Individualizing Care Within a Managed Care Context

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Individualizing Care Within a Managed Care Context

• 2006 Training Institutes
• July 2006
• Institute 4
• Ray Lederman D.O., CPSA-Tucson
• Frank Rider, AZ Division of Behavioral Health
  Services
• Toni Tramontana, ValueOptions Maricopa County
• Robin Trush, System of Care Veteran Maricopa
  County

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Institute 4 Overview

• Transforming Managed Care
• The Arizona System
• Structure
• What Happened?
• Why We Did What We Did
• How to Operationalize
• Results to Date

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Change vs. Transformation

• Definition of Change
• Changer (Old French for change) to bend or
  turn like a tree or vine searching for the sun
• Definition of Transformation
• Transformare (Latin for transform) to change
  shape

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Why is Transformation Necessary?

• Family Dissatisfaction
• Fragmented Care
• Poor Outcomes

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Arizonas Behavioral Health System
AHCCCS (State Medicaid Agency)
Acute Care Health Plans
Long Term Care Program Contractors (e.g.
DDD)
Arizona Department of Health Services/ Behavioral
Health Services
Pascua Yaqui Tribal RBHA
Gila River Tribal RBHA
Northern Arizona RBHA (NARBHA)
Community Partnership of Southern Arizona (CPSA)
Cenpatico BH
ValueOptions
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
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Arizona BH Funding for Children

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Behavioral Health Services in Arizona

• Statewide enrollment 141,393
  (children and adults)
• Statewide children lt18 39,020
• ValueOptions enrollment 73,845
• ValueOptions children lt18 20,041
• Source ADHS Enrollment and Penetration Report
  (May 2006) at http//www.azdhs.gov/bhs/enroll_pen.
  htm.

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Rapidly Expanding EnrollmentJune 2000 - June 2006
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Impetus for Change

• Community Initiatives
• Legislation Executive Order
• System of Care Grant Program
• Litigation

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Arizonas Impetus JK Litigation

• Governor ADHS
• JK Settlement was groundbreaking
• First to overhaul a state mental health
  system that operated on a
  managed care basis.

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J.K. Settlement Agreement

• Requires ADHS and AHCCCS to
• Invite and heed Family Voice
• Improve frontline practice
• Enhance capacity to deliver needed services
  
  
• Promote collaboration among public agencies
  
  
• Develop a quality management and improvement
  system
• Termination of Agreement July 1, 2007

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The Arizona Vision

• In collaboration with the child and family and
  others,
• Arizona will provide accessible behavioral health
  services
• designed to aid children to
• achieve success in school
• live with their families
• avoid delinquency
• become stable and productive adults
• Services will be tailored to the child and family
  and provided in the most appropriate setting, in
  a timely fashion, and in accordance with best
  practices, while respecting the childs and
  familys cultural heritage.
• J.K. vs. Eden et al. No. CIV 91-261 TUC JMR,
  Paragraph 18

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The 12 Arizona Principles

• Collaboration with the Child and Family
• Functional Outcomes
• Collaboration with Others
• Accessible Services
• Best Practices
• Most Appropriate Setting
• Timeliness
• Services Tailored to the Child and Family
• Stability
• Respect for the Child and Familys Unique
  Cultural Heritage
• Independence
• Connection to Natural Supports

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Child and Family Team (CFT) Process

• Based on the Wraparound Approach
• Service planning is family-centered,
  strength-based, highly individualized, culturally
  competent and collaborative across systems,
  promoting reliance on informal and natural
  supports in combination with formal services.
• Congruent with
• Family-Group Decision-Making (Child Welfare)
• Team Decision-Making (Child Welfare)
• Person-Centered Planning (Development
  Disabilities)
• Individual Family Service Planning (IDEA - Part
  C)

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Child and Family Team Process

• The Child and Family Team is a group of people
  that includes, at a minimum, the child, the
  childs family, any foster parents, a behavioral
  health representative and any individuals
  important in the childs life who are identified
  and invited to participate by the child and
  family.
• Process for Practice
• CFT Formation
  ?Engagement
• Clinical Expertise
  ?Crisis Planning
• Service Authorization
  ?Consensus
• Strength and Needs-Based Planning ?Single
  Points of Contact
• Partnerships
  ?Cultural Competence

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How to Change Organizational Thinking

• Attitudes and Values
• Language as an Organizing Framework
• Leadership
• Parent/Professional Partnerships
• Early Innovators

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Changing Organizational Thinking

• Attitudes and Values The Relational Stance
• From Problem to Competence
• From Expert to Accountable Ally
• From Professional Turf to Family Turf
• From Teaching to Learning With
• William C Madsen, Collaborative Therapy with
  Multi-Stressed Families (1999)

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Changing Organizational Thinking

• Language as an Organizing Framework
• Language creates a culture,
• Language preserves a culture.
• Bea Salazar, Four Directions Consulting, Riverton
  WY
• Example Mental Retardation

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Changing Organizational Thinking

• Parent/Professional Partnerships
• Successful Business Practices
• Family is the Constant in Communities
• Voice, Access and Ownership
• The Role of Power
• Collaboration at all Levels
  State, Local and Individual

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Changing Organizational Thinking

• Philosophical Alignment of Child-Serving
  Systems
• Behavioral Health as the Catalyst
• Child Welfare Reform in Arizona
• Juvenile Justice Transformation

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Partnerships

• Collaboration An unnatural act between
  non-consenting adults?
• -- John VanDenBerg PhD

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Changing Organizational Thinking

• Leadership
• Sustainable Transformation
• Good Practice Good Business
• Dealing with Resistance
• Overcoming Inertia

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Changing Organizational Thinking

• Early Innovators
• Urgency
• Ownership
• Commitment to Action
• Not for the Weak of Heart

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Arizonas Early Innovators 300 Kids Project

• 49. Defendant ADHS/DBHS shall initiate a 300
  Kids Project.
• Will serve multi-agency children.
• Sites to engage intensively in system improvement
  activity.
• 50. The sites will serve two purposes
• test strategies for providing behavioral health
  services according to the 12 Principles.
• Serve as the first phase of a statewide effort to
  deliver services according to the Principles.

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Going to Statewide Scale Practice Transformation

• On January 29, 2003, Gov. Janet Napolitano
  ordered the expansion of the 300 Kids Pilot to
  statewide implementation
• 1/31/2003 300 Kids (1.2 of 24,110 total
  children)
• 1/31/2005 5.8 with CFTs (n 1,895 of 32,924)
• 5/31/2006 33.04 with CFTs (n 11,284 of
  34,368)

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Structure, Process, Outcomes

• Structural Changes
• Covered Services
• Funding
• Process Changes
• Training and Coaching
• Consultants
• Professional Roles
• Clinical Guidance Documents
• Outcomes
• Quality Management

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Structural Changes Necessary

• Arizonas Covered BH Services
• Medicaid, Behavioral Health, Licensing
• Expanded Definition of professional
• Expanded Definition of family
• Expansion of Supportive Services
• Capacity and Competency, or
  Quantity v. Quality

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Structural Changes Necessary

• Arizonas Covered BH Services
• Prevention Services
• Rehabilitation Services
• Support Services
• Treatment Services
• Medical Services
• Behavioral Health Day Programs
• Crisis Intervention Services
• Inpatient Services
• Residential Services

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Covered BH Services in AZ

• Support Services
• Case Management
• Personal Assistance
• Family Support
• Peer Support
• Therapeutic Foster Care
• Respite Care
• Housing Support
• Interpreter Services
• Flex Fund Services
• Transportation

• Rehabilitation Services
• Living Skills Training
• Cognitive Rehabilitation
• Health Promotion
• Supported Employment

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Structural Changes Necessary

• Funding
• Variations in State Capitation Rates
• Maximizing State Funding
• Provider Contracting Methodology
• Sustainability of Effort

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Process Changes Necessary

• Training and Coaching
• Coaching to Support Training
• Sequencing
• Who Needs to Transform?
• Costs/Investment
• Retention/Regeneration Strategies

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Process Changes Necessary

• Consultants
• State and Local Strategies
• Choosing a Consultant
• Coordination of Effort
• Individual vs. Systemic

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Process Changes Necessary

• Professional Roles
• Transforming Roles Relational Stance
• Movement to Strengths Based
• Values-Based Hiring Practices
• Training and Re-training
• Liability Myths
• Shared Expertise with Families

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Process Changes Necessary

• Clinical Guidance Documents
• Operationalizing and Memorializing
• Process for Development
• Contract Requirements
• Standardized Assessment (0-5, too)
• Example Child and Family Team PIP
• Prior Authorization

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Process Changes Necessary

• Quality Management Systems
• Structure, Process, Outcomes
• Quality vs. Quantity
• Medicaid Requirements vs. System of Care
  Values
• Cost and Resources

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Quality Management Structure

• Examples
• Enrollment/Penetration (Latino youth? 0-3 y.o.?)
• Number of functioning Child and Family Teams
• Number of counties with cross-system protocols,
  agreements in place
• Number of children placed outside of Arizona
• Number of children placed out of home
• Percentage of children in foster care with BH
  needs assessed beginning within 24 hours after
  removal

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Quality Management Structure

• JK Structural Elements (monthly) -
• CFT Capacity
• OOH Placements
• Urgent BH Responses
• ValueOptions Key Indicators (monthly) -
• CFT Capacity by Provider
• Rehab/Support Spending as of Total BH
• Latino Penetration by Provider
• Under 12 Initiative

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Quality Management Structure

• Maricopa County
• TFC Placements - increased from 5 (09/03) to 196
  (05/06) now 50 of all children OOH
• Children Placed Out of State Decreased from 57
  (06/02) to 8 (03/06)

• Arizona
• TFC Placements increase from 9 (09/03) to 404
  (05/06) now 41 of all children OOH
• Children Placed Out of State Decreased from 100
  (06/02) to 25 (03/06)

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Quality Management Process

• CFT Process Measurement Maricopa Co.
• The Four Big Questions
• Has a trusting relationship been established with
  the family (engagement)?
• Does the Child and Family know the family and has
  it identified the strengths needs and culture of
  the family?
• Has an Individualized Service Plan been created
  that meets the needs of the child and family?
• Is the team implementing, monitoring and
  modifying the service plan toward a successful
  outcome for the child and family?

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Quality Management ProcessCFT Process
Measurement

• Fall 2005 Reviews
• Region A 67.8
• Region B 64.1
• Region C 74.1
• Region D 66.3
• Region E 73.3
• Region F 41.7
• Statewide 53.25 n 486

• Winter 2006 Reviews
• Region A 70
• Region B 64
• Region C 71
• Region D 61
• Region E 81
• Region F 53
• Statewide 60.45 n 418

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Improved Processes ? Improved Outcomes

• EXAMPLEs
• Wraparound Milwaukee
• Residential placements decreased by 60
• Psychiatric hospitalization decreased by 80
• Reduced recidivism by delinquent youth
• Overall cost of care per child decreased
• Bruce Kamradt, Child Welfare League of
  America, 2001 National Conference
• and Report of the Surgeon General on Childrens
  Mental Health (1999)
• Project MATCH (Pima County, AZ)

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Figure One Group Comparisons. Figure One shows a
comparison of the average wraparound fidelity
index (WFI) scores for the two groups at 6 months
and the average baseline scores for five of the
outcome measures at intake. The second row shows
the difference in the overall average WFI scores
for the two groups. The WFI eight point scale
has been converted to a 100 point scale for ease
of comparison. Rows three through seven show the
intake data for four of the primary child and one
primary family outcomes. These data reflect the
six months prior to initiation of the wraparound
process.
From Rast, ODay Rider (2004)

• It Even Works in Arizona

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Figure Two CAFAS and CBCL Scores. The graph on
the left of figure two shows the average Child
and Adolescent Functional Assessment Scale
(CAFAS) Scores at intake and at six and twelve
month intervals following intake. The open
circles are the average scores for all 42
children, the black diamonds show the average for
the 21 children receiving low fidelity wraparound
and the grey squares show the data for the 21
children receiving high fidelity wraparound. The
graph on the right shows the same data for the
Child Behavior Checklist (CBCL) scores.
From Rast, ODay Rider (2004)
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Figure Three Residential Outcomes. Figure Three
shows a comparison of the impact of the fidelity
of the Child and Family Team process on the
restrictiveness of residential placement (left
graph) and on the stability of placement (right
graph). The figure on the left shows the average
level of residential placement on a six level
version of the ROLES. The open circles show the
average for all 42 of the children, the black
diamonds the 21 with low fidelity wraparound and
the grey squares the 21 with high fidelity
wraparound. The graph on the right shows the
average number of residential moves for each
group using the same symbols.
From
Rast, ODay Rider (2004)
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Figure Four Family Resource Scale. Figure Four
shows the scores for the Family Resource Scale
which measures a caregivers report on the
adequacy of a variety of resources needed to meet
the needs of the family as a whole, as well as
the needs of individual family members. Higher
ratings demonstrate more adequate resources. The
graph on the left shows the average rating for
the caregivers for all 42 children. The graph on
the right shows the average rating for each
group. The gray squares are for the caregivers
with the high fidelity wraparound and the open
circles are for the care givers with low fidelity
wraparound. From Rast, ODay Rider (2004)
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Promising Data about Arizona Children

• Success in School Past Six Months
• Age 5-11 11.2 higher with CFT (64.2)
• Age 12-17 12.6 higher with CFT (65.1)
• Lives with Family Past Six Months
• Age 5-11 6.7 higher with CFT (87.0)
• Age 12-17 4.7 higher with CFT (75.5)
• ADHS CIS (05/06) N 31,690 children/families

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Promising Data about Arizona Children

• (Increased) Stability Past Six Months
• Ages 5-11 14.5 higher with CFT (74.0)
• Ages 12-17 16.9 higher with CFT (70.4)
• (Increased) Safety Past Six Months
• Ages 5-11 10.9 higher with CFT (69.2)
• Ages 12-17 11.4 higher with CFT (66.2)
• ADHS CIS (05/06) N 31,690 children/families

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Promising Data aboutArizonas Children

• Avoids Delinquency Past Six Months
• Age 5-11 9.2 higher with CFT (72.5)
• Age 12-17 11.0 higher with CFT (69.7)
• Preparation for Adulthood Past Six Months
• Age 5-11 6.3 higher with CFT (57.4)
• Age 12-17 10.1 higher with CFT (57.4)
• ADHS CIS (05/06) N 31,690 children/families

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Comparing Outcomes for Arizona Children with and
without Child and Family Teams Ages 5-11From
ADHS (9/6/06) at http//www.azdhs.gov/bhs/measures
/charts_0806.pdffor all enrolled children in
this age range
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Comparing Outcomes for Arizona Children with and
without Child and Family Teams Ages 12-17From
ADHS (9/6/06) at http//www.azdhs.gov/bhs/measures
/charts_0806.pdffor all enrolled youth in this
age range
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Family Perceptions of Outcomes

• Practice Based Evidence
• Practical approach
• Strength based
• Positive risk taking
• Gives voice to both families being served, and to
  frontline workers

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Next Steps in Arizona

• Building Capacity and Competency
• Children 0-3 y.o. and Their Families
• Substance Abuse
• Positive Behavior Support
• Child Welfare (See Institute 24)

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Next Steps in Arizona

• Natural Supports
• Youth Voice
• Adult System Transformation

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Questions?

• Thank you for your attention!
• Toni, Robin, Frank and Dr. Ray