Building FASD State Systems

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Utilizing Mentoring Modeling to Improve
Services to Youth Through a Medicaid Waiver

• Building FASD State Systems
• May 13-14, 2009
• Presenters
• L. Diane Casto, MPA Barbara Knapp
• Alaska DHSS, Behavioral Health Alaska DHSS,
  Behavioral Health
• Dan Dubovsky, MSW Cheri Scott
• FASD Center for Excellence Stone Soup Group

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Alaskas FASD History

• Alaska Native Medical Center with IHS funding
  began early alcohol-use screening for all
  pregnant women using Alaska Native Health
  Services in mid-1980s.
• Established statewide advocacy and services for
  Alaska Native women and children to reduce and
  prevention FASDprogram eliminated in mid-1990s.
• 1997 Alaska Department of Health Social
  Services holds first Alaska FAS Summit.
• 1998 Alaska Office of Fetal Alcohol Syndrome
  established with 300,000 seed-money from AK
  Mental Health Trust.

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Alaskas FASD History

• Alaskas FASD Project4 primary outcomes
• Prevention of alcohol-exposed births
• Statewide system of community-based FASD
  Diagnostic Teamsimproved diagnostic services
• Quality system of services for individuals with a
  fetal alcohol spectrum disorder and their
  families
• Statewide FASD Surveillance System.
• October 2000 -- 29 million federal earmark to
  establish a statewide FASD system of services and
  program 5.8 million per year for 5 years

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Laying Foundation for FASD Waiver Project

• FASD diagnostic data provided clear picture of
  youth with co-occurring SED and FASD diagnoses.
• Able to document need for Medicaid Waiver for
  youth ages 14-21 at high risk for out-of-state
  placement in RPTC with SED and FASD.
• Applied for SED Medicaid Waiver Demonstration
  Project in 2007 awarded 1 of 10 Waiver grants.
• 5-year award to expend 10 million in existing
  Medicaid funds on waivered services.

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Select the project
• Locate a federal grant Request For Proposal (RFP)
• Pick a project no one else has tried
• Call a meeting
• Policy makers
• Program designers
• Computer software designers
• Regulations writers
• National experts on the subject
• Stakeholders

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Pick a population to serve
• Youth age 14-20 years old
• Meet level of care for Residential Psychiatric
  Treatment Center, and
• With known prenatal exposure to alcohol or a
  Fetal Alcohol Spectrum Disorder Diagnosis

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Make up new acronyms
• TIMS Treatment Intervention Mentors
• 3M Modeling, Mentoring, Monitoring
• RPTC Residential Psychiatric Treatment Center
• Define new services
• Mentor
• Training Consultative Services
• Community Transition
• Supported Employment

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Define Service Providers
• Collaborative ventures between two previously
• unrelated service providers
• Home and Community Based Agencies
• Community Mental Health Centers

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Home and Community Based Service (HCB) Agencies
• Traditional Medicaid Waiver Service Providers
• Habilitation
• group home
• foster home
• day habilitation
• Supported employment services
• Hourly daily respite
• Community Transition services

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Community Mental Health Centers (CMHC)
• All HCB Agency services CMHC services
• Individual Group Skill Development
• Case Management
• Training Consultative Services

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An Alaskan Alternative to Residential Psychiatric
Treatment

• The ResultA Program Like No Other
• Alaskas 3M Project Modeling, Mentoring,
  Monitoring
• Unique person centered plan for each youth
• who still receives Mental Health services and
  Medicaid health care services - - -
• All this and Wraparound Services, too

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Pivotal role Mentor
• A person chosen by the family who works under the
  direction of the Mental Health Agency providing
  the regular mental health services.
• The mentor models positive behaviors and spends
  quality, one to one time with the youth.
• Also, reviews the effectiveness of the services
  and family supports, can connect family
  providers to specialized trainers consultants
  to assist family, school providers of other
  services.

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Stumbling blocks- Agencies
• Mental Health Agencies are often unfamiliar with
  how Medicaid works fee for service vs. prior
  authorization for services
• HCB Agencies - not getting a large enough share
  of the service to make it worth while
• Youth in RPTCs often out of State have to be
  released before they stop meeting Level Of Care
  (LOC) for RPTC.
• Easier to find clients close to age 18
• Harder to find younger 14-18 year olds, who could
  stay with the program longer.

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An Alaskan Alternative to Residential Psychiatric
Treatment

• Trouble points - Agencies
• Finding mentors starting out with activity
  therapists with Mental Health Agency
• Finding out-of-home placements FASD group homes
• Community placements may never have been in
  RPTC
• Getting psychological evaluations done and
  reports back in a timely manner
• Using psychiatric hospital staff
• Pioneering telemedicine for Mental Health
  clinical services

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An Alaskan Alternative to Residential Psychiatric
Treatment

• More stumbling blocks
• Unable to identify mentor
• Family wants youth in out-of-home placement but
  agency has no empty beds
• Workforce development issues

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An Alaskan Alternative to Residential Psychiatric
Treatment

• 3M Training
• Original training in 3M Model
• Started with 2x year large, week long training
• Agencies cant release staff that long
• New training model
• Moved to on-line training for FASD 101 and Core
  training
• Webinar follow up training (4 times/year)
• Bring training to the community providers train
  staff,
• do Level of Care sign off on plans on same day

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Why the 3-M Model?

• Individuals with an FASD often learn most by
  modeling the behavior of those around them
• Individuals with an FASD do better having a
  one-to-one person with them
• A mentoring type approach has been shown to be
  very effective in the prevention of FASD
• Mentoring for persons with an FASD is beginning
  to be tested
• Relationships are key to positive outcomes
• Monitoring and evaluation are an essential
  component to ensure continuation

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What is Mentoring?

• A form of teaching that includes walking
  alongside the person and inviting him or her to
  learn from your example
• Participating in activities with the person
  rather than connecting the person with activities
  and then giving the person the responsibility to
  follow through (as is typical with case
  management)
• Pointing out misinterpretations of words,
  actions, and body movements when they occur

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What is Mentoring?

• Providing advice, counsel, guidance, and
  one-to-one encouragement
• Helping the person become aware of, and engage
  in, opportunities
• Identifying strengths in the individual and
  family and building on those strengths

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What is Mentoring?

• Helping improve a persons feeling about him or
  herself (self-esteem)
• Increasing a persons competence in various areas
• Forming a positive relationship with the person
• Respect
• Caring
• No eject
• A therapeutic approach but not a clinical service

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Mentoring Is Not

• Typical case management
• Therapy
• Respite
• Guardianship
• Guarding
• A mentor is not a warden

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What is Modeling?

• The activity of recreating the steps of an
  activity so the person can mimic them
• Shaping or molding by demonstrating the best way
  to do something in a variety of situations
• An activity
• An emotion
• A method of expressing an emotion

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Modeling Is Not

• Telling someone what to do
• Once and done
• Do as I say
• Just do it

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What is Monitoring?

• Review and evaluation of specific aspects of an
  activity or program to include
• Measuring performance
• Assessing adherence to regulations, structure,
  and terms of the program
• Assessing progress
• Of the individual and family
• Of the program
• Of the approach
• Providing technical assistance as needed

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What is Monitoring?

• A key to the ability to examine whether a program
  or approach produces positive outcomes
• An ongoing process
• Begins with gathering baseline data
• Continues with gathering data on an ongoing basis
• Data gathered is analyzed for change and trends

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Monitoring Is Not

• Checking in with a person once in awhile
• Vague reports of work being accomplished
• A generalized overview of what has occurred
• Documenting events long after their occurrence

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Treatment and Intervention Mentor (TIM) Role

• Is
• Mentor
• Role model
• Coach
• Cheerleader
• For youth and family
• Is not
• Sitter
• Disciplinarian
• Spy for the family
• Reward for good behavior

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Caregiver Perspective Past experiences with
behavioral health system

• Few or no support services available until youth
  in full blown crisis
• Services not available in home community
• Caregivers had limited understanding of
  screening, placement decision making process
• Limited effective treatment options for youth
  with FASD once placed in treatment setting
• Difficulty getting proper diagnosis

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Caregiver Perspective Past experiences with
behavioral health system

• Few treatment staff understood FASD
• Limited contact with youth after placement
• Limited training of caregivers to provide needed
  structure after discharge home
• No contact with treatment staff after discharge
• Few services available in home community after
  discharge
• Damaged trust

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Caregiver Perspective Present Hopes

• Triage team works with family, educating about
  options, process
• Increased awareness of impact of FASD on all
  facets of treatment
• Continually expanding interest in staff training
  and consultation across state
• Caregivers at table in BTKH and Waiver planning

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Caregiver Perspective Present Hopes

• Agencies exploring innovative, alternative
  approaches to meet needs of youth with FASD
• Caregivers and youth able to access training and
  peer support more easily
• Wrap-Around Model

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Caregiver Perspective Dreams for the future

• Early and accurate diagnosis available statewide
• Supports available at first signs of difficulty
• Supports always address strengths of the youth
  and family family-centered care
• Services provided in home community or at least
  in region no leaving the state
• Services continue into adulthood seamlessly

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And the Demonstration Continues

• Project has 3 more years of demonstration
  project status
• Data collection and evaluation of effectiveness
  will determine permanent status of the Medicaid
  Waiver
• Alaska only state focusing on youth with
  co-occurring SED-FASDproject has the potential
  to establish an evidence-based model of
  intervention for this high-risk population this
  project is a great opportunity to establish a new
  way of serving this population.

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For More Information

• Barbara Knapp, Project Director
• Alaska DHSS, Division of Behavioral Health
• 3601 C St, Ste 878Anchorage, AK 99503-5935
• barbara.knapp_at_alaska.gov
• 907-269-3609