American Public Human Service Association Medicaid

1
American Public Human Service AssociationMedicaid
Mental Health Services How Wraparound
Milwaukee Used Medicaid Other Resources in the
Re-Design of theChildrens Mental Health System

• Bruce Kamradt, MSW
• Director Wraparound Milwaukee
• Bkamrad_at_wrapmilw.org

Washington, D.C. March 16, 2008
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Strategies/Approaches Used in Milwaukee County to
Re-Design System of Care for Children with
Serious Emotional/Mental Health Needs

• System of care re-design really began in 1995
  with Comprehensive System of Care Grant from CMHS
• Focus was developing alternatives to
  institutional care for children with SED
• Residential treatment
• Psychiatric hospitalization
• Juvenile correctional placement
• Too costly and poor outcomes
• Political motivation high costs were impacting
  on need for tax levy funds to cover deficits
• For Medicaid, there was proliferation of
  inpatient psychiatric facilities for children

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Challenges to Funding a Re-Design of the System
for These SED Youth Families

• Limited array of alternative community programs
  because most of system funds system orientation
  was spent on institutional care
• No current management model for designing an
  alternative system
• Care coordination/case manager
• No administrative structure care management or
  managed care organization model
• More than one source of funding was involved in
  funding services ie child welfare, juvenile
  justice, mental health, medicaid, education, etc.
  and no single child serving agency had sufficient
  resources
• Funding tended to be siloed and very inflexible
  in how it could be used

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Challenges to Funding a Re-Design of the System
for These SED Youth Families contd

• Agencies had little experience and orientation
  toward funding services based on achieving
  measurable outcomes
• No shared values across child serving systems as
  to what a system of care should be about ie
  individualized, strength-based, family-focused,
  coordinated etc.
• Limitations of information systems and exchange
  of data
• Medicaid funding was limited to fee-for-service
  options in existing state plan

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Wraparound Milwaukee Model

• Public managed care model organized developed
  by the public mental health system
• Wraparound Milwaukee performs programmatic
  business function

• Care coordination
• Mobile crisis
• Provider network
• Family organization
• Medical oversight
• Training education

• Finance
• Information technology
• Quality Assurance/Quality Improvement
• Utilization Review
• Evaluation

• Pooled Funding Model
• Partnership with other child serving agencies
  through contracts and MOUs
• Milwaukee contracts with state division of health
  care financing as a special managed care entity

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Wraparound Milwaukee Today

• Wraparound Milwaukee - 38 million
• 640 SED children at risk of residential
  treatment, correctional care, hospitalization
  involved in child welfare and juvenile justice
• REACH - 3.8 million
• 200 SED children, non-court involved referred
  mainly through school system
• Mental Health Mobile Crisis Teams - 2 million
• Child Welfare
• Milwaukee Public Schools
• All Milwaukee Families
• 1500 Children
• Family Intervention Support Services - 600,000
• Alternative to court for youth/families with
  parent/child conflicts
• 200 children

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Funding Strategies Used to Pool Funds in
Milwaukee County

• Mental Health/Medicaid
• HMO type contract with state Medicaid agency
  using capitated rate
• Fee-for-service billing for crisis intervention
• Child Welfare
• Case rate funding for Wraparound enrollees at
  risk of residential treatment and for FISS early
  intervention program
• Fixed contract for Mobile Crisis
• Process information for 4-E collection
• Juvenile Court
• Fixed annual budget for SED delinquent youth at
  risk of residential
• Case rate for alternative to correction
• Education
• Fixed funding for Mobile Urgent Treatment Team
• Grant funding
• In-kind contribution

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What are Pooled Funds?
CHILD WELFARE
JUVENILE JUSTICE
MEDICAID CAPITATION
MENTAL HEALTH
Funds thru Case Rate
(Funds Budgeted for
(1661 per Month per Enrollee)
CRISIS BILLING
(Budget for Institutional
Residential Treatment and

BLOCK GRANT
Care for Chips Children)
Juvenile Corrections Placements

HMO COMMERCIAL INSUR
9.5
10.5 M
11.5 M
6.5 M
WRAPAROUND MILWAUKEE
CARE MANAGEMENT ORGANIZATION
(CMO)
38.0M
CARE COORDINATION
PROVIDER NETWORK 210 Providers 80 Services
CHILD
AND FAMILY
TEAM
PLAN
OF
CARE
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What Has Been Accomplished in Wraparound Milwaukee

• Reduction in average number of youth in
  residential treatment (Delinquent Child
  Welfare) from 375 youth to 80 youth
• Reduction in utilization of inpatient psychiatric
  hospitalization from 5000 days to 150 days per
  year
• Closure of countys inpatient psychiatric
  hospital for children
• Average cost of care of Wraparound youth was
  3980 per month in 2007 versus 7600 per month
  for residential placement
• Reduction in juvenile correctional commitment
  40
• Improved clinical functioning based on CBCL and
  other instruments

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What Has Been Accomplished in Wraparound
Milwaukee contd

• Reduction in delinquency recidivism rates for
  youth in Wraparound Milwaukee Program
• Juvenile sex offenders have most significant
  reduction
• Improved school attendance
• Higher level of permanency for youth in
  Wraparound 86 achieve permanency
• Reduction in failed foster placement for youth
  seen by Mobile Urgent Treatment Team

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Current Challenges with Medicaid Funding for
Systems of Care

• Targeted Case Management Restrictions
• Limitations on Child Welfare Juvenile Justice
  billing for TCM
• No individual may have more than one case
  management
• Cannot be other third party coverage
• Education activities for IDEA not covered
• Reducing federal contribution
• Restriction in Rehabilitation Services
• Restriction in MA billing for therapeutic foster
  care
• School-based Administration and Transportation
  Costs Prohibited with Respect to IDEA costs
• Medicaid State Plan Option 1915(i)
• Alternative to restrictions of rehab services
  changes