Individual Care Grant Program Fiscal Year 2009 Report
Myra Kamran, M.D.
Deputy Clinical Director
- Constance Williams, Ph.D.
Associate Deputy Clinical Director
- Seth Harkins, Ed.D.
Coordinator, ICG Program
- Illinois Child and Adolescent Service System
Division of Mental Health
Illinois Department of Human Services
- November, 2009
- Application and Appeal Data
- Community ICG Data
- Residential ICG Data
- Annual Review
- Transition to Adult / Community / Independent Living
- Fiscal Data
INDIVIDUAL CARE GRANT PROGRAM Fiscal Year 2009 Report
Introduction This report recounts the demographic and clinical characteristics of children and adolescents who received services funded by the Illinois Department of Human Services, Division of Mental Health, Individual Care Grant (ICG) program, as well as highlights the treatment needs of seriously emotionally disturbed youth. The goal of this report is to present useful information to the child and adolescent services community, as the child and adolescent service system continues to provide child-centered and family-focused treatment.
History The ICG program was established by Illinois State legislation in 1969. In 1987 the administrative rule, Title 59 of the Illinois Administrative Code, Part 135, was established to govern the administration and operation of the ICG program. The ICG program also functions in accordance with the Consent Decree in R.R. v. Kiley (1987), which requires that all applicants declared eligible must be funded. The ICG provides financial assistance to the parents or legal guardians of severely mentally ill children and adolescents. It funds residential treatment or specialized, intensive community mental health services to severely mentally ill children and adolescents.
The ICG program became a part of the Metropolitan Child and Adolescent Network in 1998, and has since matured as a significant component of the Child and Adolescent Mental Health Service System. The program currently serves five Comprehensive Community Service System regions in the state of Illinois. In January of 1999, Rule 135 was revised. The eligibility age was extended to 21 for youth enrolled in high school. The review process also changed. Instead of a panel of three, one person reviews initial applications and Secretary-level appeals. The community-based service option was formally added to the administrative rule. Rule 135 allows for community-based services before, after and in lieu of residential treatment. Additionally, all Individual Care Grant cases are reviewed annually to determine continued eligibility for funding.
On April 1, 2008 the ICG program initiated another change in its operations, as the Division of Mental Health contracted with the Illinois Mental Health Collaborative for Access and Choice (the "Collaborative") to assume administrative and procedural functions for the residential treatment portion of the ICG program. As a result, this administrative service organization processes application requests, receives applications, and evaluates applications for initial eligibility determinations. Additionally, the Collaborative reviews Quarterly Reports and Annual Eligibility Reviews. Beginning April 1, 2009, 59 Illinois Administrative Code 132 (Rule 132) was applied to the ICG program ICG billing functions for residential and community-based services were performed through the Collaborative's billing system, ProviderConnect. At this time, the Collaborative assumed responsibility for the community-based ICG program. With the transition to Rule 132 services, providers were required to bill treatment encounters consistent with the State of Illinois Community Mental Health Services Service Definition and Reimbursement Guide. Moreover, providers were required to register ICG youth in ProviderConnect and nights of stay were authorized every ninety days. Further, residential providers were expected to facilitate Medicaid eligibility in accordance with Medicaid Category 94R, which waives family income as a requirement for eligibility on the ninety-first day of residential treatment. To facilitate this transition training events were conducted via webinars, face-to-face trainings, and weekly technical assistance calls.
Screening Assessment and Support Services (SASS)
Forty-four SASS agencies form the administrative arm of the ICG program at the community mental health level. SASS agencies are geographically grouped by region and local area networks (LANs) and provide an array of crisis as well as mental health care services to children and their families. Individual Care Grant applicants are referred to the ICG coordinator at their neighborhood SASS agency for assistance in the application process. When an ICG is awarded, an ICG/SASS coordinator helps the family to determine the type of services best suited for the Individual Care Grant recipient. The coordinator then collaborates with the parent/guardian to facilitate placement with a residential facility, or devises a plan for the provision of intensive community-based services. The ICG/SASS coordinator also provides ongoing case coordination to ICG families. This intensive service includes regular home visits, communication with service providers, and transition planning. ICG/SASS Service Requirements: Residential ICG Services Beginning July 2004, and revised in ICG Services Provider Manual (2009) the following ICG/SASS support services were instituted for community-based ICG services:
- Provide families with information that will help in the decision of applying for an ICG.
- Assist families with the documentation compilation necessary to apply for an ICG.
- Assist families in submitting a completed ICG application.
- Compile application packets for those families seeking residential services.
- Collaborate with parent/guardian, ICG youth, and residential treatment providers to develop, implement, and evaluate the individual treatment plan.
- Provide clinical services in accordance with Rule 132.
- Maintain ongoing facilitative relationships with families, schools, and the child's community in order to support the service plan.
- *Provide at least quarterly meetings with the family and the residential case manager for those youth receiving residential services.
- Provide monthly contact with the client's family for those youth receiving intensive community-based services.
- Travel to residential facilities twice a year if placed in Illinois.
- Provide quarterly and annual review reports to ICG Office.
- Assist parents/guardian with completing forms necessary for the Annual Review process.
- Assist with the discharge and transition planning when an ICG recipient transitions out of the ICG program to adult services.
- Facilitate Medicaid eligibility for youth in residential treatment for more than 90 days. In addition to the above services, ICG/SASS personnel participate in DHS/ICG training or meetings specific to residential or intensive community-based care.
ICG/SASS Service Requirements: Intensive Community-based Services
- Beginning July 2004, and revised in the ICG Services Provider Manual (2009) the following SASS-ICG support services were instituted for community-based ICG services:
- Acquire and maintain knowledge regarding intensive community-based services.
- Acquire and maintain knowledge about Rules 132 and 135.
- Have comprehensive knowledge regarding multi disciplinary and multi systems resources in the community.
- Coordinate and interface with multiple providers involved with each ICG client so that the client receives comprehensive community-based services.
- Offer the array of intensive community-based ICG services or the ability to build and maintain relationships or alternate agreements with agencies or parties that can offer the array of community-based ICG services. These services include: Support Services, Therapeutic Stabilization, Behavior Intervention, and Young Adult Services.
- Assure that services provided through alternate arrangements follow the treatment plan and are provided as intended.
- Complete an initial assessment with the child, family, and other services providers such as school, residential, and outpatient clinicians to develop a plan for services.
- Complete documentation necessary to obtain approval and authorization after funding thresholds have been met for 72M Child Support Services and 97M Behavior Intervention Services.
- Assist family with annual review documentation.
- Facilitate application for Medicaid.
- Submit quarterly reports of treatment progress.
- Submit annual review documents for continuing eligibility decision.
- Provide staff to attend DHS / ICG training, or meetings specific to intensive community-based care.
- Maintain weekly communication with the family for the first month of community ICG services and at least monthly thereafter. Monitor satisfaction with the service provision. Assist the family with problem-solving during the service delivery period.
- Maintain documentation of the support services rendered and provide that documentation to DHS / ICG program office upon request.
- Provide ongoing support functions to families regarding educational and other needs of the child, including advocating for the child within the school and support in the community.
- If the child is returning from residential treatment into the community, communicate with the residential provider and insure that a coordinated plan of care is available to the child and family at the time of discharge.
- Assist with the transition planning when an ICG recipient transitions out of the ICG program, to residential, or to adult services.
Application and Appeal Data
Families interested in applying for an ICG contact the Collaborative at 773-794-4884 or 866-359-7953. A brief phone in-take is conducted and an application is sent to the parent / guardian. A number is assigned to each application to allow for tracking of applications. When an application is sent to the family, the ICG/SASS agency in the family's geographic area is notified of the application request. SASS agencies provide assistance to the family in compiling the information for the submission of the application.
During FY2009, there were 807 applications requested and mailed to parents, an increase over FY2008. During this period 255 applications were submitted to the Collaborative for eligibility determinations. This was a decrease over FY2008. Forty-eight ICGs were awarded in FY2009 (Table 1 and Figure 1). This represents a decline of 20 awards over FY2008. However, the award rate for FY2008 and FY2009 were just about the same with 18% in FY2008 and 19% in FY2009.
When an application is approved, the Collaborative sends a Letter of Eligibility Determination to the parent / guardian and ICG/SASS agency, so the ICG/SASS coordinator can assist the family in making a decision about whether to use the ICG for residential or intensive community-based services. ICG/SASS coordinators further assist in locating an appropriate residential treatment facility or arranging intensive community-based services.
When an application is denied in the initial review, parents have the option of requesting an appeal of the denial. Of the 260 applications reviewed in Fy 2009, 103 applications were denied. Forty-one parents appealed the decisions to deny eligibility. Of the appeals, 2 decisions regarding initial applications were overturned (See Figure 3). The total number of appeals (initial application and annual review denial decisions) for FY2009 was 46 with a 15.22% overturn rate. This represents an increase in the overturn rate compared to previous years.
The number of ICG open, active cases fluctuates during the course of the year. It is important to distinguish between the number of clients served during the fiscal year and the number of active cases at the end of the fiscal year. The service chosen, community or residential, can also fluctuate daily as a client may move out of the program or from one service type to another. Throughout fiscal year 2009, 445 children and adolescents used Individual Care Grants. This is a decrease when compared to FY2008. As of June 30, 2009, there were 369 active cases. This contrasts to 421 on June 30, 2008. Of the total number of children served, 203 or 39% were served in the community. As of June 30, 2009, 224 ICG or 61% of ICG youth received residential treatment services and 145 used community-based ICG services. It is also worthy of note that 76 ICG recipients exited the ICG system either due to discharge, high school graduation or attaining age 21.
Table 1. Application Data (FY 1995 - FY 2009) (doc)
- Figure 1. Application Data
- Figure 2. Grants by Region
- Figure 3. Appeal Decisions for Initial Application
- ICG Program Eligible Applicant Demographics
- Figure 4. Clinical
- Figure 5. Sex Ratio of ICG Recipients
- Figure 6. Race Ethnicity of FY 2009, New ICG Recipients
- Figure 7. Adoption Ratio of New ICG Recipients in April 2008 to April 2009
The Individual Care Grant finances intensive community-based services. When a parent chooses specialized community services, the child remains at home and the local mental health agency develops an initial treatment plan. Four types of services can be received through the community:
- Behavior management interventions is time limited, child and family training/therapy which focuses on amelioration or management of specific behaviors that jeopardize the child's functioning in the home/family setting.
- Child support services is time limited funding that covers the cost for the child to participate in community activities when those activities are related to objectives in the child's current individual services plan.
- Therapeutic stabilization is an essential part of in-home services, providing a timely one on one relationship between the child and a SASS agent for the purpose of facilitating age appropriate, normalizing activities for the child.
- Young adult support services is time limited funding for young adults to cover the costs of services and supports, not included under other programs for which the person may be eligible, to aid the young adult in his or her transition to community living. These funds can be applied to the costs of a supported living arrangement or other appropriate transitional services that help integrate the young adult into his or her adult role in the community.
In many cases, specialized community-based services can alleviate the necessity of residential placement. Using the grant in the community assists parents in providing the extra structure and therapeutic interventions that make it possible for a child/adolescent to continue to live at home and in the community. One hundred forty-five children/adolescents used community services during fiscal year 2009. The average approved cost of community-based ICG services was $20,356.45. The highest community-based client cost was $66,493.83.
Community Services Reporting
SASS Agencies by LAN (doc)
Figure 8. Community and Residential Ratio (doc)
The parent of an ICG recipient may choose to receive residential treatment. Residential treatment can be a group home, or a 24-hour supervised residential facility. The ICG program contracts with residential facilities that offer therapeutic environments and treat children and adolescents with severe emotional disturbances. All residential facilities are licensed by the Department of Children and Family Services, or like agency if the facility is outside of the state of Illinois, and residential school programs are approved by the Illinois State Board of Education.
Currently, there are 31 contracted residential treatment providers. Seven active are out-of-state facilities. Seventy-five percent of ICG recipients who use their grant for residential treatment choose a facility within Illinois. Of the 25% of ICG clients that were placed out-of-state, the majority of these clients were placed in residential treatment centers in the adjacent states of Wisconsin and Missouri. Parents are encouraged to be active participants in their child's treatment. Placement in Illinois, close to the child's home community, is preferred and makes parental and family involvement possible and easier.
Residential providers complete quarterly reports that document diagnosis, treatment progress, treatment plans, medication, target symptoms, types of therapy used, family involvement and discharge planning. The ICG utilization reviewers analyze each quarterly report looking at eleven criteria: reason for admission, discharge criteria, treatment plan goals, individual therapy, family therapy, discharge plan, specialized treatment, diagnosis, family involvement, justification for continued treatment and overall quality of the report. Residential nights of stay are authorized every ninety days based on the quarterly report.
Range of Residential Annual Costs Per Client
Lowest per diem rate = $164 daily or $60,017 annually
Highest per diem rate = $397.51 daily or $145,091 annually
Mean per diem rate = $290.24 daily $105,937.60 annually
Residential Facilities (doc)
Annual Review and Quarterly Review
In February 2000, the Individual Care Grant Annual Review process was initiated. A determination for continued eligibility is made for each Individual Care Grant recipient on the anniversary of the initial eligibility determination letter. Continuing eligibility is based on parent participation in the treatment, continued need for intensive community or residential treatment, and clinical information received from the provider. In FY2009, 111 annual reviews were conducted.
Quarterly reviews are conducted for each ICG youth to ensure the most up-to-date diagnosis and monitoring of progress. Each quarterly review results in an authorization of ninety nights of stay. In FY2009 73 quarterly reviews were conducted.
Mental health diagnoses are found in the Diagnostic Statistical Manual IV. The most prevalent Axis I primary diagnoses of children/adolescents who received an annual review were Bipolar Disorders (Bipolar Disorder, NOS, Bipolar I, and Bipolar II) and Psychotic Disorders, which account for 68% of the Annual Review clients for FY2008 (Figure 12a). Annual Review Axis II primary diagnoses indicate 18% challenged with mental retardation and another 8% challenged with borderline intellectual functioning. Thirty percent of Axis II primary diagnostic data indicated no diagnosis and 26% were diagnosed other (Figure 12b).
Figure 9. Age Distribution of Annual Review (doc)
Adolescents and young adults in the ICG program who are age 17 or above begin a process of transitioning to adulthood and therefore adult services. Twenty-six percent of the Individual Care Grant population are in the transition group. Seventy-six ICG clients exited the ICG program in FY2009. Of the 76 clients, the ICG Office determined where the following 57 youth went upon exiting the program:
- 33 returned home
- 8 exited the program due to graduation
- 4 went to college
- 3 returned home to a relative
- 9 transitioned to adult group homes
- 3 went to permanent supportive housing
- 1 went to a transitional living program
- 1 went to independent living
- 1 went to a nursing home
- 1 went into DCFS custody
- 1 went to adult forensics
The responsibilities of the ICG program office in the transition process includes providing quarterly spreadsheets to each region, identifying all individuals in their area funded by an ICG, and notifying the appropriate adult network when an annual review has been completed for a youth age 17 or older. The results of the annual review are then forwarded to that network. Supporting documentation, also submitted to the adult network, includes the youth's address and telephone number (based on the parent/guardian address), the current diagnosis, level of functioning, treatment plan, educational status and planned date of discharge. The ICG office acts as a conduit for the initial contact between the ICG provider and the adult network so that any discharge barriers can be addressed. The ICG office forwards any relevant clinical information from the file of the transitioning youth to the adult network, along with recommendations. The ICG program may also assist the network in the development of a plan for transition into adult services.
The adult network notifies the local community mental health agency of the transitioning youth. The community mental health agency and adult network then reviews the clinical material to make a determination of potential service needs. This enables the network to ascertain the needs of the youth that is exiting the ICG program. This notification should occur a year prior to the youth's eighteenth birthday.
The local mental health agency assumes the responsibility for implementing the transition plan and assisting the young adult in accessing other state and federal entitlements. When appropriate, the community mental health agency submits a plan to the network requesting funds under the Transition to Adult Services program to be used to facilitate the young adult's reintegration into the community. Funding under the Transition to Adult Services program must be approved by the network, and is limited to one calendar year after the client has exited the ICG program. ? ICG clients applied for and received transition-to-adult services funding under Program 330.50.
Figure 12. Age Distribution of Transition Group - FY 2009 (doc)
Figure 14a. Axis I Primary Diagnoses of Annual Review Transition Group and Figure 14b. Axis II Primary Diagnoses of Annual Review Transition Group (doc)
Individual Care Grant Program Fiscal History
A review of the history of appropriations and expenditures from FY1998 to FY2007 indicates a fluctuation of expenditures within and outside the appropriation. Grant awards are based on the consistency of the clinical information submitted and the criteria for severely impaired reality testing, as defined in Title 59 of the Illinois Administrative Code , Part 135 (Table 2).
Table 2. ICG Fiscal History (FY 1998 - FY 2007) (doc)