Presentated at the Alliance for Children and Families conference in October, 2008. The presentation focused on a comprehensive framework on buiding a child welfare network.

1. A Community-Based Approach to Redesigning a Placement Continuum of Care A private, community-based lead agency model integrating clinical and permanency best practices to dramatically “right size” a child welfare system.

2. Presenters Gregory J. Kurth Chief Executive Officer Family Services of Metro Orlando Elizabeth Lewis, RN, B.Ed. Chief Operating Officer Family Services of Metro Orlando

3. What Is Community-Based Care (CBC)? Lead agency oversees a fully array of child protective services within a community network of partners.

4. 19 Community Based Care Lead Agencies

5. Service Areas FSMO is one of the largest CBC lead agencies in the state of Florida, managing formal child welfare services for over 2,800 children

7. CMO Partner Agencies

8. In 2004 FSMO Inherited Over 3,600 kids in protective services (in and out of home) “Cookie cutter” case plans High removal rate No Utilization Management No Permanency review process Limited foster home capacity

9. 2004 - A Closer Look Funding of Licensed Care: $48,000 per day/$17.5 million per year Over-utilization of residential placements; no Mental Health Integration Disrupted placements 3 times that of entries into the system No focus on Older or SED Children for permanency

10. 2004 - A Closer Look Little knowledge of community resources DJJ/DCF/SAMH: agencies operating in silos Negative perception of biological families Lack of gate keeping/utilization management

11. Children Placed Outside of Osceola County

12. Children Placed Outside of Orange County

13. In 2004 Over 400 Children in High End Placements

14. An Example of the # of Admissions and Discharges Compared to Child Movements

15. Where We Are Today Funding of Out of Home Care Licensed Care: $32,100 per day/$11.7 million per year $5.8 million savings annually 2700 kids in protective care with 780 kids in paid care Responds to 15,000 calls annually and services to 8,000 children and families

16. How FSMO Made a Difference Community Involvement Safety Focus Engagement Based Practice Prescription System Integration Relentless Management and Quality Improvement

18. DJJ Liaison

20. DJJ Kids Diverted 2004 – 1 2005 – 22 2006 – 29 2007 – 41 2008 – 45 (January – June) Total - 139

21. 83 DJJ Kids Diverted 2007-2008 Savings of $14,424/day

22. Developmentally Delayed Children FSMO hired DD/CMS Specialist in 11/07 9 children diverted from the system. Saving over $200,000.00 annualized. These kids are: Difficult to place Have very specialized needs Expensive to treat

23. Safety Focus Differentiating Risk from Safety Child Endangerment Risk Assessment Protocol (CESAP)

24. Why Implement Change? Many Children are Entering Care Unnecessarily; Some child/abuse victims may be remaining home who should be placed; In-Home families are not receiving effective child protective services; The System has not clarified the difference b/w Risk and Safety Workers lack prescriptive guidelines

25. Focus on Front-End 4.2% 25.6% 4.2% 36.5% 4.0 5.3 8.2% 31.6% 20.3% 8.2% 7.0 26.4% 8.9% 29.4% 8.9% Abuse Reports (% of Child Population) Substantiations (% of Reports) Nation State Orange/Osceola Removals (% of Substantiations) Removals (per 1,000 of Child Population)

26. Safety Risk versus Potential Harm

27. CESAP Requirements A ‘life of the case’ protocol. Assessing moderate to severe harm immediately or in the near future. Safety Determination Form. Safety Plan.

28. Engagement Based Practices Placement stabilization Families participate in staffings and case development Specialized Adoption Recruitment: Wendy’s Wonderful Kids / Heart Gallery of Metro Orlando Family Team Conferencing Community providers invited to staffings

29. Placement Stabilization Case managers take ownership Know and support foster families (e.g. foster parent liaison) 1st sign of trouble -- initiate supports “Push down” accountability Work with schools to save placement Explore extra curricular activities

31. Highlights 80 children in Orange and Osceola counties currently available for adoption

33. May 2004 - A Look at the Permanency Options Biological family rarely considered Children under 12 and siblings growing up in group care Step downs rejected due to increased work on case worker Fear of making the wrong decision lead to inappropriate child labeling

35. Focus on deficits of parents

36. Plugging families into existing services

37. Expert model

39. Focus on needs of the children

40. Crafting, individualizing and tailoring services around specific needs

41. Collaborative model

43. Placement Matrix

44. Using CANS Criteria How it was used: Match child’s characteristics to program Profiling provider based on the residential CANS survey Created placement algorithms Number 1 Benefit: Placement stabilization

46. Cost per Client per Day of Residential Services

47. Number of Residential Clients Served

48. Beyond Traditional Foster Care Services Cost per Day

49. #1 Key to Our Success Utilization Management Utilization Management Program Expert Review & implement recommendations Focus on early & appropriate treatment Decrease multiple placements Focus on safety, permanency & well being

50. System Integration Medicaid managed care - Magellan Utilize all appropriate funding streams Utilize IV-E Waiver Embedding UM in permanency

51. Child Welfare and Mental Health Needs of Children Annually, 600,000 children seen in the U.S. child welfare system do not receive mental health care to meet their needs. 48% of these children have clinically significant mental health needs. Journal of American Academy of Child and Adolescent Psychiatry, August 2004

52. Mental Health Issues Children lose funding in RTC and come into care Families need services – children come into care Adoptive families return children due to lack of services We paid for four kids at $406.00/day until Medicaid funding began $406.00 for 30 days is $12,188.00/child

54. All had psychologicals and assessments

55. All had multiple psychiatric diagnoses

56. 22 were on psychotropic medications

57. 15 were taking 3 or more medications

58. Negative view of biological families

60. Used medications to control behaviors

61. Courts changed medication dosage

62. Could take weeks before court approval

64. Beginning of purchase of service utilization

65. Authorizations required for high end services

66. RTC funding carved out

67. Full risk for RTC placements

70. Training for all Front-Line Staff

71. Quality Service Reviews and Team Performance Calls

73. Scope of Training Pre-service training Field training In-service training Supervisory training Targeted trainings driven by quality improvement initiatives

74. Transition of Training Program Train protective investigations and case management together to build collaborative relationships Build in mentor and modeling approach to training Moving from global skills development to specialization

76. Domestic Violence

77. Mental Health

78. Substance Abuse

81. Increased adoptions

82. Increased relative care placements

83. Increase # of foster homes

84. Increased prevention activities

85. Fewer children placed in foster homes

86. Kids moving through the system

87. Decreased kids in the system

88. Decreased disruptions

89. Decreased # of group homes

90. Decreased high end placements

92. Interesting Note The state of Florida operates the child welfare system at 70% of the national median of per capita funding.

94. Out of Home Care “Bottoming”

95. Continuity of medical/behavioral care

96. Adequate services for DJJ & DD kids

97. Improving well-being outcomes

99. New Initiatives Program Advisory Committee (Health, Education, Community Resources) Faith Based Initiatives Web-Based Development – Greater Network Interactivity (e.g. Blogging) Educational Liaisons

100. Contact Presenters Gregory J. Kurth, MA Chief Executive Officer gkurth@fsmetroorlando.org Elizabeth Lewis, RN, B.Ed. Chief Operating Officer blewis@fsmetroorlando.org Family Services of Metro Orlando 407-398-7975