An ongoing focus in North Carolina has been on children who are in or at-risk of being in the foster care system. No one wants a child to live out of their home setting, yet approximately 11,000 kids in North Carolina are doing just that. Children in foster care have extensive needs, including mental health, substance use and intellectual-developmental disability service needs. The foster care system exemplifies the push for integrated services and strengthened communication across health and human service systems in our state. The North Carolina Department of Health and Human Services (DHHS) has taken a strong lead in improving the state’s child welfare system and local communities are also bringing together resources to focus on this population. NC DHHS had an independent audit done on the child welfare system and they have written a Performance Improvement Plan based on the findings of that audit. An ongoing issue has been the cultural differences between local DSSs and LME/MCOs. While they are both public organizations serving a public system and both rely extensively on limited public funding, DSS offices oversee an economic and social/human service system, and LME/MCOs are plan managers for an almost insurance-like treatment and habilitation service system. The lingo that is used, the outcomes that are expected, the turnaround expectations are all different, thus causing gaps in collaborative efforts. This Policy Exchange brings together Subject Matter Experts who have extensive field experience in assisting children who are in or at-risk of being in foster care.
I’m excited to hear your insights on how we can span the cultures of social services and behavioral/I-DD services to help children in or at-risk of being in the foster care system. Let’s start the conversation with one question and see where that takes us. What would you say are the key focus areas to close the gap between the social service and behavioral health/I-DD service cultures?
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:
Warren, what else should we consider?
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:
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: