9/26/16 CCR MENTAL HEALTH WORK GROUP
MENTAL HEALTH SURVEY
During the meeting today, one of the main topics of conversation was the need for placed children youth who have mild to moderate needs (not on psychotropic meds, struggling, but not crashing and burning) having access to preventative, early intervention mental health services. 53 of the 58 California counties have County Mental Health Programs and it was stated that those programs offer preventative, early intervention mental health services.
The survey question is: are there counties where you serve in which it is difficult and/or challenging for your families and the children/youth in placement with mild to moderate needs to access preventative, early intervention mental health services? If so, which counties?
9/26/16 CCR MENTAL HEALTH WORK GROUP IFORMATION
This meeting carried quite a bit of gravitas – Will Lightbourne, Director of California Department of Social Services and Jennifer Kent, Director of the Department of Health Care Services were in attendance. There were also numerous top officials from many counties in person and on the phone.
The stated goal of this meeting was to create clarity regarding the mental health services that are available to foster children/youth. Following were the main topics of discussion during this meetings:
- The attached Mental Health Referrals power point was created in 2014 and had been updated for this meeting, although the definitions are from the DSM IV and needs to be updated to DSM V. County Mental Health Plans do the initial screening and what services they may qualify for. The County Mental Health Plans can refer the assessment to licensed clinicians. If a child/youth meets the need for medical necessity, a plan for Specialized Mental Health Services can be put in place.
- It was stated that disputes should first be discussed in CFTs (Child Family Teams). After some discussion, it was clarified that those disputes would be regarding the types of services the child/youth needs and by whom they may be provided. Any disputes regarding who is responsible for payment need to be settle between the primary providers and not in a CFT setting. It was emphasized that the determination of care for a child/youth needs to be made at the local county level.
- In the three page Medi-Cal System handout, on page 2 it was pointed out that on item (2) “a reasonable probability a child will not progress developmentally as individually appropriate” which is a common challenge for children who have experienced trauma, but at no point in the document is “mild to moderate needs” stated. CDHS stated that the decision is made at the County level. It was then pointed out that it might better delineate between specialty and non-specialty mental health services rather than specialty mental health services and children/youth with mild to moderate needs.
- A question was asked regarding the handout “CDSS Foster Care Clients by DHCS Delivery System” because the third box at the top of the table addresses “psychosocial services” but that term was in none of the other handouts or literature. It was clarified that it is a catch phrase that includes specialty mental health services. It was brought up that it would be helpful to have standardized language and terms among the different entities to provide clarity. For example, in social services, permanency for children/youth is the goal (so that every child may have a forever family), but in Mental Health permanency is that the individual is to receive mental health services for the rest of their lives and Mental Health does not want to do that. So the same word has extremely different meanings. It was suggested that to create even greater clarity that documents that explain mental health services, who provides them, and how to access them can be made specific to each entity in terms that the know and recognize.
- A Public Health Nurse brought up that in their capacity, they frequently refer to fee-for-service (also referred to as fend-for-yourself) and these services do remain with the child/youth and a rarely disrupted.
- There are counties where the County Mental Health Plan is contracting for mild-to-moderate services and a representative from LA county pointed out that the auditors that review all their financials need very clear definitions for all terms and a clear statement regarding who can provide specific services or they will disallow the costs. Clear definitions of what “mild to moderate” encompasses and who is contractually responsible for the services provided are needed. CHCS stated that the state would not oppose the counties contracting out some of the services.
- A SELPA representative asked what can be done when the school system has a child/youth who needs mental health services and neither County Mental Health nor Managed Care will provide services? He stated that there is one SELPA that is facing bankruptcy because they have been paying out on mental health services for children/youth out of their budget. The Las County representative suggested that they contact their local District Attorney.
- And, at the end, it was again requested to define what “mild to moderate” means for youth, since the legislation that addresses that issue only defines it for adults.
There were no further CCR Mental Health work group meetings announced.
8/29/16 MENTAL HEALTH/CCR WORK GROUP INFORMATION, PLUS A UNIQUE RESOURCE FOR ADOPTIVE PARENTS
he Mental Health CCR work group had been meeting for a number of months and had been working through topics to determine clarity and direction for the impact of CCR on the Mental Health system. It was thought that this was likely the last of the work group meetings and there were four items on the agenda, all focused on supporting and serving children/youth in care with mild to moderate behaviors and needs. The topics for discussion were What is the role of the Managed Care Plan, What are the MOU requirements between the Managed Care Plans and the counties, How to engage the MCPs (Managed Care Plans) in this discussion, and Fee for Services for children in foster care.
I must give a disclaimer here – there was much discussion about the nuances, details, and in-workings of Mental Health services and Managed Care. Those topics are not my forte, so there is much that went over my head and I may not do a great job in relaying the particulars of the meeting. However, attached is the power point that was shared by the representatives from Managed Care and I will do my best to summarize the meeting as I understood it. Page references are for the pages of the printed power point. FYI, there were many county Mental Health representatives both in the room and on the conference call.
The Managed Care representatives began to go through the (attached) power point slides one-by-one. There are new Federal mandates now impacting Managed Care requirements and the plans are working on implementing them. In California, there are six types of Managed Care plans (page 2). Each plan has its own procedures for coordinating services. Managed Care is tasked with oversite of preventative health care services for all medi-cal recipients under the age of 21. This does include Developmental/Behavioral Assessment that covers developmental screening, autism screening, developmental surveillance, and psychosocial/behavioral assessment (page 4). It is the task of Managed Care to organize “member care and sharing information among all the participants concerned to achieve safe and more effective outcomes of care” which includes “specialty mental health.”
This is where the meeting got both interesting and quite confusing (and not just for me). One of the greater challenges this work group faces is that the laws and regulations regarding child welfare, Mental Health, Managed Care, and educational support/counseling/special educational systems were created at different times, by different entities and, from my perspective, it appears that the “powers that be” never compared notes. So, the bottom line (from my understanding) is that although it is clear that Mental Health comes into play when there is a significant mental health diagnoses, there is no clear flow of what services Managed Care can and will provide for foster children/youth with mild to moderate needs and what criteria would allow children/youth with mild to moderate needs to receive some short term mental health style services through Managed Care under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program (page 4). Sara Rogers from the CCR division of CDSS is working hard to ensure children/youth of trauma have access to lower level (Managed Care) services as a preventative measure to keep them from decompensating and needing higher level specialty Mental Health services as a result of a significant diagnosis to what may have been a preventable event.
Education representatives also stressed that it is frequently in schools that many of the issues present themselves that result in a child/youth being referred to Managed Care or Mental Health Services. If there is an IEP, the school is mandated to provide services and, in some financially strapped counties, Managed Care and/or Mental Health will state that since the child/youth is receiving services, their help is not needed, leaving the school on their own, essentially providing mental health services without the support or funding.
There was a general consensus in the room that having CDSS, Mental Health, Managed Care, and Education in the same room discussing this issue was a long overdue and much needed. Karen Baylor of DHCS, who chairs the work group acknowledged that these issue and concerns do need to be worked through since the CCR deadline for implementation is 1/1/17 and much hinges on the gaps, questions, and details that need to be worked out in a collaborative effort by the different departments and divisions.
I cannot guarantee that my summary of the meeting is accurately representative of what occurred because I am under-informed regarding many of the nuances, nuts-and-bolts, and particulars of Mental Health and Managed Care. I hope my re-telling does not lead to any misunderstandings or significant errors.
A UNIQUE RESOURCE FOR ADOPTIVE PARENTS
It is not uncommon for adopting/adoptive parents to struggle with how to talk about adoption with the children in their home (both adoptive and birth). There is a website ADOPTION AT THE MOVIES that coaches adoptive parents how to use kid-friendly movies as an easily-accessible bridge into hard-to-access territory. Please visit http://www.adoptionlcsw.com/
7/28/16: THE NATIONAL ADOPTION COMPETENCY MENTAL HEALTH TRAINING INITIATIVE
TO BEGIN WITH…
As you either already know, or will soon come to know, accreditation requires ongoing clinically sound training for staff. How would you like the opportunity to have your staff take a high quality, evidenced based and informed, clinically focused 20-hour training, with CEUs, for FREE?
That is an opportunity FFAs in California have due to the National Adoption Competency Mental Health Training Initiative (National training Initiative or NTI for short). The Center for Adoption Support and Education (C.A.S.E.) is an organization dedicated to supporting best practices and innovation in the foster care/adoption industry and to provide premier resources and training to advance permanency for children and promote the healthy growth and development of families, nationally and internationally. They have long wanted to create a standardized, nationally applicable, adoption competency training and, with a RFP from the federal government, they now have that opportunity.
THE NATIONAL ADOPTION COMPENTENCY MENTAL HEALTH TRAINING INITIATIVE
C.A.S.E. and their partners, Children’s Bureau and the University of Maryland School of Social Work, have been working hard to make that training a reality and they are ready for the beta testing. They eventually will have the 20-hour Child Welfare focused training (which will come out in January 2017 – a date we are all very familiar with), a 23-hour child welfare supervisors training, a 25-hour mental health practitioner training, and a 4 session series on coaching for mental health practitioners. The overall goals of this series of trainings is to build capacity, improve outcomes, and to complement existing initiatives. When AB 1790 was passed in 2014, a primary goal was to remove barriers to permanency and when the state heard about NTI, they sought them out to see if California could be part of this initiative. NTI has been tasked with rolling out these trainings over the next year in 8 pilot states to “test” the trainings and receive feedback to fine tune and improve the trainings before the official national roll-out in 2019.
NTI wanted to make sure their 8 pilot states presented a broad range of populations, process, and structure with the goal of creating a final product that would work everywhere. California has been chosen as one of the 8 pilot states and with RFA, CCR, and accreditation fast upon us, a free training of this sort, at this time, is an amazing opportunity. With RFA, it is important for all FFAs to become adoption informed. What agency hasn’t had children adopted, whether it was by one of your parents or someone else? Don’t you want to support that success? The Adoption Competency Mental Health Initiative is a FREE evidence based and informed, and clinically competent, training with CEUs!. It is a godsend for FFAs.
Yes, I am “selling” this hard because I see incredible value for the FFAs in California at no cost. That is really helpful at a time when we are all spending more on accreditation and have less money available for clinical training. I am a graduate of both ACT (Adoption Clinical Training) and TAC (Training for Adoption Competency) and the people that created those trainings helped create NTI. Any agency that has taken ACT or TAC know that although the content has an adoption focus, the bulk of the information applies to all children/youth in care. The competency foci of the training include children’s mental health needs; attachment; race, culture, and diversity; loss and grief; trauma and brain development; positive identity formation; and promoting family stability pre and post placement. Increased competency of your staff on these key issues will help and support any child/youth in care, whether adoption is part of their case plan of not.
WHAT’S THE TRAINING LIKE AND WHAT’S IN IT?
During the meeting they showed us a number of parts of the training and it impressive in both presentation and content. This is not mere power point presentation or webinar; it is interesting and ”slick” in the best possible sense of that word. There is a ton of variety in the slides presented, lots of interactive functions, videos, with resources that can be opened and downloaded. Rather than give data which can become outdated, they give links to the sites that have the most current data. It is formatted so someone can’t just hit play on a video, walk away, and get created for 15 minutes of training. It is designed so the student is actively involved with the information being presented and the progress is monitored so that it someone takes a break from the training, when they open it up again, it goes to where they left off. BUT, you are not stuck only going through the material sequentially. There is a full menu on the right side of the screen and the student can go to any lesson at any time. This training is designed to be very practical, very pragmatic, and quite interesting.
WHAT’S THE CATCH?
NTI needs at least 200 students to complete the training in California in order to fulfill the requirements of the study. The good news is, there is no upper limit on the number of students. Literally, every FFA could have all of their social work staff and social work supervisors take the NTI training. There are three conditions: 1) an agency must have at least one social worker who serves children/youth in placement, plus their supervisor, take the training, 2) It is best if the participants complete the 20 hours of training in four months (5 at the most). That is just 5 hours of training a month, and 3) they need to give C.A.S.E feedback regarding their experience of the training and, most importantly, did the student’s manner of serving and supporting the children/youth and families change as a result of this training and, if so, how? That’s it.
As California FFAs, we can let other agencies and entities take part in the beta test of NTI and wait until 2019 for the final version, or we can have as many of our social work staff and supervisors as possible participate and get an incredible beta version first thing in 2017.
(I told you I would be biased)
SO, WHAT NEXT?
NTI will be working with the team of stakeholders that were invited to this meeting to create a State Implementation Team to determine who would be offered a chance at this and to work with NTI on the development of the roll-out and coordinating efforts for at least 200 students to complete the training and fulfill the three conditions outlined in the paragraph above. The good news is, FFAs are definitely part of that group that gets a chance to take the NTI training.
Again, the child welfare part of this training will be available in January of 2017 (yes, the same January 2017 with RFA, CCR, and having applied for accreditation). In the meantime, please talk this over with the leadership in your FFA. My bias is that every FFA could benefit from this, but you may not be so inclined, or you may want to have just one social worker and their supervisor take the training; obviously it is up to you. Later this year (I am not sure when) we will let you know when and how you can throw your hat in the ring to be part of this opportunity. We will keep you posted.
7/26/16 CCR STAKEHOLDER IMPLEMENTATION ADVISORY COMMITTEE MEETING INFORMATION
The official purpose for this committee is to “obtain input/recommendations on policy, best practices, and other aspects of CCR implementation.” Much of the 7/26 meeting was giving update in a number of areas.
Sara Rogers, of the CCR division of CDSS shared that CDSS had sent out an ACIN regarding AB 403 policies and implementations, including information about AB 1997 (which is in State Senate appropriations) which clarifies Mental Health integration, entrance criteria to a STRTP, plus some clarifications on RFA. Those are all statutory items. The interim written directives are in the final stages of development. They also released a RFA specific letter to the counties and sent out the county implementation guide along with the AB 403 ACINs with a lot of encouragement for the counties to collaborate with the providers in their county.
CDSS has been having regional convenings to keep the counties informed of the changes required by RFA and CCR to ensure there is truly a continuum of care at the county level. The convenings CDSS has had so far have been productive. Within a day or two a draft letter should be going out for review that talks about rate structure and level of care (LOC) protocols being developed, interim standards, and engaging in local implementation. See the attachment “CCR Updates.”
FYI, the handouts for this meeting will be attached to the email with this newsletter. Also, when I include all the handouts, the email becomes huge. So, from now on, newsletters with lots of attachments will be sent in zip files.
RATE STRUCTURE AND LEVEL OF CARE
Cheryl Treadwell of the CDSS Audit and Rates Bureau shared that they have a level of care assessment work group evaluating currently available tools that are used in specialty care. Their goal is to create a checklist approach to inform a level of care and subsequent rate. They are also looking at the number of type of youth that may be transitioning out of group homes into family settings. A group home extension letter is being developed that addresses requirements and expectations and should be released in a week or two. There will be another ACL released in about a week that that introduces the home-based and STRTP rate structure, along with the rates for TFC (previously ITFC).
There will also be a letter coming out about accreditation reimbursement that will explain the process and outlines the documentation that will be needed. Specifics regarding the criteria and time framework is still being developed. It should be done and released soon enough that as of August 1, 2016, agencies will be able to submit a request for up to $5000 reimbursement. This can be requested by agencies that have paid their accreditation fees on or after July 1, 2016.
MENTAL HEALTH PROGRAM APPROVAL/MEDI-CAL CERTIFICATION
All the information shared on this topic was in the 7/25 CCOFFA newsletter.
Sara Rogers shared that CDSS is progressing well in creating the interim standards. A copy of the revised FFA regulations for review should be sent to stakeholders within the week. Version 3 of the RFA will also be going out for review. The STRTP interim standards are expected to be released for public comment in August. Also, the outline for Program Statements will also be sent out soon for review. Sara shared that the format for Program Statements is going to look quite different with a strong emphasis on how an agency will access services for the children/youth they serve. Under AB 1997, if an agency has not submitted its updated Program Statement to CCL by 1/1/17. They can continue to work with the families they already have, they will not be able to approve any new families until the updated Program Statement has been submitted. FFAs do have until 12/31/18 to submit their updated Program Statement, but would not be able to approve new families or get the new provisional rate until the update has been submitted to CCL.
REGIONAL CONVENING/LOCAL IMPLEMENTATION
As noted above, CDSS has scheduled regional technical assistance convenings targeting county and state staff for all the various departments and divisions that will be impacted by, and participating in, CCR and RFA. Eventually, these convenings will be open to providers as well, but the focus right now is getting all the state and county elements up to speed with CCR and RFA and providing technical assistance for the implementation of CCR at the local level.
Q & A TIME
The meeting was then opened up to a question and answer session on any of the items addressed above:
- Are all ACLs and ACIN’s online? Yes, all that have been released, but not those in process. See: http://www.cdss.ca.gov/lettersnotices/
- During the transition time of group homes becoming STRTPs, can a transitioning group home have youth both under the RCL funding structure and the STRTP funding structure? The response was, “It still needs to be teased out.” A request was made that the upcoming Mental Health Certification ACL specifically address this question, even if to say it is being looked at.
- It was shared that soon the interim standards and version 3 of the written directives would both be released soon. Is there a difference? The written directives are specifically written for the counties’ implementation (although a section talks about the families). That is why there is a large section about county-based due process. FFAs are addressed in the interim standards and the standards are what FFAs should focus on. When version 3 of the written directives is released, there will be an explanation of the differences between version 2.1 and version 3. CDSS is targeting to releases bot for review by early August so they can receive feedback by August 15, so the final releases can happen on August 30.
- Regarding the upcoming CFT letter, concern was expressed that it recurrently refers to family, but rarely refers to parent. A large part of CCR is, whenever possible, a child/youth is reunified with their birth parent. It was requested that “parent” is put into the document as needed.
- Does and agency have to have a separate Program Statement for each program they have? No, each can be included as part of the single Program Statement. One shift of focus with the new approach to Program Statements is it is important to address how the children/youth will be served.
- The question was asked what to do with youth in group homes where the group home can’t or won’t transition to a STRTP, what happens if there are no homes for the child/youth to go? That is part of the reason an extension can be granted to a group home. (Up to 2 years if they extension is requested by a county; it can be longer if requested by probation.)
CYC in conjunction with Youth Engagement Project had a full day convening on how to better inform children/youth in care about CCR. The youth felt it was important that children/youth understand that CCR is something that thy are part of, rather than it being something that is done to them. Please read the following attachments for the pertinent information: “Youth Engagement in Continuum of Care Reform Convening” and the handouts starting with “Continuum of Care Reform, For a Better Foster Care System.”
The question was asked if the FFAs and Group Homes are having conversations with their children/youth in care about CCR. One respondent on the phones shared that they have not because there is so much that is still unknown to the FFA. Also, sometimes they get wrong or incomplete information and they do not want to pass on inaccurate information to the children/youth. At this point, without knowing what LOC a child/youth may qualify for, they are not even sure what funds they will have available for services. The response from the California Youth Connection representative was that FFAs should be as transparent as possible and stress that these changes are intended to improve the foster care system. It is much better to talk with the youth than simply talk about them. It was also stressed that even if a child/youth’s situation is such that they may not feel much of a change due to CCR or RFA, still let them know because it may impact one of their siblings in care elsewhere.
TARGETED RECRUITMENT/PERMANENCY SUPPORTS PRESENTATION
There was a panel discussion with representatives from Sacramento County, Families Now, and Sierra Forever Families to address targeted recruitment. Please see the following attachments for important information: “Targeted Recruitment/Permanency Supports Presentation Panel” and “Recruitment and Retention of Resource and Permanent Families.”
Sacramento County partnered with a couple of adoption FFAs to find adoptive homes for youth coming out of group homes. They stressed that is a unique opportunity to recruit for a specific child, rather than recruiting families for a specific age and gender. They shared that public private partnerships are extremely helpful in this type of recruitment. Sierra Forever Families partnered with Sacramento County for the “Destination Family” program. They focused on children/youth that had been in care for two years and had not found permanency. They reviewed five youth each month.
The philosophy is that every child needs a permanent family relationship, even if it is not a legal arrangement. There is no child that is unadoptable and those children/youth that say they are not interested are not interested in being rejected yet again. They shared that it takes two to three years of a dedicated worker working with a child/youth in a supportive manner to open up the possibility of adoption for a child/youth who is afraid of being rejected again.
A single gay foster father shared his story of how he shifted from wanting a toddler to adopting a teen who is transgender. His adopted daughter was part of the panel. He shared his story with both candor and humor. He shared that he had no interest in adopting a teen until he said he was willing to meet a specific teen. They immediately clicked and eventually he adopted her.
African American and LGBT children/youth are over represented in the foster care system, and especially in group homes and need caring families to adopt them – emotionally if not legally. Relational permanence does not mean a child/youth has to live with the person that will love them for life.
7/25/16 CCR MENTAL HEALTH WORKGROUP MEETING INFORMATION
One of the foci of the meeting was to look at CFTs, what are the guiding principles and expectations for them, and what is Mental Health’s role. Planning meetings for the child/youth and involving the birth family are not a new idea. AB403 requires that CTFs are held to inform the case plan for a child/youth in care and address potential changes in services and/or placement. CDSS is currently drafting a letter to the counties regarding the funding for CFTs and how they are to support the core models of child welfare and Pathways to Wellbeing (Katie A). The goal of giving counties additional funding is to assure high quality CFTs.
The draft of the funding letter is expected to go out to stakeholders within a day or two for feedback. AB 403 put the placing agencies, welfare or probation, in charge of setting up the CFTs. It is anticipated that a child/youth will have their first CFT within 60 days of coming into care, and then as needed. There has been discussion about regularly scheduled CFTs, but they are really supposed to be driven by the needs of the child/youth rather than a calendar. CDSS will be giving classes on CFT and are working on the requisite documents.
There was quite a bit of discussion regarding whether education will be a part of CFTs. The general consensus is that there should be educational representation, be it a teacher, school counselor, class aide, or administrator. The greater challenge will be scheduling a CFT so an education representative could attend. It was noted that general education teachers may not attend, but it would be best if special education teachers attend due to the needs of the child/youth. In LA county, they have been working hard at implementing CFTs and they discovered that when funding is available for educational representatives to attend, they showed up, but when the funding went away, they quit attending. An educational representative stated that it would be good for teachers to be made aware of CFTs so they have the opportunity to attend.
Additional information regarding CFTs:
- Parent partners will be allowed to be part of a CFT.
- As noted, there is funding for CFTs, but the Child Welfare allocations are yet to be determined.
- Mental Health has also received funding to support their participation in CFTs.
- The question was asked if the ACL creates a mandate for education, or any other entity, regarding CFTs. The answer was that the ACLs only create a mandate for the counties.
- It was shared that San Francisco county has done well implementing CFTs and it was suggested that CDSS contact them for feedback. The biggest challenge has been the logistics of getting all of the critical people to a CFT at the same time. They have even had the individuals share calendars so workable dates could be found. Once of the critical aspects of CFTs is collaboration ant it may be necessary for some CFT participants to be there via conference call.
- Someone asked what the “endgame” is for CFT. Sara Rogers shared that the endgame is to meet the needs of the child/youth with the goal of permanency.
- A representative from Uplift, which is an early implementing FFA, shared that the children/youth we serve have more complex cases and it is likely that there will be a core CFT team of 5 or 6 individuals who will make determinations from the feedback of the other participants. There will also need to be developmental considerations for children too young to actively participate in a CFT.
- It was agreed that it is very important for the provider to be present at CFTs, as well as critical Mental Health representatives.
- There was concern expressed that CFTs need to have permanency competent individuals present during decision making since much damage has been done when decisions were made by people not aware of permanency and adoption dynamics, and some decision have made things far worse for the children/youth and have even disrupted adoptions.
FFAs AND “MEDI-CAL 101”
The Department of Health Care Services (DHCS) plans to help FFAs and group homes learn about the required Mental Health certifications (program and medi-cal) and specialized mental health services. They are discussing using webinars and/or live classes. Possible topics include medical necessity, qualified services, how to obtain medi-cal certification, contracting, documentation, and training. They are still working on when these trainings would be offered and how many would be offered.
One of the greater challenges is that mental health service is complex and there is a lot of variety of expectations, requirements, and opportunities between counties. The biggest gaps for FFAs that have not yet worked with specialized mental health services is the necessary business model, which includes quality management and disallowances (where services are provided but the FFA finds out later they did not qualify for payment). Also, since providing a specialized mental health service is very expensive due to a broad range of requirements and expectations, as well as the required staff, a program that serves a small number of children/youth (20 for example) will lose money on that service.
A representative from a smaller county shared that they have just 5 children who qualify for managed mental health care and they are in three different resource homes. It takes larger FFAs with additional programs to help serve these children/youth properly.
It was shared that the higher level of care provided for a child/youth, the more it makes sense for the provider to offer those services directly (e.g a TFC program).
In response to Katie A, LA county has been geomapping where children/youth are placed and knowing what mental health services are readily available and by whom they are offered.
This lead to a discussion about how a FFA can obtain the necessary information regarding a new placement in order to have a Needs and Services Plan that serves the child/youth well and supports the goals established in the child/youth’s CFTs. FYI, “Needs and Service Plan” is a foreign term to Mental Health. It was suggested that the focus of a child/youth’s first CFT would be to gain all necessary information to create an appropriate individualized plan. It was shared that FFAs commonly get little information regarding a child/youth at time of placement and it is not uncommon for it to be quite difficult to get information after that from the county. There are times that FFAs are told by county representatives that due to confidentiality, they cannot share information about the child/youth that was just placed with the FFA. There needs to be a way to ensure that the FFAs get the necessary information regarding a child/youth in a timely manner so they may help meet the permanency goals for that child/youth.
It was shared that, at times, county counsel can be overly conservative about what a county is to do and the ACLs and ACINs are very helpful.
There also was discussion about how, depending on the counties, certain wrap services can be “locked up” by a few providers. leaving no opportunities for other FFAs to offer similar services. For smaller FFAs without licensed staff, they have no idea if they have anything to offer that the county would want. It would be helpful if county Mental Health could share what services are fully provided and which need providers.
A mental health representative also shared that if county Mental Health explains all the challenges of creating a specialized mental health service and the accompanying business model it requires; it can appear to the FFAs as if Mental Health is coming up with excuses to not work with them. It was suggested that the State take the role of informing FFAs the challenges, requirements, and expectations that come with offering specialized mental health services. Also, it was shared that if an FFA does not set up their service well, much of the work falls on the Mental Health Provider.
INFORMATION FROM THE 7/22/16 CCR FFA/STRTP WORKGROUP MEETING (with a heavy emphasis on STRTP)
This meeting’s agenda ended up with a large portion being dedicated to STRTP (short-term residential therapeutic program) issues. Group homes are not a focus of CCOFFA, but since a number of FFAs also have a group home division, that information will be included in this newsletter. However, it will start with FFA related items and then the STRTP items, so feel free to stop reading when we get to the STRTP section.
The meeting began with updates from Sara Rogers, Bureau Chief for the CCR Division of CDSS:
- There have recently been a number of All County Information Notices regarding CCR.
- AB 1997 is a bill that clarifies a number of issues within CCR and is currently being reviewed by the State Senate Appropriations Committee. For FFAs, Mental Health contracts are NOT mandated or required; however, FFAs must engage with their county Mental Health to know who is providing what services locally. There is a plan to develop a Technical Support Division for information and communications. To review the bill, go to: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160AB1997
- Counties will be receiving budget funds for foster parent recruitment and retention and Sara Rogers encouraged the FFAs to see how they may able to partner with their counties in these efforts.
- Also an ACIN was sent to the counties encouraging them to work with their providers on the various aspect of RFA and CCR.
- There will soon be a letter coming out giving clarification and guidance regarding CFTs (Child Family Team meetings) with the goal of having quality CFTs. The draft of the letter will be available for public review in a few days.
- CDSS is still working on the interim standards for CCR and they hope to have the FFA standards out in early August and the STRTP standards will come out later for public review. The standards will then be adjusted as needed based on the feedback received.
- The Mental Health workgroup is working on the medical necessity criteria, as well as discussions on trauma and how trauma may qualify as medical necessity. Also being discussed is how children/youth with mild to moderate needs can access managed care or fee for service. They are also working on a FAQ info sheet. Please send any questions for the FAQ to Theresa Thurmond at email@example.com
- CDSS is working on a letter clarifying FFAs requesting reimbursement towards their accreditation costs. FFAs that completed the process in the last two years in anticipation of the requirement asked if they could file for reimbursement as well. That topic is being discussed at CDSS.
REQUIREMENT FOR COUNTY REVIEW OF UPDATED FFA PROGRAM STATEMENTS AND PROGRAM STATEMENTS FOR NEW FFAs
Rami Chand, with the CCR Division Program and Services, shared information regarding the requirement for County review of updated FFA Program Statements and Program Statements for new FFAs (see attached Sec. 13. Section 1506.1, Program Statement Review Process, and sample request letter). With RFA and CCR, all existing FFAs need to update their Program Statements and a copy of those updated Program Statements must be sent to each county in which they have offices and from which they receive placement referrals. That review needs to also include a request for a letter of recommendation. The good news is that a FFA only needs one single letter of recommendation, regardless of how many counties they serve, to continue functioning. Also, that recommendation can come from any county and does not need to be from the county or counties in which they have offices. The bad news is, if an existing or new FFA cannot get a single letter of recommendation, they will not be able to access AFDC funding, and thereby will have to close their doors. A letter of support is considered the same thing as a letter of recommendation. Please note, since this letter of recommendation is based on the updated Program Statement, current letters of support will not fulfill this requirement. The counties have requested that they get to see of any letters of non-support issued for an FFA and CDSS is considering that request.
Additional issues and questions included:
- Some FFAs are not accepting placements from the county in which they have an office, and that is a concern to those counties.
- Some FFAs have shared that they have been trying to engage with their counties and the county either has not cooperated or are not sufficiently progressed in RFA and CCR to engage in conversations with the FFAS. It was suggested that each county have a specific contact person to engage the FFAs in the changes taking place. There will be a ACIN (All County Information Notice) again encouraging the counties to engage he FFAs that support them regarding all the upcoming changes.
- There was a question whether CDSS was still issuing state-wide adoption licenses to larger adoption FFAs that serve multiple counties, and the answer was, yes; there have been no changes to that.
- Since CCL will be flooded with updated Program Statements from 207 FFAs, they will obviously not be able to review them all by 1/1/17. So, all FFAs that submit their updated Program Statements prior to 1/1/17 will start receiving the new rates on a provisional basis until CCL has had the chance to review their updated Program Statement.
The Audit and Rates Bureau is working on an assessment protocol that will help determine the level of care (LOC) and subsequent applicable rate. This is NOT the same as CAN or TOPS assessment, which is an assessment of the child/youth; this is an assessment protocol regarding what types of needs qualify for the four levels of care (LOC). Five core domains were determined that will factor into the assessment protocol, but the details are still being worked out.
Someone asked if the CFTs (Child Family Team) meetings will determine the level of care (LOC). The answer was that it will not determine the LOC, but will help inform the final determination.
MENTAL HEALTH APPROVAL INFORMATION
There were two representatives from the Department of Health Care Services (DHCS) to discuss Mental Health Program approval. The vast majority of what they shared was regarding STRTPs and is addressed below. They did share that FFAs do NOT need Mental Health Program Approval, but just the Medi-cal billing approval, which needs to be renewed every 3 years. If FFAs have wrap or day treatment centers, those may require additional approvals.
For FFAs that do or plan to have TFC, they will need to apply for a NPI (National Provider Index) number. Evidently, it is very easy to apply for a NPI number and does not take much time.
Under AB 1299, “presumptive transfers” are being worked out so a child/youth placed in a county other than the county of origin can receive Mental Services from their county of residence.
STRTP (SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM) SPECIFIC INFORMATION
As shared above, most of this meeting dealt with STRTP specific information and CCOFFA’s focus is on FFAs. However, since a number of FFAs also have group homes, we will share the more important information:
- AB 1997 includes clarifications of on Mental Health provisions for STRTPs, including the fact that they need both a Mental Health Program certification, as well as a medi-cal billing certification. Group homes that intend to become STRTPs need a count of their youth placed that require specialized Mental Health services.
- The new rate structure letter regarding the 1/1/17 roll-out for STRTPs has been drafted which includes a range pf rates based on the level of services provided. The CWDA (County Welfare Directors Association) is reviewing the draft.
- AB 403 is requiring significant changes for group homes, so a group home can have a county ask for an extension for that group home beyond the 1/1/17 start date to give them time to convert to a STRTP. Yes, you read that right – a county has to ask on behalf of a group home. There is a draft letter being developed. The letter will be reviewed by the Audit and Rates Bureau which will check to see if the county is working on developing capacity for step down youth and they will look at the history of the group home as well. A request from a county can end up with a two-year extension. At this point, there is no time limit on an extension requested by probation. A group home cannot ask for the extension for themselves. There will be clarification letters coming out regarding Mental Health certifications and new program statements. CDWA is reviewing those letters and a third letter regarding accreditation is being drafted.
- Regarding group homes getting an extension to convert to STRTPs, they will continue to receive the current RCL rates until they convert to a STRTP. Unless a group home either successfully converts to a STRTP or has a county they serve request an extension before they end of 2016, they will no longer be funded.
- There are discussions between CDSS and the counties about to transition youth out of the group homes that are not planning on converting to STRTP or asking for an extension.
- Someone asked about the rumor that group homes, as they currently are, will continue to exist. Only Regional Center client and educationally funded group homes can continue under the current system. Any group home that receives AFDC funding will need to convert or eventually close.
- Once the new written standards for STRTPs are written, CDSS will hold regional meetings to inform, clarify, and answer questions and concerns.
- Someone asked if, during the transition to a STRTP, if a group home can have a mix of group home youth under the RCL system and other clients under the STRTP funding. CDSS stated that the issue is being discussed currently.
- It was noted that a group home cannot offer Mental Health specialized services without Mental Health Program and Medi-cal billing certifications. Similar to FFAs under CCR, if a group home cannot provide the services, they do have to have access to them.
- Provisional approvals will be given to group homes actively transitioning to STRTPs. However, their annuals will be based on the date of their site visit for STRTP approval.
- This is not a thorough list of the STRTP issues discussed at this meeting, but an overview of the main points.
ACCREDITATION ADVICE FROM AN FFA
I know everyone is extremely stressed with the CCR changes and with accreditation. However, I want to take a moment to encourage you to breath, take one step at a time, and we will get through this! I just submitted our application to CARF, which will be here in Oct/Nov of this year to the tune of $13,000 (to survey 4 different sites and about 80 placements) to give other agencies a frame of reference, it feels like a kick in the gut. I know for you larger organizations this is a small number, but it is all comparable.
With that said, I do want to take a moment to discuss with you the value of our organizations going a quantitative route with our ETO (Efforts to Outcomes) measures. In order for our industry to prove our worth, I believe it is imperative to have actual data, which proves our worth and for which we can justify our rates. I know going with a data management system seems overwhelming, but if you consider the cost of hiring a compliance officer versus the cost of implementing a system….
I have gone with two data management systems, which CARF is loving . The Apricot system by Social Solutions, which tracks all of our ETO and with Relias Learning, which tracks all of our training and has a huge wealth of online training, CEUs, and the ability for your organization to upload your own trainings, which can be accessed from anywhere. I have also been working with MediCaid in the State of Nevada for 10 years now (this is for those who are pursuing your mental health certificates), and when they heard I had with Relias, their QPI agent just said, send me your print outs for their auditing records. Trust me MediCaid audits are brutal!.
I also want to highlight that my organization just procured two grants, which total $140,000 (which paid for both of these systems), because we HAVE these systems. Without question, we would not have received these grants. These two systems were the corner stones to the grants and why we beat out 40 other organizations, which had also applied for the grants. Therefore, I want you to consider the long-term implications and the vision of what these systems will bring to your organization. The mom and pop way of running our businesses is no longer the mode of operandi, and I fear those which do not consider these methods will be left behind. I am more than willing to discuss any of this with those who are still questioning what to do. My organization has spent months researching these options.
For those of you who want to contact the companies directly, here is the contact info.
Chad Moody, an excellent and hard working individual for Relias Learning: email – firstname.lastname@example.org or phone is (919) 655-7851
Social Solutions, Jessica, another hard working individual, email: email@example.com Do not have a direct phone number for her, but can get you one if you want it
Thanks and good luck!
Dr. Shauna Rossington, DBA, LMFT (Nevada & Oregon)
Mountain Circle Family Services, Inc
If you have any questions or concerns regarding RFA, you can email the state directly at firstname.lastname@example.org
Or concerns regarding CCR at email@example.com. Please remember, many of the specifics regarding RFA, and especially CCR, are still being worked out.
INFORMATION FROM THE 6/29/16 CCR MENTAL HEALTH SUB-WORK GROUP MEETING
The Mental Health sub-group meeting was facilitated by Karen Baylor from the Department of Health Care Services and Sara Rogers from the CCR division of the California Department of Social Services. The primary foci of the work group for the next number of meetings is 1) medical necessity criteria, 2) Child and Family Teams (CFTs), 3) the FFAs’ roles in working in conjunction with Mental Health services, and 4) how to provide care for children/youth with mild to moderate needs (who do not meet the criteria for receiving specialized Mental Health services). The discussion on medical necessity filled the entire two-hour meeting.
Attached are the hand-outs from the meeting: Title 9, 1830.205 (medical necessity criteria for Specialty Mental Health Services), “For a child who meets the criteria of Section 1830.210(1)”, 1830.210 Medical necessity Criteria..for under 21 Years of Age, Mental Health Service Responsibilities, Brief Overview of Specialty Mental Health Services, and Pathways to Mental Health Services Acronyms.
There were numerous County Mental Health representatives in the room and on the phone for this meeting. Following are the main points addressed during this meeting:
- There is a challenge with children/youth in care who seem to meet medical necessity, but the Mental Health assessments say they don’t. This is particularly true for youth who are currently in group homes (STRTPs). They will need to meet medical necessity in order to be placed in the new STRTPs, which will all be level 14 homes. Because of this breakdown, the STRTPs are the first to feel the impact of required medical necessity. At this point, there are number of youths in level 10 and 11 homes, and probably only about half will meet the needs criteria to go into a level 14 STRTP; the rest will need to step down into a less restrictive level of care (resource homes).
- The first hand-out, Title 9, 1830.205, is a list of qualified Mental Health diagnoses. However, there are 21 managed care providers in the state and there is a range of assessment criteria for each, and they don’t all align.
- How does a child/youth qualify for medical necessity? One of the Mental Health experts in the room shared that the specific referral process may differ county to county. However, when a request for services is received, there will be an initial screening followed by the first assessment to determine necessity based on symptoms and, most importantly, impairments to the ability to function in life. If there is no impairment, the criteria will not be met. If there are impairments, a treatment plan will be developed with local resources in mind. A thorough assessment can take weeks or months, so a treatment plan can change. If the level of disturbance is endangering to themselves or others, they will likely be hospitalized. For children, a major criterion is if they are able to cooperate with the help offered.
- There is the understanding that children/youth in care have experienced trauma, but there needs to be consistency developed regarding the definition of medical necessity in light of that fact.
- There was concern expressed regarding the 1830.205 list for medical necessity because of a number of the criteria are rather vague, leading to some children/youth not gaining needed entry into the Mental health system. A child/youth has to “fail first” in order to qualify and there is no actual funding regarding prevention.
- Sara Rogers asked, “Are we sure we can’t diagnose it?” The response was that clinicians don’t like to label a child/youth unless necessary.
- There is an ongoing concern because approximately 60% of children/youth in care have mild to moderate challenges and therefore do not qualify for specialized Mental Health services, yet they still need help.
- There was a concern noted that the 1830.205 list does not list Oppositional Defiant Disorder or Conduct Disorder, so children/youth with those issues do not qualify, while 1830.205 does include disruptive behavior; so why doesn’t ODD and CD qualify?
- Therapeutic Behavioral Services (TBS) is a supplemental service to EPSDT (Early and Periodic Screening, Diagnostic and Treatment) so there must be other specialized Mental Health services also being offered. TBS cannot be offered as a standalone service.
- A Mental Health clinician on the phone expressed concern because none of the 21 managed care providers are willing to come to the rural, more sparsely populated counties.
- Someone brought up autism and a clinician pointed out that snice autism is neurologically-based, it does not fit into the Mental Health criteria.
- A concern was expressed about a child/youth being labeled due to a transitory incident. A Mental Health clinician shared that they can give a provisional diagnosis that can open a child/youth to service without labeling them permanently.
- Concern was expressed from three different people about a child/youth being diagnosed and labeled, when the real cause for their current distress may be that their resource parent may not be fully trained or aware of the impacts of trauma, or in the case of LGBT youth, not accepting of them, so their care may be exasperating a child’s trauma, rather than the child decompensating due to their own internal struggles. CCR does not want a child moved, yet if the skill of the resource parent isn’t meeting their need… It was noted that the CFT (Child Family Team) meeting would be vital in a situation like this.
- The question was asked if there will be a merging of the current bifurcated system of fee for service and managed care? That dual system is expected to continue.
- A concern was shared that since a valid first assessment can take weeks or months. a youth needing a STRTP could be moved to a number of homes unable to meet their needs prior to an assessment being completed. Sara Rogers shared that there are emergency provisions that allow a youth to go into a STRTP if needed while the assessment is still in process to limit the number of moves.
- Another question was raised about 1830.205 regarding 2(b) as one of the entry criteria – “A reasonable probability of significant deterioration in an important area of functioning.” Child Welfare often refers to that for a child/youth to gain services and it was stated that it would be very helpful for the Mental Health side if there could be clarification and technical support with that definition. The question was also asked if there is a mechanism for tracking a child/youth to see if they are improving. The challenge is that the current system is problem-based, so it doesn’t currently document for improvement. DHCS will need to provide clarity.
- This one I am not clear on – it appears that a child/youth may fit the criteria for Specialized Mental Health services, but still may not qualify for specific medical services. They are two different things, so a child/youth may get entry, but not services.
- There was a question about what Specialized Mental Health Services a child/youth needs to be receiving in order to qualify being placed in a STRTP. Those do need to be defined by a clinician, but entry can be provided through a variety of sources. The CFTs really need to be the deciding factor in a child/youth being referred to a STRTP.
- With STRTPs the goal is very much the ST (short term). It is hoped that no child/youth will need to be in a STRTP longer than 12 months.
- A concern was expressed that 1830.205 is written regarding adults – not children and youth, so the criteria does not work particularly well for them.
- Sara Rogers shared that CCR provides “substantive” funding so that CFTs can do the job they are intended to.
- A representative from California Youth Connection asked what can be done when a child/youth was misdiagnosed? It was noted that diagnoses can be defined as provisional or transitory, so they need not be a life-long label.
I am not a Mental Health clinician – I did my best to represent what was shared in the room. I apologize if any of my explanations missed the mark.
If you have any questions or concerns regarding RFA, you can email the state directly at firstname.lastname@example.org
Or concerns regarding CCR at email@example.com. Please remember, all the specifics regarding RFA and CCR are still being worked out.