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Service Delivery Innovation Profile

Managed Care Entity Funded By Public Agencies Reduces Institutionalization and Recidivism, and Improves School Attendance and Functional Ability Among Emotionally Disturbed Youth


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Snapshot

Summary

Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee is a managed care entity that pays for and supports the provision of coordinated mental health and support services tailored to meet the needs of children and adolescents with serious emotional and mental health needs and their families. With support from an assigned care coordinator, each family creates a team that helps to identify its unique needs and strengths. Together, the coordinator, team, and family create care and crisis safety plans specifically designed to address those needs. The care coordinator helps the family execute these plans, including accessing needed services and otherwise advocating on its behalf. A secure, Internet-based electronic medical record system allows participating providers to access care plans, progress notes, crisis plans, and service authorizations as needed. The program has reduced rates of institutionalization and recidivism and their associated costs, increased school attendance, improved youths' ability to function at home and in school, and generated high levels of satisfaction among participating families.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of youth being institutionalized in residential treatment and correctional facilities, school attendance rates, and the child's ability to function better at home and in school; additional evidence includes a comparison of program costs to the costs of placing youth in various institutional facilities; comparisons of 2-year recidivism rates among delinquent youth served by the program with countywide averages; and feedback from participating families on their satisfaction with the program.
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Developing Organizations

Milwaukee County Behavioral Health Division
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Date First Implemented

1996
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Patient Population

Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Insurance Status > Medicaidend pp

Problem Addressed

Mental disorders and emotional disturbances are common among youth served by the juvenile justice, child welfare, special education, and Medicaid systems. Even though these youth (and their families) often receive services from multiple systems, little or no effort is typically made to coordinate the services, as each system is funded separately and operates in its own "funding silo."
  • A common problem: Approximately 50 to 66 percent of youth in the juvenile justice system and roughly half of youth in the child welfare system have a mental disorder, well above the 15- to 25-percent incidence rate among youth in the general population.1,2 Roughly 15 to 20 percent of youth in the juvenile justice system have a serious emotional disturbance, compared with just 10 percent of youth in the general population.1 Youth in residential treatment centers, 69 percent of whom come from the juvenile justice and child welfare systems, have extremely high rates of mental and behavioral health disorders compared with the general population.2 About 20 percent of children with a diagnosed mental health problem have public insurance, mostly through Medicaid.3 Medicaid and the State Children's Health Insurance Program provide coverage for roughly a third of youth diagnosed with a serious emotional disturbance.4
  • Fragmented, uncoordinated services: Children with mental and emotional health needs and their families often receive care from multiple systems, including schools and special education programs, Medicaid, child welfare, juvenile justice, and private insurance.3 Funded independently, these systems tend to operate in silos, with little or no effort to coordinate activities or services.

What They Did

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Description of the Innovative Activity

Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee is a managed care entity that pays for and supports the provision of coordinated mental health and support services for children and adolescents with serious emotional and mental health needs and their families. With support from an assigned care coordinator, each family creates a team that helps to identify its needs and strengths. Together, the coordinator, team, and family create a care plan (including a crisis/safety plan) specifically designed to address those needs. The care coordinator helps the family execute the plans, including accessing needed services and otherwise advocating on its behalf. A secure, Internet-based electronic medical record (EMR) system allows participating providers to access information as needed. Key program elements include the following:
  • Managed care entity funded jointly by youth-serving systems: Wraparound Milwaukee functions as a “special managed care entity” under the Social Security Act’s 1915(a) Medicaid waiver, which allows it to act as a type of health maintenance organization (HMO) for a distinct Medicaid population (youth with a severe emotional disturbance) within a specific geographic area (Milwaukee County). The various government-funded systems that serve youth in the area contribute $52 million to the program annually, including $32 million from Medicaid, $10 million from child welfare, and $10 million from juvenile justice. (Special education programs in the county's 26 school districts do not contribute direct funding but provide in-kind support and services such as alternative school programs, classroom re-assignments, tutoring programs, etc.) The Medicaid program provides capitated monthly payments of $1,923 per enrolled youth based on Medicaid eligibility (95 percent of enrollees) and program eligibility. Child Welfare contributes $131 per day ($3,930 per month) for youth referred and found to be at risk of higher-cost institutional placement in a residential treatment center (average rate is $9,500 per month). Medicaid and the County Behavioral Health Division also provide reimbursement on a 60/40 basis for the cost of all crisis intervention and crisis stabilization services. The County Juvenile Justice System contributes $10 million through a combination of fixed funding and a case-rate methodology based on funds previously budgeted for residential treatment and juvenile corrections placements.
  • Referrals of eligible youth: The program serves youth with complex mental health, emotional, and behavioral health needs. To be eligible, youth must meet the following criteria: a diagnosis of a mental/behavioral condition or disability that has persisted for at least 6 months; impairment in functioning in the home, school, or community; involvement in at least two child-serving systems (i.e., Medicaid, child welfare, juvenile/criminal justice, mental health, special education); and at risk of placement in a residential or group home, psychiatric hospital, or correctional facility. The systems that serve youth refer eligible families to Wraparound Milwaukee based on these criteria.
  • Screening assessment and enrollment: Trained staff members screen all referred youth to confirm eligibility. Most eligible individuals agree to enroll voluntarily, although some are ordered to do so by the courts. In 2013, the program served 1,600 youth and their families, with more than 1,100 youth/families being enrolled at any given time.
  • Care coordinator and family support team: Each family is assigned a care coordinator who helps put together a team to serve the youth and family. The team consists of those in a position to provide the youth and family with formal support (e.g., therapists, physicians, tutors, job coaches) and informal support (e.g., relatives, friends, peers, clergy members).
  • Monthly meetings to develop/update care and crisis management plans: The care coordinator and family hold team meetings at least once a month (and more often if necessary) to identify psychological, educational, living situation, family, vocational, medical, and spiritual needs. The team also identifies the child’s strengths and aptitudes. Based on these discussions, the team, care coordinator, and youth/family develop and execute a care plan that details strategies to address the child’s needs and leverage his or her abilities. The plan details specific services that the family needs and/or requests, including a list of network providers who can offer them. This plan is monitored and reviewed at each team meeting and updated every 60 to 90 days. The care coordinator also helps the family create a detailed written plan to help manage crisis situations, including services to help recognize and manage stressful events.
  • Ongoing care coordinator support: Between team meetings, the care coordinator helps the family implement the plans by facilitating access to needed services and otherwise acting as an advocate for the family with the court, schools, and providers. The care coordinator meets with the family each week at home or a neutral site in the community (such as the school). During and between sessions, the care coordinator facilitates access to and coordinates services across the various systems and providers serving the child/family.
  • Provision of services by network providers: Wraparound Milwaukee serves as the single payer for care and services provided to enrolled youth and their families by any of more than 70 service and 200 provider agencies that contract with the program. The program covers all out-of-home care related to mental/behavioral health, inpatient psychiatric hospitalizations, mental and behavioral health services, and support services offered by contracted providers; it does not pay for physical care services but does coordinate with the primary care provider to ensure annual health exams and other medical needs are being addressed to promote physical health. Services for a given family may include any or all of the following:
    • Behavioral and clinical health services: These services include individual therapy, intensive in-home therapy, individual and group substance abuse therapy, medication management, day treatment programs, and respite services.
    • Mobile crisis services: A mobile urgent treatment team (MUTT) provides around-the-clock services to stabilize and resolve a family crisis. The MUTT can be dispatched to the home to provide crisis intervention, short-term therapeutic services as well as identify and authorize crisis stabilization services including a crisis "one-to-one" support in the home or short-term crisis placement in a group home or residential treatment program. (The MUTT serves all Milwaukee county families, regardless of income, including those not enrolled in Wraparound Milwaukee; more information about MUTT is available in a companion profile, at: http://www.innovations.ahrq.gov/content.aspx?id=1719).
    • Placement services: Placement services include care at a psychiatric hospital, foster home, group home, or residential treatment center, along with supported independent living arrangements.
    • Support services: The program covers various support services, including mentors, tutors, parent/family aides, life coaches, employment counselors, camps, after-school programs, suspension accountability services, transportation services, interpretive services, and equine therapy.
    • Other services: Discretionary program funds may be used to meet other related family needs, such as clothing, food, child care, furniture, appliances, and educational supplies.
    • Family advocacy services: The program contracts with a large, locally based family advocacy organization, Families United of Milwaukee, to provide family advocates and educational advocates to work on developing or modifying individualized education plans for youth. Family advocates play a large role in helping families engage in the care planning process and offer support through groups, social events, participation in management meetings, etc.
  • Data sharing through EMR: On an ongoing basis, all providers share relevant information through a secure, Internet-based EMR system that offers access to care plans, progress notes, crisis plans, and service authorizations.
  • Program discharge: The average stay for a youth and family in Wraparound Milwaukee is 18 months and occurs when a child and family have made significant progress on the care plan and no longer feel they need the intensity of the supports and services provided by Wraparound Milwaukee. Transitional planning is conducted with all families before they leave the program.

Context of the Innovation

Milwaukee County Behavioral Health Division provides care and treatment to adults, children, and adolescents in Milwaukee County who have mental illness, substance use disorders, and intellectual disabilities. Services are provided through county-operated programs and contracts with community agencies. Milwaukee County is home to 1.1 million residents, including 215,000 children and adolescents under the age of 18.

The impetus for this program came in the early 1990s, when leaders of the State’s Medicaid program and Milwaukee County child welfare, juvenile justice, and children’s mental health systems realized that too many children and adolescents served by these systems were being institutionalized in psychiatric hospitals, residential treatment centers, and juvenile correctional facilities. Studies done by a local planning organization showed these children were not improving and had high rates of recidivism; the high institutional placement numbers were creating major fiscal issues for the county due to their high costs. The vast majority of these youth had serious emotional and mental health needs that the various youth-serving systems in the county did a poor job addressing, due primarily to a very fragmented system in which each agency operated independently of other agencies. These leaders decided to redesign the structure, organization, financing, and operations of the system so that children could receive more coordinated care designed to address all of their needs simultaneously.

Did It Work?

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Results

The program has reduced rates of institutionalization and recidivism and their associated costs, increased school attendance, improved the ability to function at home and in school, and generated high levels of satisfaction among participating families.
  • Fewer institutionalized youth: The average number of Milwaukee County youth living in a residential treatment facility fell from 375 prior to program implementation in 1996 to 100 in March 2014. The number of county youth in State correctional facilities also fell substantially from nearly 300 commitments in 1996 to under 150 in 2013. As of March 2014, approximately three-quarters of those discharged from Wraparound Milwaukee have a permanent living situation with a parent, relative, adoptive resource, or guardian.
  • Below-average recidivism: In December 2013, the 2-year recidivism rate among the 425 delinquent youth served by the program (i.e., the proportion being arrested for the commission of a new delinquent act within 2 years of the initial act) was 21 percent, well below the 45-percent average for the county as a whole. The 2-year recidivism rate among juvenile sex offenders was only 5 percent. (No comparative statistics at the national or State level are available for this latter figure.)
  • Lower costs: The reduction in institutional placements and recidivism generates significant cost savings for the county. The average monthly cost of providing Wraparound Milwaukee services to a child is $3,450, well below the monthly cost of placement in a State correctional facility ($9,000), residential treatment center ($10,000) or psychiatric hospital ($38,000).
  • Fewer missed school days: As of March 2014, program participants attended school on 87.5 percent of school days, a 60-percent improvement over their attendance rates before enrolling.
  • Better functioning at home and in school: Three-quarters of enrollees achieved meaningful improvement in their ability to function at home and in school, as measured by the Achenbach Child Behavior Checklist, which is administered at enrollment and discharge.
  • High satisfaction: Families report being very satisfied with the program, with ratings averaging 4.7 on a 5-point scale.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of youth being institutionalized in residential treatment and correctional facilities, school attendance rates, and the child's ability to function better at home and in school; additional evidence includes a comparison of program costs to the costs of placing youth in various institutional facilities; comparisons of 2-year recidivism rates among delinquent youth served by the program with countywide averages; and feedback from participating families on their satisfaction with the program.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Meeting to discuss solutions: A small group of representatives from the mental health, child welfare, juvenile justice, and Medicaid systems discussed the challenges they faced and potential strategies for overcoming them. These discussions surfaced the idea of creating a new treatment approach with a philosophy of care that is family-focused, individualized, strength-based, and community-based and that could truly “wrap” services around the needs identified by families for their child. These discussions also surfaced the idea of creating a new type of administrative entity responsible for the delivery of care to children with serious emotional and mental health needs across child-service systems, including the pooling of financial resources to pay for the care. There were also components of the new system of care identified, such as care coordinators who work with very small caseloads, family and peer advocates, a comprehensive network of providers with a broad array of mental health and supportive services, and a mobile crisis response team.
  • Applying for grant funding: The county applied for and received a 6-year, $15-million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services, which funded development of Wraparound Milwaukee as a comprehensive, collaborative, community-based, family-directed program for children with serious emotional and mental health care needs.
  • Building service network: Wraparound Milwaukee identified needed services and built a network of contracted providers able to offer them.
  • Becoming an HMO: The program applied to the Wisconsin Department of Health Services (which runs the State Medicaid program) to operate as a unique type of special managed care entity or HMO model.
  • Training care coordinators: Wraparound Milwaukee developed, delivered, and expanded an 80-hour training curriculum for care coordinators, who received certification upon successful completion of the course. Newly hired care coordinators continue to take this course before being allowed to serve enrollees. Providers of mental health and other services in the network also receive training on the Wraparound philosophy and approach.
  • Developing information system: The program contracted with a vendor to develop an information system so that care coordinators, families, and network providers could access relevant information and it would become the electronic health record for the child.

Resources Used and Skills Needed

  • Staffing: Wraparound Milwaukee employs approximately 30 clinical program managers and support staff to oversee the program. Seventeen mobile crisis staff provide 24/7 crisis care to children in Milwaukee County.
  • Costs: The program cost $15 million to develop. As noted, the program’s annual budget is $52 million, which covers staffing and payments to contracted providers.
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Funding Sources

Substance Abuse and Mental Health Services Administration's (SAMHSA), Center for Mental Health Services (CMHS); Milwaukee County Behavioral Health Division; Wisconsin Department of Health Services; Milwaukee County Delinquency and Court Services; Bureau of Milwaukee Child Welfare
As noted, SAMHSA's Center for Mental Health Services provided a 6-year, $15-million grant to support program development. Wraparound Milwaukee began serving 25 children under a small State grant, grew with the receipt of the SAMHSA funds and, over 18 years, grew to serving nearly 1,600 families per year with a budget of $52 million that covers the payment of all mental health, substance abuse, and other supportive services as well as all administrative costs, including operation of the Mobile Crisis Program. Also as noted, the various youth-serving systems in the county provide ongoing funding to the program, including the Bureau of Milwaukee Child Welfare, Milwaukee County Delinquency and Court Services, Milwaukee County Behavioral Health Division, and the Wisconsin Department of Health Services.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Bring together key representatives from various agencies: The initial planning group should include high-level representatives from each child-serving system in the area. If the program is to succeed, agencies will have to give up some authority and agree to designate one entity to manage care. Involve the judicial system as a key advocacy group that can get behind the initiative.
  • Define values: Define a set of values that will drive program activities and provide a framework for program and agency staff. Such values include focusing on family centeredness, coordination and integration, cultural competence, and the child's strengths (not weaknesses).
  • Encourage unconventional thinking: While the planning group should be purposeful and goal-oriented, members should also think "outside the box" about initiatives that can help families. The focus should be on which populations to serve, what service gaps they face, how the organizational structure can support the right people and fill those service gaps, and how to measure the program's effectiveness. In addition, the planning group should consider new, innovative ways to structure funding to end the silo mentality and facilitate achievement of program goals.
  • Provide training to care coordinators: Care coordinators need to be prepared to work with each family to identify its specific needs and know how to work across systems to support them in meeting those needs.
  • Break down information-sharing barriers: Develop a system to facilitate real-time communication and sharing of relevant information. As part of this process, all participating agencies should agree to a single form that families can sign to authorize the sharing of information across providers and agencies.

Sustaining This Innovation

  • Monitor and report on program's impact: Continually measure and share information documenting the program's impact on key metrics. This process ensures that participating agencies will continue referring clients to and otherwise support the program.
  • Maintain flexibility in service offerings: Continually review service offerings, changing them and adding new ones as necessary to meet the evolving needs of the population being served.

More Information

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Contact the Innovator

Bruce Kamradt, MSW
Director
Wraparound Milwaukee
9201 Watertown Plank Road
Milwaukee, WI 53226
(414) 257-7639
E-mail: bruce.kamradt@milwaukeecountywi.gov

Innovator Disclosures

Mr. Kamradt reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

Recognition

In 2004, the President's New Freedom Commission on Mental Health named Wraparound Milwaukee as an “exemplary program.” Available at: http://govinfo.library.unt.edu/mentalhealthcommission/reports/FinalReport/downloads/downloads.html.

Wraparound Milwaukee was named the 2009 winner of the Annie E. Casey Innovations Award in Children and Family Systems Reform by the Ash Institute for Democratic Governance and Innovation at the John F. Kennedy School of Government at Harvard University for its innovative practices for “individualizing the treatment of youth through family involvement and a unified set of services.” Available at: http://www.innovations.harvard.edu/award_landing.html.

References/Related Articles

More information on Wraparound Milwaukee is available at: http://county.milwaukee.gov/WraparoundMilwaukee.htm

Achieving the promise: transforming mental health care in America. President’s New Freedom Commission on Mental Health. 2003. Available at: http://govinfo.library.unt.edu/mentalhealthcommission/reports/FinalReport/downloads/downloads.html.

Footnotes

1 Hodgdon H. Mental health of juvenile offenders. The Future of Children: A Collaboration of the Woodrow Wilson School of Public and International Affairs at Princeton University and the Brookings Institution. Available at: http://www.futureofchildren.org/futureofchildren/publications/highlights/18_02_Highlights_02.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.). Adapted from “Adolescent offenders with mental disorders” by Thomas Grisso and “Prevention and intervention programs for juvenile offenders” by Peter Greenwood, in The Future of Children: Juvenile Justice. 2008;18(2).
2 Stagman S, Cooper JL. Children’s mental health: what every policymaker should know. Columbia University National Center for Children in Poverty. 2010. Available at: http://nccp.org/publications/pdf/text_929.pdf.
3 Koppelman J. Children with mental disorders: making sense of their needs and the systems that help them. National Health Policy Forum. Issue Brief No. 799/June 4, 2004. Available at: http://www.nhpf.org/library/issue-briefs/IB799_ChildMentalHealth.pdf.
4 Mark TL, Buck JA. Characteristics of U.S. youths with serious emotional disturbance: data from the National Health Interview Survey. Psychiatr Serv. 2006;57(11):1573-8. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 13, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.