Cross-Systems Financing Project Learning Community Creates Care Integration in Five Sites
From January 2006 through December 2008, staff at the Technical Assistance Collaborative in Boston established and guided a "learning community" in which participants developed strategies to integrate funding for and improve access to mental health and substance abuse services in their states and counties.
Six jurisdictions comprised the Cross-Systems Financing Project Learning Community: Franklin County, Ohio; Philadelphia; and the states of Georgia, Iowa, New Mexico and Washington.
- Sites increased both the number of funding sources for substance abuse and mental health services and the number of agencies that contributed funds for those services.
- In Franklin County, the number of children and youth placed in residential centers outside the county decreased by 15 percent.
- In New Mexico, a new Transition Services Program refinanced and restructured services for youth ages 15 to 21 who are coming out of juvenile correctional facilities.
- In Washington, new funds sustained and expanded a Screening, Brief Intervention and Referral to Treatment protocol that identified people needing substance abuse services, offered them brief services and referred them for ongoing help.
The Robert Wood Johnson Foundation (RWJF) supported the project from January 2006 through December 2008 with a solicited grant of $699,716.
Public services for people with complex mental health and substance abuse problems are funded by a mix of federal, state, local and community sources that are rarely coordinated.
These funding "silos" make it difficult for officials to combine funds to offer people comprehensive and cohesive services, according to staff at the Technical Assistance Collaborative, a Boston-based organization that supports efforts to design, finance and manage public human services and health care strategies.
Public officials have identified several barriers to integrating services and funding, including:
- Lack of common agreement or language about goals and outcomes.
- Inability to optimize resources across funding streams.
- Multiple, disconnected advisory groups and processes.
- Multiple service delivery approaches, billing processes and reporting requirements.
- Duplication of effort and infrastructures at the state, county and local levels.
- High administrative costs to providers because of multiple state, county or local needs.
- Ineffective, insufficient, contradictory or duplicative oversight.
In response to these problems, some state and county governments have established cross-system financing initiatives that attempt to coordinate public funds on behalf of people who need mental health or substance abuse treatment services.
In 2001, RWJF decided to focus its funding for addiction on improving the quality of treatment. According to RWJF president, Risa Lavizzo-Mourey, M.D., M.B.A., the focus on treatment was needed because of "the tremendous gap between what we know about the treatment of substance abuse and addiction and what is actually done in health care settings" (Advances, Issue 1, 2003). Programs in this area have included:
- Pilot Program of Research to Integrate Substance Abuse Issues into Mainstream Medicine. See Grant Results.
- Resources for Recovery. See Grant Results.
- Paths to Recovery.
- Advancing Recovery.
See also the "Addiction" area of RWJF's Web site.
As of the first quarter of 2006, RWJF decided to focus its substance abuse funding on projects directed at vulnerable populations.
Staff from the Technical Assistance Collaborative, working with consultants from The Avisa Group, a Berkeley, Calif.-based firm, organized a Cross-Systems Financing Project Learning Community to improve access to and integrate financing for publicly funded substance abuse and mental health services.
Representatives from the National Conference of State Legislatures and the National Governor's Association worked with the Technical Assistance Collaborative in identifying project objectives, creating meeting agendas, providing speakers and other activities.
The Cross-Systems Financing Project Learning Community
A learning community is a structured process in which a group of people who share common values and beliefs agree to work together and learn from one another.
The Technical Assistance Collaborative and The Avisa Group established three objectives for the Cross-Systems Financing Project Learning Community:
- Provide information to participants about how other jurisdictions implemented integrated substance abuse and mental health services funding strategies.
- Offer participants access to experts and technical assistance in developing and implementing integrated funding systems in their jurisdictions.
- Develop and implement a cross-systems financing strategy that would change the array of services and mix of payers for substance abuse and mental health services.
Project staff solicited proposals from 10 jurisdictions that:
- Had expressed an interest in or implemented a cross-systems financing strategy.
- Had strong leaders who were not likely to leave their positions.
- Had histories of collaborative efforts.
- Were not likely to be overwhelmed by other initiatives.
The project selected six jurisdictions to participate in the learning community:
- Franklin County, Ohio (Columbus and surrounding area) proposed to develop cooperative approaches for delivering mental health and substance abuse services to children in custody of child protective services or at risk of entering custody and for youth involved with county courts.
- Georgia proposed to coordinate funds from multiple sources to improve substance abuse services for adults on parole and to help parolees make a successful transition from correctional facilities to community-based treatment.
- Iowa proposed to improve treatment for people with co-occurring mental health and substance abuse disorders by eliminating disparities in reimbursement, integrating screening instruments, changing licensing requirements and training staff to address both substance abuse and mental health problems.
- New Mexico proposed to help youth ages 15 to 21 make the transition from residential correctional facilities to community settings and from the juvenile care system to the adult care system in order to reduce out-of-state placements and increase access to treatment, housing and other services.
- Philadelphia proposed to develop collaborative financing and service strategies between the departments of Behavioral Health/Mental Retardation and Human Services in order to improve services for 43 youth "aging out" of residential foster care, allowing them to transition from residential facilities to community settings.
- Washington State proposed to replace expiring federal funds that supported a Screening, Brief Intervention and Referral to Treatment protocol and secure additional funds to expand the protocol to new locations. Under the protocol, substance abuse staff based in medical centers screen patients for substance abuse, provide them with brief services and refer them to ongoing treatment.
Representatives from agencies such as mental health, substance abuse, child welfare and juvenile justice and managed care providers participated in the learning community.
Learning Community Activities
With guidance from staff at the Technical Assistance Collaborative and The Avisa Group, Cross-Systems Financing Project Learning Community participants:
- Identified a target population for their projects and an array of services required by that population.
- Prepared two "purchasing plans." One plan described baseline funding streams and agencies involved in funding or providing services, and the other described how funding streams and involved agencies would change as a result of the project.
Participants used the purchasing plans to create funding scenarios, critique them and debate implications.
- Identified infrastructure and organizational characteristics that needed to be changed in order to increase the number of funding streams and the number of involved agencies.
The Cross-Systems Financing Project Learning Community process included:
- Five meetings held between June 2006 and June 2007. Meeting topics included:
- Managing politics and leadership.
- Prioritizing services and funds.
- Developing quality services.
- Creating a NIATx-based "walk-through" of the proposed system. NIATx, the Network for the Improvement of Addiction Treatment, is a partnership among RWJF's Paths to Recovery program, the Center for Substance Abuse Treatment and several treatment agencies.
- Developing purchasing plans and creating plans for sustaining projects.
- Regular, structured telephone conferences with participants between the meetings. During these conferences, participants and consultants discussed implementation challenges and progress.
- On- and off-site technical assistance as needed. For example, project staff hosted a visit to Connecticut for New Mexico and Franklin County participants. The visit allowed New Mexico and Franklin County staff an opportunity to learn how Connecticut had integrated child welfare and juvenile justice funding streams.
Project staff, working with staff from Laufer Green Isaac Strategic Marketing, a Los Angeles-based communications firm under contract to RWJF, prepared a Cross-Systems Financing Project Report that was released by RWJF in June 2009. The report provides an overview of the Cross-Systems Financing Project Learning Community and describes the projects developed by each site.
See the Bibliography for more information.
The Avisa Group's Web site provides detailed information about the first four of the five meetings of the learning community. Meeting agendas, PowerPoint® presentations and resource documents are available online.
Project staff presented the following results of the project in the December 2008 Cross-Systems Financing Project Report:
- Sites increased both the number of funding streams available for services and the number of partner agencies that contributed funds (payers).
- Prior to participating in the Cross-Systems Financing Project Learning Community, three sites relied heavily on state funds for services and only two used federal Medicaid funds. After participating, all six sites used both state general revenue and Medicaid funds. Some also added funds from the federal Mental Health and Substance Abuse and Housing and Urban Development Block Grants.
- Prior to participating in the learning community, sites funded services out of the budgets of only one or a few agencies (e.g., substance abuse services were funded by the public substance abuse agency). As a result of the project, participants recruited more agencies to provide services and contribute funds. These agencies included the courts and housing and mental retardation agencies.
Selected Site Results
- In Franklin County, the number of children and youth placed in out-of-county residential centers decreased by 15 percent. Out-of-county placements are undesirable because they remove children from their extended families, communities and support systems.
The county created a standardized protocol for screening children at risk of entering custody or in the custody of the child welfare system and youth involved with the county courts. Multidisciplinary teams use the standard, evidence-based instrument to determine service needs and monitor services delivered.
See Profile: Changing Substance Abuse and Child Welfare Services in Franklin County, Ohio for more details.
- In Georgia, the state substance abuse and corrections agencies jointly created a protocol aimed at reducing prison recidivism by providing timely, appropriate and coordinated services to adult offenders released to parole. This involved collaborating to identify substance abuse treatment needs of parolees, referring them to evidence-based services, training providers in treatment specifications and determining which agency would pay for treatment.
Budget shortfalls forced the Georgia legislature to stop funding the initiative in 2008, but it was considering reinstating those funds in 2009.
- In New Mexico, participants created a Transition Services Program that refinanced and restructured services for youth ages 15 to 21 coming out of juvenile correctional facilities. Traditionally, youth often entered group homes or residential centers upon release from a juvenile facility. By June 2008, Transition Services had served 278 youth with an array of family, counseling, employment, housing and other services that began while the youth was still incarcerated in the juvenile facility and continued after he or she entered the community.
Participating agencies incorporated Transition Services into their routine activities and allocated funds to support a dedicated program manager. These steps helped ensure that New Mexico's Transition Services system would be sustained after RWJF funds ended.
- Washington State replaced expiring federal funds with new county funds to sustain and expand the Screening, Brief Intervention and Referral to Treatment instrument. Federal funds for the protocol ran out in September 2008. King County (Seattle and surrounding areas) allocated $700,000 to sustain the protocol at its current site and expand it to others in the county.
Lessons for Learning Community Participants
- Bring the right people to the table and set aside adequate time to plan and implement the project. The learning community process allowed time for staff from diverse agencies to meet away from their offices and to develop and analyze options. (Project Director)
- Find a change leader in each agency, a person who has a passion for the effort. In a bureaucracy, it is sometimes difficult to find a person who will champion change, but it makes a difference. (Project Director)
Lessons for Sponsors of Future Cross-Systems Projects
- Create opportunities for participants to "walk through" their proposed protocols and receive feedback on the protocols before implementation. According to the Cross-Systems Financing Project Report, "participants reported that the NIATx walk-through process was the single most important process contributing to ultimate project design." (Project Director)
- Seek input from groups such as the National Governor's Association, the National Conference on State Legislatures and individual legislators. Agency and elected officials look to these associations and others for policy ideas. (Project Director)
- Locate prestigious and credible sources of internal and public funding in order to generate approval and interest among collaborators. Learning community participants noted that RWJF's support and involvement gave them credibility in their jurisdictions and made their efforts a higher priority among policy-makers. (Project Director)
- Build in time and funds for follow-up meetings after the project ends. Participants developed strong relationships with one another during the project, and it would have been useful to reconvene them once or twice after the project ended. These meetings would reinforce those relationships and allow participants an opportunity to talk about how they sustained their initiatives. (Project Director; Franklin County Project Co-Director/Fenner)
AFTER THE GRANT
The Cross-Systems Financing Project Learning Community ended with the grant. However, Franklin County, Ohio; New Mexico; and Washington have sustained the changes they instituted while participating in the project. Although the Georgia state legislature defunded the Georgia initiative in 2008, it was planning to add back funds to support substance abuse services for parolees as of 2009.
GRANT DETAILS & CONTACT INFORMATION
Designing and implementing integrated behavioral health funding
Technical Assistance Collaborative (Boston, MA)
Dates: January 2006 to September 2007
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Cross-Systems Financing Project Report. Princeton, NJ: Robert Wood Johnson Foundation, Spring 2009. Available online.
World Wide Web Sites
www.avisagroup.com/crosssystemfinancingstrategies/documentlibrary.html. Web site provides detailed information about four of the five meetings of the learning community, including agendas, PowerPoint® presentations and resource documents.
Report prepared by: Mary Nakashian
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe