Shift to Intensive Treatment Foster Care in Minnesota

As I was nearing graduation almost 20 years ago, I got a call from my case manager telling me about an innovative new position the agency was going to offer called Therapeutic Support Foster Care. This new position would provide skills training and psychotherapy services within the youth community. Specifically, I was asked to work with youth that needed stabilization in their current placement to prevent a disruption and higher levels of care or work with the treatment team and the family of origin on reunification. I often wondered how a weekly community based skills service could have benefited me.

TSFC has actually been a service in Minnesota since 1989 as part of the Comprehensive Children’s Mental Health Act. In 1994 TSFC was added as a Medicaid benefit. One of my memories was discussing with my supervisor how to make this service profitable. I remember discussions about the complexities of billing and coding, keeping my case notes up to date (back then I was an early adapter, I was the only social worker in the office that used a computer for my case notes, other workers were “very impressed”), and case load size.

Shortly after I left, the service evolved into a new model called Children’s Therapeutic Support Services. This evolution was meant to be more flexible for youth living with their family of origin or foster parents. CTSS is meant to be more comprehensive and includes crisis assistance and behavioral health aide services in addition to the foundations of skills training and psychotherapy. Much like TSFC, CTSS works to stabilize placement, restore functioning, and skill development through a rehabilitative mental health package covered by Minnesota Health Care Programs (MHCP). This program is still in operation today with over 70 approved providers in the state of Minnesota.

Treatment Foster Care

At one point, private agencies in Minnesota were innovative and ahead of the curve. Family Focused Treatment Association had its roots based in Minnesota in the 1980’s. I remember in 1987 being told I was going to be in a “treatment foster home”. The difference, I was told, was I would have an extra social worker as my case manager in addition to my county social worker, and live in a specially trained foster home. At the time, I remember thinking “I don’t need to be in a ‘special’ foster home, I want to be ‘normal’”. My experience was very similar to the model we discuss today; 2 kids per home, low case management work loads, more intensive engagement. I don’t know what the numbers were, but I knew my county workers cycled over and had extraordinary case loads. Several didn’t know my name nor what was happening in my life. Meanwhile, my case manager from the private agency was intimately engaged and knowledgeable, worked with my school, acted as a bridge between my foster family and family of origin. Additionally, during my 8 years in foster care I only had one case manager. In an earlier article, I wrote about how I experienced normalcy, permanency, and wellbeing as a result of my placement.

Officially TFC was recognized by the state in 1995. TFC was meant to serve children with special needs, but not necessarily a mental health diagnosis. Under this model, children would be placed in a foster home and have a comprehensive treatment team. Providers in Minnesota had a difficult time meeting the requirements of the mandate and staying financially solvent. There were conflicting standards between the placing agencies and the mandate which made it difficult to stay compliant and increased the displacement rate for youth. Additionally, recruiting foster homes that limit 2 high needs youth per home without adequate reimbursement became an obstacle. One business model showed the need for 100 licensed homes to break even on the model. Slowly the services eroded and became less intensive and less comprehensive.

In 2005, the Children’s Mental Health Division added bundled services for youth in foster care that authorized a Medicaid benefit for youth in treatment foster care. The bundled service included targeted case management, psychotherapy and skills training, and family psychoeducational services. Ironically while this legislation passed, it was not funded by the state.

Reforms were initiated again after the Federal Fostering Connections to Success and Increasing Adoptions Act of 2012. As you know this put an emphasis on kinship and pre-adoptive placements, emphasized shorter lengths of stay for more timely permanency. Additionally, there was a focus on keeping youth in family settings versus congregate care. Other evidence based best practices that were introduced included; culturally specific services, mental health and coordinated care levels and trauma informed care.

Intensive Treatment Foster Care

Enter Intensive Treatment Foster Care in 2012 as a benefit of the Minnesota Health Care Program. Statewide stakeholders requested a more flexible benefit that would include the youth’s family, foster family and members of the permanency plan. Additionally, it was strongly recommended to be framed as an in-home service regardless of placement type; traditional, treatment foster home, relative or kinship home, etc. Parents or pre-adoptive family inclusion during placement was strongly recommended when clinically appropriate.

Youth in foster care represent 10% of the Medicaid population but account for over 38% of the Medicaid dollars. As a result, an integrated approach and care coordination between physical and mental health practitioners was included. A comprehensive assessment that includes all previous care through an extended diagnosis that included a trauma assessment was incorporated. Another reason for this collaboration was to prevent the over use of psychotropic drugs. Finally, to prevent unnecessary displacements, moving to higher levels of care and or hospitalizations 24/7 support was included into the package. Lastly, providers are expected to be certified in trauma informed evidence based best practices.

The purpose of these guidelines is as follows:

  • Provide intensive clinical mental health in youth communities and stabilizing placements

  • Increased access to mental health service within current systems

  • Create flexible, coordinated care amongst all the youth treatment team members

  • Strengthen permanency through consultation, psychoeducation and therapy

  • Post-permanency transition services to support permanency and reduce recidivism

  • Promote trauma informed evidence based practices and improve outcome results

The guidelines for eligibility include:

  • Licensed foster home

  • Recipient of MHCP

  • Comprehensive diagnostic assessment within 180 days that documents mental health symptoms

  • Documentation for medical necessity to keep youth in family setting and out of higher levels of care or hospitalization

  • Have a level of care that requires a 24/7 crisis plan

Service components include; services to be delivered by a mental health professional or clinical trainee, extended diagnostic assessment within 30 days, shared information from all areas of the youths life (mental health, education, primary care physician), trauma assessment, individual treatment plan reviewed every 90 days, 24/7 crisis plan within 10 days, documented services three times a week at two hour intervals (include travel time, case documentation in this and case loads are innately in the 5-7 range), community based, developmentally and culturally specific treatment, integrated treatment team with information sharing (mental heath, primary care) with close monitoring of psychotropic medication use, all members of permanency plan included, and a transition plan within 90 days.

Some of the primary concerns I have heard already are the ability to implement a 24/7 crisis plan recruiting foster homes, and the lack of available licensed mental health professionals. First I would address the 24/7 plan. I believe there is a rather unsophisticated solution; on call rotation with incentives. This is already being done by most agencies and by information sharing of best practices those that have some concerns should consult those that are doing this already. I believe this to be a rather easy objection to overcome, but I have heard it from at least two foster care agencies.

Recruiting foster homes will take major communications and public relations strategies, plans and partnerships within the community. In a previous article, I wrote about changing public perception of foster care. High quality services and story sharing can do that. If families feel supported emotionally, educationally and fiscally, they will come to the table. I have done some unofficial research and the agencies that do the best with PR and marketing have better pipelines of families.

The more relevant hurdle is the lack of mental health professionals. This is an issue across all mental health. However, I think any child caring agency has a more difficult challenge with the financial constraints around compensation. Plain and simple most child caring agencies cannot bill or pay out at the same rates as a private practice or the medical based service providers. As I have shared before the philanthropy community generally ignores child welfare and especially foster care. This is going to take some creative recruitment strategies, partnerships with colleges, and general entrepreneurship by executive leaders within our state.

Alumni Perspective Conclusion

As I look at this, there are many components that mirror my experience almost 30 years ago. I don’t know the financial model of my case or the exact treatment model used but I do believe there is a reason my experience was more positive than so many of my alumni peers. During a recent discussion with my old case manager and other professionals it was brought up that if I was put brought into the child welfare system today, chances are I would not be in foster care. I can tell you if I wasn’t in foster care I would have followed the path of my family of origin and either been incarcerated, have addiction issues, committed suicide, or been on welfare myself as a father of multiple children I could not support. Most likely my kids would be in foster care now as many of my siblings’ kids have experienced.

My perspective is any youth, high functioning or not, experiences trauma the second their life has hit a level where social services or law enforcement must be involved. I believe all youth once engaged in health and human services should be receiving intensive mental health services that are trauma informed and evidence based. I also believe being in a community, with a family is far better than institutionalizing youth. It is no secret that I completed high school as a result of my teachers knowing my situation and making accommodations, as well as my primary care doctor knowing and understanding my placement situation (didn’t hurt that he was also the neighbor to my foster parents). I saw other foster homes that had many kids placed, they felt like a zoo, chaotic, lacked order when I stayed there. I was always grateful to return to my home where I was either the only child or one of two. Any time there was more, I felt like I didn’t really connect or belong. Having that opportunity to build connections and trust was imperative to my healing.

As for foster parent recruitment, I think many agencies are missing a real opportunity. People become foster parents because of personal connections. Right now we primarily rely on foster parent referrals. What we don’t rely on is the network of the families and youth we serve. Alumni networks across the country are valuable conduits into the communities. I personally get 1-3 inquiries a month. What if there were 2,000 of us in MN all actively sharing our stories and engaging our communities? Ohio launched a campaign specifically leveraging the alumni and youth advisory networks. I will be curious to see how that works, but my bet is if done correctly it will have an amazing outcome.

My summary is this; I am glad ITFC is finally coming to MN. Working with FFTA all these years I have seen the great work many of you do and wondered “Why can’t this be replicated in MN”. I still don’t know why with so many talented people in MN we cannot get the proper funding mechanism to provide the adequate level of care for our youth. I fear the same issues will surface; that the financial model does not invest in the services being financially soluble for the providing agencies and parents. We might start off on the right, but slowly erode and deteriorate the quality of services. I do strongly believe that this level of intensity, community collaboration, information sharing, family engagement, mental health support, etc should be for ALL youth who enter foster care. In my opinion this should be the standard model across the board and not just for the youth that exhibit the highest symptoms of severity. In order to do that there needs to be a financial investment and prioritization that these youth and their families are worth the investment. We need to shift the thinking of legislators so they can recognize the investment this has on our community’s future. We need the philanthropic community to invest as much in our community youth and families as they do youth abroad. So back to the original article I shared a couple years ago… “We need to change the public perception of foster care”