The Centre for Addiction and Mental Health and the Ontario Centre
of Excellence for Child and Youth Mental Health in partnership
with the International Initiative for Mental Health Leadership
present
A Webinar Series featuring
Bruce Kamradt
A Look into an international innovative
evidence-informed practice: Wraparound
Milwaukee April 29, 3 – 4:30 pm
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International Innovations in
Mental Health Series: Wraparound Milwaukee
2
International Innovations in
Mental Health Series: Wraparound Milwaukee
About the Series
• This series is jointly coordinated by EENet at the Centre for Addiction and
Mental Health (CAMH) and the International Innovations In Mental Health
(IIMHL) as well as supported by the Mental Health Commission of Canada
and Health Canada
• Partners include the Ontario Centre of Excellence for Child and Youth Mental
Health and the Canadian Mental Health Association, Ontario Division
• Presentations on a range of topics: Psychological therapies
Physical Activity and Mental Health
Child and Youth Mental Health
Dialogues and outcomes in treatment of acute psychosis
3
EVIDENCE EXCHANGE NETWORK
Heather Bullock Director, Knowledge Exchange April 2014
1. What is EENet?
What is EENet’s goal?
• EENet aims to make Ontario’s mental health and addictions system more evidence-informed.
• EENet builds capacity to respond to knowledge gaps in practice and policy, ensures that mental health and addictions practices and policies are informed by sound evidence, and enables stakeholders to generate and exchange knowledge.
EENet’s structure/key methods and
approaches
• EENet Management and Resource Centre (located at CAMH), with KE Leads located across province
• Communities of Interest
• Diverse stakeholders come together to co-create and share knowledge on topics of interest to system
• Partnerships to ensure alignment with and to leverage already existing system capacity e.g. Ontario Centre of Excellence for Child and Youth Mental Health, healthevidence.ca, CCSA
• Governance
• EENet Steering Committee – provides strategic guidance to network with representatives from different stakeholder groups; provincial and national organizations; and health/ KT researchers
7
2. What is EENet Connect?
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1,449 subscribers
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Almost 40,000 visitors
1746 stakeholders have joined, including: • Policymakers • Youth MH Court Workers • Service Users • MH Nurses
636 discussion threads created on: • Children & youth • Coordination, transitions & partnerships • Case studies & personal/lived experience
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As of February 2014…
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International Innovations in
Mental Health Series: Wraparound Milwaukee
Introductory Remarks
Dr. Simon Davidson is a child, adolescent and
family psychiatrist. He obtained his medical degree at
the University of Witwatersrand, Johannesburg, South
Africa and completed his residency in Psychiatry at
McMaster University, Hamilton, Ontario. He is a
Professor in the Division of Child and Adolescent
Psychiatry in the Department of Psychiatry and
Pediatrics at the University of Ottawa. He is Chief
Strategic Planning Executive of the Ontario Centre of
Excellence for Child and Youth Mental Health.
11
International Innovations in
Mental Health Series: Wraparound Milwaukee
Today’s presenter
Bruce Kamradt is the Administrator
of Childrens’ Mental Health Services
for Milwaukee County and creator of
Wraparound Milwaukee. Bruce is
recognized as a national expert in the
U.S. on designing, organizing and
financing community-based systems of
care for children.
12
Wraparound Milwaukee –
A National Model for Achieving the
Best Outcomes for Children with
Serious Emotional & Mental Health
Needs & Their Families
Toronto, Canada
April 29, 2014
Presented By:
Bruce Kamradt, MSW, Director, Wraparound Milwaukee
Background for the Development of A
System of Care in Milwaukee County and for
the Care Management Entity (CME) Model
Milwaukee County consists of a culturally and ethnic diverse
population of 1.1 million (230,00 children ages 0-18)
In the mid 1990’s Milwaukee County faced significant clinical,
programmatic and fiscal issues related to how care was
provided to children with serious emotional and mental health
needs
There was over utilization of out-of-home care for these
children, particularly in psychiatric hospitals, residential
treatment centers and correctional facilities
There was a lack of community-based treatment alternatives
14
Background for the Development of A System of
Care in Milwaukee County and for the Care
Management Entity (CME) Model – cont’d
Clinical outcomes were poor and recidivism high
Very little collaboration among mental health, Child Welfare
and Juvenile Justice systems which made for fragmented
service delivery
What Milwaukee faced was not uncommon to other
communities in the U.S.
15
The Planning Process – Bringing Key
Stakeholders Together
In 1995, the Children's Behavioral Health System brought
together a group of stakeholders from Child Welfare,
mental health, Juvenile Justice, legal system (judges),
special education, families and advocates to discuss the
issues and develop alternatives to how the system currently
looked and functioned
The group identified the target population of youth we
needed to focus on – youth with serious emotional &
mental health needs at risk of out-of-home placement or
those staying too long in such facilities
We identified the outcomes or goals we hoped to achieve
16
The Planning Process – Bringing Key
Stakeholders Together – cont’d
We identified the services and supports necessary to
serve these youth and families and what existed or did
not exist
We identified and aligned on the values and
philosophy for how the system needed to operate
We agreed on a new type of structure to oversee the
development, implementation and monitoring of the
new delivery system model—but not the traditional
managed care approach on the following slides!
17
18
19
What Were the Values We Chose to Build the
System and to Guide Service Delivery
Family Directed Care – “families needed to be seen as
the solution to meeting their child’s needs and not the
problem”
Strength-Based Care – “needed to build on child and
family strengths and not focus on perceived deficits”
20
What Were the Values We Chose to Build the
System and to Guide Service Delivery –
cont’d
Individualized Care – “every child and family is unique and
deserves a plan and services tailored to their needs –children
should get what they need, not what is only currently available”
Community-Based Care – “services are usually more effective
when delivered in the child’s own home and community –
institutional approaches should be kept to a minimum and only
for the shortest period necessary”
21
What Were the Values We Chose to Build the
System and to Guide Service Delivery –
cont’d
Coordinated Care Across Child Serving Systems – “every child
should have a single care plan across child serving systems”
Cultural Competency in Service Provision – “respect and
understanding for cultural differences is paramount to
effectively work with families”
Unconditional Responses – “we will never give up on a child or
family – plans fail, not people”
22
Wraparound Model
Wraparound is the approach we chose which is a practice and values driven approach for the planning and provision of services and supports that can be applied to any population of children and families with or at risk for intensive service needs
Wraparound puts system of care values and principles into practice for service
planning and provision.
10 Principles
of Wraparound
23
How We Chose to Develop and Implement
the Care Management Model
We needed to create a structure or organization that
could opperationalize our values and realize our goals
and organize the new service delivery model across
multiple child serving systems and move from a
traditional “categorical” to a “non-categorical system”
24
Categorical vs Non-Categorical
Categorical
System
Reforms
25
26
How We Chose to Develop and Implement
the Care Management Model – cont’d
Considerations for the model: Accountable to systems stakeholders
Flexible in service delivery
Have organizational capacity to serve a large population
Had to be able to bring financial resources together and manage those
resources
Strong data systems
Needed to be responsive to families
Had to have credibility with and confidence of stakeholders to achieve
goals and program outcomes
27
The CME Model and Governance
Considerations
Where would CME get it’s authority to act? Agreements and contracts with stakeholders
Federal waiver to allow for unique funding arrangement
How would it be governed? Under authority of local government
How would the stakeholders be represented and involved? Partnership council
How would the relationship between the CME and Providers be
developed and maintained? Provider network
Monthly provider meetings
28
The CME Model and Governance
Considerations – cont’d
How would disagreements be resolved? Conflict resolution protocols
How would funding for the system be arranged? Pooling of funds using capitation, case rates, and fixed allocation to
“funding pool”
Who would be legally and financially liable? Lead agency (mental health) with risk reserve and risk sharing
methodologies
29
Developing a Pilot to Test the CME Model –
“Twenty-Five Kid Project”
Developed by planning groups to test whether the components
and “wraparound” philosophy of this new CME model could
successfully reintegrate 25 youth who were in residential
treatment centers who had no immediate plan for discharge
There would be no “reject of applicants” or “eject” from pilot
Three teams facilitated by a care coordinator were chosen to
work with 25 youth in late 1995
17 of 25 youth returned in 120 days
30
Characteristics of Population Served by
Wraparound Milwaukee
60% of families have income under US Federal
Poverty level
70% boys
Average age 12.5
67 % African American, 25% Caucasian, 7% Hispanic
31
Characteristics of Population Served by
Wraparound Milwaukee – cont’d
Major DSM-IV Diagnosis 60% conduct disorder/oppositional defiant
50% depressive disorders
40% attention deficit
30% substance abuse
25% cognitive/developmental disabilities
8% psychotic disorders
32
Creating the Care Management Entity – What
Administrative & Service Structures We
Chose to Give It
Single Point of Access for
Screening & Assessment
Enrolment
Intensive Care Coordination
Developing a Comprehensive
Array of Services and
Maintaining a Provider
Network
Mobile Crisis Intervention
Clinical & Medical Oversight
Evaluation
Maintaining Funding Pool
and Disbursing Monies as
Single Payor of Care
Information Technology and
Data Management
Developing and Supporting
Family Advocacy
Quality Assurance/Utilization
Management
Liaison with Court System
33
Collaboration & Pooled Funding
34
Funding Consideration for Wraparound
Milwaukee – Why We Chose to Focus on the
Highest Needs Youth Versus Early Intervention
The funding “pyramid” that is found in most
communities dictated our beginning point – we would
start with the “highest cost/needs youth “and as we
successfully served that population monies saved
could be redirected to expand services to
youth/families with less intensive needs
35
2 - 5%
15%
80%
More
complex
needs
Less
complex
needs
Intensive
Services –
60% of $$ Home &
community
services;
early inter-
vention-
35% of $$
Prevention
and Universal
Health
Promotion –
5% of $$
Prevalence/Utilization Triangle
Pires, S. 2006. Human Service Collaborative. Washington, D.C. 36
How We Pool Funds
CHILD WELFARE Funds thru Case Rate
(Budget for Institutional
Care for Chips Children)
JUVENILE JUSTICE (Funds Budgeted for
Residential Treatment and
Juvenile Corrections Placements)
MEDICAID CAPITATION (1923per Month per Enrollee)
MENTAL HEALTH •CRISIS BILLING
• HTI GRANT
• HMO COMMERCIAL INSUR
WRAPAROUND MILWAUKEE
CARE MANAGEMENT ORGANIZATION
(CMO)
52.0M
CHILD & FAMILY TEAM OR
TRANSITION TEAM
PLAN OF CARE OR
10.0M 10.0M 24.0M 8.0 M
FUTURES PLAN
FAMILIES UNITED
$525,0000
37
Creating “win-win” Scenarios
System of Care
Child Welfare
Alternative to out-of-home care
high costs/poor outcomes
Juvenile Justice
Alternative to residential &
Correctional placements
Medicaid
Alternative to IP/ER-high cost
Special Education
Reduce alternative school placements
38
Why We Chose to Pool Monies to Pay for
Service Costs Across Child Serving Systems
Gave us more flexibility
Created a more adequate funding source for complex needs
children
We could create a “single payor system”
Funds can be more easily “re-directed” as program/client needs
changes
Accountability – it ended “cost shifting” from system to another
system
39
SERVICE STRUCTURES
To Deliver Wraparound Approach
& Process
40
Critical Components in the Design of the Service
Delivery System – What Components Work Best
in the Care Management/System of Care Model
1. Child & Family Teams
2. Care Coordination
3. Provider Network
4. Comprehensive Array of Services
5. Mobile Crisis
6. Family Advocacy & Peer Support
7. Information Technology
8. Quality Assurance/Evaluation/Data Sharing
9. Evaluation/Outcome Measurement
41
1. Child and Family Teams
A Child & Family Team is a group of people identified by both
the youth and the family who will work with the family
throughout the Wraparound process. A Child & Family Team is
composed of formal, natural and informal members. Child &
Family Teams meet on a regular basis, usually monthly, to
create and continuously refine a written plan of care for the
family. The meetings generally take place in the family’s home
or at a place in the community that is most convenient and
comfortable for the family.
42
Teams are facilitated by a Care Coordinator whose roles and responsibilities include:
• Home visits (weekly)
• Monthly Team Meetings
• Plan of Care Meetings, every 60 – 90 days
• Collaborating with System Partners
• Court appearances when indicated
• School meetings as needed
• Authorizing and arranging supports and services
• Ongoing monitoring of the Plan of Care and service provision
2. Care Coordination
43
Low case load – 1:8 ratio
Highly trained in wraparound approach and certified
by WAM
Court roles and responsibilities
Use of fidelity measures and coaches
Characteristics of Care Coordination
44
3. Provider Network
An organized group of agencies and individual providers that
have agreed to provide and are reimbursed for services to
enrollees of the Wraparound Milwaukee health plan and our
system of care
45
Provider Network Features
No formal contracting – Wraparound Milwaukee utilizes fee-for-service system to obtain & pay for services
Rates and service definitions established by Wraparound Milwaukee
70 services and 200 provider agencies
Wraparound Milwaukee is single payor for all services, including community-based and out-of-home services
Consumer choice of provider
Extensive Quality Assurance/Quality Management measures in place
All providers and care coordinators linked through one internet based IT system (Synthesis) for service authorizations, plan submission, invoice, payment, and progress notes
46
4. Comprehensive Service Array Behavioral & Clinical Services
Crisis intervention
Individual therapy
Intensive in-home therapy
Evaluation
Substance abuse therapy
(individual and group)
Medication management
Day treatment
Special therapy
(i.e. behavioral management team)
Placement Services
Acute hospitalization
Foster home and treatment foster home
Group home care
Residential treatment
Crisis/residential, group care, treatment
foster care
Supported independent living
Other Supportive
Camps
After school
Suspension accountability
Transportation
Interpretive services
Equine therapy
Consultation with other
professionals
Supportive Services
Mentors
Crisis 1:1 stabilizer
Tutor
Parent/family aide
Life coach – independent living
Employment preparation and
placement
Job – internship
Respite
Crisis/planned respite
Residential respite
Service Coordination
Care coordination
Discretionary
Flex Funds
Clothing
Food/groceries
Housing assistance
Child care
Furniture, appliances
YMCA membership
Educational expenses
47
Advantages of Fee-For-Service
Provider Network System
Cost No guaranteed volume of business or expenditures
Pay only for delivered units of service
Flexibility Funds follow client needs
Competition Promotes quality
Consumer choice
48
5. Mobile Crisis Services
All families have access to Wraparound Milwaukee’s Mobile Urgent Treatment Team
24/7 Availability
Mobile crisis teams gatekeep inpatient psychiatric treatment
Wraparound Milwaukee has dedicated crisis teams for Child Welfare Dept.
Mobile Crisis can make available optional crisis stabilization services
Crisis 1:1 stabilizers in home and school
Crisis group home
Short-term crisis case management
17 crisis intervention workers
49
6. Family Advocacy & Peer Support
Families United of Milwaukee – advocacy organization run by
families in Milwaukee and funded by Wraparound Milwaukee
All families have access to a family advocate who has had a child in
the program and want to help other families
Advocates are available to talk with families and participate as a
support to them on the Child & Family Team
50
6. Family Advocacy & Peer Support –cont’d
Advocacy organization operates support groups and conduct family
activities
Family advocates and family members participate on all Wraparound
committees, work groups and councils
Educational advocates work with youth needing help with
educational challenges particularly with access to special educational
programming
Peer specialists – certified to support other youth & young adults
51
7. Information Technology
One electronic health record and single information system Synthesis links all care coordinators, providers and system partners, including delinquency services
52
What Does Synthesis Automate
Screening and Assessment Data Demographic Information Enrollment History Crisis/Safety Plan Plan of Care Provider Service Authorizations Invoicing Claims Processing & Payment Progress Notes Outcome Information QA/QI Data Accessible reports for care coordinators, supervisors and system
managers
53
8. Quality Assurance/Quality
Improvement
Measures & mechanisms to ensure care & services are being
provided consistent with the philosophy & values of the
program
54
8. Quality Assurance/Quality
Improvement – cont’d
QA/QI includes:
Policies & procedures
Auditing plans, progress notes, network services
Measuring family satisfaction & needs attained
Resolving complaints/grievances
Utilization review
Agency performance reports
55
Program
Outcomes
56
9. Evaluation/Outcome Measurement
We feel it is important to create & measure a variety of
outcome measures i.e. program, clinical, fiscal, educational,
safety and consumer satisfaction that are important to system
stakeholders
57
Program Outcomes
The average daily residential treatment population has dropped
from 375 youth in 1996 to 100 today
Average length of stay in residential treatment for wraparound
youth dropped from 14 months to 4 months
58
Fiscal Outcomes
The average monthly cost of a youth enrolled in Wraparound Milwaukee is significantly less than the monthly cost of a youth in an institutional setting
Average monthly cost comparison of Wraparound to institutional care over past 6 years:
Wraparound Milwaukee $3,545
Group Home $5,998
Residential Treatment $9,116
Psychiatric Inpatient (30 day stay) $38,130
59
The Cost of Doing Nothing – Residential
Treatment Costs Without Wraparound Milwaukee
Versus Actual Residential Treatment Placement
Costs Under Wraparound
Wraparound Milwaukee developed a methodology shown in the graph
on the following slide to show what the potential for increase costs may
have been to Milwaukee County child serving agencies had the number
of RTC placements continued to increase by 5% every year and cost of
RTC placements had also increased by the same percentage (as they had
in the previous 5 years)
This graph compares the projected costs without Wraparound with the
actual expenditures for residential treatment for County youth over the
same period
Total projected expenses in 2013 without Wraparound Milwaukee
would have been approximately $88.8 million versus $12.5 million in
2013
60
Cost of Doing Nothing Residential Treatment
Placements & Costs Without Wraparound
Milwaukee
61
Clinical Outcomes
Statistically significant improvement in functioning on Child Behavioral Checklist (CBCL), Youth Self Report (YSR). Overall, 85% of youth at disenrollment have an improved level of functioning on the CBCL.
62
Educational Improvement
40% increase in school attendance from time of enrollment to disenrollment
Youth attended 87% of school days in 2012.
63
Child Permanency
85% of youth achieved permanency plan of return home, relative placement or independent living at time of discharge from Wraparound Milwaukee
64
Recidivism Rates
Wraparound Milwaukee serves 40% of youth on probation including many of those at high risk of correctional and/or residential treatment
Overall rate of recidivism of Wraparound Milwaukee youth using arrest data over the past two years (n=1309) was 21%
While no established national standards, the Public Policy Forum of Wisconsin recently conducted a 4 year study for all delinquent youth which established an overall 41% recidivism rate for Milwaukee youth in the delinquency system not including WAM youth, so WAM had a significantly lower recidivism rate
65
Lessons Learned in Replicating
Wraparound Milwaukee
It is “value” driven
Collaboration is key with system partners
Need to put aside the “turf issues”
Partnerships with families in crucial
“no family – no plan”
There has to be shared information
Single release of information across all child serving agencies
Conflict is natural – how you resolve it is critical
Written conflict resolution protocol
66
Lessons Learned in Replicating
Wraparound Milwaukee – cont’d
Cross system training of staff with families
Break down the “funding silos” and pool monies
Well trained staff in the wraparound process with “good fidelity” tools and measures
Working effectively with the courts
Never give up on kids and families
“plans fail – not people”
67
Supporting capacity building in the evaluation and implementation of evidence-informed practices
Melissa Jennings Manager, Support Services
About the Centre We bring people and knowledge together to strengthen
the quality and effectiveness of mental health services for children, youth and their families and caregivers.
Three strategic goals:
Learning
Foster a culture of organizational learning to support agencies in using evidence to improve client outcomes.
Collaboration Leadership
Be a true learning organization and lead by example.
Build and develop collaborative partnerships to sustain capacity within mental health services.
Who do we work with?
Our work…
• is targeted at child and youth mental health agencies (direct service providers, managers/coordinators, agency leaders).
• takes place in the 5 MCYS regions throughout the province.
• is aimed at supporting agencies and their staff to use the evidence in program planning and service delivery (via evaluation and implementation supports).
What do we mean by the evidence?
Evidence-informed practices (EIPs)
“Evidence-informed practices combine the best available research with the experience and judgment of practitioners, children, youth and families to deliver measurable benefits”.
User view
Practice
Research
How do we support agencies in using the evidence?
The learning journey
Gathering information
• Evidence In-Sight
• Policy papers:
o Brief services
o Transitions in mental health
o Taking mental health to school
o Pathways to care for youth with concurrent disorders (in progress)
o Technology and other media in service provision (in progress)
o Mental health in the early years (0-6) (in progress)
User view
Practice
Research
Evidence In-Brief
Gathering information
• Through program evaluation efforts to capture the client and practitioner experience (e.g. standardized measures, feedback forms, satisfaction surveys, interviews, focus groups, client data and profiles, etc.)
User view
Practice
Research
Using knowledge to grow
• Youth engagement training
• Family engagement training
• Mental health awareness
• Learning modules
o Stigma
o Bullying
o EIPs
o Anxiety
o Anti-oppression
o Suicide prevention
Sharing your story
• Grants and awards database • Regional forums • Dare to Dream program
How does the Centre support the implementation and
evaluation of EIPs?
Implementation capacity building
“Any activity that builds durable resources and enables the recipient setting or community to continue the delivery of evidence - based intervention after the external support from the donor agency is terminated.”
(Brownson, Colditz, Proctor, 2012)
Focus on: • ongoing monitoring and evaluation • ongoing coaching and clinical supervision of new staff • knowledge exchange and dissemination
SUSTAINING PHASE Learning to continually use new evidence to improve practice 03
Focus on: • professional development and training on specific programs or practices • coaching, clinical supervision and communities of practice • monitoring and evaluation
DOING PHASE Training on specific practices, implementing, adapting and evaluating 02
Focus on: • laying the groundwork among teams and
systems • organizational readiness and needs
assessment
• assessing evidence • leadership buy-in and support • evaluation framework
PLANNING PHASE Getting people and systems ready for change 01
The Centre’s implementation framework
The Centre’s implementation support
• Consultations
o with funding (People Advancing Change through Evidence-PACE)
o regular
• Resources
o toolkits
o modules
o webinars
Model for evaluation capacity-building
Transfer of learning
Leadership
2. Sustainable evaluation
practice
Preskill & Boyle (2008), modified
1. Evaluation knowledge, skills and attitudes
Culture
Systems and structures
Communication
2. Sustainable evaluation practice
Evaluation capacity
knowledge of evaluation (cognitive outcomes)
skills in evaluation (behavioural outcomes)
positive attitudes towards evaluation (affective outcomes)
Evaluation capacity is when individuals in an organization have:
Organizational learning capacity
leadership
culture
systems and structures
communication
The necessary conditions to support evaluation capacity-building activities are:
The Centre’s evaluation support
• Consultations
o with funding (Planning and Doing evaluation grants)
o regular
• Resources
o toolkits
o modules
o webinars
o measures database
The Centre’s online resource hub
The Centre’s Grants and Awards Index
For more information
Melissa Jennings
Manager, Support Services
613.737.2297 ext. 3720
@CYMH_ON
Follow the Centre on Twitter
Questions?
International Innovations in
Mental Health Series: Wraparound Milwaukee
Discussion
93
International Innovations in
Mental Health Series: Wraparound Milwaukee
Thanks to all participants for joining today.
Please complete a short feedback survey on today’s knowledge exchange event:
https://www.surveymonkey.com/s/wraparound_mke
EENet would also like to give a special THANKS to Bruce for today’s presentation!
Thank you!
94
International Innovations in
Mental Health Series: Wraparound Milwaukee
Thanks once again! Please connect with us (http://www.eenetconnect.ca/)
or visit Wraparound Milwaukee website for more information!
http://wraparoundmke.com/
Stay connected!
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