Administration and Policy in Mental Health Vol. 25, No. 5, May 1998
CASE MANAGEMENT WRAPAROUND EXPENSES: FIVE-YEAR STUDY Randy D. Oliver, Donald R. Nims, Aaron W. Hughey, and James R. Somers
ABSTRACT: Kentucky IMPACT is a unique program featuring interagency team planning, case management services, and individualized wraparound services for children with severe emotional disabilities and their families. A study was conducted concerning wraparound expense data from the first 5 years of Kentucky IMPACT program implementation. Significant differences were found between levels of wraparound expense and the additional variables of diagnosis, regional service capacity and population, and client length-of-service. No significant relationship was revealed between levels of wraparound expense and client age. The general parameters of wraparound expense for this population are also identified.
Increased attention is being paid nationally to children and adolescents with serious mental health problems (MacFarquhar, 1993). Tuma (1989) reports epidemiological data indicating that from 15% (9.5 million) to 19% of the approximately 63 million children and youth in the United States suffer from problems that require mental health treatment. The majority of these children, however, receive inadequate or inappropriate treatment (Duchnowski & Friedman, 1990). This supports Knitzer's (1982) landmark study estimating that at least two thirds of these children and adolescents do not receive necessary mental health services, while those that do often receive inadequate, inappropriate, and excessively restrictive care. Schmitz and Gilchrist (1991) suggest that health care agencies often Randy Oliver, M.P.A., is Health Program Administrator, Kentucky Division of Mental Health; Donald Nims, Ed.D., is Assistant Professor, and Aaron Hughey, Ed.D., is Associate Professor, both in the Department of Educational Leadership, Western Kentucky University; James Somers, M.A., is Associate Director of Career Services Center, Western Kentucky University. Address for correspondence: Randy Oliver, M.P.A., Kentucky Division of Mental Health, P.O. Box 10177, Bowling Green, KY 42102-4777.
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have a negative impact on the delivery of mental health services to children because the majority of these programs are still focused on restrictive and costly residential treatment and psychiatric inpatient facilities. Fiscal constraints continue to be a major concern relevant to children's mental health needs (Theut, 1994). In response to the increased concerns about the quality and cost of children's services, the National Institute of Mental Health (NIMH) established the Child and Adolescent Service System Program (CASSP) in 1983 (Nims, 1995). The primary goal of CASSP is to find alternatives to out-of-home psychiatric and residential care by promoting both philosophical and strategic changes in the systems that serve this population (Collins & Collins, 1994). The goal is to encourage states to address these needs by developing a comprehensive array of public and private services called a continuum of care or system of services that require a coordinated community-based approach across multiple agencies. While the federal CASSP initiative has failed to meet the original goal of moving the availability of these services from the state to the local level (Behar, 1993; Day & Roberts, 1991), one particular provision surfaces as a truly innovative feature. This is the individualized response known as wraparound. In contrast to the more traditional components of care, wraparound is characterized as a creative process requiring flexible funding to permit adaptability in programming that wraps needed services around the child (Kutash, 1994). Roberts (1994) writes: Wraparound services coordinate community agencies to fit services to the needs of the child and family, not to fit the child to the available services. In such services, a central case manager or coordinator works as the intermediary for the family by coordinating various care components. (p. 215)
This article describes a 5-year study of wraparound services for children and adolescents with severe emotional disabilities (SED). PROGRAM BACKGROUND In 1990, the Kentucky Department for Mental Health and Mental Retardation Services (DMHMRS) estimated that there were approximately 50,000 children in the state with severe emotional problems. Of that number, only 3,000 of Kentucky's students were actually being served in programs for pupils with emotional and behavioral disabilities (Illback, 1993). Adapting the CASSP model, the Kentucky legislature created the Cabinet for Human Resources' Plan to Service Children with Severe Emotional Problems (1990). Known as Interagency Mobilization and Planning for Adolescent and Children's Treatment (IMPACT), this plan established the State Interagency Council (SIAC) which includes representatives from the Departments of Education, Health, Social Services, Mental Health and Mental Retardation Services, the Administrative Office of the Courts, and
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a Parent Advocate. Each of the 14 area development regions in the state have a Regional Interagency Council (RIAC) with representation from most of these same agencies and groups (the two most populous regions have multiple RIACs resulting in a total of 18 across the state). At the local level, RIACs oversee the delivery of core IMPACT services: (1) interagency treatment team planning; (2) case management services; and (3) discretionary wraparound funds which are utilized by RIACs to address some of the unmet needs of those children and their families. PROGRAM DESCRIPTION As defined by the Kentucky legislature, a child with SED who is experiencing substantial limitations in the areas of self care, interpersonal relationships, family life, self direction, and education, and is at risk of being placed outside of the community is eligible for nomination to IMPACT (Nims, 1995). Any professional serving the child, such as a social worker, teacher, counselor, or the child's parent, can initiate this nomination. Once a child is accepted into the program, the intent is to coordinate and provide needed services from the treatment continuum by using the wraparound approach. Service team members, including the child's service coordinator, plan and coordinate interventions on behalf of the client. As a way of reinforcing mutual investment in the progress of the child, each team member is assigned a particular task in implementing the intervention strategy (Lewis, 1990). Perhaps the most unique feature of IMPACT is the use of discretionary Individualized Family-Based Support Services (IFBSS) funds, otherwise known as wraparound funds. According to Nims (1995), these funds are used for the purpose of maximizing strengths, such as in art or athletics, by supplying equipment and fees and by providing a big brother or big sister to act or mentor for the child. In addition, wraparound funds can also be used to purchase clothing, hire additional teaching aides, roof a house, allow a child to go to summer camp, or pay utility bills. The goal is to facilitate the intervention process by proactively addressing the child and family's needs. Such needs are often obvious to the service team members, but could not previously be addressed due to their non-clinical nature and the lack of discretionary funding. ACCESSING IFBSS FUNDS A total of $8,327,370 in IFBSS funds have been expended since the Kentucky IMPACT program began 5 years ago, as of this writing in 1996. The statewide pool of IFBSS funds, averaging slightly more than $2,000,000 per
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year, are allocated to RIACs on a per capita basis. The RIACs in turn are charged with the responsibility of approving and monitoring the expenditure of these funds on an individual client basis. RIACs exercise considerable autonomy over these funds, with the primary restriction being that these funds cannot supplant existing funding mechanisms for the acquisition of goods and services. Kentucky's 14 community mental health center's serve as both the employers of IMPACT staff, and as the financial conduit for the expenditure of IFBSS funds on a cost reimbursement basis from Kentucky's DMHMRS. The approval process for the use of IFBSS funds begins with the childspecific interagency service team meeting described earlier. The service team's request for the use of IFBSS Funds is in the form of an IFBSS Budget Sheet detailing planned expense as part of the total service plan for the child and family. The child's budget sheet is then considered by the RIAC for approval, denial, or modification. Expenditures for the child and family may begin once RIAC approval is obtained. In practical terms, the IFBSS Budget Sheet effectively establishes a checking account on behalf of the IMPACT child. The total amount of funds budgeted within seven separate expenditure categories (specialized evaluations/consultations, attendant care-respite/support, overnight care, special purchases, outpatient services, other, and administrative charge) serves as the initial deposit for that child. IFBSS Monthly Billing Reports, detailing expenses incurred within these expenditure categories for a specified child, are submitted monthly to the DMHMRS for reimbursement. Approved billings constitute withdrawal from the child's account up to the total amount budgeted. Additional funds may be budgeted through the submission of a RIAC approved IFBSS Budget Sheet Amendment. A new IFBSS Budget Sheet per child is required for each fiscal year of service. RESEARCH QUESTIONS This study examines IFBSS wraparound data acquired over the first 5 years of the program. Certain questions were asked to assist in the interpretation of the data: (1) what are the global characteristics related to wraparound expense for this service population, (2) do data show a relationship between the amount of IFBSS expended for children and the additional variables of client age and clinical diagnosis, (3) to what extent are these expenses related to regional service capacity and population, (4) is there a relationship between IFBSS expenditure levels and length of involvement in the program, and (5) what are the expenditure categories, and percentage of expense within these categories, for children receiving wraparound?
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METHOD In addition to amounts budgeted, the IFBSS Budget Sheet provided a limited set of demographic data concerning each IMPACT child. Captured fields for each child include: (1) home region, (2) home county, (3) date of birth, (4) diagnosis (both primary and secondary), (5) Medicaid card status, (6) an assessment of agency involvement, (7) client residential status, and (8) a client identification number. The IFBSS Monthly Billing Report provided service expense data for each child. A fundamental decision was made at the outset of this research to restrict investigations to expense that could be directly tracked to individual children. A consequence of this decision was that several classes of expenditure data were excluded from consideration. These included: (1) additional personnel costs not billed as respite/support services, (2) reimbursement of costs for the Parent Representative position on the RIAC, (3) equipment purchases for regional IMPACT programs, and (4) those instances (N= 692) for which an IFBSS Budget Sheet was submitted for a child, but no expenses were billed. Additional personnel cost data were utilized solely in calculating the mean expense per child per region. The total amount of IFBSS expenses excluded from consideration each fiscal year is as follows: FY91-$0; FY92-$96,899; FY93-$127,517; FY94-$ 127,678; and FY95-$162,591. Data collection for the IFBSS system began in FY91, with the first regional billing being processed in October, 1990. It was not until January 1991, that IFBSS billings were received from all regions. As such, FY91 data reflects only a partial year of service provision with a corresponding lower service capacity. Unless otherwise specified, presented data reflect the use of the duplicated count of children served. The use of the duplicated count of children was necessary as many of the children had multiple years of wraparound service. Expense data for those children with multiple years of service are reported for each individual year of service across areas of investigation, not as a cumulative expense. Descriptive statistics were calculated for each variable. Pearson productmoment correlation coefficients were computed in order to assess the relationships between wraparound expense and age and regional service capacity and population. Analysis of variance (ANOVA) was performed in order to determine if expenditures were significantly different when categorized by diagnosis. ANOVA was also employed in order to evaluate differences between expenditures on new and carryover clients. Finally, ANOVA was used to determine if expenditures were significantly different when categorized by age groupings. The .01 level of statistical significance was utilized throughout this study.
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FINDINGS A total of 2,860 separate children received some degree of IFBSS-funded wraparound service, at a total expense of $8,327,370 over this 5-year period. The number of children approved to receive these services ranged from a low of 378 in FY91, to a high of 1,702 children in FV95. Table 1 provides information concerning changes in this population over the 5 years in terms of number of children served, the mean age per child, and the mean amount expended per child. A number of children were served in multiple fiscal years, A total of 2,860 unduplicated children were served during this 5-year period. Use of the unduplicated count produces a mean cost per child served figure of $2,912. The mean amount expended per child ($1,573) was obtained using the duplicated count of children (5,294) and represents the mean cost per child per year. The mean length-of-service among these 2,860 children over the 5 years was 1.85 years. Data presented in Table 2 pertain to primary diagnoses of children being served and related expense. Data are reported for those children's diagnoses (N=14), hereafter referred to as "known diagnoses," with a cumulative frequency of greater than 10 and a cumulative expense of greater than $10,000. The category of "other diagnoses" refers to those diagnoses (N= 325) not meeting the cumulative frequency and expense criteria mentioned above. The category of "no diagnosis provided" relates to those children (N= 995) for whom no diagnosis was entered on the IFBSS Budget Sheet. The omission of a diagnosis from the IFBSS Budget Sheet was randomly distributed across regions. The mean expense per diagnosis refers to the expense of children with a given diagnosis for a single year of TABLE 1 Summary Information FY91
Number of Children Served Per Year Mean Amount Expended Per Child Mean Age of Child
378
$1,591 12.42
FY92 856
FY93
FY94
FY95
TOTAL
1,129
1,229
1,702
5,294a
$2,143 $1,569 12.68
12.73
$1,317 $1,470 12.79
12.54
$1,573a 12.65
"Use of the duplicated count of children (5,294) produces a mean expenditure per child per year of $1,573. Use of the unduplicated count of children served (2,860) produces a mean expenditure per child served of $2,912.
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TABLE 2 Frequency and Expense by Diagnosis Diagnosis
Attention deficit hyperactivity disorder Oppositional defiant disorder Major depression Conduct disorder Adjustment disorder Affective disorder Schizophrenia Bi-polar disorder Tourette's syndrome Overanxious disorder Reactive attachment disorder Psychosis Attention deficit Personality disorder Other diagnoses No diagnosis provided
Total Frequency
Total Expense
Mean Expense
1,198
$1,718,064 $1,461,367 $890,598 $588,335 $388,208 $317,873 $174,004 $103,117 $123,315 $72,668 $62,450 $65,736 $35,832 $25,695 $894,370 $1,405,738
$1,434 $1,473 $1,579 $1,482 $1,584 $1,465 $2,417 $1,516 $2,022 $1,652 $1,688 $1,933 $1,156 $1,836 $2,752 $1,413
992 564 397 245 217 72 68 61 44 37 43 31 14 325 995
service. This means that multiple expense figures are presented for children who were served during 2 or more years, regardless of whether their diagnosis changed or was retained. The extent to which carryover children retain or change diagnoses was not measured. ANOVA revealed that a statistically significant difference existed between the category of known diagnoses and the category of no diagnosis provided with respect to the mean expense per diagnosis category (F= 36.21; df= 1,4963; p=.001). Expense for children with known diagnoses was significantly greater than for children with unknown diagnoses. Similarly, ANOVA found a significant difference between the category of known diagnoses and the category of other diagnoses with respect to mean expense per diagnosis category (F=42.32; df= 1.4293; p>=.001). Expense for children with other diagnoses was significantly greater than for children within known diagnosis. Table 3 provides regional data pertaining to service capacity, the mean cost per child, and population. Regions were then ranked according to these three criteria. Regional service capacity refers to the number of children receiving wraparound services in a given region. A statistically significant positive correlation was found between the mean cost per child and
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TABLE 3 Comparison and Rankings of Regional Service Capacities, Mean Expense, and Population
Regions
1 2 3 4 5 6J 6S
7 8 9 10 11 12 13 14 15E 15S 15W
Number of Children Served
Mean Cost Per Child
Service Population Age 0-17
247 289 328 417 241 422 165 351 142 182 214 240 252 404 519 428 241 307
$930 $920 $1,652 $1,139 $1,909 $3,498 $2,056 $1,884 $1,016 $1,081 $1,534 $2,262 $1,001 $1,428 $891 $1,905 $1,711 $1,506
44,470 49,955 54,137 56,234 62,176 162,576 36,418 93,309 13,582 16,406 33,748 47,295 35,707 62,746 44,374 69,869 37,184 35,776
Capacity Ranking
Mean Cost Ranking
Population Ranking
11 9
16 17 8 12 4 1 3 6 14 13 9 2 15 11 18 5
10 8
7 10
12
7 4 12 3 17 6 18 16 15 14 10 5 1 2 12 8
7 6 5 1 13 2 18 17 16 9 11 4 11 3
14
the population of children age 0-17 (r=.78). As the population of children age 0-17 increases, the mean cost per child also increases. A significant relationship, though not as strong, was also found between the population of children age 0-17 and the number of children served (r=.57). As the population of children age 0-17 increases, the number of children served also increases. A significant relationship was found between the population ranking and service capacity ranking (r=.71). As the population ranking increases, the service capacity ranking also increases. Data contained in Table 4 pertain to age groupings and expense for children served within these age groupings. The extent to which carryover children may be represented in multiple age groupings over the course of their service period was not measured. Statistically significant relationships were found between the expense for a given fiscal year and the expense for any other fiscal year (r=.86 or higher in every instance) by age category. ANOVA revealed that the differences in expenditures noted for each age category were not statistically significant, i.e., expense per age category was relatively consistent across fiscal years (.F=1.09; df= 5,5204; p=.388). None of the correlations between age and fiscal year, including totals, were
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TABLE 4 Expense and Age Groupings Age Grouping
0-4 Years Old 5-8 Years Old 9-12 Years Old 13-16 Years Old 17-21 Years Old No Age Provided
Frequency
Total Expense
Mean Expense
30 591 1,509 1,900 618 556
$36,300 $907,098 $2,546,294 $2,951,277 $954,467 $931,934
$1,210 $1,535 $1,687 $1,483 $1,544 $1,675
significant, Expense appears to be fairly evenly distributed among age categories, though there is a strong central tendency toward the 9-16 year old age groupings. Table 5 constitutes a comparison of expense data for new and carryover clients, both by fiscal year and in total for the 5 years. New client data pertains to the frequency and expense of children receiving their first year of service. Carryover client data relates to the frequency and expense of children in their second or more year of service. A statistically significant difference was found between the categories of new client and carryover client with respect to expense. Carryover client expense was significantly greater than new client expense. Data presented in Table 6 relate to length-of-service and associated wraparound expense for IMPACT clients. A mean expense of $1,224 per child was determined for all children in their first year of service. Mean expense for children in their second-fifth year of service ranged from $1,738-12,455 (42-101% higher). Data presented in Table 7 pertain to wraparound expenses within seven separate billing categories. With the exception of FY91, more that 50% of TABLES New vs. Carryover Client Expense Data Carryover Carryover New Client New Client New Mean Client Client Total Carryover Client Frequency Total Expense Mean Expense Client Expense FY Class Frequency
'91 '92 '93 '94 '95 Total
378 532 553 512 885 2,860
$601,247 $831,584 $606,335 $505,143 $956,688 $3,500,997
$1,591 $1,563 $1,096 $987 $1,081 $1,224
N/A 324 576
720 817 2,437
N/A $996,344 $1,162,681 $1,113,351 $1,553,997 $4,826,373
N/A $3,075 $2,019 $1,546 $1,902 $1,980
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TABLE 6 Length-of-Service and Expense
Frequency Total Expense Average Expense
1st Year
2nd Year
3rd Year
4th Year
5th Year
of Service
of Service
of Service
of Service
of Service
2,860 $3,500,997 $1,224
1,484 $3,123,497 $2,105
669 $1,165,215 $1,742
225 $391,106
56 $137,466 $2,455
$1,738
all IFBSS expenditures each year were in the expenditure category of respite and support. For the purposes of IFBSS, respite and support are defined as positive role model big brother/big sister mentoring activities provided to the child. DISCUSSION Summary Information The relative constancy of the mean age per child served is immediately apparent. This finding is viewed as surprising considering the anticipated aging effect upon the overall caseload resulting from the substantial proportion of carryover children served each year. However, this aging effect may have been neutralized by an effort on the part of RIACs to prioritize younger children for service in hope of a better prognosis for successful intervention. No testing of age difference between new and carryover children was performed. Continued growth in the number of children served is noted. Increased efficiency of operations, allowing for the hiring of additional service coordinators who then serve an expanded caseload, and IFBSS funding increases enacted by the Kentucky General Assembly for FY93 and FY95, are seen as primary factors. No clear pattern is found concerning the mean amount expended per child. As mentioned earlier, FY91 data reflects only a partial year of program implementation. This observation, when coupled with the comparatively high expenditure per child of FY92, suggests that the overall level of IFBSS funding, even with the increases of FY93 and FY95, has not kept pace with the increased caseload of subsequent years. The large proportion of carryover children served each year, and the significantly greater costs associated with these carryover children, is a contributing factor. It appears that RIACs may have been forced to ration services to during the latter 3 years. Another possibility is that increased efficiency of services may have contributed to lower expenditure per child in the latter years.
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Diagnosis Expense for children within the category of other diagnoses was found to be significantly greater than for children in the category of known diagnoses. As mentioned earlier, the criteria for inclusion in the category of known diagnosis was that of a cumulative frequency of greater than 10 and a cumulative expense of greater than $10,000. Subsequent investigation found numerous instances of diagnoses with a cumulative frequency of slightly less than 10, but a cumulative expense of far greater than $10,000. Examples of these low frequency, high cost diagnoses include: Autism (N=9, mean expense = $4,213), Pervasive Developmental Disorder (N=8, mean expense = $3,687), Organic Personality Disorder (N=8, mean expense =$3,918), and Anorexia Nervosa (N=9, mean expense = $4,365). Expense for the category of no diagnosis provided was found to be significantly less than for the category of known diagnoses. This finding is viewed as both surprising and somewhat paradoxical. It is assumed that the children in the no diagnosis provided category should serve as a quasi-control group and, given the difference found between the known diagnoses and other diagnoses categories, the mean expense for this category of children should be somewhere between that found for these other categories. Service Capacity, Cost, and Population Urban area RIACs have argued that while their service capacities may be larger than that of rural regions in terms of number of children served, they are actually comparatively smaller when contrasted with their much larger overall population base. This argument is supported when you consider the ratio between population and service capacity for the three most populous regions (1 out of every 271 children served) and the three least populous regions (1 out of every 118 children served). Kentucky's Division of Mental Health (1995) reported very similar penetration rate findings. These urban RIACs further contend that this results in greater SED severity levels within their caseload of children accepted for service and, consequently, a higher mean cost per child served. It has been suggested that the actual cost of accessed services is greater for urban areas than for rural regions. It has also been proposed that the array of purchasable services is much more limited in rural areas, making them more reliant on the exchange of in-kind services between agencies. Regardless of the reasons, it is clear that the mean cost per child served in urban areas is much higher than in rural regions.
Age Almost three fourths (73.8%) of all children served were within the age range of 9-16 years old. An almost identical figure (74.3%) is noted re-
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garding the percentage of total expenses incurred for children in this same age range. Aside from expense data reported for the small number of children in the 0-4 years old age grouping (N=30), a range of only $204 is observed between the highest and lowest mean expense age grouping. New vs. Carryover Client Expense Carryover children have comprised a significant portion of the IMPACT caseload, both in respect to number of children served and wraparound expense, in every year since FY92 (the first year in which there could be carryover children). In FY93, and particularly FY94, carryover children constituted more than 50% of the total IMPACT IFBSS caseload. Moreover, cumulative expense for carryover children has ranged 20-120% higher than for new clients in every year since FY92. Similar differences are also noted concerning the mean expense per child of carryover children as compared with new clients (a range of 57-97% higher). As noted earlier, funding increases for the IMPACT program were enacted for FY93 and FY95. It is suspected that were it not for these increases, which allowed for service capacity expansion and the acceptance of new children for service, the disparity in caseload representation and expense between new and carryover clients would be even more pronounced. The extent to which limited IMPACT resources are obligated to these carryover children is viewed as a matter of critical importance to program planners and administrators. Length-of-Servlce The mean expense for children in their first year of service is considerably less than for children in their second through fifth year of service. Two factors contributing to this finding are readily identified. For the purposes of this study, a child was considered as having a year of service regardless of when they were accepted for service within the fiscal year. As such, expense for children accepted for service late in a fiscal year would be expected to be less, in general, than for children being served throughout the year. Children in their second through fifth year of service would, by definition, be eligible for service at the start of a given year. Similarly, a child was considered as having a year of service even if they exited the program after only a short period of time. No comparison of exiting rates between first year of service children and those with multiple years of service was performed. The mean expense per child for children in their fifth year of service ($2,455) is considerably higher than for all other year of service groups. These fifth year of service children (N= 56) constitute the remaining clients from those first accepted for service in FY91, Mean expense for chil-
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dren in their second year of service ($2,105) had the second highest level of expense within the year of service groups. Almost 52% of all children receiving wraparound services also had a second year of service. Just as with the discussion of carryover clients above, these findings have considerable implications for the future. Service Categories and Expense Expense for respite and support consitute more than 50% of all wraparound expense in every year except FY91. The comparatively low percentage rate in FY91 (20.8%) is viewed as primarily a function of the amount of time needed to establish the service infrastructure (advertise for respite provider positions, hold interviews with applicants, conduct police background checks, and the like) during this start-up year. A very small percentage of IFBSS expenditures, both for a given fiscal year and in total, were in the expenditure categories of evaluations and consultations and overnight care. A substantial drop in the percentage in IFBSS expenditures within the category of outpatient services occurred beginning in FY93. This drop coincided with the imposition of substantial limitations by the DMHMRS concerning the use of IFBSS funds to purchase outpatient services. A substantial drop also occurred between FY91 and FY92 in the percentage of IFBSS expenditures within the category of special purchases. A steady increase in expenditures within this category is noted in the following years. Examples of such special purchases include paying utility bills, summer camp fees, karate lessons, and food and clothing purchases for the child and his/her family. CONCLUSION This research is intended to further identify the general parameters of wraparound expense, and to look at the relationship between wraparound expense and variables such as client age, diagnosis, length-of-service, and regional population and service capacity. No portion of the data and findings should be viewed as reflective of success, whether for a given child or for the entire IMPACT program. Illback's (1995) evaluative study of this same Kentucky IMPACT program found that aspects of wraparound, and particularly the provision of respite/support services, are associated with favorable client and family outcomes. An internal study within the DMHMRS of this same database also found that parent satisfaction ratings were higher for wraparound and service coordination than for any other received IMPACT service. Despite this, the relationship between levels of wraparound expense and favorable client outcomes remains to be determined.
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