Maryland’s Proposed Title IV-E Waiver Demonstration Application A presentation by DHR to the Social Services Administration's Child and Family Advisory Board and Members of the IV-E Waiver Committee & Provider Advisory Board October 31, 2013, 9: :00 Baltimore, MD

Title IV-E Demonstration Waiver BACKGROUND ON THE TITLE IV-E DEMONSTRATION WAIVER

Title IV-E Demonstration Waiver Child and Family Services Improvement and Innovation Act HR 2883 (PL ) Bill Signing Provided HHS with authority to grant up to 10 waivers in each of FFY 2012, 2013 and Casey Family Programs, 2013

Title IV-E Demonstration Waiver New Demonstration Authority HHS can authorize up to 10 new demonstrations in each of federal fiscal years 2012, 2013, States were approved for waivers in FFY States were approved for waivers in FFY 2013

Title IV-E Demonstration Waiver Waiver States as of October 2013

Title IV-E Demonstration Waiver Key Requirements States/Tribes must demonstrate readiness. Required to implement Child Welfare Program improvement policies. States/Tribes must submit proposal covering 22 required items. (ACYF-CB-IM of May 14, 2012). Demonstrations must be cost neutral to the federal government. Requires rigorous, independent evaluation. Casey Family Programs, 2013

Title IV-E Demonstration Waiver Cost Neutrality Cost comparison method Capped allocation method – What would the State/Tribe have received in IV-E Foster Care payments in the absence of the waiver? – Capped allocation can include almost any foster care costs, but most state capped allocation waivers have included maintenance payments and administration. Casey Family Programs, 2013

Title IV-E Demonstration Waiver Child Welfare Demonstrations Implementation Time Frames Casey Family Programs, 2013

Title IV-E Demonstration Waiver Where States Are Casey Family Programs, 2013 Steps in the Process Explore application ~ Develop and Submit Application Negotiations with ACF Execute Terms and Conditions Developmental Cost Plan Initial Design & Implementation Rpt. Evaluation Plan~ Schedule of Payments~ Implement~ Key: Completed ~Underway

2012 States StateFocusTarget PopulationScope ARComprehensive practice model. Expand EB and EI practices. All children referred to CWS Statewide with 8 counties in Year 1 COSystemic reforms and innovative practices to increase family engagement All children with screened in reports Up to 64 counties ILAddress impact of early maltreatment and trauma Children age 0-3 who enter care. Cook County (Chicago) MAPerformance-based contracts of residential services Children in residential placement and can return to family Statewide – 3,400 youth 10 Casey Family Programs, 2013 Title IV-E Demonstration Waiver

2012 States (continued) 11 Casey Family Programs, 2013 Title IV-E Demonstration Waiver StateFocusTarget PopulationScope MIExpand secondary and tertiary prevention to families with young children at risk All children in specified communities 3 sites, 1,500 families over 5 years PANew case practice model focused on family engagement, assessment and expanded use of EBPs. All children in placement or receiving services 5 counties initially WAFamily Assessment Response (a differential response pathway as alternative to CPS) Families screened in representing low or moderate risk Statewide over five years. WIPost-reunification case management and support services for 12 months post discharge All children who have reunited Milwaukee County year 1, remainder of state years 2 to 5.

Summary of New Demonstrations 12 Casey Family Programs, 2013 Title IV-E Demonstration Waiver State ScopeFunding/ CostEvaluation AR Statewide Capped Allocation. Payments and Admin Outcome changes over time CO Phased – up to 64 counties Capped Allocation – Payments and Selected Admin Categories Matched case comparison and time series analysis IL Age 0-3, Cook CountyTreatment/Control ComparisonQuasi-experimental comparison MA Statewide Capped Allocation – Payments and Admin (compare to Congregate care history) Pre-post outcome comparison MI 3 sitesTreatment/Control ComparisonExperimental design PA 5 counties to start – can be expanded Capped Allocation – Payments and Admin. Interrupted time-series design using propensity score matching, and meta- analysis of common interventions. UT Statewide Capped Allocation – Payments and Admin. Outcome & cost changes over time WA Statewide – low to moderate risk families Capped Allocation – Payments and Admin. Matched case comparison design WI Milwaukee – may expand statewide Capped Allocation – Payments and Admin Matched care comparison – longitudinal outcomes

Title IV-E Demonstration Waiver Common Strategies Casey Family Programs, 2013 Many states have identified expanded use of in-home services as a strategy. Many states have identified trauma-informed assessments and care as strategies. Several states have identified implementation or expansion of differential or alternative response initiatives. Several states have identified use of Family Finding as a tool. A number of states have identified family/youth engagement and involvement as strategies. Several states focus on kinship care (supporting effective placements and moving those placements to permanency). Several states are focusing on reducing reliance on congregate care or residential treatment. Several states are collaborating with their Medicaid and/or Behavioral Health systems.

Title IV-E Demonstration Waiver Increased Federal Emphasis Casey Family Programs, 2013 What are your target populations? What interventions do you plan to use? What outcomes do you expect? What is your theory of change? How will you evaluate these outcomes? How realistic are your plans? What are the costs and savings (goes beyond cost neutrality)?

MARYLAND’S APPLICATION

PLACE MATTERS Building on the Foundation of Place Matters Engaging Families: Developed a family centered child focus practice model. Finding Permanence for Children: Keeping children in their home when safe; reducing the length of stay in care; finding permanent homes for children. Using Data: DHR set goals for key measures and used data to analyze the caseload and make better decisions for at risk children

PLACE MATTERS Out-of-home placements have decreased 43% since Using Data to Measure Success

PLACE MATTERS Group home placements have decreased 47%. 72% of youth in care are placed with families. Using Data to Measure Success

PLACE MATTERS Using Data to Measure Success

PLACE MATTERS Children who grow up with permanent families are more likely to succeed later in life. More children are finding permanent families through adoption, reunification and guardianships. Our goal is for children to have no more than two placement changes a year and to reduce the length of stay in foster care. Using Data to Measure Success

Title IV-E Demonstration Waivers Federal Priority Areas Produce positive well-being outcomes for children, youth and their families, with particular attention to addressing the trauma experienced by children who have been abused and/or neglected; Enhance the social and emotional well-being of children and youth who are available for adoption, as well as those who have been adopted, with a particular emphasis on those children who have been waiting the longest or are hardest to place in order to achieve and sustain successful adoptions; Yield more than modest improvements in the lives of children and families and contribute to the evidence base; and/or Leverage the involvement of other resources and partners to make improvements concurrently through child welfare and related program areas, including proposals to establish financial incentives based on the achievement of positive child outcomes.

Title IV-E Demonstration Waivers Federal Goals Required to be Addressed by the Waiver Application (at least one must be addressed) Increase permanency for all infants, children, and youth by reducing the time in foster placements when possible and promoting a successful transition to adulthood for older youth. Increase positive outcomes for infants, children, youth, and families in their homes and communities, including tribal communities, and improve the safety and well-being of infants, children, and youth. Prevent child abuse and neglect and the re-entry of infants, children, and youth into foster care.

Title IV-E Demonstration Waivers Maryland’s Goals Build on successes in improving safety & permanency by promoting child well-being Leverage and build upon home- and community- based service array, including evidence-based and promising practices, to enhance availability of services in the community Establish a trauma-informed child welfare system Support full implementation of Alternative Response

Title IV-E Demonstration Waivers Ages of Children & Youth Served through In-Home Services in Maryland

Title IV-E Demonstration Waivers Ages of Children & Youth Served through Out-of- Home Care in Maryland

Title IV-E Demonstration Waivers Potential EBPs & Promising Practices for Children and their Families with Child Welfare Involvement (Non-Exhaustive List—For Discussion Purposes) Brief Strategic Family Therapy (BFST)* Early Childhood Mental Health Consultation (ECMHC)* Family Connections* Family Group Decision Making* Functional Family Therapy (FFT)* Functional Family Therapy—Child Welfare Grandparent Family Connections* Homebuilders* Home Visiting* Motivational Interviewing* Multidimensional Treatment Foster Care (MTFC)* Multi-Systemic Therapy (MST)* Multi-Systemic Therapy-Child Abuse and Neglect (MST-CAN) Oregon Model, Parent Management Training Parent Child Interaction Therapy (PCIT)* Peer Support* Safe Care Social and Emotional Foundations of Early Learning (SEFEL)* The Incredible Years Triple P Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)* Wraparound* *Currently available or being implemented in at least 1 jurisdiction in Maryland

Title IV-E Demonstration Waivers Partnerships & Collaboration Key partners include the LDSS, Children’s Cabinet Agencies, providers, families and youth, universities and community organizations. DHR will connect with and leverage other initiatives, including – Children’s Cabinet EBP Implementation – Upcoming 1915(i) State Plan Amendment – System of Care Grants: MD CARES, Rural CARES, LIFT – Project Launch – C-West & Promise Heights – – Local activities and partnerships

Title IV-E Demonstration Waivers Timeline & Next Steps Winter 2014: Application submitted Spring 2014: Negotiation with HHS September 30, 2014: Final day for HHS to approve the application Fall 2014: Implementation activities begin September 30, 2019: Final day of Demonstration Waiver authority