Rate Redesign Project Overview

1. Rate Redesign Project Overview District Managers July 7, 2009

2. What is the Rate Redesign Project? • A system change for the way the state provides services to children and financial assistance to family foster care parents and relative caregivers for the care of children in the states legal care and custody. • This change includes what we use to call; base rate, special rate, personal care rate, and has impacts on other system things such as clothing, transportation, respite and daycare.

3. Why is this occurring ? • Oregon like all states rely on Federal Funding to assist the state in providing funds for family foster care. • Federal regulations and a Federal audit has required Oregon to change our practice in the way we provide foster care funding and has required Oregon to develop a more thorough and consistent methodology of rate setting in foster care. • Foster parents, department staff, judges, legislators and community partners have longed requested for a change in the Special Rate / Personal Care program.

4. Where have we been ? • Rate Redesign Project started in April 2008 with a dedicated team of three individuals with the full-time job to focus on the project. They researched other states, federal regulations, and explored various assessment tools and models. • Prior to this team there had been several workgroups internal and external to the department and previous proposals along the way that have been used in this redesign. • The work has utilized Guiding Principles along the way.

5. Guiding Principles of Rate Redesign; • Rate reimbursements must support a foster system that keeps children safe and healthy. • No surprises. The process of changing the rate reimbursement structure will be transparent to foster parents, stakeholders and interested parties. • Maximize federal dollars for foster children as we meet the new federal mandates. In responding to the new federal rules, we will design a system that ensures the greatest federal support for Oregon's foster children. • Make the system more fair, consistent and transparent. From first-time relative foster parents to seasoned veterans, the system has to work for all foster parents. • Keep foster parents involved. As we improve the rate reimbursement process, foster parent involvement will help us make the best decisions for Oregon's foster children. • Use the work done before as guidelines. The rate redesign will use the input of foster parents from prior workgroups and hearings to point the way to a better system for Oregon's foster children.

6. Where are we now ? • July 1, 2009 new administrative rules are being filed with the Secretary of State office to allow for the implementation of this system change to begin. • September 1, 2009 new base rates and rates for levels-of-care (pending Legislative approval) will be implemented for all foster parents and relative caregivers. This also includes a new daily rate for family shelter care. • Reimbursement checks for foster parents and relative caregivers received or about October 1, 2009 will reflect the base rate changes started in September.

7. So what is this new model look like ? The model is a “Child Centered” level-of-care Three primary components: • Base Level • Enhanced Supervision • Personal Care Services

8. Level-of-Care Model Level One- Moderate Enhanced Supervision Level Two-Intermediate Level Three-Advanced Base Level of Care Level One- Moderate Level Two-Intermediate Personal Care Services Level Three-Advanced Level Four-Intensive

9. Base Level • A family foster care level for all foster children in certified DHS foster homes. • Children who do not have any extraordinary ongoing medical or behavior supervision needs but may have mild to moderate level of care based on the fact of being a child in need of foster care services and support. • The base level of care will include financial assistance for; • Food Clothing Shelter • Incidentals Cost of Providing Daily Supervision

10. Two new areas not previously outlined in a base rate • Daily supervision – including teaching and directing to ensure the child or young adult is attended to appropriate to his or her age, developmental level and to ensure safety; • The cost of providing – including local travel associated with expenditure for gas and oil, vehicle maintenance and repair, and transportation to and from extracurricular, child care, recreational and cultural activities.

11. Enhanced Supervision Enhanced Supervision is a component that provides three levels-of-care based on the additional supervision needs (non-medical) of a child. • Level One : Moderate • Level two: Intermediate • Level three: Advanced

12. Enhanced Level’s Defined • Level One: Moderate to Intermediate. A child or youth requires close monitoring, frequent redirection, learning or relearning of socially acceptable behavior. • Level Two: Intermediate to Advanced. A child or youth requires a high degree of structure, frequent adult supervision which may include one-to-one monitoring and frequent redirection. • Level Three: Advanced. A child or youth requires constant high degree of structure and close monitoring, constant redirecting and close supervision for safety needs of the child. The levels of care are determined by the results of a CANS screening that is preformed by a trained CANS screener.

13. Child and Adolescent Needs and Strengths (CANS) screening tool. • CANS is a comprehensive screening instrument that identifies a child or youth needs and strengths in the areas of; Safety, Strengths and Well-Being. • CANS screening instrument is specific to age groups; • Ages Birth through Five (0-5) • Ages Six through twenty (6-20) • The CANS screening tool consist of a series of questions that will be assessed by reviewing information provided to the screener about the child and by interviews that may include; the child, parent, foster parent, caseworker, teacher, or others who may have a caretaking role in this child or youth life.

14. Level of Care Determination • Once the CANS screening and results are completed by the screener, they will send the results to the Level of Care Unit in Central Office who will make the determination of the appropriate level of care based on a standardize methodology of the screening tool. • The result of the CANS and the determination of the Level-of-Care will then be sent to the foster parent and caseworker . • This is the opportunity for the foster parent and caseworker to work together on developing a supervision plan if necessary and determining if other services for the child are needed such as; mental health counseling, additional education support such as an IEP, etc…

15. Personal Care Services • Personal Care Services is also a model that provides levels-of-care based on the additional medical interventions needs of a child. • Level one : Moderate • Level two: Intermediate • Level three: Advanced • Level four: Intensive

16. Personal Care Services – Level’s Defined • Level One: Moderate to Intermediate. A child or youth is at risk for or is experiencing infrequent or predictable changes in medical needs. Simple medical interventions that are provided by a trained Personal Care provider. • Level Two: Intermediate to Advanced. A child or youth is experiencing frequent and predicable or unpredictable changes in medical needs. Medical interventions that are provided by a trained Personal Care provider. • Level Three: Advanced to Intensive. A child or youth is experiencing frequent and unpredictable changes in medical needs. Medical interventions that can be provided by a trained Personal Care provider during unanticipated events. • Level Four: Intensive. In rare and extraordinary situations a child or youth in family foster care may have ongoing medical needs and experiencing frequent and unpredictable changes in their health that requires constant observation for medical attention and interventions that may be provided by a trained Personal Care provider.

17. Personal Care Services Assessment • A Personal Care Services Assessment (PCSA) is a tool administered by a licensed Registered Nurse through which the department employ's or contracts with and is authorized to administer this assessment. • The PCSA consists of a series of questions that will be assessed by reviewing information provided to the nurse about the child and by interviews that may include; the child, parent, foster parent, caseworker, medical providers, or others

18. Determination of the Level of Care • Once the PCSA is completed, the results are sent to Central Office for review of the assessment and the results forwarded to the Level of Care Unit in Central Office who will make the determination of the appropriate level of care based on a standardize methodology of the screening tool. • The result of the PCSA and the determination of the Level-of-Care will then be sent to the foster parent and caseworker. • This is the opportunity for the foster parent, caseworker and Registered Nurse to work together on developing a Personal Services Care Plan for the care of the child and to identify the responsibilities of each participant.

19. What other changes are occurring in this new Level-of-Care model ?

20. Level of Care follows the child • The Level-of-Care determination for Enhanced Supervision follows the child. There will not be a requirement to re-screen the child if they move to a different foster family placement. • The Level-of-Care determination for Personal Care Services does not follow the child since a Individualize Care Plan and an assessment of a Qualified Medicaid Provider must occur in each setting.

21. Re-screening • Children will be re-screened using the CANS on an annual basis. • Children with a Personal Care Service Plan will be re-assessed at a predetermined time period based on their condition but no later then an annual reassessment. • A re-screening may occur sooner then on an annual basis if a "Precipitating event" has occurred. An observed, ongoing change in a child or young adult's behavior or condition. (Trauma, a significant sustained change, etc..)

22. Family Shelter Care looks different • Relative and Foster Family Shelter Care now extends to 20 days for the initial placement rate. This “initial shelter” care rate is for only the child’s initial placement into foster care and not subsequent placement moves in foster care. • An Enhanced Shelter Care has been developed for children or youth who are stepping down from higher levels of care in Residential Treatment Programs to family foster care. This period of time extends to 20 days or less if a CANS and level of care is determined earlier.

23. Foster Family Group Homes • The foster family group home program in Oregon is ending August 31, 2009 and is being replaced by the Level-of-Care model. • All children in these homes will continue to stay in these homes if the group home providers choose to continue their foster care placement. • Children will be assessed with a CANS and a Level of Care determination will be made.

24. Respite Care – Day Care for Working Foster Parents and Clothing Allowance • Respite is not an activity that can be supported by the federal funding streams used to fund our foster care system. We will continue to advocate federally and locally to develop a formal respite program but at this time we do not have a respite care program for foster families. • Day Care for working foster parents is another identified need for foster families in Oregon, but we are unable to fund an employment related daycare program for working foster parents at this time. • Clothing Allowance is built into the base level of care rate for all children and on a limited basis an additional allowance may be provided based on extraordinary needs of a child; medical condition, health or safety related, etc…

25. Other changes • This new model provides an opportunity for a foster parent on behalf of the foster child to request a Contested Case Hearing if they find that the Level-of-Care has not been accurately determined. This formal process may include an Administrative Law Judge and a formal order at the conclusion of the process. • The Level-of-Care is determined at the Central Office Level of Care Unit and not at the caseworker, supervisor, or Special Rate Committee in the local branch. This was designed to bring a statewide consistency among levels of care setting and to remove caseworkers from the added responsibility of rate setting.

26. What are the new rates based on ? • Rate Redesign Project utilized a number of reports and studies to determine the costs of care for children. • USDA's "Cost of Raising a Child" Report, • Hitting the M.A.R.C. (Minimum Adequate Rates for Children) Report • Comparison of Other States Rates (NRCFCPPP) • Consumer Expenditure Survey, • Oregon Child Care Market Study

27. What are the new rates ? • The state budget must still be approved by the Oregon legislature, but we estimate that about 84-89% (4545-4827) children placed with foster families will have some increase in their overall monthly reimbursement rates, and 11-16% (609-891) children will see a decrease as a result of the restructuring of the system. • Base rate estimate per child per month if funded at the proposed 100%: • Age 0-5 = $639 • Age 6-12 = $728 • Age 13-21 = $823 Note: Base rate per child per month at current rate: age 0-5 = $399; age 6-12 = $414; age 13-21 = $512 • The Legislature is on track to have the final budget in place this month, and Oregon's new foster care rates will be implemented in September 2009.

28. Levels of Care Rates • Enhanced Supervision • Level One – $ 212 • Level Two – $ 414 • Level Three - $ 850 • Personal Care Services • Level One – $ 207 • Level Two – $ 413 • Level Three - $ 620 • Level Four - $ 620 (additional service may be authorized)

29. Shelter Care: means care provided to a child or young adult during the first 20 days of placement in substitute care. • Daily Payment Rates – Shelter Care • Ages 0-5 $ 24.60 • Ages 6-12 $ 28.00 • Ages 13-20 $ 31.60 • Enhanced Shelter Care: means care provided to a child or young adult when placement in a Behavior Rehabilitation Services is no longer needed. Eligibly is up to 20 days. • Daily Payment Rates – Enhanced Shelter Care • Ages 0-5 $ 29.40 • Ages 6-12 $ 33.50 • Ages 13-20 $ 37.90

30. What should Foster Parents and Relative Caregivers expect as the next steps for Level of Care Implementation ? • July 1; new rules are issued including the change in Family Shelter Care extending to 20 days. • June through August all children in foster care who currently have a Special Rate or Personal Care are expected to have a CANS or PCSA and a Level-of-Care determination. • Foster Parents will be notified and requested to participate in the CANS or PCSA screenings. • Children new to foster care may be referred for a CANS or PCSA within the first 20 days of placement, if their identified needs warrant such a screening. Otherwise there will not be a referral for CANS or PCSA during this initial phase. • Reimbursement checks for foster parents and relative caregivers received or about October 1, 2009 will reflect the base rate changes that start September 1, 2009. • When the new rates are approved and become available they will be posted online and branch offices will be notified of the rates. • January 2010, we anticipating starting to perform a CANS on all children entering foster care and remaining in care beyond 20 days.

31. For More Information For more information be visit the Rate Redesign Project page on the Departments website at: http://www.oregon.gov/DHS/children/fostercare/rates/ -- just click on "Project Updates."