AZ CFTs Institute (Orlando, 2006)

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

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

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”

Why is Transformation
Necessary?
Family Dissatisfaction
Fragmented Care
Poor Outcomes

FEDERAL GOVERNMENT
HEALTH AND HUMAN SERVICES
ARIZONA STATE
GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS)
DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST
CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and
TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL
HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND
MEDICAID SERVICES
(CMS)
$
$
$
$
$
$

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
Subcontracted
Providers
Subcontracted
Providers
Long Term Care
Program Contractors
(e.g. DDD)
Gila River
Tribal RBHA
Subcontracted
Providers

Arizona BH Funding for Children
FUND SOURCE FY 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%

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.

13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding Enrollment
June 2000 - June 2006

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

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

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

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

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

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)

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

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

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)

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

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

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

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

Thinking
Leadership
 Sustainable Transformation
 Good Practice = Good Business
 Dealing with Resistance
 Overcoming Inertia

Thinking
Early Innovators
 Urgency
 Ownership
 Commitment to Action
 Not for the Weak of Heart

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.

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)

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

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

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

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

Funding
 Variations in State Capitation Rates
 Maximizing State Funding
 Provider Contracting Methodology
 Sustainability of Effort

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

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

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

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

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

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

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

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)

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?

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]

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):

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 CFT Low Fidelity CFT
WFI Scores 85.3 53.6
CAFAS 132 128
CBCL Total 89 78
Level of Residential
Placement
1.7 1.7
Number of Moves in
Previous Six Months
2.2 1.6
Family Resource Scale 3.5 3.1
“It Even Works in Arizona…”

80
90
100
110
120
130
140
150
160
Intake
6
M
onths
12
M
onths
Time Interval
AverageCAFASScore
Overall HF CFT LF CFT
50
60
70
80
90
100
Intake
6
M
onths
12
M
onths
Time Interval
AverageCBCLTotalScore
Overall LF CFT
HF CFT
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)

1.0
1.5
2.0
2.5
3.0
3.5
4.0
Intake
6
M
onths
12
M
onths
Time Period
AverageResidentialLevel
Overall Low Fidelity
High Fidelity
0.0
0.5
1.0
1.5
2.0
2.5
Intake
6
M
onths
12
M
onths
AverageMovesperSixMonths
Overall Low Fidelity
High Fidelity
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)

2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
Intake
6
M
onths
12
M
onths
AverageFRSScore
Overall
2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
Intake
6
M
onths
12
M
onths
AverageFRSScore
Low Fidelity High Fidelity
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)

Promising Data about
Arizona Children
Success in School – Past Six Months:
 Age 5-11: 11.2% higher with CFT (64.2%)
Lives with Family – Past Six Months:
ADHS CIS (05/06): N = 31,690 children/families

Arizona Children
(Increased) Stability – Past Six Months
 Ages 5-11: 14.5% higher with CFT (74.0%)
(Increased) Safety – Past Six Months

Arizona’s Children
Avoids Delinquency – Past Six Months
Preparation for Adulthood – Past Six Months

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 range
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
CFT
No CFT
CFT 75.1% 71.1% 76.0% 58.3% 66.7% 87.7%
No CFT 59.6% 59.3% 65.8% 52.4% 54.5% 81.7%
Increased
Stability
Increased
Safety
Avoids
Deliquency
Prep for
Adulthood
Success in
School
Lives with
Family

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 range
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
CFT
No CFT
CFT 71.2% 68.5% 71.3% 56.5% 64.8% 81.1%
No CFT 55.0% 57.1% 60.8% 48.1% 53.9% 77.4%
Increased
Stability
Increased
Safety
Avoids
Deliquency
Prep for
Adulthood
Success in
School
Lives with
Family

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

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)

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

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

AZ CFTs Institute (Orlando, 2006)

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