OhioRISE Care Management Entities Empower Families to Navigate Multisystem Care

Families with children who have complex behavioral and mental health needs face more than their share of tough challenges. OhioRISE, the state’s specialized managed care program for those families, aims to eliminate one major challenge: how hard it can be to understand and navigate the web of disconnected agencies and systems that may be separately serving those children.

OhioRISE aims to shift the system of care and keep more kids and families together by creating improved access to in-home and community-based services for children with the most complex behavioral health challenges. The OhioRISE program’s child and family-centric delivery system recognizes the need to specialize services and support for this unique group of children and families.

At its core, OhioRISE is driven by an emphasis on systems of care, care coordination, and family voice and choice. That puts care management entities (CMEs) like my organization, Cadence Care Network, at the center of OhioRISE’s success.

When Cadence was chosen in 2022 to be one of 20 CMEs serving distinct geographical areas in Ohio, care coordination was nothing new to our agency, which serves Mahoning and Trumbull counties for this program. We were doing OhioRISE-type work before there was OhioRISE. Still, resources were strained. In 2022, our catchment area may have had up to four care coordinators serving 80 to 100 families per year. Today, thanks to resources and support from OhioRISE, Cadence Care Network has 65 care coordinators serving 975 families.

The services we provide are all predicated on working with a partner. We acknowledge that children and families we serve are impacted by a system of care that is often noncommunicative and confusing to those very people it intends to help. Care coordination empowers families by helping them navigate and understand how to work with our partners — including county child welfare agencies, courts, boards of developmental disabilities, schools and other healthcare providers — to reach the best outcomes possible.

The families we work with are generally under resourced; they often struggle to meet many of their basic needs. OhioRISE care coordination supports and teaches them to use their voices to best help their children succeed.

Aetna Better Health, the company chosen by the Ohio Department of Medicaid to administer OhioRISE statewide, announced the chosen CMEs months before the OhioRISE kickoff. That gave us and other community-based organizations time to begin hiring and training people to act as care coordinators, as well as establishing relationships with more community organizations that could be direct service providers.

OhioRISE runs on a service model called “high-fidelity wraparound” — something we at Cadence were using for years before the program started. In the high-fidelity wraparound model, care coordination teams consult with families to assess their strengths, as well as their needs, and arrange for integrated services to take advantage of those strengths and address the needs, rather than responding to problems with often disconnected services.

It’s never just about the child. While county child welfare agencies focus first on the safety of a child and seeking a permanent placement, CMEs are able to use their deeper knowledge of the family and neighborhood to better understand what types of intervention will work best.

We coordinate with their doctors, psychiatrists and other care providers, but we also make sure to look at the family. We do the time-consuming work of going into homes and neighborhoods. You get a whole different picture of how a kid operates when you go into their house as opposed to talking to them in an office and having them say, “everything’s fine.” Let’s say you see serious dysfunction in the household; suddenly, you have a much better understanding of why that kid is angry.

You can help a child a lot by helping the parent. Take respite services: Just by giving that parent a break, you may reduce the risk of that kid coming into the custody of child welfare services.

We’re excited about the success of OhioRISE so far. In August, the Ohio Department of Medicaid announced that, two years after launch, OhioRISE had grown from 5,500 initial enrollees to nearly 43,000, as of December 2024.

We’re also looking forward to some planned improvements:

• Mobile Response and Stabilization Services for young people in behavioral or emotional crisis are available in 45 of Ohio’s 88 counties, with plans to go statewide.
• The state has invested $10 million in intensive home-based treatment, which should put those services in reach of 76 counties within the next few years.
• Behavioral Health Respite: More than 150 organizations, as well as individuals named by families, are enrolled to provide short-term relief to caregivers either at home or in community-based settings.
• Primary Flex Funds have provided more than 10,000 OhioRISE participants with funding for goods or supports needed for their success in school, therapy and social interactions.
• Psychiatric Residential Treatment Facilities: Previously this kind of care was available only out of state. OhioRISE has opened two facilities in Ohio and has plans for more.

As an OhioRISE CME, our success is built on how we can meet the needs of families and children by partnering with them, and the systems that impact them. All challenges won’t be addressed overnight; it’s a continual journey, and the whole purpose is to empower parents and keep kids with their families — perhaps the most important challenge many children and families will face.