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| Demonstration Type: | Managed Care Payment System1 |
| Approved: | September 29, 1998 |
| Implemented: | March 27, 2002 |
| Expected Completion: | June 30, 20032 |
| Final Evaluation Report Date: | March 12, 20043 |
Children eligible for Washington’s managed care payment system demonstration were those ages 6 to 17 who were in need of mental health or special education services and either at risk of entering or already placed in high-cost group care or high-cost family foster care.
Washington had the option under the title IV-E waiver to test alternative financing mechanisms in as many as six sites (each site could contain one or more counties). However, the demonstration was only implemented in two sites: Clark and Spokane Counties.
Washington's Waiver agreement allowed the State to test different managed care strategies. Washington’s Department of Social and Health Services, Children’s Administration (CA), proposed to use blended, flexible funds to provide comprehensive services designed to serve eligible children at home or in the least restrictive setting in their communities. Services for children included placement maintenance and direct social services, such as supervision, in-home treatment services to prevent out-of-home placement, crisis foster care, 24-hour crisis intervention services and support, respite care, therapeutic care, and group care.
In Spokane County, Washington piloted the flexible funding concept by developing an Interlocal Agreement with a Regional Support Network (RSN) designed to provide a complete array of residential, in-home, and follow-up services. The RSN provided Individualized and Tailored Care (ITC) services adapted to the needs of individual children. Eligible children included those ages 8 to 17 who were involved in the child welfare system, had mental health and/or special education needs and a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis, and were at risk of entering high-cost care.
The Spokane pilot project involved a case rate financing methodology tied to foster home bed days. The State paid Spokane County a rate of $2,400 per month per child. Spokane County then contracted with the RSN contractor, a licensed foster care agency, to take responsibility for referrals and placements; the RSN contractor in turn subcontracted with another agency to provide wraparound services and to facilitate ITC services. Spokane County terminated its pilot demonstration in November 2000 after the RSN contractor reported it was unable to continue providing services at the contracted case rate.
Clark County implemented its demonstration in March 2002 using a “wraparound” service model featuring Care Coordinators. Care Coordinators trained in ITC principles convened and facilitated monthly child and family team meetings to determine the strengths, needs, and appropriate services for each child and family. Through a fiscal partnership between the local CA office and the Clark County RSN, these services were purchased from a network of community-based providers. The Clark County demonstration targeted CA clients who were either at risk of need for high-cost residential care or at risk of requiring high-cost foster care services. The CA and the Clark County RSN set rates of $4,668 and $1,556 per month per child, respectively, for these target populations. Each agency contributed a specified proportion to these caps. Clark County’s demonstration was terminated by mutual consent on June 30, 2003 with the expiration of the Clark County RSN’s contract.
Washington’s evaluation consisted of process, outcome, and cost-effectiveness components. Washington randomly assigned children to experimental and control groups in both the Spokane and Clark County demonstrations. Children in the experimental groups received services using flexible funding and wraparound services, whereas children in the control groups received traditional services. The State originally expected to assign as many as 90 children in Clark County, with 45 children in the experimental group and 45 children in the control group, and to assign 300 to 400 total children over a five-year period.
The State proposed the following outcomes:
For the Clark County demonstration, Washington used the North Carolina Family Assessment Scale (NCFAS) to measure changes in child and family functioning and well-being, and the Restrictiveness of Living Situation Scales (ROLSS) to assess living situation outcomes at intake and following discharge from care.
Process Findings
Enrollment in both of the demonstration projects was lower than expected. At the termination of the Spokane pilot project, the County had assigned eight children to the experimental group and three children to the control group. In Clark County, 15 children (eight in the experimental group and seven in the control group) were enrolled at the time of termination. Limited bed capacity hindered higher enrollment in the Spokane pilot demonstration, in part due to the contractor’s inability to recruit a sufficient number of licensed foster homes. Disagreements over eligibility criteria limited enrollment in the Clark County demonstration. For example, confusion arose across partner agencies as to whether the project could serve all children who were eligible for mental health services or only those already receiving mental health services. In addition, whereas the Clark County RSN targeted children who incurred high costs for the local mental health system, the local CA office placed more emphasis on children who were high cost to the child welfare system.
In response to lessons learned from the Spokane pilot project, the State expanded the eligibility criteria for participating in the demonstration by allowing children ages 6 and 7 to be served and by removing the requirement for a DSM diagnosis. With the exception of Clark County, however, mental health authorities and community service partners in other localities were unwilling to designate local funds to a managed care initiative and did not commit to the demonstration.
Washington’s evaluation identified several financial, service-related, and contextual challenges to successful implementation:
Despite these challenges, Washington’s evaluation highlighted the strong commitment among stakeholders at both sites to the concepts of flexible funding and tailored, wraparound services.
In response to lessons learned in the Spokane and Clark County projects, Washington’s evaluation made several recommendations for future flexible funding initiatives, including the following:
Low enrollment and early project termination limited the collection and reporting of outcomes data for both the Spokane and Clark County demonstrations. In Spokane County, termination occurred too early to draw conclusions about program outcomes. Evaluators in Clark County collected limited data regarding children’s functioning and living arrangements, with results from the NCFAS suggesting some beneficial changes in relationships between experimental group children and caregivers, siblings, and peers. ROLSS data suggest improved outcomes for both experimental and control group children in their living situations following service discharge. Structured interviews with the caregivers of children enrolled in the demonstration generally indicated enthusiasm for and satisfaction with the wraparound services model.
Evaluation results indicate different service utilization rates and costs between experimental and control group participants. Average monthly case management contacts per participant were considerably higher for the experimental group (14 contacts per month) compared to the control group (5 contacts per month); costs in the experimental group were also higher, averaging $3,000 per participant per month compared to $1,870 per participant per month in the control group.
Small sample sizes in the Clark County demonstration necessitate extreme caution in interpreting evaluation results and preclude drawing clear conclusions about youth outcomes, client satisfaction, service utilization, and costs.
1Based on information submitted by the State as of March 2004. Back
2The demonstration was terminated early due to lower-than-expected numbers of referrals and problems contracting with service providers. Back
3In lieu of interim and final evaluation reports, Washington submitted a termination summary in which it outlined issues and challenges faced during the demonstration and lessons learned. Back
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