Transcript ROSIE D. V. ROMNEY

ROSIE D. V. ROMNEY
Transforming the
Children’s Mental
Health System
Transforming the Children’s Mental
Health System
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The Litigation
The Pathway to Home-Based Services
Implementing the Remedy
I: The Litigation
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Filed in 2001 by the Center for Public
Representation (CPR) and the firm of Wilmer
Cutler Pickering Hale and Dorr
The class action lawsuit sought 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
The Litigation: Plaintiffs
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Brought by the parents or guardians of eight
children with serious emotional, behavioral,
or psychiatric conditions
These plaintiffs represent a class of
Medicaid-eligible children with serious
emotional disturbance who need homebased mental health services to be
successful in their communities
The Litigation: The Legal Claims
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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 Litigation: The Decision
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1/26/06: Court finds Massachusetts in violation of
EPSDT provisions of the Federal Medicaid Act
Orders State to develop in-home services, including
comprehensive assessments, case management,
behavior supports, and mobile crisis services
8/22/06: Plaintiffs and the Commonwealth submit
separate remedial plans after six months of
negotiations fail to achieve complete agreement
The Litigation: The Remedy
2/22/07 Court orders the State’s plan, but requires
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All Medicaid-eligible children with serious emotional
disturbance (SED) be eligible for relief
Timelines for each implementation phase
Modification of plan only by the Court
An enforceable order, overseen by the Court
4/27/07 Appoints Karen Snyder as the Court Monitor
6/18/07 Plaintiffs and Commonwealth begin regular
implementation meetings
7/16/07 Final judgment and final remedial plan
Eligibility for Home-Based Services
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Any Medicaid-eligible child (MassHealth Member)
who is determined to have a serious emotional
disturbance (SED) is eligible for care coordination
and a comprehensive home-based assessment
SED is defined by two federal agencies which use
slightly different definitions
Any child who meets EITHER definition, as
determined by the mental health evaluation, is
eligible for home-based services
Federal SAMHSA Definition of SED
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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
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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
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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.
II. The Pathway to Home-Based
Services
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Step 1: Screening or Identification
Step 2: Mental Health Evaluation
Step 3: Assign Care Manager
Step 4: Conduct Comprehensive
Assessment
Step 5: Convene Treatment Team
Step 6: Develop Treatment Plan
Step 7: Provide Home-Based Services
Step 1 - Screening or Identification
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At routine well child visits, or when requested,
primary care doctors/nurses will screen for
behavioral health concerns, using one of six
standardized screening instruments
Parents, state agencies, and other child serving
entities can also refer children in need of screening
Children with known conditions or state agency
involvement can bypass screening
MassHealth will maintain data on screenings,
referrals, and treatment
Step 2 - Referral for Evaluation
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If a positive screen occurs, a referral is made
for a mental health evaluation
If a child’s needs are identified by another
entity, or a parent, referral should be made to
a primary care doctor/nurse for formal
screening OR for a mental health evaluation
Evaluation can be conducted by mental
health professionals at clinics, centers or
local programs
Step 2 - Mental Health Evaluation
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Evaluations will use the Child and Adolescent Needs
and Strengths (CANS) as part of the assessment
process
The CANS is an established and reliable instrument
that is used in many states to determine whether a
child needs mental health services
State must
– improve mental health evaluation process
– train professionals and clinics to use the CANS
Step 3 Intensive Care Coordination
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If the child is determined to have SED, s/he is
eligible to receive intensive care coordination.
A care manager is assigned promptly by the regional
Community Service Agency (CSA)
Intensive care coordination includes:
– A comprehensive home-based assessment
– A single care coordinator for all services
– A single treatment team for all services
– A single treatment plan for all services
Step 3 – Role of Care Manager
Care manager will be responsible for:
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Completion of a comprehensive assessment
Overseeing and coordinating home-based and other
mental health services
Convening and overseeing the treatment team
Preparing, monitoring, and reviewing the treatment plan
Working directly with family and child
Step 4 – Comprehensive Home-Based
Assessment
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Visit to home
Interviews with parents, caregivers, teachers,
and other persons identified by the family
In-depth review of records and past
treatment
Collaboration with family to identify strengths
and areas of need
Step 5 -Treatment Team
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A single child/family team will work with
families to plan home-based and other
services
Team can also include all involved state and
educational agencies, family and child, and
other persons involved in the child’s life
Team determines the type, amount, intensity,
and duration of home-based services
Step 5 – Treatment Planning Process
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Treatment planning will be based upon a wraparound process and the following core values:
– strength-based
– individualized
– child-centered
– family-focused
– community-based
– multi-system
– culturally competent
Step 6 - Treatment Plan
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Team develops single plan that focuses on strengths
of child and family
Single plan integrates any other agency plans
Components of the Plan include:
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treatment goals and timetables
home-based services provided, including frequency and
intensity
specific providers identified
crisis plans and services
Step 7 – Home-Based Services
In addition to existing Medicaid (MassHealth)
services and intensive care coordination, the
four new home-based services are:
 Mobile crisis intervention and crisis
stabilization
 In-Home Behavioral services
 In-Home Therapy services
 Consumer Support services
Mobile Crisis Services
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Mobile crisis intervention will include short
term emergency care in the home to
evaluate and treat a child in crisis
Mobile crisis intervention will be available 24
hours/day, 7 days/week
Crisis stabilization will provide staff and
treatment in the home or in another
community setting for up to 7 days
Behavioral Services
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In-home behavioral services are designed to
address challenging behaviors in the home
and community
Behavioral therapist writes and monitors
behavior management plan with the family
Behavioral Aide implements the plan in the
home and community
Therapy Services
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In-home therapy services are designed to
address social or emotional issues
Therapist works with child and the family on
specific issues
May be assisted by an aide who supports the
child in the home, school, and recreational
settings
Consumer Support Services
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Independent Living Skills Mentors help child with
adaptive, social and communication skills
Child/Family Support is offered to help families
address child’s needs, including education, support
and training
Services provided by qualified paraprofessionals
working under the supervision of the treatment
professional or treatment team
Appeals
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Any disagreement with decisions on
eligibility, need for a care coordination, need
for services, amount or duration of services,
or termination of services can be appealed
through the Medicaid fair hearing process
Advocates are available to assist families in
these appeals
III. Implementing the Remedy
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Delivery of Home-Based Services
Developing the Service Delivery System
Data Collection and Evaluation
Monitoring
Ongoing Court Involvement
Implementation Timetables
Challenges to Implementation
Delivery of Home-based Services
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Once approved by federal Center for
Medicaid Services (CMS), services will be
part of the Medicaid State Plan
All services can be provided separately or in
combination, and delivered in any setting
(natural home, foster home, community)
Service descriptions, billing rates, and
utilization procedures will be developed but
cannot further restrict eligibility
The Service Delivery System
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Community service agencies (CSA) selected for
each geographic area
CSAs provide care management, oversee teams,
and coordinate services
CSAs may provide direct services
Children in all managed care organizations (MCOs)
and the Partnership (MBHP) are entitled to homebased services though the same CSA
State to establish criteria for CSA selection and
performance
Data Collection and Evaluation
Data must be collected on:
 Utilization of screening, assessment, care
management, and service recommendations
 Claims data on service utilization
Services may be evaluated:
 State may collect data on some outcomes and
consumer satisfaction
 No commitment to evaluation of child & family
outcomes, integrity of team process, or family
involvement
Monitoring and Court Oversight
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Court Monitor meets regularly with parties, providers,
professionals, and families
Compliance Coordinator guides state efforts
Parties meet monthly to discuss each element of
new system
Plaintiffs actively monitor all aspects of new system
Court Monitor reports to Court about progress
Court meets quarterly with parties and Monitor
Implementation Timelines
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November 2007: Initial report on service system and
provider network development
December 2007: Modifications to screening and
informing completed
November 2008: Assessment and evaluation
process developed and provider training completed
June 2009: Regional CSA’s in place, delivery system
operational and home-based services available
Challenges to Implementation
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Workforce shortages
Provider capacity
Ongoing training / education
Outcome measurement
Network development
Resources