While all that glitters may not be gold, this is a very hopeful vision for the future, and very easily adaptable to any community.
Wraparound plan delivers success at less cost
By SHAWN COHEN AND LEAH RAE
THE JOURNAL NEWS
(Original publication: December 15, 2002)
MILWAUKEE ? The "Wraparound" plan for treating disturbed children swept into Milwaukee like a Midwestern tornado, threatening to uproot institutions that had survived for decades.
Milwaukee County's landmark initiative would all but empty the institutions and move the youngsters back to their communities,
"wrapping" them with services such as in-home therapy, mentors and tutors at less than half the cost of the residential treatment centers, or RTCs. But RTCs wouldn't go without a fight: They were anxious to preserve a system netting them $80,000 a year for each child in their care.
These youngsters couldn't survive on the outside, they argued. In the end, the centers couldn't justify their existence.
"I remember meeting with groups of people and folks saying, 'Let's get some reports out that show they (Wraparound) are going to start hurting kids now,' " said Cathy Connolly, president of St. Charles Youth & Family Services, which operates Milwaukee's largest institution.
"Well, nobody could ever bring the reports to the meetings, 'cause there were none that existed that said we were doing anything all that great. We didn't really have any solid anything that demonstrated we were able to fix kids." Unstoppable, Wraparound took over in 1994 and transformed child welfare in Milwaukee. It
cut the number of Milwaukee children in RTCs by 90 percent, dramatically shortened their stays, reunited hundreds of families, reduced the incidence of crime and saved millions of dollars in treatment costs. It became a national model for treating emotionally disturbed children, offering a more effective and
economical means of helping youngsters without the traditional reliance on costly and controversial institutions. The program is built on principles that have been a national goal for decades: serving children at home whenever possible and moving bureaucracy out of the way so they can get the help they need.
The federal government praised the program as a superior alternative to institutional care.
"Wraparound Milwaukee demonstrates that the seemingly impossible can be made possible: Children's care can be seamlessly integrated. The services given to children not only work, in terms of better clinical results, reduced delinquency, and fewer hospitalizations, but the services are also cost-effective," the President's New Freedom Commission on Mental Health said in October.
"Imagine the nationwide impact on our juvenile justice system if this program were implemented in every community."**Hope they aren't just drugging kids into stupors to keep them out of RTCs. NFC certainly has the sale of drugs as it's primary goal.***
Several other states are following Wraparound's lead, including New Jersey, Connecticut, Massachusetts and Rhode Island. Westchester sent a delegation to Milwaukee in September to see how it works, but the county and New York state remain heavily reliant on residential institutions.
Now, Milwaukee's institutions look back on their old system of RTCs ? similar to the one New York still has in place ? as a misguided effort to help children.
The centers, which had housed children for years at a time, are now used only as a temporary fix ? three months on average ? while Wraparound caregivers figure out a longer-term treatment plan that takes place within the family home or in specialized foster homes.
With lower demand, some centers have folded, but others reinvented themselves to satisfy Wraparound's demands, using their formidable resources to establish programs for children out in the community.
How it works
Wraparound Milwaukee is basically a county-governed health maintenance organization, managing care for children who are institutionalized or at immediate risk of being sent to residential treatment centers, correctional facilities or psychiatric hospitals. It pays for all the services, breaking down barriers between agencies by pooling money from the juvenile justice, child welfare, mental health and Medicaid systems.
The goal is to help each child succeed at home, so Wraparound works with family members to tailor a treatment plan.
A case coordinator, a therapist and any number of people ? mentors, parent aides, ministers, aunts, uncles ? are enlisted to provide support. "Residential treatment has had the
luxury of basically being the sole tool out there for a very high-risk population, and they've convinced people that the only way to be safe is to have them locked up," said Stephen Gilbertson, clinical program coordinator for Wraparound Milwaukee. "We've shown that's simply not true. We've taken extremely high-risk kids and shown they can live successfully in the community."
**Damn, what a concept. Kinda what we've been saying here all along. And apparently some of these kids are far more distressed than the average program kid.
The process is a constant balancing act.
Take Leon Martin, a 13-year-old boy who would be institutionalized under the old system. He has attention deficit hyperactivity disorder, and last year pulled a steak knife on his mother, a disabled woman who raises Leon ? she calls him "Junior" ? and his sister on her own.
"I am definitely scared of my son," said his mother, Wendy Lennie, sitting beside her son in their living room in a tiny, welfare-funded apartment on the edge of Milwaukee. Leon, an imposing figure at 5-foot-10 and 210 pounds, and his sister take turns sleeping on their only bed. "He gets more stronger when he gets really mad."
During the knife incident,
Lennie paged Wraparound's 24-hour mobile crisis unit, which sent someone to the house within minutes. Then the family's Wraparound team, consisting of Leon, his mother, a friend, a therapist, a mentor and a parent aide, met in the living room and brainstormed until they came up with a plan to defuse the situation. Instead of taking Leon to a hospital to stabilize him, they placed him with Lennie's friend for a weeklong cooling-off period.**I had the idea for the Crisis Mobile years ago. Cool!!!
Leon worked through his anger with the therapist and the mentor, La Monte Smith, his school guidance counselor, who gets paid by Wraparound to see him after-hours. Lennie reached out to her parent aide, Helen, a 60-year-old woman specially trained to give advice.
"If you keep riding Junior when he's mad, you get nowhere," Lennie said. "I used to do that all the time. But Helen tells me to let Junior walk away, to speak with him later."
The team also discovered that Leon's outburst happened after he secretly skipped his ADHD medicine. So they showed Lennie how to confirm his medication use and began rewarding Leon for taking his drug. Members also safety-proofed the home and developed constructive ways for Leon to expend aggression, based on his interests: video games, drawing, movies, basketball.
Whether it's safe to have such children living in the community is still an open question.
One Wraparound child committed suicide during the winter. In September, a Wraparound boy was among a mob of nearly 20 teenagers who beat a 36-year-old man to death, the first fatal incident in eight years of the program.
Supporters of Wraparound say such violence could happen wherever these children go, and they point to dozens of crimes that have been committed inside residential centers.
The central point, as they see it, is that society can't justify institutionalizing a child long term just because he may be dangerous.
Under Wraparound, families are viewed as the key to any successful treatment regimen, because a family's well-being, more than anything else, distinguishes the long-term success or failure of the child. One of the main criticisms of residential care has been that institutions can't make a lasting difference in these children's lives because the institutions aren't dealing with them in the real world. Once children are released, their problems often return, because their home circumstances haven't changed.**Wow, how many times have we argued that point??
A 1993 Milwaukee County study found that
60 percent of children who were "successfully" discharged from residential treatment centers were returned there within six months. "Children stay two or three years in residential centers, then go home. And if you haven't worked with the family, these kids fail," said Wraparound Director Bruce Kamradt. "That's because the work has to be done with the family, in the community."
Institutions have long argued that their role is crucial because most of the children have no stable homes. But Wraparound advocates say institutions have been too quick to write off families; Wraparound seeks out families and finds ways to make them work.
"Residential treatment centers, because they don't focus on families, tend not to see families," Gilbertson said. "Since they're geographically distant from the family, there ain't no family. But the reality is, there is family, and you just have to get out there and make yourself available to them."
Statistics show that children are making progress under Wraparound. Families are staying together, school attendance has improved by 13 percent, and fewer participants are making return trips to institutions. The number of crimes committed by children after they entered Wraparound dropped by more than 50 percent, a study found. In the tracking of assaults, sexual offenses and other crimes, the rates all went down significantly once children were in Wraparound. And the rates also declined the following year.
By reducing the number of children in Milwaukee institutions from 385 to 40 children, the program has also brought great savings ?
a child's average monthly expense in Wraparound is $3,479 versus $7,200 for institutional care. Institutional placements now average three months, down from 16 months. Wraparound has used the savings to expand. The program now serves more than 800 children and their families, each an average of 16 months, with a $29 million annual budget ? about the same as was being spent for the 385 children.
Wraparound also has kept children out of psychiatric hospitals, mainly by sending out a crisis unit to defuse emergencies at home when possible. The unit, which handles calls for all Milwaukee children, has helped
reduce the annual number of hospital days for children from 5,000 to 200 , representing $2.9 million in savings.**Wow!! Impressive. We need Crisis Mobile in every city!!
The Department of Health and Human Services cited Wraparound in a 2001 report called "Promising Practices in Children's Mental Health," highlighting how the approach worked for a child named Steve, a gang member who at age 12 was participating in drug deals and drive-by shootings. Steve, whose father was a murderer and whose mother was a crack addict, was referred to Wraparound after a court ordered him into residential treatment.
The report showed how a case coordinator fostered Steve's relationship with his stepfather and, later, with the parents of Steve's girlfriend, who eventually took him in. They became part of his support network, as he gained footing at school, in community service and in a new job.
"I have no doubt in my mind that if he can keep himself out of trouble, he is going to be able to take care of himself, and I think that was our goal for him," Steve's case manager said.
At the outset, Steve's treatment was costing $7,500 a month, because of the institutional cost, but it dropped to less than $2,000 a month toward the end of his 20-month care period.
Another endorsement for Wraparound Milwaukee came from the Surgeon General's Office, the same office that has criticized residential treatment centers, saying, "There is only weak evidence of their effectiveness." Residential treatment centers nationally have fallen out of favor, as states seek to save money and treat children in a more homelike environment.
In the early 1990s, Milwaukee's institutions were experiencing some of the same problems as institutions have in New York. In both states, the centers started out as orphanages, but became increasingly burdened with children they were not designed to serve. Children with violent streaks, suicidal thoughts and severe mental illness would flood the agencies, because they were deemed too difficult to handle at home or in less restrictive foster placements.
The centers were compelled to address the children's mental health problems, to hire more clinical staff and develop programs aimed at improving behavior. But the outcomes of their efforts were not tested, even as studies suggested that community-based approaches were working.
Wisconsin's state Medicaid office demanded change in Milwaukee, when it issued a report expressing frustration over the rising use and cost of children's psychiatric hospitals ? $600 per child a day. Children in residential care were some of the most frequent hospital clients, the state pointed out.
Kamradt, who was running the county's biggest psychiatric hospital, and Eleanor McLean, then chief of the child and adolescent section of the state Bureau of Community Mental Health, began preaching Wraparound as a practical way to bring children back home from centers, which, they argued, weren't helping the children.
"There is not a single study that I'm aware of in this country that says anything they (the centers) do works," Kamradt said. "But they have such a strong political lobby because they represent a lot of dollars. And dollars can be jobs. Dollars can be viewed as power to maintaining the status quo."***Yes, $$$$$$$$$$.
The centers lobbied to maintain the existing system.
"There were a couple big fears," said Connolly, the president of St. Charles Youth & Family Services, which operates Milwaukee's largest institution. "The first was, 'How are we going to financially sustain ourselves?' "
Her agency earns more than twice as much for an institutional placement as it does for community services.
The other fear she raised was that it would be unsafe to release the children, because there weren't enough community services or viable families out there.
Wraparound told skeptics that families would be found, and that care providers would line up to capitalize on the new demand for community services. The theory was, "If we build it, they will come."
So Wraparound was launched. It started with the "25 Kid Project," targeting 25 institutionalized children who had no discharge plans.
Within four months, 17 of them, including a 14-year-old boy who had been in residential treatment for 10 years, were returned to their families. Seven others were sent to therapeutic foster homes, where specially trained foster parents care for children. Six of those children were returned home later that year.
"In most cases, these were families who said, in essence, 'We never wanted to give up on our kids, but the system told us we had to,' " Kamradt said. With the pilot's success, the county gave Wraparound authority to take on the entire population of children in residential care over the next 18 months. A $15 million federal grant would supplement costs for three years, when the program became self-sufficient and started to expand with the existing resources.
"We brought this whole new level of thinking," Kamradt said. " 'Let's see what this kid does well, see what this family does well. Let's provide services based on what they identify as their needs.' "
Therapists began making house calls, joining living-room strategy sessions in which children and their parents made decisions. Mentors became role models; parent aides became trusted friends. Team members would help in practical ways, such as giving rides to appointments or baby-sitting so the parents could take a rest. And for emergencies, a crisis unit was always on call.**Recreating community, what we had before the great divide.
"We're not miracle workers," said Kim Polki, a Wraparound care coordinator. "We're not going to make a family perfect. But what we're doing is a whole lot better than putting a kid in residential and leaving him there."
The transition was painful for the treatment centers, which were now paid by Wraparound Milwaukee for 30-, 60- and 90-day placements. "It really took that position of power away from us," Connolly said.
As a whole, the system has adapted. Dozens of community agencies have sprung up, satisfying the demand for respite and day care, after-school programs, mentoring and in-home treatment.
A few treatment centers shut down, and hundreds of staff members were laid off. Child-care workers, the least experienced staff members, were the hardest hit. But remaining centers that once feared Wraparound stepped up to play a major role in the new system.
St. Charles Youth & Family Services, though its profit margin may be lower, has grown into an even larger agency by shifting its focus to the community. A dorm with space for 12 now houses just two girls, but the agency has kept busy by arranging foster homes and mentors.
"We did what we thought was the best thing," said Connolly, speaking of her agency's old reliance on long-term, institutional care. "I think, looking back at it now, what we're doing for kids today is far more helpful." St. Aemilian-Lakeside, the second-largest institution in Milwaukee, has installed work cubicles in several of its old dormitories so it can recruit and train foster parents.
The agency's president, Teri Zywicki-Nelson, is convinced the Wraparound approach to treating these children is the way of the future, there and across the country.**That's a beautiful vision.
"Residential treatment centers better expend their energy in developing community-based programs and do less criticizing," she said, "or they won't exist."
**You go girl.
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