ROSIE D. V. PATRICK
Transforming the Medicaid Children’s Mental Health System
Transforming the Children’s Mental Health System
I. Litigation – Purpose and Outcome
II. Pathway to Home-Based Services
III. Implementation & Monitoring
IV. Opportunities and Benefits Across
Child Serving Systems
The Litigation – Purpose and Outcome
The Problem in Communities
Inadequate behavioral health services leading to negativeoutcomes for children, youth and families:
● Children stuck in ER’s or institutions● Limited early identification of mental health needs● Services without sufficient intensity or duration ● Fragmented service system● No single point of care coordination and treatment planning● Inappropriate use of juvenile justice and child welfare systems
to address conduct resulting from lack of behavioral health treatment resources
The Problem in Schools
Unaddressed behavioral health needs underlying orexacerbating students’ struggles in school:
• Children suspended more than 10 days had average of three mental health diagnoses (Rappaport 2006)
• Students with mental health needs had a much higher rate of absenteesim, tardiness and lower grades (Gall et al., 2000)
• Hospital admissions interrupting educational services• Students left considering more restrictive environments in order
to have their social, emotional and behavioral needs met
The Response
The class action lawsuit filed in 2001 to compel provision of intensive mental health treatment to Medicaid eligible children in their homes and communities, thus avoiding unnecessary hospitalization or extended out-of-home placement
Brought by the parents or guardians of eight children with serious emotional, behavioral, or psychiatric conditions representing a class of Medicaid-eligible children who needed home-based services to be successful in their communities
The Legal Claims
The federal Medicaid program mandates Early Periodic Screening Diagnosis and Treatment – EPSDT – for children under 21
EPSDT mandates screening and treatment necessary “to correct or ameliorate a physical or mental condition”
States must provide this treatment promptly and for as long as needed
The Remedy
1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act
2/22/07 Court orders development of in-home services, including comprehensive care coordination, screening, assessments and crisis services
4/27/07 Appoints Karen Snyder as the Court Monitor 6/18/07 Parties begin implementation meetings 7/16/07 Court enters judgment including detailed
remedial plan with implementation timelines.
New Court-Ordered Services
Access to Behavioral Health Screening Comprehensive Diagnostic Assessments Intensive Care Coordination In-Home Therapy Services In-Home Behavioral Services Therapeutic Mentoring Family Partners Mobile Crisis and Crisis Stabilization Units
Eligibility for Rosie D. Services
Medicaid-eligible members under 21 For intensive Care coordination (ICC) children must
have a serious emotional disturbance (SED) and be in MassHealth Standard or CommonHealth
Children with SED in other MassHealth categories can transfer to CommonHealth by completing a disability supplement
Two federal SED definitions apply. Any child who meets EITHER definition, as determined by the mental health evaluation, is eligible for ICC
Children without SED can obtain the remedial services (other than ICC) if medically necessary
Federal SAMHSA Definition of SED
From birth up to age 18 Who currently or at any time during the past
year Has had a diagnosable mental, behavioral, or
emotional disorder That resulted in functional impairment which
substantially interferes with or limits the child's role or functioning in family, school, or community activities.
Federal IDEA Definition of SED
A condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance…
Federal IDEA Definition of SED
An inability to learn that cannot be explained by intellectual, sensory, or health factors
An inability to build or maintain satisfactory interpersonal relationships with peers and teachers
Inappropriate behaviors or feelings under normal circumstances
General pervasive mood of unhappiness or depression
A tendency to develop physical symptoms or fears associated with personal or school problems
Co-morbidity and Dual Diagnosis
Children with SED, in addition to any other disabling condition, such as autism spectrum disorders, developmental disability or substance abuse will be eligible for the Rosie D. remedy.
The Pathway to Home-Based Services
Accessing a Continuum of Care
Behavioral Health Screening
Mental Health Evaluation
Referral for Care Coordination / Other Services
Comprehensive In-Home Assessment
Wrap-Around Team Process
Delivery of Home-Based Services
Screening or Identification
As of January 1, 2008, primary care doctors/nurses must offer voluntary screening for behavioral health concerns at well child visits or upon request, using one of several standardized screening instruments
State agencies and other child serving entities can recommend parents seek such a screening
Children with known conditions can bypass screening and be referred directly to a mental health professional for evaluation
MassHealth will be maintaining data on screenings, referrals, and families ability to access treatment
Mental Health Evaluation
As of November 30, 2008, all diagnostic mental health evaluations will incorporate the Child and Adolescent Needs and Strengths (CANS) survey
The CANS uses a structured interview to assess the child and family’s strengths and identify their service needs
CANS can be provided by mental health clinicians in various settings (hospitals, clinics, private practices state agencies; CSAs)
If the clinician determines SED is present, a referral to intensive care coordination should usually result
Intensive Care Coordination
● Delivered by regional network of Community Service Agencies (CSAs)
● Care coordinator works in partnership with family and youth to ensure meaningful involvement in all aspects of treatment
● Facilitates completion of a comprehensive home-based assessment and creation of a care planning team including state agencies, schools and other providers
● Prepares and monitors implementation of a single integrated treatment plan
Treatment Plan
Single plan that is child/family centered Integrates other agency/provider plans Team determines the type, amount, intensity and
duration of home-based services within parameters Components of plan include:
– Treatment goals and objectives– Identification and role of specific providers– Frequency, intensity and location of service delivery– Crisis plan
Speed of ICC Response
● Telephone contact within 24 hours of referral
● Face-to-face interview within 3 calendar days
● Upon consent to participate, immediate development of initial risk management and crisis plan
● Comprehensive home-based assessment within 10 days of consent
● Team meeting and plan development within 28 days of consent
The Values of Wraparound
ICC team and in-home providers responsible for maintaining
fidelity to several core principals:– strength-based– individualized– child-centered– family-driven– community-based– multi-system– culturally competent
The New MassHealth Service Array
Mobile Crisis Services
Mobile, face-to-face response to youth in crisis, available 24/7 and for up to 72 hours
Delivered by a clinical/paraprofessional team in the home or other community setting
Designed to assess, de-escalate and stabilize a child in crisis, offering safety planning, referrals and support to maintain the youth in their natural setting
Crisis Stabilization Units
A community-based, staff secure treatment setting offering short term crisis stabilization services for up to 7 days
Designed to facilitate immediate engagement of family/caretakers in problem solving, skill-building, crisis counseling, service linkages and coordination with existing providers
Focused on youth’s rapid return to the community, avoiding a higher level of care
In-Home Behavior Services
Clinical/paraprofessional team addresses challenging behaviors in the home and community which interfere with youth’s successful functioning
Therapist provides behavioral assessment, develops a behavior management plan with the family and reviews effectiveness of the interventions
Behavior Monitor helps implement the plan, modeling and re-enforcing behavior management strategies in the home and community
In-Home Therapy Services
Delivered in the home or community setting Includes 24/7 urgent response, flexibility in scheduling and
frequency and duration of sessions Works to foster understanding of family dynamics, develop
strategies to address stressors, enhance problem solving and communication skills, identify community resources, address risk and safety planning, offer care coordination
Therapist works with youth and the family on development of specific clinical treatment goals to improve youth’s functioning
May be assisted by a paraprofessional who supports the child and family in day to day implementation of treatment goals
Therapeutic Mentoring
Structured one-to-one relationship between paraprofessional and youth, addressing daily living, social and communication skills in variety of home and community settings
Includes coaching and training in age-appropriate behaviors, problem-solving, conflict resolution and interpersonal relationships using recreational and social activities
Delivered pursuant to plan of care and supervised by a clinician, with focus on ensuring youth’s successful navigation of various social contexts, skill acquisition and functional progress towards identified treatment goals
Family Support and Training
Available through CSA’s and stand alone providers Structured, one-to-one, strength-based relationship
with parent/caregiver of youth Delivered by a family partner with experience caring
for a child with special needs and utilizing child and family serving systems
Supports caregiver in addressing child’s behavioral health needs by identifying formal and informal supports, offering assistance in navigating child-serving systems and fostering empowerment through education, coaching and training
Appeals
Any disagreements with the MassHealth agency or Managed Care decisions regarding the need, amount, duration or the termination of services can be appealed through the MCE grievance and Medicaid fair hearing process
A dispute resolution process will be in place for Care Planning Teams and state agencies to utilize
Implementation and Monitoring
Design of Home-based Services
Each service is defined by program specifications and medical necessity criteria
With federal (CMS) approval, services will be part of Medicaid State Plan and receive federal matching money
All services can be provided separately or in combination, and delivered in a variety of settings (natural or foster home, school, community)
The Service Delivery System
Regional Community Service Agencies (CSA) have been selected to provide care coordination and family support and training
All Managed Care Entities (MCEs) will contract with CSA network and use some common UM strategies
MCE’s are undertaking workforce and provider development activities now
Commonwealth will offer wrap-around training and coaching to CSA’s and in-home therapy providers
Other training for state agency staff and schools
Monitoring and Court Oversight
Court Monitor meets regularly with parties, providers, professionals, and families
Compliance Coordinator guides state efforts Parties meet regularly to discuss each element of
new system Plaintiffs actively monitor all aspects of
implementation Monitor reports to Court about progress and
compliance Court meets quarterly with parties and Monitor
Revised Implementation Timelines
July 1, 2009: Intensive Care Coordination, Family Support and
Training, & Mobile Crisis Services
October 1, 2009: In-Home Behavior Services
and Therapeutic Mentoring
November 1, 2009: In-Home Therapy
December 1, 2009: Crisis Stabilization Units
Challenges to Implementation
Provider capacity and network development Ongoing training / coaching for Wrap fidelity Education and outreach to members Data and outcome measurement Utilization Management Effective coordination with child-serving
agencies, courts, probation
Opportunities and Benefits Across Child-Serving Systems
Relevance of Reforms
CBHI resources can support professionals and child-serving systems, while improving the experience of and outcomes for Medicaid eligible youth and families ● Schools and educational programs
● Juvenile Justice / DYS diversion programs ● CHINS and child welfare agencies
● Medical and Behavioral Health providers
Benefits of Coordination with Schools
Increased access to mental health expertise to inform service and placement decisions
Flexible delivery of services in school, after-school and other community settings
Ability to coordinate interventions across settings and promote generalization of skills
For youth in ICC a single treatment plan and point of contact through the Care Coordinator
Additional services to avoid unnecessary institutionalization and support success in more integrated community and educational programs
Challenges to Effective Coordination
Avoiding confusion regarding the interaction between two federal entitlement programs
Effectively integrating Individual Care Plans and Individual Education Plans
Limited school/staff resources for coordination Navigating confidentiality requirements including
students’ MassHealth eligibility
Promoting Effective State and Local Collaboration
● Provide meaningful information and outreach to staff / parents Offer training on the scope of remedial services, which students
are eligible, how to facilitate referrals and opportunities to coordinate educational and community-based services
Develop local and statewide guidance on MassHealth system Identify model policies and best practices for referral and service coordination for effective collaboration with parents and providers
Identify and fund infrastructure needed to establish successful linkages with community-based mental health providers and support increased communication and integration of services on behalf of students
Community Involvement in Systems of Care
CSA’s are required to convene regional Systems of Care Committees
Fosters communication and collaboration between regional state agency staff, courts, schools and other system stakeholders
Opportunity to review system-level issues impacting delivery of care, identify area resources and foster ongoing partnerships
Yolanda’s Law: Section 19 Taskforce
Created as part of the Children’s Mental Health Law of 2008
Intended to “…build a framework that promotes collaboration between schools and behavioral health services…”
Implementation plan involves piloting of framework in 10 schools, interim report (12/31/09), a statewide assessment of needs, and final report with recommendations to Governor/Child Advocate (6/30/2011)
Importance of Interagency Protocols
MassHealth required by the Judgment to develop protocols with all EOHHS agencies
Necessary to establish consistent expectations, procedures and communication across systems
Will address issues like referrals, staff training, Care Planning Team participation and dispute resolution
DCF, DYS, DMH and DPH protocols are now available with agency staff training underway; DDS and DEEC in development
Tips for Educators and School Staff
Have information about the new MassHealth available to share with eligible students and families
Maintain contacts for local CSA’s, service providers and mobile crisis intervention/ESP programs
Consider mechanisms for assisting interested families with the referral process
Participate in the ICC Wraparound Team process and communicate with care coordinator if requested
Discuss school/district wide policies and procedures needed to support access and effective collaboration
How You Can Help
Consider where Rosie D. services could be useful in your work and share those ideas with us
Help us identify best practices and address obstacles class members may confront
Assist in the development of materials/resources relevant to your field
Connect with other agencies/entities in your area who might be interested in training on Rosie D. implementation
Collaborate with DESE Taskforce and participate in the School Assessment Tool
Additional Information
The Center’s website: www.rosied.org contains:– News updates and features on implementation– An extensive library of litigation documents – Other information designed for families, providers and
professionals
Additional information on the Children’s Behavioral Health Initiative, including program specifications, regional CSA’s and provider networks and information re: access to other MassHealth resources can be found at: www.mass.gov/masshealth/childbehavioralhealth