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BUILDING SYSTEMS OF CARE: CRITICAL STRUCTURES AND PROCESSES Presentation by: Sheila A. Pires Human Service Collaborative November 3, 2005 Sponsored by the Pennsylvania Child Welfare Training Program Purpose and Structure of the Training

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BUILDING SYSTEMS OF CARE:

CRITICAL STRUCTURES AND PROCESSES

Presentation by:

Sheila A. Pires

Human Service Collaborative

November 3, 2005

Sponsored by the Pennsylvania Child Welfare Training Program


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Purpose and Structure of the Training

  • Increase knowledge about what is involved in building

  • systems of care: critical structures, essential process

  • elements, examples – Didactic, Questions/Discussion

  • Assess system-building progress and stage of

  • development – Break out by County/Facilitated Discussion

  • Develop specific action agendas to advance

  • system-building efforts – Break out by County/Facilitated

  • Discussion/Technical Assistance

  • Peer Learning – Reporting Back/Large Group Discussion


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Definition of a System of Care

A system of care incorporates a broad array

of services and supports for a defined population

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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National System of Care Activity

  • CASSP

  • RWJ MHSPY

  • CASEY MHI

  • CMHS GRANTS

  • CSAT GRANTS

  • ACF GRANTS

  • CMS GRANTS

  • PRESIDENT’S NEW FREEDOM MENTAL HEALTH COMMISSION

  • STATE INFRASTRUCTURE GRANTS

Pires, S. (2002) Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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System of care is, first and foremost, a set of

values and principles that provides an organizing

framework for systems change on behalf of

children, youth and families.

Pires, S. 2005. Human Service Collaborative. Washington, D.C.


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Values and Principles

for the System of Care

  • CORE VALUES

  • Child centered and family focused

  • Community based

  • Culturally competent

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.


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Values and Principles for the System of Care

  • Comprehensive array of services/supports

  • Individualized services guided by an individualized service plan

  • Least restrictive environment that is clinically appropriate

  • Families and surrogate families and youth full participants in all aspects of the planning and delivery of services

  • Integrated services

    Continued …

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.


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Values and Principlesfor the System of Care

  • Care management or similar mechanisms

  • Early identification and intervention

  • Smooth transitions

  • Rights protected, and effective advocacy efforts promoted

  • 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

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.


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Principles of Family Support Practice

  • Staff & families work together in relationships based on equality and respect.

  • Staff enhances families’ capacity to support the growth and development of all family members.

  • Families are resources to their own members, other families, programs, and communities.

  • Programs affirm and strengthen families’ cultural, racial, and linguistic identities.

  • Programs are embedded in their communities and contribute to the community building.

  • Programs advocate with families for services and systems that are fair, responsive, and accountable to the families served.

  • Practitioners work with families to mobilize formal and informal resources to support family development.

  • Programs are flexible & responsive to emerging family & community issues.

  • Principles of family support are modeled in all program activities.

Family Support America. (2001). Principles of Family Support Practice in Guidelines for Family Support Practice (2nd ed.). Chicago, IL.


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Adolescent Centered

Community Based

Comprehensive

Collaborative

Egalitarian

Empowering

Inclusive

Visible, Accessible, and Engaging

Flexible

Culturally Sensitive

Family Focused

Affirming

Youth Development Principles

Pires, S. & Silber, J. (1991). On their own: Runaway and homeless youth and the programs that serve them. Washington, D.C.: Georgetown University Child Development Center.


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System of Care: Operational Characteristics

  • Collaboration across agencies

  • Partnership with families

  • Cultural & linguistic competence

  • Blended, braided, or coordinated financing

  • Shared governance across systems & with families

  • Shared outcomes across systems

  • Organized pathway to services & supports

  • Interagency/family services planning teams

  • Interagency/family services monitoring teams

  • Single plan of care

  • One accountable care manager

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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System of Care: Operational Characteristics

  • Cross-agency care coordination

  • Individualized services and supports “wrapped around”

  • child/family

  • Home- & community-based alternatives

  • Broad, flexible array of services and supports

  • Integration of clinical treatment services & natural

  • supports, linkage to community resources

  • Integration of evidence-based and effective practices

  • Cross-agency MIS

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative


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Current Systems Problems

  • Lack of home and community-based services and supports

  • Patterns of utilization

  • Cost

  • Administrative inefficiencies

  • Knowledge, skills and attitudes of key stakeholders

  • Poor outcomes

  • Financing structures

  • Pathology-based/medical models, deficit-oriented, punitive systems

Pires, S. (1996). Human Service Collaborative, Washington, D.C.


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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”

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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SYSTEMS CHANGE FOCUSES ON:

  • Policy Level (e.g., financing; regs; rates)

  • Management Level (e.g., data; QI; HRD; system

  • organization)

  • Frontline Practice Level (e.g., assessment; care planning;

  • care management; services/supports provision)

  • Community Level (e.g., partnership with families, youth,

  • natural helpers; community buy-in)

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Frontline Practice Shifts

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

Orrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to Strengthen Our Community


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Examples of Family Members:

Shifts in Roles and Expectations

Lazear, K. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.


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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.


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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. Human Service Collaborative: Washington, D.C.


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Systems of Care Public Systems

More complex needs

IntensiveServices

Accessiblehigh-quality services and supports

2 - 5%

Assessment, Prevention and Universal Health Promotion

15%

80%

Less complex needs


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Child Welfare Population Issues Public Systems

  • All children and families involved in child welfare?

  • If subsets, who?

  • Demographic: e.g., infants, transition-age youth

  • Intensity of System Involvement: e.g., out of home placement,

  • multi-system, length of stay

  • At risk: e.g.,

  • Children with natural families at risk of out of home placement?

  • Children in permanent placements that are at risk of disruption ?

  • (e.g., subsidized adoption, kinship care, permanent foster care)

  • Level of severity: e.g.,

  • Children with serious emotional/behavioral disorders, serious

  • physical health problems, developmental disabilities,

  • co-occurring

Pires, S.A. 2004. Human Service Collaborative. Washington, D.C.


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Example: Transition-Age Youth Public Systems

What outcomes do we want to see for this population?

  • Policy Level:

  • What systems need to be involved?

  • e.g., Housing, Vocational Rehabilitation, Employment

  • Services, Mental Health and Substance Abuse, Medicaid,

  • Community Colleges/Universities, Physical Health, Juvenile

  • Justice, in addition to Child Welfare

  • What dollars/resources do they control?

Continued


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Example: Transition-Age Youth Public Systems

  • Management Level:

  • How do we create a locus of system management

  • accountability for this population?

  • E.g., In-house? Lead community agency?

  • Frontline Practice Level:

  • Are there evidence-based/promising approaches targeted

  • to this population?

  • What training do we need to provide and for whom to

  • create desired attitudes, knowledge, skills about this

  • population?

  • What providers know this population best in our

  • community?

Continued


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Example: Transition-Age Youth Public Systems

  • Community Level:

  • What are the partnerships we need to build with

  • youth and families?

  • How can natural helpers in the community play a role?

  • How do we create larger community buy-in?

  • What can we put in place to provide opportunities

  • for youth to contribute and feel a part of the larger

  • community?

What does our system design look like for this population?


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Child Welfare Outcomes Public Systems

  • Safety

  • Permanency

  • Well-Being

Difficult to achieve without

taking a system of care approach


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Examples of Sources of Funding for Children/Youth Public Systems

with Behavioral Health Needs in the Public Sector

  • Education

  • ED General Revenue

  • ED Medicaid Match

  • Student Services

  • Mental Health

  • MH General Revenue

  • MH Medicaid Match

  • MH Block Grant

  • Medicaid

  • Medicaid In-Patient

  • Medicaid Outpatient

  • Medicaid Rehabilitation Services Option

  • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT)

  • Targeted Case Management

  • Medicaid Waivers

  • Katie Beckett Option

  • Other

  • WAGES

  • Children’s Medical Services/Title V– Maternal and Child Health

  • Mental Retardation/ Developmental Disabilities

  • Title XXI-State Children’s 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 behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative. Revised 2005.


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WHO CONTROLS POLICY AND DOLLARS? Public Systems

  • Key

  • State Medicaid Agencies

  • State/Local Child Welfare Agencies

  • State/Local Mental Health Authorities

  • Public Health and Primary Care

  • State/Local Education Agencies

  • State and Local Juvenile Justice Systems

  • Some Others

  • Commercial Insurers

  • Employment Services

  • State/Local Substance

  • Abuse Agencies

  • Housing

Pires, S. (2004). Human Service Collaborative, Washington, D.C.


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OTHER CRITICAL PLAYERS Public Systems

  • “Gatekeepers” (e.g., managed care organizations,

    judges, interagency teams)

  • Providers

  • Natural Helpers and Community Resources

  • Families

  • Youth

Pires, S. (2004). Human Service Collaborative, Washington, D.C.


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Local Ownership Public SystemsState Commitment

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative


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Converging Trends Public Systems

Pires, S. (2003). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Efficacy of Research Public Systems(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

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Evidence-Based Practices Public Systems

And Promising Approaches

Evidence-based practices

Show evidence of effectiveness through carefully controlled scientific studies, including random clinical trials

Promising approaches

Show evidence of effectiveness through experience of key stakeholders (e.g., families, youth, providers, administrators) and by data collected by program/system

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Examples of Evidence-Based Practices Public Systems

  • Multisystemic Therapy (MST)

  • Multidimensional Treatment Foster Care (MDTFC)

  • Functional Family Therapy (FFT)

  • Cognitive Behavioral Therapy (various models)

  • Intensive Care Management (various models)

Examples of Promising Practices

  • Family Support and Education

  • Wraparound Service Approaches

  • Mobile Response and Stabilization Services

Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidence-

based interventions for severe emotional and behavioral disorders. Oxford

University Press and State of New Jersey BH Partnership (www.njkidsoc.org)


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Examples from Hawaii’s List of Evidence Based Practices Public Systems

HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd


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Examples from Hawaii’s List of Evidence Based Practices Public Systems

HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd


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Examples from Hawaii’s List of Evidence Based Practices Public Systems

HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd


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KAUFFMAN BEST PRACTICES PROJECT AND Public Systems

NATIONAL CHILD TRAUMATIC STRESS

NETWORK

  • Trauma Focused-Cognitive Behavioral Therapy (TF-CBT)

  • Abuse Focused-Cognitive Behavioral Therapy (AF-CBT)

  • Parent Child Interaction Therapy (PCIT)


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Shared Characteristics of Public SystemsEvidence-Based (and Promising)Interventions

  • Function as service components within systems of care

  • Provided in the community

  • Utilize natural supports, parents, with training and supervision provided by those with formal mental health training

  • Operate under the auspices of all child-serving systems, not just mental health

  • Studied in the field with “real world” children and families

  • 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

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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EXAMPLES OF SYSTEMS OF CARE interventions within effective, compassionate, and competent systems of care”


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  • Mental Health interventions within effective, compassionate, and competent systems of care”

  • Crisis Billing

  • Block Grant

  • HMO Commercial

  • Insurance

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

9.5M

8.5M

10M

2.0M

Wraparound Milwaukee

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

Management Entity:

Wraparound Milwaukee

Management Service Organization (MSO)

$30M

Per Participant Case Rate

Provider

Network

240 Providers

85 Services

Care

Coordination

Child and Family Teams

Plans of Care

Mngt. Entity: County Agency


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OUTCOMES (Milwaukee Wraparound) interventions within effective, compassionate, and competent systems of care”

  • 60% reduction in recidivism rates for delinquent

  • youth from one year prior to enrollment to one year

  • post enrollment

  • Decrease in average daily RTC population from 375

  • to 50

  • Reduction in psychiatric inpatient days from 5,000 days

  • to less than 200 days per year

  • Average monthly cost of $4,200 (compared to $7,200

  • for RTC, $6,000 for juvenile detention, $18,000 for

  • psychiatric hospitalization


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Next Phase of Milwaukee Wraparound interventions within effective, compassionate, and competent systems of care”

  • Partnership with HMO to become “medical/clinical”

  • home for all children in foster care in the county –

  • Locus of accountability for managing physical,

  • dental, and behavioral health care to achieve ASFA

  • well-being outcomes


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DAWN Project interventions within effective, compassionate, and competent systems of care”

Indianapolis, IN

How Dawn Project is Funded

Dawn Project Cost Allocation

Management Entity:

Non profit behavioral

health organization


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Service coordination plans, including safety and crisis plan interventions within effective, compassionate, and competent systems of care”

Broad array of treatment and supportive services

Extensive provider network, paid fee for service

More Dawn Features


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Dawn Service Array interventions within effective, compassionate, and competent systems of care”


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Dawn Service Array, Continued interventions within effective, compassionate, and competent systems of care”


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NJ Children’s System of Care Initiative interventions within effective, compassionate, and competent systems of care”

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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El Paso County, Colorado interventions within effective, compassionate, and competent systems of care”

State-Capped Out of Home Placement Allocation

County DHS acts as MCO (contracting, monitoring, utilization review)

BH Tx $$ matched by Medicaid. Capitation contract with BHO

with risk-adjusted rates for child welfare-involved children

Child Welfare $$

Case rate contract with CPA

Joint treatment planning approved by DHS

Child Placement Agencies (CPA)

Responsible for full range of Child Welfare

Services & ASFA (Adoption and Safe

Families ACT) related outcomes

Mental Health Assessment and Service Agency (BHO)

Responsible (at risk) for full range

of MH treatment services & clinical outcomes & ASO functions

Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.


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Types of Outcomes Achieved by Systems interventions within effective, compassionate, and competent systems of care”

Of Care

  • Reduction in inpatient hospitalization and residential

  • treatment placements and lengths of stay

  • Reductions in detention rates

  • Reductions in out-of-home placements and lengths of

  • stay

  • Improved clinical and functional outcomes

  • Higher family and youth satisfaction

  • Lower costs per child served for total system if

  • a range of home and community-based is in place


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Data on Outcomes Available From (Among Others): interventions within effective, compassionate, and competent systems of care”

  • Burns & Hoagwood, Community Treatment for Youth:

  • Evidence-Based Interventions for Severe Emotional and

  • Behavioral Disorders, Oxford University Press

  • Kaufman Foundation, Closing the Quality Chasm in Child

  • Abuse Treatment: Identifying and Disseminating Best

  • Practices, www.kauffmanfoundation.org

  • Wraparound Milwaukee (bkamrad@wrapmilw.org)

  • Dawn Project (krotto@choicesteam.org)

  • Coordinated Care Services, Inc. (jlevison-johnson@ccsi.org)

  • Massachusetts Mental Health Services Program for Youth

  • (katherine_grimes@nhp.org)

  • Youth Villages (tim.goldsmith@youthvillages.org)


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Process interventions within effective, compassionate, and competent systems of care”

How system builders conduct themselves

Structure

What gets built (i.e., how functions are organized)

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Structure interventions within effective, compassionate, and competent systems of care”

“Something Arranged in a

Definite Pattern of Organization”

  • I. Distributes

    • Power

    • Responsibility

  • II. Shapes and is shaped by

    • Values

  • III. Affects

    • Practice and outcomes

    • Subjective experiences (i.e., how participants feel)

Pires, S. (1995). Structure. Washington, DC: Human Service Collaborative.


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EXAMPLE interventions within effective, compassionate, and competent systems of care”

Goal: One plan of care; one care manager

  • Mental Health

  • Individualized WrapAround Approach

  • Care manager

  • Child Welfare

  • Family Group Decision Making

  • CW Case Worker

Kinship

Care

Subsidized

Adoption

Permanent

Foster

Care

Tutoring

Parent Support,

etc.

Crisis

Services

Treatment

Foster Care

In-Home

Services

Children in

out-of-home

placements

  • MCO

  • Prior Authorization

  • Clinical Coordinator

  • Education

  • Child Study Team

  • Teacher

Out-patient

services

Primary

Care

Alternative

School

EH Classroom

Related Services

Med. Mngt.

Result: Multiple plans of care; multiple care managers

Pires, S. (2004).Building Systems of Care: A Primer. Human Service Collaborative: Washington, DC


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System of Care Functions Requiring Structure interventions within effective, compassionate, and competent systems of care”

  • Planning

  • Decision Making/Policy Level Oversight

  • System Management

  • Benefit Design/Service Array

  • Evidence-Based Practice

  • Outreach and Referral

  • System Entry/Access

  • Screening, Assessment, and Evaluation

  • Decision Making and Oversight at the Service Delivery Level

    • Care Planning

    • Care Authorization

    • Care Monitoring and Review

  • Care Management or Care Coordination

  • Crisis Management at the Service Delivery and Systems Levels

  • Utilization Management

  • Family Involvement, Support, and Development at all Levels

  • Youth Involvement, Support, and Development

  • Staffing Structure

  • Staff Involvement, Support, Development

  • Orientation, Training of Key Stakeholders

  • External and Internal Communication

  • Provider Network

  • Protecting Privacy

  • Ensuring Rights

  • Transportation

  • Financing

  • Purchasing/Contracting

  • Provider Payment Rates

  • Revenue Generation and Reinvestment

  • Billing and Claims Processing

  • Information Management

  • Quality Improvement

  • Evaluation

  • System Exit

  • Technical Assistance and Consultation

  • Cultural Competence

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.


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Core Elements of an Effective System-Building Process interventions within effective, compassionate, and competent systems of care”

Leadership and Constituency Building

  • A core leadership group

  • Evolving leadership

  • Effective collaboration

  • Partnership with families and youth

  • Cultural competence

  • Connection to neighborhood resources and natural helpers

  • Bottom-up and top-down approach

  • Effective communication

  • Conflict resolution, mediation, and team-building mechanisms

  • A positive attitude

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.


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Core Elements of an interventions within effective, compassionate, and competent systems of care”Effective System-Building Process

Being Strategic

  • A strategic mindset

  • A shared vision based on common values and principles

  • A clear population focus

  • Shared outcomes

  • Community mapping—understanding strengths and needs

  • Understanding and changing traditional systems

  • Understanding of the importance of “de facto” mental health providers (e.g., schools, primary care providers, day care providers, head start)

  • Understanding of major financing streams

  • Connection to related reform initiatives

  • Clear goals, objectives, and benchmarks

  • Trigger mechanisms—being opportunistic

  • Opportunity for reflection

  • Adequate time

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative


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Challenges to Collaboration “Barrier Busters” interventions within effective, compassionate, and competent systems of care”

Wraparound Milwaukee. (1998). Challenges to collaboration/“barrier busters.” Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch.


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Cross-Cutting Characteristics interventions within effective, compassionate, and competent systems of care”

  • Cultural and linguistic competence, that is, processes and structures that support capacity to function effectively in cross-cultural situations;

  • Meaningful partnership with families, including family organizations, and youth in system building processes and structural decision making, design, and implementation;

  • A cross-agency perspective, that is, processes and structures that operate in a non-categorical fashion.

  • State and local partnership and shared commitment.

Pires, S. (2002).Building systems of care: A primer. Washington D.C.: Human Service Collaborative.


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LEVEL interventions within effective, compassionate, and competent systems of care”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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Why Culture Matters interventions within effective, compassionate, and competent systems of care”

Because it affects…

  • Attitudes and beliefs about services and systems

  • Expression of symptoms

  • Coping strategies

  • Help-seeking behaviors

  • Utilization of services

  • Appropriateness of services and supports

  • Disparities in access

Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.


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BUILDING SYSTEMS OF CARE: interventions within effective, compassionate, and competent systems of care”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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Elements of Effective Planning Processes interventions within effective, compassionate, and competent systems of care”

  • Are staffed

  • Involve key stakeholders

  • Involve families early in the process and in ways that are meaningful

  • Ensure meaningful representation of racially and ethnically diverse families

  • Develop and maintain a multi-agency focus

  • Build on and incorporate related programmatic and planning initiatives

  • Continually seek ways to build constituencies, interest, and investment

  • Pay attention to sustainability and growth of system changes from day one

Pires, S. (1991). State child mental health planning. Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center of Children’s Mental Health.


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A Planning Process for Family and Children’s Service Reform

Action Plan Political Strategy

The

System As

It Is Now

Outcomes For Children

The System As It Should Be

Principles

Reinvestment

Commitment

Financing Options

Multi Year Steps

Leadership and Professional

Development Strategy

Cross Community

Cross Agency

Governance

Strategy

State

County

Community

Combined Fiscal Program Strategy

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Friedman, M. (1994). Washington, D.C.: Center for the Study of Social Policy


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Strategies for Involving ReformParents in Planning

  • Providing special orientation and training and ongoing assistance; consulting with parents before meetings.

  • Having more than token representation.

  • Contracting with community-based and parent organizations to develop/sustain process.

  • Working through parent organizations.

  • Asking agencies that work with parents to recommend parents to participate in planning.

  • Paying stipends, transportation, child care.

  • Holding planning meetings in the evenings or on weekends, in locations such as schools.

  • Conducting surveys to elicit views of many parents.

    Continued …

Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and support services program. Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.


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Strategies for Involving ReformParents in Planning (continued)

  • Using parents who work regularly with other parents to conduct focus groups.

  • Working with family support groups to tap into informal networks.

  • Working with home visiting programs and health clinics to reach out to parents.

  • Working with family preservation and family reunification programs.

  • Conducting sessions for planning group members with trained facilitators to explore attitudes about race, culture, families.

  • Publicly acknowledging the contributions of parents.

Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and

support services program. Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.


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Definition of Governance Reform

Decision making at a policy level that has legitimacy, authority, and accountability.

Pires, S. (1995). Definition of governance. Washington, DC: Human Service Collaborative.


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System Management Reform

Day-to-day operational

decision making

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Key Issues for Reform

Governing Bodies

  • Has authority to govern

  • Is clear about what it is governing

  • Is representative

  • Has the capacity to govern

  • Has the credibility to govern

  • Assumes shared liability across systems for target population

Pires, S. (2000). Key issues for governing bodies. Washington, DC: Human Service Collaborative.


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System Management: Day-to-Day ReformOperational Decision Making

Key Issues

  • Is the reporting relationship clear?

  • Are expectations clear regarding what is to be managed and what outcomes are expected?

  • Does the system management structure have the capacity to manage?

  • Does the system management structure have the credibility to manage?

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Example of Governance/Management Structure Reform

Care Management Entity

Pires, S. (1996). Contracted system management structure. Washington, DC: Human Service Collaborative.


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Example of Governance/Management Structure Reform

BRING THE CHILDREN HOME STATE LEGISLATION

COUNTY EXECUTIVE

Local Governing Board

Agency Directors

Family/Youth Reps.

Providers Forum

SOC Team Leader

“Bring the Children Home”

Interagency Care Management Team

“Bring the Children Home”

Care Managers

Families/Youth Served

Other Agency Workers

Pires, S. (1996). Evolving governance structure. Washington, DC: Human Service Collaborative.


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Examples of Types of Family Partnership in System Governance and Management

  • Input/evaluation of key management

  • Input/evaluation of quality of services and programs

  • Local system of care input

  • Resource allocation

  • Service planning and implementation

  • Policies and procedures

  • Grievance and resolution procedures

Conlan, L. (2003). Implementing family involvement. Burlington, VT: Vermont Federation of Families for Children’s Mental Health.


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Distinctions Among and Management

Screening, Assessment and

Evaluation, and Care Planning

  • Screening

  • 1st step, triage, identify children at high risk, link to appropriate assessments

  • Assessment

  • Based on data from multiple sources

  • Comprehensive

  • Identify strengths, resources, needs

  • Leads to care planning

  • Continued …

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative


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Distinctions Among and Management

Screening, Assessment and

Evaluation, and Care Planning

  • Evaluation

  • Discipline-specific, e.g., neurological exam

  • Closer, more intensive study of a particular or suspected

  • clinical issue

  • Provides data to assessment process

  • Care planning

  • Individualized decision making process for determining services

  • and supports

  • Draws on screening, assessment, and evaluation data

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Life Domain Areas and Management

Adapted from. Dennis, K, VanDenBerg, J., & Burchard, J. (1990). Life domain areas. Chicago: Kaleidoscope.


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  • Definition of Wraparound and Management

  • Wraparound is “ . . . a definable planning process that results in a unique set of community services and natural supports that are individualized for a child and family to achieve a positive set of outcomes.”*

  • *Burns, B. & Hoagwood, K. (Eds.) Community-Based Interventions for Children and Families. Oxford: Oxford University Press.


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Wraparound and System of Care and Management

Wraparound is an important approach to care

planning and service provision within a system of care

But ….

It does not, in and of itself, constitute a system of care!

Pires., S. 2005. Human Service Collaborative. Washington, D.C.


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Examples of What You’d Want to Provide Based on and Management

Effectiveness Literature

  • Outpatient Models:

  • Cognitive Behavior Therapy (various models)

  • Functional Family Therapy (FFT)

  • Parent Child Interaction Therapy (PCIT)

  • Intensive In-Home Models:

  • Multisystemic Therapy (MST)

  • Out-of-Home Model:

  • Multidimensional Treatment Foster Care

  • Intensive Care Management

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.


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Examples of Other Home and Community-Based Services and Management

You’d Want to Provide Based on

Practice/Family Experience & Outcomes Data

  • Intensive in-home services (not just MST)

  • Child respite services

  • Mobile response and stabilization services

  • Mental health consultation 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.


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What You Don’t See Listed as Evidence-Based Practice and Management

  • Traditional office-based “talk” therapy

  • Residential Treatment

  • Group Homes

  • Day Treatment


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What Natural and ManagementHelpers Can Provide

  • Emotional support

  • System navigation

  • Resource acquisition

  • Concrete help

  • Decrease social isolation

  • Greater understanding of community

  • Community navigation

  • Effective intervention or support strategies

Lazear, K., (2003). “Primer Hands On”; A skill building curriculum. Human Service Collaborative: Washington, D.C.


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Pre-Equipo Network and Management

Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.


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Post –EQUIPO Network and Management

Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.


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Number of and ManagementScheduled Office Visits

Number ofHoursSpent inOffice Visits

Number ofHours SpentTraveling to andfrom Office Visits

Number ofMilesTraveledfor Care

Travel Miles

1250:180

Time and Travel

(Ten Month Period)

StudyFamily

Comparison Family

Office Hours

105:8

Visits

69:6

Travel Hours

29:6

Lazear, K. (2003). Family Experience of the Mental Health System, Research and Training Center for Children’s Mental Health, Tampa, FL.


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Service Array Focused on and Managementa Total Eligible Population

Universal Targeted

  • Family Support Services

  • Youth Development Program/Activities

  • Coordinated Intake Assessment & Treatment Planning

  • Intensive Case Management/Care Coordination

  • Wraparound Services & Supports

  • Clinical Services

Core Services Prevention Early Intervention Intensive Services

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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As technical assistance providers & consultants and Management

Training

Evaluation

Research

Support

Outreach

As direct service providers

Family Liaisons

Care Coordinators

Family Educators

Specific Program Managers (respite, etc)

Where Family Organizations Fit Into Service Array

Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.


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Case Management and Management

Little authority over resources

Child centered

Reactive

Service provided to placement

Organization of existing services

Uses current system

Care Management

More control over resources

Family centered

Proactive

Unconditional care

Creation of services when not available

Family and community supports

Comparison of Case Management and Care Management

Adapted from: Community Care Systems. (2000). Comparison of case management and care coordination. Madison, WI.


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Care Management and ManagementContinuum

Children needing intensive and extended level of services and supports

Children needing only brief short-term services and supports

Children needing intermediate level of services and supports

UM-type care management

No “caseloads”

Service coordination

Large caseloads

Intensive care management Very small caseloads

Pires, S. (2001). Case/care management continuum. Washington, DC: Human Service Collaborative.


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Care Management/Service Coordination and Management

Structure Principles

  • Support a unitary (i.e., across agencies) care management/coordination approach even though multiple systems are involved, just as the care planning structure needs to support development of one care plan.

  • Support the goals of continuity and coordination of care across multiple services and systems over time.

  • Encompass families and youth as partners in the process of managing/coordinating care.

  • Incorporate the strengths of families and youth, including the natural and social support networks on which families rely.

Pires, S. (20O2). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Utilization Management Concerns and Management

Who is using services?

What services are being used?

How much service is being used?

What is the cost of the services being used?

What effect are the services having on those using them? (i.e., Are clinical/functional outcomes improving? Are families and youth satisfied? Are children returning home?)

UM

Pires, S. (2001). Utilization management concerns. Washington, DC: Human Service Collaborative.


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Principles for and ManagementUtilization Management

  • UM must be understood and embraced by all key stakeholders

  • UM must concern itself with both the cost and quality of care

  • The UM structure needs to be tied to the quality improvement structure

Pires.. S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Purposes of UM/Evaluation Data: Examples and Management

  • Planning and Decision Support (Day-to-Day and

  • Retrospectively)

  • Quality Improvement

  • Cost/Benefit Monitoring

  • Research

  • Marketing

  • Accountability

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.


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Evaluation & Data Gathering and Management

  • To eliminate disparities, disproportionalities, and improve quality of care, we need to collect data.

  • Questionnaires

  • Surveys

  • Interviews

  • Focus groups

  • Clinical outcome data

  • Using a participatory evaluation framework

  • Lazear, K. (2003). “Primer Hands On” A skill building curriculum. Washington. D.C.


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Financing Strategies to Support Improved Outcomes for Children & Families

  • FIRST PRINCIPLE:

    • System Design Drives Financing

  • REDEPLOYMENT:

    • Using the Money We Already Have

    • The Cost of Doing Nothing

    • Shifting Funds from Treatment to Early Intervention

    • 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)

Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Center for the Study of Social Policy: Washington, D.C..


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Financing Strategies to Support Children & Families

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. Center for the Study of Social Policy: Washington, D.C.


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Where to Look for Money Children & Families

and Other Types of Support

e

e

Pires, S. (1994). Where to look for money and other types of support. Human Service Collaborative: Washington, D.C.


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Milwaukee Wraparound Children & Families

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.


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How to Finance/Implement Systems of Care Children & Families

  • Adopt a Population Focus: Who are the populations

  • of youth for whom you want to change practice/outcomes

  • Adopt a Cross-Systems Approach: What other systems

  • serve these youngsters; who controls potential or actual

  • match 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 to Finance/Implement Systems of Care

Pires, S. 2005. Human Service Collaborative. Washington, D.C.


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Examples of Incentives to Various Children & Families

Child-Serving Systems

Medicaid: slowing rate of growth in “deep end” services

Child Welfare: meeting Adoptions and Safe Families Act

outcomes; reducing out-of-home placements

Juvenile Justice: creating alternatives to incarceration;

reducing detention costs

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 Children & Families

and Implement Evidence-Based and Promising Practices

District of Columbia – MST, Mobile Response, In-Home

Medicaid Rehab Option pays for MST, Intensive

Home-Based Services (Ohio model), Mobile Response

and Stabilization Services (NJ model)

Child Welfare provides match and paid for initial

training, coaching, provider capacity development;

Mental health/child welfare share costs of outcomes tracking

Juvenile Justice now paying 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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Examples of Cross-System Partnerships to Finance Children & Families

and Implement Evidence-Based and Promising Practices

New Mexico - MST

Medicaid managed care pays for service costs of MST

Juvenile Justice pays for training/coaching/fidelity

monitoring

Hawaii – Range of EBPs

Medicaid managed care, Education special ed, mental

health general revenue/block grant pay for range of

EBPs, training, monitoring

Pires, S. 2005. Human Service Collaborative. Washington, D.C.


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Examples of Cross-System Partnerships to Finance Children & Families

and Implement Evidence-Based and Promising Practices

New Jersey – In-Home, Mobile Response, Intensive Case

Management, Family Support

Medicaid Rehab Option pays for in-home, Mobile

Response and Stabilization, intensive case management,

family support

Child welfare contributed match dollars

Tennessee – MST, Multi-Dimensional Treatment

Foster Care

Medicaid managed care and mental health GR pay for

MST and MDTFC

Pires, S. 2005. Human Service Collaborative. Washington, D.C.


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Characteristics of Children & Families

Effective Provider Networks

  • Responsive to the population that is the focus of the system of care.

  • Encompass both clinical treatment service providers and natural,

  • social support resources, such as mentors and respite workers.

  • Include both traditional and non traditional, indigenous providers.

  • Include culturally and linguistically diverse providers.

  • Include families and youth as providers of services and supports.

  • Are flexible, structured in a way that allows for additions/deletions.

  • Are accountable, structured to serve the system of care.

  • Have a commitment to evidence-based and promising practices.

  • Encompass choice for families.

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Examples of Children & FamiliesIncentives to Providers

  • Decent rates

  • Flexibility and control

  • Timely reimbursements

  • Back up support for difficult administrative and clinical challenges

  • Access to training and staff development

  • Capacity building grants

  • Less paperwork

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Purchasing/Contracting Options Children & Families

  • Pre-Approved Provider Lists:

  • Flexibility for system of care +

  • Choice for families +

  • Could disadvantage small indigenous providers –

  • Could create overload on some providers –

  • Risk-Based Contracts (e.g., capitation, case rates)

  • 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. Human Service Collaborative: Washington, D.C..


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Progression of Risk by Children & Families

Contracting Arrangement

  • TYPE OF CONTRACTING

  • ARRANGEMENT

  • Grant

  • Fee-for-Service

  • Case Rate

  • Capitation

RISK TO

SYSTEM

OF CARE

HIGHEST

RISK

LOWEST

RISK

RISK TO

PROVIDER

LOWEST

RISK

HIGHEST

RISK

Adapted from Broskowski, A. (1996). Progression of provider’s risks. In Managed care: Challenges for children and family services.

Baltimore, MD: Annie E. Casey Foundation.


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Human Resource Children & FamiliesDevelopment Functions

  • Assessment of workforce requirements (i.e., What skills are needed, what types of staff, how many staff) in the context of systems change

  • Recruitment, retention, staff distribution

  • Education and training (pre-service and in-service)

  • Standards and licensure

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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Staffing Systems of Care Children & Families

Re-deploy and Retrain Existing Staff

Contract Out

Hire New Staff

Partner withOthers

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.


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A Developmental Training Curriculum Children & Families

TRADITIONAL MODIFIED INTEGRATED UNIFIED

SYSTEM

PROGRAM

State systems

develop training

along specialty

guild lines –

Promotion of

stronger specialty

focus

Community

agencies and

universities

operate in isolation

Disciplines train

in isolation from

one another

Instruction is

didactic, “expert”

No support for cross-training

State systems

independently

adopt similar

philosophy,

promoting

Collaboration

Community

agencies and

Universities

begin joint

research and

evaluation

Pre-service

training remains

separate from

the field

State systems

begin sharing

training calendars

Promotion of

cross-training;

joint funding

Community

agencies and

universities begin

to integrate field

staff/families into

pre-service training

Student field place-

ments cross agency

boundaries

Cross-agency

training gains

support

State systems

pool training

staff, merge

training events

Community

agencies and

universities

collaborate

with larger

community, e.g.

families as co-

instructors;

curricula reflect

practice goals

Training geared

to system goals

Meyers, J., Kaufman, M. & Goldman, S. (1991). Training strategies for serving children with serious emotional disturbances and their families in a system of care. Promising Practices in children’s mental health. 5. Washington, D.C.: American Institutes for Research.


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A Developmental Children & Families

Training Curriculum

TRADITIONAL MODIFIED INTEGRATED UNIFIED

PRACTICE

Participation

in professional

conferences on

individual basis

within agency

boundaries

Services are

provided within

agency boundaries

Staff receive

training that

promotes

collaboration,

but receive it

within agency

boundaries

Specialty focus

predominant

Services remain

within agency

boundaries

Service

teaming is

promoted

through cross-

agency training

Service teams

with full family

inclusion are the

norm

Redefined specialty

practice roles develop

to support

professional identity

while promoting

collaboration

Meyers, J., Kaufman, M. & Goldman, S. (1991). Training strategies for serving children with serious emotional disturbances and their families in a system of care. Promising practices in children’s mental health. 5. Washington, D.C.: American Institutes for Research.


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Summary: Common Elements of Re-Structured Systems Children & Families

  • Values-based systems/Family and youth partnership

  • Identified target population, costs associated with

    population, funders

  • Locus of accountability (and risk) for target population

  • Organized pathway to services for target population

  • Strengths-based and individualized service planning

  • and care monitoring (e.g., wraparound approach)

  • Intensive care management

  • continued …

Pires, S. 2004. Human Service Collaborative. Washington, D.C.


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Summary:Common Elements of Re-Structured Systems Children & Families

  • Flexible financing and contracting arrangements

    (e.g., case rates, qualified provider panel – fee-for-service )

  • Broad provider network: sufficient types

    of services and supports (including natural helpers)

  • Combined funding from multiple funders (e.g., Medicaid,

  • child welfare, mental health, juvenile justice, education)

  • Real time data across systems to support clinical decision-

  • making, utilization management, quality improvement

  • Outcomes tracking – child/family level, systems level

  • continued…

Pires, S. 2004. Human Service Collaborative. Washington, D.C.


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Summary: Common Elements of Re-Structured Systems Children & Families

  • Utilization management

  • Mobile crisis capacity

  • Judiciary buy-in

  • Re-engineered residential treatment centers

  • Shared governance/liability

  • Training and technical assistance

Pires, S. 2004. Human Service Collaborative. Washington, D.C.


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Transformation Children & Families

  • Need to connect related reforms in child-serving systems

  • and Medicaid needs to be a partner in reform:

  • SAMHSA Transformation Grants, Infrastructure Grants,

  • System of Care Grants

  • Child Welfare System of Care Grants, Program

  • Improvement Plans

  • Juvenile Justice MH/SA Initiatives

  • CMS Feasibility and Real Choice Grants

Pires, S. 2005. Human Service Collaborative. Washington, D.C.


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“The world that we have made as a result of the level of thinking we have done thus far creates problems that we cannot solve at the same level at which we created them.”

Albert Einstein

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.


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The measure of success is not whether you have a tough problem to deal with, but whether it’s the same problem you had last year.

John Foster Dulles


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To Obtain Copies of problem to deal with, but whether it’s the same problem you had last year.Building Systems of Care: A Primer

Contact:

Mary Moreland, Publications Manager

Georgetown University National Technical Assistance

Center for Children’s Mental Health

202 687-8803

E-mail: deaconm@georgetown.edu

For Further Information About Building Systems of Care,

Contact:

Sheila A. Pires

Human Service Collaborative

202 333-1892

E-mail: sapires@aol.com