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Efective FinancingStrategies or Systems o Care:Examples from the Field

A Resource Compendium for Developing a Comprehensive Financing Plan

Beth A. Stroul, M.Ed.Sheila A. Pires, M.P.A.

Mary I. Armstrong, Ph.D.

Jan McCarthy, M.S.W.

Karabelle Pizzigati, Ph.D.

Ginny M. Wood, B.S.

RTC Study 3

Financing Structures and Strategiesto Support Efective Systems o Care

The Research andTraining Center forChildren’s Mental Health



Eective Financing Strategies or Systems o Care: Examples from the Field i

Suggested Citation:

Stroul, B.A., Pires, S.A., Armstrong, M. I., McCarthy, J., Pizzigati, K., & Wood, G.M., (2008). Eective fnancing strategiesor systems o care: Examples rom the feld—A resource compendium or developing a comprehensive fnancing plan(RTC study 3: Financing structures and strategies to support eective systems o care, FMHI pub. # 235-02). Tampa, FL:University o South Florida, Louis de la Parte Florida Mental Health Institute (FMHI), Research and Training Center orChildren’s Mental Health. (FMHI Publication #235–02)

FMHI Publication #235–02

Series Note: RTC study 3: Financing structures and strategies to support eectivesystems o care, FMHI pub. # 235-02)

First Printing: March 2008© 2008 The Louis de la Parte Florida Mental Health Institute

RTC Study 3: Financing Structures and Strategies to Support Efective Systems o Care is a study o the Research and TrainingCenter or Children’s Mental Health. The Center is jointly unded by the National Institute on Disability and Rehabilitation Research, U.S.Department o Education and the Center or Mental Health Services, Substance Abuse and Mental Health Services Administration undergrant number H133B040024.

Permission to copy all or portions o this book is granted as long as this publication, the Louis de laParte Florida Mental Health Institute, and The University o South Florida are acknowledged as thesource in any reproduction, quotation or use.

Partial Contents: Introduction – RTC: Study 3 Background – How to Use this Document – Overviewo Sites Studied – Eective Financing Strategies Framework – I. Identifcation o Current Spendingand Utilization Patterns Across Agencies – II. Realignment o Funding Streams and Structures – III.Financing o Appropriate Services and Supports – IV. Financing to Support Family and YouthPartnerships – V. Financing to Improve Cultural and Linguistic Competence and Reduce Disparitiesin Care – VI. Financing to Improve the Workorce and Provider Network – VII. Financing orAccountability – VIII. Financing Strategies or Tribal Systems o Care – Conclusion – Order Formsor RTC Study 3 publications.

Available from:

Department o Child and Family StudiesDivision o State and Local SupportLouis de la Parte Florida Mental Health InstituteUniversity of South Florida 13301 Bruce B. Downs Boulevard

Tampa, FL 33612-3899 (813) 974-6271

This publication is also available free on-line as an Adobe Acrobat PDF fle:

http://rtckids.fmhi.usf.edu/study03.cfm or

http://pubs.fmhi.usf.edu click Online Publications (By Subject)

National Instituteon Disability and

Rehabilitation Research

Events, activities, programs and acilities o The University o South Florida areavailable to all without regard to race, color, marital status, sex, religion, national

origin, disability, age, Vietnam or disabled veteran status as provided by law andin accordance with the University’s respect or personal dignity.

Research and Training CenterFor Children’s Mental Health

RTC Study 3:

Financing Structures and Strategies

to Support Eective Systems o Care

Efective Financing Strategies orSystems o Care: Examples from the Field A Resource Compendium or Developing a Comprehensive Financing Plan

Beth A. Stroul, M.Ed., Sheila A. Pires, M.P.A., Mary I. Armstrong, Ph.D. , Jan McCarthy, M.S.W., Karabelle Pizzigati, Ph.D., & Ginny M. Wood, B.S.

3



ii Eective Financing Strategies or Systems o Care: Examples rom the Field

AcknowledgementsEective Financing Strategies or Systems o Care: Examples rom the Field is one in a series o technical

assistance tools and resources that are produced by the ve-year study,Financing Structures and

Strategies to Support Eective Systems o Care. During the study period, the support and participation

o many individuals has been invaluable to the study team in clariying the study questions and goals.First, we want to thank the ederal agencies that have unded this project and recognize the importance

o nancing in developing eective systems o care — the National Institute on Disability and Rehabilitation

Research (NIDRR) o the U. S. Department o Education and the Child, Adolescent and Family Branch o the

Center For Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration

(SAMHSA), U. S. Department o Health and Human Services.

We also thank the members o our national Panel o Financing Experts, who contributed their time

and expertise in helping us to rame the critical questions and issues or the study:

Kamala Allen Doreen Cavanaugh Nadia Cayce Joseph Cocozza

Mark DeKrai Richard Dougherty Holly Echo-Hawk David Fairbanks

Jamie Halpern Cheryl Hayes Bruce Kamradt Judith Katz-Leavy

Chris Koyanagi Jody Levison-Johnson Ken Martinez Mary Jo MeyersPeggy Nikkel David Sanders Tessie Schweitzer Harry Shallcross

Sue Smith Constance Thomas Robin Thrush Nancy Weller

Rita Vandivort-Warren

Thanks also to Vivian Jackson o the National Center or Cultural Competence at Georgetown University

or her review o issues related to cultural competence and racial and ethnic disparities; to Roxann McNeish

or her assistance with editing and revisions; and to Bill Leader or the page layout and design o this

document.



Eective Financing Strategies or Systems o Care: Examples rom the Field iii

RTC Study 3:



Efective Financing Strategies orSystems o Care: Examples from the Field A Resource Compendium for Developing a Comprehensive Financing Plan


For Inormation Contact: Mary I. Armstrong, Ph.D.

Louis de la Parte Florida Mental Health InstituteDepartment of Child and Family Studies • Division of State and Local Support

University of South Florida • 13301 Bruce B. Downs Boulevard • MHC2414 • Tampa, FL 33612

813-974-4601 (Phone) • 813-974-7376 (Fax) E-mail: [email protected]

March 2008

Research and Training Center or Children’s Mental HealthDepartment o Child and Family Studies

Louis de la Parte Florida Mental Health InstituteUniversity o South Florida

Tampa, FL

Human Service CollaborativeWashington, DC

National Technical Assistance Center or Children’s Mental HealthGeorgetown University Center or Child and Human Development

Washington, DC

Family Support Systems, Inc.Peoria, AZ


3



iv Eective Financing Strategies or Systems o Care: Examples rom the Field

Table of Contents Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

RTC Study 3 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

How to Use this Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Overview o Sites Studied. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Eective Financing Strategies Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Developing a Strategic Financing Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

I. Identifcation o Current Spending and Utilization Patterns Across Agencies. . . . . . . . . . . . . . . . . . . .17

A. Determine and Track Utilization and Cost

o Behavioral Health Services or a Dened Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

B. Identiy the Types and Amounts o Funding or Behavioral Health Services Across Systems . . . . . . .23

II. Realignment o Funding Streams and Structures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

A. Utilize Diverse Funding Streams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

B. Maximize Federal Entitlement Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

C. Redirect Spending rom “Deep-End” Placements to Home and Community-Based Services . . . . . . .48

D. Support a Locus o Accountability or Service, Cost, andCare Management or Children With Intensive Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

E. Increase the Flexibility o State and/or Local Funding Streams and Budget Structures . . . . . . . . . . . .67

F. Coordinate Cross-System Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

G. Incorporate Mechanisms to Finance Services or Uninsured and

Under insured Children and their Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

III. Financing o Appropriate Services and Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

A. Provide a Broad Array o Services and Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

B. Promote Individualized, Flexible Service Deliver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86

C. Support and Provide Incentives or Evidence-Based and Promising Practices . . . . . . . . . . . . . . . . . . . .92

D. Promote and Support Early Childhood Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

E. Promote and Support Early Identication and Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102F. Support Cross-Agency Service Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108

IV. Financing to Support Family and Youth Partnerships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112

A. Support Family and Youth Involvement and Choice in Service Planning and Delivery . . . . . . . . . . . .113

B. Finance Family and Youth Involvement in Policy Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

C. Finance Services and Supports or Families and Other Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128

V. Financing to Improve Cultural and Linguistic Competence and Reduce Disparities in Care . . . . . 1 3 3

A. Provide Culturally and Linguistically Competent Services and Supports . . . . . . . . . . . . . . . . . . . . . . . . .133

B. Reduce Disparities in Access to and Quality o Services and Supports . . . . . . . . . . . . . . . . . . . . . . . . . . .142

VI. Financing to Improve the Workorce and Provider Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

A. Support a Broad, Diversied, Qualied Workorce and Provider Network . . . . . . . . . . . . . . . . . . . . . . . . .146

B. Providing Adequate Provider Payment Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154



Eective Financing Strategies or Systems o Care: Examples rom the Field v

VII. Financing or Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157

A. Incorporate Utilization, Quality, Cost, and Outcomes Management Mechanisms . . . . . . . . . . . . . . . . .158

B. Utilize Perormance-Based or Outcomes-Based Contracting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169

C. Support Leadership, Policy, and Management Inrastructure or Systems o Care . . . . . . . . . . . . . . . . .170

D. Evaluate Financing Policies to Ensure that they Support and

Promote System o Care Goals and Continuous Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . .173VIII. Financing Strategies or Tribal Systems o Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176

Finance Tribal Systems o Care Through Collaboration Among States and

Tribes and Coordination o Federal, State, Local, and Tribal Financing Streams . . . . . . . . . . . . . . . . . . .176

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181

Technical Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181

Contextual, Environmental, Fiscal or Other Factors that Will Infuence

Financing Policies and Strategies or Systems o Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181

Order Forms or Study 3 Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182

List of TablesPage

Table 1 Use o Multiple System Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 2 Use o Multiple Medicaid Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Table 3 Array o Services and Supports Examined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77



Eective Financing Strategies or Systems o Care: Examples from the Field 1

3

Introduction

RTC Study 3 Background The Research and Training Center or Children’s Mental Health (RTC) at the University o South Florida is

conducting several ve-year studies to identiy critical implementation actors which support communities

and states in their eorts to build eective systems o care to serve children and adolescents with or at risk

or serious emotional disturbances and their amilies. One o these studies examines nancing strategies

used by states, communities, and tribes to support the inrastructure, services, and supports that comprise

systems o care.

The study o eective nancing practices or systems o care was initiated in October 2004 and is

conducted jointly by the RTC, the Human Service Collaborative o Washington, DC, the National Technical

Assistance Center or Children’s Mental Health at Georgetown University, and Family Support Systems, Inc.

o Arizona.

The purposes of the study are to:• Developabetterunderstandingofthecriticalnancingstructuresandstrategies

to support systems o care or children and adolescents with behavioral health

disorders and their amilies

• Examinehowthesenancingstrategiesoperateseparatelyandcollectively

• Promotepolicychangethroughdisseminationofstudyndingsandtechnical

assistance to state and local policymakers and their partners

The study o eective nancing strategies or systems o care uses a participatory action research

approach, involving a continuous dialogue with key users on study methods, ndings, and products.

The study uses a multiple case study design; and data collection and analysis includes a mix o qualitativeand quantitative methods.

RTC Study 3:



Efective Financing Strategies orSystems o Care: Examples rom the Field A Resource Compendium or Developing a Comprehensive Financing Plan




I n t r o d u c t i

o n : S t u d y B a c k g r o u n d

2 Eective Financing Strategies or Systems o Care: Examples from the Field

Initial study tasks included convening a panel o nancing experts, including state and county

administrators, representatives o tribal organizations, providers, amily members, and national nancing

consultants to develop a list o critical nancing strategies and study questions. The critical nancing

strategies were used to create the rst study product — A Sel Assessment and Planning Guide: Developing

a Comprehensive Financing Plan1 — that addresses seven important areas to assist service systems or sites

(states, tribes, territories, regions, counties, cities, communities, or organizations) to develop comprehensiveand strategic nancing plans or systems o care:

I. Identifying spending and utilization patterns across agencies

II. Realigning funding streams and structures

III. Financing appropriate services and supports

IV. Financing to support family and youth partnerships

V. Financing to improve cultural and linguistic competence and reduce

disparities in care

VI. Financing to improve the workforce and provider network

VII. Financing for accountability

The critical nancing strategies also were used as the basis or developing site visit protocols to explore

the implementation o these strategies in a purposively selected sample o states and communities. Study

team members and members o the national expert panel nominated a number o states and communities

as potential sites to study, based on the knowledge o eective nancing strategies at those sites.

Telephone interviews with key inormants knowledgeable about each o the sites nominated, along with

review o documents and inormation rom prior related studies, led to the identication o a sample o sites

to include in the rst wave o site visits and interviews. The sample included our states and our regional or

local areas:

States:

• ArizonaandMaricopaCounty,AZ,• Hawaii,

• NewJersey,and

• Vermont

Regional/Local Areas:• Bethel,Alaska,

• CentralNebraska,

• ChoicesbasedinIndianapolis,Indiana,and

• WraparoundMilwaukee

1This publication is available on-line at: http://rtckids.fmhi.usf.edu/study03.cfm




Site visits and telephone interviews with key inormants in these sites were conducted rom September

2006 to February 2007. Site visits were conducted in Arizona at the State level and in Maricopa County

(Phoenix),Hawaii,Vermont,Bethel,andCentralNebraskaandinvolvedin-depthinterviewswithkey

stakeholders about the various nancing approaches in use. Abbreviated site visits and telephone

interviewswereusedtogatherupdateddatafromNewJersey,Choices,andWraparoundMilwaukee,all

o which had been studied previously by members o the study team. Examples o eective nancingstrategies in each o the sites were reviewed and analyzed by the study team.

How to Use this Document This document presents the results o the rst wave o site visits and is intended to be a companion to the

Sel-Assessment and Planning Guide. It presents examples o eective nancing strategies or each o the

seven areas discussed in the Guide, based on inormation gathered through the site visit and interview

process. It is intended as a technical assistance document to assist stakeholders to identiy strategies that

might be implemented or adapted in their own states and communities. As stakeholders use the Guide to

crat a strategic nancing plan, this document can be used to identiy and learn about specic strategies in

each area that have been ound to be eective in other states and communities.

While all seven areas are important components o a strategic nancing plan, it is not necessary tomove sequentially through the seven areas. Readers can review the table o contents to nd strategies in

specic areas o interest or need. Thus, this document is designed to serve as a compendium o strategies,

and can be used as a reerence and resource as states and communities are designing and implementing

strategic nancing plans or systems o care.

Overview of Sites Studied

Full descriptions of each of the sites are provided below.To summarize, the sites included:

•

Arizona and Maricopa County : A statewide behavioral health carve out operatedunderan1115waiverutilizinglocally-based,capitatedRegionalBehavioralHealth

Authorities(i.e.,behavioralhealthmanagedcareorganizations—BHOs);theBHOin

MaricopaCounty(Phoenix)atthetimeofthesitevisitwasValueOptions

• Hawaii : A statewide behavioral health system operated through the schools and

managed care organizations or children needing short-term services and through

the state Child and Adolescent Mental Health Division or children with serious

emotional challenges and their amilies

• New Jersey : A behavioral health carve out utilizing a statewide Administrative

Services Organization and locally-based Care Management Organizations and

Family Support Organizations

• Vermont : A statewide mental health system managed by the Department o Mental

Health utilizing legislatively-mandated state and local interagency teams anddesignated provider agencies



I n t r o d u c t i



• Bethel, Alaska: The administrative and transportation hub or the 56 villages in the

Yukon-Kuskokwim Delta, with behavioral health services administered by the Yukon

Kuskokwim Health Corporation (YKHC), a Tribal Organization, which administers a

comprehensive health care delivery system or the rural communities in southwest

Alaska• Central Nebraska:A22-countypartnershipamongRegion3BehavioralHealth

Services,theCentralServiceAreaoftheOfficeofProtectionandSafety,theState

Department o Health and Human Services (DHHS), and Families CARE, a amily-run

organization, providing services and supports to several sub-populations o children

with serious behavioral health challenges or at high risk

• Choices, Inc : A nonprot, community care management organization operating in

Marion County, Indiana; Hamilton County, Ohio; Montgomery County, Maryland;

andBaltimoreCity,MD,whichcoordinatesservicesforchildrenandfamilieswith

serious behavioral health challenges who are involved in one or more governmental

systems

• Wraparound Milwaukee: A behavioral health population carve-out, operated by

theMilwaukeeCounty,WisconsinBehavioralHealthDivision,servingseveralsubsetso children and youth with serious behavioral health challenges and their amilies

who also are involved in child welare and juvenile justice systems

AZ Arizona and Maricopa County Arizona provides behavioral health services to children and adolescents and their amilies

through an 1115 Medicaid managed care research and demonstration waiver. The Arizona

State Medicaid agency contracts with the Arizona Department o Health Services (ADHS),

DivisionofBehavioralHealthServices(BHS),tomanageabehavioralhealthcarve-out.

ADHS/BHS,inturn,contractswithfourRegionalBehavioralHealthAuthorities(RBHAs),

coveringsixgeographicareasthroughoutthestate,andtwoTribalBehavioralHealthAuthorities(TRBHAs).RBHAsreceiveacapitationforMedicaidandStateChildren’sHealth

Insurance(S-CHIP)coveredservices;theyalsoreceivestategeneralrevenuedollarsandfederalmental

healthandsubstanceabuseblockgrantmoniestoprovideservicestonon-Medicaid/S-CHIPpopulations

and to pay or non Medicaid-covered services.

Arizona has a population o about six million, with nearly two million children under 18 (about 32% o

theoverallstatepopulation).MaricopaCounty(Phoenix)hasmostofthestate’spopulation,withover3.5

milliontotaland1.2millionchildrenunder18(34%).TheRBHAinMaricopaCountyatthetimeofthesite

visitwasValueOptions(VO),acommercialbehavioralhealthmanagedcarecompany.2VOinMaricopa

CountycontractswithsevenComprehensiveServiceProviders(CSPs),whoreceiveasubcapitation(which

2 ValueOptionswastheBHOatthetimeofthesitevisit.Througharecentre-procurement,MagellanbecametheBHOin the county.




excludesresidentialtreatmentfacilities,whichVOauthorizesdirectly).TheCSPscontractonafee-for-

servicebasiswithmanyotherproviders,andVOalsoholdsabout20contractswith“niche”providersand

Community Service Agencies (CSAs), which are community-based, oten nontraditional providers that are

not required to meet ull licensure requirements as a behavioral health agency. These are a new type o

provider developed by the state, and they are paid on a ee-or-service basis.

In1993,anEPSDT-relatedlawsuit,knownas“JasonK”or“JK,”wasledinArizonaonbehalfofthenow34,000Medicaid-eligibleclassmembersunderage21inneedofbehavioralhealthservices.TheJKsuit

wassettledin2001,andtheJKsettlementagreementformsthebasisforthechild/adolescentbehavioral

health system in the state. Technically, the agreement applies to the State Medicaid agency (i.e., the

Medicaidmanagedcaresystem)andADHS/BHS;however,thesesystemsworkcollaborativelyacross

systems on implementation since the suit covers children in child welare and juvenile justice, as well as

NativeAmericanyouth.Whathascometobeknownas“theArizonaVision”underpinsthesettlement

agreement.The“vision”isastatementof12principlesbasedonsystemofcarevalues.Theprinciples

include: collaboration with the child and amily, (priority on) unctional outcomes, collaboration with

others, accessible services, best practices, most appropriate setting, timeliness, services tailored to the child

and amily, stability, respect or the child’s and amily’s cultural heritage, independence, and connection to

natural supports.

The principles provide the philosophical oundation or reorm o the system, including expansion o covered services, intake, assessment, and service planning processes, which involve a child and amily team

(or wraparound) approach. More inormation about the Arizona system can be ound at:

http://www.azdhs.gov/bhs .

HI HawaiiHawaii , located 2,300 miles southwest o San Francisco, is a 1,523-mile chain o

islets and eight main islands —Hawaii, Kahoolawe, Maui, Lanai, Molokai, Oahu,

Kauai, and Niihau. The state’s population is approximately 1.3 million; 23.5% o

the population is under age 18. The population is diverse, with more ethnic and

cultural groups represented in Hawaii than in any other state. According to recent

census data, 27% o the population is White, 41% Asian, 9% Native Hawaiian andotherPacicIslander,8%Hispanic,2%Black,and20%reportingtwoormoreraces.

Nearly 27% o households reported speaking a language other than English at home. Signicant challenges

to service delivery are presented by the state’s island geography, as well as by its diverse population, and

numerous cultures and languages.

Hawaii’s children’s mental health system is administered by the state government, specically the Child

and Adolescent Mental Health Division (CAMHD) o the Hawaii Department o Health (DOH). CAMHD’s

missionis“toprovidetimelyandeectivementalhealthservicestochildrenandyouthwithemotionaland

behavioral challenges and their amilies….within a system o care that integrates [system o care] principles,

evidence-basedservices,andcontinuousmonitoring.”Amajorsystememphasisisonensuringthatall

services and supports are individualized, youth-guided, and amily-centered, as well as on services being

locally available, community-based, and least restrictive.

Under the CAMHD structure are seven public Family Guidance Centers (community mental health

centers) located throughout the state that are responsible or mental health service delivery to children and

adolescents and their amilies. CAMHD also contracts with a range o private organizations to provide a ull

arrayofmentalhealthservicestochildrenandadolescentsandtheirfamilies.Publicemployeeswithinthe



I n t r o d u c t i



Family Guidance Centers provide care coordination services, some assessment and outpatient services, and

arrange or additional services with contracted provider agencies. Additionally, one branch (Family Court

LiaisonBranch)providesmentalhealthassessmentsandtreatmentatthejuveniledetentionhomeandthe

youth correctional acility.

In 1993, a class action lawsuit was led alleging that the Hawaii Departments o Health and Education

were ailing to provide adequate and appropriate educational and mental health services to youth withemotional and/or behavioral challenges under the Individuals with Disabilities Education Act (IDEA) and

Section 504 o the Rehabilitation Act o 1973. The ollowing year, the state entered into what is reerred to

asthe“FelixConsentDecree”inwhichitagreedtoexpandandimproveservicesaccordingtoadetailed

implementationplan,withthegoalofcreatinga“systemofcare”thateectivelyintegratestheactivitiesof

diverse service-providing agencies and provides a comprehensive array o services. As a result o the Felix

Consent Decree in 1994, the legislature sharply increased appropriations or CAMHD and the Department o

Education to expand and improve services. In 2004, the court ruled that the state had achieved substantial

compliance with the Felix Consent Decree and that court monitoring would be continued or an additional

periodoftimetoensurethatprogressissustained.CourtmonitoringendedinJune2005.Moreinformation

can be ound at http://www.hawaii.gov/health/mental-health/camhd/index.html.

Over the past ve years, CAMHD’s system o care shited rom a comprehensive mental health

service system or all children and youth to a system ocused on providing more intensive mental healthservices to the population o youth with more serious and complex behavioral health disorders and

their amilies. Beginningwithscalyear2000–2001,theDepartmentofEducationtookresponsibility

or serving students with less severe emotional and/or behavioral challenges through newly established

school-based behavioral health services. Youth needing less intensive mental health services, such as

outpatientcounseling,nowreceivetheseservicesthroughschool-basedmentalhealth(SBMH)services.

The coordinated relationship between the education and mental health systems provides a system o care

with the school as the central access point or mental health services or youth with educational disabilities.

Youth with emotional challenges that are not impacting their education receive basic mental health

services through their private insurance or through their Medicaid health plans which provide assessment

and basic levels o outpatient treatment. More intensive services, i needed, or Medicaid-eligible youth, are

then obtained through the CAMHD children’s mental health system.

Through a Memorandum o Understanding (MOU) with the state Medicaid agency, CAMHD operates

a carve-out under the state Medicaid program that serves youth with serious emotional and behavioral

disorders(theSupportfortheEmotionalandBehavioralDevelopmentofYouthorSEBDProgram).CAMHD

receives a case rate rom Medicaid or each child in service and provides a comprehensive array o services

and supports. Operation as the prepaid mental health plan or Medicaid-eligible youth began in 2002.




NJ New JerseyNew Jersey has a population o about 8.7 million people, with over two million children.

Itisoneofthemostdenselypopulatedstatesinthecountry.TheNewJerseyChildren’s

System o Care Initiative, which was begun in 2000, is a behavioral health carve out,

serving a statewide, total population o children and adolescents with emotional and

behavioral disturbances who depend on public systems o care and their amilies. Thepopulation includes both Medicaid and non-Medicaid-eligible children and includes

both children with acute and extended service needs. The state describes the initiative

as,“notachildwelfare,mentalhealth,Medicaid,orjuvenilejusticeinitiative,butonethat

crossessystems.”Theinitiativecreatesasinglestatewideintegratedsystemofbehavioral

health care to replace the previous system in which each child-serving system provided

itsownsetofbehavioralhealthservices.TheNewJerseyDivisionofChildBehavioralHealthServices,

Department o Children and Families, oversees the initiative, the goals o which are to increase unding

or children’s behavioral health care; provide a broader array o services; organize and manage services;

and provide care that is based on the core system o care values o individualized service planning, amily/

proessional partnerships; culturally competent services; and a strengths-based approach to care.

TheNewJerseysystemofcareusesastatewideAdministrativeServicesOrganization(ASO),calledaContracted Systems Administrator (CSA) to coordinate, authorize, and track care or all children entering

the system and to assist the state agency to manage the system o care and improve quality. A non

risk-basedcontractwasawardedtoValueOptions(VO),acommercialbehavioralhealthmanagedcare

company, to perorm this role. Newly ormed nonprot entities, called Care Management Organizations

(CMOs), were created at the local level — one per region — that provide individualized service planning and

care coordination or children with intensive, complex service needs. CMOs use child and amily teams to

develop individualized service plans which are required to be strengths-based and culturally relevant; the

CMOs employ care managers who carry small caseloads. The system also incorporates partnership with

amilies by creating and unding Family Support Organizations (FSOs) in each region that ulll a range o

support and advocacy unctions and also provide Family Support Coordinators and Community Resource

Development Specialists to provide peer support, inormal community resources, and advocacy to amilies

served by the CMOs. TheNewJerseysystemofcareincorporatesabroad,exiblebenetdesignthatincludesarangeof

traditional clinical services, as well as nontraditional services and supports. To achieve this, the initiative

expanded services covered under Medicaid through the Rehabilitation Services Option and covers

otherservicesthroughnon-Medicaiddollars.Theinitiativeusesa“singlepayersystem”throughthe

state Medicaid agency or both Medicaid and non-Medicaid eligible children served in the system. More

inormation can be ound at http://www.nj.gov/dcf/behavioral .



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VT VermontU.S. census data estimate Vermont’s population at 623,000 persons in 2005; slightly more

than 135,000 — about 22% — were children under age 18. In the late 1990s, it was estimated

thatabout12%ofVermont’schildrenandyouth(16,200childrenandadolescents)experience

serious or severe emotional disturbance each year. The number o children who received

public children’s mental health services increased rom about 3,750 in 1989 to slightly morethan 10,000 in 2005.

Vermont’ssystemofcareforchildrenandadolescentswithsevereemotionaldisturbanceandtheir

familiestookshapeinthe1980s.In1982,VermontwastherststatetosecureandimplementaMedicaid

home and community-based services waiver or children with serious emotional disorders. In 1985,

VermontreceivedanNIMH-fundedChildandAdolescentServiceSystemProgram(CASSP)planninggrant

that provided the means to develop the vision and values necessary to create and sustain a system o

care.In1988,VermontenactedAct264,whichcodieditsvisionandstructureforacoordinatedsystem

o care or this population. Act 264 articulated system o care values and principles and established an

inrastructure to advance the system o care approach statewide. The law institutionalizes interagency

cooperation and coordination at the state and local levels by: establishing a denition o severe emotional

disturbance or all agencies to use; mandating state and local interagency teams; creating an advisoryboard appointed by the governor to advise the partnering state agencies on the development and

operation o the system o care; entitling eligible children and youth to a coordinated services plan; and,

mandating and setting orth a structure or amily involvement.

Vermont’sDepartmentofMentalHealthistheleadstateofficeforchildren’smentalhealth.Itisclosely

aligned with the state’s Department o Health due to a recent reorganization within the umbrella Agency

o Human Services. A Designated Agency within each region (e.g., a community mental health center)

serves as the local ocal point or management and coordination o the system o care. Five core services

are available within each geographic area o the state. Additional services and support are provided under

contract with the designated agency, as well as several statewide services. The core services are categorized

as immediate crisis response; clinic-based and outreach treatment; amily support; and prevention,

screening, reerral and community consultation. Statewide services are emergency/hospital diversion,

intensive residential services, and hospital inpatient services.Operationally, an interagency treatment team o amily members and service providers that is led by

a care coordinator develops the individualized coordinated service plan or each child. One agency has

legal responsibility or ensuring that a coordinated service plan is in place. I the child is in the custody o

the state’s child welare agency, the Department or Children and Families, that agency is responsible. I

the issues are primarily associated with the child’s educational environment and unctioning and the child

is not in state custody, then the local school district is responsible. In all other cases, the mental health

system’s Designated Agency (e.g., community mental health center) is responsible or developing the

coordinated services plan that outlines goals and needed supports and services. I problems or issues arise

that the individual treatment team cannot resolve, the team or any member may initiate a reerral to the

Local Interagency Team (LIT) in the region or help. The State Interagency Team is a state-level orum or the

next round o consideration or assistance should issues not be resolved locally.

The Agency o Human Services and the Department o Education signed a new agreement in 2006

that broadened the scope o eligible youth and the group o providers who participate in and contribute

to service planning or them. With the new interagency agreement, eligibility expanded rom the original

single disability o severe emotional disturbance to include youth with any o the 14 disabilities in state and




federalspecialeducationlaw.Thesechildrenandtheirfamiliescanaccesscoordinatedplansthat“include

but are not limited to developmental services, alcohol and drug abuse programs, traumatic brain injury

programsandpreandpostadoptionservices.”

Vermont´schildren´smentalhealthpartnersalsoareexploringnewapproachestonancingservices

or children with multiple, severe needs. Under the authority o the State’s Global Commitment Medicaid

waiver received in 2005, the state is working to establish a mental health unding resource that wouldcreate a pool o resources unded by several agencies or services and supports or children with multiple

and serious needs. More inormation can be ound at http://healthvermont.gov/mh/programs/cafu/

child-services.aspx.

AK Bethel, AlaskaBethel is a city located 340 miles west o Anchorage. According to 2005 Census

Bureauestimates,thepopulationofthecityis6,262.Bethelisthelargestcommunity

in western Alaska and the 9th largest municipality in the state. It lies inside the

largest wildlie reuge in the United States. It is an administrative and transportation

hub or the 56 villages in the Yukon-Kuskokwim Delta, one o the biggest river deltas

in the world, roughly the size o Oregon. The Delta has approximately 20,000 residents; 85% o these are Alaska Natives, both Yup’ik Eskimos and

Athabaskan Indians. Nearly hal o the region’s population is children due to the high birth rate and young

medianage.ThemainpopulationcenterandservicehubisthecityofBethel;eachofthe56villageswithin

the Delta has up to 850 people. Most residents live a traditional subsistence liestyle o hunting, shing, and

gathering, and over 30% have cash incomes well below the ederal poverty threshold.

Precipitationaverages16inchesayearinthisarea,withsnowfallof50inches.Theaveragelow

temperatureinJulyis49°Fandtheaveragehighis63°F,althoughtemperaturesaslowas32°Forashigh

as87°FhavebeenrecordedinJuly.InJanuary,theaveragelowis1°Fandtheaveragehighis12°F,while

extremesof–49to49°Fhavebeenrecorded.

Health and behavioral health services in this region are the responsibility o the Yukon Kuskokwim

Health Corporation (YKHC), which administers a comprehensive health care delivery system or the 56 rural

communities in southwest Alaska. The system includes community clinics, sub-regional clinics, a regional

hospital, dental services, behavioral health services, including substance abuse counseling and treatment,

health promotion and disease prevention programs, and environmental health services.

YKHC is a Tribal Organization authorized by each the 58 ederally recognized tribes in its service area to

negotiate with the ederal Indian Health Service to provide health care services under Title III o the Indian

Sel-Determination and Education Assistance Act o 1975. YKHC, along with 12 other Tribal Organizations,

is a co-signer to the All-Alaska Tribal Health Compact, a consortium which negotiates annual unding

agreements with the ederal government to provide health care services to Alaska Natives and Native

Americans throughout the state.

Community health aides provide village-based primary health care in 47 village clinics in the Yukon-

Kuskokwim Delta. Health aides receive extensive training in acute, chronic and emergency care, have a ve-

tiered career ladder and are certied by a board operated by the Alaska Native Tribal Health Consortium.Health aides are nominated or training by their local village councils, and usually serve the villages where

they grew up. The village health clinic is typically the rst point o access to the YKHC health and behavioral

healthcaresystem.HealthaidesconsultwithfamilymedicineprovidersorspecialistsinBethelandeither

treat patients locally or make reerrals or individuals needing more comprehensive care.



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The programmatic approach or children’s mental health services is core teams o licensed mental

health proessionals and behavioral health aides who are responsible or the provision o children’s mental

health services in the rural villages o the Delta area. The core teams are modeled on the Community Health

AideProgram,theruralhealthcareprogramthatusesindigenouscommunityhealthaides(CHAs)and

communityhealthpractitioners(CHPs),speciallytrainedandcertiedindividualswhooerhealthservices,

including preventive care and health screening services to small groups o individuals living in widelyscattered villages in bush Alaska. More inormation about YKHC can be ound at http://www.ykhc.org .

NE Central NebraskaRegion3BehavioralHealthServices(BHS)serves22countiesinCentral and

South Central Nebraska. The service area covers 15,000 square miles and has

a population o 223,000. Approximately hal o the population in the Region 3

service area lives in three urban centers (Grand Island, Kearney, and Hastings).

The remainder o Region 3 is rural.

With the support o the partners listed below and a ederal grant, an eective service system, guided by

system o care values and principles, has been created and sustained in Central Nebraska. These partners

include:• Region3BHS,oneofsixregionalbehavioralhealthauthoritiesinNebraska,governedbyaboard

consisting o elected of cials rom the 22 counties served

• NebraskaDepartmentofHealthandHumanServices(DHHS),DivisionofBehavioralHealthServices

(DBHS),thestatementalhealthauthoritythatcontractswitheachregionalbehavioralhealthauthority

and has been actively engaged in the work in Region 3

• NebraskaDepartmentofHealthandHumanServices(DHHS),CentralServiceArea,OfficeofProtection

and Saety, a state-administered agency that provides services in child welare, juvenile justice, and

developmental disabilities or 21 o the 22 counties in Region 3

• FamiliesCARE,thefamilysupportandadvocacyorganizationinCentralNebraska

• SchooldistrictsandeducationalcooperativesincludingGrandIslandPublicSchools,KearneyPublic

Schools, and Educational Service Units 9 and 10.

Eorts to build a strong behavioral health service system or children and amilies in Central Nebraska

beganin1989whenRegion3hiredaChildandAdolescentServicesSystemProgram(CASSP)Coordinator.

Central Nebraska had the benet o a ve-year system o care grant rom the ederal Center or Mental

HealthServices,beginningin1997.PriortoimplementingasystemofcareinCentralNebraska,only10%

oftheRegion3BHSannualbudgetwasallocatedtochildren’sservices,andfourchildren’sservicessta

were employed. Ater receipt o the ederal grant, the sta increased to approximately 48 FTEs related to

child/familyservices.Inscalyear2005,almost50%oftheRegion3BHSbudgetwasallocatedforchildren’s

services.

Within the system o care in Central Nebraska, there are several programs designed to serve children

with diering needs, which are unded through collaborative nancing strategies. These include:

• Professional Partners (PP)— Wraparound process or children who meet the denition or seriousemotional disturbance and have other risk actors (implemented statewide)

• Integrated Care Coordination (ICCU) — Intensive care management based on principles o the

wraparound process and amily-centered practice, or children in state custody who have complex

behavioral health needs and multiple agency involvement




• Early Intensive Care Coordination (EICC) — Similar to ICCU, but works with amilies in the child

welare system earlier, to prevent children rom entering state custody

• Family Advocacy/Support/Education and Youth Encouraging Support—Bothprogramsareoered

by Central Nebraska’s amily organization, Families CARE

• Multisystemic Therapy (MST)— Intensive, time-limited home-based treatment to help amilies o

children with behavioral health needs make changes in their child’s environment• School Wraparound — School-based wraparound approach to stabilize and maintain in the most

normalized environment students who are experiencing emotional and behavioral challenges.

In scal year 2005, these six programs together served approximately 1,000 children and their amilies.

A case rate methodology, created in Central Nebraska by blending unding sources, serves as a primary

unding strategy to support and sustain an intensive care management model, the work o Families

CARE, a number o the services described above, and the system o care. Use o case rates has provided

theexibilitytooerindividualizedcareanddevelopnewservices.Costsavingshavebeenreinvestedin

the child-serving system by providing technical assistance to replicate the program in other areas o the

state and by expanding the population o children and amilies served in Central Nebraska. This case rate

methodology is now used by ve o the six regional behavioral health authorities in Nebraska.

Medicaidfundsarenotincludedinthecaserate.TheNebraskaDHHS/DBHSfundsthepublic,non-Medicaid statementalhealthsystem.Region3BHSdoesnotreceiveormanageMedicaidfunds.Behavioral

healthservicesreimbursedbyMedicaidareauthorizedbyMagellanBehavioralHealthCare,Inc.,Nebraska’s

statewide managed care administrative services organization (ASO), and reimbursements are made on a

ee-or-service basis to providers. More inormation can be ound at http://www.region3.net .

Choices Choices ( IN Marion County, Indiana; OH Hamilton County, Ohio;MD Montgomery County and Baltimore City, Maryland)

Choices, Inc . is a nonprot, community care management organization that coordinates

services or individuals and amilies involved in one or more governmental systems. Choices

uses the system o care philosophy and approach with wraparound values and blends

them with managed care technologies to provide a wide range o services and supports tohigh-risk populations with multiple and complex service needs. Choices programs serve

both children and adults; the core o each program is that services are amily centered,

community based, culturally competent, outcome driven, and scally accountable.

Choices, Inc. was incorporated in 1997 as a private, nonprot entity. It was created by

our Marion County communitymentalhealthcenterstocoordinatetheDawnProject,

a collaborative eort among child welare, education, juvenile justice and mental health

agencies to serve youth with severe emotional disturbances and their amilies in Marion

County, Indiana. Dawn began as a pilot and served its rst ten youth in 1997. In 1999, a ve-

year ederal grant rom the Comprehensive Community Mental Health Services or Children

andTheirFamiliesProgramwasawardedtotheDawnProject,enablinganincreaseinthe

number o children and amilies served, including an expansion in the target population to serve children

at risk or out-o-home care, as well as support or the development o a amily support and advocacy

organization (Families Reaching or Rainbows) and evaluation activities.

Choices was conceived as a separate and independent entity to manage the Dawn system o care.

Fulllingtheroleofa“caremanagementorganization,”Choicesprovidesthenecessaryadministrative,

nancial, clinical, and technical support structure to support service delivery and manages the contracts



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with the provider network that serves youth and their amilies. The responsibilities o Choices include:

providing nancial and clinical structure; providing training; organizing and maintaining a comprehensive

provider network (including private providers); providing system accountability to the interagency

consortium; managing community resources; creating community collaboration and partnerships; and

collecting data on service utilization, outcomes, and costs. Choices now operates programs in several states

thatserveyouthwithseriousemotionaldisorders—theDawnProjectinMarionCounty(Indianapolis),Indiana; Hamilton Choices in Hamilton County (Cincinnati), Ohio; and Maryland Choices in Montgomery

CountyandBaltimoreCity,Maryland .

The goal o Dawn (and Choices programs or youth and amilies in Ohio and Maryland) is to improve

services or youth with serious emotional disorders and to enable them to remain in their homes and

communities by providing a system o care comprised o a network o individualized, coordinated,

community-based services and supports, using managed care technologies. The managed care system

is designed to serve youngsters with the most serious and complex disorders and needs across child-

serving systems, those who typically are the most costly to serve and who are in residential care or at

riskforresidentialplacement.Inessence,thedesigncreatesaseparate“systemofcarecarve-out”forthis

population. Dawn and Choices Ohio program are unded by case rates provided by the participating child-

serving systems. The recently initiated program in Maryland is in the developmental stages; it is not as yet

risk based and is not using the case rate approach at this time.Over time, Choices has developed other services or high-need, complex populations, lling particular

high-priority service gaps in the community. The Action Coalition to Ensure Stability (ACES) program serves

adults who are homeless and who have co-occurring mental health and substance abuse disorders; Youth

EmergencyServices(YES)isa24-hourmobilecrisisserviceforabusedandneglectedchildren;andBackto

Home serves runaway youth in the county. The common threads in all the programs operated by Choices

include the use o managed care approaches, blended unding rom participating agencies, individualized

andexibleservices,andcaremanagement.

In addition to its direct services, Choices has become a resource or technical assistance in Indiana. The

Indiana Divisions o Mental Health and Family and Children began providing start-up resources in 2000 or

the development o systems o care based on Dawn’s experience in other areas o the state. Choices has

been a key technical assistance resource or these sites and, in 2002, was ofcially unded by the State as a

technicalassistancecenter(TechnicalAssistanceCenterforSystemsofCareandEvidence-BasedPractices

or Children and Families) to provide assistance in developing similar community based systems o care

throughout the state. More inormation about Choices can be ound at: http://www.choicesteam.org.




Wraparound Milwaukee Wraparound MilwaukeeWraparound Milwaukee is a behavioral health carve-out, serving several subsets

o children and youth with serious behavioral health challenges and their amilies

in Milwaukee County, Wisconsin. Milwaukee County has a population o about

240,000 children under 18. The primary ocus o Wraparound Milwaukee is on

children who have serious emotional disorders and who are identied by the childwelare or juvenile justice system as being at risk or residential or correctional

placement. Wraparound Milwaukee serves about 1,000 children a year over age ve.

(Itdoesnotservethe0–5populationingeneral.)Acombinationofseveralstate

and county agencies, including child welare, Medicaid, juvenile probation services, and the county mental

health agency, nance the system. Their dollars create, in eect, a pooled und that supports Wraparound

Milwaukee,whichisasystemofcareadministeredbytheMilwaukeeCountyBehavioralHealthDivision

in the County Department o Health and Human Services. Wraparound Milwaukee organizes an extensive

provider network and utilizes care coordinators, who work within a wraparound, strengths-based approach.

Wraparound Milwaukee involves amilies at all levels o the system and aggressively monitors quality and

outcomes. It has an articulated values base that emphasizes: building on strengths to meet needs; one

amily-one plan o care; cost-eective community alternatives to residential placements and psychiatric

hospitalization; increased parent choice and amily independence; care or children in the context o their

amilies; and unconditional care.

Wraparound Milwaukee operates as a special managed care entity under its contract with the state

Medicaid program. It operates under a 1915 (a) waiver and a sole source contract between the state

Medicaid agency and Milwaukee County, which allows it to blend unds rom multiple child-serving

systems.GovernanceisthroughtheMilwaukeeCountyBoardofSupervisors.

WraparoundMilwaukeepreferstodesignateitselfa“caremanagement,”ratherthanmanagedcare,

entity, emphasizing a values base which it eels is more consistent with its public sector responsibilities

thantheterm“managedcare”mayconnote.Theprogram,however,utilizesmanagedcaretechnologies,

including a management inormation system designed specically or Wraparound Milwaukee, capitation

and case rate nancing, service authorization mechanisms, provider network development and

management, accountability mechanisms, and utilization management, in addition to care management.More inormation about Wraparound Milwaukee can be ound at: http://www.milwaukeecounty.org/

wraparoundmilwaukee .



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Efective Financing Strategies Framework

A Strategic Approach to FinancingA strategic approach to nancing begins with system o care stakeholders answering two key

questions: Financing or whom? and Financing or what?

To answer these questions, system of care planners must achieveconsensus on the following:

• Identifypopulation(s)offocus,includingthedemographics,size,strengthsand

needs, current utilization patterns, and disparities and disproportionality in service

use among the identied population(s)

• Agreeonunderlyingvaluesandintendedoutcomes

• Identifytheservicesandsupportsandthedesiredpracticemodel(forexample,a

strengths-based, individualized, culturally competent, amily-driven and youth-

guided practice approach) to achieve outcomes• Determinehowservicesandsupportswillbeorganizedintoacoherentsystem

design

• Identifytheadministrativeinfrastructureneededtosupportthedeliverysystem

• Costoutthesystemofcare

Once these issues are addressed, then system builders can undertake a strategic nancing

analysis, which includes attention to the ollowing:

• Identifythestateandlocalagenciesthatspenddollarsonbehavioralhealthservices

and supports or the populations o ocus• Identifyhowmucheachagencyspendsandtypesofdollarsspent(e.g.,federal,

state, local, tribal, etc.; also, entitlement, ormula, discretionary, etc.)

• Identifyresourcesthatareuntappedorunder-utilized,suchasMedicaid

• Identifyutilizationpatternsandexpendituresthatareassociatedwithhighcosts

and/or poor outcomes

• Identifydisparitiesanddisproportionalityinserviceaccessandutilization

• Determinethefundingstructuresthatwillbestsupportthesystemdesign,suchas

blended unding or risk-based nancing

• Identifyshortandlong-termnancingstrategies(forexample,federalrevenue

maximization; redirection o spending rom restrictive levels o care; taxpayer

reerenda, etc.)




Developing a Strategic Financing Plan The ollowing seven areas must be addressed in a strategic nancing plan or a system o care:

I. Identifying spending and utilization patterns across agencies

II. Realigning funding streams and structuresIII. Financing appropriate services and supports

IV. Financing to support family and youth partnerships

V. Financing to improve cultural and linguistic competence and reduce

disparities in care

VI. Financing to improve the workforce and provider network

VII. Financing for accountability

This report describes each o these areas and provides examples o eective strategies related

to each rom the states and communities studied. While a given state or locality may not be

implementing comprehensive strategies in every area, collectively, the states and communities

studied provide a breadth o examples to illustrate eective nancing approaches or systems o care, and all o the sites in the study sample have articulated in policy a commitment to system o

care values and approaches.

Hawaii provides an example o a state that has developed a strategic nancing plan as part o

its overall strategic plan or children’s mental health services.

HI HawaiiDeveloping a Strategic Financing Plan

The legislature requires a our-year strategic plan or children’s mental health services. A new plan was

completedfortheperiod2007–2010,withsevenpriorityareas:

• Decreasestigmaandincreaseaccesstocare

• Implementandmonitoreectivenessofacomprehensiveresourcemanagementprogram

• Implementapubliclyaccountableperformancemanagementprogram

• Implementandmonitoracomprehensivepracticedevelopmentprogram

• Implementandmonitorastrategicpersonnelmanagementplan

• Implement and monitor a strategic fnancial plan

• Implementandmonitorastrategicinformationtechnologyprogram

Development o the strategic nancing plan involved collection o inormation, including

obtaining input rom stakeholders, partner agencies, and others through meetings. The nancing

plan, as part o the larger strategic plan, builds on what is already in place and includes specication

o thresholds/benchmarks and an emphasis on linking utilization, costs, and outcomes, nancingincentives to drive system o care principles in provider agencies, and cost/quality efciencies.



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The broad goals o the nancing plan are to demonstrate a diversity o sustainable unding

streams, strengthen the expertise o the children’s mental health branch (Child and Adolescent

Mental Health Division [CAMHD]) in nancial operations, achieve established thresholds or each

unding source, demonstrate braided and blended unding programs with all child-serving agencies,

and demonstrate routine nancial reporting to the management team and community stakeholders.Specic goals are to:

• StrengthenTitleXIXMedicaidbillingpractices

• StrengthentheRandomMomentsStudiesbilling

• StrengthenTitleIV-Ebilling

• Strengthenbraidedandblendedfunding

• Maximizefundingopportunitiesbypursuingfederalandcommunitygrants

• Developthird-partybillingagreements

• Implementroutinenancialreporting

Foreachgoal,theplandelineatesspecic“initiatives,”deliverableproducts,unitsresponsible,

and due dates. For example, or the goal on strengthening braided and blended unding, the plan

species completing a review o all CAMHD agreements on joint unding, identiying possible optionsor other joint unding opportunities, and expanding the number o agreements or joint unding.

Thenalproduct,alistingofjointfundingMOAs,istobecompletedbyJune2008.




g

I. Identifcation o Current Spending and UtilizationPatterns Across Agencies

The identication o current spending and utilization patterns is an important rst stepin the development o a strategic nancing plan or systems o care. This process enables

a state, tribe, or community to understand how unds across all child-serving systems

currently are being spent and or which children and amilies. It also assists in projecting

expected utilization and costs, identiying potential resources, and planning accordingly.

Financing Strategies Include:

A. Determine and Track Utilization and Cost o Behavioral Health

Services or a Defned Population

B. Identiy the Types and Amounts o Funding or Behavioral HealthServices Across Systems

A. Determine Expected Utilization and Cost andTrack Utilization and Cost

Arizona, Hawaii, New Jersey, Vermont, Choicesand Central Nebraska oer examples o

determining and tracking utilization and costs or a variety o planning, rate setting, and

accountability purposes.

AZ ArizonaTracking Utilization and Cost for the Child Welfare Population

The Arizona Department o Health Services, Division o Behavioral Health Services (ADHS/BHS), has

worked with the state child welare agency to identiy utilization and costs associated with behavioral

health services nanced by the child welare system that were being provided to Medicaid-eligible

children and which could be covered by Medicaid instead o using all state general revenue dollars.

This was part o a revenue maximization strategy. ADHS/BHS worked with child welare and Medicaid

actuaries to determine the cost o services to child welare-involved children in licensed Level I out-

o-home placements (i.e., secure and non-secure residential treatment centers and acute inpatient

hospital care). The assumptions refected that not all children would meet Medicaid criteria orplacement (i.e., medical necessity criteria). The prior authorization criteria were expanded to allow

or a decision to place or maintain a child in an out-o-home treatment setting i the child, along

with having a mental health diagnosis, did not have a home to go to or the opportunity to obtain

community-based services to maintain unctioning. Specic dollars were allocated to Value Options



I . I d e n t i f c a t i o n o

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(VO), the contracted managed care organization in Maricopa County , to begin unding these out-o-

home treatment services (as well as alternatives to out o home placement). Subsequently, additional

unds were earmarked or child welare-involved children to support their involvement in Level II and

III placements (i.e., out o home placements less restrictive than residential treatment centers and

inpatient hospital care, such as therapeutic oster care), as well as outpatient programs. As a result o this eort, the agencies identied a number o child welare-involved children whom they elt should

be in Medicaid-nanced therapeutic oster care or in Medicaid-nanced counseling services . The

numbers o children were arrived at based on actual mental health services provided by child welare

or children eligible or Medicaid services.

The analyses undertaken with child welare led to a revision upward in the capitation rate or

child welare-involved children (i.e., development o a risk-adjusted rate). Dollars were not shited

rom child welare as part o this process due to that system’s experiencing an increase in children

coming into custody; however, behavioral health received additional resources through the state

budget process. Following these analyses, ADHS/BHS also expanded the denition o “urgent” as it

relates to provision o crisis services. In the new denition, children who are removed rom home by

child welare are considered to have “urgent behavioral health needs,” requiring a 24-hour response

by the behavioral health system to conduct an initial assessment. This expansion was made bothto ensure timely response to children removed rom home, and to intervene early to prevent the

need or out-o-home therapeutic placements urther down the road. While most o these children

become state wards and thus eligible or Medicaid, at the time o the “urgent care” response, nancial

eligibility verication is not required.

Both statewide and in Maricopa County, about 60% o the oster care population was receiving

behavioral health services through the managed care system at the time o the site visit. (That is now

reportedly up to 75%.) In Maricopa, this is a sizeable increase over what had historically been a 30%

oster care involvement rate. Increased access or children in child welare is a goal o the Arizona

reorm.

The state develops a yearly utilization management report or children, ages 18 and under (and

or 21 and under), that looks at units o service and nancial expenditures. The largest percentage o

dollars (36.4%) or children and youth is spent on what Arizona calls “support services,” which includes

case management, therapeutic oster care, respite care, amily support, transportation, personal

assistance, fex und services, peer support, housing support services, and interpreter services.

HI HawaiiRegular Tracking and Reporting of Utilization and Cost TrendsSince 1997–98, the state children’s mental health system in Hawaii has systematically tracked

mental health service utilization to determine the amount o services to purchase rom provider

agencies. The Child and Adolescent Mental Health Division (CAMHD) produces a nancial report on

a regular basis (monthly and quarterly) that analyzes inormation regarding nancial resources andexpenditures. For example, the quarterly report species:

• HowmuchMedicaid(TitleXIX)revenueCAMHDreceivesperclient/permonth

• HowmuchSpecialFundrevenueCAMHDreceivedinthescalyearandhowmuchmoney

remained in the Special Fund accounts (Medicaid capitation and ee or service, investment pool,

Title IV-E)




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• HowmuchTitleIV-ErevenueCAMHDreceived

• UtilizationtrendforCAMHDemergencyservices,including24hourcrisistelephoneconsultation,24 hour mobile outreach, and crisis stabilization (average monthly cost per registered client)

• UtilizationtrendsforCAMHDintensiveservices,includingintensivein-homeandMultisystemic

Therapy–MST (average cost per client per month)• UtilizationtrendforCAMHDresidentialservices(averagecostperregisteredclientpermonth)

• Utilizationtrendforhospital-basedresidentialcare(averagecostperregisteredclientpermonth)

• ComparisonofexpensesfromauthorizationsperunduplicatedclientamongFamilyGuidanceCenters

• HowCAMHDoperationalexpensescomparetoquarterlyallocations

Included in the nancial report are charts showing operational expenses per month within

GeneralFunds,SpecialFund(TitleXIX),andfederalandinterdepartmentaltransfers(suchasfederalgrants and Title IV-E unds). These expenses are broken down by service within categories including

emergency services, intensive services, residential services, and other services (such as ancillary/fex

services and respite services).

NJ New JerseyRegular Tracking of Utilization and Cost DataNew Jersey’s Administrative Services Organization, called the Contracted Systems Administrator

(CSA), authorizes, coordinates and tracks care or all children entering the system. Providers are paid

using a single method and this allows or the maintenance o one electronic record o behavioral

healthcareacrosssystemsthatservechildren.TheCSA’sABSOLUTEInformationSystemhasthe

capacity to produce reliable cost and utilization data. Examples o the types o data that are tracked

include:

• Numberofreferralsbysource,location(countyorCMOarea),age,ethnicityandsex.• Numberofreferralsscreened(EPSDT),assessed,multi-systemassessedbydiagnosis,location,

age, ethnicity, and sex.

• NumberofreferralsassignedtotheCMOsstatewideandbydiagnosis,location,age,ethnicity,sexand reerral source.

• NumberofreferralsandacceptedchildreneligibleforMedicaid,NJKidcare/Familycare

• Number/PercentofchildrenacceptedintheChildren’sInitiativewithserviceplancompleted

within required time rame by diagnosis, location, age, ethnicity and sex.

• AmountofdollarsspentforchildrenintheChildren’sInitiativebychild,diagnosis,eligibilitytype

(CMO, CSA care coordination), location, age, ethnicity, sex, service type

• Amountandtypeofserviceused(hours,days)perchildbydiagnosis,eligibilitygroup,location,

age, ethnicity, sex




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• Timelinessofserviceauthorization—Percentofserviceauthorizationdecisionsforcontinuedstay in inpatient services made within 24 hours ater receiving assessment inormation rom a

clinicalproviderorscreeningteam(CSAUMsystem)

• Timelinessofserviceauthorization—Percentofadmissionandcontinuationofcaredecisionsfor

routine care or non-CMO children made within 5 working days ater receiving a service requestwithalloftheclinicalinformationrequiredby,andstatedin,writtenCSApolicy(CSAUMsystem)

• FSOinvolvement—PercentofCMOfamiliesreferredtoFSOs;percentoffamiliesincrisisreferred

toFSOs(CSAUMsystem)

• Restrictivenessoflivingenvironment—Percentandnumberofchildrenwhomovedtoalessrestrictive living environment rom entry to exit

• Readmissionrate—Percentofchildrendischargedfromaninpatientfacilityreadmittedwithin7,

30, 90, and 180 days ater discharge, stratied by age

• Functioning—PercentchangeinStrengthandNeedsAssessmentscores(entryscore,scoreat

review period, exit score)

• Placementstability—Numberofchildrenunabletobemaintainedincurrentplacementfor

emotional or behavioral reasons• RTClengthofstay—PercentchangeinRTClengthsofstay:·Perchild·Per100children

• Adequacyofcrisismanagement—NumberofcrisisscreeningsreportedtotheCSA:·Perchild

·Per100children

• Timelinessofcrisismanagementfollow-up—Percentofchildrendischargedfromcrisis

management that receive a service within three days

• Timelyoutpatientorcommunity-basedservicesfollow-uptoinpatienttreatment—Percentof

children discharged rom inpatient care who receive outpatient or community-based services

within seven days

• CoordinationwiththeMedicaidHMOprimarycarephysician(PCP)—Percentofchildren

receiving psychotropic medications whose provider is actively coordinating with the Medicaid

HMO PCP, excluding children without an assigned PCP.




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VT VermontTracking Utilization and Costs for Planning and Accountability Vermont routinely tracks utilization and costs associated with mental health and system o care

services. The data are used or accountability unctions and to document ongoing and changing

needs in the community. They also provide basic inormation (presented to and reviewed by the

legislature) that infuences program and policy directions or children’s behavioral health services. In

addition to providing inormation or required scal reporting and monitoring by the state and local

agencies, university partnerships also exist that utilize the data in special studies.

The designated community agencies report client and service inormation to the state

Department o Mental Health on a monthly basis. These provider agencies have the responsibility

or the development and maintenance o their respective management inormation systems. The

data collected populate the state’s mental health database that is used by the Department o Mental

Health’s research and statistics sta or tracking, analyzing, and reporting mental health inormation.

A state-level, multi-stakeholder advisory group developed recommendations that guide these eorts.

An annual statistical report provides data on all aspects o mental health services in the state by

variouscategories,includingchildren’sservices.Regularlyreporteddataonchildren’sservicescover,in the aggregate and by community service provider: age and gender; nancial responsibility or

service; diagnosis o clients served; length o stay; clinical intervention; individual, amily, and group

therapy; medication and medical support and consultation services; clinical assessment services;

service planning and coordination; community supports; emergency/crisis assessment, support and

reerral; emergency/crisis beds; housing and home supports; and respite services.

The state also has reporting through the Vermont Perormance Indicator Project (PIP) that issues

brie reports on a weekly basis that provide inormation about dierent aspects o the behavioral

healthcare system (http://healthvermont.gov/mh/docs/pips/pip-reports.aspx). These reports

(PIPs) are available on the state’s site and investigate indicators such as:

• Accesstocare

• Practicepatterns• Treatmentoutcomes

• Concernsofcriminaljusticeinvolvement

• Employment

• Hospitalization

These reviews oten examine the relationship o mental health services with other programs and

state agencies. Cross-agency data analysis is acilitated by the use o a statistical methodology that

provides unduplicated counts o the number o individuals served by multiple agencies, without

reerence to personally identiying inormation, thus protecting condentiality and complying with

HIPAA.




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Choices ChoicesTracking Utilization and Cost for Case RatesChoices uses a method to determine utilization and cost or a dened population in order to

develop their case rate and to determine and document the need or case rate adjustments. At

present, Choices has an actuarial database on 1200 children. Data are analyzed by grouping children

according to level o service need in order to correctly estimate utilization and costs or populations

o youth rom dierent reerral sources and at dierent levels o need. The analytic process looks at

cost o care, regardless o unding sources. It allows or utilization targets to be established or the

various types and units o care within the case rate structure. Children are coded by reerral source

(such as child welare or juvenile justice), and data are analyzed to determine what each population

group would cost. The method involves computing the cost o particular services, the utilization o

those services, plus the expected volume o services to be provided through Choices. This analysis

determines i it is scally easible to use a case rate approach or i ee-or-service must be used. Data

are primarily rom Choices utilization and cost data. Choices has had varying success obtaining

utilization and cost data rom the various agencies reerring youth or services, but its own database

produces reliable cost estimates.

NE Central NebraskaTracking Utilization and Expenditures for Case Rates ThemonthlycaserateforchildrenservedbytheIntegratedCareCoordinationUnit(ICCU)is$2136/

month.Totrackutilizationandaccountforhowthesefundsarespent,Region3BehavioralHealthServices (BHS) prepares a monthly report that identies, by child, direct service costs (including

services provided, fex unds spent, and concrete expenditures such as transportation or rent) and

non-direct service costs. This monthly report shows the extent to which the case rate was under-spentorover-spentforeachchild.Fromthesereportsonindividualchildren/families,Region3BHSis able to track trends, such as: average cost per amily, average cost o direct services, costs or youth

who are in placement compared to costs or youth who are not in out-o-home placements, average

monthly costs or dierent types o placements, and monthly associated non-service costs (including

sta personnel costs). Yearly and monthly increases and decreases in expenditures by placement type

also are tracked.




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B. Identify the Types and Amounts of Fundingfor Behavioral Health Services Across Systems(i.e., Map Cross System Funding)

This Strategy analyzes systematically expenditures or behavioral health services across systems and

types o dollars spent and identies under tapped unding sources.

Central Nebraska analyzed and “mapped” expenditures across child-serving systems to

establish a case rate to support its system o care.

NE Central NebraskaMapping Cross-System Funding to Establish a Case RateWhen Nebraska proposed in 2000 to develop an individualized system o care or approximately

200youthandtheirfamiliesinCentralNebraska,ithadtoidentifyfundingsourcesforbehavioral

health services across child-serving systems. The target population was youth in state custody with

intensive behavioral health needs who were placed in Agency-Based Foster Care and higher levels o

care such as group homes, treatment oster care, and residential treatment. The state and the regionbelieved that through partnering across systems and with the regional amily organization, they

could provide more appropriate care with better outcomes or amilies and youth at a lower cost.

Nebraskausedacaseratemethodologyasthenancingstructuretofundthissystemofcare.To

establish the case rate amount, the current cost o care (both the types and amounts o unding) or

201 youth was analyzed. This included all the child placement costs or each o the 201 children over

a six-month period (1/00–6/00). It did not include treatment services that were unded by Medicaid.

These treatment services remained available to the youth as needed, outside o the case rate. In 2000,

the primary unding sources or the cost o care or these 200 children were state child welare unds,

juvenile services unds, and Title IV-E (ederal). A small amount o “other” unds came rom block grant

unds, child care unds, reunication unds, and state-only unds.



I I . R e a l i g n m e n t o f F u n d i n g S t r e

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S t r u c t u r e s

24 Eective Financing Strategies or Systems o Care: Examples rom the Field

II. Realignment of Funding Streams and Structures

A multitude o unding streams at ederal, state, and local levels can be drawn upon to

support systems o care. However, the maze o unding streams that nance children’s

mental health services must be better aligned, better coordinated, and, oten, redirected,to provide individualized, exible, home and community-based services and supports.

Based on a careul analysis, a strategic nancing plan “realigns” resources to develop

a more coherent, eective, and efcient approach to nancing the inrastructure and

services that comprise systems o care. Such realignment involves using resources rom

multiple unding streams, maximizing the use o entitlement programs (such as Medicaid),

redirecting and redeploying resources, and improving the management and coordination

o resources.


A. Utilize Diverse Funding Streams

B. Maximize Federal Entitlement Funding

C. Redirect Spending from “Deep-End” Placements to Home andCommunity-Based Services

D. Support a Locus of Accountability for Service, Cost, and Care

Management for Children With Intensive Needs

E. Increase the Flexibility of State and/or Local Funding Streamsand Budget Structures

F. Coordinate Cross-System Funding

G. Incorporate Mechanisms to Finance Services for Uninsured andUnderinsured Children and their Families



Eective Financing Strategies or Systems o Care: Examples rom the Field 25

A. Utilize Diverse Funding Streams

Strategies include:• Utilizingfundingfrommultipleagenciestonancetheservicesandsupportswithin

systems o care• Poolingorblendingfunds

• Sharingcostsforspecicservicesandsupports

• Utilizingspecialfundingstreams

▶ Utilizing Funding rom Multiple Agenciesto Finance Services and Supports

The sites studied use resources rom multiple child-serving systems to nance services and

supports. Resources rom mental health, Medicaid, child welare, juvenile justice, and education are

used by all o the sites. Resources rom the substance abuse, developmental disabilities, and healthsystems are included in the nancing mix less requently, but are included in some o the sites.

Table 1 shows the extensive use o cross-system unding to contribute to nancing a broad array o

services and supports.

Table 1.

Use o Multiple System Resources

Source Arizona Hawaii Vermont Central

Nebraska

Choices Wraparound

Milwaukee

New

Jersey

Mental Health X X X X X X X

Medicaid X X X X X X X

Child Welfare X X X X X X XJuvenile Justice X X X X X X X

Education X X X X X X

Substance Abuse X X X

Developmental Disability X X X X

Health X

Hawaii and Vermont provide examples o how resources rom multiple systems contribute to

nancing systems o care and their component services.




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HI HawaiiUtilizing Resources rom Multiple SystemsResources rom multiple agencies/sources include:

• Mental health general revenue — Funds sta, services and supports not covered by Medicaid,payments to providers above the Medicaid rate (which “makes it or breaks it” or providers)

• Medicaid— through a carve-out operated by the Child and Adolescent Mental Health Division

(CAMHD)’s children’s mental health system

• Block Grant — Funds screening and assessment o children in amily court, screening and

assessment o children in the child welare system, statewide amily organization, young adult

support organization, early intervention and prevention, services or homeless children, etc.

• Title IV-E — Funds training, administrative costs, some costs or treatment o children in oster

care system

• SAMHSA Grants — Fund system o care development, alternatives to seclusion and restraint,

data inrastructure development. A grant rom the Comprehensive Community Mental Health

ServicesforChildrenandtheirFamiliesProgramfundedsystemofcaredevelopmentintwo

areas on Oahu; a new grant rom SAMHSA is nancing system o care development or youth in

transition to adulthood in one area o the state.

• Education System — Funds the cost o education in residential treatment programs

• Oce o Youth Services — Funds an array o community-based services or children at risk or

incarceration, including some community gang interventions, substance abuse services, sex

oender services, sex abuse services, youth development, and some cost sharing on an individual

case basis

• Developmental Disabilities—Providescostsharingasneededonanindividualcasebasis

VT VermontUtilizing Resources rom Multiple Systems

The Department o Mental Health, the Department o Education, and the Department or Children

and Families are the principal partners and unding sources, with Medicaid making the largest

contribution. Vermont Health Department data show that Medicaid had responsibility or at least

some o the cost or 77% o the children’s behavioral health services provided in 2005. In Chittenden

County, or example, Howard Center (the designated local service agency) estimated that Medicaid

would contribute about 45% to the agency’s total budget or children’s services unding in 2007.

This does not include mental health services to children in residential care, which is listed separately

and covered by a per diem that includes but does not break out mental health services. Education

contributes unding in several ways, including support or an approved Vermont Department o Education school under the auspices o the local designated agency that provides a therapeutic,

regional educational program to meet the needs o junior and early high school age students

experiencing serious emotional, social, behavioral, and academic problems. Reerring school districts

pay tuition or students placed in the program directly to the agency operating the school. The school

utilizes a portion o this revenue as match to bill Medicaid or treatment-related services.




Innancingearlychildhoodmentalhealthservices,fundingstreamscomefromPartCofIDEA,Medicaid/S-CHIP,mentalhealthgrants,maternalandchildhealth,childandfamilyservicesfunding

(Head Start), private insurance, and amily contributions. Funding rom these resources nance a mix

o services through a variety o providers and programs, including early intervention centers, shelters

with child care, substance abuse treatment programs, etc.State agency partners contribute some o their general und allotment to the mental health

agency in order to draw down ederal Medicaid unds to pay or services. This approach can be seen

in schools with school-based services, as well as with mental health services provided in homes and

at community agencies. School-based services use Medicaid, education dollars, and other grant

anddiscretionaryfundsforbehavioralhealthscreenings,counselingservices,andtraining.EPSDTis administered through the health department, which contracts with school districts. Schools pay

nurses and guidance counselors or the work, which allows the early detection o behavioral health

issues.

Funding is also shared between mental health, the Division o Vocational Rehabilitation (in the

Department or Children and Families) and the Department o Corrections to und the JOBS program

or youth at high risk as they transition to adult lie.

Inaddition,thecreationofachild’sCoordinatedServicesPlanunderVermont’sAct264pulls

together whatever public and private providers and supportive individuals are relevant to a specic

child and amily to assess needs, to determine desired goals, and to plan who can provide those

services and supports as well as who can pay or them.

▶ Pool or Blend FundsCentral Nebraska blends unds rom multiple systems to create case rates to nance services.

Choices and Wraparound Milwaukee also provide examples o braiding or blending unds to

nance services and use o case rates. Vermont , through its new Medicaid waiver, is working to

establish a pool o resources rom multiple agencies to nance services or children with multipleand serious needs.

NE Central NebraskaBlending Funds through Case RatesIn Central Nebraska, a case rate methodology, created with blended unding sources, serves as a

primary unding strategy to support and sustain an intensive care management model, the work o

the amily support organization, a number o services and its system o care. Funds were blended

toachievetheIntegratedCareCoordinationUnit(ICCU)caserateof$2,136.53perchildpermonth.

The case rate was established in 2000 ater an analysis o placement costs or 200 children in statecustody. The primary unding sources or these children were state child welare unds, juvenile

services unds, and Title IV-E (ederal). A small amount o “other” unds came rom block grants, child

carefunds,reunicationfundsandstate-onlyfunding.Currently,theICCUcaserateconsistsofstateunding (child welare, state general unds and some juvenile justice unding) and ederal unding

(Title IV-E).




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ThecaseratefortheProfessionalPartnerProgram(PPP),awraparoundprogramforchildrenwithserious emotional disorders, is set by the state Division o Behavioral Health based on regional costs.

Fundingsourcesare89.7%stategeneralfundsand10.3%federalmentalhealthblockgrantfunds. The majority o placement costs are not includedinthe$698.75/child/monthcaserate;however,

some service costs are paid through ex unds included in the case rate.Neither o these case rates includes unding or treatment services. Funding rom Medicaid, Kid

Connect(theNebraskaS-CHIPprogram)andthird-partyreimbursementareusedtopayfortreatment

services.WhilethesefundsarenotwithinthecontrolofRegion3BehavioralHealthServices(BHS),care coordinators and clinicians on the child and amily teams work closely with Magellan (the

administrative services organization or Medicaid) to und the plan o care or each child.

Useofcaserateshasprovidedtheexibilitytooerindividualizedcareanddevelopnewprograms. This case rate methodology has been expanded to other areas o the state and is now used

by ve o the six regional behavioral health authorities in Nebraska.

Choices ChoicesBlending or Braiding Funds rom Multiple Systems

In the areas currently served by Choices, various child-serving agencies contribute to the nancing o

care. The method o contributing, however, varies. In Indiana, each reerring agency — child welare,

juvenile justice, and education — pays the case rate or each child reerred or care, which could be

characterized as a braided unding approach. The state’s mental health managed care system adds to

the case rate paid by the reerring agency or each child served in Indiana as part o its contribution to

building Indianapolis’ system o care; it amounts to a 4% contribution. Additionally, the state’s mental

healthsystempaysthematchfortheMedicaidRehabilitationOption,whichamountstoanother$1

million contribution in billable services.

In Ohio, the participating agencies include child welare, mental health and addictions,

juvenile justice, and developmental disabilities. Each participating agency contributes a negotiated

percentage amount o unding into a large pot o money, which is then blended by Choices.

A “shareholder” reerral system is used whereby a committee with cross-agency representation makes

the decisions about youth who are reerred to services based on eligibility criteria.

Choices also bills Medicaid or covered services or eligible youth. The case rates cover all services

and supports that are not covered by Medicaid. In both Indiana and Ohio, the case rate dollars can be

used to purchase any services that are included in the individualized service plan that is developed by

the child and amily team. The care plan drives the service delivery process, and any type o service or

support included in the service plan is considered “authorized.”




Wraparound Milwaukee Wraparound MilwaukeeBlending Funds rom Multiple Systems,Including Medicaid, Through Case Rates and Capitation

Wraparound Milwaukee blends several unding streams: Medicaid dollars through a capitation romthestateMedicaidagencyof$1,589permemberpermonth(pmpm);childwelfaredollarsthroughacaserateof$3,900pmpm;mentalhealthblockgrantdollars;andbothcontractdollarsandcaserate

dollars rom the juvenile justice system.

Blending o unds or youth in the delinquency system is based on two target populations.

These include youth whom the delinquency program would otherwise place and und in residential

treatmentcenters(about350youth),forwhomWraparoundMilwaukeereceives$8.2millionin

xed unds rom the budget that Delinquency and Court Services would otherwise use to pay or

this level o care. The second target group is youth who would otherwise be committed to the

state Department or Corrections or placement in a locked correctional acility (about 45 youth).

DelinquencyandCourtServicespaysWraparoundMilwaukeeacaserateof$3,500peryouthpermonth or these youth. I these youth were placed in a correctional acility, Milwaukee County would

bechargedabout$7,000peryouthpermonthforthecostoftheseplacementsunderthestate’scharge-back mechanism to counties. These youth are diverted to Wraparound Milwaukee through a

“Stayed State Order” versus a direct County order. All o these youth must be Medicaid-eligible and

have a serious emotional disorder.

As noted, because the county juvenile justice system gets charged the cost o correctional

placements,whichrunabout$7,000pmpm,ithasanincentivetoutilizeWraparoundMilwaukee,whosecostsrunabout$3,500pmpmforthejuvenilejusticepopulation.Similarly,becausebothchild

welare and juvenile justice, prior to Wraparound Milwaukee, paid or residential treatment, both

systems have incentives to utilize Wraparound Milwaukee, which delivers lower per member per

month costs and better outcomes. The child welare and juvenile justice systems share 50/50 the cost

o youth with dual delinquency and dependency court orders.

In addition to these unding streams, Wraparound Milwaukee operates the County’s mobile crisisprogramforcountyyouth(MobileUrgentTreatmentTeam–MUTT),whichalsoissupportedbydollarsblended rom multiple unding streams. Every child enrolled in Wraparound Milwaukee automatically

iseligibleforservicesfromMUTT,andotherfamiliesinthecountymayuseitforacrisisrelatedtoachild.ThechildwelfaresystemandMilwaukeePublicSchoolswantedanenhanced,dedicatedmobile

crisisteamtoprovidecrisisinterventionandon-going(30-day)follow-up.Eachprovidesannualfundingof$450,000tosupportthisenhancedcapacity.WraparoundMilwaukeealsoisabletobill

MedicaidforthisserviceunderWisconsin’scrisisbenet.ThisincludestheMUTTcrisisteam;aportiono care managers’ time spent preventing or ameliorating crises; 60% o the cost o crisis placement in

agrouphome,fosterhomeorresidentialtreatmentfacility;andthecostof1:1crisisstabilizersinthehome. Since Wraparound can recover a percentage o its costs by billing Medicaid, it is able to add

about$180,000totheMilwaukeePublicSchoolsenhancedcapacityandabout$200,000tothechild

welfarecapacity.Wraparound’stotalMedicaidcrisisreimbursementwasnearly$6millionin2006.In addition to these unding streams, the developmental disabilities system gives Wraparound

Milwaukee ve o its Home and Community Based Waiver slots. There is no county tax levy or mental

health services. The Wraparound Milwaukee MIS system interaces with both the state child welare

(SACWIS) and state Medicaid data systems to keep track o Medicaid and Title IV-E expenditures or

ederal claiming and audit purposes.




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VT VermontExploring a Medicaid Waiver to Pool Resourcesor Children with Multiple Needs

Thestatenegotiatedarstofitskind1115(a)Medicaidwaiverwiththefederalgovernmentin2005.Called the Global Commitment Waiver, it is designed to reorm the state’s Medicaid program by

helping both the state and ederal governments manage Medicaid expenditures at a sustainable level

overtheveyearpilotperiod.Underthiswaiver,thestateacceptsacaponitsMedicaidfundinginexchange or greater exibility in how it spends its Medicaid unds, and with the increased exibility,

the state hopes to provide more individualized services and to produce better outcomes. Related to

this, Vermont´s child-serving partner agencies identied difculties in unding services or children

withmultiple,severeneedsasahighpriority.UndertheauthorityoftheGlobalCommitmentMedicaid waiver, the state is working to establish a mental health unding resource that would create

a pool o resources unded by several agencies or services and supports or children with multiple

and serious needs. Contributing agencies are likely to include: mental health, child welare, education,

health and substance abuse, developmental services, and juvenile justice.

▶ Share Costs or Specic Services and Supports Arizona, Hawaii, Vermont, Central Nebraska, and Wraparound Milwaukee provide examples o

sharing costs or specic services.

AZ ArizonaSharing Funding Responsibility or Specifc Services

The Arizona Department o Health Services, Division o Behavioral Health Services (ADHS/BHS)

partners with other systems to share unding responsibility or certain programs. For example, themanaged care system uses only therapeutic oster homes licensed by child welare or the Regional

Behavioral Health Authority (RBHA) networks (with the exception that tribes may license homes),

which enables Title IV-E unds to be used or room and board costs or eligible children. Similarly, all

child welare in-home providers must be Medicaid providers, providing a oundation or a common

network o service providers between these two systems. The managed care system also provides

behavioral health services to about 78% o adult amily members with substance abuse problems

who are involved in child welare.




HI HawaiiSharing Costs with Child Welare, Juvenile Justice, and EducationCost sharing is used in nancing several o Hawaii’s services. Cross-agency relationships are

considered key to accomplishing these approaches and take signicant time to develop. Examples o cost sharing include:

• Costsharingwiththechildwelfaresystemoftherapeuticfosterhomecoststoallowpermanentplacements or troubled youth, maintaining them in a stable home with a reduced cost o

services over time

• CostsharingwiththejuvenilejusticesystemtoprovideapsychologistwithBlockGrantfunds

and to place a mental health care coordinator at the detention acility to prevent unnecessary

incarceration

• Mentalhealthsystembuiltasystemofschool-basedservicesandthentransferredthefunding

legislatively to the education system. The Department o Education (DOE) now manages these

services on a statewide basis and has developed a system to bill Medicaid or mental health

services. The Child and Adolescent Mental Health Division (CAMHD) provides more intensiveservices based on identied needs.

VT VermontSharing Costs or Specifc ServicesUnderVermont’s Act 264 and in practice, agencies share costs or specic services and supports.

Achild’sCoordinatedServicePlanislegallyanaddendumtootherstateandfederallymandated

plans(e.g.,educational504planorIndividualizedEducationPlan,mentalhealthIndividualPlanofCare,childwelfarecaseplan).ThePlandrivesservicesandfundsrequired.Typically,eachofthe

partner agencies (mental health, education, children and amilies, developmental disabilities, etc.)

unds those services or which it is responsible either through memoranda o understanding with

the local lead agency or directly, depending on the service and delivery arrangement. Funds are

also transerred across agencies or specic services (e.g., crisis services, respite) and state agency

partners contribute unds rom their general und allotment to the mental health agency in order to

draw down Medicaid unds to pay or service. Transers include those especially aimed at building

system capacity. For example, the Department or Children and Families has provided unds to the

Department o Mental Health or preventive and early intervention serevices with children and

amilies to avert placement into state care and to expand capacity in the mental health system. The

ocused eort to improve system response to amilies approaching or in crisis by blending planning

and unding rom the Department o Mental Health and the Department or Children and Families

has signicantly reduced the number o youth entering custody under emergency CHINS (Children in

Need o Supervision) court orders.




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Another example involves local education agencies (LEAs) and local mental health Designated

Agencies, which are co-unding the Success Beyond Six initiative. This strategy uses state general

unds rom LEAs as match to draw down mental health Medicaid unds through a contracting process.

The LEA species what types and amount o services it wants or its Medicaid eligible students, such

as a ull- or part-time therapist to conduct groups on social skills or anger management, individualbehavior intervention specialists, or home school coordinators. The mental health agency hires and

supervises appropriately trained and credentialed sta to provide the services.

NE Central NebraskaSharing Costs or Specifc ServicesIn addition to blending unds to achieve case rates, Central Nebraska shares costs across agencies,

systems, and programs:

IntegratedCareCoordination(ICCU)—Carecoordinatorsfromchildwelfareandmentalhealthareco-locatedatICCUsitestofacilitatetheintegrationofservicesandtoshareresources.Forexample,

theRegion3BehavioralHealthServices(BHS)andtheCentralAreaOceofProtectionandSafety(child welare) share the cost or personnel, space, supplies, and urniture or the Integrated Care

CoordinationUnit(ICCU).EachagencyemployshalfofthecarecoordinatorsinICCUanddividesthe

costofsupervision.Eventhoughthecarecoordinatorsareemployedbydierentagencies,ICCU

directors indicated that the only way to tell the dierence is to know who signs the pay check.

• Multisystemic Therapy (MST)— The development o MST was unded by the ederal system

o care grant. A variety o unding sources cover the actual service costs. MST providers are paid

a case rate based on outcomes achieved with each youth/amily. Within the case rate, Medicaid

pays or intensive outpatient services. I the provider does not receive the maximum case rate

earned,Region3BHSpaystheremainder,ater all other appropriate parties have been billed

andpaymenthasbeenreceived.Region3BHSalsopurchasesMSTforfamilieswhodonothaveanother payer source.

• School Wraparound — Although there is no exchange o unds between the local school

systemandRegion3BHS,theysharethecostsforspaceandpersonnel.Theschoolspayfortheeducationalfacilitator.Region3BHSpaysfortheprofessionalpartner(familyfacilitator).These

two acilitators become a school wraparound team, work together with each child and amily

team, and are housed in the same ofce.

• Family Support and Advocacy — Families CARE shares ofce space and cars with the Grand

Island Health and Human Services Ofce.




Wraparound Milwaukee Wraparound MilwaukeeSharing Costs or Crisis ServicesMentalhealth,childwelfareandMilwaukeePublicSchoolsco-nancemobilecrisisservices,which

also are billable to Medicaid or Medicaid-eligible children. Wraparound Milwaukee operates theCounty’smobilecrisisprogramforcountyyouth(MobileUrgentTreatmentTeam[MUTT]).EverychildenrolledinWraparoundMilwaukeeautomaticallyiseligibleforservicesfromMUTT,andother

amilies in the county may use it or a crisis related to a child. The child welare system and Milwaukee

PublicSchoolswantedanenhanced,dedicatedmobilecrisisteamtoprovidecrisisinterventionand

on-going(30-day)follow-up.Eachprovidesfundingof$450,000tosupportthisenhancedcapacity.Wraparound Milwaukee also is able to bill Medicaid or this service under Wisconsin’s crisis benet.

ThisincludestheMUTTcrisisteam;aportionofcaremanagers’timespentpreventingoramelioratingcrises; 60% o the cost o crisis placement in a group home, oster home or residential treatment

facility;andthecostof1:1crisisstabilizersinthehome.SinceWraparoundMilwaukeecanrecoverapercentageofitscostsbybillingMedicaid,itisabletoaddabout$180,000totheMilwaukeePublic

Schoolsenhancedcapacityandabout$200,000tothechildwelfarecapacitythroughMedicaid

billings.WraparoundMilwaukee’stotalMedicaidcrisisreimbursementwasnearly$6millionin2006.Inadditiontoco-nancingforMUTT,juvenilejusticeandchildwelfareco-nancecrisisresidentialservices, certain costs o which also can be billed to Medicaid.




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B. Maximize Federal Entitlement Funding

Strategies include:• Maximizingeligibilityand/orenrollmentforMedicaidandS-CHIP

• CoveringabroadarrayofservicesandsupportsunderMedicaid• UsingmultipleMedicaidoptionsandstrategies

• UsingMedicaidinlieuofstate-onlygeneralfunds

• GeneratingMedicaidmatch

▶ Maximizing Eligibility and/or Enrollmentor Medicaid and S-CHIP

Arizona, Hawaii, and Vermont and Bethel, Alaska have worked to maximize eligibility and

enrollmentforthestateMedicaidandS-CHIPprograms.

AZ ArizonaImproving Medicaid Eligibility Determinationor Youth in Juvenile Justice

The Arizona Department o Health Services (ADHS) and juvenile justice have collaborated to

improve Medicaid eligibility determination or youth in juvenile justice as a result o state legislation

mandating that the juvenile justice system implement a system to track the number o youth who

are Medicaid eligible. The juvenile justice system is looking at the Medicaid eligibility o every youth

coming into detention or otherwise involved with the court, and probation workers have to check

eligibility. This work is supported by both a telephone hook-up to the state Medicaid agency and a

website. The legislature also allocated unds to the juvenile justice system or mental health services

or non-Medicaid eligible youth, and juvenile justice has been able to spend more on non-Medicaid

youth because o doing a better job identiying those who are eligible or Medicaid. In Maricopa

County, the juvenile justice system has a goal o linking every Medicaid-eligible youth in need o

mentalhealthservicestoaComprehensiveServiceProvider(CSP),whichisthebehavioralhealth

system’s core service provider. ADHS, Division o Behavioral Health Services (BHS), developed a

technical assistance document ocused on Medicaid eligibility or youth involved in juvenile justice,

which is available on their website. (See: http://www.azdhs.gov/bhs/guidance/cid.pd ) Value

Options co-located sta in juvenile detention to ensure that youth are enrolled with the Regional

BehavioralHealthAuthority(RBHA),ifeligible,areenrolledwithaCSP,andtoworkwithdetention

to oer a community placement to the courts. This is a strategy to prevent youngsters involved in

juvenile justice rom losing their Medicaid eligibility and to divert youth rom deep-end services.




HI Hawaii and VT VermontHigh Eligibility Levels or Medicaid and S-CHIP

• InHawaii ,Medicaideligibilitylevelis300%ofthefederalpovertylevel.S-CHIPisaMedicaid

expansion and covers additional children. Higher levels o eligibility are accomplished by allowingindividuals to buy into the Medicaid program.

• InVermont ,MedicaidandS-CHIParehighlyintegrated.Medicaidcoversuninsuredchildren

upto223%ofthefederalpovertylevel,andunderinsuredchildrenupto300%.S-CHIPcoversuninsuredchildrenbetween225%and300%ofthefederalpovertylevel.Theapplicationprocess

is the same or both programs, and the benet package and delivery systems also are the same.

Vermont began providing health care coverage to children through age 20 under the Medicaid

programin1967.“Dr.Dynasaur”wascreatedin1989asastate-fundedprogramforpregnantwomen and children through age 6, who did not have health insurance and did not qualiy

fortraditionalMedicaid.In1992,“Dr.Dynasaur”wasintegratedintoMedicaidandexpandedtochildrenthroughuptoage18.ItlaterincorporatedtheS-CHIPprogram.Allchildren(and

pregnant women) are covered under the “Dr. Dynasaur” program, regardless o whether they

areMedicaidorS-CHIPenrolled.Vermont’sMedicaidprogramnowincludes“Dr.Dynasaur,”traditionalMedicaid,theVermontHealthAccessPlan(VHAP),VHAPManagedCare,MedicaidManagedCare,VHAPPharmacyandVScript.Togetherwithprivateinsurancecoverage,these

programs provide almost universal health coverage or Vermont children.

AK Bethel, AlaskaImplementing Outreach to Maximize Enrollment Medicaid services or every American Indian and AlaskaNativearereimbursedtothestatewith100%

ederal match dollars i the services are provided through a Tribal provider. Additionally, services

rendered to Medicaid-enrolled children by the Yukon Kuskokwim Health Corporation (YKHC) that are

included in their children’s agreement are reimbursed at ull cost through an annual cost settlement

process.

About80–85%ofyouthareMedicaideligible,buttherearesignicantbarrierstoenrollmentas

documentedintheDecember2003study, American Indian and Alaska Native Eligibility and Enrollment

in Medicaid, S-CHIP and Medicare, unded by the ederal Centers or Medicare and Medicaid Services

(CMS). The barriers include general distrust o government, the perception o ederal responsibility or

health care or the American Indian and Alaska Native population as an entitlement to care through

the Indian Health Service, transportation, distance, lack o knowledge about the programs, language,

literacy and other cultural barriers. For these reasons, YKHC implemented outreach eorts that

specically target enrollment in Medicaid. Children are eligible or Medicaid or six-month periods at atime (except disabled children and newborns eligible or one year), so an additional challenge or the

Delta is the seasonal activities or subsistence during which amilies travel to remote camps and have

no phone or mail services or months at a time, making it impossible to reach amilies or eligibility

re-determination.Alaska’seligibilitylevelforS-CHIPis185%ofthe2004FederalPovertyLevel.




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▶ Cover a Broad Array o Services and SupportsUnder Medicaid

All o the states included in the sample cover a broad array o services and supports under their

Medicaid programs. Arizona, Hawaii, New Jersey, Vermont, and Alaska are examples o states

that have included an extensive list o services in their state Medicaid plans, including services suchas respite, amily and peer support, supported employment, therapeutic oster care, one-to-one

personal care, skills training, intensive in-home services, and many others. Alaska has developed a

mechanism to cover traditional Native healing services under its state Medicaid program.

AZ ArizonaIncluding a Broad Array o Services in the State Medicaid Plan In connection with the JK settlement agreement, Arizona Department o Health Services, Division o

Behavioral Health Services (ADHS/BHS) and the state Medicaid agency expanded covered services

andrevisedlicensurerulesandrates.PriortoJK,theMedicaidbenetwasfairlytraditional,covering

counseling, medication management, day treatment, partial hospitalization, inpatient, residentialtreatment and therapeutic group homes. With JK, the state deliberately tried to get coverage or a

very broad array o services and supports rom wraparound to community-based to medical, either

by adding new covered services or by changing denitions or already covered services. The ollowing

new services were added: sub-acute step down, respite, case management, peer and amily support,

supported employment, and therapeutic oster care. Also, a new provider type — community service

agencies — was created to provide rehabilitation services so that these services would not have to

be provided solely by clinics or hospitals. The denition o day treatment was expanded to include

a less intensive version, such as ater school, which can be provided as a rehab service by behavioral

health technicians and can be provided in schools. At the same time, a more intensive day program

with a medical component was added or children who are medically ragile, and the state added a

1:1personalcareprovider.Thestateremovedlimitationsonplaceofservicesothatservicescanbe

provided in any location. The state also added general revenue unds to cover non-Medicaid services,such as traditional Native healing and acupuncture or substance abuse.

In addition to expanding the array o covered services, in an eort to change practice, the state

also increased rates so that out-o-ofce rates are higher than ofce-based rates. Reportedly, the

state Medicaid sta that worked with BHS had a good understanding o service delivery or children’s

behavioral health (many came rom the service side), and both agencies worked cooperatively. Also,

the two agencies did a lot o training on the new array o covered services. Arizona’s list o services

covered under Medicaid include:

• Behavioralcounselingandtherapy

• Assessment,evaluationandscreening

• Skillstraininganddevelopmentandpsychosocialrehabilitationskillstraining

• Cognitiverehabilitation• Behavioralhealthprevention/promotioneducationandmedicationtrainingandsupportservices

• Psychoeducationalservicesandongoingsupporttomaintainemployment

• Medicationservices

• Laboratory,radiologyandmedicalimaging




• Medicalmanagement

• Casemanagement

• Personalcareservices

• Homecaretraining(Familysupport)

• Self-help/peerservices(Peersupport)

• Therapeuticfostercare

• Unskilledrespitecare

• Supportedhousing

• Signlanguageororalinterpretiveservices

• Nonmedicallynecessaryservices(exfundservices)

• Transportation

• Mobilecrisisintervention

• Crisisstabilization

• Telephonecrisisintervention

• Hospital• Subacutefacility

• Residentialtreatmentcenter

• Behavioralhealthshort-termresidential,withoutroomandboard

• Behavioralhealthlongtermresidential(nonmedical,nonacute),withoutroomandboard

• Supervisedbehavioralhealthdaytreatmentanddayprograms

• Therapeuticbehavioralhealthservicesanddayprograms

• Communitypsychiatricsupportivetreatmentandmedicaldayprograms

• Preventionservices

For a complete description o Arizona’s covered services, see the state’s Covered Behavioral Health

Services Guide, available at: http://www.azdhs.gov/bhs/bhs_gde.pd . Appendix B2 to the guidedescribes provider types and ee or service rate guidance, available at: http://www.azdhs.gov/bhs/

app_b2.pd .




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HI HawaiiIncluding a Broad Array o Services in the State Medicaid Plan

The state Medicaid plan covers a broad array o mental health services and supports. Modication

o the state Medicaid plan to add the broad array o services provided through the Child andAdolescent Mental Health Division (CAMHD) system (the Medicaid carve-out) was accomplished by

developing a strong relationship with the leadership o the Medicaid agency through requent ace-

to-ace meetings. CAMHD’s eorts have included identiying services to be added to the Medicaid

plan; proposing denitions, rates, and credentialing status; and identiying scal incentives or the

state (such as how much is currently being spent using state resources and any savings that can be

realized).UnderthecategoryofCommunityMentalHealthRehabilitativeServices,arangeofservices

is covered to promote the “maximum reduction and/or restoration o a recipient to his/her best

possible unctional level relevant to their diagnosis o mental illness and/or abuse o drugs/alcohol.”

Covered services include the ollowing:

• Crisis management— telephone hotline, ace to ace, and mobile crisis assessment and

intervention in a variety o community settings

• Crisis residential services— short-term interventions to address a crisis and avert or delay theneed or acute psychiatric inpatient services or similar levels o care

• Biopsychosocial rehabilitative programs— therapeutic day rehabilitative social skill building

service

• Intensive amily intervention— time-limited interventions to stabilize the client and amily and

promote reunication or prevent the utilization o out-o-home therapeutic resources, including

Multisystemic Therapy (MST) and intensive in-home services

• Therapeutic living supports — therapeutic services (not room and board) in group homes

• Therapeutic oster care supports— therapeutic services (not room and board) in therapeutic

oster home settings

• Intensive outpatient hospital services — to provide stabilization o psychiatric impairments and

enable individuals to reside in the community or return to the community rom a more restrictivesetting (partial hospitalization)

• Assertive community treatment— intensive community rehabilitation service including a range

o therapeutic and supportive interventions

At the time o the site visit, a number o additional services were being added to the state

Medicaid plan or scal year 2007, with drat denitions developed. These have not as yet been

approved, but include:

• Peer supports — services provided by peer counselors to youth, young adults, and their

amilies to promote socialization, recovery, sel-advocacy, development o natural supports, and

maintenance o community living skills

• Parent (skills) training — teaching evidence-based behavior management interventions to

parents or caregivers in order to develop eective parenting skills to promote more competencies

in the parent/caregiver’s ability to manage the child’s behavior

• Intensive outpatient substance abuse independent living— a package o services designed

to assist youth and young adults with co-occurring mental health and substance abuse issues to

enable them to remain in their home environments while receiving treatment




• Community hospital crisis stabilization— short-term crisis intervention to youth or young

adults experiencing mental health crises as a closely supervised, structured alternative to or

diversion rom acute psychiatric hospitalization

• Multisystemic Therapy (MST)— an intensive amily and community-based model o treatment

or youth and their amilies who are at risk o out-o-home placement, based on evidence-basedinterventions that target specic behaviors with individualized behavioral interventions (currently

covered under intensive amily interventions)

• Multidimensional Treatment Foster Care (could go under therapeutic oster care supports)

• Functional Family Therapy — an evidence-based amily treatment system provided in a home or

clinic setting with the goal o engaging all amily members and targeting and changing specic

risk behaviors

• Community Based Clinical Detox — a short-term, 24 hour clinically managed detoxication

service delivered with medical and nursing support in a secure residential acility

Consideration is being given to transerring responsibility or acute psychiatric hospitalization

andassessmentandoutpatientservicesfromtheQuestHealthPlanstotheCAMHDsystem.Eective

2/07, CAMHD will be responsible or all services including acute and outpatient services or youthenrolled in the CAMHD carve-out.

VT VermontIncluding a Broad Array o Services in the State Medicaid PlanMedicaid is the principal payer or behavioral health and system o care services. The state has sought

throughitsMedicaidplan,EPSDT,S-CHIP/“Dr.Dynasaur”andwaiverstofundanarrayofprevention,

treatment and support services that are provided to children in a variety o settings. Medicaid coversthe ollowing categories and services:

• Inpatienthospitalservicesprescribedbyaphysician,includingdiagnosticinterviewswithimmediate amily members and psychotherapy i a component o the treatment plan; most o the

child screenings by community mental health centers prior to emergency hospitalization

NJ New JerseyIncluding a Broad Array o Services in the State Medicaid PlanIn order to achieve a more expansive benet design, the state expanded services covered under

Medicaid through the Rehabilitation Service Option. The services now covered under Medicaid

include non traditional and traditional services. These services include: assessment, mobile crisis/

emergency services, group home care, treatment homes/therapeutic oster care, intensive ace-to-ace care management, wraparound, out-o-home crisis stabilization, intensive in-home services,

behavioral assistance, wraparound services, and amily-to-amily support.




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• Outpatienthospitalclinic(includingruralhealthcenterandFederallyQualiedHealthCenter)services — mental health services, directed by a physician or psychologist that would be covered

i provided in another setting

• Evaluation,diagnosisandtreatmentservicesfromlicensedindependentlypracticingpsychologists

• Inpatientpsychiatricfacilityservices,crisisdiversionbeds,inpatienthospitalization,residentialtreatment, therapeutic oster care — must be physician prescribed, have interagency team

certication that beneciary cannot be treated eectively in the community, and prior

authorization by external review

• Mentalhealthclinicevaluation,diagnosticandtreatmentservices—psychotherapy,grouptherapy, day treatment, prescribed drugs or treatment and prevention, emergency care

services — that are specied in a treatment plan directed by or ormulated with physician input

• Rehabilitationservicesprovidedbyqualiedprofessionalstaindesignatedcommunitymentalhealth centers that cover services listed in the preceding plus specialized rehab services including

basic living skills, social skills, and counseling, as specied in the treatment plan

• Schoolhealthservices—mentalhealthassessmentandevaluation,medicalconsultation,mental

health counseling, developmental and assistive therapy, case management — ordered by an

individualeducationplan(IEP)orindividualizedfamilyserviceplanforspecialeducationstudents

• Childsexualabuseandjuvenilesexoendertreatmentservices—individual,group,andclient-

centered amily counseling; care coordination, clinical review and consultation

• Intensivefamily-basedservices—family-focused,in-hometreatmentservicesthatincludecrisis

intervention, individual and amily counseling, basic living skills and care coordination

• Targetedcasemanagementservices—assessment,caseplandevelopment,monitoringandollow-up services, and discharge planning

• Homeandcommunity-basedwaiverservices—casemanagement,respitecare,residentialand

day services

• Transportation

AK Bethel, AlaskaIncluding a Broad Array o Services in the State Medicaid Plan

Alaska’s state Medicaid plan covers a broad array o mental health services. The Yukon Kuskokwim

Health Corporation (YKHC) provides these services and then bills Medicaid or reimbursement. The

Medicaid reimbursable services include: assessment and evaluation; individual, group, and amily

therapy; home-based services; day treatment; crisis services; psychiatric inpatient care; group homes;

residential treatment; case management; school-based services; respite; and behavior management

skills development. For Alaskan Native populations, specialized traditional Native healing servicesare reimbursed by Medicaid. YKHC has developed a crosswalk that places traditional Native healing

services into the appropriate “western” slot. YKHC bills or the Medicaid service, and Medicaid pays or

the “western” service.




▶ Use Multiple Medicaid Options and Strategies The sites studied have maximized Medicaid nancing o behavioral health services or children by

taking advantage o the multiple options available to states under the Medicaid program, including

theclinicandrehabilitationoptions,targetedcasemanagement,EPSDT,andseveraldierenttypes

o waivers. Table 2 demonstrates the extensive use o multiple options.

Table 2

Use o Multiple Medicaid Options

Arizona Hawaii Vermont Nebraska New Jersey

Clinic Option X X X X X

Rehab Option X X X X X

Targeted Case Management X X X X

Psych Under 21 X X X X X

EPSDT X X X X X

Katie Becket (TEFRA) X X

H & CB Waiver (1915c) DD* DD* X** DD* DD*1915b Waiver X

1115 Waiver X X X***

Family of One X

*DD = Developmental Disabilities **DD and SED waivers ***1115 (a) Global Commitment Waiver

Arizona, Hawaii, Vermont, Wraparound Milwaukee, and Choices provide examples o states

that have implemented strategies to maximize their ability to use Medicaid.

AZ

ArizonaUsing Tribal Behavioral Health Authorities Two o Arizona’s21tribesoptedtoprovidetheirownbehavioralhealthservicesasTribalRegionalBehavioral Health Authorities (TRBHAs) through the Arizona Department o Health Services, Division

o Behavioral Health Services (ADHS/BHS) managed care system. They saw the TRBHA as a means to

maximize their ability to use Medicaid and integrate Tribal-run and county-based services under the

TRBHA network. Health and behavioral health services provided by Indian-run acilities are eligible or

100%federalMedicaidcontribution,knownasthefederalpass-throughprogram.Ineect,Arizona

tribesdealwithabifurcatedMedicaidsystem–the1115waiverinthestateandthefederalpass-through or tribes. The ederal pass-through benet is more traditional than the array o services

coveredunderthe1115waiver,butthefederalrateishigherthanstaterates,andthereis100%ederal unding. For example, case management is not a covered service by the pass-through, but it

canbepaidforthroughthe1115waiver.TheTRBHAcan“pickandchoose”whethertobillthefederalpass-throughorthe1115waiver.Thefederalpass-throughcanonlybeusedforservicesdirectly

provided by the tribe.




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HI HawaiiCreating a Behavioral Health Carve-Out or Children and Adolescents and Partnering with the Schools The state has maximized the use o Medicaid to und children’s behavioral health services and

supports. Hawaii hasan1115Medicaidwaiver.Themanagedcaresystem(“Quest”)isimplemented

bythreehealthplans.Withrespecttomentalhealth,theseplansareresponsibleforallEPSDTservices, outpatient mental health services, acute psychiatric hospitalization, and pharmacy services.

The strategy used or Medicaid nancing was to create a behavioral health carve-out or children

and adolescents with serious emotional problems that is administered by the Child and Adolescent

MentalHealthDivision(CAMHD).In1994,amemorandumofunderstanding(MOU)withthestateMedicaid agency created this carve-out, called the Support or the Emotional and Behavioral

DevelopmentofYouth(SEBD)Program.Childrenfromthreeto20yearsofagemaybeeligibletoreceive the services provided through the CAMHD system. Children and their amilies in the plan

receive case management services and access to a comprehensive array o services and support.

Medicaid pays CAMHD a negotiated case rate per member (i.e., child in service) per month. Thecase rate is negotiated based on demonstrated service utilization and setting “reasonable” rates or

services. Reconciliation to cost is accomplished at the end o each year. Enrollment in the carve-out is

limitedtoyouthwithseriousdisorders;eligibilityfortheSEBDProgramisdeterminedbytheCAMHDmedical director and is based on diagnosis and unctional impairment. The array o services provided

through the CAMHD system was added to the Medicaid state plan; some services are still pending

approval.TheSEBDHealthPlanhasresultedinbenetsincludingincreasedaccountabilityinthe

children’s behavioral health system, greater ocus on the rights o youth and amilies, and increased

evaluation o the system.

In addition, the state Department o Education is a Medicaid provider and provides outpatient

counseling (individual, group, and amily) as well as assessments, medication management, and

supportsinschools.Providersmaybeemployedbytheschooldistrictorbycontractedproviders

(both agencies and individual providers).




AZ Arizona and Wraparound Milwaukee Wraparound MilwaukeeUsing Family o One“Family o One” allows States to waive parental income limits or a child who is expected to utilize an

institutionallevelofcarefor30daysormore.• Arizona uses the “Family o One” strategy or inpatient and residential treatment services, in

addition to other Medicaid options.

• Wisconsin uses this strategy or inpatient services only.

VT VermontImplementing a Home and Community-Based Services Waiver One o the early steps taken by Vermont to cover children with serious emotional disturbances,

including those not eligible or Medicaid, was to secure a home and community-based services(HCBS)waiver.Intheearly1980s,Vermontsoughtthewaivertoprovidehomeandcommunityalternatives or children in residential programs whose number had been growing substantially, in

partduetotheclosingofthestatepsychiatrichospital.Thewaiverprogram,implementedin1982,wastherstHCBSwaiverinthecountryforchildrenwithSEDandallowedthestateto:1)cover

additional children, some o whom were otherwise ineligible or Medicaid and 2) oer additional

home and community services (e.g., respite care, crisis intervention, therapeutic oster-care, amily

supports, community/social supports, and environmental modications) than the state could support

priortothewaiver.In1988,VermontAct264waspassed,givingthestateacodiedstructureto

expand and coordinate services in increasing state unding that could be used to und services

directly and to provide Medicaid match. Further expansion and investment to support home and

community-basedservicesoccurredin1991whenthestatebegancoveringchildrenwithserious

emotional disturbance and other disabilities under the Katie Beckett option, and later under anexpanded rehabilitation option that includes targeted case management. These strategies orm the

oundation o nancing home and community-based services in Vermont’s system o care.




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Choices ChoicesEmploying Care Coordinators in Medicaid Provider AgenciesChoices uses several strategies to maximize the use o Medicaid to nance service delivery. In

both Indiana and Ohio, the case rates do not necessarily nance all o the services included in theservice coordination plan. For children who are Medicaid eligible (about 90% qualiy or Medicaid),

Medicaid is billed or allowable behavioral health services, such as individual and group therapy, day

treatment, and inpatient hospitalization, as well as or case management and other services through

the rehabilitation option, leaving the case rate unds to nance many o the supportive services that

might not be covered by Medicaid.

In Indiana, care coordinators are hired by the mental health centers and are employees o those

centers although they work with Dawn. In this way, Medicaid can be billed or care coordination

servicesundertheRehabilitationOption,bringing$1.7millionofMedicaidresourcesintothemixofresources supporting service delivery. Also in Indiana, Medicaid can be billed or individual, amily,

and group therapy; day treatment; and acute hospitalization or eligible youngsters, bringing in

nancing to support services above and beyond the case rate provided by the reerring agencies.

In Ohio, Choices became a Medicaid provider, thereby allowing care coordination sta employedby Choices to receive Medicaid reimbursement under Ohio’s Medicaid regulations. This brings

approximately$800-900,000inresourcesintothesystem.ThestateMedicaidplaninOhioincludes

a broad package o covered services. Choices bills Medicaid or services delivered that are covered

under Medicaid. I Medicaid denies payment, or i services are not covered, Choices nances these

services and supports rom the case rate unds.




▶ Use Medicaid in Lieu o Other Funds(i.e., State General Revenue)

Arizona, New Jersey, and Central Nebraska oer examples o strategies or using Medicaid to

nance services and support instead o state-only unds.

NJ New Jersey Adding Services to State Medicaid PlanNew Jersey identied services previously supported solely with state dollars that could be considered

part o the state Medicaid plan. The state then covered these services under Medicaid through the

Rehabilitative Services Option. This allowed the state to secure ederal unding or services that it had

providedtochildrenbefore2001forwhichithadnotclaimedfederalmatch.NewJerseyusedthese

“reed” state dollars as seed money to build the inrastructure or new community services across the

state. In the rst year o its system o care reorm, New Jersey nanced its share o Medicaid costs by

combining$167millioninexistingstatedollarsforchildrenwithseriousemotionaldisordersfrom

thechildwelfareandmentalhealthdivisions(including$117millionwhichwaspreviouslyexpendedbytheDepartmentofYouthandFamilyServices[DYFS]onresidentialcare)with$39millioninnew

fundsauthorizedforchildrenwithseriousemotionaldisordersintheGovernor’s2001budget.

AZ ArizonaIdentiying Medicaid-Reimbursable Services and Expanding Authorization CriteriaState Medicaid ofcials indicated that in planning or implementation o the JK settlement

agreement, they went through a process o matching services provided by the juvenile justice

system to Medicaid-codeable services. Also, the mental health and child welare systems worked

to identiy utilization and costs associated with behavioral health services nanced by the child

welare system that were being provided to Medicaid-eligible children and which could be covered

by Medicaid instead o using all state general revenue dollars. Specically, the two systems, workingwith Medicaid actuaries, determined what was being spent by child welare on services to Medicaid-

eligible children in licensed secure and non-secure residential treatment centers and acute inpatient

hospital care. The analysis also showed that most o these children were in Maricopa County. Specic

dollars were re-allocated to the contracted Medicaid behavioral health managed care organization

in Maricopa County to begin unding these services through the behavioral health managed care

system. Through their analysis o service utilization, the agencies also identied a number o child

welare-involved children whom they elt should be in Medicaid-nanced therapeutic oster care or

in Medicaid-nanced counseling services. Additional unds were earmarked or the behavioral health

managed care system or child welare-involved children to support their involvement in these less

restrictive services, including therapeutic oster care and outpatient programs.




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NE Central NebraskaRedefning Services to be Medicaid Reimbursable

The state child welare system had paid the cost o care or youth placed in a “Group Home 2.” These

homes actually were serving youth with signicant treatment needs and oered 24-hour awakesupervision, maintained a high sta-to-child ratio, and oered specic treatment techniques. The

state believed that this was a mental health service rather than a placement service, renamed it as

“enhanced group home” care, built it as a medical model, and began using Medicaid, rather than child

welare, unds to reimburse or the treatment services.

▶ Generate Medicaid MatchBoth Vermont and Wraparound Milwaukee demonstrate how unds rom other programs and

systems can be used to provide Medicaid match.

VT VermontUsing Funds rom Other Programs and Systems or Match

The state uses unding contributed by other child-serving systems and mental health general

revenue to provide the Medicaid match. Vermont’s success in identiying and securing unds or

Medicaid match rom other systems is a signicant actor in being able to maintain and expand

services. For example, the autism spectrum program operated by the Howard Center (the Designated

Agency in Chittenden County) has expanded since its beginnings in 2000 to now provide a

continuum o specialized, comprehensive educational and behavioral support and treatment services

tochildren,youth,andyoungadultsages2–21.Theprogramisdirectlyfundedbyschooldistricts,

whose payments to the Howard Center serve as match or the billing o Medicaid or treatment-

related services. This unding mechanism supports Vermont’s vision o partnership between local

schools and community mental health centers to meet the needs o children with mental health and

developmental disabilities. Medicaid has become a greater proportion o all revenues as children’s

mental health services have expanded. State agency partners also expanded in number and

participation in the system o care; and support rom their general und allotments has provided a

source to draw down ederal Medicaid unds to pay or services.




Wraparound Milwaukee Wraparound MilwaukeeUsing Funds rom Other Systems or MatchUseofMilwaukeePublicSchoolsandchildwelfaregeneralrevenueformobilecrisisserviceshelps

to generate Medicaid match or this service. Wraparound Milwaukee operates the County’s mobilecrisisprogramforcountyyouth(MobileUrgentTreatmentTeam[MUTT]),whichissupportedbymultiple unding streams. Every child enrolled in Wraparound Milwaukee automatically is eligible or

servicesfromMUTT,andotherfamiliesinthecountymayuseitforacrisisrelatedtoachild.ThechildwelfaresystemandMilwaukeePublicSchoolswantedanenhanced,dedicatedmobilecrisisteamto

providecrisisinterventionandon-going(30-day)follow-up.Eachprovidesfundingof$450,000tosupport this enhanced capacity. Wraparound Milwaukee also is able to bill Medicaid or this service

underWisconsin’scrisisbenet.ThisincludestheMUTTcrisisteam;aportionofcaremanagers’time spent preventing or ameliorating crises; 60% o the cost o crisis placement in a group home,

fosterhomeorresidentialtreatmentfacility;andthecostof1:1crisisstabilizersinthehome.SinceWraparoundcanrecoverapercentageofitscostsbybillingMedicaid,itisabletoaddabout$180,000

totheMilwaukeePublicSchoolsenhancedcapacityandabout$200,000tothechildwelfarecapacity.

Wraparound’stotalMedicaidcrisisreimbursementwasnearly$6millionin2006.

▶ Maximize Education/Special Education FundsAn example o maximizing special education unds is provided by Choices, where the education

system pays a case rate to obtain services to avert the need or an out-o-school or residential

placement.

Choices

ChoicesReceiving Case Rates rom the Education SystemO children served in Indiana by Choices (Dawn), 70% are in special education. When children are

reerred by the education system, their case rate is paid by the education system. Some o these

childrenareinthe“atrisk”tierofservices(withacaserateat$1,809permonth),withthegoalof

averting the need or an out-o-school or residential placement.




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C. Redirect Spending from “Deep-End” Placements

Strategies include:• Redirectingdollarsfromdeep-endplacementstohomeandcommunity-based

services and supports

• Investingfundstobuildhomeandcommunity-basedservicecapacity

• Promotingthediversicationofresidentialtreatmentproviderstoprovidehomeand community-based services

▶ Redirect Dollars rom Deep-End Placements to Homeand Community-Based Services and Supports andMonitor Efects on Service Utilization

All o the sites have implemented strategies to redirect resources rom deep-end placements to

home and community-based services and supports. This is an absolutely critical nancing strategyas there are seldom new dollars or children’s services; expansion o home and community-based

capacity must depend on redirected resources to a great extent.

AZ ArizonaUsing 1115 Waiver to Develop Home and Community-Based Services Theentirethrustofthe1115Medicaidwaiveristodevelophomeandcommunity-basedalternatives

to out-o-home services. The Arizona behavioral health system, working in partnership with the

state Medicaid agency, signicantly expanded the array o covered services and supports by addingnew service types to the Medicaid benet and expanding service denitions o already covered

services. In addition, rates were restructured to better correspond to system goals o encouraging

the provision o home and community-based services and reduced reliance on residential treatment.

Rates or residential treatment, or example, decline as lengths o stay increase. The state reported

thatin2003,39%ofthechildbehavioralhealthbudgetwentto3.6%ofenrolledchildrenserved

in residential treatment centers (RTC) and inpatient hospitals. In 2005, this had been reduced to

29%–16.25%oninpatienthospitalizationand13.4%onotherout-of-home(residentialLevelsI,II,III,

includingtherapeuticfostercare).Currently,2.6%ofthe33,000youthservedstatewide(about850

youth) are served in out-o-home treatment settings, but 40% o those placements are in amily-

basedtherapeuticfostercare(TFC),ratherthancongregatesettings.In2003,thesystemhadnineTFC

placements statewide, compared to about 400 today. Value Options (VO) in Maricopa reported that

itspent$25–30millionofitsbudget(about25%)onout-of-homeservicesand$70–90million(about75%) on home and community-based services. At the same time, child welare in Maricopa reported

that it is spending less on RTC because o successul appeals to get VO to pay or the service.




VO indicated that “while we never used to talk to judges, court appointed special advocates, or

guardians ad litem,” they have begun trying to educate these stakeholders about alternatives to RTCs.

In addition, Arizona Department o Health Services, Division o Behavioral Health Services (ADHS/

BHS)developedPracticeImprovementProtocolsrelatedtouseofRTCs,includingoneonUseof

Out-o-Home Care Services and one on Therapeutic Foster Care. (See: http://www.azdhs.gov/bhs/guidance/guidance.htm .)

HI HawaiiUsing Training and Individualized Service Approach toShit Practice and ResourcesHawaii has sought to redirect dollars rom deep-end placements to home and community-based

services and supports as the service array has been expanded. Access to deep-end services has not

been restricted, and there are no specic line items in the budget or residential vs. nonresidential

services. Rather, education/training and technical assistance have been used in an attempt to shitpractice to a home and community-based approach. As community-based service capacity has

expanded, utilization o residential services has been reduced. The approach taken by the state

has relied upon training and encouragement to shit to a home and community-based service

philosophy. Child and amily teams, however, are empowered to authorize whatever services they

deem necessary, and the Child and Adolescent Mental Health Division (CAMHD) is obligated to pay

or the services they authorize or a child and amily.

The state has had a ocused initiative on bringing children back rom out-o-state placements.

The initiative represents a collaboration among the mental health system (Department o Health),

educationsystem,andthecourtsystem.In1999,therewere89childrenoutofstate.Individualizedservice plans were developed child by child to bring these children back. Currently, there are only

6 children in out-o-state placements. In order to send a child to the mainland or treatment, all

three departments (Departments o Health, Education, and Human Services) must sign o; thisrequirement alone creates a disincentive to out-o-state placements.

CAMHD in the Department o Health bears the cost o out-o-state placements. The state has

ound that it is not necessarily less costly to develop and implement a wraparound plan and to keep

a child in the community as compared with an out-o-state placement. This approach, however,

is considered to be better practice. Attempts are made to bring children back rom out-o-state

placements to therapeutic oster care rather than residential treatment centers. Dollars in the budget

are not held to line items, so that dollars can ollow the child. Thus, dollars can be moved rom mental

health residential care to community-based services as the locus o treatment shits.

A Resource Management Section o CAMHD’s Clinical Services Ofce tracks matches between

children’s needs and system resources to acilitate development activities that ocus on ensuring

sucientcapacityandecientuseofavailableresources.Patternsandtrendsinservicedeliveryare examined that identiy and discourage the prolonged use o ineectual services, overly

restrictive services, or non-evidence-based interventions. Regular reviews are conducted to examine

documented needs and the intensity o services provided. When problems are identied, this section

provides the data necessary or CAMHD to take action to align services with CAMHD’s practice

guidelines and policy.




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NJ New JerseyImplementing a Statewide System o Care Reorm withCare Management Organizations or Youth with Complex,

Multi-System IssuesNew Jersey has committed to move dollars rom deep-end placements to community-based

services by creating entities such as a Contracted Systems Administrator (CSA), Care Management

Organizations (CMOs), and Family Support Organizations (FSO’s). Though the state has struggled

in this area and a lot o monies are still used or residential services, the amount has been steadily

declining over time. There is one CMO and FSO per region; they are slated to work together to provide

care coordination and create individualized plans or children with complicated and intensive needs.

The FSOs employ Family Support Coordinators and Community Resource Development Specialists,

who are responsible or identiying and ormulating natural helpers and inormal community

supports to enhance treatment services.

Spending on residential care has increased in recent years because New Jersey has provided

services to more children, expanded the capacity o the residential system to meet the need, and

raised the reimbursement it pays to acilities. However, growth in spending or community services

has dramatically outpaced growth in spending or residential care, meaning that residential care now

constitutes a smaller raction o the overall budget or children’s mental health than it did beore New

Jersey implemented its system o care reorm — 60% instead o 90%. State ofcials, however, believe

that the amount spent on residential care, while a signicant improvement, remains signicantly

too high.

Data are also available on cost per child served on a county basis. In scal year 2000, New Jersey

spent the bulk o its children’s mental health service expenditures, 72%, on inpatient and residential

care. The percent o total expenditures utilized or residential and inpatient services ranged rom

48% (a signicant outlier) to 85%. This picture has changed considerably in all counties. In 2005, the

statewideaveragewas39%spentoninpatientandresidentialcare.OceanCountyhadthelowest

rate, 20%, and Warren County the highest at 56%.A urther examination o 2005 data stratied by county reveals how system o care

implementation, still underway in New Jersey, aects the use o out-o-home care. There appears

to be little dierence in the way that system o care has aected the number o children using

inpatientservices.BothPhase1,theoriginalsystemofcareimplementers,andPhase3counties

useinpatientservicesatasimilarrate,withPhase2showingasmallerrangeinratesforitssmallernumber o counties. But the use o residential care appears to have shited considerably with the

implementationofsystemsofcare.Phase1andPhase2countiesuseresidentialforfewerchildrenthandoPhase3countieswhohadnotyetimplementedsystemsofcare.




VT VermontImplementing Gate-Keeping Process and Developing Home and Community-Based Capacity

The state’s vision and goal seeks to build home and community-based services capacity resulting in alow use o residential services. Savings rom reduced utilization o residential treatment services are

captured and redirected to community-based services. While there are specialized residential services

and a hospital or statewide access, the system o care vision, state law and practice have worked

to establish home and community-based capacity and expand services, utilizing dollars that would

have otherwise been allocated to more costly options (i.e., redirection), as well as using new unds or

community services..

Intheearly1980s,fewtypesofmentalhealthserviceswereavailableinVermont;typicallythere

was a 50-minute therapy session or psychiatric in-patient care or a ew weeks. The system o care

concept encouraged the state to develop an array o services to meet needs in the home, school,

and community, most notably case management, respite, and short-term hospital diversion beds.

Thenumberofchildrenages0–12and13–19whoreceivedchildren’sservicesthroughcommunity

mentalhealthcenterstripledfrom1989through2005,fromabout3,200to10,000.Thisisahighpenetration rate, about 8%, compared to most states, and very ew o the children served are in

hospital-level care.

Vermont used its Medicaid Home and Community-Based Services waiver as one nancing

component in building the system o care and supporting eective services to more children with

serious disturbances in their communities rather than in inpatient settings. Evaluation o the Vermont

waiverprogramfoundthatthecostperchildunderthewaiverwasabout$150perdaycomparedto

$1,200perdayforinpatientservices.

Training has also been provided over several years to sta on how to wrap intensive services

around children with high needs and their amilies, thus helping to avoid unnecessary disruption

to a child’s amily lie and school/social environment.

In addition to expanding home and community based service capacity, the state also createda gate-keeping mechanism or intensive, restrictive services. Vermont’s Case Review Committee

(CRC) was established by the State Interagency Team to provide assistance to local teams as they

identiy, access and/or develop less restrictive resources, or when less restrictive alternatives are

not appropriate, to ensure the best possible match between child and residential treatment acility.

The CRC reviews all requests or intensive residential placement and intensive wraparound services

that provide overnight sta 24 hours a day, seven days a week or children or adolescents with

severe emotional disturbance. While the representatives rom the departments review the proposed

services together, unding decisions are made on a child-specic basis. CRC and/or agency sta may

also provide technical assistance to ensure the child’s return to home and community as quickly as

possible.




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NE Central NebraskaDeveloping a System o Care or Children in State Custody

The Cooperative Agreement between the Nebraska Department o Health and Human Services

(DHHS)andRegion3BehavioralHealthServices(BHS)tocreateanindividualizedsystemofcareor children in state custody who have extensive behavioral health needs identies reinvestment o

cost savings to allow or more preventative, ront-end, community-based services as one o its core

principles.TheagreementstipulatesthatifRegion3BHSexperiencescostslessthantheagreementamount, an expected outcome o the program, the cost savings may be used to: develop a risk pool

(nomorethan10%),serveadditionalyouthinthetargetpopulationorexpandservicestoyouthatrisk o becoming part o the target population, and provide technical assistance to other Regions/

Service Areas to implement similar programming statewide.

Inits2005AnnualReport,Region3BHSdemonstratesthattheIntegratedCareCoordinationUnithasreducedout-of-homeplacementsandincreasedthepercentageofchildrenwholiveinthe

community:

• Atenrollment,35.8%ofthechildren(n=341)werelivingingrouporresidentialcare;at

disenrollment 5.4% o the children were in group or residential care• Atenrollment2.3%werelivinginpsychiatrichospitals;atdisenrollmentnochildrenwere

hospitalized

• Atenrollment7%werelivinginjuveniledetentionorcorrectionalfacilities;atdisenrollmentno

children were in these acilities

• Atenrollment41.4%werelivinginthecommunity(athome–4.4%,witharelative—1.5%,orin

fostercare—35.5%);atdisenrollment,87.1%livedinthecommunity(athome—53.5%,witharelative—7.6%,infostercare—14.5%,independentliving—11.5%).

Other outcome measures show that CAFAS scores dropped signicantly (i.e., improved) or

childrenenrolledintheProfessionalPartnersProgram,IntegratedCareCoordinationUnit,orEarly

Intensive Care Coordination, and their living situations improved.

Choices ChoicesUsing Redirection to Home and Community-Based Care asBasis or Service Delivery

The philosophy o Choices, and how its services are marketed, is the concept o redirecting care rom

deep-end placements to home and community-based services. This orms the basis or the entire

concept o service delivery.




Wraparound Milwaukee Wraparound MilwaukeeUsing Redirection to Home and Community-Based Care asBasis or Service Delivery

Wraparound Milwaukee has achieved signicant reductions in use o deep-end placements, namelyin use o inpatient hospitalization, residential treatment, and juvenile corrections acilities.

PriortoWraparoundMilwaukee,MilwaukeeCounty’sChildandAdolescentServicesBranchoperateda120-bedinpatientunitwithanaveragelengthofstay(ALOS)of70days.Overabouta

15yearperiod,asWraparoundMilwaukeedeveloped,theBranchclosedbeds.ThestateMedicaid

agency provided “bridge” money to close inpatient beds by giving the Branch 40% o the DRG

(Diagnosis Related Group) rate or every child diverted rom inpatient care. These dollars helped

tobuildhomeandcommunity-basedservicecapacity.Today,theALOSis1.7days,andinpatient

utilization has declined rom 5,000 days a year to 200.

In Milwaukee County, the child welare and juvenile justice systems pay or residential treatment

centers (RTC); RTC level o care is not paid or by Medicaid, mental health or education systems.

Wraparound Milwaukee has reduced the use o residential treatment centers (RTCs) rom an average

dailypopulationof375to50youth.TheALOSis90–100days.WraparoundMilwaukeeestimatesthat

ifthechildwelfaresystemhadnotinvestedinWraparoundMilwaukee,the$18millionthatchildwelfarewasspendingtenyearsagoonresidentialtreatmentwouldbe$46milliontoday.Instead,

Wraparound Milwaukee essentially is using the same monies that were in the system ten years ago,

without new state or county revenues, to serve more children in home and community services with

better outcomes. Even with the results it has achieved, Wraparound Milwaukee stakeholders note

that out-o-home placements are expensive, and the costs o out-o-home care have been rising. Sixty

percent o Wraparound Milwaukee’s budget goes to residential treatment, group home, therapeutic

andregularfostercare.Theaverageper-child-per-monthcostofcareis$3,500,whereastheaverage

costforachildusingonlyhomeandcommunityservicesandsupportsis$1,700.(Note.Thesecostsmust be considered within the context o Wraparound Milwaukee’s very “high-end” target population,

which is those youth with the most serious behavioral health challenges, who also are involved inmultiple systems. These are not costs spread across all children in the county. They also need to be

consideredinthecontextofthecostsofresidentialtreatment,whichrunabout$7,000permemberpermonth(pmpm),inpatienthospitalization,whichrunabout$18,000pmpm,andcorrectional

placements,whichrunabout$6,000pmpm.)

The county juvenile justice system pays or the cost o placements or youth in state corrections

acilities. By diverting youth to Wraparound Milwaukee, the county juvenile justice system can save

dollars and get better outcomes. Wraparound Milwaukee’s average monthly costs or youth reerred

byjuvenilejusticeareabout$3,500pmpm,comparedto$6,000pmpmforjuveniledetention.

Wraparound Milwaukee also has reduced recidivism rates or youth in juvenile justice by 60% rom

one year prior to enrollment to one year post enrollment. Looking at subsets o the juvenile justice

population,WraparoundMilwaukeeachieveda34%decreaseintheaverageperchildpermonthcost

ofresidentialcareforyouthwithsexoenses.(Thiswasinspiteofa15%increaseinresidentialfeesduringthesameperiod.)Useofgrouphomesdropped75%.Inplaceofcongregatecare,WraparoundMilwaukee provides crisis one-to-one stabilization, parent assistance, therapeutic oster care, oense-

specic doctoral-level individual therapy, in-home therapy, parent education and support, saety

plans, and a range o other individualized services to this population.




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In addition to use o the wraparound approach to reduce use o deep-end services, Wraparound

Milwaukeealsooperatesamobilecrisisteam—MobileUrgentTreatmentTeam(MUTT)—paid

or by a Medicaid crisis benet (separate rom the Medicaid capitation Wraparound Milwaukee

receives). The county provides 40% o the match and receives 60% o ederal reimbursement rom

the state. Milwaukee’s mobile crisis capacity can be utilized very exibly, including providing accessto psychiatrist, psychologist, and paraproessional services (using dierent billing codes). The team

itsel is comprised o three licensed psychologists and ve clinical social workers and is available

24 hours a day. The crisis benet is utilized or mobile crisis stabilization by the crisis team, as well

as by Wraparound Milwaukee care coordinators, who can use the benet or time spent on crisis

planning and crisis stabilization activities. Time spent by crisis team members or by care coordinators

on activities related to preventing crises, ameliorating crises, or linking youth and amilies to crisis

services is covered under the crisis benet. The benet also can be used to cover crisis group homes

andcrisisfosterhomes,upto$88/dayinnon-roomandboardcosts.Milwaukeehasfoundthatthe crisis benet is a key actor in reducing use o deep-end services. Wraparound Milwaukee has

aseparate$450,000contractwiththechildwelfaresystemforuseofMUTT,whichithasfoundishelping to prevent placement disruption o children in child welare; this unding rom child welare

enabledMUTTtoaddsta,whoalsocanbillMedicaid.Theplacementdisruptionrateinchildwelfarehasbeenreducedfrom65%to38%.Recently,MilwaukeePublicSchoolscontractedwithWraparound

Milwaukee(a$450,000contract)toutilizeMUTTintheschools.

▶ Invest Funds to Build Home and Community-BasedService Capacity

Arizona, Hawaii, New Jersey, Vermont, Central Nebraska, and Wraparound Milwaukee have

invested unds to develop home and community-based service capacity.

AZ ArizonaIncreasing Funds Spent on Home and Community-Based Services

Through the managed care system and as a result o the JK lawsuit, there has been an increase in

dollars spent on home and community-based services. The behavioral health system, working in

partnership with the state Medicaid agency, signicantly expanded the array o Medicaid-covered

services, both by adding new service types and expanding service denitions o already covered

services. Rates were restructured to encourage provision o home and community-based services.

A new type o Medicaid provider was created — community service agencies — specically to

broaden the availability o home and community based services. In addition, Arizona Department

o Health Services, Division o Behavioral Health Services (ADHS/BHS) includes non-Medicaid dollars,

including state general revenue and block grant unds, in the capitation that Regional BehavioralHealth Authorities (RBHAs) receive, which can be used or expanding the availability o home and

community-based services. Any “savings” generated through managed care are re-invested, and there

is a legislative prohibition against using savings generated by children’s programs or adult services.

Value Options (VO) in Maricopa County has used savings to expand the availability o therapeutic

oster care.




HI Hawaii and NJ New JerseyInvesting in Service Capacity Development with State Funds

• InHawaii , capacity building and start-up unds come rom the existing Child and Adolescent

Mental Health Division (CAMHD) budget. CAMHD resources have been used to build capacity toprovide services such as Multisystemic Therapy (MST), and Multi-Dimensional Treatment Foster

Care.

• InNew Jersey , the state changed its Medicaid plan to include reimbursement or more

comprehensive services and to create new service capacity. State dollars were also used to uel

this initiative by investing in service capacity development. Some o the community-based

services that were added include: care management, mobile crisis services, wraparound, amily

care homes and amily support services.

VT

VermontUsing Multiple Funding Sources or Service Capacity Development Vermont’s system o care history illustrates capacity building nanced by ederal Medicaid and

grant dollars, state general revenues and private resources. The state’s Home and Community-Based

ServicesMedicaidwaiverandCASSPfundinginthe1980s,alongwithstatedollarsandagrantfrom

the Robert Wood Johnson Foundation, spurred the creation o interagency networks and services

leading to the establishment o the system o care. Federal Medicaid and grant unding, along with

state statutes and policies, oster and und continuing growth in behavioral health services or

children. Medicaid is the principal payer or most services and the state’s high levels o Medicaid

andS-CHIPeligibilityandbroadpackageofcoveragehavecontributedsignicantlytoserviceexpansion. Funding or new services comes rom a variety o sources. For example, the Children’s

UpstreamServicesproject(CUPS),fundedbyafederalsystemofcaregrant,seededVermont’s

community-based mental health services or young children experiencing emotional disturbance. The initiative ocused attention on very young children, the kinds o services they and their amilies

needed,andtheresourcesandnetworksrequired.TheinitialCUPSnancingmodelsupported

only “pull-out” services (i.e., services that call or removing a child rom a setting or treatment/

intervention with subsequent reintegration back into the initial setting). However, interagency teams

o parents and providers engaged in the process identied a primary need or early education and

consultation services to public and private child care and service providers to increase their skill level

in working with young children with mental health issues and their amilies and in developing more

supportive environments or them. This reduced the need or removal o the child and increased

the knowledge and skills o community providers about the development o all children. The latter

involved conversations with the state’s higher education community and, ultimately, led to expanded

curricula,certication,anddegreeoptions.BasedonpositiveoutcomesoftheCUPSinitiative,mentalhealth, other agencies, and amily representatives at state and local levels partnered successully to

secure unds (ederal grant, state general revenue) to develop service capacities in these areas so that

children would not have to be removed rom pre-school classrooms, child care programs and the like.




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NE Central NebraskaUsing Savings to Invest in Service Capacity Development Inadditiontoimprovedoutcomes,theIntegratedCareCoordinationprogram(ICCU)hasalso

achieved a cost savings. With this savings, Central Nebraska has been able to implement theprinciple o reinvestment and expand services or youth at risk o becoming part o the target

population.In2001,ICCUproducedacostsavingsof$500,000(thislatergrewto$900,000).There

was discussion o returning these unds to the state to help with a signicant budget decit acing

child welare. Instead, the director o the Department o Health and Human Services supported the

alternatives that were laid out in the cooperative agreement. Central Nebraska kept the cost savings

and used it both to provide technical assistance to other regions/service areas to implement similar

programming and to expand the population o children and amilies served.

AportionoftheICCUcostsavingswasusedtocreatetheEarlyIntensiveCareCoordinationProgram(EICC),whichseekstopreventchildrenwhohaveenteredthechildwelfaresystemfrom

being removed rom their homes and rom remaining in the system. I they are removed, EICC works

to expedite their return home by using the wraparound approach and amily-centered services. EICC

served 67 youth and their amilies in scal year 2005. They prevented placement in state custody or88.1%oftheseyouth.(Note:Currently,CentralNebraskaisunabletocontinueitsEICCProgramdueto

state policy changes limiting the use o these unds to children who are currently in state custody. As

a result, the local system o care identied other service gaps or children already in custody who are

servedbyICCU.ThefundsarenowbeingusedtoprovideaSchool-BasedInterventionProgramforthese youth.)

Wraparound Milwaukee Wraparound Milwaukee

Using Savings to Invest in Service Capacity Development All o the savings generated by Wraparound Milwaukee are reinvested in the system to serve more

youth or build more service capacity. Wraparound Milwaukee has over 200 providers (agencies and

individuals) in its network, representing 85 dierent services and supports and including over 40

racially and culturally diverse providers. The approach it takes to building capacity is to build “target

population by target population.” At the time o the site visit, additional service capacity issues were

identied or girls and or youngsters with co-occurring emotional disturbance and developmental

disabilities and youngsters with autism, who are at risk or residential placement and whose amilies

are involved with child welare. These children oten end up in Wraparound Milwaukee, constituting

about10%oftheWraparoundpopulation.WraparoundMilwaukee’sapproachistodevelop

customized service network responses to population issues as they arise.




▶ Promote Diversication o Residential TreatmentProviders to Home and Community-Based Services

Most o the states and communities studied have worked with residential treatment providers to

encourage them to adopt the system o care philosophy and approach, to work in partnership with

local systems o care, and to diversiy by providing new types o services and supports.

AZ ArizonaCollaborating with Residential Treatment Providers to Diversiy

Arizona is undertaking a number o strategies, including putting a workgroup together to look

at service gaps and what the research says or particular subsets o youth, such as those with

sexual oenses, who oten are sent to out-o-state residential treatment centers (RTCs). The state

is then looking at getting the in-state RTC providers to the table to look at service development

issues. Therapeutic oster care will continue to play a bigger role, with the state looking at possibly

increasing rates or therapeutic oster care and developing or implementing a training curriculum or

therapeutic oster homes. The curriculum would be built on the curriculum or child welare osterhomes, which emphasizes the role o active support or amily reunication.

Value Options (VO) in Maricopa County reported that it is rewriting scopes o work or residential

providersandComprehensiveServicesProviders(CSPs)intheirnetworktoputresponsibilityontheRTCsandCSPsforcontinuingchildandfamilyteamswhileyoungstersareinresidentialfacilities,and

VO is putting language in RTC contracts that these providers must work with the amily o origin.

VO also reported that they are talking to the state’s child welare system about training RTCs and

others in use o “Family Finding” (e.g., using Internet search engines to locate extended amily o

youth in oster care in RTCs). VO also is trying to change its own case management rom one o prior

authorization/utilization management to one o coaching and acilitating skill sets to get RTCs and

othersmoreinvolvedinthechildandfamilyteamapproach.VOalsolaunchedan“under12”initiative

tokeepyoungstersundertheageof12outofRTCsandhastalkedtotheRTCsaboutdiversifyingto

provide more home and community-based care. Reportedly, VO has reduced the number o children

underage12inRTCs,someRTCshavediversied,andtwoRTCsservingyoungerchildrenclosed.VOalso is consciously trying to move youngsters to lower levels o care and is considering re-directing

any “savings” to urther developing community-based supports, rather than simply renewing RTC

contracts. Most o the RTCs in the state are located in Maricopa County.

ProvidersindicatedthatmostoftheRTCsarediversifyingtheirservices(reportedly,allbut

one in Maricopa), and apparently beds are closing (one 80-bed acility in Maricopa, or example).

One example given was that o Touchstone, an RTC provider in Maricopa that is now providing

Multisystemic Therapy (MST), Functional Family Therapy (FFT), and therapeutic oster care.




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HI Hawaii and VT VermontWorking with Residential Providers to Adopt System o Care Approach and Diversiy

RTCs developed a broader service array as part o the system o care:• In Hawaii , residential treatment centers are contract provider agencies to the children’s mental

health system. Some have diversied and now provide a broader service array, including such

services as intensive in-home services and therapeutic oster care.

• InVermont , residential treatment centers/programs have diversied and incorporated the

system o care vision. For example, the child mental health program at Howard Center, the lead

community mental health provider in Chittenden County, ormerly served as a major residential

treatment acility in the state. It now oers an array o programs and services rom an integrated

pre-school program (or pre-schoolers with and without mental health issues) to a day school to a

residential program.

Choices ChoicesWorking with Residential Providers to Adopt System o Care Approach and Develop New Types o ServicesChoices has worked with residential providers, particularly in Indiana, to develop new types o

services within the overall system o care. These include residential services which are based on

system o care values and principles such that children are signicantly more involved in their homes

and communities and amilies are ull partners in the service delivery process. A unique addition

tothecontinuumofcareprovidedthroughtheDawnProjectistheFamilyCommunityProgramatthe Lutherwood Residential Treatment Center. Operated in partnership with Dawn, the program

oers a nontraditional, strength-based residential program in which youngsters are integrated in thecommunity as much as possible, amily reunication is the goal, and parents are highly involved in

treatment and decision making as members o the treatment team. Innovations include: amilies are

engaged in new ways in the intake process; youth and amilies co-design the goals and interventions;

youth are able to go home at night; no level systems are required beore getting the “right” to go

home; the strengths and culture o child and amily are tied to the solutions; amilies are consulted or

solutions to problem behaviors; a mobile support team or intensive amily preservation is provided;

amilies can be on the unit at any time; medications are let in charge o the amily and community

physician with consultation by the acility psychiatrist; an educational liaison is provided; and many

youth remain in their home schools.




Wraparound Milwaukee Wraparound MilwaukeeUsing Market Forces to Create Changesin Residential Treatment Centers

In eect, Wraparound Milwaukee let the market dictate the uture o residential treatment centers(RTCs). Milwaukee made it clear it was going to utilize RTCs dierently and was in the market or a

broad range o services and supports. Virtually all o the RTCs in Milwaukee diversied in response to

what Milwaukee Wraparound indicated it was willing to purchase, including contracting to provide

care coordination. While ew RTCs actually closed, beds were reduced, in some cases, campus acilities

were sold or leased, and new home and community-based products were developed.

D. Support a Locus of Accountability for Service,Cost and Care Management for Children with

Intensive Needs

Strategies include:• Financingcaremanagemententitiesasalocusofaccountability

• Incorporatingrisk-basednancingstrategiesforhigh-needpopulations

▶ Finance Care Management Entities asLocus o Accountability

Many o the sites nance some type o entity as a locus o accountability and management or

children with serious and complex challenges, who are involved in or at risk or involvementin multiple systems. These may be either a government entity or a private, nonprot entity.

Government entities are ound in Hawaii, where the state children’s mental health agency

administerstheSupportfortheEmotionalandBehavioralDevelopmentofYouthorSEBDProgramthrough a carve-out under the state Medicaid program and utilizes seven public mental health

agencies located throughout the state to coordinate service delivery. The regional government

behavioral health and child welare authorities are the locus o accountability in Central Nebraska

throughtheiruseofaCareManagementteamandcreationofIntegratedCareCoordinationUnits,and a local government agency is the locus o accountability or Wraparound Milwaukee.Private

nonprot entities are ound in New Jersey , which contracts with nonprot Care Management

Organizationsineachregionofthestate.Vermontcontractswith10localnonprotleadagencies

to ulll similar unctions, and Choices is a private nonprot corporation that is contracted by

government agencies to serve as a care management entity and locus o accountability.




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HI HawaiiUsing a State Government Agency Hawaii’s children’s mental health system is administered by the state government, specically the

Child and Adolescent Mental Health Division (CAMHD) o the Hawaii Department o Health (DOH).Over the past ve years, CAMHD’s system o care shited rom a comprehensive mental health service

system or all children and youth to a system ocused on providing more intensive mental health

services to the population o youth with more serious and complex behavioral health disorders and

theirfamilies.Throughamemorandumofunderstanding(MOU)withthestateMedicaidagency,

CAMHD operates a carve-out under the state Medicaid program that serves youth with serious

emotional and behavioral disorders (the Support or the Emotional and Behavioral Development

ofYouthorSEBDProgram).CAMHDreceivesacaseratefromMedicaidforeachchildinserviceandprovides a comprehensive array o services and supports. Operation as the prepaid health plan or

Medicaid eligible youth began in 2002. The unctions under the purview o the state ofce include

governance o the system, perormance management, business and operational management,

researchandevaluation,andtrainingandpracticedevelopment/improvement.UndertheCAMHD

structure are seven public Family Guidance Centers (community mental health centers), locatedthroughout the state, which are responsible or mental health service delivery to children and

adolescents and their amilies. CAMHD also contracts with a range o private organizations to provide

afullarrayofmentalhealthservices.PublicemployeeswithintheFamilyGuidanceCentersprovidecare coordination services, assessment and outpatient services, and arrange or additional services

with contracted provider agencies.

NJ New Jersey

Using Nonproft Care Management OrganizationsNew Jersey’s system o care initiative created Care Management Organizations (CMOs), which are

nonprot entities at the local level (one per region) that provide individualized service planning and

care coordination or children with intensive service needs under contract with the state. Currently,

contracts are non risk-based. CMOs use child and amily teams to develop individualized plans,

which are required to be strengths-based and culturally relevant. They also must address saety and

permanency issues or those children reerred to CMOs who are involved with the child welare and

juvenilejusticesystems.TheCMOsemploycaremanagers,whocarrysmallcaseloads(1:10)and

who receive close supervision and support rom clinical supervisors. Care managers and child and

amily teams are supported by amily support coordinators and community resource development

specialists, whose job it is to identiy and develop inormal community supports and natural helpers

to augment treatment services. The Care Management Organizations work closely with Family

Support Organizations (i.e., amily-run organizations) to link amilies to natural supports and a peer

network.




VT VermontUsing Local Lead Agencies and Interagency TeamsVermont’s system o care or children with behavioral health problems has state and local structures

that serve as ocal points at each level and across systems or policy and management. TheDepartment o Mental Health is the lead state ofce or children’s mental health. The Department’s

Child,AdolescentandFamilyUnitcontractswithtenlocalDesignatedAgencies(nonprot,

designatedbytheCommissioner)thatservethestate’s14countiestoprovidecommunitymentalhealth services or a specic geographic region. The Designated Agency is the locus o accountability

or services, cost, and care management or children with intensive mental health needs. The local

agency that has lead responsibility or ensuring that the coordinated service plan (developed by

an individual interagency treatment team) is in place can vary depending on the needs o the child

and amily. I the child is in the custody o the Department or Children and Families (child welare

agency), then that agency takes the lead. I the issues are primarily exhibited in the child’s educational

environment and the child is not in state custody, then the local school district is responsible. In all

other cases, the designated community mental health agency is responsible or developing and

making sure that the coordinated services plan that outlines goals and needed services and supportsis carried out. Decisions about services, care and cost are made at the local level, driven by the needs

o the child and amily and provided within the limits o legislative mandates and existing resources.

I problems or issues arise that the individual treatment team cannot resolve, the team or any

member may initiate a reerral to the Local Interagency Team in the region or help. The State

Interagency Team is a mandated state-level unit or urther consideration o issues that are not

resolved locally and or additional assistance with implementation o the coordinated service plan.

NE

Central NebraskaUsing Integrated Care Coordination Units Supported by Regional Behavioral Health and Child Welare AuthoritiesRegion3baseditssystemofcareonanexistinginfrastructure(Region3BehavioralHealthServices

[BHS]).Whenitreceivedafederalsystemofcaregrantin1997,therewasnoneedtocreateandsupportanewstructuretoimplementthesystemofcare.Region3BHSalreadyhadastatutory

responsibilitytoadministerbehavioralhealthservices.Usingtheexistinginfrastructureratherthan

creating a new, separate entity with grant unds greatly enhanced the chances or sustainability. The

cooperative agreement between the Nebraska Department o Health and Human Services (DHHS)

andRegion3BHStoestablishanindividualizedsystemofcareforyouthwithintensiveneedswho

are in state custody included a joint responsibility or utilization management to monitor utilization

o higher levels o care and assist care coordinators in accessing alternative placement and treatment

services. The Care Management Team (CMT) serves this unction. It was developed to ensure that

children/youth are cared or in the least restrictive, highest quality, and most appropriate level o care.

It serves children at risk o out-o-home placement, as well as children in out-o-home placement.

To determine the most appropriate level o care, the CMT administers an initial assessment using

the Child and Adolescent Functional Assessment Scale (CAFAS), interviews caregivers, reviews youth




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records (including mental health assessments and risk assessment) and participates in the child

and amily team meetings when necessary. The CMT tracks reerrals rom DHHS and other service

providers, determines needed services and supports, and identies service gaps. The CMT determines

which children/amilies in Central Nebraska meet the criteria or the Intensive Care Coordination

Unit(ICCU),whichICCUhasthecapacitytoacceptthem,andwhichchildrenshouldbeprioritizedtoreceivecarerst.IfthereisnoopeninginanICCU,theCMTwillfacilitateachildandfamilyteam

meeting.TheCMTconductsongoingutilizationreviewofchildreninICCU.TheCMTisstaedbylicensed mental health clinicians. This is very helpul in the negotiations with Magellan, the statewide

Administrative Services Organization, or access to Medicaid services or individual children. Region

3BHSandtheCentralAreaOceofProtectionandSafetyfundtheCMT.InFY2005,210youthwere

reerred to the CMT.

Choices ChoicesUsing a Private, Nonproft Corporation

Choices is the care management entity that serves as the locus o accountability or youth withintensive service needs.The county (Marion County, Indiana and Hamilton County, Ohio) or state

(or Montgomery County and Baltimore City, Maryland ) contracts with Choices to assume this

role. Choices is a private nonprot corporation that was created by our Marion County community

mental health centers as a separate and independent entity to manage the Dawn system o care.

Fullling the role o a “care management organization,” Choices provides the necessary administrative,

nancial, clinical, and technical support structure to support service delivery and manages the

contracts with the provider network that serves youth and their amilies.The responsibilities o

Choices include providing nancial and clinical structure; providing training; organizing and

maintaining a comprehensive provider network (including private providers); providing system

accountability to the interagency consortium; managing community resources; creating community

collaboration and partnerships; and collecting data on service utilization, outcomes, and costs.

Wraparound Milwaukee Wraparound MilwaukeeUsing a Local Government Agency Wraparound Milwaukee’s primary unction is to serve as a designated locus o accountability or

children and youth with intensive needs and their amilies, specically those with serious behavioral

health challenges who are at risk or inpatient, residential treatment or correctional placement. At

the administrative level, the locus o accountability is through the Child and Adolescent Services

Branch o the Milwaukee County Behavioral Health Agency, which serves as a “Management Services

Organization,” similar to an Administrative Services Organization in managed care. The Branch utilizes

the tools o managed care to manage utilization and quality and is at nancial risk through theMedicaid capitation it receives, as well as through case rates rom child welare and juvenile justice. At

theservicedeliverylevel,carecoordinatorswithcaseratiosofnomorethan1:8serveasthelocusofaccountability or individual children and their amilies. Also, individualized child and amily teams are

accountable or ensuring appropriate plans o care or individual children and their amilies. The plans

o care they develop constitute “medical necessity” or Medicaid purposes.




▶ Incorporate Risk-Based Financing Strategies orChildren and Youth with Intensive Needs

Most o the sites use some type o risk-based nancing and various risk adjustment strategies or

children and youth with complex needs. Arizona contracts with our Regional Behavioral Health

Authorities and nances them with capitation rates; higher, risk adjusted rates are provided orchildren in state custody. Hawaii’s system o care (operated by the Child and Adolescent Mental

Health Division) receives a case rate rom Medicaid or each child with a serious emotional disorder

deemed eligible or services. Central Nebraska uses case rate nancing, with dierential case rates

based on the target population and a risk pool to protect against higher than anticipated expenses.

Choices has a case rate structure with our tiers, based on youth with dierent levels o need, and

Wraparound Milwaukee receives risk adjusted capitation rates rom Medicaid and case rates rom

the child welare and juvenile justice systems.

AZ ArizonaUsing Capitation Financing and Risk Adjusted Rates

The Arizona State Medicaid agency contracts with the Arizona Department o Health Services

(ADHS), Division o Behavioral Health Services (BHS), to manage a behavioral health carve-out.

ADHS/BHS, in turn, contracts with our Regional Behavioral Health Authorities (RBHAs), covering

six geographic areas throughout the state, and two Tribal Behavioral Health Authorities (TRBHAs).

Arizonahasapopulationofaboutsixmillion,withnearlytwomillionchildrenunder18(about32%).

MaricopaCounty(Phoenix)hasmostofthestate’spopulation,withover3.5milliontotaland1.2millionchildrenunder18(34%).Atthetimeofthesitevisit,theRBHAinMaricopaCountywasValue

Options (VO), a commercial behavioral health managed care company. RBHAs receive a capitation

forMedicaidandStateChildren’sHealthInsurance(S-CHIP)coveredservices;theyalsoreceivestate

general revenue dollars and ederal mental health and substance abuse block grant monies to

provideservicestonon-Medicaid/S-CHIPpopulationsandtopayfornon-coveredservices.

There are risk-adjusted capitation rates or children in state custody that are nearly 20 timeshigherthanforotherchildren.InMaricopaCounty,thecapitationrateforchildrenincustodyis$600permemberpermonth(pmpm);forotherchildren,therateis$35pmpm.Theratewasdetermined

by projecting the number o children in child welare expected to use therapeutic oster care, the

number expected to use counseling services, and the number expected to use residential treatment

and group home care. Case rates (i.e., population-based nancing strategies) are not used in the

behavioral health system.




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HI HawaiiUsing Case RatesMedicaidpaysacaserateof$542perchildpermonthifthechildmeetsthedenitionandis

enrolled in mental health services. There are interagency provisions or reconciliation to the ederalshare o cost at the end o each scal year (because this rate is acknowledged up-ront as too low).

Determination o eligibility is made by the Child and Adolescent Mental Health Division (CAMHD)

MedicalDirector,basedonguidelinesinthememorandumofunderstanding(MOU)betweenCAMHD

andthestateMedicaidagency.Eligibilityisbasedoncriteria,includinganAxis1DiagnosisandaCAFAS score o 80, though there is some exibility allowing youth to become eligible provisionally

with a CAFAS score as low as 50. Each child is reviewed by a psychiatrist at the Family Guidance Center

and the CAMHD Medical Director reviews and approves each case. This process was developed in

response to a concern o the Medicaid agency regarding the potential or over-identiying children

as having serious emotional disorders and qualiying or this case rate. Concern about the case rate

possibly being too low has been expressed, although it is a Medicaid-only nanced case rate and

does not include the multiple unding sources that nance children’s behavioral health services in

the state. The state has attempted analyses on service utilization and costs; however, the populationsize is small and it was, thereore, difcult to obtain deensible utilization and cost data only on the

Medicaid-eligible population o children with serious disorders. The state plans to attempt new

analyses.

NE Central NebraskaUsing Case Rates and a Risk Pool Central Nebraskautilizesacaserateof$2,136.53perchildpermonthforthechildreninstate

custodywhoareservedbytheIntegratedCareCoordinationUnit(ICCU).Thisratedoesnotinclude

treatment costs paid or by Medicaid; it includes placement costs and support services that arenotcoveredbyMedicaid.CentralNebraskaalsousesacaserateof$698.75perchildpermonthforchildrenintheProfessionalPartnerProgram(PPP).Themajorityofplacementcostsarenotincluded

inthePPPcaserate,however,thisisanearlyinterventionstrategytargetedtochildrenwhohavenotyet had considerable “deep-end” service involvement. State administrators have the responsibility to

determine whether the case rates are sufcient and to make adjustments i they are not; the case rate

has remained at the same level or the past ve years.

Region3BehavioralHealthServices(BHS)hasappliedothermanagedcareprinciplesto

operatingitssystemofcare.TheyhaveanoperatingreserveandariskpoolforICCU.Theriskpoolis10%oftheannualcaseraterevenue.Thepoolwasestablishedforchildrenwhoseexpensesare

higherthantherevenuefromthecaserate.However,Region3BHSmustuseitscurrentrevenuetoreplace any unds it spends rom the risk pool, so the Region does not tend to tap into the risk pool.

The operating reserve is one month’s case rate (e.g., 220 youth x amount o case rate). It is intendedto cover the cost o wrapping up the program in the event the State would decide not to continue

itspartnershipwithRegion3BHS,oriffundswerenotavailabletocontinuetheICCU.Region3BHSalso reinvests costs savings, as stipulated in the cooperative agreement. Thus, when the risk pool is

ully unded, and they achieve a cost savings, these savings are reinvested in either programs and

services or earlier intervention (to prevent youth rom becoming state wards) or is used to expand

the program to serve more children who are already in custody.




Choices ChoicesUsing Tiered Case RatesChoices uses a case rate approach in Marion County, Indiana and Hamilton County, Ohio. A tiered

case rate structure accounts or dierences in anticipated level o service need. In 2007, Indiana adopted a our-tiered case rate system, with matching eligibility that embeds the Child and

Adolescent Needs and Strengths (CANS) instrument into the eligibility and reerral process. At the

highestlevel,thecaserateisapproximately$6,500perchildpermonth.Youthinthisgrouparelikelytorequireresidentialtreatmentfacilities.Acertainnumberofyouth(140)mustbeinthishighestlevel

o care in order to oer the rate, based on the assumption that some youth will require expensive

out-o-home care, while others will be served with less costly alternatives. Without the variance in

cost created by the volume o youth served, the cost o this highest tier would increase. The second-

leveltiercaserateisapproximately$4,290perchildpermonth,consideredtobeforyouthinout-

of-homeplacementoratriskofplacement.Thethirdtiercaserateof$2,780isintendedtosupportcommunity-based care, without residential treatment, therapeutic oster care or hospitalization. The

lowesttiercaserateisapproximately$1,565perchildpermonth,intendedforyouthwithlessintense

service needs and lower levels o risk and which is intended to cover care coordination and home-based supports through exible unds.

The addition o tiers adds complexity to the case rate approach in terms o determining which

tier is the most appropriate or a child reerred or services. The temptation among reerring agencies

is to believe that a child ts within the lower rate categories. However, to achieve the volume

needed within each tier to provide sufcient resources or services across all three tiers (similar to

insurance premiums), Choices must “manage” the tiered rate structure careully. A matrix with criteria

or determining the appropriate case rate tier or children was developed. The nancial viability o

the tiered case rate structure is dependent upon “volume purchasing.” With enough youth served,

the case rate dollars will be sufcient to account or the percentage o youth who will need costly

residential care.

The tiered case rates establish a xed and predictable cost or payers and allow greater exibility

in using unds or individualized services. The case rate is given to a scal intermediary (Choices)to cover the costs o treating all children in care, regardless o actual utilization. Thus, the scal

intermediary holds the risk and is incentivized to manage care in a way that keeps the average cost

o treating the population in services at or below the aggregate o the case rates. The child and amily

team approach is seen as the key ingredient to achieving cost containment balanced with eective

results. Monthly eedback on the service package allows an opportunity or immediate adjustment to

services, discarding ineective directions and implementing new, more eective approaches.




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Wraparound Milwaukee Wraparound MilwaukeeUsing Risk Adjusted Capitation Rates and Case RatesWraparound Milwaukee is a specialty service delivery system or youth with serious emotional

disorders. As such, it receives a risk-adjusted capitation rate or youth with serious emotionaldisordersfromthestateMedicaidagencyforthepopulationitserves($1,589perchildpermonth),

higher than the rate paid to other entities serving the Medicaid population in general. It also receives

caseratesfromchildwelfareandjuvenilejustice(averageof$3,900perchildpermonth).The

capitation rate was developed by an actuary who looked at utilization and expenditures or 200 “high

utilizing” children in each o two years or mental health care paid or by Medicaid and then gave

Wraparound Milwaukee 95% o that or the capitation. The child welare case rate was determined

by looking at what child welare was spending on residential treatment; that amount was reduced

by 40% to comprise the case rate, on the basis o more children remaining at home and/or staying

in residential treatment centers (RTCs) or shorter periods o time and the costs o the home and

community-based care that Milwaukee would provide.

Wraparound Milwaukee maintains auditable trails or its dierent unding streams. It reports that

the state Medicaid audit has shited over time rom a traditional audit ocused on episodes o careand case record reviews to one that is process and outcomes-oriented, looking at whether youth

have child and amily teams and integrated plans o care, what outcomes youth are experiencing, the

adequacy o the provider network, and the like.

There is not a risk sharing pool connected to Wraparound Milwaukee, but the program can roll

dollars over into the next scal year, and it can deer billing because billing can be done up to a year

ater the service is provided.




E. Increase Flexibility of State and/or LocalFunding Streams and Budget Structures

Strategies include:• incorporatingexibilityatstateandlocallevelsintheuseoffundingstreamstonanceservices and supports

▶ Incorporate Flexibility at State and Local Levelsin Use o Funding Streams to Finance Servicesand Supports

Flexible use o resources is an important element in nancing systems o care and services. In

Hawaii , local lead agencies (Family Guidance Centers) have signicant exibility in the use o

resources and the child and amily teams determine how resources will be used or each individual

child and amily. Similarly, Vermont incorporates local exibility in the use o resources or local

lead agencies and child and amily teams. Arizona, Central Nebraska, Choices, and Wraparound

Milwaukee use managed care approaches and managed care nancing mechanisms (capitation

and case rates) which allow or the exible use o resources to meet individual needs.

HI HawaiiIncorporating Local Flexibility At the state level, Hawaii is able to move unds across budget categories in mental health (e.g., rom

out o home to community-based services), move unds across scal years in Medicaid and Title

IV-E, move some unds across systems with memoranda o understanding, and utilize savings in

one budget category to und increases in another within mental health (e.g., residential to intensive

community-based services, as long as the bottom line is not aected).

At the local level, communities (primarily Family Guidance Centers as the primary provider

agencies) have signicant exibility in the use o resources. Child and amily teams decide how

resources are spent on an individual case basis, with signicant exibility in how resources within the

mental health budget are used. The only restriction is the requirement to answer a series o questions

prior to sending a child to the mainland or treatment.




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VT VermontIncorporating Local Flexibility Vermont’s system incorporates exibility at state and local levels in the use o unding streams to

nance services and supports. The individual treatment team in the local lead agency assesses needs,determines the service plan and identies the resources that t based on und requirements. While

specic unding sources maintain their budget identity (have appropriate identiying codes used

or reporting and monitoring purposes at local and state levels), local agencies have the authority

to decide and utilize budget resources to deliver the individual plan. Medicaid is the principal

unding source with wide application, and most services are covered under that stream. For those

services that cannot be covered using Medicaid, local agency sta considers an array o options that

include other ederal and state unding sources. Depending on governing statutes and agreements,

unds may be moved and used across child-serving systems (e.g., the Department or Children and

Families unds mental health or early intervention and crisis prevention services); savings realized in

one category support other services, as is the case with the Home and Community-Based Services

Medicaid waiver; and the use o state dollars as exible unding.

AZ Arizona, NE Central Nebraska, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Incorporating Flexibility throughManaged Care Approaches and FinancingFlexibility due to managed care approaches with capitation and case rate nancing:

• Arizona stakeholders maintain that they have exibility because o the managed care structure,

which eliminates rigid budget categories across Medicaid, mental health and substance abuseblock grant and state general revenue unds and gives Regional Behavioral Health Authorities

exibility.

• InCentral Nebraska, the case rate structure provides exibility at the system level in how unds

are expended and at the practice level to allow the exible use o unds to meet individualized

needs o children and amilies and to und services/supports that are not reimbursable with more

traditional unding streams.

• InChoices, the case rate nancing approach allows considerable exibility in the use o unds

rom multiple unding streams.

• Wraparound Milwaukee’s blended unding, supported by capitation and case rate approaches,

allows or considerable exibility in use o multiple unding streams.




HI HawaiiImplementing Memoranda o UnderstandingMemorandaofUnderstanding(MOUs)helpwithcoordinationoffundingacrosssystems.Forexample, the child welare and mental health systems have agreements in place regarding Title IV-E

unds, including an agreement that allows a child in therapeutic oster care to remain in the same

placement to avoid a disruption and maintain treatment gains, even ater their needed level o care

maynotbeasintensive.AnMOUwiththestateMedicaidAgency(Med-Quest)givesresponsibilityand resources to the Child and Adolescent Mental Health Division (CAMHD) or providing intensive

mental health services to eligible children and adolescents through the Support or EmotionalandBehavioralDevelopment(SEBD)program.AnMOUwiththeDepartmentofEducationclaries

responsibilities or service delivery and nancing between the children’s mental health and the

educationsystems.AnMOUwiththeJudicialCircuitCourt(FamilyCourt)providesresourcesfor

CAMHD to provide proessional sta and mental health services at juvenile justice acilities (including

consultation to acility, court sta and ofcers) through CAMHD’s Family Court Liaison Branch.

The success o coordinating services and unding on an individual child level depends in large

part on how well the child and amily team unctions. The most difcult decisions regarding services

and nancial responsibility can be “bumped up” to higher levels in the agencies; these decisions

typically are related to responsibility or payment or residential placements where there may still be

lack o clarity regarding responsibility or providing and paying or specic services.

Cross-agency training is provided to the education and child welare systems regarding the SEBD

program, system responsibilities, and coordinating services and resources. There are interagency

MOUsandsomefundingforcross-agencytraining(TitleIV-Eresources).

F. Coordinate Cross-System Funding

Strategies include:• Coordinatingfundingacrosschild-servingsystemsatthesystemlevel

• Coordinatingtheprocurementofservicesandsupportsacrossagencies

▶ Coordinate Funding Across Child-Serving Systemsat the System Level

The sites use various mechanisms to coordinate unding across child-serving systems. InHawaii ,

memoranda o understanding have been negotiated between the mental health system and

the Medicaid agency, as well as with the child welare, education, and juvenile justice systems.

Vermont enacted legislation mandating interagency coordination and establishing local and state

interagency teams that address the coordination o resources and services.




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CAMHD also has a Resources Development Section that is responsible or developing, managing,

and coordinating ederal revenues such as Title XIX and Title IV-E. This section collaborates with other

state agencies to maximize ederal revenues and to generate reimbursement and savings or CAMHD.

Localcoordinatingbodies(CommunityChildren’sCouncils[CCCs])werecreatedaspart

o the Felix Consent Decree to give communities a voice in the children’s mental health system. They are comprised o amilies, providers, and others who serve on a volunteer basis to assess local

needs,coordinateactivities,andprovideinputonstate-levelpolicies.Thereare17CCCsacrossthe

state. A state-level coordinating body is housed in a separate ofce o the Department o Education.

Quarterly statewide meetings o CCCs are held. The CCCs’ current role ocuses on accountability/

quality assurance and advocacy.

VT VermontEnacting Legislation Mandating Interagency Coordination

The system o care has as a undamental goal, structure and unctions to coordinate services and

nancing to meet the needs o the child and amily. Many vehicles support that eort: Act 264,

with mandated Local Interagency Teams (LIT) and a State Interagency Team (SIT) and a statutory,

appointed state board that advises agency commissioners; interagency expenditure plans;

interagencymemorandaofunderstanding(thesehaveexpandedsincetheSystemofCarePlan

began); a joint vision statement by the umbrella agency o human services and the Department o

Education; cross-agency training and continuing education.

The LIT assists treatment teams to reach consensus on or nd ways to implement a child’s

coordinated service plan when they need extra support. It may review a plan and make

recommendations on the content o the treatment plan; suggest possible additional resources or

support to implement the plan; recommend that an agency waive or modiy a policy; or, i necessary,

reer the situation to the SIT or urther consideration. Each LIT has a coordinator based at the local

mental health center. I the LIT cannot resolve a problem or assist adequately, the SIT is a state levelorum or the next round o consideration. Its role and objectives are to:

• AssistLITstoimplementcoordinatedserviceplans.Theymayreviewaplanandmake

recommendations on content; suggest possible additional resources to help implement the plan;

and/or recommend that an agency waive or modiy a policy

• Ensurethecoordinateddevelopmentofthesystemofcareintheareasofservice,policy,and

scal management; and ensure that inormation on best practices is disseminated to agency sta

and to the general community.

These teams have authority to review and make recommendations but cannot order any agency

to provide services. The Vermont law provides appeal rights and a process or parties to ollow.

A second appeal process exists or children receiving services under IDEA.




HI HawaiiDeveloping Uniorm Contracting Protocols

There are some uniorm contracting protocols comprised o perormance standards and practice

guidelines that are shared between the education system and the children’s mental health system.

In addition, the Department o Health (DOH) and Department o Education (DOE) jointly developed

a manual detailing interagency perormance standards and practice guidelines or use by DOH and

DOE personnel and contracted providers when developing and implementing individualized service

plans or youth and their amilies. These standards and guidelines are designed to dene services

and improve the eectiveness o both school-based mental health services and the intensive mental

health services provided through CAMHD’s system o care.

VT VermontUsing Uniorm Contracting and Procurement ProtocolsVermont’s system o care utilizes purchasing collaboratives, joint procurement practices, uniorm

contracting protocols, and a uniorm rate structure to coordinate procurement o services and

supports. Vermont’s local Designated Agencies (DAs) or the provision o community mental health

services operate as a preerred provider network in the state and work together in a consortium

through the Vermont Council or Developmental and Mental Health Services and with the

Department o Mental Health to address service and business issues. They share the same basic

contract and operate as a ull group or in sub-groups. They use the same protocols to make purchases

or operations (relevant services, inormation technology, and material items). Various DA leadership

groups (CEOs, CFOs/business directors) meet regularly to discuss issues under their purview. They

have, or example, discussed bond issues or capital improvements and service expansions, as well asnegotiated a master contract with all Agency o Human Services’ departments.

▶ Coordinate the Procurement o Services andSupports Across Agencies

Strategies or coordinating the procurement o services across agencies were ound in Hawaii and

Vermont . Hawaii developed some uniorm contracting protocols that include both perormance

standards and practice guidelines that are shared between the education and mental healthsystems. In Vermont, local lead agencies unction as a network and may use uniorm contracting

and procurement protocols or operations and or services, working through the Vermont Council

or Developmental and Mental Health Services or through individual agency partnerships on

specic issues. Wraparound Milwaukee has centralized the procurement o residential treatment

services.




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Wraparound Milwaukee Wraparound MilwaukeeUsing Centralized Procurement or Residential Treatment Wraparound Milwaukee, in eect, has eliminated the practice o individual child-serving systems

purchasingresidentialtreatmentontheirown.Procurementofservicesforthepopulationsneedingthis level o care is done through Wraparound Milwaukee.

G. Incorporate Mechanisms to Finance Services orUninsured and Underinsured Children and theirFamilies

Strategies include:• Financingservicesforuninsuredandunderinsuredchildrenandtheirfamilies

• Incorporatingstrategiestoaccessserviceswithoutcustodyrelinquishment

• Encouragingprivateinsurerstocoverabroaderarrayofservicesandsupports

▶ Finance Services or Uninsured/UnderinsuredChildren and their Families

Hawaii, New Jersey, Arizona, and Central Nebraska have implemented strategies to nance

services or uninsured and underinsured children and their amilies.

HI HawaiiUsing General Revenue to Finance Services or Uninsured/ Underinsured and Allowing Families to Buy Into Medicaid Recently, Hawaii added a mechanism to und behavioral health services through general revenue

unds in the category o “mental health only.” This category was created to serve youth not eligible or

services through other mechanisms, but who are determined to be in need o mental health services

by the Child and Adolescent Mental Health Division (CAMHD) Medical Director. To be eligible or this

category, a child cannot be eligible or any other program — not educationally disabled and in need

ofservicesthroughanindividualeducationplan(IEP),notMedicaideligibleoreligiblefortheSupport

or Emotional and Behavioral Development (SEBD) plan through Medicaid, and not incarcerated. Thepopulation includes youth ound eligible by their schools or Section 504 o the Rehabilitation Act,

uninsured youth, youth who may have lost Medicaid eligibility due to incarceration or urlough, and

youth with private insurance but with uncovered service needs. CAMHD serves these youth with

general unds that are legislatively appropriated. I ound eligible, a child can then access services

that are paid by general revenue unds. The CAMHD Medical Director makes service decisions and




can authorize necessary services or children with serious emotional disorders. The entire range o

services can be authorized with no predetermined limits, though the overall availability o unds

is limited. I the child has private insurance, attempts are made to bill insurers or covered services;

however, the state’s insurance parity law does not apply to childhood diagnoses so that many

children’s mental health services are not covered by private insurance plans.In addition, the state Medicaid program allows amilies above the eligibility level to buy into the

Medicaid program.

NJ New JerseyEstablishing Eligibility as a “Children’s System o Care Child”

The children’s system o care initiative allows or presumptive eligibility or children needing

behavioral health care i they are Medicaid eligible or eligible or New Jersey’sS-CHIPprogram(New

Jersey Family Care). In addition, children are eligible as a “children’s system o care child,” a childwho has a serious emotional disorder and is involved or at risk or involvement in multiple systems.

Regardless o whether the child is eligible or the system o care through a Medicaid or non-Medicaid

eligible route, and regardless o the other systems in which the child may be involved (e.g., child

welare or juvenile justice), he/she is assigned a “system o care” identier number that is tracked

through the state Medicaid agency’s management inormation system.

In addition, the state allows or designation o a child with a serious disorder as a “amily o one” to

qualiy or Medicaid-reimbursed residential treatment services.

AZ

Arizona andNE

Central NebraskaUsing Sliding Fee Scales and State Funds• In Arizona, Regional Behavioral Health Authorities (RBHAs) are required to screen amilies or

implementing sliding ee scales, and they receive state general revenue and mental health/

substance abuse block grant unds which they can use to serve children not eligible or Medicaid

orS-CHIP.Thesedollarsmakeupabout8-10%ofthetotalfundingforthesystem.Arizonaalso

uses the “amily o one” option, which, according to Arizona Department o Health Services,

Division o Behavioral Health Services (ADHS/BHS), can give a child 5-6 months o Medicaid

eligibility even i he/she is not in an out-o-home setting that entire time.

• InCentral Nebraska,theProfessionalPartnerProgramincludesexfundsthatcanbeusedtopay or treatment when a amily does not have access to a third party payer (Medicaid, private

insuranceorKidConnection—Nebraska’sS-CHIP).Whencarecoordinatorsrequestexiblefunds,

they must show how using the unds will lead to specic outcomes. Families are not charged toparticipateintheProfessionalPartnersProgramorIntegratedCareCoordinationprogram.Region3BehavioralHealthServices(BHS)oersaslidingfeelscaletoassistfamiliesinpayingforspecic

treatment services.




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▶ Incorporate Strategies to Access Services withoutCustody Relinquishment

Vermont has enacted legislation that prohibits custody relinquishment or the purpose o obtaining

needed mental health care. In Central Nebraska, a wraparound approach to services is used

to work with youth and amilies to avoid placing youth in state custody; voluntary placementagreements are used when necessary.

VT VermontEnacting State Statutes to Prohibit Custody Relinquishment or ServicesVermont statute[Title33HumanServices§4305(g)]prohibitsrequiringcustodyrelinquishmentin

order or parents to obtain mental health care or their children. In addition, years ago, state level data

analysis revealed that a signicant percentage o children in parental custody would experience a

“crisis,” and then be admitted to state custody on an Emergency Detention Order (EDO) as a child in

needofsupervision(CHINS).Thesechildrenthenwouldemergefromstatecustodywithin30daysonce the “crisis” was understood and a plan o supports and services was developed and begun. To

prevent amilies rom having to relinquish custody in these situations, the state initiated a major

eort, supported by a ederal grant, to re-think “crisis” response services. Signicant reductions in

EMOs or CHINS have occurred and been sustained over the last decade.

NE Central NebraskaImplementing Wraparound Approach to Prevent Custody Relinquishment ThemissionoftheEarlyIntensiveCareCoordinationProgram(EICC)istousethewraparoundapproach and amily-centered practice to coordinate services and supports or amilies whose

children are at risk o being placed in state custody and to ensure that amilies have a voice,

ownership and access to a comprehensive, individualized amily support plan. O the 67 children

servedinEICCduringscalyear2005,88.1%werepreventedfrombeingplacedinthestate’scustody.FamiliesinRegion3rarelytransfercustodyoftheirchildrentoaccessservices.Whenchildrendo

need to be placed to access treatment services, a voluntary placement agreement will be pursued,

ratherthaninvolvingthecourt.TheOceofProtectionandSafetyandRegion3BehavioralHealth

Services (BHS) work together to determine how to avoid inappropriate custody relinquishment. Some

respondents indicate that additional care coordination services are needed statewide. Nebraska’s

Child and Adolescent State Inrastructure Grant has ormed a subcommittee to gather more data on

the custody relinquishment issue and reintroduce legislation that did not pass previously. (Note: Sincethe site visit, Central NebraskahasbeenunabletocontinueitsEICCProgramduetostatepolicychanges limiting the use o unds to children who are currently in state custody. In place o EICC, a

newSchool-BasedInterventionProgramforchildrenandyouthincustodyisbeingimplemented.)




▶ Encourage Private Insurers to Covera Broader Array o Services and Supports

Hawaii attempts to bill private insurers or covered services and, in addition, has had preliminary

talks with Blue Cross about allowing their insured access to the Child and Adolescent Mental Health

Division (CAMHD) service array. Vermont enacted a parity law requiring health plans to covermental health and substance abuse services to the same extent as other health services.

HI HawaiiBilling Private InsurersUnderthe“mentalhealthonly”category,ifthechildhasprivateinsurance,attemptsaremadetobill

insurers or covered services; however, the state’s insurance parity law does not apply to childhood

diagnoses so that many children’s mental health services are not covered by private insurance plans.

Blue Cross has approached the state to allow some o their covered lives to access the Child

and Adolescent Mental Health Division (CAMHD) service array. The state is attempting to determine

how to bill the insurance company or services and to build the capacity to do so. Concern has beenexpressed that the state’s children’s mental health system could become a provider or amilies with

insurance, and would, thereore, have diminished capacity to serve uninsured children and amilies.

This has led to a discussion on the mission and role o the public mental health system. This is still

being worked on at present.

VT VermontEnacting Parity LegislationVermont’smentalhealthparitylaw,whichwentintoeectinJanuary1998,requireshealthinsurance

plans to cover mental health and substance abuse services at no greater cost to the consumer than

insurance or other health services. The law eliminates separate and unequal deductibles and out-

o-pocket costs or mental health and substance abuse services. The law applies to all health plans

oered by Vermont insurance companies, including health maintenance organizations (HMOs), but

it does not apply to sel-insured plans. It requires a single deductible and the same out-o-pocket

co-payments or co-insurance or mental health and substance abuse services and all other covered

health services. It also removes separate yearly and lietime visit limits and dollar maximums. State

leaders acknowledge that the law has been signicant in helping to change some practice and to

continue calling attention to disparities. They point out that there are still a lot o loopholes or private

insurers that are not based in Vermont.

In 2006 Vermont passed a law that establishes a new state-unded insurance program or the

uninsured, called Catamount Health, which requires employers to pay assessments i they do not

oer health care coverage to their workers. (This program will provide individual adult and amilycoverage or those not eligible or Medicaid and its extended programs; children and adolescents

arealreadycoveredundertheVermontMedicaid“Dr.Dynasaur”programupto300%ofthefederal

poverty level.)


http://slidepdf.com/reader/full/study03-exp-fr-field 84/194 I I I . F i n a n c i n g o

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III. Financing of Appropriate Servicesand Supports

By denition, systems o care include a comprehensive array o services and supportsto meet the multiple and changing needs o children and adolescents with emotional

disorders and their amilies. Financing to cover this broad array o both clinical and

supportive services is a undamental requirement. The system o care philosophy and

approach also emphasizes an individualized approach to service delivery, such that the

needs, strengths, and preerences o the youth and amily dictate the types, mix, and

duration o services and supports. Thus, in addition to nancing that covers a broad

service array, nancing mechanisms must support and promote individualized, exible

service delivery. Financing strategies also are needed to support the incorporation o

evidence-based and promising practices to improve the eectiveness o services, mental

health services to young children and their amilies, early identication and intervention,

and the coordination o services across child-serving agencies and systems.


A. Provide a Broad Array o Services and Supports

B. Promote Individualized, Flexible Service Delivery

C. Support and Provide Incentives or Evidence-Basedand Promising Practices

D. Promote and Support Early Childhood Mental Health Services

E. Promote and Support Early Identifcation and Intervention

F. Support Cross-Agency Service Coordination




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A. Provide a Broad Array o Services and Supports

Strategies include:• CoveringabroadarrayofservicesandsupportsthroughMedicaidandotherfunding

streams

▶ Cover a Broad Array o Services and Supportsthrough Medicaid and Other Funding Streams

The study examined coverage o the array o services and supports shown below onTable 3. All o

the sites studied cover virtually all o these services and supports and, oten, additional services and

supports, such as supported employment, peer support, traditional healing, exible unds, respite

homes, respite therapeutic oster care, supported independent living services, intensive outpatient

services, treatment/service planning, parent skills training, ancillary support services, amily and

individual education, consultation, peer support, emergency/hospital diversion beds, ater school

and summer programs, substance abuse prevention, youth development, and mentor services. TheseservicesandsupportstypicallyarecoveredusingMedicaidandavarietyofadditionalnancing streams rom mental health and other child-serving systems.

.

Table 3

Array o Services and Supports Examined

Nonresidential Services Residential Services Supportive Services

• Assessmentanddiagnostic

evaluation

• Outpatienttherapy–

individual, amily, group

• Medicationmanagement

• Home-basedservices

• School-basedservices

• Daytreatment/partial

hospitalization

• Crisisservices

• Mobilecrisisresponse

• Behavioralaideservices

• Behaviormanagement

skills training

• Therapeuticnursery/preschool


• Therapeuticgrouphomes

• Residentialtreatment

center services

• Inpatienthospitalservices

• Caremanagement

• Respiteservices

• Wraparoundprocess

• Familysupport/education

• Transportation• Mentalhealthconsultation




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AZ ArizonaCovering a Broad Array o Services and SupportsIn Arizona,servicesarenancedprimarilybyMedicaiddollarsthroughthebehavioralhealth

managed care system. The managed care system covers a very broad array o services and supports.ArizonahasusedtheJKlawsuittoexpandthearrayofcoveredservicesunderMedicaidand

redirection o spending rom out-o-home to home and community based services to expand

availability o these covered services. The managed care system also includes state general revenue

andblockgrantdollars,inadditiontoMedicaidandS-CHIP,whichcanbeusedtopayforservicesthatarenotcoveredwithintheMedicaidbenet.Forexample,non-Medicaiddollarscanbeusedtopay

or traditional Native healers. The array o covered services includes:

• Behavioralcounselingandtherapy

• Assessment,evaluationandscreening

• Skillstraininganddevelopmentandpsychosocialrehabilitationskillstraining

• Cognitiverehabilitation

• Behavioralhealthprevention/promotioneducationandmedicationtrainingandsupportservices• Psychoeducationalservicesandongoingsupporttomaintainemployment(supported

employment)

• Medicationservices

• Laboratory,radiologyandmedicalimaging

• Medicalmanagement

• Casemanagement

• Personalcareservices

• Homecaretrainingfamily(Familysupport)

• Self-Help/Peerservices(Peersupport)


• Unskilledrespitecare

• Supportedhousing

• Signlanguageororalinterpretiveservices

• Nonmedicallynecessaryservices(exfundservices)

• Transportation

• Mobilecrisisintervention

• Crisisstabilization

• Telephonecrisisintervention

• Hospital

• Subacutefacility

• Residentialtreatmentcenter• Behavioralhealthshort-termresidential,withoutroomandboard

• Behavioralhealthlongtermresidential(nonmedical,nonacute),withoutroomandboard

• Supervisedbehavioralhealthdaytreatmentanddayprograms




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• Therapeuticbehavioralhealthservicesanddayprograms

• Communitypsychiatricsupportivetreatmentandmedicaldayprograms

• Preventionservices

• MST,FFT,ACTteams

• Traditionalhealing(nonMedicaidfunds)

• Flexfundsfordiscretionaryservices(thesearesmall—about$850,000statewide)

ArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)is

tryingtogettelephoneconsultationcoveredunderMedicaidandjustcompletedawhitepaperontheissueforMedicaid(e-mailconsultationiscovered).

ForacompletedescriptionofArizona’scoveredservices,seethestate’sCoveredBehavioralHealth

Services Guide, available at: http://www.azdhs.gov/bhs/bhs_gde.pd . Appendix B2 to the guide

describes provider types and ee or service rate guidance, available at: http://www.azdhs.gov/bhs/

app_b2.pd .

HI HawaiiCovering a Broad Array o Services and SupportsAllservicesinthechartarecoveredunderMedicaid,withmatchfrommentalhealthgeneralfunds.Mentalhealthservicesatlowerlevelsofintensityareprovidedthroughtheeducationsystemthrough

school-basedmentalhealthservicedeliveryapproaches(School-BasedBehavioralHealthServicesandSupports[SBBH]).Iftheneedformoreintensiveservicesisidentied,theyouthisreferredtothe

FamilyGuidanceCenterinhis/herarea.TheseyouthareenrolledintheEducationallySupportive(ES)IntensiveMentalHealthProgram(theygenerallyareIDEA-eligibleandhaveanindividualeducation

plan(IEP)witharecommendationformentalhealthservicesfromtheChildandAdolescentMental

HealthDivision[CAMHD]).Medicaid-eligibleyouthmayalsoreceivebasicmentalhealthservicesfromtheirQuesthealthplan.Iftheyrequirementalhealthservicesthatexceedthescopeandintensitythat

can be provided by their health plan, they are enrolled in the Support or Emotional and Behavioral

Development(SEBD)program(criteriaincludeMedicaideligibility,aDSMIVdiagnosisofatleastsix

months,andaCAFASorPECAFSscoreof80orgreater,witheligibilitydeterminedbytheCAMHDMedicalDirector).

CAMHD’swebsitedescribesitsservicearrayasincluding:EmergencyCrisisIntervention

Services—24-hourcrisistelephonestabilization,mobilecrisisoutreach,residentialcrisisstabilization;IntensiveCareCoordination,whichisprovidedbyCAMHDmentalhealthcarecoordinators(MHCCs)

locatedinFamilyGuidanceCenters(intensiveclinicalcasemanagement);IntensiveTreatmentServices,whichareintensivehomeandcommunity-basedinterventions,MultisystemicTherapy




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(MST);andCommunity-BasedTreatmentServicesincludingtherapeuticfosterhomes,therapeuticgroup homes, community-based residential programs, and hospital-based residential programs.

CAMHD’sservicearrayisdescribedinitsRFPtoproviders(Nov.2005)anddenedfurtherinitsInteragencyPerformanceStandardsandPracticeGuidelines:

Emergency Public Mental Health Services – Crisis telephone stabilization

– Crisis mobile outreach

– Crisis therapeutic foster home

– Community-based crisis group home

Educationally Supportive Intensive Mental Health Services – Psychosocial assessments

– Intensive in-home intervention

– MST

– Respite therapeutic foster home

– Respite homes

– Community mental health shelter (24 hour temporary care for youth awaiting placement

in an appropriate treatment facility) – Therapeutic foster homes

– Multidimensional treatment foster care

– Therapeutic group homes

– Independent living programs (16–18 and 18–21)

– Community-based residential (Levels I, II, and III)

– Hospital-based residential (inpatient treatment)

Support or Emotional and Behavioral Development (SEBD) Program Services – Comprehensive mental health assessment

– Focused mental health assessments

– Summary annual assessments

– Psychiatric evaluation

– Medication management

– Individual therapy

– Group therapy

– Family therapy

– Partial hospitalization

– Functional family therapy

– Peer support

– Parent skills training

– Intensive outpatient treatment for co-occurring substance abuse

– Intensive outpatient services for independent living skills

– Community-basedclinicaldetoxifcation

– Community hospital crisis stabilization

– Acute psychiatric hospitalization




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Care Coordination (not sought through RFP, provided by CAMHD personnel) – Mental heath care coordination

– Treatment/service planning participation/IEP participation

– School consultation

– Case consultation

– Family court testimony

Support Services (not sought through RFP, provided by CAMHD personnel) – Ancillary support services

– Respite supports

NJ New JerseyCovering a Broad Array o Services and Supports ThestatehasexpandedtheservicescoveredbyMedicaiddollarsaswellasthosecoveredbynon-

Medicaiddollars.Thesystemdesignfeaturesaexible,broadbenetplanthatcoversawidearrayo traditional and non-traditional services. Services covered include: assessment, mobile crisis/

emergency services, group home care, treatment homes/therapeutic oster care, acute psychiatric

inpatient care, intensive ace-to-ace care management, wraparound, out-o-home crisis stabilization,

intensive in-home services, psychotropic medications, medication management, behavioral

assistance,andfamily-to-familysupport.ThestatealsoallowstheCareManagementOrganizations

(CMOs)touseexfundsinordertomeetadditionalindividualneedsthatarenotmetthroughcovered services.

VT VermontCovering a Broad Array o Services and Supports The Vermont system o care includes the ollowing services and supports, which are available

regionally:

• Immediate Response:EachDesignatedAgency(DA)providesaccesstoanimmediateresponseservice and/or short-term assistance or children and adolescents who are experiencing a crisis

andtheirfamilies.Crisisservicesaretime-limited(usuallyupto2–3days)andintensiveandinclude the ollowing:

– Assessment,support,andreferraloverthetelephone

– Crisisassessment,outreach,andstabilizationface-to-face

– Familyandindividualeducation,consultation,andtraining

– Serviceplanningandcoordination

– Screeningforcrisisbed(hospitaldiversion)andforinpatientpsychiatrichospitalization




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• Clinic-based Treatment:EachDAoersclinic-basedtreatmentservicesforchildrenandfamilies. These services are available during daytime and evening hours or school-age children and/or

when amilies can easily access them. The intensity o the service is based on the needs o the

child and amily, and the amily’s request or one or more the ollowing elements:

– Clinicalassessment– Group,individual,andfamilytherapies


– Medicationservices

• Outreach Treatment:EachDAoersoutreachtreatmentservicesforchildrenandfamilies.These

services are available in the home, school, and general community settings. The intensity o the

service is based on the needs o the child and amily and the amily’s request or one or more the

ollowing elements:

– Clinicalassessment

– Group,individualandfamilytherapies


– Intensivein-homeandout-of-homecommunityservicestochildandfamily

– Medicationservices


• Family Support: Support services can be very important in reducing amily stress and providing

parents and caregivers with the guidance, support, and skill to deal with a difcult-to-care-or

child.EachDAprovidesand/orhasdirectcommunityconnectionstosupportservicesforfamilies

and youth. These services are oered in partnership with parents and consumer advocates.

Participationinoneormoreofthefollowingsupportservicesisvoluntaryandbasedonthe

amily’s needs and desires:

– Skillstrainingandsocialsupport

– Peersupportandadvocacy– Respite


• Prevention, Screening, Reerral and Community Consultation: The goal is to provide

prevention or all by: promoting healthy development, increasing protective actors and

reducingriskfactors;earlyscreeningandinterventionactivitiesforthoseatrisk;and,communityconsultation activities or non-mental health proessionals, community groups, and the public.

• Inaddition,thefollowingservicesareavailablestatewide:

– Emergency/HospitalDiversionBeds

– IntensiveResidentialServices

– HospitalInpatientServices




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NE Central NebraskaCovering a Broad Array o ServicesDuringscalyear2005,Region3BehavioralHealthServices(BHS)expendedatotalof$6,313,638

or the purchase o services or children and amilies, intensive case management, youth leadership,

familyempowerment,evaluationandsystemcoordinationactivities.Region3BHScontractswitha

network o providers that oer the ollowing services and supports or children and their amilies:

• 24hourcrisisservices

• Mobilecrisisservices

• School-basedoutpatientfamilyeducation,information,supportandadvocacy

• Familycarepartners

• YouthEncouragingSupport(YES)

• Children’sdaytreatment

• Medicationmanagement

• Mentalhealthoutpatienttherapy

• Multi-Systemictherapy• Crisisinpatientservices

• Substanceabuseoutpatienttherapy

• Youthassessment(SA)

• Adolescentintensiveoutpatient

• Respite

Region 3 BHS provides directly:

• Professionalpartnerprogram

• Integratedcarecoordinationunit

• Earlyintensivecarecoordination(wraparoundmodel)

• Alcohol,tobaccoandotherdrugabuseprevention• Mentorservices

InadditiontotheserviceslistedabovethatareprovidedorpurchasedbyRegion3BHS,specic

treatmentservicesforMedicaid-eligiblechildrenandfamiliesareauthorizedbyMagellan,thestatewideMedicaidbehavioralhealthmanagedcareorganization.Theseincludetherapeuticfoster

care, therapeutic group homes, residential treatment centers, inpatient hospital services, case

management services, transportation, and mental health consultation.




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Choices ChoicesCovering a Broad Array o Services and SupportsChoices provides a broad array o services and supports, covered under the case rate structure in all

thecommunitiesserved.Inadditiontotheservicesandsupports,thereare11dierentcategoriesof

exible unds, which allows or creative service delivery and the provision o whatever services and

supports may be needed by the youth and amily.

Service Array

Behavioral Health Psychiatric Mentor Placement

• Behavior management

• Crisis intervention

• Day treatment

• Evaluation

• Family assessment

• Family preservation

• Family therapy

• Group therapy• Individual therapy

• Parenting/family skills

training

• Substance abuse therapy,

individual and group

• Special therapy

• Assessment

• Medication follow-

up,

• Psychiatric review

• Nursing services

• Community case

management/case aide

• Clinical mentor

• Educational mentor

• Life Coach/independent

• Living skills mentor

• Parent and family mentor

• Recreational/social mentor• Supported work environment

• Tutor

• Community supervision

• Intensive supervision

• Acute psychiatric

hospitalization

• Foster care — non

therapeutic

• Therapeutic foster care

• Group home care

• Relative placement

• Residential treatment• Shelter care

• Crisis residential

• Supported independent

living

Respite Service Coordination Discretionary Other

• Crisis respite (daily or

hourly)

• Planned respite (daily or

hourly)

• Residential respite

• Case management

• Service coordination

• Intensive case

management

• Activities

• Automobile repair

• Childcare/supervision

• Clothing

• Educational expenses

• Furnishings/appliances

• Housing (rent, security

deposits)

• Medical

• Monitoring equipment

• Paid roommate

• Supplies/groceries

• Utilities

• Incentive money

• Camp

• Team meeting

• Consultation with other

professionals

• Guardian ad litem

Transportation

• Interpretive services




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Wraparound Milwaukee Wraparound MilwaukeeCovering a Broad Array o Services and Supports.ServicesarefundedprimarilybyMedicaid,childwelfare,juvenilejustice,andmentalhealththrough

capitation and case rate nancing. Wraparound Milwaukeehasover200providers(agenciesandindividuals)initsnetwork,representing85dierentservicesandsupportsandincludingover40raciallyandculturallydiverseproviders.Theservicesandsupportsitcoversrangefromhighly

specialized clinical treatment services to nontraditional services and natural supports, including:

Service Array

• Care Coordination

• Individual and Family Therapy

• Substance Abuse Counseling

• Group therapy

• Crisis 1:1 Stabilization

• Mentors

• Tutors

• Intensive In-Home Therapy• Psychiatric In-Patient Treatment

• Residential Treatment

• Group Home

• Foster Care

• Therapeutic Foster Care

• Professional Foster Care

• Medical Day Treatment

• Crisis/Respite Group Home

• Specialized Sexual Oender Services

• FOCUS – Alternatives to Correctional Care

• Medication Management

• Transportation

• After school

• Job coaches

• Independent Living

• Housing

• Child care

• Household management

• Specialized educational services• Behavioral Aides

• Supervised Apartments

• Intensive In-Home Monitoring for Court

• Discretionary funds

• Parent Aides

• Interpretation

• Kinship Care

• Rent/Food Assistance

• Employment Training/Placement

• Transitional care

AK Bethel, AlaskaCovering a Broad Array o Services and SupportsInadditiontothementalhealthassessmentandtreatmentservicesthatareavailableatthevillagelevel through teams o licensed mental health proessionals and behavioral health aides, the

ollowing unique services are available in Bethel and oered to youth and amilies throughout the

YKHCregion:

• Fetal Alcohol Spectrum Disorders Diagnostic Team—Amultidisciplinaryteamcomposedof

pediatricians, pediatric nurse practitioner, behavioral health clinician, Family Advocate, Clinical

Psychologist,OccupationalTherapist,SpeechPathologistandcasemanagerprovidediagnostic

assessments or children and youth suspected o prenatal alcohol exposure.




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• Kuskokwim Emergency Youth Services—Thisisa12-bedfacilitythathousestwoemergencyshelterprograms.Oneprogram,aResidentialDiagnosticTreatmentCenter,providesevaluation

and short-term residential treatment or children experiencing a lie crisis so disruptive that it

cannotbemanagedinanoutpatientsetting.TheRDToersanalternativetohospitalizationin

Anchorage or many youth and has the ability to address youth and amily needs in a culturallyappropriate way by providing services closer to the home community, thus allowing amily

participation in treatment, and by primarily employing sta who are Alaska Native.

• Inhalant Abuse Treatment Center—Thisistheonlyresidentialtreatmentprograminthenationspecicallyaddressingtheproblemofinhalantabuse,oeringa14–16weektreatmentprogram

foruptosixyoungpeopleages10–17.Highlightsoftheprogramincludeafour-phaseprogramstarting with detoxication, then treatment. The amily is integrated into all parts o the program,

and the center works closely with the child’s home community to develop a network o support

or the child ollowing treatment.

B. Promote Individualized, Flexible Service DeliveryStrategies include:• Incorporatingexiblefundsforindividualizedservicesandsupports

• Financingstaparticipationinindividualizedserviceplanningprocessesandtheunctions o child and amily teams

• Incorporatingcareauthorizationmechanismsthatsupportindividualized,exible

service delivery

▶ Incorporate Flexible Funds or Individualized

Services and SupportsMostofthesitesincorporateexiblefundsthatcanbeusedtopayforservicesandsupportsthatarenotcoveredbyMedicaidorothersources. Arizona, Hawaii, New Jersey, and Vermont

designate unds or this purpose. Typically, child and amily teams can access these unds to provide

theseancillaryservicesandsupportsasneeded.Inothersites,suchasCentral Nebraska and

Wraparound Milwaukee, the managed care nancing approaches make the resources within the

system inherently exible and available to meet individualized needs. Choices also uses its case rate

nancing to provide exible unds.

AZ Arizona, HI Hawaii, NJ New Jersey, and VT VermontUsing Funds Designated as “Flexible Funds” • The ArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/

BHS)distributesabout$850,000indiscreteexiblefundingtotheRegionalBehavioralHealth

Authorities(RBHAs),usinggeneralrevenueandblockgrantdollars.RBHAshaveexibilityin

howtheyspendthesedollarsforindividualchildren.However,theyaresmall,amountingto




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$23perchildperyear.ValueOptionsindicatedthatindividualizedandcoordinatedplansofcareare acilitated primarily by the child and amily team approach and not by nancing or single

purchasing strategies.

• InHawaii,exiblefundsareprovidedbytheChildandAdolescentMentalHealthDivision

(CAMHD)andareavailabletochildandfamilyteamstonanceservicesandsupportsnotcoveredby other sources. Flexible unds or “ancillary” services and supports can be used or a variety o

purposes or children and their amilies as needed.

• InNew Jersey,CareManagementOrganizations(CMOs)haveallocationsofexiblefundstoassistinthedevelopmentofindividualserviceplans(ISPs)forthefamiliestheyserve.Thisisdone

inconjunctionwiththechildandfamilyteams.

• InVermont, exible unds derived rom mental health state general revenue dollars and ederal

grantfundsareusedtocoverservicesandsupportsthatarenotallowableunderMedicaid,the

principalpayerforservicesandsupports.Decisionsmadebytheindividualchildandfamilyteamandlocalleadagencydrivetheuseoffundsbasedonindividualchildandfamilyneeds.Many

children have needs across departmental lines o responsibility and are entitled to a Coordinated

ServicePlan.Thisbroadensthescopeofthechildandfamily’splantoincludebothpublicand

private services and unding resources.

NE Central Nebraska andWraparound Milwaukee Wraparound Milwaukee

Using Managed Care Approaches to Provide Flexible Funds• Central Nebraska’scaseratesystemallowscarecoordinatorsintheIntegratedCareCoordination

program(ICCU)andProfessionalPartnersProgramtohaveaccesstoexiblefundsthatcanbeused to meet individualized needs o children and amilies and to und services/supports that are

notreimbursablewithmoretraditionalfundingstreams.ProvidersnotedthatcarecoordinatorsinICCUsarewillingtoexperimentwithnewstrategiesandthatservicesarelessrestrictedand

categorical.

• Milwaukee’s use o blended unding and o managed care approaches, such as capitation and

case rates, and its broad, diverse provider network enable it to use unds in a exible manner to

implement an individualized approach to service delivery.




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Choices ChoicesCreating Categories o Flexible Funds or Discretionary Services and Supports

ThematrixlistingservicecodesthatcanbeprovidedbyDawnincludes11categoriesofexibleunds, including activities, automobile repair, childcare/supervision, clothing, educational expenses,

urnishing/appliances, housing, medical, monitoring equipment, paid roommate, supplies/groceries,

utilities and incentive money. This demonstrates the degree o exibility that child and amily teams

are given in planning services and supports that are tailored to the specic needs o each child and

family.Theexiblefundsareusedtonancesupportsincludingtransportation(bus,carrepairs,etc.),

housing,utilities,clothing,food,summercamps(includingforsiblings),homerepairs,andothers. The expenditures must be within the care plan structure, and the plan must document how such

expenditures will support the service plan goals or the child and amily.

▶ Finance Staf and Provider Participation inIndividualized Service Planning Processes and theFunctions o Child and Family Teams

Inadditiontoexiblefunds,individualizedcarerequirestheconveningofachildandfamily

team that, in partnership with the youth and amily, develops and implements an individualized

service plan. Strategies to nance the participation o sta and providers in the individualized

serviceplanningprocessandonchildandfamilyteamshavebeenimplementedbythesites.In

severalsites( Arizona, Vermont, and Choices), sta can bill or time spent in child and amily team

processesascasemanagement.Inaddition,contractproviderscanbillthelocalleadagencyin

VermontorChoicesfortheirtime.Hawaii has a billing code or “treatment planning.” Central

Nebraska and Wraparound Milwaukee use their blended resources to cover sta and provider

participation.

AZ ArizonaCovering Provider Participation as Billable Case Management Child and amily teams are mandated in and covered by the managed care system. The state has

givendirectiontoprovidersastohowtobillforchildandfamilyteams(CFTs).Essentially,theCFTprocess is billed as case management. Elements o the process also can be billed as assessment,

transportation, amily or peer support, and interpretation services. The costs o transportation or

familiestoparticipatearebuiltintotheratespaidtoproviders,unlessthedistanceexceeds25miles

inwhichcaseproviderscanbillseparately.ThestateMedicaidagencyhasbeencautiousaboutusinga case rate or bundled rate or CFTs. Child and amily teams are required to be held at detention or

youth in detention.




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ChildwelfareusesTeamDecisionMaking(TDM)whenthesystemisconsideringremovalortemporaryremovalandhastobeimplementedwithin48hours.Itfocusesprimarilyonsafetyissues,

and then a child and amily may move to a CFT process in the behavioral health managed care

system. Behavioral health providers expressed concern that, while they can bill or participation in

CFTs,theycannotbillforparticipationinTDM.

HI HawaiiUsing Billable Code or Treatment PlanningChildandfamilyteamsareorganizedaspartoftheCoordinatedServicePlan(CSP)process.TheCSPis an over arching, strengths-based plan that coordinates all services and supports or an individual

childandfamily.Mentalhealthcarecoordinators(MHCCs)playapivotalroleinservicedeliverybyconveninganinitialCSPmeetingandcoordinatingthedevelopmentoftheserviceplan.Allservices

includedintheCSParethenauthorized.MHCCsarestateemployeeswhoareattachedtotheFamily

GuidanceCentersthatarepartoftheChildandAdolescentMentalHealthDivision(CAMHD).Theirleadroleinindividualizedserviceplanningisanintegralpartoftheirresponsibilities.Manyotheragency sta who participate in teams are also state employees and participation is considered to be

partoftheirrole.Forcontractproviders(suchasoutpatienttherapists),participationinindividualized

service planning process is billable time under a service code or “treatment planning.” For some

providers(suchasintensivein-homeserviceproviders),participationinthewraparoundplanning

process is considered part o their unit cost. Some provider agencies suggested that this creates

pressure, particularly i the provider must travel to another island or the child and amily team

meeting.Parentpartnersparticipateintheindividualizedserviceplanningprocessifrequestedby

a amily and are paid through a contract with the amily organization that is unded through block

grant dollars.

Teleconferencingisbeingusedtoagreaterextenttofacilitatethisprocess;videoconferencing

would be helpul but the capability is not ully developed.




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VT VermontCovering Provider Participation as Case Management and Individualized Service Planning

Vermont’ssystemofcareprovidesnancingviaMedicaid,blockgrant,andgeneralfunddollarstosupport sta participation in the service planning and the work o individual child and amily teams.

These teams have the responsibility o developing the individual service plan or the child. System o

carenancingsupportsthedevelopmentofaCoordinatedServicePlan,whichisrequiredbystate

statuteforchildrenwithsevereemotionaldisturbanceandtheirfamilies.PaymentforparticipationinteamplanningcanbebilledascasemanagementunderMedicaid.Inaddition,providerparticipants

notlocatedintheDesignatedAgency(DA)canbilltheDAfortheirtimeparticipatingonchildandamily teams or individualized service planning. Family members on child and amily teams may

receivesomesupporttoaidparticipation(e.g.,transportation).

Choices ChoicesCovering Participation as Case Management and Additional Service HoursParticipationinchildandfamilyteammeetingsisbillabletimeunderMedicaidforcaremanagers.Providersparticipatinginchildandfamilyteammeetingsinsupportofindividualizedservices

may request payment or their participation by adding extra hours onto their care authorizations.

A primary role o the care coordinator is to create and convene a child and amily team, which

isdoneassoonaspossible,alwayswithin30daysofthereferral,andcontinuestomeetatleastmonthly thereater. Child and amily teams are comprised o all the individuals who can contribute

tothechildandfamily’sservicesandsupport(parentsorothercaregivers,childifappropriate,care

coordinator, reerring worker, currently involved service providers, therapist, school representative,other natural or community supports identied by the amily, e.g., minister, relative, respite provider).

Team members participate in a care planning process reerred to as the “strengths discovery process,”

usedasaframeworktojointlydevelopandreachconsensusongoalsandacourseofaction.Thisprocess involves analyzing the child and amily’s strengths and needs across signicant lie domains,

including health/medical, saety/crisis, amily/relationships, educational/vocational, psychological/

emotional, substance abuse, social/recreational, daily living, cultural/spiritual, nancial, and legal. The

resources and strengths o the child and amily are used as tools to create solutions and to build a

“care coordination plan,” which is the individualized service and support plan. The care coordination

plan ocuses on three to ve o the identied needs determined to be the top priorities to be

addressedduringthenext30days.Foreachneed,theplanspeciesdesiredoutcomes(measurable),

specicinterventions(services,supports,orresources)plannedtoachievetheoutcomes,andwhois

responsible or providing each o the specied interventions. A saety and crisis plan also is developedby the team and includes clear-cut instructions or what to do whenever a crisis may occur. The child

andfamilyteamisresponsibleforreviewingandmonitoringprogresstowardgoalsatleastevery30

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Wraparound Milwaukee Wraparound MilwaukeeCovering Participation with Blended FundsParticipationbyclinicalstainteammeetingsisnotabillableserviceforMedicaidpurposes.

However,Wraparound Milwaukee pays therapists and other sta as needed to participate in teammeetings, using its other unding sources.

▶ Incorporate Care Authorization Mechanisms thatSupport Individualized, Flexible Service Delivery

Anumberofthesitesusechildandfamilyteamsasthemechanismforauthorizingservices.In Arizona, Hawaii, Vermont, Choices, and Wraparound Milwaukee, the plan o care developed by

the child and amily team determines medical necessity and all services specied by the plan are

considered to be authorized.

AZ Arizona, HI Hawaii, NJ New Jersey,VT Vermont, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Using Child and Family Teams to Authorize Services• In Arizona, except or residential treatment, which requires prior authorization, the child and

amily team plan o care determines medical necessity and drives service authorization.

• InHawaii ,thechildandfamilyteamsdeveloptheserviceplan(CoordinatedServicePlan),andall

servicesintheplanareauthorized;thementalhealthcarecoordinatorcompletesneededwritten

service authorizations. The team is the decision maker regarding care authorization.

• InNew Jersey ,theCareManagementOrganizations(CMOs)areresponsibleforthecoordination

o care or children with serious emotional problems and their amilies. To enable care managersto provide intensive care management, caseloads are capped at a ratio o one care manager

to ten children. Care coordinators use child and amily teams to plan and coordinate services

and supports, and services included in the plan are authorized by the Contracted Systems

Administrator(CSA).

• InVermont , care authorization takes place at the local agency level, based on the treatment team

plan. Should questions or disputes arise or children with serious emotional disorders receiving

servicesunderthesystemofcare,theLocalInteragencyTeamisavailabletoassistandhelpachieveresolution.FurtherassistancemayberequestedoftheStateInteragencyTeamshould

issues remain unresolved through the local orums.

• InChoices, the child and amily team creates a care coordination plan or each child and

amily. This care plan is the authorizing document, in that any service prescribed in the plan is

consideredtobeauthorized.Providerssubmitbillsbasedonthisauthorizationandarepaidonaee-or-service basis.

• InWraparound Milwaukee, the child and amily team, using a strengths-based, individualized

approach,determines“medicalnecessity”,includingforMedicaidpurposes,andservicesspecied

by the team are considered authorized, except or inpatient hospitalization, residential treatment,

and day treatment which require prior authorization.




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C. Support and Provide Incentives orEvidence-Based Support and Promising Practices

Strategies include:• Incorporatingnancingandincentivesforusingevidence-basedand

promising practices

• Incorporatingnancingfordevelopment,training,anddelitymonitoring

▶ Incorporate Financing/Incentives or Using Evidence-Based and Promising Practices and Financing orDevelopment, Training, and Fidelity Monitoring

The sites are involved in promoting and nancing the implementation o evidence-based and

promising practices. Their strategies range rom establishing billing codes or specic evidence-based practices to providing nancial support or the initial training and start-up or developmental

costs involved in adopting evidence-based practices, and, in some cases, providing resources or

ongoing training and delity monitoring. A range o evidence-based approaches is supported in

the sites.

AZ ArizonaFinancing Specifc Evidence-Based PracticesInadditiontoitscommitmenttofundawraparoundapproachthroughoutthesystem,the

systemcurrentlyisalsofundingMultisystemicTherapy(MST),FunctionalFamilyTherapy(FFT),MultidimensionalTreatmentFosterCareinMaricopaCountyonly,andDialecticalBehaviorTherapy.

AtboththestateandRegionalBehavioralHealthAuthority(RBHA)levels,therealsoisinterestindevelopingseveralevidence-basedpractices(EBPs)inthesubstanceabusearea,including:Stages

ofChange,MotivationalInterviewing,SevenChallenges,andtheMatrixModel.The Arizona

DepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)hasabest

practicescommitteestructure,whichincludesrepresentationfromtheRBHAsandfamilies,butdoesnotyetincludetheothersystempartnerslikechildwelfare.(Thiscommitteewasintheprocessof

being restructured at the time o the site visit.)

MSTcurrentlyisfundedonasingledayrateof$65/day,asapartialdayprogram.AtthetimeMSTwasinstituted(2004),thiswastheonlyoptionforcodingtheservice;currently,ADHS/BHSislookingatusingthefederalMSTcode.Ingeneral,ratesarenegotiatedforeachEBP,andqualitysupervision

isbuiltintotherate.Providersindicatedthatthemanagedcarestructureprovidesmoreexibilityto

tailorratestoindividualEBPs.DevelopmentofEBPsisnancedthroughADHS/BHS,usingmainlygrantfundingandsome

blockgrantmonies,aswellasbyotherstateagencies.Forexample,MSTandFFTweredevelopedinitiallybyjuvenilejustice,usingstategeneralrevenuefunds,andthentheseprovidersbecamepart

ofRBHAnetworks.Also,theRBHAsareallowedtospendupto7%oftheirbudgetsonadministration,




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whichcouldincludedevelopmentofEBPs.ADHS/BHS,usinggrantdollars,hasfundedconsultantsandtrainersandhassubsidizedproviderssotheycanparticipateintraining(i.e.payingthemforlost

billabletime).ValueOptions(VO)indicatedthatbecausemostrevenueisbasedonactualencounters,itisdiculttonddollarsforEBPdevelopmentanddelitymonitoring,althoughVOhassupported

agenciesinthenetworktodevelopcertainEBPs,usingspeciccontractsforthatpurpose.

HI HawaiiPromoting the Use o Evidence-Based Practice Components and FinancingSpecifc Evidence-Based Practices

There are nancial incentives or using evidence-based practices, including evidence-based decision-

makingandusingpracticesthatproduceresults.Oneofthegoalsinthestrategicplanfor2003–2006

was to consistently apply current knowledge o evidence-based services in the development

o individualized plans and to ensure that the design o the mental health system acilitates the

application o these services. TheChildandAdolescentMentalHealthDivision(CAMHD)hasanEvidence-BasedServices

Committeecomprisedofacademicians,CAMHDleadership,providers,andfamiliestoreviewand

evaluate relevant research to inorm service delivery and practice development. The committee

completed extensive work to identiy the specic “practice components” or elements that comprise

those clinical approaches that are supported by research evidence. The state is now collecting

inormation rom providers about the use o these practice components as part o the clinical

intervention process in service delivery. A coding system was developed and an accompanying

codebook to dene and identiy the various practice components or intervention strategies. Some

o these components/strategies include: assertiveness training, bioeedback, cognitive/coping,

commands/limit setting, communication skills, crisis management, educational support, emotional

processing, amily engagement, amily therapy, unctional analysis, hypnosis, insight building,

interpretation, mentoring, modeling, natural and logical consequences, parent coping, peermodeling, play therapy, problem solving, relationship/rapport building, relaxation, response cost,

sel-reward, social skills training, supportive listening, tangible rewards, time out, and twelve-step

programming.

However,practicehasnotshiftedsignicantlytowardincreaseduseofthepracticecomponentsashasbeenintended.CAMHDcontractswithapproximately48agencieswithover500clinicians.

Although supervisors may attend training, not all clinicians are reached through training eorts.

Despiteevidencethatcliniciansarenotadoptingandusingthepracticecomponentstotheextent

intended, measurement has produced better outcome data than in the past, leading to questions

astowhatfactorsaretiedtoimprovedoutcomes.Ithasbeensuggestedthatengagementwith

clinicians may be a better predictor o good outcomes than use o the evidence-based practice

components.Regardless,Hawaii’s approach is not to be “wedded” to any particular evidence-based

treatment, but rather to oer the practice components that comprise evidence-based treatments as

options that providers can use to improve their practice approaches.

RFPsforprovidersemphasizethecommitmenttoevidence-basedpractices.Inaddition,the

state invests resources in practice development, including training, supervision, workshops, and the

developmentofmaterialsandtoolstosupporttheadoptionofevidence-basedpractices(suchas

menus or “blue cards”, act sheets, and curricula).




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Variousevidence-basedpracticesarebeingaddedasservicesthatwillbecoveredunderthestate’sMedicaidplan,includingMultisystemicTherapy(MST),FunctionalFamilyTherapy,ParentSkills

Training,andMultidimensionalTreatmentFosterCare.Thereisfundingforthedevelopment,training,and delity monitoring o evidence-based practices. The state has “practice development specialists”,

who have provided training and technical assistance to supervisors and clinicians. The state hasprovidedresourcesforstart-up,training,supervision,anddelitymonitoringofMSTandwillbe

doingthisforMultidimensionalTreatmentFosterCareandFunctionalFamilyTherapy.

Thestatehascontractedfortheseevidence-basedservices.Forexample,CAMHDhascontractedforeightMSTteamsstatewide,andwillbecontractingforFunctionalFamilyTherapystatewide

atallagencies.MultidimensionalTreatmentFosterCarewillbestartedintwositesandoutcomeswill be examined. General und dollars are used to support the training, start-up, supervision,

delity monitoring and other expenses attendant to developing the capacity and delivering these

interventions.

NE Central NebraskaFinancing Specifc Evidence-Based Practices

Through cross-system collaboration and strategic nancing at the state and regional level, Central

NebraskafamiliesnowhaveaccesstoMultisystemicTherapy(MST).NebraskabuiltMSTintoits

applicationforafederalsystemofcaregrant.ThestateviewedMSTasatherapeuticinterventionwithgoodoutcomesforyouthinthejuvenilejusticesystem.Federalgrantfundswereusedfor

thedevelopmentphaseofMST,forclinicalconsultation,andtotraintwomentalhealthcenterstobecomeMSTproviders.Nebraska“grewitsown”MST,ratherthaninvitingaMSTprovidertocomeinto

thestateandsetupshop.AlthoughnoonesystemisabletopayforallthecostsofMST,bysharingthenancingresponsibilities,theproviderisguaranteedtoreceivethefullcaserateamount.One

mentalhealthcentercontinuestooerMST;thesecondcenter,locatedinaruralarea,wasnotableto

sustaintheprogram.Approximately226youthandfamiliesparticipateinMSTeachyear.Nebraska’sfederalStateInfrastructureGrant(SIG)hasenabledthestatetoreviewevidence-

basedpractices(EBPs)fromastatewideperspective;tostudythe“real”costsforimplementingEBPs,includingdevelopment,training,monitoring,licensing;andtomakedecisionsabouthowtoproceed.

There has been discussion o shiting unds rom services that are not evidence-based to those that

are, but this raises concern about limiting the types o services that are available and prescribing

specic services, which is counter to Nebraska’s philosophy o individualized and amily-centered

care.ThroughitsSIGwork,Nebraskaisengagedinacomprehensiveprocesstoassessandselect

evidence-based practices that t the unique character and needs o the state.

The wraparound approach is the basis or the work in Central Nebraska’s system o care. To ensure

delitytothewraparoundmodel,Region3BehavioralHealthServices(BHS)contractswithFamilies

CAREtocollectWraparoundFidelityIndexinformationfromparents,youthandcarecoordinators. This eedback allows or continual improvements o the program and builds a capacity or parent-to-

parentsupportbyusingafamilyevaluator.Otherteammemberswhoparticipateonthechildandamily teams also are asked to assess wraparound delity on a semi-annual basis.




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Choices ChoicesProviding Technical Assistance on Implementation o Evidence-Based Practices

The state mental health agency contracts with Choices to operate a Technical Assistance Center(TACenter)toprovidetraining,coachingandtechnicalassistanceformorethan60%ofIndiana’s

counties that are developing local systems o care. The state and the TA Center are now exploring

mechanismsforidentifyinganddisseminatingeectivemodelsofcare(i.e.,evidence-basedpractices

[EBPs])andstrategiesfor“buildingaculture”supportiveofimplementation.Onebarrieristhat,asiderom some resources or technical assistance, there are no extra resources or the capital expenditures

that are required to become a provider o particular evidence-based practices, nor are there resources

forongoingtraining,support,anddelitymonitoring.ReimbursementmechanismsforEBPsalso

areneeded,e.g.,Medicaidbillingcodes.MSTandFunctionalFamilyTherapycanbebilledunderthecurrentMedicaidplan.TheTACentercurrentlyisassemblingagroupofstakeholderstoexplorewhat

EBPsarebeingimplementedinIndianawithdelityandtoassessgaps.

Inaddition,toassessdelitytothewraparoundapproachthatformsthebasisforservicedelivery

in systems o care, the TA Center is responsible through a subcontractor or completion o theWraparoundFidelityIndex(version4)forasampleofmorethan100caregivers,carecoordinatorsandyouthin2007.

AK Bethel, AlaskaFinancing Specifc Evidence-Based PracticesSomestategrantfundingisavailableforevidence-basedpractices(e.g.FetalAlcoholSyndrome,YouthSubstanceAbusetreatment).Trainingonevidence-basedpractices(EBPs),forexample,isonly

oeredifitiscoveredbyastategrant.Inaddition,MedicaidincentivizestheuseofEBPsthroughtheidenticationofcoveredservicesthatcanbeusedforvariousEBPs.

Alaska’sDepartmentofJuvenileJustice(DJJ)stronglysupportsimplementationofEBPs

includingMultisystemicTherapy(MST)andAggressionReplacementTherapy.DJJalsousesYouthLevelofServices(YLS),arequiredintakeformwhichcollectscriminalhistory,mentalhealthneeds,

and amily history. There is a strong ocus on amily strengths and eorts to get the amily involved.

DJJisalsoparticipatinginanOceofJuvenileJusticeandDelinquencyPrevention-fundedproject

onperformancebasedstandardsforjuvenilefacilities.




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D. Promote and Support Early ChildhoodMental Health Services

Strategies include:• MaximizingPartCandChildFindnancing

• Financingabroadarrayofservicesandsupportsforyoungchildrenandtheir

amilies

• Usingmultiplesourcesofnancingforearlychildhoodmentalhealthservices

• Financingearlychildhoodmentalhealthconsultationtonaturalsettings

• Financingservicestofamiliesofyoungchildren

▶ Maximize Part C and Child Find FinancingIn Arizona,thebehavioralhealthsystemhascollaboratedwithPartCtodevelopworkshopsinearly

childhoodmentalhealth,tocreateanassessmenttoolforthe0–5populationandaccompanyingtraining or providers, and to build provider capacity or working with young children. Vermont’s

ChildFindsystem,withresponsibilitygiventotheDepartmentofEducation,ischargedwith

identifyingandevaluatingyoungchildrenwhoareeligibleforservicesunderPartC.CollaborationbetweenthementalhealthandeducationsystemsspeciesrolesandresponsibilitiesrelatedtoPart

CofIDEAandresponsibilityforprovidingandnancingearlychildhoodmentalhealthservices.

AZ ArizonaUsing Part C FundsIn Arizona, there has been increasing recognition o early childhood mental health issues by the

mentalhealthsystem.Forexample,theArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)gavethePartCprogramfundstodevelopaseven-partseriesof

workshopsonearlychildhoodmentalhealth;mostofthosewhoattended,however,wereprovidersinthePartCnetwork,nottheRegionalBehavioralHealthAuthorities(RBHAs).

ADHS/BHSnowrequiresRBHAstousea0–5assessmenttool.Inlate2005,ADHS/BHScontracted

withaproviderthatspecializesinthe0–5populationtohelpdevelopthe0–5assessmenttoolandtrainprovidersonitsuse.ADHS/BHSisusingfederalChildandAdolescentSystemInfrastructure

(CA-SIG)grantdollarstosupportthiseort.OneimpetusbehinduseofthetoolwasthechangesintheChildAbusePreventionandTreatmentAct,requiringreferralofyoungchildreninvolved

withchildprotectiveservices(CPS)toPartC.The0–5assessmenttoolwasdevelopedbyfamilies,providers,PartCandotherstakeholders.RBHAsarerequiredtoscreenCPS-involvedchildren,

0–5,within24hoursandthenrefertoPartCifappropriate.PartCstakeholdersindicatedthat,

initially,only18%ofreferralsmetPartCeligibilitycriteriasoadevelopmentalscreenwasadded;nowchildrenarereferredifthereisadevelopmentalissueinvolved.ADHS/BHSalsoaddedanewcontractualrequirementinRBHAcontracts,requiringRBHAstohire0–5specialists,(whichValue

Optionsindicatedithadsometroublending).ThestateisusingfederalSIGgrantdollarstosupportacompetencyroll-outforthe0–5population,usingtheHarrisTrainingCenterin-servicemodelof

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Atthetimeofthesitevisit,PartCandADHS/BHSwereinvolvedinfurtherdiscussionsabouthowtoimprovecoordinationandcapacityforthe0–5population.AfewprovidersareinbothPartCand

RBHAnetworksand,reportedly,areovertaxedbecauseofhighneedandinsucientcapacity.ValueOptions(VO)inMaricopaCountyhastakentheleadershipinputtingtogetheragroupofPartC,

provider, child welare, amily and other stakeholders to develop a training program or building morecapacity,butthisisintheearlydevelopmentstage.VOalsowasconcernedaboutgettingtheadult

system involved, particularly to coordinate services or adults with substance abuse problems who

haveyoungchildren.Also,theGovernor’sOceonChildren,YouthandFamiliesistryingtodevelop

aninfantmentalhealthplanthatcouldbeendorsedbyallagencies.PartChasaninteragencyearlyinterventionteam,onwhichADHS/BHSsits.Inthepast,PartCandADHS/BHSworkedtogetherto

developanearlychildhoodSAMHSAgrantapplication,butitwasnotfunded.

VT VermontUsing Part C FundsInVermont ,theEarlyInterventionProgramunderPartC,isknownastheFamilyInfantandToddler

Program.VermonthasacomprehensiveChildFindsystemincludingpoliciesandproceduresthatensureallinfantsandtoddlerswhomaybeeligibleforservicesunderPartCareidentiedand

evaluated.(Aneligiblechildisachildfrombirthtothreeyearsofagewhoisatriskforand/orwhoexperiences measurable developmental delays and/or has a diagnosed physical or mental condition

that is likely to result in developmental delay.) State education policy gives the local education

agenciesChildFindresponsibilityforchildrenbirthtoagethree.TheDepartmentofEducation

hasultimateresponsibilityforensuringthatacomprehensiveChildFindsystemexistsinVermont. TheAgencyforHumanServices(AHS),theumbrellaagencythathousestheDepartmentofMental

Health,hasspecicsupportingrolesandresponsibilities,includingadministrationoffunds.ChildFindisfundedunderPartBsothat“eachnon-educationalpublicagency,includingstateMedicaid,

precedesthenancialresponsibilityofthelocaleducationagency.”PartCfundsareutilizedaspayero last resort or the services covered.

AHSandtheDepartmentofEducation,theco-leadagenciesforeortsunderPartC,have

aformalagreement(July2006)thatspeciesrolesandresponsibilities.AHSspecicallyfundscoordination and early intervention services, consistent with ederal rules governing expenditure o

PartCdollars(requiringnon-supplantation,statemaintenanceofeort,andpayeroflastresort).




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▶ Finance a Broad Array o Services and Supports orYoung Children and their Families

Both Arizona and Vermont nance a broad array o services and supports or young children and

their amilies.

AZ ArizonaFinancing a Broad Array o Early Childhood Mental Health Services and Supports

The ArizonaDepartmentofHumanServices/BehavioralHealthServices(ADHS/BHS)conductedacross-walkofDC0–3andICD9-CMserviceswithMedicaid-coveredservicestoprovideguidanceto

providersonhowtobillMedicaidfor0–3services.(See:http://www.azdhs.gov/bhs/provider/icd.

pd )Manycoveredservicescanbeprovidedinnaturalsettings.Thesystemcancovermentalhealthconsultationservicestochildcare,HeadStart,etc.evenifthechildisnotpresentaslongasthe

consultation pertains to an identied child. The system also can provide consultation to amilies even

when the child is not present, again, as long as the consultation pertains to the identied child. Thesystem also covers amily education and support services.

VT VermontFinancing a Broad Array o Early Childhood Mental Health Services and SupportsAs part o its case or enhancing early childhood mental health services, Vermont estimates that

approximately10–15percentofalltypicallydevelopingpreschoolchildrenhavechronicmildto

moderate levels o behavior problems, with much higher prevalence rates in the population o children who are poor. The state also has documented the difcult developmental path children and

their amilies ace without intervention and support and the costly consequences o ailure to act.

The problems impact many aspects o the lives o the children, their amilies and the communities in

whichtheylive.Theearlychildhoodmentalhealth(ECMH)systemisviewedasmorethanamental

healthsystemofcare.Ithasexpandeddirecttreatmentandconsultation,encompassingprevention,earlyinterventionandtreatmentservices.Itisdesignedto:

• Incorporatementalhealthinearlychildhoodnaturalsettings—“wherekidsare”

• Useathree-prongedpublichealthmodel:promotionforhealthysocial-emotionaldevelopmentofallchildrenandfamilies;preventionthatfocusessupportsforchildrenandfamiliesconsidered

at-risk;andinterventiontoservechildrenwithdiagnosedproblems.

• Acknowledgeandapproachtheworkasapartnershipengagingandinvolvingfamilies,

caregivers, early childhood providers, mental health providers, and the community.




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ECMHpromotioneortsincludedisseminationofinformationonhealthysocial-emotionaldevelopment, provision o developmental screening and high-quality child care, and the use o an

evidence-basedcurriculum.Preventionincludeshomevisiting,mentalhealthconsultation,familymentors,usingcurriculathatfosterssocialskills,andfamilyandcaregiversupports.Intervention

servicesincludeon-sitementalhealthconsultation(childorfamily-centered,orprogram/agency ocus), crisis teams, wraparound services, relationship-based therapy, hot line or amilies,

behaviorally-based programs, and in-home treatment.

Vermontreceivedafederalchildren’sservicesmentalhealthgrantin1997($5.7millionover5years)tocreatetheChildren’sUPstreamServicesproject(CUPS),acomprehensiveearlychildhood

mentalhealthinitiative.TheCUPSprogramwasdesignedtoexpandcommunity-basedmentalhealthservices or young children experiencing a severe emotional disturbance and their amilies, and

strengthen local interagency coordination to increase the number o children who enter kindergarten

with the emotional and social skills necessary to be active learners in schools. The initiative served

as the oundation or the development o a strategic approach to maximizing the impact o ederal

grantdollarswithutilizationofMedicaidandEPSDTfunds,aswellasstatematchfunds.Services

supportedthroughCUPSinclude:

• Interventionservicesincludingcrisisoutreach,casemanagement,intensivehome-basedservices,respite care

• Consultationforchildcareandotherdirectserviceproviders

• Cross-agencytraining

• Parentpeersupport

• Informationandreferral

AnumberofotherprogramsalsoareconsideredpartoftheECMHarray:TheFamily,Infantand ToddlerProgram(FITP)whichprovidesafamily-centered,coordinatedsystemofearlyintervention

services or inants and toddlers with developmental delays and disabilities and their amilies. This

programprovidesaccessthroughasingle,integrated,individualizedfamilyserviceplan.TheHealthy

BabiesprogramhelpsMedicaid-eligiblepregnantwomenandfamilieswithyoungchildrenconnect

withhighqualityhealthcareandsupportservicesinthecommunity.VermonthasemployedtheSuccess by Six umbrella to encompass these and other initiatives designed to ensure that children are

ready or primary school.




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▶ Use Multiple Sources o Financing or Early ChildhoodMental Health Services

Strategies include

• Financingbehavioralhealthscreeningofhigh-riskpopulationsandlinkagestoservices as needed

• IncorporatingbehavioralhealthscreeninginEPSDT-fundedscreens

• Financingearlyinterventionservicesforat-riskpopulations

• Incorporatingnancingandincentivesforlinkageswithandtrainingofprimary

care practitioners

Multiplesourcesoffundingareutilizedtonanceearlychildhoodmentalhealthservicesin Arizona

and Vermont ,includingMedicaid,generalrevenue,PartCofIDEA,HeadStart,andavarietyofother

ederal, state, and local unding streams.

AZ Arizona and VT VermontUsing Multiple Funding Streams or Early Childhood Mental Health Services• In Arizona, sources o nancing or early childhood behavioral health services and supports

include:Medicaid,stategeneralrevenue,PartC,childwelfare,education(StateSchoolforthe

DeafandBlind),mentalretardation/developmentaldisabilities,generalrevenue,MedicaidDevelopmentalDisabilitieswaiver,HeadStart,andsomelocalschooldistrictfunding.

• InVermont , ederal, state, and private unding contribute to nancing or early childhood mental

healthservices.Theseresourcesinclude:IDEA,PartBandPartC,Medicaid(includingEPSDTand

waiveroptions),S-CHIP,SAMHSAblockgrantandspecialinitiativefunding,MCH(TitleV)andHRSAfunding,HeadStart,ChildCareDevelopmentFund,TANFfunding,privatesectorgrants,

private insurance, and amily contributions.




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▶ Finance Early Childhood Mental Health Consultationto Natural Settings

Mentalhealthconsultationtoearlychildhoodsettings(suchasdaycarecenters,HeadStart,preschools, pediatricians’ ofces, etc.) is an important component o the array o early childhood

mental health services and supports. Arizona and Vermont nance early childhood mental healthconsultationusingMedicaiddollarsinArizonaandmentalhealthgeneralrevenuefunds

inVermont.

AZ Arizona and VT VermontFinancing Early Childhood Mental Health Consultation• In Arizona,thesystemcancovermentalhealthconsultationservices,usingMedicaiddollars,to

childcare,HeadStart,etc.aslongastheservicespertaintoanidentiedchild(thechilddoesnot

havetobepresent).PartCstakeholdersindicatedthatEarlyHeadStartandHeadStartprogramshavetheirownmentalhealthstawithwhomtheycontractorhiredirectly(i.e.,notthrough

RegionalBehavioralHealthAuthorities[RBHAs]).TheyalsoindicatedthatthereissomediscussionoccurringattheGovernor’sOceonChildren,YouthandFamiliesaboutexpandingmental

healthcapacityforconsultationtochildcaresettings.InMaricopa,ValueOptionsusedpreventiondollarstocontractwithaprovidertoimplementthe“IncredibleYears”inchildcarecenters.

• InVermont , consultation is covered both to amilies and other proessionals in a variety o

“natural settings.” Besides in-home mental health services, consultations take place in child

carecenters,parent-childcenters,preschools,HeadStart,pediatricians’oces,andothers.Early

childhood mental health consultation is nanced by mental health general revenue dollars.

▶ Finance Services to Families o Young Children Arizona and Vermont both nance services to amilies o young children, without the requirement

o the child being present. These services are reimbursable as long as the services relate to the

child’s behavioral health needs and are outlined in the individualized service plan.

AZ Arizona and VT VermontFinancing Services to Families o Young Children• In Arizona, the managed care system can provide services to the amily when the child is not

present as long as the services relate to the child’s behavioral health issues and needs.

• InVermont , many dierent services to amilies o young children are nanced, including home

visiting and other parenting services, amily support, respite care and nancing to support and

engage parents as part o decision-making teams. The child does not need to be present, but theservices must relate to the issues/problems outlined on the service plan.




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E. Promote and Support Early Identifcation andIntervention

▶ Finance Behavioral Health Screening o Children and

Youth at Risk and Linkages to Services as NeededStrategies or screening children and youth at high risk or behavioral health problems and linking

youth to needed services were ound in the sites. Typically, sites screen youth entering the child

welfareorjuvenilejusticesystemsandmakeappropriatereferralsforfurtherevaluationorforservices as indicated.

AZ ArizonaScreening Child Welare and Juvenile Justice PopulationsInresponsetotheChildAbusePreventionandTreatmentAct(CAPTA), ArizonaDepartmentofHealth

Services,DivisionofBehavioralHealthServices(ADHS/BHS),thePartCprogramandchildwelfareworked out a system or rapid reerral o children under age three, who come to the attention o Child

ProtectiveServices(CPS),toreceiveadevelopmentalassessmentthroughthemanagedcaresystem

within24hoursandreferraltothePartCprogramifadevelopmentalissueisfound.Inaddition,childwelfareandADHS/BHShavedevelopedanurgentresponsesystemwithreferraltothemanagedcare

systemwithin24hourswhenachildofanyagecomesintocontactwithCPSandisremovedfromhome.ADHS/BHStooktheleadindevelopingaPracticeImprovementProtocolfocusedonserving

children and amilies involved in child welare, which also describes the urgent response system

requirements.(Seehttp://azdhs/gov/guidance/unique_cps.pd .)

ThejuvenilejusticesysteminMaricopaCountyhasrecentlyimplementeduseoftheMAYSI-2

(MassachusettsYouthScreeningInstrument,Version2)toidentifyhighriskyouthcomingintodetention;alldetainedyouthareadministeredtheMAYSI-2within48hoursofcomingintodetention.

Thejuvenilejusticesystemusesitsownsta(anddollars)toadministerthescreening.AnissueinservingyouthindetentionisthatComprehensiveServiceProvidersintheRegionalBehavioralHealth

Authority(RBHA)networkcannotalwaysbillMedicaidforservicesprovidedonsiteatdetention,dependingontheyouth’slegalstatus,eveniftheyouthiseligibleforMedicaid.ADHS/BHShasissued

a technical assistance document specic to youth in detention settings to clariy and maximize ability

toutilizeMedicaidforthispopulationtotheextentpossible.(See:http://www.azdhs.gov/bhs/

provider/sec.5_1pd .)




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HI HawaiiScreening the Child Welare PopulationAmultidisciplinaryteam(MDT)iscontractedbythechildwelfaresystemtoassesschildrento

determineifamentalhealthassessment(psychologicalorpsychiatricevaluation)isneeded.TheChildandAdolescentMentalHealthDivision(CAMHD)hasrecentlyenteredintoamemorandumof

understanding(MOA)withchildwelfaretogivethemadditionalfundstosupportexpandingtheir

contract as a means o increasing access to care.

NJ New JerseyUsing Common Screening and Assessment Tools Across Agencies

The state utilizes common screening and assessment tools that are used across various systems

and agencies that serve children. The tools are used at the point o access into the various systems,

toscreenandevaluatechildrenforriskandmentalhealthtreatmentneeds.TheCANS(Childand

Adolescent Needs and Strengths) tool is a standardized assessment instrument that incorporatesaquantitativeratingsystemwithinanindividualizedassessmentprocess.VersionsoftheCANSare

usedforinitialscreeningandassessment,forcrisisassessment,andforusebyCareManagementOrganizationstoguideserviceplanningforyouthwiththemostintensiveserviceneeds.The

statemandatesthattheCrisisAssessmentTool(CAT)beusedbythestate’smobileresponseandstabilization providers. The Needs Assessment tool is mandated or use by the Contracted Systems

Administratorandsystempartners(suchaschildwelfareworkersandproviders)atentrytoscreenor level o intensity o service need. The Comprehensive Strengths and Needs Assessment tool is

mandatedforusebyCareManagementOrganizations,youthcasemanagementproviders,andbyresidential treatment providers or individualized service planning. The tools are part o the state’s

InformationManagementandDecisionSupport(IMDS)system.

VT VermontScreening the Child Welare and Juvenile Justice PopulationsVermont supportsscreeningforeverychildcomingintochildwelfareorjuvenilejusticecustody.

TheDepartmentforChildrenandFamilies(DCF)hastakentheresponsibilityforcreatingascreeningprocessforchildrenenteringcustody.Aspartofthescreeningprocess,DCFcontractswithvarious

agencies throughout the state or the ollowing activities: gather existing medical, educational, and

psychologicalinformationonnewentrantsintocustody;meetwithyouth,familiesandtreatment

teamstogatherthefamily’shistory;andutilizeseveralscreeningtoolstoidentifyconcernsandtoassistwithcareplanning.Thegoalisthatthisprocesswillbecompletedwithin30daysofassignment

toascreener.TheDCFscreeningmaybedoneinconjunctionwithadditionalexpertassessmentsofspecic issues. Screening tools used are based on the age and known background o the child and

mayinclude:ChildBehaviorChecklist(CBCL),MassachusettsYouthScreeningInstrument(MAYSI),geno-grams,eco-maps,andtheAnsell-CaseyLifeSkillsAssessment.Medicaidnancesthescreening

and assessment.




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NE Central NebraskaScreening the Juvenile Justice PopulationMedicaidcurrentlyisleadingeortsinNebraska(statewide)toprovideaComprehensiveChild

andAdolescentAssessment(CCAA)foryouthwhoenterthejuvenilejusticesystem.Medicaidhas

contracted with a number o providers to conduct clinical evaluations o mental health/substance

abuse treatment needs beore youth are committed. Although a number o assessment tools

have been identied or these evaluations, the clinicians are not required to use a specic one.

Instead,theyareaskedtoselectthemostappropriatetool(s)foreachyouth.Theirassessmentsand

recommendations ocus on clinical issues and the level o care that may be needed or each youth.

Medicaidpays$1,500foreachofthesecomprehensiveevaluations.AuthorizationoftheservicesthatarerecommendedrestswithMagellan(thestatewidebehavioralhealthmanagedcareentity).

▶ Incorporate Behavioral Health Screening in EPSDT-

Funded ScreensInVermont ,EPSDTscreens,paidforbyMedicaid,incorporatebehavioralhealthscreening

components.Nospecicinstrumentsarerequired.AlsoinVermont,mentalhealthprofessionalsareco-located in pediatric settings to improve access to behavioral health assessment and intervention.

VT VermontIncorporating Behavioral Health Screening in EPSDT ScreensEPSDT,administeredthroughtheDepartmentofHealth,providescomprehensiveassessmentsfor

young children and has played a key role in growing early childhood mental health services in the

state.TrainedhealthandmentalhealthcarepersonnelconductEPSDTscreens,includingappropriate

behavioral health screens in an increasing variety o locations, including in schools under contractwith some districts. Vermont’s eorts recognize the need or appropriate screening tools and

interventions. The state does not prescribe a single tool but rather provides a menu o state-approved

tools.Severalscreeningtoolsandguidelinesareavailable,includingthePediatricSymptomChecklist

and the Child Behavior Checklist, along with reerences or additional resources.

Opportunitiesforidenticationofbehavioralhealthproblemsandreferralfortreatmentalsoareprovided in the pediatric collaborative eorts that the state has undertaken. The model co-locates

acommunitymentalhealthprofessionaljointlytrainedinmentalhealthandsubstanceabuseinapediatric or amily practice ofce to screen, reer as appropriate, and coordinate mental health and

substance abuse treatment, provide short-term intervention, and provide sta consultation. This

model augments the primary care practice, provides assessment and intervention resources, creates

a smooth connection or amilies, helps train proessionals in the eld, and increases community

awarenessabouttheimportanceofaddressingmentalhealth.About15mentalhealthprofessionalsare working to improve screening and services in primary care and private agency settings across the

state.MedicaidnancestheEPSDTscreens.




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▶ Finance Early Intervention Services orChildren and Youth at Risk

Financing strategies to provide early intervention services or children at-risk were ound in Hawaii,

Vermont, Central Nebraska, and Wraparound Milwaukee.

HI HawaiiProviding Behavioral Health Services to At-Risk Children in Schools TheDepartmentofEducation(DOE)providesa“ComprehensiveStudentSupportSystem”thatoersa range o short-term behavioral health services with the goal o early identication and intervention

with students beore they may become eligible or special education services through an individual

educationplan(IEP).Followingtheidenticationofaneed(throughconsultationwithteachers)

and initiation o services, the team reconvenes to decide i a more ormal evaluation is needed to

determine i there is a disability which requires more intensive or longer-term services.

Beginningwithscalyear2000–2001,DOEalsotookresponsibilityforservingstudentswithless

severe emotional and/or behavioral challenges through newly established school-based behavioral

healthservices.Youthneedinglessintensivementalhealthservices,suchasoutpatientcounseling,nowreceivetheseservicesthroughschool-basedmentalhealth(SBBH)services.Thecoordinatedrelationship between the education and mental health systems provides a system o care with the

school as the central access point or mental health services or youth with educational disabilities.

Medicaidhealthplansalsoprovideassessmentandbasiclevelsofoutpatienttreatment,whichcanbe

consideredearlyintervention.Moreintensiveservices,ifneededfortheMedicaideligibleyouth,areobtainedthroughtheChildandAdolescentMentalHealthDivision(CAMHD)children’smental

health system.

VT VermontProviding Services to High-Risk FamiliesFinancing or screening, assessment and a range o services is available or children and their amilies

with identied problems, as well as those at risk. There are eorts through Vermont’s system o

caretoidentifyhigh-riskfamilies.Forexample,theCUPSearlychildhoodinitiativehasfocusedon identiying high-risk amilies with young children including teen parents, amilies aected by

substance abuse, amilies in crisis, amilies with children exposed to domestic violence, and others.

Linkageswiththechildwelfareagency(DepartmentforChildrenandFamilies)andthestate’s

domestic violence network have both been used to ocus attention on high-risk amilies and identiy

thoseinneedofintervention.Eachlocaleducationagency(LEA)isresponsibleforoperatinga

Student Support System that identies and intervenes with students beore they require special

educationservices,includingyouthwithbehavioralhealthissuesReferralmaybemadetoalocalmentalhealthDesignatedAgency(DA)orservicesmaybeprovidedattheschoolunderacontract

withtheDA.AlmosthalfofallpublicmentalhealthservicestoMedicaideligiblechildrenandadolescentsinVermontareprovidedinconjunctionwithaschool—amajorbenetinaruralstate

with little public transportation.




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NE Central NebraskaProviding Wraparound Approach to At-Risk Children and Families ThemissionoftheEarlyIntensiveCareCoordinationProgram(EICC)istousethewraparound

approach and amily-centered practice to coordinate services and supports or amilies involved

withthechildwelfaresystemwhosechildrenareatriskofbecomingwardsofthestate.TheEICCisa

voluntary program intended to prevent children rom being removed rom their homes or going into

higherlevelsofcare(ifnotneeded).TheEICCalsoaddressesparentalmentalhealth,substanceabuse,

anddevelopmentalissues.ThereisconcernaboutsustainedfundingforEICCatthecurrentcaserate.Inscalyear2005,$355,780wasinvestedinEICC;however,theIntegratedCareCoordination(ICCU)

programcostsavingsforscalyear2005wasonly$66,608.Therefore,Region3BehavioralHealthServices(BHS)hadtodrawuponitspreviouslyaccumulatedsavingstofullyfundEICCinscalyear

2005.(Note:Sincethesitevisit,Central NebraskahasbeenunabletocontinueitsEICCProgramdue

tostatepolicychangeslimitingtheuseoffundstochildrenwhoarecurrentwardsofthestate.In

placeofEICC,anewSchool-BasedInterventionProgramisbeingimplementedforchildrenand

youth in custody.)

Wraparound Milwaukee Wraparound MilwaukeeProviding Wraparound Approach at an Earlier StageWisconsinhasanewComprehensiveCommunityServicesMedicaidbenetthatcoversmorecommunity-based interventions than outpatient and that allows or cost reimbursement up to a

certainlevelofcostperday;theproviderhastoshowtheactualcostofcare,soitisratherlabor-intensive.Thecountiesco-nancethebenetbyputtingup40%ofthematch.Wraparound

Milwaukeeislookingatuseofthisnewbenettoimplementa“WrapLight”thatwouldprovidelessintensiveservicesthanWraparoundMilwaukeebutatanearlierstage.Itisconsideringthepossibility

ofusingchildwelfareandjuvenilejusticedollarstocoverthematch;forexample,thejuvenilejusticesystemhasaccesstocountylevymoney(whichmentalhealthdoesnot)andcouldusethesetypesof

dollars as match.




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▶ Incorporate Financing/Incentives or Linkages withand Training o Primary Care Practitioners

Vermont, Choices, and Wraparound Milwaukee incorporate nancing or linkages with primary

care practitioners.

VT VermontImplementing a Pediatric Collaborative ApproachVermont has been piloting a pediatric collaborative approach or the past ve years, and it has

been an eective model or provision o preventive care, early screening, early intervention, and

service coordination or children and their amilies at risk or mental illness and/or substance abuse

disorders. The primary care ofce seems to be a less stigmatizing environment where parents and

children are more likely to address many health concerns, including issues o social and emotional

health.Themodelco-locatesacommunitymentalhealthprofessionaljointlytrainedinmentalhealthand substance abuse in a pediatric or amily practice ofce to screen, coordinate mental health and

substance abuse treatment, provide short-term intervention, and provide sta consultation. The state

does not mandate any special instrumentation or behavioral health screens but has an approvedlistoftools.Inaddition,theprimarycareocewillhaveregularconsultationwithachildpsychiatristor two hours a week. Finally, the model provides immediate access to more intensive mental health

and substance abuse treatment when necessary and allows early interventions which result in the

reductionofmentalhealthandsubstanceabuserelatedissues.Morethanadozenmentalhealth

proessionals are working to improve screening and services in primary care and private agency

settings across the state, and there is great interest in expanding the eort and increasing the

numberofpracticesandpractitionersinvolved.Medicaidfundsservicesusingthisapproach.

Choices Choices Addressing Health/Medical DomainOneofthelifedomainsaddressedinserviceplansis“health/medical.”Assuch,itisseenastheresponsibility o Choices to see that every child has a medical home and that medical, dental, and

eyecareneedsareaddressed.IfthechildandfamilydonothaveprivateinsuranceorMedicaid,thanexible unds are used to pay or health services. Care coordinators assist the amily to determine i

theyareeligibleforprivateorpublichealthinsurance;exiblefundsalsocanbeusedtocover co-payments, prescriptions, or emergency room visits.

Wraparound Milwaukee Wraparound MilwaukeeConducting Reviews with Primary Care PractitionersWraparound Milwaukee conducts weekly reviews with primary care practitioners at the city’s

FederallyQualiedHealthCenter(FQHC),wheremostofitspopulationgoesforprimarycare.Italsoisconsideringdevelopingawalk-inpsychiatricclinicattheFQHC.




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F. Support Cross-Agency Service Coordination andDedicated Care Coordinators

Strategies include:

• Financingcross-agencyservicecoordinationattheservicedeliverylevel

• Financingdedicatedcarecoordinators

▶ Finance Cross-Agency Service/Care Coordination atthe Service Delivery Level

Cross-agency service coordination at the service delivery level is nanced by the sites, typically by

nancing dedicated care managers through various mechanisms.

HI HawaiiUsing State- Employed Mental Health Care CoordinatorsMentalhealthcarecoordinators(MHCCs)arestateemployeesoftheChildandAdolescentMentalHealthDivision(CAMHD),placedineachoftheFamilyGuidanceCenters.Thesecarecoordinators

are responsible or the individualized service planning process, involving the convening o child and

familyteamstodevelopandimplementaCoordinatedServicePlan(CSP).Thecarecoordinatorsare

responsible or authorizing and coordinating the services specied in the plan across providers and

agencies. A key unction o the care coordinators is to develop collaborative working relationships

withotherchildservingagencies.ThespecicresponsibilitiesoftheMHCCsincludethefollowing:

• Ensuringasoundclinicalassessmentisconducted

• Conveningteammeetingstoconductstrength-basedplanningviatheCSPprocess

• DevelopingthewrittenCSPandobtainingagreementandsignaturesofallparticipants

• ImplementingtheCSP,includinglinkagestootherservicesandprograms,referralstonatural

community supports, advocacy, and coordination with agencies and individuals

• PerformingongoingmonitoringandevaluationoftheeectivenessoftheCSPandservices

• Revising/adaptingtheplanasneedschangethroughteamparticipation

• Ensuringthatsystemofcareprinciplesalwaysguideplanningforallservices

Tofullltheirduties,MHCCsaretrainedin:engagementskills,intensivecasemanagement,the

CSPprocess,mentalhealthassessments,CAMHDoutcomemeasures(CAFAS,CALOCUS,AchenbachChild Behavior Checklist), and evidence-based services/best practices.




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NJ New JerseyUsing Care Management Organizations with Care ManagersCross-agency care management is provided through New Jersey’sCareManagementOrganizations

(CMOs),whicharenonprotorganizationsspecicallycreatedtoperformthisfunction.TheCMOsarefundedthroughperformance-basedcontractswiththeNewJerseyDepartmentofChildrenand

Families.CMOsaredesignedtoservetheneedsofchildrenwiththemostseriousbehavioralhealth

challenges and their amilies and unction as a community-based alternative to more restrictive

out-o-home services. To enable care managers to provide intensive care management, caseloads are

capped at a ratio o one care manager to ten children.

VT VermontUsing Designated Agencies with Care ManagersStatelawandpolicyxtheresponsibilityforsystemofcaremanagement.TheDesignatedAgency

is the locus o accountability or planning and implementing services and or care management or

children with intensive mental health needs. The local agency that has lead responsibility or ensuring

thattheCoordinatedServicePlan,developedbyanindividualtreatmentteam,isinplacecanvarydependingontheneedsofthechildandfamily.IfthechildisinthecustodyoftheDepartment

forChildrenandFamilies,thenthatdepartmenttakesthelead.Iftheissuesoccurprimarilyintheeducational setting and the child is not in state custody, then the local school district is responsible.

Inallothercases,thedesignatedcommunitymentalhealthagencyisresponsiblefordevelopingtheCoordinatedServicesPlanthatoutlinesgoalsandforensuringthattheplanisimplementedand

modiedasappropriate.Whicheveragencytakesthelead,anagencycasemanagerhastheprincipal

role in activating the coordinated service plan process. The system o care supports dedicated care/casemanagersfortheapproximately200childreninthesystemwhorequirehigh-endservices.Ifproblems or issues arise that the individual treatment team cannot resolve in case planning or service

implementation,theteamoranymembermayinitiateareferraltotheLocalInteragencyTeam(LIT)intheregionforhelp.CasemanagementnancingcomeslargelyfromMedicaid,butmayvary

depending on the lead agency and scope o activities.




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NE Central NebraskaUsing Care Coordination Programs

The service system in Central Nebraska is built on a belie in cross-agency coordination, one care

coordinator per amily, and partnering with amilies. This philosophy is reinorced by unding

severalcarecoordinationprograms.TheProfessionalPartnersProgram(PPP),theIntegrated

CareCoordinationUnits(ICCU),theEarlyIntensiveCareCoordinationProgram(EICC),theSchoolWraparoundProgram,andtheCareManagementTeamalloercarecoordinationtocertaintargeted

populationsofchildrenandfamilies.AcaseratemethodologyfundsthecarecoordinatorsinthePPPandtheICCU.TheCentralServiceAreaoftheDept.ofHealthandHumanServices(childwelfare)and

Region3BehavioralHealthServices(BHS)sharethecostofthecarecoordinatorsinICCUandEICCandco-fundtheCareManagementTeam.Region3BHSandtheschoolsystemsharethecostsof

employingthefacilitatorsintheSchoolWraparoundProgram.Reachingagreementonthecareplanoftenrequiresnegotiation,e.g.,ifthecareplancallsforspecicMedicaid-fundedservices,rstthe

child and amily team must agree upon recommended services and then the clinician rom the team

negotiateswithaliaisonatMagellan.(Note:Sincethesitevisit,CentralNebraskahasbeenunable

tocontinueitsEICCProgramduetostatepolicychangeslimitingtheuseoffundstochildrenwhoarecurrentwardsofthestate.InplaceofEICC,anewSchool-BasedInterventionProgramisbeing

implemented or children in custody.)

Choices ChoicesUsing Care CoordinatorsEach child and amily served by Choices is assigned to a care coordinator who works with the amily

to orm a child and amily team. Each care coordinator belongs to a team, typically comprised o

asupervisor,vecarecoordinators,andonetothreecasemanagers.InIndiana,theteamsare

physicallylocatedatDawn,andmostoftheirtrainingandsupervisionoccursatDawn,buttheyareactuallyemployedbythefourcommunitymentalhealthcenterstoenablethemtobillMedicaid

throughtheRehabilitationOptionforthecaremanagementservicesprovidedtoeligiblechildren.CarecoordinatorsareemployedbyChoicesinOhioandMaryland.Eachcarecoordinatorcarriesa

caseloadofabouteighttotenchildren;casemanagersareconsidered“carecoordinators-in-training”and play a supportive role. The responsibilities o the care coordinator are extensive and involve:

organizing and convening a child and amily team, acilitating a strength-based discovery/assessment

process, developing an individualized care coordination plan with the team, assisting teams in

nding the services and supports necessary to address care plan goals, authorizing services monthly

or the upcoming month, monitoring and evaluating service provision and outcome attainment,

coordinating service delivery among all involved providers and the amily, writing all required reports,

providing inormation to reerring workers and other team members, and serving as an educator

and acilitator or the amily and the various systems. The approach used by the care coordinators is

referredtoas“participatorycaremanagement.”DevelopedbyChoices,theapproachuniquelyblends

the concepts o both managed care and systems o care by integrating the system o care philosophy

anditscorevalues(e.g.,familyinvolvement,individualized/wraparoundapproach,coordinatedcare)withmanagedcaretechnologiesforclinicalandscalmanagement(e.g.,caserates,outcome,focus).




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Wraparound Milwaukee Wraparound MilwaukeeUsing Care CoordinatorsChild and amily teams address issues across systems at the service delivery level, and their unctions

are nanced through Wraparound Milwaukee. Additionally, the system contracts with carecoordinatorswhoworkwithsmallnumbersofchildrenandtheirfamilies(1:8)andareresponsibleforoutcomesacrosssystems.CarecoordinatorsarenancedthroughWraparoundMilwaukee’sblended

unding pool.



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IV. Financing to Support Family and Youth Partnerships

A central tenet o the systems o care philosophy is that amilies and youth are ullpartners in all aspects o the planning and delivery o services. The concept o amily and

youth involvement has been strengthened over time, and the new concept o family-

driven, youth-guided care is achieving broad acceptance. Family-driven care means that

amilies have a primary decision making role in the care o their own children, as well asin the policies and procedures governing care or all children in their community, state,

tribe, and nation. Similarly, youth-guided care means that young people have the rightto be empowered, educated, and given a decision making role in their own care and in

the policies and procedures governing care or all youth in their community, state, tribe,and nation. Financing strategies are needed to support partnerships with amilies and

youth at the service delivery level in planning and delivering their own care and at thesystem level in designing, implementing, and evaluating systems o care. In addition,

partnering with amilies and youth requires nancing or services and supports not onlyor the identied child, but also or amily members to support them in their caregiving

role. Financing to und program and sta roles or amily members and youth alsoreects a system o care that is committed to partnerships, as does nancing or amily-

and youth-run organizations.


A. Support Family and Youth Involvement and Choice in Service Planning

and Delivery

B. Finance Family and Youth Involvement in Policy Making

C. Finance Services and Supports for Families and Other Caregivers




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A. Support Family and Youth Involvement andChoice in Service Planning and Delivery

Strategies include:• Financingsupportsforfamiliesandyouthtoparticipateinserviceplanning

meetings

• Financingfamilyandyouthpeeradvocates

• Incorporatingnancingtoprovidefamiliesandyouthwithchoicesofservicesand/or providers

• Incorporatingnancingtotrainprovidersonhowtopartnerwithfamiliesandyouth

▶ Finance Supports for Families and Youth toParticipate in Service Planning Meetings

The sites studied incorporate nancing to support amily and youth participation in service

planning meetings. They typically pay or such supports as transportation, child care, ood, andinterpretation on an as-needed basis.

AZ Arizona, HI Hawaii, VT Vermont,NE Central Nebraska, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Financing Transportation, Child Care, Food, and Interpretation to Support

Family/Youth Participation in Service Planning Meetings• In Arizona, amily and youth participation on child and amily teams is one o the core principles

o the system. The managed care system pays or child care, transportation, ood, and interpretersas needed.

• InHawaii , child care may be provided i the amily member has to y to another island to

participate in a child and amily team meeting. In some instances, a child may be servedon another island, or example, i a child needs to be in a dierent environment or requires

hospitalization, which is available only on Oahu. Transportation and ood are unded out o ancillary unds. Parent partners can advise amilies as to the availability o these resources and

can help amilies to obtain them rom the Family Guidance Centers when necessary. In addition,Hawaii Families As Allies (HFAA) provides some training or amilies on how to participate in

service planning (such as training in advocacy, communication, how to speak up, how to becomeinormed about what services are available, etc.)



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• InVermont ,theparticipationofparents/familymembersonchildandfamilyteamsisundamental to system o care assessment, service planning and plan implementation. The local

team determines the appropriate unding resources or supports, such as child care, interpreterservicesand/ortransportation,thatpermitandfacilitatefamilyparticipation(andwithoutwhich

theparent/familymembermightnotbeabletoparticipate).Thefundingresourcesdependonthe supports required (e.g., interpreter services would be covered by Medicaid; others by state

mental health, other partner agency unding, or available exible unds.)

• Choices attempts to remove all potential barriers to the participation o amily members at teammeetings, such as transportation, child care, and conicts with work, to acilitate and maximize

their involvement. Depending on a amily’s needs, payments can be provided or bus passes,reimbursement or gas, and child care — even providing checks or child care in advance o the

meeting. I necessary, arrangements can be made or someone at Choices ofces to provide childcare during child and amily team meetings. Sta is empowered to do whatever is needed to

remove barriers to participation. Flexible unds are used to cover costs such as these.

• InWraparound Milwaukee, amily and youth participation on child and amily teams is a core

principle. The system pays or child care, transportation, ood, and interpreters to ensure that

amilies can participate, using dollars rom its blended unds pool.

▶ Finance Family and Youth Peer AdvocatesMostofthesitesprovidenancingforfamilyand/oryouthpeeradvocates.Theroleofthesepeeradvocates typically includes working with amilies and youth to support them through the service

planning and delivery process and providing a variety o types o direct assistance.

AZ Arizona

Requiring Core Service Agencies to Hire Family Support Partners and Covering Family and Youth Peer Support Under Medicaid All Comprehensive Service Providers (core service agencies) are required to hire Family SupportPartners (FSPs). In Maricopa County, FSPs are recruited, trained, and coached by the Family

Involvement Center, though they are employed by the Comprehensive Service Providers. Thisarrangement enables FSPs to eel part o and supported by a larger amily movement. The managed

care system also covers amily and youth peer support, which is a Medicaid-covered service. Anew type o Medicaid provider which the state created, called Community Service Agencies (CSA),

employs, trains, and supervises amily and youth peer support providers. CSAs are agencies that donot have to be licensed as behavioral health clinics. For example, the Family Involvement Center in

Maricopa County is a CSA and provides amily-to-amily and youth-to-youth peer support directlyand bills Value Options or the service.

Also, ArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)

is working with other child-serving systems to encourage them to und amily-to-amily deliveredpeer support within their own systems and was making some headway with the juvenile justice

system at the time o the study.




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HI HawaiiFinancing Parent PartnersFinancing is provided or parent partners who serve as peer advocates and provide assistance and

support to other amily members. Parent partners are employees o Hawaii Families As Allies (HFAA)whose role involves supporting parents in advocating or their children and themselves. Parent

partners attend meetings such as individual education plan (IEP) meetings and court proceedingswith amilies, conduct workshops and support groups or amilies, and support amilies in a variety

o other ways. Typically, parent partners work out o their homes, but they are tied to the variousFamily Guidance Centers, and they serve on Family Guidance Center committees and management

teams, representing the interests o and advocating or amilies. Care coordinators provide a packeto materials about the availability o parent partners and about HFAA to amily members receiving

services. In addition, Family Guidance Centers make reerrals to the parent partners or support. Theregistration process at Family Guidance Centers was modied to include a review by parent partners

and to obtain consent or the parent partner to contact the amily to provide support. New work currently is being undertaken to develop youth mentors to provide positive role models to other

youth in areas including social and lie skills. Some mentors will receive stipends rom the new ederalsystem o care grant in Hawaii. Curriculum development to provide training or this role is underway.

A new RFP requires provider agencies to have a Family Specialist and a Youth Specialist. These rolescan be assigned to direct service sta, but must be at least hal-time positions.

NJ New JerseyFinancing Family Support Organizations with Family Support Coordinators

The state unds Family Support Organizations (FSOs) in each region, which provide advocacy, supportand education at the system and service delivery levels. They are unded with a combination o state

general revenue, Medicaid administrative case management dollars, and ederal discretionary grants.FSOs are required to und Family Support Coordinators to work closely with amilies served by Care

Management Organizations (CMOs), providing peer support and advocacy. The Family SupportCoordinators are individuals with children involved in the system or who have been diagnosed

with emotional problems and are available or amilies who request their help. A primary ocus is tosupport the amily’s involvement in the individualized service planning process to ensure that the

plan is supportive o their concerns, values, and preerences.



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VT VermontFinancing Peer Support

The Vermont Federation o Families or Children’s Mental Health provides the most extensive amily

organizational support or the system o care. It is the designated organizational representative instate law and policy and provides an array o services and supports (e.g., peer navigation, parent and

provider training, inormation, and reerral to resources).

Peer Navigator eorts, initially developed through a statewide collaboration with amilyorganizations (nanced through a ederal grant rom the Administration on Developmental

Disabilities and the Administration on Children and Families), oers service participants the supporto someone who has experienced the system rst-hand. Peer Navigators assist individuals and

amilies with accessing and navigating the health, education and human service systems. System o care principles and practice have brought these systems together to work in an integrated ashion to

reduce crises and improve child and amily health, mental health and well-being. Peer navigation issupported by agency grant and contract unds.

NE Central NebraskaFinancing Family Partners

To urther support amilies in the ormalized service system, a Family Partner, employed by FamiliesCARE, provides support or each amily served through the wraparound process in Central Nebraska.

EachFamilyPartnerisrecruitedfromandbasedwithinthecommunityinwhichhe/sheresides.

In addition, Families CARE coordinates Youth Encouraging Support (YES), a group o 200–300youth in Region 3, who work to educate proessionals, amilies, and peers on mental health issues

and to reduce the stigma within their communities. YES also provides support to other youth whohave mental health disorders and provides a youth voice within the local systems o care. Youth and

parents who were interviewed applauded the work o YES and indicated that these connectionswith other youth make a signicant dierence in the lie o each youth. Family Partners and YES areprograms that Families CARE operates through its contract with Region 3 Behavioral Health Services

(BHS). Funding or the contract comes rom the case rate or the Integrated Care Coordination Unit(ICCU). In addition, YES applies or small grants or specic activities, and the youth undraise.

Choices ChoicesPurchasing Family Advocate Services rom Family Organization

Family advocates are paid by Choices on a ee-or-service basis. Every amily served has access toa amily advocate to accompany them to child and amily team meetings and or other sources o

support. Family advocates are employed by the amily organization (Rainbows) and are available onan as-needed basis. They are unded ee-or-service to provide amily mentoring and support.




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Wraparound Milwaukee Wraparound MilwaukeePurchasing Family and Youth Peer Support Wraparound Milwaukee pays or amily peer support and youth peer support on a ee-or-service

basis. Family and youth peer support are provided through individuals and agencies that are part o Milwaukee Wraparound’s extensive provider network. They are paid or through Milwaukee’s blendedunding pool.

▶ Incorporate Financing to Provide Families and Youthwith Choice of Services and/or Providers

Most o the sites use an individualized care planning process with child and amily teams in whichthe youth and amily are integral to decision making about the services and supports that will be

provided. In addition, the sites also oer choices o providers to amilies and youth when possible.

AZ ArizonaUsing Individualized Care Process and Ofering Options o Providers

Arizona stakeholders believe that the managed care structure, which allows amilies choice o providers, and the broad benet design allow amilies choice, as well as the Child and Family Team

process that closely involves amilies. In addition, the system can enter into individual contracts with aprovider that is outside the managed care network i there is a need or the service. These are known

as “single case agreements”. Also, the system uses ex unds (though limited) to support amily choice.

HI HawaiiOfering Options o ProvidersFinancingallowsforfamiliesandyouthtohavesomechoiceofservicesand/orproviders.For

example, options are available or providers o intensive in-home services, and attempts are madeto address needs based on gender, ethnicity, language, etc. However, in some remote areas where

there are ew providers, it is difcult to oer choices. In some areas o the state, providers are ownin to provide services on a weekly basis; erries are used in cases in which islands are closer, such

as between Maui and Lanai. Family members reported that due to limited resources, shortages o providers, and high rates o turnover among providers in many areas, in actuality, ew choices o

services or providers may be available to amilies and youth, particularly in rural communities andsmaller islands.



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Choices ChoicesUsing Individualized Care Process and Ofering Options o ProvidersIn child and amily team meetings, amilies are oered options o providers i there is a sufcient

volume o providers or the services in question. To the extent possible, providers o servicesare customized to the community or neighborhood in which the amily resides, with the goal o

establishing connections with providers that amilies will be able to maintain independently atertheir involvement with Choices has ended. Typically, two or three suggestions o providers or a

service are brought to the child and amily team meeting. The amily is able to choose or may rely onthe recommendation o the care coordinator.

Wraparound Milwaukee Wraparound MilwaukeeUsing Individualized Care Process and Ofering Options o Providers

The child and amily team, on which the amily and youth are key players, determines the array o services and supports or a child and amily, drawing rom a very broad provider network o over 200providers and 85 services and supports and access to exible, individualized (e.g., one-time) supports

as well. The plan o care developed by the team details the specic services and supports that will beprovided, but not the specic provider. The amily itsel may choose the provider. This also creates

a built-in quality improvement check or the system because i amilies are not choosing particularproviders, the system will have that inormation and can begin to analyze the underlying reasons.




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▶ Incorporate Financing to Train Providers onHow to Partner with Families and Youth

Strategies include:

• Providingpaymentandsupportsforfamilyandyouthparticipationatthepolicylevel

• Contractingwithfamilyorganizationsforparticipationinpolicymaking

• Incorporatingotherstrategiestonancefamilyandyouthparticipationatthepolicy

level

• Financingtrainingandleadershipdevelopmenttopreparefamiliesandyouthforparticipation in policy making

The sites use various approaches to nance training or providers on how to partner with amiliesand youth.

AZ ArizonaFinancing Training or Families and Providers

Arizona has spent $7 million since the JK settlement agreement in tobacco settlement monies,as well as discretionary and ormula grants and Regional Behavioral Health Authority (RBHA)

investments, to pay or training and coaching o amilies, providers and others to develop a statewidepractice approach designed to actualize Arizona’s vision o amily-centered practice and the 12

system o care principles. The Family Involvement Center partnered with the Value Options (VO)training department, Comprehensive Services Providers (i.e., core service agencies), and others

designated by VO to design a curriculum on how to partner with amilies and youth. (See www.

familyinvolvementcenter.org)

HI HawaiiIncorporating Focus on Partnering with Families and Youth in All Training

Training or providers always includes a ocus on partnering with amilies. Family members areemployed as trainers and provide training on eective partnerships and collaboration with amilies.

There also are resources in the current Hawaii Families as Allies budget to train providers in howto partner with amilies and youth. The state points out that just being in the same room does not

necessarily result in meaningul amily participation or eective partnerships between providers and

amilies. The state plan is or parent partners to provide group and individual training to line sta onpartnering with amilies and youth.

In addition, the second annual Young Adult Support Group Planning Summit will be held this yearwith the theme o “Why Not Me?” This will be used as a vehicle to share with providers the vision o

youth voice and youth involvement and provide training about how to partner with youth.



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VT VermontFinancing the Family Organization to Train ProvidersVermont’s Department o Mental Health has a long-standing partnership with the Vermont

Federation o Families or Children’s Mental Health, which was the rst state chapter o the nationalFederation o Families or Children’s Mental Health organization. The Federation has received unding

rom its inception rom the Department o Mental Health, as well as signicant multi-year ederalgrant unds, to engage in a variety o ways with parents, providers and policymakers in building the

system o care with strong amily participation. The Federation’s current state contract ($93,000),along with other resources, unds eorts with the Department o Mental Health to help design

and conduct training or mental health, other state agency and local provider agency sta, and towork directly with amily members and others in improving mental health services and policies. The

Federation conducts extensive amily outreach, education and leadership development and serves asthe amily organization representative on several ormal advisory and review bodies.

Choices ChoicesUsing a Community Resource Manager to Train Providers

The community resource manager is the designated individual in each site who works closelywith providers, including identiying providers to participate in the network; negotiating rates;

and arranging or, coordinating, or providing training on best practices, innovations, etc. Oneaspect o the training or providers in the network is on amily-driven care. Community resource

managers arrange or training provided by amily members; amily members employed by the amilyorganization, Rainbows, can provide such training locally or can travel to other sites. The contract with

Rainbows covers these costs.

Wraparound Milwaukee Wraparound MilwaukeeProviding Training to ProvidersWraparound Milwaukee trains all providers in its underlying principles, values and operating

procedures, in the child and amily team concept and operations, and in the wraparound approach.It also tracks delity through its quality improvement (QI) system.




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B. Finance Family and Youth Involvementin Policy Making

▶ Provide Payments and Supports for Family and Youth

Participation at the Policy Level Arizona, Hawaii, Vermont, Central Nebraska, Choices, and Wraparound Milwaukee providepayments and supports or amily and youth participation at the policy level. The mechanism used

in all o these sites is a contract with a amily organization which, in turn, provides payments andsupports to amily members and youth. Typically, supports include stipends and, on an as-needed

basis, may also include transportation, child care, and ood.

AZ Arizona, HI Hawaii, VT Vermont,NE Central Nebraska, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Contracting with a Family Organization to Provide Payments and Supports or Policy-Level Participation• In Arizona,ArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/

BHS) uses ederal discretionary and block grant dollars to support amily involvement in policymaking. There is not a strong youth involvement eort yet, but amily involvement is a major

priority. In the space o about our years (since the JK settlement agreement), amily partnershiphasgrownconsiderablyatthestatelevelwithinADHS/BHSandattheplanlevelsuchthat

Arizona’sfamilyleadersarerecognizednationally.BothADHS/BHSandValueOptionsinMaricopareported that they would not be as ar along in their reorm without the amily partnership

component. They believe that the philosophical shit among providers and plans is due largely to

amilies being “at the table” and to amilies providing technical assistance to providers and plans.Both the state and Value Options reported that the amily organizations taught them how toengage amilies at system and practice levels and support amilies, not just as advocates, but as

system and service delivery partners. Families served on the committee to select the contractedRegional Behavioral Health Authorities (RBHAs). Providers employ amily members as amily

support partners and as sta, and amilies serve on agency boards. The state contracts with MiKid(the statewide amily organization) and the Family Involvement Center in Maricopa County to

provide stipends or amily involvement in policy making and to ensure that amilies have accessto other supports to participate eectively, as needed. The state also paid the rst year dues o

these organizations to belong to the Arizona Council o Providers to ensure that their voice isheard at that level o the system.



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• InHawaii ,mostofthesupportsforfamily/youthparticipationatthepolicylevelareprovidedthrough a contract with Hawaii Families As Allies (HFAA), the statewide amily organization.

The Child and Adolescent Mental Health Division (CAMHD) has been a strong advocate andsupporter o amily and youth involvement. CAMHD’s contracts with provider agencies require

the submission o youth engagement and amily engagement policies that include a statemento the agency’s commitment to involve youth and amilies in all levels o the organization, as

well as a means o ensuring that youth and amily members are engaged in their own treatmentplan development and evaluation, organizational quality assurance activities, and organizational

management and planning activities.

• InVermont ,thestatesystemofcarestatuteprescribesfundingforparticipationforparents/amily members and amily organization representatives on local and state interagency teams

and various advisory panels. Vermont law (Act 264 – Title 33 Human Services §§ 4301-4305)mandatesfamilyparticipationatalllevelsofthesystemofcare(individualcase/treatmentteams,

Local Interagency Teams [LIT], State Interagency Team [SIT] and State Advisory Board). The SIT hasa Case Review Committee that provides assistance to local teams as they work to identiy, access,

and/ordevelopresourcestoservechildrenandyouthintheleastrestrictivesettingsappropriate

to their needs. This review committee has representatives rom the lead state agencies and theVermont Federation o Families or Children’s Mental Health, specically. Support or individualamily member representation is paid by state mental health unds. Financing or the amily

organization representatives is covered under the state contract with the Vermont Federation o Families or Children’s Mental Health (currently $93,000), which includes participation in system o care decision-making and support roles.

• InCentral Nebraska, a contract with the amily organization, Families CARE, is the mechanism

used to support amily involvement in policy making. Families CARE reimburses amilies or theirexpenses (provides meals, gas money, and child care).

• InChoices, support or amily participation at the system level is provided through a contract

with Rainbows, the amily organization. The Governor’s Ofce in Indiana oers scholarships oramilies to attend policy meetings, conerences, and training.

• InWraparound Milwaukee, a contract with the amily organization, Families United orMilwaukee County, provides a vehicle or support o amily participation at the policy level. The

amily organization pays or parent stipends to participate in policy and team meetings andprovides other supports.




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▶ Contract with Family Organizations for Participationin Policy Making

Contracts with amily organizations are the most requent vehicle used to ensure amilyparticipation in policy making. Arizona, Hawaii, Vermont, Central Nebraska, Choices, and

Wraparound Milwaukee contract with amily organizations to ulll a wide variety o policymaking and system management roles, including serving on committees and advisory bodies;

participating in evaluation activities; providing training; providing amily advocates, peer mentors,and ombudspersons; developing and disseminating inormation; and organizing and acilitating

youth groups and youth councils.

AZ ArizonaContracting with Two Family Organizations

The ArizonaDept.ofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)usesboth

discretionary (e.g., ederal State Inrastructure Grant) and ormula grant dollars to contract with twoamily organizations — MIKID, a statewide amily organization, and the Family Involvement Center

(FIC) in Maricopa County. The amily organizations hold both mini-conerences and a statewideconferencetoreachmorefamilies.Atthetimeofthestudy,ADHS/BHSwasissuinganewRequestfor

Proposals (RFP) or consumer and amily involvement at the policy level — or example, to supportamilies to serve on committees, to participate in practice evaluation, to create a hotline or amilies,

etc. The RFP includes a priority on establishing a amily advocacy center serving Latino amilies. MIKIDand FIC submitted a joint proposal to ensure statewide amily involvement at the policy level and to

clariy their respective roles. The state also received a ederal Center on Substance Abuse Treatment(CSAT) adolescent substance abuse grant and included both MIKID and FIC in the grant.

In Maricopa County, the FIC is seen as an “extension o Value Options” (VO) in terms o expanding

VO’s capacity to advance system o care goals. (Initially, FIC got started with a small grant rom St.Luke’s Health Initiative and then became unded with system dollars.) VO has unded FIC or several

years, and FIC has also been a direct service provider within the VO provider network since 2005.VO also unds MIKID. VO’s contract with FIC is or $900,000 or “system transormation” activities in

Maricopa County, including stafng and participating on the Children’s Advisory Committee or VO,amily recruitment and training, organizing open education opportunities or amilies, inormation

and reerral, co-acilitation o meetings, recruitment and training o amily support partners (whoare out-stationed with each o the Comprehensive Service Providers), and technical assistance to

providers and others on amily partnership. Every amily enrolled with VO receives a Family Handbook developed by FIC and is invited to attend orientation sessions conducted by FIC. VO also has several

ull-time amily members on sta, with two devoted to the children’s system at the time o the sitevisit.

At the time o the site visit, FIC received the ollowing unding:

• ContractwithVOforthe“systemtransformation”activitiesnotedearlier,including:recruitfamily

support partners or provider agencies in the VO network, train and coach amily members andproviders in a amily partnership model, train and supervise amily members to participate in

perormance improvement reviews, and pay stipends to amilies.



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• ContractwithVOtobeaMedicaidComprehensiveServicesAgency(CSA)provider(allbillablework has to be ace-to-ace contacts) and to hire eight amily support partners to provide amily-

to-amily services as part o the provider network. Also, ater the site visit or this study, FICbecame licensed as an outpatient behavioral health provider, which allows it to bill or telephone

contact and provide case management, in addition to providing respite, peer support and amilyeducation as a CSA Medicaid provider.

• FederalSIGgrantfundingfromthestatetoexpandthefamilymovement.

For more inormation about the Family Involvement Center, see http://www.

familyinvolvementcenter.org

HI HawaiiContracting with the Statewide Family OrganizationCAMHD contracts with Hawaii Families as Allies (HFAA), the statewide amily organization or

participation in policy making and system management. The rst such contract was executed in 2002.State general und dollars and ederal block grant unds are used to und the activities o the amily

organization. Funding levels were at approximately $722,000 last year. HFAA reports a sta o 17–18people who are available to participate on a range o committees and other policy-level activities

through the contract resources. CAMHD may nance transportation to support some policy-levelparticipation outside o this contract; this is nanced through exible unds or ancillary services. In

particular, assistance is available i transportation to another island is necessary.

The amily organization is providing assistance in the newly received ederal system o caregrant ocusing on youth in transition to adulthood. Among other activities, assistance is being

providedinestablishingayoungadultsupportorganizationandpreparing/mentoringyouthtoparticipate in policy making activities. Family members also serve as co-chairs with proessionals on

the Community Children’s Councils (CCCs); there are 17 o these in the state. These councils meetmonthly to plan or and assess the strengths and needs o the children’s mental health system in

their respective communities. Quarterly statewide meetings o the CCC chairpersons are held. Thesecouncils were initiated as a result o the Felix lawsuit. During the lawsuit, HFAA was used as a vehicle

or supporting amily involvement on the CCCs.

Parent partners are employees o HFAA whose role involves supporting parents in advocatingor their children and themselves. Parent partners attend meetings such as individual education

plan (IEP) meetings and court proceedings with amilies, conduct workshops and support groups oramilies, and support amilies in a variety o other ways. Parent partners are tied to the various FamilyGuidance Centers, and they serve on Family Guidance Center committees and management teams

representing the interests o and advocating or amilies.




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HFAA reported initiating a strong marketing campaign to create greater awareness o HFAA andthe various supports that the organization oers. The contract with Hawaii Families as Allies species

a scope o work that involves providing amily involvement and support to amilies with youthexperiencingemotionaland/orbehavioralchallengesinthestateincluding:

• Ensurethatthefamilyperspectiveatthecommunityandstateleveliseectivelypresentedandconsidered in all policy decisions (including providing representatives or CAMHD ExecutiveManagement Team, State Mental Health Council, the children’s policy group o the Governor’s

Cabinet, and various CAMHD committees)

• Develop,implement,andcoordinateaprogramonabroadrangeoftopicsrelevanttoenhance

attitudes, skills, and knowledge o youth and amilies

• Develop,implement,andevaluateaprogramoftrainingthataddressesabroadrangeoftopicsincluding, but not limited to educational issues, health issues, child welare issues, juvenile justice

issues, substance abuse issues, eective parenting, and community collaboration

• Disseminateinformationbyobtainingordevelopingdocuments(yers,checklists)thatprovideinormation using amily riendly language

• Publicizetheavailabilityofdocumentsthroughthenewsletteroffamily-focusedorganizations

• Disseminateanddistributedocumentsthroughallsuitableavenuesincludingdevelopingawebsite

• Conductworkshopsonspecictopicsrelatedtofamiliesinthecommunity

• Organize,widelypublicizeandhostatleastoneconferenceannuallyforparents,fosterparents,andcaregiversofyouthwithemotionaland/orbehavioralchallenges

• OrganizeandfacilitateaYouthCouncilcomprisedofyouthtoconductpublicawarenessandpeer

support activities developed by youth

• Operateandpublicizeastatewidephonelinetorespondtorequestsforinformationandhelpin

accessingservicesandsupportforchildrenwithemotionaland/orbehavioralchallenges

• EmployConsumer/FamilyRelationsSpecialiststobeaccessibleviathestatewidephonelinetoadvisefamiliesaboutappropriateservicesforchildrenwithemotionaland/orbehavioral

challenges

• Developandmaintaintworesourcemanualsofavailableservicesandsupports(anEmpowerment Resource Manual with inormation identiying community resources and a

Recreational Resource Manual with inormation about recreational, leisure, and educationalresources)

• Providecomprehensivepeersupportforfamiliesofchildrenwithemotionaland/orbehavioralchallenges by recruiting, training, and supervising Parent Partners who will serve amilies in the

community

• Assistfamiliesseekinghelpfortheirchildrenwithemotionaland/orbehavioralchallengestoaccess and navigate through the available services

• Increasesocialacceptanceandreducethestigmatizationandbullyingofyouthwithemotional

and/orbehavioralchallengesonastatewidelevel.• ParticipateintheCAMHDStrategicPlan

• Collectandreportinformationaboutactivitiesandoutcomesofthoseactivities,andregularlyuse

evaluation results to identiy and address areas that need improvement.



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VT VermontContracting with the Statewide Family Organization

The state has a contract with the Vermont Federation o Families or Children’s Mental Health

(currently $93,000 and indexed or increases) or participating in system o care decision-making andadvisory roles, or developing and carrying out parent and provider training activities, or outreach,

peersupport,andreferral,andconductingspecialprojectstostrengthenparent/familyawarenessabout the system o care and its resources. The Federation also serves as a resource to the state and

local mental health agencies, and works as well to grow parent leadership on children’s mental health. This includes making connections between amily members ready to move into system-level work

and policy groups and those committees and groups looking or new members at the regional andstate levels.

NE Central NebraskaContracting with a Family Organization

The behavioral health system or children and amilies in Central Nebraska operates as a “three leggedstool”, including 1) Region 3 Behavioral Health Services (BHS); 2) Nebraska Department o Health and

Human Services, Central Service Area, Ofce o Protection and Saety; and 3) Families CARE. WhenNebraska received a CMHS grant in 1997, Region 3 called amilies together to talk about how to build

a system o care and to learn what amilies needed. Parents told them they needed an independentamily organization; thus, Families CARE was created to provide support, advocacy, education and

care management services or amilies who have children with emotional and behavioral difculties.Region 3 BHS also contracts with Families CARE or certain evaluation components that measure

wraparound delity and amily and youth satisaction. Initially, CMHS grant unds were used tofundFamiliesCARE.NowRegion3BHScontractswithFamiliesCAREfor$472,000/year(withfunds

saved rom the Integrated Care Coordination — ICCU program case rate). This began as a costreimbursement contract, and then moved to 8% o the case rate, based on actual costs.




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Choices ChoicesContracting with a Family OrganizationChoices contracts with Rainbows, a amily organization in Marion County, Indiana in the amount

o $225,000 per year. The contract supports our ull-time sta, ofces (provided by Choices at aminimal rent), technology, etc. The sta o Rainbows is employed by Choices, and, as such, receives

the Choices benet package. Essentially, the Choices contract supports the inrastructure or theamily organization. Although there may be the perception that the amily organization is “owned” by

Choices, this is the only viable nancing strategy to support the organization. As part o the contract,Rainbows is required to operate a hotline, oer a amily support group with monthly meetings, a

newsletter, trouble shooting, training, and public speaking. Participation in policy making unctionsrelated to Dawn is included in Rainbow’s role, such as participation on the Marion County System o

Care Collaborative. In addition to these unctions, Rainbows sta is paid or additional services ona ee-or-service basis. These include mentoring — either mentoring a child or an entire amily — or

serving as a amily advocate. Family advocates can bill at the market rate or mentors. Theyaccompany the amily to child and amily team meetings and provide other supportive services.

Wraparound Milwaukee Wraparound MilwaukeeContracting with a Family OrganizationWraparound MilwaukeecontractswithFamiliesUnitedforMilwaukeeCountyat$300,000/year.Theamily organization pays or parent stipends to participate in policy and team meetings, conducts

training o care coordinators, employs the education advocate, holds amily events, provides amilyeducation and support, provides 1:1 amily peer support, and publishes a newsletter. There is also a

Youth Advisory Committee, but it is not as well established.

▶ Finance Training and Leadership Development toPrepare Families and Youth for Participation in PolicyMaking

Leadership development activities are nanced in some o the sites to prepare amilies and youth

or participation in policy making and system management activities.

HI Hawaii

Among other activities, the contract with Hawaii Families As Allies (HFAA) includes amily leadershiptraining. The curriculum developed or this purpose is now used nationally. The Leadership

Academy is comprised o three days o training and is held 3 times per year, according to HFAA. Thetraining provides amily members with a range o knowledge and skills, including: understanding

the legislative system, the structure o the mental health system, how to build relationships withpolicymakers, how to speak in ront o an audience, how to make their voices heard, etc.



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AZ Arizona, VT Vermont,Wraparound Milwaukee Wraparound Milwaukee• Arizona has spent $7 million to date in tobacco monies, discretionary and ormula grants and

RBHA investments to pay or training. This has included training and coaching o amilies relatedto policy level participation.

• InVermont , the contract with the Vermont Federation o Families or Children’s Mental Healthprovides training and supports or amilies and others. These trainings ocus on a range o issues,

rom service-related matters to leadership development. A current SAMHSA grant also supportsthe Federation as the Vermont Statewide Family and Consumer Driven Leadership Team “to drive

the implementation, sustainability and improvement o eective mental health and substanceabuse prevention and treatment services or children, youth, young adults and their amilies.”

• InWraparound Milwaukee, the contract with Families United includes this type o training or

amilies.

C. Finance Services and Supports for Families andOther Caregivers

Strategies include:• IncorporatingstrategiesunderMedicaidandothernancingmechanismsthatallow

services and supports to amilies

• Financingfamilyorganizationstoprovideservicesandsupports

▶ Incorporate Strategies Under Medicaid and OtherFinancing Mechanisms that Allow Services andSupports to Families

The sites have incorporated strategies to ensure that services and supports can be provided to

amilies and are not limited to the “identied child.” These include coverage under Medicaid, use o other agencies’ unds, use o ex unds, and use o blended or braided unding structures supported

by case rates.

AZ Arizona

Covering Services and Supports to Families Under Medicaid Medicaid can pay or amily education and peer support, respite, behavioral management skills

training and other supports to amilies i these supports are geared toward improving outcomesor the identied child. The child does not have to be present. Medicaid also can be used to pay

or transportation and interpretation services or amilies. Non-Medicaid allowable services — orexample, certain cultural supports, such as Native healers — can be paid or with non-Medicaid




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dollars in the Regional Behavioral Health Authority (RBHA) capitation. Arizona also denes “amily”broadly. The Medicaid Covered Services Guide provides the ollowing denition o amily and

guidance regarding coverage o services to amily members.

“For purposes o services coverage and this guide, amily is dened as: The primary care giving

unit and is inclusive o the wide diversity o primary care giving units in our culture. Family is abiological,adoptiveorself-createdunitofpeopleresidingtogetherconsistingofadult(s)and/or child(ren) with adult(s) perorming duties o parenthood or the child(ren). Persons within this

unit share bonds, culture, practices and a signicant relationship. Biological parents, siblings andothers with signicant attachment to the individual living outside the home are included in the

denition o amily. In many instances, it is important to provide behavioral health services to theamily member as well as the person seeking services. For example, amily members may need

help with parenting skills, education regarding the nature and management o the mental healthdisorder, or relie rom care giving. Many o the services listed in the service array can be provided

to amily members, regardless o their enrollment or entitlement status as long as the enrolledperson’s treatment record reects that the provision o these services is aimed at accomplishing

the service plan goals (i.e. they show a direct, positive eect on the individual). This also means

that the enrolled person does not have to be present when the services are being provided toamily members.” (See http://www.azdhs.gov/bhs /bhs_guide.pd or Arizona’s Covered ServicesGuide)

At the time o the visit, the Family Involvement Center in Maricopa County had just agreed

todevelopforthechildwelfaresystemcommunity/familysupportsforfamiliesatriskbutwhosechildren are not yet removed rom home (in a “Family-to-Family” approach) in one zip code in the

county. Child welare also was launching a “Building Better Futures” initiative that would assign parentmentors who had had involvement with child welare to at-risk parents. Child welare is hoping to

recruit these parent mentors through its substance abuse providers. Child welare has used the MAPPtraining (National Model Approach to Partnership in Parenting out o Atlanta) and indicated that the

ArizonaDept.ofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)alsoadaptedthismodel statewide with a therapeutic overlay or its therapeutic oster care providers.

HI HawaiiCovering Services and Supports to Families Under Medicaid Medicaid allows services and support to be provided to amilies in addition to the identied child,

and or which the identied child does not necessarily have to be present. For example, amilytherapy is billable even i the child is not present, and or young children, the amily can receiveservices to address issues related to the child, even i the child is not present (e.g., substance abuse).

For services not covered by Medicaid, unds or ancillary services are used to nance services andsupportstofamilies/caregivers.Theroleofcasemanagersincludeshelpingfamiliestoaccessneeded

services through the adult mental health system or other systems or agencies as needed.

Additionally, the contract with Hawaii Families As Allies (HFAA), the statewide amilyorganization,isusedtoprovideservicesandpeersupportstofamilies/caregivers.HFAAwouldliketo

deliver a parent skills training program as a billable service under Medicaid.



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NE Central NebraskaUsing Flexible Funds to Finance Services to Families

The Proessional Partners Program includes ex unds that can be used to pay or treatment and

services when a amily does not have access to a third party payer. When care coordinators requestexible unds, they must show how using the unds will lead to specic outcomes There is no charge

to amilies or the care coordination they receive when they are enrolled in Proessional PartnersProgram or the Integrated Care Coordination (ICCU) program.

At the state level, $310,000 has been set aside ($274,000 rom the Division o Protection and

Saety [child welare] and $36,000 rom the Division o Behavioral Health Services) to serve amilymembers o children served through the ve ICCUs across the state. The care coordinator and amily

determine service needs, and use these ex unds to purchase some o these services.

Choices

Choices andWraparound Milwaukee Wraparound MilwaukeeUsing Case Rates and Blended Funds to Finance Services to Families• InChoices, the case rate approach oers complete exibility to provide whatever services and

supports are needed by the child and amily with no medical necessity or prior authorization

necessary. The child is not required to be present in order to provide services to parents andother amily members, including amily therapy, alcohol or drug treatment, and others. Choices

maintains data on the wide range o services and supports provided to amilies. Flexible undscan be used to nance supports to amilies, including transportation (bus, car repairs, etc.),

housing, utilities, clothing, ood, summer camps (including or siblings), home repairs, and others. The expenditures must be within the care plan structure, and the plan must document how such

expenditures will support the service plan goals or the child and amily.• InWraparound Milwaukee, services to amily members are nanced through its blended undingapproach. It also pays or substance abuse services or parents i necessary and has partnered

with the adult substance abuse system to adopt a wraparound approach.




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▶ Finance Family Organizations toProvide Services and Supports

In some sites, amily organizations can provide specic services and supports, with resources orthese services included in contracts with these organizations or by allowing them to bill Medicaid.

AZ ArizonaUsing Family Organizations as Direct Service Providers

The amily organizations not only receive contracts rom the state and rom individual RegionalBehavioral Health Authorities (RBHAs), but they also can be direct service providers. The Family

Involvement Center (FIC) in Maricopa, or example, is a Community Service Agency and providesdirect services like respite and behavioral coaching. (Subsequent to the site visit, FIC also became

licensed as a behavioral health provider, which allows it to provide case management). Medicaidbillings thus generate revenue or the organization. In addition, each o the Comprehensive Services

Providers (CSPs) in the Value Options network in Maricopa County must have amily support partnerson sta, who are paid or by the managed care system. These amily support partners can provide

services in any location (e.g., school, court, home, etc.).As part o the JK settlement agreement, Medicaid expanded covered services to include a new

provider type, called a “community service agency,” (CSA) to allow amily organizations and others to

be unded like a licensed Medicaid provider. Both FIC and MiKid (the statewide amily organization)became CSAs, authorized to provide certain rehabilitation services. As a CSA, FIC can bill Medicaid

or rehab services, including skills training and development and health promotion, and supportservices, including peer and amily support, respite and personal care services. One challenge noted

by amilies, however, is that they can only provide services to amilies reerred by the CSPs; in otherwords, they cannot serve walk-ins directly. A need or FIC services has to be documented in the child

and amily team plan o care, and amilies access the CFT process through the CSPs. Families notedthat on the adult side, the system unds adult drop-in centers that can serve adults directly, and FIC is

advocatingforasimilararrangementonthechild/familysidewhereFICandMiKidwouldgetdirectservice unding.

HI HawaiiUsing a Family Organization as a Direct Service Provider Hawaii Families As Allies is receiving training to provide Common Sense Parenting. However, there

is concern about shiting this organization to a provider agency, rather than an advocacy and peersupport organization. All provider agencies are now obligated through their contracts to haveparent and youth specialists on sta to address issues and partnerships with amilies and youth. The

requests or proposals (RFPs) or provider agencies speciy this and request the submission o positiondescriptions with other application materials.

Consumer and amily-run services are supported through Medicaid, block grant, and general

revenue unds. Block grant and general unds nance parent partners, parent skills training, peermentoring services or youth, and parent-to-parent supports. An attempt is being made to have all o

these services covered under Medicaid through an amendment to the state plan; approval is pending.



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Choices ChoicesUsing a Family Organization as a Direct Service Provider In Indiana, the amily organization (Rainbows) is a provider o some services. In this role, it is treated

like any other service provider and is paid on a ee-or-service basis or services, such as mentoring.Financing comes rom the case rates. Services provided include amily-to-amily mentoring. In

addition, members o the organization currently are being trained to oer a amily training program,Common Sense Parenting. Currently, the county child welare system contracts with Rainbows to

provide Common Sense Parenting and has begun to provide this service to Dawn amilies. Thetrainers will be paid to provide this training. Rainbows also provides parent support groups, nanced

as part o the contract with the amily organization.

VT Vermont, NJ New Jersey andWraparound Milwaukee Wraparound Milwaukee

Using Family Organizations as Direct Service Providers• Vermont’s Department o Mental Health has a contract with the Vermont Federation o Families

or Children’s Mental Health (currently $93,000 and indexed or increases) or a range o decision-

making and advisory roles, as well as or some direct services. Direct services include developingand carrying out parent and provider training activities and peer support.

• InNew Jersey , Family Support Organizations (FSOs) are unded via contract with the state in

every region and are nanced using a combination o state general revenue and Medicaidadministrative case management dollars. They are amily-run, not-or-prot organizations

designed to ensure that the amily voice is incorporated at the system and service level. TheFSO acts as peer support or amilies and as a guide or proessionals. The Care Management

Organizations are required to utilize the services o the FSOs by way o a Family SupportCoordinator. The FSOs provide advocacy, inormation, reerral, education, and mentorship.

• InWraparound Milwaukee, Families United is contracted to provide amily peer support andeducational advocacy.




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V. Financing to Improve Cultural and Linguistic Competence and Reduce Disparities in Care

A core value o systems o care is that they are culturally and linguistically competent, withagencies, programs, and services that respect, understand, and are responsive to the cultural,

racial, and ethnic dierences o the populations they serve. In recognition o the unique culturalbackgrounds o children and amilies served within systems o care, nancing strategies are

needed to incorporate specialized services, culturally and linguistically competent providers,and translation and interpretation. Financing strategies also are needed to support leadership

capacity or cultural and linguistic competence at the system level and to allow or analysiso utilization and expenditure data by culturally and linguistically diverse populations, which

contributes to the identication o disparities and disproportionalities in service delivery.Systems o care also must incorporate strategies to proactively address the disparities in access

to care and in the quality o care experienced by culturally and linguistically diverse groups, aswell as in underserved geographical areas.


A. Provide Culturally and Linguistically Competent Services and Supports

B. Reduce Disparities in Access to and Quality of Services and Supports

A. Provide Culturally and Linguistically CompetentServices and Supports

Strategies include:• Financingspecializedservices

• Incorporatingnancingandincentivesforculturallyandlinguisticallycompetentproviders,

nontraditional providers, and natural helpers

• Financingtranslationandinterpretation

• Analyzingutilizationandexpendituresbyculturallyandlinguisticallydiversepopulations

• Financingculturalcompetencecoordinatorsand/orleadershipcapacityatthestateorlocal

levels

▶ Finance Specialized ServicesSome o the sites cover “cultural” services, that is, specialized services that are specically designed

to respond to the ethnic and cultural characteristics o children and amilies served.



V . F i n a n c i n g t o I m p r o

v e C u l t u r a l / L i n g u i s t i c

C o m p e t e n c e a n d R e d u c e D i s p r o p o r t i o n a l i t y

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AZ ArizonaCovering Cultural ServicesMany covered services within the managed care system, such as counseling, can be provided in

any location, including locations that may be more culturally appropriate, such as a sweat lodge. Translation and interpretation are services covered by Medicaid. Certain cultural activities, such as

traditional Native healing, can be paid or by the managed care system, though not with Medicaiddollars, but using the other dollars in the system. The managed care system also uses “promotores,”

outreach workers and counselors or the Latino community, which it covers in a number o ways, e.g.,as “health promotion,” amily support, or peer support under Medicaid.

The state used unding rom a ederal Center or Substance Abuse Treatment grant to develop a

cultural competence training curriculum. The state also developed a Practice Improvement Protocolrelated to cultural competence and requires RBHAs to do cultural organizational sel-assessments.

For inormation about Arizona’s Practice Improvement Protocol, see: http://www.azdhs.gov/bhs/

provider/sec3_23.pdf

HI HawaiiCovering Cultural Services

The entire state is highly diverse with a multi-ethnic and multi-cultural population. There isnancingforspecializedservicestoculturally/linguisticallydiversepopulations.Forexample,

interpretative services are provided through exible unding or ancillary services and supports, asare nontraditional services and supports, such as martial arts provided as a therapeutic service or

children. Traditional healer services and other Eastern approaches to treatment (such as Asian healerservices) are unded under Medicaid or mental health general und resources. The state is attempting

to integrate Eastern and Western approaches to medicine to meet the needs o the diverse culturaland ethnic groups services, including Chook, Samoan, Micronesian, Chinese, and other cultures.

AK Bethel, AlaskaCovering Cultural ServicesYukon-Kuskokwim Health Corporation (YKHC) sponsors the ollowing projects that are designed to

oer and support culturally competent services and supports:

Family Spirit Project Family Spirit Project is a collaborative eort o the communities o the Yukon-Kuskokwim region,the Department o Health and Social Services, Division o Alcohol and Drug Abuse, the Ofce

o Children’s Services, the YKHC and other community providers in the Delta. Emphasizingtraditional amily lie and values, the collaboration builds a community development model to

strengthen amilies so that children will be saer in their homes. Parents who could lose theirparental rights due to abuse and neglect o their children are encouraged to enter substance

abuse treatment in a culturally appropriate and supportive manner. These parents are a prioritypopulation or YKHCs substance abuse treatment services.




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Community Holistic Development Drawing on local resources, the Holistic Development Program conducts presentations ongrie processes, youth conerences, healing circles, “Spirit Camps,” and other health promotion

activities. This program integrates the cultural, traditional, and spiritual values o the people in

partnership with other amily-based counseling services.

Choices ChoicesCovering Cultural ServicesIn Choices, any service can be provided within the case rate structure, depending on the childand amily’s need and what is included in the individualized care plan. I the child and amily team

identies a service need that is not readily available, it is the responsibility o the care coordinatorand community resource manager to look or an appropriate resource. Culture and language are

considered by child and amily teams in developing the service plan and identiying resources to

provide services and supports. For example, some Arican American youth have attended a campprogram that uses a retreat approach or rituals around the transition rom boys to men.

▶ Incorporate Financing/Incentives for Culturally andLinguistically Competent Providers, NontraditionalProviders, and Natural Helpers

Sites have incorporated nancing and various types o incentives or culturally and linguistically

competent providers, including natural helpers and traditional healers.

AZ ArizonaIncorporating Requirements in Contracts

There are clear expectations in Regional Behavioral Health Authority (RHBA) contracts with providers

related to serving culturally diverse populations, and scal penalties may be attached to serving aninadequate number o culturally diverse members. These are specic to each RBHA contract. There

also are requirements or recruitment and retention o Latino providers, and RBHAs are requiredcontractually to have specialized Native American providers in their networks.

Value Options (VO) in Maricopa County indicated that the state will be conducting cultural

competenceassessmentsofprovidersandmayimplementdirectincentivestoprovidersand/orto

RBHAs in the uture. VO also indicated that it has implemented both incentives and sanctions or theComprehensive Service Providers in its network related to access or the Latino population. Providers

could receive up to $10,000 a month depending on their meeting certain access standards (e.g.,$2500 per month i reaching 40% o Latino eligibles).

The state also reported that it is working on a loan orgiveness program or various types o

behavioral health sta. (Note. The legislature approved unding or this in scal year 2007).






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Nontraditional providers, paraproessionals and natural helpers can be included in managed carenetworks as community service, or direct service, agencies. For example, the Family Involvement

Center (FIC) in Maricopa County and Boys and Girls Clubs in other parts o the state are providers.Also, FIC is developing a teaching video and toolkit as part o its contract with the state (nanced

through ederal State Inrastructure Grant dollars) on use o natural supports. (Note. This video andtoolkit are now available. Contact: http://www.familyinvolvementcenter.org .)

Also, providers reported that there are “inormal incentives” provided by VO in Maricopa. For

example, VO loaned a sta person or a year to the People o Color Network in Maricopa to help themdevelop the inrastructure needed to join the VO Medicaid network.

HI HawaiiUsing Financial IncentivesFinancial incentives are oered or culturally and linguistically competent providers, and provider

agencies generally have culturally diverse sta and sta able to speak many languages. The Child andAdolescent Mental Health Division (CAMHD) pays higher rates i the clinician is uent in the needed

language. Providers under contract with CAMHD are required to submit a cultural competence policyto ensure that all employees and subcontractors are trained and supervised in providing services in a

culturally aware manner, including requirements or cultural assessment and cultural considerationsin the treatment planning process. There also are nancing mechanisms or nontraditional services

and natural helpers such as Native Hawaiian healers and Asian healers, both unded with Medicaidand mental health general und resources.

NE Central NebraskaProviding Language Classes for ProvidersRegion 3 Behavioral Health Services unds and hosts a weekly Spanish language class or its Region 3

sta, Families CARE sta and providers.




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Choices ChoicesRecruiting and Developing Culturally Appropriate ProvidersChoices has worked with minority communities to identiy culturally and linguistically competent

providers, as well as nontraditional providers appropriate or particular racial and ethnic populations.Work with the Arican American community has resulted in the identication o Arican American

treatment oster parents who serve predominantly Arican American youth. In addition, Choicescollaborates with a church, paying or an additional sta person to enable the provision o ater

school care or youth in this natural, culturally appropriate community setting. Oten, culturallyappropriate providers are developed on an individual case basis. For example, collaboration with

a Korean church was undertaken to meet the support needs o a Korean youth and amily. Theresources developed or individual youth and amilies become part o the database and are shared

among sta; these resources can then be enlisted in the uture on behal o other clients.

Choices has engaged consultants both in Indiana and Ohio to assist in doing culturalassessments and in developing strategies to improve cultural and linguistic competence. Consultants

also have worked with providers in the provider network (including mentors, therapists, therapeutic

oster care agencies, and others) to provide training related to cultural and linguistic competence. Inaddition, Choices has worked internally to add diversity to its own sta. The sta now is 40% AricanAmerican.

Wraparound Milwaukee Wraparound MilwaukeeIncluding Diverse Providers in Network

There are over 40 racially and ethnically diverse providers in Milwaukee’s provider network. Also,

the system will pay or interpretation and translation services and uses nontraditional providers.It also tracks use o inormal helping supports through its management inormation (MIS) system.

Wraparound Milwaukee believes that its ee-or-service structure does allow diverse providersto compete eectively and that lack o a “guarantee” or a certain service amount has not been an

impediment to diverse providers’ participating in the provider network.






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▶ Finance Translation andInterpretation Services

All o the sites nance translation and interpretation services either with Medicaid, managed caresystem resources, or with exible unds.

AZ Arizona; HI Hawaii; NJ New Jersey; VT Vermont;AK Bethel, Alaska; NE Central Nebraska, Choices Choices,

and Wraparound Milwaukee Wraparound MilwaukeeFinancing Translation and Interpretation with Medicaid,Managed Care System Resources, or Flexible Funds• In Arizona, translation and interpretation are paid or by the managed care system and are a

covered Medicaid benet. The sta o the Family Involvement Center in Maricopa is 35% Latinoand oten provides translation services.

• InHawaii , there is nancing or translation and interpretation services through exible undingor ancillary services and supports. The most common languages include Mandarin, Korean,Ilocano, and Tagalog. CAMHD also produces documents in large print and on CD or people with

vision impairments.

• InNew Jersey , translation and interpretation are paid or by the CSA and are a covered Medicaid

benet.

• InVermont , the system o care nancing mix supports translation and interpretation services asneeded. Local agencies typically subcontract or these services. Medicaid pays or them.

• InBethel, Alaska, the Yukon-Kuskokwim Health Corporation provides and pays or translationand interpretation services using a mix o unding sources.

• InCentral Nebraska, Medicaid reimburses or interpretation services during treatment. Region 3

maintains a list o interpreters and translators they can call upon.

• InChoices, translation and interpretation are nanced on a ee-or-service basis as needed,including interpretation or persons with hearing impairments. Choices has sta members who

are Hmong and Hispanic and, thus, has internal capability in Hmong and Spanish.

• InWraparound Milwaukee, the system will pay or interpretation and translation services, using

its blended unding pool.




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▶ Analyze Utilization, Expenditures, and Outcomes byCulturally and Linguistically Diverse Populations

Analysis o utilization, expenditure, and outcome data by culturally and linguistically diversepopulations allows systems o care to identiy potential problems or disproportionalities in access

to services, in service utilization, and in the quality and outcomes o care.

AZ Arizona Analyzing Data by Racial/Ethnic Groups Thesystemisabletoanalyzeutilizationandcostsbyracial/ethnicbreakdownbutdoesnotrun

this analysis regularly. Instead, it engages in special studies, or example, a study looking at under-

utilization o services by the Latino community, and another long term project involving juvenile justice and Value Options to look at over representation o youth o color in the juvenile justice

system.

HI Hawaii Analyzing Data by Racial/Ethnic GroupsServiceutilization,expenditures,andoutcomesareanalyzedbyculturally/linguisticallydiverse

populations. No dierences in outcomes by specic groups have been ound; the entire state’spopulationisculturally/linguisticallydiverse,andmostyouthandtheirfamiliesaremulti-ethnic.

However, better outcomes have been ound or youth eligible or the Medicaid program than non-Medicaid eligible youth, regardless o cultural group. This is attributed to the richer service array

available or the Medicaid eligible population.

Wraparound Milwaukee Wraparound Milwaukee Analyzing Data by Racial/Ethnic Groups Thesystemdoesanalyzeutilizationandcostsbyracial/ethnicbreakdownandanalyzes

disproportionality and disparity issues. It has been able to tap into ederal Disproportionate Minority

Connement (DMC) dollars through its partnership with the juvenile justice system. Specically,Wraparound Milwaukee has reduced placement o Arican American youth in corrections acilities,which enables the juvenile justice system to draw down DMC monies, which, in turn, it uses to pay

Wraparound Milwaukee.






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▶ Finance Cultural Competence Coordinators and/orLeadership Capacity at State or Local Levels

Strategies include:

• Incorporatingnancingstrategiestoreduceracialandethnicdisparitiesinaccessand quality o care

• Financingoutreachtoculturallyandlinguisticallydiversepopulations

• Incorporatingstrategiestoreducegeographicdisparities

• Financingtheuseoftechnologytoserveunderservedgeographicareas

• Financingtransportation

Some o the sites nance leadership or cultural and linguistic competence — either cultural

competencecoordinatorsatstateand/orlocallevelsorvarioustypesofculturalcompetence

advisory committees or teams.

AZ Arizona, HI Hawaii, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Financing Cultural Competence Leadership• In Arizona, the Chie o Substance Abuse Prevention in the Arizona Department o Health

Services (ADHS) reportedly is a leader in the cultural competence eld and has served in an adhoc position as coordinator or cultural competence activities. At the time o the study visit, the

state was looking at use o discretionary grant dollars to und a cultural competence coordinatorposition. There is a three-year old Cultural Competence Advisory Committee, which the Chie

o Substance Abuse Prevention chairs, and which has developed a ramework or culturalcompetence in the behavioral health system. The committee includes representation rom child

welare, juvenile justice, amilies, etc. The committee devoted its rst oundational year to lookingat research and data on utilization, disparities, etc. There are three committees: one on data, one

ontranslation/interpretation,andoneontraining(chairedbytheADHStrainingcoordinator).

Each Regional Behavioral Health Authority (RBHA) also is required to have a cultural expert and to

conduct a cultural competence organizational sel-assessment that leads to a plan or each RBHA. The committee is developing a tool to measure cultural competence at the RBHA level.

RBHA Cultural Competency Plans, at a minimum, must address the ollowing:

– Identication o diverse population groups in the service area

– Determining and addressing any disparity in access and utilization

– Outreach strategies to diverse communities– Recruitment and retention strategies to attract and develop culturally competent sta

– Obtaining input and consultation rom diverse groups in its service area

– Collaboratively working with local diverse groups to review service delivery to individuals,amilies, communities




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– Receiving consultation on planning, providing, evaluating and improving services to diverseindividuals, amilies and communities

– Regular quality monitoring program with indicators that evaluate both the quality and

outcomes o services with respect to culturally diverse populations

– Use multi-aceted approaches to assess satisaction o diverse individuals, amilies andcommunities

– Monitoring service delivery to diverse individuals

– Ensuring identication o minority responses in the tabulation o client satisaction surveys

– Ensuring cultural competency training is required and obtained by all sta at all levels o the

organization(s) providing behavioral health services

– Ensuring persons’ and amilies’ cultural preerences are assessed and included in thedevelopment o treatment plans.

• InHawaii , as o July 1, 2006, in the Child and Adolescent Mental Health Division’s (CAMHD) new

requestforproposals(RFP),agencieswereaskedtoestablishpositionsforculturalcoordinators/

specialists. There is no ormal cultural competence coordinator at the state level, although a sta

member within CAMHD plays that role.• InChoices, there was a cultural competence coordinator during the time that Choices had a

ederal system o care grant, Currently, Choices has a “cultural competence team” that is ongoingand meets quarterly with an outside consultant. The team, currently comprised o Choices sta

and representatives o a number o community agencies, receives training, shares resources,discusses diversity challenges, and oers support and suggestions to each other. Choices hosts a

Diversity Team list serve so that members can ask questions or share resources electronically.

• InWraparound Milwaukee, there is a cultural competence committee.






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B. Reduce Disparities in Access to and Quality of Services and Supports

▶ Incorporate Financing Strategies to Reduce Racial

and Ethnic Disparities in Access and Quality of Care Arizona has implemented strategies to reduce racial and ethnic disparities in care, includingoutreach, service provision in culturally appropriate sites, special studies to identiy and elucidate

disparities, and requirements or Regional Behavioral Health Authorities to serve under-servedpopulations (such as the Latino population). Financial incentives in Maricopa County reward

providers or meeting access standards or the Latino population.

AZ Arizona The managed care system pays or various outreach activities, uses general revenue and block grantdollars to pay or services that are not Medicaid-covered, allows provision o Medicaid services at

sites that may be more culturally appropriate, conducts special studies in an eort to identiy andreduce disparities, and incorporates contract requirements or Regional Behavioral Health Authorities

(RBHAs) to serve under-served populations, such as the Latino population. Arizona DepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS),aspartofits“NewFreedom”

transormation agenda, issued a new advocacy request or proposals (RFP) that called or structuredoutreach to all culturally diverse populations, including, or example, development o a new Latino

amily organization and the involvement o aith-based organizations to reach out to the AricanAmerican community. Value Options (VO) in Maricopa County has implemented both incentives and

sanctions or Comprehensive Service Providers related to access or the Latino population. Providerscan receive up to $10,000 a month depending on their meeting certain access standards (e.g., $2500

per month i reaching 40% o Latino eligibles). The state also has developed practice improvementprotocols (PIPs) and a curriculum on cultural competency. ( See: http://www:azdhs.gov/bhs/

policies/cd1-2.pdf )

▶ Incorporate Financing Strategies to ReduceGeographic Disparities

Strategies to reduce geographic disparities were ound in several sites.

AZ ArizonaEstablishing Higher Rates for Home and Community-Based Services

The ee-or-service rate schedule intentionally pays more or home and community-based versus

clinic-based services in an eort to get services to rural areas, among other goals. Also, there isexibility in the capitation paid to Regional Behavioral Health Authorities (RBHAs) that allows them to

pay more or getting providers to rural areas.




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HI HawaiiProviding Incentive Pay to Work in Underserved Areas

There are special nancing mechanisms to provide services in underserved geographic areas.

Incentive pay that is 10% above the standard pay scale is oered as an incentive to work inunderserved areas. In addition, transportation is paid or providers to y to the Islands, and travel time

is considered billable time. Service utilization patterns and expenditures are analyzed by geographicareas. According to providers, the provider array is dierent on the smaller islands, and there is a cost

dierential in providing care in remote areas or areas with a smaller population base. These actorscreate geographic disparities in the availability o proessionals and services.

AK Bethel, AlaskaUsing Village Health Clinics

The entire region is an underserved geographic area. The Yukon-Kuskokwim Health Corporation(YKHC) has put extensive resources into the building and development o village health clinicsoering both health and behavioral health services. YKHC’s nance system is set up by village and

type o service. The system has the capacity to analyze service utilization and expenditures byvillages.

Like YKHC, the school districts and the Department o Juvenile Justice struggle to recruit and

retain sta to work in the villages. Currently in Bethel, the probation agency is oering incentives orpeople to get a college degree with an internship that provides needed work experience. The goal is

that these individuals will return to Bethel and become probation ofcers.

▶ Finance the Use of Technology to Serve Underserved

Geographic AreasExamples o using technology to address geographic disparities were ound in the sites. Arizona,

Hawaii, Vermont, and Central Nebraska are using strategies including telemedicine, video-

conerencing, web-based technology, and teleconerencing or services including medicationmanagement, psychological and psychiatric evaluation, consultation, and education.

AZ ArizonaUsing Telemedicine

The state has set up a telemedicine system serving remote areas, using ederal grant dollars.Medicaid can then be used to pay or certain services provided through the telemedicine system,

such as medication management, psychological evaluation, and health promotion and education(or example, teaching parents about attention decit-hyperactivity disorder). At the time o the site

visit, ArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS),

MiKid (the statewide amily organization) and Family Involvement Center in Maricopa County were

developing an issue paper or the state Medicaid agency on the potential o covering telephonesupport services.






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HI HawaiiUsing Teleconferencing and Video-Conferencing

Teleconerencing or medication management is used in some o the Islands and is nanced

by General Fund and Medicaid resources. The state has not been as successul in using video-conerencing due to some o the logistical and technical issues involved. The state has a statewide

video-conerencing system. This requires participants to go to specic locations (typically in healthcenters); advance scheduling is required. The system is used or interviewing, training, meetings o

providers, provision o psychiatric consultation, etc. The only direct service that is provided throughthis system is medication management. Participants have indicated that a two-second delay involved

in video-conerencing has been problematic.

VT VermontUsing Web-Based Technology for Psychiatric Consultation and TelemedicineVermont is experimenting with the delivery o psychiatric consultation services using technology(e-mail and web-based “ace-to-ace” encounters) to provide services in underserved geographic

areas. A Department o Labor Grant supports links or telemedicine in three northern very rural andunderserved Vermont counties. The state is exploring ways to do more using technology and create

additional unding options.

NE Central NebraskaUsing Telemedicine and TeleconferencingNebraska was one o the rst rural telemedicine sites unded by the ederal government. Throughunding rom the Nebraska Ofce o Rural Health, the Richard Young Hospital is able to conerence

in amilies rom 23 counties. They also do medication checks via teleconerence. South CentralBehavioral Services soon will have telemedicine capacity in two sites.




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▶ Finance Outreach and Transportation The sites nance outreach to culturally diverse populations and transportation to increase access toservices and reduce disparities. .

AZ ArizonaRequiring Outreach to Culturally Diverse Populations and “Promotores” Financed by Managed Care SystemOutreach activities can be paid or out o the managed care system. Arizona Department o

HealthServices,DivisionofBehavioralHealthServices(ADHS/BHS),aspartofits“NewFreedom”

transormation agenda, issued a new advocacy request or proposals (RFP) that called or structured

outreach to all culturally diverse populations, including, or example, development o a new Latinoamily organization and the involvement o aith-based organizations to reach out to the Arican

American community. The managed care system also uses “promotores,” health promoters, to reachout to the Latino community. Value Options in Maricopa has set a target or itsel o reaching 40% o

the eligible Latino youth population.

AZ Arizona and HI HawaiiFinancing Transportation for Families and Providers• In Arizona, transportation is a covered service in the managed care system. The system can

either pay a amily or its transportation costs, or pay to bring the service to the amily, or pay atransportation provider.

• InHawaii , transportation is paid or amilies to attend child and amily team meetings or orservices only available on another island. Additionally, transportation is paid or providers to y to

the Islands, and travel time is considered billable time.



V I . F i n a n c i n g t o I m p r o v e t h e W o

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VI. Financing to Improve the Workforce andProvider Network

Systematic attention is needed to develop a workorce with the attitudes, knowledgeand skills needed to administer systems o care and to provide services within them.

Financing strategies are needed to support a broad, diversied network o providersthat is capable o providing the wide ranges o services and supports oered through

systems o care and is committed to the system o care philosophy underlying servicedelivery, such as accepting and valuing the inclusion o amilies and youth as partners in

service delivery and the shit rom oce and clinic-based practice to an individualizedhome and community-based service approach. In addition to supporting a broad

provider network, workorce development strategies are needed to address pre-servicetraining programs to prepare individuals or work within community-based systems o

care, as well as to implement in-service training strategies to help the existing workorceto inuse the new philosophy, values, approaches, and evidence-based practices into

their work. The payment rates established or providers must allow systems o care toattract and retain qualied providers within their provider networks and must create

incentives or providers to develop and provide home and community-based services.


A. Support a Broad, Diversifed, Qualifed Workorce and Provider Network

B. Providing Adequate Provider Payment Rates

A. Support a Broad, Diversifed, Qualifed Workorceand Provider Network

Strategies include:• Financingabroadarrayofproviders

• Financingworkforcedevelopmentactivities

▶ Finance a Broad Array o Providers The sites have implemented several strategies to nance a broad array o providers.




AZ ArizonaCreating New Types o ProvidersDevelopment o a new “community service agency” designation within the managed care system

opened up the provider network to new provider types, including amily organizations andcommunity agencies, who do not have to be licensed as an outpatient mental health clinic to provide

certain Medicaid services. These services include: respite, peer support, habilitation, skills training,and crisis services. Also, there is a category o outpatient provider called a paraproessional, whose

services can be reimbursed under Medicaid. There also is a category called, habilitation workers, thatwas derived rom the developmental disabilities long term care system.

As Maricopa County redirected spending rom residential treatment centers, it has been able

to expand its use o community service agencies, with over 20 contracts currently providing suchservices as mobile crisis, behavioral coaches, amily peer support, etc. To support involvement o

these community and amily-run organizations, Value Options (VO) in Maricopa County pays them ona prospective basis — 12% o the contract each month; eventually, VO wants to move them to a ee-

or-service basis.

HI HawaiiFinancing a Broad Array o Providers

The state nances a broad array o providers, including nontraditional providers (such as Native

Hawaiian healers) through Medicaid and General Fund resources. Supporting a broad, diversiedprovider array is more challenging on the smaller islands, as there is a cost dierential in providing

care in remote areas or areas with a smaller population base. These actors create geographicdisparities in the availability o proessionals and services.

Choices ChoicesBuilding an Extensive Provider Network

The fexibility in service delivery is supported by an extensive provider network comprised o both

agencies and individual practitioners under contract with Choices. Some providers may oer a singleservice, while large agencies may oer multiple services. The network as a whole oers a unique

blend o traditional and ormal services coupled with nontraditional and alternative services andsupports. Providers are not at risk, but rather are paid on a ee-or-service basis. For each individual

youth and amily, providers are identied to provide the services specied in the service coordinationplan. Private psychiatrists or psychiatrists rom the aliated community mental health centers are

used or psychiatric assessment and or medication trials and ollow-up. (Choices resources cover

the cost o medications or children who do not have coverage through Medicaid or through privateinsurance, or or those whose insurance coverage is exhausted.) In addition, Choices may contract orspecialized services to meet a particular need. In this way, the provider network can be expanded and

enhanced in a fexible and timely manner in response to the service needs presented by children andtheir amilies. The role o the community resource manager in each location is critical in developing

and managing the provider network.




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Wraparound Milwaukee Wraparound MilwaukeeBuilding an Extensive Provider Network Wraparound Milwaukee has a very large provider network o over 200 providers, which is diverse

and meets the qualications Milwaukee has developed. Included in the provider network are bothindividuals and agencies, including over 40 racially and ethnically diverse providers. The network includes clinical treatment providers as well as providers o supports, such as respite and mentoring.

No ormal contracting with providers is used. Wraparound Milwaukee develops service denitions,rates and standards or 85 dierent services and supports. Community agencies and individual

practitioners are invited during the rst 90 days o each calendar year to apply to provide one or moreo the services. Wraparound Milwaukee then credentials providers to be part o a qualied provider

pool. Child and amily teams that develop plans o care and amilies can draw rom any providerson the list. Providers are paid on a ee-or-service basis. For certain high cost and restrictive services,

such as psychiatric hospitalization, residential treatment and day treatment, prior authorization isrequired. For most services, authorization to a provider to provide services is simply based on a care

coordinator’s entering the requested services (based on the plan o care developed by the child and

amily team), units needed, and name o provider into the automated inormation system. Providersare immediately notied on-line o units o service approved or the upcoming month. The broadprovider network is overseen by Wraparound Milwaukee’s Quality Assurance Oce.

▶ Finance Workorce Development ActivitiesA variety o workorce development activities is nanced in the sites.

AZ

ArizonaFinancing Training and Coaching The state has used general revenue, block grant, tobacco unds, and ederal State Inrastructure Grant(SIG) discretionary dollars to pay or training and coaching. Much o the training has ocused on

Arizona’s vision and implementation o the 12 system o care principles, or example, partnering withamilies, implementing a child and amily team (i.e., wraparound) approach, cultural competence, and

the requirements o the reormed system o care. There also has been training related to particularsubpopulations, such as children in child welare and the 0-3 population.

The Arizona vision states: “In collaboration with the child and amily and others, Arizona will

provide accessible behavioral health services designed to aid children to achieve success in school,live with their amilies, and become stable and productive adults. Services will be tailored to the child

and amily and provided in the most appropriate setting, in a timely ashion and in accordance with

best practices, while respecting the child’s and amily’s cultural heritage.”

The 12 Principles include:

• Collaborationwiththechildandfamily

• (Priorityon)Functionaloutcomes




• Collaborationwithothers

• Accessibleservices

• Bestpractices

• Mostappropriatesetting

• Timeliness

• Servicestailoredtothechildandfamily

• Stability

• Respectforthechild’sandfamily’sculturalheritage

• Independence

• Connectiontonaturalsupports.

In the rst year couple o years o implementation ater the JK agreement, the state contracteddirectlyfortrainingandcoaching.Beginninginthethirdyear,itgavetrainingdollarstothe

RegionalBehavioralHealthAuthorities(RBHAs),andRBHAshavetakentheleadingettingcertaintraining curricula developed. For example, in Maricopa County, Value Options (VO) took the lead

in developing 18 hours o pre-service training or oster parents wanting to be therapeutic osterparents. The state also has developed statewide training in a number o areas. For example, at

the time o the site visit, the state had ormed a workgroup with child welare to develop trainingrelated to trauma and permanency, and was in the process o retaining a national consultant to help

develop training curricula. The state also used the SIG grant to bring up telemedicine or a numberofthetribes,identiedsubstanceabuseleadsineachRBHAandsentthemtoaweekoftraining,

and sponsored a conerence related to methadone maintenance. Also, child welare training or newworkers in the child welare system includes training provided by the Family Involvement Center and

VO on the child and amily team process; at the time o the visit, the two systems were working on amore in-depth training.

ArizonaDepartmentofHealthServices,DivisionofBehavioralHealthServices(ADHS/BHS)

also indicated that it is looking at ways o trying to build stronger coaching and supervision into the

behavioral health system to shore up training gains. This is a current priority.

HI HawaiiImplementing a State-Level Practice Development Focus and Contractingwith Universities TheChildandAdolescentMentalHealthDivision(CAMHD)nancesaProviderRelationsLiaison

position within CAMHD to serve as a communication linkage with providers and to promote positiverelationshipswithCAMHD.ThebroadgoaloftheProviderRelationsLiaisonistostrengthenthe

relationship between CAMHD and its network o contracted providers. General Fund and Title IV-E

resources are used to nance workorce development activities.A Practice Development Section o CAMHD’s Clinical Services Oce oversees a range o activities

on evidence-based clinical practice and care coordination practice or CAMHD sta, contractedproviders, sta o other state agencies, and amilies o children and youth with special needs. The

section’s ocus includes care coordination and provider practice in areas including evidence-basedinterventions, evidence-based practice components, core practice elements such as assessment and




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engagement, measurement tools such as the Child and Adolescent Functional Assessment Scale(CAFAS)andtheChildandAdolescentLevelofCareUtilizationSystem(CALOCUS),nowknownas

the CASII (Child and Adolescent Service Intensity Instrument), etc. Practice development specialistpositions are nanced within CAMHD through general unds to provide consultation, training,

and supervision to sta and contracted providers. Training on “parents as partners” is part o mosttraining, and amily members participate as trainers. Consultants are contracted to provide training

as needed. Materials, training, supervision, consultation, practice guidelines, and other resourcesdeveloped or identied by the Practice Development Section are disseminated to Family Guidance

Centers, provider agencies, partner agencies, and amilies through courses, consultations, small groupdiscussions,casereviews,conferences,orwrittenmaterials.APracticeDevelopment/ClinicalTraining

Plan or 2006–2007 includes goals with objectives and specic strategies that will be implemented bypractice development specialists and other CAMHD sta and consultants. Goals ocus on supporting

the implementation o evidence-based practices among clinicians; improving practice within CAMHDcontracted residential programs; improving the transition to adulthood or CAMHD youth; improving

planning or crisis prevention and intervention; identiying youth in need o intensive mental healthservices at younger ages; strengthening amily involvement in treatment and in planning and policy

throughout the system o care; implementing strong models o clinical supervision throughout thesystem; strengthening core components on children’s mental health in higher education curricula;

developing a comprehensive system o care or youth with sexualized behavior; developingstandards o practice or the CAMHD system; and developing policies, procedures, and plans that

refect clinical best practices and commitment to system o care principles.

Pre-service education is provided through signicant contracts with the state university and smallcontracts with some private universities. Through these agreements, university aculty teach courses

on systems o care, evidence-based practices, and other subjects critical to the public children’smentalhealthsystem.UniversityfacultymembersalsoserveonvariousCAMHDcommittees.In

addition, the contracts provide a mechanism or trainees across mental health disciplines to rotatethrough the children’s mental health system to obtain real lie experience. Contracts range in size

rom under $200,000 to about $600,000. These contracts have been strategically used as mechanisms

to shape university curricula to support the priorities and needs o the public children’s mental healthsystem.AnexampleofacontractwiththeUniversityofHawaiispeciesthattheUniversitywill:

• Collaborateonthedevelopmentofopportunitiesforinterdisciplinaryseminars,lectures,and/or

discussions when appropriate with the Schools including Psychiatry, Psychology, Social Work, andNursing

• Provideinterdisciplinaryseminarsandlecturesonsystemofcareprinciplesandvalues,family-

driven services, youth-guided services, cultural competency in mental health, evidence-basedservices (psychosocial interventions, prevention programs, and psychopharmacology), public

child-serving systems (child welare, education, mental health, and juvenile justice), communitymental health, and core components o intensive clinical case management services

• Provideyouthandfamily-ledvisits,discussions,andlectures

• TraineesshallattendandparticipateinthemonthlyEvidence-BasedServicesCommittee• Providequarterlyreportsofservicesprovidedbytraineesandprogresswithinterdisciplinary

lectures/seminars

• ParticipateinCase-BasedReviewtrainingandobservations




AcontractwiththeUniversityprovidespsychiatristsexperiencedinchildandadolescentpsychiatric services to provide clinical and administrative services within the state’s Family Guidance

Centers, youth correctional acility, and other sites, including medical and clinical supervision. Inaddition, the contracting mechanism is used to secure psychiatric residents to perorm services in

child and adolescent psychiatry in the Family Guidance Centers, including: diagnostic evaluations,ongoing psychiatric treatment, psychotherapy (individual, amily, and group), prescribing and

monitoring medications, maintaining medical records, consultation to provider agencies, educationalseminars and case consultation to Family Guidance Center sta, mental health education to the

community (including police departments), and research in community and cultural child psychiatry.Similarly,acontractwiththeUniversity’sSchoolofSocialWorkprovidestraineesattheMaster’slevel

to work in the children’s mental health system, and a contract provides graduate level psychologystudents to participate in CAMHD’s evaluation activities. Doctoral level psychology students also

arecontractedtoprovideservicesinFamilyGuidanceCenters.AnothercontractwiththeUniversityestablishesanAdvancePracticeRegisteredNurse(APRN)programinchildandadolescentmental

health nursing or qualied students to prepare them to integrate with CAMHD’s children’s mentalhealth system to provide services.

NJ New JerseyCreating a Behavioral Research and Training InstituteFinancing or these activities is built into all aspects o the children’s behavioral health system.

Training and technical assistance are available to key sta at all levels and are ongoing. The statecontractedwiththeUniversityofMedicineandDentistryofNewJerseytobethescalagentfor

trainingandtechnicalassistanceresources,andtheUniversitycreatedtheBehavioralResearchand Training Institute to provide such services. Choosing this design allowed fexibility in using

dollars to meet the technical assistance and training needs o sta. The state also has built in certain

requirements or workorce development activities. All new sta has to go through training ororientation on the system o care, and the state also provided work specic training, e.g. all CareManagement Organizations are trained to use the assessment and screening tool relevant to their

job. New Jersey also has web-based certication in use o the Child and Adolescent Needs andStrengths (CANS) screening and assessment tools.

Choices ChoicesUsing Community Resource Managers and Training CoordinatorsPrior to contracting with providers to become part o the network, eorts are made to assess their

competencies, as well as their values and belies regarding the care o children, amily involvement,strengths-based practice, cultural issues, and the like to ensure consistency with Choice’s philosophyand approach. The community resource managers provide training opportunities or providers in a

variety o orms, including brown bag “lunch and learns.” Quarterly orums are held with providers inthe network to discuss themes, trends, the philosophy o care, the wraparound approach, and other

topics to enhance their ability to work with children and amilies. Training topics may include cultural




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competence, wraparound, the role and unctioning o child and amily teams, and others. Clusterso providers also may meet periodically or training purposes and to maintain positive provider

relations. Additional support to providers is provided through Choice’s care coordinators who areconsidered “ambassadors” to the providers and who consistently communicate Choice’s philosophy

and approach to care.Choices has training coordinators in both Indiana and Ohio to provide in-house training to

Choices sta. These coordinators, in collaboration with the site director, provide or arrange or

90-minute weekly training sessions that are mandatory or all sta. Attendance is taken at thesetrainings and participation in training is examined in perormance reviews. New sta is provided

with a checklist o required training and mentoring rom veteran sta. Training is provided on TCM(The Clinical Manager management inormation system) and computer systems, as well as on

the philosophy and process o providing individualized care. Though not ully developed as yet,Choices is working on developing “manuals” or written documents that detail its philosophy, service

approach, and administrative processes.

ManyChoicesstahaveMaster’sDegreesorobtainedthemwhileworking.Universitiesoftenask sta to return to the university and speak to graduate students. Proessionals rom Choices give

presentations at various universities at least our or ve time per semester. Topics include strengths-based care planning, what is wraparound, what is a system o care, etc. In addition, Choices provides

placements or student interns in both Indiana and Ohio and oten hire interns ater they havecompleted their proessional training programs.

Choices has a contract rom the State o Indiana to operate a technical assistance center (TA

Center) that provides training to other counties on the development and operation o systems o care.Thecurrentcontractisforapproximately$402,000/peryearandcoversadirectorandthree

coaches. The TA Center works with all communities currently unded and many previously undedto build systems o care, as well as communities that have never received unding or this purpose.

Communities may apply or a $50,000 planning grant rom the state; one o the TA Center’s roles isto support them in the planning process to develop a viable, sustainable strategy to build a system

o care. The participating communities have access to Choices database to assist in developing caserates, as well as to job descriptions and other structures and processes used by Choices that can be

adapted in their respective communities. The TA Center has provided training and consultation tomore than 60 o Indiana’s 92 counties.

Wraparound Milwaukee Wraparound MilwaukeeProviding Training on the Wraparound ApproachWraparound Milwaukee provides training to providers in all aspects o the wraparound approachand Wraparound Milwaukee’s operations. It also provides close supervision and coaching or care

coordinators. Care coordinators must be certied by completing 40 hours o mandatory training,and there are mandatory, monthly in-service trainings on clinical and program issues. Wraparound

Milwaukeepartnerswithparentco-trainersandhasacontractwithFamiliesUnitedtoprovidetraining. It also has a contract with the child welare system to train all 400 child welare workers in

the county on the wraparound approach and other elements o the program.




AK Bethel, AlaskaCreating a Health Education Center Yukon-Kuskokwim Health Corporation (YKHC) has a strong recruitment program or Native hires and

a number o workorce development activities. Currently at YKHC, 71% o the sta is Alaskan Nativeor Native American. YKHC has a ormal commitment to increasing this number and placing more

tribal members in proessional positions.

For the past year, YKHC has planned and developed a new Yukon-Kuskokwim Area HealthEducationCenter(AHEC)incollaborationwiththeUniversityofAlaska,Anchorage(UAA)Schoolof

Nursing and internal partners. YKHC’s corporate training and development unctions and currentsta,formerlyknownastheLearningCenter@YKHC,willbeincorporatedintotheYKAHEC.Thisnew

partnership provides an opportunity or YKHC to enhance sta development as well as sustain itsCareer Pathways program. AHECs create ormal relationships between universities and community

partners to strengthen the health workorce in underserved communities. They encourage youth inunderserved areas to go to college and pursue a health career, encourage health proessions students

to go to work in underserved areas, and support continuing education opportunities or health

proessionals who are working in underserved areas. TheRuralHumanServicesProgramisoperatedbyastrategicpartnershipbetweentheUniversity

o Alaska-Fairbanks and YKHC. The State o Alaska Department o Health and Human Services undstheprogram.RuralHumanServicesgraduatesandstudentsdealwithcrisissituations;theirstrengths

areenhancedbycompletionoftheRuralHumanServicesprogram.Theylearnaboutresourcesavailable and the processes involved in their line o work.

YuutElitnaurviator“ThePeople’sLearningCenter”isanotherworkforcedevelopmentresource

implementedthoughapartnershipbetweenYKHC,LowerKuskokwimSchoolDistrict,theAssociationofVillageCouncilPresidents,CityofBethel,CoastalVillagesRegionFund,BethelNativeCorporation,

AVCPRegionalHousingAuthority,andtheKuskokwimCampusoftheUniversityofAlaskaatFairbanks. These organizations have come together to construct a vocational training center that will

ocus on those in the 8th to 14th grades and lead them into career paths in the construction, health,education,andchildhooddevelopmentelds.TheLearningCenterisplayingakeyroleinthisproject

by developing the health careers curriculum and providing resources to the partnership in manyways.




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B. Providing Adequate Provider Rates

Strategies include:• Incorporatingpaymentratesandpoliciesthatsupportandincentivizeprovidersto

develop and provide home and community-based services• Incorporatingpaymentratesandpoliciesthataresucienttorecruitandretain

qualied sta

• Incorporatingmechanismsforproviderstodemonstratethecostofcareandrequestamended rates

▶ Incorporate Payment Rates/Policies that Support andIncentivize Providers to Develop and Provide Homeand Community-Based Services

To create incentives or providers to develop and provide home and community-based services, Arizona set higher payment rates or services delivered in out-o-oce settings. In addition, therates paid or residential care decrease with longer stays to discourage inappropriate use o out-o-

homecare.BothChoices and Wraparound Milwaukee purchase primarily home and community-based services, in eect, creating a strong market or these services and incentives or providers to

develop home and community-based service capacity.

AZ ArizonaEstablishing Higher Rates or Services in Out-o-Ofce Settings

The state established higher rates or out-o-oce than or in-oce services to encourage therapists

to provide services in homes and schools and not just in oces. Also, it pays a tiered system o ratesor out-o-home care, with rates decreasing with longer stays. In addition, there are multiple levelso case management provided by paraproessionals, mental health techs and licensed proessionals.

The system pays the lowest rate to paraproessionals in oce-based settings and the highest rate tolicensed proessionals in out-o-oce settings.

Value Options says that being able to be a provider in the network is an incentive to provide

home and community-based services (since that is the thrust o the system reorm). Also, the sizeand growth o the provider is contingent on the provider’s perormance in providing home and

community-based services.

For out-o-home services, there is a tiered rate structure. The longer the length o stay in a levelone placement (i.e., hospital or residential treatment center), the rate drops (with the exception o

level one programs serving youth with sex oenses).




Choices ChoicesPurchasing Primarily Home and Community-Based ServicesChoices purchases primarily home and community-based services; 80% o the dollars go to

community providers. The rates paid by Choices are comparable to the rates paid by publicsector agencies. Choices has, in eect, created new home and community-based services, such as

mentoring. Its demand to purchase this service resulted in the establishment o a new “industry.”

Wraparound Milwaukee Wraparound MilwaukeePurchasing Primarily Home and Community-Based ServicesMilwaukee’s entire orientation is toward home and community-based services. It has systematically

conveyed that message to providers and has made clear the types o services it is most interested

in buying. Wraparound Milwaukee developed denitions and rates or over 85 specic servicesandsupportsinitssystem.Itsetsitsownratesforalloftheservices/supportsinitsnetwork,exceptresidential treatment, the rates or which are set by the state.

▶ Incorporate Payment Rates/Policies that are Sucientto Recruit and Retain Qualied Staf

Payment rates and policies to help recruit and retain qualied sta were ound in several sites.

AZ ArizonaPaying College Loans or Behavioral Health ProessionalsArizona stakeholders reported that the system (as in many states) has diculty recruiting and

retainingsta.Legislationhadbeenpassedtopayocollegeloansofsomeprofessionalsgoingintothebehavioralhealthsystem,whichRegionalBehavioralHealthAuthorities(RBHAs)areusingasan

incentive or recruitment.




r k f o r c e a n d



Choices ChoicesPaying Usual and Customary RatesChoices pays providers their “usual and customary” ee, as documented in existing contracts or the

service in question. Choices must pay rates that are comparable rates that providers receive or theservice rom other payers. The community resource manager has those average rates or particular

services and then negotiates with individual providers and provider agencies. For new services,such as mentoring, Choices enters into negotiation with providers and establishes a new scale or

payments.SmallproviderstendtogetagreatershareofChoicesbusiness.Largerprovideragenciesoten are more demanding o higher rates, and, thus, may not receive the volume o reerrals. The

system is based on competition. Providers with avorable rates, and who consistently demonstratepositive outcomes, will receive the most consistent rate o reerrals.

Wraparound Milwaukee

Wraparound MilwaukeePaying Providers Promptly Given the breadth o the Milwaukee network, the system pays rates that are sucient to attract andretain providers. At the same time, Wraparound Milwaukee pays its providers very quickly, which

is another incentive or providers to participate (and which can help to oset concerns about ratesuciency). Providers are able to bill every week or services rendered, and they get paid within ve

days.




VII. Financing for Accountability

Systems o care need reliable, practical data and accountability mechanisms to guide

decision-making and quality improvement in the provision o services to children

and adolescents and their amilies. The development o strong accountability andcontinuous quality improvement procedures requires investment in good inormationsystems, as well as nancing to support the collection, analysis, and use o data

by administrators and other stakeholders to build on system strengths, remediatedeciencies, and make decisions about resource allocation. Accountability and quality

improvement procedures require data on the population being served, serviceutilization, service quality, cost, and outcomes at multiple levels (the system level,

service level, and child and amily level). Use o perormance-based or outcomes-basedcontracting allows systems o care to incorporate accountability procedures in contracts

with providers. In addition, nancing is required or a ocal point o accountability orsystems o care, that is, an agency, oce, or entity that is responsible or policy and

management o the system o care. Accountability procedures also should involve

periodic assessment o nancing policies and strategies to ensure their consistency andsupport or system o care goals.

Specifc Financing Strategies are:

A. Incorporate Utilization, Quality, Cost, and Outcomes ManagementMechanisms

B. Utilize Performance-Based or Outcomes-BasedContracting

C. Support Leadership, Policy, and Management Infrastructure for Systemsof Care

D . Evaluate Financing Policies to Ensure that they Support and PromoteSystem of Care Goals and Continuous Quality Improvement


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I I . F i n a n c i n g

f o r A c c o u n t a b i l i t y


A. Incorporate Utilization, Quality, Cost, andOutcomes Management Mechanisms

Strategies include:• Incorporatingmechanismstotrackandmanageutilization,quality,cost,and

outcomes

• Usingdatatoguidenancingandservicedeliverypolicies

• Usingcaremanagerstoplayaroleinaccountability

• Incorporatingincentivesorsanctionsassociatedwithutilization,quality,cost,or

outcomes

• Financingthedevelopmentofelectronicmedicalrecordssystems.

▶ Incorporate Mechanisms to Track and ManageUtilization, Quality, Cost and Outcomes

The sites studied make extensive use o mechanisms or tracking inormation related to service

utilization, quality, cost, and outcomes and use this inormation or system improvement.

AZ ArizonaImplementing a Quality Monitoring System Tied to PrinciplesAt the time o the study visit, Arizona Department o Health Services, Division o Behavioral Health

Services (ADHS/BHS) was in the early stages o implementing a new quality monitoring (QM)system driven by the JK settlement agreement and is interested in using data to drive quality and

eectiveness. In the past, quality monitoring was driven by Medicaid and ocused on generic practice

standards, such as access to care and physical/behavioral health coordination. Now, there is a QMchildren’s subcommittee. The new quality system is tied to the 12 principles in the JK settlementagreement and includes both process and outcome measures. This includes a Child and Family Team

Practice Review and reporting requirements related to outcomes.

Each Regional Behavioral Health Authority (RBHA) now undertakes an intensive review o thechild and amily team processes throughout its provider network. This is done through chart reviews

and interviews with amilies conducted by independent teams o amily members and wraparoundspecialists. This Practice Review is looking at process issues, not outcomes. In Maricopa County, 110

case reviews in one quarter were conducted. At the time o the visit, ADHS/BHS had just receivedthe rst round o data rom RBHAs and will use the data to inorm quality improvement eorts. For

example, areas needing improvement identied by the rst round o practice reviews included:a need or better use o natural helpers; a need or better crisis and saety plans; an issue with

timeliness o service provision; and concerns about the adequacy o provider networks. Strengthsincluded cultural competence and amily involvement. As part o quality improvement, the Best

Practices Committee is recommending a ocus on supervisory-level training and coaching.




With respect to the new reporting requirements related to outcomes, or every child in thesystem, RBHAs are required to report outcomes in several areas — success in school; saety;

preparation or adulthood; decreased criminal justice involvement; lives with amily; and, increasedstability in amily and living conditions. There is a dierent set o outcomes or the 0–5 population,

which include: emotional regulation, readiness to learn, saety and stability. Outcomes are reportedby child and amily teams at enrollment and at six months in response to “yes or no” questions, or

by clinical liaisons or children who do not have a child and amily team, who have to document aprocess involving children and amilies to answer the questions. These data can be ound on the

ADHS/BHS website under “What’s New: JK Measures.”

The system also tracks cost by unding source and cost by rate group (e.g., child welarepopulation) — there are 22 dierent unding categories. The cost data are broken out by child/youth

and adult. These cost data are part o RBHA deliverables.

Arizona uses independent quality monitoring teams that include amily members; also, there isa quality monitoring process mandated by Medicaid that involves independent case reviews o 1500

cases (adult and child) a year. ADHS/BHS also has access to 16,000 sets o data representing over50,000 children and youth, and the data can be cut by age, ethnicity, region and whether a child has

a child and amily team, to support special analyses. Penetration rates o the child welare populationcan be tracked and their use o out o home placements (but not o counseling services). Reportedly,

the system is experiencing better outcomes or children who have child and amily teams.

In terms o utilization management, this is a managed care system in which there are utilizationmanagement mechanisms at state, plan and program levels. Value Options monitors utilization in

Maricopa County and pre-authorizes higher levels o care, such as residential treatment. Child andamily teams manage utilization at an individual child/amily level.

HI HawaiiImplementing a Quality Assurance and Improvement Program

The system has utilization, cost, quality and outcome data, managed by the Child and AdolescentMental Health Management Inormation System (CAMHMIS) through its various modules. The Child

and Adolescent Mental Health Division (CAMHD) has a Quality Assurance and Improvement Program(QAIP) operated by its central oce and guided by a Perormance Improvement Steering Committee.

The types o data used to inorm the quality improvement process include: utilization review, sentinelevents, grievances and appeals, monitoring, caseloads and vacancies, access, credentialing, acility

certications, training, and other aspects o CAMHD’s perormance. Each Family Guidance Centerhas an internal structure or reviewing perormance data and managing perormance improvement

initiatives (an interdisciplinary Quality Assurance Team); a Quality Assurance Specialist at each FamilyGuidance Center manages these eorts.






In addition, each provider agency with which CAMHD contracts is required to have a continuousquality improvement system. Contractors are required to submit quarterly reports on the agency’s

Quality Assurance and Improvement Program. Providers also are required to submit the ollowingquality data to CAMHD on a quarterly basis:

• Access data— number and percentage o reerrals reviewed within 48 hours, number andpercentage o youth accepted upon reerral, number and percentage o youth seen within vedays o reerral, number and percentage o youth ejected rom program

• Quality o service provision measure— number and percentage o sta ully credentialed

• Least restrictive measure— average length o treatment

• Treatment measure — number and percentage o youth that have met treatment goals

Outcome data are collected on each child served by CAMHD to enable evaluation o theperormance o the system and its providers. Measures tracked include:

• NumberandpercentageofyouthwithimprovedfunctioningasmeasuredbyCAFASorPECAFAS,

Achenbach and CALOCUS

• Numberofyouthservedinanoutofstatesetting

• Numberandpercentageofyouthservedwithinthecommunitysetting

• Numberandpercentageofyouthwithgoodschoolattendance

• Numberandpercentageofyoutharrested

• Numberandpercentageofyouthinvolvedinschoolandcommunitypro-socialactivities

• Satisfaction

An example o tracking quality is the quality review ocused on the Coordinated Service Plans(CSPs). A number o indicators were identied and dened operationally regarding this individualized

service planning process, resulting in a “review scale.” The indicators speciy that:

1. The plan includes all relevant stakeholders including the child and amily as evidenced bysignature and/or explanation.

2. The plan provides evidence that there is a clear understanding o what the child needs.

3. The plan is individualized and clearly identies and links strategies to the preerences andstrengths o the child, amily and community.

4. There is evidence that inormal/natural supports are indicated and inused into the plan.

5. Evidence-based strategies/interventions are included in the plan and are appropriate to thediagnosis.

6. Focal concerns and priority needs are addressed.

7. The plan conveys a long-term view that will lead the child toward desired goals and outcomes.

8. Services and strategies are accountable (includes persons responsible or implementation,timeliness, and resource provision.)

9. A contingency and crisis component is evident.

10. Transitions/discharges are adequately addressed.11. I child is in an out-o-home placement, conditions and strategies or return home or appropriate

least restrictive setting are clearly indicated.




CAMHD studied the rate o child improvements during scal years 2002–2004, including analysesacross measures o unctioning, service needs, and symptomatology. The study ound youth were

improving more rapidly at the end o the study than at the beginning. This time period coincidedwith perormance improvement initiatives within CAMHD including the dissemination o evidence-

based practices, improvement o care coordination practice, increased inormation eedback tostakeholders, improved utilization management, adoption o the use o statewide perormance

measures, restructuring quality improvement operations, and the integration o practice-ocusedperormance management (i.e., quality assurance eorts that are discretely ocused on specic

practices, such as youth/amily engagement, individualized planning, or coordination o services) atvarious levels o the service system. It was suggested that these system improvements may have an

impact on improved youth outcomes.

The state routinely collects system perormance inormation, including inormation on: thepopulation served, service utilization data on the type and amount o direct services provided,

nancial inormation about the cost o services, system perormance inormation about the qualityand operation o the inrastructure that supports services, and outcome inormation regarding

unctioning and satisaction o children, youth and amilies.

A statewide perormance improvement committee reviews data and provides the data along withrecommendations to the governing body. In addition, data are provided to the quality assurance (QA)

teams at each o the Family Guidance Centers or review. Two Family Guidance Centers have emergedas being the most ecient while achieving the same outcomes as others. The state plans to study

these centers to determine the strategies used by these centers to maintain both cost-eciency andoutcomes.

Utilization management eorts may suggest special studies that are then conducted in

particular areas to ocus on a systemic issue. For example, a study was conducted on utilization o therapeutic group homes to determine why utilization o this service was decreasing statewide. It

was determined that schools did not reer youth to therapeutic group homes because there was noeducational component. This led to identication o the need or an alternative school component to

some therapeutic group homes to avoid placement in a residential treatment center.

A number o perormance measures or the children’s mental health system operated by CAMHDare tracked to monitor the unctioning o the system. For each o these perormance measures,

CAMHD has specied “statements” that break them down into specic indicators, thresholds orachievement, data to be used to derive the perormance inormation, data source, and benchmarks.

1. CAMHD will maintain sucient personnel to serve the eligible population– 95% o mental health care coordinator positions are lled

– 90% o central administration positions are lled– Average care coordinator caseloads are in range o 15–20 per ull time coordinator

2. CAMHD will maintain sucient scal allocation to sustain service delivery.

– Sustain within quarterly budget allocation

3. CAMHD will maintain timely payment to provider agencies.

– 95% contracted providers are paid within 30 days

4. CAMHD will provide timely access to a ull array o community-based services.– 98% o youth receive services within 30 days o request

– 95% o youth receive the specic services identied by the educational team plan






5. CAMHD will timely and eectively respond to stakeholders’ concerns.– 95% o youth served have no documented complaint received

– 85% o provider agencies have no documented complaint received– 85% o provider agencies will have no documented complaint about CAMHD perormance

6. Youth will receive the necessary treatment services in a community-based environment withinthe least restrictive setting.– 95% o youth receive treatment within the State o Hawaii

– 65% o youth are able to receive treatment while living in their home

7. CAMHD will consistently implement an individualized client and amily centered planning

process.– 85% o youth have a current Coordinated Service Plan (CSP)

– 85% o Coordinated Service Plan review indicators meet quality standards

8. There will be a statewide community-based inrastructure to ensure quality service delivery in allcommunities

9. Mental health services will be provided by an array o quality provider agencies.

– 85% o perormance indicators are met or each Family Guidance Center

– 100% o complexes will maintain acceptable scoring on internal reviews– 100% o provider agencies are monitored annually– 85% o provider agencies are rated as perorming at an acceptable level

10. CAMHD will demonstrate improvement in child status.– 60% o youth sampled show improvement in unctioning since entering CAMHD as measured

by the CAFAS or Achenbach– 85% o those with case-based reviews show acceptable child status

11. Families will be engaged as partners in the planning process.

– 85% o amilies surveyed report satisaction with CAMHD services

12. There will be state-level quality perormance that ensures eective inrastructure to support the

system.

– 85% o CAMHD Central Oce perormance measures will be metData are used or system improvement. For example, data rom the Annual Evaluation Report

or scal year 2005 showed that disruptive behavior disorders comprised the most commonproblem among youth registered in the CAMHD system, with 48% having a primary or secondary

diagnosis in the disruptive behavior category. Two evidence-based interventions with demonstratedeectiveness or youth with disruptive behaviors have been increased in the system — Multisystemic

Therapy (MST) — (utilization increased in FY 2005) and Multidimensional Treatment Foster Care (anRFP or this service was recently released). In addition, the annual report showed that the growth

in utilization o community residential services was contained, which was a system goal, althoughcosts or this service increased. Data showed that evidence-based practices were not being used to

the extent desired among CAMHD providers, prompting actions to increase their use in therapeuticinterventions. Data also pointed to the need or urther exploration o the actors that have resulted

in youth being discharged rom the CAMHD system with more problematic unctioning and greaterservice needs than youth discharged in prior years, despite the act that they showed improvement

with services at a more rapid pace. Similarly, although out-o-state placements remained low, thereport ound an increase in the use o hospital services, suggesting the need or more aggressive

strategies to reduce hospital utilization.




VT VermontReporting State and Local Perormance InormationAt local and state levels, the system o care incorporates a variety o utilization, quality, cost, and

outcomes management mechanisms. Local agencies have a schedule o reported utilization and costdata to the state, and these are routinely reported. The state tracks:

• Qualityofchildbehavioralhealthservices

• Costsofchildbehavioralhealthservicesintotal

• Costsofservicesbychildserved

• Outliers(i.e.,highutilizersofservices)

• Utilizationandcostbytypeofpopulationserved

The state publishes many o these data in a statistical inormation resource rom the Departmento Mental Health and in periodic reports issued by the Vermont Perormance Indicator Project, which

issues brie reports on a weekly basis providing inormation about dierent aspects o the behavioralhealthcare system (http://healthvermont.gov/mh/docs/pips/pip-reports.aspx). These reports

(PIPs) are available on the state’s website and investigate indicators such as:• Accesstocare

• Practicepatterns

• Treatmentoutcomes

• Concernsofcriminaljusticeinvolvement

• Employment

• Hospitalization

These reviews oten examine the relationship o mental health services with other programs andstate agencies. Cross-agency data analysis is acilitated by the use o a statistical methodology that

provides unduplicated counts o the number o individuals served by multiple agencies, withoutreerence to personally identiying inormation, thus protecting condentiality and complying with

HIPAA.In addition, the local Designated Agencies receive periodic reviews and a comprehensive review

at least every our years to assure quality perormance. Every two years, agency sta and members

o the State Program Standing Committee conduct a separate program review as part o the State’scontinuous quality improvement plan. Detailed data are gathered on our quality domains: access to

care; practice patterns o care; results o care; and agency structure/administration. The ndings o this review orm the basis or ongoing discussions and planning or program development, resource

allocation, and budgeting. The state tracking and monitoring also has developed and relies onregular measurements o how caseloads overlap across agencies and on satisaction with services by

adolescents served and by parents o children served.






NE Central NebraskaTracking Utilization, Outcomes, Quality, and CostsTracking Utilization— The cooperative agreement between the Nebraska Department o Health and

Human Services and Region 3 Behavioral Health Services (BHS) to establish an individualized systemo care or high need youth who are in state custody included a joint responsibility or utilization

management. The Care Management Team (CMT), unded jointly by Region 3 BHS and the CentralArea Oce o Protection and Saety, serves this unction. The CMT ensures that children/youth are

cared or in the least restrictive, highest quality, and most appropriate level o care.

The Care Management Team (CMT) provides utilization management and review througha systematic process using the CAFAS, risk assessment tools, caregiver and youth interviews,

psychological evaluations and other clinical and education/vocational inormation. It conductspre-admission screening and ongoing review o children in higher levels o care. The CMT maintains

an up-to-date database which tracks youth placement and monitors length-o-stay inormation. The CMT is staed by licensed mental health clinicians. This is very helpul in the negotiations with

Magellan or access to services or individual children. In FY 2005, 210 youth were reerred to the CMT.

Tracking Outcomes — While amilies are receiving services, Proessional Partners and CareCoordinators receive management inormation reports incorporating scores rom the variety o assessment tools that are administered at intake and at regular intervals during service delivery.

Integrated Care Coordination (ICCU) program directors are provided an executive summary whichdescribes the children who have been accepted into an ICCU each month and the children who

have been disenrolled. Areas tracked or accepted youth include: diagnosis, CAFAS scores, types o behavior displayed by the youth accepted, levels o care, assessment o parental behavioral health

issues, each child’s permanency plan, and status o adjudications. The report also summarizes theplacement status or each child who is disenrolled.

Tracking Quality — The contract with Families CARE, the amily support and advocacy organizationin Central Nebraska, includes monitoring delity to the wraparound model. Families CARE sta collect

inormation rom parents, youth, and care coordinators to measure delity and to assess satisaction. The results are aggregated and distributed to the various wraparound based programs. This eedback

allows or continual improvements o the programs and builds capacity or parent-to-parent supportby using amily members as evaluators. Team members who participate on child and amily teams are

also asked to assess wraparound delity on a semi-annual basis.

Tracking Costs — To track utilization and account or how the Integrated Care Coordination (ICCU)

program spends its case rate, Region 3 Behavioral Health Services (BHS) administrators prepare amonthly report that identies, by child, direct service costs (including services provided, fex unds

spent, and concrete expenditures such as transportation or rent) and non-direct service costs. Thismonthly report shows the extent to which the case rate was under — or over-spent or each child.

From these reports on individual children/amilies, Region 3 BHS is able to track trends over a periodo time such as: average cost per amily, average cost o direct services, costs or youth who are in

placement compared to costs or youth who are not in out-o-home placements, average monthlycosts or dierent types o placements, and monthly associated non-service costs (including sta

personnel costs). Yearly and monthly increases and decreases in expenditures by placement type alsoare tracked.




Choices ChoicesUsing an Integrated Management Inormation SystemAn integrated management inormation system, called The Clinical Manager (TCM), was developed

as a tool or system management in both the clinical and scal arenas. Encompassing all aspects o

Choices’ data requirements, TCM includes clinical inormation and plan o care, claims adjudication,

service authorization, service utilization, tracking progress, tracking outcomes, tracking costs,medication management, historical inormation, and contract management. Clinical and scal

records or a child and amily can be viewed together, aording team members prompt access toboth types o data and resulting in more ecient care management. Data are analyzed by: payers,

team, and individual care coordinator. The Child and Adolescent Needs and Strengths (CANS),measuring clinical and amily outcomes, has been integrated into the TCM process and is now a part

o the sotware package.

Utilization is tracked based on service authorizations. Services are authorized prospectivelyand then authorization is compared with actual utilization. Monitoring utilization allows or an

understanding o service utilization patterns, costs, and outcomes, and helps to identiy team

dynamics, training needs, provider management needs, and scal issues needing attention.Choices contracted with the Indiana Consortium or Mental Health Services Research to conduct

evaluation activities relative to Dawn in areas including proles o Dawn Project participants,patterns o service use, the dynamics o the service coordination teams, client outcomes and service

eectiveness, system-level unctioning (the implementation o system o care principles within themanaged care system), and the unctioning o the amily support and advocacy organization.

Recent evaluation data on Dawn demonstrated:

• Dawnwasabletomaintainthemajorityofitsparticipantswithincommunity-basedcaresettings.

• RatingsoffunctionalimpairmentsimprovedsignicantlyasratedbytheChildandAdolescent

Functional Assessment Scale (CAFAS), Child Behavior Checklist (CBCL), and Behavioral andEmotional Rating Scale (BERS)

• NumberofdelinquentoensescommittedbyyouthinDawndeclinedovertime• Youthshowedsignicantimprovementovertimeinschoolattendance,levelofdiscipline

problems, and academic perormance

• 65%ofyouthleavetheprogrambymeetinggoalsestablishedbytheirchildandfamilyteam

• Majorityofcaregivers(andyouth)areeithersatisedorverysatisedwithservicesprovided,level

o cultural competence, and their level o involvement in planning treatment

• Caregiversreportedsignicantimprovementintheiroverallfunctioningandperceivedlevelofcaregiver strain

• Dawnprovidesadiversemixofservices.

• Twoservicesmostcloselyrelatedtolesspositiveoutcomesandincreasedexpendituresarecrisis/respite and residential treatment services

• Dawnincreasedcollaborationamongchild-servingsystemsinMarionCounty,highlightedimportance o amily involvement, and drew attention to amily strengths as the basis o

treatment planning.






Wraparound Milwaukee Wraparound MilwaukeeUsing a Web-Based Management Inormation SystemWraparound Milwaukee is a data-driven system that is supported by Synthesis, a web-based

management inormation system, built and owned by Wraparound Milwaukee. Synthesis allows thesystem to capture real time, as well as retrospective, data. For example, progress notes on individualchildren are automated through Synthesis so that the MIS system is used, not only by managers

and policymakers, but by clinicians and care managers. Synthesis captures all care planning, crisisplans, saety plans, and progress notes. It tracks all services/supports provided, or which youngsters

and at what cost. It captures demographic data and outcome data. It is used or billing and claimsadjudication and links to a system or automatic check writing. Providers are able to bill every week

or services rendered, and they get paid within ve days. Synthesis data also are used by WraparoundMilwaukee’s quality improvement (QI) sta. Over 300 people use Synthesis; Milwaukee uses a “train

the trainers” approach to build capacity to use Synthesis.

Wraparound Milwaukee tracks program, clinical, scal, system and saety outcomes. It addressesthe ollowing:

• IsthereimprovedclinicalfunctioningasmeasuredbytheChildandAdolescentFunctionalAssessment Scale (CAFAS)? (Note: Wraparound Milwaukee is considering abandoning use o the

CAFAS, perhaps moving to use o the Child and Adolescent Needs and Strengths (CANS).

• Hastherebeenareductionintherestrictivenessoflivingenvironment?

• Isthereareductioninjuvenilejusticecontacts?

• Hasschoolattendanceimproved?

• Arethewraparoundcostscomparabletoorlessthanresidentialtreatmentcosts?

• Arefamiliesandyouthsatisedwithservices?

In terms o utilization management, this is a managed care system, in eect, in which there areutilization management mechanisms at the care coordinator and system management levels. Certain

high-cost services, such as residential treatment and inpatient hospitalization, may require prior

authorization, and outliers are reviewed. However, most providers are notied o units o servicesapproved or the upcoming month, based on the plans o care and service authorization requestssubmitted by care coordinators. Providers invoice online, and Synthesis matches services provided

with those authorized under the plan o care.




▶ Use Care Managers to Play a Role in Utilization,Quality, Cost, and/or Outcomes Management

Care managers play important roles in managing utilization, quality, cost, and outcomes in the sites. Arizona, Hawaii, and Wraparound Milwaukee provide data on a regular basis to care managers to

monitor their assigned children and amilies and to enable them to compare their practice patternswith those o other care managers. Choices provides data to child and amily teams, team leaders,

and care managers enabling them to assess their approaches, costs, and outcomes and to makeappropriate adjustments.

AZ Arizona, HI Hawaii, andWraparound Milwaukee Wraparound Milwaukee

Providing Data to Care Managers• In Arizona, Child and Family Team acilitators must ensure that child and amily teams review all

outcome domains at least every six months.• InHawaii , care managers acilitate the child and amily team process. The Coordinated Service

Plan developed by the child and amily team serves as the mechanism or service authorization,

as all services and supports included in the plan are considered to be authorized. Care managersreceive data reports on their practice, documenting services they are authorizing through the

child and amily team process and comparing their service utilization patterns with those o othercare managers and with statewide patterns.

• InWraparound Milwaukee, care coordinators and child and amily teams have a responsibility tomonitor outcomes and costs or individual children and amilies.

Choices ChoicesProviding Data to Child and Family Teams, Team Leaders, and Care ManagersChild and amily teams can review and respond to trends in service provision and cost data amongthe population assigned to their team, enabling them to assess their approach more globally and

plan their service strategies. The management inormation system (The Clinical Case Manager or TCM)helps to link process, outcome, service utilization, and cost data in a way that assists Choices to assess

what services work, in what ways, or which children, and at what cost. Data reports are produced byworker and by team so that team leaders can review how workers use particular services and trends

o teams. Inquiries ocus on: (1) number o children in out-o-home placements, (2) types o out-o-

home placements used, (3) our-month trends regarding out-o-home placements, (4) overall cost perchild, and (5) mentoring costs.






▶ Incorporate Incentives or Sanctions Associated withUtilization, Quality, and/or Cost Management

In Arizona, incentives are included in contracts with Regional Behavioral Health Authorities relatedto standards or access, unctional improvement, satisaction, consumer and amily involvement,

and others. In other sites (Hawaii, Vermont, Choices, and Wraparound Milwaukee), sanctionsprimarily involve discontinuing the participation o the provider i appropriate corrective actions are

not taken in response to identied problems associated with utilization, quality, cost, or outcomes.

AZ ArizonaUsing IncentivesContract requirements with the Regional Behavioral Health Authorities (RHBAs), to which incentives

are attached, relate to: access standards; measurement o unctional improvement; consumer andamily satisaction; coordination o care; cultural competence; and consumer and amily involvement.

These are also the measures used or quality improvement. The incentive pool represents 1% o the

entire capitation pool. I RBHAs meet perormance standards, they may receive unding rom theincentive pool.

HI Hawaii, VT Vermont, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Using Sanctions• InHawaii , reerrals to a provider agency may be stopped i there are concerns about utilization,

quality or cost. Typically, data highlighting problems with utilization, quality, or cost are shared

with the agency and corrective action is requested. In some cases, a provider agency may beclosed or continued substandard perormance. First, admissions at the agency could be closed

or a period o time; then children could be moved to other providers and the agency closedtemporarily; then, the agency could be closed permanently. This has occurred once over the past

six months.

• InVermont , the process o agency reviews results in a rating that indicates quality perormance,may identiy areas or improvement that are detailed in a corrective action plan, or begin a

process to cut the agency rom the contractor network because it ailed to meet standards.

• InChoices, sanctions available or providers involve primarily declining to make new reerrals

based on eedback rom amilies and sta. Providers receive eedback rom the communityresource manager.

• InWraparound Milwaukee, the system has an incentive to pay attention to cost and quality

issues among providers, since the bulk o its unding is risk-based (either capitation or caserates). Providers are paid on a ee-or-service basis, and Wraparound Milwaukee monitors their

perormance closely. I a given provider is not providing the types o services or quality care thesystem wants, it will not be used. Wraparound Milwaukee believes that its use o a “qualied

provider panel,” rom which providers are paid on a ee-or-service basis i they are used, gives itthe mechanism to better manage quality and cost o care provided.




B. Utilize Perormance-Based or Outcomes-BasedContracting

▶ Use Perormance or Outcomes-Based ContractingPerormance or outcomes-based contracting is not utilized widely in the sites studied. However,some o the sites are working towards implementing perormance-based contracting.

AZ ArizonaUsing Perormance Standards in Contracts withRegional Behavioral Health Authorities

The Arizona Department o Health Services, Division o Behavioral Health Services’ (ADHS/BHS) contracts with Regional Behavioral Health Authorities (RBHAs) include penalties or poor

perormance, but the state is interested in pay or perormance arrangements in the uture. Thestate does allot extra unds to plans that meet access to care standards. Value Options (VO) reported

that they met the standards to receive the extra unding and then had to decide how to allocate themonies to providers in the network. None o the providers met all standards, but some met several o

them so VO decided to give unds to all o the providers who met at least one standard.

VO also indicated that it has implemented both incentives and sanctions or ComprehensiveService Providers related to access or the Latino population. Providers can receive up to $10,000 a

month depending on their meeting certain access standards (e.g., $2500 per month i reaching 40%o Latino eligibles).

Choices Choices

Developing a “Score Card” or Provider OutcomesChoices is working to develop a “score card” which would provide indicators or providers regardingthe outcomes o particular services by provider. One aspect o this would involve tying Child and

Adolescent Needs and Strengths (CANS) data to providers to assess whether behavior is improvingwith a service, such as individual therapy.






C. Support Leadership, Policy and ManagementInrastructure or Systems o Care

Strategies include:• Supportingafocalpointforpolicyandmanagementofsystemsofcare

• Financingleadershipdevelopmentactivitiesforsystemsofcare

▶ Finance a Focal Point or Policy and Managemento Systems o Care and or Identifed System o CareLeaders

All o the sites nance some type o ocal point or management o the system o care. In most

cases, this involves a state-level ocal point o responsibility, as well as a local agency or entity or

local system management.

AZ Arizona, HI Hawaii, NJ New Jersey, VT Vermont,NE Central Nebraska, Choices Choices, andWraparound Milwaukee Wraparound Milwaukee

Financing a Focal Point or System o Care Management • In Arizona, state-level leadership is provided by Arizona Department o Health Services, Division

o Behavioral Health Services (ADHS/BHS) in partnership with its sister agencies. Leadership orthe system at the county level in Maricopa County is provided by the Regional Behaviorial Health

Authority (at the time o the site visit, this was Value Options) and the Family Involvement Center,working with other child-serving systems and stakeholders on an ad hoc basis.

• InHawaii , the Child and Adolescent Mental Health Division (CAMHD), within the Department o

Health, serves as the ocal point or system management or the public children’s mental healthsystem. A governing body oversees all policy making and management related to systems o

care; this body does not involve cross-agency representation. The governing body is comprisedo the CAMHD Division Chie, Medical Director, Perormance Manager, the Executive Director o

Hawaii Families As Allies, Branch Chies, and the Provider Relations Specialist. An interagencyquality assurance committee plays a monitoring and advisory role to the system. Community

interagency quality assurance committees play a similar role at the local level. Leaders or systems

o care are positions within CAMHD at the state level, and within Family Guidance Centers at thelocal level.

• InNew Jersey , the Division o Child Behavioral Health Services, Department o Children andFamilies, is the ocal point or management o the statewide system o care initiative. The

state contracts with an ASO-type entity (the Contracted Systems Administrator) to coordinate,authorize, and track care or all children entering the system and to assist in managing the system




o care and improving quality. Locally, a Care Management Organization (CMO) in each regionprovides care coordination and accountability or children with intensive service needs. The CMO

partners with a Family Support Organization (FSO) whose role is to provide education, support,and advocacy or caregivers and amily members o children with serious emotional problems.

• InVermont , the Department o Mental Health is the lead state oce or children’s mental health.Vermont’s system o care legislation (Act 264) identies agency partners and their responsibilities,as well as the undamental partnership with amilies. A lead agency (Designated Agency) in each

region is responsible or local management and operation. These structures are supported bylocal interagency teams and a state interagency team, which provide technical assistance and

consultation on individual cases and a vehicle or problem-solving on systemic issues. The systemlevel work is enhanced by a state level Advisory Board whose nine members are appointed by the

Governor to advise the stakeholders on annual priority recommendations to urther improve theinteragency system o care.

• InCentral Nebraska, when a ederal grant was received in 1997, the system o care was basedon an existing inrastructure. Region 3 Behavioral Health Services (BHS) is the entity with a

statutory responsibility to administer behavioral health services in Central Nebraska. This greatly

enhanced the chances or sustainability. A cooperative agreement exists between the NebraskaDepartment o Health and Human Services (DHHS) and Region 3 BHS to create an individualizedsystem o care or children in state custody who have extensive behavioral health needs. Within

Central Nebraska, the system o care is managed as a “three legged stool” including Region 3 BHS(behavioral health) the Nebraska DHHS Central Service Area Oce o Protection and Saety (child

welare) and Families CARE (amily support and advocacy organization).

• Choices is the ocal point or system management or high-need youth in Marion County, Indiana;Hamilton County, Ohio; and Montgomery County and Baltimore City, Maryland.

• Milwaukee has created a ocal point or the management o high-need youth throughWraparound Milwaukee, which is nanced through multiple cross-system unding streams.

▶ Finance Leadership Development or Systems o Care The sites have implemented strategies to nance leadership development and training or systemso care.

AZ ArizonaFinancing Leadership Development and Training

The state has used tobacco monies, discretionary and ormula grant unds to support leadershipdevelopment across stakeholder groups (such as children’s systems, amilies, providers, and BHOs) in

support o the JK settlement agreement.






HI HawaiiOperating a State-Sponsored Leadership Development ProgramA ten-week leadership development program was sponsored by the state agency within the last year,ocusing on both the theory and practice o leadership. The comprehensive leadership development

course involved a ull day o participation each week or the duration o the program. Families romHawaii Families As Allies participated along with mental health system representatives including

branch chies and one level below branch chies throughout the agency. The goal was to create“empowered teams” throughout the system.

NE Central NebraskaUsing Federally Funded System o Care to Provide Technical Assistance

The state has assumed a leadership role in developing systems o care across the six regions in

Nebraska. Once Region 3 began to show positive results and a cost savings, its system o careleaders were encouraged by the Nebraska Department o Health and Human Services (DHHS) toprovide technical assistance to other regions/service areas to implement similar systems. Five o the

six regions in Nebraska now have a care coordination system in place or children with signicantmental health needs. One o the regions (Lincoln) also beneted rom a ederal system o care grant.

However, the other three regions have implemented systems o care with some additional DHHSunding and the technical assistance provided with Region 3 cost savings.

Choices Choices

Creating a State-Funded Technical Assistance Center or Systems o CareChoices has been a key technical assistance resource or other areas o Indiana working to developsystems o care. In 2002, Choices was ocially unded by the state as a technical assistance center

(Technical Assistance Center or Systems o Care and Evidence-Based Practice) to provide assistancein developing systems o care throughout the state. The training and coaching provided through this

center has been an important strategy or developing knowledgeable and skilled leaders or systemso care in Indiana.

Wraparound Milwaukee Wraparound MilwaukeeProviding Training in System o Care Principles and Operations

Through its unding o Families United, training o providers, and sta development in system o care

principles and operations, Wraparound Milwaukee is creating leaders among stakeholder groups, orexample among care coordinators, amily members, judges, and others.




D. Evaluate Financing Policies to Ensure that TheySupport and Promote System o Care Goals andContinuous Quality Improvement

Strategies include:• Assessingnancingpoliciesandstrategiestoensurethattheypromotesystemofcaregoals

and continuous quality improvement

• Collectingandusingcost-benetdata

▶ Assess Financing Policies and Strategies orPromotion o System o Care Goals and ContinuousQuality Improvement

Measurement o progress toward the nancing goals established in Hawaii’s strategic plan providesa ramework or the periodic assessment o nancing strategies and their eectiveness in achievingsystem o care goals.

HI HawaiiUsing Strategic Plan Goals and Progress Assessment

The new strategic plan species nancing policies and strategies to promote the system’s goals.

This has set the stage or assessment o the eectiveness o these nancing strategies during thecourse o implementing the strategic plan or the next period. In addition, cost is examined as a part

o assessing quality. Financial targets are set by the system, and nancial reports are reviewed as a

component o perormance monitoring






▶ Collect and Use Cost-Beneft DataHawaii collects and uses cost-benet data through a process reerred to as Data Envelope Analysis(DEA). Wraparound Milwaukee collects and uses data on cost savings or youth who would

otherwise be in residential treatment or correctional acilities.

HI HawaiiCollecting and Using Cost-Beneft Data romData Envelope Analysis (DEA)Cost-benet data is used by the system. Inormation rom Data Envelope Analysis (DEA) analysesis provided to the governing body. DEA is a linear programming methodology that examines therelative eciencies o six mental health centers (Family Guidance Centers). The methodology is

considered to be an important decision support tool or ocusing quality and nancial improvementeorts within a mental health service delivery system. The method involves examining multiple

resource inputs (such as costs o operating expenses, stang patterns, etc.) along with multiplequality outputs (such as youth outcomes, quantity o services, etc.). These multiple input and

disparate input and output (cost and quality) measures are converted to a single comprehensivemeasure o “eciency.” In an example o the application o this methodology, indicators o quality

outputs were compiled rom the Child and Adolescent Mental Health Division’s (CAMHD) usualperormance monitoring reports. Quality indicators included the percentage o youth receiving

intensive in-home services not removed rom their homes, percentage o youth with CoordinatedService Plans meeting quality standards, percentage o youth showing improvement on the Child

and Adolescent Functional Assessment Scale (CAFAS) or Achenbach System or Empirically BasedAssessment, and percentage o youth with no documented complaint or grievance. Input indicators

were taken rom CAMHD’s routine stang and nancial summary reports and included oceexpenses per average client day per month, salary expenses per average client day per month,

number o ull time equivalents o care coordinators per average client day per month, selectedsummary costs o therapeutic services per average client day per month, and selected costs o out-o-

home treatment services per average client day per month. The results showed that ve o the mentalhealth centers could be considered “ecient,” but one o the six mental health centers had the lowest

percentage o clients showing improvement on the CAFAS or Achenbach System or EmpiricallyBased Assessment, as well as the highest input o resources per client day or three o the ve

resource inputs. The application o the DEA methodology allowed managers to compare themselvesto those with the lowest costs and highest outputs. The analysis also indicated the need or additional

data or operational evaluations to clariy results.




Wraparound Milwaukee Wraparound MilwaukeeCollecting and Using Data on Cost SavingsMilwaukee does not have cost/benet data per se, but it does have data available showing the cost

savings or youth who would otherwise be in residential treatment or correctional placements and orchildren in child welare who are in more permanent living arrangements. Wraparound Milwaukee

contracts or a ull-time evaluator who can conduct analyses using data directly rom the Synthesismanagement inormation system. The system also has a strong quality improvement inrastructure.

Wraparound Milwaukee outcomes include the ollowing:

• Decreaseindailyresidentialtreatmentcenter(RTC)populationfrom375to50

• Reductioninpsychiatricinpatientdaysfrom5,000daystolessthan200daysperyear

• Averagemonthlycostof$4,200(comparedto$7,200forRTC,$6,000forjuveniledetention,

$18,000 or psychiatric hospitalization)

• 60%reductioninrecidivismratesfordelinquentyouthfromoneyearpriortoenrollmenttooneyear post enrollment

• Schoolattendanceforchildwelfare-involvedchildrenimprovedfrom71%ofdaysattendedto

86% days attended

• Reductioninplacementdisruptionratesinchildwelfarefrom65%to30%

• 91%offamiliesreportedthattheyandtheirchildweretreatedwithrespect

• 91%offamiliesreportedthatstaweresensitivetotheircultural,ethnicandspiritualneeds




V I I I . F i n a n

c i n g S t r a t e g i e s f o r

T r i b a l S y s t e m s o f C a r e

AZ ArizonaUsing Tribal Regional Behavioral Health Authorities (TRBHAs) Only two o Arizona’s 21 tribes opted to provide their own behavioral health services as TribalRegional Behavioral Health Authorities (TRBHAs) through the Arizona Department o Health Services,

Division o Behavioral Health Services (ADHS/BHS) managed care system. The TRBHAs may serve any

tribal member; that is, they are not restricted by geography or particular tribal aliation, which is oneo the reasons that the TRBHAs are not capitated. Tribal members also may receive services throughthe Indian Health Service (IHS). Native Americans who live o the reservation, and are tribal members

o a community that operates a TRBHA, can choose to enroll in the community’s TRBHA or enroll inthe regular RBHA in their geographic area.

VIII. Financing Strategies for TribalSystems of Care

Financing systems o care and their component services is particularly challenging

in tribal communities. The complications that arise when attempting to coordinateacross multiple jurisdictions (or example, multiple states, tribal governments, the

Indian Health Service, etc.) are complex and dicult to navigate. Systems o care intribal communities may dier signicantly rom other systems o care in that they

must t within the reality o the multiple jurisdictions and bureaucracies that aectthem. Strong leadership, coupled with political and policy support, are critical actors

in developing and implementing eective nancing strategies or tribal systems o care. In addition, system o care development in tribal communities occurs in the

context o historical trauma and in the context o a non-Western view o mentalheath problems and treatment. Thus, application o the system o care approach

must be adapted to consider the conceptualization o illness and traditional healingapproaches ound in Native American communities. Eective nancing strategies

in tribal communities involve collaboration among states and tribes, as well ascoordination o ederal, state, local, and tribal nancing streams.

Finance Tribal Systems of Care Through CollaborationAmong States and Tribes and Coordination of Federal,State, Local, and Tribal Financing Streams

Arizona and Bethel, Alaska provide examples o eective nancing strategies or tribal systems o care.In Arizona, Tribal Regional Behavioral Health Authorities (TRBHAs) operate within the state’s managed care

system and may serve any tribal member. In Bethel, Alaska, a tribal organization (the Yukon-KuskokwimHealth Corporation [YKHC]) administers a comprehensive health care delivery system or the 56 rural

communities comprising this area. Both approaches involve collaboration between the state and tribes,coupled with coordination o multiple ederal, state, local, and tribal nancing streams.




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Those tribes that chose to set up a TRBHA typically had the inrastructure and revenue romcasinos and were already making good investments in tribal health care. They saw the TRBHA as a

means to maximize their ability to use Medicaid and improve access to and coordination o services.Health and behavioral health services provided by Indian-run acilities are eligible or 100% ederal

Medicaid contribution, known as the ederal pass-through program. In eect, Arizona tribes mustdeal with a biurcated Medicaid system — the 1115 waiver in the state and the ederal pass-through

or tribes. The ederal pass-through benet is more traditional than the array o services coveredunder the 1115 waiver, but the ederal rate ends up being higher than state rates, and there is 100%

ederal unding. For example, case management is not a covered service by the pass-through, butit can be paid or through the 1115 waiver. The TRBHA will “pick and choose” whether to bill the

ederal pass-through or the 1115 waiver. The ederal pass-through can only be used or servicesdirectly provided by the tribe. There are over 60 providers — adult and child — in the Gila River TRBHA

network. Only those that are Gila River community providers can be billed through the ederal pass-through; the o-reservation providers are billed through the 1115 waiver. The Gila River TRBHA is

actively looking at how to integrate TRBHA and IHS behavioral health services.

An issue or the TRBHAs is that, unlike the RBHAs, they must use the state rates or services since

they are not capitated. (The RBHAs may establish their own rates within broader State guidelines.)So, reportedly, Value Options in Maricopa pays higher rates or some services in short supply, suchas therapeutic oster care, which aggravates the Gila River TRBHA’s ability to expand capacity. This

also aects utilization since home and community-based alternatives are in short supply and, thus,more restrictive services end up being used. One example provided by the Gila River TRBHA was the

rate paid or sub-acute care. Value Options’ rate was $595/day, compared to the state rate, which was$240/day. Reportedly, the rate was increased by the state to $700/day, and ADHS/BHS is looking at

increasing the state rate or therapeutic oster care as well.

The Gila River TRBHA indicated that it started with the basics – crisis services and counselingservices in home and at schools. It is now moving to more home and community-based services, such

as amily support. It is recruiting amily members as peer support providers (paying $9-13/hour); since job opportunities are very scarce on the reservation, they eel they will not have diculty recruiting.

The Indian Health Service (IHS) behavioral health clinic was not part o the TRBHA network at the

time o the site visit. The IHS clinic was described as having long waiting lists and as reerring to the TRBHA. The TRBHA would like to move this clinic into their network, which would also allow them to

manage the quality o care. IHS also operates a drug and alcohol program at Gila River, and the tribe isbuilding a residential substance abuse program. These services also are outside o the TRBHA network

at present. (Since the site visit, the TRBHA has made progress and the IHS behavioral health clinic is inthe process now o enrolling in the TRBHA network, and the residential substance abuse acility will

become part o the TRBHA network once the acility is open.)

The Gila River TRBHA indicated that it does not have the inrastructure to be capitated and thatit is trying to work around problems created by rates and lack o capacity on an ad hoc basis, rather

than seeking capitation. For example, it contracts with Value Options to be able to reer youth to

Value Option’s walk-in urgent care centers.RBHAs are required contractually to have specialized Native American providers in their networks.

In Maricopa County, there is reportedly one (o reservation) provider that specializes in servingNative American youth. There is some overlap between populations served by Value Options and

Gila River. The Gila River TRBHA serves about 400 youth, about a 15–17% penetration rate, whichthey describe as low penetration given the need, although they also noted that they have the




V I I I . F i n a n


T r i b a l S y s t e m s o f C a r e highest penetration rate in the state. (As noted earlier, the statewide average penetration rate or

the Medicaid/S-CHIP population is about 10%–12%. Also, since the site visit, the TRBHA penetration

rate reportedly has increased to 21%.) Sel-reerral is the leading reerral source, with the Indianbehavioral health clinic, the schools, juvenile justice and Indian child welare also reerring youth.

Reportedly, the percentage o tribal youth in out-o-home care is higher than with other populationso youth because o the lack o alternatives. However, the number also reportedly is decreasing with

use o the child and amily team approach. Community buy-in remains an issue, however, to keepingyouth at home. The Gila River TRBHA reported good relations with Tribal social services and with

juvenile justice. Indian child welare does not have its own dollars or behavioral health services so itlooks to the TRBHA as a resource. They collaborated to develop a therapeutic oster home, with Indian

child welare covering room and board. There is not, however, a strong interagency policy groupor the tribe, and services are described as very compartmentalized. There is, however, increasing

recognition o the potential o the TRBHA.

The TRBHA describes the child and amily team (CFT) process as a “good t” with the valuesin the community. Case management caseloads, which were running very high (1:50–60), are

now down to about 1:38 as a result o ADHS/BHS providing additional unds to the TRBHA (about

$250,000). The TRBHA also is getting some State Inrastructure Grant (SIG) dollars or training in CFTimplementation, will get a hal-time coach, and dollars or telemedicine and video conerencing romthe state. The TRBHA is implementing mentoring, peer supports or amilies and use o stipends or

amily partnership. There is a parent group, called Purple Onions, which at the time o the site visitwas not interacing with FIC or MIKID (recently, these organizations have begun to provide technical

assistance to Purple Onions). The TRBHA indicated that it can incorporate Native traditions, such astraditional Native healers, by using general revenue state dollars (not Medicaid).

Since the time o the site visit, the TRBHA has moved more to a “sta model” o owning its own

services and clinical sta, rather than exclusively contracting out or services. For example, it hasimplemented an intensive outpatient program (IOP) or women recovering rom methamphetamine

use that it operates directly and has hired its own in-home therapist so that it does not have to relysolely on county providers. The TRBHA also has hired an ater care therapist or substance abuse

services. Most o this new service capacity has been made possible with unding rom the state(ADHS/BHS). The TRBHA believes that this approach will accomplish several goals: a higher degree

o culturally relevant care; easier access to care; greater continuity and coordination o care betweentherapists and case managers (who are employed by the TRBHA); and, generation o revenue rom the

sta model (i.e., through Medicaid billings) that can be used to expand services. The state does priorauthorization or all out o home placements or the TRBHA, but the TRBHA indicated that this is not

an adversarial process.




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AK Bethel, AlaskaUsing a Tribal Health CorporationAt the state level, Alaska has been a national leader in collaboration among tribes, tribal health

programs, Indian Health Services, and the Alaska Department o Health and Social Services.Collaboration between the state and tribes is demonstrated by joint work around Medicaid and

S-CHIP. The Medicaid authority has dedicated sta at the state level or administration o the TribalHealth System. Further, a State/Tribal Medicaid Task Force was implemented that, among other

unctions, was responsible or the design o Alaska’s S-CHIP program and development o a uniormset o billing policies. Agreements are in place between Medicaid and Tribal Authorities, and a Tribal

billing manual has been produced.

A reorganization o services to Tribes (reerred to as “638 compacting”) began in the mid-1960s and resulted in the 1994 All Alaska Tribal Compact. Under the statewide compact, the Tribal

organizations took over the operations o health care acilities ormerly operated by the Indian HealthService (IHS), as well as certain centralized services. Each o the Tribal organizations negotiates a

unding agreement with the IHS annually, although ederal IHS unding is available or only 40% o

the need or health care services. Today, 12 regional Tribal health corporations administer 7 hospitals,28 clinics, and 176 village clinics. The Tribal corporations are the sole health and behavioral healthprovider in most areas, and the state is dependent on these Tribal health providers to oer a variety

o programs and services. The Tribal corporations are unded by state grants, Medicaid, Indian HealthService, and ederal grants. One hundred per cent o costs or dental, health, mental health, and

substance abuse services or Medicaid eligible individuals are reimbursed to the Tribes by Medicaidunds. Medicaid administration and training related costs are matched at the 50% ederal match level.

Operational costs o the health care corporations are high, due to the challenges o oering

services in vast remote areas, dicult transportation challenges, harsh weather, and constantworkorce shortages.

Health and behavioral health services in the region are the responsibility o the Yukon-Kuskokwim

Health Corporation (YKHC), a tribal organization which administers a comprehensive health caredelivery system or the 56 rural communities in southwest Alaska. YKHC has put extensive resources

into the building and development o village health clinics oering both health and behavioralhealth services. In addition to the community health clinics in the villages, the system includes

our sub-regional clinics, a regional hospital, dental services, behavioral health services includingsubstance abuse counseling and treatment, health promotion and disease prevention programs,

and environmental health services. The programmatic approach or children’s mental health serviceswas adopted with a ederal system o care grant and is comprised o core teams o licensed mental

health proessionals and behavioral health aides that are responsible or service delivery in the ruralvillages o the Delta area. Behavioral health aides are indigenous practitioners specially trained to

provide behavioral health services to individuals living in the widely scattered villages in Alaska. Thecore service teams were developed and organized around the existing our sub-regional clinics and

currently include an itinerant clinician and behavioral health aides. The core teams are nanced byAlaska’s Medicaid authority in the Department o Health and Human Services, Tribes, Tribal health

programs, and the Indian Health Service.

To illustrate, the clinician who covers Upper Kalskag lives in Aniak (the sub-regional cliniclocation) and is responsible or 15 villages and ve behavioral health aides. She fies rom village to

village three to our days a week. The clinician’s supervisor is located in Bethel. The child protection




V I I I . F i n a n


T r i b a l S y s t e m s o f C a r e oce or Upper Kalskag is also located in Aniak. The child welare system has a worker who gets

involved with amilies where child abuse has occurred and makes reerrals to the behavioral health

aide or both children and parents. The reerral is oten or substance abuse issues, but the clinicianand behavioral health aide look at the whole person and amily. The clinician has a small caseload in

Aniak. Typically, she sees people once in the villages as part o the assessment to make a diagnosis;she is not the primary counselor except when there are complex amily issues. Services are provided

by behavioral health aides receiving supervision rom the clinician.

Emergency on-call mental health services are operated rom Bethel. Emergency Servicesclinicians and complex care managers are available 24 hours a day to respond to behavioral health

crises. The clinicians are master’s level with both experience and specialized training in mental healthand substance abuse treatment. The complex care managers are experienced counselors whose

specialty area is working in the eld o substance abuse treatment. I there is a crisis, the crisis personin Bethel talks with the behavioral health aide about what to do. The crisis counselor sometimes

provides crisis intervention counseling by telephone.

Behavioral health aides typically have strong partnerships with schools. Coordination o unding at the village level primarily takes place with the school district. For example, a request or a

neurological assessment may be on a child’s individual education plan (IEP). I the request is on theIEP, the school district pays or the assessment. I the request is not on the IEP, the request would be

reerred to a physician and a medical acility; Medicaid would likely be the payer.

YKHC sponsors several projects that are designed to oer and support culturally competentservices and supports. The Family Spirit Project, or example, is a collaborative eort o the

communities o the Yukon-Kuskokwim region, the Department o Health and Social Services,Division o Alcohol and Drug Abuse, Oce o Children’s Services, the YKHC, and others. Emphasizing

traditional amily lie and values, the collaboration builds a community development model tostrengthen amilies so that children will be saer in their homes. Parents who could lose their parental

rights due to abuse and neglect o their children are encouraged to enter substance abuse treatmentin a culturally appropriate and supportive manner. These parents are a priority population or

YKHC’s substance abuse treatment services. A Community Holistic Development Program conductspresentations on grie processes, youth conerences, healing circles, “Spirit Camps,” and other health

promotion activities. This program integrates the cultural, traditional, and spiritual values o thepeople in partnership with other amily-based counseling services.

YKHC experiences signicant challenges in several areas including: capacity and administrative

inrastructure, such as billing, business technology, and data; sta recruitment and retention;enrollment and re-enrollment o children into Medicaid; transportation to and rom the villages;

and a lack o service capacity. However, a number o strategies have been implemented to addresssome o these challenges. For example, YKHC nances the education o behavioral health aides as a

strategy or recruiting and retaining qualied sta to provide children’s behavioral health services.Many training activities are provided, and YKHC pays sta while they are in training.




Conclusion

Technical Assistance The sites reported a number o common technical assistance needs to help them to urther develop and

improve their nancing strategies or their systems o care. The technical assistance deemed necessary orprogress includes the ollowing:

• Medicaid— Several o the sites indicated that technical assistance related to Medicaid is an increasingly

urgent need. Technical assistance is needed to understand the Medicaid program, avoid pitalls with the

program in the current climate, and improve documentation in preparation or ederal audits. Concern

was raised by several sites about the potential impact o ederal audits, as well as administrative rulings

requiring unbundling o program costs, on their systems o care and behavioral health services that are

unded by Medicaid. For most sites, Medicaid nancing is the oundation o their systems. Partnership

and technical assistance rom the state Medicaid agency was considered essential by a number o the

sites.

• Developing a Comprehensive, Cross-Agency Financing Plan— Although many o the sites

studied have numerous eective nancing strategies in place, they identied a need or assistance in

developing a comprehensive nancing plan that takes an even greater cross-agency view o nancingchildren’s behavioral health services.

• Pay for Performance Arrangements — Several sites indicated a need or technical assistance on pay

or perormance arrangements or perormance-based contracting.

• Determining Costs and Setting Rates

Contextual, Environmental, Fiscal or Other Factorsthat Will Infuence Financing Policies and Strategiesor Systems o Care

The sites identied a number o actors that are likely to infuence nancing policies and strategies or their

systems o care. These include a host o contextual, environmental, scal, and other actors that may impactthe sites in the uture:

• Leadershipchangesatthestatelevelandresultantchangesinpolicythatleavesystemofcarereforms

vulnerable

• ShiftsinMedicaidnancingfederally

• Increasedscrutinyofstates’useofMedicaid

• Endoflawsuitsandaccompanyingcourtmonitoringandpotentialdicultyinmaintainingstate’s

nancial and policy investment in the children’s mental health system

• Reductionsinfederalfunding

• Shrinkingpsychiatricservicesandqualiedproviders

• Needtobetterlinkhealthcareandbehavioralhealthcare

• Emergingnewpopulations(e.g.,childrenandadolescentswithco-occurringconditions,suchasautism)andburgeoningexistingpopulations(juvenilecorrections)thatincreasinglycompeteforscare

resources

As a ollow-up to this study, each o these sites will be interviewed by telephone to urther identiy and

discuss the impact o contextual, environmental, scal, and other actors on their nancing policies and

strategiesforsystemsofcareandwhatactionsoradjustmentsthesesiteshaveimplementedinresponse.


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SunCom Phone: 574-7241 SunCom Fax: 574-7242

This publication is also available FREE on-line as a downloadable Adobe Acrobat PDF le:

http://rtckids.fmhi.usf.edu/study03.cfm orhttp://pubs.fmhi.usf.edu click Online Publications (By Subject)

□ Please send _____ copies of FMHI Pub #235-02 with payment to the person/organization, and address listed below.

Eective Financing Strategies for Systems of Care: Examples from the Field

Name Title Quantity at $15.00 Each Total $ Amount of Order

Organization/Agency

Street/Shipping Address Suite

City State Zip

County Country

Area Code Phone Number Area Code Fax Number

E-mail Address Web Address

Make Payment to Louis de la Parte FMHI Auxiliary Fund ☐ Payment by PO Number ☐ Payment by Check Number

Payment by Credit Card Type ☐ Master Card ☐ Visa ☐ Discover Card ☐ American Express

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M a i l o r F a x t

h i s O R D E R F O R M f o

r # 2 3 5 - 0 2

( ) ( )

Produced in Cooperation with:Research and Training Centerfor Children’s Mental Health

Department of Child and Family StudiesLouis de la Parte Florida Mental Health Institute

University of South Florida Tampa, FL

National Technical Assistance Centerfor Children’s Mental Health

Georgetown University Center for Childand Human Development

Washington, DC



Second Technical Assistance Document assistingchild mental health care advocates, stakeholders and policy-makers to identify and implement eective nancial strategiesand approaches to improved care for children and their families.

Research and TrainingCenterFor Children’s Mental Health



Eective Financing Strategies for Systems of Care: Examples from the Field 183

To Order FMHI Pub #235-01

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A Self-Assessment and Planning Guide:Developing a Comprehensive Financing PlanMary I. Armstrong, Ph.D., Sheila A. Pires, M.P.A., Beth A. Stroul, M.Ed., Jan McCarthy, M.S.W., Ginny M. Wood, B.S., & Karabelle Pizzigati, Ph.D.





To order a printed copy of FMHI Pub #235-01mail or fax order form below with payment to:


Tampa, FL 33612-3899

Phone: (813) 974-4471 Fax: (813) 974-7242 Email: [email protected]

SunCom Phone: 574-7241 SunCom Fax: 574-7242

This publication is also available FREE on-line as a downloadable Adobe Acrobat PDF le:

http://rtckids.fmhi.usf.edu/study03.cfm orhttp://pubs.fmhi.usf.edu click Online Publications (By Subject)

□ Please send _____ copies of FMHI Pub #235-01 with payment to the person/organization, and address listed below.

A Self-Assessment and Planning Guide:Developing a Comprehensive Financing Plan


Organization/Agency


City State Zip

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M a i l o r F a x t

h i s O R D E R F O R M f o

r # 2 3 5 - 0 1

( ) ( )

First Technical Assistance Document assisting childmental health care advocates, stakeholders and policy makersto identify and implement eective nancial strategies and

approaches to improved care for children and their families.

$ 1 0. 0 0

F M H I P u b #

2 3 5 - 0 1

5 4 p a g e s

Produced in Cooperation with:Research and Training Centerfor Children’s Mental Health

Department of Child and Family StudiesLouis de la Parte Florida Mental Health Institute

University of South Florida Tampa, FL

National Technical Assistance Center

for Children’s Mental HealthGeorgetown University Center for Child

and Human DevelopmentWashington, DC



Research and TrainingCenterFor Children’s Mental Health


http://slidepdf.com/reader/full/study03-exp-fr-field 192/194 O

r d e r F o r m s 184 Eective Financing Strategies for Systems of Care: Examples from the Field

Research and TrainingCenterFor Children’s Mental Health Issue Brief 1

Issue Brief 2

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6.

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Issue Brief 1: Eective Strategies to Finance a Broad Array of Services and SupportsBeth A. Stroul, M.Ed.

Suggested Citation:

Stroul, B. A., (2007). Issue brief 1: Eective strategies to nance a broad array of services and supports ( RTC study 3: Financingstructures and strategies to support eective systems of care, FMHI pub. #235-IB1). Tampa, FL: University of South Florida,Louis de la Parte Florida Mental Health Institute (FMHI), Research and Training Center for Children’s Mental Health.

(FMHI Publication #235–IB1)

Issue Brief 2: Eective Strategies to Finance Family and Youth Partnerships

Sheila A. Pires, M.P.A. and Ginny Wood

Suggested Citation:

Pires, S.A., & Wood, G. (2007). Issue brief 2: Eective strategies to nance family and youth partnerships (RTC study 3: Financingstructures and strategies to support eective systems of care, FMHI pub. #235-IB2). Tampa, FL: University of South Florida,Louis de la Parte Florida Mental Health Institute (FMHI), Research and Training Center for Children’s Mental Health.(FMHI Publication #235–IB2)

To order a printed copy of FMHI Pub #235-IB1 and/or #235-IB2 mail or fax the order form below with payment to:


Tampa, FL 33612-3899

Phone: (813) 974-4471 Fax: (813) 974-7242SunCom Phone: 574-7241 SunCom Fax: 574-7242 Email: [email protected]

□ Please send _____ copies of

FMHI Pub #235-IB1with payment to the person/organization, and address listed below.

Issue Brief 1: Eective Strategies to Finance a Broad Array of Services and Supports

□ Please send _____ copies of FMHI Pub #235-IB2 with payment to the person/organization, and address listed below.

Issue Brief 2: Eective Strategies to Finance Family and Youth Partnerships


Organization/Agency


City State Zip

County Country






M a i l o r F a x t h i s O r d e r F o r m f o

r # 2 3 5 - I B 1 & # 2 3 5 - I B 2

( ) ( )

RTC Study 3 publications are also available FREEon-line as downloadable Adobe Acrobat PDF les:

http://rtckids.fmhi.usf.edu/study03.cfm or

http://pubs.fmhi.usf.edu click Online Publications (By Subject)







The Research andTraining Center forChildren’s Mental Health

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Study03 Exp Fr Field

Documents

Transcript of Study03 Exp Fr Field