West Virginia’s Child Welfare Crisis - Home |...

West Virginia’s Child Welfare Crisis

A Path Forward

Jeremiah SamplesDeputy Cabinet SecretaryMay 2018

West Virginia Moving Forward

At 3%, WV has 3rd lowest child uninsured rate in US At 6.17%, WV has 12th lowest adult uninsured rate in US Since 2010, WV has 7th biggest decline in uninsured in US Children with parents uninsured declined from 18% to 6%

(2009-2015) Teen birth rate decline from 44 to 32 per 1000 (2011-2015) National Kids Count Rank Improved from 41 to 36 (2015-2017) Children in out of state placement declined from 630 to 425

(2008-2018) WV’s adoption rate has increased 113% since 2006, highest

nationally. Growth nationally has been 6% with PA, OH, and MD seeing declines ranging from 5-28%.

1

Sources: Kaiser Family FoundationWalletHubAnnie E. Casey Foundation

West Virginia Moving Forward

WV is a national leader in child support, ranking 14th in paternity match, 9th in support orders, and 15th in child support collections.

WV demonstrated a 17% increase in the number of infants placed to sleep on their backs from 2007 to 2014, surpassing the national average.

WV was first state in nation to be granted Neonatal Abstinence Syndrome State Plan in 2017.

WV is one of only 10 states awarded a Title IV-E wraparound service waiver, known as Safe at Home

The National Children’s Health Survey shows that WV ranks 11thin the country for preventative medical care visits with 88.7%.

2Sources: Bureau for Public Health, West Virginia

West Virginia Safe At Home IVE Demonstration Project Cumulative Data April 2018

3

760

58

174

16

818

63

197

19

879

65

198

20

954

66

209

25

1025

69

218

25

1120

73

223

26

1193

73

225

28

Prevented from Entering Residential Care

Return to Community from Out of State Residential

Return to Community from In State Residential

Return to Community from Shelter Placement

Number of Safe at Home WV Participants by Outcome(Cumulative Count)

Oct-17

Nov-17

Dec-18

Jan-18

Feb-18

Mar-18

April-18

PresenterPresentation Notes

May 14, 2018, 1,920 youth have been enrolled in Safe at Home West Virginia. West Virginia has returned 73 youth from out-of-state residential placement back to West Virginia, 226 Youth have stepped down from in-state residential placement to their communities, and 28 youth have returned home from an emergency shelter placement. West Virginia has been able to prevent the residential placement of 1227 at risk youth.

Socio-Economic Challenges Third Most Rural State: 51% of West Virginians live in a rural setting

Age of Population: Median age 41.3 years; third oldest in nation 16% of population is elderly; second oldest in nation

Educational Attainment: WV ranks 43rd in US for high school diploma attainment WV ranks 50th in US for college degree attainment

Report Disabled: WV has highest disabled rate in US at 18.9%

Life Expectancy: WV has second lowest life expectancy in US

Per Capita Income: WV ranks 48th nationally

Median Household income: WV ranks 49th nationally

Labor Force Participation: WV has lowest rate in US4

Source: West Virginia Department of Health and Human Resources

WV Risk Factor Indicators

Risk Factor WV Prevalence Rank Nationally

Current Smoking 1

Smokeless Tobacco Use 1

Obesity 1

5Data Source: WV Health Statistics Center, Behavioral Risk Factor Surveillance System, 2013

Behavioral Health Measure WV Prevalence Rank Nationally

Severe Mental Illness 1

Poor Mental Health Days (unable to function) 1

Prescriptions for Controlled Substances 1

Drug Induced Deaths 1

Any Mental Illness 3

Major Depressive Episode 5

Suicide 7

WV Mortality Rates

Mortality Cause WV Prevalence Rank Nationally

Overall Mortality Rate 1

Cancer 1

Chronic Lower Respiratory Disease 1

All Accidents 1

Diabetes 1

Stroke 1

Drug Overdose 1

Influenza/ pneumonia 2

Nephritis/ Nephrotic Syndrome/ Nephrosis 2

Heart Disease 4

6Data Source: WV Health Statistics Center, Behavioral Risk Factor Surveillance System, 2014

West Virginia versus United States

Data Source: WV Health Statistics Center, Vital Surveillance System and CDC WonderRates are age-adjusted to the 2000 US Standard Million

7

PresenterPresentation Notes West Virginia has the highest overdose rate in the United States, and no other state is even close.

Chart1

200120012001

200220022002

200320032003

200420042004

200520052005

200620062006

200720072007

200820082008

200920092009

201020102010

201120112011

201220122012

201320132013

201420142014

201520152015

201620162016

WV

US

Column1

Per 100,000

2001-2016 Resident Drug Overdose Mortality RatesWest Virginia and United States

11.5

6.8

12.9

8.2

15.1

8.9

18.8

9.4

22.3

10.1

20.4

11.5

22.4

11.9

25.7

11.9

25.9

11.9

28.9

12.3

36.3

13.2

32

13.1

32.2

13.8

35.5

14.7

41.5

16.3

52

19.8

Sheet1

YearWVUSColumn1

200111.56.8

200212.98.2

200315.18.9

200418.89.4

200522.310.1

200620.411.5

200722.411.9

200825.711.9

200925.911.9

201028.912.3

201136.313.2

201232.013.1

201332.213.8

201435.514.7

201541.516.3

201652.019.8

Interactions with Health Systems

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Healthcare systems included BBHHF, EMS, and CSMP. Neither Medicaid or Corrections were included.

81% of decedents interacted with one or more systems. Just under 40% of decedents interacted with only one system.

Chart1

None

One

Two

Three

Males: Interactions with Healthcare Systems


22

38

30

10

Sheet1


None22

One38

Two30

Three10

Females: Interactions with Healthcare Systems

None13

One39

Two30

Three18

Sheet1




Chart1

None

One

Two

Three



13

39

30

18

Sheet1


None22

One38

Two30

Three10


None13

One39

Two30

Three18

Sheet1




Neonatal Abstinence Syndrome

9Source: HCUP – State Inpatient Databaseshttps://mchb.tvisdata.hrsa.gov/PrioritiesAndMeasures/NationalOutcomeMeasures

PresenterPresentation NotesAccording to data presented above from the State Inpatient Databases, rates for NAS in WV increased 284% from 2009 to 2014.

https://mchb.tvisdata.hrsa.gov/PrioritiesAndMeasures/NationalOutcomeMeasuresChart1

20092009

20102010

20112011

20122012

20132013

20142014

WV

US

Rate of Infants Born with NAS per 1,000 Delivery Hospitalizations

18

5

21.2

6

25.2

7

31.2

8.3

45.4

9.7

51.2

10.7

Sheet1

WVUS

2009185

201021.26

201125.27

201231.28.3

201345.49.7

201451.210.7

West Virginia Babies

Intrauterine Substance Exposure: 143 per 1,000 or 14.3% NAS: 50.6 per 1,000 or 5.06%

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PresenterPresentation NotesThis slide shows the results of our surveillance work with NAS rates by county. County level data was released publicly this week for the first time. Overall, 14.3 percent of all WV infants are born substance exposed and 5% are diagnosed with NAS. These rates have remained relatively stable each month of our data collection.

Adverse Childhood EventsImpact of ACE score of 0 compared to Ace score of 4

242% more likely to smoke 222% more likely to become obese 357% more likely to experience depression 443% more likely to use illicit drugs 1133% more likely to use injected drugs 298% more likely to contract an STD 1525% more likely attempt suicide 555% more likely to develop alcoholism

Source: Dr. Allison Sampson-Jackson, Virginia, Integration Solutions

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Child Protective Service Referrals

12

2012 2013 2014 2015 2016 2017

Statewide Referrals 45,000

39,636 39,604 40,000 35,658 36,045 36,579

35,000 i

30,000 25,700

25,000 23,325

18,502 18,630 20,194 27,359 20,000

15,000 18,279

10,000

5,000

0

• Received Count • Accepted Count 2017 Jan to Aug Only

PresenterPresentation NotesBCF continues to see a high volume of calls and CPS referrals to the Centralized intake unit – part of our overall operation that supports Child Protective Services workThis unit continues to have a high vacancy rate and chronic turnover as well

• Accepted Count

2017 Jan to Aug Only

18,502

18,630

20,194

23,325

25,700

18,279

2017

2016

2015

2014

2013

2012

Statewide Referrals

45,000

39,636

39,604

40,000

35,658

36,045

36,579

35,000

i

30,000

25,000

27,359

20,000

15,000

10,000

5,000

0

· Received Count

Growth in Foster Care

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4,265 4,449 4,708

5,310

6,095

0

1000

2000

3000

4000

5000

6000

7000

2013 2014 2015 2016 2017

West Virginia Children in Foster Care

Children in Foster Care Total Clients

Child Welfare Indicators: Children in Care

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Source: 1) WV Bureau for Children and Families2) Annie E. Casey Foundation

A Growing CrisisWV is experiencing a child welfare crisis that is being driven by the drug epidemic 83% of open child abuse/neglect cases involve drugs Since 2014 the number of youth in the custody of the state

has steadily increased. When comparing October 2014 with October 2017, there was a 46% increase.

22% increase in accepted abuse/neglect referrals over 3 years 34% increase in open CPS cases over 3 years Averaging 23% vacancy rate for CPS positions 63% of the children entering care are age 10 and younger WV is #1 in children removals nationally 43% of the children are in kinship/relative placements WV adoptions have increased 113% since 2005

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“The best way to predict the futureis to create it.”

~ Abraham Lincoln

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Child Welfare Reform

Child Welfare Reform Strategic Plan- 5 objectives, 25 strategiesBetter serve youth in the Foster Care system by increasing the

percentage of children in family home settings Improve healthcare and behavioral health outcomes for youth by

implementing care coordination strategies for children at risk oftrauma

Improve juvenile care and placementEnhance the availability of behavioral health options statewide by

maintaining and expanding the availability of community-basedChild Welfare programs

Engage stakeholders to drive change, specifically the JudicialBranch

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PresenterPresentation NotesWV DHHR over this past years has developed two work plans that address workforce issues, community resources and practices for children in the foster care system and children at risk of out of home placement or in need of mental health services and supports.

CPS Reform is a fluent document that includes Workforce recruitment and retentionImproving our compliance with the federal Child Family Services Review AndWorking to improve permanency timelines and reunification while increasing resources to reduce the need for children staying in offices or hotels in emergency situations

Child Welfare Reform is a coordinated effort among the Bureaus to work to enhance the availability of resources, increase substance abuse treatment and services and improve healthcare and behavioral health outcomes for WV children.

Child Protective Service Reform

CPS Reform Strategic Plan- 59 different projects, tasks beingtracked in a PMO portfolio to ensure timely implementation Improve recruitment and retention Improve compliance with the Federal Child Family Services

Review (examples: permanency, reunification timelines)Reduce situations where children stay in offices or hotels in

emergency situations Improve CPS pay

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PresenterPresentation NotesWV DHHR over this past years has developed two work plans that address workforce issues, community resources and practices for children in the foster care system and children at risk of out of home placement or in need of mental health services and supports.

CPS Reform is a fluent document that includes Workforce recruitment and retentionImproving our compliance with the federal Child Family Services Review AndWorking to improve permanency timelines and reunification while increasing resources to reduce the need for children staying in offices or hotels in emergency situations

Child Welfare Reform is a coordinated effort among the Bureaus to work to enhance the availability of resources, increase substance abuse treatment and services and improve healthcare and behavioral health outcomes for WV children.

Care Management Benefits in Child Welfare

1. Improve coordination of wrap around and other services for children and parents to mitigate number of children that need taken into state custody

2. Improve clinical oversight in order to move children into most appropriate care in least restrictive setting

3. Ensure that medical records follow a child wherever they receive services

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The Urgency of Now

Beyond the moral and societal responsibility to protect and empower every child, now represents an ideal time to adopt a care management approach for several reasons: Historic DHHR system changes Department of Justice Investigation Record numbers of child and families requiring Child

Protective Service intervention due to drug crisis Skyrocketing expenditures to address child welfare crisis Passage of Family First Act

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Family First Prevention Services Act

On 9 February 2018, President Trump signed into law the landmark bipartisan Family First Prevention Services Act, as part of the Bipartisan Budget Act of 2018.

The Family First Prevention Services Act redirects federal funds to provide services to keep children safely with their families and out of foster care, and when foster care is needed allows federal reimbursement for care in family-based settings and certain residential treatment programs for children with emotional and behavioral disturbance requiring special treatment.

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PresenterPresentation NotesThe Family First Prevention Act will change the way child welfare agencies work with families. After October 2019, no longer will the federal government incentivize out-of-home placements by only paying Title IV-E after children are removed. The prevention services act will allow states to claim funds for providing in-home services parenting education, mental health and substance abuse services to at risk families in an effort to keep families together. If states continue to remove children at the current rates, there will never be enough residential or foster care beds to meet our needs. Through serving families at home, the hope is to reduce the trauma to families and children that remval causes.

Family First Prevention Services Act Eligibility:

Candidates for foster care (includes those who have previously been adopted or are in guardianship care) Children in foster care who are pregnant or parenting Parents and kinship caregivers who need services to prevent

disruptions

Types of services: Mental health and substance abuse prevention and treatment In-home parent skill-based programs, parent education,

individual and family counseling in the home Services must meet Evidence-based requirements: promising,

supported, or well-supported. Allows IV-E funds to be utilized for residential programs that

serve parents with substance use disorders AND their children; Additional investments to keep children safely with families

(and kin) and lead to permanency and/or reunification, such as Kinship Navigator programs.

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PresenterPresentation NotesA foster care candidate is a youth who is at imminent risk of removal, through either court interventions or an on-going case that reflects the risks of removal if in-home services do not control safety. Through the delivery of prevention services, children can remain in their home communities, with their meaningful family and friends, and remain in their school of origin. These services can help complement and strengthen the services provided within the school system to enable families to care for their children at home.

Care Management Research

A number of care management strategies for children have been explored and discussed in WV

DHHR has shared concepts with a number of stakeholders Legislation to move foster care into managed care has been

evaluated by the Legislature Active participant in Annie E. Casey Foundation efforts to improve

child welfare across the United States DHHR has conducted research on foster care in managed care,

including conducting an RFI and exploring efforts in other states, including the Georgia 360 model

Providers have expressed concern about managed care DHHR recently met with officials from Connecticut and is now

exploring the ASO approach for foster children and children at risk

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ASO vs MCO

Administrative Service Organization- Provides care management, ensures care coordination, and performs utilization management services in an incentive/ disincentive, non-risk based contract. Example: Connecticut

Managed Care Organization- Provides care management, ensures care coordination, and performs utilization management services in an experience driven, risk based contract. Examples: Georgia

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Care Management Concept

Develop contract for an array of services for children in foster care and children at risk of entering foster care

Link various Federal funding sources to maximize resources and ensure continuity to infrastructure developed

Manage social service needs and medical needs of children and families under one contractual arrangement

Build in incentives and penalties to ensure that vendor accomplishes goals set forth

Create additional resources for circuit judges, prosecutors, law enforcement and child protective services to maximize supports for children in need

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Holistic Strategy for Health & Human Services General Approach Risk identification via broad based health and social service

predictive modeling Combine health and human service funding streams to leverage

private market for measurable outcomes Risk mitigation through enhanced management of social

determinants

Serving at Risk Children Holistically Combine funding streams to maximize resources for children Attach case manager to foster children and at risk children/ parents Leverage private sector with contract outcomes to improve child

safety, reduce childhood trauma, and empower salvageable parents

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PresenterPresentation NotesSYSTEMS Must work together

Manage Risks Driving Health Care Costs

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Source: Care Source

Pyramid of Care

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Family unable to protect or treat at home

Families in crisis

Families needing specialized help

Families needing increased support

Families needing some support

All Families

PresenterPresentation NotesVickie JonesThe Pyramid of Care is a model for describing and examining the system of services for children and families. In the ideal world there would be preventive services readily available to meet families’ needs before there is a crisis. A pyramid like this is used to show that the majority of services and expenditures should be made at the base of the pyramid, where services are less costly and more preventive in nature. Crisis services are also more costly than preventive services, should be fewer in number, and are represented at the top of the pyramid.

The Pyramid of Care is based on the philosophy of moving resources from more intensive to less intensive services whenever possible. It also provides a framework for assessing which services may best meet the needs of an individual child and family, the families in a particular community, and the families in a specific region of the state.

The Pyramid is a tool that can be used by local communities, regional and state groups in determining what services are available and what groups can and should work toward establishing in their communities. These services are provided through a mixture of public, private, and voluntary sectors.

The “levels” on the pyramid represent an array of community and family support services. For example, “all families” can benefit from recreation opportunities and preventive health services. “Families needing some support “could find assistance through peer support groups or an advocate assisting with a school service planning meeting. In-home visitation programs for parents of premature infants or outpatient therapy are invaluable to “families needing increased support.” Child Protective Services and Youth Services are usually not involved with families until they reach the point of needing “specialized help” or are “in crisis.” Most of the out of home care system is represented in the very top level of the pyramid.

The Pyramid provides a common concept for discussing the behavioral health “continuum of care” and the child welfare array of residential and community supports.

Behavioral Health: Prevention – Early Intervention – Treatment – RecoveryChild Welfare: similar concepts, slightly different terminology……….transition to Sue

Despite the different terminology that may be used, the DHHR has come together with local behavioral health providers to create standardized definitions.

Critical Questions

What populations will be served? Foster children – Yes Adoptive children - Yes Children at risk of entering foster care - ? Parents of children in or at risk of entering foster care - ?

What services will be covered? Medicaid services – Yes Child Residential/ Emergency Shelter Services - Yes Socially Necessary Services - ? Wrap Around Services - ?

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Critical Questions What assessment should be used to identify at risk children?

What should be penalties/ bonuses in contract?

How can vendor be used to support CPS and Court System?

Should additional services be opened up? Functional Family Therapy, Therapeutic Foster Care, etc

What Federal Funding sources can be leveraged to maximize funding and build continuity across the system?

Should recruitment of foster care parents and critical providers be included in contract?

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Critical Questions

What data will be tracked?

How will vendor interact with CPS?

Should pharmacy be included?

Should children entering juvenile justice be included?

How do we integrate services into MDT process?

Should an ombudsman position be created and how should it be crafted?

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Stakeholders Circuit Judges Prosecutors Law Enforcement Education Officials Providers- Medical, Social Service, Behavioral Health Payers Child Advocates Probation Officers Education Officials Child Protective Services Social Workers Families Lawmakers ?

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Timeline

DHHR will complete an outline of proposed services to be covered in a new care management contract by July 1

Up to four public forums will be held across West Virginia from July through September. This will transition into monthly meetings on this subject to provide updates and gather additional feedback.

A procurement will be completed for care management services by the end of CY2018

Contract to be awarded and services in place by July 2019

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Contact Information for Feedback/ Questions

Jeremiah SamplesDeputy Cabinet SecretaryOne Davis Square, Suite 100 EastCharleston, West Virginia 25301Phone: 304-558-0684Fax: 304-558-1130Email: [email protected]: www.dhhr.wv.gov

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http://www.dhhr.wv.gov/

West Virginia’s Child Welfare Crisis�A Path Forward��West Virginia Moving ForwardWest Virginia Moving ForwardWest Virginia Safe At Home Socio-Economic ChallengesWV Risk Factor IndicatorsWV Mortality RatesWest Virginia versus United StatesInteractions with Health SystemsNeonatal Abstinence SyndromeWest Virginia BabiesAdverse Childhood EventsChild Protective Service Referrals Growth in Foster CareChild Welfare Indicators: Children in CareA Growing CrisisSlide Number 17Child Welfare ReformChild Protective Service ReformCare Management Benefits in Child WelfareThe Urgency of NowFamily First Prevention Services ActFamily First Prevention Services ActCare Management ResearchASO vs MCOCare Management ConceptHolistic Strategy for Health & Human Services Manage Risks Driving Health Care CostsPyramid of CareCritical QuestionsCritical QuestionsCritical QuestionsStakeholdersTimelineContact Information for Feedback/ Questions

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