“Key Strategies to Design, Develop and Implement a System of Care for Children from the Juvenile Justice and Child Welfare Systems with Serious Emotional and Mental Health Needs”Bruce Kamradt, MSW, Director, Wraparound Milwaukee

Illinois Child Care AssociationNovember 13, 2013

What is Wraparound Milwaukee

Created in 1995, it is a unique system of care for Milwaukee County children & adolescents with serious emotional, mental health and behavioral needs that cross child serving systems (e.g. Mental health, juvenile justice, child welfare) who are at imminent risk of institutional type placements

1,500 youth/families served (1050 daily census) Operated by Milwaukee County government as a

unique Care Management Entity (CME) under the 1915a provision of Social Security Act, it acts as a type of behavioral health HMO

What is Wraparound Milwaukee – cont’d

Pools funds across child serving systems ($51 million for 2013) to increase flexibility and availability of funding – Wraparound Milwaukee is single payer

One service plan and one care manager 47% of youth served are from juvenile justice

system and 25% are court-ordered from child welfare system.

2009—Named by Harvard University—Kennedy School of Government as Best Innovation in American Government

Rationale for the Creation of Wraparound Milwaukee

Over utilization of out of home care for juvenile justice and child welfare youth including group/residential treatment, juvenile correctional placements, and psychiatric in-patient care – Too many kids being placed and for too long

High cost of out of home care expenditures was causing serious deficits in juvenile justice/child welfare budget in Milwaukee County

Poor outcomes for youth coming out of institutional placements concerned court, advocates and juvenile justice/child welfare officials

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Eligibility for Wraparound Milwaukee

Youth must meet the State eligibility definition under the Medicaid Program

DSM-IV diagnosis Functional or psychiatric impairment Condition that is likely to persist for a year or

more Involvement in two or more child serving

systems i.e. mental health, Child Welfare, Juvenile Justice or special education

At immediate risk of institutionalization in a residential treatment center, psychiatric hospital or juvenile correctional facility

Characteristics of Population Served

60% of families under U.S. federal poverty level 70% boys Average age 13.5; 11.0 for voluntary REACH

program 67% African American, 23% Caucasian, 9 %

Hispanic Major DSM-IV Diagnosis

◦ 60% Conduct disorder/oppositional defiant◦ 50% Depressive disorders◦ 40% Attention deficit◦ 30% Substance abuse◦ 30% Learning /developmental disabilities◦ 8% Psychotic disorders

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Populations & Programs Served By Wraparound Milwaukee

Regular wraparound – youth under a child welfare order or adjudicated delinquent youth with serious emotional disturbance (SED) at risk of placement in a psychiatric impatient hospital , residential treatment center or juvenile correctional placement – 610 youth

FOCUS – youth with SED committed to the State Dept. of Corrections with “stayed order” – 40 youth

Re-Entry – youth with SED being transitioned out of a state juvenile correctional facility – 25 youth

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Populations & Programs (cont’d)

REACH – non-adjudicated SED youth and their families who are at risk of imminent placement in a group home, residential treatment center, psychiatric hospital who have had contact with two or more child serving systems – 350 children/families

Healthy Transitions – 17 to 24 year old, young adults with SED transitioning out of foster care settings – 75 young adults

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The Value Shift We Needed to Make

Family Directed Care – “Families needed to be seen as the solution to meeting their children’s needs and not the problem”

Strength-Based Care – “Needed to build on child and family strengths and resources and not focus on their perceived deficits”

Individualized Care – “Every child and family is unique and deserves a care plan that addresses their unique needs and is tailored to meet those needs – categorical approaches don’t work”

Community-Based Care – “Services are usually more effective when delivered in the child’s own home and community versus institutional settings”

The Value Shift We Needed to Make

Coordinated Care Across Serving Systems – “Coordinated care across child serving systems works better than fragmented care – One Family – One Plan”

Culturally Competency in Service Provision - “Respect and understanding for cultural differences is paramount to effectively work with families”

Unconditional Responses – “ We never can give up – plans fail, not people”

Ten Critical Strategies for Designing, Developing and Implementing Systems of Care

•An effective and logical administrative structure

•A blended financing model

•Strong collaboration across child serving systems

•Strong family and youth partnerships

•Ability to provide individualized, tailored care to participants

Ten Critical Strategies for Designing, Developing and Implementing Systems of Care

•Availability of mobile crisis services and crisis supports 24/7

•A high quality and diverse Provider Network

•A comprehensive array of mental health and support services that are evidence-informed

•Ability to create a good quality assurance, quality improvements and outcomes measurement program

• Effective Information Technology System

1. An effective and logical administrative structure

•It is best to create a separate administrative structure for the day-to-day operation of the system of care, called a Care Management Entity (CME)

What is a Care Management Entity (CME)?

•An organizational entity that serves as the “locus of accountability” for defined populations of youth with complex challenges across service systems

•Is accountable for improving the quality, outcomes and cost of care for historically high-cost/poor outcomes populations

•In Milwaukee County, most youth with serious emotional mental health needs at risk of institutional placement served in the juvenile justice and child welfare systems are referred to the Wraparound Milwaukee CME

Wraparound Milwaukee Care Management Functions

Administration Program oversight Enrollment Finance – claims

processing and payment of providers

Quality assurance/quality management including utilization review

Evaluation Information technology Contracting/procurement Public relations Liaison with courts Dispute resolution

Programmatic Assessment Care Coordination Provider Network Crisis services Medical/clinical oversight Family Advocacy Training/consultation

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2. A blended funding system

•It is desirable for child serving systems to pool, or “blend” funds to create a more sufficient and flexible funding source

•A single payor system is more efficient than having each child serving system funding care separately for the same children

How We Pool Funds

CHILD WELFARE$131.00 Case Rate

(Budget for Institutional Care for CHIPS Children)

JUVENILE JUSTICE(Funds Budgeted for

Residential Treatment and Juvenile Corrections Placements)

MEDICAID CAPITATION(1923 per Month per Enrollee)

MENTAL HEALTH•CRISIS BILLING•HTI GRANT•HMO COMMERCIAL INSUR

WRAPAROUND MILWAUKEECARE MANAGEMENT ORGANIZATION

(CMO)$51.0 M

CHILD & FAMILY TEAMOR

TRANSITION TEAM

PLAN OF CAREOR

10.0M 10.0M 23.0M 8.0 M

CARECOORDINATION

OR

TRANISITIONAL SPECIALIST

PROVIDER NETWORK

210 Providers

60 Services

FUTURES PLAN

FAMILIES UNITED$475,000

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

Alternative to DayTreatment costs

Negotiating a Plan with Child Welfare and Juvenile Justice to Create and Fund Wraparound Milwaukee

With help of managed care consultant, we costed out potential costs of caring for residential treatment youth in the community including shorter RTC stays, anticipated service needs, etc.

Proposed $3300 per month case rate versus $5600 average cost of RTC placement (1996)

18 month period of time to enroll all existing youth in residential treatment plus all newly identified youth needing RTC level of care

MHD’s Wraparound Milwaukee Program would assume fiscal risk

Negotiating a Plan With Medicaid to Create A Special Managed Care Entity

Dane County (Madison) and Milwaukee County began negotiating with Medicaid in 1995 to create “behavioral health carve-outs” in the two most populous Wisconsin counties proposed model would include access to child welfare/juvenile justice funds though this was not absolutely required under waiver

Used 1915(a) provision of Social Security Act to create a voluntary managed care program for this defined group of youth

Ability to access child welfare/juvenile justice funds plus potential of reducing RTC placements offered Medicaid potential cost savings in reduced acute inpatient psychiatric bed days

Actual Analysis of costs of these RTC/SED youth performed and Wraparound Milwaukee (Milwaukee County) offered 95% of per child per month cost and would assume fiscal risk

3. Strong collaboration across child serving systems

Challenges to Collaboration Across Systems Barrier Busters

CHALLENGE1. Language Differences

“Mental Health Jargon vs. Court Jargon”◦ Cross Training Needs◦ Share Literature On Wraparound

2. Role Definition: “Who’s in Charge?”◦ Family Driven / Philosophy◦ Team Development Training◦ Job Shadowing

Challenges to Collaboration Across Systems Barrier Busters

CHALLENGE3. Information Sharing Between Systems

◦ Set up a Common Data Base for Shared Access to Information

◦ Share Org. Charts / Phone Lists◦ Share Paperwork Responsibility ie: Court Letters,

Reports, etc.◦ Promote Flexibility in Schedules to Support

Attendance in Meetings

4. Addressing Issues of Community Safety◦ Document Safety Plans◦ Develop Protocol for High Risk Kids◦ Demonstrate Adherence to Court Orders

CHALLENGE5. Maintaining Investment from

Stakeholders ◦ Invest in Relationships with Partners in Collaboration

ie: Judges, DA’s, Probation, etc.◦ Track & Provide Meaningful Outcomes

6. Sharing Value Base◦ Infuse Values into all Meetings, Trainings &

Workshops ◦ Share Documentation and Include Parents in as

Many Meetings as Possible

Challenges to Collaboration Across Systems Barrier Busters

Other Keys to Collaboration with System Partners/Funders– Child Welfare & Juvenile Justice & Mental Health

Having a written memorandum of

understanding (MOU) for key stakeholders/funders

Define roles to avoid “Turf Issues” Financial arrangements Reporting requirements

Creating a conflict resolution protocol

Conflict Resolution Protocol

Care Coordinator & Bureau Worker

Care Coordinator &

Probation Officer

Care Coordinator Supervisor &

Bureau Supervisor

Care Coordinator Supervisor &

Probation Supervisor

Wraparound Milwaukee

Liaison & Bureau Section Manager

Wraparound Milwaukee Liaison

& Probation Program Manager

Wraparound Milwaukee Director & Director

Delinquency Services or Director Bureau of

Milwaukee Child Welfare

Other Keys to Collaboration with System Partners – Child Welfare & Juvenile Justice

& Mental Health – cont’d

Developing a standard curriculum for training of all staff

Creating and disseminating meaningful program, fiscal and clinical outcomes

Making available a single information system for improved data sharing

Delinquency & court services uses Synthesis for their IT needs

Standardizing flexible court orders Each system’s role with child/family is specifically

written into court order Child Welfare workers, Probation and Wraparound

Milwaukee care coordinators share court duties regarding reports, filing of legal documents, etc.

Other Keys to Collaboration with System Partners – Child Welfare & Juvenile Justice

& Mental Health – cont’d

Participating on Child Welfare & Juvenile Justice committees, workgroups, councils, e and expecting Child Welfare & Juvenile Justice staff to participate in plan of care and other wraparound meetings.

Developing a coordinating Committee of Key Stakeholders.

Wraparound Milwaukee Partnership Council

Advisory committee to the Wraparound Milwaukee Program

Consists of representatives from key child serving agencies i.e. Child Welfare, Juvenile Justice, schools, Medicaid, etc.

Judicial representation Families/advocates Providers from network CEO’s from 8 care coordination agencies Advise Wraparound management on program,

fiscal, and clinical issues, etc.; review QA/QI and evaluation studies; review training/education needs of program, etc.

4. Strong Family and Youth Partnerships

•Families want “Voice, Choice and Ownership” in decisions related to their children and families need to be actively engaged in directing the care of these children

•Systems of care utilize Family Advocacy agencies to provide 1:1 advocacy and other supports for families

•Developing a Youth Council, Clubhouse Model, Young Adult Peer Specialists and other approaches can provide positive community experiences for youth

•Families and Youth need to be invited to participate on all agency committees, councils, training and staff development and other activities

Components of Advocacy

Families United

Orientations

Crisis Intervention

Serve on Wrap Committees/Work

Groups

Recruitment/Training of Families

Assist Families in Court

Youth Council/Youth Advocacy

Educational Advocacy

Family Events

Relaxation and Support

Groups

Advocacy on Child &

Family Team

5. Ability to provide individualized, tailored care to participants

•It is best to utilize a family driven process called “wraparound approach” where a care plan is created unique to each family and utilizing the strengths of the Child and Family Team to meet their needs and reach desired outcomes

•Child and Family Teams, made up of the family, friends, and providers chosen by the family, create the individualized tailored care plan

•Care Coordinators facilitate coordinated service teams and help the family identify and arrange for needed services

•Care Coordinators should work with no more than eight families -- The goal is to have “One Family – One Plan”

Wraparound is a family driven process where a plan unique to the family is created utilizing the strengths and supports of the Child and Family to meet their needs and reach their desired outcomes

In Wraparound, Child and Family teams are formed, made up of the family, friends & providers to create an individualized tailored care plan

What is Wraparound

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

Who Facilitates the Process?

Strengths

Unconditional Care

Normalization

Cultural Competency

Collaboration

Needs Driven

Refinancing

Family Centered

System Integration

Community Based

Values & Principles

Elements of WraparoundNeeded for an Individualized, Tailored Care

Approach

Values in Action: Family Centered/Youth Guided

Agencies provide a welcoming environment

Staff use family friendly language Information is shared with permission only

and on a need to Know basis Meetings are not held without the youth

and family present Brochures, documents, spaces are sought

out, reviewed and approved by the families they will be serving

Values in Action: Strengths

Staff embrace and adhere to strength based language in conversation and documentation

Staff are taught to reframe in a meaningful way that leads to hope for the families and realistic planning

Creative resource development and planning is encouraged and supported

Values in Action: Needs

Agencies respond to the unique needs of families in their communities

Staff are trained to listen to needs rather than diagnoses and deficits only

Plans of care are developed that are responsive to the individualized needs of youth and families rather than service driven based on what we have and know

Values in Action: Culture & Normalization

• Agencies demonstrate diversity in their hiring practices, policies and training

• All committees, trainings and events have youth and family input, membership and participation

• Family norms and culture are sought out, embraced and incorporated into the family’s plan for the success of the family

Values in Action: Community Based/Refinancing

Money flows in the system of care to support needs at the community and individual family level

Agencies are imbedded in the communities where the families live and/or are easily accessible.

Operating hours of business, meetings, trainings and events are responsive to families’ schedules

Families get what they need rather than what we have

Community Stakeholders are easily mobilized to take action in times of need

Values in Action: Collaboration

Agencies are at the table to break down barriers and partner in an effective and sustainable way on behalf of families

A single care plan format has been developed to decrease confusion, avoid duplication of efforts or dollars and enhance coordination for the best care of youth and families

Values in Action: Never Give up/Unconditional Care

Agencies are not permitted to kick kids and families out of the very programs established to meet their needs.

Blame the plan if it isn’t working, not the family

Develop methods to hold everyone accountable for follow through on promised actions in committees as well as plan of care meetings

Develop methods to measure outcomes and remain outcome driven

6. Availability of mobile crisis services and crisis supports 24/7

•Crisis Safety Plans need to be created for all youth with serious emotional and mental health needs

•Mobile Crisis Teams need to provide crisis intervention services, 24/7 and see the child and family in the community wherever the crisis occurs, whether at home, school or other location

•It is advantageous to create an array of crisis stabilization services such as utilizing crisis 1:1 stabilizers to provide follow-up support to families, teachers and others and can implement crisis/safety plans to prevent re-occurrence of the crisis and/or teach strategies to the family to more effectively deal with future crisis

Core Components of a Mobile Crisis Service

Crisis Teams (24/7) Crisis Plans Crisis Beds in foster, group homes and

residential centers Crisis 1:1 Stabilizers Preferred Inpatient Providers

7. A high quality and diverse Provider Network

•Rather than contracting for a more limited array of programs, Wraparound Milwaukee created a network of nearly 200 mental health and social service agencies to provide a broader array of services – whatever the family needs

•Providers are paid on a fee-for-service basis and emphasis is put on quality and achieving positive outcomes

•Families need to have a choice of service providers rather than be assigned to a specific agency

8. A Comprehensive Array of Mental Health and Support Services

•To individualize care based on needs, systems of care need a broad service array of mental health and supportive – “one size or service does not fit all” services available to children and families

•Systems of care need both formal “paid services” as well as informal or “unpaid services”

Comprehensive Service Array

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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

9. Ability to create a good quality assurance/quality improvement and outcomes measurement

program

•Policies and mechanisms should be put in place to ensure that care and services are being provided consistent with program expectations

•Outcomes to be measured should be meaningful to stakeholders

10. Effective Information Technology Systems

•One electronic health record and single information system should link all Care Coordinators, Service Providers and System Partners

•Create immediate access for system partners, care coordinators and managers to information including demographic and enrollment information, care plans, services authorized, vendor lists, program notes as well as utilization data, medical information and other reports should be available to support system

1. QA/QI Workplan2. Policies and Procedures3. Auditing

a. Plans of Careb. Progress Notesc. Chartsd. Provider Network

4. Family Satisfaction Surveys

a. Care Coordinatorb. Providerc. Out of Home

5. Complaint/Grievance /Critical Incident Process

6. Outcome Evaluation7. Utilization Review8. Agency Performance

Reportsa. Care Coordination monitoring

Quality Assurance and Quality Improvement

Outcomes for the System & Youth Served in Wraparound

MilwaukeeOutcomes currently being measured include programmatic, fiscal, clinical, public safety, child permanency and consumer satisfaction Programmatically – the average daily residential treatment

population has dropped from 375 youth to 80 youth, inpatient psychiatric days from 5000 to under 500 days per year

Fiscally – the averages cost for a child/family in Wraparound is about $3,400 per month (2013)versus nearly $9,500 per month for a residential treatment placement, nearly $9000 per month for a correctional placement or well over $10,000 for a 7-day hospital stay

Clinically – children function better at home, school and in the community based on administration of nationally normed measures such as the CBCL (Achenbach) used at the time of enrollment and discharge

Outcomes for the System & Youth Served in Wraparound Milwaukee

(cont’d)

Public Safety – recidivism rates for delinquents are low (15.2%) for youth in the program for at least one year and even lower (6.7%) for high risk offenders including juvenile sex offenders (this is considerably under national standards)

Child Permanence – 80% of youth achieve permanency, i.e., return to parents, relatives, adoptive resources or subsidized guardianship upon leaving Wraparound

Family Satisfaction – families surveyed upon completing Wraparound (average 18 months) gave the program a rating of 4.4 out of 5 points in terms of their perception of the progress their child made while in the program

Recidivism Study(Juv. Justice)

Overall recidivism rate for Wraparound Milwaukee(Oct 2009 – June 2012)

Recidivism Study cont’d

Re-offending rate for high risk (juvenile delinquent) youth in Wraparound Milwaukee

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.

Educational Improvement

40% increase in school attendance from time of enrollment to disenrollment. Youth attended 87% of school days in 2012.

Child Permanency

85% of youth achieved permanency plan of return home, relative placement or independent living at time of discharge from Wraparound Milwaukee

Cost EffectivenessWraparound Milwaukee vs. Institutional Placements

Over Past Five Years(average monthly cost of service)

Wraparound Milwaukee’s Impact on Reducing Utilization of State Correctional Placements and Costs Over Past Six Years*

*Wraparound Milwaukee serves 40% of youth in Milwaukee County on probation and most of youths at immediate risk of residential treatment/correctional placement.