a community based approach to redesigning a placement continuum of care

Protecting Children. Strengthening Families.

A Community-Based Approach to Redesigning a Placement

Continuum of Care

A private, community-based lead agency model integrating clinical and permanency best practices to dramatically “right

size” a child welfare system.


Presenters

• Gregory J. Kurth Chief Executive Officer Family Services of Metro Orlando

• Elizabeth Lewis, RN, B.Ed.

Chief Operating Officer Family Services of Metro Orlando


What Is Community-Based Care (CBC)?

Lead agency oversees a fully array of child protective services within a community network of partners.


19 Community Based Care Lead Agencies


Service Areas

FSMO is one of the largest CBC lead agencies in the state of Florida, managing formal child welfare services for over 2,800 children


CMO Partner Agencies


In 2004 FSMO Inherited

• Over 3,600 kids in protective services (in and out of home)

• “Cookie cutter” case plans

• High removal rate

• No Utilization Management

• No Permanency review process

• Limited foster home capacity


2004 - A Closer Look

• Funding of Licensed Care: $48,000 per day/$17.5 million per year

• Over-utilization of residential placements; no Mental Health Integration

• Disrupted placements 3 times that of entries into the system

• No focus on Older or SED Children for permanency


2004 - A Closer Look

• Little knowledge of community resources

• DJJ/DCF/SAMH: agencies operating in silos

• Negative perception of biological families

• Lack of gate keeping/utilization management


Children Placed Outside of Osceola County

% of Children Placed Outside of County by Type Source: HSn Clients Active as Case Dependents 9-29-05

Type of Placement % Out of County

Traditional Foster Homes 68.3%

Group Homes 71.6%

DD Foster Homes 80.0%

DD Group Homes 80.0%

Medical Foster Homes 100.0%

Mental Health Facilities 33.3%

Residential Treatment Centers 77.8%

Therapeutic Foster Homes 70.0%

Shelters 100.0%

Overall 68.9%


Children Placed Outside of Orange County

% of Children Placed Outside of County by Type Source: HSn Clients Active as Case Dependents 9-29-05

Type of Placement % Out of County

Traditional Foster Homes 28.2%

Group Homes 48.0%

DD Foster Homes 66.7%

DD Group Homes 60.0%

Medical Foster Homes 41.2%

Mental Health Facilities 30.8%

Residential Treatment Centers 22.2%

Therapeutic Foster Homes 37.9%

Shelters 70.8%

Overall 37.4%


In 2004 Over 400 Children in High End Placements

PIL5%

RTC20%

TFC & STFC17%

RGC39%

Group Home19%

PIL

Group Home

RGC

TFC & STFC

RTC


An Example of the # of Admissions and Discharges

Compared to Child Movements

One CMO -- July 2005 - April 2006

Transfers, 109, 18%

Admits, 197, 33%

Disruptions, 118, 20%

Discharges, 176, 29%


Where We Are Today

• Funding of Out of Home Care Licensed Care: $32,100 per day/$11.7 million per year

• $5.8 million savings annually

• 2700 kids in protective care with 780 kids in paid care

• Responds to 15,000 calls annually and services to 8,000 children and families


How FSMO Made a Difference

• Community Involvement • Safety Focus

• Engagement Based Practice

• Prescription

• System Integration

• Relentless Management and Quality Improvement


Community Involvement

Resource Specialists co-location DJJ Liaison DD/CMS Specialist


The Resource SpecialistFunctions

as a ‘resource’ for placement

stabilization via consultation.

Works closely with the CPI on

diverting children from coming into

care.

Conducts and maintains a ‘mapping’

of the community’s ‘traditional’ and ‘non-traditional resources.

Assists the CPI in the

assessment of

safety vs. risk.

Consults with the

CPI in the development of a safety plan.

Assists in generating

referrals for CBA

services.

Assists the CPI in the diligent search for

relative placements.


DJJ Kids Diverted

2004 – 1

2005 – 22

2006 – 29

2007 – 41

2008 – 45(January – June)

Total - 139


83 DJJ Kids Diverted 2007-

2008 Savings of $14,424/day

J uly Augus t S ept Oc t Nov Dec J an F eb Marc h April May J une

10

5 63 7

69 8 10

58

6

Monthly # of Kids DivertedMonthly # Diverted


Developmentally Delayed Children

FSMO hired DD/CMS Specialist in 11/079 children diverted from the system. Saving over $200,000.00 annualized. These kids are:– Difficult to place– Have very specialized needs– Expensive to treat


Safety Focus

• Differentiating Risk from Safety

• Child Endangerment Risk Assessment Protocol (CESAP)


Why Implement Change?

• Many Children are Entering Care Unnecessarily;

• Some child/abuse victims may be remaining home who should be placed;

• In-Home families are not receiving effective child protective services;

• The System has not clarified the difference b/w Risk and Safety

• Workers lack prescriptive guidelines


Focus on Front-End

Orange/Osceola

State

Nation

7.0

5.3

4.0

Abuse Reports (% of Child Population) Substantiations (%

of Reports)

Removals (% of Substantiations)

Removals (per 1,000 of Child Population)

8.2%

4.2%

8.9%

31.6%

36.5%

29.4%

20.3%

25.6%

26.4%

8.2%

4.2%

8.9%


Safety versusRisk

Now or Near FutureHigher DegreePrevention (short term)

Longer TermLower to Moderate DegreeMitigation (long term)

Potential Harm


CESAP Requirements

• A ‘life of the case’ protocol.• Assessing moderate to severe harm

immediately or in the near future.• Safety Determination Form.• Safety Plan.


• Placement stabilization

• Families participate in staffings and case development

• Specialized Adoption Recruitment: Wendy’s Wonderful Kids / Heart Gallery of Metro Orlando

• Family Team Conferencing

• Community providers invited to staffings

Engagement Based Practices


Placement Stabilization

• Case managers take ownership• Know and support foster families (e.g.

foster parent liaison)• 1st sign of trouble -- initiate supports• “Push down” accountability• Work with schools to save placement• Explore extra curricular activities


Innovative gallery-style photo exhibit that rotates throughout the community

Highlights 80 children in Orange and Osceola counties currently available for adoption

The Heart Gallery is a unique way to engage Central Florida in the child welfare system


Prescription• Case Plan Conferences / Permanency Case

Reviews

• Utilization Management: Level of Care Committee and Authorization of placements

• Placement matrix

• CANS (Child Adolescent Needs and Services) survey of group care


May 2004 - A Look at the Permanency Options

• Biological family rarely considered

• Children under 12 and siblings growing up in group care

• Step downs rejected due to increased work on case worker

• Fear of making the wrong decision lead to inappropriate child labeling


Permanency Strength/Need Approach

Moving From:

Seeing families as the problem

Focus on deficits of parents

Plugging families into existing services

Expert model

Identifying needs and funding sources

Moving To:

Seeing families as allies

Focus on needs of the children

Crafting, individualizing and tailoring services around specific needs

Collaborative model

Connecting families to services regardless of funding sources


90 Day Reviews• All cases reviewed by “third party” Child

Welfare Specialist

• Families part of the solution

• Services authorized at time of need

• Safety issues addressed immediately

• Immedate Feedback


Placement Matrix

Placement Type Child CharacteristicsTraditional Care Functions well in a family

Residential Care Defiant, 24 hour supervision

Enhanced Care Moderate Psychiatric

Specialized Foster Intense Psychiatric

Specialized Group Serious Disturbance

Residential Treatment Unable to function

Medical Care Medically Compromised


Using CANS Criteria

How it was used:• Match child’s characteristics to program• Profiling provider based on the

residential CANS survey• Created placement algorithms

Number 1 Benefit:• Placement stabilization


Children in Paid Placement by Age - Trendlines July 1, 2004 vs. October 1, 2008

25

35

45

55

65

75

85

95

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Age

Ch

ild

ren

Poly. (2004) Poly. (2008)


Cost per Client per Day of Residential Services

275

325

375

425

475

525

4/19

/2004

6/19

/2004

8/19

/2004

10/19

/200

4

12/19

/200

4

2/19

/2005

4/19

/2005

6/19

/2005

8/19

/2005

10/19

/200

5

12/19

/200

5

2/19

/2006

4/19

/2006

6/19

/2006

8/19

/2006

10/19

/200

6

12/19

/200

6

2/19

/2007

4/19

/2007


Number of Residential Clients Served

250

300

350

400

450

500

550


Beyond Traditional Foster Care Services Cost per Day


#1 Key to Our Success Utilization Management

Utilization Management Program

• Expert Review & implement recommendations

• Focus on early & appropriate treatment

• Decrease multiple placements

• Focus on safety, permanency & well being


System Integration

• Medicaid managed care - Magellan

• Utilize all appropriate funding streams

• Utilize IV-E Waiver

• Embedding UM in permanency


Child Welfare and Mental Health Needs of Children

• Annually, 600,000 children seen in the U.S. child welfare system do not receive mental health care to meet their needs.

• 48% of these children have clinically significant mental health needs.

Journal of American Academy of Child and Adolescent Psychiatry, August 2004


Mental Health Issues

• Children lose funding in RTC and come into care

• Families need services – children come into care

• Adoptive families return children due to lack of services

• We paid for four kids at $406.00/day until Medicaid funding began

• $406.00 for 30 days is $12,188.00/child


May 2004 - An Overview of Treatment in High End Facilities

& Therapeutic Foster Homes

25 Children Reviewed in staffings

11 kids were 12 years old or younger

All had psychologicals and assessments

All had multiple psychiatric diagnoses

22 were on psychotropic medications

15 were taking 3 or more medications

Negative view of biological families

Delay in school enrollment


May 2004 - A View of Medication Management

Lacking continuity of care

Used medications to control behaviors

Courts changed medication dosage

Could take weeks before court approval

Little parental involvement in decision-making


Pre-Paid Medicaid Plan

FSMO is Limited Partner Beginning of purchase of service

utilization Authorizations required for high end

services RTC funding carved out Full risk for RTC placements Today a shared risk model


IV-E Waiver

• Implemented in October 2006• All IV-E (except for Adoption

Assistance) can be used for child protection-related activities


Relentless Management and Quality Improvement

Provider Meetings and Supervisors Forum

Training for all Front-Line Staff

Quality Service Reviews and Team Performance Calls

Balanced Quality Scorecards


FSMO Training Accomplishments

• FSMO began training the System of Care January 2006

• 298 Case Managers and Protective Investigators trained since inception

• Deliver 7-week training cycles 6 times a year

• 94% of all trainees have passed the competency based pre-service training program


Scope of Training

• Pre-service training• Field training • In-service training• Supervisory training• Targeted trainings driven by quality

improvement initiatives


Transition of Training Program

• Train protective investigations and case management together to build collaborative relationships

• Build in mentor and modeling approach to training

• Moving from global skills development to specialization


Specialization Trainings

• Goal is to develop subject matter experts within operational centers

• Competency based trainings• Trainings offered in:

• Impact of Trauma on Early Development• Domestic Violence• Mental Health• Substance Abuse• Sexual and Physical Abuse


Partnership with IT Vendor to Develop an

Internal Database

• Authorize/track placements

• DJJ diversion

• Purchase of services

• Licensing & inquiries

• UM, Contracts, Fiscal


FSMO Accomplishments 2004-2007

COA Accreditation for Network Standards Increased adoptions Increased relative care placements Increase # of foster homes Increased prevention activities Fewer children placed in foster homes Kids moving through the system

Decreased kids in the system Decreased disruptions Decreased # of group homes Decreased high end placements Decreased # of psychotropic medications


FSMO Awards

• 2006 Congressional Angel in Adoption

• 2006 Computer World Laureate

• 2007 Davis Productivity Nomination


Interesting Note

The state of Florida

operates the child

welfare system at

70% of the national

median of per capita

funding.


Challenges Moving Forward

Augmenting residential programsOut of Home Care “Bottoming”Continuity of medical/behavioral careAdequate services for DJJ & DD kidsImproving well-being outcomesTransition from foster care


FSMO Child Population 347,741

Statistic 2007 FSMO

Abuse Rate: 1 out of every 239 children is the subject of an abuse call

Removal Rate: 1 out of every 379 children is removed

Exiting Care within 12 Months:

22% more children were removed from their homes than exited the

child welfare system


New Initiatives

• Program Advisory Committee (Health, Education, Community Resources)

• Faith Based Initiatives• Web-Based Development – Greater

Network Interactivity (e.g. Blogging)• Educational Liaisons


Contact Presenters

• Gregory J. Kurth, MA Chief Executive Officer

[email protected]

• Elizabeth Lewis, RN, B.Ed. Chief Operating Officer [email protected]

Family Services of Metro Orlando 407-398-7975

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