Policy Exchange

Rhonda Cox, Chief Population Health Officer, Vaya Health

Probably the most important factor to quote a retired DSS Director from our area is “someone who shares my pain”. She said it with a smile, but she was referencing the value of a bi-directional relationship that had been built on trust, accountability and responsiveness. I believe LME-MCOs and DSS share a mutual commitment to stabilizing families whenever possible and not detrimental to a child’s well-being. However, DSS and LME-MCOs have different mandates which can impact collaboration. While there are many factors, I believe there are three key elements that would close the gap:

1. Relationship, ideally at both administrative level and a line staff level within DSS and the LME-MCO. This allows for both a systemic and case specific interventions and removal of barriers re services and supports for children and families. Our DSS Service Continuum was born because seven DSS Directors, key providers and the LME-MCO came together to address service gaps, service quality issues and create a more accountable system for a region which ultimately benefitted the entire catchment regardless of county size. The LME-MCO worked with a provider to create an intensive DSS team that ultimately could be supported by Medicaid funds. They wanted something similar to what our Juvenile Justice teams had in our area. We mutually committed staff resources, DSS and the LME-MCO committed financial resources and providers took some unfunded cases during launch phase. Administrative level teams and local care teams still meet to ensure the care continuum stays on track. We had very difficult conversations in all directions, but we stayed together. Understanding the realities and limitations of each partner, allows systems for realistic, sustainable implementation of strategies.
2. A proactive strategy for identifying and supporting at-risk children and families before the child or children are removed from the home. This is probably one of the most important strategies because many parents have treatment needs that are driving the child’s risk factors (vs. the child’s behavioral health or IDD service or support needs). In recent years, parental substance dependence has been the largest driver of children being removed from their homes both locally and nationally. However, state funded treatment services for uninsured and underinsured adults continue to be de-allocated from LME-MCOs. Parents with Medicaid frequently lose their coverage when their children are removed from the home which then significantly reduces the likelihood of parents getting adequate substance use treatment and being able to reunify with their children. At a policy level, enabling parents to retain their Medicaid if actively pursuing treatment would have significant impact on diverting or shortening children’s stay in the foster care system. Additionally, parents who are in treatment for substance dependence will have relapses and typically need treatment for an extended period of time. Impoverished parents may struggle with getting to treatment due to lack of transportation. Treatment services may run at the same time as a parent’s job, etc. Slow initial engagement in treatment and relapse is normative in the recovery process and long term addictions or addiction to certain substances are very difficult to overcome. Parents may “run out of time” in their recovery resulting in children being permanently being removed from the home because of time frames designed to keep children from languishing in care. Again, at a policy level, a change in TPR processes within certain parameters would reduce the numbers of children in care. At a local level, having a multi-systemic team that can wrap around families, balance realistic expectations about treatment and social supports while families are intact supports a more integrated, collaborative approach between agencies and families. And finally,
3. A behavioral health and IDD community based clinical infrastructure that support families in learning, gaining or regaining skills necessary to be able to safely and effectively parent children who also have behavioral health and/or intellectual/developmental disabilities. Providers who serve these families must also be aware of mandates of DSS such as time frames for court, clearly written assessments and concrete recommendations, a feedback loop to the care team. Providers who focus on family strengths are far more successful in outcomes. The LME-MCO can also be a resource in accountability for service providers in terms of quality.

Warren Ludwig, PhD, Independent Consultant, Fellow, UNC School
 of Social Work

I agree with Rhonda’s points.

As Rhonda suggests, cultural differences between social services and behavioral health services exist within a context of differences in rules, mandates and roles. I was confronted with cultural differences between the two systems 20 years ago when I began supervising both child mental health and child welfare services for Wake County. Behavioral health clinicians felt child welfare workers did not respect their advice and clinical expertise. When I asked child welfare social workers why this was, I received a stark reply: “They go home at 5 o’clock.” Another major source of cultural differences and sometimes resentments is control or lack of control over caseload. Behavioral health providers usually can limit caseloads to assure quality whereas social services workers’ caseloads typically must expand to include all children and families mandated to be served.

Similar differences and tensions at the leadership level are exemplified when emergency placements are sought for behaviorally challenging youth. Although DSS is theoretically responsible for placement and the LME/MCO for treatment, most North Carolina placements that serve behaviorally challenging youth are treatment placements operated by behavioral health providers and reimbursed by Medicaid. DSS leaders need to place children safely the same day they enter foster care or disrupt from a placement. LME/MCO leaders are sometimes perceived as satisfied if they meet time frames to determine medical necessity after information has been submitted to them. As Rhonda suggests, LME/MCO leadership can help by conveying a sense that it shares the pain of the DSS and by attempting to be responsive to the needs. Similarly, DSS staff and leadership can help by understanding the mandates and rules under which LME/MCOs operate. Where mutual understanding of each other’s system and a sense of “being in it together” exists at the local level, DSSs and LME/MCOs are more likely to work out solutions to urgent placements and other issues as well.

Although the focus is often on DSS clients’ critical needs for accessible and effective behavioral health services, the DSS and LME/MCO systems are each dependent on the success of the other. Because North Carolina funds its high-end foster care services almost entirely through the Medicaid system and because adults who were involved with child welfare as children also are high users of behavioral health services, a disproportionately high percentage of behavioral health funds is spent on current and former child welfare clients. Demands on the behavioral health system are highly correlated with the success or failure of child welfare services.

Because of this mutual dependence, the two systems can both benefit by collaborating on upstream efforts to improve child and family outcomes and reduce costs such as:

• Working together with public health to prevent abuse and neglect from occurring in the first place
• Supporting families in which maltreatment has occurred to maintain children safely in their homes and
• Supporting regular foster and kinship placements to improve stability and reduce the need for residential treatment.

Across the state, DSSs and LME/MCOs are also collaborating to develop more effective downstream treatment systems. In several jurisdictions, efforts are well underway to develop trauma informed systems of care. The comprehensive community-based continuum of services referred to by Rhonda that is being implemented in the Vaya catchment area through Youth Villages also deserves to be highlighted. Tailored to the needs of children involved with juvenile justice and child welfare, it includes an array of services that are evidence supported or promising practices focusing on both the child and the family. The single point of assessment co-located at DSS or DJJ offices is empowered to refer children to the most appropriate initial services rather than requiring a child to qualify by failing at less intensive service levels.

Opportunities exist for the state to enhance its support of efforts by LME/MCOs and DSSs to improve outcomes for children and families through cross-system collaboration. For example, state leadership can seek ways to:

• adjust rules and mandates to bring the two systems into better alignment
• help fund upstream strategies that require initial investments to achieve future benefits and savings
• support evaluations of the effectiveness and cross-system cost savings of upstream and downstream initiatives, and
• incentivize and bring to scale cross-system collaborations found to be effective.