3. Connect the dots by drawing four straight, continuous lines, without lifting the pencil from the paper. Nine Dot Challenge:

4. CDSS Review Process Foster Care Program Foster Care Rates & Eligibility Fiscal RBS Steering Committee Dept of Mental Health LegalCCL ?

7. Mark Lane Bay Area Consortium RBS Local Implementation Coordinator Transforming Bay Area Residential Services

8. Planning Process 5 Counties x 3 Departments = Chaos

9. 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.

10. 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

11. DEVELOPING THE MOU Nature of the Relationship Vision Shared expectations Roles and Responsibilities

12. ENGAGING THE PROVIDERS THROUGH AN RFQ Refining the Target Population Restating the Guiding Principles Outlining the Program Design Defining the Criteria to Deliver Services

13. KEY INNOVATIONS for TRANSFORMING BAY AREA RESIDENTIAL SERVICES

14. Provider Innovations Flexible 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

15. 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.

16. County Worker Innovations RBS is seen as an affirmative choice Use of RBS should be a decision of first resort, rather than last resort

17. Next Steps Issue the RFQ Engage the qualified providers Complete the funding model Outline the Waiver Requests Plan for Implementation

18. Target Populations Bay Area Consortium Residentially Based Services Lois Rutten, Contra Costa County

19. Who Are These Youth?

20. Phase 1 Target Populations n 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 n Pathways to Permanency –Children and youth who are growing up in placement and do not have a permanent plan

21. Phase 2 Target Populations n 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 n Reconnecting and Reconstructing –Sexually exploited girls who are unable to stay in placement using current approaches

22. How Many Youth? n 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 n Family Reattachment – 100 n Pathways to Permanence – 600

23. Criteria for Determining Target Population n Statistical case review – CWS/CMS n Individual case review – look for common characteristics n Optimal volume to sustain population? n Is there an existing cross-system partnership? n Can a program be regionally implemented?

24. Common Characteristics n Age and Gender –Male –12-16 years old n Ethnicity –African American n Average length of placement in group care –More than 2 years n Average number of placements –5-7 –Out of county n Minimal family and community connections n Multiple psychotropic medications n Multiple assessments/evaluations for treatment –Diagnosis?

25. Next Steps n RFQ response n Intake & referral process n Project entry/exit/capacity n Training –Providers –Staff –Community n Measure results

26. Residentially Based Services Proposed Funding Streams BAY AREA CONSORTIUM Presented by: Liz Crudo, San Fransisco County and Ellen Bucci, San Mateo County

28. Objective To provide an overview of potential funding streams; Discuss potential funding model; Next steps.

29. Current funding sources Residential stay  AFDC-FC  Medi-cal / EPSDT Community stay  AB 163 Wraparound Funding  Medi-cal / EPSDT

30. Potential Funding Streams EPSDT –Case mgmt –Medication support –Therapy SB 163 Wraparound AFDC Residential Rate –Monthly bed rate board and care –In house stabilization

31. 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

32. 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;

33. 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

34. 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?

35. Next Steps Complete RFQ; Hold discussions with providers; Create funding model.

37. Los Angeles County Proposed RBS Demonstration Project RBS Forum Sacramento, CA September 4/5, 2008

38. Mission, Vision, Collaboration Sept., 4/5, 2008Los Angeles County RBS Demonstration38 Mission The 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 Collaborative In November of 2007, the RBS Collaborative design group was formed and is composed of county, provider and community stakeholders.

39. LAC Group Home Trend Data

40. 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, 2008Los Angeles County RBS Demonstration40

41. Page - 41 Baseline Data: RCL-12 Children 50% 90% 80% All RCL 12 FY 2006-07 Exit Cohort Data

42. Baseline Data Continued (collaborative profile applied)

43. Page - 43 LOS Data Analysis Notes: 1.For RCL 12, 24 mo. analysis captures ~90% of population 2.For ‘Collaborative Profile’ - 24 mo. analysis captures ~80% of population

44. Proposed Outcomes Sept., 4/5, 2008Los Angeles County RBS Demonstration44 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

45. Wraparound and Group Home Enrollment (FY 2003 – 2007)

46. 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, 2008Los Angeles County RBS Demonstration46

47. System Design Sept., 4/5, 2008Los Angeles County RBS Demonstration47

48. 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 1 st 12 months of care Cost reconciliation – Either annually or semi-annually – Share risk and benefit Sept., 4/5, 2008Los Angeles County RBS Demonstration48

49. Potential Waiver Requests RCL and related point systems No new placement agreement for respite Sept., 4/5, 2008Los Angeles County RBS Demonstration49

50. Current Status Request for interest letter to be issued mid- Sept. Provider selection by end of Sept. Contract negotiations to follow Sept., 4/5, 2008Los Angeles County RBS Demonstration50

51. Concerns/Issues/Requests for Help Cost neutrality calculation Interaction with Title IV-E Waiver Administration and claiming processes CCL implications Sept., 4/5, 2008Los Angeles County RBS Demonstration51

54. Sacramento County RBS Reform Collaborative Reform in Progress

55. Who are we? County Agencies (CW, MH, Probation, DHA, Education) Group Home Providers Parents Youth

56. 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

57. 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

58. 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

59. 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

60. Our Theory of Change

62. 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

63. The RBS Program Design Service Array→ Service Options→ Program Model Assessment & Matching Plan of Care Facility Based Services Community Based Services Permanency Services What’s new that will make the difference?

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

65. 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

66. 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

67. 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

68. Coordinated by CFT Blend of parallel and aftercare Family & youth focused Comprehensive -treatment -respite -educational -recreational Community Based Services

69. Lead Agency Model Authorization & Resource Mgt. Provider Facilitated CFT Plan of Care Integrated Arc of Care Full Array of Services TDM Discharge from RBS County Worker Identifies Need for Group Care Enhanced

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

71. 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

72. 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

73. Average Placement Cost* $133,401 in AFDC Payments + WRAP $17,471 = $150,872** Fed/Non-Fed71.5% / 28.5% Male/Female60% / 40% Average Age16.4 years *Does not include additional payments for Mental Health, 26.5, Out of state, and/or Hospitalization. **Preliminary figures, rough, not yet reliable! Results

74. Service Areas Responsibilities to carry out components of each service Expected Funding Sources for each component within the service Provider Estimates of RBS Services

75. 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

78. Funding Components of the RBS Rate Provider Cost156,489 Monthly8,694 EPSDT2,90633.4% AFDC3,64541.9% AFDC/Flex2,14224.6% 8,694

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

81. 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

82. 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

83. 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!!!

84. Presenter Contact Information Jim MartinGeri Wilson Executive DirectorSacramento County Martin’s Achievement PlaceRBS Reform Project Coord. (916) 338-1001(916) 875-2-2023 (916) 338-1044 fax(916) 599-3828 cell J_Martin@mapinc.netwilsoga@saccounty.net Dan Petrie Sr. Program Director Milhous Children’s Services (916) 265-9057 (916) 215-9057 cell dpetrie@milhous.us

86. San Bernardino County RBS Demonstration RBS Forum Sacramento, CA September 4/5, 2008

87. Overall Approach Transform 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, 2008San Bernardino County RBS Demonstration87 County, Provider, and Community Partnership

88. Mission, Vision, Values Mission Working together to safely build and sustain positive, successful family connections and children’s futures. Vision The 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. Values Stability, permanency and safety focus Flexibility Integration across systems Continuous planning and evaluation across the arc of enrollment Continuity of care Partnership and engagement Sept., 4/5, 2008San Bernardino County RBS Demonstration88 Family Driven - Youth Guided

89. Cornerstone Innovations Family Passport Care Coordination Team Wrap approach throughout trajectory of care ITFC-like foster care consistent with RBS Sept., 4/5, 2008San Bernardino County RBS Demonstration89 A Continuum of Care with No Handoffs

90. Primary Outcome Focus Sept., 4/5, 2008San Bernardino County RBS Demonstration90 1.Reduced Length of Stay 1.Reduced level of care including out of state 2.Reduced Hospitalizations 3.Reduced AWOL incidents 4.Improved Permanency a.Stable placement b.Increased pro-social behavior c.Life long connections Stakeholder-Driven

91. Baseline Sample Demographics* Frequency% Male1539% Female2361% Black1129% Latino616% Native American13% White2053% * Sample of 38 youth who had at least one RCL-14 placement day in 2007

92. Outcome Baselines Sept., 4/5, 2008San Bernardino County RBS Demonstration92 PERMANENCYBL Avg. current GH stay7.7 mos 2 in foster home, LOS0.9 mos 1 at home, length of stay3.8 mos Avg. Time in Foster Care6.2 yrs Avg. # of prior placements3.0 Reentry in to foster caretbd Exits to permanencytbd #of supportive connectionstbd WELL BEING:BL Avg. time in GH care24.5 mos Avg. # days AWOL24.8 days Avg. # of AWOL episodes3.2 Avg. # days in hospital40.8

93. Cost Baseline Sept., 4/5, 2008San Bernardino County RBS Demonstration93 COSTBL Total cost of FC (sample) $7.5M GH Cost$5.6M Out of state costs$1.6M Non Tx foster home costs$30K FFA costs$206K Other 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

94. “Rachel” - A candidate for RBS (16.8 yrs old) Sept., 4/5, 2008San Bernardino County RBS Demonstration94 1995 - 19992000 - 2003 200420052006 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 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) Respite GH #5 1 st hospitalization GH #6 Apr – Substantiated physical abuse by step parent; removal to FFA May-Dec 4 GH placements Dec Home under FM (Wrap) Respite GH #5 1 st hospitalization GH #6 Jan Home under FM (Wrap) School and AWOL incident BM requests removal Back to GH #6 May AWOL from GH #6 FBM and GM return to DCS GH #7, AWOL GH #4, AWOL Jun-Sep AWOL from GH #4, AWOL from 2 FFA Placements, ends up w/ BF Sep-Oct GH #8, pregnant AWOL (Las Vegas) Return by BM to temp. FFA AWOL x2, returns to GH #8 Oct-Dec AWOL in LA w/boy friend and GM Jan Home under FM (Wrap) School and AWOL incident BM requests removal Back to GH #6 May AWOL from GH #6 FBM and GM return to DCS GH #7, AWOL GH #4, AWOL Jun-Sep AWOL from GH #4, AWOL from 2 FFA Placements, ends up w/ BF Sep-Oct GH #8, pregnant AWOL (Las Vegas) Return by BM to temp. FFA AWOL x2, returns to GH #8 Oct-Dec AWOL in LA w/boy friend and GM Jan-Jun Still AWOL, rape, miscarriage Jul-Oct FFA #3 AWOL (Back to GM) Oct-Dec 2 nd hospitalization Conservatorship Dec-Present Placed out of state (RCL- 14) Jan-Jun Still AWOL, rape, miscarriage Jul-Oct FFA #3 AWOL (Back to GM) Oct-Dec 2 nd hospitalization Conservatorship Dec-Present Placed 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 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 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

95. Sept., 4/5, 2008San Bernardino County RBS Demonstration95 Designing a New System for Rachel Rachel

96. 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, 2008San Bernardino County RBS Demonstration96

97. Potential Waiver Requests Still under consideration Waivers need to be provider driven Sept., 4/5, 2008San Bernardino County RBS Demonstration97

98. 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, 2008San Bernardino County RBS Demonstration98

99. Concerns/Issues/Requests for Help Models will evolve during implementation Sept., 4/5, 2008San Bernardino County RBS Demonstration99