The State of Missouri has formed the Missouri Interdepartmental Initiative for Children with Severe Needs, which is a consortium of child-serving divisions from the Department of Social Services, Department of Mental Health, Department of Health, and Department of Elementary and Secondary Education. The Initiative integrates funding from all the participating Departments to support comprehensive, integrated Plans of Care for children with severe behavioral health needs and their families, implemented under a single, unified care management process.
The Initiative operates in two regions of the State, an eastern region (an urban area comprising St. Louis and surrounding suburbs) and a central region (a more rural area in the center of the State). It targets children and families with disruption likely to result in long-term residential care. Eligible children for enrollment are between the ages of 4 and 18 who (1) reside in those regions, (2) are currently in or at serious risk of long-term residential placement, and (3) have serious behavioral health needs as measured by a standardized instrument (Childhood Severity of Psychiatric Illness, or CSPI). This population of children is likely to need services funded by multiple State agencies, and the State realized that better coordination of services was needed to reduce barriers, enhance effectiveness and efficiency, and prevent children from “falling through the cracks.” In addition, the State hoped to enable many of the children to stay in their homes or return home or to their home communities by providing community-based wraparound support services, thus avoiding unnecessarily long and expensive residential placements.
The State contracts with two agencies to deliver services and provide operational support. The Care Management Organization (CMO), currently the Missouri Alliance for Children and Families, has responsibility for developing a network of resources, assigning care managers, purchasing services, and monitoring the quality and utilization of services. The Technical Support Organization (TSO), currently ValueOption, supports the initiative by managing information, finances, quality improvement, and communication. An interdepartmental management team manages the planning, procurement and contracting, start-up, and implementation of the Initiative and oversees system operation.
On March 1, 1999 the first children were enrolled. Currently there are about 250 children being served at any given time. The Initiative was originally designed to enroll 1,000 children in multiple CMO’s, but there is only one CMO and the maximum capacity of that CMO is 250. Child welfare workers, juvenile corrections workers, and mental health workers refer children to the Initiative through interagency teams (IT’s), which consists of local representatives from each participating State agency. About 60 percent of the referrals are from child welfare, 20 percent from juvenile corrections, and 20 percent from mental health. The IT enrolls and assigns children and families, reaching all decisions by consensus. Each eligible child must meet the criteria specified previously; there is a cut-off score for the CSPI, then all children who meet the criteria are enrolled as long as slots are available. Teams are notified each month how many openings are available.
The date that the IT enrolls a child is the day that State services cease and the CMO becomes responsible for all care and costs. The State’s practice is to give the CMO about two weeks lead time to review the referral and become acquainted with the child and family before becoming responsible for services. The minimum services required for each child include care management, team meetings, and development of a Plan of Care. The contract specifies that the CMO may not refuse any referral or disenroll any child from the Initiative until all plan of care objectives are met and the IT approves disenrollment (a “no reject, no eject” policy). The CMO is required to deliver services required by the treatment plan and is responsible for all costs except physical health, which is covered by Medicaid. Children are enrolled for six months; if necessary, an additional three-month period may be authorized.
The CMO is required to assess the child and family within 7 days of enrollment, and have in place an individualized, community-based Plan of Care within 14 days of enrollment. A family support team, consisting of the care manager, the family, the child, providers, neighbors, school personnel, the referring agency, juvenile court) develops the Plan of Care, monitors progress, and recommends disenrollment. The list of services that the CMO is required to make available is extensive, and includes inpatient psychiatric evaluation and treatment, residential treatment, residential sexual abuse and offender treatment, alcohol and drug abuse treatment (inpatient and outpatient), foster care, respite care, adoption services, educational services, outpatient psychiatric services, psychological consultation services, medication management/monitoring, individual/group/family therapy, crisis intervention stabilization, assessment, case management, intensive in-home services, day treatment, family support group services, wraparound services, crisis intervention access, residential support services, community integration support services, transitional living services, school-based behavioral support services, transportation, recreation, parent aide, supported work services, and mentor services.
The CMO, the Missouri Alliance for Children and Families, is a limited liability corporation (private for-profit) set up specifically for the contract under the Initiative. Its primary mission is to provide wraparound services under case rates to move children from restrictive placements to their home or other places within the community. It consists of nine member agencies – eight residential treatment providers and one psychological counseling agency – and was established in response to the growing movement of child welfare into managed care.
The CMO is paid a case rate that begins when a child is enrolled. Currently the case rate is $3,329 per month, with $226 per child for case management. The case rate was originally set up based on the 1,000 most expensive children in the two regions, and the Initiative was designed to include at least four CMO’s, each of which would receive a cross-section of the 1,000 children. As it turned out, only one CMO bid on the contract (probably due at least in part to companies concerned that the cost would exceed the case rate), and the most expensive (rather than a cross-section) of the children were referred to the initiative. Accordingly, the case rate was low. After the CMO lost money the first year, the state covered part of the loss. The CMO contract specifies 3 percent risk sharing – 3 percent of the budget was set aside to handle high-cost children – but there was no procedure established to access that risk pool.
The case rate is financed by contributions from divisions within the Department of Mental Health (DMH) and the Department of Social Services (DSS). The percentage at which each division participates was calculated from the actual expenditures identified in the historical costs for the target population. The contributing percentages are as follows:
- DMH/Alcohol & Drug Abuse – 0.57%
- DMH/Mental Retardation & Developmental Disabilities – 1.72%
- DMH/Comprehensive Psychiatric Services – 12%
- DSS/Youth Services – 7.22%
- DSS/Medical Services – 17.51%
- DSS/Family Services – 60.99%
The TSO, ValuOptions, documents performance and collects data pertaining to quality and outcomes. The CMO is required to report data on outcome, but that process is still being refined. The CMO monitors quality of services – the care managers monitor children’s progress and CMO staff conduct site visits to the residential facilities. The CMO reviews service utilization weekly, especially for the most expensive children, to make sure the teams understand that the goal is to move the children into the communities. Researchers at Washington University are evaluating the initiative, with a comparison group of children, but the evaluation is just beginning.
The goal of the initiative was to design a more efficient and effective way to spend the dollars, and provide flexibility to enhance outcomes. The creation of interagency teams resulted in broader cooperation generally between the member public agencies, and they now enjoy enhanced relationships across the board, not just with initiative cases. When the system moved from fee-for-service to case rates, a different composition of services was needed – especially more workers to work directly with families. And the initiative has not had a drastic impact on the court’s role, but it does divert some children who came into the child welfare system only because placement with the State could get them services, not because there were child abuse and neglect issues. Now the children do not have to be in the custody of one of the agencies to receive services.