Care Management Entity Quality Collaborative Technical Assistance Webinar Series … ·...

Care Management Entity Quality Collaborative

Technical Assistance Webinar Series

CME Considerations for

Serving Youth in Transition

June 27,2012 2:00 – 4:00 p.m., ET

For audio and to participate, dial: (800) 273-7043

Pass code: 596413

In case of technical difficulties, call (609) 528-8400

This document was developed under grant CFDA 93.767 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid

Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume

endorsement by the Federal Government.

.

2

CHCS Priorities

Our work with state and federal agencies, Medicaid health

plans, providers, and consumers focuses on:

2

Integrating Care for People with

Complex and Special Needs

Improving Quality and

Reducing Racial and Ethnic Disparities

Building Medicaid Leadership and Capacity

Enhancing Access to Coverage and Services

Maryland, Georgia and Wyoming Collaborative CHIPRA Grant Project

Goal: Improving the health and social outcomes

for children with serious behavioral health

needs.

Implement and/or expand a Care Management

Entity (CME) provider model to improve the

quality - and better control the cost - of care for

children with serious behavioral health

challenges who are enrolled in Medicaid or the

Children’s Health Insurance Program.

3

Care Management Entity Quality Collaborative

Technical Assistance Webinar Series

CME Considerations for

Serving Youth in Transition

.

Presented by Maryann Davis, PhD

Learning &Working During the Transition to Adulthood

Rehabilitation Research and Training Center

LEARNING AND WORKING DURING THE TRANSITION TO ADULTHOOD REHABILITATION RESEARCH AND TRAINING CENTER University of Massachusetts Medical School, Department of Psychiatry, Center for Mental Health Services Research. Visit us at:

http://labs.umassmed.edu/transitionsRTC/index.htm

The contents of this presentation were developed with funding from the US Department of Education, National Institute on Disability and Rehabilitation Research, and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (NIDRR grant H133B090018). Additional funding provided by UMass Medical School’s Commonwealth Medicine division. The content of this presentation does not necessarily reflect the views of the funding agencies and you should not assume endorsement by the Federal Government.

Acknowledgements

Describe important unique characteristics

relative to other age groups

Outcomes during young adulthood

Services that are needed to support movement

into work

Adaptations of existing services models

Peer Services

Factor Relative to Children Relative to Adults

Autonomy More developed –

help with self-

determination skills

Less developed – help

with self-

determination skills

Family Less family role –

help move parents to

passenger seat

More family role –

help include parents

as appropriate

Peer Influence &

Social Life

Greater Greater

Schooling/Training More about

completion & Post

secondary

choices/success

More school

involvement, often

while

needing/wanting

work


Working Work becomes a focus;

early career development

support

Need support for EARLY

career development, more

job changing, more

concurrent schooling

Independent

Living &

Housing

Independent living

becomes focus,

increasingly not living at

home, skills need to

develop

More are still living with

family, couch surfing, multi-

roommates age typical,

immature skills

&knowledge

Risks Adult risks more common;

substance use,

homelessness, justice

system, pregnancy, STDs

Higher risk than adults

(peak age of risk)


Stigma More aware More felt – yet MH also

more accepted among

peers

Psychosocial

Development

(think, reason,

cognitive control,

identity

formation)

More mature – insight

available, action-

consequence more

connected, evaluate

several ideas

concurrently

Less mature – still not

as organized, more

distraction, action less

consistent with

knowledge, may be more

concrete

Legal issues more “adult rights”, &

held more accountable

“Rights” less complete

• Eligibility issues are huge • Different definitions of disability for children and

adults

• SSI – no adult ADHD

• State MH Authorities – 65% include PTSD

• SAMHSA – define functional disabilities differently

• Different ages that define adult status

• State services use different definitions of SED

Birth 18-21yrs Death

CHILD SYSTEM ADULT SYSTEM

Child Welfare

Education

Juvenile Justice Criminal Justice

Child Mental Health Adult Mental Health

Medicaid Medicaid

Substance Abuse

Vocational Rehabilitation

Housing

Labor

Health Insurance Health Insurance

Valdes et al., 1990; Wagner et al., 1991; Wagner et al., 1992; Wagner et al., 1993; Kutash et al., 1995; Silver et al., 1992; Embry

et al., 2000; Vander Stoep, 1992; Vander Stoep and Taub, 1994; Vander Stoep et al., 1994; Vander Stoep et al., 2000; Davis &

Vander Stoep, 1997; Newman et al., 2009

Young Adult Functioning Compromised in Many Areas

Functioning

among 18-21 yr olds

SMHC* in Public Services

General

Population/ without SMHC

Graduate High

School 23-65% 81-93%

Employed 46-51% 78-80%

Homeless 30% 7%

Pregnancy (in

girls) 38-50% 14-17%

Multiple Arrests

by 25yrs 44% 21%

*SMHC=Serious Mental Health Condition

Age Group

─ Transition Age (16-30yrs)

─ Adult (31-55yrs)

─ Young Adolescents (13-15yrs)

─ Children (5-12yrs)

Cum

ula

tive %

Rem

ain

ing in T

reatm

ent

Days Since Treatment Initiation

Services to Facilitate ENGAGEMENT are Needed

187 292

350 448

Put youth in the driver’s seat

Family involvement less than children’s services but more than typical adults

Nuances to working with less mature psychosocial development (rejection of authority, self-evaluation skills, making work concrete etc.)

BUILDING SKILLS

COMPREHENSIVE – treatment/rehabilitation and support housing, education, work, community participation

NANA (Not Adolescents Not Adults)

Multisystemic Therapy for Emerging Adults: ◦ Shifts from parent intervention to EA intervention

◦ Extensive engagement component

◦ Teaches planning, coping, problem-solving skills

◦ Teaches specific skills through Life Coach:

Career Development

Work Preparation and Support

School Completion

Parenting Young Children

Relationships with Social Network

◦ Therapists deliver home-based MH, SU, antisocial behavior reduction therapy – place of EA choice

Proportion of each age group

that worked in competitive employment

by study condition.

Interaction of age by condition

Significant (ANOVA; p<.05).

Burke-Miller, J., Razzano, L., Grey, D., Blyler, C., & Cook, J.(2012). Supported employment outcomes for transition

age youth and young adults. Psychiatric Rehabilitation Journal, 35, 171-179.

Individualized Placement and Supports ◦ Add Supported Education to Supported

Employment

◦ Add More Pre- or Concurrent Training About

Working & Career Development

◦ Address Substance Use Issues

◦ Provide the Family Information

◦ Add Peer Mentor

Questions? To submit a question please use one of the following options:

•Ask a Question Online: Click the Q&A icon located in the hidden toolbar at the top of your screen.

•Ask a Question via Phone: Phone lines will now be un-muted.

Slides and a video archive of this event will be

available on our website, at www.chcs.org.

19

Meeting the Unique Needs of Emerging Adults with Serious Mental Health

Conditions:

Challenges, Empirically Supported Approaches, and Implications for Wraparound

CHIPRA CME Collaborative Webinar 27 June 2012

Research & Training Center for Pathways to Positive Futures, Portland State University

Services and Supports for Emerging Adults

with Serious Mental Health Conditions

The age of instability,

uncertainty and exploration…

• Average number of job changes from age 20-29 in U.S. : ~7

• Shifting career goals

• Mobility/changes in residence

• Commitments come and go

• Separation from family


…coupled with very high

expectations • “I am very sure that someday I will get to

where I want to be in life.”

– ~96% of Americans ages 18-24 agree

• Work

– Searching for self-fulfillment… and money

– Career aspirations: arts/creative; own business

• Love : “When you marry, you want to find your soul mate, first and foremost.”

– 94 % of Americans 20-29 agree


For all young people…

• Adulthood takes longer to “emerge” than it used to

• Many choices and options are explored: living, working, commitments

• Need to find some kind of compromise between big dreams and possibly harsh realities

• The path is not straight


It’s tough on mental health

• Feeling in-between, uncertainty and constant change anxiety

• Becoming independent from family, moving, changing jobs disrupts social support

• Age of possibilities disappointment

• Rates of substance use, sexual risk behavior, are part of peer culture

• Current economic condition adds to stress: high unemployment, job insecurity, costs of education, debt


What approach to take?

• Our population of young people experiences challenges beyond what is typical

– Existing/newly recognized serious mental health condition

– Multiple areas of need

– Systems experience

• Need service/support approaches that are

– Designed to fit both with these challenges and the unique stage of life

– Attractive to young people and perceived as relevant

– Empirically supported


Review of existing information….

• Empirically supported approaches for young people with SMHC – Older youth/young adult MH

– Ongoing research at Pathways RTC and with partners

• Additional literature – Psychosis/early psychosis, trauma, co-occurring

– Empirically supported approaches with high-needs populations: young offenders, youth transitioning from foster care

– Research that provides evidence about how to build key elements: self-efficacy, positive self image, feelings of competence, etc.

• Follow-up interviews with authors – Looking for curricula, specific practices, recommendations

• Other interviews – Leaders in model programs

– Young people


… with the aim of… • Determining the extent to which there is consistency

in

– Philosophical underpinnings, principles, theory

– Model for practice (What are the steps? – What’s in the manual?)

– Expectations for communication (How to engage young people? How should interactions go?)

• If so,

– can this be the basis for a “common factors” /”common elements”–type approach

– What are the implications for wraparound specifically


Also published as: Walker, J. S. & Gowen, L. K. (2011). Transition for youth with serious mental health conditions. In M.L. Wehmeyer & K. W. Webb (Eds.), Handbook of Adolescent Transition Education for Youth with Disabilities, New York: Routledge.

Positive development

• Our review of empirically supported programs for emerging adults with SMHC universally took a positive development approach

• Focuses on the importance of

– Building assets/capacities appropriate to the developmental stage of life

– Promoting thriving and well-being across the life span , even—or especially—in the face of adversity and challenge

• Growing evidence base and emerging consensus* for youth with highest levels of needs– paradigm shift

• Clinical strategies are in service to positive development *e.g., Altschuler, Stangler, Berkley, & Burton, 2009; Gagnon & Richards, 2008; e.g., Institute of Medicine, 2006

Summary: Model Linking

Empirically Supported

Approaches and Outcomes

Young people experience

Positive Developmental Outcomes

Young people build

Key developmental capacities






Young people build


Providers employ

Specific practices

What do they do?




Providers collaborate with young people using a

Primary mode



Young people build


Providers employ

Specific practices

How?




Providers collaborate with young people using a

Primary mode



Organizational support

Training and coaching

Young people build


Providers employ

Specific practices

Positive Developmental

Outcomes:

• Meet basic needs, carry out daily

living

• housing, health, safety

• shopping, cooking, managing

finances,

• Have skills and knowledge for adult

roles

• social skills

• intrapersonal skills

• skills for managing specific

challenges

• education/ vocational skills

• Have a pro-social, satisfying place

in community and society:

• employment/career/ occupation

• relationships

• “play”

Developmental

Capacities, learn to …

• Take action– be

proactive/intentional in

moving toward desired

outcomes

• Maintain “fortitude”

• Engage with resources

and support in different

contexts (people,

organizations, institutions,

systems)

Central Developmental Challenge

Become the primary person responsible for achieving developmental outcomes

– Be proactive in moving toward goals • Be motivated and capable of developing plans connected to

personally meaningful goals

• (failing, refocusing, trying again)

– Maintain “fortitude”/psychological resilience in the face of challenge, uncertainty and failure/ “failure”

• Making compromises between high hopes and hard realities

• Maintaining a positive sense of self in the face of cultural messages and depictions

– Engage with “contexts” that offer help, support, belonging, opportunity

• Family, friends, romantic partners, organizations, institutions


Why our young people need extra

support …

… for acquiring developmental capacities and achieving outcomes

– Specific challenges related to MH conditions

– Past history of instability in care giving, relationships, place of residence, school

– History of trauma, including trauma from services and systems

– Services may be experienced as punitive, oppressive; providers not trustworthy

– Young people often respond by being overly compliant and/or oppositional

– Exaggerated sense of self-sufficiency or dependency/ combination of the two

– Main modality is reactive

– Heightened sensitivity to stigma


How much does wraparound need to

change? • Wraparound is in theory entirely consistent with

supporting the developmental capacities

– Actual practice often does not live up to the aspiration

• What are the options?

– Wraparound as is

– Enhanced wraparound– more specific practice, enhance mode of interaction

– Significantly adapted wraparound– practice is significantly tweaked

– Not wraparound– differences are more than tweaks, don’t fall under principles any more


Recently published findings (Psychiatric Rehabilitation Journal, January 2012)

– Perceptions of participation among matched pairs of young people 16-21* and their caregivers

– Using items from WFI and other assessments

– Young people overall slightly lower perceptions of participation than caregivers (did not increase with age)

– No evidence of “crowding out” with age

– Supported idea that higher ratings from both related more to quality of facilitation


Intentional enhancement

• Achieve My Plan– be more intentional about the “what” and the “how”– improve youth participation and team satisfaction (PRJ, 2010)

• What: Engagement on par with what wraparound expects with caregivers

– Find out what the young person really cares about, tap that motivation

– Find out what the young person enjoys, is good at: reinforce and build on competence

– Prepare the young person for the strange situation of being in a meeting with a bunch of providers

– Facilitate communication with caregivers so they are on the same page with the young person

Intentional enhancement (cont.)

• What: Impact on what gets planned

– Young person places own items on the agenda, asks team support– typically leads this section of the meeting with facilitator/coach back-up

– Include activities for which the young person is the primary driver

– Young person prepares with the coach to speak on all agenda items

Intentional enhancement (cont.)

• How: Impact on interactions

– Video-based training and coaching: youth-driven and “transparent”/non-coercive, sensitive to what youth finds meaningful, alert to connections to context, alert to examples of competence, “motivated” toward positive development

– Ground rules and strong facilitation keep the meeting from turning negative or getting off track

– Shift in balance of emphasis from outcomes to process

Further enhancement • Use of peer as coach, not just for engagement, but as

ongoing support

– Unique advantages of this, when provided in a high quality manner

• Overall shift of focus away from diagnosis-driven to functioning/wellness

– Employment, housing, etc., can be the main focus

– Non-traditional and wellness services/supports can be main strategies

– Clinical services are accessed when young person sees the need and for specific purposes; coordinated with the needs/goals that young person has prioritized

Adaptation

• Explicit shift to young-adult driven

– Young person takes the lead in choosing the team

• With coaching/support about the usefulness of including specific people

• Decides who is “family”

– Young person takes lead on needs, goals, service/support strategies

– Lots of flexibility about what a “team” is and which team members are “core”; as well as the nature of team collaboration


For any approach…

• Strategies for initial engagement and retention

• Keep young person engaged with immediate benefits or incentives

• Acknowledge not only young person’s accomplishments often but the process

• Immediate establishment/contributions of roles of each team member


www.pathwaysrtc.pdx.edu

http://www.pathways.pdx.edu/

Acknowledgments/Funders

The development of the contents of this presentation were supported by funding from the National Institute of Disability and Rehabilitation Research, United States Department of Education, and the Center for Mental Health Services Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services (NIDRR grant H133B090019). The content does not represent the views or policies of the funding agencies. In addition, you should not assume endorsement by the Federal Government.






50

Transitioning Youth to Adulthood: Wraparound Milwaukee’s Healthy Transitions Initiative

CHIPRA CME Collaborative Webinar

June 27, 2012

Bruce Kamradt, MSW

Administrator of Children’s Mental Health Services for Milwaukee County

Director, Wraparound Milwaukee

Brian McBride

Project Coordinator for Milwaukee County & Wraparound Milwaukee’s Transitions Initiative (Project O-YEAH)

Why Develop a Specialized Program for Transitional Age Youth with Serious Emotional and Mental

Health Needs

Transitional age youth (18 – 24), were experiencing poor outcomes:

not finishing school

higher likelihood of involvement in criminal justice system

high rate of homelessness

high rates of unemployment

The Adult Services System was focused on serving adults with chronic, persistent mental illness but was not focused on the transitional age youth with SED. Many young adults would simply not qualify for adult services

While many of these young adults had qualified for Medicaid as youth, they began facing loss of their health care coverage at a time they still had physical health needs and needed access to critical mental health & alcohol and other drug addiction services.

Many of these young adults no longer had their family support system or chose themselves not to avail themselves of those systems – “they wanted to be on their own”

Employment & Housing services were particularly difficult for youth/young adults with serious emotional needs to identify, access and maintain

Healthy Transitions Initiative (HTI) and Wraparound Milwaukee’s Implementation of the Transitional

Care Model

Federally funded (5 year/$2.5 million SAMHSA), grant to help states and communities create developmentally appropriate and effective youth guided local systems of care to improve outcomes for youth and young adults with serious mental health conditions in areas such as education, employment, housing, mental health and co-occurring disorders

State of WI Dept. of Health, Bureau of Mental Health was recipient

Milwaukee County Behavioral Health – Wraparound Milwaukee was the site selected to develop the local transitional model in Milwaukee County

Design of Milwaukee’s HTI Program (Project

O-YEAH): Assumptions Underlying

Better outcomes for youth & young adults transitioning to adult roles can occur by providing four interventions:

1. Form trusting and strength-based relationships with them in their roles as young adults and with the circles of support they choose to build around themselves

2. Help them develop and embrace hope and their dreams through the development of person-centered, future-oriented plans

3. Provide access to the resources, support and assistance needed to implement their plans

4. Offer one-on-one coaching to help them develop the knowledge, skills and insights that will help them find success as adults

Components of Project O-YEAH

Service Tiers

Person-Centered Planning Curriculum Wraparound model/Transition to Independence process

Transitional Specialists

Club House Model

Partnerships/Satellite Centers established with homeless youth/young adult provider (Pathfinders) & with agency servicing youth aging out of foster care (Lad Lake)

Collaboration with county adult community services agency through MOUs

Components Project O-YEAH (cont’d)

Program Evaluation that is Youth/Adult Friendly

Creation of Peer Specialists

Expansion of Provider Network System to Include Specialized Providers

Housing

Employment

Emerging shelter

Expanded Eligibility for Pooled Funding (by covering the 18-

21 year olds aging out of foster care )

Family Involvement

Three Tiers of Support for Young Adults

Transitioning to Adulthood

Tier One – youth/young adults with emotional needs who need some help with resources & support which they can get with membership or participation in Club House Program and from club house staff

Tier Two – youth/young adults with serious emotional & mental health needs who need the help & support of a Transitional Specialist with their mental health, education, employment or housing needs and need the help of the Transitional Specialist to facilitate a person-centered plan & coaching as they navigate the adult system/adult roles

Tier Three – youth /young adults with serious and potentially long-term mental health issues and challenges who need help accessing the adult community mental health system and enrollment in Community Support Programs (CSP) or other services provided by adult system

Person-Centered Planning

Tailored to the individual based on their needs and desires

Incorporates the wraparound process (i.e. strength based, individualized)

Individualized

Engages through relationship building (trust)

Uses young adult’s “vision” for what it means to be successful

Transitional specialist is advocate and works with young adult’s identified strengths

Assists young adult to meet needs but doesn’t do it for them, build supports around them

Personal choice and tailored services to work towards independence

Uses their chosen support network

Needs driven and outcome based

Allows for and embraces failure while modeling positive responses

Needs and Barriers That Youth & Young

Adults Need Help With

Employment

Housing – do I have somewhere to sleep that is safe, affordable?

Transportation – even in big city how do I get around?

Educational – College? GED? High School?

Financial/ money management - How do I survive on minimum wage or SSI?

Continuation of service providers

Pregnancy/child

Support of family

Insurance/medical care

Role of Transitional Specialist

Partner with young adult to identify strengths and needs

Be a trusted advocate for young adults

Help create an individualized future plan

Motivate and coach on knowledge, skills and appropriate adult roles

Connect young adult with appropriate services both formal and informal

Monitor futures plan with young adult

Connect the young adult with adult community mental health systems as needed

Be there as needed

Creating Transitional Centers/Specialists

through Partnerships

Local Project Coordinator, three Transitional Specialists housed together at Wraparound Milwaukee

One Transitional Specialist at each of two satellite transitional centers created at: Pathfinders - largest provider of services to homeless young & young adults

Lad Lake, Inc. - contractor to provide services to the Bureau of Milwaukee Child Welfare for youth aging out of foster care

Satellite centers use person centered, HTI curriculum and Wraparound Milwaukee’s IT system but generate own referrals and maintain on site supervision of staff

70 young adults currently being served, caseload 1:15 to 1:20

Plan is to expand to one or two additional satellite sites in 2013

Clubhouse Model to Support Youth/Young Adults

Gathering place to socialize

Resource center Employment resources

Housing resources

Practice daily living skills

Food & meals available, showers, laundry, etc.

Hosts classes in

Health

Banking

Cooking

Employment preparation

Learning about Medicaid, SSI, social security

Clubhouse Model to Support Youth/Young Adults – cont’d

Recreation Availability of gym and other physical activities

Connect with peer specialists, mentors

Work on “portfolio” of things that need to get done in order to move toward independence

Connect youth/young adults who need & desire more help with a transitional specialist

Peer Specialists

Young adults who are or have been recipients of services who support other youth/young adults who are currently enrolled in the program

Must be at least 18 years of age

Can be certified in Wisconsin and are eligible for Medicaid reimbursement under the state’s Comprehensive Community Services (CCS) benefit (1915(i)), and crisis benefit

Engage and encourage current young adults in HTI/Project O-YEAH and promote independent living and self-direction

Help other young adults through their own experience to identify resources in the community and to “navigate” the system of care

Provide counsel and support in crisis, facilitate groups, and advocate on behalf of youth/young adults

Creating Avenues of Collaboration with Adult

Community Services Related to Transitional Services

Written memorandums of understanding (MOUs)

Identified liaisons/contact people to enhance a coordinated approach from Wraparound Milwaukee/HTI project and from adult services

Written criteria/flow chart for how youth/young adults are referred, assessed and services provided by each system

Enhancement of provider network through identification of shared providers between adult and youth serving systems, particularly around targeted case management, community-support providers (CSP) and housing, etc.

Protocol for information sharing and single release of information form

Able to overlap services between systems to improve transitions and prevent “gaps”

Regularly scheduled collaborative meetings

Joint initiatives Comprehensive community services/1915(i) Peer specialists Congregate housing

Provider Network Services Needed by Transitional Population

Care Coordinator/Transitional Specialists Peer Specialists Housing Employment Crisis Housing/Emergency Shelters Crisis 1:1 Medication Management Daily Living Skills/Independent Living Health Care Coverage and Advocacy Therapy Medical Home (Coordination & Primary Care Providers)

Information Technology Considerations

One information system, Synthesis, is used for both child (Wraparound) and youth/young adults in transition:

Crisis plans

Person-centered planning

Service authorization

Electronic medical record

Reports

No need for separate data systems

Funding The Healthy Transitions Initiative

Five year, $2.5 million SAMHSA grant

Expanded eligibility under 1915a agreement with WI Medicaid for Wraparound Milwaukee (as special managed care entity) to cover youth/young adults, 18 – 21 years old, who are aging out of foster care (now covered by capitation payment)

Utilizing pooled funding from Medicaid, Child Welfare, and Juvenile Justice – funding pool currently at $47 million

Expanding service benefit covered under Medicaid to include peer supports, employment and other services by applying for Wisconsin’s Comprehensive Community Service (CCS) under the 1915(i) Home and Community Services State Plan benefit

Working with adult services to “fast track” eligible youth to Family Care or Community Support programs

Benefit advocacy with Medicaid

Wraparound Milwaukee Pooled Funds

CHILD WELFARE Funds thru Case Rate

(Budget for Institutional

Care for CHIP Children)

JUVENILE JUSTICE (Funds Budgeted for

Residential Treatment and

Juvenile Corrections Placements)

MEDICAID CAPITATION ($2052per Month per Enrollee)

MENTAL HEALTH •CRISIS BILLING

• HTI GRANT

• HMO COMMERCIAL INSUR

WRAPAROUND MILWAUKEE

CARE MANAGEMENT ORGANIZATION

(CMO)

$46.5 M

CHILD & FAMILY TEAM OR

TRANSITION TEAM

PLAN OF CARE

OR

$10.0M $10.0M $19.5M $7.0 M

FUTURE PLAN

Program Evaluation

Purpose of evaluation model is to observe and assess change related to:

Identification of needs

Feelings of empowerment

Overall accomplishments within the developmental domains

Management of crisis

as young adults participate in the HTI Program (Project O-YEAH)






71

Care Management Entity Quality Collaborative Technical Assistance Webinar Series … ·...

Documents

Transcript of Care Management Entity Quality Collaborative Technical Assistance Webinar Series … ·...