Presented By: Bruce Kamradt, MSW

1. Utilizing A Care Management Entity (CME) to Improve the Quality & Cost of Care for Youth with Complex, Multi System NeedsFor: Division of Behavioral HealthColorado Dept. of Human ServicesMay 31, 2012 Presented By: Bruce Kamradt, MSW Administrator of Childrens Mental Health Services for Milwaukee County Director, Wraparound Milwaukee

2. What is a Care Management Entity (CME) An organizational entity that serves as the “locus of accountability” for defined populations of youth with complex emotional, behavioral and mental health challenges and their families who are served in multiple systems The CME is accountable for improving the quality, outcomes and cost of care for populations historically experiencing high costs and poor outcomes

3. Children & Youth Populations Typically Served by CME’s Children & adolescents with serious emotional and behavioral challenges at risk for out-of-home placement in residential treatment centers, group homes or other institutional settings Children in Child Welfare Youth at risk of incarceration or placement in juvenile correctional facilities Children in institutional placements who need help in returning to their home and community or to reduce the length of stay Youth in detention or detention diversion Youth at risk of inpatient psychiatric hospitalization or returning from such settings Other populations (i.e. youth in special education at risk of alternative school placement) All of the above (as in Wraparound Milwaukee)

4. Redirecting “Deep End” Spending Through Use of Care Management Entities Strategies: Re-direct dollars from high cost/poor outcome institutional care to community-based care (ex. Reducing residential treatment spending and using money for community-based alternatives) Investing savings per youth served in expanded community services and in-home service capacity Re-engineer residential treatment and other institutional services to become more community-based

5. CME’s are Value-Based Care is: Individualized Strength-Based Family Driven & Youth Guided Culturally Competent Community-Based Coordinated Across Systems Data Driven/Evaluation Focused Unconditional – “Never Give Up”

6. Care Management Entity Goals Improve: Clinical and functional outcomes System level improvements (i.e. reduce residential treatment placements, length of stay, inpatient bed days, etc) Lower cost of care Improve or maintain community safety Achieve child permanency Improve educational outcomes (i.e. school attendance, performance, reduce school suspensions, etc) Child and family satisfaction and experience with care Other systems improved experience with care and improved perception of each other’s agencies

7. Care Management Entity Functions – What Do They Do? At the Service Level: Child & Family Team facilitation using a wraparound practice model Screening and assessment for eligibility and need Clinical oversight of service delivery Intensive care coordination Care plan monitoring and review Crisis intervention Family and peer support

8. Care Management Entity Functions – What Do They Do? – cont’d At the Administration Level: Financial oversight Provider Network development Quality Assurance/Quality Improvement Utilization Management Information and Data Management Training/Coaching Evaluation Public Relations

9. Care Management Entity Financing Mechanisms Use of multiple funding streams Blended or braided funding Use of case rates, capitation or fixed funding

10. Financing Strategies That Support Care Management Entities Redirection Reinvestment of savings Risk pools New monies

11. Types of CME Entities Public agency as CME – Wraparound Milwaukee Newly formed non-profit organizations with no direct service role – New Jersey Care Management Model Existing non-profit organization with other direct service capability – Massachusetts Community Services Agencies For profit or managed care companies – Choices, Inc in DAWN Model in Ohio Non-profit HMO Hybrid – non-profit organization with other direct service capability in formal partnership with neighborhood organization – Cuyahoga County (Cleveland, Ohio)

12. Public Agency Model – Wraparound Milwaukee Created in 1995, it is a unique CME model overseeing a system of care for Milwaukee County children and adolescents with serious emotional or mental health needs and their families that cross two or more child serving systems (i.e. Mental Health, Child Welfare, Juvenile Justice, Special Education) Serves 1500 youth/young adults/families per year Operated by Milwaukee County Government – Behavioral Health Division within Human Service Dept. under 1915a provisions of Social Security Act as type of specialized managed care entity One other similar program created in Dane County, Madison, WI

13. Rationale for the Creation of Wraparound Milwaukee Over utilization of institutional care for Juvenile Justice and Child Welfare, particularly residential treatment and correctional placements leading to budget deficits Over utilization of psychiatric inpatient admissions and poor use of emergency rooms causing fiscal problems and concerns for State Medicaid agency Poor outcomes for youth coming out of institutional placements primarily high recidivism

14. What is Governance Structure of Wraparound Milwaukee Governance with the Milwaukee County Human Service Dept. – Behavioral Health Division Behavioral Health Division contracts with Dept. of Health under 1915a provision for a sole source “capitated” contract to establish a voluntary managed care plan for SED youth in Milwaukee County (Wraparound Milwaukee) BHD and Wraparound CME contracts with Child Welfare and Juvenile Justice for case rate funding to cover cost for services and placements not covered by Medicaid capitation rate

15. What is Governance Structure of Wraparound Milwaukee – cont’d Administrator of Children Mental Health for BHD serves as Director of Wraparound CME responsible to the administration of BHD and Director of Human Service Dept. Milwaukee County Board of Supervisors is ultimately responsible for operation of the CME such as approving contracts, etc. Milwaukee County bears “risk” of service and program costs exceeding revenue; capitation risk adjusted annually Partnership Council is the voluntary advisory committee to the program

16. Specific Populations Wraparound Milwaukee Serves Youth with a DSM-IV diagnosis With a more chronic condition likely to require services for a year or more Currently or previously served across two or more child serving systems i.e. Child Welfare, Juvenile Justice, Mental Health, special education At imminent risk of placement in a : Residential treatment center Psychiatric hospital Juvenile correctional facility

17. What Functions Does Wraparound Milwaukee CME Do? Program Administration Assessment/Screening Care Coordination Operates Provider Network Provides 24/7 Crisis Intervention Finance – claims processing, vendor payments, etc. Clinical Oversight Medication Clinics/Management Quality Assurance/Improvement Utilization Management Program Evaluation Data & Information Management Arranges for Family Advocacy Contraction with Child Welfare, Juvenile Justice & Education Public Relations Training Liaison with court & certain legal function Dispute Resolution Transitional Care Services

18. How We Pool Funds CHILD WELFARE JUVENILE JUSTICE MEDICAID CAPITATION MENTAL HEALTH Funds thru Case Rate (Funds Budgeted for (2052per Month per Enrollee) •CRISIS BILLING (Budget for Institutional Residential Treatment and BLOCK GRANT • Care for Chips Children) Juvenile Corrections Placements) HMO COMMERCIAL INSUR • 10.0M 10.0M 19.5M 7.0 M WRAPAROUND MILWAUKEE CARE MANAGEMENT ORGANIZATION (CMO) 46.5 M CARE COORDINATION PROVIDER NETWORK 210 Providers 80 Services CHILD AND FAMILY TEAM PLAN OF CARE

19. Creating “win-win” Scenarios Child Welfare Medicaid Alternative to out-of-home care high costs/poor outcomes Alternative to IP/ER-high cost System of Care Alternative to detention-high cost/poor outcomes Alternative to out-of-school placements – high cost Juvenile Justice Special Education

20. Some of the Unique Funding Mechanisms Used by Wraparound Milwaukee and Other Child Serving Systems to Pool Funding • Case Rate – a fixed monthly amount of money paid for each person who presents for covered services • Capitation Rate – a fixed amount of money paid for every person enrolled in a health plan whether or not they present for services during a specific time • Fee-For-Service – a set fee is paid for a specific unit of service (usually an hourly or less)

21. Some of the Unique Funding Mechanisms Used by Wraparound Milwaukee and Other Child Serving Systems to Pool Funding – cont’d • Fixed Funding – a specific budgeted amount of money is allocated and paid to the provider • Re-Directing Funding – funds not expended for a specific service or use (ex. Residential treatment, psychiatric inpatient care) are made available to fund other services (usually community-based care) • 1915a – allows for a voluntary managed care system for a defined population in a defined geographical area

22. Key Components of Wraparound Milwaukee CME Delivery Model Care Coordination Provider Network Mobile Crisis Family Advocacy Information Technology

23. Care Coordination Services Wraparound Milwaukee contracts with 8 community agencies to provide care coordination services 1:10 ratio of care coordinators to families Responsibilities : Facilitate care planning teams using wraparound approach Identify & obtain formal & informal services Monitor care plan Maintain weekly face to face contact Coordinate with probation & Child Welfare workers

24. Provider Network Array of 70 services and 200 provider agencies No formal contracting – Wraparound Milwaukee utilizes fee-for-service system Rates, units of service, service definitions established by Wraparound Milwaukee Wraparound Milwaukee is single payor for all services including mental health, social, supportive and placement services All providers linked on one IT system

25. Wraparound Milwaukee’s Comprehensive Service Array Supportive Services • Mentors • Crisis 1:1 stabilizer • Tutor • Parent/family aide • Life coach – independent living • Employment preparation and placement • Job – internship • Other Respite • Crisis/planned respite • Residential respite Service Coordination • Care Coordination • Discretionary • Flex Funds • Clothing • Food/groceries • Housing assistance • Child care • Furniture, appliances • YMCA membership • Educational expenses Behavioral & Clinical Services • Crisis intervention • Individual therapy • Intensive in-home therapy • Evaluation • Substance abuse therapy – individual and group • Medication management • Day treatment • Special therapy i.e. behavioral management team Placement Services • Acute hospitalization • Foster home and treatment foster home • Group home care • Residential treatment • Crisis/residential, group care, treatment foster care • Supported independent living Other Supportive • Camps • After school • Suspension accountability • Transportation • Interpretive services • Equine therapy • Consultation with other professionals

26. Mobile Crisis 24/7 mobile crisis availability (MUTT) CME operates all crisis services for enrollees & all county residents Mobile crisis is gatekeeper for inpatient psychiatric treatment Optional crisis stabilization services used extensive i.e. crisis 1:1 stabilizers, crisis respite/group care, etc. Wraparound – MUTT Team serves Child Welfare Dept.

27. Family AdvocacyFamilies United of Milwaukee 1:1 Advocacy Support Groups Family & System Education Satisfaction Surveys Serve on Committee & Boards Train Care Coordinators Resource Development Educational Advocacy

28. Information Technology One electronic health record and single information system links all care coordinators, providers and system partners Single release of information across all child serving systems

29. Outcomes for Wraparound Milwaukee Financial – average cost per month for a child in Wraparound Milwaukee is $3700 versus nearly $9000 per month in a DOC correctional facility, over $9000 per month in a RCCCY and over $10,000 for a 7 day stay in a psychiatric hospital Programmatically – average Milwaukee County population in RCCCY dropped from 375 to 90 youth; large drop in DOC population resulting in closure of two state facilities, reduction in psychiatric inpatient beds from over 250 to 50 beds Clinically – improved functioning of youth at home and in school based on CBCL (Achenbach) administered at enrollment and discharge Recidivism – most recent study of 669 delinquent youth enrolled in Wraparound Milwaukee for a period of 15 months showed a 15.2% rate of reoffending. Among 210 “high risk youth” i.e. juvenile sex offenders, etc. the rate was even lower at 6.7% Child Permanency – 75% of youth were in permanent setting with parent, relative, adoptive resource or subsidized guardianship

30. Is Wraparound Milwaukee an Evidence-Based Practice? There are at least 10 studies currently supporting Wraparound as a EBP (National Wraparound Initiative NWI – lists on web-site) We believe in Evidence Informed Approaches versus EBP’s We don’t buy off the shelf programs ie. MST, etec We look at innovative approaches and “best practices” Adapt to our community circumstances and characteristics of our population We measure overall impact on our youth/families through established outcomes measures Market forces usually drive families to utilize providers and services who are more innovative, get better outcomes and provide a better quality service

31. Examples of Other Care Management Entities New Jersey Maryland DAWN – Indianapolis Nebraska

32. New Jersey System of Care Initiative & Care Management Design Pooled Funding at State Level • Registration • Screening for eligibility • Tracking referral • Authorization of services • Support network development Lead non-profit agencies managing high utilizing child/youth population; get $1100 per child per month for care mgmt & utilization mgmt only, mental health services are still purchased fee-for-service Any licensed provider Family Support Org

33. New Jersey of Care Funding Streams State appropriations Mental Health Child Welfare Medicaid Federal Revenue Sources Medicaid/SCHIP Uses Rehab Option, fee-for-service, targeted case management

34. Maryland System of Care Initiative & Care Management Model State Governance Entity 1915c Waiver • Child & Family Team • Intensive Care Mgmt • Utilization Mgmt • Develop Provider Network • Link to Family Support Services • Evaluation Contracted private non-profit agencies; get about $1200 per child per month for care mgmt and utilization mgmt, not services Provider Network remains fee-for-service

35. Maryland Funding Streams Childrens Cabinet General funds budgeted for RTC youth Rehab option funds Federal Medicaid Match for public mental health system services and PRTF waiver services Match for administrative funding for care coordination Title IV-E Federal matching funds for placement cost for eligible youth

36. Maryland Funding Streams – cont’d Dept. of Human Services Child Welfare general funds for placement cost Dept. of Juvenile Services Juvenile Justice general funds share of placement costs System of Care Grants Federal funds to carry out specific project

37. DAWN Project – Marion County, Indiana (Indianapolis) 4068 + 186 = 4254 Child Welfare Bill Medicaid for covered services on fee-for-service basis Dept of Mental Health or DAWN CMO Funding & Utilization Mgmt Juvenile Justice or Child & Family Teams Special Ed 90% Direct Care 6% Indirect 4% Admin

38. Nebraska Region 3 (22 Rural Counties) $2137 includes placement & support services & care coordination costs but not Medicaid service costs which is billed fee-for-service Integrated Care Coordination Unit Reducing time to reach permanency & reducing recidivism Care Managers 1:10 Formal & Informal Services

39. Milwaukee County Medical Home Model for Foster Care(Proposed & Planned in 2006 – But Not Implemented) IPN Physicians & Provider Network Wraparound Milwaukee Behavioral Network Dental Network

40. Strategic Funding Consideration for CME’s Identify your population focus Identify all agencies that spend dollars on services to the target population How much Types of dollars being spent (i.e. federal, state, local) Identify resources untapped or underutilized (Medicaid, Child Welfare, IV-E, education, etc.) Identify utilization patterns & expenditures associated with high costs/poor outcomes & strategies for redirection (state correctional charges, residential treatment, etc.)

41. Strategic Funding Consideration for CME’s – cont’d Identify disproportionate & disparities in how resources & monies are currently directed Identify the funding structures that will best support the system design (pooled or braided, purchasing collaborative, etc.) Identify short-term & long-term financing strategies (i.e. re-direct funds from reduced psychiatric hospitalization, waivers, grants, performance-based contracting, etc.)