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Transcript ROSIE D. V. ROMNEY

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 negative
outcomes 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 or
exacerbating 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
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
relationships with peers
and teachers
Inappropriate behaviors
or feelings under
normal circumstances
General pervasive
mood of unhappiness or
A tendency to develop
physical symptoms or
fears associated with
personal or school
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
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
● 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:
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, skillbuilding, 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 childserving systems and fostering empowerment
through education, coaching and training
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,
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
Monitor reports to Court about progress and
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
● 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
 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
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
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.
Collaborate with DESE Taskforce and participate in
the School Assessment Tool
Additional Information
The Center’s website: contains:
– News updates and features on implementation
– An extensive library of litigation documents
– Other information designed for families, providers and
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: