Utilizing mentoring modeling to improve services to youth through a medicaid waiver
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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

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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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Alaska’s FASD History Through a Medicaid Waiver

  • Alaska Native Medical Center with IHS funding began early alcohol-use screening for all pregnant women using Alaska Native Health Services in mid-1980’s.

  • Established statewide advocacy and services for Alaska Native women and children to reduce and prevention FASD—program eliminated in mid-1990’s.

  • 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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Alaska’s FASD History Through a Medicaid Waiver

  • Alaska’s FASD Project—4 primary outcomes:

    • Prevention of alcohol-exposed births;

    • Statewide system of community-based FASD Diagnostic Teams—improved 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • The Result—A Program Like No Other:

      Alaska’s 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 3M Training

      Original training in 3M Model

      Started with 2x year large, week long training

      Agencies can’t 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? Through a Medicaid Waiver

    • 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? Through a Medicaid Waiver

    • 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? Through a Medicaid Waiver

    • 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? Through a Medicaid Waiver

    • Helping improve a person’s feeling about him or herself (self-esteem)

    • Increasing a person’s 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… Through a Medicaid Waiver

    • Typical case management

    • Therapy

    • Respite

    • Guardianship

    • Guarding

      • A mentor is not a warden


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    What is Modeling? Through a Medicaid Waiver

    • 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… Through a Medicaid Waiver

    • Telling someone what to do

    • “Once and done”

    • “Do as I say”

    • “Just do it”


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    What is Monitoring? Through a Medicaid Waiver

    • 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? Through a Medicaid Waiver

    • 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… Through a Medicaid Waiver

    • 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 Through a Medicaid Waiver

    • 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 – Through a Medicaid WaiverPast 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 – Through a Medicaid WaiverPast 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 Through a Medicaid Waiver– 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 – Through a Medicaid WaiverPresent 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 Through a Medicaid Waiver

    • 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… Through a Medicaid Waiver

    • 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-FASD—project 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 Through a Medicaid Waiver

    Barbara Knapp, Project Director

    Alaska DHSS, Division of Behavioral Health

    3601 C St, Ste 878Anchorage, AK 99503-5935

    [email protected]

    907-269-3609


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