Because Minds Matter: Collaborating to Strengthen Psychotropic Medication
Management for Children and Youth in Foster Care
Maximizing Opportunities to Increase
Child and Family Well Being Through
Innovative Funding Approaches
Sheila A. Pires
Human Service Collaborative
Washington, DC
August 27-28, 2012
Washington, DC
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Effectiveness Research
(Barbara Burns’ Research at Duke University)
• Most evidence of efficacy: Intensive case
management, in-home services, therapeutic foster
care
• Less evidence (because not much research done):
Crisis services, respite, mentoring, family
education and support
• Least evidence (and lots of research): Inpatient,
residential treatment, therapeutic group home
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
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Examples of What You Don’t See Listed as
Evidence-Based Practice
(though they may be standard practice)
•
•
•
•
Traditional office-based “talk” therapy
Residential Treatment
Group Homes
Day Treatment
_______________________________________________
Examples of Potentially Harmful Programs and Effective
Alternatives in Dodge, K., Dishion, T., & Lansford, J. (2006).
“Deviant Peer Influences in Intervention and Public Policy for Youth,”
Social Policy Report, Vol. XX, No. 1, January 2006.
Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7.
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
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Broad, Flexible Service Array
Example: Dawn Project Services & Supports
Behavioral Health
Psychiatric
Other
•Behavior management
•Crisis intervention
•Day treatment
•Evaluation
•Family assessment
•Family preservation
•Family therapy
•Group therapy
•Individual therapy
•Parenting/family skills training
•Substance abuse therapy,
individual and group
•Special therapy
•Assessment
•Medication follow-up/psychiatric review
•Nursing services
•Camp
•Team meeting
•Consultation with other
professionals
•Guardian ad litem
•Transportation
•Interpretive services
Placement
•Acute hospitalization
•Foster care
•Therapeutic foster care
•Group home care
•Relative placement
•Residential treatment
•Shelter care
•Crisis residential
•Supported independent living
Mentor
•Community case management/case aide
•Clinical mentor
•Educational mentor
•Life coach/independent living skills
mentor
•Parent and family mentor
•Recreational/social mentor
•Supported work environment
•Tutor
•Community supervision
Respite
•Crisis respite
•Planned respite
•Residential respite
Service Coordination
•Case management
•Service coordination
•Intensive case management
Discretionary
•Activities
•Automobile repair
•Childcare/supervision
•Clothing
•Educational expenses
•Furnishings/appliances
•Housing (rent, security deposits)
•Medical
•Monitoring equipment
•Paid roommate
•Supplies/groceries
•Utilities
•Incentive money
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2005 CHIOCES, Inc., Indianapolis, IN
Types of Medicaid Services in Systems of Care
• Assessment and diagnosis
• Inpatient hospital services
• Outpatient psychotherapy
• Case management services
• Medical management
• School-based services
• Home-based services
• Respite services
• Day treatment/partial
hospitalization
• Wraparound
• Crisis services – mobile &
residential
• Youth peer support
• Behavioral aide services
• Behavioral management skills
training
• Therapeutic foster care
• Therapeutic group homes
• Targeted Case Management
• Family peer support/education
• Transportation
• Mental health consultation
• Early intervention and
prevention services
• Supported independent living
• Residential treatment centers
• Telehealth
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Examples of Sources of Funding for Children/ Youth
Medicaid
• Medicaid Inpatient
• Medicaid Outpatient
• Medicaid
Rehabilitation
Services Option
• Medicaid Early
Periodic Screening,
Diagnosis and
Treatment (EPSDT)
• Targeted Case
Management
• Medicaid Waivers
• TEFRA Option
• ACA options
Mental Health
• MH General Revenue
• MH Medicaid Match
• MH Block Grant
Child Welfare
• CW General Revenue
• CW Medicaid Match
• IV-E (Foster Care and
Adoption Assistance)
• IV-B (Child Welfare
Services)
• Family
Preservation/Family
Support
Substance Abuse
• SA General Revenue
• SA Medicaid Match
• SA Block Grant
Juvenile Justice
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants
Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector.
Washington, DC: Human Service Collaborative.
Education
• ED General Revenue
• ED Medicaid Match
• Student Services
Other
• TANF
• Children’s Medical
Services/Title V–
Maternal and Child
Health
• Mental Retardation/
Developmental
Disabilities
• Title XXI-State
Children’s Health
Insurance Program
(SCHIP)
• Vocational
Rehabilitation
• Supplemental Security
Income (SSI)
• Local Funds
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Financing Strategies and Structures
FIRST PRINCIPLE: System Design Drives Financing
REDIRECTION
Using the money we already have
The cost of doing nothing
Shifting funds from treatment to early
intervention and prevention
Moving across fiscal years
REFINANCING
Generating new money by increasing
federal claims
The commitment to reinvest funds for
families and children
Foster Care and Adoption Assistance (Title
IV-E)
Medicaid (Title XIX)
RAISING OTHER REVENUE TO
SUPPORT FAMILIES AND CHILDREN
Donations
Special taxes and taxing districts for
children
Fees & third party collections
Trust funds
FINANCING STRUCTURES THAT
SUPPORT GOALS
Seamless services: Financial claiming
invisible to families
Funding pools: Breaking the lock of agency
ownership of funds
Flexible Dollars: Removing the barriers to
meeting the unique needs of families
Incentives: Rewarding good practice
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Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.
Redirection
Where are you spending resources on
high costs and/or poor outcomes?
Residential Treatment?
Group Homes?
Detention?
Hospital admissions/re-admissions?
Too long stays in therapeutic foster care?
Inappropriate psychotropic drug use?
“Cookie-cutter” psychiatric and psychological
evaluations?
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Implications for How RTCs are Utilized
• Movement away from “placement” orientation and long
lengths of stay
• Residential as part of an integrated continuum, connected
to community
• Shared decision making with families/youth and other
providers and agencies
• Individualized treatment approaches through a child and
family team process
• Trauma-informed care
For more information, go to Building Bridges Initiative:
Data Trends #127, February 2006,University of South Florida.
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The Cost of Doing Nothing
If Milwaukee County had done nothing:
the $18m. spent by child welfare ten years ago would be
$48m. today
Project Bloom “Cost of Failure Study”
Early childhood services at an average cost per child of
$987/year save $5,693/year in special education
If New Jersey had done nothing:
it would have spent $30m more in inpatient psychiatric
hospitalization over the last three years
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The Cost of Doing Nothing:
Racial & Ethnic Disparities/Disproportionality
“…youths of color were less likely to receive outpatient
therapy…..
and more likely to receive residential services.” (1)
“The study finds greater use of residential treatment
centers by black persons and Hispanic persons that
is attributable in part to (public sector) managed care” (2)
1.
2.
McMillen, J., Scott, L.et. al. Use of Mental Health Services Among Older Youths In
Foster Care. 2004. Psychiatric Services 55:811-817. American Psychiatric
Association
Snowden, L., Cuellar, E. & Libby, A. Minority Youth in Foster Care: Managed
Care and Access to Mental Health Treatment. 2003. Med Care. 41(2): 264-74).
University of California Berkley
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Strategic Financing Analysis
1. Identify state and local agencies that spend on
youth/families at risk
How much? What kind of $?
2. Identify resources that are untapped or under-utilized
(e.g., Medicaid)
3. Identify utilization patterns and expenditures
Consider high cost/poor outcome
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
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Strategic Financing Analysis
4. Identify disparities and disproportionality in access to
service/supports
What are the strategies to address?
5. Identify the funding structures that will best support the
system design
Braided, blended, risk-based, purchasing
collaborative???
6. Identify short and long term financing strategies
Federal revenue maximization; re-direction from
restrictive levels of care; waiver; performance
incentives; legislative proposal; taxpayer
referendum
Aligning Incentives Across Agencies
Child Welfare
Alternative to out-of-home care
high costs/poor outcomes
Medicaid
Alternative to IP/ER/PRTF; multiple
psychotropic meds
System of Care
Alternative to detentionhigh cost/poor outcomes
Juvenile Justice
Alternative to out-of-school
placements, high special ed costs
Education
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Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
BH, CW, MA $$ - Single Payer
New Jersey
Department of Children and Families
Division of Child Behavioral Health Services
Dept. of Human Services
Medicaid Division
UMDNJ Training
& TA Institute
•1-800 number
•Screening
•Utilization management
•Outcomes tracking
Contracted Systems
Administrator- PerformCare
Provider
Network
Family Support
Organizations
Family peer support,
education and advocacy
Youth movement
Care Management
Organizations - CMOs
Any licensed DCF provider
Lead non profit agencies managing children with serious
challenges, multi-system involvement
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Louisiana
Children’s System of Care
(CSoC) Governing Body
1915 b and c waivers
Medicaid, Behavioral
Health and Child Welfare
dollars
Regional Care
Management
Organizations
Statewide
Management
Organization (ASO)
Family Support
Organizations
Magellan
Provider
Network
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Care Management Entity Functions
At the Service Level:
 Child and family team facilitation using high quality
Wraparound practice model
 Screening, assessment, clinical oversight
 Intensive care coordination
 Care monitoring and review
 Peer support partners
 Access to mobile crisis supports
At the Administrative Level:
 Information management – real time data; web-based IT
 Provider network recruitment and management (including
natural supports)
 Utilization management
 Continuous quality improvement; outcomes monitoring
 Training
Pires, S. 2010. Human Service Collaborative
Affordable Care Act Opportunities and Challenges
Medicaid Re-Design
Renewed interest in various waivers/options
•
1115, 1915b, 1915i, Money Follows the
Person, health homes
Renewed interest in managed care, including
for populations with high use/cost (e.g., chronic
conditions, foster care, SSI)
I. Customizing Medicaid Managed Care for
Children/Youth in Child Welfare and At Risk
Requirements for:
Incorporation of State and federal requirements for child welfare
population, e.g. PH and BH screens within certain timeframe,
monitoring of psychotropic meds (requirement for all children)
Risk-adjusted rate for children in child welfare and children
with serious behavioral health challenges
Special liaison for child welfare-involved children,
children enrolled in Care Management Entities, youth transitioning
Hire/contract with family and youth organizations to serve as
family and youth advocates and peer supports
Incentives to require out-of-office care
Specific performance measures related to children in child welfare
Reinvestment back into child home and community services
Pires, S. 2012.Washington DC: Human Service Collaborative
II. Customizing Medicaid Managed Care for
Children/Youth in Child Welfare and At Risk
Requirements for:
EPSDT inclusion of behavioral health screens and linkage
to BH services when indicated
Broad BH benefit, inclusive of in-home, respite, family and
youth peer support, mobile response and stabilization, behavioral
management consultation, therapeutic foster care, telebehavioral health
Provider network requirements to include: providers trained
in child welfare population issues, EBPs, trauma-informed care;
racially/ethnically diverse providers; inclusion of families/youth as
providers/advocates
Enhanced rates for providers trained in EBPs and traumainformed care
Timely provider payments
Pires, S. 2012. Washington DC: Human Service Collaborative
III. Customizing Medicaid Managed Care for
Children/Youth in Child Welfare and At Risk
Requirements for:
No “fail first” policies regarding access to service type or
psychotropic med type
Specific “pass-through” case rate for Care Management Entity
or wraparound team approach for children with most complex
challenges
Use of standardized tools for screening, and determination of
service intensity needed
Prior authorization parameters that enable “ready access” to
services (e.g., first 12 visits do not require prior auth)
Prior authorization parameters that allow wraparound plan of
care to drive medical necessity (with outlier management)
Pires, S. 2012. Washington DC: Human Service Collaborative
IV. Customizing Medicaid Managed Care for
Children/Youth in Child Welfare and At Risk
Requirements for:
Quality review process that involves families and youth
with lived experience on quality review teams and requires
input from child welfare system
Data tracking requirements to include: service use
and expenditures of children in foster care, including psychotropic
meds – stratifiable by age, gender, race/ethnicity, aid category,
region, diagnosis, service type, medication type
Engagement in quality improvement initiatives involving
children’s behavioral health and children in child welfare
Focus groups and satisfaction surveys of youth and families
involved in child welfare and of child welfare workers
Pires, S. 2012. Washington DC: Human Service Collaborative
Summary of Financing Characteristics
of Systems of Care for Children/Youth and Families
in Child Welfare and At Risk
Maximize Medicaid (e.g., flexible Rehab Option)
Blend, braid or intentionally coordinate funding streams
across systems
Re-direct spending from high cost and/or poor outcome
services to effective practices
Manage dollars through managed care arrangements that
are tied to values and goals
Risk adjust payment for complex populations of children
(e.g., risk-adjusted capitation rates to MCOs; case rates to
providers)
Finance locus of accountability – e.g., care management entities
for most complex, cross-system
Finance family and youth partnerships at policy, management
and service levels
 Finance training, capacity building, quality and outcomes monitoring
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
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For further information, contact:
Sheila A. Pires
Human Service Collaborative
sapires@aol.com