PRTF Lessons LearnedSuccesses and Challenges in the 9 PRTF Waiver Initiative StatesOctober 18, 2011

2011 MFP Summit: Advancing Community Living Through Systems Transformation

Maryland RTC Waiver

Georgia CBAY Kansas PRTF-CBA

South Carolina CHANCE

Alaska RPTC/FASD WaiverIndiana CA-PRTF

Montana PRTF Waiver

Virginia Children’s Mental Health Program

Mississippi MYPAC

Overview of Psychiatric Residential Treatment Facility (PRTF) Waiver DemonstrationSherry Peters, MSW, ACSW Director of PRTF Waiver Initiative National Technical Assistance Center for Children's Mental Health Georgetown University Center for Child and Human Development Phone: (202) 687-7157 Fax: (202) 687-1954 slp45@georgetown.edu Website: http://gucchd.georgetown.edu/

PRTF WaiverOverview

• Section 6063 of the Deficit Reduction Act (DRA) of 2005 ▫ authorized up to $218 million for a 5 year Community

Based Alternative to Psychiatric Residential Treatment Facilities (CBA to PRTF) demonstration (FY07 through FY11).

• PRTF opportunity:▫ to be recognized as a type of institution for which a home

and community based waiver program could be established.

• CMS Initial Award▫ At beginning of FY 2007 CMS awarded demonstration

grants of over $55 million to 10 states (currently 9 states are included in the demonstration)

Overview Continued• Transitions and Diversions:

▫Over 3000 children have been transitioned or diverted from PRTF institutions since the beginning of the demonstration.

• Demonstration to Permanent Waiver:▫Legislation is being considered to make the waiver

permanent beyond September 30, 2012• Funding:

▫As of September 30, 2011, CMS awarded the funding for the final year of the demonstration plus two years to allow the states to build capacity to continue to serve children and youth in the community.

Maryland Residential Treatment Center (RTC) WaiverJennifer Lowther, LCSW-CRTC Waiver Program DirectorPh: 410-706-6316Fax: 410-706-0998Jlowther@psych.umaryland.edu

Maryland - Successes• System of Care recognition and support in Medicaid

regulations▫Care Coordination embedded in CMEs with a

practice model of High Fidelity Wraparound▫System of Care principles adopted

• Quality Assurance Plan development and implementation▫ CME chart reviews provided opportunity to improve

Waiver procedures, policies and care for Waiver youth

▫ Collaborative process with state, local jurisdictions and other SOC grants’ perspectives

Maryland – Challenges • Building sufficient provider capacity

▫(-) Unable to open in Western MD due to lack of waiver crisis/stabilization and respite providers

▫(+) Growing expressive therapists across state and motivated crisis/stabilization provider network

• Cumbersome Medicaid application process▫ (-) Slow medical, financial and technical eligibility

process▫ (+) Technical assistance and policy created to

improve application process

Georgia Community Based Alternatives for Youth (CBAY)Linda Y. Henderson-Smith, PhD Assistant Director C & A Mental Health Department of Behavioral Health and Developmental Disabilities Division of Mental HealthOffice of Community Mental Health 404-657-6087 - office 404-275-8304 - blackberry 770-342-7172 – faxlyhenderson@dhr.state.ga.us

Georgia - Successes• Developed and implemented statewide Care

Management Entity system in the state of Georgia

• Implemented Wraparound model in the state of Georgia

• FY10 financial data - $78,406 institutional care, $29,492 – CBAY

• Served over 500. Only about15% returned to PRTF for longer than 60 day period, but most returned to the program and have been successful thus far.

Georgia - Challenges• Culture Shift for system to accept Wraparound

Model and CBAY Policies – other child-serving agencies policies and

regulations not shifting to adjust to this population Procedures – shifting the core system to attending

meetings and having one plan and providing the clinical level of services needed

Families - shifting families from viewing the institution as respite versus utilizing community-based respite

• Sustainability

Kansas Psychiatric Residential Treatment Facility-Community Based Alternatives (PRTF-CBA)Krista MorrisSRS DBHS Mental HealthCommunity Based Managed Care Team, Project ManagerKrista.Morris@srs.ks.gov

Kansas - Successes• The SED Waiver provided for infrastructure and a

vast provider network for the implementation of the PRTF CBA on April 1, 2008

• Since April 1, 2008, 601 youth have been served on the PRTF CBA - Current Enrollment:▫210 males▫104 females▫74 age 12 years and under▫224 age13-18 years old▫16 age 19-21 years old

Kansas - Challenges

•The children/youth served on the CBA tend to remain on the program for shorter durations, but return more frequently than on the SED Waiver.▫ALOS SED= 9 months ALOS CBA=6 months▫Of 256 enrollments this grant year, 37 were

re-enrollees (approximately 15%)

South Carolina Children’s Health Access in Community Environments (CHANCE)Erin DonovanDONOVAN@scdhhs.gov Jeanne CarltonCarlton@scdhhs.gov

South Carolina - Successes• Our relationship with our advocacy group

(Federation of Families)▫ Ensures family choice in provider(s) and services▫ Independent entity to report family concerns▫ Maintains relationship with families over course of waiver starting at

intake

• Positive Outcomes for youth enrolled in the PRTF Waiver and positive feedback from families▫ Providing support services in the home and community has resulted

in adequate parental support, increased safety precautions, and reduced placement in PRTF facilities per surveys conducted

▫ Families have reported that the support services received have allowed youth to improve their socialization skills, achievement in school, improved health, and behaviors.

South Carolina - Challenges

•Coordination of Care between providers

•Built in conflict of interest due to providers conducting initial level of care assessment

•Overcoming these challenges▫Looking at policy revisions▫Considering contracting out with

independent person to provide level of care assessments

Mississippi Youth Programs Around the Clock (MYPAC)Jennifer R. GrantDivision Director IISpecial Mental Health InitiativesBureau of Mental Health ProgramsMississippi Division of Medicaid(601) 359-3809  Fax: (601) 359-6294jennifer.grant@medicaid.ms.gov

Mississippi - Successes

•Annual MYPAC Mission Training for 150+ provider staff hosted by MS Division of Medicaid

•Development of a secure web based application for the purpose of sharing information and gathering data

Mississippi - Challenges• Lack of technical assistance to begin the data collection

piece for the National Evaluation▫ Through trial and error, the MS Division of Medicaid

MYPAC staff began with Excel spreadsheets and later worked with a team from Medicaid’s Bureau of Systems Management to develop the secure web based application we now call eEVALUATION.

• Getting the communities in the Mississippi Delta to “buy-in” to the program.▫ Through efforts by several child serving state agencies,

as well as the MYPAC providers, education and outreach in the MS Delta increased the awareness for an alternative to a PRTF placement for youth in the Delta counties.

Montana Psychiatric Residential Treatment Facility (PRTF) WaiverLaura TaffsPRTF Waiver SupervisorChildren's Mental Health Bureau(406)444-1460    cell (406)438-1041fax (406)444-5913ltaffs@mt.gov  

Montana - Successes• High-Fidelity wraparound facilitation as a Waiver service• Engagement with providers once they understand the

Waiver• Serving high-needs youth and their families in their

homes and communities• Family and youth empowerment and development of

self-efficacy• High-Fidelity wraparound facilitated team approach:

provider collaboration on teams, family and youth voice and choice

• Involvement of natural supports on teams• CMS staff at all levels have been great partners

Montana - Challenges• Some psychiatrists’ concerns about liability when serving high-

needs youth at home• Engaging some providers in serving high-needs youth and

families through non-traditional approaches • Some families’ reluctance to participate in High-Fidelity

wraparound team approach (preference for targeted case management)

• National Evaluation MDS requirements and reporting difficulties• Development of Caregiver Peer to Peer Support Specialists

(Family Support Partners)• Provider development in very rural areas• Capacity building for the High-Fidelity wraparound facilitation

process and preventing drift from fidelity to the skill sets are time- and labor-intensive.

Indiana Community Alternatives to Psychiatric Residential Treatment Facility (CA-PRTF)Rebecca Buhner Assistant Deputy Director - Office of Integrated Recovery Policy and Planning FSSA/Indiana Division of Mental Health and Addiction 317.233.3251Rebecca.Buhner@fssa.IN.gov

Indiana - Successes

•Large Number of Participants Enrolled – State had basic understanding of Wraparound and System of Care prior to CA-PRTF Grant

•Data Driven Decisions – Grant Team uses all data available to assist providers with quality improvement.

Indiana - Challenges

•Communication with Community (Providers and Participants) – Started a public SharePoint website to enhance communication between DMHA/OMPP and the community

•Providers lacking knowledge to effectively do their job – We have increased amount of required training and opportunities, Wraparound Facilitator Certification Process

ALASKA RPTC/Fetal Alcohol Spectrum Disorder (RPTC/FASD) WaiverBarbara KnappProject DirectorRPTC/FASD WaiverDivision of Behavioral Health907 269 3609 (phone)907 269 3623 (fax)barbara.knapp@alaska.gov

 

Alaska - Successes• PRTF Grant has increased awareness of how FASD affects

behavioral challenges▫ Youth are frequently diagnosed with ADHD, poor impulse control,

Bipolar, Oppositional Defiance, Conduct Disorder, Reactive Attachment Disorder

▫ Because of FASD Behavioral health treatment must be approached differently

▫ Behavioral challenges may be brought under control – but the FASD will always be there.

• How has this knowledge helped Alaskan youth with behavioral health challenges?▫ Increased use of one to one service providers▫ Successful diversion from Residential Psychiatric Treatment and

criminal justice system ▫ Maintained youth in community placements longer, behaviors not

escalating to PRTF levels

Alaska – Challenges •Lack of front-line workers - program is only

as strong as the workers who do the everyday work▫ New job concepts take time to get through

large corporations▫Flexible shifts result in Agency anxiety over

less than full time employees▫Frontline workers worry about making a living

while working at low wages ▫Mentors may not offer billable skills every 15

minutes

Virginia Children’s Mental Health ProgramMendy MeeksChildren's Mental Health Program Director(804) 225-4285Fax (804) 612-0045Mendy.Meeks@dmas.virginia.gov

Virginia - Successes

•July 1, 2010 VA allows financial eligibility to be based solely on the child/youth’s income.

•Though the numbers may be low the projected enrollment numbers, children/youth being served in the program are doing well.

Virginia - Challenges Low enrollment due to several factors:• Not diversional waiver (participants must reside

in PRTF for at least 90 days)• Parental income (causing more youth to be

ineligible for Medicaid/Program)• Lack of continued case management• Local agencies using other funding sources and

not promoting program• Limited Medicaid providers that specialize with

mental health needs of youth or accept rates of services offered under the program

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Wrap-Up and Summary of Lessons LearnedRon Hendler, MPATechnical Director - MFP and PRTF ProgramsDivision of Community Systems TransformationDisabled and Elderly Health Programs GroupCenter for Medicaid, CHIP and Survey and Certification 410-786-2267 ronald.hendler@cms.hhs.gov

Wrap-Up With Ron Hendler

•Overall lessons learned•Successes•Challenges•Next Steps