Maryland’s Proposed Title IV-E Waiver Demonstration Application A presentation by DHR to the Social Services Administration's Child and Family Advisory

Maryland’s Proposed Title IV-E Waiver Demonstration

ApplicationA presentation by DHR to the

Social Services Administration's Child and Family Advisory Board and

Members of the IV-E Waiver Committee & Provider Advisory Board

October 31, 2013, 9:30 - 12:00Baltimore, MD

Title IV-E Demonstration Waiver

BACKGROUND ON THE TITLE IV-E DEMONSTRATION WAIVER


Child and Family Services Improvement and Innovation Act HR 2883 (PL 112-34) Bill Signing

Provided HHS with authority to grant up to 10 waivers in each of FFY 2012, 2013 and 2014.

Casey Family Programs, 2013


New Demonstration Authority• HHS can authorize up to 10

new demonstrations in each of federal fiscal years 2012, 2013, 2014.

• 9 States were approved for waivers in FFY 2012.

• 8 States were approved for waivers in FFY 2013


Waiver States as of October 2013

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Key Requirements• States/Tribes must demonstrate readiness.• Required to implement Child Welfare Program

improvement policies.• States/Tribes must submit proposal covering 22

required items. (ACYF-CB-IM-12-05 of May 14, 2012).

• Demonstrations must be cost neutral to the federal government.

• Requires rigorous, independent evaluation.Casey Family Programs, 2013


Cost Neutrality

• Cost comparison method• Capped allocation method

– What would the State/Tribe have received in IV-E Foster Care payments in the absence of the waiver?

– Capped allocation can include almost any foster care costs, but most state capped allocation waivers have included maintenance payments and administration.



Child Welfare DemonstrationsImplementation Time Frames


State O-12 N-12 D-12 J-13 F-13 M-13 A-13 M-13 J-13 J-13 A-13 S-13 O-13 N-13 D-13

FL

CAOH 9/30/2015IN 6/30/2017OR 6/30/2016AR

CO

IL

MA

MI

PA

UT

WA

WI

June 2014 ->Dec. 2013


Where States Are


Steps in the Process 2012 2013 2014Explore application ~Develop and Submit Application Negotiations with ACF Execute Terms and Conditions Developmental Cost Plan Initial Design & Implementation Rpt.

Evaluation Plan ~Schedule of Payments ~Implement ~

Key: Completed ~Underway

2012 StatesState Focus Target Population Scope

AR Comprehensive practice model. Expand EB and EI practices.

All children referred to CWS

Statewide with 8 counties in Year 1

CO Systemic reforms and innovative practices to increase family engagement

All children with screened in reports

Up to 64 counties

IL Address impact of early maltreatment and trauma

Children age 0-3 who enter care.

Cook County (Chicago)

MA Performance-based contracts of residential services

Children in residential placement and can return to family

Statewide – 3,400 youth

10



2012 States (continued)

11



State Focus Target Population Scope

MI Expand secondary and tertiary prevention to families with young children at risk

All children in specified communities

3 sites, 1,500 families over 5 years

PA New case practice model focused on family engagement, assessment and expanded use of EBPs.

All children in placement or receiving services

5 counties initially

WA Family Assessment Response (a differential response pathway as alternative to CPS)

Families screened in representing low or moderate risk

Statewide over five years.

WI Post-reunification case management and support services for 12 months post discharge

All children who have reunited

Milwaukee County year 1, remainder of state years 2 to 5.

Summary of New Demonstrations

12Casey Family Programs, 2013


State Scope Funding/ Cost Evaluation

AR Statewide Capped Allocation. Payments and Admin Outcome changes over time

CO Phased – up to 64 counties Capped Allocation – Payments and Selected Admin Categories

Matched case comparison and time series analysis

IL Age 0-3, Cook County Treatment/Control Comparison Quasi-experimental comparison

MA StatewideCapped Allocation – Payments and Admin (compare to Congregate care history)

Pre-post outcome comparison

MI 3 sites Treatment/Control Comparison Experimental design

PA 5 counties to start – can be expanded

Capped Allocation – Payments and Admin.

Interrupted time-series design using propensity score matching, and meta-analysis of common interventions.

UT Statewide Capped Allocation – Payments and Admin. Outcome & cost changes over time

WA Statewide – low to moderate risk families

Capped Allocation – Payments and Admin. Matched case comparison design

WI Milwaukee – may expand statewide

Capped Allocation – Payments and Admin

Matched care comparison – longitudinal outcomes


Common Strategies


• Many states have identified expanded use of in-home services as a strategy.• Many states have identified trauma-informed assessments and care as

strategies. • Several states have identified implementation or expansion of differential or

alternative response initiatives.• Several states have identified use of Family Finding as a tool.• A number of states have identified family/youth engagement and

involvement as strategies.• Several states focus on kinship care (supporting effective placements and

moving those placements to permanency).• Several states are focusing on reducing reliance on congregate care or

residential treatment.• Several states are collaborating with their Medicaid and/or Behavioral

Health systems.


Increased Federal Emphasis


• What are your target populations?• What interventions do you plan to use?• What outcomes do you expect?• What is your theory of change?• How will you evaluate these outcomes?• How realistic are your plans?• What are the costs and savings (goes beyond

cost neutrality)?

MARYLAND’S APPLICATION

PLACE MATTERS

Building on the Foundation of Place Matters

•Engaging Families: Developed a family centered child focus practice model. •Finding Permanence for Children: Keeping children in their home when safe; reducing the length of stay in care; finding permanent homes for children. •Using Data: DHR set goals for key measures and used data to analyze the caseload and make better decisions for at risk children

PLACE MATTERS

Out-of-home placements have

decreased 43% since 2007.

Using Data to Measure Success

0

2,000

4,000

6,000

8,000

10,000

12,000

Children in Out-of-Home Care

PLACE MATTERS

Group home placements have decreased 47%.

72% of youth in care are placed with families.

Using Data to Measure SuccessSep

-07

Dec

-07

Mar

-08

Jun-

08Sep

-08

Dec

-08

Mar

-09

Jun-

09Sep

-09

Dec

-09

Mar

-10

Jun-

10Sep

-10

Dec

-10

Mar

-11

Jun-

11Sep

-11

Dec

-11

Mar

-12

Jun-

12Sep

-12

Dec

-12

Mar

-13

Apr-1

3M

ay-1

3Ju

n-13

Jul-1

3

0

500

1,000

1,500

2,000

2,500

0%

5%

10%

15%

20%

2,053

1,685

1,485

1,412

1,2441,261

1,218

1,116

1,039994

954912

872841

798811

816792

741691

673644

627643

637599

588

20%

17%

15%13% 14%

12% 11% 11% 10%11%

10% 10% 10% 10%

Children in Group Homes # in GH % in GH

PLACE MATTERS


FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 -

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500 4,130 3,775

3,190 3,207 3,479

3,235

Average # of Families Served in In-Home Services

Average FY

PLACE MATTERS

Children who grow up with permanent families are more likely to succeed later in life.

More children are finding permanent families through adoption, reunification and guardianships.

Our goal is for children to have no more than two placement changes a year and to reduce the length of stay in foster care.


Title IV-E Demonstration Waivers

Federal Priority Areas

• Produce positive well-being outcomes for children, youth and their families, with particular attention to addressing the trauma experienced by children who have been abused and/or neglected;

• Enhance the social and emotional well-being of children and youth who are

available for adoption, as well as those who have been adopted, with a particular emphasis on those children who have been waiting the longest or are hardest to place in order to achieve and sustain successful adoptions;

• Yield more than modest improvements in the lives of children and families and contribute to the evidence base; and/or

• Leverage the involvement of other resources and partners to make improvements concurrently through child welfare and related program areas, including proposals to establish financial incentives based on the achievement of positive child outcomes.


Federal Goals Required to be Addressed by the

Waiver Application (at least one must be addressed)

• Increase permanency for all infants, children, and youth by reducing the time in foster placements when possible and promoting a successful transition to adulthood for older youth.

• Increase positive outcomes for infants, children, youth, and families in their homes and communities, including tribal communities, and improve the safety and well-being of infants, children, and youth.

• Prevent child abuse and neglect and the re-entry of infants, children, and youth into foster care.


Maryland’s Goals

• Build on successes in improving safety & permanency by promoting child well-being

• Leverage and build upon home- and community-based service array, including evidence-based and promising practices, to enhance availability of services in the community

• Establish a trauma-informed child welfare system• Support full implementation of Alternative Response


Ages of Children & Youth Served through In-Home Services in Maryland

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

50100150200250300350400450

Children in In-Home Services, June 2013, by Age


Ages of Children & Youth Served through Out-of-Home Care in Maryland

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 200

100

200

300

400

500

600

Children in OOH Care, June 2013, by Age


Potential EBPs & Promising Practices for Children and their Families with Child Welfare Involvement

(Non-Exhaustive List—For Discussion Purposes)

• Brief Strategic Family Therapy (BFST)*• Early Childhood Mental Health

Consultation (ECMHC)*• Family Connections*• Family Group Decision Making*• Functional Family Therapy (FFT)*• Functional Family Therapy—Child

Welfare• Grandparent Family Connections*• Homebuilders*• Home Visiting*• Motivational Interviewing*• Multidimensional Treatment Foster

Care (MTFC)*

• Multi-Systemic Therapy (MST)*• Multi-Systemic Therapy-Child Abuse

and Neglect (MST-CAN)• Oregon Model, Parent Management

Training• Parent Child Interaction Therapy

(PCIT)*• Peer Support*• Safe Care• Social and Emotional Foundations of

Early Learning (SEFEL)*• The Incredible Years• Triple P• Trauma-Focused Cognitive Behavioral

Therapy (TF-CBT)*• Wraparound**Currently available or being implemented in at least 1 jurisdiction in Maryland


Partnerships & Collaboration

• Key partners include the LDSS, Children’s Cabinet Agencies, providers, families and youth, universities and community organizations.

• DHR will connect with and leverage other initiatives, including– Children’s Cabinet EBP Implementation– Upcoming 1915(i) State Plan Amendment– System of Care Grants: MD CARES, Rural CARES, LIFT– Project Launch– C-West & Promise Heights– Thrive@25– Local activities and partnerships


Timeline & Next Steps

• Winter 2014: Application submitted• Spring 2014: Negotiation with HHS• September 30, 2014: Final day for

HHS to approve the application• Fall 2014: Implementation activities

begin• September 30, 2019: Final day of

Demonstration Waiver authority

Documents

Maryland’s Proposed Title IV-E Waiver Demonstration Application A presentation by DHR to the Social Services Administration's Child and Family Advisory