Appendix 3

Materials for Wisconsin Leadership Workshop

Health Services and Supports for Children in Out-of-Home Placement in Milwaukee County and in Wisconsin

Children with special health care needs (CSHCN) are defined as children under 21 who have or are at risk
for a chronic physical, developmental, behavioral, or emotional condition, and require health and related
services of a type or amount beyond that which is required by children generally.¹ These children may
have a variety of conditions, but all have a need for specialized health care services, care plans, and care
coordination.

The target population for this Request for Proposal (RFP) is the Medicaid eligible children in out-of-home
care living in Milwaukee County, who are under the child welfare/child protection system in the County.
Virtually all children in out-of-home placement have one or more special health needs. An estimated 80
percent of children in foster care have at least one chronic medical conditions and an estimated 30-70
percent have severe emotional problems.² Among school-aged children involved in child welfare
systems, one national survey found that 27 percent had high levels of behavioral and emotional problems,
compared to 7 percent of their peers who live at home in their parents care.³ Children in foster care tend
to have complex medical needs and often do not have adequate medical records, making ongoing care
management problematic. Moreover, while a significant number of these children experience emotional
trauma as a result of being removed from the home, most do not receive timely mental health screening,
assessment, and treatment.^{4 5}

Benefits and Services

• Special components of routine health care services specific to children in foster care might include:
  
  1. Health Information gathering at the time of removal (performed by child welfare staff with
     medical/health care manager consultation as indicated).
  2. EPSDT screening within five days of removal from the home and periodically thereafter,
     including developmental and mental health screening.
  3. Comprehensive Health Assessment (enhanced EPSDT screen) within six weeks of
     enrollment.
  4. Specialist evaluation of developmental and mental health status as necessary.
  5. Health Care Manager assigned.
  6. Comprehensive Health Care Plan completed and updated every six months.
  7. Medically necessary treatment for medical, behavioral, developmental, or related conditions.
  8. Transitional planning provided to ensure continuity of care at permanency/discharge
     encounters.
     
     
• Through managed care contracts, some States have demonstrated success in improving health care
  and health for children in out-of-home placement. A study of nine States using behavioral health
  managed care plans in the child welfare system⁶ found consensus on the following positive effects:

1. Improved access to appropriate mental health services
2. More completed initial screens and behavioral health assessment
3. Primary care physicians for medical care/physical health
4. Flexible, more individualized services developed under capitation
5. More cross-system communication for better planning, fiscal management, and training.
   * The same study found that managed care in these nine State reform projects did not improve
   early identification rates or cultural competence in the service system for African-American
   children.

Case Management and Care Coordination Services

States may choose to place care coordination under MCO contracts or to provide them on a fee-forservice
basis through other State or local agencies or private organizations. While Federal Medicaid law
does not define “care coordination,” either the category of “administrative case management” or “targeted
case management” may be in fee-for-service systems and it may be incorporated into managed care
contracts.

• Case Management is a collaborative process of assessment, planning, facilitation, and advocacy for
  options and services to meet an individual’s health needs through communication and available
  resources to promote quality, cost-effective outcomes. Examples could include: helping families to
  understand their child’s insurance benefits, helping families to identify and use community based
  services and other public programs, coordinating care, or finding alternative funds to pay for nonhealth,
  uncovered services.⁷
• Care Coordination is a process that links children and their families to services and resources in a
  coordinated effort to maximize the potential of children and provide them with optimal health care.
  The focus of care coordination in this context is on the physical and mental health care needs of the
  child.⁸ For example, care coordination can help to ensure appropriate and timely service delivery and
  to communicate service specific information to the case worker, foster family, birth family, and health
  providers.

Levels of care coordination might include:
1. Level I - Short-term technical assistance that typically involves information sharing, referral,
and/or brief follow-up calls;
2. Level II - Significant but not necessarily long-term assistance in planning and coordinating
multiple services; and
3. Level III - Intensive case management (kids at risk of institutionalization, family experiencing
severe social and environmental risk factors and is at risk for disintegration).⁹

“Health Care Managers” (HCM) would be employed as part of this model, to arrange, coordinate,
monitor and evaluate basic and comprehensive care, treatment and services for the child. An HCM is a
clinical specialist who can coordinate services, ensure access to services in accordance with the Medicaid
program, and facilitate health care management for children in out-of-home placement.

Ideally, for children in out-of-home placement, MCO care management would include linkages, at a
minimum, to child welfare agencies, hospital emergency departments, mental health agencies, public
schools, and early intervention/special education programs. MCOs also would have mechanisms for
referrals to medically necessary, specialty, secondary and tertiary care to meet physical,
mental/behavioral, and developmental needs.

I. Assuring Quality Care, Plan Performance, and Child Outcomes

The target population for this RFP is the Medicaid eligible children in out-of-home care living in
Milwaukee County, who are under the child welfare/child protection system in the County. The
population eligible to enroll in an contracting MCO will include children who are in foster care, courtordered
kinship care or subsidized adoption and are not participating in a Home and Community Based
Waiver (HCBW) Program.¹⁰

The State is strongly committed to on-going collaboration in the area of service and clinical care
improvements by the development and sharing of “best practices” and use of encounter data-driven
performance measures. General areas for performance measurement are described below. More specific
performance improvement topics must take into account: the prevalence of a condition among, or need
for a specific service by, the MCO enrollees served under this agreement, enrollee demographic
characteristics and health risks, and the interest of consumers or purchasers in the aspect of care or
services to be addressed.

What are the State’s objectives?

• The State of Wisconsin process objectives are that all children in out-of-home
  placement will:

1. Receive coordinated, comprehensive, quality health care within a medical home;
2. Have a coordinated health care service plan based on their comprehensive health assessment
   that involves all providers and identifies a health care manager who communicates with the
   family;
3. Be evaluated within six weeks after enrollment (comprehensive assessment), then
   periodically (as defined by the HealthCheck / EPSDT periodicity schedule at a minimum) for
   medical, behavioral/mental health, developmental and oral health care needs;
4. Receive the transitional planning and follow-up services necessary to ensure continuity of
   health care; and
5. Have foster families of children that are satisfied with the health education and services that
   they receive.

Examples of process topics to measure

• Timeliness process measure examples:
  1. percent of initial intake screens completed on schedule,
  2. percent of comprehensive assessments/evaluations completed on schedule,
  3. percent of children screened according to the State’s HealthCheck periodicity schedule,
  4. percent of children with up-to-date immunizations,
  5. average waiting times for an appointment to see a primary care provider or medical specialist
     or to receive a specialized service or piece of equipment,
  6. percent of child enrollees who had an ambulatory mental health visit within 7 days of hospital
     discharge, and
  7. number of filed grievances related to timing of services.
     
• Individual care process and cultural competency measure examples:
  1. rate of HealthCheck screens equal to or greater than 80 percent of the expected number of
     screens,
  2. percent of children with an up-to-date care plan (consider age adjusted ratios),
  3. percent of children who had a medical home provider trained in pediatric care,
  4. measures of translator availability,
  5. reading level of information and enrollment materials,
  6. rate of access to specialized transportation services (based on requests or estimated need), and
  7. rate of providers speaking most prevalent non-English language spoken in Milwaukee
     population.
• System of care process measures:
1. percent of required MOU signed and operational,
2. percent of required data collection/reporting completed,
3. quality assessment/performance improvement (QAPI) committee and plan in place,
4. percent of advisors or board members who are self-identified foster or adoptive parents of
   children served through the child welfare system,
5. percent of foster parents reporting satisfaction with the MCO services and supports, and
6. percent of those covered services in court-ordered plans that were received by child.
• Network Adequacy:
  
  1. number of mental health providers with training in early childhood issues per child enrollee
     under age six,
  2. percentage of pediatric primary care providers who have training in developmental or
     behavioral issues,
  3. percentage of prescribing clinicians who have training in established guidelines for
     prescribing medications for behavioral health conditions (could be adjusted for percentage of
     children that receive such medications),
  4. adequacy of the behavioral and mental health network with regard to geographic accessibility
     to its members.

Examples of child outcomes measures

• Children’s general health outcomes:
  1. percent of enrolled children under age six who had emergency room visits for non-urgent
     care,
  2. percent of enrolled adolescents (ages 12-19) who had an STD or confirmed pregnancy, and
  3. percent of enrolled children who improve results on standardized developmental tests.
• Children’s mental health outcomes:
  1. percent of enrolled children under age six who have received evaluation and/or treatment for
     mental/behavioral health conditions,
  2. percent of enrolled school age children/adolescents whose unexcused absences have
     decreased while receiving services,
  3. rate of children/adolescents per 1,000 of the eligible population diagnosed with mental health
     or substance use disorders that have received both mental health and alcohol-drug treatment,
     and
  4. percent of children/adolescent in behavioral health services who have improved, maintained,
     or reduced levels of need/symptoms.
• Child welfare and family preservation outcomes:
  1. percent of enrolled children adopted, reunited, or in permanent placement within expected
     time frames, and
  2. percent of enrolled children who had recurrence of maltreatment.

Setting Quality Standards to Monitor Health Services for Children in Out-of-Home Placement

Sample Categories for Performance Measures/Goals Used by States/Plans

[D]

II. Screening and Assessment for Children in Out-of-Home Placement

In clinical practice, the terms screening, assessment, and evaluation have general, but not precise
meanings and are sometimes confused in usage. Assessment is often confused with screening.
Professionals within and across fields do not use these terms consistently, in part because the terms are
confused in Medicaid/EPSDT guidance to States. Since these terms are not precise, it’s important to reach
agreement on what they mean in this context.

Screening is used to identify possible problems, and intended to be followed-up with additional tests if a
problem is suspected. In most cases, screening is brief and has a structured format. Screening tools can
be specific to a disorder (e.g., autism or fetal alcohol syndrome), be focused on one area or domain of
development (e.g., language or motor skill), or be general.¹¹ Ideally, developmental and
mental/behavioral health screening tools for children should: identify those children with or at risk of
problems, be quick and inexpensive to administer, be of demonstrated value to the patient, provide
information that can lead to action or follow-up, and be sensitive and specific enough to avoid
mislabeling many children.¹² Screening does not result in diagnoses.

When a possible problem is identified through screening, the next step is assessment (also sometimes
called evaluation). Assessment is more in depth and helps child health professionals to determine the
nature of the condition and to consider possible treatments. Assessment tools or (more often) processes
might be considered diagnostic. An assessment may measure a child’s condition on a specific area such
as physical, cognitive, or behavioral development. A “comprehensive assessment” looks across domains
of development and is designed to yield information about the child’s overall condition.

How does this fit with Medicaid and EPSDT/ screening?

In this context, the word “screening” also reflects the definition in Medicaid’s Early Periodic, Screening,
Diagnosis, and Treatment (EPSDT) program,¹³ known in Wisconsin as HealthCheck.

• EPSDT/HealthCheck covers comprehensive screening (check-up) visits and treatment for any health
  problems found during the checkup including medical care, mental health services, vision, hearing,
  and dental care. This is essentially a comprehensive well child examination.
• By law, an EPSDT/HealthCheck screening examinations include comprehensive and age-appropriate:
  health history, physical exam, developmental tests, blood and urine lab tests, immunizations, and
  health education/anticipatory guidance.
• Under Federal law, screening visits/exams may be provided according to the State established
  (periodicity) schedule or on an interperiodic basis, as necessary. Hearing, vision, and dental
  screening must have their own periodicity schedules, based on appropriate professional guidelines.
  Children age three and older must be referred to a dentist.

What are the proposed components of a Comprehensive Assessment?

For children in out-of-home placement, a HealthCheck screen is the basis for a comprehensive
assessment; however, these children need enhancements that go beyond the basic HealthCheck screen
protocol. Such additional elements include, but are not limited to:

• Inspection for and documentation of any signs of child abuse, neglect, or maltreatment.
• Observation of “goodness of fit” between the child and the foster family.
• More detailed assessment/evaluation of developmental status.
• Behavioral/mental health screening, with full evaluation to follow, if indicated (see below).
• Review of family background, stressors, strengths and weaknesses, and home environment (e.g.,
  provides emotional safety, comfort, appropriate structure, discipline).
• Anticipatory guidance including education and counseling on topics specific to foster care, such as:
  1. General adjustments to new home, grief and loss issues,
  2. Behavioral problems that may have surfaced,
  3. Appetite/unusual eating habits,
  4. School problems behavioral/academic,
  5. Interaction with foster parents and other children in the home,
  6. Contact with birth family including difficulties around visits.
  7. Sexual abuse, and for adolescents sexual activity.

What about evaluation of behavioral/mental health and developmental needs?

According to the American Academy of Pediatrics (AAP),^{14 15} the mental health assessment/evaluation
would review: mental health; circumstances of placement, family life event, traumatic events; regulation
of affect and behavior in different settings; relatedness and relationship to family members, caregivers,
peers, examiner; interests and activities; strengths and coping style; and preferred mode of expression
with attention to culture and ethnicity. The professional conducting a mental health evaluation should
also look for signs and symptoms of: 1) risks for suicide and/or violence; 2) substance exposure, misuse,
abuse, and addiction; 3) maltreatment, including physical, sexual, emotional abuse and neglect; 4) risk of
placement disruption; 5) risk of sexual behavior; and 6) risk of antisocial behavior.

Developmental screening is a basic component of an EPSDT screen for a child or adolescent of any age
and, thus, should be part of a comprehensive screen. If developmental problems are suspected or detected
as part of a screen, a more thorough developmental assessment by a trained professional (e.g.,
developmental pediatrician, child development specialist) should occur as soon as possible. ¹⁶ While
measurement tools will vary depending upon the child’s age and developmental stage, developmental
screening and evaluation should include measurement using standardized tools of the following domains:
gross and fine motor, cognitive, language, psycho-social, and activities of daily living skills. Children
under three years of age can be referred to the Birth to Three Early Intervention Program for more
comprehensive evaluation.

Examples of Possible Contract Specifications for Screening and Assessment

• For a child in out-of-home care, an initial screen should occur no later than [to be inserted for final
  contract] after the Bureau of Milwaukee Child Welfare takes custody of the child. The purpose of
  this “initial” or entry screen is to identify health problems that would affect placement or require
  immediate medical, dental, or mental health care.
• HealthCheck routine screens should be provided according to the periodicity schedule. Interperiodic
  screens should be completed within [to be inserted for final contract] days of a the request from a
  caregiver or case worker who suspects the existence of a physical, mental or developmental health
  problem (or possible worsening of a preexisting physical, mental or developmental health condition).
  In addition, a comprehensive assessment (or evaluation) of the child should be conducted within [to
  be inserted for final contract] days of enrollment.

III. Provider Networks for Children in Out-of-Home Placement

• Assure equal access. The MCO should provide medical care to its Medicaid enrollees, which is as
  accessible to them, in terms of timeliness, amount, duration, and scope, as those available to nonenrolled
  Medicaid recipients within the MCO service area.
• Assure that the MCO provider network is appropriate for this special needs
  population. Specific network considerations include: a) the number and types of providers required
  to furnish the contracted services, b) the geographic distribution of providers and enrollees, c)
  accessibility of provider sites for persons with disability, and d) the experience of providers in caring
  for children in out of home placement
• Give families and caregivers of enrolled children the option of choosing the child’s
  primary care provider for their medical home. The term “medical home” describes a
  coordinated medical care for children with special needs. The medical home provider might be
  either (1) a primary care practitioner, or (2) a specialist in pediatrics, including pediatric medical subspecialists,
  pediatric surgical specialists, and child psychiatrists and psychologists. Regardless of the
  providers’ credentials, the medical home assists in early identification of special needs; provides
  ongoing primary care; and links with a broad range of other services
• Use memoranda of understanding (MOU) to define interagency connections. The MCO
  must negotiate and sign a MOU with the Bureau of Milwaukee Child Welfare (BMCW) for
  collaboration including coordination of Medicaid-covered services for children in out-of-home care.
  To assure a systems approach, MCOs also need a MOU with School-Based Services, Birth to Three
  agencies, other Medicaid/BadgerCare MCOs, Wraparound Milwaukee, and other child health
  providers (e.g., local health departments, WIC, community-based organizations, hospitals)
• Assure expertise in/arrangements for mental/behavioral health care. MCOs arrange for
  screens and assessments that include developmental and mental/behavioral health components.
  When mental/behavioral needs are suspected or identified, MCOs arrange for exams and treatment
  by providers with expertise and experienced in mental health/substance abuse issues of children and
  adolescents. MCOs also arrange for the provision of examination and treatment services by providers
  with expertise and experience in dealing with the medical/psychiatric aspects of caring for victims
  and perpetrators of child abuse and neglect and domestic violence
• Encourage involvement of “traditional” providers in an MCO network: A “traditional”
  provider has experience serving a substantial number of uninsured low-income children, including:
  1) Federally qualified health centers (FQHCs), 2) rural health clinics, 3) city or county health
  departments operating clinics, 4) other maternal and child health clinics receiving funds under Title
  V, 5) providers funded under the Ryan White Comprehensive AIDS Research and Education Act,
  and 6) family planning clinics receiving funds under Title X.

¹ McPherson et al. A New Definition of Children with Special Health Care Needs. Pediatrics. 1998;102:137-140.
²Mauery DR, Collins J, McCarthy J, McCullough C, and Pires S. Contracting for Coordination of Behavioral Health Services in Privatized Child Welfare and Medicaid Managed Care Princeton, NJ: Center for Health Care Strategies, June 2003.
³ Vandivere S, Gallagher M, and Moore KA. Changes in children’s well-being and family environments. Snapshots of America’s Families III. Washington, DC: Urban Institute. 2000; No. 18.
⁴ Rosenbaum, S., Sonosky, C., Shaw, K., and Mauery, D.R. Policy Brief #5: Behavioral Health and Managed Care Contracting Under SCHIP. September 2002.
⁵ McCarthy J and McCullough C. Promising Approaches for Behavioral Health Services to Children and Adolescents and their Families in Managed Care Systems: A view from the child welfare system. Washington, DC: Georgetown University. March 2003.
⁶ Schulzinger R, McCarthy J, Meyers J, Irvine M and Vincent P. Health Care Reform Tracking Project: Tracking
state health care reforms as they affect children and adolescent with emotional disorders and their families –
Special Analysis on Child Welfare Managed Care Reform Initiatives. Washington, DC: Georgetown University
Child Development Center, 1999.
⁷ CMSA Standards of Practice for Case Management, Revised 2002.
⁸ American Academy of Pediatrics, Committee on Children with Disabilities Policy Statement Care Coordination:
Integrating Health and Related Systems of Care for Children with Special Health Care Needs. Pediatrics. 1999:104.
⁹ Health Systems Research 1996 Policy Document.
¹⁰ Child in out-of-home care: A child under the age of nineteen who consistent with §1932 (a) (2) (A) of the Social
Security Act, 42 U.S.C. §1936 u-2(a) (2) (A) is: a child described in 1902 (e) (3) of the Social Security Act, 42
U.S.C. §1936a(e)(3); a child receiving foster care maintenance payments under §472 of the Social Security Act, 42
U.S.C. §672; a child receiving adoption assistance under §473 of the Social Security Act, 42 U.S.C. §673; or a child
who is in foster care or otherwise in an out-of-home placement.
¹¹ See information from the Centers for Disease Control and Prevention, National Center for Birth Defects,
Developmental Disabilities, and Disability Health.
¹² Bergman D. Screening for Behavioral Developmental Problems: Issues, obstacles, and opportunities for change.
National Academy of State Health Policy. August, 2004.
¹³ Rosenbaum S and Sonosky C. Federal EPSDT Coverage Policy, Prepared by the George Washington University
Center for Health Services Research and Policy under contract to the Health Care Finance Administration, 2000.
¹⁴ American Academy of Pediatrics, District II, NYS. Copyright, 2001.
¹⁵ Jellinek M. Bright Futures in Practice: Mental Health—Volume I. Practice Guide. Washington, DC: National
Center for Education in Maternal and Child Health and Georgetown University, 2002.
¹⁶ VanLandeghem K, Curtis D, and Abrams M. Reasons and Strategies for Strengthening Childhood Development
Services in the Healthcare System. Portland, ME: National Academy for State Health Policy, October, 2002.