Perspectives to inform the development of the NYS Children’s Health Home Care Management Model

 Empowering and Equipping families and children to manage their own health and wellness

The Hillside Family of Agencies and Northern Rivers Family Services are pleased to provide a shared perspective on developing a model to be used by New York State in delivering children’s health home care management services. We hope that this information is helpful in finalizing the approach to be taken in delivering this crucial program.

Our shared perspective includes key themes we believe should drive a program model that will achieve the best possible outcomes. Included are ideas about how the “NYS Principles for Serving Children in Health Homes”, as well the Six Core Requirements of NYS Health Homes, may be operationalized.

 Setting the Stage

 Hillside & Northern Rivers envision a care management approach that builds robust family teams who become their own natural care coordination network. A paid Care Manager trained in the High Fidelity Wraparound Approach acts as coach for the family team. Family Finding is used when youth have been disconnected from their broad range of family members.

 

Critical considerations:

Societal challenges, like poverty, behavioral health struggles, and substance abuse present threats to the immediate and long-term health of children that may be life-long and irreversible;

Children have unique needs. Service systems that support children are diverse. Nationally, two-thirds of children receiving intensive care coordination services are served by other diverse service systems (e.g., OCFS, OPWDD, SED). The gates into these systems are complex and require sophisticated System of Care knowledge and linkages.

Rare, early-onset genetically-based conditions and severe, chronic illnesses constitute challenges that may overwhelm a family’s ability to manage the care of its own children, imperiling child health and driving medical costs to extraordinary levels.

Chronic, co-morbid, physical health conditions are considerably fewer in children than in adults. This means that acuity among children is less obvious than with adults, whose level of need may be more visilevisible through Medicaid claims data.  Cost savings and positive outcomes among the youth population will not come from short term medical cost reduction, but from improved cross-system utilization, standardized assessment (e.g. CANS-NY) and prevention of more serious problems in the future.  . 

Physical and behavioral conditions often germinate early in the life cycle and come to full-flower later.  Adult conditions that eventually prove costly and highly resistant to treatment may be identified and prevented in childhood.

Adverse Childhood Experiences (ACES) research demonstrates that increased trauma events have a lifelong negative effect on health needs and costs.

The unique needs and circumstances of children in foster care must be considered. Each element of the model should give attention to this population in the following ways:

(i) the provider network must include foster care agencies;

(ii) flexibility must be allowed in determination of eligibility;

(iii) foster care providers need to be able to provide care management services;

(iv) “family” should be defined according to the unique situations that come with foster care placement; and

(v) consideration must be made for transition from foster care.

Children must have robust family networks in order to thrive.  At-risk families must be supported by effective care management.  Families that have been fragmented by external and internal forces, must be supported to reconstitute themselves. Care management must locate and recruit supports to meet the needs of families who do not have adequate resources.

Northern Rivers and Hillside encourage New York State to consider the following concepts as Children’s Health Home Care Management model is finalized:

High Fidelity Wraparound:   A high fidelity wraparound approach should be implemented for those children and families whose acuity of need is highest. In these circumstances, the case load should be 1:10 to allow fidelity to the approach, including the extensive paperwork and fidelity measures. This is critical to achieving the desired outcomes for these most at-risk families.

In cases of lower acuity, where caseloads may be as high as 1:20, practice should be informed by the Ten Wraparound Principles:  

(i) Family Voice and Choice; (ii)

 Team based;

(iii) Natural Supports; (iv)

 Collaboration;

(v) Community Based; (vi)  

Culturally Competent; (vii)  

Individualized; (viii)

Strengths Based;  

(ix) Persistence; (x)

Outcome Based

Use of a Multi-Disciplinary Team: To allow the right expertise at the right time, the Care Team must incorporate participants from a multitude of systems and organizations, as determined by the family, including family and youth peer supports.

Determination of acuity: Insofar as acuity is used to determine level of service intensity and rates, the “assigned” acuity must take family structure and functioning into account. The strength of the family system will impact how much time and energy will go into care management to meet the child’s needs. A tool like the CANS-NY will allow for consideration of the wide range of ecological factors.

Model that builds on strengths: The tools selected for the assessment of need must be driven by a strengths-based approach. The assessment tool must ensure engagement by supporting families to tell their story in a way that honors their culture, history and vision. To ensure the child/family’s strengths are in the forefront, staff members should be trained and have the time to write the Hi Fidelity Wrap-Around “”Strengths, Needs and Culture Discovery”, or other similar document, with the family.

Family driven, youth-guided planning within a changing environment: The model must allow time and tools to enable the family, through the Care Manager, to clearly articulate their specific needs, as opposed to the traditional approach of identifying a level of service. In today’s changing environment of reduced residential and inpatient placements and increasing community-based alternatives, families need opportunities to identify innovative solutions and supports. Creating and coordinating such innovative approaches require sufficient time be built into the model for this element of care planning.

Funds for stabilization: Current case management models include funds to meet the immediate concrete needs that must be addressed before a child and family can concentrate on other health issues, both physical and behavioral. The new system must include comparable access to flexible dollars and ensure a robust service network.

Child-specific, nationally recognized measures to monitor quality & outcomes: The standard cost,  utilization, and clinical measures used for adult care management neither fully nor appropriately capture savings and improved outcomes for children AND their families. Outcome measures must extend beyond Medicaid to other related systems, as well as beyond the individual child to the family system. CANS-NY might be a good start, but we should continuously assess other tools.

Families as managers of their own care: Health Home Care Managers should coach and support parents/caregivers to be the primary coordinators for their children’s care. Although the Care Manager ultimately retains the accountability and responsibility for ensuring the provision of the core Health Home services, parents/caregivers, along with the youth, must be empowered to move toward self-management and “recovery”.

Family-Finding: Care coordination cannot be successful for children unless a robust lifetime network is able to support the needs of the child and their family.  Family Finding should be used to develop this lifetime network for children who have no permanent adult in their lives. Family Finding can also be used to develop a network of support for parents/caregivers who are not able to coordinate their children’s care on their own.

 

 

NYS DOH Principles for Serving Children in Health Homes: Operational Considerations

The operational considerations that Northern Rivers and Hillside believe will support an effective implementation of the NYS DOH Pprinciples for Sserving cChildren in Health Homes include the following:


Principle: Ensure managed care and care coordination networks provide comprehensive, integrated physical and behavioral health care that recognizes the unique needs of children and their families

Input from providers with expertise in working with children across services, including the foster care, mental health, developmental disabilities, and specialized physical health realms.

Informal or formal (no or low cost) natural network providers (no- or low-cost) who support family systems and address social service issues (e.g., faith based organizations, support groups, community centers).

Family “peer” support (see NYS OMH Definition) and youth peer mentor roles.

Partnership with the MCO to ensure and/or expand coverage of less traditional supports (e.g.,   acupuncture, massage, healing services, art/music therapies) and waiver-like services, including respite and family support.

Clear definitions of desired competencies, requiring that all Network Providers demonstrate them.

Training for Network Providers to ensure an understanding of the model and their responsibilities as Care Team participants. The Network Coordinator in each region should be charged with coordinating the entire Health Home Network and working with each Network Provider organization to support engagement with the Health Home. The Network Providers need to be able to fully contribute to the wraparound process and communicate as needed outside the billable hour.

Training for Care Management Staff regarding network partners, the importance of understanding partner goals (e.g., pediatric physical/mental health care, reducing no-shows, engaging parents) and the need to support integrated care.

Access to Primary Care and Specialty Physicians for all family members. Family members should all be enrolled in the same Health Home, recognizing that medical needs of caregivers may be overlooked and/or compounded as a result of stressful circumstances.

Adequate physical health care, including physical health consultant, such as a Licensed Health Practitioner, as part of the care management team, enabling an understanding of complex health needs and partnerships with the medical partners supporting these needs.

Operational structure to continuously identify gaps or capacity issues and address these concerns to guarantee access to physical/behavioral health services and community supports and resources.


Principle: Provide care coordination and planning that is family-and-youth driven, supporting a system of care that builds upon the strengths of the child and family.

Follow the Family Driven-Youth Guided approach. Support the youth and family’s investment in their own goals and outcomes to increase success, reduce no-show rates. 

Provide continuous care. Allow parents and caregivers to be served by the same Health Home as child.

Allow for reasonable caseloads. The highest-need families receive the full High Fidelity Wraparound model, administered to full fidelity to the model; a high-acuity caseload must never exceed 1:10. In lower acuity, following the wraparound philosophy, caseloads do not exceed 1:20.

Use Comprehensive, evidence-based assessment tools. Tools are sensitive to cultural nuances and linguistic needs, driven by a strengths-based approach supporting both the child and the family. Include a Strengths, Needs and Culture Discovery (Wrap-Around) with every family. The family should be empowered to tell their story in a way that honors their own culture and recognizes the frustration of retelling it to everyone.

Develop Individualized Care Teams in every case. Multi-disciplinary teams are developed in partnership with the child and family.

Include a Strengths, Needs and Culture Discovery (Wrap-Around) with every family. The family should beis empowered to tell their story in a way that honors their own culture and recognizes the frustration of retelling it to everyone. 

Provide Flex funding to support wraparound. Given the variety of family needs identified in a good planning process, it is critical that flex dollars be available. A small amount of money can give a family what they really need. Knowing such resources are available enables creativity in wraparound.

Develop Individualized Care Teams in every case. Multi-disciplinary teams are developed in pPartnership with the child and familyy; participants are multidisciplinary, identified by youth/family. Care Plan is shared among participants in real time and is a living document that changes as needs change. The Care Teams should reconvene at least quarterly but more frequently as needs arise.

Include Family “Peer” Support Partners, offering teams a participant with shared experience.

Provide Flex funding to support wraparound. Given the variety of family needs identified in a good planning process, it is critical that flex dollars be available. A small amount of money can give a family what they really need. Knowing such resources are available enables creativity in wraparound.

Ensure system flexibility and open-mindedness. Given the unique situations that arise in supporting families, all members of the Health Home system must be flexible in expectations and willing to take risks and share accountability.

Include Family “Peer” Support Partners, offering teams a participant with shared experience.

Consider Legal and relational permanency as key components of physical and behavioral well-being.  If the youth does not have permanency, their needs are not being fully met.  Care Managers need to address permanency as part of the youth’s comprehensive care.

 Ensure system flexibility and open-mindedness. Given the unique situations that arise in supporting families, all members of the Health Home system must be flexible in expectations and, willing to take  riskstake risks and share , while sharing aaccountability.

Consider Legal and relational permanency as key components of physical and behavioral well-being.  If the youth does not have permanency, their needs are not being fully met.  Care Managers need to address permanency as part of the youth’s comprehensive care.


Principle: Ensure managed care staff and systems care coordinators are trained in working with families and children with unique, complex health needs.

Training on the following topics: (i) family-driven/ youth guided principles; (ii) the model for Children’s Health Home care management (including standards of practice and expectations); (iii) trauma informed practices, (iii) Cchildren’s System of Care principles; (iv) integrated care for physical health and behavioral health care; (v) understanding of the role and needs of all partners; and (vi) the nature of complex health conditions among children and youth.

Training to the following partners’ staff:  Care management, community based agencies, Family Peer Support, MCO’s, Juvenile Justice, Child Welfare, Schools, Network Providers.

The collection and sharing of effective practices that support Children’s Health Home outcomes across Health Homes. Adequate physical health care, including physical health consultant, such as a Licensed Health Practitioner, as part of the team, enabling an understanding of complex health needs and partnerships with the medical partners supporting these needs.

Access to Primary Care and Specialty Physicians for all family members. Family members should all be enrolled in the same Health Home, recognizing that medical needs of caregivers may be overlooked and/or compounded as a result of stressful circumstances.

The collection and sharing of effective practices that support Children’s Health Home outcomes across Health Homes.


Principle: Ensure continuity of care and comprehensive transitional care from service to service (education, foster care, juvenile justice, child to adult).

Simplified referral and rapid access to Health Home enrollment and care management services at a transition point (e.gE.G., Admission/ discharge, transition between levels of care services).

SPOA as a resource to determine if a child/family is already linked to a Care Coordinator.

Comprehensive care management plans that include all stakeholders and allow for real time changes to respond to emerging needs and effective transition planning.

Variable intensity of care management to account for transition points, overlap of coordination - enrollment month bills at higher rate. An HIT system that allows for effective, timely, increased information sharing among all the partners.

Enrollment into Health Home prior to discharge from hospital/inpatient and/or residential care. Allows for transitional billing and the Care Manager to act as the responsible/appointed point-person during transition. Variable intensity of care management to account for transition points, overlap of coordination - enrollment month bills at higher rate.

Enrollment into Health Home prior to discharge from hospital/inpatient and/or residential care. Allows for transitional billing and the Care Manager to act as the responsible/appointed point-person during transition.

Commitment to consistent and thorough to investing a significant amount of time to increase to this level of communication between systems.

Clear linkage and engagement processes with schools, providers, social service agencies. 

System of Care-wide commitments and adequate  toHIT to allow sharing of information, as well as risk and accountability.

Funding of services during transition periods.

Commitment to the concept of permanency. Recognizes a time commitment that necessitates a lower case load to allow for the intensity of the work.


Principle: Incorporate a child/family specific assent/consent process that recognizes the legal right of a child to seek specific care without parental/guardian consent.

Providers’ understanding of Informed Consent. Skill using and educating youth/families regarding the value and process around consent and how it impacts coordination of care.

Balance between family and individual rights, including understanding of information that can and cannot be shared between minors and families.

CThere are clear guidelines around the legal rights of a child to seek care without guardian consent. Care management and Network Providers must be fully educated regardingon this, including: the care that is implicated, the care that needs consent, and the proper consent forms to use.

Family and Youth “Peer” Support - critical factor to developingin developing a consent process that recognizes youth and family rights.

Clear policies for managing consent for youth living with HIV/AIDs and SUD. SUD services

RecognitionClarification of the NYS law related to minors giving birth: the decisions the minor canmay make and the decisions that reside with the minor’s family.


Principle: Track clinical and functional outcomes using standardized pediatric tools that are validated for the screening and assessing children.

Partnerships between physical, behavioral, other stakeholders - to support outcomes assessment.

A system of coordinated Health Information Technology use (EMRs, RHIO, etc.) to track, communicate and share functional outcomes.

Paperwork that is not overwhelming, but detailed enough to ensure quality and coordination as one plan.

Use Comprehensive, evidence-based assessment tools. Tools are sensitive to cultural nuances and linguistic needs, driven by a strengths-based approach supporting both the child and the familyWell defined, mutually accepted assessment tools - age and culturally appropriate; allow for common measures to be used across the Health Home. 

Paperwork that is not overwhelming, but detailed enough to ensure quality and coordination as one plan.

Use Comprehensive, evidence-based assessment tools. Tools are sensitive to cultural nuances and linguistic needs, driven by a strengths-based approach supporting both the child and the family


Principle: Adopt child-specific and nationally recognized measures to monitor quality and outcomes.

The Wraparound Fidelity Index, for families with most acute needs, to monitor fidelity to practice/quality of care.

Measures related to cost savings (cost avoidance) resulting from decreased: days in out-of-home placement (non-Medicaid paid), juvenile arrest/incarceration, parent stability in employment, etc. 

Monitoring of a variety of insightful measures, including:

  • Outreach/identification of unconnected youth and families
  • Measures of care management responsiveness (time from referral to outreach)
  • Rates of engagement/ability to engage families referred into care management services
  • Track Recommendations, linkages, barriers, service gaps, and unmet needs of families

Use of CANS-NY and FANS, particularly to be able to monitor quality and outcomes of family support. Commit to seeking continuously seeking increasingly effective measurement tools.

The Youth Connections Scale to measure relational permanency;

An assessment process that captures all the needs of the child and family.

Assurance that the Health Home Acuity Score will be based on results from the comprehensive assessment.


Principle: Ensure smooth transition from current care management models to Health Home, including transition plan for care management payments.

Transition training for all care management agencies to ensure an understanding of the standards of practice, required staff competencies, and movement from a model driven by regulation to one that that is outcome focused;

Provider Education on the fiscal model/rate methodology and fiscal modeling strategies to project staff ratios based on level of intensity of staff effort/case load mix; 

Use of existing technology to support children and youth care management;

Forms and manuals that are user friendly and are issued in advance of CHH Start-upwith plenty of time to review and revise;

Small caseloads in the beginning while learning to acclimate to the new system; and

Cost analysis to understand impact for converting CMs.


 Six Core Requirements of NYS Health Homes: Operational Considerations

Both the Health Home, as the lead organization, its network of care management agencies, and its network of service providers should demonstrate the following competencies, skills, and knowledge to effectively deliver Health Home services to children and families.

 

I.              Comprehensive Care Management

Demonstrate:

  • Development of diverse, nimble interdisciplinary teams, including Family and Youth Peer Support, with demonstrated cross-systems experience (e.g. JJ, Child Welfare, Schools, Behavioral and Physical Health)
  • That Youth and family have input concerning those who will be a part of their team,
  • Commitment to an assessment/planning model that supports youth/families guided by one or more of the following: Child & Family Team process, Hi-Fidelity Wrap Around, Strength based approaches,
  • Family driven/youth guided practices
  • Child & Family Team process,
  • Hi-Fidelity Wrap Around, Wraparound principles
  • Strength based approaches,.
  •  Family driven/youth guided practices,
  • An ability to work collaboratively with the medical community to best support children’s physical health needs,
  • An ability to understand the importance of and approaches to creating permanency,
  • An ability to use the Family Development Plan, or similar tool, to inform care,
  • A willingness to empower families to initiate changes to the Care Plan, understanding that its development is a family driven process,
  • A willingness to update the plan as needs change, not just according to a specific time frame,
  • The recognition that  coordination must involve more than just the youth, but the entire family, and systems with whom they are involved.
  • Staff competency in working with children/youth with complex needs
  • A willingness to establish minimum requirements for various roles.

 

II.            Care Coordination and Health Promotion

Demonstrate:

  • Ability to develop, with families, a network of natural supports and linkages to community supports,
  • Partnerships with local community supports,
  • Ability to share critical health information with the care team to prevent crisis, using health information technology whenever feasible,
  • Consistent assessment/planning model,
  • Access to respite services: planned, emergency, hourly and overnight,
  • Willingness to accompany clients to appointments; a possible role for Family Peer Support,
  • Recognition of the need for flex dollars and the ability to spend these dollars to achieve the goals of the care plan and in the best interest of the entire family, and
  • Ability to provide education on general wellness topics -- make appropriate referrals if needed.

 

III.           Comprehensive Transitional Care

Demonstrate:

  • A seamless approach to the transition between child and adult systems, inpatient/residential care and the community, etc. Transitions should include overlap of care management preceding transitions,
  • Staff experience in navigating multiple systems to break down “silos,
  • Support for early notification when children enter the hospital (e.g., RHIO) and ability for care team to share information quickly and accurately, 
  • Access to respite services: use of residential or foster care as a strategic intervention,
  • A commitment to shared risk and accountability,
  • A commitment to linking clients to family support organizations and embedded family peer supports, and
  • The ability of transitional care to support children when they are out of their home network.

 

IV.           Individual and Family Support

Demonstrate:

  • Effective assessment /delivery model: Include tool to assure family inclusion,
  • Training is offered for staff in strengths- and needs-based planning,
  • Role of family and youth peer support (consumer voice and choice) in the process,
  • Flexible scheduling to support the needs of the child and family,
  • Home-based services are offered to the entire family,
  • The family approach is used for the identification of needs, and
  • Commitment to a practice that encourages families to invite others to be members of their care team.

 

V.            Referral to Community and Social Support Services

Demonstrate:

  • Care Managers need to have a presence in the communities they serve. Place-based services should be utilized when possible,
  • Ability to establish relationship with school districts -- help children stay connected to communities,
  • Access to Skill Builders who are embedded into local school, sports, youth programs,
  • Family and Youth Peer Support;
  • Inclusion of a Family Support Organization in the network of referrals,
  • Understanding of and partnerships with resources/providers in the community who support families in meeting their basic needs (food, clothing, shelter, recreation centers), and
  • Understanding of the Strengths, Needs, Cultural Discovery process and its relationship to guiding families to better connect with natural supports.   

 

VI.           Health Information Technology

Demonstrate:

  • Understanding of the importance of Health Information Technology (HIT) to facilitate accurate, timely communication,
  • Availability of a Family and Youth Portal,
  • Willingness to leverage technology to support the needs of the youth and families,,
  • Health Home ability to meet the HIT standards, and
  • Plan for Development of connectivity to Network Providers in education and other systems to allow for communication and sharing of the Care Plan.

 

Conclusion

Northern Rivers & Hillside appreciate the opportunity to provide feedback on the Children’s Health Home Care Management Program being developed by New York State. We believe that such a program will positively impact outcomes for our children, youth and their families and look forward to further conversation with the New York State Department of Health concerning this undertaking.