Financing Local Systems of Care September 4, 2003

1
Financing Local Systems of CareSeptember 4, 2003

• Jim Wotring
• Director of Programs for Children with a
• Serious Emotional Disturbance
• Michigan Department of Community Health
• Phone [phone]
• E-mail wotringj_at_state.mi.us

2

Year 1 Yippee
3
Year 3 No Its My Money
4
Year 6 We can Work Togetheror Too Tired to
Fight Anymore
5
Financing Local Systems of Care

• 1995-98 -- RWJ Grant-Case Rate Pilots
• 1997 -- SAMHSA Grant
• 1998 -- Managed Care
• 2001-- New Finance Project Started
• 2003 New Governor

6
RWJ Grant-Case Rate Pilots

• Two Counties - Livingston and VanBuren
• 3,000 PMPM full risk
• Combined Title XIX (Medicaid) and Title IV-A-EA
  (Now TANF)
• Used existing State and Local Funds as match and
  flowed through the Federal funds to the CMHSP's.
• Similar to Wraparound Milwaukee

7
SAMHSA Grant 1997/98

• Received SAMHSA Grant from Feds with Plan to
  Expand Finance Pilots using Medicaid to Sustain
  Grant.
• First year of grant everything going very well,
  lots of new money, hiring staff.
• County working collaboratively
• State working collaboratively

8
Changes in the State Systems This is now 1998/99

• Managed Care (Health and Mental Health)
• Leadership Changes at the State Level
• Early Retirement
• DCH Created (Medicaid, MH, SA, PH, Aging)
• Child Welfare Changes
• IV-A-EA gone

9
Changes in State System1999/00

• Proposed Managed Care Plan to Include Medicaid
  Case Rate Rejected by State Leadership Team
• Worried About Upper Payment Limit
• This Was Our Sustainability Plan
• Child Welfare Submits IV-E Waiver
• Juvenile Justice Staff remain Strong Partner at
  State Level

10
Changes in the County System1998-2003

• New Mental Health Director Every Year for the
  Next 4 Years (Continue to Provide Match for
  Grant)
• Two New Child Welfare Directors
• Find stable Partner Inside the System
• Two New School Superintendents
• Never Recover Solid County School Partner
• Juvenile Justice Director Partners with Southwest
  Community Partnership and State

11
Partnership with Juvenile Justice Becomes
Critical to Grant

• Juvenile Justice Provides Match for Grant
• Juvenile Justice Uses Consultants from Grant
• Technical Assistance Becomes Critical to
  Partnership with Juvenile Justice
• County Level Collaboration Begins to Fall
  Apart Except Juvenile Justice

12
State Level Activities 2000/01

• Rested Some and Licked our Wounds
• Developed a Juvenile Justice/Mental Health
  Committee
• Continue to Partner with Families
• Continue to Put Pressure on System from the
  Outside to Better Serve Children in Juvenile
  Justice and Child Welfare
• Continue to Pressure System from the Outside
  About Need to Blend Funds

13
New Finance Effort at State Level Initiated 2001

• Director Feels the Heat and Wants a New Workgroup
  on Integrating Financing Across Systems
• Child Welfare Reluctantly Participates
• Education Reluctantly Participates
• State Systems Fearful of Takeover
• Juvenile Justice remains Strong Partner at State
  and County Level
• Begin Building New Relationships at State and
  County Level with Systems

14
New Finance Planning Workgroup

• New workgroup Child Welfare, Community Health,
  Education
• New Finance and Program Staff
• Finance Matrix
• Functional Budget

15
(No Transcript)
16
Functional State Budget Across Systems MH, PH,
ED, CW, JJ

• Prevention/Early Intervention
• Basic Needs
• Medical/Health Services
• Educational Services
• Community-Based Services
• Child Care
• Out-of-Home Care
• Child Protection and Investigation

17
Functional State Budget Across Systems-MH,PH,ED,CW
,JJ
18
Findings from Functional Budget

• General Fund General Purpose (GFGP) funds that
  were not matched to Federal fund.
• Matched our mission and values.
• Matched our target population.
• -- Multi-system at risk of removal from home.
• ? Cost Neutral to the State

19
Options Considered

• Connecticut/New Jersey - No
• -- Fear of takeover.
• Case Rate - Okay
• Lets just coordinate again.

20
Directors Support New Concept Paper

• Case Rate
• Medicaid and County Funds as match
• 200,000,000 Below Upper Payment Limit
• Child Welfare Reluctantly Agrees
• Juvenile Justice Supportive
• Education at the Table

21
Build Support for New Concept Paper

• Continue to Build Supports Within State
  Departments and Outside State Departments
• Juvenile Justice (State and County)
• Community Mental Health Centers
• Advocacy Groups
• Family Groups

22
Election One Year Away

• Decide to Slow Down Finance Pilots and Take
  Chance on New Governor
• Continue to Build Support Across Systems and Sell
  Product to Anyone Who Will Listen
• Continue to Meet with Staff Inside Department to
  Work out Details of Funding Flow, Audits etc.

23
New Governor Elected

• Staff Supportive of Blended Funding get on
  Governors Various Transition Teams
• Two New Directors Hired who Have Worked on Multi
  System Projects and Know About Multi System
  Children are Supportive.
• Continue Building Support Outside of the System

24
New Governor Elected

• Change in Department Directors
• New Job to Sell Concept to New Directors and
  Governor
• Child Welfare Tries to Deep Six Effort
• Changes made in Child Welfare Staffing
• Directors Love Project
• Governor and Legislature to Support with
  Additional Funding From Child Welfare

25
Approached by Juvenile Justice Staff to Develop
New Finance Committee Supportive of Blending Funds

• Approach Child Welfare/Juvenile Justice
  Directors New Administrative Assistant with Idea
  to Blend Funds. She is Supportive.
• Project Now Includes Additional TANF Funding and
  Changes in State and Local Match Ratios
• New Directors Support new Concept Paper

26
New Outside Committee Formed to Support and
Advise on Project

• Committee Reviewing Concept paper and Providing
  Support and Advise
• Directors Taking Proposal to Governors Office
  for Support
• Plan to Begin Working with Communities this
  summer in preparation for implementation during
  FY 2004/5

27
New Plan

• 34,000,000 to 50,000,000 in TANF funding.
• 20,000,000 to 30,000,000 in Medicaid Funding

28
New Plan Cont.

• TANF Passes Senate and House Finance
• Committees
• TANF Removed in Senate and House Conference
  Committee and Never Reaches House and Senate for
  a vote this past summer so TANF is off the table
  in FY 04.
• Plan to Ask for Additional TANF funds Again in FY
  05. Have Directors Support.

29
New Plan Cont.

• Plan to use Medicaid with Local Communities
  Putting up the Match Using Existing 1915(b)(c)
  Waiver, Being Renewed this Fall.
• Adjustment to the Intensity Factor in the Waiver.
  
• Traveling the State to Inform Communities of
  Medicaid Options

30
Medicaid Title XIX

• Federal insurance
• Eligibility
• Poor
• Disabled
• Minor out of home over 30 days

31
Medicaid Title XIX

• 56 Federal funds/44 State/local funds
• Must track funds
• Need to involve CMHSP as fiduciary

32
(No Transcript)
33
Case Rate

• A set amount of money for each eligible child per
  month
• Must provide covered services for eligible child
• May also provide additional services and supports
  for child and family
• Full risk model
• Additional Federal and state dollars not
  currently in CMH budgets

34
(No Transcript)
35
Four creative examples identified

• Enhanced Medicaid Case Rate
• Expanded Child Care Fund
• Combination
• Blended Pool Enhanced Medicaid Case Rate

36
Creative Funding Example 1 Enhanced Medicaid
Case Rate

• Allows for collaboratively-governed funding and
  service partnerships to provide individualized
  services
• New Medicaid dollars for Child Welfare and
  Juvenile Justice population
• For Medicaid eligible children served by the case
  rate, pulls down additional Federal dollars new
  to the community
• For every 44 dollars of local and state money,
  receive 56 in Federal dollars (44/56 match)

37
Case Rate Model

• Example of How Blended Funds Work Using a Case
  Rate Model.
•  

Other
Court
Federal Medicaid 56 1,904
Local Match 44 1,496
CCF
Schools
CMH
3,400/Child/Month
FIA
Purchase Services
38
Creative Funding Example 2 Expanded Child
Care Fund

• Local agencies develop contracts/agreements with
  county commissioners/administrators for services
  and identify
• added to the CCF ? Expanded child care fund
  
• Purchase reimbursable services for CCF eligible
  children
• For every 100 spent locally, receive 50 back
  (50/50 match)

39
Option 2 Expanded Child Care Fund (through
local contributions and interagency contracts)
County 1,000 Commissioners
Net county cost is 252
Expanded County Child Care Fund
40
Creative Funding Example 3 Combine 1 and 2

• Combine Expanded County Child Care Fund with
  the Enhanced Medicaid Case Rate
• For CCF eligible children, expanded child care
  fund spends 100 and receives 50 reimbursement
  from CCF
• For Medicaid eligible child, blended pool
  receives 44 local money and 56 in Federal match

41
Option 3 Expanded Child Care Fund and
Medicaid Case Rate
County 1,000 Commissioners
42
Example 4 Blended funds in case rate model

• Case rate is blend of local and state or Federal
  dollars depending on eligibility of child
• Single local fiduciary with collaborative
  oversight
• Finances support community child philosophy
• Full array of services and supports for each
  child enrolled
• Overall savings between 50 and 56 depends
  on of Medicaid and CCF children served

43
Option 4 Blended CCF/MA case rate

• Blends multiple funding sources
• Matches child eligibility to fund source
• Keeps same case rate for each child
• Allows community to draw down additional money
  from CCF and Medicaid
• Do not monitor services to fund source by child,
  rather child eligibility to fund source

44
Child eligibility
CCF
Medicaid
CCF and Medicaid
Non-CCF or Medicaid
45
Option 4 Blended Child Care Fund/Medicaid Case
Rate
Enterprise Fund
46
Option 4 Blended Case Rate for Medicaid/CCF
eligible child
Assume 3,400 Case Rate per child per
month Non-covered Medicaid CCF 200
1,600 1,600
47
Option 4 Blended Case Rate for CCF only
eligible child
Assume 3,400 Case Rate per child per
month Non-covered CCF 200 3,200
48
Option 4 Blended Case Rate for Medicaid only
eligible child
Assume 3,400 Case Rate per child per
month Non-covered Medicaid 200
3,200
49
Option 4 Blended Case Rate for Non-CCF or
Medicaid eligible child
Assume 3,400 Case Rate per child per
month Non-covered 3,400 local
50
Never Give Up, Never Give Up Be Like a Dog on a
Bone
51
Financing Local Systems of Care

• Jim Wotring
• Director of Programs for Children with a
• Serious Emotional Disturbance
• Michigan Department of Community Health
• Phone [phone]
• E-mail wotringj_at_state.mi.us

52
PARTNERSHIP FOR CHILDREN andBurlington
PartnershipNew Jerseys Childrens ReformFOR
CHILDREN AND ADOLESCENTS WITH EMOTIONAL AND
BEHAVIORAL DISTURBANCESAND THEIR FAMILIES
STRATEGIES FOR SUSTAINABILITY
AND LESSONS LEARNED
Lucy Keating, Assistant Director NJ Division of
Mental Health Services September 4, 2003
Sept. 4, 2003
53
Focus

• Children and Adolescents with emotional
• and behavioral disturbances and their families
• across child-serving systems.
• Child Welfare
• Mental Health
• MEDICAID
• Juvenile Justice
• We are working toward greater inclusion and
• partnership with the Education, Special
  Education, Substance Abuse and Developmental
  Disabilities Systems.

54
Planning Preparation

• 18 Months Planning
• Reviewed successful, unsuccessful and sustained
• reform efforts of other states
• Reviewed use of
• - Rehab Option
• - EPSDT
• - Waivers
• Identified need for significant expansion and for
  managing service expansion
• Pooled Mental Health and Child Welfare funds
• in Medicaid budget. Began discussions with
  providers regarding fee for service.

55
Partnership is Guided by
Values Principles
Cultural Competency
Meet Childs Holistic Needs
Child-Centered Family-Focused
Parents as Partners
Community-Based Responsiveness
Integrated System of Care
Strengths-Based
56
Agenda for Change

• A partnership with families and natural,
  informal and formal
• providers to develop a system of care
• A single comprehensive system of flexible,
  accessible,
• community-based resources and clinical services
• A coordinated system of care that supports
• comprehensive child/family, need driven
• individual service planning across
  child-serving systems
• Increased revenue to expand the array of
• community services and resources
• Uniform screening and assessment tools and
  protocols
• Responsive and effective crisis management at
  the
• community level
• Management service expansion to assure greatest

57
MEDICAID AS A PARTNER

• Provides resources for enhancing statewide access
  to the services
• Additional financial resources for service system
  expansion
• Services now an entitlement for Medicaid eligible
  children statewide
• Incorporated the services into the standard
  benefit package for eligible children

58
Medicaid State Plan Amendments

• FEE FOR SERVICE SYSTEM
• INCREASE FEDERAL FUNDING
• NEWLY MEDICAID ENROLLED SERVICES
• Residential Treatment Centers
• Group Homes
• Treatment Homes
• Intensive In-Home Service
• Behavioral Assistance
• Mobile Response and Stabilization Services
• Care Management
• Youth Case Management
• Care Coordination
• Family to Family Support

59
Enrollment
Child and Family Determined in Need of Mental
Health Services
Medicaid/Family Care Eligibility
No
Yes
Partnership and Mental Health Benefits Only
Full Medicaid Benefits (Health Mental Health
Child gets served Provider gets paid
60
LESSONS LEARNED

• Value Principle Driven Reform
• Family Partners at ALL levels Service Provision,
  Decision and Policy Making
• Medicaid Partnership
• Training, Training, Coaching, Training and more
• Course correct along the way
• Include all interested stakeholders
• Clear and frequent communication

61
STRATEGIES FOR SUSTAINABILITY
AND LESSONS LEARNED
If you have any questions or would like to
discuss New Jerseys Reform, Lucy Keating may be
reached at [phone] or by e-mail
Lucy.Keating_at_dhs.state.nj.us
9
Sept. 4, 2003