Appendix
3
Materials for Wisconsin Leadership Workshop
This
document was prepared for a Leadership
Workshop on Managed Care and Child
Health held on September 8, 2004 in
Milwaukee, Wisconsin. The workshop
is based on work by the Center for
Health Services Research and Policy
at The George Washington University
(GWU), and conducted with support
from the Health Resources and Services
Administration, Maternal and Child
Health Bureau (HRSA-MCHB) and the
Managed Care and Health Services Financing
Technical Assistance Center (MCTAC).
Senior policy makers and professionals
attending the workshop will discuss
approaches to ensure that plan enrollees
receive the highest quality pediatric
care. This information was designed
to provide a framework for discussion,
offering options for solutions to
concerns shared by State agencies,
managed care organizations, and consumer
advocates. These documents have not
been endorsed by Federal or State
officials. Prepared by Kay Johnson,
Johnson Group Consulting; and Jeff
Levi, Center for Health Services Research
and Policy under contract with HRSA. |
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:
-
Health Information gathering at
the time of removal (performed by
child welfare staff with
medical/health care manager consultation
as indicated).
-
EPSDT screening within five days
of removal from the home and periodically
thereafter,
including developmental and mental
health screening.
-
Comprehensive Health Assessment
(enhanced EPSDT screen) within six
weeks of
enrollment.
-
Specialist evaluation of developmental
and mental health status as necessary.
-
Health Care Manager assigned.
-
Comprehensive Health Care Plan completed
and updated every six months.
-
Medically necessary treatment for
medical, behavioral, developmental,
or related conditions.
-
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:
-
Improved access to appropriate mental
health services
-
More completed initial screens and
behavioral health assessment
-
Primary care physicians for medical
care/physical health
-
Flexible, more individualized services
developed under capitation
-
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:
-
Receive coordinated, comprehensive,
quality health care within a medical
home;
-
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;
- 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;
- Receive
the transitional planning and follow-up
services necessary to ensure continuity
of
health care; and
- 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:
-
percent of initial intake screens
completed on schedule,
-
percent of comprehensive assessments/evaluations
completed on schedule,
-
percent of children screened according
to the State’s HealthCheck
periodicity schedule,
-
percent of children with up-to-date
immunizations,
-
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,
-
percent of child enrollees who
had an ambulatory mental health
visit within 7 days of hospital
discharge, and
-
number of filed grievances related
to timing of services.
-
Individual care process and
cultural competency measure examples:
-
rate of HealthCheck screens equal
to or greater than 80 percent
of the expected number of
screens,
-
percent of children with an up-to-date
care plan (consider age adjusted
ratios),
- percent
of children who had a medical
home provider trained in pediatric
care,
-
measures of translator availability,
-
reading level of information and
enrollment materials,
-
rate of access to specialized
transportation services (based
on requests or estimated need),
and
-
rate of providers speaking most
prevalent non-English language
spoken in Milwaukee
population.
-
System of care process measures:
-
percent of required MOU signed and
operational,
-
percent of required data collection/reporting
completed,
-
quality assessment/performance improvement
(QAPI) committee and plan in place,
- percent
of advisors or board members who
are self-identified foster or adoptive
parents of
children served through the child
welfare system,
- percent
of foster parents reporting satisfaction
with the MCO services and supports,
and
- percent
of those covered services in court-ordered
plans that were received by child.
- Network
Adequacy:
-
number of mental health providers
with training in early childhood
issues per child enrollee
under age six,
-
percentage of pediatric primary
care providers who have training
in developmental or
behavioral issues,
-
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),
-
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:
-
percent of enrolled children under
age six who had emergency room visits
for non-urgent
care,
-
percent of enrolled adolescents
(ages 12-19) who had an STD or confirmed
pregnancy, and
-
percent of enrolled children who
improve results on standardized
developmental tests.
- Children’s
mental health outcomes:
-
percent of enrolled children under
age six who have received evaluation
and/or treatment for
mental/behavioral health conditions,
-
percent of enrolled school age children/adolescents
whose unexcused absences have
decreased while receiving services,
-
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
-
percent of children/adolescent in
behavioral health services who have
improved, maintained,
or reduced levels of need/symptoms.
-
Child welfare and family preservation
outcomes:
-
percent of enrolled children adopted,
reunited, or in permanent placement
within expected
time frames, and
-
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
- Administration
measures
- Affect
on members
- Interval
between enrollment and
PCP assignment/selection
- Grievances
and appeals within
time frames
- Affect
on Medicaid
- Paying
claims for covered services
“out-of-network”
(e.g., emergency
room, public health)
- Paying
clean claims on time
- Information
technology
- Ability
to integrate/report clinical
data in a timely manner
- Use
of decision-support software
- Effectiveness
of care
-
Immunization up-to-date
-
Asthma care (ER, disparities,
medications)
-
Antibiotics for young children
with
sickle cell
-
Reduced mental health symptoms
after
treatment
-
Follow-up after hospitalization
for
mental health
-
Ratio of clinicians trained
to manage
psycho-pharmacology for children
-
STD screening for adolescents
- Use
of Services
-
EPSDT screening visits on
schedule
-
Well-child visits on schedule
-
Non-essential emergency room
visits
-
Inpatient discharge for mental
health
concerns
-
Inpatient discharge for chemical
dependency
|
- Access
measures
-
Availability/access
-
Prompt initiation of services
-
Access to primary care provider
(PCP)
(e.g., interval from enrollment
to first
PCP visit)
-
Annual dental visits (or in
first 6
months)
-
Travel times/geographic access
-
Time between requests and
appointments (e.g., time between
assessment referral and completed
visit for mental health services)
-
Time spent in waiting rooms
-
Language access (translation)
-
Quality and Satisfaction
-
Racial/ethnic disparities
-
Satisfaction
-
Perceptions
- Received
services needed
- Services
received promptly
- Received
quality services
- Services
were accessible
- Clinical
care measures
- Preventive
care
- Immunizations
up to date
-
EPSDT screening visits /
child or
adolescent well care visits
-
First pediatric visit for
infant
- Chronic
care
- Asthma
- Behavioral
health
- Children
with special health needs
- Diabetes
- Epilepsy
- Urgent/emergency
services (e.g.,
members seeking ER receive services
immediately)
|
[D]
This
document was prepared for a Leadership
Workshop on Managed Care and Child
Health held on September 8, 2004 in
Milwaukee, Wisconsin. The workshop
is based on work by the Center for
Health Services Research and Policy
at The George Washington University
(GWU), and conducted with support
from the Health Resources and Services
Administration, Maternal and Child
Health Bureau (HRSA-MCHB) and the
Managed Care and Health Services Financing
Technical Assistance Center (MCTAC).
Senior policy makers and professionals
attending the workshop will discuss
approaches to ensure that plan enrollees
receive the highest quality pediatric
care. This information was designed
to provide a framework for discussion,
offering options for solutions to
concerns shared by State agencies,
managed care organizations, and consumer
advocates. These documents have not
been endorsed by Federal or State
officials. Prepared by Kay Johnson,
Johnson Group Consulting; and Jeff
Levi, Center for Health Services Research
and Policy under contract with HRSA.
|
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:
-
General adjustments to new home,
grief and loss issues,
-
Behavioral problems that may have
surfaced,
-
Appetite/unusual eating habits,
-
School problems behavioral/academic,
-
Interaction with foster parents
and other children in the home,
-
Contact with birth family including
difficulties around visits.
-
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. |