1. Individualizing Care Within a Managed Care Context 2006 Training Institutes July 2006 Institute #4 Ray Lederman D.O., CPSA-Tucson Frank Rider, AZ Division of Behavioral Health Services Toni Tramontana, ValueOptions – Maricopa County Robin Trush, System of Care Veteran – Maricopa County

2. Institute #4 Overview  Transforming Managed Care  The Arizona System:  Structure  What Happened?  Why We Did What We Did  How to Operationalize  Results to Date

3. Change vs. Transformation Definition of Change: Changer (Old French for “change”) ; to bend or turn like a tree or vine searching for the sun Definition of Transformation: Transformare (Latin for transform): “to change shape”

4. Why is Transformation Necessary? Family Dissatisfaction Fragmented Care Poor Outcomes

6. Arizona’s Behavioral Health System AHCCCS ( State Medicaid Agency ) Arizona Department of Health Services/ Behavioral Health Services Pascua Yaqui Tribal RBHA Community Partnership of Southern Arizona (CPSA) ValueOptions Northern Arizona RBHA (NARBHA) Acute Care Health Plans Cenpatico BH Subcontracted Providers Long Term Care Program Contractors (e.g. DDD) Gila River Tribal RBHA Subcontracted Providers

7. Arizona BH Funding for Children FUND SOURCEFY 2006 FUNDS TOTAL FY 2006 FUNDS Children’s Percent of Children’s $ Medicaid/Title XIX (67.4% federal) $760,640,800 $269,079,100 88.68% SCHIP/Title XXI (77.185% federal) $15,130,000 $15,130,000 4.99% Federal Grants $44,631,300 $10,981,200 3.62% County Funds (Maricopa, Pima) $39,161,500 $1,803,000 0.59% State Appropriations $117,516,600 $6,444,600 2.12% Other $3,778,200 0 0.00% Total Funding $980,858,400 $303,438,500 100.00%

8. Behavioral Health Services in Arizona Statewide enrollment: 141,393 (children and adults) Statewide children <18: 39,020 ValueOptions enrollment: 73,845 ValueOptions children <18: 20,041 Source: ADHS Enrollment and Penetration Report (May 2006) at http://www.azdhs.gov/bhs/enroll_pen.htm.

9. Rapidly Expanding Enrollment June 2000 - June 2006

10. Impetus for Change Community Initiatives Legislation – Executive Order System of Care Grant Program Litigation

11. Arizona’s Impetus: JK Litigation Governor ADHS JK Settlement was groundbreaking: First to overhaul a state mental health system that operated on a managed care basis. http://www.azdhs.gov/bhs/jkfinaleng.pdf

12. J.K. Settlement Agreement Requires ADHS and AHCCCS to:  Invite and heed Family Voice  Improve frontline practice  Enhance capacity to deliver needed services  Promote collaboration among public agencies  Develop a quality management and improvement system  Termination of Agreement: July 1, 2007

13. The Arizona Vision “In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to:  achieve success in school  live with their families  avoid delinquency  become stable and productive adults Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion, and in accordance with best practices, while respecting the child’s and family’s cultural heritage.” J.K. vs. Eden et al. No. CIV 91-261 TUC JMR, Paragraph 18

14. The 12 Arizona Principles  Collaboration with the Child and Family  Functional Outcomes  Collaboration with Others  Accessible Services  Best Practices  Most Appropriate Setting  Timeliness  Services Tailored to the Child and Family  Stability  Respect for the Child and Family’s Unique Cultural Heritage  Independence  Connection to Natural Supports

15. Child and Family Team (CFT) Process Based on the Wraparound Approach: Service planning is family-centered, strength-based, highly individualized, culturally competent and collaborative across systems, promoting reliance on informal and natural supports in combination with formal services. Congruent with:  Family-Group Decision-Making (Child Welfare)  Team Decision-Making (Child Welfare)  Person-Centered Planning (Development Disabilities)  Individual Family Service Planning (IDEA - Part C)

16. Child and Family Team Process The Child and Family Team is a group of people that includes, at a minimum, the child, the child’s family, any foster parents, a behavioral health representative and any individuals important in the child’s life who are identified and invited to participate by the child and family. Process for Practice CFT Formation ·Engagement Clinical Expertise ·Crisis Planning Service Authorization ·Consensus Strength and Needs-Based Planning ·Single Points of Contact Partnerships ·Cultural Competence

17. How to Change Organizational Thinking Attitudes and Values Language as an Organizing Framework Leadership Parent/Professional Partnerships Early Innovators

18. Changing Organizational Thinking Attitudes and Values: The Relational Stance  From Problem to Competence  From Expert to Accountable Ally  From Professional Turf to Family Turf  From Teaching to “Learning With” William C Madsen, Collaborative Therapy with Multi-Stressed Families (1999)

19. Changing Organizational Thinking Language as an Organizing Framework “Language creates a culture, Language preserves a culture.” Bea Salazar, Four Directions Consulting, Riverton WY  Example: Mental Retardation

20. Changing Organizational Thinking Parent/Professional Partnerships  Successful Business Practices  Family is the Constant in Communities  Voice, Access and Ownership  The Role of Power  Collaboration at all Levels: State, Local and Individual

21. Changing Organizational Thinking Philosophical Alignment of Child-Serving Systems  Behavioral Health as the Catalyst  Child Welfare Reform in Arizona  Juvenile Justice Transformation

22. Partnerships “Collaboration: An unnatural act between non- consenting adults?” -- John VanDenBerg PhD

23. Changing Organizational Thinking Leadership  Sustainable Transformation  Good Practice = Good Business  Dealing with Resistance  Overcoming Inertia

24. Changing Organizational Thinking Early Innovators  Urgency  Ownership  Commitment to Action  Not for the Weak of Heart

25. Arizona’s Early Innovators: 300 Kids Project “49. Defendant ADHS/DBHS shall initiate a 300 Kids Project.” Will serve multi-agency children. Sites to engage intensively in system improvement activity. 50. The sites will serve two purposes: test strategies for providing behavioral health services according to the 12 Principles. Serve as the first phase of a statewide effort to deliver services according to the Principles.

26. Going to Statewide Scale: Practice Transformation On January 29, 2003, Gov. Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide implementation:  1/31/2003 “300 Kids” (1.2% of 24,110 total children)  1/31/2005: 5.8% with CFTs (n = 1,895 of 32,924)  5/31/2006: 33.04% with CFTs (n = 11,284 of 34,368)

27. Structure, Process, Outcomes  Structural Changes:  Covered Services  Funding  Process Changes:  Training and Coaching  Consultants  Professional Roles  Clinical Guidance Documents  Outcomes  Quality Management

28. Structural Changes Necessary Arizona’s Covered BH Services  Medicaid, Behavioral Health, Licensing  Expanded Definition of “professional”  Expanded Definition of “family”  Expansion of Supportive Services  Capacity and Competency, or Quantity v. Quality

29. Structural Changes Necessary Arizona’s Covered BH Services: Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

30. Covered BH Services in AZ Support Services Case Management Personal Assistance Family Support Peer Support Therapeutic Foster Care Respite Care Housing Support Interpreter Services Flex Fund Services Transportation Rehabilitation Services Living Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

31. Structural Changes Necessary Funding  Variations in State Capitation Rates  Maximizing State Funding  Provider Contracting Methodology  Sustainability of Effort

32. Process Changes Necessary Training and Coaching  Coaching to Support Training  Sequencing  Who Needs to Transform?  Costs/Investment  Retention/Regeneration Strategies

33. Process Changes Necessary Consultants  State and Local Strategies  Choosing a Consultant  Coordination of Effort  Individual vs. Systemic

34. Process Changes Necessary Professional Roles  Transforming Roles – Relational Stance  Movement to Strengths Based  Values-Based Hiring Practices  Training and Re-training  Liability Myths  Shared Expertise with Families

35. Process Changes Necessary Clinical Guidance Documents  Operationalizing and Memorializing  Process for Development  Contract Requirements  Standardized Assessment (0-5, too)  Example: Child and Family Team PIP  Prior Authorization

36. Process Changes Necessary Quality Management Systems  “Structure, Process, Outcomes”  Quality vs. Quantity  Medicaid Requirements vs. System of Care Values  Cost and Resources

37. Quality Management: Structure Examples:  Enrollment/Penetration (Latino youth? 0-3 y.o.?)  Number of functioning Child and Family Teams  Number of counties with cross-system protocols, agreements in place  Number of children placed outside of Arizona  Number of children placed out of home  Percentage of children in foster care with BH needs assessed beginning within 24 hours after removal

38. Quality Management: Structure  JK “Structural Elements” (monthly) -  CFT Capacity  OOH Placements  Urgent BH Responses  ValueOptions Key Indicators (monthly) -  CFT Capacity by Provider  Rehab/Support Spending as % of Total BH $  Latino Penetration by Provider  “Under 12” Initiative

39. Quality Management: Structure Maricopa County TFC Placements - increased from 5 (09/03) to 196 (05/06) – now 50% of all children OOH Children Placed Out of State – Decreased from 57 (06/02) to 8 (03/06) Arizona TFC Placements – increase from 9 (09/03) to 404 (05/06) – now 41% of all children OOH Children Placed Out of State – Decreased from 100 (06/02) to 25 (03/06)

40. Quality Management: Process CFT Process Measurement [Maricopa Co.]: “The Four Big Questions” 1. Has a trusting relationship been established with the family (engagement)? 2. Does the Child and Family know the family and has it identified the strengths needs and culture of the family? 3. Has an Individualized Service Plan been created that meets the needs of the child and family? 4. Is the team implementing, monitoring and modifying the service plan toward a successful outcome for the child and family?

41. Quality Management: Process CFT Process Measurement Fall 2005 Reviews Region A – 67.8% Region B – 64.1% Region C – 74.1% Region D – 66.3% Region E – 73.3% Region F – 41.7% Statewide: 53.25% [n = 486] Winter 2006 Reviews Region A – 70% Region B – 64% Region C – 71% Region D – 61% Region E – 81% Region F – 53% Statewide: 60.45% [n = 418]

42. Improved Processes  Improved Outcomes EXAMPLEs: Wraparound Milwaukee:  Residential placements decreased by 60%  Psychiatric hospitalization decreased by 80%  Reduced recidivism by delinquent youth  Overall cost of care per child decreased Bruce Kamradt, Child Welfare League of America, 2001 National Conference; and Report of the Surgeon General on Children’s Mental Health (1999) Project MATCH (Pima County, AZ):

43. Figure One Group Comparisons. Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake. The second row shows the difference in the overall average WFI scores for the two groups. The WFI eight point scale has been converted to a 100 point scale for ease of comparison. Rows three through seven show the intake data for four of the primary child and one primary family outcomes. These data reflect the six months prior to initiation of the wraparound process. From Rast, O’Day & Rider (2004) High Fidelity CFTLow Fidelity CFT WFI Scores85.353.6 CAFAS132128 CBCL Total8978 Level of Residential Placement 1.7 Number of Moves in Previous Six Months 2.21.6 Family Resource Scale3.53.1 “It Even Works in Arizona…”

44. Figure Two CAFAS and CBCL Scores. The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake. The open circles are the average scores for all 42 children, the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound. The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores. From Rast, O’Day & Rider (2004)

45. Figure Three Residential Outcomes. Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph). The figure on the left shows the average level of residential placement on a six level version of the ROLES. The open circles show the average for all 42 of the children, the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound. The graph on the right shows the average number of residential moves for each group using the same symbols. From Rast, O’Day & Rider (2004)

46. Figure Four Family Resource Scale. Figure Four shows the scores for the Family Resource Scale which measures a caregiver’s report on the adequacy of a variety of resources needed to meet the needs of the family as a whole, as well as the needs of individual family members. Higher ratings demonstrate more adequate resources. The graph on the left shows the average rating for the caregivers for all 42 children. The graph on the right shows the average rating for each group. The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound. From Rast, O’Day & Rider (2004)

47. Promising Data about Arizona Children Success in School – Past Six Months: Age 5-11: 11.2% higher with CFT (64.2%) Age 12-17: 12.6% higher with CFT (65.1%) Lives with Family – Past Six Months: Age 5-11: 6.7% higher with CFT (87.0%) Age 12-17: 4.7% higher with CFT (75.5%) ADHS CIS (05/06): N = 31,690 children/families

48. Promising Data about Arizona Children (Increased) Stability – Past Six Months Ages 5-11: 14.5% higher with CFT (74.0%) Ages 12-17: 16.9% higher with CFT (70.4%) (Increased) Safety – Past Six Months Ages 5-11: 10.9% higher with CFT (69.2%) Ages 12-17: 11.4% higher with CFT (66.2%) ADHS CIS (05/06): N = 31,690 children/families

49. Promising Data about Arizona’s Children Avoids Delinquency – Past Six Months Age 5-11: 9.2% higher with CFT (72.5%) Age 12-17: 11.0% higher with CFT (69.7%) Preparation for Adulthood – Past Six Months Age 5-11: 6.3% higher with CFT (57.4%) Age 12-17: 10.1% higher with CFT (57.4%) ADHS CIS (05/06): N = 31,690 children/families

50. Comparing Outcomes for Arizona Children with and without Child and Family Teams: Ages 5-11 From ADHS (9/6/06) at http://www.azdhs.gov/bhs/measures/charts_0806.pdf for all enrolled children in this age rangehttp://www.azdhs.gov/bhs/measures/charts_0806.pdf

51. Comparing Outcomes for Arizona Children with and without Child and Family Teams: Ages 12-17 From ADHS (9/6/06) at http://www.azdhs.gov/bhs/measures/charts_0806.pdf for all enrolled youth in this age rangehttp://www.azdhs.gov/bhs/measures/charts_0806.pdf

52. Family Perceptions of Outcomes Practice Based Evidence  Practical approach  Strength based  Positive risk taking  Gives voice to both families being served, and to frontline workers

53. Next Steps in Arizona Building Capacity and Competency  Children 0-3 y.o. and Their Families  Substance Abuse  Positive Behavior Support  Child Welfare (See Institute #24)

54. Next Steps in Arizona  Natural Supports  Youth Voice  Adult System Transformation

55. Questions? Thank you for your attention! Toni, Robin, Frank and Dr. Ray