Home-based (wraparound) mental health services for foster youth

(June 1, 2003)

by Martha Shirk

Campbell, Calif.—It’s been a little more than a decade since Jerry Doyle launched an initiative that drove his agency into debt and nearly cost him his job.

Not only has Doyle kept his paycheck, but his agency now brings in more money than ever, and that initiative has significantly changed the treatment options for emotionally disturbed and mentally ill children throughout California.

It began when staff members at EMQ Children & Family Services experienced a collective epiphany.They were caring for 130 emotionally disturbed or mentally ill children in their residential treatment facilities in San Jose and its suburbs, at a cost of about $90,000 a year for each child. These children often arrived at EMQ angry, depressed, suicidal or combative. When they left 18 months later, some were even worse.

“We kept saying, ‘There’s got to be a better way to deal with these high-end kids,’” recalls Doyle, EMQ’s chief executive officer.The agency’s board authorized Doyle to find a better way.

After investigating promising practices for two years, EMQ decided to shift its focus from residential treatment to wraparound – a philosophy of care, rather than a service, which begins with an inclusive planning process and focuses on individualized, in-home services and links to natural community supports.

There was one problem: California wouldn’t reimburse providers for wraparound.

So EMQ set out to change the law. It took almost four years, during which EMQ ran up $1.2 million in deficits. Today, EMQ is unrecognizable from the bed-based agency it once was. It has shut down all but 30 of its beds, but is serving more children than ever. Its staff has grown from 165 in 1994 to almost 600. And annual revenues have more than tripled, to $40 million, as EMQ has expanded wraparound in several counties and added new services (such as independent living for teens) in Santa Clara.

In reinventing itself, EMQ has also helped to reinvent children’s services in California. Counties ranging from Siskiyou in the far north to Imperial in the far south are getting advice from EMQ on how to “wrap” families. Los Angeles County is the most enthusiastic convert: It recently closed a 120-bed group home and instead plans to provide wraparound to at least 325 of its most disturbed children. (See sidebar.)

The story of how wraparound services came to California shows how a single nonprofit agency with a visionary leader can change the child welfare landscape for a whole state. “Jerry took a huge risk when he retooled his whole organization to move in that direction,” says Carroll Schroeder, executive director of the California Alliance of Child and Family Services, an association of almost 200 children’s services agencies. “He deserves an enormous amount of credit for having pushed this. If he hadn’t pushed it, I don’t know who would have.”

The Vision Thing

California is actually a latecomer to the wraparound approach. The roots go back almost 40 years, to John Brown’s Brownsdale programs in Canada. The approach gained currency in the United States in the 1980s and ‘90s as mental health agencies developed systems of care to deliver services to children in their own homes.

John VanDenBerg, who pioneered wraparound in Alaska and now heads Vroon VanDenBerg, a consulting firm in Colorado, puts the number of children receiving wraparound services in the United States today at more than 400,000. “It’s growing extremely rapidly around the country,” he says. “There are hundreds of people around the country like Jerry Doyle saying, ‘This is the right thing to do.’ ”

EMQ was formed in 1987 by the merger of two old-line residential treatment agencies: Eastfield Children’s Center and Ming Quong. Overnight, EMQ became the largest nonprofit children’s services agency in Santa Clara County, with a $9.5 million annual budget and 130 residential treatment beds. One of the first things Doyle did as the new agency’s CEO was negotiate a $2 million payment from Santa Clara County to augment the state’s group home rate, which didn’t cover mental health treatment.

But the county imposed a condition: EMQ had to accept any child it referred.“And then the county decided to give us the 37 kids they had sent to Napa State Hospital, so we ended up taking kids with very high-end needs into our unlocked facility,” recalls Doyle, who’d been with Eastfield since 1971. “Most had been in foster care and had been moved five, six or seven times. A lot had serious sexual acting-out behaviors, because they’d been molested and abused. Some had early-onset schizophrenia, some were bipolar and some were simply reacting to traumatic experiences in their lives.

“You’re just asking for trouble when you put these kids together. Bad behavior is contagious, like measles. Though we were successful with a lot of kids, with a lot of others, we weren’t.”

In 1991, EMQ convened a “visioning process” for its staff. “We said, ‘We’ve got 100-plus years of history, but we’re going to pretend it doesn’t exist,’ ” Doyle says. “We’re going to talk about what we really believe in. If we could collectively imagine the best organization for kids in the world, what would it look like?”

Everyone agreed that EMQ should focus on providing families with the services and supports they need to keep emotionally disturbed and mentally ill children at home. “We think that before you move any kid from his home, you ought to ask what would it take to keep him there safely,” Doyle says. “Kids need families.”

The staff then looked for promising practices around the country. They particularly liked what they learned about wraparound, a home-based intervention used successfully at Kaleidoscope, a nonprofit agency in Chicago, and in statewide initiatives in Alaska and Vermont.EMQ took the best wraparound practices it saw and modified them to fit the needs of Santa Clara’s population, one of the most ethnically diverse in the United States. (A language other than English is spoken in almost half of the county’s households.) EMQ enlisted five parents of special needs children to help design its model.

In 1994, in partnership with the county departments of social services, juvenile probation and mental health, EMQ launched California’s first wraparound program, called UPLIFT (Uniting Partners to Link and Invest in Families of Today). The program was reserved for “Level 14” youth: those living in the highest level of residential treatment (one step down from a locked psychiatric unit) because of multiple, complex mental health and behavioral problems.

At the time, keeping a child in a Level 14 facility in California cost $5,013 a month, not counting treatment. Today it costs $6,371.

When a child came into UPLIFT, the agency “wrapped” his family with services like counseling, family therapy and in-home family support. Family service teams also linked the family to formal and informal community supports that the family could count on indefinitely, such as recreation centers, faith-based organizations, tutors and mentoring programs.

In some cases UPLIFT helped with housing, food, childcare, transportation and utilities. The families themselves decided what they needed.In the parlance of the social services world, EMQ’s wraparound model was strength-based, child-focused, family-centered, collaborative, team-based and needs-driven. It was a far cry from the medical model that EMQ had employed before.

“The wraparound philosophy directly confronts the existing paradigm, ‘I’m the therapist. Let me tell you what you need to do to get your life together,’” Doyle says. “We focus on what’s right with the family and help them build their plan for their kid.”

Job on the Line

Settling on a new approach was one thing. Figuring out how to pay for it was another. There was no funding for wraparound in California.California’s system of services is state-supervised and county-administered – which means, in essence, that there are 58 different systems. The state covers 40 percent of the non-federal share of residential care, with the county paying 60 percent. That meant EMQ had to persuade both the county and the state to pay for wraparound. EMQ had a good relationship with Santa Clara County, so Doyle began there.

“Right now, you’re spending about $10 million a year for 130 residential treatment beds,” Doyle recalls telling county officials in 1993. “We propose to shut down 100 of our 130 residential treatment beds. But we’d like you to keep giving us the same amount of money, which we’ll use for wraparound services. There are no immediate cost savings to you. The benefit will be better outcomes.”

The county agreed, which meant EMQ could count on $3,008 a month for each child receiving wraparound services. The agency decided to draw on its reserves to subsidize the rest of the cost while it worked on state legislation to allow foster care money to be used to help children in their own homes.

“We started shutting down beds based upon our faith that we could make it happen,” Doyle says. “It was a leap of faith.” The first bill that EMQ promoted in the Legislature, in 1993, never got out of committee. Although EMQ got enabling language inserted into a budget conference committee report, the language was dropped at the last minute. EMQ tried both approaches again in 1994. This time, Eloise Anderson, director of the California Department of Social Services, asked EMQ to back off because she feared that Gov. Pete Wilson (R) would veto a wraparound bill. She told Doyle that she would try to get the money for EMQ administratively. But other administrators in Sacramento nixed that idea.

“Convincing other people in state government that we could use foster money to support kids in their families was like trying to convince them that they could jump off a building and be safe,” says Anderson, now director of the Claremont Institute’s Program for the American Family. “They weren’t going for it.”

Without state reimbursement for its wraparound clients and with 100 fewer residential treatment beds, EMQ’s annual revenues plummeted to $8.8 million in 1994, down from nearly $12 million in 1991. Doyle had to lay off 100 of the 265 staff members.

Relief appeared to be on the way in 1995, when the Legislature approved a budget conference committee report that included state funding for wraparound. But Wilson used his line-item veto authority to eliminate it. Meanwhile, EMQ’s deficits grew.

“We’d lost $166,000 the first year we did wraparound, $204,000 the second year, $240,000 the third year, and then almost $700,000 in the fourth year,” Doyle recalls. “That was the year I almost got fired.”

So EMQ rethought its legislative strategy.“We had learned some things,” Doyle says. “We learned that if we wrote this legislation in a way that scared the whole group home industry, we were never going to get anything passed. So we proposed instead a demonstration program in Santa Clara County only.

“And we had learned also that, because we had a Republican governor, we better get a Republican sponsor if we wanted him to sign it.” EMQ got state Assemblyman Jim Cunneen, a Republican from its area, to become the principal sponsor.

In 1996, the Legislature unanimously approved the use of state funds to provide wraparound for up to 125 children annually during a five-year demonstration program in Santa Clara County. Wilson signed the bill.

“Thank God,” Doyle says, “because I was about to lose my job.”

‘Works Better Than Anything’

Almost as soon as the ink dried on the 1996 law, other counties in California began clamoring for wraparound funds. In 1997, Los Angeles and Sacramento counties asked the Legislature to expand the pilot project statewide. It did so through a law that, at EMQ’s suggestion, also set statewide wraparound standards and required training and technical assistance by state-approved trainers before state funds could be used. (EMQ’s Family Partnership Institute, started in 1996, became the sole provider of state-paid technical assistance on wraparound, with a contract worth $363,000 this year.)

Also in 1997, California received a waiver from the federal foster care program, Title IV-E, to use federal foster care money for wraparound services in a demonstration project in up to 12 counties. EMQ went back to the Legislature one more time, in 2000, to expand wraparound eligibility to more children (those living in or likely to be placed in Level 12 or 13 group homes) and to end the enabling law’s sunset provision, which would have stopped state funding for wraparound in October 2003.

“That law was very easy to get passed because by then, everybody had seen that this does work,” Doyle says. “If wraparound is done well, it works better than anything else out there. Parents who have gone through this with their kids say they feel like they’ve got their lives back under control, that their kids are on track, and that they did it.”

Brad Norman is director of EMQ’s Family Partnership Institute, which provides technical assistance to the 30 California counties that are implementing wraparound. “Every large county in California is using wraparound, and many smaller counties are, too,” he says. “In a county like Del Norte, they may only be serving six families. But before they had wraparound, those six kids had would have been shipped to high-level group homes in other counties, because Del Norte didn’t have its own.”

The incentive for counties is twofold, Norman says. “It is going to cost them less in the long run, because the kids are more likely to spend a shorter time in wraparound and be less likely to have to return for additional services. And the courts can end their jurisdiction earlier, with all the costs associated with that. But the biggest incentive is that it works.” (See sidebar.)

As of January, the state Department of Social Services was helping to pay for wraparound for 630 children, most of them foster children. In addition, 373 foster youth and 37 youth on probation were receiving wraparound as part of the federal demonstration project. Others receive wraparound services through the Department of Mental Health (via Medicaid’s Early Periodic Screening, Diagnosis and Treatment program) and county probation departments, with grants from the state Department of Corrections.

Hurdles Ahead

Although the use of wraparound is expected to grow in California, barriers to expansion remain.

One is a control group requirement for gaining access to federal foster care dollars. For every five children who receive federally paid wraparound services, three children must go into group homes. Many California counties, including Santa Clara, find that requirement repugnant, so only five are drawing federal funds for wraparound – Los Angeles, Alameda, San Luis Obispo, Sacramento and Humboldt.

In addition, the culture in many agencies must change before wraparound services can be regarded as mainstream, proponents say. “Working with families in their homes is a whole different way of thinking about things,” notes Schroeder of the California Alliance of Child and Family Services. “And offering wraparound requires a certain amount of collaboration between mental health and child welfare, which varies wildly from county to county, and is certainly not modeled at the state level.”

Despite sinking into the red while working to change state law, EMQ has no regrets about its role in bringing wraparound to California. In 1992, residential treatment had generated 72 percent of EMQ’s billings. Today, residential treatment accounts for just 15 percent, with wraparound services accounting for 42 percent, foster family services 12 percent, and the rest coming from non-residential services such as crisis intervention and addiction prevention. “Our mission is to work with kids and families to transform their lives,” Doyle says. “But it also is to transform the systems that serve them, because we think that the systems that work with kids often do more harm than good.”