What is Wraparound Milwaukee

1. “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 Association November 13, 2013

2. 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

3. 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

4. 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 4

5. 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

6. 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 6

7. 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 7

8. 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 8

9. 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”

10. 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”

11. 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

12. 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

13. 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)

14. 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

15. Wraparound Milwaukee Care Management Functions Programmatic • Assessment • Care Coordination • Provider Network • Crisis services • Medical/clinical oversight • Family Advocacy • Training/consultation 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 15

16. 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

17. How We Pool Funds CHILD WELFARE JUVENILE JUSTICE MEDICAID CAPITATION MENTAL HEALTH $131.00 Case Rate (Funds Budgeted for (1923 per Month per Enrollee) •CRISIS BILLING (Budget for Institutional Care for CHIPS Children) Residential Treatment and HTI GRANT • Juvenile Corrections Placements) HMO COMMERCIAL INSUR • 10.0M 10.0M 23.0M 8.0 M WRAPAROUND MILWAUKEE CARE MANAGEMENT ORGANIZATION (CMO) $51.0 M CARE COORDINATION OR TRANISITIONAL SPECIALIST PROVIDER NETWORK 210 Providers 60 Services FAMILIES UNITED $475,000 CHILD & FAMILY TEAM OR TRANSITION TEAM PLAN OF CARE OR FUTURES PLAN

18. Creating “win-win” Scenarios Child Welfare Medicaid Alternative to out-of-home care high costs/poor outcomes Alternative to IP/ER-high cost System of Care Alternative to Residential & Correctional placements Alternative to DayTreatment costs Juvenile Justice Special Education

19. 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

20. 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

21. Strong collaboration across child serving systems

22. Challenges to Collaboration Across Systems  Barrier Busters CHALLENGE 1. 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

23. Challenges to Collaboration Across Systems  Barrier Busters CHALLENGE 3. 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

24. Challenges to Collaboration Across Systems  Barrier Busters CHALLENGE 5. 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

25. 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

26. Conflict Resolution Protocol

27. 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.

28. 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.

29. 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.

30. 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

31. Components of Advocacy

32. 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 shouldwork with no more than eight families -- • The goal is to have “One Family – One Plan”

33. What is Wraparound • 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

34. Who Facilitates the Process? 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

35. Elements of WraparoundNeeded for an Individualized, Tailored Care Approach Values & Principles

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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”

47. Comprehensive Service Array 47

48. 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

49. 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

50. QA/QI Workplan • Policies and Procedures • Auditing • Plans of Care • Progress Notes • Charts • Provider Network • Family Satisfaction Surveys • Care Coordinator • Provider • Out of Home • Complaint/Grievance /Critical Incident Process • Outcome Evaluation • Utilization Review • Agency Performance Reports • Care Coordination monitoring Quality Assurance and Quality Improvement