1. 1 THE SKILL BUILDING CURRICULUM Module 7 Service Array and Financing Developed by: Sheila A. Pires Human Service Collaborative Washington, D.C. In partnership with: Katherine J. Lazear Research and Training Center for Children’s Mental Health University of South Florida, Tampa, FL Lisa Conlan Federation of Families for Children’s Mental Health Washington, D.C. Primer Hands On-Child Welfare

2. 2 Medicaid is the primary source for health/mental health care for children in child welfare. Most states (86%) are applying managed care approaches to their Medicaid programs. Why Focus on Medicaid Managed Care? Health Care Reform Tracking Project 2003 State Survey. Research and Training Center for Children’s Mental Health, University of South Florida, Tampa, FL

3. 3 Children in Child Welfare in Medicaid Managed Care HMO Enrollment: 245,313 BHO Enrollment: 174,584 ________________________ Total Enrollment: 419,897 Source: CMS/MSIS State Summary Data, FY 2003 53% - 72% of foster care population is enrolled in Medicaid managed care – Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

4. 4 State Coverage of Child Welfare Population in Medicaid Managed Care 26 states include the child welfare population in Medicaid managed care – 22 with mandatory enrollment 4 with voluntary enrollment Source: Health Care Reform Tracking Project 2003 State Survey Pires, S. (2002). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

5. 5 NRCOI Framework for a Full Service Array in Child Welfare 1.Assessment of Current Practices in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. 2.Assessment of Current Leadership and Systemic Culture in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. 3.Assessment of Current Services in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. 4.Assessment of the Need for Other Services Not Currently Available in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. “Collaborative, strategic, population-focused process, guided by set of tools, to identify array of practices, services, and supports needed in a SOC for child welfare populations” Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource Center for Organizational Improvement

6. 6 Purposes of NRCOI Framework Create a service directory Prepare for the CFSR, the Statewide Assessment, and in developing the PIP re the service array Meet CAPTA requirement to conduct annual inventory Help define array of services needed in SOC when specific target population has been chosen Identify gaps and strategies to improve service array Can lead to better collaboration among providers and a better functioning community collaborative Examples Pulaski, Co., Virginia Nebraska – 14-county rural area Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource Center for Organizational Improvement

7. 7 PRIMER HANDS ON- CHILD WELFARE HANDOUT 7.1 National Child Welfare Resource Center for Organizational Improvement: Service Array Framework www.nrcoi.org Primer Hands On - Child Welfare (2007)

8. 8 Dawn Services & Supports Behavioral Health 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 Placement Acute hospitalization Foster care Therapeutic foster care Group home care Relative placement Residential treatment Shelter care Crisis residential Supported independent living Psychiatric Assessment Medication follow-up/psychiatric review Nursing services Mentor 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 Respite Crisis respite Planned respite Residential respite Service Coordination Case management Service coordination Intensive case management Other Camp Team meeting Consultation with other professionals Guardian ad litem Transportation Interpretive services Discretionary Activities Automobile repair Childcare/supervision Clothing Educational expenses Furnishings/appliances Housing (rent, security deposits) Medical Monitoring equipment Paid roommate Supplies/groceries Utilities Incentive money 2005 CHIOCES, Inc., Indianapolis, IN

9. 9 Programs Addressing Safety - Abuse-Focused Cognitive Behavioral Therapy (AF-CBT) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Project Connect - Child Parent Psychotherapy for Family Violence (CPP-FV) – Trauma Treatment Rated - Project SafeCare - Domestic Abuse Intervention Project (DAIP) - Nurturing Parenting Programs - Project SUPPORT - Intensive Reunification Program (IRP) Motivational Interviewing (MI) - Nurturing Program for Families in Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - Supported Housing Program (SHP) - The Community Advocacy Project - Triple P – Positive Parenting Program Programs Addressing Permanency HOMEBUILDERS - Intensive Reunification Program (IRP) - Project CONNECT - Shared Family Care Programs Addressing Well-Being 1-2-3 Magic: Effective Discipline for Children 2-12 - Abuse-Focused Cognitive Behavioral Therapy - Alcoholics Anonymous (A.A.) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Child Parent Psychotherapy for Family Violence (CPP-FV): Trauma Treatment Rated - Community Reinforcement + Vouchers Approach (CRA + Vouchers) - Community Reinforcement Approach - Domestic Abuse Intervention Project (DAIP) - Eye Movement Desensitization and Reprocessing (EMDR) - Intensive Reunification Program (IRP) - Motivational Interviewing (MI)Nurturing Parenting Programs - Nurturing Program for Families in Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Parenting Wisely - Project CONNECT - Project SUPPORT - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - STEP: Systematic Training for Effective Parenting - Supported Housing Program (SHP) - The Community Advocacy Project - The Incredible Years – Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - Triple P – Positive Parenting Program Examples of Evidence Based Practices Related to CFSR Outcomes California Evidence-Based Clearinghouse at: http://www.cachildwelfareclearinghouse.org

10. 10 Examples of Other Services You’d Want to Provide Based on Practice/Family Experience & Outcomes Data Family Group Decision Making Wraparound Integration of natural helping networks Intensive in-home services (not just MST) Respite services Mobile response and stabilization services Independent living skills and supports Family/youth education and peer support Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

11. 11 Examples of What You Don’t See Listed as Evidence-Based Practice (though they may be standard practice) Residential Treatment Group Homes Day Treatment Traditional office-based “talk” therapy Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

12. 12 Examples from Hawaii’s List of Evidence Based Practices Problem AreaBest SupportGood SupportModerate Support Anxious or Avoidant Behaviors Cognitive Behavior Therapy (CBT); Exposure Modeling CBT with Parents; Group CBT; CBT for Child & Parent; Educational Support None Depressive or Withdrawn Behaviors CBT CBT with Parents; Inter-Personal Tx. (Manualized); Relaxation None Disruptive & Oppositional Behaviors Known Risks: Group Therapy Parent & Teacher Training; Parent Child Interaction Therapy Anger Coping Therapy; Assertiveness Training; Problem Solving Skills Training, Rational Emotive Therapy, AC-SIT, PATHS & FAST Track Programs Social Relations Training; Project Achieve Juvenile Sex OffendersNone Multisystemic Therapy Delinquency & Willful Misconduct Behavior Known Risks: Group Therapy NoneMultisystemic Therapy; Functional Family Therapy Multi- Dimensional Treatment Foster Care;Wraparound Foster Care Substance Use Known Risks: Group Therapy CBTBehavior Therapy; Purdue Brief Family Therapy None HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd

13. 13 PRIMER HANDS ON- CHILD WELFARE HANDOUT 7.2 Examples of Potentially Harmful Programs and Effective Alternatives Source: Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer Influences in Intervention and Public Policy for Youth,” Social Policy Report, Vol. XX, No. 1, January 2006. As published in Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7. www.youthtoday.orgwww.youthtoday.org Primer Hands On - Child Welfare (2007)

14. 14 Challenges to Financing and Implementing Evidence-Based/Promising Practices Financing & Infrastructure needed for: Training Consultation Coaching Provider Capacity Development Fidelity Monitoring Outcomes Tracking Pires, S. 2005. Human Service Collaborative. Washington, D.C.

15. 15 How to Finance/Implement Evidence-Based and Promising Practices Adopt a Population Focus: Who are the populations of families and youth for whom you want to change practice/outcomes? Adopt a Cross-Systems Approach: What other systems serve these children and families? Who controls potential or actual dollars? Which systems now spend a lot on restrictive levels of care with poor outcomes or on deficit-based assessments not linked to effective services - opportunities for re-direction? Identify Incentives and Supports to finance/implement evidence based practices Pires, S. 2005. Human Service Collaborative. Washington, D.C.

16. 16 Examples of Incentives to Various Systems Serving Children and Families Medicaid : slowing rate of growth in inpatient, emergency room, residential treatment and pharmacy costs Child Welfare : meeting Adoptions and Safe Families Act outcomes; reducing out-of-home placements Juvenile Justice : creating alternatives to incarceration Mental Health : more effective delivery system Education : reducing special education expenditures Pires, S. 2005. Human Service Collaborative. Washington, D.C.

17. 17 Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices Pires, S. 2005. Human Service Collaborative. Washington, D.C. District of Columbia Multi Systemic Therapy (MST), Mobile Response, In-Home Medicaid Rehab Option to pay for MST, Intensive Home-Based Services (Ohio model), Mobile Response and Stabilization Services (NJ model) Child Welfare provided match and paid for initial training, coaching, provider capacity development ; Mental health/child welfare to share costs of outcomes tracking Juvenile Justice also to pay match, training costs as well Medicaid HMO expressing interest in Mobile Crisis

18. 18 Service Array Focused on a Total Population  Family Support Services  Youth Development Program/Activities  Service Coordination  Intensive Service Management  Wraparound Services & Supports; Family Group Decision Making Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative. Core Services Prevention Early Intervention Intensive Services Universal Targeted

19. 19 Driven by family/youth-preferred choices; Understands the needs/help-seeking behaviors of youth/families; Embraces principles of equal access/non-discriminatory practices; Designs/implements services and supports that are tailored or matched to the unique needs of children, youth, families, organizations and communities served; Recognizes well-being crosses life domains; Understands that cultural competence must be defined and required for Evidence Based Practices (EBP), and that Practice Based Evidence (PBE) must be taken into consideration as a critical component of EBPs in communities of color. Lazear, K. J Primer Hands On Human Service Collaborative, Washington, DC. 2006 Characteristics of a Culturally and Linguistically Competent Service Design & Practice

20. 20 Families and Youth Provide Valuable Services and Supports As technical assistance providers & consultants  Training  Evaluation  Research  Support  Outreach As direct service providers  Foster Parents  Mentors  Service Coordinators  Family Educators  Specific Program Managers (respite, etc) Adapted from Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

21. 21 Family and Youth Roles in Building Evidence-Based Practice (EBP) Advocate for ethical, culturally sensitive research Participate in the development and analysis of research to support EBP Assist in data collection to support EBP Educate families, family leaders and youth about EBP Wells, C. & Pires, S. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

22. 22 Examples of Strategies to Address Lack of Home and Community-Based Services Support family and youth movements Engage natural helpers and culturally diverse communities Implement a meaningful Medicaid rehab option Write child and family appropriate service definitions Collapse out-of-home and home and community-based budget structures Re-direct dollars from out-of-home to home and community- based Implement flexible rate structures (e.g., bundled rates/case rates) Implement pilots or phase in system change Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

23. 23 Implement capacity-building grants Implement performance-based contracts Develop practice and implementation guidelines Train providers, judges, families, etc. – use training resources across systems Implement quality and utilization management Apply for federal demonstration grants Collect data on child and family outcomes, family/youth satisfaction, and cost/benefits Educate key constituencies (e.g., legislators, Governor’s Office, State Insurance Commissioner) Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C. Examples of Strategies to Address Lack of Home and Community-Based Services

24. 24 Examples of Sources of Funding for Children/Youth with Individualized Needs in the Public Sector Pires, S. (1995). Examples of sources of funding for children & families in the public sector. Washington, DC: Human Service Collaborative. Medicaid Medicaid In-Patient Medicaid Outpatient Medicaid Rehabilitation Services Option Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) Targeted Case Management Medicaid Waivers TEFRA Option Substance Abuse SA General Revenue SA Medicaid Match SA Block Grant Juvenile Justice JJ General Revenue JJ Medicaid Match JJ Federal Grants Mental Health MH General Revenue MH Medicaid Match MH Block Grant Child Welfare CW General Revenue CW Medicaid Match IV-E (Foster Care and Adoption Assistance) IV-B (Child Welfare Services) Family Preservation/Family Support Education ED General Revenue ED Medicaid Match Student Services Other TANF Children’s Medical Services/Title V– Maternal and Child Health Mental Retardation/ Developmental Disabilities Title XXI-State Children’s Health Insurance Program (SCHIP) Vocational Rehabilitation Supplemental Security Income (SSI) Local Funds

25. 25 Major Child Welfare Funding Streams Child Welfare Services – Title IV-B Foster Care & Adoption Assistance – Title IV-E Social Services Block Grant Temporary Assistance to Needy Families (TANF) Medicaid – Title IX State and local general revenue Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

26. 26 TypeAdvantagesDrawbacks IV-B Flexible, includes family preservation and support $$ Capped allocation from federal government to states and represents a relatively small percentage of available $$ IV-E Uncapped entitlement $$Can be used only for room/board costs for eligible children in out-of-home placements and certain administrative and training costs Medicaid Important source of revenue for health and behavioral health services for children in or at risk for child welfare involvement Medicaid agencies are concerned about increasing costs and assuming too much responsibility for “high-cost” populations; Adult family members may not be eligible TANF Important source of emergency funds for families Capped SS Block Grant FlexibleCapped and shrinking Advantages and Drawbacks of Specific Child Welfare Financing Streams Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

27. 27 Creating “Win-Win” Scenarios System of Care Child Welfare Alternative to out-of-home care high costs/poor outcomes Juvenile Justice Alternative to detention- high cost/poor outcomes Medicaid Alternative to Inpatient/Emergency Room- high cost Special Education Alternative to out-of-school placements – high cost Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

28. 28 Thinking Across Systems Serving Children, Youth and Families Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

29. 29 Financing Strategies to Support Improved Outcomes for Children, Youth and Families FIRST PRINCIPLE: System Design Drives Financing Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy. REDEPLOYMENT Using the money we already have The cost of doing nothing Shifting funds from treatment to prevention Moving across fiscal years REFINANCING Generating new money by increasing federal claims The commitment to reinvest funds for families and children Foster Care and Adoption Assistance (Title IV-E) Medicaid (Title XIX) RAISING OTHER REVENUE TO SUPPORT FAMILIES AND CHILDREN Donations Special taxes and taxing districts for children Fees & third party collections including child support Trust funds FINANCING STRUCTURES THAT SUPPORT GOALS Seamless services: Financial claiming invisible to families Funding pools: Breaking the lock of agency ownership of funds Flexible Dollars: Removing the barriers to meeting the unique needs of families Incentives: Rewarding good practice

30. 30 What Are the Pooled Funds? Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch. CHILD WELFARE Funds thru Case Rate (Budget for Institutional Care for CHIPS Children) JUVENILE JUSTICE (Funds budgeted for Residential Treatment for Delinquent Youth) MEDICAID CAPITATION (1557 per month per enrollee) MENTAL HEALTH Crisis Billing Block Grant HMO Commercial Insurance Wraparound Milwaukee Management Service Organization (MSO) $30M Per Participant Case Rate Care Coordination Child and Family Team Provider Network 240 Providers 85 Services Plan of Care 9.5M 8.5M10M2.0M

31. 31 Example: Pooled Funds for Nebraska’s Integrated Care Coordination Units Child Welfare State General Revenue, IV-E, IV-B Juvenile Justice State General Revenue Federal Mental Health Block Grant Case Rate Integrated Care Coordination Unity Services and supports for children in state custody with complex needs Families Care 8% of Case Rate Pires, S. (2007) Primer Hands On - Child Welfare

32. 32 Financing – Cuyahoga County (Cleveland) FCFC $$ Fast/ABC $$ Residential Treatment Center $$$$ Therapeutic Foster Care $$$ “Unruly”/shelter care $ Tapestry $$ SCY $$ County Administrative Services Organization Neighborhood Collaboratives & Lead Provider Agency Partnerships Community Providers and Natural Helping Networks Reinvestment of savings Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative. } } State Early Intervention and Family Preservation System of Care Grants System of Care Oversight Committee

33. 33 Youth who are at-risk of entering a RTC The three sources of funding stream into the local management entity from the state and federal government. The local management entity is held accountable to the state. The three sources of funding are from Medicaid, Mental Hygiene, and a combination of DHR and DJS. Medicaid Federal and State (MHS Match Mental Hygiene Block Money DHR and DJS Example of Redirecting Funds Adapted from State of Maryland, 2004 Treatment services (in patient (treatment facility) and out-patient (in-home) services) Support services (respite, behavioral supports, nutrition, etc.) Housing/Placement services (foster care, group home, adoption, etc.) Youth referred to a local management entity At risk pool is created for the local managemen t entities Local Management Entity Controls the management of treatment services, support services, and housing/placements. Money form the three funding sources are streamlined into the local management entity $ $ $ $

34. 34 Where to Look for Money and Other Types of Support Pires, S. (1994). Where to look for money and other types of support. Washington, DC: Human Service Collaborative. e e

35. 35 SOURCESYSTEMDESCRIPTION State Mental Health General fund, Medicaid (including FFS/managed care/waivers), federal mental health block grant, redirected institutional funds, and funds allocated as a result of court decrees Child Welfare Title IV-B (family preservation), Title IV-B (foster care services), Title IV-E (adoption assistance, training, administration), and technical assistance and in-kind staff resources Juvenile Justice Federal formula grant funds to states for juvenile justice prevention, state juvenile justice appropriations, and juvenile courts. Education Special education, general education, training, technical assistance, and in-kind staff resources Governor’s Office/Cabinet Special children’s initiatives, often including interagency blended funding Social ServicesTitle XX funds and realigned welfare funds (TANF) Bureau of Children with Special Needs Title V federal funds and state resources Diversity of Federal Grant Sites Funding Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

36. 36 CMHS GRANT SITES FUNDING DIVERSITY SOURCESYSTEMDESCRIPTION State Health DepartmentState funds Public UniversitiesIn-kind support, partner in activities Department of Children In states where child mental health services are the responsibility of child agency, not mental health, sources of funds similar to above Vocational Rehabilitation Federal- and state-supported employment funds HousingVarious sources Local County, City, or Local Township General fund Juvenile JusticeLocally controlled funds Education Courts, probation department, and community corrections County May levy tax for specific purposes (mental health) Food ProgramsIn-kind donations of time and food HealthLocal health authority-controlled resources Public Universities and Community Colleges Substance AbuseIn-kind support Diversity of Federal Grant Sites Funding (continued) Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

37. 37 Diversity of Federal Grant Sites Funding (continued) SOURCESYSTEMDESCRIPTION Private Third Party ReimbursementPrivate insurance and family fees Local BusinessesDonations and in-kind support Foundations Robert Wood Johnson, Annie E. Casey, Soros Foundation, and various local foundations Charitable Lutheran Social Services, Catholic Charities, faith organizations, homeless programs, and food programs (in-kind) Family OrganizationsIn-kind Support Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

38. 38 Example: Diversified Funding Sources & Approaches at the Parent Support Network, RI Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources. CHILD WELFARE IVB FUNDS STATE APPROPRIATION FUNDS BEHAVIORAL HEALTH DEPARTMENT OF EDUCATION DISCRETIONARY FUNDS FEDERAL GRANTS & PRIVATE DONATIONS Administrative Infrastructure (4.0 FTE) Executive Director, Assistant Director, Administrative Assistant, and Data and Technology Specialist Peer Mentor Program (3.25 FTE) Information & Referral Child & Family Teams Education Planning Support Groups/ Youth Speaking Out Training Family & Youth Leadership Program (2.50 FTE) System Reform Training & TA Placement on Policy Boards Focus Groups Social Marketing/ Presentations

39. 39 Medicaid OptionAdvantagesIssuesExample Rehabilitation Services Option Flexibility to cover a broad array of services and supports provided in different settings (e.g., home, school) Service definitions often adult-oriented Provider-service mismacth OH – developing new service definitions and case rates for intensive home-based services and Multisystemic Therapy Managed Care Demos and Waivers - 1115 and 1915 (b) Accountability and management of cost through risk structuring/sharing Flexibility to cover wide range of services and populations Managed care not without risks/challenges Federal waiver process can be challenging Cost neutrality issues NM – covering Multisystemic Therapy AZ – covering family support and urgent response for child welfare Home and Community- Based Waivers - 1915 (c) Flexibility, broader coverage, waiver of income limits and comparability Alternative to hospital- level of care but PRTF (i.e., residential tx.) may be issue Cost and management concerns/limited to small number KS, NY, VT, IN, WI – have HCBS Waivers AK, FL, GA, IN, KN, MD, MS, MT, SC, VA – have community alternatives to psychiatric residential treatment facilities demonstration grant Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (1) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

40. 40 Medicaid Option AdvantagesIssuesExample Early and Periodic Screening, Diagnosis and Treatment - EPSDT Broadest entitlement Supports holistic assessments and services No waiver or state plan amendment requirements Management mechanism critical because of cost concerns Oriented more to physical health in practice RH PA Targeted Case Management Can be targeted to high need populations, such as child welfare Supports small case load focus (e.g., 1-10) Not sufficient without other services Federal attention VT NY Administrative Case Management Ability to cover basic case management services to support enrollment access Not sufficient without other services NJ – covering some activities of family-run organizations Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (2) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

41. 41 Medicaid Option AdvantagesIssuesExample Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) Avenue to eligibility to community-based services for children who meet SSI disability criteria – allows disregard of family income SSI criteria not easy to meet for children with SED Does not expand types of covered services Cost issues, so generally small program MN WI Medicaid as Part of a Blended or Braided Funding Approach (without a waiver) Holistic, integrated (across systems) financing, supports broad array of services, natural supports and individualized care Involves significant restructuring Milwaukee Wraparound DAWN Project Massachusetts Mental Health Services Program for Youth New Jersey Partnership Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (3) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

42. 42 Bottom Line State Medicaid agencies are cobbling together a variety of Medicaid options in attempt to cover and contain community-based services for children and families - often without involvement of other systems serving children and families. What is needed is a more integrated, strategic financing approach across systems. Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

43. 43 If you have answered the questions: Financing For Whom? Financing for What? Then You Are Ready To Talk About Financing! Pires, S. 2006. Human Service Collaborative. Washington, D.C. I.E., Identified your population(s) of focus Agreed on underlying values and intended outcomes Identified services/supports and practice model to achieve outcomes Identified how services/supports will be organized (so that all key stakeholders can draw the system design) Identified the administrative/system infrastructure needed to support the delivery system Costed out your system of care

44. 44 Strategic Financing Analysis 1.Identify state and local agencies that spend dollars on the identified population(s). (How much each agency is spending and types of dollars being spent, e.g., federal, state, local, tribal, non-governmental) 2.Identify resources that are untapped or under-utilized (e.g., Medicaid). 3.Identify utilization patterns and expenditures associated with high costs/poor outcomes, and strategies for re-direction. 4.Identify disparities and disproportionality in access to services/supports, and strategies to address. 5.Identify the funding structures that will best support the system design (e.g., blended or braided funding; risk-based financing; purchasing collaboratives). 6.Identify short and long term financing strategies (e.g., Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum, etc.). Pires, S. 2006. Human Service Collaborative. Washington, D.C.

45. 45 Example: Program Budget for a Neighborhood-Based System of Care Cost Categories Proposed Total Costs Neighbor- hood Governance Family Leadership Family Service/ Support Removal of Barriers Community Organizing School Linkage Tracking & Evaluating VolunteersPartnership Building Exec. Direction &Support Salaries446,00021,00029,000190,00021,00026,00035,00015,00030,00018,00063,000 Fringe133,0006,3008,70057,0006,3007,80010,5003,9009,0005,40018,900 Building Occupancy 93,6008,70012,30036,8002,4004,3004,0002,5004,3002,50015,800 Professional Services 109,00017,60022,10032,4003,6002,700 18.6002,7002,9003,700 Travel43,70012,3005,30010,3009,0001,2003,000500 1,600 Equipment6,000600 Food Services 25,00004,0001,00018,00001,0000 00 Subcontract89,00000 0000000 Operating Supplies & Expenses 21,5001,8007008,6002001,3002,1005001,5004,100 Other (stipends, transport, child care) 84,000040,0009,00035,000000000 Equipment Lease 25,0002,500 Property25,0002,500 Insurance13,5002,7001,200 GRAND TOTALS: 1,115,100 80,000 125,900 459,900 84,300 51,100 64,100 45,800 55,300 36,800 113,900 Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.

46. 46 Proposed Total Costs Neighbor- hood Governance Family Leadership Family Service/ Support Removal of Barriers Community Organizing School Linkage Tracking & Evaluating VolunteersPartnership Building Exec. Direction &Support Revenue Totals Across Sources Foundation217,10040,00030,00025,00028,30024,000022,80012,00015,00020,000 State Mental Health & Substance Abuse 258,8002,50028,400157,9003,00020,00005,00012,0005,00025,000 County- Child Welfare 124,90020,00030,000 10,0005,00003,00012,0002,00012,900 Dept of Education 70,1002,5001,60000060,0000006,000 State Family Preservation Grant 373,4005,00020,000230,00035,0000012,00018,00014,00039,400 In-Kind29,300010,000 5,0001,0000080002,500 Donations21,3005,0009005,0001,0001002,1003,0005008005,000 Other Grants 20,2005,0009005,0001,0001002,1003,000003,100 GRAND TOTALS 1,115,100 80,000125,900459,90084,30051,10064,10045,80055,30036,800113,900 Revenue Allocation By Program Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center. Example: Program Budget for a Neighborhood-Based System of Care (continued)

47. 47 PRIMER HANDS ON- CHILD WELFARE HANDOUT 7.3 The “Matrix” from Oregon How to Fund the Service Array and How to Process Includes: Client Related Expenditures Resource Priorities Payment Documents Primer Hands On - Child Welfare (2007)