1. Accessibility and Community Involvement and the Role of Residential in Systems of Care Bruce Kamradt Cathy Connolly July 19, 2007

2. Values That Guide Accessible Community-Based Care  Individualize the Provision of Services to Meet The Child’s and Family’s Unique Needs  Provide Access To A Comprehensive Array of Services and Supports  Strength-based approaches work best  Services and Treatment are provided in the community whenever possible  Child and Family Team Guides Treatment and Service Planning no matter where the child resides  Success determined thru Measurable Outcomes

3. What Is Wraparound Milwaukee- I.Organized as a Unique Type of Public Care Management Organization--HMO II.Defined Populations for Enrollment—children at immediate risk of Institutional placement—640 enrollees III.Operates with Pooled Funds--$37 million—single payor of all services for SED youth  Child Welfare  Juvenile Justice  Mental Health  Medicaid IV.No Formal Contracts -- Utilizes A Comprehensive Fee for Service Approach with Extensive Provider Network—Residential Treatment is a network service V.Employs Care Coordinators who facilitate Child and Family Teams—one family and one plan Continued

4. Wraparound Milwaukee - What Is It? VI.Strong Mobile Crisis Services—24/7 VII.Strong QA/QI and Single internet-based Information System Serves All 230 Provider Agencies VIII.Organized Family Advocacy and Support System Partners with Families Continued

5.  Daily Living Skills - Training  Independent Living Apt.  Parent Aide  Child Care  Housekeeping  Mentoring  Tutor  Life Coach  Recreation  After School Programming  Specialized Camps  Discretionary Funds  Supported Work Environment List of Available Services in Social / Mental Health Plan  Case Management  Referral Assessment  Medication Management  Outpatient Individual/Family  Outpatient - Group  Outpatient - AODA  Psychiatric Assessment  Psychological Evaluation  Mental Health  Assessment/Evaluation  Inpatient Psychiatric  Nursing Assessment/Managemen t  Consultation with Other Professionals  Group Home Care  Respite  Respite - Foster Care  Respite - Residential  Crisis Bed - RTC  Crisis Home  Foster Care  Treatment Foster Care  In-Home Treatment (Case Aide)  Day Treatment  Residential Treatment  Transportation  Crisis 1:1 Stabilizers/Aides

6. Utilization of Residential Services Within Our System of Care  Average of 80 youth in Residential Treatment Centers and 75 youth in Group Homes-Out of Average Daily Enrollment of 640 youth  Average about $1800 per month per enrollee for above services or 45% of Service Costs  4 of our 9 Care Coordination Agencies are Residential or Group Home Providers  Overall Utilization of Residential Tx. has Decreased Over past 12 years from 375 Average RTC placements to 80 and Length of Stay from 12 months to 3.5 months

7. Best Practice Approaches for Residential Treatment In A System of Care  Residential Care should and can be Short-Term (30 – 90 Days)  Residential Care should be Pre-Authorized by the Purchaser  Integrate Residential Plan into Community Plan—Residential Care Is Part of A Strategy To Meet A Need  Involve and Engage Parents  High Risk Youth Need a Good Safety Plan

8. Best Practice Approaches for Residential Treatment …. continued  Outcomes should be Clear, Measurable and Time-Limited  Residential Staff should Participate with Community Professionals, Neighbors, Informal Supports on the Care Planning Team—The CFT Designs and Oversees The Care Plan Regardless of Where The Child Resides  Discharge should Occur When Immediate Needs are Met and Community Resources Put in Place to Meet longer Term Treatment Needs

9. Challenges For Purchasers And Providers  Political Support for Changing Role of Residential Care  Legal Support for Changing Role of Residential Care  Learning To Share The Same Values, Approaches and Goals  Expanding Array of Community Services Residential Centers Provide While Often Reducing The Physical Infrastructure  Training and Technical Assistance Required

10. Challenges For Purchasers And Providers …continued  Familiarizing Residential Centers and Other Agencies with Managed Care Techniques –Participating in a Provider Network –Fee-For-Service –Prior Authorization  Establishing Outcomes for Youth in Residential Care—We May Each Be Evaluating Progress In Different Ways With Different Timelines

11. St. Charles: Brief History  Established in 1920 by Archdiocese as single service organization on 57-acre campus in Milwaukee, Wisconsin  Exclusively boys residence for 65+ years  Children were generally referred by family & others for “delinquency”

12. A Business Case for Change 3-4 years  Typical residential stay in 1960s-1970s was 3-4 years in length 1 year  By 1980s, typical stay fell to 1 year with ability to extend an additional year 30 days 3-6 months  Since Wraparound began, the initial commitment is generally 30 days with average stay being 3-6 months

13. Strategic Internal Questions St. Charles had to question itself in the face of change:  Who would we be if we were no longer defined by the facilities we had invested in over decades?  What would we do with all those facilities if multi-year residential stays were not going to return?

14. Elements of Immediate Change  Mission  Internal “Self-Image”  Name  Residentially Focused Staff  Abundance of Residential Facilities  Excess Land

15. Change Forces New Vision  We would no longer be facilities- driven…we would serve youth & families wherever they might be  We would embrace the trend away from residential services, and transform ourselves to meet new market As a result of strategic planning:

16. Planning Meets Reality Completing Strategic Planning & Visioning, and making initial changes were just the start …. The transition to deal with the new realities raised significant challenges.

17. The Challenges of Change 1.DECISION-MAKING: From “experts” role exclusively making treatment decisions to “team members” providing input

18. The Challenges of Change 2.STRENGTH-BASED: From managing behavior to facilitating self- management

19. The Challenges of Change 3.PERFORMANCE: From individual definitions of performance and quality to standardized community-wide indicators

20. The Challenges of Change 4.RESIDENTIAL POPULATION: From nearly 500 area youth receiving residential services to only 50

21. The Challenges of Change 5.SERVICE DELIVERY: From on-site residential treatment to in-home and community-based service delivery

22. The Challenges of Change 6.WORKFORCE DIVERSITY: From emphasis on residential staff/staff training to seeking/training for more diverse skills sets

23. The Challenges of Change 7.FINANCIAL PRESSURE: From full beds and balanced budgets with 1+ year stays to greater financial uncertainty and need to diversify funding sources

24. The Results of Embracing Change  Agency grew from $3 million to $13 million in annual revenues  Staff grew from 25 to 300  Most importantly, positive results for youth & families Much has improved as a result of embracing change:

25. The Results of Embracing Change  Wraparound Care Coordination  Safety Services  Medical Day Treatment  Alternative Education  Intensive Family Development Services St. Charles transitioned from a single service to a wide range of programming, including:

26. The Results of Embracing Change  Mentoring  Residential Treatment  Shelter Care  Family Preservation  First Time Juvenile Offender Program  Alternatives to Incarceration St. Charles transitioned from a single service to a wide range of programming, including:

27. St. Charles: Programming Today Today, St. Charles Youth & Family Services is a well diversified service provider with no more than 20% of revenues being received from a single source.