Serving Children and Families with Complex Needs

1

• Serving Children and Families with Complex Needs

Operated by Milwaukee County Behavioral Health
Division Child Adolescent Services Branch
2
Bruce KamradtWraparound Milwaukee
Presented by

• Evidence Based Practices and Supports for
  Children with Serious Emotional Disturbance

3
WRAPAROUND MILWAUKEE

• Never doubt that a small group of committed
  citizens can change the world indeed, its the
  only thing that ever does.
• Margaret Mead

4
What is Wraparound?

• A Process and an Approach to How Services in a
  Community Are Organized and Delivered to Children
  With Serious Emotional Needs and Their Families

5
Wraparound is Not

• Not a Pure Therapeutic Intervention
• like MST or Functional Family Therapy, etc.
• Distinguishing between evidence-based and best
  practice
• Controlled studies versus a preponderance of
  outcome data

6
What Has Been Achieved In Wraparound Milwaukee
forChildren with Severe Emotional Needs

• Better Clinical Outcomes
• Children Families Function Better
• Reduced Recidivism of Delinquent Youth Served
• Improved School Attendance
• Reduction in the Use of Residential Treatment
  Psychiatric Hospitalization
• Reduction in Cost of Care
• How Did We Get There?

7
We Got There Through . . .

• A Commitment to Changing the System of Care for
  Children with Serious Emotional Needs and Their
  Families

ONE CHILD AT A TIME!
8
Values and Philosophy
of Wraparound Milwaukee
9
Wraparound A Cluster of Technologies
Technology Cluster
10
System Elements

• Community Team
• Administering Agency
• Lead Agencies
• Service Coordinators
• Child and Family Teams
• Specialized Providers
• Informal Community Supports

11
What Is Wraparound Milwaukee?How Is It Different
in Terms of a System of Care?

• I. Organized as a Unique Type of Public Care
  Management Organization
• II. Defined Populations for Enrollment
• III. Operates with Pooled Funds
• ? Child Welfare ? Juvenile Justice
• ? Mental Health ? Medicaid
• IV. No Formal Contracts -- Utilizes A
  Comprehensive Fee for Service Approach with
  Extensive Provider Network
• V. Employs Care Managers Working Within A
  Wraparound Approach that is Strengths and Needs
  Based
• Continued

12
Wraparound Milwaukee - What Is It? A Care
Management Organization
Continued

• VI. Involves Families at ALL Levels of
  Decision-Making
• VII. Continually Monitors the Quality and
  Effectiveness of the Program Through Strong QA/QI
  and Established Outcomes
• VIII. Organized Family Advocacy and Support System

13
What is a Public Care Management Organization?

• Administrative entity responsible for
  operationalizing the values of Wraparound and
  creating a structure to deliver services to
  children with serious emotional and mental health
  needs and their families
• Public versus Private Care Management
  Organization
• Control
• Accountability
• Closer to funding sources
• Trust
• Intangibles

14
What Does the Care Management Organization Do?

• Human Resource Functions
• Fiscal Management
• Provides or Contracts for Care Coordination
• Information Technology
• Creates and Manages a Provider Network
• Quality Assurance
• Assessment
• Training
• Program Evaluation
• Clinical and Medical Supervision
• Public Relations

15
Wraparound Milwaukee Organizational Chart
16
Key Child Serving Agencies Contracting With
Wraparound Milwaukee

• Bureau of Milwaukee Child Welfare
• State Administered - Privately Operated
• Milwaukee County Childrens Court
• County Operated Probation Services
• Division of Health Care Financing
• State Agency Operating Medicaid
• Milwaukee County Mental Health Division

17
Key Cooperating Agencies

• Milwaukee Public Schools and 26 Other School
  Districts
• State Bureau of Mental Health
• Adult Services Division
• (County Alcohol/Substance Abuse Services)

18

• HOW DID WE BUILD
• THE SYSTEM OF CARE
• IN MILWAUKEE?

Wraparound
Milwaukee
19
How Do You Begin to Develop a System of Care

• Shared Issue or Crisis in Your Community
• Consensus that Something Needs to Be Done
• Ability to Identify Who is Affected by the
  Problem/Issue
• Ability thru Existing/New Relationships to Get
  People to Come Together
• A Plan that Meets Everyones Needs
• Test Plan thru a Pilot Project
• Evaluate the Outcomes
• Have a Plan (assuming pilot works) to Expand and
  Sustain Your Project

20
Steps Taken in Milwaukee to Develop New System
of Care

• Issue
• Over Utilization of Residential Treatment
  Services
• 375 youth in Placement
• Consensus Around Issue
• Too Costly -- Causing County Deficit
• Poor Outcomes
• 40 of youth go AWOL
• 60 recidivism rate in 6 mos.

21
Steps Taken in Milwaukee to Develop New System
of Care

• Ability to Identify Who is Affected
• Child Welfare Juvenile Justice pay for
  placements
• Medicaid and Mental Health Pay for some clinical
  costs plus costs of psychiatric hospitalization
  for these youth
• Ability to Get People to Come Together
• Mental Health and Judge get Child Welfare and
  Juvenile Justice Directors Together

22
Steps Taken in Milwaukee to Develop New System
of Care

• A Plan
• Use Wraparound Approach and Program Elements to
  Return Youth from Residential Treatment Centers
  and Divert Youth from Going into Residential
  Treatment Facilities
• Test Plan Thru a Pilot
• 25 Kid Project
• Evaluate Results of Pilot
• Goals Established for Pilot
• Evaluator Put in Place

23
Steps Taken in Milwaukee to Develop New System
of Care

• Have a Plan to Sustain
• Create a Public Managed Care/Health Benefits type
  entity
• Pool Funds through various funding techniques
• Incrementally enroll youth in residential centers
  and those at immediate risk of placement
• On-going Evaluation

24

• DEMOGRAPHICS
• POPULATION
• SERVED IN
• WRAPAROUND
• MILWAUKEE

25
Gender of Youth in Program
N 835
2003 Data
26
Age of Youth in Program
AVERAGE AGE 13.7 N 835
2003 Data
27
Ethnic Representation of Youth
N 835
2003 Data
28
Family Income
N 471
2003 Data
29
DSM-IV Diagnoses of Youth in the Program
2003 Data
N 801
30
Funding Wraparound
Milwaukee
31
What are Pooled Funds?
CHILD WELFARE
JUVENILE JUSTICE
MEDICAID CAPITATION
MENTAL HEALTH
Funds thru Case Rate
(Funds Budgeted for
(1557 per Month per Enrollee)
CRISIS BILLING
(Budget for Institutional
Residential Treatment and

BLOCK GRANT
Care for Chips Children)
Juvenile Corrections Placements

HMO COMMERCIAL INSUR
8.0 M
9.0 M
10 M
3.0 M
WRAPAROUND MILWAUKEE
MANAGEMENT SERVICE ORGANIZATION
(MSO)
30 M
CARE COORDINATION
PROVIDER NETWORK 240 Providers 85 Services
CHILD
AND FAMILY
TEAM
PLAN
OF
CARE
32
Impact of Wraparound Program On Utilization Cost
REDUCTION IN EXPENDITURE FOR RTC CARE AVE.
DAIILY CENSUS WITH INITIATION OF WRAPAROUND
MILWAUKEE
338
328
324
273
229
152
MILLIONS
135
105
75
67
JULY OF 1996 WRAPAROUND MILWAUKEE ASSUMES
RESPONSIBILITY FOR RTC POPULATION
AVERAGE DAILY CENSUS IN RTC
33
List of Available Servicesin Social / Mental
Health Plan

• Daily Living Skills - Individual
• Daily Living Skills - Group
• Parent Aide
• Child Care
• Housekeeping
• Mentoring
• Tutor
• Life Coach
• Recreation
• After School Programming
• Specialized Camps
• Discretionary Funds
• Supported Work Environment

• Case Management
• Referral Assessment
• Medication Management
• Outpatient
• Individual/Family
• Outpatient - Group
• Outpatient - AODA
• Psychiatric Assessment
• Psychological Evaluation
• Mental Health
• Assessment/Evaluation
• Inpatient Psychiatric
• Nursing Assessment/Management
• Consultation with Other Professionals

• Group Home Care
• Respite
• Respite - Foster Care
• Respite - Residential
• Crisis Bed - RTC
• Crisis Home
• Foster Care
• Treatment Foster Care
• In-Home Treatment (Case Aide)
• Day Treatment
• Residential Treatment
• Transportation

34

• SERVICE STRUCTURES
• To Deliver
• Wraparound Approach
• Process

35
System Components
36
Care Coordination Services

• Meet the Child and Family
• Strength Based Inventory
• Convene Child and Family Team to Develop the
  Wraparound Plan
• Establish Goals
• Identify and Prioritize Needs
• Formal Services From a Provider Network
• Informal Services Within Familys Support System
• Obtain Commitments to Implement Plan
• Evaluate and Modify Plan as Needed

37
What is a Child Family Team

• The team of individuals identified by the family
  who will work with them to address their needs.
• The team should be composed of informal and
  formal members who will continue to support the
  family after system involvement.
• The Team should be 50 formal/professionals, 50
  informal/natural supports and meet as frequently
  as needed.

38
Provider Network

• 80 Services
• No Formal Contracting -- services purchased on a
  fee-for-service basis -- rates established by
  Wraparound Milwaukee
• Extensive Quality Assurance/Quality Monitoring
• Residential Treatment Vendors were asked to
  re-engineer institutional services to
  community-based services
• Consumer Choice of Providers
• All Providers Care Managers linked through
  internet-based IT system for authorizations, plan
  submission, invoicing, etc.

39
Mobile Crisis Team

• Available 9 am - 10 pm M-F / 130 - 10 pm Sat
  Sun
• Psychiatric Crisis Line Handles Calls After 10 pm
• Crisis is Defined as a Situation in Which a
  Childs Behaviors Threaten Removal from School,
  Home, etc.
• M.U.T.T. Assesses Situation, Identifies
  Alternative to Hospitalization Makes Referrals
  as Needed
• SERVICES Crisis Intervention Short Term Case
  Management Intensive Case Management - 30
  Days Family Pres. Services - 60 Days Crisis
  Group Home

40
Natural/Informal Supports and Community Resources
41
Natural Support

• Family or friend relationship
• Examples
• Parent
• Childhood friend
• Sibling
• Cousin

42
Informal Support

• Community relationship
• Examples
• Church Pastor
• Next door neighbor
• Sponsor
• Support Group Leader

43
Family Advocacy Component Families United of
Milwaukee

• Advocacy
• Support Groups Activities
• Family System Education
• Satisfaction Surveys
• Serve on Committees, Boards, etc.
• Train Care Coordinators
• Crisis Intervention
• Resource Development
• Develop Newsletter, Brochures, Other Info.

44
Program Outcomes
45
Outcomes - Program

• Average daily Residential Treatment population
  reduced from 375 placements to 55 placements
  (FOCUS Project 10)
• Psychiatric Inpatient Utilization reduced from
  5000 days per year to under 200 days (ave. LOS of
  2.1 days)
• Reduction in Juvenile Correctional Commitments
  from 385 per year to 285

46
Outcomes - Financial

• Wraparound Milwaukee average monthly costs is
  4200 per child per month versus 7200 for
  residential treatment, 6000 monthly for a
  correctional placement or 600 per day for
  Psychiatric Inpatient Care

47
Caregiver, Care Coordinator, Youth Reported
Improvement In Functioning For Clients Active In
2003
Child Behavior Checklist (CBCL), n136 Youth
Self-Report (YSR), N109 Child Adolescent
Functional Assessment Scale (CAFAS), N210.
Reductions are significant at the plt.001 level of
significance using a repeated measures analysis
of variance.
48
Increase In School Attendance For Clients Active
In 2003
N 142
49
Specific Offense Types Three Years Prior To
Enrollment Three Years Following Disenrollment
In Wraparound Milwaukee
Other Offenses consist primarily of disorderly
conduct and/or resisting arrest/obstruction of
justice charges
n 490
50
Legal Offense Referrals Adjudications One Year
Prior to Enrollment, During Enrollment, One
Year Following Disenrollment
n 802 Data through 1/31/04
51

• Serving Children and Families with Complex Needs

Operated by Milwaukee County Behavioral Health
Division Child Adolescent Services Branch
52
(No Transcript)