Proposed Alaska Children’s Behavioral Health System of Care Submitted by: OPEN MINDS November 16, 2009 Dan M. Aune, Senior Consultant

Proposed Alaska Children’s Behavioral Health System of

Care

Submitted by:

OPEN MINDS

November 16, 2009

Dan M. Aune, Senior Consultant

http://www.alaska-in-pictures.com/rainbow-children-anchorage-alaska-3976-pictures.htm

Children’s Behavioral Health System of Care - Outline

I. Executive Summary

II. Background of Alaska System of Care Initiative

III. Current Child and Youth Service System

IV. Project Methodology

V. Coordinated & Sequenced Transition Plan to the Proposed Alaska Children’s Behavioral Health System of Care

VI. Sources of Funding Methods

VII. Outcome Measure Recommendations

VIII. Sustaining the Proposed Alaska SOC

2OPEN MINDS © 2009. All rights reserved.

OPEN MINDS © 2009. All rights reserved.3

I. Executive Summary

4

The Goal

A behavioral health services system that would be

functional as welcoming, accessible, integrated,

comprehensive and continuous at a client/consumer,

clinician, program, and system level.

OPEN MINDS © 2009. All rights reserved.

5

Key Findings

1. Alaska has a demonstrated history of: commitment and creativity in providing services for

children, youth, and families funding a service system with a multitude of funding

entities (e.g. federal, state general funds, Indian Health Services, private grants).

addressing the issues of children placed out-of-state through the Bring The Kids Home initiative (BTKH)


Key Findings (Cont.)

2. One result of BTKH in bringing children and youth back to Alaska has been the development of residential service facilities beyond the current placement demands

3. The Joint Management Team (JMT) is actively: Involved in working on the children’s service system Advocating for the Behavioral Rehabilitation Services

(BRS) to be moved from the Office of Children’s Services (OCS) to the Division of Behavior Health (DBH)


4. OCS currently provides the Medicaid billing for the providers

5. The Division of Behavioral Health initiated the Alaska Automated Information Management System (AKIMS) was initiated in 2003 and continues to move toward integration of clinical and billing medical record system


6. The Division of Juvenile Justice, Office of Children’s Services, and Senior Disabilities Services Division all have information management systems different from AKIMS and are in the process of working with DBH to provide for some inter-operability between information management systems.

7. Workforce development continues to be a critical factor for providers of services within the SOC

Recommendations

1. Accept the proposed Alaska SOC model which has a heavy emphasis on service development in the community or village

2. Develop a universal care plan model for children and youth (treatment plans, LOC instrument assessments, progress reports, crisis plans, and community resources)

3. Adopt the behavioral health treatment model as the center of the planning efforts for the SOC

4. Accept DBH as the division managing the proposed Alaska SOC

5. Adopt the Education/Training Plan


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Recommendations (Cont.)

6. Develop the proposed Alaska SOC framework of stakeholders (Local Advisory Councils on Children’s Services, State Collaborative, DBH as SOC manager, Policy Performa Group, Family Teams, and Children/Youth/Families)

7. Develop structure and the flow of accountability for all groups (LACs, State Collaborative, DBH, PPG, and Children, Youth and Families) within the proposed framework

8. Develop a strong case management model to lead the Family Teams of the proposed framework



9. Accept the transfer of BRS from OCS to DBH

10. Determine the Level of Care instrument that best meets the needs of the proposed Alaska SOC

11. Develop relationships with providers to ensure rewards for providers achieving outcomes, increase creativity in meeting new service needs within the SOC, and developing accountability in the care of children, youth, and families

12. Initiate an informed development of evidence-based practices (EBP) group



13. Adopt strategies for financing the proposed Alaska SOC:

Set up an extensive provider network with performance based contracts

Implement shared-risk contracts between the state of Alaska and Grantees with a focus on flexibility, creative collaboration, and risk management in regards to immediate needs of the SOC

Implement a model ‘one care plan’ model that is coordinated through a single accountable entity


14. Adopt strategies for financing the proposed Alaska SOC (cont.): Establish a blended or braided model of funding or a

combination of both Establish a SOC planning team made up of DBH, OCS,

& DJJ to provide oversight of funding for the SOC


15. The Policy Performa Group and State Collaborative need to go beyond memoranda of agreement among child-serving agencies at the State and be put into State of Alaska statute to ensure the roles, accountability and authority of each group are clearly specified


16. Develop a central case or care manager for each case to provide continuity in decision making and offer each child, youth and family a key contact person in the Family Teams to the SOC

17. Strengthen organizational partnerships across traditional child-serving service sectors

18. Make use of key system stabilizers such as relationships with community and family organizations


19. Support Care Coordination Functions as essential to the SOC Case load limitations Administrative support Statewide training

• Introduction to case management

• Case management supervision

• Advanced case management strategies

20. Establish twice a year meetings to review and assess the progress in the implementation of the proposed Alaska SOC through DBH and the Policy Performa Group


21. Invest in community voice and buy-in through the

development of Local Advisory Councils on Children’s Services in communities and villages across Alaska. Develop this model in the form of a state statute to ensure the model has a state and SOC value that is reported on in the Legislative process.


22. Establish a cross-division training initiative which encourages and promotes understanding of the goals of the divisions under DHSS, the funding models utilized to support service delivery, and develop potential future leadership for DHSS and the SOC

23. Enhance the utilization of AK-AIMs throughout the proposed Alaska SOC. Mobilize the clinical and financial components to AK-AIMs to establish a data driven decision-making SOC

24. Continue to sponsor the Change Agent Conferences for SOC stakeholders to promote the SOC and enhance the effectiveness of the SOC


II. Background of Alaska System of Care Initiative

History of Children’s System Initiatives

Alaska Youth InitiativeEstablished in the mid 1980’s Improve care to Alaska

children, youth, and family

system of care by: providing community-based care individualized services to children and youth who would otherwise be

institutionalized outside the state

By 1990 the initiative had developed into: full service delivery model with a philosophy dependent on

individualized or wraparound services


History of Children’s System Initiatives (Cont.)


Bring The Kids Home - Established in 2004 Sponsored by the DHSS in partnership with the Alaska

Mental Health Trust Authority (AMHTA), the Denali Commission and other stakeholders

Mission is to return children being served in out-of-state facilities back to in-state residential or community-based care

Goals of BTKH:Build/develop and sustain the community-based and residential

capacity Develop an integrated, seamless service system in Alaska Reduce the existing numbers of children and youth in out-of-state

care

History of Children’s System Initiatives (Cont.)

Figure One. Timeline: Alaska System of Care Development 1985 Alaska Youth Initiative (AYI) begins 1991 AYI ends 1993 Alaska became eligible for Medicaid funding 2002 Children and Youth Needs Assessment (CAYNA) introduced 2003 Bring The Kids Home initiated 2005 Alaska Partnership for Health Communities:

Governance & Financing White Paper

2008 Alaska Children's Policy Work Group recommendation

for SOC development 2009 SOC RFIP solicitation by DHSS - DBH

III. Current Child and Youth Service System


A. Alaska in Context

Alaska is the largest state in the United States in terms of land area at 570,380 square miles (1,477,300 km²), over twice as large as Texas, the next largest state.

Alaska’s estimated 2008 population is 686,293 people, with 7.5% under the age of five years and 26.7% under the age of 18 years

The racial/ethnic composition of Alaska is: Caucasian 70.8% American Indian and Alaska Native (AIAN) 15.2% African American 4.1% Asian 4.6% Native Hawaiian and Other Pacific Islander 0.6% Persons of Hispanic or Latino origin 5.9% *(U.S. Census Bureau, 2000)


B. Alaska System of Care Partners Department of Health and Social Services – Division of

Behavioral Health (Project Lead Division)

Division of Juvenile Justice

Office of Children’s Services

Senior Disabilities Services Division

Joint Management TeamSenior leadership of OCS, SDSD, DJJ, & DBH

Established to maintain a collaborative decision-making process in support of staff who are working to create a cohesive, smoothly operating system of care for children in Alaska

Charged with oversight in the redesign of the current levels of care into a seamless system of care


B. Alaska System of Care Partners

External Stakeholder Advisory Group (ESAG) DHSS / Juvenile Justice Department of Corrections Alaska Mental Health Board Alaska Board of Alcohol and Drug Addiction The Alaska Mental Health Trust Authority Grantee Organizations (Representative of the four DBH Regions and

Funded Services) Alaska Behavioral Health Association Substance Abuse Directors Association National Alliance on Mental Illness Alaska Native Tribal Health Consortium University of Alaska

B. Alaska System of Care Partners (cont.)Division of Behavioral Health DBH is responsible for the State's public behavioral health

programs.

DBH administers the statewide system of community mental health programs for:Delivery of residential and community-based treatment and

recovery servicesManages the state's only public psychiatric hospitalAdministers grants to the state's network of local community mental

health programs (Grantees)Coordinates with other government, tribal, and private providers of

mental health services to ensure the provision of comprehensive mental health services to Alaska residents.


B. Alaska System of Care Partners (cont.)

Anchorage region – 25 Grantees (17 treatment, 8 early intervention)

Northern region – 32 Grantees (16 treatment, 16 early intervention)

South central region – 34 Grantees (22 treatment, 12 early intervention)

Southeast region – 27 Grantees (20 treatment, 7 early intervention)


DBH Grantee breakdown by region:

B. Alaska System of Care Partners (cont.)Division of Juvenile Justice DJJ is responsible for:

Holding juvenile offenders accountable for their behaviors Promoting the safety and restoration of victims and communitiesAssisting offenders and their families in developing skills to prevent

crime.

DJJ mission is based on the “restorative justice” model DJJ also works to prevent crime by supporting competency

and skill development for offenders so they have alternatives to law-breaking behavior

DJJ has sixteen field offices and eight youth facilities, divided into four geographical management areas (Anchorage, Northern, Southcentral, and Southeast Alaska)




Office of Children’s Services OCS has four broad goals for children 0 – 18 years:

1. Cultural Continuity for Children

2. Permanency for Children

3. Child Safety

4. Child and Family Well-being


Senior and Disabilities Services Division SDSD promotes:

Personal dignity and respectProvides an opportunity for individuals to receive services that

further their physical, mental, spiritual and emotional health

Children within the SOC that SDSD would serve include those children with developmental disabilities and those challenged with physical and emotional disabilities


C. Current Alaska System of Care

Medicaid Based Alaska SOC has a focus of serving children and youth who

are Medicaid eligible, meaning they fit the diagnosis for seriously emotionally disturbed (SED)

DHSS made a strategic policy shift to: Increase utilization of Medicaid fundingRe-mobilize the general fund dollars to create new programsEnhance the SOC developmentCreate a flexible funding stream for programs like the

Individualized Service Agreements (ISA)


C. Current Alaska System of Care (cont.)

Core Values

Child centered and family focused

Community-based

Culturally and linguistically competent



Guiding Principles:1. Kids belong in their homes (least restrictive, most

appropriate setting, community based)

2. Strengthen families first (strength based, preventative)

3. Families and youth are equal partners (family driven, youth driven)

4. Help is accessible (coordinated and collaborative)



Guiding Principles:5. Normalize the situation (meet the child where they are,

respect normal life cycles, promote normal and healthy development

6. Consumers are satisfied and collaborative meaningful outcomes are achieved (emphasis on research, evidence, quality improvement, accountability)

7. Respect individual, family and community values (culturally competent, individualized care, community-specific solutions)



Out-of-state residential placements

Education

Alaska Native & American

Indian Corporations

Key Informant

SOC Stakeholders

Children, Youth,

Families & Advocates

Division of Behavioral

Health

Senior & Disabilities

Services Division

Grantees

Division of Juvenile Justice

Office of Children’s Services

Current Alaska DHSS

Children’s SOC


Current System Roadblocks

Intra-division fragmentation

Failure to address children and youth outside the SED diagnostic population

Lack of the ability to use ‘cross-division’ resources

D. 2009 System of Care Initiative

Why develop a SOC?

Meet the demands of the children, youth, and families seeking services in Alaska

Develop a delivery system that is efficient and maximizes DHSS division’s resources

Create a comprehensive system with an emphasis on services being provided in the community/village

Emphasis wellness and prevention in orientation to more intense levels of service

Utilize an array of financing Develop a system that is coordinated, responsive, and

creative


IV. System of Care Development Methodology

A. Project Activities A structured process for planning, prioritizing, and

documenting the progress of the coordinated, sequenced transition plan for a children’s system of care initiative activities.

A multimodal, redundant communication and information sharing process with convenient access for JMT, key informant stakeholder groups, and work groups.

Use of the OPEN MINDS team’s extensive knowledge of, and experience with, a range of state children’s services and funding sources – at both the state policy level and at the community level – for early identification of both problems for resolution and opportunities for service delivery synergy.


A. Project Activities


Project DeliverablesDeliverable One Initial Work Plan

Deliverable Two Joint Management Team Meetings

Deliverable Three Communication Plan

Deliverable Four Project Plan

Deliverable Five System of Care Model

Deliverable Six Stakeholder Workgroups

Deliverable Seven Education and Training Plan

Deliverable Eight Final Report


V. Coordinated and Sequenced Transition Plan for a New Alaska Behavioral Health System of Care for

Children

“First comes thought; then

organization of that thought,

into ideas and plans; then

transformation of those plans

into reality. The beginning, as

you will observe, is in your

imagination.”

Napoleon Hill

A. The Framework of the Proposed Alaska System of Care


Local Advisory Councils of Children’s Services

State Collaborative

Division of Behavioral Health

Policy Performa Group

Family Teams

Children, Youth, & Families

A. The Framework of the Proposed Alaska System of Care (cont.)

Local Advisory Councils on Children’s Services Members are consumers (children, youth, and families),

providers, advocates, and government (local and state) officials

Responsible for identifying the system needs and resources at the local level and communicating this to the State Collaborative and DBH

LAC will hold regular monthly meetings and have a representative at the State Collaborative meetings


State Collaborative Members are external stakeholders of the SOC, including

Grantees, advocates, children, youth and families

Responsible for communicating system needs and resources from the LACs and from the greater Grantee stakeholders to DBH

State Collaborative will hold regular monthly meetings and invite DHSS divisions to attend and be on the regular agenda



Division of Behavioral Health Responsible for the governance of the SOC and overseeing

the roles and operations of the participating DHSS divisions

Ensure the development or promotion of the range of services within the five levels of the SOC

Participate in the State Collaborative and when available the LAC meetings

Enlist both the State Collaborative and the LACs to assist in evaluating the SOC, identifying local needs, and in the development of new services within the SOC.



Policy Performa Group Members are made up of key leadership from DBH, DJJ,

and OCS

Modeled after the current Joint Management Team (JMT)

Purpose of this group will be to resolve system issues that develop in the operation of the SOC

PPG will meet bi-weekly and include key leaders from DBH in an effort to work through points of accountability for the SOC and the DHSS divisions



Family Team Name emulates the vision of the SOC Members are made up of the child or youth family, DHSS

division staff, advocates, and providers in the SOC Family Team makes decisions about the level of care most

appropriate for a child, youth, and their families Meet initially when a child enters the SOC and then

quarterly to review the status of the child or youth and determine the needed resources in the SOC to meet the needs of the child or youth most effectively


Family Team Meet more frequently for children or youth that are involved

in level five services in the SOC

Case manager on the Family Team is responsible to coordinate the meetings, coordinate and monitor services provided, and advocate for the needs of the child, youth, and family


Children, Youth, & Families Foundation of the SOC is the children, youth, and families

the SOC is designed to serve

Children and families have multiple paths to participate in and impact the SOC, including the Family Teams, State Collaborative, and the LACs

B. The Infrastructure of the Proposed Alaska System of Care

Vision Creating a comprehensive sustainable continuum of

family centered care through efficient and effective partnerships with children, youth, and families

Core Values Child-centered and family-focused care Community-based decision-making Culturally and linguistically competent

B. The Infrastructure of the Proposed Alaska System of Care (cont.)

Guiding Principles Kids belong in their homes (least restrictive, most appropriate setting,

community based) Strengthen families first (strength based, preventative) Families and youth are equal partners (family driven, youth driven);

Normalize the situation (meet the child where they are, respect normal life cycles, promote normal and healthy development

Help is accessible (coordinated and collaborative) Consumers are satisfied and collaborative meaningful outcomes are

achieved (emphasis on research, evidence, quality improvement, accountability)

Respect individual, family and community values (culturally competent, individualized care, community-specific solutions)


Level One: Recovery, Maintenance, & Health

Management Community and family. Services provide wellness,

prevention, and follow-up care to mobilize family strengths and reinforce linkages to natural supports. Those appropriate for this level may be either substantially recovered from an emotional disorder or service needs require minimal system involvement and are manageable within the consumer’s family and community.

Level One - Sample

Service Service Definition

Clinical Profile of Child &

Youth Medical Necessity

Com-munity Mental Well-being Initia-tives

Community mental well-being initiatives involve any action taken to enhance the mental well-being of individuals, families,organizations, and communities. These actions work to prevent mental health problems and aim to reduce the stigma associated with mental illness. Effective mental health promotion always presupposes respect for consumers, their rights, and their recovery. Some specific goals of mental health promotion:• Improve physical health and well-being• Prevent or reduce the risk of mental health problems• Assist with recovery from mental health problems• Improve mental health services• Improve quality of life for people with mental health

problems• Strengthen community capacity to support social

inclusion • Reduce vulnerability to social and economic stresses• Improve health at work, thereby increasing

productivity and reducing sick leave• Assisting parents, caregivers with developing

sustainable supports for their children

Profile:• Any child or

youth in the community who participates in the defined service

Criteria:• Child or youth who

are able to live with minimal external interventions related to mental health or substance abuse


Level Two: Low-Intensity Community Based

Services Community support and wraparound: Services

provide follow-up care to children, youth and their families who need ongoing treatment within the community. Those appropriate for this level need minimal assistance and do not require frequent contact and supervision.

Level Two - Sample



Youth Medical

Necessity

Assessment & Evaluation

Assessment and evaluation includes screening, diagnostic, and treatment planning services. Included is a continuum of assessment services ranging from a comprehensive psychiatric or psychological evaluation to the administration of one or a combination of psychological tests to examine a particular personality variable. Services may be provided in a variety of settings including hospitals and community-based clinics.There are other assessments as well. Office of Children’s Services (OCS) uses a safety assessment tool/process to assess safety threats and impending danger for children. There are assessment processes and tools utilized for resource families, some of which dovetail with the licensing process.

Profile:• Child or youth that

is experiencing behavioral and emotional problems in their daily living to include school, peers, community, and family settings.

• Children/youth who have a family history of mental health and substance abuse.

Criteria: • Impairment in

daily functioning is not stabilized by structure of home or school environment

• Behavioral acting out identified in home and school settings

• Complex medical problems may have an underlying impact in behavior


Level Three: High-Intensity Community-Based Services Services are provided to children and youth who

need intensive support and treatment, but who are living with their families with natural supports or living in an alternative family home or group home. Service coordination is essential to supplement natural supports with daily supervision of client provided by family or staff. Wraparound plans include informal community supports, i.e., church or self-help groups, family support.

Level Three - Sample

Service Service DefinitionClinical Profile of Child &


Mental Health and Sub-stance Abuse Day Treat-ment

Mental Health and Substance Abuse Day Treatment provides day based psychiatric services in a school or residential setting to children/youth diagnosed with severe and persistent mental illness, behavioral problems, and those struggling with substance abuse. The goal is to optimize independent living skills and offer support in the recovery process with emphasis on developing healthy coping skills.

Profile:•Child or youth with an impairment in psychosocial functioning due to the presence of severe symptoms and or behaviors caused by a mental health or substance-related disorder, which cannot be safely managed on a traditional outpatient basis.

Criteria:•Demonstrates symptomatology consistent with DSM-IV diagnosis•Co-occurring medical conditions, if any, can be safely managed in an outpatient setting.•Co-occurring mental health conditions, if present, can be treated in a dual diagnosis program, or can be safely managed at this level of care.•There is no indication of severe withdrawal, or the symptoms of withdrawal can be safely managed.•The child or youth’s condition requires a coordinated multi-modal treatment plan as well as the structure and intensity of services offered in a Day Treatment Program.•The child or youth or his/her support system understands and can comply with the requirements of a Day Treatment.


Level Four: Medically Monitored Non-Residential

Services Services are provided to children and youth who

need intensive support and treatment but are capable of living in the community either in their family or community placements. Intensive case management by a multidisciplinary treatment team is required to coordinate interventions, provide a wraparound plan, and provide formal supports and crisis intervention services.

Level Four - SampleService Service Definition

Clinical Profile of Child & Youth Medical Necessity

Youth Assertive

Com-munity

Treatment(ACT)

Youth ACT is an intensive community-based program that uses a multidisciplinary team of behavioral health professionals and trained peers to provide or coordinate treatment, rehabilitation, and community support services for members who are recovering from severe behavioral health conditions.

Profile:• Youth who are under

18 years of age:

1. Have severe and persistent mental illness

2. Have a history of:

a. Multiple hospitalizations

b. Poor performance in school

c. Placement in emergency shelters or residential treatment facilities

d. Chemical dependency or abuse

1. Have been placed on probation by a juvenile court

Criteria:• Youth with a

diagnosis of schizophrenia, schizoaffective disorder, bipolar, and depression recurrent

• History of psychiatric hospitalization, residential placement, and therapeutic foster care

• Youth who is impaired in activities of daily living and benefits from participation with intensive supportive services


Level Five: Medically Monitored and Managed

Residential Services Services are provided to children and youth who

need the most intensive support and treatment in a secure/locked in-patient psychiatric setting or highly programmed residential facility. Services may be provided in a community setting if security needs can be met through intensive case management and extensive wraparound support.

Level Five - Sample




Residential Sex Offender Treatment

Residential sex offender treatment is a facility or program in a facility that specifically treats sex offenders through an approach including a safe milieu (one in which they can not offend or being offended on), cognitive behavioral treatment, and a psychopharmacology intervention. The core of the treatment processfor sex offenders involves the engagement of the resident and family in treatment, helping residents face up to their sexually harmful behavior, identifying the effects of previous trauma, and then developing and practicing a plan for eliminating harmful behavior.

Profile:• Child or youth

charged and/or adjudicated for a sex offense in the state of Alaska

• Child/youth may or may not have a mental health or substance abuse diagnosis

Criteria:• Youth with a history of a

lower LOC that was community based and re-offends; or

• Youth who is adjudicated meets the Alaska criteria of a sex offender; or

• Youth who participates in sex offender treatment through weekly outpatient group treatment lasting 8 to 28 months; or

• Youth who has motivation to participate in all treatment parameters to include mental health and substance abuse services; or

• Youth or child who is a danger to self or other; or

• Co-occurring diagnosis

C. The Introduction of a Level of Care (LOC) Instrument

LOC instrument is a tool that can be completed by the child or youth, parent, teacher, counselor, case manager, residential and foster care staff, etc.

Goal of the LOC instrument is to document functional behavior exhibited by the child or youth

Provides a systemic base for decision-making about the necessary level of care for a child or youth

C. The Introduction of a Level of Care (LOC) Instrument (cont.)

Provides information to support the level of care necessary to assist the child or youth and the family

Provides a common language across the SOC

Identifies needs for the child or youth that may or may not be available in the SOC

Compiles data – both individual and aggregate - to support SOC funding and innovation

C. The Introduction of a Level of Care (LOC) Instrument (cont.)

LOC instrument is not the sole decision-making tool in a SOC

The instrument provides a common language Supports the identification of services at the

appropriate level of care that may support the child or youth and the family

LOC Instrument Options

Child & Adolescent Functional Assessment Scale (CAFAS) Child & Adolescent Needs & Strengths (CANS) for children

and adolescents, including CANS-CW, CANS-DD, CANS-JJ, CANS-MH, and CANS-SD

Child Behavior Checklist (CBCL) Child and Adolescent Service Intensity Instrument (CASII) Strengths and Difficulties Questionnaire (SDQ) INTERQUAL Ohio Youth Problems (Ohio Scale) Diagnostic Interview Schedule for Children (DISC) Behavioral Assessment System for Children (BASC) ASAM

LOC Instrument Survey Question #1










D. The Building Blocks of the System of Care

A community partnership among families, youth, schools, and public and private organizations to provide coordinated mental health services

Children Youth Families Community

Culturally/Linguistic Competent Community Based Decision-making Child-Centered & Family Focus Care

Individualized Coordinated Strengths-Based Accessible

Social Services Education Behavioral Health Juvenile Justice

Child Welfare Health Vocational Community SupportsLevel One

Level Two

Level Three

Level Four

Level Five

D. The Building Blocks of the System of Care

Layers One and Two Offer a diverse array of mental health and non-mental health

services and supports: social service educational mental health juvenile justice recreational vocational health substance abuse ‘informal’ community supports

D. The Building Blocks of the System of Care (cont.)

Layer Three Characteristics of services provided are individually

designed for and tailored to the particular strengths and needs of individual families

Family Team will devise a detailed and highly individualized service plan with specific, achievable, strengths-based behavior and treatment goals

Ensure services are accessible to families Coordination of services through agreed-upon eligibility

criteria and shared intake processes, systematic information sharing, routine updates and recording of all services received, and the institutionalization of sharing the service plan across agencies and DHSS divisions


Layer Three (cont.) State Collaborative & Policy Performa Group will need to:

Provide the leadership necessary to marshal resources, reduce barriers, blend or ‘braid’ funding streams, integrate and alter policies and procedures needed to promote implementation

Go beyond memoranda of agreement among child-serving agencies at the State and be put into State of Alaska statute ensuring accountability and longevity to the roles of each

Assist in clarifying roles, responsibilities and ensure coordination and accountability in the SOC

Craft mechanisms in policy to provide a source of de-categorized funds to Family Teams which are essential to facilitate wraparound approaches necessary to fill in gaps between formal services and fully individualize care in the SOC


Level Four Represents how all services and service delivery practices

are influenced by the core values of the Alaska SOC Incorporates the family as the service provision unit and uses a

broad definition of ‘family’ so that non-custodial caregivers are involved in services and service decision-making

Family voice in the SOC decisions is represented in decision-making bodies, with voting rights when relevant

SOC promotes the development of family advocacy capacity and family empowerment

Cultural and linguistic competence will be formalized throughout the system


Level Four (cont.) Policy Performa Group and State Collaborative, DHSS

divisions, and service providers will develop statements of practice and standards with training

SOC utilizes a locus of decision-making at a local (community/village) level which can be accomplished through the development of local advisory councils (LAC) on children’s services

LACs will need to work with DBH to obtain needed resources, identifying and making decisions about service gaps, blending funds to maximize resources, identifying and addressing training needs to build local capacity, and ultimately, by holding each other accountable to meet the needs of their children and families

D. The Building Blocks of the System of Care Works (cont.)

Layer Five Represents the relational model described involving the SOC stakeholders,

DHSS divisions, State Collaborative, Policy Performa Group, and LACs

System of Care Stakeholders

Policy Performa Group

Department of Health & Social Services Divisions (DBH, DJJ, OCS, & SDSD)

State Collaborative (child serving agencies, families, advocates)

Local Advisory Councils on Children’s Services

Children, Youth, Families, & Community or Village

E. Coordinated and Sequenced Transition to the New SOC

“The Future is something which everyone reaches at the rate of sixty minutes an hour, whatever he does,

whoever he is.” ~C.S. Lewis

E. Coordinated and Sequenced Transition to the New SOC (cont.)

Division of Behavioral Health will take the lead role in the implementation of the children’s behavioral health system of care for Alaska

The OPEN MINDS team recommends a three year transition plan for the implementation of the proposed Alaska SOC Year One - Education and training, governance transition, and

development of SOC framework Year Two - Development of the infrastructure changes in the

Department of Health and Social Service’s divisions, building of funding planning committee, and implementation of changes in the AKAIMS

Year Three - Development of the on-the-ground implications for children, youth and their families; SOC providers; and community stakeholders


Year One Activities Implement the Education/Training Plan Transition the Division of Behavioral Health to take the lead

role in governance of SOC model and operationalizing the transition plan

Develop a Policy Performa Group to replace the JMT Transition the residential services from the Office of

Children’s Services division to the Division of Behavioral Health

Continue support from DBH for the Alaska National Accreditation initiative

E. Coordinated and Sequenced Transition to the New SOC (cont.)Year Two Activities Develop the full framework of SOC stakeholders Develop statements for cultural and linguistic competence

practice standards and training Develop and adopt common standards of practice with

specialty treatment needs such as youth sex offenders, MR/DD children or youth with behavioral health concerns, children or youth diagnosed with FASD, children or youth diagnosed with traumatic brain disorders, autism spectrum disorders, etc…

Establish a funding pool advisory team to begin develop process of effectively bundling and braiding funding resources


Year Two Activities (cont.) Initiate an informed development of evidence-based practices

(EBP) group

2. Identify critical system issues (e.g. too many youth in high and

out-of-home care, too many youth out-of-state

3. Select services with empirical support to address specific needs of

target population

1. Collect relevant information about target population to inform development of services – Define

population and needs

4. Develop evidence-based services and infrastructure to ensure their

success

5. Evaluate the input on critical system issues and make

modifications

Service Standards and clinical guidelinesReimbursement rates that cover costsProgram certification standardsAutomatic adaptation to unique care and populationsWorkforce analysis retention and recruitmentTraining and skill developmentSupervisory structuresAssessment and referral processesFidelity monitoringUtilization management structuresOutcome monitoringInformation management and reporting requirements


Year Three Evaluate the services within the five levels of the proposed

Alaska SOC and determine which services meet the vision of the SOC, the needs of the community or village, and the availability of resources to activate the services

Develop a five year plan to maintain and build the service base

DBH, DJJ, OCS, and SDSD to blend and braid funding into a pool for the SOC to include federal, state, and foundation grants


Year Three (cont.) Integrate the proposed Alaska SOC into the AKAIMs

initiative to include both the clinical electronic health record and the billing component of the information system, performance measures are adopted, and outcome data is gathered for regular use in SOC maintenance and new service development

On going evaluation of the system with the use of the LACs, State Collaborative, DBH, Policy Performa Group, Family Teams, and the Children, Youth and Families utilizing the SOC


VI. Sources of Funding Methods

A. Sources of Funding Methods

Medicaid is the most important driver of children’s mental health fiscal policy

States across the country fund the services in their SOCs with a diverse pool of funds but all have a heavy investment in Medicaid

Complexities of the finance system for children’s behavioral health are in-part related to both the purchasers of services and deliverers of the services

A. Sources of Funding Methods (cont.)

SOC Funding Sources State and local general revenue (including those from tribal

jurisdictions) Federal discretionary funds, entitlements and formula and

block grants: Medicaid and the State Children’s Health Insurance Program (SCHIP) Temporary Assistance to Needy Families (TANF) Social Services Block Grant (SSBG) Federal categorical revenue allocated toward specific health and

human service agencies, in particular but not limited to the federal Departments of Health and Human Services (DHHS), which includes SAMHSA Education and Justice;


SOC Funding Sources (cont.) Indian Health Service A host of private payers including insurers and employers For substance abuse, it also includes:

Substance Abuse Prevention and Treatment Block Grant Medicaid and EPSDT SCHIP Indian Health Service State general funds



Elements of service that typify state fiscal policy: Over-reliance on residential treatment Lack of access to, or the availability of, community-based

treatment alternatives Fiscal practices, particularly through Medicaid, are

inconsistent with the knowledge base about effective children’s behavioral health services

Insensitivity to prevention and early intervention Limited incentives to plan strategically and to support

leadership informed by children’s behavioral health knowledge


Elements of service typify state fiscal policy (cont.): State-based service inequities driven by variation in the use

of available Medicaid provisions Fiscal policies that are often out of sync with the

developmental needs of children and youth Poor information technology Inadequate alignment of fiscal policy with quality initiatives Missed opportunities to seize the initiative at the federal

level to embed best fiscal practices


B. Alaska SOC Financing

Seven areas must be addressed in a strategic

financing plan for the proposed SOC:1. Identifying spending and utilization patterns across

agencies through the AK-AIMs

2. Realigning funding streams and structures through the use of the SOC Performa Policy Group

3. Financing appropriate services and supports identified by the Performa Policy Group and State Collaborative


Seven areas must be addressed in a strategic financing

plan for the propose SOC:4. Financing to support family and youth partnerships

identified by the State Collaborative

5. Financing to improve cultural and linguistic competence and reduce disparities in care identified by the Performa Policy Group

6. Financing to improve the workforce and provider network

7. Financing for accountability


Strategies to Successfully Fund the Proposed SOC:1. Set up an extensive provider network with performance

based contracts demonstrating: Outcomes with children, youth, and families Continuous improvement processes typically associated with

national accreditation Flexible systems for children and youth to move through services

and levels2. Implement shared-risk contracts between the state of Alaska

and Grantees with a focus on flexibility, creative collaboration, and risk management in regards to immediate needs of the SOC.

3. Implement a model ‘one care plan’ model that is coordinated through a single accountable entity but funded with resources from various programs.


Strategies to Successfully Fund the Proposed SOC

(cont.):4. Establish a blended or braided model of funding or a

combination of both Blended funding can allow systems to fund activities that are not

reimbursable through specific categorical programs Braided funding allows resources to be tracked more closely for

the purpose of accounting to federal program administrators Combination funding requires the funding management to be put

under the structure of one division and in the case of the Alaska SOC, DBH would be the logical choice


Strategies to Successfully Fund the Proposed SOC

(cont.):5. Establish a SOC planning team made up of DBH, OCS, &

DJJ to provide oversight of funding for the SOC and determine different ways of using two categories of federal funding : Ongoing funding streams such as block grants or entitlement

programs that provide resources year after year in a reliable fashion

Discretionary grants, which are time-limited and often require state or local matching funds




VII. Outcome Measure Recommendation

Recommendations

Recommendation One: Develop points of accountability for all groups (LACs, State Collaborative, DBH, PPG, and Children, Youth and Families) within the proposed framework in Figure Five

Recommendation Two: Invest in community voice and buy-in through the development of Local Advisory Councils on Children’s Services in communities and villages across Alaska. Develop this model in the form of a state statute to ensure the model has a state and SOC value that is reported on in the Legislative process

Recommendations (cont.)

Recommendation Three: Promote fidelity to the proposed Alaska SOC model through the Policy Performa Group to provide SOC fidelity monitoring

Recommendation Four: Establish a cross-division training initiative which encourages and promotes understanding of the goals of the divisions under DHSS, the funding models utilized to support service delivery, and develop potential future leadership for DHSS

Recommendation Five: Enhance the utilization of AK-AIMs throughout the proposed Alaska SOC. Mobilize the clinical and financial components to AK-AIMs to establish a data driven decision-making SOC


Recommendation Six: Continue to sponsor the Change Agent Conferences for SOC stakeholders to promote the SOC and enhance the effectiveness of the SOC

Recommendation Seven: Identify spending and utilization patterns across agencies in the SOC to develop performance based standards

Recommendation Eight: Develop shared risk and performance based contracts with SOC stakeholders


Recommendation Nine: Establish a plan to adopt and develop informed evidence-based practices within the SOC.

Recommendation Ten: Establish twice a year meetings to review and assess the progress in the implementation of the proposed Alaska SOC through DBH and the Policy Performa Group

112

VIII. Sustaining the Behavioral Health System of Care for Children


Recommendations for sustainability of the Alaska SOC

1. Strengthen organizational partnerships across traditional child-serving service sectors.

Cross-agency Partnerships Provider Relationships Shared System Management School-Based Mental Health


114


2. Make use of key system stabilizers such as relationships with community and family organizations.

Revitalize Community Voice through Local Advisory Councils on Children Services.

Strengthen Partnerships with Children, Youth, and Families particularly in community/village wellbeing initiatives


115


3. Support Care Coordination function Case load limitations Administrative support Statewide training

• Introduction to case management

• Case management supervision

• Advanced case management strategies


116


Conclusion - the sustainability of the Alaska System of Care

requires a single division with accountability for the SOC

governance. The framework of the proposed Alaska SOC is

built on the development of the Performa Policy Group, State

Collaborative, LACs for Children Services, and the Family

teams. The SOC also requires a commitment to a level of care

instrument that provides for common language about the SOC,

the SOC resources, and the needs of children, youth, and

families.


117 OPEN MINDS © 2009 All rights reserved.117

Questions & Discussion

Proposed Alaska Children’s Behavioral Health System of

Care

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Documents

Proposed Alaska Children’s Behavioral Health System of Care Submitted by: OPEN MINDS November 16, 2009 Dan M. Aune, Senior Consultant