RBS: OUT OF THE BOX

Connect the dots by drawing four straight, continuous lines, without lifting the pencil from the paper.

Nine Dot Challenge:

CDSS Review Process

Foster Care Program

Foster Care Rates & Eligibility

Fiscal

Fiscal

Fiscal RBS SteeringCommittee

Dept of Mental Health

Legal CCL

?

Mark LaneBay Area Consortium

RBS Local Implementation Coordinator

TransformingBay Area

Residential Services

Planning Process

5 Counties

x 3 Departments

= Chaos

Developing consensus(July 11 TA meeting)

How are we going to work together?

Lead County vs. Shared Coordination vs. Shared Purchase ….

Who decides?

What approach makes sense?

Mission: To work together to help the children and families in our target populations build and sustain whole lives.

Guiding Principles

Service-based, rather than place-based

Families will be part of the team and the decision-making process

Locally provided continuity of care and services

Culturally competent and strength-based services

Minimal disruptions in connections for youth and families

Focus on safe, stable, permanent living environment

Services customized to meet the family’s unique situation

DEVELOPING THE MOU

Nature of the Relationship

Vision

Shared expectations

Roles and Responsibilities

ENGAGING THE PROVIDERSTHROUGH AN RFQ

Refining the Target Population

Restating the Guiding Principles

Outlining the Program Design

Defining the Criteria to Deliver Services

KEY INNOVATIONS forTRANSFORMING BAY AREA

RESIDENTIAL SERVICES

Provider InnovationsFlexible use of staff resources

Flexible use of facility-based interventions

Increased trend of community-based interventions

Ongoing and flexible decision-making

Balance between place-based and community-based activities

Funder Innovations

Building contracts with an assumption of trust and based on anticipated transactions throughout the duration of the project.

Family involvement as a key business practice.

Process-based contracting in which key actions are outlined, agreed-upon, and monitored.

County Worker Innovations

RBS is seen as an affirmative choice

Use of RBS should be a decision of first resort, rather than last resort

Next Steps

Issue the RFQ

Engage the qualified providers

Complete the funding model

Outline the Waiver Requests

Plan for Implementation

Target PopulationsBay Area Consortium

Residentially Based Services

Lois Rutten, Contra Costa County

Who Are These Youth?

Phase 1 Target Populations

Family Reattachment– Younger children who are in

placement due to a combination of family disruption, abuse and/or dangerous behaviors that can’t be managed in other settings

Pathways to Permanency– Children and youth who are growing

up in placement and do not have a permanent plan

Phase 2 Target Populations

Bridge to Success and Safety– Youth with complex needs who are

mandated to out of home placement in the juvenile justice system but are currently in detention

Reconnecting and Reconstructing– Sexually exploited girls who are

unable to stay in placement using current approaches

How Many Youth?

All youth/children in this pilot must be:– A dependent or ward of the court

described in section 300 or 602 of the Welfare & Institutions Code and/or,

– Receiving services under AB 3632

Family Reattachment – 100 Pathways to Permanence – 600

Criteria for Determining Target Population

Statistical case review – CWS/CMS

Individual case review – look for common characteristics

Optimal volume to sustain population?

Is there an existing cross-system partnership?

Can a program be regionally implemented?

Common Characteristics

Age and Gender– Male – 12-16 years old

Ethnicity– African American

Average length of placement in group care– More than 2 years

Average number of placements– 5-7– Out of county

Minimal family and community connections

Multiple psychotropic medications Multiple assessments/evaluations

for treatment– Diagnosis?

Next Steps

RFQ response Intake & referral process Project entry/exit/capacity Training

– Providers– Staff– Community

Measure results

Residentially Based Services Proposed Funding Streams

BAY AREA CONSORTIUM

Presented by: Liz Crudo, San Fransisco County and Ellen Bucci, San Mateo

County

Objective

• To provide an overview of potential funding streams;

• Discuss potential funding model;

• Next steps.

Current funding sources

• Residential stay AFDC-FC Medi-cal / EPSDT

• Community stayAB 163 Wraparound FundingMedi-cal / EPSDT

Potential Funding Streams

• EPSDT– Case mgmt– Medication support– Therapy

• SB 163 Wraparound

• AFDC Residential Rate– Monthly bed rate board and care– In house stabilization

Potential Funding Streams (con’t)

• Other Wrap Dollars– New or unused slots– Wrap Savings

• Mental Health Services Act (MHSA)

• PSSF / CAPIT / STOP / TANF/Family Preservation/TCM/CALWORKS

• County General Fund

New Funding Model Assumptions

No new moneys;

Impact of State budget;

Providers will need to be Medi-cal certified for billing and leverage purposes;

Will require waivers and utilization of multiple funding streams;

New Funding Model Assumptions (con’t)

Need to build service model first, then funding structure (What do we want to achieve, rather than how much money do we have?);

Providers need to be WRAP eligible; and

Counties will need to apply for additional WRAP slots.

Counties would each need to contract with the provider for Medi-cal

New Funding Model Questions to be answered

• Service Model needs to be discussed and explored with Providers (Providers have knowledge re:making funding work);

• Need cost information from Providers; – Cost per individual youth will vary greatly?– Price Point? (average fair price)– Existing staff to be utilized or new staff?– How will youth without Medi-Cal be served?

Next Steps

• Complete RFQ;

• Hold discussions with providers;

• Create funding model.

Los Angeles CountyProposed RBS

Demonstration ProjectRBS Forum

Sacramento, CA

September 4/5, 2008

Mission, Vision, Collaboration

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 38

MissionThe Los Angeles RBS Demonstration will transform intensive mental health services within the child welfare system to empower families and achieve permanency for youth.

Vision The creation of a strength-based, family-centered, needs-driven system of care that transforms group homes from long-term placements to short-term interventions, which are not place-based, which provide for seamless transitions to continuing care, and which support the safety and permanency needs of youth and their families

LA RBS CollaborativeIn November of 2007, the RBS Collaborative design group was formed and is composed of county, provider and community stakeholders.

LAC Group Home Trend Data

LA DCFS Children in Group Homes Trend 2004-Present

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RCL 14 RCL 12 RCL 11 RCL 10 RCL 9 RCL 8 RCL 7 RCL 6 RCL 5 RCL 4

Target Population

• Children in or approved for RCL 12 or 14 placements– CANS will be the assessment tool

• Approximately 200 DCFS children will be served– Over 24 mos– Using up to 64 RCL 12 or 14 beds and 192 Wrap slots

• Average age – 15.8 years

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 40

Page - 41

Baseline Data: RCL-12 Children

Total Time in Current GH (36 mo view)

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All RCL 12 FY 2006-07 Exit Cohort Data

Baseline Data Continued(collaborative profile applied)

Page - 43

LOS Data Analysis

Notes:1. For RCL 12, 24 mo. analysis captures ~90% of population2. For ‘Collaborative Profile’ - 24 mo. analysis captures ~80% of

population

Total FC(mos)

Total GH(mos)

Curr. GH(mos)

All RCL 12s 62 22 10RCL 12/14 Combined 65 27 15Collaborative Profile 66 26 18

Proposed Outcomes

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 44

SAFETY• Safety in placement• Safety in home-based settings

PERMANENCY• Shortened timelines to permanency for youth• Limited, shortened length of stay in RCL 12 and 14 placements• Stability in home-based settings

WELL BEING• Family and youth satisfaction with RBS services• Family identification and connection for disconnected youth• Culturally and linguistically sensitive family involvement (visitation, participation in

and ratification of planning process, agency contact, connectedness)• Educational improvement (attendance, stability, GPA)• Socio-behavioral improvement (evidenced by CANS)

COST• Cost neutrality

Wraparound and Group Home Enrollment (FY 2003 – 2007)

Wraparound vs. Group Home Enrollment 2003 - 2007

1096979

799

575528490406368327

175

1289134514561471

165218361873

205320532184

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Wraparound Enrollment Group Home Enrollment (RCL 4 - 14)

Cornerstone Innovations• Wraparound-based Child and Family Teams

during residential tx.

• Family finding, engagement, preparation and support during residential tx.

• Residential therapeutic milieu influenced by Wraparound principles

• Shared risk/benefit between County and providers

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 46

System Design

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 47

Proposed Funding Model• Augmented residential rate for facility based services

– RCL-12 = $5,891+ $2,300 RBS rate– RCL-14 = $6,694 + $2,300 RBS rate– Modeled at 9 months

• RBS Rate covers– Family finding, engagement, preparation and support– Child and Family Team– Flex funds

• LAC Wrap rate for community based services ($4,184 excluding placement costs)

• Risk pool– Could possibly be used for

• Extended LOS• Respite• Unanticipated costs• Placement costs during Wraparound

– $1,000 set aside per month per child for 1st 12 months of care

• Cost reconciliation – Either annually or semi-annually– Share risk and benefit

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 48

Potential Waiver Requests

• RCL and related point systems• No new placement agreement for respite

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 49

Current Status

• Request for interest letter to be issued mid-Sept.

• Provider selection by end of Sept.

• Contract negotiations to follow

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 50

Concerns/Issues/Requests for Help

• Cost neutrality calculation

• Interaction with Title IV-E Waiver

• Administration and claiming processes

• CCL implications

Sept., 4/5, 2008 Los Angeles County RBS Demonstration 51

Sacramento County RBS Reform

Collaborative Reform in Progress

Who are we?

County Agencies (CW, MH, Probation, DHA, Education)

Group Home Providers Parents Youth

Our Vision, Mission, Values & Guiding Principles

“Roots to Grow, Wings to Fly”

Vision Reconnecting children, families & community

Mission Insure that all children and youth who receive residential services

are ultimately able to connect or reconnect with family, school & community so they can achieve productive adult life outcomes

Statement of Shared Principles & Core Values

RBS reform is critical to improving the ability of children and families in Sacramento County to get the right services, at the right time and the right location.

Residentially Based Services should:

√Demonstrate respect for the culture, individuality and humanity of children, youth and families

√Provide and use thorough assessments to drive services

that are tailored to individual, youth and families

√Help children and youth in placement quickly return to and

remain safe within their families, successful in their schools and integrate into their communities

√Hold all providers and systems accountable for actions and

outcomes

RBS Outcome Goals Increased % of children and youth discharged to

permanency Improved placement stability for children and

youth in group care Decreased % of children and youth re-entering

after discharge from group care Shortened length of career stay for children and

youth in group care Decreased % of children and youth placed in out

of county group care

Target Population & Start-up Criteria

Initial Target Population

CW, MH, Prob youth ages 12-16 Assessed to need or already in RCL 12 or above 30 slots/beds to start Child Welfare 12 Probation 12 Mental Health 6 2-3 providers w/plan to increase number of youth &

providers annually

Referral Criteria

Presents safety issues for self or others that requires 24 hours supervision and needs cannot be met in family setting or lower level of care

Not currently receiving Wrap Unmet mental health needs present and likely to

continue for extended time without RBS, and for Initial Start-Up Only Current connection w/family or NFREM

Service Inputs→ Should produce these outputs→ Which should result in these improved outcomes:

Thorough assessment Good fit: right level, right services Placement stability, and matching shorter LOS Parent and youth Active participation in case Increased ownership engagement planning process w/case plan: process placement stability: shorter LOS Intensive short-term Stabilization, safety; improved Continuity of family residential stabilization ability to cope; pro-social skills; and community and assessment pro-social competence connection: increase

in # of kids discharged to perm

On-going family in-home Improved family functioning Kids have needs met services at home; decrease # children returning to OH care

Our Theory of Change

Our Theory of ChangeService Inputs→ Should produce these outputs→ Which should result in these improved outcomes: Individual child and family Improved family functioning: “right Decrease in psych. Services in or out of services, right time, right place” hospitalizations and Of placement across continuum of care and juvenile hall episodes; relationships decreased re-entry into CWS or Juv Justice Educational engagement Educational continuity Academic achievement, and enrichment svcs placement and enrichment svcs stability Comprehensive care Integrated services delivered All coordination under a single case plan Non-traditional support Informal support network Decrease # children services strengthened; culturally re-entering care appropriate services delivered Intensive permanency Reconnection/Strengthening All services family ties, or finding alt permanency

The RBS Service Array

1. Comprehensive Care Coordination

2. Family Engagement & Empowerment

3. Intensive Short-term Residential Stabilization &

Assessment

4. Intensive Permanency

5. Ongoing Family Support

6. Education Engagement & Enrichment

7. Individualized child, Youth & Family Behavioral

8. Non-traditional Support & Assistance

9. Other Innovative Options & Approaches

The RBS Program Design

Service Array→ Service Options→ Program Model

Assessment & MatchingPlan of CareFacility Based ServicesCommunity Based ServicesPermanency Services

What’s new that will make the difference?

Assessment & Matching

Enhanced TDM Use of CANS as standardized assessment tool Child, youth & family participation Includes placement matching Provider presence Begins resource management process

Child/youth enrolled in RBS, not “placed” “CFT like” Team to develop and coordinate

plan of care Facilitated by RBS provider…Fred

√ Facilitate√ Reunify√ Engage√ Discharge

Plan updates at 30 day & quarterly intervals Continues after residential discharge Cross system collaboration

Plan of Care

Facility Based Services

Family membership in facility treatment team Integrated facility & community based staff for continuity of

connections, relationships, service delivery Individualized treatment Recruitment & retention of talented staff Flexible services that promote & provide for individualized interest Enrichment opportunities that anchor child in community and family Normalization w/safety contingencies Alignment of county caseworker with residential staff Active participation of caseworkers in CFT

Permanency Services

No “old step down”, only step toward permanency

Strengthening and developing child/youth’s ties to community

Finding, developing & supporting family connections

Build knowledge, skill & expertise of county and provider RBS staff

Youth advocacy

Coordinated by CFT Blend of parallel and aftercare Family & youth focused Comprehensive

-treatment

-respite

-educational

-recreational

Community Based Services

Lead Agency Model

Authorization& Resource

Mgt.

ProviderFacilitated

CFTPlan of Care

Integrated Arc of Care

Full Array ofServices

TDMDischargefrom RBS

County Worker Identifies Need for Group Care

Enhanced

Partnership Roles & Responsibilities Collaborative Process Staffing Model QA Mechanism Preliminary Training Plan Provider Selection for Next Steps...

Operational Design

Total Cost of Care and outcome components: All clients who have left care during 2006 and 2007 From RCL 12-14 Placed by Child Welfare, Mental Health, or Probation Federal and Non-federal (to be utilized to estimate correct ratio of FED : NONFED

AFDC Costs) Dollar totals are for each time span of placement during these 2 years With Lifetime cost listed as an additional column WRAP payments are also listed and are not included in the Lifetime Cost Mental Health Treatment Costs, EPSDT and/or 26.5 Non-AFDC Costs for out of state placements and hospitalization Permanency Outcomes data Age of Clients Client Gender Distance of Provider from Sacramento Metropolitan Statistical Area Only consider Clients with Group Home placements of 90 days or longer

Identifying Necessary Data Elements

Multiple Databases contain relevant information Requires collaboration across DHA, County

CMS/CWS Workers, Children’s Mental Health Manually combining information from databases Multiple refinements of Data Requests from each

database Large data set of approx. 850 clients

Challenges

Average Placement Cost* $133,401 in AFDC Payments + WRAP

$17,471 = $150,872** Fed/Non-Fed 71.5% / 28.5% Male/Female 60% / 40% Average Age 16.4 years

*Does not include additional payments for Mental Health, 26.5, Out of state, and/or Hospitalization.

**Preliminary figures, rough, not yet reliable!

Results

Service Areas Responsibilities to carry out components of

each service Expected Funding Sources for each

component within the service

Provider Estimates of RBS Services

1. Comprehensive Care Coordination 2. Family Engagement & Empowerment 3. Intensive Short-term Residential Stabilization &

Assessment 4. Intensive Permanency 5. Ongoing Family Support 6. Education Engagement & Enrichment 7. Individualized child, Youth & Family Behavioral 8. Non-traditional Support & Assistance 9. Other Innovative Options & Approaches

The RBS Service Array

Funding Components of the RBS RateProvider Cost 156,489

Monthly 8,694

EPSDT 2,906 33.4%

AFDC 3,645 41.9%

AFDC/Flex 2,142 24.6%

8,694

Next Steps

Continue to Refine reliability of Data Adjust Funding Shares as necessary Determine Payment Strategy Determine Risk Pool Strategy

Regulatory Interpretation-”Strict Liability” be replaced with a “Standards of Care” or “Prudent Parent” standard-AWOL “violations” be replaced with “Standards of Care for AWOL Behavior”

Licensed Capacity- 84068.1(c)(1), 84088(a)1-Request waiver for regs to accommodate emergency placements when not in conflict with fire clearance or use permits

Facility-84065.2(d),(e)1&2-Personnel Duties-Request flexible use of staff-Request waiver to be able use logical and natural consequences

as determined by the treatment team Training Requirements- 84065(3)

-Allow expansion of approved trainings to prepare staff to work between residential, community and home

Regulatory Waiver Overview

Fiscal Waivers

Rate Classification Level System (RCL) Section 11.402.000-Waive entire RCL system to be replaced by provisional rate with cost

settlement -Provides more flexible and efficient use of FC $$-Costs to be reported on semi-annual basis -Annual audit to follow A122 and 133 auditing standards

AFDC-FC State Share Waiver-Waiver to create funding stream specific to RBS

community based services for aftercare and parallel services-To be used for non EPSDT billable services throughout continuum of care

What We’ve Learned & Where We’re Going

Collaboration is slow, but the way to go Vision, Mission & Values were key to moving

forward It’s hard to crawl outside the box Program and funding Model development is a

dance

Next Steps Close gaps & finalize work to date Develop Operational & Evaluation Model Meet 10/3 deliverable deadline!!!

Presenter Contact Information

Jim Martin Geri WilsonExecutive Director Sacramento County

Martin’s Achievement Place RBS Reform Project Coord.(916) 338-1001 (916) 875-2-2023(916) 338-1044 fax (916) 599-3828 cellJ_Martin@mapinc.net wilsoga@saccounty.net

Dan PetrieSr. Program DirectorMilhous Children’s Services(916) 265-9057(916) 215-9057 celldpetrie@milhous.us

San Bernardino CountyRBS Demonstration

RBS ForumSacramento, CA

September 4/5, 2008

Overall ApproachTransform the child and family experience for children placed in RCL-14, out of state, and in psychiatric hospitals so the

•Voice and choice for the child and family is present

•Continuity of care exists throughout the trajectory of care (no hand-offs, no drop-offs)

•Continuum of care is planned, managed and reviewed regularly

•Outcome focus of the demonstration is achieved

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 87

County, Provider, and Community Partnership

Mission, Vision, ValuesMission

Working together to safely build and sustain positive, successful family connections and children’s futures.

VisionThe transformed system will provide resources specifically designed to facilitate

the ongoing movement of children and youth who have complex emotional and behavioral needs toward more enduring and positive connection or reconnection with their families, schools and communities. The transformed system will create effective partnership and collaboration across systems in the interest of better outcomes for those youth and their families.

ValuesStability, permanency and safety focus

FlexibilityIntegration across systems

Continuous planning and evaluation across the arc of enrollmentContinuity of care

Partnership and engagement

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 88

Family Driven - Youth Guided

Cornerstone Innovations• Family Passport

• Care Coordination Team

• Wrap approach throughout trajectory of care

• ITFC-like foster care consistent with RBS

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 89

A Continuum of Care with No Handoffs

Primary Outcome Focus

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 90

1. Reduced Length of Stay

2. Reduced level of care including out of state

3. Reduced Hospitalizations

4. Reduced AWOL incidents

5. Improved Permanency

a. Stable placementb. Increased pro-social behaviorc. Life long connections

Stakeholder-Driven

Baseline Sample Demographics*

Frequency %

Male 15 39%

Female 23 61%

Black 11 29%

Latino 6 16%

Native American 1 3%

White 20 53%

* Sample of 38 youth who had at least one RCL-14 placement day in 2007

Outcome Baselines

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 92

PERMANENCY BLAvg. current GH stay 7.7 mos2 in foster home, LOS 0.9 mos1 at home, length of stay 3.8 mosAvg. Time in Foster Care 6.2 yrsAvg. # of prior placements 3.0Reentry in to foster care tbdExits to permanency tbd#of supportive connections tbd

WELL BEING: BL

Avg. time in GH care 24.5 mos

Avg. # days AWOL 24.8 daysAvg. # of AWOL episodes 3.2Avg. # days in hospital 40.8

Cost Baseline

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 93

COST BL

Total cost of FC (sample) $7.5MGH Cost $5.6MOut of state costs $1.6MNon Tx foster home costs $30KFFA costs $206KOther small family homes $90K

Hospitalization cost $760K

Total 3-yr cost $8.2M

• Reflects costs over 2004 to 2007 for baseline sample• Average cost of $72,000 per yr per child

“Rachel” - A candidate for RBS (16.8 yrs old)

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 94

1995 - 1999 2000 - 2003 2004 2005 2006

1995-98 - six unsubstantiated abuse/neglect referrals concerning younger sister

1996 – BM incarcerated 20 months; children w/GM

1999 – 1 referral concerning all 3 children

No activity

Apr – Substantiated physical abuse by step parent; removal to FFA

May-Dec 4 GH placements

Dec Home under FM (Wrap)RespiteGH #51st hospitalizationGH #6

Jan Home under FM (Wrap)School and AWOL incidentBM requests removalBack to GH #6

May AWOL from GH #6FBM and GM return to DCSGH #7, AWOLGH #4, AWOL

Jun-Sep AWOL from GH #4, AWOL from 2 FFA Placements, ends up w/ BF

Sep-Oct GH #8, pregnantAWOL (Las Vegas)Return by BM to temp. FFAAWOL x2, returns to GH #8

Oct-Dec AWOL in LA w/boy friend and GM

Jan Home under FM (Wrap)School and AWOL incidentBM requests removalBack to GH #6

May AWOL from GH #6FBM and GM return to DCSGH #7, AWOLGH #4, AWOL

Jun-Sep AWOL from GH #4, AWOL from 2 FFA Placements, ends up w/ BF

Sep-Oct GH #8, pregnantAWOL (Las Vegas)Return by BM to temp. FFAAWOL x2, returns to GH #8

Oct-Dec AWOL in LA w/boy friend and GM

Jan-JunStill AWOL, rape, miscarriage

Jul-OctFFA #3AWOL (Back to GM)

Oct-Dec 2nd hospitalizationConservatorship

Dec-PresentPlaced out of state (RCL- 14)

• 2 abuse/neglect referrals• 12 GH placements in 9 GHs• 5 FFA placements in 3 FFAs• 2 psych hospitalizations• 12 AWOL incidents• 2 Wrap failures• 1 rape• 2 pregnancies, 2 miscarriages

• Motivated to be with family• Maintains family contact• Searches for extended family• Stable out of state for 2 years• Engages in goal setting• Survival skills

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 95

Designing a New System for Rachel

Rachel

Proposed Funding Model

• “Success First Wrap” MHSA – Funds Care Coordination Team across arc of

enrollment for 12 slots

– Approximately $3,000/mo/child

• SB 163 Wrap takes over when MHSA ends

• Rate for Facility Based Services - TBD

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 96

Potential Waiver Requests

Still under considerationWaivers need to be provider driven

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 97

Current Status

• One provider tentatively selected with both Wrap and residential beds

• Funding streams identified and model under construction

• High level System Design complete

• Facility based service model under construction

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 98

Concerns/Issues/Requests for Help

Models will evolve during implementation

Sept., 4/5, 2008 San Bernardino County RBS Demonstration 99