Data Leads to Quality Supported Employment Program and Partnerships Cathy Callaway Judy Vohland Nebraska VR

History of Behavioral Health Supported Employment in Nebraska First Co-Operative Supported Employment Program started in 1994 in Omaha. Six (6) Supported Employment Contracts covering 12 cities/towns by 2008. Agreements covered the state and included three (3) smaller communities. Each Supported Employment Program differed in design and service delivery. Two (2) sites were Clubhouses. Two (2) agreements were not tied to a behavioral health day program.

Evolution of Contracts: Co-Operative Agreements The initial contract model was a co-operative agreement with the Nebraska Division of Behavioral Health. All of the agreements were expenditure based. Served individuals with severe and persistent mental illness. The average cost per outcome for this model in 2006/ 2007 was $9529.60. (Total Outcomes-190) (Five programs) Each proposal contained costs to deliver supported employment services and projected a number of outcomes. VR performed fiscal audits.

Evolution of Contracts: Outcome Based Nebraska VR and Nebraska Division of Behavioral Health met in 2007 and 2008 to review Supported Employment Service Delivery. Nebraska VR no longer needed the DBH dollars for match. Outcomes varied from site to site. Nebraska VR agreed to fund the Supported Employment Services. Nebraska DBH agreed to fund long term supports. Nebraska DBH expanded eligibility for Supported Employment Services to include anxiety disorders and substance abuse.

Evolution of Contracts: Outcome Based Nebraska VR paid $5000 per outcome The Supported Employment provider projected the number of outcomes to be achieved for the year. The amount of the contract was based on the number of outcomes times $5000. (i.e. 20 outcomes x 5000=$100,000.) VR paid 60% up front quarterly. $2000 paid for each successful outcome quarterly. (40%) Provider was not paid for any outcomes over projection nor made to pay back any of advanced 60% if outcomes not achieved.

The Path to the Milestone Supported Employment Model Nebraska Division of Behavioral Health along with Nebraska VR set up a series of meetings to review the Supported Employment Model at the beginning of 2012. Members of the group included VR Director, Fiscal Administrative Specialist, VR Program Director, DBH Director, Director of Community Based Services, Administrators of Federal & Fiscal Performance; Prevention, Treatment & Supportive Health Services and Quality & Data Performance Measurement. Challenges: The funding model; The fidelity model; Systems’ rules and regulations; Increasing the numbers of people served; Outcomes.

The Path: Nebraska Behavioral Health System and Nebraska VR Nebraska Division of Behavioral Health is part of Health and Human Services. The Division disperses funding to six (6) Behavioral Health Regions which are not part of DBH. The Regions fund local behavioral health services including supported employment. Nebraska VR is part of the Department of Education. Nebraska VR provides direct services including assessment, planning, placement. Partners for services for Supported Employment, Assistive Technology, Benefits Planning, Self Employment and AgrAbility.

The Path: Tools Review of fidelity models. (see Supported Employment Fidelity Scale) IPS Training for all providers and VR. Cross Reference of all clients served under SE for VR and DBH. Sharing of client data. Agreement signed for sharing information. Shared information on VR contract costs and amounts and DBH (Regions) payments to Supported Employment Providers. VR analysis of outcome contracts using VR reporting standards including the rehab rate.

The Path: Tools DBH contracted for a study: "Supported & Transitional Employment Cost Models" by Consultant Barbara W. Thomas Study included a fiscal analysis of each provider and costs for the DBH contribution. VR conducted a review of the blended funding and the cost per outcome for fiscal year 2011-2012. Total number of Supported Employment outcomes for 2011-2012 was 222 and an average rehab rate 61.54%. The cost per outcome with blended funding was $15,123.18. The cost per VR outcome was $8,569.55.

The Path: Tools VR conducted internal case reviews, program reviews and conducted surveys of SE staff and VR Staff using Survey Monkey. Reports developed and shared with all parties. Examined milestone payment system. VR Director led the discussion. Reviewed literature. Contacted Maryland, Missouri, Kansas, Oklahoma and Indiana. Held telephone conferences with states. Visited an IPS SE site in Kansas City that utilized milestone payments. Fiscal analysis led to a tentative milestone payment proposal.

The Path: Tools - Communication Regular face to face meetings were held monthly. Monthly conference calls with the Regional Behavioral Health Administrators and the Supported Employment Providers. VR Program Director met with the Providers face to face on a quarterly basis. Communication between all of the partners was key. All information gathered from the tools were shared and discussed. Continual analysis of performance and costs.

The Path: Implementation Milestones development. VR pays Milestone 1, 3 and 4. DBH pays Milestone 2 and long term support based on an hourly rate ($68). Total cost for service $5000. VR pays $4000. DBH pays $1000 and long term supports. VR lifts the cap on the number of outcomes. VR will provide Benefits Orientation and Analysis. More clients may be served using this model. MOU developed between VR and DBH.

The Path: Implementation DBH developed a pilot for providers to compare income from the contract models and the milestone payments. Pilot ran March 1, 2014-June 30, 2014. Monthly phone conferences. Result of study-DBH agreed to pay transitional dollars to providers upon start of the milestone system. The payments ended on March 30, 2015. VR responsible for benefits planning. VR developed training for VR staff and for VR Providers for new system.

The Path: Implementation Training provided during the Summer, 2015. Providers and VR Program Director developed a standard Milestone Reporting and Billing form for each milestone. The Division of Behavioral Health instituted a " Supported Employment Payment Protocol Manual- Milestones and Payment for Services". (See manual) VR changed the VR Program Manual to reflect changes in the Supported Employment Programs. (See Nebraska VR-Supported Employment) New Milestone System implemented October 1, 2014.

Challenges and Quality Control Transition from guaranteed funding to performance based funding. Billing glitches. Changes in computer program to flag milestones. Learning curve for all. Internal VR case reviews and provider program reviews completed August 18, 2015. Tracked the individual through both processes. Seven (7) programs today and a variety of performance. Three (3) programs have more outcomes than last year.

Challenges and Quality Control Recommendations from Program Review include revising Milestone Sheets, Better training on identifying needed services, Development of a standard referral form to include certain basic information. Certain best practices are emerging including "referral meeting" between partners and the client, intensive job advocacy including job development along with employer advocacy and regular contact with client and with the employer for job maintenance. Regular meetings with VR staff and SE providers. Continued meetings with DBH and VR.

Model Outcome and Costs Comparisons Year Total Outcomes Average cost per outcome VR DBH Cooperative 2006/2007 190 $9,529.60 Performance Based (60/40-VR) (Blended) 2012/2013 222 $15,123.18 $8,569.55 $6,553.63 Milestones (Braided) 2014/2015 220 As of 8/24/15 $5,500.00 (Placement rate change by DBH) $4,000.00 $1,500.00* 7/2015 $68 per hour long term rate

Samples of Tools & Research Samples of Provider and VR Staff Surveys on Supported Employment. Sample of Report on first Program Review and Internal Review. Supported Employment Payment Protocol Manual-Milestones & Payment for Services(Final 11/24/14) Division of Behavioral Health, Nebraska Department of Health & Human Services Nebraska VR Program Manual: Supported Employment-Behavioral Health, Acquired Brain Injury, Autism, Intellectual Disabilities (10/27/14)

SPECIAL THANKS TO OUR PARTNERS Susan Adams, M.A., Network Services Administrator Division of Behavioral Health, NE Department of Health & Human Services Susan.Adams@nebraska.gov Sheri Dawson, Director Division of Behavioral Health NE Department of Health and Human Services Sheri.Dawson@nebraska.gov Karen Harker, Fiscal & Federal Performance Administrator Division Of Behavioral Health, NE Department Of Health & Human Services Karen.Harker@nebraska.gov Heather Wood, M.S., Quality Improvement & Data Performance Administrator Heather.Wood@nebraska.gov

Website link: http://www.vr.nebraska.gov/partners/mental_health.html Nebraska VR Cathy Callaway, Administrative Specialist-Fiscal NE Department of Education-Nebraska VR cathy.callaway@nebraska.gov Mark Schultz, Director-Nebraska VR NE Department of Education, Nebraska VR mark.schultz@nebraska.gov Judy Vohland, Program Director-Community Services judy.vohland@nebraska.gov Website link: http://www.vr.nebraska.gov/partners/mental_health.html