Governance and System Management

Sheila A. PiresHuman Service Collaborativesapires@aol.com

Lisa ConlanParent Support Network of Rhode Islandlisaconlan2@aol.com

Michelle ZabelUniversity of Marylandmzabel@psych.umaryland.edu

Bruce StrahlTechnical Assistance Partnershipbstrahl@ffcmh.org

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Definition of Governance

Decision making at a policy level that has legitimacy, authority, and accountability.

Definition of System ManagementDay-to-day operational decision making

Pires, S. (1995). Definition of governance. Washington, DC: Human Service Collaborative.

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Key Issues for Governing Bodies

Has authority to govern Is clear about what it is governing Is representative Has the capacity to govern Has the credibility to govern Assumes shared liability across systems for

the population(s) of focus

Pires, S. (2000). Key issues for governing bodies. Washington, DC: Human Service Collaborative.

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Examples of Types of Governance Structures

• State and/or local interagency body

• Non profit board of directors

• Quasi governmental entity

• Tribal governance

• Hybrids

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

5Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

System Management: Day-to-Day Operational Decision Making

Key Issues

• Is the reporting relationship clear?

• Are expectations clear regarding what is to be managed and what outcomes are expected?

• Does the system management structure have the capacity to manage?

• Does the system management structure have the credibility to manage?

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Examples of Types of SystemManagement Structures

• State and/or local interagency body

• Quasi-governmental entity

• Non profit lead agency

• Public sector lead agency

• For profit commercial managed care entity

• Shared management structure/hybrid

• Tribal authorityPires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

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New Jersey - Contracted Management Structure

CHILD

Screening with Uniform Protocols

Child Welfare

Juvenile Justice/Court

SchoolReferral

Community Agencies

Family & Self

Other

Contracted Systems Administrator CSA

•Registration•Screening for self-referrals•Tracking•Assessment of level of care needed•Care coordination•Authorization of services

Community Agencies•Uncomplicated care•Service authorized•Service delivered

Care Management Organization•Complex multi-system involved children•Individualized plan developed•Full plan of care authorized

Family Support OrganizationFamily to Family Support

Adapted from NJ System of Care

Youth Support Organizations

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Wraparound Milwaukee - Lead Public Agency Management Structure

Child WelfareFunds thru Case Rate

(Budget for InstitutionalCare for CHIPS Children)

Mental Health•Crisis Billing•Block Grant

•HMO Commercial Insurance

Medicaid Capitation(1557 per Month

per Enrollee

Juvenile Justice(Funds Budgeted for

Residential Treatment for Delinquent Youth)

Management Entity:Wraparound Milwaukee

Management Service Organization (MSO)$30M

Child and Family Teams

ProviderNetwork

240 Providers85 Services

CareCoordination

Plans of Care

9.5M 2.0M10M8.5M

Per Participant Case Rate

Family Organization$300,000

Mgt. Entity: Co. BH Div.

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

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Deputy County Administrator for Human Services

System of Care Office*

Children in or at risk for residential

placement

Youth with status offenses

Children with serious behavioral health

challenges

0-3 population Early Intervention engagement challenges

Subsets of Children & Families –Focus of Care Coordination

Partnerships

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

Cuyahoga County OH - In-House Management Structure

System of Care Oversight Committee

*Functions as anAdministrative ServicesOrganization

Lead Family Coordinator

Lead Youth Coordinator

{

{

1010

Regional CareManagement Entities

•Ensure child & family team plan of care**•Ensure intensive care coordination•Manage utilization at servicelevel

**Plans of Care (w/priority on community-based/naturalsupports) determine medicalnecessity, except inpatient, residential/group, which require prior authorization

DCHMCO MCO MCO

MHDDAD

ASO TPA

DFCS

DJS

DOE

Care Management Entities:Locus of management accountability for children

with complex, multi-system involvement

Use Same Decision Support Tool –CANS – to determine need for CME

Pires, S. 2008. Washington, D.C.: Human Service Collaborative

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• At the Youth & Family Level:– Child Family Team (CFT) Facilitation using Wraparound Model – Care Coordination with assessment tools– Care Monitoring and Review– Peer Support Partners

• At the Systems Level:– Information Management & Web-based Information System – Provider Network Recruitment and Management– Utilization Review – Evaluation, Outcomes and Continuous Quality Improvement

• Financing Model- Case Rate

Maryland Specific Supports & Functions of a Care Management Entity

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Pires, S. (1996). Contracted system management structure. Washington, DC: Human Service Collaborative.

Example of Governance/Management Structure

State Funding Pool

Local Allocation

County Alliance

Case Rate for each enrolled child

Provider ProviderProvider

Financer/Payers

Purchaser

Care Management Entity – Lead Non Profit•Organize and manage provider network•Staff and manage child and family team process• Intensive care management •Utilization management•Quality assurance•Outcomes management /monitoring•Management Information System (tracks children, services, dollars)

State Interagency

Body

Natural Supports Natural Supports

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BOARD POLICY STATEMENTThe Governing Board of All Children System of Care, in recognition of the growing diversity in the population of children and youth needing behavioral health services, seeks to create and maintain a culturally responsive helping environment capable of comprehensively addressing the unique needs of children of color. Children of color have historically been under referred to treatment and specifically in Alden County. It is the responsibility of ACSC to not only make its services accessible to all, but to affirm by policy and action its commitment to children of all cultures.

It is the policy of ACSC to develop and maintain: links with key referral sources in our state’s communities of color; standards for providing services to ethnically, culturally diverse children; a culturally competent work force, reflective of the cultural diversity of the service population; intake procedures, treatment planning, and therapeutic interventions which recognize, enhance and strengthen cultural identity, dignity, and esteem; a treatment milieu in which racism, stereotyping, bigotry and prejudices are inappropriate and not tolerated.

Example: Board Policy Statement Addressing Cultural and Linguistic Competence

Adapted from: People of Color Leadership Institute and Day, P.A. Cultural Competence Materials for MSW Students, Staff, Faculty and the CommunityUniversity of Minnesota, Duluth

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• Input/evaluation of key management• Input/evaluation of quality of services and

programs• Local system of care input• Resource allocation• Service planning and implementation• Policies and procedures• Grievance and resolution procedures

Examples of Types of Family/Youth Partnership in System Governance and Management

Conlan, L. (2003). Implementing family involvement. Burlington, VT: Vermont Federation of Families for Children’s Mental Health.

Presented by Michelle Zabel, MSSDirector, Maryland Child & Adolescent Innovations Institute, Mental

Health Institute & Juvenile Justice InstituteDivision of Child & Adolescent Psychiatry, School of Medicine,

University of Maryland, Baltimore

Governance & System Management

The Maryland Children’s Cabinet and the Governor’s Office for Children

VISION Children’s Cabinet: All Maryland’s children are successful in life. Governor’s Office for Children: Maryland will achieve child well-being through

interagency collaboration and state/local partnerships.

MISSION The Children’s Cabinet, led by the Executive Director of the Governor’s Office

for Children (GOC), will develop and implement coordinated State policies to improve the health and welfare of children and families. The Children’s Cabinet will work collaboratively to create an integrated, community-based service delivery system for Maryland’s children, youth and families. Our mission is to promote the well being of Maryland’s children.

COMPOSITION The Secretaries of the Departments of Budget and Management, Disabilities,

Health and Mental Hygiene, Human Resources, and Juvenile Services, and the State Superintendent of the Maryland State Department of Education.

Chaired by the Executive Director of the Governor’s Office for Children.

Individual Care Planning with Child and Family Teams: Care Management Entity (CME)

Local Systems Management

State Systems Management

Local Governance

State Governance

Family Support Organizations

A Scenario for State and Local Governance Structures

Local Management Boards• Purpose is to “ensure the implementation of a local interagency service

delivery system for children, youth, and families.” (Human Services Article, Annotated Code of Maryland)

• Composed of:– Public and private community representatives and,– A senior representative or department head of the:  (i) local health

department;  (ii) local office of the Department of Juvenile Services;  (iii) core service agency;  (iv) local school system; and  (v) local department of social services. 

• LMBs are tasked with:– Strengthening the decision-making at the local level; – Designing and implementing strategies that achieve clearly defined

results for children, youth, and families as outlined in a local 5-year strategic plan;

– Maintaining accountability standards for locally agreed upon results for children, youth, and families;

– Influencing the allocation of resources across systems to accomplish desired results;

– Building local partnerships to coordinate children, youth and family services within the county to eliminate fragmentation and duplication of services; and,

– Creating an effective system of services, supports, and opportunities to improve outcomes for all children, youth and families.

Infrastructure

Administrative Service Organization

• Key Functions Include:

• Care Authorization

• Provider Credentialing and Enrollment

• Billing/Reimbursement and Provider Payment

• Utilization Management

• Continuous Quality Improvement

• Outcomes Data

• Information Management

Regional Care Management Entities

• A CME is a structure that serves as a “locus of accountability” for youth with complex needs and their families.

• Provide Supports to Youth and Families:– Child Family Team Facilitation using Wraparound Service Delivery Model– Care Coordination using Standardized Assessment Tools– Care Monitoring and Review– Peer Support Partners

• Provide System Level Functions:– Information Management & Web-based Information System– Provider Network Recruitment and Management– Utilization Review of Service Use, Cost, and Effectiveness – Evaluation and Continuous Quality Improvement– Cross-System and Jurisdiction Financing

• Populations to Be Served:– 1915(c) Psychiatric Residential Treatment Facilities (PRTF) Demonstration Project

Medicaid Waiver– SAMHSA funded SOC grants – MD CARES and Rural CARES– Child Welfare’s Place Matters Group Home Diversion using Resource Coordinators– Other Out-of-Home Diversion using Care Coordination

Local System Management and Service Delivery Infrastructure

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Wicomico County, MD System of Care Structure

211 System(screening)

Service Coordination/SystemsNavigation - CANS

Care Management EntityCare Coordinators

Family Partners

Family Partner-Ship Center

Families andYouth

Agencies/Court

SOC Community Advisory Board

Adapted from Wicomico County, MD

Local Management Board

Governance and System Management

Bruce Strahl

Technical Assistance Partnership

Great Governance

Starts With Great Collaboration

Collaboration Defined: A mutually beneficial relationship between two or more parties

who work toward common goals by sharing responsibility, authority and accountability for achieving results

Critical Characteristics of SOC Governance

• Balanced-true sharing of responsibility, power and authority

• Inclusive-with significant and authentic decision making roles for all who desire a role

• Broad-Many places available to be a part of decision making for family, youth state and community partners

• Defined- Roles concise, clear and understandable

• Simple

Governance Characteristics (continued)

• Culturally and linguistically competent• Clear communications flow and work flow

and easily explainable to all stakeholders with diagram

• Efficient and effective• Clear roles and procedures for decision

making• Responds quickly but also accommodates a

more deliberate approach when needed

Broad Based Governance SystemSTAKEHOLDERS

MEETING EVERY OTHER MONTHFull Partnership

Facilitator

Agenda 2 Framed Major Challenges

Work Group Meet

Work Group (Some) Report Progress

Agency Pitch – NetworkingMemorandum of Agreement

WG WGWGWG WG

Odd Number Group 11-13-17-19 PD, PI, Community Leaders, Lead Family,

Family Member, Youth, Policy Makers, Lead Evaluator

Role

Frame Major Strategic challenges to go to full partnership

Set agenda for full partnership meeting

Model SOC principles

Barrier busting

Conscience of SOC, Cultural competency, family inclusion, collaboration

Help the PD

Model Change

Do It 1st

High Standard of Care/Quality

Administrative Team Grant Requirements

Grant Administration

Staffing

Budget

Quality

Decisions Broad SOC Community Strategy

Intake System

Social Marketing

Referrals to Community Services

Participation in Child & Family Teams

Family Involvement

Coordinating Committee

Standing or Ad Hoc

OK

OK

Send a Work Group Out

Family and Youth Involvement in Your Governance System

• Where should Family and Youth be in your governance system?

• Pair family members and pair youth

• Prepare a welcome for them

• Provide background information and meeting protocols to new families

• More tips

The 7 Keys to Governance Success

1) A cross functional team including youth, families, required partners and community partners participate in the development of a broad based governance structure.

2) The broad based governance structure provides a variety of meaningful decision making opportunities for partners to participate and be involved in governance on the coordinating council, full partnership, work groups and administrative team.

7 Keys (continued)

3) Diagrams and procedures exist of the governance structure and all partners have a clear understanding of how work and communications flow as well as how decisions are made. SOC decisions are not made outside of the agreed upon governance structure and process.

4) The governance structure reflects the cultural make up of the community and population served.

7 Keys (continued)

5) An evident commitment exists to review and enhance the governance system at regular intervals using broad community and partnership involvement.

6) Orientation, preparation and education must be utilized for all partners for authentic and meaningful participation to take place in the governance system.

7) “Collective Will” is the most important ingredient. Without it, structures and processes will not work and can be manipulated but with it, structural challenges can be overcome.