Performance audit, HB2003 children's behavioral health services monies

              A REPORT
TO THE
ARIZONA LEGISLATURE
Debra K. Davenport
Auditor General
HB2003 Children’s
Behavioral Health
Services Monies
Performance Audit Division
December • 2002
REPORT NO. 02 – 12
Performance Audit
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five
senators and five representatives. Her mission is to provide independent and impartial information and specific
recommendations to improve the operations of state and local government entities. To this end, she provides financial
audits and accounting services to the State and political subdivisions, investigates possible misuse of public monies, and
conducts performance audits of school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Representative Roberta L. Voss, Chair Senator Ken Bennett, Vice Chair
Representative Robert Blendu Senator Herb Guenther
Representative Gabrielle Giffords Senator Dean Martin
Representative Barbara Leff Senator Peter Rios
Representative James Sedillo Senator Tom Smith
Representative James Weiers (ex-officio) Senator Randall Gnant (ex-officio)
Audit Staff
Shan Hays, Manager and Contact Person
Monique Cordova, Team leader Joe McKersie
Mary Edmonds Kristie Waldron
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You may request them by contacting us at:
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2910 NORTH 44 th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553 -0333 • FAX (602) 553 -0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
December 26, 2002
Members of the Arizona Legislature
The Honorable Jane Dee Hull, Governor
Ms. Catherine R. Eden, Ph.D., Director
Department of Health Services
Transmitted herewith is a report of the Auditor General, A Performance Audit of the HB2003
Children’s Behavioral Health Services Monies. This report is in response to Laws 2000, Fifth
Special Session, Ch. 2, §5 and was conducted under the authority vested in the Auditor
General by A.R.S. §41-1279.03. I am also transmitting with this report a copy of the Report
Highlights for this audit to provide a quick summary for your convenience.
As outlined in its response, the Department of Health Services agrees with all of the findings
and plans to implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on December 30, 2002.
Sincerely,
Debbie Davenport
Auditor General
Enclosure
The Office of the Auditor General has conducted a performance audit of the House
Bill 2003 Children’s Services monies (HB2003) that the Legislature appropriated to
the Department of Health Services, Division of Behavioral Health Services (Division)
for children’s behavioral health services and programs in compliance with Laws
2000, Fifth Special Session, Chapter 2, §5.1 The Legislature appropriated $20 million
from the State General Fund’s tobacco litigation settlement account to be used for
children’s behavioral health services. The legislation also stipulated that the Office of
the Auditor General complete a performance audit of the program on or before
January 1, 2003.2
In 2001, the Legislature made a one-time, non-lapsing appropriation of $20 million for
children’s behavioral health programs. The legislation mandated that the monies be
used to provide services to children and families served by the Department of Health
Services, the Department of Economic Security, the Administrative Office of the Courts,
or the Arizona Department of Juvenile Corrections. The legislation also authorized the
money to support telemedicine programs to make it easier to provide behavioral health
services to people who live in the State’s medically underserved areas. The legislation
did not establish a deadline for spending the money.
The Division is distributing most of this funding to its five Regional Behavioral Health
Authorities (RBHAs) to provide services. The Division has allocated $17.85 million to
the RBHAs based on population. To obtain the money, the RBHAs were required to
submit spending plans consistent with legislative intent. In addition, the Division
directed the RBHAs to focus mainly on serving children who are ineligible to receive
medical and behavioral health services through the federally funded Medicaid and
KidsCare programs administered by the Arizona Health Care Cost Containment
System (AHCCCS). The Division reserved the remaining $2 million for training RBHA
staff and others on a new system-of-care approach to service provision.
This audit focuses on three areas related to the Division’s use of HB2003 monies:
programs created with these monies, training on the new system-of-care approach,
and collaboration between the Division and other state agencies listed in the legislation.
page i
1 The Division refers to this funding as “House Bill 2003” funding, and to the programs as “House Bill 2003 Programs,”
after the legislation that created the funding.
2 Laws 2000, Fifth Special Session, Chapter 2, §5 also appropriated $50 million for funding housing and recovery support
services for adults with serious mental illness. A separate audit on the House Bill 2003 Adult Services Program is due on
or before January 1, 2004.
Office of the Auditor General
SUMMARY
Enrollment and services increasing after slow start (see
pages 9 through 18)
Behavioral health programs developed with HB2003 monies target the population
specified by the Legislature and are consistent with court-ordered reform, but they
had a slower start than the RBHAs had planned. The Division has used HB2003
monies to provide services to children involved in one or more of the four state
agencies specified in legislation—the Department of Health Services, the
Department of Economic Security, the Administrative Office of the Courts, and the
Arizona Department of Juvenile Corrections. The RBHAs proposed several programs
and services tailored to these children’s behavioral health needs. For example,
several RBHAs developed programs for children in the juvenile justice system, such
as assessment and transitional services for incarcerated children. Although some of
these children may be Medicaid-eligible, Medicaid will not reimburse services
provided to incarcerated individuals. More than half of the 938 enrolled children as of
July 1, 2002, were involved with the Division as well as at least one of the three other
agencies. In addition, as permitted in legislation, two rural RBHAs used their monies
to expand telemedicine services.
The Division has also used HB2003 monies to develop programs that are consistent
with the State’s new child- and family-centered system-of-care approach to service
provision. This new approach is the result of the J.K v. Eden settlement agreement,
which addressed Medicaid-eligible children who need mental health services.1
Consistent with the settlement agreement, the RBHAs developed some programs
with HB2003 funding to reflect the new system’s principles and family-centered
nature, such as intensive in-home services and multi-agency teams.
However, due to a variety of factors, behavioral health programs developed with
HB2003 monies had a slower start than the RBHAs had originally planned. For
example, the Maricopa County RBHA ValueOptions started its program 3 months
after the Division’s proposed July 1, 2001, start date to allow its HB2003 programs to
coincide with changes in Medicaid coverage. The Yuma RBHA Excel broadened the
eligibility criteria for its program in November 2001 because it had not received the
expected number of referrals under its original, narrower criteria. Two new policy
changes in the State’s Medicaid program, administered by AHCCCS, that became
fully effective in October 2001 also contributed to the slower than expected program
start. During HB2003 program implementation, the State expanded Medicaid
eligibility and also expanded the list of Medicaid-covered services. According to
department officials, these changes required planning and time to ensure that they
were implemented effectively, delaying the Division’s and RBHAs’ ability to focus on
planning and implementing the HB2003 programs. Due to the delayed program
starts, total enrollment was less than expected in the program’s early months.
page ii
State of Arizona
1 J.K. v. Eden, Arizona Federal District Court Case, No. CIV91-261.
In response to the low enrollment, the Division and the RBHAs have made changes
in the program plans and worked with other state agencies to increase referrals. The
Division needed to educate other agencies on the availability of new services. In the
past, agencies did not always refer non-Medicaid clients because services were not
always available. After the slow start, enrollment appears to be increasing. Between
July and October 2001, average new enrollments were 15 per month. By contrast,
between November 2001 and June 2002, new enrollments per month averaged 104.
Altogether, as of July 1, 2002, 938 children had enrolled in the program, and
participation rates may ultimately reach the RBHAs’ estimates of over 1,200 total
enrollments. Due to the slower than expected enrollments, analysis of program
expenditures shows that total spending appears low, compared to the amount
appropriated. Although complete service data is unavailable, the Division’s records
indicate that more than 80 percent of the program’s allocation remained unspent as
of June 30, 2002. Those records reflect expenditures for hiring staff and purchasing
equipment as well as the value of services reported by providers. At that time,
ValueOptions had spent only 9 percent of its total $10.5 million allocation. Total
spending in some other regions came closer to the total budgeted, particularly at
Excel, which provides services directly and does not have to wait for providers to
report services. Delays in reporting services to the Division may result in understating
actual program expenditures and services provided to date, since by law the RBHAs
are allowed to take up to a year to submit accurate service data.
The Division should continue efforts to ensure state-wide
training on its new system (see pages 19 through 24)
In accordance with the J.K. v. Eden settlement agreement, the Division is using $2
million to provide training on the required new system. The J.K. v. Eden lawsuit, which
was filed in 1991 and certified as a class action lawsuit in 1993 on behalf of Medicaid-eligible
children, and the resulting settlement agreement, provided the foundation for
a new philosophy for caring for children in the State’s behavioral health system. The
settlement agreement emphasizes a number of principles, including partnering with
families and children, collaborating with other agencies, and providing individualized
services aimed at achieving meaningful outcomes for families and children. The new
system of care emphasizes the strengths of a child and family instead of their
problems and deficits.
The Division has retained a consultant to develop and initially provide this training,
which is consistent with best practices identified in federal studies and in interviews
with officials from similar programs in other states. This training has been provided in
several regions of the State. So far, 38 training sessions have been provided, with
total attendance of over 2,300 including representatives from the Division, the
RBHAs, service providers, and other child-serving agencies. The Maricopa County
RBHA ValueOptions and the Northern Arizona Regional Behavioral Health Authority
page iii
Office of the Auditor General
have received most of the training, since they are part of a pilot program to
implement the new system of care across the State.
The Division has taken steps to expand ongoing training throughout the State after
its contract ends with its training consultants, as other agencies, locations, and new
staff continue to need training on the State’s new child- and family-centered system
of care. To ensure training continuity, the Division is developing training kits,
identifying internal trainers to facilitate future training, and providing supervisory
training in order to obtain management support for the new system. As it expands
training state-wide, the Division should also assist the RBHAs with future training
plans. It has already approved the ValueOptions training plan, and has asked the
other four RBHAs to submit training plans by January 1, 2003. As it reviews these
plans, the Division should ensure that they include key factors, such as detailed tasks
and time frames. In addition, the Division should ensure that the RBHAs plan to
include employees of other state agencies in future training.
The Division can further foster interagency collaboration
(see pages 25 through 28)
While the Division and the RBHAs took steps to collaborate with other agencies, they
can take further action to promote interagency collaboration for children served by
multiple agencies. Overall, the RBHAs solicited input from all the agencies mentioned
in the legislation prior to submitting program plans for using their HB2003 monies,
although not all county probation offices were consulted, and an official at the
Arizona Department of Juvenile Corrections stated that two RBHAs did not discuss
regional service priorities with them before the RBHAs submitted their program plans
to the Division. In most cases, the RBHAs incorporated other agency priorities into
their program plans, although they could not adopt all service-planning priorities. The
Division has also made collaborative inroads at the state leadership and client levels.
For example, the Division is working to develop agreed-upon clinical protocols for
treating children involved in multiple state agencies. In addition, the Division has a
full-time executive-level position dedicated to fostering collaboration.
To continue its focus on collaboration, the Division should continue to work with the
other state agencies to strengthen local commitment to the new system of care within
each RBHA’s service area. Most of the RBHAs’ service areas have interagency
teams and steering committees or councils in place to foster collaboration. However,
the Maricopa County Steering Committee has taken this process a step further by
developing a formal agreement that commits each individual state agency to actions
such as supporting service plans designed by child and family teams, providing a
representative at team meetings, incorporating the collaboratively designed service
plan into the agency’s service plan, and collaborating with the team before changing
the approved plan.
page iv
State of Arizona
pagev
Office of the Auditor General
TABLE OF CONTENTS
continued
1
9
9
11
‘
13
18
19
20
22
22
24
25
26
27
28
Introduction & Background
Finding 1: Enrollment and services increasing after
slow start
Programs consistent with legislative requirements
Programs consistent with new system of care
Programs had slower start than anticipated start
Recommendation
Finding 2: The Division should continue efforts to
ensure state-wide training on its new system 19
Training helps implement new system of care
Training is consistent with best practices
Extent of training provided varies by region
Plans to train staff can be enhanced
Recommendations
Finding 3: The Division can further foster interagency
collaboration 25
Collaboration a central goal
Service plans developed collaboratively
Division should augment efforts
Recommendation
Agency Response
page vi
State of Arizona
TABLE OF CONTENTS
concluded
Figures:
1 Regional Behavioral Health Authorities
Allocations Through June 30, 2003
2 Children Served by State Agencies
Named in HB2003 Legislation
As of July 1, 2002
3 Number of Clients Enrolled in HB2003 Children’s Program
February 1, 2001, Through June 30, 2002
4 HB2003 Children’s Program
$2 Million Training Allocation
Tables:
1 Types of Services Provided To HB2003 Children
Month Ended January 31, 2002 12
2 HB2003 Children’s Program
Clients Served As of July 1, 2002 16
3 HB2003 Children’s Program Expenditures
from Program Inception Through June 30, 2002 17
3
11
15
22
The Office of the Auditor General has conducted a performance audit of the House
Bill 2003 Children’s Services (HB2003) monies that the Legislature appropriated to
the Department of Health Services, Division of Behavioral Health Services (Division)
for children’s behavioral health services and programs in compliance with Laws
2000, Fifth Special Session, Chapter 2, §5.1 The Legislature appropriated $20 million
from the State General Fund’s tobacco litigation settlement account to be used for
children’s behavioral health services. The legislation also stipulated that the Office of
the Auditor General complete a performance audit of the program on or before
January 1, 2003.2
Legislative intent
The one-time, non-lapsing $20 million HB2003 funding was appropriated in fiscal
year 2001 to provide behavioral health services to children and families served by the
Department of Health Services or other state agencies—specifically, the Department
of Economic Security, the Administrative Office of the Courts, and the Arizona
Department of Juvenile Corrections. According to the bill’s primary sponsor, the
monies were primarily intended to provide behavioral health services to children in
the juvenile justice system who are ineligible to receive services through the Arizona
Health Care Cost Containment System (AHCCCS). AHCCCS administers Arizona’s
Medicaid and KidsCare programs, the two major federal programs that provide
medical and behavioral health services for the State’s lower-income children.3 In
fiscal year 2002, the Division received more than $104 million from AHCCCS to
provide services to children eligible for federal programs. It received more than $26
million from non-Medicaid sources such as the State General Fund to provide
behavioral healthcare to children who were not eligible for federal programs.
page1
1 The Division refers to this funding as “House Bill 2003” funding, and to the programs as “House Bill 2003 Programs,”
after the legislation that created the funding.
2 Laws 2000, Fifth Special Session, Chapter 2, §5 also appropriated $50 million for funding housing and recovery support
services for adults with serious mental illness. A separate audit on the House Bill 2003 Program for adults with serious
mental illness is due on or before January 1, 2004.
3 Medicaid refers to the federal healthcare program for indigent persons authorized under Title XIX of the Social Security
Act. KidsCare is Arizona’s version of the federal Children’s Health Insurance Program, which is authorized under Title XXI
of the Social Security Act.
Office of the Auditor General
INTRODUCTION
& BACKGROUND
According to legislative staff and division officials, the Legislature intended to provide
the Division and the State’s five Regional Behavioral Health Authorities (RBHAs) with
some needed flexibility in providing services to children. For example, they
anticipated that although the monies were intended primarily for non-Medicaid or
non-KidsCare eligible children, some of the monies could be used to help some
Medicaid-eligible children by paying for services Medicaid does not cover. In
addition, since Medicaid covers only healthcare services, the RBHAs could use
HB2003 monies for hiring staff, buying equipment, and obtaining training to enhance
their ability to provide services to children.
page2
State of Arizona
Other Child-Service State Agencies’ Missions
􀁺􇩄 Department of Economic Security/Child Protective Services (DES/CPS)—CPS
provides specialized child welfare services that seek to prevent dependency,
abuse, and exploitation of children. Such children may be living with their natural
families or with foster care families. In general, they need individual counseling—
including specialized therapy to deal with issues such as sexual abuse—and
intensive family services designed to promote family stabilization.
􀁺􇩄 Department of Economic Security/Division of Development Disabilities (DDD)—
This Division provides services to Arizonans and their families who have autism,
cerebral palsy, epilepsy, or mental retardation that is manifested before the age of
18, or children who are below the age of 6 and at risk of having a developmental
disability. Like other children and youth, their behavioral health needs will vary. They
may need individual counseling, medication, or family counseling.
􀁺􇨠 Administrative Office of the Courts/Juvenile Probation (AOC)—The Administrative
Office of the Courts administers the State’s judiciary system, including county
juvenile justice courts. AOC, in cooperation with county juvenile probation,
promotes community protection by requiring juvenile accountability and providing
treatment opportunities that result in law-abiding behavior. The county courts
oversee youth who are placed in juvenile detention and juvenile probation. Similar
to Juvenile Corrections, youth placed on juvenile probation may need services such
as case management, counseling, and substance abuse services. Medicaid will
not pay for their services while children are incarcerated in county detention
centers.
􀁺􇩁 Arizona Department of Juvenile Corrections (ADJC)—Juvenile Corrections is
responsible for delinquent juveniles committed to its jurisdiction by the county
juvenile courts. It oversees incarcerated youth and youth who are placed on juvenile
parole following the completion of their sentences. In general, these youth need
services such as case management, counseling, and substance abuse services.
Since Medicaid will not cover services for incarcerated youth, youth who are about
to be paroled may also need psychological assessments and bridging medications
to facilitate their transition into the State’s behavioral health system.
In addition to serving children and families involved with other state agencies, the
Legislature also allowed the Department of Health Services to use the monies to
support telemedicine programs for persons who live in the State’s medically
underserved areas.1 Telemedicine involves using videoconferencing equipment to
provide services to patients who do not live near behavioral healthcare service
providers.
Program monies distributed
to RBHAs
The Division is distributing most of
the funding to the State’s five
Regional Behavioral Health
Authorities (RBHAs) to provide
services across the State. The
Division does not directly provide
behavioral health services. Instead, it
contracts with the five RBHAs, which
function in a fashion similar to health
maintenance organizations by
subcontracting with behavioral
health providers in their geographic
service areas to provide services to
clients.2 In all, the Division allocated
$17.85 million of the $20 million to
the RBHAs based on population.
Figure 1 shows the five RBHAs, the
six geographic areas they serve, and
their HB2003 funding allocations.
Following passage of the legislation,
the Division issued HB2003 Plan
Specifications to the five RBHAs. To
obtain HB2003 monies, each RBHA
had to develop a plan consistent
with the specifications, addressing
three general areas:
􀁺􇩎 Non-Medicaid Eligible Children—Provision of behavioral health services to non-
Medicaid eligible children and family members. Within this area, the RBHAs
page3
1 Medically underserved areas are defined in state statute at A.R.S. §36-2352. They include areas that the federal
government has designated as a Health Professional Shortage Area (HPSA), and other areas that meet state criteria set
forth in statute.
2 Four of the five RBHAs follow this model. The fifth, the Excel Group in Yuma, provides most services directly instead of
through subcontractors.
Office of the Auditor General
Source: Division of Behavioral Health Services
CPSA
Region 3
Excel
$629,544
NARBHA
$1,893,905
ValueOptions
$10,778,050
PGBHA
$760,508
CPSA-5
$2,949,193
CPSA-3
$838,800
Northern Arizona Behavioral Health Authority (NARBHA)
Excel
ValueOptions
Pinal Gila Behavioral Health Authority (PGBHA)
Community Partnership of Southern Arizona, Region 5 (CPSA-5)
Community Partnership of Southern Arizona, Region 3 (CPSA-3)
Figure 1 Regional Behavioral Health Authorities
Allocations Through June 30, 2003
Source: Auditor General staff analysis of Division of Behavioral Health Services House
Bill 2003 Regional Behavioral Health Authorities Plan Specification, September 2002.
were directed to make Department of Economic Security children and their
families the first priority.
􀁺􇩊 Juvenile Justice Children—Provision of behavioral health services to children
referred by the Administrative Office of the Courts and the Arizona Department
of Juvenile Corrections. The Division required that 30 percent of the monies
allocated to each RBHA be used for non-Medicaid eligible children involved in
the juvenile justice system.
􀁺􇩔 Telemedicine—RBHAs could propose using a portion of the HB2003 monies to
expand telemedicine services in Arizona’s medically underserved areas.
Program monies support system
reform
The Department also designated $2 million of the HB2003
monies to design, develop, and deliver a state-wide
training program aimed at implementing state-wide system
reform in children’s behavioral healthcare. Much of this
reform has been in response to the J.K. v. Eden lawsuit,
certified as a class action in 1993 on behalf of Medicaid-eligible
children, and the resulting settlement agreement
executed on March 20, 2001, and approved on June 26,
2001.1 The settlement agreement sets out a vision
statement and a set of 12 principles (see text box) known
as “The Arizona Vision” and “The 12 Principles,” which
provide the foundation for system reform. Among other
things, the settlement agreement:
􀁺􇩅 Emphasizes partnering with families and children,
collaborating with other state agencies, and
providing individualized services aimed at achieving
meaningful outcomes for families and children.
􀁺􇩅 Emphasizes that services should be accessible,
timely, reflect best practices, and be tailored and
appropriate for the particular child and family.
􀁺􇩃 Commits the State to a series of concrete steps,
including state-wide training on a new child- and
family-centered system of care, and improvements
in the structure of the managed care arrangement.
page4
1 J.K. v. Eden, Arizona Federal District Court Case, No. CIV91-261, has provided the impetus for much of the system reform
activities. Plaintiffs contended that the State was not providing Medicaid-eligible children timely and adequate mental
health services to which they were entitled.
State of Arizona
The Arizona Vision and
the 12 Principles
The Arizona Vision
In collaboration with the child, family, and others,
Arizona will provide accessible behavioral health
services designed to aid children to achieve success
in school, live with their families, avoid delinquency,
and become stable and productive adults. Services
will be tailored to the child and family and provided in
the most appropriate setting, in a timely fashion, and in
accordance with best practices, while respecting the
child’s and family’s cultural heritage.
The 12 Principles
1. Collaboration with the child and family
2. Functional outcomes
3. Collaboration with others
4. Accessible services
5. Best practices
6. Most appropriate setting
7. Timeliness
8. Services tailored to the child and family
9. Stability
10. Respect for the child and family’s unique cultural
heritage
11. Independence
12. Connection to natural supports
Source: J.K. v. Eden settlement agreement, March 20, 2001.
page5
Office of the Auditor General
􀁺􇩒 Requires the defendants to develop and implement a pilot program in Maricopa
County and another Arizona region, known as the 300 Kids Project, to try out
new practices that can then be implemented state-wide.
Audit scope and methodology
This audit report focused on three areas related to the Division’s use of the HB2003
funding and contains findings in all three:
􀁺􇩆 First, the audit reviewed the Division’s efforts to provide services to children and
families consistent with the legislation and the Division’s Plan Specifications.
Review of program plans indicates that the RBHAs have used the HB2003
monies to develop programs that are consistent with legislative intent, and the
Division’s Plan Specifications. In addition, some RBHAs have developed
programs consistent with preliminary efforts to implement court-ordered system
reform. However, auditors found that the program had a slow start. Enrollment
was lower than expected during the program’s early months until November
2001. Enrollment has since increased, and the RBHAs are on track to meet the
enrollment targets.
􀁺􇨠 Second, the audit reviewed the Division’s efforts to provide training required by the
J.K. v. Eden settlement agreement, and its plans to expand training state-wide.
Auditors found that the Division is using HB2003 monies to provide best practices-based
training on the new system of care. Because the training represents a
significant effort, the Division should take measures to ensure its sustainability.
􀁺􇩔 Third, the audit reviewed the Division’s and the RBHAs’ efforts to improve
collaboration with the other state agencies identified in legislation. The audit
found that the funding fostered interagency collaboration in program planning.
Because interagency collaboration is important to reduce behavioral health
costs and improve outcomes, the Division should continue its efforts to foster
collaboration and take additional steps to further enhance it.
Auditors used a number of research methods to study the issues addressed in this
report. Specifically:
􀁺􇩔 To determine which children and their families have received services from
HB2003 funding and how the monies have been used to provide behavioral
health services, auditors analyzed the Division’s enrollment, assessment, and
encounter databases. To ensure accuracy, auditors compared this data to a
random sample of provider enrollment and assessment records for 47 children
on the RBHAs’ rosters for the HB2003 program. Additionally, auditors reviewed
the Division’s HB2003 spending plan requirements, the RBHAs’ spending plans,
page6
1 Proposition 204, approved by voters in November 2000, authorized the use of the State’s share of the multi-state tobacco
litigation settlement to help pay for medical coverage in Arizona to all individuals who fall below the Federal Poverty Level.
2 Contractors contacted during this audit: Child Welfare Policy and Practice Group, Kaleidoscope, and Vroon VanDenBerg, LLP.
3 Auditors contacted North Carolina for information on the Guilford County Family and Communities Equal Success grant
site, Wisconsin for information on Wraparound Milwaukee, and Illinois for information on Kaleidoscope, all programs
representing a change in care systems for children’s behavioral health services.
State of Arizona
the HB2003 expenditure reports, the RBHAs’ quarterly financial statements, and
HB2003 progress reports. To determine services covered by Medicaid, auditors
interviewed AHCCCS management and reviewed state and federal rules and
guidelines related to Medicaid and KidsCare behavioral health coverage,
including statutes pertaining to expansion of Medicaid eligibility under Arizona’s
Proposition 204.1 To understand the various system reform efforts taking place
in the State, auditors reviewed documentation related to the J.K vs. Eden class
action lawsuit, and the Covered Services Project undertaken by the Department
of Health Services and the AHCCCS administration, which expanded Arizona’s
list of services eligible for Medicaid or KidsCare reimbursement.
􀁺􇩔 To determine if training paid for with HB2003 monies was consistent with best
practices, and to determine the sustainability of the training program, auditors
reviewed training materials and attendance records, observed a training
session, and interviewed division staff who oversee the training program.
Further, auditors interviewed RBHA staff who facilitated the training and who are
responsible for internal training on the system of care, provider-level staff and
staff from other child-serving agencies who received the training to gain their
perspective on its effectiveness. Auditors also interviewed the Division’s and
ValueOptions’ training contractors to obtain information on training development
and focus.2 Further, auditors reviewed pertinent literature and nationally
recognized program models in systems of care for information on best practices
in system-of-care training. Finally, auditors contacted other states that have
implemented system changes for additional comparative information.3
􀁺􇩔 To assess the effectiveness of the Division’s effort to collaborate in HB2003
service planning, auditors reviewed the Division’s HB2003 Plan Specifications
and approved RBHA plans. In addition, auditors reviewed HB2003 progress
reports, documentation of interagency meetings, interagency agreements, and
collaboratively developed protocols and procedures. Auditors also interviewed
Division and RBHA program administrators and RBHA regional collaborating
agencies, including representatives of the Department of Economic Security, the
Administrative Office of the Courts, county juvenile probation offices, and the
Arizona Department of Juvenile Corrections. Auditors also reviewed literature
about best practices in interagency collaboration related to service delivery.
Audit limitations
While this audit focused on how HB2003 monies were spent and services provided
to children enrolled in the HB2003 program, it could not determine the exact number
and nature of services provided with HB2003 monies. The Division and the RBHAs
designed a method to identify which services HB2003 paid for, but did not
consistently use the method. In addition, because the RBHAs have up to a year to
submit accurate service data, the Division’s computer system has relatively complete
service information for only the first few months of program implementation. As a
result, auditors relied on the RBHAs’ financial statements and HB2003 progress
reports to identify total spending from HB2003 monies. To characterize the kinds of
services actually provided to children enrolled in the HB2003 program, auditors relied
on analysis of January 2002 service data, the latest month with relatively complete
information.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the director of the Department
of Health Services, and management and staff of the Division of Behavioral Health
Services and its Regional Behavioral Health Authorities, for their cooperation and
assistance throughout the audit.
page7
Office of the Auditor General
page8
State of Arizona
page9
Office of the Auditor General
FINDING 1
Enrollment and services increasing after slow
start
Programs developed with HB2003 monies target the population specified by the
Legislature and are consistent with court-ordered reform. While the legislation did not
establish a deadline for spending the money, the programs had a slower start than
originally planned. Consistent with legislation, the programs are designed to serve
children involved with other agencies as well as the Division, and many of the
services provided focus on families, not just children. The Division has also used the
HB2003 funding to create new programs consistent with its efforts to implement
state-wide system reform in children’s behavioral health services. However, early
enrollment did not meet expectations, although it has increased in recent months. As
a result of the low early enrollment and statutes that allow up to a year for submitting
service claims, total expenditures to date appear low.
Programs consistent with legislative requirements
To address the goals of the HB2003 legislation, the RBHAs developed programs to
serve families and children targeted by the funding. The legislation directed the
Department of Health Services to use the monies to serve families whose children
received behavioral health services from the Department or other agencies—the
Department of Economic Security(DES), the Administrative Office of the Courts, or
the Arizona Department of Juvenile Corrections. It also allowed the use of HB2003
monies for telemedicine. The legislation did not establish a deadline for spending the
monies. To reflect the other agencies’ interests, the Division required the RBHAs to
obtain the agencies’ input into their plans for the HB2003 program, and focus on
services for children and families who were not eligible for Medicaid or KidsCare,
which are administered by AHCCCS. In their plans, the RBHAs proposed several
programs and services tailored to the behavioral health needs of these children. For
example:
Programs developed to
serve families and
children targeted by
legislation.
􀁺􇩃 Comprehensive Behavioral Health Services—ValueOptions developed an
enhanced benefits package that provides a full range of behavioral health
services to children who are involved with Juvenile Corrections, the
Administrative Office of the Courts, or DES and are not eligible for Medicaid or
KidsCare. Such children typically receive very limited services. For example, they
generally cannot receive medications, lab services, therapeutic day programs,
and rehabilitation. The enhanced benefits package is designed to provide up to
404 of these children with all medically necessary outpatient services, including
medication, treatment programs, and respite services.
􀁺􇩐 Programs for Children in the Juvenile Justice System—Medicaid will not
reimburse services provided to incarcerated individuals, so these types of
services must be funded through non-Medicaid sources. For such children,
three RBHAs (PGBHA, CPSA, and the Excel Group) provide assessments to
determine behavioral health needs, as well as the behavioral health services
themselves, such as counseling and medications, to children detained in
juvenile detention centers. Although PGBHA and CPSA provided some
assessment and transitional services before the HB2003 funding was provided,
the funding allowed them to provide these services to more children and to add
new counseling and medication services for children who need them. For
example, PGBHA’s contractor reported that it had completed assessments for
approximately 500 children in detention centers as of June 30, 2002.
􀁺􇩃 Community Programs—In Yuma, the Excel Group partnered with the Wellton
School District to create an after-school program for children in the Wellton,
Dateland, and Tacna area who are not enrolled in Medicaid. The program is
intended to help children address problems in their family life, academic life, and
peer relations.
􀁺􇩔 Telemedicine—Both PGBHA and the Excel Group have used a portion of their
monies to increase telemedicine services in primarily rural service areas. Excel
provided telemedicine to East Yuma County and to Quartzsite in La Paz County.
PGBHA installed equipment in Eloy, Casa Grande, Payson, Globe, Apache
Junction, Kearney, and Oracle.
One of the program’s major objectives was to serve children involved with other state
agencies. As Figure 2 shows (see page 11), slightly more than half of the 938
children enrolled were also involved with other state agencies. Another objective was
to serve children who are not eligible for Medicaid or KidsCare. Altogether, 49 percent
of the children had never been enrolled in Medicaid or KidsCare. The remaining
children had at some time been enrolled, but according to AHCCCS officials,
children frequently drop in and out of Medicaid eligibility due to changes in family
income or living situation.
page10
State of Arizona
page11
Office of the Auditor General
1 Because the Division had limited data (see page 7), the numbers reported here reflect only (a) children who were not
eligible for Medicaid or KidsCare at the time the service was provided, and (b) services that are not on the
Medicaid/KidsCare covered services list. Because some children are enrolled in Medicaid or KidsCare as well as
HB2003, the numbers reported here may understate the services provided with HB2003 monies.
Children enrolled in HB2003 have
received a variety of services. Many of
these services focused on families, not
just children. For example, in January
2002, 64 children and their families
received family psychotherapy. Table 1
(see page 12) illustrates the number of
children receiving various services in
January 2002.1
Programs consistent with
new system of care
In addition to serving children
mentioned in the HB2003 legislation,
the Division has used the monies to
create and staff new programs in
keeping with the new system of care
prescribed by the settlement agreement
for the J.K. v. Eden class action lawsuit.
Many of the programs in the RBHAs’
plans for using the HB2003 funding
reflect the principles enumerated in the
settlement, such as collaboration,
providing services in the most
appropriate setting, and the new system’s family-centered nature. For example:
􀁺􇩍 Multi-Agency Teams—NARBHA used HB2003 monies to establish a
collaborative case-planning system for the Northern Arizona region. This system
uses teams that include representatives from children’s programs within the
Department of Economic Security, the Administrative Office of the Courts, and
the Department of Juvenile Corrections. Together, these representatives provide
collaborative case planning for behavioral health needs for non-Medicaid
children referred through these other agencies. Each team also receives
treatment recommendations from a Child and Family Team composed of the
child and family and any other individuals who are important in the child’s life,
such as teachers.
􀁺􇩉 Intensive In-home Services—The plan developed for the Southern Arizona
region by CPSA includes an integrated family-focused program to provide
Some programs focus
on children and families.
Administrative Office
of the Courts (152)
Juvenile
Corrections (87)
Involved with two or more
other state agencies
(33)
Source: Auditor General staff analysis of assessment data provided by the Division of
Behavioral Health Services.
Department of
Economic Security—
Developmental
Disabilities (7)
2 Assessment information is missing for 117 of these clients. Some may be involved
with other agencies. In addition, auditors found approximately 10 percent of children
may be misclassified in the Division's data.
Department of
Economic Security—
Child Protective Services (160)
Division of Behavioral
Health Services (499)2
1 All children are served by the Division of Behavioral Health Services. Some are also
served by other agencies.
Figure 2 Children Served by State Agencies
Named in HB2003 Legislation1
As of July 1, 2002
behavioral health services to non-Medicaid eligible families and their children.
These services include in-home family counseling, respite care, medication,
transportation, and other services. Prior to the HB2003 program, family
members who were not eligible for Medicaid services received little or no
services outside of traditional family therapy. The HB2003 funding allows
treatment programs to address the whole family as a functional unit.
page12
State of Arizona
Table 1 Types of Services Provided To HB2003 Children1
Month Ended January 31, 20022
Service
Number of Children
Receiving Services
Behavioral health day program 103
Counseling and psychotherapy
Family psychotherapy 64
Family counseling in the office 48
Family counseling in the home 17
Family support 48
Individual counseling in the office 33
Individual counseling in the home 30
Individual psychotherapy 2
Group counseling 8
Case management, assessment, and screening
Case management 113
Screening 88
Consultation and assessment 76
Comprehensive assessment 31
Assessment 6
Psychiatric evaluation 2
Other 101
1 This table represents children enrolled in HB2003 who received services not covered by
Medicaid or KidsCare because either the child or the service was ineligible. For January 2002,
there were 302 such children.
2 Data may be incomplete because Regional Behavioral Heath Authorities and their contracted
providers have 1 year to submit accurate data. However, auditor analysis indicates this data
should be nearly complete.
Source: Auditor General staff analysis of data obtained from the Division of Behavioral Health
Services' Client Information System for January 2002. The children identified through
matches with the Division's Client Enrollment, Disenrollment and Assessment report
database and HB2003 enrollment rosters obtained from the Regional Behavioral Health
Authorities.
page13
Office of the Auditor General
􀁺􇨳 300 Kids Project—Value Options used HB2003 monies to support staffing for its
portion of the 300 Kids Project. This project is intended to test approaches that
might be used state-wide in implementing the new system-of-care approach to
delivering behavioral health services. The J.K. v. Eden settlement agreement
requires the pilot program to be implemented for 200 children in Maricopa
County and 100 children in another Arizona region. ValueOptions used the
HB2003 monies to hire a project manager and administrative assistant; one
liaison each for Juvenile Courts, Juvenile Corrections, and Child Protective
Services; a family liaison and an educational liaison; and an outcomes analyst.
Programs had slower start than anticipated start
Although designed to address legislative goals and support creating a new system
of care, the HB2003 programs had a slower start than anticipated. Early enrollment
did not meet projections, but has increased since the RBHAs made program
adjustments and worked with other agencies to obtain more referrals. Changes in
Medicaid coverage and other factors help to explain the low initial enrollment. Still, as
a result of the slow start, complete service data is unavailable and state-wide
expenditures to date appear low.
Programs had low early enrollment—Enrollment in the first few months of the
program did not meet the RBHAs’ original expectations. The Division began making
monthly distributions of monies to the RBHAs in December 2000. It required the
RBHAs to begin their programs on July 1, 2001, and continue them at least through
June 30, 2003. By October 31, 2001, however, the RBHAs had not enrolled as many
children as expected. For example:
􀁺􇩎 NARBHA started its program early in May 2001. It planned to enroll children
through multi-agency teams, which could provide a broad spectrum of services
to maintain or improve family stability. It identified nine criteria for enrollment
eligibility, such as involvement with Child Protective Services or juvenile
probation. Despite the early start, NARBHA had enrolled only 15 children by
October 31, 2001. By comparison, NARBHA had projected the teams could
serve 150 children when fully implemented.
Altogether, by the end of the first 4 months after the Division’s target start date of July
1, 2001, only 111 children and families had been enrolled in the HB2003 programs
(see Figure 3, page 14). This was 9 percent of the total projected enrollment for the
programs. Between July and October 2001, average new enrollments were only 15
per month, less than one-third of the rate required to reach the projected enrollment
of over 1,200 by June 2003.
page14
State of Arizona
With the Division’s approval, one RBHA—Value Options—waited to start its program
until October 3, 2001, to coincide with changes in Medicaid coverage. Another
RBHA—Excel in Yuma—did not enroll most of its children until December 2001.
According to a division official, Excel modified its program in November 2001 by
broadening the eligibility criteria because it had not received the number of referrals
it had originally expected. The modified program accepted children who did not have
multi-agency involvement. These delayed start dates contributed to the low overall
early enrollment. However, ValueOptions continued to experience low enrollment in
some programs during the first few months after they started. Specifically:
􀁺􇩖 ValueOptions planned to enroll children and families in six programs, two each
for children involved with DES, Maricopa County Juvenile Probation, and the
Department of Juvenile Corrections. One program for each group offered
substance abuse services, and the other program offered an enhanced benefits
package for non-Medicaid eligible children. ValueOptions estimated the
capacity of each program; for example, 100 families and 210 children at a time
could receive services in the programs for DES-involved children. These
programs started on October 3, 2001. However, by December 31, 2001, Value
Options reported that only 11 families and 5 children involved with DES had
received services. In contrast, its programs for children in the juvenile justice
system were closer to capacity at that date: 40 enrolled from Juvenile Probation
(177 capacity) and 55 enrolled from Juvenile Corrections (90 capacity).
Medicaid changes contributed to slow program start—During the
implementation of the HB2003 programs, Medicaid coverage increased, affecting
the Division’s and the RBHAs’ ability to focus on planning and implementing the
HB2003 programs. These changes were completed by October 2001, just 3 months
after the Division planned to initiate the HB2003 programs. Specifically:
􀁺􇩍 More people became eligible for Medicaid—The State implemented Proposition
204, which revised the eligibility requirements for Medicaid participation and
expanded the number of adults eligible for Medicaid. These revised eligibility
requirements were in place by October 1, 2001. Although eligibility for children
did not change, the number of Medicaid-eligible children who received division
services grew by 4,684 to 19,504 from October 2001 to August 2002. By
comparison, the number increased by only 723 from October 2000 to August
2001. The number of Medicaid children may have increased due to adults
enrolling themselves and their children in AHCCCS.
􀁺􇩍 Medicaid began covering more services—The Division also changed the scope
of services that were covered by Medicaid. RBHAs can use HB2003 money to
pay for services Medicaid will not pay for, including some services for children
who are eligible for Medicaid. The Covered Services Project, implemented in
October 2001, increased the number of different types of behavioral health
services covered by Medicaid. The new services include expanded respite care
Two RBHAs started
program after the target
start date.
page15
Office of the Auditor General
and day treatment programs. The same project increased the number of
providers authorized to provide Medicaid services.
According to division officials, these system-wide changes required a great deal of
coordination and education of service providers. Both the Division and the RBHAs
needed to focus their attention on making these changes.
Division and RBHAs have worked to increase enrollment—In response
to the low enrollment, the Division and the RBHAs made changes to the program
plans and worked with other agencies to increase referrals. The Division needed to
educate other agencies on the availability of new services. In the past, agencies did
not always refer non-Medicaid clients because services were not always available. To
increase enrollment, ValueOptions submitted a revised plan to the Division on
November 1, 2001. The plan shifted some of ValueOptions’ planned spending from
programs for DES children to children
referred by the probation offices and
Juvenile Corrections. According to
ValueOptions officials, most of the
children DES referred were found to be
eligible for Medicaid, in contrast to
children referred by juvenile justice
agencies. In addition, ValueOptions
officials implemented a simpler, fax-based
referral process for DES
caseworkers, and asked DES officials
for their assistance in increasing
referrals.
After the slow start, enrollment in the
HB2003 programs has increased in
recent months. Figure 3 illustrates the
total cumulative enrollment during each
month of the program. Altogether, 938
children have been enrolled in the
program since inception to July 1, 2002.
Table 2 (see page 16) shows the clients’
gender, age, race, and ethnicity as
reported in their latest enrollment forms.
Participation rates in some programs
may ultimately reach the RBHAs’
estimates. New enrollments averaged
104 per month from November 2001 to
June 2002. The ValueOptions program
for DES-involved children has grown from 2 percent of capacity in December 2001
1 3 25 37 51 61 75 95 111
231
356
513
600
686
774
843
938
0
100
200
300
400
500
600
700
800
900
1000
Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June
Enrollment Number
2001 2002
Figure 3 Number of Clients Enrolled in HB2003
Children’s Program1
February 1, 2001, Through June 30, 2002
1 Each bar represents the cumulative number of children who have been
enrolled since the program’s inception, not the total current enrollment.
Source: Auditor General staff analysis of data provided by the Division of
Behavioral Health Services and its Regional Behavioral Health
Authorities.
to 50 percent as of October 2002. Similarly, PGBHA, which had enrolled only 5
children in all its programs by October 2001, reported it had served 23 families, or
nearly 60 percent of the number it had expected to serve in its Functional Family
Therapy Program for parole violators by June 30, 2002.
Total expenditures appear low—Analysis of program expenditures indicates
that spending appears low, which may be due, in part, to service data reporting
policies that give the RBHAs up to 1 year to submit accurate claims. Most HB2003
page16
State of Arizona
CPSA-3
CPSA-5
Excel
NARBHA
PGBHA
ValueOptions
Statewide
Total
Number of children served with
HB2003 monies
43
135
197
62
33
469
939 1
Gender
Female 10 57 94 21 13 124 319
Male 33 78 102 40 17 331 601
No data 19
Age groups
Under 13 years 4 54 123 24 8 107 320
13 to 17 years 38 72 71 36 21 329 567
18 years and over 1 9 2 1 1 19 33
No data 19
Ethnicity and Race
Non-Hispanic
White 42 125 52 50 11 268 548
Black 1 7 2 2 34 46
Native American 1 5 1 6 13
Asian 2 2
Other 2 1 5 8
Total Non-Hispanic 42 134 54 57 14 315 617
Hispanic
White 4 2 15 56 77
Black 1 1
Native American 1 7 8
Asian 0
Other 138 1 1 76 216
Total Hispanic 0 0 142 4 16 140 302
No data 19 19
1 Count includes one girl who transferred from CPSA-3 to CPSA-5 and is counted in both regions.
CPSA-3 = Community Partnership of Southern Arizona — Cochise, Graham, Greenlee, and Santa Cruz Counties
CPSA-5 = Community Partnership of Southern Arizona — Pima County
NARBHA = Northern Arizona Regional Behavioral Health Authority
PGBHA = Pinal Gila Behavioral Health Authority
Source: Auditor General staff analysis of enrollment data provided by the Division of Behavioral Health Services and
its Regional Behavioral Health Authorities.
Table 2 HB2003 Children’s Program
Clients Served As of July 1, 2002
program services occurred less than 1 year ago, so complete service data is
unavailable. However, the RBHAs submit quarterly progress reports showing
expenditures for hiring staff, purchasing equipment, and the value of services
reported by their providers. These progress reports for fiscal years 2001 and 2002
show that of the $17.85 million the Division allocated to the RBHAs for children’s
programs, approximately 18 percent had been spent for services, programs, and
capital expenditures as of June 30, 2002 (see Table 3 for details). Most of the unspent
monies are allocated for ValueOptions. Specifically:
􀁺􇩔 Total spending reported by ValueOptions was only 9 percent of the total $10.5
million budgeted by June 30, 2002. ValueOptions had spent nearly 50 percent
of its $1 million budget for its portion of the 300 Kids Project. However,
expenditures in the program to give DES-involved children a full range of
services were only 5 percent of the budgeted $2.7 million. Similarly,
ValueOptions had spent only 2 percent of the $1 million budget for its substance
abuse program for children involved with Juvenile Probation. ValueOptions did
not begin spending on the latter program until May 2002.
Total spending by the other RBHAs comes closer to the total budgeted. For example:
􀁺􇩔 Total spending reported by PGBHA as of June 30, 2002, was approximately 50
percent of its $760,000 budget. PGBHA had spent nearly 90 percent of its
$230,000 budget to purchase telemedicine equipment. It had also spent 43
page17
Office of the Auditor General
Regional
Behavioral Health
Authority
Allocation
Program
Expenditures 1
Percentage
Spent
ValueOptions $10,778,050 $ 982,889 9.1%
CPSA Region 3 838,800 71,806 8.6
CPSA Region 5 2,949,193 818,971 27.8
NARBHA 1,893,905 528,243 27.9
PGBHA 760,508 378,589 49.8
Excel 629,544 417,340 66.3
Total $17,850,000 $3,197,838 17.9%
1 Program expenditures include expenditures on programs, services, and capital equipment
such as telemedicine equipment.
Source: Auditor General staff analysis of Division of Behavioral Health Services recap of
HB2003 children’s program as of June 30, 2002.
Table 3 HB2003 Children’s Program Expenditures
from Program Inception Through June 30, 2002
(Unaudited)
ValueOptions reports
low expenditures as of
June 30, 2002.
percent of its $235,613 budget to provide assessments, counseling, and other
services to children in detention centers. PGBHA also reported it had spent
about 25 percent of its $156,248 budget for providing multi-agency team
services to children involved with DES and other agencies.
􀁺􇩔 Total spending by Excel, which provides services directly instead of through
contracted providers, is closest to the budgeted total, about 66 percent of its
nearly $630,000 allocation. As of June 30, 2002, Excel reported that it had spent
71 percent of its $392,138 budgeted to provide a full continuum of services to
children involved with DES and the juvenile justice agencies, as well as 51
percent of the $186,206 it had budgeted for constructing and operating a team
challenge course in Yuma. Excel’s reported expenditures may reflect more
complete information than the other RBHAs because Excel does not have to
wait for providers to report services.
Delays in reporting services to the Division may result in understating actual program
expenditures and services provided to date. Although they are encouraged to submit
service data as quickly as possible, the RBHAs are allowed to take almost a year to
submit accurate service data to the Division. This timetable, outlined in A.R.S. §36-
3411, gives them enough time to obtain data from service providers and reconcile
any discrepancies, such as Medicaid enrollment dates that disagree with data
provided by AHCCCS. Since reported expenditures are based on reported services,
program expenditures on the progress reports may appear artificially low. Because
of this lag in reporting, it is difficult to accurately determine what services have been
provided to date.
Recommendation
This finding provides information only. Therefore, no recommendations are
presented.
page18
State of Arizona
Service reporting
policies result in
understated
expenditures.
The Division should continue efforts to ensure
state-wide training on its new system
The Division has used some HB2003 monies to train staff on a new system for
delivering behavioral healthcare, and it should continue to take steps to ensure the
training is provided state-wide. The training, required by the J.K. v. Eden settlement
agreement, is consistent with best practices identified in federal studies and in
interviews with officials from similar programs in other states. Training has been
provided in several regions of the State, but an ongoing effort will be needed to carry
it to other agencies and locations and to continue to offer it to new staff. The
Division’s efforts to sustain training would be enhanced by ensuring that the RBHAs’
future training plans include key factors such as detailed tasks, time frames, and
other necessary elements to expand training state-wide.
Training helps implement new system of care
In accordance with the J.K. v. Eden settlement agreement, the Division is using $2
million to provide extensive classroom training and one-on-one coaching on its new
system for providing children’s behavioral healthcare. This new system of care
represents a significant philosophical shift from the traditional system. The traditional
system of care views families as the cause of their children’s problems and focuses
on families’ deficits. In contrast, the new system of care emphasizes outcome-focused,
strengths-based services centered on the child and family. The new system
of care treats parents and children as partners, respects the child and family’s unique
cultural heritage, and tailors services to the child and family. Individuals trained on the
new system of care include division staff and the RBHAs, as well as service
providers, family members, and personnel from other child-serving state agencies.
To design and facilitate the state-wide training and coaching program, the Division
contracted with Vroon VanDenBerg LLP (VanDenBerg), an international expert in
developing systems of care. VanDenBerg has provided training in all 50 states and
page19
Office of the Auditor General
FINDING 2
J.K. v. Eden settlement
and RBHA plan
specifications require
training.
page20
State of Arizona
has worked with states and communities to develop, implement, finance, and sustain
systems of care. According to the VanDenBerg contract, Arizona’s training and
coaching program will be accomplished in three phases:
􀁺􇩁 Assessment—The first phase of the contract focused on assessment activities
to identify system-of-care elements that need to be in place and what type of
training would need to be provided. These activities included meeting with
stakeholders, observing service providers, and identifying barriers to system
implementation. The assessment activities occurred over a 6-month period and
were completed in October 2001.
􀁺􇩃 Curriculum Development and Initial Training—This phase consists of curriculum
development, training, and coaching on the new system of care. The training
includes several different modules that address the new system-of-care and its
core values. For example, one module provides an overview of the new system,
while another provides skills-based training on how to lead a child’s service team.
According to a division official, this phase will be complete in January 2003.
􀁺􇨠 Project Management—The project management phase focuses on transitioning
from delivery of the training program to staff in a portion of the State to a state-wide
training program. This includes an assessment of future training needs at
all the RBHAs and the tracking of state-wide training implementation through a
database. This phase began in November 2001 and is expected to be complete
by May 2003.
Training is consistent with best practices
Several elements of Arizona’s training are consistent with “best practices” identified
in a federal Center for Mental Health Services (CMHS) report and in interviews with
officials from similar programs in other states.1 Specifically:
􀁺􇩆 Focus on values and skills—Because the new system of care represents a
significantly different approach to providing services, training is important to
facilitate system change. According to the CMHS training report, programs such
as California’s Santa Clara County program and Illinois’ La Grange Network
trained staff on core values and specific skills integral to the system of care.
Additionally, an official from North Carolina’s Guilford County program indicated
that training focused on these same elements. Similarly, the Division of
Behavioral Health Services’ training focuses on the values and skills necessary
for implementing the new system of care.
1 Auditors examined the following programs included in a CMHS report entitled Systems of Care: Promising Practices in
Children’s Mental Health, 1998 series, volume IV: Wisconsin’s Wraparound Milwaukee program, Illinois’ La Grange Area
Department of Special Education Emotional and Behavioral Disorders Network, and California’s Santa Clara County
Program: Uniting Partners to Link and Invest in Families Today. Auditors interviewed officials from Wraparound Milwaukee,
Illinois’ Kaleidoscope Program in Bloomfield and Chicago, and the Guilford County site of North Carolina’s Families and
Communities Equal Success grant.
page21
Office of the Auditor General
􀁺􇩆 Facilitator role—Similar to programs in other states, Arizona is providing training
on the role of “facilitator.” Facilitators, who work directly with family members and
persons on the child’s service team to plan and implement services, are integral
to Arizona’s new system of care. According to the CMHS report, Wraparound
Milwaukee has developed a comprehensive training and certification program
for its version of the facilitator. The La Grange Illinois Network also provides
training for facilitators. Arizona’s intensive course includes role playing and
coaching on the specific skills related to facilitation. In interviews with auditors,
six of six facilitator trainees indicated that the training was helpful in teaching
hands-on skills such as how to plan for family crises.1
􀁺􇩉 Involvement of other agencies—A core value of the new system of care is
collaboration between behavioral health and other child-serving agencies. This
means other child-serving agency employees also need training on the new
system of care. According to the CMHS report, Wraparound Milwaukee and the
La Grange Illinois Network developed and provided training for other agencies
involved in the system of care. Similarly, representatives from other Arizona
child-serving agencies, including the Administrative Office of the Courts and the
Departments of Juvenile Corrections, Economic Security, and Education, were
invited to attend training sessions on the new system of care. In interviews with
auditors, four of six trainees from other agencies indicated that the training was
good, and two trainees indicated that it was excellent.2 However, five of the six
trainees also commented that additional training, such as how the model works
with delinquent youth, would be helpful.
Extent of training provided varies by region
Regions of the State vary widely in the degree of VanDenBerg training received to date.
As of August 8, 2002, VanDenBerg had provided 38 training sessions ranging from
several hours to several days in length. According to VanDenBerg’s rosters,
attendance at those sessions totaled 2,300 including representatives from the Division,
the RBHAs, service providers, and other child-serving agencies. Consistent with the
J.K. v. Eden settlement agreement, most of the initial training targeted provider staff
from the ValueOptions and NARBHA regions that work with a small group of children
known as the 300 Kids Project.3 The CPSA region has also received some similar
training and coaching. So far, PGBHA and Excel have each received only one training
Initial training targeted
staff involved in the 300
Kids Project.
Facilitators work with
family members on the
child’s service team to
plan services.
1 Auditors interviewed six provider staff from the ValueOptions, NARBHA, and CPSA regions. Each of the interviewees
received the facilitator training from VanDenBerg.
2 Auditors interviewed six staff from other child-serving agencies in Arizona, including the Administrative Office of the Courts
and the Departments of Education, Juvenile Corrections, and Economic Security.
3 In accordance with the settlement agreement, the 300 Kids Project is a pilot project for 200 children in Maricopa County
and 100 children in Northern Arizona. The project was used to demonstrate the efficacy of the system-of-care approach,
to work out the details of how to best provide services and supports, and to develop strategies and materials to support
system change for the entire State.
page22
State of Arizona
Videotaped vignettes
will help trainees learn
specific skills.
session, paid for by a CMHS block grant. The RBHAs are currently developing plans
for future training in all parts of the State.
The Division plans to use $2 million of the HB2003 monies
to provide training and coaching on the new system of care.
As of October 30, 2002, and as illustrated in Figure 4, the
Division reports that it has already allocated more than $1.3
million of these monies for training. The Division has
allocated $335,818 of this amount for VanDenBerg training
and coaching services.1 The total allocated also includes
$961,511 for ValueOptions to conduct additional training
and coaching for behavioral health staff, parents, and other
agency staff, because ValueOptions was furthest ahead in
adopting the new system of care. Further, CPSA has
received more than $58,600 to contract independently for
training and coaching from VanDenBerg and another
training organization.2 The Division plans to allocate the
remaining $644,030 to the RBHAs based on population
once the phase three assessments are complete and the
RBHAs have submitted a plan to use the remaining monies.
Plans to train staff can be enhanced
While the Division has taken steps to continue to provide
training once its contract with VanDenBerg expires, it can take additional steps to
ensure all appropriate personnel receive the training in a timely manner. Specifically,
the Division should work with the RBHAs to develop regional plans to ensure that
state-wide training continues.
The Division has taken steps to provide ongoing training—The Division
has taken steps to continue to provide training after the current contract ends in order
to help ensure the new system is successfully implemented. The settlement
agreement requires state-wide training for front-line staff and supervisors. Also,
because employee turnover is a common challenge for systems of care, it is
important to make sure that training continues as new employees enter the system.
To ensure training continuity, the Division is taking the following measures:
􀁺􇩔 Training Kits—The Division’s contract requires VanDenBerg to develop training
kits for use with trainees. These kits will be used in addition to classroom training
and one-on-one coaching. The kits consist of videotaped vignettes illustrating
1 This amount includes $25,000 reserved for the development of training kits, $25,000 reserved for the provision of a “train
the trainer” program, and approximately $285,817 for ValueOptions and NARBHA as they implemented the 300 Kids
Project.
2 CPSA’s training and coaching was funded by a combination of HB2003 and federal match grant monies.
Figure 4 House Bill 2003 Children's Program
$2 Million Training Allocation
ValueOptions
$961,511
VanDenBerg
$335,818
Community Partnership of
Southern Arizona (CPSA)
$58,641
Unallocated
$644,030
Source: Auditor General staff analysis of House Bill 2003 Children's Set-aside,
July 31, 2002, and additional information provided by a
division official.
Figure 4 HB2003 Children’s Program
$2 Million Training Allocation
page23
Office of the Auditor General
the key elements of the new system of care, such as how to develop a plan for
addressing family crises. VanDenBerg anticipates that the kits will facilitate the
transfer of skills taught during the formal training and coaching.
􀁺􇨠 Internal Training—The development of internal training capacity will allow the
RBHAs to facilitate future training. The Division and ValueOptions are acquiring
the training curriculum and materials VanDenBerg and others developed for
Arizona. This will allow the Division and the RBHAs to reproduce the training and
coaching once the contracted trainers are no longer available. All RBHAs
indicate that they are identifying and training staff to facilitate future training on
the new system of care. Further, according to the Division, it is developing a
train-the-trainer program for internal trainers.
􀁺􇩓 Supervisory Training—In order to obtain management support for the new
system of care, VanDenBerg and other trainers have trained some service
providers’ supervisors. According to a division representative, VanDenBerg, and
other system-of-care experts, supervisors are critical to ensuring the training’s
success, as they provide support and encouragement for their staff.
The Division should continue its plans to use training kits and ensure that the RBHAs
continue to develop internal training capacity and provide supervisory training. This
will help ensure that the training becomes institutionalized.
Division should assist the RBHAs with plans for future training—As it
expands training state-wide, the Division should continue to assist the RBHAs with
future training plans. The Division is assessing the RBHAs’ training needs and
obtaining their training plans. The Division has already approved ValueOptions’ plan,
and expects all plans to be submitted by January 1, 2003. As the remaining plans are
submitted, the Division needs to ensure they include key factors such as detailed
tasks, time frames, and other elements necessary for achieving timely training and
coaching in all areas of the State. The Division plans to intensify training efforts in
areas that have not had the opportunity to participate fully in the training, particularly
in the PGBHA, Excel, and CPSA-3 regions.1
Additionally, because other child-serving agencies must be a partner in the system
of care, the Division should continue to ensure the RBHAs include other state agency
employees in future training. The Division should continue to work with the
Administrative Office of the Courts and the Departments of Juvenile Corrections,
Economic Security, and Education, while RBHAs work with local counterparts of
those departments and county probation offices and continue to invite other agency
representatives to training.
1 CPSA-3 serves Cochise, Graham, Greenlee, and Santa Cruz Counties.
The Division’s FY2003
Strategic Plan includes
developing training
plans for rural RBHAs.
page24
State of Arizona
Recommendations
1. The Division should continue its plans to use training kits and ensure that the
RBHAs continue to develop internal training capacity and provide supervisory
training.
2. The Division should ensure that RBHA training plans includes tasks, time
frames, and other elements necessary for achieving timely training throughout
the State.
3. The Division and the RBHAs should continue to invite other agency
representatives to training. Specifically:
a. The Division should continue to work with the Administrative Office of the
Courts and the Departments of Juvenile Corrections, Economic Security,
and Education to encourage them to send representatives to the training.
b. The RBHAs should continue to work with counterparts of these agencies
and county probation offices to encourage them to send representatives to
the training.
The Division can further foster interagency
collaboration
The Division can take further action to promote interagency collaboration for multi-agency
children. Collaboration is an integral part of the HB2003 program, and the
Division required each RBHA to solicit input from other agencies in developing its
spending plans for HB2003 monies. Overall, the RBHAs solicited input from all the
collaborating agencies and incorporated their priorities in planning, but some local
administrators of these agencies reported that their input was not considered or that
they disagreed with the final decisions. To continue its focus on collaboration, the
Division should work with the other state agencies to strengthen local commitment to
the new system of care within the specific geographic service areas that each of the
RBHAs serve.
Collaboration a central goal
Collaboration is central to the HB2003 Children’s Services programs, because the
Legislature specifically directed that the HB2003 funding be used for families whose
children are served by various agencies. Collaborative efforts are important because
without effective interagency service planning, the state agencies that serve any one
child can sometimes have conflicting service and treatment goals. In addition to
being costly, such conflicts do not lead to effective behavioral health outcomes.
Increased collaboration is not only a goal for the HB2003 Children’s Services
program, but has been identified several times in the past two decades as a state-wide
goal for children’s behavioral health services. For example, in 1999, six state
agencies signed a Visioning Agreement that committed them to improve interagency
service planning in children’s services.1 The settlement agreement in the J.K. v. Eden
lawsuit focused additional attention on collaboration. Under the settlement
agreement, collaboration is one of the 12 Arizona Principles that the Division must
support.
page25
Office of the Auditor General
FINDING 3
Collaboration is one of
the 12 Arizona
Principles.
1 The six agencies were the Departments of Education, Economic Security, Health Services, Juvenile Corrections, the
Administrative Office of the Courts, and the Arizona Health Care Cost Containment System.
As it implemented the HB2003 program, the Division sought to improve regional
interagency collaboration among the RBHAs and other state agencies. Specifically,
the Division’s HB2003 plan specifications required each RBHA to demonstrate that it
had collaborated with other child-serving agencies to develop its plan.
Service plans developed collaboratively
The RBHAs made efforts to collaborate with the other agencies specified in the
HB2003 legislation. They solicited input during the planning process and generally
included other agencies’ priorities in their program plans. Additionally, the Division
established longer-term inroads to collaboration at both the agency leadership and
client levels.
Views of other agencies solicited during planning—Consistent with the
Division’s plan specifications, the RBHAs solicited input from the agencies
mentioned in the legislation prior to submitting their HB2003 program plans. Auditors’
review of meeting minutes, sign-in logs, and interviews indicate that all the RBHAs
solicited input from regional administrations within the Department of Economic
Security, and three RBHAs solicited regional input from the Department of Juvenile
Corrections’ administrators, prior to developing their spending plans. Additionally,
input from the Administrative Office of the Courts was obtained, although not all local
probation offices were represented. For example, CPSA held meetings with regional
agency representatives during the planning phases, and also scheduled regular
meetings during implementation. In PGBHA’s region, collaborating agencies
submitted their service priorities in writing prior to plan development.
While overall perceptions of the RBHAs’ planning efforts were more positive than
negative, some state agency representatives reported that they were not included in
the RBHAs’ service planning activities. Officials in two of the seven county juvenile
probation offices auditors contacted said that their county’s service priorities were not
solicited by the RBHA. In addition, a state Juvenile Corrections official reported that
neither NARBHA nor the Excel Group discussed regional service priorities with
Juvenile Corrections prior to submitting their initial spending plans.
Priorities of other agencies incorporated—A review of submitted plans
indicates that in most cases, the RBHAs incorporated other agency priorities into the
program plans they submitted to the Division. Specifically, juvenile justice agencies’
priorities included psychological assessments, “bridging” medications to prevent a
lapse in a child’s medication between release from the justice system and entry into
the behavioral health system, and in-home and family substance abuse services for
youth on juvenile probation or juvenile parole. Five of the plans for the six geographic
service areas included these types of services. The Department of Economic
page26
State of Arizona
The Division required
the RBHAs to
demonstrate
collaboration in
planning.
page27
Office of the Auditor General
Security priorities included family preservation services, meaning counseling and
other types of support services that are designed to keep a family intact, and
“wraparound” services, an individualized array of services decided upon by the child
and family team. All of the six regional plans included one or both of these priorities.
In other cases, some RBHAs chose not to adopt all of the priorities and
recommendations that other state agencies presented to them. For example,
􀁺􇨠 In Pima County, representatives of DES Child Protective Services disagreed with
CPSA’s plan to use dollars targeted for DES to fund three court liaisons to
perform behavioral health screenings and referrals. Instead, DES officials
reported they would have preferred the funding go to direct services.
􀁺􇩐 Probation administrators working with PGBHA reported that, while probation
office representatives were asked to identify service priorities, they disagreed
with PGBHA’s funding allocation to telemedicine equipment.1
These examples illustrate the challenges in maintaining collaborative relationships
when agencies may have different priorities for how to spend limited monies.
PGBHA’s decision to provide funding for telemedicine, for example, operated within
legislative intent and division guidelines, and may have benefited the region.
Nonetheless, the decision may have affected the other state agencies’ perception of
collaboration.
Collaborative inroads established at leadership and client levels—The
Division and the RBHAs have made important inroads to accomplishing
collaboration at the state agency leadership level and the client level. At the state
level, the Division is working with the other child-serving agencies to develop agreed-upon
clinical protocols for treating behavioral health problems that are common to
multiple-agency children. The Division has a full-time, executive-level position
dedicated to fostering collaboration, and is fostering client service level collaboration
by encouraging the RBHAs and the other state agencies to provide services through
the child and family team model, which is a major component of the new system of
care under implementation state-wide.
Division should augment efforts
The Division may be able to achieve significant gains in collaboration by focusing on
the county and regional leadership within the agencies of its child-serving partners.
Most of the geographic service areas that the five RBHAs serve already have some
mechanisms in place that are designed to foster and improve interagency
collaboration on behalf of children. Most of the RBHAs have had multi-agency teams
that predate the system-of-care reform effort and the HB2003 program. Similarly, the
Gains can be made at
county and regional
levels.
1 PGBHA’s plan allocated $230,000 of its $760,508 total allotment to telemedicine.
various regions also have different regional council or committee mechanisms in
place to improve service planning for children. For example, in Northern Arizona, the
Children’s Behavioral Health Council of Northern Arizona includes a Collaborative
Projects Steering Committee. In Maricopa County, an interagency steering
committee has been formed to provide leadership and oversight to child and family
teams, and to ensure services are aligned with the 12 Arizona Principles for all
Maricopa County children. Division staff—and in particular, the full-time, executive-level
position dedicated to fostering collaboration—should identify positive practices
in each of the regions and encourage other regions to adopt such practices.
An interagency agreement recently developed by the Maricopa County Steering
Committee provides an example of an approach that could be replicated elsewhere.
Committee members have adopted a formal letter of agreement that, among other
things, specifically commits each individual agency to:
􀁺􇩓 Support the service plan designed by the child and family team,
􀁺􇩐 Provide representation at team meetings,
􀁺􇩉 Incorporate the collaboratively designed service plan into the agency’s service
plan for the child/family, and
􀁺􇩐 Participate collaboratively with the team before changing the approved plan.
Such an agreement reflects recent best practices in building systems of care and
could serve as a model for the Division to enhance collaboration in all of Arizona’s 15
counties.
Recommendation
1. The Division, in partnership with the directors of other child-serving agencies,
should assess the effectiveness of interagency teams and other mechanisms
available for collaboration and encourage the adoption of county- or regional-level
interagency agreements aimed at stronger collaboration.
page28
State of Arizona
Interagency agreement
in Maricopa County is
strong commitment to
collaboration.
Office of the Auditor General
AGENCY RESPONSE
State of Arizona
Office of the Director
1740 W. Adams Street JANE DEE HULL, GOVERNOR
Phoenix, Arizona 85007-2670 CATHERINE R. EDEN, DIRECTOR
(602) 542-1025
(602) 542-1062 FAX
Debra K. Davenport
Office of the Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
Dear Ms. Davenport:
Thank you for giving us an opportunity to respond to your office's evaluation of the
implementation of House Bill 2003. We agree with all of the report's findings. In addition, we
plan to implement all of the report's recommendations.
We were quite pleased that the report found that the Department is implementing services
consistent with the legislation. In addition, we appreciate your recognition of our extensive
efforts training providers, staff, and clients on our new system of care, and the great strides
we've made collaborating with other state agencies in providing services.
As noted in the report, the purpose of the House Bill 2003 funding was to provide needed
flexibility in providing services to children needing behavioral health services. This funding is
critical to serving such children, especially those not eligible to receive services through the
Arizona Health Care Cost Containment System (AHCCCS) or KidsCare. There is very limited
funding other than the House Bill 2003 Children's appropriation for this population.
Moreover, House Bill 2003 monies support needed infrastructure enhancements, interagency
liaison positions, and needed services that Medicaid does not cover.
While the implementation of Proposition 204 and the subsequent expansion of the federal
poverty level have resulted in more children being enrolled in Medicaid, the need to provide
services to children who are not enrolled in this federal program still exists. As of October
2002, there were 7,045 children not eligible for AHCCCS enrolled in the behavioral health
system. These children are often uninsured or underinsured. Without House Bill 2003 monies,
these children would otherwise receive limited services, if any services at all.
We agree that the many changes experienced by the behavioral health system at the time that
House Bill 2003 began resulted in us expending such monies more slowly than we initially
anticipated. These changes, including implementation of a new system of care spurred by
settlement of the Jason K v. Eden lawsuit, the implementation of Proposition 204, and efforts
to expand covered services available to the Medicaid population, required extensive system
redesign and development. However, several points need to be emphasized.
• First, as the Auditor General's report notes, the Legislature did not establish a
deadline for spending the House Bill 2003 allocation.
Leadership for a Healthy Arizona
Debra K. Davenport
BHS Audit Response
Page 2
• Second, House Bill 2003 monies were intended to be used over the long-term. The
Department never expected that House Bill 2003 programs would be operating at full
capacity at program implementation or by the time of the audit.
As the audit report indicates, the House Bill 2003 Children's appropriation has resulted in
the implementation of many exemplary programs for children needing behavioral health
services. For example:
• The Community Partnership of Southern Arizona (CPSA) is funding coordinators to be
co-located at the juvenile courts, Child Protective Services (CPS) and state agency offices
to better serve multi-agency children.
• A new Wellton satellite office operated by the Excel Group has been embraced by
the communities of Dateland, Tacna and Wellton.
• The Northern Arizona Regional Behavioral Health Authority (NARBHA) and Pinal
Gila Behavioral Health Association (PGBHA) respectively used House Bill 2003
funding to provide collaboratively based services to families.
• ValueOptions is able to offer an enhanced benefit package, including medications and
psychiatric treatment, to children not eligible for services through the Arizona Health Care
Cost Containment System (AHCCCS). These vital services would not be available for this
children or families without House Bill 2003 funds.
Thank you for giving us an opportunity to respond to the report. We appreciate your staff's
professionalism and responsiveness in conducting this evaluation.
Sincerely,
Catherine R.
Eden Director
CRE:mI
CC: Leslie Schwalbe
Michael Franczak,
Ph.D. Melissa Thomas
Leadership for a Healthy Arizona
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