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Statement of Problem

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Statement of Problem Powered By Docstoc
					Financing Interagency Systems
            of Care


             Chris Koyanagi
   Bazelon Center for Mental Health Law


              NASMHPD Meeting
                San Francisco
                June 23, 2004
Extent of the Problem
   Prevalence of kids MH disorders:
       20% some mh disorder
       10% significantly impaired
       5% are severely impaired
       Same in young children as in older
Statement of Problem
   How resources are distributed, organized and
    disbursed makes little sense
       High level of support for residential
       Crisis-focused response
       Significant gaps as funding drives system
   Conflicting agency goals; overlapping case
    managers
   Lack of Access
       Custody relinquishment
Statement of Problem
   Child eligible for some federal
    programs, not others—creates gaps
   Children provided services that can be
    funded; not what is needed
   Families have limited choices, see long
    delay in identification & services
   Families cannot receive supports
But
   States have found ways to address these
    issues
   Integrate resources behind common plan for
    each and family
   All collaborating systems are committed to
    same goals and objectives
   Flexible funding approaches focused on
    outcomes
   Continuous efforts to improve quality
Need
   Clear vision of goals and how to finance
   Collaborations (agencies and families)
   Understand resource options fully
   Funding strategy to merge and
    maximize different streams
   Rigorous cost accounting to show how
    program requirements are met, while
    funds are flexible
First steps
   Maximize Medicaid and S-CHIP
   Combine with Title IV-E
   Maximize Title IV-B & Safe/Stable
    Families Act
   Ensure IDEA services are furnished
Consider
   Other federal sources:
       Maternal and child health
       TANF
       Housing
       Child care block grant
       Vocational rehabilitation
       ESEA, Title I
       Social Services block grant
Add
   More flexible funds:
       MH/SA block grants
       Juvenile justice block grants
       Federal discretionary grants
       State and local general funds
Medicaid: primary funder
   Clinic
   Rehabilitation
   Prescription drugs
   Transportation
   Residential
   Waivers
Service                       Code   Service                      Code
Screening                           Day treatment                 
Assess/eval/diagnosis               Comm-based wraparound         
Anticipatory guidance               Multi-systemic therapy        
Service planning                    Crisis residential            
Indiv, grp, fam therp               Ther. Recreation              
Crisis intervention+mobile          Dev delay/prevent             
Case man (+ACT & intensive)         Home visits, newborn          
Targeted case management            Social skills/daily living    
Meds management +meds               Supported employment          
Intensive in-home                   Supported housing             
SA-OP tx (+ integrated tx)          Respite care, not in-home     
Parent ed. on disorder               Ther. foster care
Parent hotlines                     Group home servs              
Behavioral aide                     Sex offender treatment        
No Specific Code: Covered
   Engaging natural supports
       Service planning/wraparound
   Summer/after school programs/therapeutic
    nurseries and preschools
       Day treatment
   Therapeutic Foster Care
       Rehabilitation funds services/treatment
   Family Supports
       Psychoeducation
       Services to benefit child
Non-Covered Activities
   Education (tutoring)
   Job training
   Services for family members who are
    not themselves Medicaid eligible
   Room and board – foster care or group
    homes
   Purchase of goods or opportunities for
    child
Rules are Important For…
   Respite
   Family support services
   Behavioral aides
   Targeted Case management
   School-based
   Vocational programs for transition youth
Careful Rulemaking
   Respite
       Child respite, not family
       Prevents permanent disruption/placement
       Supervision and structured services
   Family support
       Psycho-education on child disorder
       Services tied directly to help child
   Behavioral Aides
       Prevent removal from home
       Social skills development, anger management, etc.
New Rules: TCM
   Appropriate target group
   Coordinating health/mental health as
    well as other services/supports
   Provider may be MH, CW, JJ or other
   Must not be possible to fund thru
    another source and a non-health
    related service
Limits: School-Based
   Services listed in state plan
   Those included in IEP
   Provider meets Medicaid qualifications
   Cannot be offered free to other non-
    Medicaid children
       This does not apply to special education
        children
Vocational Services
   No job training
   Services and supports to youth in
    training or job
       Social skills training
       Getting along on the job
       Getting to job appropriately
       Behavioral supports
       Anger management
Home & Community-Based
Waivers
   Expands Medicaid coverage
   Expands service array
       Respite
       Family support
       Supported employment
   Reduces costs
       KS: $12,900 compared with $25,600
       VT: $23,344 compared with $52,988
       NY $40,000 compared with $77,429
Child Welfare programs
   Title IV-E services, for example:
       Screening, assessment, etc.
       Behavioral aide
       Social skills training
       After school, summer programs
       Service team meetings
       Wraparound facilitation
       Respite for foster family
       Parent-to-parent support/engaging natural
        supports
Child Welfare
   Training and Admin funds
       Wraparound facilitation
       Service team meetings
       Intensive case management
       Engaging natural supports
       Family participation in policy/program
       Advocacy services
       TA, MIS
Child Welfare
   IV-B & Promoting Safe-Stable Families
       Wide array of community services
       Pays for non-Medicaid costs:
            Family Services
            Respite
            Resources for family organization
   Waivers with MH services funding
       Child/adults in guardianship care (DE)
       Capped flexible allocations to local CW agencies
        (IN, NC, OH, OR)
       MC payment systems (CO, CT, MI, WA)
       Intensive services (CA, MS)
Creating Flexibility
   Blend
   Braid
   Case rates
   Administrative services organizations
   Capitation, at-risk, managed care
Financing Approaches
   Blending
       Combines funds from several agencies into
        unified funding stream so they are
        indistinguishable
       Generally small pots of money
       Agencies reluctant to give up control
       Provides greatest flexibility
Financing Approaches
   Braiding
       Combines funds so different sources remain visible
        but used in combination
       Complete flexibility given to service team
       Single billing process
       Consistent data collection, management &
        reporting for local providers
       Need capacity to track expenditures & match to
        funding source
       Map funding opportunities and constraints
Financing Approaches
   Case rates
       Wraparound Milwaukee
   ASOs
       Assists in braiding funds
       Ensures appropriate service at appropriate
        time
       No risk
       New Jersey (MH-CW)
Capitation: At risk contracts
   Systems of care as at-risk providers in
    network (single case rate)
   System of care is managed care entity
    (Wraparound Milwaukee)
   All system of care services covered in
    MC contract; system bill FFS
   Success stories: Colorado, Arizona
Other Interesting Strategies
   Embedding staff
       Allows MH staff to furnish services
       Allows billing to Medicaid
       Opens doors to reluctant partners
   Dedicated taxes
       Florida (Hillsborough county)
       California (pending initiative)
       Missouri developing
Conclusion
   Need new commitment to funding child
    services
   Mechanisms exist
   Opportunities maximized when agencies
    collaborate on funding
   Tough fiscal times can create
    opportunities for collaboration and for
    innovation in approach

				
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