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Response to RCW 13.34.803 (Chapter 13, Laws of 1998, Section 40) 

Executive Summary

RCW 13.34.803 requires the Department of Social and Health Services (DSHS) and the Department of Health (DOH) to design a comprehensive program for Medicaid-eligible women who gave birth to a drug or alcohol exposed infant. That program is to be based on an inventory of program services and gaps and a fiscal impact analysis. This report summarizes the results of those reviews and analyses and presents the proposed program.

The Comprehensive Program
The comprehensive program seeks to improve the health and welfare of substance-abusing mothers and their children by early identification of pregnant substance abusers, improved access to and coordination of health care services and chemical dependency treatment, and family-oriented early intervention services for mothers and their children. This program, described in detail on pages 33-43, involves expansion and coordination of the following six core services.

Targeted Intensive Case Management (TICM): This comprehensive plan is built around intensive case management for these women and their families. Ideally this case management would begin prenatally and continue until the child's third birthday. The targeted intensive case management team would: provide active outreach; develop and monitor the case plan; refer and establish linkages to community; coordinate the PROFESSIONALs working with the family; screen for delays in the children; provide early childhood development skill training for parents; offer family planning education and referrals; provide behavioral health services and education to families, and monitor or provide in-home child development activities.

Flexible Funding for Rural Areas: Ten percent of these mothers and children live in the 24 counties with fewer than 25 substance-using women and children per year. In these areas, it would be extremely costly to provide the full team for Targeted Intensive Case Management. However, under this section, these communities could apply for funds to train current Maternity Case Management staff in child development/parenting techniques or to hire on a contract hourly basis a behavioral health counselor to bring those component activities into rural communities.

Child Development Services: The period from birth through three years of age is critical for brain development. Appropriate child development activities, coordinated by the case manager, would delivered in child care centers or at home. The standards for the appropriate amount and kind of child development activity would be the Early Head Start standards.

Family Planning Services: Family planning education and referral to appropriate services would be part of intensive case management and chemical dependency treatment.

Enhanced Residential and Outpatient Chemical Dependency Treatment for Pregnant and Parenting Women: Traditional chemical dependency treatment would be enhanced to include on-site child development services and education, child care, family planning education, family issues including domestic violence, and enhanced vocational services.

Transportation and Housing Funds: To support women and families as they transition from residential to outpatient treatment modalities, transportation and housing funding would be needed to decrease barriers to accessi/ms/rdang services and provide housing supports necessary for stability and maintenance of recovery programs for women and their children.

The plan also includes a central evaluation component, for monitoring and development and implementation of a program evaluation.

Inventory of Community-based Programs
A continuum of family-oriented services was identified. These include: chemical dependency treatment; mental health services; housing; family planning; outreach; First Steps (Maternity Support Services and Maternity Case Management; parenting education/parent support; Women, Infants and Children (WIC); vocational programs or employment; financial support; medical services; medical coverage for pregnant women in county jails; child care; early intervention services for children at high risk for health, behavioral, and developmental problems; and child welfare/child protective services. Most of these services are also utilized by families without chemical dependency issues, but are especially critical for this vulnerable population.

Details on these community-based services and the gaps in their coverage may be found in Appendix F. The most important gaps include: a shortage of residential and recovery beds for pregnant and parenting women; no case management after age one; limited outreach or intensive case management during pregnancy and the first year of life; no systematic developmental screening or developmental planning for these children; limited child development training for parents; limited mental health counseling or training dealing with family issues, and ongoing problems with transportation and housing which foster treatment attrition.

Fiscal Impact Analysis and Literature Review
The studies reviewed indicate that the following characteristics of a comprehensive program are most likely to yield successful outcomes:

• Family-focused services that address the needs of both mother and child.

• A continuum of services from early pregnancy through childhood, with varying levels of intensity appropriate to individual needs.

• Coordinated or, ideally, collocated services (such as health care, drug treatment, family planning, parenting education, and early intervention).

• Chemical dependency treatment tailored to the needs of women, with a continuum of care including detoxification, intensive treatment (residential or outpatient), with aftercare and follow-up outpatient care.

• Parenting skills training and family relationship enhancement to promote continually-improving parent-child relationships.

Nearly three hundred published reports were reviewed to determine (1) rates of use of publicly-funded services (medical, juvenile justice, public assistance, and dependency) by substance-abusing mothers and their children and (2) changes in the baseline service use rates that would potentially result from a comprehensive plan. Actual data from Washington State were compiled when available. (The literature is discussed on pages 5-12; the fiscal impacts on pages 13-29)

The fiscal impact analysis suggests potential long-term reductions in government expenditures per 100 mothers and children fully served in a comprehensive program of $6.26 million ($3.5 million general fund state). These impacts were, as directed by the legislature, in the areas of medical, juvenile and adult justice, public assistance, special education, and dependency systems. They accrue gradually, between the birth and nineteenth birthday of the program child. Most occur after the program child is six years old.

Conclusions
Three-year new costs to implement the comprehensive program for each 100 mother-child pairs were estimated at $3.4 million overall, $2.1 million general fund state. These costs include start-up costs and initial administrative overhead. The costs for program services which the family would already use (such as TANF childcare) were displayed in the budget spreadsheets, but were subtracted from the overall program costs, since they were not new services. (These costs are detailed for the average mother/child pair in the program in Table 3, page 51).

As Table 1 below shows, the difference between the estimated three-year new program costs, and the fiscal impact over 18 years following program implementation indicates a potential savings of $2.8 million, $1.4 million general fund state, for each 100 mother-child pairs fully engaged in the program

Table 1: Costs to Serve 100 Mother/Child Pairs in the Comprehensive Program, Compared with Potential Fiscal Impacts (Savings) in Medical, Juvenile and Criminal Justice, Public Assistance, Special Education, and Dependency Systems

	Overall Potential Impact for 100 Mother-Child Pairs	State Share of Potential Impact for 100 Mother-Child Pairs
Fiscal Impacts (Savings) while program child is under 6 years of age	$ 826,858	$ 330,611
Fiscal Impacts (Savings) while program child is between 6 and 19 years of age	$ 5,431,796	$ 3,170,759
Total Fiscal Impacts (Savings) through program child's 19th Birthday	$ 6,258,654	$ 3,501,370
New Program Costs, delivered while program child is under 3 years of age)	($ 3,427,000)	($ 2,104,000)
NET SAVINGS	$ 2,831,700	$ 1,397,370

Despite these savings, the comprehensive program could be difficult to fund statewide. Enrolling and serving all the 2,600 women and children eligible in one year would cost over $30 million each year ($14.4 million in general fund state). (For details, see spreadsheet page 55).

The recommended strategy for reducing implementation costs for this comprehensive program is to identiFiscal Year a set of pilot sites to test three versions of this comprehensive plan. With a preliminary evaluation at these initial sites, it could be determined whether outcomes change more or less than predicted and whether efficiencies in program operations could be gained. (Costs, pilots and other cost-reduction options are discussed on pages 45 through 58).

Decision-making around this program should recognize that limited program areas were addressed by the fiscal impact analysis. The fiscal impacts do not represent all direct or indirect potential savings that might result for the mother and her child, or to the state if such a comprehensive program were implemented. A number of intangible benefits are likely to occur in addition to those identified; these could include reduced mortality, reduced crime victim costs, and improved self-esteem and life accomplishments for mothers and their children.

Modified: Thursday November 17 2005

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