ROSIE D. V. ROMNEY

1
ROSIE D. V. ROMNEY

• Transforming the Medicaid Childrens Mental
  Health System

2
Transforming the Childrens Mental Health System

• I. The Litigation Purpose and Outcome
• II. The Pathway to Home-Based Services
• III. The Status of Implementation
• IV. Issues in the Juvenile
• Justice and Child Welfare
• Case Contexts

3
The Problem in Communities

• Inadequate behavioral health services leading to
  negative
• outcomes for children, youth and families
• ? Children stuck in ERs 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

4
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

5
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

6
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.

7
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

8
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

9
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.

10
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 childs educational performance

11
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

12
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.

13
The Pathway to Medicaid Home-Based Services

• Behavioral Health Screening
• Mental Health Evaluation
• Referral for Care Coordination
• Comprehensive In-Home Assessment
• Wrap-Around Team Process
• Delivery of Home-Based Services

14
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

15
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 familys 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

16
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

17
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

18
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

19
The Values of Wrap-Around

• 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

20
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

21
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 youths rapid return to the community,
  avoiding a higher level of care

22
Behavior Management Therapy and Behavior
Monitoring

• Clinical/paraprofessional team addresses
  challenging behaviors in the home and community
  which interfere with youths 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

23
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 youths functioning
• May be assisted by a paraprofessional who
  supports the child and family in day to day
  implementation of treatment goals

24
Therapeutic Mentoring Services

• 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 youths
  successful navigation of various social contexts,
  skill acquisition and functional progress towards
  identified treatment goals

25
Family Support and Training

• Available through CSAs 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 childs
  behavioral health needs by identifying formal and
  informal supports, offering assistance in
  navigating child-serving systems and fostering
  empowerment through education, coaching and
  training

26
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

27
III. Implementing the Remedy

• Design of Home-Based Services
• Developing the Service Delivery System
• Monitoring
• Ongoing Court Involvement
• Implementation Timetables
• Challenges to Implementation

28
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)

29
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
• MCEs are undertaking workforce and provider
  development activities now
• Commonwealth will offer wrap-around training and
  coaching to CSAs and in-home therapy providers
• Other training for state agency staff and schools

30
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

31
Revised Implementation Timelines

• July 1, 2009 Intensive Care Coordination,
  Family Support and Training,
• Mobile Crisis
  Services
• October 1, 2009 In-home Behavioral Services
• and Therapeutic Mentoring
• November 1, 2009 In-Home Therapy
• December 1, 2009 Crisis Stabilization Units

32
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

33
Issues in the Juvenile Justice and Child Welfare
Systems

• The Relevance of CBHI reforms
• The Importance of Interagency Protocols
• Community Involvement in Systems of Care
• Benefits of Participation/Collaboration
• Challenges in the JJ/Child welfare context
• Tips for Advocates

34
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

35
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 and DMH protocols are now available with
  agency staff training underway DMR and DEEC in
  development

36
Community Involvement in Systems of Care

• CSAs are required to convene regional Systems of
  Care Committees
• Important for communication and collaboration
  between various agencies, courts, schools, and
  other stakeholders,
• Opportunity to review system-level issues
  impacting delivery of care, identify area
  resources and foster ongoing partnerships

37
Promoting Effective Collaboration With The JJ and
Child Welfare Systems

• Offer information/outreach to system
  stakeholders attorneys, court clinics, clerk
  magistrates, judges, probation officers
• Encourage membership on CSA Systems of Care
  Committees
• Consider use and impact of CBHI resources in
  existing or expanded diversion programs
• Develop model motions or other practice aides for
  court appointed counsel seeking to access or
  present CBHI resources as part of alternative
  dispositions
• Collect and review initial experiences with
  system interfaces
• Identify strategies and infrastructure needed to
  establish successful linkages between community
  mental health services and children in the
  juvenile justice and child welfare systems

38
Yolandas Law Behavioral Health Advisory Council

• Created as part of the Childrens Mental Health
  Law of 2008
• Intended to develop proposals relating to best
  practices, inter-agency coordination of services,
  and extent of involvement of children with
  behavioral health issues within the JJ and child
  welfare systems
• Also provides for inter-agency review teams to
  collaborate on complex cases. Specifically
  provides that juvenile probation may be invited
  to participate where appropriate. Team
  determines what services child should receive and
  who will provide them

39
Potential Benefits of CBHI Involvement

• Increased access to mental health expertise to
  inform childs service and placement decisions
• Delivery of services in school, after-school and
  other community settings
• Availability of resources to coordinate services
  across settings and promote generalization of
  skills
• Single point of contact through ICC team and care
  coordinator
• Additional services to avoid institutional care
  and support childrens success in more integrated
  community programs

40
Potential Challenges in the Juvenile Justice and
Child Welfare Context

• Cooperation in the context of an adversarial
  proceeding
• Protocols for early identification of children
  with behavioral health needs
• Confidentiality issues
• Stigma
• Prompt access to clinically, linguistically and
  culturally appropriate behavioral health services
• Medicaid eligibility determinations
• Assessment of behavioral health status,
  determination of appropriate and medically
  necessary services
• Delivery of services identified as medically
  necessary

41
Tips for Advocates Navigating the New CBHI System

• Ask about insurance status any existing
  disability or diagnosis
• Get releases for clients MCE and MassHealth
  (PSI)
• Inquire about potential for SED determinations
• Be aware of local CSAs, contacts for referral
  and other resources for rapid clinical assessment
• Take opportunities to educate court staff about
  voluntary diversion options using CBHI

42
Tips for Advocates Navigating the New CBHI System

• Have information about CBHI available to share
  with clients/families
• Ask to be included in the ICC Team and for
  permission to communicate with care coordinator
• Monitor youth and families ICC participation for
  appropriate team development, access to necessary
  services, degree of state agency involvement and
  extent to which protected health information is
  shared with Team members orally or in writing

43
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 Childrens Behavioral Health
  Advisory council members regarding issues unique
  to the child welfare and juvenile justice systems
  

44
Additional Information

• The Centers 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 Childrens
  Behavioral Health Initiative, including program
  specifications, regional CSAs and provider
  networks and information re access to other
  MassHealth resources can be found at
• www.mass.gov/masshealth/childbehavioralhealth