A Waiver for Children with a Serious Emotional Disturbance (SEDW)

1. A Waiver for Children with a Serious Emotional Disturbance(SEDW) A collaborative effort to achieve better outcomes for children with serious emotional disturbance September 2010 Waiver Conference

2. Welcome & IntroductionsConnie Conklin, MDCHJoan Deschamps, MDCHBeth Ann Meints, MDCH

3. Today’s Presentation • Overview the SEDW • Eligibility requirements • Services • DHS SEDW Pilot • Currently participating sites • Wraparound • Blended funding and the SED Waiver

4. History of 1915 (c) Waivers • Legislation • Enacted under the Reagan administration • Title XIX of the Social Security Act • Michigan DCH’s (c) and (b)(c) Waivers • Waiver for children with a serious emotional disturbance • Children’s Waiver Program • Habilitation Supports Waiver

5. SEDW • The SEDW is a 1915 (c) waiver that: • Is separate from the Mental Health 1915 (b) (c) Medicaid managed care waiver for specialty mental health services and supports, using a capitation payment system • Is billed “fee for service”, and • Provides enhancements or additions to Medicaid State Plan mental health coverage • Federal match funds to support collaborative service delivery in a child’s community

6. SEDW • Currently approved through Sept. 2013 • Administered by the DCH and managed by CMHSPs • Provide in-home services and supports to children with serious emotional disturbance and their families • Available in enrolled counties only

7. Purpose of 1915 (c) Waiver • Provide Medicaid coverage to children who: • Without the provisions of this waiver would require hospitalization or institutionalization • Would otherwise not be Medicaid eligible while residing with their birth or adoptive families

8. Accessing the SEDW Technical Assistance Manual

9. http://www.michigan.gov/mdch/0,1607,7-132-2941_4868_7145-168285--,00.htmlhttp://www.michigan.gov/mdch/0,1607,7-132-2941_4868_7145-168285--,00.html

10. Billing and Reimbursement Outside the Mental Health Managed Care System Fee - For- Service As part of application an individualized budget is submitted which indicates State Match Source 10

11. Quality Assurance & Improvement DCH - SEDW staff conduct: • State level reviews of all applications and re-certifications, and • On-site reviews: • Use a SEDW quality management protocol to ensure that federal requirements and assurances of quality are met • Wraparound Model Fidelity Assurance • Are conducted bi-annually • Report of the findings • Plans of correction 11

12. SEDW Eligibility Criteria • The child must: • Be under the age of 18 when approved for the waiver, but can remain on the waiver until age 20 if other eligibility requirements are met. • Reside with his/her birth/adoptive parents(s), a relative who is the child’s legal guardian, or in foster care with a permanency plan. • Have a primary DSM Axis I mental health diagnosis, • Be in need of and receive at least one Waiver service per month • MeetCMHSP contract criteria for and is at risk of inpatient hospitalization in the state psychiatric hospital

13. Inpatient Admission Criteria: Children Through Age 21 “Inpatient psychiatric care may be used to treat a child or adolescent with mental illness or serious emotional disturbance who requires care in a 24-hour medically structured and supervised facility. The SI/IS criteria for admission are based on the assumption that the beneficiary is displaying signs and symptoms of a serious psychiatric disorder, demonstrating functional impairments and manifesting a level of clinical instability (risk) that are, either individually or collectively, of such severity that treatment in an alternative setting would be unsafe or ineffective.”

14. Eligibility Criteria…continued • The child must have at least one of the following: • Severe psychiatric signs and symptoms • Disruptions of self-care and independent functioning • Harm to self or others • Drug/Medication complications or co-existing general mental condition requiring care • Special consideration: If Substance Abuse Psychiatric condition must be primary

15. Eligible Criteria … continued • The Child must demonstrate serious functional limitations that impair his/her ability to function in the community (functional criteria is identified using the Child and Adolescent Functional Assessment Scale [CAFAS]) • CAFAS score of 90 or greater for children age 12 or younger; or • CAFAS score of 120 or greater for children age 13 to 18.

16. Financial Eligibility • The Child must meet Medicaid eligibility criteria • Note: If a child is not Medicaid eligible while residing with his/her family and determined clinically eligible for the SEDW, the child can be viewed as a “family of one” to meet financial eligibility for Medicaid.

17. Covered Waiver Services • Wraparound Services • Community Living Supports • Family Training • Family Training & Support (family support partners) • Respite Care • Therapeutic Activities (art, music, rec) • Therapeutic Child Foster Care • Therapeutic Overnight Camp • Transitional Services

18. OtherCovered Services • Mental Health State Plan services that can be billed to Medicaid on a fee for service basis by the CMHSPs • Natural supports • In-kind services provided by community agencies

19. Skill development activities of daily living Skills, such as: Personal hygiene Household chores School attendance Staff assistance, support and/or training with: socialization skills, interactions, and internal controls Community Living Services (CLS)

20. Family Home Care Training • Training and counseling services provided by professional staff for the families of individuals served on the waiver. • Instruction about treatment interventions and support intervention • Counseling service for family members

21. Family Support & Training (FS&T) • FS&T, provided by a parent support partner, which supports parents/families of children with SED to: • Be empowered, • Be confident, and • Have skills that will enable them to assist their child to improve in functioning.

22. Respite Care • Respite care is a service provided to individuals unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care.

23. Therapeutic Activities • The focus of therapeutic activities is to interact with the child to accomplish the goals identified in the POS. • Service Activities include: • Music Therapy, • Recreation Therapy, and • Art Therapy.

24. Child Therapeutic Foster Care • Provides an intensive therapeutic living environment for a child with challenging behaviors. Important components of CTFC include: • Intensive parental supervision • Positive adult-youth relationships • Reduced contact with other children with behavioral disorders • Family behavior management skills

25. Therapeutic Overnight Camp • A group recreational and skill building service in a camp setting aimed at meeting goals detailed in the child’s plan of service. A session can be one or more days and nights of camp.

26. Transition Services • This is a one-time-only expense to assist a child returning to the family home and community while the family is in the process of securing other benefits (e.g. SSI) or resources (e.g., governmental rental assistance and/or home ownership programs) that may be available to assume these obligations and provide needed assistance.

27. Wraparound • Wraparound Service Facilitation and Coordination for Children and Adolescents is: • a highly individualized planning process • performed by specialized wraparound facilitators • coordinate the planning for, and delivery of, services and supports for the identified child

28. Current SEDW Sites

29. Waiver Slot –FY 2010 • Added: • 91 traditional enrollment (Match provided by CMHSP or Child Care Funds (local court) • 266 DHS referred children (Pilot) • Total 357 slots

30. Why utilize 1915C Waivers Filling the Cracks DHS EDUC CMH SA COURT

31. Why do Blended Braided Funding? Helps you build local systems of care and builds statewide capacity for systems of care. Helps sustain SAMSHA grants Builds capacity and trust across systems Cost share vs. Cost shift Shares gate-keeping of high need children Brings additional state and federal revenue to your community Makes children eligible for Medicaid who would not otherwise be eligible 31

32. Common Funds Sources for Children’s Services Mental Health: Medicaid, Medicaid Waivers, General funds, Federal Mental Health Block Grant Child Welfare: Strong Families/Safe Children, Child safety permanency planning, Child protection/Child Permanency (IVB), General funds, Child care Funds Juvenile Justice: County Child Care Funds, Local dollars, some counties have juvenile justice millage SAMSHA System of Care Grants Foundations United Way Local Dollars 32

33. How does Wraparound Fit In? • Wraparound is a planning process: It is about ACTION • The planning process identifies strengths, needs, strategies (staffed services and non-staff items) and outcomes. • Wraparound utilizes a Child and Family Team with team members determined by the family, often representing multiple agencies, and informal supports. • The Child and Family Team creates a highly individualized plan for the child and family that consists of services and supports

34. Key Features • Child and Family Team • Team Facilitator • Strengths and normalized needs • Family access, voice and ownership • Unconditional • Cultural Competency • Creativity • Monitoring/evaluation: Outcome oriented • Community ownership • Community safety

35. Things to Think About • Who are the underserved children in our community? • Who do we fight the most over trying not to serve? • What are their financial and personal eligibility characteristics SED/CMH, Court CCF-CW or JJ, DHS, Special Ed • Will the children meet the above eligibility criteria? • What percent are Medicaid eligible or CCF eligible?

36. Things to Think About • Will the children benefit from intensive community based services? • Do we have experience in providing intensive community based services? • Do we currently have wraparound available in our community? Do we have other funding to serve non-waiver eligible children • Do we currently blend/braid funds? • Do we have a community gate-keeping team?

37. The Child Care Fund

38. Child Care Fund • Cost share between state and county • County incurs expenses • State reimburses 50% (without limit) • Used to fund • Out of home costs • In-home community based care • While a large majority of Child Care Funds are for Juvenile Justice, 54% of the children are neglect/abuse

39. Child Care Fund • Local agencies develop contracts/agreements with county commissioners/administrators for services and identify $$$ • $$$ added to the CCF “Expanded” child care fund • Purchase reimbursable services for CCF eligible children • For every $100 spent locally, receive $50 back (50/50 match)

40. Eligible Programs - CCF In-Home Care • Programs must be intensive • Prevent need for out-of-home placement OR • Provide for an early return home from placement • Meet documentation and reporting requirements

41. Social Welfare Act (Excerpt) 400.117c • County treasurer as custodian of money; creation and maintenance of child care fund; deposits in fund; use of fund; separate account for fund; subaccounts; plan and budget for funding foster care services; records of juvenile services and expenditures; applicability of section to county juvenile agency. • (f) All funds made available to the county for the foster care of children from any other source, except gifts that are conditioned on a different disposition or reimbursement of the general fund

42. “Building a Collaborative Community budget, No It’s My Money”

43. Finance Planning • Discussion about current funding and how it works (Medicaid, Child Care Fund) • Finance matrix • Finance strategies identified (maximize Medicaid, redirect out of home care, reallocate existing revenue, new funding) • Interagency agreements developed • Target population more specific (juvenile justice – child care fund involved only, foster care-not abuse or neglect, SED at risk of hospitalization only)

44. Readiness Checklist • Systems Planning • CMHSP Infrastructure • Funding • Family Driven and Youth Guided • Wraparound Experience

45. DHS SED Waiver Pilot

46. Interagency Collaboration Through SED Waiver Department of Community Health(DCH) and Department of Human Services (DHS) • Children’s Services Administration and Mental Health and Substance Abuse Administration-a true equal partnership • DHS providing 1.76 million in funding to draw down additional Medicaid funds to serve 266 children across eight counties in Michigan • Infrastructure that supports this partnership to ensure smooth implementation and accountability to outcomes 46

47. DHS Target Population Children in DHS foster care: • with extensive mental health needs • who are in the “permanency backlog” (have been awaiting reunification or adoption for over a year) • Expand population to children in foster care working toward reunification or permanency • meet all SEDW eligibility requirements 47

48. Desired Outcomes for DHS SEDW Pilot • Maximized fiscal efficiencies across service systems • Children to live in the least restrictive family setting in the community • Children are able to achieve permanency with a family • Children have improved functioning across life domains

49. SEDW Evaluation & Reporting Evaluation plan using agreed upon outcomes: CAFAS at intake, quarterly, annually and exit Wraparound Program Evaluation Development of fiscal, legislative & program reports: • Based on data analysis using a web-based application and data base • Progress • Implementation • Outcomes • Cost effectiveness 49

50. questions? Questions? Questions? questions? Questions? Questions?