Title XIX children's behavioral health annual action plan: November 1, 2004 to October 31, 2005

              Annual Action Plan

Arizona Department of Health Services

and

Arizona Health Care Cost Containment System

1

TITLE XIX

CHILDREN’S BEHAVIORAL HEALTH

ANNUAL ACTION PLAN *

November 1, 2004

To

October 31, 2005

Submitted By

Arizona Department of Health Services

And

Arizona Health Care Cost Containment System

* In compliance with June 2001 Jason K. Settlement Agreement

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and

Arizona Health Care Cost Containment System

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TABLE OF CONTENTS

INTRODUCTION 3

ANNUAL ACTION PLAN AND STRATEGIES FOR THE FUTURE 4

ACCOMPLISHMENTS 16

Training Program 19

Respite 25

Specialty Providers 26

Title XIX Services 28

Flex Funds 35

Medication Practices 36

300 Kids Project 37

Substance Abuse Services 39

Quality Management and Improvement System 40

Stakeholder Participation 43

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Introduction

In November of 2001, the Arizona Department of Health Services ( ADHS) and the Arizona

Health Care Cost Containment System ( AHCCCS) provided the first Annual Action Plan to

Plaintiffs’ Counsel under the Jason K. Settlement Agreement. Under the Settlement, ADHS and

AHCCCS are required to meet the obligations set forth in Section III, paragraphs 14 through 17

by July 1, 2007.

Many of the obligations must be addressed through simultaneous efforts and activities. Over the

past three years, several obligations outlined in Section III of the settlement agreement have been

met, and those that remain are being substantially addressed. This fourth Annual Action Plan

reviews these accomplishments and presents both continuing and new strategies and action steps

to meet obligations noted in paragraphs 15 and 16. Paragraph 14 is met by the extent of effort put

forth to achieve the obligations stated in paragraphs 15, 16, and 17.

In meeting the requirements of the agreement, ADHS and AHCCCS are both committed to and

expect that all Title XIX eligible children will be evaluated, treated and supported by approaches

that are consistent with the Arizona Vision, within a system of care that supports and sustains

such practice.

The initial emphasis was intended to target children and families with multiple and/ or complex

needs who are enrolled in the behavioral health system. ADHS and AHCCCS tested new

strategies for children in the Maricopa County’s 200 Kids Project, in Northern Arizona’s 100

Kids Project, and within Project MATCH in Pima County. Important lessons learned through

those early efforts continue to be applied as practice improvements spread and as infrastructure

continues to be developed, to foster and sustain progress.

This year’s Annual Action Plan will continue to direct efforts to assure that, regardless of

intensity of need and level of acuity, the care provided to all Title XIX eligible children

throughout Arizona will reflect and maintain our obligation to the Arizona Vision and its 12

Principles. In particular, this year's plan is intended to culminate in the application of the Child

and Family Team ( CFT) process Arizona has now developed and described for 50% of the

enrolled Title XIX children and their families by December 31, 2005. ADHS' strategic goal is

that Title XIX children and their families enrolled in the behavioral health system will be served

in accordance with the 12 Arizona Principles by December 31, 2006.

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Annual Action Plan and Strategies for the Future:

The six- pronged strategy has been updated and extended in this fourth Annual Action Plan, with

the addition of a seventh prong targeting specific service capacity priorities necessary to address

the needs of children and families. Within these strategies attention remains focused on

implementation requirements at the individual team, the local/ regional and state levels.

Over the next year, ADHS will make measurable progress in implementing seven key strategies

to foster statewide implementation of the Arizona Vision and its 12 Principles. These strategies,

and the principles they most directly support include:

1. Create sustainable and trusting partnerships with families and other child- serving systems.

( Principles: collaboration with the child and family, respect for unique cultural heritage,

connection to natural supports independence, collaboration with others, and functional outcomes)

2. Develop, train, and implement effective practice improvement protocols.

( Principles: best practices, services tailored to the child and family, stability, and collaboration

with others)

3. Continue to train and coach system staff, partners, and families.

( Principles: collaboration with the child and family, collaboration with others, independence)

4. Improve the effectiveness of barriers identification, resolution and feedback processes.

( Principles: accessible services, collaboration with the youth and family, collaboration with others)

5. Improve the quality management system.

( Principles: accessible services, timeliness, and functional outcomes)

6. Internalize the understanding of system reform.

( Principles: collaboration with the child and family, respect for unique cultural heritage, and

collaboration with others).

7. Expand available capacity to furnish critical services and supports.

( Principles: services tailored to the child and family, accessible services, timeliness, best practices,

most appropriate setting, stability, functional outcomes and independence.)

ADHS and AHCCCS remain responsible for overall implementation of these strategies. Their

successful implementation, however, also demands vital input and strong support from key

stakeholders, and will be optimized if congruent changes among other child- serving systems are

made.

Implementation of these strategies will occur through a variety of actions at local, regional and

statewide levels. In some instances different approaches may be used in certain geographic

service areas reflecting their varying developmental statuses. ADHS and AHCCCS intend that

this fourth Annual Action Plan will lead to more even system development in all regions of the

state.

The plan is divided into two parts: a description of the fourth year strategies and major action

steps; and a review of the past year’s accomplishments.

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Strategy 1. Create Sustainable and Trusting Partnerships with Families and Other Child-

Serving Systems

Successful reform of the public behavioral health system for children and families in Arizona is

based on building and maintaining strong, sustainable partnerships with all fellow stakeholders

in our system of care. Partnership begins primarily with the children and families our system

serves, and extends across other child- serving agencies, among contractors and service providers,

and throughout the communities in which they work.

In the first Annual Action Plan, the action steps were largely targeted within the behavioral

health system. During years two and three, focus expanded toward better understanding the

mandates, needs and expectations of other child- serving systems that interact with the same

children and families served by the behavioral health system. Over the same period of time,

family members have been increasingly asked to share their input, and to help shape and support

implementation of efforts to improve intake, assessment, service planning, service delivery and

performance improvement processes.

During the next year ADHS and AHCCCS will continue to foster cross- system understanding of

the needs and cultures of families as well as of the expectations of child- serving system partners.

This work will further deepen and strengthen our essential collaborative partnerships, and will

ultimately contribute toward improving outcomes for children and families. This will happen in

a variety of ways.

Improve understanding of the unique cultures of families, their traditions and heritage.

Appreciating and respecting the cultures of families is essential to creating true partnership with

families. ADHS will ensure that its Cultural Competency Plan will be understood and embraced

by its own workforce. ADHS will develop and communicate to the RBHAs standards of care

( e. g. CLAS standards) designed to specifically improve cultural and linguistic competency.

These expectations will be incorporated into ADHS contracts with RBHAs and throughout the

ADHS clinical guidance documents and its quality management processes. Understanding of

cultural diversity within each region of Arizona will be reflected in provider networks and will

be evident in quarterly network analysis and development reports.

Advance the focused work of leadership through the Executive Committee.

In early 2004, the Arizona Children’s Executive Committee reviewed its influential role in

leading development of a statewide system of care for children and families, and determined to

be proactive by focusing on a clear set of priorities. The Executive Committee will extend its

leadership in four specific ways:

1. Assist the Department of Economic Security ( DES) to implement Governor Janet

Napolitano’s Child Protective Services ( CPS) reforms;

2. Increase family involvement in all of Arizona’s child- serving agencies;

3. Identify and work toward resolution of cross system issues and barriers; and

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4. Guide the development of statewide infrastructure that supports implementation

of the JK Settlement agreement ( SIG).

Already, the Executive Committee has reviewed an action plan to address the unique behavioral

health needs of children involved with CPS which will:

·   Sensitize the behavioral health workforce on the child welfare context for those children

through new practice improvement protocols, and

·   Develop behavioral health system capacity to provide clinical “ best practices” to children

involved with CPS, their families and caregivers.

The Executive Committee will act in accordance with the family involvement framework it

adopted in 2004. According to that framework, family members should be recognized as

experts, and be utilized in training and consultative roles within the behavioral health and related

child- serving systems. Family involvement requires a sacrifice of time and energy on the part of

family members, so ADHS will continue to support the contributions of families with stipend

and travel reimbursements, tele- communications access and sensitive scheduling consideration.

The Family Involvement subcommittee will expand its partnership with ADHS, the RBHAs and

other Executive Committee member systems by:

·   Recruiting and equipping family members to participate in policy development

and review, provider capacity development, quality improvement and systems

advocacy activities;

·   Ensuring that families are aware of the wide array of covered behavioral health

services available;

·   Contributing teaching ( training) and consultative expertise to service systems.

ADHS and AHCCCS will participate in Governor Janet Napolitano’s statewide summit on

Family Involvement in April 2005. New efforts will begin to encourage youth involvement in

many comparable aspects of policy and systems development, quality improvement, teaching

and advocacy activities. ADHS will coordinate its efforts with those of DES and other agencies

encouraging youth involvement, in order to access youth already participating in such activities.

Those young people will be actively recruited to participate in leadership development activities

and focus groups designed to bring their primary perspectives to system reform.

Specific emphasis will encourage education systems to understand and participate in the Child

and Family Team Process to more effectively address the learning needs of children served by

multiple agencies. ADHS will also participate in the cross- system transition leadership

workgroup, and will spread understanding of its practice improvement protocol, Transitioning to

Adult Services.

Continue to make system improvements for children in foster care.

In the coming year, ADHS and RBHAs will work closely with DES- ACYF to develop effective

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family support and preservation, placement strengthening and family reunification services in the

behavioral health system to:

·   Help minimize the number of children who must be removed from their families

to remain safe,

·   Reduce unintended harm to children placed in the protective custody of the state,

and

·   Expedite the connection of foster children to strong, stable permanent families.

ADHS and ValueOptions will partner with DES- ACYF to implement a family reunification pilot

supported by Arizona’s new Title IV- E waiver opportunity in Maricopa County, intending to

expand its potential to more broadly benefit children and families across Arizona. Similarly,

ValueOptions and ADHS will work closely with DES- ACYF to begin implementing a Family-to-

Family approach to foster care in Maricopa County.

The behavioral health system will help foster parents understand the Arizona Vision and its 12

Principles, how to participate effectively as members of Child and Family Teams, and how to

serve as vital resources for the birth families of children involved with CPS, as well as for kin,

legal guardians and adopting families who may raise these children permanently.

ADHS will continue its many current initiatives to improve service for children involved with

CPS, and will encourage new, related initiatives at the RBHA level. With input from DES-ACYF,

development priorities are currently being identified, and regional network development

plans are now funded in order to addresses service gaps for CMDP- enrolled children, their

families and caregivers.

Expand co- location of behavioral health staff with partnering child- serving agencies.

Co- location, already successfully implementing in several Pima County and Maricopa County

child welfare and juvenile court sites, will be expanded, including in several northern Arizona

communities where it is appropriate to support cross- system teams to serve youth and families

receiving behavioral health and other public ( e. g. child welfare, juvenile justice) services. In

Maricopa County, ValueOptions will establish new co- location sites with CPS in Mesa, in

Tempe, in South Phoenix, at Thunderbird and in Maryvale by 7/ 1/ 05, while maintaining its

existing CPS co- location in Tempe. ValueOptions will also establish “ detention teams” to be

located at both Maricopa County ( Durango and SEF) juvenile justice facilities by 7/ 1/ 05. In

Pima County, CPSA will maintain the existing four CPS co- location sites, as well as the current

co- location of behavioral health providers at the Pima County Juvenile Court Complex. In

Northern Arizona, NARBHA will maintain its Fredonia co- location with CPS, and will

implement new co- locations in two other communities jointly prioritized with CPS by 11/ 1/ 05.

Support and encourage ongoing implementation of joint behavioral health assessment and

behavioral health service planning processes.

ADHS and RBHAs will continue to work with child welfare, juvenile justice and other child-serving

systems to achieve this goal. Collaborative agreements have already been established

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between ValueOptions and Child Protective Services. Collaborative letters of agreement

supporting the Child and Family Teams process have been developed and endorsed by multiple

child- serving agencies in Arizona’s five southeastern counties. ADHS contracts with RBHAs in

effect on 7/ 1/ 05 will require development and implementation of collaborative protocols with

regional child welfare and juvenile justice systems.

Strategy 2: Develop, Train, and Implement Effective Practice Improvement Protocols

ADHS will continue to lead the development of clinical guidance documents, tools and teaching

resources to support practice approaches that effectively actualize the Arizona Vision and

Principles for children and families served. Concerted efforts will be made to ensure consistency

and compatibility between ADHS clinical guidance and parallel guidance of other child- serving

systems ( e. g. DES- ACYF’s Family to Family initiative). Practice Improvement Protocols [ PIPs]

and, when necessary to support their implementation, Technical Assistance Documents [ TADs],

will be shaped with appropriate consumer, family and stakeholder input; published at the ADHS

website; incorporated by reference into ADHS contracts with RBHAs; integrated into ongoing

teaching/ training and supervision processes at the RBHA and service provider levels; and will

progress from “ desired” to “ expected” status when appropriate.

Ensure clinical guidance on prioritized topics is available to frontline workers.

ADHS will complete statewide training on the recently completed clinical guidance documents:

·   Therapeutic Foster Care Services PIP

·   Transitioning to Adult Services PIP

In addition, ADHS will develop clinical guidance surrounding:

·   Use of out- of- home services by 4/ 1/ 05, and will train and implement by 7/ 1/ 05.

·   Unique behavioral health needs of children involved with CPS by 2/ 1/ 05, and will train

and implement by 5/ 1/ 05.

·   Assessing behavioral health needs of infants, toddlers and preschoolers ( birth to 5), their

families and other caregivers by 7/ 1/ 05.

·   Treating children and youth who act out sexually by 4/ 1/ 05, and will train and implement

by 7/ 1/ 05.

Teaching to improve practice will target a broad array of CFT members and other key players.

ADHS will demonstrate the application of the new practice improvement protocol, Use of Out-of-

Home Services, at the Adolescent Treatment Unit of the Arizona State Hospital.

Establish a Best Practice structure within ADHS.

The ADHS Clinical Coordinators Committee has developed clinical guidance for RBHAs and

behavioral health service providers since the beginning of this Settlement. Its new Best Practice

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Subcommittee will strengthen the impact of ADHS clinical guidance on practice. Convening in

December 2004, the Best Practice Subcommittee will:

·   Help to identify areas where clinical guidance should be developed, or updated to reflect

emerging strides in the behavioral health field;

·   Define specific factors that might necessitate adjustments to best practices;

·   Monitor application of best practices in each geographic service area, assuring that

application is sensitive and responsive to individual, family and community cultural

considerations and other unique factors;

·   Involve consumers and family members, arranging for their direct participation on the

Subcommittee;

·   Implement a process that helps clinical guidance and other best practice expectations

to move from desired/ optional to expected/ required status in predominant behavioral

health system practice as appropriate; and

·   Use the Higher Education Partnership to help spread knowledge of best practices.

Strategy 3: Continue to Train and Coach System Staff, Partners and Families

RBHAs are required to develop and implement workforce development plans. ADHS will play a

strong role in shaping those plans, helping to design, approve, and provide resource support by

2/ 15/ 05. ADHS will then monitor implementation and effectiveness of overall workforce and

CFT capacity development. At a minimum, each RBHA’s approved workforce development

plan will:

·   Focus on development of effective supervision skills and process;

·   Continue to involve system partners in training and coaching; and

·   Involve youth and families in training and coaching.

Calibrate training and coaching to a 50% CFT capacity target.

ADHS will require that each RBHA’s plan be designed to reach the intermediate target that

functioning Child and Family Teams will serve at least 50% of enrolled children by 12/ 31/ 05.

In addition to learning to implement the CFT process in general, training and coaching will also

need to account for the prioritization of specific subpopulations in building to that 50% level ( see

Strategy 7).

Support and share an integrated basic training template.

To streamline trainings and increase efficiency, ValueOptions will develop and deliver integrated

curriculum covering strength- based assessment and CFT facilitation for new clinical liaisons by

5/ 1/ 05. Upon approval by ADHS, the integrated curriculum template will be shared to support

initial training for new clinical liaisons in the remaining geographic service areas by 9/ 1/ 05.

Implement the Higher Education Partnership’s strategic plan.

In April 2004 ADHS initiated a watershed meeting with representatives from Arizona’s higher

education community, including university and college professors, deans and department heads.

The purpose was to create a collaborative partnership between the Arizona’s behavioral health

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system and its higher education resources intended to provide an early staging ground for system

of care development, as well as specific educational opportunities to teach the Arizona Vision

and 12 Principles prior to individuals entering the workforce. Further meetings of this group

have been scheduled in the coming months.

Strategy 4: Improve the Effectiveness of Barriers Identification, Resolution and Feedback

Processes

Directly involved behavioral health leadership.

ADHS will require its own management personnel and RBHA chief executive officers to

periodically participate in the Child and Family Teams process, and conduct record reviews as a

specific means of identifying challenges and to model resolution and feedback processes. The

first review, examining cases of children involved with Child Protective Services in the

behavioral health system, will be completed by 2/ 15/ 05.

Establish processes in all regions.

In its contract for the regional behavioral health authority for Maricopa County effective July 1,

2004, ADHS has required that ValueOptions establish collaborative protocols with each major

child- serving system by 12/ 31/ 04 that shall address several items, including mechanisms for

solving problems. Contracts for regional behavioral health authorities for all other geographic

service areas of Arizona will be established effective 7/ 1/ 05, and will include this same

requirement. Through this mechanism, ADHS will request and support development of effective

methods for identifying challenges, providing feedback and creating opportunities for

resolution.

Processes, both within the behavioral health system, and among other child- serving and

community agencies, should start with the fundamental question “ What can be done to address

impediments to children and families’ meeting their objectives and achieving their goals?”

Within provider agencies, RBHAs will encourage processes that build on existing relationships

based on trust and respect, to create needs identification- resolution- feedback loops that join

direct care, supervisor, administrative, clinical, support and executive personnel. Effective

processes must invite discovery beginning at the CFT level, and analysis and action at each

successive higher level as may be necessary to resolve identified challenges, even connecting to

the Children’s Executive Committee.

Provide training to support effective processes.

Training needs to equip the behavioral health workforce and the system’s many stakeholders,

including family members, with skills of “ win/ win” conflict resolution. By 7/ 1/ 05 ADHS will

develop curriculum components to teach these skills. RBHAs will be expected to apply these

lessons within their own systems, and to offer similar training in appropriate local forums for

cross- system and community audiences. Participants will learn how adversarial approaches to

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needs identification and problem- resolution are often counterproductive, that it is both possible

and usually preferable to reach consensus solutions by following strength- based principles.

Strategy 5: Improve the Quality Management System

A strong Quality Management ( QM) System is capable of accurately measuring the Arizona

Vision and the12 Principles and is a critical link in a feedback loop that supports continuous

practice improvement and ongoing system reform. Quality Management processes should

identify areas for targeted improvement efforts, and be able to confirm their effectiveness.

Current quality measurement processes that assess the behavioral health system’s performance

include:

·   Independent case reviews. Required by AHCCCS and carried out by an independent

contractor on a statistically significant sample of Title XIX/ XXI members statewide, this

includes a review of records and interviews with the child/ family/ guardian and the

behavioral health representative ( e. g. CFT facilitator, clinical liaison).

·   Monitoring key indicators. ADHS produces regular reports of key indicators ( e. g. growth

in CFT facilitation capacity each quarter; measures of access to and timeliness of care, of

lengths- of- stay in acute care settings, data on the financial stability and spending patterns

of the RBHAs). Key indicators are trended over time and reviewed by ADHS’ QM/ UM

Committee, which identifies areas for improvement.

·   Utilization review. These data measure how covered behavioral services are used,

offering insight into over- or underutilization of particular services, and supporting

prioritization of provider network capacity development activities.

·   Complaint review. Consumer complaints, grievances and appeals are included as key

indicators and are reviewed quarterly.

·   Provider network review. RBHA provider network gains and losses are monitored on a

quarterly basis and compared against network development plans approved by ADHS

and by AHCCCS.

·   Consumer satisfaction survey. ADHS conducts this survey every two years of a

statistically significant sample of consumers, using standardized national measures.

Resultant data is also compared with behavioral health systems in other states.

·   Operational/ administrative reviews. Conducted annually of the RBHAs by ADHS, and

of ADHS by AHCCCS, these audits focus on overall contract compliance, and include

clinical, financial, administrative, data and quality management measures.

When quality improvement issues emerge from such measurement processes, AHCCCS and

ADHS contracts call for development, implementation, monitoring and enforcement of

performance improvement plans.

In addition to these established approaches, significant experimentation with additional quality

measurement efforts in the context of the 300 Kids Pilot, Project MATCH and subsequent

regional system development, as well as broad efforts by system reformers to identify and study

similarly- intended approaches beyond Arizona’s borders, have brought Arizona’s behavioral

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health system to the point where it is poised to adjust its quality management system to more

substantially support the practice improvement and overall system reform work now well

underway. During the next year ADHS and AHCCCS, with input from youth/ families and other

stakeholders, will:

Monitor growth of Child and Family Teams process and related covered services capacity.

Beginning 1/ 1/ 05 each RBHA will submit data on a monthly basis quantifying the number of

children participating on Child and Family Teams, and of qualified staff available to support

those teams. RBHAs will also provide monthly reports of the use of out- of- home ( that is, Level

I, II and III residential) services, as well as therapeutic foster care services. ADHS will provide

regular reports of encounters of targeted ( see Strategy 7) covered services, and of out- of- state

placements. Data will be trended quarterly to identify areas in need of improvement, and will be

published at the ADHS website.

Make decisions to change the overall QM system.

By 2/ 15/ 05 a small but representative ADHS workgroup will propose a system of monitoring and

measuring practice that defines responsibility at all levels: CFT, work unit, provider agency,

RBHA, ADHS and AHCCCS. The proposal will identify specific tools and processes for

clinical supervision, and to measure our obligation to the 12 Principles, and will determine

substantive roles for youth/ families and community leadership teams within the recommended

system.

By 5/ 1/ 05, the ADHS workgroup will propose a set of quantifiable indicators of the following

outcomes: that children are aided to achieve success in school, live with their families, avoid

delinquency and become stable and productive adults. By 7/ 1/ 05 application of outcomes

indicators will be supported by contract requirements and any necessary ADHS data system

changes.

Determine feedback processes to ensure that data on functional outcomes and practice will

underpin performance improvement strategies.

This strategy as a whole intends to support data- driven performance improvement. Collecting

and analyzing data purposefully identifies the need for, and helps to inform, specific methods of

corrective response. Based on data analysis, ADHS, the RBHAs and other key stakeholders will

identify opportunities for improvement. ADHS will then review and monitor performance

improvement activities.

Improve effective supervision capacities within the behavioral health workforce.

ADHS will require that RBHA workforce development plans increasingly concentrate on

building effective ( clinical) supervision and leadership skills. ADHS will develop and support

processes/ tools and expectations upon consideration of the earlier identified workgroup whose

task involves proposing tools and processes for clinical supervision by 2/ 15/ 05. The targeted

date for implementation is 7/ 1/ 05.

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Strategy 6: Internalize the Understanding of System Reform.

In progressing from the original, discrete 300 Kids and Project MATCH pilots toward statewide

spread of practice improvement, the importance of this strategy becomes increasingly important.

When personnel at all levels and within all parts of the system demonstrate internal

understanding of the principles and the further sense of personal ownership, urgency and

commitment to action then a huge force of reformers will take the place of the initially small

core of champions, early adopters and external experts. The myriad daily decisions they make in

their respective roles – large or small, central to or at the periphery of the core change – will

create incremental, relentless and cumulative momentum in the direction of the Arizona Vision.

Deep internalization may not fully develop in a single year or two, but will require persistent

encouragement and pressure over time to take root. ADHS and AHCCCS will continue and

expand efforts to support internalization of behavioral health system reform. Some of the other

strategies support this, including:

·   Strategy 2, in which ADHS will continue to ensure that its policies and clinical guidance

align with the 12 Arizona Principles

·   Strategy 3, in which ADHS will require that RBHA workforce development plans will

accelerate the transfer of CFT process expertise from external consultants and internal

coaches to the supervisory staff, and

·   Strategy 4, in which ADHS and RBHA leadership will be directly involved in reviewing

records.

ADHS and AHCCCS will influence RBHA executive and administrative personnel to

understand their key roles in supporting practice improvement.

Periodic leadership meetings, already occurring within the Maricopa County region, focus on

communicating expectations and key responsibilities, have participatory learning components,

and incidentally provide AHCCCS and ADHS with feedback on the effectiveness of current

efforts. These events will now be extended to statewide scope. ADHS will work with RBHAs

to train administrative ( e. g. reception, monitoring, claims audit, human resources) personnel and

all service providers in the 12 AZ Principles and the CFT process. In addition, ADHS will

request that RBHAs conduct cross- departmental planning and policy development, so that

leadership within the organization can understand interconnected operations vital to successful

implementation of the reform.

ADHS, RBHA and service provider administrative and support personnel will avail themselves

of opportunities to observe and experience the Child and Family Teams process firsthand.

One expects that all deliberate teaching/ learning activities, over time, contribute toward

internalization of the principles and values that underpin the Settlement Agreement. But

opportunities to “ get out” will allow personnel outside the direct sphere of clinical work to see

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the Arizona 12 Principles in action, to gain deep appreciation for the work they support, and to

bolster their personal investment in the process.

ADHS and RBHAs will spread understanding of system reform beyond the behavioral health

community.

At every opportunity, behavioral health system employees will work to educate judges, CPS

workers, probation officers, teachers, community leaders and other partners about the 12 Arizona

Principles and the Child and Family Teams process.

Strategy 7: Expand Available Capacity to Furnish Critical Services and Supports.

A final critical consideration in implementing the Settlement Agreement is development of

sufficient capacity in the statewide behavioral health provider network to make available the full

range of services and supports needed by the children and families that we serve. The fourth and

fifth years of the Settlement Agreement will see a dramatic increase in the number and

percentage of children and families directly affected by improvements in behavioral health

practice and service delivery.

Every RBHA will be required to reach a 50% target of Child and Family Teams functioning in

accordance with the 12 Principles by 12/ 31/ 05.

Regional workforce development plans ( see Strategy 2) will be implemented to accomplish this

capacity milestone. Sufficient case management services will be reflected in workforce

development and training plans. In developing new CFT capacity, RBHAs will prioritize:

·   children in out- of- home care services,

·   children involved with CPS,

·   children in the Adoption Subsidy program,

·   youth who are leaving juvenile detention or correctional settings, and

·   children and youth who are identified ( e. g. by families, other child- serving systems, or

through initial or ongoing behavioral health assessment) as at risk of out- of- home

placement.

Critical services and supports will be targeted for expedited capacity expansion.

ADHS, AHCCCS and RBHAs will, through the Annual Provider Network Sufficiency planning

process, and utilizing input from families, advocates, and state agency partners, set region-specific

capacity targets and timeframes by 5/ 1/ 05, and will monitor network development

accomplishments against capacity targets, prioritizing especially:

·   Home and community- based rehabilitation services ( skills training and development,

health promotion)

·   Home and community- based support services ( case management, home care training

family [ family support], unskilled respite care and therapeutic foster care),

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·   Specific applications of covered behavioral health services ( e. g. family support and

preservation, placement stabilization, family reunification and adoption supports) that

address unique behavioral health needs of children involved with CPS, and

·   Specific applications of covered behavioral health services ( e. g. multi- systemic treatment,

functional family therapy) that address specific behavioral health needs of youth in

counties targeted by Arizona’s juvenile justice systems.

ADHS and RBHAs will continue all current initiatives ( e. g. development of therapeutic foster

care, respite care, multi- systemic treatment, functional family therapy, youth transitioning to

adulthood) that address the needs of children and youth involved with CPS and/ or the juvenile

justice system, their families and caregivers. In addition, ADHS and its system partners will

work together to implement the action plan to address the unique needs of children involved with

CPS. RBHAs will submit network development plans to ADHS by 3/ 1/ 05 that reflect

appropriate targeting of CMDP funds to address identified gaps and to increase needed capacity

to meet the needs of children involved with CPS.

Conduct rate study.

ADHS will re- assess rates for services for targeted covered services to ensure their adequacy

to support necessary release time for training and clinical supervision activities described earlier

in this Action Plan.

Examine staff retention issues.

ADHS will gather information ( e. g. targeted employee survey, focus group) to identify factors

associated with personnel satisfaction, retention and mobility; as well as suggestions to

maximize retention of competent, effective personnel; and to reduce undesirable turnover.

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November 1, 2003 through October 31, 2004 Accomplishments

Settlement Agreement paragraph 14: Defendants agree to foster the development of a Title

XIX behavioral health system that delivers services according to the Principles set forth in

Section V

Status: Partially met and ongoing

Settlement Agreement paragraph 15: Defendants will move as quickly as is practicable to

develop a Title XIX behavioral health system that delivers services according to the Principles.

Once developed, Defendants will maintain the system in accordance with the Principles for the

term of this Agreement.

Status: Partially met and ongoing

During the first three years of the Settlement Agreement, ADHS and AHCCCS have made

significant strides toward development of the Title XIX behavioral health system to deliver

services according to the 12 Arizona Principles. This consistent commitment is evidenced by the

amount of energy and initiative displayed by the staff at all levels of the system, as well as the

attraction and dedication of targeted resources to support system transformation, and the growing

incorporation of congruent expectations in system structure, policy and procedure, and

contracting processes. The commitment of ADHS and AHCCCS, as well as various other key

stakeholders throughout the state, is evidenced by the following:

1 Dedication of Governor Napolitano's Children's Cabinet to the 12 Arizona Principles,

inclusion of the behavioral health system in shaping and carrying out the concurrent

Executive- driven reform of Arizona's child welfare system, and implementation

accomplishments in all regions of Arizona to fulfill Governor Napolitano's 2003 direction

to spread Child and Family Team practice developed in the 300 Kids Pilot statewide.

2 The expanding buy- in by other state agencies and their employees to implementation of

the behavioral health system reform, as especially reflected in multiplying cross- system

practice protocols, local/ regional collaborative agreements, establishment and

strengthening of cross- system leadership teams in local regions, and focused leadership at

the Children's Executive Committee level and throughout the respective systems

represented there.

3 The commitment of over $ 400,000 in CMHS block grant funds to support statewide

training and consultative services to implement the system reform.

4 The successful application, endorsed by other major child- serving systems, resulting in

the award to ADHS of one of seven five- year statewide infrastructure grants by

SAMHSA, specifically underwriting up to $ 3.75- million in costs associated with the

strategies and action steps in the JK Settlement Agreement, predicated on federal

recognition of the effective foundation of collaboration now existing in Arizona, and on

the wisdom of the strategies in the Annual Action Plan; and

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5 Auditor General Report NO. 02- 12, its subsequent and final reviews, confirming

substantial completion of ADHS’ commitments using appropriated HB 2003 funds

supporting JK Action Plan strategies in the areas of collaboration, coaching, and training.

Settlement Agreement paragraph 16: As quickly as practicable, Defendants will conform all

contracts, decisions, practice guidelines and policies related to the delivery of Title XIX

behavioral health services to be consistent with an designed to achieve the Principles for class

members

Status: Partially Met and ongoing

In 2003 ADHS reorganized its hierarchy of documents to provide a set of clear, concise

documents, eliminating redundancies, directing requirements to their intended audiences, and,

most importantly, clearly stating ADHS’ policy regarding key clinical and administrative

practices in alignment with the 12 Principles.

One of the most significant changes in the ADHS document organization included developing a

Provider Manual with specific information for Providers. Since institution of the Provider

Manual in January 2004, the RBHAs no longer develop their own policies and procedures

related to specific content areas. Instead, ADHS’ now focuses on implementing consistent

policy and strong clinical practices statewide. [ RBHAs continue to develop policies and

procedures that guide their internal operations only.]

Another significant change to ADHS’ reorganization of documents includes the complete

rewriting and restructuring of ADHS’ contracts with the RBHAs. Following is a summary of the

work towards and status of this endeavor.

Beginning in 2001, ADHS began a process to write a Request for Proposals ( RFP) for RBHA

services that would ultimately result in new contracts for all geographic service areas. For

Maricopa County, a RFP was issued in September of 2003 and a contract award was made early

2004 with the new contract in effect for July 1, 2004. For the remainder of the state, a RFP for

Greater Arizona was issued for all geographic service areas except Maricopa County. ADHS

will make a contract award in the first quarter of the 2005 calendar year for contracts to be

effective July 1, 2005 in Greater Arizona. Therefore, all Contractors statewide will be

operating under the new contracts by July 1, 2005.

Following is a summary of some new contract language that was written for the purpose of

addressing the needs of Title XIX children and addressing ADHS’ obligations under the

Settlement Agreement.

·   In listing the eligibility groups that are covered under the contract, language was added to

specifically identify Title XIX coverage for children who are in the care in custody of the

state including Child Protective Services, Juvenile Corrections and Juvenile Probation.

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·   In addition to the general clinical services section, the contract contains a section

regarding the specific service delivery requirements for services delivered to Title XIX

children. Content within this section includes the following requirements:

o The Contractor shall operate a delivery system in accordance with the Arizona

Vision set forth in the JK Settlement Agreement. The vision is included verbatim

in the contract.

o The Contractor shall serve all children in accordance with the Arizona Children’s

Principles. The Principles are listed verbatim from the JK Settlement Agreement.

o The Contractor shall ensure that all children are served through child and family

teams.

o The Contractor shall meet the unique service needs of children in the care and

custody of state and minimize placement disruptions.

o The Contractor shall ensure the delivery of all serves including support services

and in a timeframe needed by the child and family.

o The Contractor shall provide Contractor personnel, service providers and family

members training to ensure practice in accordance with the Arizona Vision and

Principles

o The Contractor shall seek and utilize stakeholder input in designing and managing

the behavioral health delivery system.

o The Contractor shall provide services to children to the extent possible in their

home and community.

·   Other sections of the contract include the following requirements:

o The Contractor shall be administratively organized to achieve the Arizona

Children’s Vision and Principles.

o The Contractor shall have processes to rapidly adjust subcontracts to meet the

needs of individuals.

o The Contractor shall have written protocols with the local administration of state

agencies that jointly serve children including Child Protective Services, Division

of Developmental Disability, Administrative Office of the Courts, and Juvenile

Corrections.

As specified in paragraph 16, for the past two and a half years ADHS has consistently acted to

ensure that all policies and procedures reflect the Arizona Vision and its 12 Principles, including

modifications when they are indicated. As all existing clinical guidance documents are reviewed,

for example, attention is given to ensure that they focus not only on the specific treatment needs

of the child, but as well on the service and support needs of the family and other caregivers

related to the behavioral health needs of that child. Following is a list of policies modified

during the third year if the Settlement Agreement that impact the children’s delivery system:

Provider Manual Sections:

- PM Section 3.2: Appointment Standards and Timeliness of Service

- PM Section 3.14: Securing Services and Prior Authorization

- PM Section 3.15: Psychotropic Medications: Prescribing and Monitoring

- PM Section 3.17: Transition of Persons

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- PM Section 3.22: Out- of- State Placements for Children and Young Adults

- PM Section 4.3: Coordination of Care with AHCCCS Health Plans and Primary Care

Providers

- PM Section 4.4: Coordination of Care with Other Governmental Entities

- PM Section 5.5: Notice and Appeal Requirements ( SMI and Non- SMI/

Non- Title XIX/ XXI)

Policies and Procedures:

- CO 1.1: Inter- RBHA Coordination of Services

- GA 3.7: Reporting and Review of Deaths of Enrolled Children and Persons with Serious

Mental Illness

Supplemental to the Provider Manuals are ADHS clinical guidance documents, which are

categorized as:

·   Clinical Practice Guidelines ( usually nationally developed practice guidelines

such as those published through the American Psychiatric Association);

·   Practice Improvement Protocols [ PIP]; and

·   Technical Assistance Documents [ TAD].

All ADHS clinical guidance documents are accessible at the agency website

( www. azdhs. gov/ bhs), and each is developed by an appropriate team including individuals with

relevant professional expertise, as well as family members and other stakeholders. Developing

clinical guidance documents are rigorously vetted and refined through internal ADHS

committees, and through a public input process. A tailored training plan/ strategy supports each

document, and RBHAs are then expected to incorporate new guidance into existing curriculae,

showing ADHS how such content will be incorporated into RBHA training, quality management

and other relevant processes to ensure that awareness of the guidance persists and is regularly

applied to benefit children and families served.

During this past year, the following new clinical guidance documents were created:

·   PIP 7: The Adult Clinical Team

·   PIP 10: Substance Abuse Treatment in Children

·   PIP 12: Therapeutic Foster Care Services for Children

·   TAD 3: The Child and Family Team Process

·   TAD 8: Informed Consent for Psychotropic Medication Treatment

In addition, ADHS consolidated a major strategic initiative begun in July 2002 when it unveiled

and began statewide implementation of a standard intake, assessment and service planning

process that is strength- based, family friendly, culturally sensitive, clinically sound and

supervised -- in short, directly supportive of the Child and Family Team practice developed to

ensure children and families are served in accordance with the 12 Arizona Principles. ADHS

delivered training in all regions of Arizona late in 2003 and began to require, effective January 1,

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2004, that all new children and adults enrolling in the behavioral health system be thoughtfully

considered within the context of:

·   Input from the person and family/ significant others regarding their special needs,

important cultural considerations, strengths and preferences;

·   Input from other individuals who have integral relationships with the person; and

·   Informed clinical expertise, offered primarily via the behavioral health clinical liaison.

The assessment process is specifically designed to support and begin the Child and Family

Teams process. The Child and Family Teams technical assistance document clearly integrates

the new assessment approach within the CFT process. An additional full- day training

component helps to qualify certain behavioral health technicians to be able to facilitate the

assessment process. All necessary training required to support use of the new assessment is now

being sustained at the RBHA/ provider level and strengthened through supervision. Some

RBHAs are now beginning to integrate training in the assessment and the CFT process ( see

Strategy 3), and such integration will be expected in this 4th Annual Action Plan. ADHS

maintains a quality management process to ensure that the new assessment approach is being

used with fidelity in all regions of Arizona.

Statewide Training Program: Settlement Agreement Paragraph 17 ( a) Develop and implement

a statewide training program, as described in paragraphs 32- 39

Status: Met

Background

During 2001- 2002 the 300 Kids Pilot and Project MATCH sites served as laboratories for the

development of the Child and Family Team approach. VVDB guided the initial development of

this approach through a combination of training and coaching activities. By mid- 2002 early

transfer of “ ownership” of the process, supportive curriculum and coaching methods began to

emerge, first within Maricopa County. ADHS identified compatible processes within other child-serving

systems ( notably DES- DDD and DES- ACYF). Those early sites developed and began to

implement approved workforce development, training and coaching plans as the first efforts to

grow CFT practice from early pilots toward statewide spread. Maricopa County became the first

region to assume local responsibility for providing training and coaching support, to which ADHS

had allocated a total of $ 1,711,000 between April 2002 and June 2004.

By early 2003 both Maricopa and Pima Counties had accessed and/ or developed curriculae to

teach individuals how to facilitate the Child and Family Team process with families, had begun to

develop training focused primarily for supervisory personnel, and had also begun to specialize

training for certain other members of the behavioral health workforce – notably psychiatrists. Both

regions had begun to offer an overview of the 12 Arizona Principles and an orientation to the Child

and Family Team process broadly throughout the behavioral health workforce, partners from other

child- serving systems, family and community members. Both regions, in fact, had begun to offer

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the overview training in Spanish as well as in English. Each round of CFT facilitation training in

the early pilot sites had been closely monitored and analyzed by VVDB, ADHS, local leaders and

participants to identify lessons learned, and those lessons have been routinely incorporated into

improved design of subsequent teaching and coaching across Arizona. [ Based on early learning in

Maricopa County, for example, ADHS worked with CPSA, Excel and PGBHA regions to ensure

early training for supervisors, and their close inclusion in the teaching and coaching their direct

line staff have been receiving.]

Following a major statewide kick- off event in March 2003, the Child and Family Teams training

program has now been extended into every region of Arizona. All RBHA regions have received

combinations of HB 2003, CMHS block grant and/ or Project MATCH federal grant funds to

support regional training, coaching and consultation plans approved and monitored by ADHS.

Beginning October 1, 2004, a new federal statewide infrastructure grant ( SIG) is now infusing

additional federal funds into the regional workforce development efforts. The Excel Group,

PGBHA and CPSA 3 regions began initial Child and Family Team process training in 2003, and

robust workforce development guided by these plans continues in all regions of the state. Experts

from VVDB, from the Child Welfare Policy & Practice Group, from Child & Family Support

Services Inc., from), Native American Training Institute ( Pascua Yaqui Tribe), Four Directions

Consulting LLC/ Human Service Consultants, and occasional other experts ( e. g. Karl Dennis, Jon

Eagle Susan Smith, Pat Miles, are providing and guiding instruction, coaching and consultative

support. The Gila River TRBHA began working with VVDB in a parallel effort in June 2004.

An amount of $ 350,000 in CMHS block grant funds were applied to support the approved regional

plans between December 2003 and September 2004 in the EXCEL, PGBHA, CPSA- 3, NARBHA

and Gila River regions. An identical allocation of block grant funds is being made during autumn

2004, now enhanced by more than $ 480,000 in new federal grant funds secured from CMHS as

part of Arizona's state infrastructure grant ( SIG). In addition, CMHS approval was secured

effective September 1, 2004 to include the CPSA- 3 region within the jurisdiction of Project

MATCH, allowing final year federal funding under that grant to extend beyond Pima County. By

1/ 31/ 05 ADHS will formally request that CMHS grant access to unspent funds accumulated in this

grant program since 1999 to be invested in capacity development in this final year of that grant.

ValueOptions has made a significant commitment of its own funds to support continuing teaching

and coaching within its new contract with ADHS effective July 1, 2004. In every region,

personnel from partnering child- serving systems ( including, for example, CPS caseworkers and

juvenile probation officers) have participated in CFT facilitation training.

Continuous improvements in the effectiveness of training and coaching approaches have been

made by VVDB, by several RBHAs, and with support from other experts. At the same time,

supplemental training on specific related topics ( e. g. addressing the needs of children in foster

care, by Rick Delaney PhD in the NARBHA region during April 2004) is routinely adjusted now

to integrating material within the context of the 12 Arizona Principles and the Child and Family

Teams process, minimizing the burden on the RBHA/ provider workforce to have to translate or

interpret such learning to Arizona- specific practice and therefore optimizing its positive impact on

change in actual practice.

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In July 2003 VVDB delivered complete Child and Family Team facilitation training kits to each

RBHA region that provide portable, multi- media support for sustainable training and coaching in

Child and Family Team facilitation processes and skills. These useful teaching materials have

been incorporated into local coaching work by supervisors in some communities, and have also

been applied by ADHS to support training in the statewide assessment process. In Maricopa

County, ValueOptions and the Family Involvement Center ( FIC) developed and regularly deliver

intensive classroom training to all incoming staff who will work with more complex CFTs. In

addition, VO and FIC have partnered to prepare over 165 Clinical Liaisons to facilitate the

statewide assessment and the CFT process for children and families with less complex needs.

All Children’s Program staff in Yuma and Parker completed the four- day VVDB CFT training and

received subsequent coaching from VVDB, including supervisory coaching in the use of coaching/

supervision tools to monitor fidelity to the Arizona Vision. New employee orientation now

includes specific training on the 12 Arizona Principles and a basic overview of the CFT process.

As a step toward transferring practice expertise to internal staff, EXCEL contracted with an

internal coach, whose initial CFT training was conducted in October 2004. Internally delivered

training will continue on a quarterly basis.

In September 2004 ADHS published a technical assistance document ( TAD) on the Child and

Family Teams process, detailing effective facilitation of CFTs in a step- by- step process. The final

step of the CFT process is transition, as when a young person leaves adolescence for adulthood.

ADHS also developed a practice improvement protocol ( PIP) to guide transitions for youth to adult

services. In late summer ADHS provided statewide training about these processes.

ADHS ( Frank Rider) and Family Involvement Center ( Josie Bejerano, Jane Kallal) representatives

have actively participated in the National Wraparound Initiative ( NWI), hosted by Portland State

University’s federally funded research and training center to develop a consensus definition of the

wraparound ( in Arizona, the Child and Family Teams) process and supportive teaching and

technical assistance materials. Arizona’s representatives have helped to shape the national model

( e. g. reflects clinical liaison concept, and mirrors Arizona’s CFT PIP and TAD). In October 2004

the NWI published its first three work products. ADHS is currently comparing these documents to

its existing clinical guidance, expecting that initiative’s publications will be able to serve as

additional curriculum to support Arizona’s workforce development.

Over 500 CFT facilitators had completed training and were available to facilitate the Child and

Family Teams process in Arizona as of October 1, 2004:

CPSA- 3 44

CPSA- 5 139

NARBHA 39

ValueOptions 203

PGBHA 27

EXCEL Group 50

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Increasing attention continues to be paid to the development of supervisor skills and capacity to

support effective Child and Family Team practice in Arizona. In Maricopa County, ValueOptions

and the Child Welfare Policy and Practice Group developed a three- day supervisory training

curriculum, whose elements will now be integrated into a more effective teaching approach to

ensure sufficient support for facilitators of Child and Family Teams. In Pima, Graham, Greenlee,

Yuma, LaPaz, Santa Cruz and Cochise counties, VVDB has developed and is teaching the use of a

set of supervision tools and methods intended to build self- perpetuating capacity within

supervision structures to coach, mentor and guide CFT facilitators. In September 2004 a special

leadership event hosted by ADHS and ValueOptions represented the beginning of a new intensity

of focus on the importance of effective clinical supervision to support continuous performance

improvement.

Maricopa, Pima, Mohave, Coconino, Navajo, Apache and Yavapai Counties have matured to the

point where they are now producing internally sustainable teaching capacities to help spread and

maintain Child and Family Teams practice.

ADHS' collaboration with the DES Child Welfare Training Institute ( CWTI) has now devolved to

coincide with the decentralization of that training program to the regional CPS districts.

Curriculum content initially created by ADHS to help CPS workers to understand and effectively

participate in the CFT process has been passed to the local CPS districts who now host that

training for new child welfare workers. RBHA representatives have been encouraged to co- teach

some of the training for CPS workers. In Maricopa County, a detailed protocol developed jointly

by ValueOptions and CPS now describes how the two systems work with the Child and Family

Teams process. This protocol was made official CPS policy in Maricopa County during summer

2004, accompanied by a joint training effort by the two partnering systems. Similarly, CPSA and

CPS have developed and regularly deliver cross- system training in Pima County.

NARBHA's preparation of CFT trainers has included child welfare as well as behavioral health

personnel. Its April 2004 training by national expert Rick Delaney PhD on the needs of children in

foster care attracted dozens of child welfare workers alongside their behavioral health partners, and

was customized by the instructor so that participants can understand how to most effectively use

Arizona’s CFT process to effectively serve this special population.

A joint training plan developed by ADHS, ValueOptions and the Arizona Department of Juvenile

Corrections [ ADJC] applies HB 2003 funds to support training for parole officers and for ADJC

employees in secure settings to be able to participate in, and to facilitate, the CFT process for

youth served by that system. ADHS approval of regional workforce development, teaching,

coaching and consultation plans has routinely required such outreach to child- serving system

partners in all regions of Arizona.

In regions such as Pima County and northern Arizona, local cross training initiatives with DES

have begun. The CPSA training team has partnered with representatives of DES developing two

cross- training curricula focused on integrating the work of both systems on behalf of victims of

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abuse and neglect, their families and protective foster caregivers. The new training classes were

first delivered during the summer of 2003. NARBHA and DES District III are jointly training all

of the NARBHA Service Area Agencies on the purpose of the Child and Family Team process as a

precursor to the full facilitation training.

As in previous years, ADHS and RBHAs have sought out opportunities to promote practice

changes congruent with the 12 Arizona Principles through several cross- system training events

around the state. These included:

11/ 20/ 03 – DES- ACYF Management Team, at Family- Group Decision- Making summit

12/ 02/ 03 – DES- ACYF Child Welfare Training Institute – Tucson

12/ 04/ 03 – Child and Family Teams PIP for CPSA/ Providers and DES- ACYF Districts II

and VI leadership – Tucson

12/ 05/ 03 – Administrative Office of the Courts - juvenile court judges

01/ 08/ 04 – Child Abuse Prevention Conference, Mesa

02/ 03/ 04 – DES- ACYF Child Welfare Training Institute – Phoenix

02/ 04/ 04 – Arizona State University School of Social Work – integrating 12 Arizona

Principles & CFT concepts into pre- service curriculum

02/ 06/ 04 – Juvenile court judges training conference at ASU Downtown

02/ 11/ 04 – ASU Graduate School of Social Work curriculum ( Scott Okamoto PhD)

02/ 19/ 04 – ASU Social Work undergraduate curriculum ( Layne Stromwall PhD)

03/ 23/ 04 – Juvenile court judges training conference at ASU Downtown

05/ 04/ 04 – ALTCS Program Contractors @ AHCCCS

05/ 04/ 04 – South Mountain Community College

05/ 21/ 04 – Foster Care Review Board 25th Anniversary Statewide Conference

( 2 sessions) in Chandler

05/ 26/ 04 – DES Adoption Subsidy/ DES- ACYF/ ValueOptions/ CSPs in Phoenix

05/ 27/ 04 – DES Adoption Subsidy/ DES- ACYF/ RBHAs – statewide telemedicine

07/ 26/ 04 – Summer Institutes ( Sedona) – Substance abuse treatment via CFTs

09/ 27/ 04 – Pilot for Birth to age five PIP – ADHS, Arizona’s Children Association,

Blake Foundation, Child Crisis Center, CPSA, Ebony House and

ValueOptions

09/ 30/ 04 – Functional Assessment of Challenging Behavior – ADHS, DDD and

NARBHA

09/ 04- – Child and Family Teams process technical assistance document:

10/ 04 cross- agency training audiences attended these 7 training sessions by the

ADHS Bureau for Children’s Services in Nogales, Yuma, Tucson ( 2),

Flagstaff, Phoenix and Apache Junction

The family perspective is increasingly reflected in the statewide training program, a perspective

expected to proliferate both within behavioral health capacity development, and across other child-serving

systems. Early in 2004 the Children’s Executive Committee adopted a Family

Involvement Framework detailing a list of specific means for integration of the expertise of family

members into outreach, training and coaching, policy development and other system- building

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work. During summer/ fall 2004 the Executive Committee’s family involvement subcommittee

began to focus its attention on increasing family involvement in CPS reform and foster parent

training. CPS’ new “ Family to Family” Initiative ( Casey Family Foundation) pilot, soon to begin

in Maricopa County, has already invited participation from MIKID and the Family Involvement

Center.

The new statewide infrastructure grant ( SIG) awarded to ADHS by SAMHSA on October 1, 2004

has developed contracts with both MIKID and Family Involvement Center to serve as the state’s

primary sources of expertise in continuing to infuse family expertise in the development of

expanding system capacity. MIKID was also awarded a statewide family network grant by

SAMHSA in August 2004, which includes a specific dedication of resources to build family

involvement infrastructures in some of Arizona’s rural [ e. g. Colorado River, White Mountains]

communities.

Most RBHAs have now established contracts or other effective partnerships with family

organizations ( e. g. Family Involvement Center in Maricopa County, MIKID in Pima County, in

the PGBHA and NARBHA regions, OCSHCNs in NARBHA region). These family- run

organizations, in addition to other system- building work, now recruit and train qualified family

members for positions within the behavioral health workforce. MIKID and Family Involvement

Center have both developed and delivered specialized training for behavioral health workers to

help them to understand how to provide truly family- centered practice, and how to effectively use

the Child and Family Team process.

Teaching, coaching and consultation efforts have multiplied geographically and geometrically

during the past year that substantially address the obligation for a statewide training program.

During this upcoming year, ADHS and AHCCCS will continue statewide implementation of the

strategies and action steps outlined in this 4th Annual Action Plan.

ADHS has also organized a Higher Education Partnership to build, in collaboration with Arizona

community colleges, universities and others, a future behavioral health workforce that will meet

the needs of children, their families and communities in the years to come. In October 2004, this

partnership adopted as its three strategies:

·   Promote integration of Arizona practice models ( primarily Child and Family Team

process, Adult Clinical Teams process, Recovery Model, and nationally accepted best

practices) into higher education curriculae;

·   Recruit students who represent the composition of local communities; and

·   Market human service academic/ training programs to prospective students.

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Respite Care: Settlement Agreement paragraph 17( b) add respite to the list of covered services

as described in paragraph 40

Status: Met

Background

As specified in paragraph 40 of the Settlement, respite was added as a covered service. Since

2002 respite capacity development has been a priority for all regions.

The EXCEL Group in Yuma and LaPaz counties has built regular respite activities to offer

planned, scheduled relief for family caregivers and constructive activities for their enrolled

children. EXCEL also contracts with Child and Family Services to provide out- of- home,

overnight respite in the Yuma region. In GSA- 3, CPSA’s provider network has subcontracted

with a variety of outpatient clinics, community service agencies and habilitation providers to

expand available respite capacity. CPSA Region 5 ( Pima County) has develop outpatient respite

options, but also crisis respite capacity through Intermountain Centers for Human Development,

and through its Sandero crisis stabilization facility. Mary’s Mission also provides overnight

respite and therapeutic day services in a Level II DES shelter, and a recent Habilitation Provider

fair promises to add additional respite capacity through existing DDD providers.

NARBHA continues to prioritize non- skilled respite services within its network development

plan, and currently offers respite capacity through its service area agencies, and through

subcontracts with Creative Networks, ASKAN Foundation and Arizona’s Children Association.

NARBHA convened family members and respite providers to develop guidance about respite

practices. PGBHA has developed a uniquely rich program through Red Mountain Respite, a

community service agency, combining family therapy, family support, living skills training and

other active treatment with its respite program. PGBHA has in- home respite available across its

region, and also offers facility- based respite through subcontractor Devereux.

As part of a $ 12- million dollar contracting effort in FY 2005 to rapidly ramp up capacity to

provide direct supports, ValueOptions continues to develop and refine its network of respite

providers, to meet both ad hoc needs as well as offer planned day program activities on

weekends and after school to provide rest and relief to family caregivers. Many of the

Comprehensive Service Providers ( CSPs) have developed respite capacity within their agency or

subcontract with other providers ( e. g. Arizona’s Children Association, Rio Salado Behavioral

Health, Family Support Resources, MARC Center) to deliver in- home respite. MIKID’s new

contract with ValueOptions will provide a respite group on Saturdays for children ages three to

12, offering not only rest and relief for primary caregivers, but also social activities and skill-building

opportunities for the children.

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2004

During the period July 1, 2003 through June 30, 2004, the total value of encountered respite

services for 1,502 children’s family caregivers reported to ADHS by RBHAs was over

$ 2.2- million:

RBHA Members Service

Code

Units of

Service Value

5150 76,033

ValueOptions 694

5151 726

$ 1,215,643.92

5150 1,474

CPSA- 3 and CPSA- 5 90

5151 289

$ 74,427.76

5150 16,572

NARBHA 277

5151 427

$ 304,926.25

5150 817

EXCEL Group 191

5151 0

$ 11,441.50

5150 38,794

PGBHA 250

5151 161

$ 615,457.00

* 5150 units represent 15 minutes; 5151 units represent 1 full day

ADHS continues to monitor the use and availability of respite services through a number of

different mechanisms. This includes utilization data reflected in submitted encounters, quarterly

Network Development meeting with each RBHA and consumer complaints.

Two additional approaches augment the provision of nonskilled respite services to provide critical

relief and rest for family caregivers. First, the provision of living skills training, personal

assistance and similar active treatment strategies are often scheduled to provide incidental relief to

caregivers as a more efficient use of covered services. Second, as the Child and Family Team

proliferates, and as its full potential for effective practice is reached, the identification, attraction

and accommodation of natural supports and other informal resources becomes an increasingly

viable avenue through which families of children needing mental health services can enjoy

opportunities to “ recharge their batteries.”

Specialty Providers: Settlement Agreement paragraph 17 ( c ) devise and implement a means

of allowing RBHAs to contract with certified Masters level behavioral health professionals as

described in paragraph 41

Status: Met

AHCCCS and ADHS have employed a variety of strategies to meet this specific objective and

increase availability of access for children and families to clinical professionals with special

areas of expertise.

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In January of 2001, AHCCCS began expanding the number of Independent Biller provider types

to include certain types of so- called specialty providers. In April 2002, AHCCCS further

expanded the definition of Independent Biller to include Masters level behavioral health

professionals who are certified by the Arizona Board of Behavioral Health Examiners

( AZBBHE) as Certified Independent Social Workers ( CISW), Certified Professional Counselors

( CPC) and Certified Marriage and Family Therapists ( CMFT). These professionals may now

register with AHCCCS as Independent Billers, allowing RBHAs more options to secure access

to their services.

Regular tracking by ADHS and AHCCCS shows that these changes have, in fact, helped to

enrich RBHA provider networks with clinicians who can provide services relevant to identified

member needs. AHCCCS has monitored its ALTCS Program Contractors on the development of

capacity and implementation of this Masters level provider type. The Program Contractors have

actively recruited these individuals, and have been successful in expanding their networks to

include clinicians who can meet the unique needs of their members. ADHS continues to require

the RBHA’s to have a tracking system in place to monitor the capacity and availability of

providers with one or more of six long- established areas of special expertise: PTSD, attachment

and bonding, sex offender, sexual abuse survivor, eating disorders and adoption. In addition,

ADHS tracks RBHA capacity to meet the needs of persons with developmental disabilities.

Reporting of such capacity is included in quarterly network development meetings between

ADHS and its contracted RBHAs.

In addition to the specialty providers identified in paragraph 41 of the Settlement Agreement,

RBHAs have expanded their networks to include other specialty providers. ValueOptions offers

dialectic behavioral therapy. NARBHA and ValueOptions offer multi- systemic treatment

[ AHCCCS established a special rate code for MST in 2004 to better support cost- effective

provision of this highly effective service approach] through highly trained and certified teams.

ValueOptions likewise offers functional family therapy, and other RBHAs are currently

considering the need to add either or both of these evidence- based intervention approaches to

address the needs of children/ adolescents with conduct- related problems, and their families.

PGBHA, CPSA and ValueOptions offer “ equine therapy” ( therapeutic horsemanship) services.

CPSA provides specialized services for pregnant teenagers. CPSA also contracts to provide

assessments through the 24- hour urgent response protocol for children age birth through four

who have been removed from their homes. CPSA maintains a psychologist and master’s level

staff within each of its provider networks with expertise in working with CPS- involved children.

ValueOptions now contracts with the East Valley Child Crisis Center to provide specialized

services for children between birth and 11 years of age who have attachment and bonding

problems, as well as specialized services for children ages birth to five. Specialized respite,

living skills training, family support, home care training and personal assistance supports are

furnished. ValueOptions provider Christian Family Care Agency Inc. offers expertise to children

with disorders of attachment and bonding and their families or other caregivers. Looking first to

existing providers whose track records have satisfied CPS, ValueOptions has already begun to

establish, and NARBHA and CPSA are exploring potential, contractual relationships to

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appropriately apply Medicaid funding for family support and family preservation services for

eligible families involved with CPS. Similarly, ADHS is examining the clinical components of

traditional AOC RAFT ( Renewing Arizona Family Traditions) programs to explore appropriate

applications of Medicaid funding for similar services to families of youth involved with juvenile

justice systems.

Expansion of Title XIX Services: Settlement Agreement Paragraph ( d) expand Title XIX

services as described in paragraphs 42- 45

Status: Met

ADHS and AHCCCS use an Annual Provider Network Sufficiency planning process to ensure

the development and availability of covered behavioral health services for children and their

families. ADHS network development teams meet with each RBHA through this process on a

quarterly basis. A logic model is applied by the RBHAs to bring data from multiple points

( especially quality management and utilization data, but also stakeholder input, complaints, and

integration of statewide best practice initiatives) together for analysis and prioritization of service

development priorities. Dynamic rate study and capitation work helps ensure financial resources

will support needed service development, and active development of clinical guidance by ADHS

provides technical assistance in optimizing the potential of Arizona’s wide service array.

Beginning July 1, 2004, for example, ADHS and AHCCCS instituted a targeted capitation rate

for children in the child welfare and juvenile justice systems covered by the CMDP health plan,

offering RBHAs a significantly enhanced level of funding to support the special needs of that

target population. During the two previous years capitation rates had been increased predicated

on planned rises in the number of behavioral health Level I, Level II and therapeutic foster care

placements to address specific capacity needs identified in the child welfare and juvenile justice

populations.

Effectiveness of behavioral health services for children involved with CPS depends in part on

earlier interventions, so as part of the behavioral health system’s role in Governor Janet

Napolitano’s CPS reform, ADHS instituted an August 2003 change in its policy to require an

urgent ( that is, within 24 hours) response by RBHAs for all children entering foster care who are

referred by CPS. ( CPS, for its part, made a parallel policy change requiring its workers to refer

all children being removed into foster care to the RBHA in anticipation of the RBHA’s urgent

response.) Initiation of the ADHS policy change was described in the Year Three Action Plan.

Since the inception of that change, and through October 31, 2004, fully 2,975 new foster children

have received the urgent response:

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RBHA Urgent Responses for Children

Entering Foster Care

ValueOptions 1,265

CPSA- 3 223

CPSA- 5 853

NARBHA 366

EXCEL Group 117

PGBHA 151

Focused efforts to develop capacity for direct support services ( e. g. unskilled respite, living skills

training, personals assistance) often needed for children and families began in 2002. AHCCCS

added Habilitation providers to the array of allowable behavioral health providers effective April

1, 2003. With the addition of that provider type, RBHAs gained a new way to increase the

available pool from which support services ( i. e. unskilled respite care, living skills training,

personal assistance and non- emergency transportation) can be delivered. When the inclusion of

habilitation providers proved to be slow, ADHS completed a RBHA- by- RBHA analysis during

April 2004 to identify impediments. Most RBHAs reported that support services were already

being developed and offered by outpatient clinics in their regions, and that few specific requests

for habilitation providers had been received. CPSA held a successful Habilitation Fair and all

RBHAs were encouraged once again to explore potential to enhance their support service

capacities through this provider type.

Case management and therapeutic foster care capacity have also been early priorities. Since late

2002 ADHS has worked with DES- ACYF to review all children in Level I and II placements for

potential Medicaid funding or for viable community- based alternatives. ADHS’ recent Out of

State Placement Policy ( Policy 2.11) sets clear guidelines surrounding the use of out of state

placements, striving to keep children in Arizona. Many are children in the foster care system.

Significant progress has been made by the RBHAs to return children to Arizona and to avoid

making new placements outside the state. Since June 2002, the total number of out- of- state

placements by the behavioral health system has decreased from 100 to 23. The behavioral health

and child welfare systems have worked to identify all existing professionally licensed foster care

homes for potential Medicaid funding, and many of those homes are subsequently being funded

through Medicaid.

Given the demonstrated effectiveness and cost- effectiveness of therapeutic foster care services,

several RBHAs ( e. g. NARBHA, ValueOptions, CPSA) during 2004 have also undertaken

initiatives to recruit new families to provide those services in their regions. Through a

collaborative process involving foster parents, DES- ACYF and others, ADHS developed a

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practice improvement protocol to guide use of these services in October 2004. That protocol will

be supported with statewide training by April 2005. 232 TFC beds were available statewide by

October 31, 2004.

ADHS recognized last year that, for most RBHAs, the cost of serving individuals with

developmental disabilities significantly exceeds the capitation amount they receive for this

purpose. ADHS analysis and requests for program enhancements from the Division of

Development Disabilities ( DDD) combined to support a proposal to AHCCCS to adjust the

capitation rate. Effective January 1, 2005, the rate will increase by more than 40% ( from $ 66.35

to $ 95.06 per DDD- ALTCS member per month) to reflect actual costs plus substantial program

enhancements. ADHS studied the service needs of this population. ADHS will work with

RBHAs to implement program enhancements in several areas, including contracts with DDD

specialists and additional specialized services to assist with behavior management.

2004 covered services development highlights in each region are outlined below:

EXCEL

Therapeutic Foster Care Homes ( TFCH):

In 2004, EXCEL developed a contract with Arizona Children’s Association ( AzCA) to create

Therapeutic Foster Care homes. Currently, EXCEL has one TFCH with two beds available in

region. EXCEL has also contracted with Providence and Touchstone Behavioral Health for

additional TFCH capacity out of region.

Family Support:

EXCEL has contracted with MIKID to provide training, beginning in January 2005, to

volunteers who will serve as mentors to others with children receiving behavioral health services.

Level I and II Residential Programs:

The EXCEL Group opened a Level I facility in Yuma during 2003. As a 24- bed facility, the

Bridges RTC has allowed EXCEL to provide intensive out of home services to children and

families within their own community/ region, instead of travel at least 180 miles away in

Phoenix, Tucson or beyond. The Bridges program is designed to allow for short- term/ crisis

stabilization ( 1- 7 days) as well as for longer stays, and uses an integrated CFT approach for

community transitioning. EXCEL has successfully used the Bridges resource to return virtually

all youth from distant placements back to their own region, and is currently considering a

reduction in the number of permanent Level I beds, perhaps creating an adolescent Level II

substance abuse treatment resource by separating part of the facility.

GILA RIVER RBHA

The Gila River RBHA has expanded its provider network to include implementation of a 24/ 7

on- reservation crisis response network, expansion of in- home treatment and support services,

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implementation of best practice prevention programming in schools, and the development of

dedicated therapeutic foster care homes for children. During Year Three Gila River has

developed Red Mountain respite as a community service agency providing respite and other

support services.

CPSA

Direct Support Services:

ADHS and the Project Match grant have supported development of MIKID as a family

involvement resource in Pima County. Family members can receive information and support,

training about participating in the CFT process, and training to fulfill family mentoring and

leadership roles within CPSA’s provider network. MIKID has actively collaborated with the FIC

to support multiple roles for family members within the behavioral health system. MIKID

provided its inaugural Pima County training during 2003, adapting and creating curriculum in

consultation with national consultant Pat Miles. Pat provided direct training for MIKID and for

Project MATCH staff to improve their engagement skills and to teach of the expertise,

perspectives and voices of families. Currently CPSA- 5 employs 13 family support specialists

and CPSA- 3 employs four.

Therapeutic Foster Care Homes:

Therapeutic Foster Care is a priority for capacity development at CPSA. Pima County has the

largest total number of DES professionally licensed homes in the state. Like all RBHAs, and as

an ADHS expectation underlying the CMDP- specific RBHA capitation rates that became

effective 7/ 1/ 04, CPSA is, in partnership with DES- ACYF District II personnel, continuing to

assess the status of all DES- ACYF foster children currently placed in its licensed professional

family foster homes, to convert such placements to RBHA funding and management and

optimize Medicaid funding. CPSA providers hold current capacity for over 110 children and

adolescents in therapeutic foster care beds. CPSA has led a very rich cross- system foster family

recruitment initiative during fall 2004, applying Project MATCH grant funds to enhance other

resources offered by DES- ACYF and a number of community organizations.

Community Service Agencies ( CSA):

CPSA boasts ten separate community service agency providers of respite and other support

services throughout the five southeastern Arizona counties, including several Boys and Girls

Clubs, the Tucson Urban League, multiple therapeutic horsemanship programs and several other

innovative programs ( e. g. mentoring through University of Arizona, supervised day

programming through the Humane Society of Southern Arizona). The Boys and Girls Club of

Tucson specifically target the Latino and Pascua Yaqui youth population. Another contracted

CSA, MIKID provides support to CPS- involved children and their families.

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Crisis Services:

In the fall of 2003, CPSA opened its Sandero Adolescent Crisis Stabilization Unit, a 10 bed

facility for children 12 years and older. The facility is located at CPSA’s Plaza Arboleda and

operated under a contract with Sonora Behavioral Health. The purpose of this facility is to

maintain children in a community setting. Admissions are predicated on active CFT

participation in both the placement and course of treatment, as well as post- discharge support

and strengthening activities.

Tohono O’odham

CPSA continues to support the partnership among Intermountain Centers for Human

Development, the Pantano Network, tribal agencies and the Tohono O’odham community,

providing home and community based supports and services for over 70 on- reservation children

and families. Creative use of Project MATCH grant funds led to the establishment of a satellite-based

tele- medicine connection in Sells that now allows direct services ( e. g. medication

monitoring) to be furnished far more frequently and readily than had previously been the case,

when residents would travel over 100 miles to Tucson or await the twice- monthly visit by the

traveling psychiatrist.

NARBHA

Therapeutic Foster Care Homes:

NARBHA continues to expand capacity for Therapeutic Foster Care ( TFC) services, with 11

family homes and 34 total beds by 10/ 31/ 04.

Community Service Agencies:

NARBHA has added Parenting Arizona Inc. ( formerly Parents Anonymous) and MIKID to join

Creative Networks and ASKAN Foundation as community service agencies providing respite

and other support services.

Multi- Systemic Therapy ( MST):

NARBHA has contracted with Touchstone Behavioral health for the provision of MST, and

monitors utilization and outcomes of youth receiving this service. In addition, Apache

Behavioral Health Services ( Fort Apache Reservation) has received a grant to develop MST

within its service area.

Level I and II Residential Programs:

NARBHA has expanded its local capacity for Level II residential programs, in order to help local

youth needing intensive treatment to remain close to their home communities and families,

instead of being placed in Phoenix, St. George or other distant locations. In September 2004,

Daybreak Behavioral Resources opened a new home in Dewey serving female youth, including

some with sexual acting out behaviors. NARBHA and DDD are combining efforts to open a

home for children who have a lower level of functioning. At this time NARBHA and DDD have

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developed and executed a Memorandum of Understanding specifying program admission,

coordination and evaluation. They have also begun to solicit interest from providers for this

home.

PGBHA

Therapeutic Foster Care Homes:

PGBHA contracts with Arizona Children’s Association, Devereux, Human Service Consultants

and Providence to provide Therapeutic Foster Care ( TFC) homes within its region. Sixteen TFC

homes have been added to PGBHA’s capacity in the past year, bringing total capacity in the

region to 24 beds.

Community Service Agencies:

PGBHA increased its contracts with Community Service Agencies to four this year, adding

Presbyterian Service Agency/ Art Awakenings to provide art therapy to children and families,

Red Mountain Respite ( three sites), Maricopa ACE Foundation/ Ak Chin CAASA and MIKID to

provide respite and other support services. MIKID specifically provides family and peer

support, living skills training, health promotion, supervised day and personal assistance. MIKID

is now developing and facilitating local family support groups in Apache Junction and Eloy.

PGBHA funds a full- time position to coordinate these activities. In order to provide more

culturally appropriate services for this region, MIKID has also added an additional Spanish-speaking

family support partner to its team.

ValueOptions

Direct Support Services:

ValueOptions has set aside twelve million dollars this year to provide direct support services for

children and their families via direct contracts with the RBHA, in addition to those support

services already provided by its Comprehensive Service Providers [ CSPs]. Efficiency savings

through this direct contracting mechanism in turn free up resources that are invested in building

case management, family support and other needed capacity within the CSPs. CSP staff are able

to refer directly to any of more than 20 new contractors for support services. ValueOptions is

monitoring usage of the new providers and allowing for expansion of initial contracts within the

agencies that prove to be in the most demand.

One new support service provider, MIKID, has launched an innovative program to provide

special support for caregivers of young children from birth to age five. This program provides

parenting skills classes, a parent support group and parent mentors for individuals who are

substitute caregivers such as grandparents.

Recently, FIC also contracted with ValueOptions to become a direct service provider. FIC has

created a new branch, called “ Family- to- Family Services,” to provide in- home and community-

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based supports for biological parents, foster parents and adult caregivers. All staff hired to

provide services within this program are parents of persons with mental illness.

Therapeutic Foster Care Homes ( TFCH):

By October 31, 2004, ValueOptions had contracts with nine agencies to develop TFC homes.

ValueOptions has contracted with Valle del Sol to recruit homes for Latino children, Black

Family and Children’s Service to recruit homes for African American children and Prehab of

Arizona to recruit homes for children who act out sexually. Currently, ValueOptions has 88

licensed homes providing a total of 109 beds.

Family Support:

ValueOptions deploys 58 Family Support Partners ( FSPs), who are directly employed by the

Comprehensive Service Providers ( CSPs). ValueOptions has given approval for an additional 14

FSPs to be hired.

The Family Involvement Center ( FIC) is a not- for- profit, parent- run resource and training center

focused on the issues of children and youth with behavioral health needs and their families.

ValueOptions continues to support FIC and vice versa. FIC partners with ValueOptions in

recruiting and training Family Support Partners, in training new Case Managers and Clinical

Liaisons. In November 2004, ValueOptions will begin to hold its monthly Children’s Advisory

Council meetings at FIC. The intent of this change in location is to increase parent participation

in, and therefore the effectiveness and credibility of the advisory council.

Community Service Agencies:

ValueOptions has, in the past year, increased its contracts with Community Service Agencies

from one ( Rio Salado Behavioral Health) to five, adding MARC Center – Mesa, FIC, MIKID

and Aid to Adoption of Special Kids [ AASK] to provide support and respite services.

Some of ValueOptions’ earlier CSA subcontractors have now become OBHL- licensed clinics,

expanding the array of services they can provide. Child and Family Support Services ( CFSS),

for example, originally contracted with ValueOptions to provide only direct support services.

Since obtaining behavioral health licensure CFSS now provides case coordination ( e. g. CFT

facilitation), in- home counseling, living and social skills training, positive behavior support

programs and respite care. CFSS particularly focuses on supporting children in out of home

placements to remain stable and successful in their placements, and also supports children as

they return home to their families. Youth Etc. is another example of a CSA turned licensed

behavioral health provider. Youth Etc. provides direct support services for youth ages eight to

17 who are at high risk for residential treatment. Youth Etc. provides in- home behavior

management, family support, therapy, mentoring, substance abuse treatment, family nights and

structured recreational activities.

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Crisis Stabilization Services:

ValueOptions considerably strengthened its crisis services this fall, when Empact added two

crisis teams to its existing ones. Empact is now able to serve 160 families. Terros also now has

two crisis teams serving 80 families. Both Empact and Terros crisis teams have shifted their

focus from purely crisis management to include crisis prevention, and are now being referred to

as “ DES Stabilization Units.” The Stabilization Units regularly visit children placed out of their

homes by CPS who are at high risk for disrupting their placement. These units help to assess

needs and identify ways to help maintain placements. Stabilization teams may develop crisis

plans, teach behavior modification techniques to caregivers and teachers and support children

and families as reunification occurs.

Flex Funds: Settlement Agreement paragraph 17 ( e) designate $ 600,000 for use as flex funds

as described in paragraphs 46- 47

Status: Met

Background

Beginning in March 2001, ADHS had allocated $ 600,000 of flexible funds to ValueOptions and

NARBHA for use in the 300 Kids Pilots. A similar pool of flex funds was created in Pima

County through the federal grant- funded Project MATCH. Those funds were established to

supplement any necessary covered services and supports not reimbursable through Medicaid.

Regular reports about the use of flex funds from both 300 Kids Pilot sites were made to the

Children’s Executive Committee between through and March 2002, and by Project MATCH to

grantee ADHS. The Children’s Executive Committee and ADHS both agreed that flex funds are

an important component of the Child and Family Team process, and those initial pilot

experiences led to ADHS’ decision to make flex funds available through every RBHA. In May

2002, ADHS secured CMHS block grant funding for statewide availability of flex funds, and

made its first statewide allocation for state FY 2003. Nearly $ 285,000 were expended by the

RBHAs as flex funds that year, and ADHS subsequently allocated an additional $ 729,700 in flex

funds for children and families for FY 2004.

2004

Use of flex funds is one of several areas ( family involvement, adult clinical teams process) where

implementation of the Settlement Agreement is impacting Arizona’s entire behavioral health

system. ADHS has begun to allocate federal block grant funds as flex funds to RBHAs to serve

persons age 18 and over, and significantly increased that allocation for RBHAs for FY 2005. In

addition, RBHAs have discretion to apply additional funds as flexible funds, and ValueOptions

has supported significant spending beyond funds allocated by ADHS.

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Regional Behavioral

Health Authority

FY 2005

Allocations

CPSA5 $ 114,200

EXCEL $ 27,947

ValueOptions $ 458,171

NARBHA $ 67,938

PGBHA $ 30,043

CPSA3 $ 31,401

Grand Total $ 729,700

ADHS tracks RBHA flex funds encounters and expenditures. In June 2003, ADHS featured

more than a dozen actual examples of effective uses of flex funds for an audience of about 70

practitioners at the annual Family- Centered Practice conference it co- sponsors with DES- ACYF.

In 2003 ADHS met with RBHA CEOs to reinforce the importance of these flex funds as a tool

available to child and family teams. Several instructive examples of effective uses of flex funds

have been furnished to RBHAs as technical assistance. Guidelines for use of flex funds are

publicly available in the ADHS Covered Services Guide ( on- line). Flex funds are cited in the

ADHS practice improvement protocol for Child and Family Teams. In the coming year ADHS

and RBHAs will continue to integrate strategies on the use of flex funds in both training and

technical assistance opportunities. Contingent on availability of funds, ADHS will seek to

allocate at least the same aggregate level of flex funds to RBHAs in FY 2006 as in FY 2005.

Some other child- serving systems have shown interest in making some flexible funds available

to children and families they serve ( in common with ADHS). The Administrative Office of the

Courts ( AOC)’ guidance to all county juvenile probation offices, and DES- ACYF family

preservation service contracts are two examples. DES- ACYF is currently negotiating a Title IV-E

funding waiver with the DHHS Administration for Children, Youth and Families to support

expedited reunification of children from foster care with their families of origin. Flex funds are

one of three primary waiver strategies, and federal approval and Maricopa County pilot

implementation are said to be imminent.

Medication Practices: Settlement Agreement paragraph 17 ( f) develop practice guidelines for

the monitoring of medications as described in paragraph 48.

Status: Met

The Practice Improvement Protocol for Psychotropic Medication Use in Children and

Adolescents was finalized and training was completed in each RBHA during 2003. ADHS

Policy 1.16, Psychotropic Medication Prescribing and Monitoring, was also finalized and

training completed.

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In March 2003, ADHS began a Quality Improvement Project ( QIP), " Informed Consent for

Psychotropic Medication Prescription", in order to improve the acquisition and documentation of

informed consent for medications prescribed by behavioral health providers. This effort is in

accordance with ADHS Policy 1.16 and 1.7 ( Consent to Treatment), as well as the related ADHS

Practice Improvement Protocol ( The Use of Psychotropic Medications in Children and

Adolescents). The statewide work group includes the ADHS Medical Director as the Chair,

RBHA Medical Directors or their designees, and a consumer/ family representative. As of

September 2003, the project workgroup developed a standardized format for documenting

informed consent and a detailed set of guidelines for the process. The format and guidelines

have been aligned with ADHS policies and protocols, as well as newly revised AAC R9- 20

licensing requirements. Statewide implementation of the new format and guidelines began in

late 2003.

During 2004, several RBHAs ( PGBHA, CPSA, ValueOptions) have reported measurable

reductions in the incidence of polypharmacy.

300 Kids Project: Settlement Agreement paragraph 17 ( g) initiate a 300 Kids Project as

described in paragraphs 49- 51

Status: Met

Background

The 300 Kids Project began in spring of 2001 as a way to test strategies for providing behavioral

health services according to the 12 Arizona Principles. The two initial sites in Northern Arizona

( NARBHA) and Maricopa County ( ValueOptions) served as a first phase of statewide effort to

serve children and families according to those Principles. The 300 Kids Pilot, and beginning in

fall 2001 Project MATCH in Tucson, all began serving as laboratories for the development and

refinement practice methods to actualize the 12 Arizona Principles. Arizona’s Child and Family

Teams process ( see ADHS CFT practice improvement protocol of August 2003, and ADHS CFT

technical assistance document of September 2004) is a direct, perhaps most significant

outgrowth of the 300 Kids Pilot.

One early strategy established a learning community to share best practices and lessons learned

among these pilot efforts, in order to help promote the continued infusion of the 12 Principles

into increasingly unified work among several child- serving systems. Several activities begun

during that era have persisted and evolved, including:

·   ADHS is using its website and the Children’s Executive Committee as vehicles to share

progress reports, technical assistance guides, success stories and other information that

that supports Arizona practitioners in the emerging system of care.

·   Each region has developed a core team of system developers who work closely with

external consultants and ADHS Bureau for Children’s Services to create and compile

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tools, processes, guides, training curriculae, job descriptions and supervision other and

quality improvement tools.

·   The ADHS Children’s Bureau Chief conducts periodic meetings with all RBHA

Children’s Services Coordinators to systematically transfer lessons and technologies from

the early pilots, from ADHS, from national technical assistance resources and from one

region of the state to all. These meetings will be accelerated from quarterly to six times a

year in 2005 to reflect the accelerating need for robust cross- teaching as early

experimentation and development has evolved to full- scale statewide implementation

On January 29, 2003, Governor Janet Napolitano issued a press release announcing that the

Arizona Department of Health Services was expanding statewide the “ 300 Kids Project” - a new

approach to providing mental health services to children. The approach endorsed by the

Governor “ seeks to involve the entire family in a child’s treatment, as well as neighbors,

community organizations and even churches.”

The initial purposes of the 300 Kids Pilot have been largely fulfilled. More and more, desired

practice stemming from the Child and Family Teams process developed within it is becoming

systematized, documented and integrated into RBHA human resource, training, supervisory,

clinical, financial, quality management, operational and executive functions. Testing of new

strategies to help realize the full Arizona Vision now occurs in the context of the statewide

spread of practice changes.

Applying uniform statewide definitions setting minimum criteria1, RBHA regions currently ( as

of September 30, 2004) report the following extent of Child and Family Team practice:

CPSA- 3 122 Children currently have functioning CFTs.

CPSA- 5 873 Children currently have functioning CFTs.

NARBHA 247 Children currently have functioning CFTs.

ValueOptions 1,496 Children currently have functioning CFTs.

PGBHA 45 Children currently have functioning CFTs.

EXCEL Group 60 Children currently have functioning CFTs.

Statewide Total: 2,843 Children currently have functioning CFTs.

1 “ functioning Child and Family Team,” as defined by ADHS April 2004:

a. is facilitated by a trained person;

b. the CFT has met at least one time; and

c. an initial strengths, needs and culture discovery has been completed.

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Annual Action Plan and Substance Abuse Plan as Part of the First Annual Action Plan:

Settlement Agreement Paragraph ( h) develop annual action plans as described in paragraphs

53- 54

Status: Met

Background

AHCCCS and ADHS prepared the first Annual Action Plan in accordance with paragraph 17 ( h).

Additionally, in paragraph 52, a Substance Abuse Plan was required in the first year. This

requirement has been met. A Substance Abuse Plan was developed and implemented for the

expansion of substance abuse treatment services. Targets for capacity were established in year

one and achieved.

During the second year, once again RBHA- specific capacity targets were established through

ADHS’ Network Sufficiency process. Each RBHA met its capacity development target, and

ADHS continued to monitor access to substance abuse services through quarterly RBHA

reporting and RBHA Network Development Team meetings.

During Year Three, ADHS published clinical guidance and provided training on practice

improvement protocol # 10, Substance Abuse Treatment in Children.

The EXCEL Group in Yuma and Arizona’s Children Association trained 16 families specifically

to provide therapeutic foster care services to youth from substance abuse backgrounds.

Additionally, EXCEL has developed a program specifically for substance abuse treatment for

children and adolescents, as well as a curriculum to train staff on this program. CPSA initiated a

contract to provide 5 Level II adolescent substance abuse beds within its service area.

In Maricopa, many new direct support service providers, as well as new MST and FFT teams

described elsewhere in this plan, represent expanded new options to address the needs of young

substance- abusing youth. PGBHA has developed several intensive outpatient programs and

groups for adolescent substance abuse treatment. Superstition Mountain Mental Health in

Apache Junction added a youth substance abuse group and an intensive outpatient program to the

array of services they provide. Arizona Children’s Association and Corazon both developed

substance abuse programs for adolescents. Furthermore, Horizon Human Services developed a

bicultural/ bilingual intensive outpatient substance abuse program for adolescents.

In Yavapai County, a juvenile drug court program has been active for the past three years, with

active participation by NARBHA’s local service area agency. In southeastern Arizona, CPSA

recently began to leverage Project MATCH grant funds to support a juvenile drug court

enhancement effort to better address the needs of youth who become involved with the courts

due to substance abusing behaviors. This collaborative effort between CPSA, several public

schools and the Pima County juvenile court provides valuable new opportunities for participating

children and families. The juvenile court is committed to providing weekly status hearings,

intensive probation surveillance, parent education classes and randomized drug screenings, while

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CPSA provides an array of appropriate services to therapeutically impact and support the child

and family. A Drug Court Liaison oversees the referral and placement of the youth into the

program. CODAC’s Step Forward program ( federally funded through a Strengthening

Community Youth / SCY grant) provides an evaluation component to track each participant to

measure treatment efficacy across the various participating providers. Meanwhile, the

University of Arizona’s evaluation team, through a subcontract with CODAC, tracks Title XIX

and non- Title XIX youth who are participating in Step Forward’s treatment programs.

Arizona’s new 5- year statewide infrastructure grant from SAMHSA has as one of its four

specific focus areas the further development of effective substance abuse treatment capacity.

Grant funds and concomitant national technical assistance resources bring with them the promise

of additional enhancement of the behavioral health system’s capacity to address the needs of

substance- abusing youth.

Quality Management and Improvement System: Settlement Agreement paragraph 17 ( i)

change their quality management and improvement system as described in paragraph 55

Status: 2nd Year of Development

The ADHS Quality Management System measures the quality of behavioral health services to

enrolled members and makes recommendations for improvements in care, administrative

management and fiscal efficiency. This process is conducted under a Quality and Utilization

Management ( QM/ UM) Plan that is developed on an annual basis. This plan identifies

monitoring and other activities that ADHS will undertake throughout the year.

As part of the Quality Management System, information is obtained through various monitoring

and other data collection activities. This information is analyzed by staff in the Bureau of

Quality Management and Evaluation and is subsequently presented to the ADHS QM/ UM

Committee for further analysis, review and direction. ADHS and the RBHAs develop plans to

alleviate problems or improve processes in order to achieve the overall goal of improved quality

of care, administrative management and fiscal efficiency. Plans of correction or improvement are

monitored and effectiveness is evaluated.

Background

During the first year following the settlement agreement, ADHS began a review of the quality

management system in light of the 12 Principles. As adjustments to the quality management

system are made to focus more substantially on practice improvements stimulated by the

Settlement Agreement, ADHS intends to avoid increases in reporting/ monitoring requirements,

by utilizing an “ adjust/ replace” approach to achieve desired monitoring efforts.

The ADHS QM/ UM Plan includes a QM/ UM Committee that is chaired by the Medical Director

and has representatives from throughout the organization, including consumer representation.

This allows a systematic approach to analysis of trends analysis in data generated about an array

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of aspects of system performance, in order to focus performance improvement activities. Service

network development, utilization of services and the in vivo effects of all key clinical initiatives

are reviewed and discussed during by this Committee.

ADHS and AHCCCS have undertaken the following activities in reviewing and changing the

quality management system:

·   A review of performance measures and other monitoring activities for alignment with the

12 Principles was completed in 2002. That review informed subsequent amendments to

ADHS contracts with all RBHAs. Effective July 1, 2002 were substantive contract

changes negotiated by AHCCCS and ADHS establishing new performance measures and

reporting of minimum performance expectations, goals, and benchmarks. At present,

ADHS and the RBHAs have begun to collect and report quality management data

representing the following aspects of care germane to the Arizona 12 Principles: access to

care/ appointment availability; coordination of care with AHCCCS acute contractor

primary care providers; sufficiency of assessments; member/ family involvement in

developing treatment recommendations; considering member/ family cultural preferences

in treatment/ service planning; appropriateness of services; informed consent; and

effectiveness as indicative by positive clinical outcomes.

Though more focused than prior measures and reporting on Principles and actions

required in the Settlement Agreement, subcontractors still have fewer reporting

requirements overall than before the Settlement Agreement date. While monitoring,

measurement and reporting are integral activities within Quality Management and

Improvement systems, efficient processes and reporting can allow contracted RBHAs to

devote more efforts and resources to overall systems improvement.

·   ADHS’ two most recent annual Independent Case Review ( conducted in 2003 and 2004)

have included specific samples of children and families experiencing practice changes

developed precisely to apply the 12 Arizona Principles. In 2003 a sample of children and

families were reviewed to test strategies and review tool questions for monitoring the

Child and Family Team process. 25 Child and Family Teams were reviewed within the

NARBHA region in 2004, applying a guided interview tool based on the Wraparound

Fidelity Index ( 3.0) also used by the Assessment and Outcomes subcommittee of the

Maricopa County Collaborative for similar purposes. Overall, both families and

facilitators expressed a positive view regarding the impact of the Child and Family

Teams process. Of the twenty- four minimum performance scores, the CFT population

met or exceeded sixteen.

·   In addition to the Child and Family Teams interview process, 30 chart reviews were

completed for children receiving treatment in residential treatment centers. Review

questions include standards from the Independent Case Review ( ICR) in addition to nine

RTC- specific standards. Overall, six of the nine RTC- specific addendum questions met

or exceeded the overall score of 76.7 percent. One hundred percent of the records

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reviewed indicated that services provided at the RTC reflect the goal pf preparing the

child to return home expeditiously. The lowest score was related to cultural competency,

and is consistent with the results of the ICR.

Systematic Quality Improvement Example - Assessment Process:

The following example illustrates how AHCCCS and ADHS use quality management processes

as effective links within a practice improvement feedback loop.

AHCCCS included a standard in its ALTCS Program Contractor Operational and Financial

Review for FY 2003 related to including the child and family in assessment and treatment

planning processes. Findings showed a need for significant improvement in this area. At the

same time, feedback from the growing statewide learning community supporting development of

Child and Family Team practice concluded that existing RBHA assessment traditions were not

only not supportive of, but in many cases actually contradicted some of the principles and key

steps of the developing practice approach. Consumers’ diagnoses and functional deficits were

being traditionally identified by professionals and served as the basis for fairly standard

treatment plans, while the emerging practice approach featured discovery of consumers’ own

goals, needs, strengths and available and potential natural supports as the basis for planning.

As a consequence, ADHS made a Strategic Plan commitment to develop and implement a

standardized statewide assessment process that would identify goals and needs from the

standpoint of the client and family, build on individual and familial strengths, provide timely

crisis intervention, lead to highly individualized service planning and provision respectful of

their important cultural and linguistic considerations, and do so in a manner consistent and

congruent with the mandates and interests of other involved systems ( e. g. health care, juvenile

justice, corrections, education and protective services).

In 2003, as part of the ADHS Strategic Plan, a standardized assessment process was developed

with input from over 100 staff, providers, consumers, family members and stakeholders.

Members of the informal 300 Kids learning community, including consultant John VanDenBerg

PhD, helped to develop the assessment process, its supporting tool and guide. Statewide training

in the new assessment was completed over the four month period immediately preceding

statewide implementation of the new assessment. A subcommittee of the Assessment

Workgroup was established to review data requirements and outcome reporting.

The resultant, uniform statewide behavioral health assessment has been required for use with all

clients of the behavioral health system since January 1, 2004. ADHS modified its existing

administrative review process for RBHAs to gauge the implementation and early quality of the

new assessment process. Quarterly meetings of ADHS’ residual Assessment Workgroup review

those results, and other ongoing feedback from the assessment to feed and focus performance

improvement planning. Based on that feedback, the statewide assessment process has been

specifically adapted to two specific situations during 2004:

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·   In support of ADHS’ Urgent Behavioral Health Response for Children Entering Foster

Care, and

·   For infants, toddlers, preschoolers and their families ( pilot completed in Fall 2004,

statewide training and full implementation of the Birth through Four assessment is

scheduled for Summer 2005.

Additional accomplishments, including changes to improve the Quality Management and

Improvement System during the past year, include:

·   Modification of the biennial consumer satisfaction survey to better reflect the Arizona

Principles and the set of functional outcomes it incorporates.

·   Involvement in and dissemination of empirical research triangulating Wraparound

Fidelity Index measurements with several elements of outcome data on 63 Project

MATCH families. This research, involving Jim Rast PhD of VVDB and the University

of Arizona, demonstrated a strong association between high fidelity CFT practice and

positive child and family outcomes, and was shared at the annual national research

conference on children’s mental health in Tampa ( March 2004).

·   Maricopa County’s Steering Committee’s Assessment and Outcomes Subcommittee has

piloted both Child and Family Team service plan reviews and guided interviews with

families and other team members to assess application of several of the 12 Arizona

Principles in emerging practice. This effort continues in Maricopa County.

·   ADHS has established a dedicated position in its Bureau of Quality Management and

Evaluation to support the development and implementation of changes to improve that

system’s adherence to the 12 Arizona Principles as described in Strategy 5.

Stakeholder Participation: Settlement Agreement paragraph 17 ( j) involve Plaintiffs’ counsel

and other stakeholders as described in paragraph 73 and 74

Status: Met and ongoing

2004

ADHS, AHCCCS and Plaintiffs’ Counsel continued to meet regularly during Year Three of the

Settlement Agreement, at least once each quarter and in a variety of forums, to discuss the status

of Settlement Agreement actions, implementation, challenges and emerging lessons. Plaintiffs’

Counsel continued to access a multiple system development venues, especially within Maricopa

County, including playing an active role in the Maricopa County Collaborative’s assessment and

outcomes subcommittee to pilot and apply guided interviews and related case reviews to measure

the experience of children and families against the 12 Arizona Principles. All these parties

joined together for a series of leadership meetings designed through interactive activities to bring

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to life aspects of the essential changes in values and practice required by the Settlement

Agreement.

Plaintiffs’ counsel also participated in developing new ADHS clinical guidance surrounding the

use of out- of- home services.

Efforts to involve other stakeholders in implementation of the Settlement Agreement were

plentiful at both the state and regional/ local levels.

Children’s Executive Committee

Throughout the year, ADHS and AHCCCS continued their participation on the Children’s

Executive Committee and its Clinical and Family Involvement subcommittees. The Executive

Committee established three priorities for its work in 2004, beginning with support for Governor

Janet Napolitano’s reform of Arizona’s child welfare system. ADHS and AHCCCS had

participated fully in the work of Governor Janet Napolitano’s Advisory Commission on Child

Protective Services since its creation in January 2003. The Executive Committee agreed to

oversee implementation of the ADHS policy change requiring an urgent behavioral health

response for all children entering foster care referred to the behavioral health system by DES-ACYF.

( The success and