Planning for Sustainability: Being Strategic Presented by Michelle Zabel, MSS

1. Planning for Sustainability: Being Strategic Presented by Michelle Zabel, MSS Director, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice Institute Division of Child & Adolescent Psychiatry, School of Medicine, University of Maryland, Baltimore

2. Seizing Opportunities, Being Realistic Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change Be aware of the fiscal, political, and cultural climate Budget issues Political timeframes Competing pressures and interests

3. Creating Linkages, Connecting the Dots Review and synthesize existing documents and strategic plans—before beginning the work Populations & Outcomes: Identify results and indicators already in use Use measures that have strong Communication Power (Does the indicator communicate to a broad range of audiences?) Proxy Power (Does the indicator say something of central importance about the result?) Data Power (Quality data available on a timely basis) Connect the data requirements across grants and contracts

4. Using Results Accountability to Frame the Maryland Child & Family Services Interagency Strategic Plan Result (a quality of life condition we want to achieve): All of Maryland’s children involved with or at-risk for involvement with multiple child-family serving agencies will be successful in life. • Indicators (how we measure this condition): • Out-of-home placement: Rate of children under 18 entering out-of-home placement • Education: • Percentage of 3rd grade students scoring proficient or advanced in reading on the Maryland School Assessment. • Percentage of youth, 18-24, by highest educational attainment (less than a high school diploma or equivalent, high school graduate/equivalent, some college or associate’s degree, and bachelor’s degree or higher) • Juvenile Offense Arrests: • The rate of arrests of youth ages 15-17 for violent offenses. • The rate of arrests of youth ages 15-17 for serious non-violent offenses. Population of Focus (focus for the strategic planning process): Children and youth involved in or at-risk for involvement with multiple child-family serving systems.

5. THE IMPLEMENTATION OF A COORDINATED INTERAGENCY EFFORT TO DEVELOP A YOUTH SERVICE SYSTEM THAT CAN BETTER MEET THE NEEDS OF YOUTH AND THEIR FAMILIES AND TARGET CHILDREN WHO ARE AT-RISK Maryland Child & Family Services Interagency Strategic Plan

6. CREATED A SERIES OF RECOMMENDATIONS UNDER EIGHT DIFFERENT THEMES: Family & Youth Partnership Interagency Structures Workforce Development & Training Information-Sharing Improving Access to Opportunities and Care Continuum of Opportunities, Services & Care Financing Education IMPLEMENTATION IS OCCURRING AND STATE AND LOCAL LEVELS, WITHIN AGENCIES AND ACROSS SYSTEMS Maryland Child & Family Services Interagency Strategic Plan

7. Embed System of Care Values and Principals into Policy and Regulation Terms that have been institutionalized with definitions in Medicaid regulations (10.09.79) include: Care Coordinator Caregiver Caregiver peer-to-peer support Care management entity Child and Family Team Family support organization Family support partner Peer-to-peer support Plan of Care Wraparound Youth Peer-to-Peer Support Youth Support Partner Other systems of care concepts and processes in the Medicaid regulations include: The components of a comprehensive and individualized Plan of Care The role and responsibilities of the Care Management Entity The role and responsibilities of the Child and Family Team Service descriptions, including caregiver peer-to-peer support, youth peer-to-peer support, and family and youth training Rates are provided for family members and youth to bill Medicaid for services provided under the Waiver

8. Governance & System Management Presented by Michelle Zabel, MSS Director, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice Institute Division of Child & Adolescent Psychiatry, School of Medicine, University of Maryland, Baltimore

9. Interagency Structures Interagency structures need to be redesigned to support the culture shift to a more individualized, family-centered service delivery system. Communication needs to flow easily between the state and local levels, as well as between and across agencies, systems, community members and families. Recommendation 1: The Children’s Cabinet should ensure that there are regular opportunities for direct communication between the Local Management Boards and the Children’s Cabinet or the Children’s Cabinet Results Team. Recommendation 2: There should be a commitment from all child-family serving agencies at the state and local levels to support an improved interagency structure and individualized plans of care for children and families.

10. The Maryland Children’s Cabinet and the Governor’s Office for Children VISION • Children’s Cabinet: All Maryland’s children are successful in life. • Governor’s Office for Children: Maryland will achieve child well-being through interagency collaboration and state/local partnerships. MISSION • The Children’s Cabinet, led by the Executive Director of the Governor’s Office for Children (GOC), will develop and implement coordinated State policies to improve the health and welfare of children and families. The Children’s Cabinet will work collaboratively to create an integrated, community-based service delivery system for Maryland’s children, youth and families. Our mission is to promote the well being of Maryland’s children. COMPOSITION • The Secretaries of the Departments of Budget and Management, Disabilities, Health and Mental Hygiene, Human Resources, and Juvenile Services, and the State Superintendent of the Maryland State Department of Education. • Chaired by the Executive Director of the Governor’s Office for Children.

12. A Scenario for State and Local Governance Structures State Governance State Systems Management Local Governance Local Systems Management Family Support Organizations Individual Care Planning with Child and Family Teams: Care Management Entity (CME)

13. Purpose is to “ensure the implementation of a local interagency service delivery system for children, youth, and families.” (Human Services Article, Annotated Code of Maryland) Composed of: Public and private community representatives and, A senior representative or department head of the:  (i) local health department;  (ii) local office of the Department of Juvenile Services;  (iii) core service agency;  (iv) local school system; and  (v) local department of social services.  LMBs are tasked with: Strengthening the decision-making at the local level; Designing and implementing strategies that achieve clearly defined results for children, youth, and families as outlined in a local 5-year strategic plan; Maintaining accountability standards for locally agreed upon results for children, youth, and families; Influencing the allocation of resources across systems to accomplish desired results; Building local partnerships to coordinate children, youth and family services within the county to eliminate fragmentation and duplication of services; and, Creating an effective system of services, supports, and opportunities to improve outcomes for all children, youth and families. Local Management Boards

14. Key Functions Include: Care Authorization Provider Credentialing and Enrollment Billing/Reimbursement and Provider Payment Utilization Management Continuous Quality Improvement Outcomes Data Information Management Administrative Service Organization

15. A CME is a structure that serves as a “locus of accountability” for youth with complex needs and their families. Provide Supports to Youth and Families: Child Family Team Facilitation using Wraparound Service Delivery Model Care Coordination using Standardized Assessment Tools Care Monitoring and Review Peer Support Partners Provide System Level Functions: Information Management & Web-based Information System Provider Network Recruitment and Management Utilization Review of Service Use, Cost, and Effectiveness Evaluation and Continuous Quality Improvement Cross-System and Jurisdiction Financing Populations to Be Served: 1915(c) Psychiatric Residential Treatment Facilities (PRTF) Demonstration Project Medicaid Waiver SAMHSA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion using Resource Coordinators Other Out-of-Home Diversion using Care Coordination Regional Care Management Entities

16. Wicomico County, MD System of Care Structure Local Management Board Family Partner- Ship Center SOC Community Advisory Board Care Management Entity Care Coordinators Family Partners 211 System (screening) Service Coordination/Systems Navigation - CANS Families and Youth Agencies/Court Adapted from Wicomico County, MD

17. Outreach and Engagement: Organized Pathway to Service System and Intake/Referral Presented by Michelle Zabel, MSS Director, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice Institute Division of Child & Adolescent Psychiatry, School of Medicine, University of Maryland, Baltimore

19. Access to Care and Opportunities Prompt access to opportunities and appropriate resources empowers families and youth to address identified needs, build on strengths, and participate in individualized services and supports. Families and youth should receive timely and respectful support to navigate systems. Recommendation: Families and youth should have access to support and assistance and make connections with appropriate opportunities and resources to address identified needs and enhance strengths and assets.

20. Maryland’s Local Access Mechanisms Single Point of Access: A single point of entry for families who wish to obtain information or enter the system, regardless of the intensity of the needs of their children.

21. Navigation Services Navigation Services: Services for families who need additional assistance beyond a simple referral, including assistance in identifying strengths and needs and obtaining necessary services. Family Navigation: Navigation services provided by a legacy parent or primary caregiver who is caring for or has cared for a child with mental health needs and/or developmental disabilities, including a child with intensive needs. Systems Navigation: Navigation services provided by a professional or paraprofessional, not necessarily a legacy parent or primary caregiver.

22. Data-Driven Decision Making Presented by Michelle Zabel, MSS Director, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice Institute Division of Child & Adolescent Psychiatry, School of Medicine, University of Maryland, Baltimore

23. Align Outcomes with Shared Results and Indicators and Performance Measures Already in Use across Systems Overarching Long Term Outcomes for Populations of Focus Maryland’s Children’s Cabinet Results for Child Well-Being Maryland Child and Family Services Interagency Strategic Plan Consistent Performance Measures Connect the data requirements across grants and contracts 1915(c) Psychiatric Residential Treatment Facilities (PRTF) Waiver SAMSHA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion Other Out-of-Home Diversion using Care Coordination

24. Demystifying Data:Using Understandable Language and Structure to Collect and Analyze Service Data Performance Accountability How much service was provided? Number of customers served (by customer characteristic) Number of activities (by type of activity) How well was the service provided? Customer satisfaction, unit cost, percent of staff fully trained Activity-specific measures: Percent of clients completing activity, percent of actions meeting standard Is Anyone Better Off? (What effect are the services having?) Measurable changes in Skills/Knowledge, Attitude/Opinion, Behavior, Circumstance Adapted from Friedman, M. 2005. Trying Hard is Not Good Enough. Trafford Publishing, Victoria, BC

25. Establishing a CORE Set of Data Elements Collected across Populations Align your data collection efforts where possible to avoid redundant data collection and reporting Federally-funded initiatives will require instruments and tools (performance measures) around which your cross-initiative evaluation plans can be built Local evaluations can be allowed for collection of additional measures of interest, such as: Education – achievement, completion Child Welfare – permanency, child safety Juvenile Services – restrictiveness of placement, recidivism

26. Making the Data Work for You:Proving Your Initiative’s Effectiveness to Funders and the larger Community Planning and day-to-day decision making is reasoned. Utilization Management changes effectively redirect resources to where they are needed most. Quality improvement efforts can be focused on subgroups of concern with methods of proven effectiveness. Cost monitoring will show return on the dollar in terms of desired outcomes. Research and evaluation questions are answered in clear measurable terms as well as with effective anecdotal evidence. Use data to strengthen social marketing efforts, to target training efforts, to educate about and to advocate for your children, youth and families across venues.

27. Examples of Statewide Quality Improvement Efforts in Maryland Focus on quality statewide and by site Identify local programs and practices Identify types of youth served and practices associated with good outcomes (and practices associated with bad outcomes) Inform use of evidence-based practices (e.g. CBT for depression) Support providers with training informed by data Inform performance-based contracting

28. Service/Support Array, Provider Network, Natural Helpers and Financing Presented by Michelle Zabel, MSS Director, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice Institute Division of Child & Adolescent Psychiatry, School of Medicine, University of Maryland, Baltimore

29. Continuum of Opportunities, Supports, and Care There is a need for the Children’s Cabinet to agree on a continuum of opportunities, supports, and care, including evidence-based and promising practices, and work toward ensuring that appropriate levels of services and supports are available to every jurisdiction and community to meet their specific population needs, with the intent of improving outcomes and reducing out-of-home placements. Recommendation 1: The Children’s Cabinet is committed to the creation of a full community-based continuum of opportunities, supports, and care that is developed in partnership with local jurisdictions, families and the provider community to meet the specific, individualized needs of children and families. The Children’s Cabinet should prioritize efforts to safely and effectively serve children in their own homes by expanding the continuum of services. These efforts should include increased diversity, quality, and accessibility of in-home services with an emphasis on reunifying children with their families at the earliest possible time. Services should be culturally competent and responsive, and children should receive all supports to which they are entitled.

30. Continuum of Opportunities, Supports, and Care Recommendation 2: The Children’s Cabinet should work collaboratively to serve children who are in an out-of-home placement in their home schools and communities more effectively with fewer placement disruptions resulting in better permanency outcomes for children and families. Recommendation 3: There should be a commitment to diverting youth from detention and commitment within the juvenile justice system. Subject to the availability of funding, consideration should be given to an expansion of the availability and use of delinquency prevention and diversion services with a focus on creating a range of community service and education options while increasing empathy and caring in youth. Recommendation 4: The Children’s Cabinet should continue to make a commitment to utilizing evidence-based and promising practices to ensure that effective community education, opportunities, support, and treatment options are available to the children, youth and families for whom they are appropriate.

31. Youth Peer-to-Peer Support Provided to a youth enrolled in a CME by a youth support partner (YSP) who: Assists in describing the program model Supports the family and/or participant to participate effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation; Works with the Care Coordinator, participant and family to develop the plan of care; and, Assists in accessing services and removing barriers to care. Are individuals with experience with State or local services and systems as a consumer who has had emotional, behavioral or mental health challenges, are 18-26 years old, have completed the required training programs, and are employed by a Family Support Organization.

32. Caregiver Peer-to-Peer Support Provided to the caregiver of a youth enrolled in a CME by a family support partner (FSP) who: Assists in describing the program model Supports the family and/or participant to participate effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation; Works with the Care Coordinator, participant and family to develop the plan of care; and, Assists in accessing services and removing barriers to care. Are legacy family members (individuals who have current or prior experience as a caregiver of a child with Serious Emotional Disturbance (SED) or a young adult with Serious Mental Illness (SMI) who are 21 or older, have completed the required training programs, and are employed by a Family Support Organization

33. EBP Implementation in Maryland: Our Child and Youth Trajectory • 2008, Maryland Child and Family Services Interagency Strategic Plan: Includes evidence-based and promising practices in the theme, “Continuum of Opportunities, Supports and Care:” • Specific Recommendation in the Plan: The Children’s Cabinet should continue to make a commitment to utilizing evidence-based and promising practices to ensure that effective community education, opportunities, support, and treatment options are available to the children, youth and families for whom they are appropriate. • 2008, Children’s Cabinet joins efforts to improve practice and implement EBSs for children, youth and families in Maryland through funding to support implementation, fidelity and outcomes monitoring, and fiscal analysis of EBPs.

34. EBP IMPLEMENTATION CENTER • Obtain data on existing EBPs in Maryland • Conduct a “sizing” of the EBPs to determine which EBPs should be expanded or brought into the state • Provide training on identified EBPs • Identify funding mechanisms to support the ongoing implementation and sustainment of EBPs • Conduct fidelity monitoring on EBP implementation • Evaluate outcomes of EBPs

35. Prioritized EBP’s Trauma Cognitive Behavioral Therapy Functional Family Therapy Multi Systemic Therapy Brief Strategic Family Therapy Multi Dimensional Treatment Foster Care 35

36. Be both strategic and opportunistic Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change: CMHI Grants – MD CARES and Rural CARES Mental Health Transformation and Block Grants PRTF 1915(c) Demonstration Waiver Healthy Transitions Grant (Transition-Aged Youth) National Child Traumatic Stress Network Grants Children’s Bureau Grants to Child Welfare OJJDP Grants to Juvenile Justice State Agency Initiatives Legislative Mandates

37. A CME is a structure that serves as a “locus of accountability” for youth with complex needs and their families. Provide Supports to Youth and Families: Child Family Team Facilitation using Wraparound Service Delivery Model Care Coordination using Standardized Assessment Tools Care Monitoring and Review Peer Support Partners Provide System Level Functions: Information Management & Web-based Information System Provider Network Recruitment and Management Utilization Review of Service Use, Cost, and Effectiveness Evaluation and Continuous Quality Improvement Cross-System and Jurisdiction Financing Populations to Be Served: 1915(c) Psychiatric Residential Treatment Facilities (PRTF) Demonstration Project Medicaid Waiver SAMHSA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion using Resource Coordinators Other Out-of-Home Diversion using Care Coordination Regional Care Management Entities

38. Caregiver Peer-to-Peer Support Provided to the caregiver of a youth enrolled in a CME by a family support partner (FSP) who: Assists in describing the program model Supports the family and/or participant to participate effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation; Works with the Care Coordinator, participant and family to develop the plan of care; and, Assists in accessing services and removing barriers to care. Are legacy family members (individuals who have current or prior experience as a caregiver of a child with Serious Emotional Disturbance (SED) or a young adult with Serious Mental Illness (SMI) who are 21 or older, have completed the required training programs, and are employed by a Family Support Organization

39. EBP IMPLEMENTATION CENTER • Obtain data on existing EBPs in Maryland • Conduct a “sizing” of the EBPs to determine which EBPs should be expanded or brought into the state • Provide training on identified EBPs • Identify funding mechanisms to support the ongoing implementation and sustainment of EBPs • Conduct fidelity monitoring on EBP implementation • Evaluate outcomes of EBPs

40. Be both strategic and opportunistic Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change: CMHI Grants – MD CARES and Rural CARES Mental Health Transformation and Block Grants PRTF 1915(c) Demonstration Waiver Healthy Transitions Grant (Transition-Aged Youth) National Child Traumatic Stress Network Grants Children’s Bureau Grants to Child Welfare OJJDP Grants to Juvenile Justice State Agency Initiatives Legislative Mandates