care4kids: wisconsin’s foster care medical home initiativesends daily report on all foster care...
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Care4Kids: Wisconsin’s Foster Care Medical Home Initiative Fredi-Ellen Bove, Wisconsin Department of Children and Families Rachel Currans-Henry, Wisconsin Department of Health Services Mike Boeder, Children’s Community Health Plan of Wisconsin
May 2016
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Presentation Outline
• Background o Wisconsin context and child welfare structure
o Program development
• Medicaid framework o Authority and benefits
o Eligibility, enrollment, and rate components
o Quality monitoring
• Medical home model program features o Care coordination
o Initial screen and comprehensive assessment
o Polypharmacy management
• Initial quality statistics of program
• Lessons learned: challenges and critical success factors
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Wisconsin Care4Kids
• Care4Kids (C4K) is a Medicaid program following the medical home model that provides comprehensive and coordinated health care for children in out-of-home care, in a way that reflects the unique health needs of these children.
• Collaboration among o Wisconsin Department of Children and Families (DCF) (state child
welfare agency)
o Wisconsin Department of Health Services (DHS) (state Medicaid agency)
o Children’s Hospital of Wisconsin – operates C4K
o Wisconsin county child welfare agencies
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Context: Wisconsin • Wisconsin o Mid-sized state , 5.7 million population
o 72 counties
• Child welfare system o State-supervised, county-administered with the exception of the
largest county, Milwaukee, which is state-administered
o Approximately 7,300 children in out-of-home care (point in time)
• Government structure o As of 2008, state Medicaid agency and state child welfare agency
are housed in separate state agencies
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Pre-Care4Kids: Flawed Healthcare System for Foster Children
• Services were fragmented and uncoordinated
• Some needed services, such as dental or mental health services, had waiting lists or were not available at all
• Services may not be trauma-informed
• Medical information was generally not shared among a child’s healthcare providers
Care4Kids: Fixes Flaws in Prior Healthcare System • Provides comprehensive and timely health services,
including physical, behavioral, and dental health services • Coordinates delivery and oversight of services • Develops an individualized care plan tailored to each child’s
unique needs • Provides trauma-informed and evidence-informed services
• Overall, improves the quality, timeliness and access of
health services for foster kids 6
Program Development • 2004, 2006, 2007: Failed attempts to implement managed care
for foster children
• Spring 2011: DHS and DCF agency leaders direct initiative to be developed
• August 2011- May 2013:
o DCF/DHS steering committee and workgroups develop program design
o DCF/DHS hold extensive consultations with stakeholder groups
• July 2012: CMS approves Medicaid State Plan Amendment
• May 2013: Children’s Hospital of Wisconsin certified as Care4Kids provider
• May-December 2013:
o DCF/DHS/Children’s Hospital/county workgroup plans program implementation
• January 2014: Program goes live
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Program Implementation • Program operates initially in six southeast counties in
Wisconsin o Area accounts for approximately 50 percent
of Wisconsin’s out-of-home care population
• Current enrollment is approximately 3,000 children
• Children can stay enrolled in C4K for 12 months after leaving out-of-home care, contingent on full benefit Medicaid eligibility
• Intent is to expand the program statewide in the future
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Federal Authority
• Authorized under Alternative Benchmark Plan state plan amendment (TN#13-034) under Section 1937 of the Social Security Act o Flexibility to limit target group and geographic area
o Allows choice of service delivery vehicle
o CMS required non-risk based financing arrangement
o All Wisconsin Medicaid 1905 (a) services and essential health benefit services are provided
o Requires “voluntary enrollment”
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Certification and Contracting Process • Use state managed care BadgerCare Plus and Medicaid
Supplemental Security Income (SSI) contract as the “base” o Two-year contract with one-year rates (with reconciliation process)
o Not a procurement
o Certification process and review by state
• Unique aspects of Care4Kids contract o Detailed health care management requirements and timeframes
o Enhanced benefits
o Enhanced access to after-hours care
o Trauma-informed training requirements
o Psychotropic and metabolic monitoring policies
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Care4Kids Covered Services • All Wisconsin Medicaid-covered benefits
• Additional benefits, unique to foster children population: o Out-of-home care health screen within two business days of
entering care
o Comprehensive initial health assessment within 30 days
o Mental health and/or developmental screenings required prior to or as part of exam
o Mental health and/or developmental assessment (if needed based on screening)
o Comprehensive health care plan within 60 days
o Initial comprehensive dental exam within three months of entering care
o Continuous comprehensive dental exam
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Care4Kids Covered Services (cont.) oAdditional benefits, unique to foster children population
(continued) o Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
exams at enhanced periodicity
o Metabolic monitoring for any child prescribed antipsychotic medication(s)
o Psychotropic medication monitoring for any child prescribed psychotropic medication(s)
o Transition health care plan for all children at discharge from Care4Kids
o Care management
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Care4Kids Care Management • Require assignment of health care coordinators and
outreach coordinators with ratio expectations
• Guidelines to assess child’s level of service needs to ensure efficient use of staff
• Clearly identified duties of care management delineated as a Medicaid “benefit”
• Require clinical evaluation team to promote Interdisciplinary Care Team (ICT) as vehicle for providing member-centered care management that will meet face-to-face as determined by member needs
• Child-centric care plan requirements
• Require coordination with child welfare agencies for any home visits
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Program Quality Monitoring • Aligned quality measures across programs where
possible, in concert with state Medicaid quality plan
• Focused on unique monitoring and performance measure development aligned with new benefits/enhancements
• Require separate reporting outside of claims data for process objectives that track timely access to care and service utilization
• Performance targets based on initial two years of data added in year three- no pay for performance based contracting due to “non-risk” contract
• Required focus on trauma-informed training for externally validated performance improvement project
• Challenges with multiple entities responsible for actions
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Care4Kids Quality LifeCycle
Removal from home
Initial assessments ED and
Inpatient Care
Current C4Kids Performance Measures Measures TBD
• 2-business days acute OHC health screen
• Comprehensive assessment (30 days)* • Lead screen • Developmental / Mental health screen * • Developmental / Mental health
assessment * • Comprehensive Health Care Plan * • Preventive well child checks (EPSDT) • Dental exams * • Immunizations
• FUH-30 • AMB (ED
Utilization) • Inpatient
Utilization • Metabolic
monitoring for Anti-psychotic Rx; Psychotropic Rx
Outcomes Measures • Member
Satisfaction • Impact of trauma
informed care on member outcomes
• C4K impact on education/school absenteeism
Time-driven measures Event-driven measures
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Start = Year 1 2014
Year 2 2015
Year 3 2016
Year 4 2017
Prepare and set infrastructure
1st year of performance; data used as baselines to set 2016 targets.
1st year of performance targets; data will be used to set 2017 targets.
Analyze performance data, re-assess performance measures and targets for 2018.
Note * Asterisk indicates that measure has a specific target for 2016.
Care4Kids Eligibility Model
Eligibility parameters for C4K: o Child is identified as categorically eligible for out-of-home care
by county child welfare agency
o Children in residential care centers or secure facilities are not eligible for C4K
o Child is under jurisdiction and placed within six county catchment area
o C4K is a retroactive program - eligibility is back-dated to the date in which the child is removed from the household
o Children/youth discharging from out-of-home care may be eligible for Care4Kids for 12 additional months after discharge
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Care4Kids Enrollment Model • Care4Kids is a voluntary enrollment program o The parent/legal guardian can decide to not enroll their child
o Blanket court orders in all but one county allow for enrollment if the parent/legal guardian is not able to be reached
• The Medicaid Enrollment Specialists (Broker) contracted with DHS are responsible for enrollment into the managed care model
• Enrollment information is held in the Medicaid Management Information System (MMIS)
• DCF and DHS communicate daily on eligibility and enrollment
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Care4Kids Enrollment Model
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Child in out-of-home care
Parent/legal guardian consent to C4K
enrollment?
Child remains in
Medicaid FFS
Child enrolls in C4Kids
Yes No No Contact
Court order for child to
enroll in C4K?
Child enrolls in C4Kids
Yes
Child remains in
Medicaid FFS
No
Care4Kids Systems, Operations and Reports
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Places child in Out of Home Care (OHC)
Child County
eWiSACWIS
DCF
• Child Welfare Worker opens case.
• Foster Care Medicaid eligibility is updated.
MMIS
DHS Sends data daily
• Updates Foster Care Medicaid eligibility in MMIS.
Sends daily report on all foster care children
Enrollment Broker
Sends daily report to
AHSI
Uses report for outreach on
C4Kids enrollment
Enrollment Broker Parent/
legal guardian
give input?
Court order
for child to enroll
in C4K?
No contact
Enrolls child in C4Kids
Enrollment Broker
Consented
Child remains in Medicaid
FFS
Yes
No
CCHP
CCHP Database
• Data used for care management
Care4Kids Rate Setting • C4K receives monthly capitation rates for benefits and
administration o Based on fee-for-service foster care claims (year 1) and previous
year’s experience (years 2 and 3) with utilization adjustment for additional services
• Care management is paid as a benefit
• Not at risk for benefit costs
• Annual reconciliation to fee-for-service rates o C4K is paying providers over Medicaid rate for certain services
oAdministration expenses based on C4K budget
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Care4Kids Rate Setting (cont.) • The table below provides an overview of the average monthly
payments made in 2016 to Care4Kids, regular Medicaid managed care children under 21 years of age, and SSI children under 21 years in non-managed fee-for-service Medicaid
• These payments exclude pharmacy and transportation
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Children’s Hospital of Wisconsin
• Roots as a pediatric hospital provider (1894) in Milwaukee, Wisconsin
• Now a national leader in pediatric care
and one the busiest pediatric hospitals in the nation
• The region’s only independent health
care system dedicated solely to the health and well being of children
• Private, independent and not-for-profit
• An organization with integrated services focusing on care, advocacy, research and education
• Major teaching affiliate of the Medical College of Wisconsin
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Children’s Services Prevention & Wellness
Population-Based Risk-Based
Small Groups to Families Distress Intervention
Individual Focus
Community supports
Behavioral Health
School and Community Health
Medicaid Insurance (CCHP/C4K)
Foster Care and Adoption
Primary Care Specialty Care
Hospital Care Education and Prevention
Development and Family Support CARE
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Children’s Community Health Plan • Children’s Community Health Plan (CCHP) is a licensed
Health Maintenance Organization (HMO)
• Not-for-profit; owned by Children’s Hospital of Wisconsin
• Contracts with the DHS for BadgerCare Plus and Medicaid members o Launching commercial product on January 1, 2017, and will be
available on the healthcare exchange
• CCHP began operations in 2006 with 36 members and is now the largest Medicaid HMO in Wisconsin serving 140,000 members (inclusive of Care4Kids youth)
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Care4Kids Health Care Coordination • Creation of a Health Care Coordination (HCC) team
is key to the Care4Kids initiative
o Healthcare information gathering and organizing
o Healthcare recommendations and referral tracking
o Facilitation of coordinated healthcare delivery
o Information sharing among healthcare providers
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Care4Kids Program Staffing • Health Care Coordinator : o Registered nurse or an advanced practice social worker
o Oversees and ensures access to healthcare services for children in Care4Kids
o Develops and revises individualized Comprehensive Health Care Plan (CHCP) and distributes to all stakeholders involved in the child’s care
• Outreach Coordinator: o Minimum of a bachelor level professional that assists health care
coordinators with duties related to service coordination
o Executes various outreach efforts (i.e. phone, electronic, mail, community interface as needed) with all stakeholders
o Conducts validated mental health and/or developmental health screening
o Facilitates service referrals and recommendations from providers and assists in scheduling timely appointments, address access to care issues, etc.
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Care4Kids Medical Director Role
Healthcare Delivery: Initial Foster Care Health Screen • Medical appointment completed within two business days
of entering foster care
• Screen is focused on: o identifying any signs of abuse or neglect
o checking for communicable diseases
o ensuring the child has all necessary medications and equipment
• Identifying any acute medical and/or psychiatric issues that need immediate attention
• Child is assigned a triage level using a medical triage tool: o 1 or 2 = needs immediate medical care, Care4Kids prioritizes follow
up
o 3 = does not immediate medical care, Care4Kids manages follow up within first 30 days of enrollment
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Initial Foster Care Health Screen Triage Tool • Goal of tool is to stratify youth based on unmet health
care needs so coordination can be prioritized
• Triage level is assigned by the medical provider for all youth at the initial foster care health screen
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Child Advocacy Centers • Nearly 100 percent of initial foster care health screens are
completed at Children’s Hospital of Wisconsin’s Child Advocacy Centers (CAC)
• Statewide presence
• CAC core service array includes the provision of initial foster care screens and forensic evaluations to any children who may have been harmed
• CAC staff are trained physicians and nurse practitioners who: o Have expertise in caring for children who have suffered
maltreatment or who are in foster care
o Trained to recognize signs of abuse and neglect
o Interacts with children in ways that do not cause additional trauma to the child
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Differences Between Forensic Evaluation and Initial Foster Care Health Screen
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Healthcare Delivery: Initial Comprehensive Health Exams
• Initial comprehensive health exams are comprehensive health assessments designed specifically for youth who have been placed in foster care
• Preferably performed at a “Center of Excellence” (COE) o COE’s are primary care clinics with an expertise and interest in
caring for youth in foster care who have agreed to prioritize access for the population
o NOT mandatory – caregiver choice – child may be seen by any primary care provider within the CCHP network
o Caregivers/youth encouraged to stay with the COE as their medical home provider when transitioning placements per medical home model
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Healthcare Delivery: Comparison
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Healthcare Service:
Care4Kids Other Foster Care
Non Foster Care
Periodicity of well child checks
AAP enhanced periodicity required
AAP enhanced periodicity recommended
Routine periodicity
Developmental screening tools
Standardized tool required (e.g. ASQ, PEDS)
Standardized tool recommended
Multiple tools available
Mental health screening tools
Standardized tools required (e.g. ASQ:SE, PSC-17)
Standardized tool recommended
Multiple tools available
Care coordination Facilitated by Health care coordinator team required
Primarily up to primary care provider and child welfare worker
Primary care provider
Program Innovation: Polypharmacy Interdisciplinary Case Review
What is the polypharmacy interdisciplinary case review (PICR)?
• A multi-tiered approach to evaluate enrolled Care4Kids members who
have been prescribed four or more psychotropic medications for three consecutive months.
• Care4Kids healthcare coordination teams lead the multi-layered process.
• The focus of the process is to discuss barriers to accessing services, identify any unmet needs or areas of potential support for member and caregivers, and review planned future changes and their impact on stability of child
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Program Innovation: Polypharmacy Interdisciplinary Case Review (cont.)
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Focus • Enhancing support to caregivers and child • Assuring stakeholders and caregivers are “on the same page” • Working to ensure stability in the child’s life, whenever possible
Goal • Ensure child has the services (and providers) needed to help
support their mental health needs • Assess need for caregiver to have access to additional
support or training • Ensure stakeholders are “on the same page” • Ensure services are trauma-focused
Long Term Goal • Potential reduction in dose of psychotropic
medications • Potential reduction in number of
psychotropic medications
Initial Findings: Polypharmacy Interdisciplinary Case Review
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Me
dic
aid
do
llars
sp
en
t/m
on
th
Costs per child per month: 3 months prior to and 3 months after PICR
Source: Children’s Community Health Plan Data
Program Structure Evolution
• Adjusted team/pod structures and added staff to lower caseloads
• Created intake coordination staff to be co-located at CACs within the communities served
• Trained outreach coordination staff to conduct validated mental health and developmental health screens in preparation for the initial comprehensive health exam by primary care provider
• Development of Care4Kids clinical assessment team (SPP, OT, PT and licensed mental health provider) and other support staff in an effort to improve operations and impact outcomes
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Quality – National Comparisons
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NCQA HEDIS Measures 2014 National HEDIS Medicaid Average
Care4Kids 2014 Modified HEDIS
Childhood Immunizations (CIS) – Combination 2
74.12% 87.44%
Immunizations for Adolescents (IMA) – Combination 1
52.17% 93.51%
Lead Screening for Children (LSC) 66.25% 84.30%
30 Day Follow-Up After Mental Health Hospitalization (FUH-30)
63.84% 80.65%
Emergency Department Utilization (AMB) *– ED Visits per 1,000 member months
61.99 54.24
Care4Kids Performance vs. National Averages
Quality– Program Specific Monitoring
39 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MY 2011 MY 2014 MY 2015
23%
55.1%
66.9%
33%
20.0%
24.3%
56%
75.1%
91.3%
Prior to C4K Implementation
Comprehensive Initial Health Assessment
Completed after 31 days
Completed within 30 days
Lessons Learned: Challenges
• Development of IT infrastructure more complex than anticipated, due to multiple data systems involved (SACWIS, MMIS, EHR)
• Program design and implementation needs to address time-sensitivity of certain steps in the child welfare process
• Outcome measures are influenced by multiple parties and not completely under the control of the medical home provider
• Successful implementation is dependent on changing behavior of individuals (e.g. health professionals and foster parents), which takes time
• Other high priority demands that emerge in both state agencies compete for management and staff time and resources
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Lessons Learned: Critical Success Factors
• Strong commitment by leadership of state child welfare and state Medicaid agencies
• Strong collaboration at management/staff levels between state child welfare and state Medicaid agencies o Many of the key managers had prior cross-system work
experience and knowledge
• State Medicaid agency willing to invest increased fiscal resources to achieve better health outcomes and long-run cost savings across both systems
• Health care providers committed to creating high quality program
• Alignment of missions across the three partner agencies (DCF, DHS, CHW)
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Lessons Learned: Critical Success Factors (cont.)
• Early, open communication with stakeholders
• Stakeholder recognition of flaws in prior system and support for system change
• Engagement of county child welfare agencies pre and post implementation o Commitment to preserve county flexibility in local practices
• Strong physician champions as part of program model development and implementation
• Patience and perseverance (three years of planning)
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Questions/Comments?
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Contact Information
Fredi-Ellen Bove, Wisconsin Department of Children and Families
Rachel Currans-Henry, Wisconsin Department of Health Services
Mike Boeder, Children’s Community Health Plan of Wisconsin
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