THE SKILL BUILDING CURRICULUM

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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 Childrens Mental Health University of
South Florida, Tampa, FL Lisa Conlan Federation
of Families for Childrens Mental
Health Washington, D.C.
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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
Childrens Mental Health, University of South
Florida, Tampa, FL
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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.
4
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.
5
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

• 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
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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
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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)
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Dawn Services Supports
2005 CHIOCES, Inc., Indianapolis, IN
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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
California Evidence-Based Clearinghouse at
http//www.cachildwelfareclearinghouse.org
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Examples of Other Services Youd 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.
11
Examples of What You Dont 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.
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Examples from Hawaiis List of Evidence Based
Practices
HA Dept. of Health, Child Adolescent Division
(2005). Available from http//www.hawaii.gov/heal
th/mentalhealth/camhd
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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)
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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.
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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.
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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.
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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.
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Service Array Focused on a Total Population
Universal Targeted
Core Services Prevention 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.
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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-discrimina
  tory 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
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Families and Youth Provide Valuable Services and
Supports

• As technical assistance providers consultants
• Training
• Evaluation
• Research
• Support
• Outreach

• As direct service providers
• Foster Parents
• Mentors
• Service Coordinators
• Family Educators
• Specific Program Managers (respite, etc)

Adapted from Wells, C. (2004). Primer Hands On
for Family Organizations. Human Service
Collaborative Washington, D.C.
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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.
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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
  community-based
• 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.
23
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,
  Governors Office, State Insurance Commissioner)

Pires, S. 2005. Building systems of care..Human
Service Collaborative. Washington, D.C.
24
Examples of Sources of Funding for Children/Youth
with Individualized Needs in the Public Sector

• Education
• ED General Revenue
• ED Medicaid Match
• Student Services

• 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

• Mental Health
• MH General Revenue
• MH Medicaid Match
• MH Block Grant

• Other
• TANF
• Childrens Medical Services/Title V Maternal and
  Child Health
• Mental Retardation/ Developmental Disabilities
• Title XXI-State Childrens Health Insurance
  Program (SCHIP)
• Vocational Rehabilitation
• Supplemental Security Income (SSI)
• Local Funds

• 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 funding
for children families in the public sector.
Washington, DC Human Service Collaborative.
25
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.
26
Advantages and Drawbacks of Specific Child
Welfare Financing Streams
Pires, S. (2006). Primer Hands On Child
Welfare. Washington, D.C. Human Service
Collaborative.
27
Creating Win-Win Scenarios
Child Welfare
Medicaid
Alternative to out-of-home care high costs/poor
outcomes
Alternative to Inpatient/Emergency Room-high cost
System of Care
Alternative to detention-high cost/poor outcomes
Alternative to out-of-school placements high
cost
Juvenile Justice
Special Education
Pires, S. (2006). Primer Hands On Child
Welfare. Washington, D.C. Human Service
Collaborative.
28
Thinking Across Systems Serving Children, Youth
and Families
Pires, S. (2006). Primer Hands On Child
Welfare. Washington, D.C. Human Service
Collaborative.
29
Financing Strategies to Support Improved
Outcomes for Children, Youth and Families
FIRST PRINCIPLE System Design Drives
Financing
Friedman, M. (1995). Financing strategies to
support improved outcomes for children.
Washington, DC Center for the Study of Social
Policy.
30
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)
MEDICAID CAPITATION (1557 per month per enrollee)

• MENTAL HEALTH
• Crisis Billing
• Block Grant
• HMO Commercial Insurance

9.5M
8.5M
10M
2.0M
Wraparound Milwaukee Management Service
Organization (MSO) 30M
Per Participant Case Rate
Provider Network 240 Providers 85 Services
Care Coordination
Child and Family Team
Plan of Care
Wraparound Milwaukee. (2002). What are the pooled
funds? Milwaukee, WI Milwaukee Count Mental
Health Division, Child and Adolescent Services
Branch.
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Example Pooled Funds for Nebraskas 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
32
Financing Cuyahoga County (Cleveland)
System of Care Oversight Committee
County Administrative Services Organization
FCFC Fast/ABC Residential Treatment Center
Therapeutic Foster Care Unruly/shelter
care Tapestry SCY
State Early Intervention and Family Preservation


System of Care Grants
Neighborhood Collaboratives Lead Provider
Agency Partnerships
Reinvestment of savings
Community Providers and Natural Helping Networks
Pires, S. (2006). Primer Hands On Child
Welfare. Washington, D.C. Human Service
Collaborative.
33
Example of Redirecting Funds
Youth who are at-risk of entering a RTC
Medicaid Federal and State (MHS Match
DHR and DJS
Mental Hygiene Block Money
Youth referred to a local management entity



At risk pool is created for the local management
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.
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
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
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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.
35
Diversity of Federal Grant Sites Funding
Koyanagi, C. Feres-Merchant, D. (2000). For the
long haul Maintaining systems of care beyond the
federal investment. Systems of care Promising
practices in childrens mental health, 3.
Washington, DC American Institutes for Research,
Center for Effective Collaboration and Practice.
36
Diversity of Federal Grant Sites Funding
(continued)
CMHS GRANT SITES FUNDING DIVERSITY
Koyanagi, C. Feres-Merchant, D. (2000). For the
long haul Maintaining systems of care beyond the
federal investment. Systems of care Promising
practices in childrens mental health, 3.
Washington, DC American Institutes for Research,
Center for Effective Collaboration and Practice.
37
Diversity of Federal Grant Sites Funding
(continued)
Koyanagi, C. Feres-Merchant, D. (2000). For the
long haul Maintaining systems of care beyond the
federal investment. Systems of care Promising
practices in childrens mental health, 3.
Washington, DC American Institutes for Research,
Center for Effective Collaboration and Practice.
38
Example Diversified Funding Sources Approaches
at the Parent Support Network, RI
STATE APPROPRIATION FUNDS BEHAVIORAL HEALTH
CHILD WELFARE IVB FUNDS
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.
39
Examples of Medicaid Options States Use to Cover
Evidence-Based and Promising Community-Based
Practices (1)
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 (2)
Pires, S. 2005. Building systems of care. Human
Service Collaborative. Washington, D.C.
41
Examples of Medicaid Options States Use to Cover
Evidence-Based and Promising Community-Based
Practices (3)
Pires, S. 2005. Building systems of care. Human
Service Collaborative. Washington, D.C.
42
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.
43
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.
44
Strategic Financing Analysis

• 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)
• Identify resources that are untapped or
  under-utilized (e.g., Medicaid).
• Identify utilization patterns and expenditures
  associated with high costs/poor outcomes, and
  strategies for re-direction.
• Identify disparities and disproportionality in
  access to services/supports, and strategies to
  address.
• Identify the funding structures that will best
  support the system design (e.g., blended or
  braided funding risk-based financing purchasing
  collaboratives).
• 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.
45
Example Program Budget for a Neighborhood-Based
System of Care
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
Example Program Budget for a Neighborhood-Based
System of Care (continued)
Revenue Allocation By Program
Pires, S. (2002). Building systems of care A
primer. Human Service Collaborative Washington,
D.C. Adapted from Abriendo Puertas Family Center.
47
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)