FINANCING TREATMENT FOSTER CARE

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FINANCING TREATMENT FOSTER CARE WITHIN A SYSTEM
OF CARE Sheila A. Pires Human Service
Collaborative Washington, D.C. Foster
Family-Based Treatment Association 17th Annual
Conference Universal City, CA July 20, 2003
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AGENDA - MORNING
930-945 Introduction and Overview of
Institute 945-1030 Systems of
Care Definition History and Current
Status Values, Principles, Operational
Characteristics 1030-1045 Question/Discussion
Who is or has been involved in systems of
care? Based on your experience, what are the
opportunities and challenges for treatment
foster care within systems of care?

1045-1100 Evidence-Based Practices in
Systems of Care 1100-1115 Question/Discussion
Who is implementing evidence-based practices?
What are the challenges and strengths of
the evidence-based practices you are
implementing? 1115-1130
Break 1130-1230 Financing Treatment Foster Care
Within Systems of Care
Examples of federal, state, and
local funding streams Other funding
possibilities Financing strategies 1230-130 L
unch Break
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AGENDA - AFTERNOON
130-215 Examples of State and Local Systems of
Care Financing
Treatment Foster Care 215-300 Question/Discussio
n What are the funding streams you
are using to finance treatment foster care?
What are the strengths and challenges of
these particular financing streams (e.g.,
Medicaid, IV-E)? 300-315 Break 315-330 Purchas
ing/Contracting Issues 330-400 Question/Discussi
on What contracting mechanisms are you using?
What are the pros and cons of these particular
contracting mechanisms (e.g., case rate, fixed
price, performance-based)? 400-420 Family/Youth
Partnerships Trigger Mechanisms for
Change Strategically Managing Complex
Change 420-430 Wrap Up
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INSTITUTE OBJECTIVES

• Define systems of care for children and
  adolescents with emotional/behavioral needs and
  their families
• Describe the history and current status of
  systems of care
• Review values, principles, and operational
  characteristics of systems of care
• Explore place of evidence-based practices within
  systems of care
• Describe implications of systems of care for
  treatment foster care
• Describe financing options for treatment foster
  care within a system of care
• Provide examples of state and local systems of
  care that finance treatment foster care
• Explore advantages and challenges of various
  financing and contracting mechanisms for
  treatment foster care
• Discuss importance of strategic partnerships for
  program integrity and sustainability,
  particularly with families/youth

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To Obtain Copies of Building Systems of Care A
Primer Contact Mary Moreland, Publications
Manager Georgetown University National Technical
Assistance Center for Childrens Mental
Health 202 687-8803 E-mail deaconm_at_georgetown.edu
For Further Information About the Primer,
Contact Sheila A. Pires Human Service
Collaborative 202 333-1892 E-mail sapires_at_aol.com
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DEFINITION OF A SYSTEM OF CARE
A system of care incorporates a broad array of
services and supports that is organized into a
coordinated network, integrates care planning and
management across multiple levels, is culturally
and linguistically competent, and builds
meaningful partnerships with families and youth
at service delivery, management, and policy
levels.
Pires, S. 2002. Building systems of care A
primer. Washington, D.C. Human Service
Collaborative
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SYSTEM OF CARE FRAMEWORK
Stroul, B., Friedman, R. (1986). A system of
care for children and youth with severe emotional
disturbances (Rev. ed.) Washington, DC
Georgetown University Child Development Center,
National Technical Assistance Center for
Childrens Mental Health. Reprinted by permission.
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• Lack of home and community-based services and
  supports
• Patterns of utilization
• Cost
• Administrative inefficiencies
• Knowledge, skills and attitudes of key
  stakeholders
• Poor outcomes

Current Systems Problems Pires, S.
(1996). Human Service Collaborative, Washington,
D.C.
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NATIONAL SYSTEM OF CARE ACTIVITY

• CASSP systems of care for children with sed
• RWJ MHSPY systems of care for children with sed
• CASEY MHI systems of care for inner city
  children
• CMHS GRANTS systems of care for children with
  serious emotional/behavioral disorders
• CSAT GRANTS systems of care for adolescents
  with substance abuse problems
• ACF GRANTS systems of care for children
  involved in the child welfare system
• CMS GRANTS home and community based systems of
  care for youth in residential treatment
• PRESIDENTS NEW FREEDOM MENTAL HEALTH COMMISSION
  home and community based systems of care

Pires, S. 2002 Building systems of care A
primer. Washington, D.C. Human Service
Collaborative
10
FEDERAL WEBSITES AND TECHNICAL ASISTANCE CENTERS

• WWW.SAMHSA.GOV
• WWW.CMS.GOV
• WWW.ACF.DHHS.GOV.
• WWW.GUCDC.GEORGETOWN.EDU
• WWW.AIR.ORG/TAPARTNERSHIP
• WWW.FFFCMH.ORG

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Values and Principles for the System of Care

• Core Values
• 1. The system of care should be child centered
  and family focused, with the needs of the child
  and family dictating the types and mix of
  services provided.
• 2. The system of care should be community based,
  with the locus of services as well as management
  and decision-making responsibility resting at the
  community level.
• 3. The system of care should be culturally
  competent, with agencies, programs, and services
  that are responsive to the cultural, racial, and
  ethnic differences of the populations they serve.

Stroul, B., Friedman, R. (1986). A system of
care for children and youth with severe emotional
disturbances (Rev. ed.) Washington, DC
Georgetown University Child Development Center,
National Technical Assistance Center for
Children's Mental Health. Reprinted by permission.
12
Values and Principles for the System of Care

• Children with emotional disturbances should have
  access to a
• comprehensive array of services that address
  their physical, emotional,
• social, and educational needs.
• Children with emotional disturbances should
  receive individualized
• services in accordance with the unique needs and
  potentials of each child
• and guided by an individualized service plan.
• Children with emotional disturbances should
  receive services within the
• least restrictive, most normative environment
  that is clinically appropriate.
• The families and surrogate families of children
  with emotional
• disturbances should be full participants in all
  aspects of the planning
• and delivery of services.
• Children with emotional disturbances should
  receive services that
• are integrated, with linkages between
  child-serving agencies and programs
• and mechanisms for planning, developing, and
  coordinating services.

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Values and Principles for the System of Care

• Children with emotional disturbances should be
  provided with
• case management or similar mechanisms to ensure
  that multiple services are
• delivered in a coordinated and therapeutic manner
  and that they can move
• through the system of services in accordance with
  their changing needs.
• Early identification and intervention for
  children with emotional
• disturbances should be promoted by the system of
  care in order to enhance
• the likelihood of positive outcomes.
• Children with emotional disturbances should be
  ensured smooth transitions
• to the adult services system as they reach
  maturity.
• The rights of children with emotional
  disturbances should be protected,
• and effective advocacy efforts for children and
  adolescents with emotional
• disturbances should be promoted.
• Children with emotional disturbances should
  receive services without regard
• to race, religion, national origin, sex, physical
  disability, or other characteristics
• and services should be sensitive and responsive
  to cultural differences
• and special needs.

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System of Care Specific, Defined Approach to
Customizing Care for Children with
Emotional/Behavioral Disorders and Their
Families-Operational Characteristics

• Characteristics
• Collaboration across agencies
• Partnership with families
• Cultural and linguistic competence
• Blended, braided, or coordinated financing
• Shared governance across systems
• and with families
• Shared outcomes across systems
• Organized pathway to services and supports
• Interagency/family services planning teams
• Interagency/family services monitoring teams
• Single plan of care
• One accountable care manager

• Cross-agency care coordination
• Individualized service/supports
• "wrapped around" child and family
• Home- and community-based
• alternatives
• Broad, flexible array of services
• and supports
• Integration of clinical treatment
• services and natural supports,
• linkage to community resources
• Integration of evidence-based
• treatment approaches
• Cross-agency MIS

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Characteristics of Systems of Care as Systems
Reform Initiatives
FROM Fragmented service delivery Categorical
programs/funding Limited services Reactive,
crisis-oriented Focus on deep end, restrictive
Children out-of-home Centralized
authority Creation of dependency
TO Coordinated service delivery Blended
resources Comprehensive service array Focus on
prevention/early intervention Least restrictive
settings Children within families Community-based
ownership Creation of self-help
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Control by professionals Partnerships
with families Only professional services
Partnership between
natural and professional
supports and
services Multiple case managers One
service coordinator Multiple service plans for
child Single plan for child and
family Family blaming Family
partnerships Deficits Strengths Mono
Cultural Cultural Competence
Frontline Practice ShiftsOrrego, M.
E. Lazear, K. J. (1998) EQUIPO Working as
Partners to Strengthen Our Community
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Categorical vs. Non-Categorical System Reforms
Categorical System Reforms
Non-Categorical Reforms
Pires, S. (2001). Categorical vs. non-categorical
system reforms. Washington, DC Human Service
Collaborative.
Pires, S. (2001). Categorical vs. non-categorical
system reforms. Washington, DC Human Service
Collaborative.
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The Total Population of Children and Families
Who Depend on Public Systems

• Children and families eligible for Medicaid
• Children and families eligible for the State
  Children's Health
• Insurance Program (SCHIP)
• Poor and uninsured children and families who do
  not qualify
• for Medicaid or SCHIP
• Families who are not poor or uninsured but who
  exhaust their private
• insurance, often because they have a child with a
  serious disorder
• Families who are not poor or uninsured and who
  may not yet
• have exhausted their private insurance but who
  need a particular type
• of service not available through their private
  insurer and only
• available from the public sector.

Pires, S. (1997). The total population of
children and families who depend on public
systems. Washington, DC Human Service
Collaborative.
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Local OwnershipState Commitment
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Contracted System Management Structure
Pires, S. (1996). Contracted system management
structure. Washington, DC Human Service
Collaborative.
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IN-HOUSE SYSTEM MANAGEMENT STRUCTURE
Pires, S. (1996). In-house system management
structure. Washington, DC Human Service
Collaborative.
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CONVERGING TRENDS
Pires, S. 2003. Building systems of care A
primer. Washington, D.C. Human Srevice
Collaborative
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Types of Services in Systems of Care

• Assessment and diagnosis
• Outpatient psychotherapy
• Medical management
• Home-based services
• Day treatment/partial hospitalization
• Crisis services
• Behavioral aide services
• Therapeutic foster care
• Therapeutic group homes
• Residential treatment centers

• Crisis residential services
• Inpatient hospital services
• Case management services
• School-based services
• Respite services
• Wraparound services
• Family support/education
• Transportation
• Mental health consultation
• Other, specify

Stroul, B.A., Pires, S.A., Armstrong, M.I.
(2001). Health care reform tracking project
Tracking state managed care reforms as they
affect children and adolescents with behavioral
health disorders and their families-2000 State
Survey. Tampa University of South Florida, Louis
de la Parte Florida Mental Health Institute,
Research and Training Center for Childrens
Mental Health, Department of Child and Family
Studies, Division of State and Local Support.
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EFFICACY OF SERVICES(Barbara Burns Research at
Duke University)

• Most evidence of efficacy Intensive case
  management,
• in-home services, therapeutic foster care
• Weaker 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

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SHARED CHARACTERISTICS OF EVIDENCE-BASED INTERVENT
IONS

• They function as service components within
  systems of care
• They are provided in the community
• They utilize natural supports, parents, with
  training and
• supervision provided by those with formal mental
  health training
• They operate under the auspices of all
  child-serving systems, not
• just mental health
• They were studied in the field with real world
  children and families
• They are less expensive than institutional care
  (when the full
• continuum is in place)

Burns, B. and Hoagwood, K. 2002. Community
treatment for youth. New York Oxford University
Press
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THE CURRENT NEED IS FOR BUILDING EFFICACIOUS
TREATMENT INTERVENTIONS WITHIN EFFECTIVE,
COMPASSIONATE, AND COMPETENT SYSTEMS OF CARE
Peter Jensen, M.D. Building Community Treatment
for Youth
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Examples of Sources of Behavioral Health Funding
for Children and Families in the Public Sector

• Medicaid
• Medicaid In-Patient
• Medicaid Outpatient
• Medicaid Rehabilitation Services
• Medicaid Early Periodic Screening, Diagnosis and
  Treatment (EPSDT)

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

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

• Child Welfare
• CW General Revenue
• CW Medicaid Match
• IV-E (Foster Care and Adoption Assistance)
• IV-B (Child Welfare Services)
• Family Preservation/Family Support

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

• 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.
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Where to Look for Money and Other Types of Support
Pires, S. (994). Where to look for money and
other types of support. Washington, DC human
Service Collaborative.
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Financing Strategies to Support Improved Outcomes
for Children

• FIRST PRINCIPLE
• Program 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)

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Financing Strategies to Support Improved Outcomes

• RAISING OTHER REVENUE TO SUPPORT FAMILIES AND
• CHILDREN
• Donations
• Special Taxes and Taxing Districts for Children
• Fees and 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.
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CMHS GRANT SITES FUNDING DIVERSITY
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CMHS GRANT SITES FUNDING DIVERSITY
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CMHS GRANT SITES FUNDNG 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.
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What Are the Pooled Funds?
Wraparound Milwaukee. (2002). What are the pooled
funds? Milwaukee, WI Milwaukee Count Mental
Health Division, Child and Adolescent Services
Branch.
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DAWN Project Indianapolis, IN
How Dawn Project is Funded
Dawn Project Cost Allocation
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MA-MHSPY Cambridge-Somerville, MA
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NJ Childrens System of Care Initiative
Other
School Referral
Family Self
CHILD
Child Welfare
JJC Court
Community Agencies
Screening with Uniform Protocols

• Contracted
• Systems
• Administrator CSA
• Registration
• Screening for self-referrals
• Tracking
• Assessment of Level of Care Needed
• Care Coordination
• Authorization of Services

• Community
• Agencies
• Uncomplicated Care
• Service Authorized
• Service Delivered

• CMO
• Complex Multi-System
• Children
• ISP Developed
• Full Plan of Care
• Authorized

FSO Family to Family Support
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Risk-Based Contracting Arrangement
Pires, S. (1999). El paso county, colorado
risk-based contracting arrangement. Washington,
DC Human Service Collaborative.
39
Finance the art of passing currency from hand to
hand until it finally disappears.

Robert W. Sarnoff, son of David Sarnoff and head
of NBC
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PURCHASING/CONTRACTING OPTIONS

• Pre-Approved Provider Lists
• Choice for families
• Flexibility for system of care
• Could disadvantage small indigenous providers
• Could create overload on some providers
• Risk-Based Contracts
• Flexibility for providers
• Individualized care for families
• Potential for under-service
• Potential for overpaying for services
• Fixed Price/Service Contracts
• Predictability and stability for providers
• Inflexible-families have to fit what is
  available

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative
41
LEVEL STRUCTURE Policy At least 51 vote on
governing bodies As members of teams to
write and review RFPs and contracts As
members of system design workgroups and
advisory boards Management As part of quality
improvement processes As evaluators of system
performance As trainers in training
activities As advisors to selecting
personnel Services As members of team for
own children As family support workers, care
managers, peer mentors, system navigators for
other families
How Systems of Care are Structuring Family
Involvement at Various Levels of the System
Pires, S. (1996). Human Service
Collaborative, Washington, D.C.
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CATALYST/TRIGGER MECHANISMS

• Legislative Mandates (new or existing)
• Study Findings (needs assessments, research, or
  evaluation)
• Judicial Decisions-Class Actions Suits
• Charismatic/Powerful Leader
• Outside Funding Sources (federal, foundations)
• Funding Changes
• Local Scandals and Other Tragedies
• Coverage of Successes

Pires, S. (1996). Catalyst/trigger mechanisms.
Washington, DC Human Service Collaborative.
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STRATEGICALLY MANAGING COMPLEX CHANGE
Human Service Collaborative. (1996). Building
local systems of care Strategically managing
complex change. Adapted from T. Knosler (1991),
TASH Presentations. Washington DC.
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The measure of success is not whether you have a
tough problem to deal with, but whether its the
same problem you had last year.
John Foster Dulles