Health and Recovery Plan (HARP)/ Behavioral Health Archive

EHA Empire Health Advisors

  • Studies is also available in Portable Document Format (PDF)

TWO STUDIES TO INFORM THE TRANSITION OF CHILDREN IN FOSTER CARE IN NEW YORK STATE INTO MEDICAID MANAGED CARE

November 3, 2015
1 pm – 3 pm

Today´s Agenda and Speakers

  1. Welcome and Introductions
  2. Overview of Foster Care Readiness Activities
  3. Data Collection Activities:
    • Medical Record Review
    • Activity Study
  4. Conclusions
  5. Questions

Presented By Empire Health Advisors:

  • Jack Knowlton, President
  • Patricia HasBrouck, Consultant
  • Dorothy Knowlton, Record Reviewer

Foster Care Managed Care Readiness Activities

A collaboration between IPRO, the New York State (NYS) Department of Health´s Office of Health Insurance Programs (OHIP) and the New York State Office of Children and Family Services (OCFS). Its purpose is to ensure the achievement of important activities that will facilitate the transition of children placed in voluntary agencies to Medicaid Managed Care.

IPRO Project Partners

  • IPRO Improving Healthcare for the Common Good®
  • EHA
  • New York Care Coordination Program
    • Creating a person–centered, recovery–focused system of care
  • CTAC The Community Technical Assistance Center of New York
    • Efficient Practices
    • Effective Care
IPRO engaged a panel of highly qualified consultants and subject matter experts to accomplish project activities:
  • Empire Health Advisors (EHA): Data Collection & Analysis
  • New York Care Coordination Program (NYCCP): Health Home Training
  • Raymond Schimmer: Foster Care Subject Matter Expert
  • Community Technical Assistance Center (CTAC) of New York at the NYU McSilver Institute for Poverty Policy and Research: Readiness Assessment, Technical Assistance, and Medicaid Managed Care Training

OBJECTIVES OF THE TWO STUDIES

A. MEDICAL RECORD REVIEW

  • Document the health and behavioral health service utilization of a sample of children in foster care in New York State.
  • Collect data from foster care agency medical records, CONNECTIONS and MMIS to provide a comprehensive view of services provided.
  • Provide State policy and rate–setting staff and its actuarial consultants information regarding utilization assumptions for the foster care population in the development of Medicaid managed care costs for this population.

B. STAFF ACTIVITY STUDY

  • Inform DOH and OCFS about activities that may be reimbursable through the Medicaid Health Homes.
  • Inform the development of the foster care residual per diem.
  • Identify and quantify time spent by medical, behavioral healthcare, and care management staff on:
    • Direct patient care;
    • Treatment planning & care management;
    • Clinical administration;
    • Medication administration; and
    • Other activities

MEDICAL RECORD REVIEW

PROJECT METHODOLOGY

  • Workgroup that included Department of Health, OCFS, IPRO and Empire Health Advisors representatives agreed upon project design.
  • Dr. Fred Wulczyn developed a sample of 624 children from 26 foster care agencies throughout New York State.
  • Sample provided data which permit analyses based upon a number of variables including:
    • Age
    • Gender
    • Length of Stay (2012 and 2013)
    • Family care or Group care
    • Behavioral health history before foster care placement or not.
  • Empire Health Advisors conducted pilot study at Berkshire Farm Center and Services for Youth which identified the need to review CONNECTIONS data.
  • Seven agencies with a total of 11 sample cases were not included in the review due to timing and staffing constraints.
  • Ultimately 556 records of children in the initial and revised sample were reviewed.

NUMBER OF RECORDS IN SAMPLE AND NUMBER REVIEWED

Agency Number in Sample Number Reviewed Percent
Total 613 556 91%

Ninety–one percent of the sample records (including the additional sample records at three agencies) were reviewed and data included in the report.

SERVICES PROVIDED TO 556 CHILDREN IN FOSTER CARE SAMPLE BY DATA SOURCE

Source Number Percent
Record Review 5,714 66.9%
CONNECTIONS 358 4.2
MMIS 2,467 28.9
Total 8,539 100.0%

Two–thirds (66.9 percent) of the services utilized by children in the 556 sample were identified in the medical record; 4.2 percent in the CONNECTIONS medical tab; and 28.9 percent in MMIS.

NUMBER OF CHILDREN BY LENGTH OF STAY AND GENDER

Length of Stay Gender Children Average Length of Stay
0 to 30 days Female 37 15.14
  Male 35 17.03
31 to 90 days Female 45 58.00
  Male 47 61.87
91 to 180 days Female 46 134.98
  Male 54 129.04
181 to 360 days Female 82 268.72
  Male 78 260.54
361+ days Female 67 521.69
  Male 65 518.48
Subtotal Female 277 239.59
  Male 279 231.16
Total All 556 235.36

The number of males and females in the 556 member sample is similar as are their lengths of stay in foster care during the 2012–13 period.

UTILIZATION PER PERSON PER YEAR FOR SAMPLE OF 556 FOSTER CARE CHILDREN

Primary Care Emergency Services Inpatient Dental Mental Health Chemical Dependency Specialist Physician Lab
7.92 0.80 0.12 2.06 4.45 3.38 0.68 2.91
  • Primary care visits averaged nearly eight visits per year and dental visits just above two per year.
  • Mental health visits were over four per year and chemical dependency over three.

UTILIZATION PERPERSON PERYEAR, BY AGE GROUP AND CARE SETTING

Ages Setting Children Primary Care Visits Emergency Services Inpatient Hospital Dental Mental Health Chemical Dependency Specialist Physician Lab
0 to 5 Family 170 9.06 0.56 0.09 0.60 0.34 – 0.64 1.22
  Group 1 8.60 – – – – – – 1.98
6 to 11 Family 76 5.79 0.60 0.19 2.23 4.10 0.10 0.48 1.67
  Group 5 11.45 1.27 0.64 4.45 20.35 – 0.64 6.36
0 to 5 Family 65 4.76 0.58 0.07 2.45 5.29 1.37 0.31 1.85
  Group 206 9.06 1.34 0.14 3.67 9.62 10.71 1.03 6.20
0 to 5 Family 8 4.32 0.86 0.17 1.90 5.53 2.42 0.17 3.45
  Group 25 7.76 0.86 0.09 3.71 6.21 6.21 0.95 4.31
  • Higher utilization of primary care than is the norm for children and youth enrolled in Medicaid is found, particularly in the age 0–5 category as well as youth in Group settings.
  • Dental visits were two to four per year except in the 0–5 age group.
  • Mental health visits for children in Group settings ages 12–17 and 18– 21 we 9.62 and 6.21 per year.

UTILIZATION PER PERSON PER YEAR, BY LENGTH OF STAY AND MENTAL HEALTH DIAGNOSIS

Prior Mental Health Diagnosis Children Primary Care Visits Emergency Services Inpatient Hospital Dental Mental Health Chemical Dependency Specialist Physician Lab
NO 391 7.58 0.58 0.09 1.62 2.97 2.22 0.57 2.27
YES 165 9.09 1.55 0.24 3.60 9.56 7.38 1.09 5.10
Total 556 7.92 0.80 0.12 2.06 4.45 3.38 0.68 2.91
  • Children with a prior mental health diagnosis prior to entering foster care were high utilizers of services in all categories.
  • Most services experienced two to three times use by children with a prior mental health diagnosis than by those without with the exception of primary care.

PRIMARY CARE VISITS PER PERSON PER YEAR, BY AGENCY BY SETTING

  Family Care Group Care
Agency Children Primary Care Visits Children Primary Care Visits
1 25 6.97 1 6.89
2 33 8.98 0 N/A
3 7 4.36 22 12.09
4 28 6.54 4 10.85
5 2 15.87 23 7.83
6 13 5.35 20 7.37
7 1 10.36 28 11.01
8 19 7.05 10 7.80
9 0 NA 31 10.19
10 0 NA 32 9.66
11 22 8.65 10 8.27
12 25 5.49 0 NA
13 27 10.37 1 8.60
14 27 7.62 0 NA
15 27 5.87 1 9.36
16 12 7.15 13 7.07
17 30 7.03 0 NA
18 10 8.54 21 6.22
19 11 9.56 20 7.81
Total 319 7.44 237 8.95
  • Children in Group Care received 1.5 more primary care visits than those in Family Care.
  • Most children in Family Care had six to nine primary care visits with only four agencies showing fewer than six.
  • Group care agencies had only one with fewer than seven visits per year.

DENTAL VISITS PER PERSON PER YEAR, BY AGENCY BY SETTING

  Family Care Group Care
Agency Children Primary Care Visits Children Primary Care Visits
1 25 1.08 1 0.00
2 33 0.83 0 NA
3 7 4.07 22 2.81
4 28 0.94 4 1.48
5 2 6.35 23 5.95
6 13 0.89 20 2.80
7 1 0.00 28 2.69
8 19 1.24 10 4.20
9 0 NA 31 3.05
10 0 NA 32 2.52
11 22 3.01 10 1.77
12 25 2.20 0 NA
13 27 0.75 1 0.00
14 27 1.46 0 NA
15 27 1.67 1 1.87
16 12 0.43 13 3.46
17 30 1.44 0 NA
18 10 0.52 21 10.32
19 11 1.84 20 3.06
Total 319 1.33 237 3.63
  • Children in Group Care averaged 3.63 dental visits per year while children in Family Care averaged 1.33.
  • The Group Care average is influenced by the average utilization of 10.32 visits per year by an agency with 21 children.
  • The dental service utilization for children in Family Care appears to be lower than desired according to the American Academy of Pediatric Dental Periodicity Schedule with six agencies averaging less than one visit per year.

STAFF ACTIVITY STUDY

PROJECT METHODOLOGY

  • Pilot study conducted at Berkshire Farm Center and Services for Youth identified need for minor changes to data collection tools and activity categories.
  • OCFS identified 12 representative agencies. o Upstate / Downstate – 6 agencies each o Programs reflecting care continuum:
    • FBH – 3 agencies, 160 staff
    • TFBH – 3 agencies, 49 staff
    • Group – 3 agencies, 119 staff
    • Residential – 3 agencies, 113 staff
  • Two distinct studies were conducted at each agency:
    • Medical, Dental and Behavioral Healthcare
      • Medical – 105 staff
      • Behavioral – 131 staff
    • Care Management and Coordination – 154 staff
    • Staff Hours Recorded:
      • 11,586 total hours
      • 29.7 average hours per participant
    • Discussions were held with key program staff at each agency to provide context.

    CATEGORIZATION OF STAFF ACTIVITY DATA

    Staff were categorized based on function

    Service Type Admin Level 1 Level 2 Level 3
    Medical Medical Office Asst Medical Assistant, LPN RN, Nurse Coordinator MD, NP, Dentist, Optometrist
    Participants 2 38 44 21
    Behavioral Director, Administrator Social Worker, Case Worker, Intake Coordinator LCSW, LMSW, Therapist, Behavioral Health Specialist MD, NP, Psychologist
    Participants 5 34 49 43

    ...Also by foster care program type

    Program Type Participants
    Foster Boarding Home 132
    Group 80
    Residential 57
    Therapeutic Foster Boarding Home 10
    Total Participants by Program 279

    ACTIVITY BY PROGRAM TYPE

    Medical

    Program Type Staff Hours Reported Direct Patient Care Treatment Planning and Care Mgmt Clinical Admin Medication Admin Patient Education Other
    FBH 1,123 33% 19.8% 21.3% 1.7% 3.1% 20.9%
    Group 629 25% 9.7% 21.1% 20.1% 2.0% 22.3%
    Residential 653 23% 8.3% 39.1% 15.1% 1.4% 13.1%
    TFBH 119 47% 17.5% 20.4% 0.2% 7.2% 7.4%
    Total 2,524 29% 14.2% 25.8% 9.7% 2.6% 18.6%
    • Providers spend less than a third of their time in direct patient care.
    • Clinical administration consumes more than 25 percent of staff time.
    • Administering medications takes 15 to 20 percent of time in group or residential settings.
    • Treatment planning and care management consumes a much greater portion of staff time in foster boarding homes.

    DIRECT PATIENT CARE BY PROGRAM TYPE

    Medical

      Assessment or
    Wellness    		 Crisis Treatment
    FBH 69.7% 1.7% 28.6%
    Group 58.7% 0.5% 40.9%
    Residential 60.9% 2.8% 36.3%
    TFBH 31.6% 5.3% 63.1%
    Total 62.6% 2.0% 35.4%
    • For children in all settings other than TFBH, the majority of direct patient care is for assessment or wellness.
    • For TBFH, more than 5 percent of care is for crisis care and nearly two–thirds for treatment.

    ACTIVITY BY STAFF CATEGORY

    Medical

    Staff Category Staff
    Hours
    Reported    		 Direct
    Patient
    Care    		 Treatment
    Planning
    & Care
    Mgmt    		 Clinical
    Admin    		 Medication
    Admin    		 Patient
    Education    		 Other
    1 (LPN, Med Asst) 1,106 30% 15.6% 23.1% 10.2% 2.4% 18.4%
    2 (RN) 998 25% 12.0% 26.8% 12.2% 2.1% 21.8%
    3 (MD, NP, Dentist) 363 40% 17.6% 22.3% 2.6% 4.9% 12.3%
    Admin 57 6% 3.5% 85.6% 0.0% 0.0% 4.8%
    Total 2,524 29% 14.2% 25.8% 9.7% 2.6% 18.6%
    • High level medical staff spend:
      • 40 percent of time in direct patient care
      • Minimal time in medication administration
      • Double the time in patient education.
      • Nearly 18 percent of time in treatment planning and care management
    • RNs spent the greatest percentage of time in clinical administration outside of administrative staff.

    ACTIVITY BY PROGRAM TYPE

    Behavioral Healthcare

    Program Type Staff Hours Reported Direct Patient Care Treatment Planning and Care Management Clinical Administration Family Support Other
    FBH 1,289 27% 23.2% 27.5% 6.0% 16.1%
    Group 1,032 30% 26.9% 23.3% 2.8% 17.5%
    Residential 1,066 31% 28.4% 19.5% 5.7% 15.5%
    TFBH 492 21% 31.9% 22.0% 8.0% 17.2%
    Total 3,879 28% 26.7% 23.5% 5.3% 16.5%
    • Providers spend less than thirty percent of their time in direct patient care.... For the TFBH population, only 21 percent.
    • Clinical administration:
      • Averages more than 20 percent of time
      • In FBH, nearly 28 percent of time
    • Family support services take a small but notable amount of time.
    • For residential staff, clinical administrative activities related to regulatory requirements represents 37 percent of total administrative time, for FBH staff 13 percent and for group and TFBH 21 to 22 percent.

      ACTIVITY BY STAFF CATEGORY

      Behavioral Healthcare

      Staff Category Count Staff Hours Reported Direct Patient Care Treatment Planning and Care Mgmt Clinical Admin Family Support Other
      1 Social Worker, Case worker 34 1,125 30% 29.3% 16.8% 6.5% 17.0%
      2 Therapist, LCSW, LMSW 49 1,602 26% 28.1% 20.8% 7.1% 17.8%
      3 Psychiatrist, Psychologist 43 960 33% 24.4% 28.0% 2.0% 12.7%
      Admin 5 193 4% 11.4% 63.0% 0.5% 21.0%
      Total 131 3,879 28% 26.7% 23.5% 5.3% 16.5%
      • Behavioral healthcare staff spend more time in treatment planning and care management than their medical counterparts.
      • Family support activities take up a notable amount of time for social worker, counseling and therapy staff.

      DIRECT PATIENT CARE BY STAFF CATEGORY

      Behavioral Healthcare

      Staff Category Assessment or
      Wellness      		 Crisis Treatment
      1 Social Worker, Case worker 11.2% 7.6% 81.2%
      2 Therapist, LCSW, LMSW 13.8% 6.9% 79.3%
      3 Psychiatrist, Psychologist 51.4% 3.4% 45.2%
      Total 23.9% 6.5% 69.7%
      • Six percent of direct patient care is spent in crisis intervention.
      • Social workers, counselors and therapists spend time providing treatment.
      • Psychiatrists and psychologists split their time between assessment/wellness and treatment.

      CATEGORIZATION OF STAFF ACTIVITY DATA

      Care Management and Care Coordination

      Staff were categorized based on function

      Staff Category Participants Hours Reported Average Hours/ Participant
      1 Case Planner, Case Worker, Care Coordinator 94 3,263 34.7
      2 Social Worker, Nurse, Nurse Manager, Program Manager, Family Specialist, Clinical Manager 54 1,784 33.0
      3 Program Directors, Administrators 6 137 22.8
        Total 154 5,183 33.7

      ...Also by foster care program

      Program Type Participants
      Foster Boarding Home (FBH) 50
      Group 44
      Residential 38
      Therapeutic Foster Boarding Home (TFBH) 22
      Total 154

      ACTIVITY BY PROGRAM TYPE

      Care Management and Care Coordination

      Program Type Foster Care Specific Activity Direct Patient Services Health Home Activity Travel Time Other
      FBH 48.7% 9.3% 14.2% 7.6% 20.2%
      Group 48.4% 13.6% 6.9% 12.9% 18.2%
      Residential 45.3% 10.3% 16.9% 7.1% 20.4%
      TFBH 62.0% 3.3% 5.5% 10.4% 18.9%
      Total 49.5% 10.0% 11.6% 9.4% 19.5%
      • Staff have a primary obligation to perform foster care activities.
      • Activities reimbursable through Medicaid Health Homes constitute less than 12 percent of time.
      • Travel time is significant.
      • Medicaid Health Home activities are greater for FBH and Residential populations.

      Health Home Activities

        Comprehensive Care Management Care Coordination and Health Promotion Comprehensive transitional care Individual and family support Referral to community and social support services
      As a Percent of All Staff Activity 3.8% 3.8% 0.9% 1.6% 1.6%

      ACTIVITY BY STAFF CATEGORY

      Care Management and Care Coordination

      Staff Category Participants Foster Care Specific Activity Direct Patient Services Health Home Activity Travel Time Other
      1 Case Planner, Case Worker, Care Coordinator 94 58.4% 7.8% 6.7% 10.4% 16.7%
      2 Social Worker, Nurse, Nurse Manager, Program Manager, Family Specialist, Clinical Manager 54 36.0% 14.6% 19.5% 6.2% 23.7%
      3 Program Directors, Administrators 6 30.6% 2.4% 28.4% 0.7% 37.9%
        Total 154 49.9% 10.0% 11.7% 8.7% 19.7%
      • Case planners and case workers spend:
        • The majority of their time on foster care specific activities
        • More than 10 percent of time in transit
        • Very little time on Health Home functions
      • Program directors and higher–level administrators were those most likely to spend time on Health Home activities, at nearly 30 percent.
      • Category 2 staff spent nearly 20 percent of their time on Health Home activities.

        • OBSERVATIONS FROM SITE VISITS AND INTERVIEWS

        • Most agencies provide services in unlicensed settings.
        • OCFS requirements establish need:
          • For providers to be readily accessible for assessments, and
          • To provide services during transitions rather than periodically.
        • Children enrolled in Medicaid managed care in NYC that are in foster care Upstate have been required to use providers in NYC.
        • Ongoing relationships with providers are essential to the quality of care.
          • Trauma–informed care
          • Psychiatrist access
          • Concern about appropriate and timely access.
        • After–hours care: agencies have clinical staff on–call.
        • Agency staff provide transportation to medical visits.
        • Nurses play a central role as educators, in medication administration, as first–line medical assessment, and collaborators with other agency staff and families.
        • Concerns about managed care:
          • Policy conflicts with county mandates and managed care guidance / standards.
          • Access to medications.
          • Access to medical equipment.

        CONCLUSIONS

        • Children in foster care are high service utilizers.
        • Most agencies employ or contract with providers that provide much of the routine care, particularly for services rendered during admission and transfer processes.
        • A majority of agencies visited offer on–site medical and behavioral health care, typically without licensure or oversight from Department of Health or the Office of Mental Health.
        • Agencies have agreements with community–based providers for primary care, specialty care, dental, pharmacy and mental health services.
        • Agency medical and behavioral health care staff activity reflects a wide range of responsibility and work with direct patient care consuming less than 30 percent of their time.
        • Most agency care management and coordination staff have a primary obligation to perform foster care case support activities while also providing direct patient care, family support, and community referrals. Activities eligible for reimbursement through Health Homes constitute only a small portion of staff time.
        • Agencies employ and contract with providers that are experienced in working with the population and providing trauma–informed care, and who are readily accessible to meet urgent needs.

        CONSIDERATIONS

        With the implementation of Medicaid managed care for the foster care population, challenges will need to be overcome if continuity and quality of care are to be maintained. These include:

        • Ensuring the delivery systems in place at VFCAs can participate in Medicaid managed care organization provider networks.
        • The inclusion of agency–contracted community–based providers currently serving foster care children in Medicaid managed care organization networks.
        • Timely access to medical and behavioral health care services, particularly psychiatry and non–generic prescription medications.
        • Ensuring that managed care network providers are capable of providing trauma–informed care to the population.
        • Maintaining the current level of integration, collaboration and communication among and between foster care case planners, medical care manager/coordinators, medical providers, behavioral health care providers and families. Introducing Health Home care managers to the existing interdisciplinary team will change the dynamic.
        • Enabling funding for the continuation of agency– provided medical, behavioral health care and care coordination services that would not be identified as discrete Medicaid managed care billable services (i.e. mental health screenings, nursing services provided to children in residential care, medication administration, staff escorts to off–site providers, travel time and expense for providers making home visits, family support, obtaining consent for treatment, etc.)
        • Funding for court, local department of social services, or other agency–mandated provision of medical or behavioral health care services.