Implementation
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Wraparound Milwaukee: Aiding Youth With Mental Health Needs

Wraparound Milwaukee adapted the Wraparound process to its system of care in some very unique ways. In Milwaukee, the multiple needs of youth who cross juvenile justice, child welfare, and mental health system lines are coordinated through a public managed care organization. Youth and families are offered enrollment in a type of social/medical health maintenance organization (HMO) with a comprehensive benefit plan that offers more than 60 services. These services are individualized for each youth and family, based on their identified needs.

History

Wraparound Milwaukee is part of the Milwaukee County Human Services Department, Milwaukee County Mental Health Division, which provides juvenile probation and child welfare services. In 1994, Milwaukee County received a 5-year Federal grant from the Center for Mental Health Services to initiate system reform in the community. Although Wraparound Milwaukee experienced initial success in providing services to youth and families in the mental health system, it was not until it targeted youth in the child welfare and juvenile justice systems that it demonstrated the effectiveness of the Wraparound approach with youth who have multiple needs.

Mental Health Issues of the Population in Wraparound Milwaukee

  • Predominant diagnoses when using the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition, DSM-IV (American Psychiatric Association, 1994). Ninety-seven percent conduct disorder/oppositional defiant, 58 percent depression, 44 percent attention deficit, and 42 percent serious alcohol and substance abuse problems.

  • Primary identified concerns at intake for youth. Fifty-two percent school/community, 40 percent acting out, 37 percent alcohol and substance abuse, and 33 percent severe aggressiveness.

  • Attempted suicide. One in eight youth.

  • Primary family concerns at intake. Fifty percent of parents have significant abuse issues, 33 percent of parents have a history of domestic abuse, 24 percent of parents have been incarcerated, and 22 percent of families have documented mental illness.
In May 1996, Wraparound Milwaukee initiated a pilot project, The 25 Kid Project, to use Wraparound philosophy with both delinquent and nondelinquent youth placed in residential treatment centers. Prior to this project, child welfare and juvenile justice placements had reached record proportions—more than 360 youth were in placement on an average day at a cost of more than $18 million per year. Wraparound Milwaukee targeted 25 youth in residential treatment centers, identified by child welfare and juvenile justice professionals, who had no immediate discharge plans. The goal was to demonstrate that by using a Wraparound model most of these youth could be returned home or to community-based foster or kinship care, that they could be maintained safely in those settings, and that it would cost less than a residential placement. Within 90 days, Wraparound Milwaukee returned 17 of the youth to the community. Eventually, 24 of the 25 youth were placed in the community. Seven youth entered foster homes; the remaining 17 successfully returned to their families.

Key Components

The structural and design aspects of Wraparound incorporate components of care that are integrated to meet the specific needs of each child and family. The following components are essential to the success of the project:

Bullet Care coordination. Care coordinators are the cornerstone of the system. They perform strength-based assessments, assemble the Child and Family Team, conduct plan-of-care meetings, help determine needs and resources with the youth and family, assist the team in identifying services to meet those needs, arrange for community agencies to provide specific services, and monitor the implementation of the case plan. Care coordinators in the Wraparound Milwaukee Project typically work with small caseloads (a ratio of one worker to eight families), which provides more time for the personal contact needed to work with youth with complex needs.

Bullet The Child and Family Team. Wraparound plans are family driven. The care coordinator asks the family to identify all those who are providing support to the family. With this information, the care coordinator assembles the family members; the family's natural supports such as relatives, church members, and friends; and systems people, including probation or child welfare workers. These individuals form the core of the support system for the child and family.

Bullet A mobile crisis team. To meet the needs of youth and families when a care coordinator might not be available, 24-hour crisis intervention services are available through the Mobile Urgent Treatment Team. The team consists of psychologists and social workers trained in intervening in family crisis situations that might otherwise result in the removal of youth from their home, school, or community. Youth participating in Wraparound are automatically enrolled in this crisis service, and their care plans include a crisis safety plan that the team can immediately access. The Mobile Urgent Treatment Team reviews all requests for inpatient psychiatric hospital admissions and operates two 8-bed group homes that provide short-term (up to 14 days) crisis stabilization. The crisis team and care coordinator work with the family to return the child to the community. Because of the crisis team's availability, Wraparound Milwaukee has nearly eliminated the use of inpatient psychiatric care for most youth in the project.

Bullet A provider network. Wraparound Milwaukee has an array of services and resources to respond to the multiple needs identified by families. This enables the program to move beyond the few categorical services historically prescribed for youth and families. As a result, Wraparound has expanded its portfolio of services from 20 to 60. Practitioners provide services on a fee-for-service basis, with Wraparound setting the price of each category of service. Rather than creating fixed-price contracts, vendors apply to provide one or more of the services as part of a provider network. The provider network now includes more than 170 agencies, a number that allows for a diverse list of providers and increases the choices families have when selecting agencies in the network from which to receive services.

Managed Care and Blended Funding

Because Wraparound Milwaukee blends system funds, it can provide a flexible and comprehensive array of services to delinquent youth and their families. Wraparound Milwaukee pools funds through case rates paid by the child welfare and juvenile justice systems, receives a monthly capitation payment for each Medicaid child enrolled, and coordinates other insurance and Supplemental Security Income payments to form a type of insurance pool. In 1999, Wraparound Milwaukee received more than $26 million in pooled funds. The child welfare and juvenile justice systems fund Wraparound at $3,300 per month per child. Prior to Wraparound, these funds were used entirely for residential treatment care for which the systems paid $5,000 or more per month per child. The $1,542 per month per child capitation payment from Medicaid covers the projected cost for all mental health and substance abuse services and is based on pre-Wraparound actuarial costs for services for these youth.

After all funds are pooled and decategorized, Wraparound Milwaukee can use them to cover any services that families need. Wraparound offers the same range of services to all enrolled families and covers any costs that exceed the pooled funds.

Informal Services

While Wraparound Milwaukee offers an array of formal services to youth and their families, informal services that the care coordinator and Child and Family Team identify through strengths assessment are often even more effective. The Wraparound care plan, therefore, should use a mix of formal and informal services. One family may identify a friend or relative whose positive relationship with the youth indicates suitability as a mentor. Another family may identify a relative to provide respite care to the parent. These supports will remain with the family beyond their enrollment in Wraparound Milwaukee. Other examples of informal supports are a neighbor who provides transportation, a local church with a peer support group, or a YMCA program that offers recreation and summer camp programs. These services often can be mobilized at little cost and offer the advantage of always being there for the youth and family in their own community.

Services in the Wraparound Milwaukee Benefit Plan
  • Care Coordination
  • In-Home Therapy
  • Medication Management
  • Outpatient—Individual Family Therapy
  • Alcohol/Substance Abuse Counseling
  • Psychiatric Assessment
  • Psychological Evaluation
  • Housing Assistance
  • Mental Health Assessment/Evaluation
  • Mentoring
  • Parent Aide
  • Group Home Care
  • Respite Care
  • Child Care for Parent
  • Tutor
  • Specialized Camps
  • Emergency Food Pantry
  • Crisis Home Care
  • Treatment Foster Care
  • Residential Treatment
  • Foster Care
  • Day Treatment/Alternative School
  • Nursing Assessment/Management
  • Job Development/Placement
  • Kinship Care
  • Transportation Services
  • Supervision/Observation in Home
  • Afterschool Programming
  • Recreation/Child-Oriented Activities
  • Discretionary Funds/Flexible Funds
  • Housekeeping/Chore Services
  • Independent Living Support
  • Psychiatric Inpatient Hospital


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Juvenile Justice - Youth With Mental Health Disorders:
Issues and Emerging Responses
April 2000,
Volume VII · Number 1