Integrated Care for Children with Specific Diagnoses

A number of states have blended funding from multiple state agencies to pay for services delivered through integrated models of care for children with specific conditions or diagnoses. In different states, these may include children with serious emotional disturbance, children with autism, or children in foster care.

While many of these programs have demonstrated excel­lent outcomes, including cost savings and improved fam­ily satisfaction, they usually serve only small numbers of children and often operate on a limited geographic scale.

Children with Serious Emotional Disturbance

Several states have developed integrated care programs for children with serious emotional disturbance. In some states these services are delivered through a managed care organization on a capitated basis. In other states community mental health providers serve children on a fee-for-service basis.

The Children’s Behavioral Health Initiative (CBHI) is a broad interagency approach to integrating behavioral services for children in Massachusetts, regardless of the agency with which they are primarily involved. The result of a lawsuit, CBHI aims to increase access to intensive community-based services for Medicaid-enrolled children with mental health problems.  Formal screening by pediatric practices for behavioral health problems began December 31, 2007 and a standard behavioral health-assessment tool is being used by all outpatient providers of Medicaid mental health services. Services include intensive care coordination and planning, emergency mobile crisis intervention, in-home therapy and behavioral services, therapeutic mentoring services for children, caregiver and family support, and training.

Michigan was one of the first states to implement a Medicaid waiver for children with serious emotional disturbance who would otherwise be in state psychiatric hospitals. This waiver permits payment for wrap-around services, respite care, community-living services, and therapeutic foster care. Community mental health centers must provide the state match, however, so the program is limited to centers that have agreed to meet this requirement.

Mississippi is among nine states, including Alaska, Indiana, Kansas, Maryland, Montana, South Carolina, Virginia, and Georgia that have a demonstration waiver to serve children and youth between the ages of 0-22 with serious emotional disturbances under the Family Opportunity Act.  Participants must have a serious emotional disturbance; meet Medicaid Psychiatric Residential Treatment Facility level of care and Medicaid financial eligibility. They must have an IQ above 60.  This project uses a wraparound service model (individualized, adjustable services) designed by the family and providers. Providers have access to flexible, not-categorical funding.  Services include mental health services (in-home therapy, day treatment, group therapy, crisis outreach, family therapy, substance abuse treatment, community-based respite, psychiatric services, aide services), social services, educational services (tutoring, in-school support, assistance forming Individualized Education Plans, vocational services, recreational services (physical fitness, art and music therapy), transportation and transitional living.

Virginia Medicaid also implemented a waiver program authorized under the Family Opportunity Act: Community-Based Alternatives to Psychiatric Residential Treatment Facilities.  The program offers home and community-based services for children who have resided in a Psychiatric Residential Treatment Facility (PRTF) for at least 90 days.  The services available include environmental modifications, companion services (consumer/agency directed), therapeutic consultation, in-home residential supports, respite (consumer/agency directed), family and caregiver training, service facilitation (consumer-directed services only), and transition coordination.

The Texas Integrated Funding Initiative (TIFI) is a fund­ing collaboration among state agencies, families, and community groups—the latter composed of public and private providers who come together to develop individual service plans for children, youth, and adults with serious emotional disturbance and their families. Half of the TIFI governing board are family members and the other half are state agency staff from five child-serving agencies. Services are provided through four county-based mental health organizations.

Arkansas’ Together We Can (TWC) program, operated by the Divisions of Health, Developmental Disabilities, and Children and Family Services, also serves children with mental health diagnoses. TWC is administered at the county level, and each agency contributes care teams to the program including clinical, administrative, and mana­gerial staff. Social Services Block Grant funds are used to purchase services.

Under a contract with Magellan Behavioral Care of Iowa and a waiver, the Medicaid program has established a telehealth network that can be used to access a child psychiatrist for children and youth with special health care needs and their families at Title V CSHCN Regional Centers around the state.  In addition, Iowa has secured a grant through the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to provide care coordination, family support, and early intervention using wrap-around strategies for children with behavioral or emotional disorders.

Children in Foster Care

Some states have developed integrated care programs for children served by the child welfare system, with a particular focus on children in foster care. As with the integrated programs for children with serious emotional disturbance described previously, some of these operate on a fee-for-service or contractual basis, and others are capitated, managed care models.

Kentucky, North Dakota, and Florida operate fee-for-service models, while Massachusetts, South Carolina, Arizona, and Florida operate managed care models.

Kentucky’s IMPACT Plus program is a collaboration of Medicaid, the Departments of Mental Health and Mental Retardation, Juvenile Justice, Social Services, and parent representatives. It uses a parent support and guidance model to serve 3,320 children ages 3-18 with serious emotional disturbance who are living outside their homes or have a history of hospitalization or insti­tutional placement. Using blended funding, the enhanced package of services includes school support, in-home services, respite, and therapeutic foster care.  Also, in 2005, Kentucky’s Title V program developed a pilot program to provide home visits to medically fragile children in foster care.  The program, called The Medically Fragile Foster Care Program, operates under a Memorandum of Agreement between the Title V program and the Department of Community Based Services and serves about 150 children.

In North Dakota the Professional Association of Treatment Homes (PATH) family support program pairs biological families with specially trained foster families who provide mentoring and respite care to help keep chil­dren with serious emotional disturbance from entering residential placement or the foster care system.

The South Carolina and Massachusetts programs were designed as capitated, integrated care programs for medi­cally complex foster children through collaboration among state Medicaid programs, child welfare departments, and health care providers.

South Carolina’s Medically Fragile Children’s Program began in 1996 as an all-inclusive health care program for medically complex children in foster care. Today, it has expanded to serve approximately 150 children from birth through age 21 who live with either foster or bio­logical families. Services are provided by an interdisci­plinary team that works closely with families to support the child’s health and development. The program oper­ates out of a day health resource center as a partially capitated managed care program.

In Massachusetts, approximately 100 children are en­rolled in Special Kids/Special Care, which is operated by the Neighborhood Health Plan managed care organiza­tion to serve medically complex foster children from birth through age 21. The program uses nurse practitioners to provide home-based care and care coordination, and to assure prompt access to medical equipment, supplies and specialty care, in collaboration with pediatricians and foster families. Neighborhood Health Plan receives a specially derived rate for enrolled children.

In Florida, children in foster care may be enrolled in a Medicaid prepaid plan or a primary care case management program. Children in foster care with complex medical problems may be offered enrollment in the Children’s Medical Services (CMS) Network.  Foster parents receive special training in the care of these children by CMS staff.  The foster parents receive supplemental payments for being CMS medical foster care parents through Medicaid and CMS provides intense nursing and social support for the families.  CMS staff also works with the biological parents in anticipation of reunification.  When reunification does not occur, CMS works with the child welfare agency in moving the children toward adoption.

Utah offers the Fostering Healthy Children Program.  The program is operated through a contract between the Department of Human Services and the Department of Health to provide care coordination for children in foster care. This is a nurse care coordination program supported by state Human Service funds and Medicaid match.  The Utah Department of Health supports 32 public health nurse consultants who are co-located with Human Service workers throughout the state.  The nurses oversee the health requirements for children in the foster care system, including medical, dental, and mental health.  In addition, the nurses help foster parents access Medicaid services for other health needs of the child.

Children with Autism

A third group of CYSHCN for whom several states are developing integrated delivery systems is children with autism. Maryland was the first state to implement an autism waiver, which covers intensive family support and training, therapeutic integration services, respite care, and home modifications. Maryland’s waiver also covers intensive individual support in the home, at school or in the community. Nine hundred children with autism are currently served under this waiver.

South Carolina has recently implemented a Home and Community-Based Services (HCBS) waiver to provide Applied Behavioral Analysis (ABA) therapy for children with autism. Under this program, school districts can bill Medicaid for care coordination, therapy, and counseling. Rhode Island Medicaid also cov­ers home-based therapy and the development of family care plans for children with autism as a fee-for-service benefit under their state plan.