The National Wraparound Initiative (NWI) has demonstrated that wraparound—when the practice model is implemented as defined by the NWI— leads to positive outcomes for youth and their families. This evidence based approach to Wraparound is being implemented throughout the country for youth with serious mental health challenges and multi-system involvement.
Pennsylvania began implementing what is called High Fidelity Wraparound (to differentiate from previous “wraparound” which was not evidence based) in 2009. The Office of Mental Health and Substance Abuse Services (OMHSAS) established the Youth and Family Training Institute to provide the training, coaching, credentialing and monitoring of county-based HFW teams throughout the Commonwealth. OMHSAS worked with Mercer Human Services Consultants to develop a funding mechanism for High Fidelity Wraparound.
The 11 counties that have begun High Fidelity Wraparound have served over 700 youths and their families. In 2011, there were 113 graduates from HFW. Preliminary outcome studies for these youth show the following:
- · 70% of families reported moderate to a great deal of positive change in managing crises.
- · 79% of youth reported moderate to a great deal of positive change in the frequency, intensity and duration of crises.
- · 80% of youth reported things are getting better (less stress, improved relationships and improved optimism).
- · 51% improved their educational placement.
33% of the 113 HFW graduates had previous and/or current involvement with Juvenile Justice when they enrolled in HFW. Of these:
- · Only 5% re-offended by the time they graduated from HFW.
- · 60% were discharged from the JJ system while in HFW.
50% of the 113 HFW graduates were involved with Child Welfare. Of these:
- · 54% of these youth were discharged from the CW system by the time they graduated from HFW.
- · 48% of these were considered to be successful discharges.
In addition to these very promising data, there is evidence of the cost effectiveness of High Fidelity Wraparound. Pennsylvania has primarily utilized Medicaid to finance all related costs of providing and measuring HFW. Medicaid 42 CFR 438.208 authority allows managed care organizations to perform joint treatment planning involving identification, assessment and development of individual service plans, for high need individuals with special health care needs. The term Joint Planning Team (JPT) is the term for High Fidelity Wraparound financed with Medicaid funds through this authority.
OMHSAS requested that Mercer Human Services Consultants analyze the cost experience of some of the first counties that implemented HFW in Pennsylvania. The Mercer study was limited to five counties that utilized the JPT Medicaid funding approach and had sufficient enrollment in High Fidelity Wraparound to allow for an examination of the costs for six months after the HFW process was initiated for a youth and family. Mercer acknowledged the limitations of the study by noting that “…a typical JPT episode lasts 12 to 18 months, so a full accounting for cost-effectiveness should involve at least 12 months post enrollment in JPT. Furthermore, much of the cost savings attributable to JPT in the research base accrue after six months.”
Nonetheless, the data showed that for the 185 youth studied there was a 25% reduction in BH claims costs in the initial six months. This is consistent with a study in Maine that showed a 28% cost reduction in 12 month mental health costs for youth involved in Wraparound. In the Pennsylvania study, when total JPT costs are added back in, the savings cover the entire cost of JPT and still showed a 4.3% savings. Mercer concluded that “This level of savings in the initial six months is a strong indication of the cost effectiveness of the model.”
There were some specific findings that provided context to the study. Despite the overall trend, not all counties experienced cost effectiveness. The major driver of cost effectiveness in the first six months was the set of enrollees involving youth who received Residential Treatment Facility services sometime in the six months prior to JPT. The group of youth who were involved in Family Based Mental Health Services also experienced a cost reduction, though much smaller. Preliminarily, these data support the concept that HFW should focus on high needs youth and their families.
The study found that HFW for youth receiving Therapeutic Staff Support (TSS) had the potential to be cost-effective but reducing TSS has apparently not been a focus. Furthermore, the data show that JPT does not seem cost effective at the six-month point for children with Autism Spectrum Disorders.
The costs reviewed only include Health Choices behavioral health claims (Medicaid). The Mercer analysis noted that JPT can affect a wider range of costs, including placements and services by other child-serving agencies (for example, child welfare and juvenile justice placements paid for by the Office of Children, Youth and Families). Counties may incur a wide range of cost savings and other offsets related to JPT delivery outside of Health Choices. The Mercer study concluded that an analysis of these costs, as well as analysis of the data for one year after enrollment in High Fidelity Wraparound is expected to demonstrate even more significant cost savings.