Residential Care: Another Perspective

1. Residential Care: Another Perspective Normer Adams, Executive Director Georgia Association of Homes and Services for Children March 9, 2007

2. Residential Care: Another Perspective Subtitles: • The Feds have the Power • The Given Reason and the Real Reason • Your sins will find you out. • The Assault on Residential Care

3. The Assault on Residential Care • 1980 – AACWA- Adoptive Assistance and Child Welfare Act mandated the “least restrictive setting” and “reasonable efforts” made to reunite with families. • System driven by failure • Rigid Service system • Misunderstanding of Residential Care • Unrealistic Expectations of families

4. The Assault on Residential Care • Child and Family Services Review by HHS • Premiums on shorten lengths of stays • Rigid expectations of families • Residential Care is “care of last resort” regardless of appropriateness of care

5. The Assault on Residential Care • Centers for Medicare and Medicaid Services • Balanced Budget Act of 1997 and 2001 • Driven by Budget Reform • Escalating Costs

6. The Georgia Perspective • The Rumors Spread • Georgia Hit Early by CMS • Colorado First, Georgia Second by 6 months • 30 States Targeted • S.C. is ID’ed • What are the rumors • What do you want clarified?

7. The Georgia Perspective • Changes in Residential Care • In 2000 5% foster children in Privatized Care • In 2000 9% were classified as in Therapeutic Care • In 2006 50% of foster children in Privatized Care • In 2006 28% were classified as in Therapeutic Care • In 2000 budget for residential care = $100 million • In 2006 budget for residential care = $300 million

8. Changes in Georgia • Increased Capacity • 50% increase in group home capacity in 3 years • From 2000 beds to 3000 beds • 600 % in foster care capacity in 3 years • From 400 beds to 2400 beds • Tripling of the budget • From $100 million to $300 million

9. The Georgia Perspective • Funding Streams • In 2000 – 70% state dollars • In 2006 – 50% state dollars • Shift was made to Medicaid Funding in 2002 • Rehab Option Used • Georgia was late to “game” of using Medicaid • SC used as a model.

10. Georgia Timeline Year 2000 • Budget Office talked of moving more to Rehab Option for foster care. • Governor in hit hard in media about care of foster children. • Governor forms “Action Committee for Safe Children” • Need to address escalating treatment costs in foster children.

11. Georgia Timeline Year 2002 • Georgia pilots Level of Care system of services • 6 levels of services in both foster care and congregate care Per Diems • congregate care range from $80 to $320 • Foster care range from $34 to $135 • Medicaid was proposed to pay for per diems

12. Georgia Timeline Year 2003 • New Republican Governor • A “foster care” Governor • Proposes $200 million in new dollars for foster care. • Half secured through Medicaid Reimbursement • State billed Medicaid for the “treatment services” to foster children.

13. The Web We Did Weave • All children in private care had a diagnosis. • Level of Care became synonymous with privatized care. • Level of Care was “therapeutic services.” • Openly acknowledged a “gaming of system.” (no one knew who was benefiting.)

14. From Bad to Worse • Change of Administrations • New Governor • New Commissioner of DHR • New Commissioner of DCH • New State Child Welfare Director • Most from out of Georgia (“ya’ll are NOT from around here, are ya?”)

15. From Bad to Worse • Institutional Knowledge Lost • No history of community stakeholders • No history of funding strategies • No history of institutional processes • Someone forgot to file a Medicaid Plan

16. Medicaid 101 • Title XIX of the Social Security Act in 1965 to provide medical assistance to the poor. • Match Program – State and Federal participation • Administered by an State Medicaid Agency • Required to have an approved plan • Required to comply with plan

17. Medicaid 101 • Each State is to provide monitoring for efficiency, economy and quality of care.

18. GAO Report – June 2005 • GAO reviewed contingency-fee consultants in the 2 states, Georgia and Massachusetts • From these and other projects, for state fiscal years 2000 through 2004, Georgia obtained an estimated $1.5 billion in additional federal reimbursements • Georgia Paid consultants $82 million

19. First Signs of Trouble • GAO Report – June 2005 • Rumors about problems with Medicaid circulated fall 2005 • Announcement in March 2006 problems with Medicaid and implementation of the “debundling of services”. Some called it “debuggling.”

20. CMS Findings All Medicaid payments will be withheld because of the following: • No Medicaid Plan • No Prior Approval of Services • No Oversight of Service provision • Contracting of providers through the Child Welfare Agency

21. Other findings • Cost shifting of child welfare expenditures to Medicaid • No proof of medical necessity • Some facilities were more than 16 beds and billed as primary in the treatment of mental disease (IMD – Institutions of Mental Disease)

22. Corrective Action Required by CMS • Actual Services must be documented • Services provided must be an approved Medicaid Service • Clients must have freedom of choice for services • Must have an approved State Plan • Providers must be enrolled through the Medicaid agency • Systemic changes are demanded

23. Georgia’s Plan • We have “de-bundled” • No more bundling of services paid for by per diem. • No more residential treatment except our specialized psychiatric residential treatment facilities which are licensed as hospitals. (PRTF) • Unlawful • “Gaming the System”

24. The New System • Room and Board and Watchful Oversight (RBWO) • Three levels of care – Basic, additional oversight and Intensive Oversight • Non therapeutic • Premium services rewarded

25. Therapy by Therapist • Mental Health Agencies approved to be mental health service providers • Professionals approved to be providers • All treatment will be provided through these providers • 16 providers have made application to be providers.

26. Mental Health Division • Our mental health division will approve providers and direct service provision for all mental health and behavioral health services. • Audited through a “care management organization” (CMO) • Paid for by our Medicaid Department

27. Public Health Division • Public Health Division will do all prevention work such as family support, preservation and abuse and neglect prevention.

28. Foster Care Division • They will provide all child protection services and investigations. • They will provide all placement services and contracting of placement services.

29. Future of Residential Care Order of Preference for placement (if appropriate) will not be going away. • Family • Relative Care • Foster Care • Congregate Facility

30. Future of Residential Care • More Home and Community based services • More family and relative care • Less Money • Less Federal Participation

31. Impact on Association • More Competition, more conflict • Role as prophet versus advocate. • Killing the messenger. • Proactive versus Reactive • Collaboration with State is a must

32. The Visionary Future • Best Practice for Children and their Families? • Creating a Funding Vision. • How to implement a vision when there is not funding in place. • Role of the Association

33. Questions and Comments