Design to Implementation: Delivering the New Children & Family TreatmentSupport Services

Objectives‣ To provide an overview of the multi-level change that

accompanies implementation of new services‣ To describe the different roles and functions of providers

involved in the oversight and delivery of Children & Family Treatment & Support Services

‣ To delineate the barriers to implementation‣ To identify and understand the critical factors for

implementation

Children’s System Transformation and Draft Timelines‣ Six new State Plan services to be phased in over time with 3

new services available Jan 2019 ‣ Transition to Health Homes begins Jan 2019‣ Transition six children’s waivers to Managed Care: April 2019‣ Provide an aligned Home and Community Based Service (HCBS)

array and phase in the expansion of children eligible for HCBS‣ Aligned HCBS service array available: April 2019 ‣ 3 year phase in of Level of Care: Begins July 2019‣ Transition behavioral health benefits to Managed Care: July 2019‣ Transition foster care population to Managed Care: July 2019

Children & Family Treatment & Support Services

State Plan services will

become part of the Managed Care

benefit on their implementation

date

State Plan Service Effective Datedraft dates pending CMS approval

Other Licensed Practitioner

January 1, 2019

PsychosocialRehabilitation

January 1, 2019

Community Psychiatric Treatment and Supports

January 1, 2019

Family Peer Support July, 1, 2019

Youth Peer Support and Training January 1, 2020

Crisis Intervention State Plan

January 1, 2020

VisionThe development of the six new services are intended to:‣ Better meet children’s needs‣ Expand access to clinical

treatment services‣ Provide a greater array of

approaches for rehabilitative interventions

Key Points• These services can be accessed individually or in a coordinated

comprehensive manner when identified in the treatment plan.• Services provided to children and youth must include communication

and coordination with the family, caregiver and/or legal guardians. • Coordination with other child-serving systems should occur to achieve

the treatment goals.• In order to be eligible to provide Children and Family Treatment and

Support Services, an organization must become a designated provider by submitting an application.

• These practitioners must operate within a designated agency.

Important to KnowEach new Children and Family Treatment and Support Service will have very distinct:

• Agency Qualifications• Individual Staff Qualifications• Supervisory Qualifications• Required Trainings• Billing Requirements• Medical Necessity• Limitations and Exclusions

Shift Requires multi-level change:• Organizational Level

• How the organization supports the delivery of these services • Provider Level

• Willingness to deliver these services in community based environments• Ability to be adaptable to the family’s needs

• Provider Relationships• Ability to partner with a variety of traditional and non traditional service

providers in the community• Participant

• Willingness to be open to receive services

SYNCServing Youth IN their CommunitiesAstor: Bronx, NY

SYNC Services‣ Astor’s Tilden Day Treatment Program closed in August 2015

‣ Tilden was serving 48 children ages 5-8

‣ A Pilot of the new kids’ Children & Family Treatment & Support

services was developed to provide community-based services to

support the children impacted

Goals‣ Test-drive the new kids’ Children & Family Treatment & Support

services.‣ Keep children with serious emotional and behavioral difficulties in

their communities and out of restrictive settings.‣ Collect outcome measures to analyze the effectiveness of services‣ Identify implementation challenges.‣ Reflect on lessons learned to potentially inform the statewide

delivery of these new services.

Preparing for Implementation

Children & Family Treatment & Support Services‣ SYNC identified they could provide the following services:

• Other Licensed Practitioner (OLP)• Community Psychiatric Supports & Treatment (CPST)• Psychosocial Rehabilitation Services (PSR)• Family Peer Support Services (FPSS)

Population‣ Target Population: Approximately 40-50 children being

discharged from our day treatment• Elementary & Middle School aged • Originally High Needs/High Risk• Previously enrolled in Day Treatment• Almost all Medicaid Eligible

Expanded Population‣ Added other populations:

• School Referrals• High Risk Clinic• Day Treatment Diversion

‣ And later :◦ School Based Behavioral Health & Training Program

Staffing Model‣ Other Licensed Practitioner (LCSW, LMSW, LMHC, LMFT)-2

• Program Director • Supervisor

‣ Behavioral Health Specialist (BHS)- 4• CPST• PSR

‣ Family Peer Advocates (FPA)-2• FPSS

Training‣ Staff were trained in the following:

• Child and Adolescent Needs and Strengths (CANS-NY) • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)• Client Access to Lethal Means (CALM) Treatment Planning• Therapeutic Crisis Intervention (TCI)• Motivational Interviewing• Safety in the Community

Total training time averaged 15 hoursTeam meetings held frequently to discuss service provision, review

data, and identify participant needs

Staffing‣ Recruitment/Retention

• Required a significant amount of coordination with Human Resources to find and hire qualified staff ◦ Screened for staff who had previous community-based experience

and experience working with SED population◦ Transferred qualified staff from our Transitions Program ◦ Sought internal recommendations for Family Peer Advocates

• Approximately 3 – 6 months to get staff fully trained in service provision• Services were provided during the training period• New staff shadowed experienced personnel to provide community-

based services

Communication Strategies ‣ Schools

• NYC DOE Superintendent of District 75 Schools ✓ Described new SPA services ✓ Pilot in schools to support the discharged children

• Superintendent and Principals of 3 Schools with most children impacted by Tilden closure

• Met with School Personnel at the 3 schools initially targeted

Communication Strategies‣ Engaging Youth & Families

• Contacted and informed caregivers• SYNC services described

◦ Access◦ Type◦ Frequency ◦ Duration

• Determination by caregivers to participate• Re-assessed current level of need

Delivering Services

Delivering Services ‣ Requires Flexibility in Hours

• To provide services at convenient times for caregivers• To provide services to child after school hours• To provide services during school recess• To provide services in other community settings

Collaboration‣ Outpatient Treatment Providers

• Clinicians (Social Workers; Psychologists; Mental Health Counselors)• Nurse Practitioners• Psychiatrists

‣ Schools• Teachers/Guidance Counselors• Teacher Assistants/Paraprofessionals • Committee on Special Education

‣ Care Managers (excluding Waiver Service Providers)‣ In-Patient Hospital Providers‣ Summer Camps‣ Afterschool Programs‣

Service Provision

Children receiving each service:‣ OLP* – 132‣ CPST-109‣ PSR-106‣ FPSS-109

*Includes assessments when completed 0

20

40

60

80

100

120

140

OLP CPST PSR FPSS

Children Receiving Each Service

OPC8%

On Site12% Other

7%

Home30% School

43%

Off Site80%

LOCATION

OPC On Site Other Home School

Where Services are Provided

Where Services are Provided

31% 18% 21% 25% 30%

7% 43%

24%

32%

47% 24%

23%

30%

30%

14% 38%

17% 25%

13% 10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Schools Home Tilden SYNC Astor OPC Other Place of Service

Service Type by Location

PSR

OLP

FPSS

CPST

Documentation‣ Assessments

• Child and Adolescent Needs and Strengths (CANS-NY)• IOWA Conners• Parent/Teacher Questionnaire• Family Inventory of Resources & Stressors (FIRST)

‣ Treatment Plan‣ Progress Notes

Treatment Plans‣ Goals/Objectives developed by the OLP in collaboration with

child, caregiver, school, and referral source‣ Identification of specific CFTS services, including:

• Type of Service• Provider• Method (e.g. individual, group, family)• Frequency (e.g. daily, weekly, bi-weekly)• Location (e.g. home, school, community)• Identification of Collaterals

Progress Notes ‣ Had to refine the fields in our Electronic Health Record (EHR) to

include:• Type of Service• Location of Contact• Length of Contact• Travel Time• Collaterals Present• Client Present

Case Example (Donald)Reason for Referral:‣ Donald is a 12 year old Hispanic male, diagnosed with Major

Depressive Disorder with Anxious Distress referred by his school Counselor due to school refusal. He was enrolled at ABC Behavioral Health Outpatient Clinic though his attendance was inconsistent. Donald was at risk of losing his school and home placement.

Goal:‣ Donald will re-engage in his outpatient program, improve his school

attendance, and decrease depressive and anxiety symptoms

Recommended Services‣ OLP: provide in-home individual and family therapy to decrease anxiety to

improve school and outpatient clinic attendance

‣ CPST: provide caregiver with psychoeducation on depressive symptoms and identify strategies to promote socialization

‣ PSR: teach new coping skills to reduce depressed moods and anxiety

‣ FPSS: support caregiver with decreasing feelings of hopelessness, assist caregiver with learning, practicing, and implementing parenting strategies to reinforce positive behaviors

OLP‣ Treatment Objective: Licensed Behavioral Health Practitioner will meet with Donald

weekly, for 60 minutes, in his home setting, to teach him how his thoughts and feelings influence his depressive moods and avoidant behaviors; teach him how to challenge and stop negative thoughts; and provide him with a 4-step plan to use when feeling anxious.

‣ Progress Note: Provider met with Donald individually to continue teaching him a 4-step plan [Cognitive: Anxiety (STOP)] to use when he is feeling anxious. Focused on Steps 2: Thoughts that make him upset (Thoughts) and 3: Think of things to do or think to feel less anxious (Other Thoughts). Assisted Donald with identifying the "negative" thoughts that make him feel anxious and reviewed ways in which recognizing other "positive" thoughts can help in anxious situations. Also, discussed his own ideas about what he can do to better cope with his scared/worried feelings. Provided examples of "Other" coping thoughts that could help him feel less anxious.

CPST‣ Treatment Objective: Behavioral Health Specialist will meet with Ms.

Brown, bi-weekly, for 15-30 minutes, in her home setting, to teach her strategies to minimize the negative effects of Donald's depressive moods and anxious distress. For example, Monitoring, Activity Selection, Relaxation, etc.

‣ Progress Note: BHS met with Donald's primary caregiver, Ms. Brown, to educate her about depressive and anxiety symptoms and how they impact Donald’s ability to regularly attend school and socialize with others. BHS assisted Ms. Brown with identifying strategies (Cognitive Anxiety STOP, Self-monitoring, Exposure, etc.) to minimize Donald's anxiety and depression and how she can reinforce learned skills.

PSR‣ Treatment Objective: Behavioral Health Specialist will provide PSR services bi-weekly in the

home for 15-30 minutes to introduce Donald to relaxation and exposure training and its use in affecting the way that he feels (e. g. irritable, anxious, etc.) Donald will learn and implement 3/5 calming skills bi-weekly in the home to reduce overall tension and moments of increased anxiety and/or arousal.

‣ Progress Note: Behavioral Health Specialist (BHS) met with Donald in the home to implement anxiety exposure exercise as the plan was to walk to his school. During their walk, BHS incorporated the cognitive anxiety STOP activity with Donald to minimize anxiety symptoms. Donald described the ‘situation’ (i.e. going to school) and mentioned he did not have any negative ‘thoughts’. BHS encouraged Donald to walk through the parking lot in front of the school. Donald hesitated at first, then engaged in the exercise. Once complete, he smiled at BHS and did not rush to get back home. On their way back home, Donald ‘praised’ himself and stated he was proud of himself for getting closer to the school.

FPSS‣ Treatment Objective: Family Peer Advocate will meet with Ms. Brown, weekly, for

45-60 minutes, to encourage and teach her how to assist Donald in applying newly learned skills (Thought Stopping, Self-Monitoring, Relaxation, etc.) and to increase the frequency of positive family activities (Activity Selection, Attending, etc.)

‣ Progress Note: Family Peer Advocate conducted a home visit to identify and role play strategies that Ms. Brown can utilize to decrease Donald’s excessive worry about going to school. Ms. Brown expressed concern that Donald has a hard time falling asleep and does not sleep through the night. FPA encouraged Ms. Brown to utilize a possible reward system to motivate Donald to turn off the video game when requested. FPA encouraged Ms. Brown to begin implementing a bedtime routine as it could decrease Donald’s irritability, anxiety, and school refusal. FPA and Ms. Brown explored the importance of consistent routines.

Outcome‣ Donald increased his school attendance from 2 days per month to 3

days per week. ‣ Donald increased his engagement in weekly outpatient services and

was able to sustain medication management.‣ Ms. Brown decreased feelings of hopelessness and consented to

Health Homes Services to provide support for Donald’s siblings that resided in the home.

‣ SYNC services were discontinued due to goals being achieved. ‣ *School Counselor increased the frequency of SYNC referrals

Evaluation

Evaluation‣ Data Collected

• Children Screened/Admitted • Referral Sources• Length of Stay• Goals Met• Iowa Conners• Satisfaction Surveys

Children Screened and Admitted

Admission Category N %Not indicated 55 27%

Services declined 16 8%TBD 21 10%

Admitted 115 56%Grand Total 207 100%

27%

8% 10%

56%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AdmissionCategoryBreakdown

Admitted

TBD

Servicesdeclined

Notindicated

Children Served by Referral Source

Referral Category N %DT Discharge 13 11%DT Diversion 10 9%High Needs OPC 18 16%Parent 7 6%SBBHT 40 35%School 27 23%Grand Total 115 100%

11%

9%

16%

6%

35%

23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Children Served By Referral SourceDT DischargeDT Diversion

High Needs OPCParent

SBBHT

School

Length of Service By Referral Source

Referral Category Months of Treatment

DT Discharge 15.4DT Diversion 11.1

High Needs OPC 7.9Parent 8.4SBBHT 5.3School 10.6Grand Total 8.8

15 11 8 8 5 110

2

4

6

8

10

12

14

16

18

DT Discharge

DT Diversion

High Needs OPC

Parent SBBHT School

Average Months of Treatment by Referral Category

Service Provision

Children receiving each service:‣ OLP* – 132‣ CPST-109‣ PSR-106‣ FPSS-109

*Includes assessments when completed 0

20

40

60

80

100

120

140

OLP CPST PSR FPSS

Children Receiving Each Service

Behavioral Health Specialist

‣ BHS Service Mix62%

43% 40%

38% 57% 60%

0%

20%

40%

60%

80%

100%

2016 2017 2018

BHS

Service Type by Staff Title by Year

PSR

CPST

Evaluation

Some Activities are unbillable‣ FPSS ‣ OLP

84% 52% 63% 97% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CPST FPSS OLP PSR

Billable % by Service Type

Impact‣ Services proved to be very flexible and effective‣ Forty of the 115 admitted children were discharged with goals met‣ Eighty of the children were either admitted during service provision to

a clinic or received the services in support of their clinic treatment‣ Services are provided in 38 schools ‣ We needed to cap services in high user schools (E.g.; PS 94 needed

to cap referrals. They are looking for funding to purchase services when pilot ends.)

Impact ‣ Current Referral sources see the value and are reaching out for

additional services for their children‣ Clinics/CMA/Schools are concerned about services for Non-MA

children‣ Other school referrers are also looking for funding to purchase SYNC

service package developed including consultation and professional development • Four schools have purchased the SYNC service package for a

school’s variant of these services aside from pilot‣ Office of School Health (OSH) included them in a poster presentation

of innovative NYC School behavioral health services at a national

Implementation Challenges

Challenges‣ Understanding the Children & Family Treatment & Support services‣ Adapting to changes in the Provider Manual & design

• Realigning staff to services based upon credentials‣ Developing Treatment Plans ‣ Adapting Electronic Health Record (EHR)‣ Training Staff‣ Transportation Issues

• How to provide services in a timely and cost effective manner

Coordination Challenges with Other Providers‣ Establishing relationships and engaging schools

‣ Inconsistent communication impedes coordination

‣ The use of phone contact to collaborate and coordinate with agencies has been vital in sustaining relationships

‣ Differentiating SYNC services from services already received by particular children and their families

Reimbursement Considerations‣ OLP is the only service that can bill for an assessment

‣ Family Peer Advocates (FPAs) have been crucial to family engagement, yet not reimbursable prior to development of the treatment plan

‣ All SYNC staff have provided crisis intervention with children and/or families but currently only reimbursable under OLP & CPST master’s level.

‣ How to balance travel with productivity

Critical Success Factors‣ Create an agency implementation team to make sure all aspects of

implementation are considered and planned for!• How to rollout the services.• How to integrate CFTS services within the existing continuum of

care.• How to train staff to provide CFTS services?

‣ How to coordinate with other agencies when the child is not in a Health Home?

‣ Who will be responsible for developing and authorizing the CFTS services in the treatment plan?

Critical Success Factors ‣ Compliance and audit risks

• Services must be delivered and documented consistent with guidance• The guidance is still evolving• Inconsistencies or lack of clarity increase risk

‣ EHR and billing adaptations• Costs• Programming• Staff resources to implement

Critical Success Factors‣ Fiscal Viability

• What are the reimbursable activities?• How well do the reimbursable activities reflect what staff are

actually doing?• Do the rates support the costs?• Can the agency afford the start-up costs? (e.g. staff, training,

software, etc.)• Will there be enough volume to support sustainability?

Resources & Links

Additional ResourcesChildren’s Managed Care Design: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/index.htm

Trainings on Children’s System Transformation• Children and Family Treatment and Support Services- Service Reviewhttps://ctacny.org/training/children-and-family-treatment-and-support-services-training• CFTSS FAQ document from in-person traininghttps://ctacny.org/sites/default/files/Final%20FAQ%20for%20CFTSS%20Trainings.pdf• Children and Family Treatment and Support Services Billing and RCM Traininghttps://ctacny.org/training/billing-childrens-system-transformation• Children and Family Treatment and Support Services Utilization Managementhttps://ctacny.org/training/utilization-managment-children-and-family-treatment-and-support-services-olp-cpst-and-psr

Additional Resources RESOURCES TO STAY INFORMED:

• Subscribe to children’s managed care listserv http://www.omh.ny.gov/omhweb/childservice/

• Subscribe to DOH Health Home listserv http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/listserv.htm

• Health Home Bureau Mail Log (BML) https://apps.health.ny.gov/pubdoh/health_care/medicaid/program/medicaid_health_homes/emailHealthHome.action

Contact us!

Visit www.ctacny.org to view past trainings, sign-up for updates and

event announcements, and access resources

Please send questions to: mctac.info@nyu.edu

Logistical questions usually receive a response in 1 business day or less.

Longer & more complicated questions

can take longer.

We appreciate your interest and patience!