The policies, procedures, regulations and rules of Louisiana’s Coordinated System of Care must not become concrete too quickly. The System still requires significant tweaks.

The Coordinated System of Care is the Department of Health and Hospitals’ Medicaid-funded (and consequently, Medicaid-restricted) reorganization of the former child welfare system. I believe it is still too early to shout, “Success!”, because, in important ways, CSoC seems to be at cross purposes with itself on some points.

One significant Medicaid-restriction which I believe requires correction is that a family cannot receive Wraparound services if their child is also receiving out-of-home care. This is a significant, self-imposed barrier to good outcomes for children and families.

During its development, one of the most exciting “features” of CSoC was that families of children who cannot live at home would be able to participate in active treatment through services arranged for them by a local Wraparound agency. The family would receive treatment in their community while their child was receiving treatment in out-of-home care.

Imagine how much progress a family can make and how better prepared a family would be to reintegrate their child if, while the child was in out-of-home care, the family was also participating in an ideal array of community-based services which were wrapped around them? In a word, it would be awesome!

However, as I understand the current situation, Louisiana Medicaid rules stipulate that providing care to a child in out-of-home care and providing care to the family at the same time would constitute some form of double dipping. Medicaid will not pay for two services at the same time.

Originally, this did not present as a barrier because the array of CSoC services available to families was to be funded with “blended and braiding funding streams”. If Medicaid funds were not available to pay for a service, then the large pot of money available to CSoC could be stirred to find non-Medicaid funds to cover the full array of services a family and child might require. Somewhere along the way, “blended and braided” seems to have become so mixed with Medicaid that Medicaid rules govern the entire pot.

Family Care is Critical

This concept of family care is extremely important. Whether it happens or not makes or breaks the continued success of a child and family when a child returns home from residential care.

Residential Care without Family Care is Not Enough

First, an aside. Some of the early CSoC documents and presentations sought to show residential care in negative light. For example, “Louisiana’s children with the highest level of need are often detained in secure or residential settings, which are proven the highest cost services with the poorest outcomes.” (063010_CSOC_Overview.pdf, Louisiana Department of Health and Hospitals)

Ironically, the cost of providing care in residential settings is now much higher than ever before because of CSoC, Medicaid and DHH regulations. It is what it is. But what about that, “poorest outcomes”? What is that about?

When asked in one meeting for evidence of poor residential outcomes, fingers pointed toward the 1999 U.S. Surgeon General’s report, “Mental Health: A Report of the Surgeon General”. The Surgeon General’s report is not a document many would read for pleasure, but it does contain 494 pages of earlier context.

So here’s what the Surgeon General’s report actually states about residential treatment:

“The evidence for outcomes of residential treatment comes from research published largely in the 1970s and 1980s and, with three exceptions, consists of uncontrolled studies.” (Surgeon General’s Report on Mental Health, Page 170)

It seems disingenuous, but to help support a case that a coordinated system of care was needed, the residential care available in Louisiana was repeatedly devalued. To build a case against residential care and for home and community-based services, the Surgeon General’s report from 1999 was used – even though it admitted its own primary sources were uncontrolled studies that were nearly 30 years old. When CSoC was coming together in 2010, the poorly conducted, (and by then) 40-year-old studies, were of little value except for propaganda purposes.

Quality Residential Care is Effective

The castigation of residential care was intended to build support for a coordinated system of care. It was an unfounded argument.

In fact, DHH’s CSoC documents and presentations failed to report the positive outcomes of residential care mentioned in the Surgeon General’s document:

“Despite strong caveats about the quality, sophistication, and import of uncontrolled studies, several consistent findings have emerged. For most children (60 to 80 percent), gains are reported in areas such as clinical status, academic skills, and peer relationships.” (Surgeon General’s Report on Mental Health, Page 171)

Residential Care without Family Care is Not Enough

Quality residential care for children provides positive outcomes – but here’s where the value of a well coordinated system of care becomes extremely important. The CSoC documents never mention what I believe to be the most important statement about residential care contained in the Surgeon General’s report:

“Whether gains are sustained following treatment appears to depend on the supportiveness of the child’s post-discharge environment (Wells, 1991).”
(Surgeon General’s Report on Mental Health, Page 171)

It seems so obvious and logical. Louisiana’s Coordinated System of Care must simultaneously support residential treatment AND wraparound treatment for “the child’s post-discharge environment” (aka, “the family”). Quality outcomes for children and families require BOTH!

Family Care is Critical

A child can make significant gains in out-of-home care but – if returned to the same, unchanged family system without support – he or she can be expected to regress quickly. (This is the reason we are Louisiana United Methodist “Children and Family Services”.) The provision of quality services to the child AND the family are BOTH required.

It boils down to this: a well-designed coordinated system of care for children ensures the family is able to make changes while the child is in residential treatment. It ensures the family receives the continued, community-based care it requires. What better way to avoid dropping the ball in the “post-discharge environment” than to actively engage the family in local community supports while the child is in out-of-home care?

Here’s what I believe needs to be one of the next steps for Louisiana’s Coordinated System of Care: stir that pot of “blended and braided funding” to support simultaneous Wraparound services for the families of children in out-of-home care.

Note: The recommended citation for the Surgeon General’s report on Mental Health is: U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. The document is available online at: http://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf