Melissa Bailey, MA

April 10, 2019

During my time working in the Vermont state government — close to two decades — integrating services for children, youth, and families was a key focus for creating a system that is supportive and helps families live better lives. Over time, I have come to realize that integration is a term that gets used a lot, but means different things to different people. For state government and service providers, it often means streamlined requirements, payment, and oversight. For children, youth, and their families, integration means easier access to services, elimination of conflicting service requirements or eligibility, and reduction of multiple case managers — obstacles to actually getting the care they need and getting that care earlier in order to avoid more intense treatment needs later. Ideally, integration would incorporate both of these perspectives, which is something the new Integrated Care for Kids (InCK) Model seeks to do.

The InCk Model, an initiative recently announced by the Center for Medicare and Medicaid Innovation (CMMI), provides new opportunities for states seeking integrated approaches for children under age 21 covered by Medicaid or the Children’s Health Insurance Program. The initiative will support new ways to better integrate children’s care across providers, such as physical and behavioral health practitioners. It will include a variety of populations — children involved with child welfare, young children, school age, and transition age young adults — in order to improve health outcomes and decrease out-of-home placements, such as inpatient, residential, or foster care. My experience in the Vermont Agency of Human Services provides a helpful lens into key considerations for implementing the InCK Model in a way that works for children, youth, and their families as well as for state government and service providers.

Integrating Children’s Services in Vermont

While I was working in the Vermont Agency of Human Services, families had been telling us for years that the multiple door access, having several treatment plans, and different case managers only created more complications in their lives. Those of us working in the system were also often frustrated by barriers of our own creation and the inability to get families the variety of services they needed. In an effort to create a seamless, no-wrong-door system in Vermont, the Agency of Human Services created an office focused exclusively on cross-agency integration within its child and family services departments.

With a focus on integrating services, we undertook a system redesign — a challenging process. It was difficult to get colleagues to let go of old systems, even those that had not been working well, but were what they knew, in favor of something new and unknown. We knew that building in a payment model that created more flexibility and allowed the focus to shift from billable services to quality and outcomes could only lead to an improved system for families and for the individuals working within the system. Our integration efforts may not have addressed every aspect of a family’s need, but they did allow for a reduction in conflicting expectations and gave families easier access to the services they needed.

Key Considerations to Integrating Services

There are many lessons from Vermont’s experiences in building an integrated approach to care. This type of work is never completed but rather an evolving process. Some key considerations include:

  • Build strong partnerships between departments and providers. Challenging long-held beliefs, roles, and responsibilities can only be successful with an overarching trust across sectors.
  • Engage family members and the youth voice in the process — you don’t want to create something that doesn’t meet their needs.
  • Complete a fiscal map inventorying all available dollars, how they are directed to services, and the totality of funding to understand your current landscape, and how best to move forward with integrating services.
  • Create an inventory of requirements for items like eligibility criteria, treatment plan development and reviews, and documentation and reporting of services provided. Often, states can streamline and align such regulations to reduce duplication, paperwork, and reporting, as well as better aligning individual service goals.
  • Assure leadership support and participation in the change process at all levels of leadership as well as the management and frontline service level.

InCK Funding Opportunity

Integration is not easy work, but it is possible — and offers potentially great rewards for children, youth, and their families as well as the health care system. The CMMI funding opportunity to develop an integrated model for serving children, youth, and their families from prenatal to age 21 will give up to eight states, territories, or other jurisdictions the opportunity to design and implement a model of integration that goes even further than what we did in Vermont. Building a system that is comprehensive, coordinated, and seamless is an incredible opportunity to create improvements for children, youth, and their families.

The InCK grant opportunity will award funding for up to eight sites at a maximum of $16 million each to implement the seven-year model. The application is now open and has a closing date of June 10, 2019. For more information about InCK and the grant opportunity, please see the website. For additional descriptions of the InCK model, the Center for Health Care Strategies is part of a resource network, InCK Marks, that provides information to child health experts, practitioners, and advocates on this federal opportunity.

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Carmela

Will the integration be specific to each child/family; include coordination among providers/staff across agencies/disciplines at local and direct care levels; use a common case record; focus on shared objectives; work toward the attainment of interdependent goals; use pre-agreed upon common outcome measures; and share in potential fiscal rewards and risks?

Melissa Bailey, Center for Health Care Strategies

Thanks for your interest, you raise a variety of key issues common to effective integration models. For more information about the InCK opportunity, we encourage you to visit CMS’ website: https://innovation.cms.gov/initiatives/integrated-care-for-kids-model/