Primer Hands On-Child Welfare
THE SKILL BUILDING CURRICULUM
Module 7
Service Array and Financing
Developed by:
Sheila A. Pires
Human Service Collaborative
Washington, D.C.
In partnership with:
Katherine J. Lazear
Research and Training Center for Children’s Mental Health
University of South Florida, Tampa, FL
Lisa Conlan
Federation of Families for Children’s Mental Health
Washington, D.C.
1
Why Focus on Medicaid Managed Care?
Medicaid is the primary source for health/mental
health care for children in child welfare.
Most states (86%) are applying managed care
approaches to their Medicaid programs.
Health Care Reform Tracking Project 2003 State Survey. Research and Training Center for Children’s Mental Health,
University of South Florida, Tampa, FL
2
Children in Child Welfare in Medicaid
Managed Care
Source: CMS/MSIS State Summary Data, FY 2003
53% - 72% of foster care population is enrolled
in Medicaid managed care –
HMO Enrollment: 245,313
BHO Enrollment: 174,584
________________________
Total Enrollment: 419,897
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
3
State Coverage of Child Welfare Population
in Medicaid Managed Care
Source: Health Care Reform Tracking Project 2003 State Survey
26 states include the child welfare population in
Medicaid managed care –
• 22 with mandatory enrollment
• 4 with voluntary enrollment
Pires, S. (2002). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
4
NRCOI Framework for a Full Service
Array in Child Welfare
“Collaborative, strategic, population-focused process,
guided by set of tools, to identify array of practices, services,
and supports needed in a SOC for child welfare populations”
1.
2.
3.
4.
Assessment of Current Practices in the Jurisdiction as They Relate to
Building Specified, Needed Child Welfare Capacities.
Assessment of Current Leadership and Systemic Culture in the Jurisdiction
as They Relate to Building Specified, Needed Child Welfare Capacities.
Assessment of Current Services in the Jurisdiction as They Relate to Building
Specified, Needed Child Welfare Capacities.
Assessment of the Need for Other Services Not Currently Available in the
Jurisdiction as They Relate to Building Specified, Needed Child Welfare
Capacities.
Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National
Child Welfare Resource Center for Organizational Improvement
5
Purposes of NRCOI Framework
• Create a service directory
• Prepare for the CFSR, the Statewide Assessment, and in
developing the PIP re the service array
• Meet CAPTA requirement to conduct annual inventory
• Help define array of services needed in SOC when
specific target population has been chosen
• Identify gaps and strategies to improve service array
• Can lead to better collaboration among providers and
a better functioning community collaborative
Examples
Pulaski, Co., Virginia
Nebraska – 14-county rural area
Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource
Center for Organizational Improvement
6
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 7.1
National Child Welfare Resource Center for
Organizational Improvement:
Service Array Framework
www.nrcoi.org
Primer Hands On - Child Welfare (2007)
7
Dawn Services & Supports
Behavioral Health
•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
Placement
•Acute hospitalization
•Foster care
•Therapeutic foster care
•Group home care
•Relative placement
•Residential treatment
•Shelter care
•Crisis residential
•Supported independent living
Psychiatric
Other
•Assessment
•Camp
•Medication follow-up/psychiatric
•Team meeting
review
•Consultation with other
•Nursing services
professionals
Mentor
•Guardian ad litem
•Community case management/case
•Transportation
aide
•Interpretive services
•Clinical mentor
Discretionary
•Educational mentor
•Activities
•Life coach/independent living skills •Automobile repair
mentor
•Childcare/supervision
•Parent and family mentor
•Clothing
•Recreational/social mentor
•Educational expenses
•Supported work environment
•Furnishings/appliances
•Tutor
•Housing (rent, security
•Community supervision
deposits)
Respite
•Medical
•Crisis respite
•Monitoring equipment
•Planned respite
•Paid roommate
•Residential respite
•Supplies/groceries
Service Coordination
•Utilities
•Case management
•Incentive money
8
•Service coordination
2005 CHIOCES, Inc., Indianapolis, IN
•Intensive case management
Examples of Evidence Based Practices Related to CFSR Outcomes
Programs Addressing Safety
- Abuse-Focused Cognitive Behavioral Therapy (AF-CBT) - AMEND, Inc. (Abusive Men Exploring New
Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Project
Connect - Child Parent Psychotherapy for Family Violence (CPP-FV) – Trauma Treatment Rated - Project
SafeCare - Domestic Abuse Intervention Project (DAIP) - Nurturing Parenting Programs - Project SUPPORT
- Intensive Reunification Program (IRP) Motivational Interviewing (MI) - Nurturing Program for Families in
Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Self-Motivation
Group (SM Group) - Shared Family Care (SFC) - Supported Housing Program (SHP) - The Community
Advocacy Project - Triple P – Positive Parenting Program
Programs Addressing Permanency
HOMEBUILDERS - Intensive Reunification Program (IRP) - Project CONNECT - Shared Family Care
Programs Addressing Well-Being
1-2-3 Magic: Effective Discipline for Children 2-12 - Abuse-Focused Cognitive Behavioral Therapy Alcoholics Anonymous (A.A.) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent
Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Child Parent Psychotherapy for
Family Violence (CPP-FV): Trauma Treatment Rated - Community Reinforcement + Vouchers Approach
(CRA + Vouchers) - Community Reinforcement Approach - Domestic Abuse Intervention Project (DAIP) Eye Movement Desensitization and Reprocessing (EMDR) - Intensive Reunification Program (IRP) Motivational Interviewing (MI)Nurturing Parenting Programs - Nurturing Program for Families in Substance
Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Parenting Wisely - Project
CONNECT - Project SUPPORT - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - STEP:
Systematic Training for Effective Parenting - Supported Housing Program (SHP) - The Community
Advocacy Project - The Incredible Years – Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - Triple
P – Positive Parenting Program
9
California Evidence-Based Clearinghouse at: http://www.cachildwelfareclearinghouse.org
Examples of Other Services
You’d Want to Provide Based on
Practice/Family Experience & Outcomes Data
• Family Group Decision Making
• Wraparound
• Integration of natural helping networks
• Intensive in-home services (not just MST)
• Respite services
• Mobile response and stabilization services
• Independent living skills and supports
• Family/youth education and peer support
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
10
Examples of What You Don’t See Listed as
Evidence-Based Practice
(though they may be standard practice)
• Residential Treatment
• Group Homes
• Day Treatment
• Traditional office-based “talk” therapy
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
11
Examples from Hawaii’s List of Evidence Based Practices
Problem Area
Anxious or Avoidant
Behaviors
Depressive or Withdrawn
Behaviors
Disruptive & Oppositional
Behaviors
Best Support
Good Support
Cognitive Behavior
Therapy (CBT);
Exposure Modeling
CBT with Parents; Group CBT;
CBT for Child & Parent;
Educational Support
CBT
CBT with Parents; Inter-Personal
Tx. (Manualized); Relaxation
Parent & Teacher
Training; Parent
Child Interaction
Therapy
Anger Coping Therapy;
Assertiveness Training; Problem
Solving Skills Training, Rational
Emotive Therapy, AC-SIT, PATHS
& FAST Track Programs
Juvenile Sex Offenders
None
None
Delinquency & Willful
Misconduct Behavior
Known Risks: Group
Therapy
None
Multisystemic Therapy; Functional
Family Therapy
Substance Use
Known Risks:
Group Therapy
CBT
Behavior Therapy; Purdue Brief
Family Therapy
Known Risks:
Group Therapy
Moderate
Support
None
None
Social Relations
Training; Project
Achieve
Multisystemic
Therapy
MultiDimensional
Treatment Foster
Care;Wraparound
Foster Care
None
12
HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 7.2
Examples of Potentially Harmful Programs
and Effective Alternatives
Source: 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. As published in Youth Today: The
Newspaper on Youth Work, Vol. 15, No. 7. www.youthtoday.org
Primer Hands On - Child Welfare (2007)
13
Challenges to Financing and Implementing
Evidence-Based/Promising Practices
Financing & Infrastructure needed for:
Training
Consultation
Coaching
Provider Capacity Development
Fidelity Monitoring
Outcomes Tracking
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
14
How to Finance/Implement Evidence-Based
and Promising Practices
Adopt a Population Focus: Who are the populations of families
and youth for whom you want to change practice/outcomes?
Adopt a Cross-Systems Approach: What other systems serve
these children and families? Who controls potential or actual
dollars? Which systems now spend a lot on restrictive levels of
care with poor outcomes or on deficit-based assessments not
linked to effective services - opportunities for re-direction?
Identify Incentives and Supports to finance/implement evidence
based practices
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
15
Examples of Incentives to Various Systems
Serving Children and Families
Medicaid: slowing rate of growth in inpatient, emergency
room, residential treatment and pharmacy costs
Child Welfare: meeting Adoptions and Safe Families Act
outcomes; reducing out-of-home placements
Juvenile Justice: creating alternatives to incarceration
Mental Health: more effective delivery system
Education: reducing special education expenditures
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
16
Examples of Cross-System Partnerships to Finance
and Implement Evidence-Based and Promising Practices
District of Columbia
Multi Systemic Therapy (MST), Mobile Response, In-Home
Medicaid Rehab Option
to pay for MST, Intensive Home-Based
Services (Ohio model), Mobile Response
and Stabilization Services (NJ model)
Child Welfare
provided match and paid for initial
training, coaching, provider
capacity development;
Mental health/child welfare to share costs of outcomes tracking
Juvenile Justice
also to pay match, training costs as well
Medicaid HMO
expressing interest in Mobile Crisis
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
17
Service Array Focused on a Total Population
Universal
Core Services
Prevention
Targeted
Early Intervention
Intensive Services
 Family Support
Services
 Youth Development
Program/Activities
 Service Coordination
 Intensive Service
Management
 Wraparound Services
& Supports; Family
Group Decision
Making
Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health
Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative.
18
Characteristics of a Culturally and Linguistically
Competent Service Design & Practice
•
•
•
•
Driven by family/youth-preferred choices;
Understands the needs/help-seeking behaviors of youth/families;
Embraces principles of equal access/non-discriminatory practices;
Designs/implements services and supports that are tailored or
matched to the unique needs of children, youth, families,
organizations and communities served;
• Recognizes well-being crosses life domains;
• Understands that cultural competence must be defined and
required for Evidence Based Practices (EBP), and that Practice
Based Evidence (PBE) must be taken into consideration as a
critical component of EBPs in communities of color.
Lazear, K. J Primer Hands On Human Service Collaborative, Washington, DC. 2006
19
Families and Youth Provide Valuable
Services and Supports
As technical assistance
providers & consultants
As direct service providers
Training
 Foster Parents
Evaluation
 Mentors
Research
 Service Coordinators
Support
 Family Educators
Outreach
 Specific Program
Managers (respite, etc)
Adapted from Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
20
Family and Youth Roles in Building
Evidence-Based Practice (EBP)
• Advocate for ethical, culturally sensitive research
• Participate in the development and analysis of
research to support EBP
• Assist in data collection to support EBP
• Educate families, family leaders and youth about
EBP
Wells, C. & Pires, S. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
21
Examples of Strategies to Address Lack of
Home and Community-Based Services
•
•
•
•
•
Support family and youth movements
Engage natural helpers and culturally diverse communities
Implement a meaningful Medicaid rehab option
Write child and family appropriate service definitions
Collapse out-of-home and home and community-based budget
structures
• Re-direct dollars from out-of-home to home and communitybased
• Implement flexible rate structures (e.g., bundled rates/case
rates)
• Implement pilots or phase in system change
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
22
Examples of Strategies to Address Lack of
Home and Community-Based Services
•
•
•
•
•
•
•
•
Implement capacity-building grants
Implement performance-based contracts
Develop practice and implementation guidelines
Train providers, judges, families, etc. – use training resources
across systems
Implement quality and utilization management
Apply for federal demonstration grants
Collect data on child and family outcomes, family/youth
satisfaction, and cost/benefits
Educate key constituencies (e.g., legislators, Governor’s Office,
State Insurance Commissioner)
Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.
23
Examples of Sources of Funding for Children/Youth
with Individualized Needs in the Public Sector
Medicaid
• Medicaid In-Patient
• Medicaid Outpatient
• Medicaid Rehabilitation
Services Option
• Medicaid Early Periodic
Screening, Diagnosis and
Treatment (EPSDT)
• Targeted Case
Management
• Medicaid Waivers
• TEFRA Option
Substance Abuse
• SA General Revenue
• SA Medicaid Match
• SA Block Grant
Mental Health
• MH General Revenue
• MH Medicaid Match
• MH Block Grant
Education
• ED General Revenue
• ED Medicaid Match
• Student Services
Other
Child Welfare
• CW General Revenue
• CW Medicaid Match
• IV-E (Foster Care and
Adoption Assistance)
• IV-B (Child Welfare
Services)
• Family
Preservation/Family
Support
Juvenile Justice
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants
Pires, S. (1995). Examples of sources of funding for children & families in the public sector. Washington,
DC: Human Service Collaborative.
• 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
24
Major Child Welfare Funding Streams
• Child Welfare Services – Title IV-B
• Foster Care & Adoption Assistance – Title IV-E
• Social Services Block Grant
• Temporary Assistance to Needy Families (TANF)
• Medicaid – Title IX
• State and local general revenue
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
25
Advantages and Drawbacks of Specific Child Welfare
Financing Streams
Type
IV-B
Advantages
Flexible, includes family
preservation and support $$
Capped allocation from federal government
to states and represents a relatively small
percentage of available $$
Uncapped entitlement $$
Can be used only for room/board costs for
eligible children in out-of-home
placements and certain administrative and
training costs
Important source of revenue
for health and behavioral
health services for children in
or at risk for child welfare
involvement
Medicaid agencies are concerned about
increasing costs and assuming too much
responsibility for “high-cost” populations;
Adult family members may not be eligible
Important source of
emergency funds for families
Capped
IV-E
Medicaid
TANF
Drawbacks
SS Block Grant Flexible
Capped and shrinking
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
26
Creating “Win-Win” Scenarios
Child Welfare
Alternative to out-of-home care
high costs/poor outcomes
Medicaid
Alternative to
Inpatient/Emergency Roomhigh cost
System of Care
Alternative to detentionhigh cost/poor outcomes
Juvenile Justice
Alternative to out-of-school
placements – high cost
Special Education
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
27
Thinking Across Systems Serving Children,
Youth and Families
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
28
Financing Strategies to Support Improved
Outcomes for Children, Youth and Families
FIRST PRINCIPLE: System Design Drives Financing
REDEPLOYMENT
Using the money we already have
The cost of doing nothing
Shifting funds from treatment to 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 including
child support
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
Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.
29
What Are the Pooled Funds?
CHILD WELFARE
Funds thru Case Rate
(Budget for Institutional
Care for CHIPS Children)
JUVENILE JUSTICE
(Funds budgeted for
Residential Treatment for
Delinquent Youth)
9.5M
MEDICAID CAPITATION
(1557 per month
per enrollee)
8.5M
10M
MENTAL HEALTH
•Crisis Billing
•Block Grant
•HMO Commercial Insurance
2.0M
Wraparound Milwaukee
Management Service Organization (MSO)
$30M
Per Participant Case Rate
Care
Coordination
Child and Family Team
Provider Network
240 Providers
85 Services
Plan of Care
Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and
Adolescent Services Branch.
30
Example: Pooled Funds for
Nebraska’s Integrated Care Coordination Units
Child Welfare
State General Revenue,
IV-E, IV-B
Juvenile Justice
State General Revenue
Federal Mental Health
Block Grant
Case Rate
Integrated Care Coordination Unity
Services and supports for
children in state custody
with complex needs
Families Care
8% of Case Rate
Pires, S. (2007) Primer Hands On - Child Welfare
31
Financing – Cuyahoga County (Cleveland)
System of Care Oversight Committee
County
Administrative
Services
Organization
}
Neighborhood Collaboratives &
Lead Provider Agency
Partnerships
State
Early Intervention and
Family Preservation
FCFC $$
Fast/ABC $$
Residential Treatment Center $$$$
Therapeutic Foster Care $$$
“Unruly”/shelter care $
Tapestry $$
System of Care Grants
SCY $$
}
Reinvestment of savings
Community Providers and Natural Helping Networks
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
32
Example of Redirecting Funds
Youth who are at-risk of
entering a RTC
Medicaid
DHR and DJS
Federal and State
(MHS Match Mental Hygiene
Block Money
Youth referred to a
local management
entity
Local
Management
Entity
Controls the
management of
treatment services,
support services, and
housing/placements.
Money form the three
funding sources are
streamlined into the
local management
entity
$
At risk pool
is created
for the local
managemen
t entities
$
$
$
The three sources of funding stream into the
local management entity from the state and
federal government. The local management
entity is held accountable to the state. The three
sources of funding are from Medicaid, Mental
Hygiene, and a combination of DHR and DJS.
Treatment services (in patient
(treatment facility) and out-patient
(in-home) services)
Support services (respite,
behavioral supports, nutrition, etc.)
Housing/Placement services
(foster care, group home, adoption,
etc.)
Adapted from State of Maryland, 2004
33
Where to Look for Money
and Other Types of Support
e
e
Pires, S. (1994). Where to look for money and other types of support. Washington, DC: Human Service Collaborative.
34
Diversity of Federal Grant Sites Funding
SOURCE
State
SYSTEM
DESCRIPTION
Mental Health
General fund, Medicaid (including FFS/managed care/waivers),
federal mental health block grant, redirected institutional funds,
and funds allocated as a result of court decrees
Child Welfare
Title IV-B (family preservation), Title IV-B (foster care
services), Title IV-E (adoption assistance, training,
administration), and technical assistance and in-kind staff
resources
Juvenile Justice
Federal formula grant funds to states for juvenile justice
prevention, state juvenile justice appropriations, and juvenile
courts.
Education
Special education, general education, training, technical
assistance, and in-kind staff resources
Governor’s Office/Cabinet
Special children’s initiatives, often including interagency
blended funding
Social Services
Title XX funds and realigned welfare funds (TANF)
Bureau of Children with
Special Needs
Title V federal funds and state resources
Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising
practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.
35
Diversity of Federal Grant Sites Funding (continued)
SOURCE
SYSTEM
CMHS GRANT
State
Local
SITES FUNDINGDESCRIPTION
DIVERSITY
Health Department
State funds
Public Universities
In-kind support, partner in activities
Department of Children
In states where child mental health services
are the responsibility of child agency, not
mental health, sources of funds similar to
above
Vocational Rehabilitation
Federal- and state-supported employment
funds
Housing
Various sources
County, City, or Local
Township
General fund
Juvenile Justice
Locally controlled funds
Education
Courts, probation department, and community
corrections
County
May levy tax for specific purposes (mental
health)
Food Programs
In-kind donations of time and food
Health
Local health authority-controlled resources
Public Universities and
Community Colleges
Substance Abuse
In-kind support
Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s
mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.
36
Diversity of Federal Grant Sites Funding (continued)
SOURCE
Private
SYSTEM
DESCRIPTION
Third Party Reimbursement
Private insurance and family fees
Local Businesses
Donations and in-kind support
Foundations
Robert Wood Johnson, Annie E. Casey, Soros
Foundation, and various local foundations
Charitable
Lutheran Social Services, Catholic Charities, faith
organizations, homeless programs, and food
programs (in-kind)
Family Organizations
In-kind Support
Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care:
Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and
Practice.
37
Example: Diversified Funding Sources & Approaches
at the Parent Support Network, RI
CHILD
WELFARE
IVB FUNDS
STATE
APPROPRIATION
FUNDS
BEHAVIORAL
HEALTH
DEPARTMENT OF
EDUCATION
DISCRETIONARY
FUNDS
FEDERAL GRANTS
&
PRIVATE
DONATIONS
Administrative Infrastructure (4.0 FTE)
Executive Director, Assistant Director, Administrative Assistant, and Data and
Technology Specialist
Peer Mentor Program (3.25 FTE)
Information & Referral
Child & Family Teams
Education Planning
Support Groups/ Youth Speaking Out
Training
Family & Youth Leadership Program
(2.50 FTE)
System Reform Training & TA
Placement on Policy Boards
Focus Groups
Social Marketing/ Presentations
Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.
38
Examples of Medicaid Options States Use to Cover Evidence-Based and
Promising Community-Based Practices (1)
Medicaid Option
Advantages
Issues
Example
Rehabilitation
Services Option
•Flexibility to cover a
broad array of services and
supports provided in
different settings (e.g.,
home, school)
•Service definitions often
adult-oriented
•Provider-service mismacth
•OH – developing new
service definitions and
case rates for intensive
home-based services and
Multisystemic Therapy
Managed Care
Demos and
Waivers - 1115
and 1915 (b)
•Accountability and
management of cost
through risk
structuring/sharing
•Flexibility to cover wide
range of services and
populations
•Managed care not without
risks/challenges
•Federal waiver process can
be challenging
•Cost neutrality issues
•NM – covering
Multisystemic Therapy
•AZ – covering family
support and urgent
response for child
welfare
Home and
CommunityBased Waivers 1915 (c)
•Flexibility, broader
coverage, waiver of
income limits and
comparability
•Alternative to hospitallevel of care but PRTF (i.e.,
residential tx.) may be issue
•Cost and management
concerns/limited to small
number
•KS, NY, VT, IN, WI – have
HCBS Waivers
•AK, FL, GA, IN, KN, MD,
MS, MT, SC, VA – have
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
community alternatives
to psychiatric residential
treatment facilities
demonstration grant
39
Examples of Medicaid Options States Use to Cover Evidence-Based and
Promising Community-Based Practices (2)
Medicaid
Option
Advantages
Issues
Example
Early and
Periodic
Screening,
Diagnosis and
Treatment EPSDT
•Broadest entitlement
•Supports holistic
assessments and services
•No waiver or state plan
amendment requirements
•Management mechanism
critical because of cost
concerns
•Oriented more to physical
health in practice
•RH
•PA
Targeted Case
Management
•Can be targeted to high
need populations, such as
child welfare
•Supports small case load
focus (e.g., 1-10)
•Not sufficient without
other services
•Federal attention
•VT
•NY
Administrative
Case
Management
•Ability to cover basic case
management services to
support enrollment access
•Not sufficient without
other services
•NJ – covering
some activities of
family-run
organizations
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
40
Examples of Medicaid Options States Use to Cover Evidence-Based and
Promising Community-Based Practices (3)
Medicaid
Option
Advantages
Issues
Tax Equity and
Fiscal
Responsibility
Act of 1982
(TEFRA)
•Avenue to eligibility to
community-based services
for children who meet SSI
disability criteria – allows
disregard of family income
•SSI criteria not easy to
meet for children with SED
•Does not expand types of
covered services
•Cost issues, so generally
small program
•MN
•WI
Medicaid as
Part of a
Blended or
Braided
Funding
Approach
(without a
waiver)
•Holistic, integrated
(across systems) financing,
supports broad array of
services, natural supports
and individualized care
•Involves significant
restructuring
•Milwaukee
Wraparound
•DAWN Project
•Massachusetts
Mental Health
Services Program
for Youth
•New Jersey
Partnership
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
Example
41
Bottom Line
State Medicaid agencies are cobbling together a
variety of Medicaid options in attempt to cover and
contain community-based services for children and
families - often without involvement of other systems
serving children and families.
What is needed is a more integrated, strategic
financing approach across systems.
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
42
If you have answered the questions:
Financing For Whom?
Financing for What?
I.E.,
Identified your population(s) of focus
Agreed on underlying values and intended outcomes
Identified services/supports and practice model to achieve outcomes
Identified how services/supports will be organized
(so that all key stakeholders can draw the system design)
Identified the administrative/system infrastructure needed to support
the delivery system
Costed out your system of care
Then You Are Ready To
Talk About Financing!
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
43
Strategic Financing Analysis
1. Identify state and local agencies that spend dollars on the identified
population(s). (How much each agency is spending and types of
dollars being spent, e.g., federal, state, local, tribal, non-governmental)
2. Identify resources that are untapped or under-utilized (e.g., Medicaid).
3. Identify utilization patterns and expenditures associated with high
costs/poor outcomes, and strategies for re-direction.
4. Identify disparities and disproportionality in access to
services/supports, and strategies to address.
5. Identify the funding structures that will best support the system
design (e.g., blended or braided funding; risk-based financing; purchasing
collaboratives).
6. Identify short and long term financing strategies (e.g., Federal revenue
maximization; re-direction from restrictive levels of care; waiver; performance
incentives; legislative proposal; taxpayer referendum, etc.).
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
44
Example: Program Budget for a Neighborhood-Based System of Care
Cost
Categories
Proposed
Total
Costs
Neighborhood
Governance
Family
Leadership
Family
Service/
Support
Removal
of Barriers
Community
Organizing
School
Linkage
Tracking
&
Evaluating
Volunteers
Partnership
Building
Exec.
Direction
&Support
Salaries
446,000
21,000
29,000
190,000
21,000
26,000
35,000
15,000
30,000
18,000
63,000
Fringe
133,000
6,300
8,700
57,000
6,300
7,800
10,500
3,900
9,000
5,400
18,900
Building
Occupancy
93,600
8,700
12,300
36,800
2,400
4,300
4,000
2,500
4,300
2,500
15,800
Professional
Services
109,000
17,600
22,100
32,400
3,600
2,700
2,700
18.600
2,700
2,900
3,700
Travel
43,700
12,300
5,300
10,300
9,000
1,200
3,000
500
500
500
1,600
Equipment
6,000
600
600
600
600
600
600
600
600
600
600
Food
Services
25,000
0
4,000
1,000
18,000
0
1,000
0
1,000
0
0
Subcontract
89,000
0
0
89,000
0
0
0
0
0
0
0
Operating
Supplies &
Expenses
21,500
1,800
700
8,600
200
1,300
2,100
500
1,500
4,100
4,100
Other
(stipends,
transport,
child care)
84,000
0
40,000
9,000
35,000
0
0
0
0
0
0
Equipment
Lease
25,000
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
Property
25,000
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
Insurance
13,500
2,700
1,200
1,200
1,200
1,200
1,200
1,200
1,200
1,200
1,200
125,900
459,900
64,100
45,800
GRAND TOTALS: 1,115,100 80,000
84,300
51,100
55,300
Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.
36,800
45
113,900
Example: Program Budget for a Neighborhood-Based System of Care
(continued)
Proposed
Total
Costs
Neighborhood
Governance
Family
Leadership
Revenue
Totals
Across
Sources
Family
Service/
Support
Removal
of
Barriers
Community
Organizing
School
Linkage
Tracking
&
Evaluating
Volunteers
Partnership
Building
Exec.
Direction
&Support
Revenue Allocation By Program
Foundation
217,100
40,000
30,000
25,000
28,300
24,000
0
22,800
12,000
15,000
20,000
State Mental
Health &
Substance
Abuse
258,800
2,500
28,400
157,900
3,000
20,000
0
5,000
12,000
5,000
25,000
CountyChild
Welfare
124,900
20,000
30,000
30,000
10,000
5,000
0
3,000
12,000
2,000
12,900
Dept of
Education
70,100
2,500
1,600
0
0
0
60,000
0
0
0
6,000
State Family
Preservation
Grant
373,400
5,000
20,000
230,000
35,000
0
0
12,000
18,000
14,000
39,400
In-Kind
29,300
0
10,000
10,000
5,000
1,000
0
0
800
0
2,500
Donations
21,300
5,000
900
5,000
1,000
100
2,100
3,000
500
800
5,000
Other
Grants
20,200
5,000
900
5,000
1,000
100
2,100
3,000
0
0
3,100
GRAND
TOTALS
1,115,100
80,000
125,900
459,900
84,300
51,100
64,100
45,800
55,300
36,800
113,900
Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas
Family Center.
46
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 7.3
The “Matrix” from Oregon
How to Fund the Service Array and How to Process
Includes:
Client Related Expenditures
Resource Priorities
Payment Documents
Primer Hands On - Child Welfare (2007)
47