Children’s Waiver and CSPOA

1. Children’s Waiver and CSPOA Presentation to Ambulatory Care Committee May 23, 2011

2. The Ambulatory Restructuring JourneyWhere Have We Been? 2008: Children’s Ambulatory Restructuring begins • Focused on Case Management, Waiver, Day Treatment and Partial Hospital • In-depth review and recommended program design - align with the vision and values of the Children’s Plan • Years since services updated • Effort to create consistent services and themes across the continuum • Program focus – fiscals in second phase 2009: Span of Project Focused on: • Waiver • Case Management • Access Processes (SPOA andPACC)

3. Where Have We Been? 2010: • Ambulatory Care Restructuring Subcommittees crafted in-depth recommendations on programmatic changes to Case Management, Waiver, CSPOA and PACC. • “Super Waiver” concept (combining Waiver and Case Management) • Standardization across NYS on specific functions of CSPOA • Tweaks to PACC process • Assignment: OMH – Jim Rast/Roger Auerbach to develop two models for review and comment • 2 program models for Case Management and Waiver • 1 program model for CSPOA 2011: • Presentation of Superwaiver Models and CSPOA Recommendations

4. Crafting Program Models Within a Changing Landscape • New Administration • State Fiscal Crisis • Medicaid Redesign • Federal Shifts for Targeted Case Management • Health Homes likely to subsume TCM in some manner • Regional Behavioral Health Organizations

5. CSPOA/PACC • CSPOA – defer action until BHO picture develops • PACC – Make improvements that we can – seek opportunities through BHO to align PACC

6. Putting Things Into Perspective Waiver and Case Management for children and youth: • Strong impact in supporting families to raise their child in their home and community. Believe that these service reduce residential/hospital use. • Current program and fiscal models CAN be improved to: • Reduce barriers and burdens that drive cost and limit flexibility • Better aligned with evolving values and systems • Be more efficient • Serve more kids – improving access • How do we evolve these programs in a “new world”

7. Criteria to Evaluate Mental Health Waiver Models Do the models: • Position us for the new environment? • Encourage the development of natural and non-traditional supports (do with families and cheer on verses do for them)? • Enhance the engagement of youth and families? • Simplify services and fiscal models? • Ease eligibility? • Serve more children?

8. Model 2Case Management and the Waiver

9. Model 2Revised Waiver and Case Management The Mental Health Waiver and Case Management remain independent programs with slight changes to each program model.

10. Model 2Revised Waiver and Case Management • Case Management: • All Case Management (ICM,SCM,BCM) will become blended case management teams • Case Managers will have a 1:14 caseload (weighted average based on change from blending ICM (1:12) and SCM (1:20)) • Enrolled children/youth will have limited access to: Respite, Skill Building and Parent and Youth Peer Support Services through enhanced service dollars • Case Management functions will comply with Federal definitions (Linkage and Coordination)

11. Model 2Revised Waiver and Case Management • Waiver: • Five services: Care Coordination, Respite, Skill Building, Therapeutic Application and Parent and Youth Peer Support • All Waiver services, with the exception of Care Coordination, will be fee for service • Crisis Response becomes part of Care Coordination job description • Care Coordinator has a 1:6 caseload

12. Model 2 Waiver and Case ManagementFiscal Assumptions • Case rates for Case Management will remain the same • Service dollars associated with Case Management will increase to allow the purchase of limited Waiver services: Skill Building, Respite, Parent/Youth Peer Support • Funding for this increase in Case Management service dollars will come from: • Reallocation of the State share of dollars available due to historic underutilization of Waiver’s Intensive In-Home Services. • Decreasing the Waiver flex dollars from $2,500 to $1,500 per child and reallocating the State portion of the difference ($500 per child). • The rates for these services will not change and will be the same for both Waiver and Case Management.

13. Model 2 Fiscal Model Utilizing the assumptions: • Reallocation of $2.6m from Waiver to Case Management. Of that amount: • $1.8m will come from intensive in-home. This is the State share of “out the door” $ that were not utilized. (2009 Data) • $ 796,500 will be available as a result of flex $ reduction (State share) • Employing the 1:14 caseload, the number of units of service that could be purchased at the current rates ($46 Upstate, $49 Downstate) would be 83 units Upstate and 79 unitsDownstate annually, per caseload, per case manager • This results in about 6 units (hours) of service per case management child, per year. • Note these calculations do not include the current service dollars already associated with case management.

14. Model 2 Strengths/Limitations For Families: • Although limited, this model allows for children/youth in Case Management to receive Waiver services thereby eliminating the step down from Waiver. For Children’s Mental Health System: • Smaller change from a provider perspective. The question with this model is rooted in the State and Federal TCM considerations. Will this model support service delivery given MRT and Federal Medicaid reforms?

15. Model 1Integrated Mental Health Waiver

16. Model 1Integrated Mental Health Waiver The goal of the Waiver process is to create a culture for families and their natural helpers to come together regularly to create and implement plans in a way which builds and sustains hope.

17. Model 1Revised Waiver Design Approach: • Strengthen families and build natural supports to reduce and ultimately eliminate on-going reliance on formal MH services • Expand to enroll proportion of high needs children/youth currently in ICM Eligibility of Enrollment Enhanced: • Lower enrollment age to three years • Increase enrollment age limit to 20 years and 6 months Service Simplified: • 2 Staff functions • Care Coordination • Parent Peer Support • 2 Contracted Services • Skill Building • Respite

18. Model 1 Revised Service Elements Care Coordination: • Support family and youth in engagement in the service plan and the development of natural supports • Facilitation of Family Team Meetings • Coordination of all services and support of families in learning to assume this role • Collaboration with other providers/systems involved in the child’s care • Coaching of youth and family to support clinical treatment plan goals (Current-Intensive In Home/Therapeutic Application) • Crisis planning and intervention • Provision is initially (first 3 months) intensive to promote engagement; gradually diminishes as a family and their natural supports take on this role

19. Model 1 Revised Service Elements Parent Peer Support: • Teach parents to develop collaborative relationships with natural and formal supports • Teach and support parents in becoming the best possible advocates for their children • Liaison between Waiver workers and parents/caregivers • Connects with Family Support Services agencies • Initially (first 3 months) intensive to promote engagement

20. Model 1 Revised Service Elements: Contract Services Skill Building and Respite: • Skill Builders partner with a child and family to assist a child in acquiring social life skills and also assist the family and their natural support system in support the child’s progress post-Waiver • Youth Peer Support embedded in Skill Building • Encourage Peer and Family Support agencies to become independent contractors for each of these services • Both are initially (first 3 months) provided to a child/youth, family, and natural supports by the formal service system, if indicated in plan • Roles transition to that of coach for a parent and their natural support system as formal service intensity decreases during the last 6 months of Waiver episode; fiscals designed to incentivize this new approach

21. Model 1 Strengths/Limitations For Families: • Eliminates the service step-down between HCBS Waiver and Intensive Case Management • Keeps children at home in their own communities • Strengthens families and shortens time needed for formal behavioral health services For the Children’s Mental Health System: • Simplifies Waiver • Increases Flexibility • Expands Waiver to serve Intensive Case Management youth under the Waiver umbrella • Bigger change for the system, but potential for greater ROI

22. Model 1 Revised Waiver Design Caseloads: Care Coordinator • 1:9 • Minimum required contacts spread across caseload Parent Partner • 1:27 • Minimum required contacts spread across caseload

23. Model 1 Revised Waiver DesignFiscal Assumptions Norm to insert

24. Model 1 Revised Waiver Fiscal Model • Norm to insert

25. Discussion