolescents

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Gender # PctFemale 616 36%Male 1077 64%Total 1693 100%

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E Team ‐ OU

• Measurement (E‐TEAM) Department of the University of Oklahoma. The E‐TEAM is a full service social research department with senior researchers, data analysts, technical writers, data base developers and managers, and a pool of p g , presearch assistants representing decades of experience in all phases of research data processing and analysis. Belinda Biscoe Boni, Ph.D., Associate Vice President, Public and Community Services, at the University of Oklahoma, College of Continuing Education, is the Director of E‐TEAM.

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Youth Information System (YIS)

YIS provides a wide range of reports for use by managers, site personnel and community stakeholders also provides a wide range of reports for use by managers, site personnel and community stakeholders . YIS tracks the following:g

• Process monitoring: Referrals, enrollments, discharges• Flex fund expenditures• Wraparound implementation• Outcomes measures: periodic (6‐month) assessments.

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OutcomesAfter Six months, SFY2013 (n=836)

• Reduced Days of Out‐of‐Home Placement 49%• Reduced School Detentions 51%• Reduced Number of Youths Self Harming 42%• Reduced Number of Youths Self‐Harming 42%• Reduced Arrests 66%• Reduced Contacts with Law Enforcement 51%• Reduced Days Absent from School 46%• Reduced Days Suspended from School

155 156

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Massachusetts Quality/Fidelity Monitoring

• Wraparound Fidelity Assessment System ‐MA WFAS (NWI)

• Wraparound Fidelity Index (WFI 4) – initially

• Wraparound Fidelity Index Parent/Caregiver

• Treatment Observation Measure (TOM)

• Document Review Measure (DRM) ‐ initially

• MCE Medical Record Review (standardized tool)• System of Care Practice Review ‐ SOCPR (USF)

157Louisiana Department of Health and Hospitals – Office of Behavioral

Dayana Simons, Center for Health Care Strategies, 2014

Massachusetts Outcomes Tracked

Multiple process variables including:• Utilization of:

• Mobile Crisis Intervention• Inpatient PsychiatricInpatient Psychiatric• Home and Community Based Services

• Out of Home placements• Costs

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Dayana Simons, Center for Health Care Strategies, 2014

Massachusetts Outcomes: Reduced Use of Inpatient Care

Penetration Rate and Bed Days per 1000 Members Under 19 of Psychiatric Inpatient Services(Based on MBHP Claims thru 1/13/12)

0.25%

0.30%

0.35%

0.40%

ion

200

240

280

320

Massachusetts Executive Office of Health and Human Services159

0.00%

0.05%

0.10%

0.15%

0.20%

Quarter

Penetrati

0

40

80

120

160

Penetration 0.30% 0.32% 0.32% 0.27% 0.21% 0.25% 0.27% 0.27% 0.21% 0.27% 0.25% 0.28% 0.21%

Units/1000 216 215 209 243 153 168 178 186 144 175 176 200 147

2009 Q 1 2009 Q 2 2009 Q 3 2009 Q 4 2010 Q 1 2010 Q 2 2010 Q 3 2010 Q 4 2011 Q 1 2011 Q 2 2011 Q 3 2011 Q 4 2012 Q 1

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Outcomes & Evaluation• Fidelity and quality of the CME is monitored by The Institute at UM

SSW under contract with GOC• The Institute utilizes the WFI‐EZ, COMET, TOMS, IOTTA, California

Health Kids Survey ‐ Resilience & Youth Development Module, and Family Empowerment Scale data from the families being served to y p gmonitor and measure ICC/Wraparound quality and fidelity.

• Use of TMS WrapLogic will support the fidelity monitoring and the additional data collection

• Resiliency measures are incorporated into the WFI process as part of CHIRPA

• Outcomes related to clinical and functional status and cost are being assessed, both independently and through the use of an administrative comparison group


Reasons for Discharge from the CME: July to December, 2013

Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD.


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Semi‐Annual Trend in Successful Completions: July, 2012 to December,

2013



163

Wraparound Fidelity Index – Short Term (WFI‐EZ)



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Additional CME Outcomes• 75% of youth discharged to a stable, non‐restrictive living situation

(parent or relative’s home, regular foster home, adoptive home, or living independently) during the first and second quarters of FY14. This is an increase from the previous reporting period (68%) and the first and second quarters of FY13 (63%).

• The number of CANS Needs items on which youth demonstrated d f i i ( f 2 3) di h h i dneed for intervention (score of 2 or 3) at discharge has remained

consistently low, with an average of 5.5 (sd=5.70) out of 41 items during the first and second quarters of FY14

• These continued improvements in youth outcomes may reflect Maryland Choices, LLC adapting to the demands of serving as Maryland’s single Statewide CME provider and working on ways to improve its implementation of the Wraparound model over the past 18 months.



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Costs of Care: Results from MD’s PRTF Demonstration

• Youth enrolled in the PRTF Demonstration Grant and served by the CME had an average per member, per year cost of care of $32,987 (Medicaid costs only; n=174)

• Youth enrolled in a PRTF during the same time (not served by the CME) had an average per member, per year cost of care of

166

) g p , p y$153,417 (Medicaid costs only; n=1,119)

• These costs include the capitated MCO rate, medications, inpatient hospitalizations, oral health care, home health services and all services covered by Medicaid.

Time Period: September 30, 2009‐June 30, 2011 (claims paid through 10/31/11)

Source: Medicaid claims data provided by The Hilltop Institute to the University of Maryland under the CHIPRA Quality Demonstration Grant (November 2011)


Federal Medicaid Guidance

7/11/13 State Medicaid Director’s Tri‐Agency Letter onTrauma‐Informed Treatment http://www.medicaid.gov/Federal‐Policy‐Guidance/Downloads/SMD‐13‐07‐11.pdf

5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children,Youth and Young Adults with Significant Mental Health Conditionshttp://www.medicaid.gov/federal‐policy‐guidance/downloads/CIB‐05‐07‐2013.pdf

3/27/13 Informational Bulletin on Prevention and Early Identification of MentalHealth and Substance use Conditionshttp://www.medicaid.gov/federal‐policy‐guidance/downloads/CIB‐03‐27‐2013.pdf

8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populationshttp://www.medicaid.gov/Federal‐Policy‐Guidance/Downloads/CIB‐08‐24‐12.pdf

11/21/11 State Medicaid Directors Tri‐Agency Letter on Appropriate Use ofPsychotropic Medications Among Children in Foster Carehttp://www.medicaid.gov/federal‐policy‐guidance/downloads/SMD‐11‐23‐11.pdf

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Resources

Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditureshttp://www.chcs.org/publications3960/publications_show.htm?doc_id=1261588#.U1gmMvldUud

Making Medicaid Work for Children in Child Welfare: Examples from the Fieldhttp://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf

Customizing Health Homes for Children with Serious Behavioral Health Challengeshttp://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_‐p // g/ _ / g_ _ _f _ _ _ _ _ g __SPires.pdf

Psychotropic Medications Quality Improvement Collaborative:Improving the Use of Psychotropic Medications Among Children in Foster Carehttp://www.chcs.org/info‐url_nocat3961/info‐url_nocat_show.htm?doc_id=1261326

CHIPRA Care Management Entity Quality Collaborativehttp://www.chcs.org/info‐url_nocat3961/info‐url_nocat_show.htm?doc_id=1250388

Return on Investment in Systems of Care for Children with Behavioral Health Challengeshttp://gucchdtacenter.georgetown.edu/publications/Return_onInvestment_inSOCsReport6‐15‐14.pdf

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Massachusetts Resources

• CBHI website: www.mass.gov/masshealth/childbehavioralhealth

• Rosie D. v. Patrick (United States District Court, District of Massachusetts), Civil Action Number 01‐30199‐MAP

• National Wraparound Initiative website:• National Wraparound Initiative website: www.rtc.pdx.edu/nwi

• Building Systems of Care: A Primer, Sheila A. Pires, MPA, Human Service Collaborative Download at: http://gucchd.georgetown.edu/72377.html

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For further information, contact:

Sheila A. [email protected]

Contact Information

Jody Levison‐JohnsonDeputy Assistant SecretaryOffice of Behavioral [email protected]


For more information…1

Elizabeth Manley, Division Director CSOC [email protected]

Children’s System of Care

172172

http://www.state.nj.us/dcf/families/csc/

PerformCare Member Services: www.performcarenj.org

Presented byJackie Shipppp

Director of Community Based ServicesODMHSAS

405‐522‐[email protected]

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Contact Information

Dayana SimonsSenior Program OfficerCenter for Health Care Strategies IncCenter for Health Care Strategies, [email protected]

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Contact Information

Michelle Zabel, MSSDirector & Clinical Instructor,


175

Director, The Technical Assistance Network for Children’s Behavioral Health (TA

Network)[email protected]

http://theinstitute.umaryland.edu


Documents

Customizing Care Coordination in Medicaid for Children with