planning for sustainability: being strategic presented by michelle zabel, mss

Planning for Sustainability: Being Strategic

Presented by Michelle Zabel, MSSDirector, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice

InstituteDivision of Child & Adolescent Psychiatry, School of

Medicine, University of Maryland, Baltimore

Seizing Opportunities, Being Realistic

Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change

Be aware of the fiscal, political, and cultural climate Budget issues Political timeframes Competing pressures and interests

Creating Linkages, Connecting the Dots

Review and synthesize existing documents and strategic plans—before beginning the work

Populations & Outcomes: Identify results and indicators already in use Use measures that have strong

Communication Power (Does the indicator communicate to a broad range of audiences?)

Proxy Power (Does the indicator say something of central importance about the result?)

Data Power (Quality data available on a timely basis)

Connect the data requirements across grants and contracts

Using Results Accountability to Frame the Maryland Child & Family Services Interagency Strategic Plan

Result (a quality of life condition we want to achieve): All of Maryland’s children involved with or at-risk for involvement with multiple child-family serving agencies will be successful in life.

Population of Focus (focus for the strategic planning process): Children and youth involved in or at-risk for involvement with multiple child-family serving systems.

Indicators (how we measure this condition):Out-of-home placement: Rate of children under 18 entering out-of-home placementEducation:

o Percentage of 3rd grade students scoring proficient or advanced in reading on the Maryland School Assessment.o Percentage of youth, 18-24, by highest educational attainment (less than a high school diploma or equivalent, high school graduate/equivalent, some college or associate’s degree, and bachelor’s degree or higher)

Juvenile Offense Arrests: oThe rate of arrests of youth ages 15-17 for violent offenses.oThe rate of arrests of youth ages 15-17 for serious non-violent offenses.

THE IMPLEMENTATION OF A COORDINATED INTERAGENCY EFFORT TO DEVELOP A

YOUTH SERVICE SYSTEM THAT CAN BETTER MEET THE NEEDS OF YOUTH AND THEIR

FAMILIES AND TARGET CHILDREN WHO ARE AT-RISK

Maryland Child & Family Services Interagency Strategic Plan

CREATED A SERIES OF RECOMMENDATIONS UNDER EIGHT DIFFERENT THEMES:

•Family & Youth Partnership•Interagency Structures•Workforce Development & Training•Information-Sharing•Improving Access to Opportunities and Care•Continuum of Opportunities, Services & Care•Financing•Education

IMPLEMENTATION IS OCCURRING AND STATE AND LOCAL LEVELS, WITHIN AGENCIES AND ACROSS

SYSTEMS

Maryland Child & Family Services Interagency Strategic Plan

Embed System of Care Values and Principals into Policy and Regulation

Terms that have been institutionalized with definitions in Medicaid regulations (10.09.79) include: Care Coordinator Caregiver Caregiver peer-to-peer

support Care management entity Child and Family Team Family support organization Family support partner Peer-to-peer support Plan of Care Wraparound Youth Peer-to-Peer Support Youth Support Partner

Other systems of care concepts and processes in the Medicaid regulations include: The components of a

comprehensive and individualized Plan of Care

The role and responsibilities of the Care Management Entity

The role and responsibilities of the Child and Family Team

Service descriptions, including caregiver peer-to-peer support, youth peer-to-peer support, and family and youth training

Rates are provided for family members and youth to bill Medicaid for services provided under the Waiver




Governance & System Management

Interagency Structures

Interagency structures need to be redesigned to support the culture shift to a more

individualized, family-centered service delivery system. Communication needs to flow easily

between the state and local levels, as well as between and across agencies, systems,

community members and families.

Recommendation 1: The Children’s Cabinet should ensure that there are regular opportunities for direct communication between the Local Management Boards and the Children’s Cabinet or the Children’s Cabinet Results Team.

Recommendation 2: There should be a commitment from all child-family serving agencies at the state and local levels to support an improved interagency structure and individualized plans of care for children and families.

The Maryland Children’s Cabinet and

the Governor’s Office for Children

VISION Children’s Cabinet: All Maryland’s children are successful in life. Governor’s Office for Children: Maryland will achieve child well-being

through interagency collaboration and state/local partnerships.

MISSION The Children’s Cabinet, led by the Executive Director of the Governor’s

Office for Children (GOC), will develop and implement coordinated State policies to improve the health and welfare of children and families. The Children’s Cabinet will work collaboratively to create an integrated, community-based service delivery system for Maryland’s children, youth and families. Our mission is to promote the well being of Maryland’s children.

COMPOSITION The Secretaries of the Departments of Budget and Management, Disabilities,

Health and Mental Hygiene, Human Resources, and Juvenile Services, and the State Superintendent of the Maryland State Department of Education.

Chaired by the Executive Director of the Governor’s Office for Children.

Individual Care Planning with Child and Family Teams: Care Management Entity (CME)

Local Systems Management

State Systems Management

Local Governance

State Governance

Family Support Organizations

A Scenario for State and Local Governance Structures

Local Management Boards Purpose is to “ensure the implementation of a local interagency service

delivery system for children, youth, and families.” (Human Services Article, Annotated Code of Maryland) Composed of: Public and private community representatives and, A senior representative or department head of the: (i) local health

department; (ii) local office of the Department of Juvenile Services; (iii) core service agency; (iv) local school system; and (v) local department of social services.

LMBs are tasked with: Strengthening the decision-making at the local level; Designing and implementing strategies that achieve clearly defined results for children, youth, and families as outlined in a local 5-year strategic plan; Maintaining accountability standards for locally agreed upon results for children, youth, and families; Influencing the allocation of resources across systems to accomplish desired results; Building local partnerships to coordinate children, youth and family services within the county to eliminate fragmentation and duplication of services; and, Creating an effective system of services, supports, and opportunities to improve outcomes for all children, youth and families.

Administrative Service Organization

Key Functions Include:Care AuthorizationProvider Credentialing and EnrollmentBilling/Reimbursement and Provider PaymentUtilization ManagementContinuous Quality ImprovementOutcomes DataInformation Management

Regional Care Management Entities

A CME is a structure that serves as a “locus of accountability” for youth with complex needs and their families.

Provide Supports to Youth and Families: Child Family Team Facilitation using Wraparound Service Delivery Model Care Coordination using Standardized Assessment Tools Care Monitoring and Review Peer Support Partners

Provide System Level Functions: Information Management & Web-based Information System Provider Network Recruitment and Management Utilization Review of Service Use, Cost, and Effectiveness Evaluation and Continuous Quality Improvement Cross-System and Jurisdiction Financing

Populations to Be Served: 1915(c) Psychiatric Residential Treatment Facilities (PRTF)

Demonstration Project Medicaid Waiver SAMHSA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion using Resource

Coordinators Other Out-of-Home Diversion using Care Coordination

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Wicomico County, MD System of Care Structure

211 System(screening)

Service Coordination/SystemsNavigation - CANS

Care Management EntityCare Coordinators

Family Partners

Family Partner-Ship Center

Families andYouth

Agencies/Court

SOC Community Advisory Board

Adapted from Wicomico County, MD

Local Management Board




Outreach and Engagement: Organized Pathway to Service System and

Intake/Referral

Access to Care and Opportunities

Prompt access to opportunities and appropriate resources empowers

families and youth to address identified needs, build on strengths, and

participate in individualized services and supports. Families and youth

should receive timely and respectful support to navigate systems.

Recommendation: Families and youth should have access to support and assistance and make connections with appropriate opportunities and resources to address identified needs and enhance strengths and assets.

Maryland’s Local Access Mechanisms

Single Point of Access: A single point of entry for families who wish to obtain information or enter the system, regardless of the intensity of the needs of their children.

Navigation Services

Navigation Services: Services for families who need additional assistance beyond a simple referral, including assistance in identifying strengths and needs and obtaining necessary services. Family Navigation: Navigation services provided by a

legacy parent or primary caregiver who is caring for or has cared for a child with mental health needs and/or developmental disabilities, including a child with intensive needs.

Systems Navigation: Navigation services provided by a professional or paraprofessional, not necessarily a legacy parent or primary caregiver.




Data-Driven Decision Making

Align Outcomes with Shared Results and Indicators and Performance Measures Already in Use

across SystemsOverarching Long Term Outcomes for Populations of

Focus Maryland’s Children’s Cabinet Results for Child Well-Being Maryland Child and Family Services Interagency Strategic

PlanConsistent Performance Measures

Connect the data requirements across grants and contracts 1915(c) Psychiatric Residential Treatment Facilities (PRTF) Waiver SAMSHA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion Other Out-of-Home Diversion using Care Coordination

Demystifying Data:Using Understandable Language and

Structure to Collect and Analyze Service Data

Performance AccountabilityHow much service was provided?

Number of customers served (by customer characteristic) Number of activities (by type of activity)

How well was the service provided? Customer satisfaction, unit cost, percent of staff fully trained Activity-specific measures: Percent of clients completing

activity, percent of actions meeting standardIs Anyone Better Off? (What effect are the services

having?) Measurable changes in Skills/Knowledge, Attitude/Opinion,

Behavior, CircumstanceAdapted from Friedman, M. 2005. Trying Hard is Not Good Enough. Trafford Publishing, Victoria,

BC

Establishing a CORE Set of Data Elements Collected across Populations

Align your data collection efforts where possible to avoid redundant data collection and reporting

Federally-funded initiatives will require instruments and tools (performance measures) around which your cross-initiative evaluation plans can be built

Local evaluations can be allowed for collection of additional measures of interest, such as: Education – achievement, completion Child Welfare – permanency, child safety Juvenile Services – restrictiveness of placement, recidivism

Making the Data Work for You:Proving Your Initiative’s Effectiveness to

Funders and the larger CommunityPlanning and day-to-day decision making is reasoned.Utilization Management changes effectively redirect

resources to where they are needed most.Quality improvement efforts can be focused on

subgroups of concern with methods of proven effectiveness.

Cost monitoring will show return on the dollar in terms of desired outcomes.

Research and evaluation questions are answered in clear measurable terms as well as with effective anecdotal evidence.

Use data to strengthen social marketing efforts, to target training efforts, to educate about and to advocate for your children, youth and families across venues.

Examples of Statewide Quality Improvement Efforts in Maryland

Focus on quality statewide and by siteIdentify local programs and practicesIdentify types of youth served and practices

associated with good outcomes (and practices associated with bad outcomes)

Inform use of evidence-based practices (e.g. CBT for depression)

Support providers with training informed by data

Inform performance-based contracting




Service/Support Array, Provider Network, Natural Helpers and

Financing

Continuum of Opportunities, Supports, and Care

There is a need for the Children’s Cabinet to agree on a continuum of opportunities,supports, and care, including evidence-based and promising practices, and work towardensuring that appropriate levels of services and supports are available to every

jurisdictionand community to meet their specific population needs, with the intent of improvingoutcomes and reducing out-of-home placements.

Recommendation 1: The Children’s Cabinet is committed to the creation of a full community-based continuum of opportunities, supports, and care that is developed in partnership with local jurisdictions, families and the provider community to meet the specific, individualized needs of children and families. The Children’s Cabinet should prioritize efforts to safely and effectively serve children in their own homes by expanding the continuum of services. These efforts should include increased diversity, quality, and accessibility of in-home services with an emphasis on reunifying children with their families at the earliest possible time. Services should be culturally competent and responsive, and children should receive all supports to which they are entitled.

Continuum of Opportunities, Supports, and Care

Recommendation 2: The Children’s Cabinet should work collaboratively to serve childrenwho are in an out-of-home placement in their home schools and communities moreeffectively with fewer placement disruptions resulting in better permanency outcomes for children and families.

Recommendation 3: There should be a commitment to diverting youth from detentionand commitment within the juvenile justice system. Subject to the availability of funding,consideration should be given to an expansion of the availability and use of delinquencyprevention and diversion services with a focus on creating a range of community service andeducation options while increasing empathy and caring in youth.

Recommendation 4: The Children’s Cabinet should continue to make a commitment toutilizing evidence-based and promising practices to ensure that effective communityeducation, opportunities, support, and treatment options are available to the children, youth

and families for whom they are appropriate.

Youth Peer-to-Peer Support

Provided to a youth enrolled in a CME by a youth support partner (YSP) who: Assists in describing the program model Supports the family and/or participant to participate

effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation;

Works with the Care Coordinator, participant and family to develop the plan of care; and,

Assists in accessing services and removing barriers to care.

Are individuals with experience with State or local services and systems as a consumer who has had emotional, behavioral or mental health challenges, are 18-26 years old, have completed the required training programs, and are employed by a Family Support Organization.

Caregiver Peer-to-Peer Support

Provided to the caregiver of a youth enrolled in a CME by a family support partner (FSP) who: Assists in describing the program model Supports the family and/or participant to participate




Are legacy family members (individuals who have current or prior experience as a caregiver of a child with Serious Emotional Disturbance (SED) or a young adult with Serious Mental Illness (SMI) who are 21 or older, have completed the required training programs, and are employed by a Family Support Organization

EBP Implementation in Maryland: Our Child and Youth Trajectory

2008, Maryland Child and Family Services Interagency Strategic Plan: Includes evidence-based and promising practices in the theme, “Continuum of Opportunities, Supports and Care:”

Specific Recommendation in the Plan: The Children’s Cabinet should continue to make a commitment to utilizing evidence-based and promising practices to ensure that effective community education, opportunities, support, and treatment options are available to the children, youth and families for whom they are appropriate.

2008, Children’s Cabinet joins efforts to improve practice and implement EBSs for children, youth and families in Maryland through funding to support implementation, fidelity and outcomes monitoring, and fiscal analysis of EBPs.

EBP IMPLEMENTATION CENTER

o Obtain data on existing EBPs in Maryland

o Conduct a “sizing” of the EBPs to determine which EBPs should be expanded or brought into the state

o Provide training on identified EBPs

o Identify funding mechanisms to support the ongoing implementation and sustainment of EBPs

o Conduct fidelity monitoring on EBP implementation

o Evaluate outcomes of EBPs

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Prioritized EBP’s

Trauma Cognitive Behavioral TherapyFunctional Family TherapyMulti Systemic TherapyBrief Strategic Family TherapyMulti Dimensional Treatment Foster Care

Be both strategic and opportunistic

Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change:

CMHI Grants – MD CARES and Rural CARES Mental Health Transformation and Block Grants PRTF 1915(c) Demonstration Waiver Healthy Transitions Grant (Transition-Aged Youth) National Child Traumatic Stress Network Grants Children’s Bureau Grants to Child Welfare OJJDP Grants to Juvenile Justice State Agency Initiatives Legislative Mandates

Regional Care Management Entities

A CME is a structure that serves as a “locus of accountability” for youth with complex needs and their families.

Provide Supports to Youth and Families: Child Family Team Facilitation using Wraparound Service Delivery Model Care Coordination using Standardized Assessment Tools Care Monitoring and Review Peer Support Partners

Provide System Level Functions: Information Management & Web-based Information System Provider Network Recruitment and Management Utilization Review of Service Use, Cost, and Effectiveness Evaluation and Continuous Quality Improvement Cross-System and Jurisdiction Financing

Populations to Be Served: 1915(c) Psychiatric Residential Treatment Facilities (PRTF)

Demonstration Project Medicaid Waiver SAMHSA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion using Resource

Coordinators Other Out-of-Home Diversion using Care Coordination

Caregiver Peer-to-Peer Support

Provided to the caregiver of a youth enrolled in a CME by a family support partner (FSP) who: Assists in describing the program model Supports the family and/or participant to participate




Are legacy family members (individuals who have current or prior experience as a caregiver of a child with Serious Emotional Disturbance (SED) or a young adult with Serious Mental Illness (SMI) who are 21 or older, have completed the required training programs, and are employed by a Family Support Organization

EBP IMPLEMENTATION CENTER

o Obtain data on existing EBPs in Maryland

o Conduct a “sizing” of the EBPs to determine which EBPs should be expanded or brought into the state

o Provide training on identified EBPs

o Identify funding mechanisms to support the ongoing implementation and sustainment of EBPs

o Conduct fidelity monitoring on EBP implementation

o Evaluate outcomes of EBPs

Be both strategic and opportunistic

Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change:

CMHI Grants – MD CARES and Rural CARES Mental Health Transformation and Block Grants PRTF 1915(c) Demonstration Waiver Healthy Transitions Grant (Transition-Aged Youth) National Child Traumatic Stress Network Grants Children’s Bureau Grants to Child Welfare OJJDP Grants to Juvenile Justice State Agency Initiatives Legislative Mandates

planning for sustainability: being strategic presented by michelle zabel, mss

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