A Webinar Series featuring Bruce Kamradt - EENet - Evidence Exchange … · 2019. 12. 12. ·...

The Centre for Addiction and Mental Health and the Ontario Centre

of Excellence for Child and Youth Mental Health in partnership

with the International Initiative for Mental Health Leadership

present

A Webinar Series featuring

Bruce Kamradt

A Look into an international innovative

evidence-informed practice: Wraparound

Milwaukee April 29, 3 – 4:30 pm

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International Innovations in

Mental Health Series: Wraparound Milwaukee

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About the Series

• This series is jointly coordinated by EENet at the Centre for Addiction and

Mental Health (CAMH) and the International Innovations In Mental Health

(IIMHL) as well as supported by the Mental Health Commission of Canada

and Health Canada

• Partners include the Ontario Centre of Excellence for Child and Youth Mental

Health and the Canadian Mental Health Association, Ontario Division

• Presentations on a range of topics: Psychological therapies

Physical Activity and Mental Health

Child and Youth Mental Health

Dialogues and outcomes in treatment of acute psychosis

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EVIDENCE EXCHANGE NETWORK

Heather Bullock Director, Knowledge Exchange April 2014

1. What is EENet?

What is EENet’s goal?

• EENet aims to make Ontario’s mental health and addictions system more evidence-informed.

• EENet builds capacity to respond to knowledge gaps in practice and policy, ensures that mental health and addictions practices and policies are informed by sound evidence, and enables stakeholders to generate and exchange knowledge.

EENet’s structure/key methods and

approaches

• EENet Management and Resource Centre (located at CAMH), with KE Leads located across province

• Communities of Interest

• Diverse stakeholders come together to co-create and share knowledge on topics of interest to system

• Partnerships to ensure alignment with and to leverage already existing system capacity e.g. Ontario Centre of Excellence for Child and Youth Mental Health, healthevidence.ca, CCSA

• Governance

• EENet Steering Committee – provides strategic guidance to network with representatives from different stakeholder groups; provincial and national organizations; and health/ KT researchers

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2. What is EENet Connect?

1,746 EENet connect members 129,791 page views

1,449 subscribers

782 followers on Twitter

Almost 40,000 visitors

1746 stakeholders have joined, including: • Policymakers • Youth MH Court Workers • Service Users • MH Nurses

636 discussion threads created on: • Children & youth • Coordination, transitions & partnerships • Case studies & personal/lived experience

532 events posted, including: • Webinars • Conferences • Live chats

As of February 2014…

Visit us!

@eenet_news

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www.eenetconnect.ca

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Introductory Remarks

Dr. Simon Davidson is a child, adolescent and

family psychiatrist. He obtained his medical degree at

the University of Witwatersrand, Johannesburg, South

Africa and completed his residency in Psychiatry at

McMaster University, Hamilton, Ontario. He is a

Professor in the Division of Child and Adolescent

Psychiatry in the Department of Psychiatry and

Pediatrics at the University of Ottawa. He is Chief

Strategic Planning Executive of the Ontario Centre of

Excellence for Child and Youth Mental Health.

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Today’s presenter

Bruce Kamradt is the Administrator

of Childrens’ Mental Health Services

for Milwaukee County and creator of

Wraparound Milwaukee. Bruce is

recognized as a national expert in the

U.S. on designing, organizing and

financing community-based systems of

care for children.

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Wraparound Milwaukee –

A National Model for Achieving the

Best Outcomes for Children with

Serious Emotional & Mental Health

Needs & Their Families

Toronto, Canada

April 29, 2014

Presented By:

Bruce Kamradt, MSW, Director, Wraparound Milwaukee

Background for the Development of A

System of Care in Milwaukee County and for

the Care Management Entity (CME) Model

Milwaukee County consists of a culturally and ethnic diverse

population of 1.1 million (230,00 children ages 0-18)

In the mid 1990’s Milwaukee County faced significant clinical,

programmatic and fiscal issues related to how care was

provided to children with serious emotional and mental health

needs

There was over utilization of out-of-home care for these

children, particularly in psychiatric hospitals, residential

treatment centers and correctional facilities

There was a lack of community-based treatment alternatives

14

Background for the Development of A System of

Care in Milwaukee County and for the Care

Management Entity (CME) Model – cont’d

Clinical outcomes were poor and recidivism high

Very little collaboration among mental health, Child Welfare

and Juvenile Justice systems which made for fragmented

service delivery

What Milwaukee faced was not uncommon to other

communities in the U.S.

15

The Planning Process – Bringing Key

Stakeholders Together

In 1995, the Children's Behavioral Health System brought

together a group of stakeholders from Child Welfare,

mental health, Juvenile Justice, legal system (judges),

special education, families and advocates to discuss the

issues and develop alternatives to how the system currently

looked and functioned

The group identified the target population of youth we

needed to focus on – youth with serious emotional &

mental health needs at risk of out-of-home placement or

those staying too long in such facilities

We identified the outcomes or goals we hoped to achieve

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The Planning Process – Bringing Key

Stakeholders Together – cont’d

We identified the services and supports necessary to

serve these youth and families and what existed or did

not exist

We identified and aligned on the values and

philosophy for how the system needed to operate

We agreed on a new type of structure to oversee the

development, implementation and monitoring of the

new delivery system model—but not the traditional

managed care approach on the following slides!

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What Were the Values We Chose to Build the

System and to Guide Service Delivery

Family Directed Care – “families needed to be seen as

the solution to meeting their child’s needs and not the

problem”

Strength-Based Care – “needed to build on child and

family strengths and not focus on perceived deficits”

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System and to Guide Service Delivery –

cont’d

Individualized Care – “every child and family is unique and

deserves a plan and services tailored to their needs –children

should get what they need, not what is only currently available”

Community-Based Care – “services are usually more effective

when delivered in the child’s own home and community –

institutional approaches should be kept to a minimum and only

for the shortest period necessary”

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System and to Guide Service Delivery –

cont’d

Coordinated Care Across Child Serving Systems – “every child

should have a single care plan across child serving systems”

Cultural Competency in Service Provision – “respect and

understanding for cultural differences is paramount to

effectively work with families”

Unconditional Responses – “we will never give up on a child or

family – plans fail, not people”

22

Wraparound Model

Wraparound is the approach we chose which is a practice and values driven approach for the planning and provision of services and supports that can be applied to any population of children and families with or at risk for intensive service needs

Wraparound puts system of care values and principles into practice for service

planning and provision.

10 Principles

of Wraparound

23

How We Chose to Develop and Implement

the Care Management Model

We needed to create a structure or organization that

could opperationalize our values and realize our goals

and organize the new service delivery model across

multiple child serving systems and move from a

traditional “categorical” to a “non-categorical system”

24

Categorical vs Non-Categorical

Categorical

System

Reforms

25

How We Chose to Develop and Implement

the Care Management Model – cont’d

Considerations for the model: Accountable to systems stakeholders

Flexible in service delivery

Have organizational capacity to serve a large population

Had to be able to bring financial resources together and manage those

resources

Strong data systems

Needed to be responsive to families

Had to have credibility with and confidence of stakeholders to achieve

goals and program outcomes

27

The CME Model and Governance

Considerations

Where would CME get it’s authority to act? Agreements and contracts with stakeholders

Federal waiver to allow for unique funding arrangement

How would it be governed? Under authority of local government

How would the stakeholders be represented and involved? Partnership council

How would the relationship between the CME and Providers be

developed and maintained? Provider network

Monthly provider meetings

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The CME Model and Governance

Considerations – cont’d

How would disagreements be resolved? Conflict resolution protocols

How would funding for the system be arranged? Pooling of funds using capitation, case rates, and fixed allocation to

“funding pool”

Who would be legally and financially liable? Lead agency (mental health) with risk reserve and risk sharing

methodologies

29

Developing a Pilot to Test the CME Model –

“Twenty-Five Kid Project”

Developed by planning groups to test whether the components

and “wraparound” philosophy of this new CME model could

successfully reintegrate 25 youth who were in residential

treatment centers who had no immediate plan for discharge

There would be no “reject of applicants” or “eject” from pilot

Three teams facilitated by a care coordinator were chosen to

work with 25 youth in late 1995

17 of 25 youth returned in 120 days

30

Characteristics of Population Served by

Wraparound Milwaukee

60% of families have income under US Federal

Poverty level

70% boys

Average age 12.5

67 % African American, 25% Caucasian, 7% Hispanic

31

Characteristics of Population Served by

Wraparound Milwaukee – cont’d

Major DSM-IV Diagnosis 60% conduct disorder/oppositional defiant

50% depressive disorders

40% attention deficit

30% substance abuse

25% cognitive/developmental disabilities

8% psychotic disorders

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Creating the Care Management Entity – What

Administrative & Service Structures We

Chose to Give It

Single Point of Access for

Screening & Assessment

Enrolment

Intensive Care Coordination

Developing a Comprehensive

Array of Services and

Maintaining a Provider

Network

Mobile Crisis Intervention

Clinical & Medical Oversight

Evaluation

Maintaining Funding Pool

and Disbursing Monies as

Single Payor of Care

Information Technology and

Data Management

Developing and Supporting

Family Advocacy

Quality Assurance/Utilization

Management

Liaison with Court System

33

Collaboration & Pooled Funding

34

Funding Consideration for Wraparound

Milwaukee – Why We Chose to Focus on the

Highest Needs Youth Versus Early Intervention

The funding “pyramid” that is found in most

communities dictated our beginning point – we would

start with the “highest cost/needs youth “and as we

successfully served that population monies saved

could be redirected to expand services to

youth/families with less intensive needs

35

2 - 5%

15%

80%

More

complex

needs

Less

complex

needs

Intensive

Services –

60% of $$ Home &

community

services;

early inter-

vention-

35% of $$

Prevention

and Universal

Health

Promotion –

5% of $$

Prevalence/Utilization Triangle

Pires, S. 2006. Human Service Collaborative. Washington, D.C. 36

How We Pool Funds

CHILD WELFARE Funds thru Case Rate

(Budget for Institutional

Care for Chips Children)

JUVENILE JUSTICE (Funds Budgeted for

Residential Treatment and

Juvenile Corrections Placements)

MEDICAID CAPITATION (1923per Month per Enrollee)

MENTAL HEALTH •CRISIS BILLING

• HTI GRANT

• HMO COMMERCIAL INSUR

WRAPAROUND MILWAUKEE

CARE MANAGEMENT ORGANIZATION

(CMO)

52.0M

CHILD & FAMILY TEAM OR

TRANSITION TEAM

PLAN OF CARE OR

10.0M 10.0M 24.0M 8.0 M

FUTURES PLAN

FAMILIES UNITED

$525,0000

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Creating “win-win” Scenarios

System of Care

Child Welfare

Alternative to out-of-home care

high costs/poor outcomes

Juvenile Justice

Alternative to residential &

Correctional placements

Medicaid

Alternative to IP/ER-high cost

Special Education

Reduce alternative school placements

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Why We Chose to Pool Monies to Pay for

Service Costs Across Child Serving Systems

Gave us more flexibility

Created a more adequate funding source for complex needs

children

We could create a “single payor system”

Funds can be more easily “re-directed” as program/client needs

changes

Accountability – it ended “cost shifting” from system to another

system

39

SERVICE STRUCTURES

To Deliver Wraparound Approach

& Process

40

Critical Components in the Design of the Service

Delivery System – What Components Work Best

in the Care Management/System of Care Model

1. Child & Family Teams

2. Care Coordination

3. Provider Network

4. Comprehensive Array of Services

5. Mobile Crisis

6. Family Advocacy & Peer Support

7. Information Technology

8. Quality Assurance/Evaluation/Data Sharing

9. Evaluation/Outcome Measurement

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1. Child and Family Teams

A Child & Family Team is a group of people identified by both

the youth and the family who will work with the family

throughout the Wraparound process. A Child & Family Team is

composed of formal, natural and informal members. Child &

Family Teams meet on a regular basis, usually monthly, to

create and continuously refine a written plan of care for the

family. The meetings generally take place in the family’s home

or at a place in the community that is most convenient and

comfortable for the family.

42

Teams are facilitated by a Care Coordinator whose roles and responsibilities include:

• Home visits (weekly)

• Monthly Team Meetings

• Plan of Care Meetings, every 60 – 90 days

• Collaborating with System Partners

• Court appearances when indicated

• School meetings as needed

• Authorizing and arranging supports and services

• Ongoing monitoring of the Plan of Care and service provision

2. Care Coordination

43

Low case load – 1:8 ratio

Highly trained in wraparound approach and certified

by WAM

Court roles and responsibilities

Use of fidelity measures and coaches

Characteristics of Care Coordination

44

3. Provider Network

An organized group of agencies and individual providers that

have agreed to provide and are reimbursed for services to

enrollees of the Wraparound Milwaukee health plan and our

system of care

45

Provider Network Features

No formal contracting – Wraparound Milwaukee utilizes fee-for-service system to obtain & pay for services

Rates and service definitions established by Wraparound Milwaukee

70 services and 200 provider agencies

Wraparound Milwaukee is single payor for all services, including community-based and out-of-home services

Consumer choice of provider

Extensive Quality Assurance/Quality Management measures in place

All providers and care coordinators linked through one internet based IT system (Synthesis) for service authorizations, plan submission, invoice, payment, and progress notes

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4. Comprehensive Service Array Behavioral & Clinical Services

Crisis intervention

Individual therapy

Intensive in-home therapy

Evaluation

Substance abuse therapy

(individual and group)

Medication management

Day treatment

Special therapy

(i.e. behavioral management team)

Placement Services

Acute hospitalization

Foster home and treatment foster home

Group home care

Residential treatment

Crisis/residential, group care, treatment

foster care

Supported independent living

Other Supportive

Camps

After school

Suspension accountability

Transportation

Interpretive services

Equine therapy

Consultation with other

professionals

Supportive Services

Mentors

Crisis 1:1 stabilizer

Tutor

Parent/family aide

Life coach – independent living

Employment preparation and

placement

Job – internship

Respite

Crisis/planned respite

Residential respite

Service Coordination

Care coordination

Discretionary

Flex Funds

Clothing

Food/groceries

Housing assistance

Child care

Furniture, appliances

YMCA membership

Educational expenses

47

Advantages of Fee-For-Service

Provider Network System

Cost No guaranteed volume of business or expenditures

Pay only for delivered units of service

Flexibility Funds follow client needs

Competition Promotes quality

Consumer choice

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5. Mobile Crisis Services

All families have access to Wraparound Milwaukee’s Mobile Urgent Treatment Team

24/7 Availability

Mobile crisis teams gatekeep inpatient psychiatric treatment

Wraparound Milwaukee has dedicated crisis teams for Child Welfare Dept.

Mobile Crisis can make available optional crisis stabilization services

Crisis 1:1 stabilizers in home and school

Crisis group home

Short-term crisis case management

17 crisis intervention workers

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6. Family Advocacy & Peer Support

Families United of Milwaukee – advocacy organization run by

families in Milwaukee and funded by Wraparound Milwaukee

All families have access to a family advocate who has had a child in

the program and want to help other families

Advocates are available to talk with families and participate as a

support to them on the Child & Family Team

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6. Family Advocacy & Peer Support –cont’d

Advocacy organization operates support groups and conduct family

activities

Family advocates and family members participate on all Wraparound

committees, work groups and councils

Educational advocates work with youth needing help with

educational challenges particularly with access to special educational

programming

Peer specialists – certified to support other youth & young adults

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7. Information Technology

One electronic health record and single information system Synthesis links all care coordinators, providers and system partners, including delinquency services

52

What Does Synthesis Automate

Screening and Assessment Data Demographic Information Enrollment History Crisis/Safety Plan Plan of Care Provider Service Authorizations Invoicing Claims Processing & Payment Progress Notes Outcome Information QA/QI Data Accessible reports for care coordinators, supervisors and system

managers

53

8. Quality Assurance/Quality

Improvement

Measures & mechanisms to ensure care & services are being

provided consistent with the philosophy & values of the

program

54

8. Quality Assurance/Quality

Improvement – cont’d

QA/QI includes:

Policies & procedures

Auditing plans, progress notes, network services

Measuring family satisfaction & needs attained

Resolving complaints/grievances

Utilization review

Agency performance reports

55

Program

Outcomes

56

9. Evaluation/Outcome Measurement

We feel it is important to create & measure a variety of

outcome measures i.e. program, clinical, fiscal, educational,

safety and consumer satisfaction that are important to system

stakeholders

57

Program Outcomes

The average daily residential treatment population has dropped

from 375 youth in 1996 to 100 today

Average length of stay in residential treatment for wraparound

youth dropped from 14 months to 4 months

58

Fiscal Outcomes

The average monthly cost of a youth enrolled in Wraparound Milwaukee is significantly less than the monthly cost of a youth in an institutional setting

Average monthly cost comparison of Wraparound to institutional care over past 6 years:

Wraparound Milwaukee $3,545

Group Home $5,998

Residential Treatment $9,116

Psychiatric Inpatient (30 day stay) $38,130

59

The Cost of Doing Nothing – Residential

Treatment Costs Without Wraparound Milwaukee

Versus Actual Residential Treatment Placement

Costs Under Wraparound

Wraparound Milwaukee developed a methodology shown in the graph

on the following slide to show what the potential for increase costs may

have been to Milwaukee County child serving agencies had the number

of RTC placements continued to increase by 5% every year and cost of

RTC placements had also increased by the same percentage (as they had

in the previous 5 years)

This graph compares the projected costs without Wraparound with the

actual expenditures for residential treatment for County youth over the

same period

Total projected expenses in 2013 without Wraparound Milwaukee

would have been approximately $88.8 million versus $12.5 million in

2013

60

Cost of Doing Nothing Residential Treatment

Placements & Costs Without Wraparound

Milwaukee

61

Clinical Outcomes

Statistically significant improvement in functioning on Child Behavioral Checklist (CBCL), Youth Self Report (YSR). Overall, 85% of youth at disenrollment have an improved level of functioning on the CBCL.

62

Educational Improvement

40% increase in school attendance from time of enrollment to disenrollment

Youth attended 87% of school days in 2012.

63

Child Permanency

85% of youth achieved permanency plan of return home, relative placement or independent living at time of discharge from Wraparound Milwaukee

64

Recidivism Rates

Wraparound Milwaukee serves 40% of youth on probation including many of those at high risk of correctional and/or residential treatment

Overall rate of recidivism of Wraparound Milwaukee youth using arrest data over the past two years (n=1309) was 21%

While no established national standards, the Public Policy Forum of Wisconsin recently conducted a 4 year study for all delinquent youth which established an overall 41% recidivism rate for Milwaukee youth in the delinquency system not including WAM youth, so WAM had a significantly lower recidivism rate

65

Lessons Learned in Replicating

Wraparound Milwaukee

It is “value” driven

Collaboration is key with system partners

Need to put aside the “turf issues”

Partnerships with families in crucial

“no family – no plan”

There has to be shared information

Single release of information across all child serving agencies

Conflict is natural – how you resolve it is critical

Written conflict resolution protocol

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Lessons Learned in Replicating

Wraparound Milwaukee – cont’d

Cross system training of staff with families

Break down the “funding silos” and pool monies

Well trained staff in the wraparound process with “good fidelity” tools and measures

Working effectively with the courts

Never give up on kids and families

“plans fail – not people”

67

Supporting capacity building in the evaluation and implementation of evidence-informed practices

Melissa Jennings Manager, Support Services

About the Centre We bring people and knowledge together to strengthen

the quality and effectiveness of mental health services for children, youth and their families and caregivers.

Three strategic goals:

Learning

Foster a culture of organizational learning to support agencies in using evidence to improve client outcomes.

Collaboration Leadership

Be a true learning organization and lead by example.

Build and develop collaborative partnerships to sustain capacity within mental health services.

Who do we work with?

Our work…

• is targeted at child and youth mental health agencies (direct service providers, managers/coordinators, agency leaders).

• takes place in the 5 MCYS regions throughout the province.

• is aimed at supporting agencies and their staff to use the evidence in program planning and service delivery (via evaluation and implementation supports).

What do we mean by the evidence?

Evidence-informed practices (EIPs)

“Evidence-informed practices combine the best available research with the experience and judgment of practitioners, children, youth and families to deliver measurable benefits”.

User view

Practice

Research

How do we support agencies in using the evidence?

The learning journey

Gathering information

• Evidence In-Sight

• Policy papers:

o Brief services

o Transitions in mental health

o Taking mental health to school

o Pathways to care for youth with concurrent disorders (in progress)

o Technology and other media in service provision (in progress)

o Mental health in the early years (0-6) (in progress)

User view

Practice

Research

Evidence In-Brief

Gathering information

• Through program evaluation efforts to capture the client and practitioner experience (e.g. standardized measures, feedback forms, satisfaction surveys, interviews, focus groups, client data and profiles, etc.)

User view

Practice

Research

Using knowledge to grow

• Youth engagement training

• Family engagement training

• Mental health awareness

• Learning modules

o Stigma

o Bullying

o EIPs

o Anxiety

o Anti-oppression

o Suicide prevention

Sharing your story

• Grants and awards database • Regional forums • Dare to Dream program

How does the Centre support the implementation and

evaluation of EIPs?

Implementation capacity building

“Any activity that builds durable resources and enables the recipient setting or community to continue the delivery of evidence - based intervention after the external support from the donor agency is terminated.”

(Brownson, Colditz, Proctor, 2012)

Focus on: • ongoing monitoring and evaluation • ongoing coaching and clinical supervision of new staff • knowledge exchange and dissemination

SUSTAINING PHASE Learning to continually use new evidence to improve practice 03

Focus on: • professional development and training on specific programs or practices • coaching, clinical supervision and communities of practice • monitoring and evaluation

DOING PHASE Training on specific practices, implementing, adapting and evaluating 02

Focus on: • laying the groundwork among teams and

systems • organizational readiness and needs

assessment

• assessing evidence • leadership buy-in and support • evaluation framework

PLANNING PHASE Getting people and systems ready for change 01

The Centre’s implementation framework

The Centre’s implementation support

• Consultations

o with funding (People Advancing Change through Evidence-PACE)

o regular

• Resources

o toolkits

o modules

o webinars

Model for evaluation capacity-building

Transfer of learning

Leadership

2. Sustainable evaluation

practice

Preskill & Boyle (2008), modified

1. Evaluation knowledge, skills and attitudes

Culture

Systems and structures

Communication

2. Sustainable evaluation practice

Evaluation capacity

knowledge of evaluation (cognitive outcomes)

skills in evaluation (behavioural outcomes)

positive attitudes towards evaluation (affective outcomes)

Evaluation capacity is when individuals in an organization have:

Organizational learning capacity

leadership

culture

systems and structures

communication

The necessary conditions to support evaluation capacity-building activities are:

The Centre’s evaluation support

• Consultations

o with funding (Planning and Doing evaluation grants)

o regular

• Resources

o toolkits

o modules

o webinars

o measures database

The Centre’s online resource hub

The Centre’s Grants and Awards Index

For more information

Melissa Jennings

Manager, Support Services

[email protected]

613.737.2297 ext. 3720

@CYMH_ON

Follow the Centre on Twitter

Questions?



Discussion

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Thanks to all participants for joining today.

Please complete a short feedback survey on today’s knowledge exchange event:

https://www.surveymonkey.com/s/wraparound_mke

EENet would also like to give a special THANKS to Bruce for today’s presentation!

Thank you!

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Thanks once again! Please connect with us (http://www.eenetconnect.ca/)

or visit Wraparound Milwaukee website for more information!

http://wraparoundmke.com/

Stay connected!

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A Webinar Series featuring Bruce Kamradt - EENet - Evidence Exchange … · 2019. 12. 12. ·...

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