Transcript Strategies for Success

Strategies for
Success
Using Educational and Medicaid
Entitlements to Address Children’s
Behavioral Health Needs
Topics for Discussion
Preparing for the New Medicaid
Behavioral Health System
 Accessing Educational Entitlements for
Children with Serious Emotional
Disturbance
 Opportunities for the Coordination of
Community and School-Based Mental
Health Supports
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Part I: Preparing for the New
Medicaid Behavioral Health System
Summary of Rosie D. v. Romney
 The Pathway to Home-Based Services
 New Service Descriptions
 What this means for children and families
 What this means for the parent advocate
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Rosie D. v. Romney
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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
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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
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The federal Medicaid program mandates Early
Periodic Screening Diagnosis and Treatment –
EPSDT – for children under 21
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EPSDT mandates screening and treatment
necessary “to correct or ameliorate a physical or
mental condition”
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States must provide this treatment promptly and
for as long as needed
The Remedy
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Court finds Massachusetts in violation of EPSDT
provisions of the Federal Medicaid Act
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Court orders the State to develop in-home
services, including comprehensive care
coordination, screening, assessments, in–home
supports and crisis services
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Plaintiffs and Commonwealth begin regular
implementation meetings
New Court-Ordered Services
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Access to behavioral health screening
Comprehensive diagnostic assessments
Intensive Care Coordination
In-Home Therapy Services
In-Home Behavioral Services
Therapeutic Mentoring
Parent Partners
Mobile Crisis and Crisis Stabilization Units
Eligibility for Services
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Any Medicaid-eligible child (MassHealth
Member) who is determined to have a serious
emotional disturbance (SED) is eligible for
intensive care coordination
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
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.
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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.
Children who meet medical necessity criteria for
the remaining in-home services can be eligible
without a finding of SED.
Pathway to Home-Based Services
Screening or Identification
 Mental Health Evaluation
 Referral for Care Coordination
 Comprehensive Home-Based Assessment
 Wraparound Treatment Planning
 Delivery of Services
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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
 Parents, state agencies, and other child serving
entities can also refer children in need of 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
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If a positive screen occurs, a referral can be made for a
mental health evaluation
Parents can also seek behavioral health evaluations
directly if a need has already been identified
As of November 30, 2008, all diagnostic evaluations will
incorporate the Child and Adolescent Needs and
Strengths (CANS) survey
The CANS includes a structured interview to assess and
child and family’s strengths and their service needs
State has trained mental health professionals in
hospitals, clinics and state agencies to use the CANS,
increasing rates and time for conducting evaluations
Intensive Care Coordination
 Provided
by a 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 homebased assessment and development of a care
planning team including state agencies, schools and
other providers
 Prepares and oversees implementation of a single
integrated treatment plan
 Parents can self-refer or be referred by a mental
health clinician or other professional
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
 Components of plan include:
 Treatment goals and objectives
 Identification and role of specific providers
 Frequency, intensity and location of service
delivery
 Crisis plans
The Value 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
Home-Based Service Descriptions
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Mobile Crisis Services
Crisis Stabilization Units
In-Home Behavioral Services
In-Home Therapy
Therapeutic Mentoring
Parent Partners
Mobile Crisis Services
 Mobile,
on-site, face-to-face response to
youth in crisis, available 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
Behavior Management Therapy
and Behavior Monitoring
 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
 Includes
24/7 urgent response, flexibility in
scheduling, 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, coordinate care
 Therapist works with youth and the family on
development of specific clinical treatment goals to
improve youth’s functioning
 A paraprofessional may assist by supporting the
youth and family in day-to-day implementation of
treatment goals
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, focus on ensuring youth’s successful
navigation of various social contexts, skill acquisition
and functional progress towards treatment goals
Caregiver/Peer to Peer Support
 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
What this means for children and
their families
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A new array of home and community–based
services
Supports available with the length and intensity
that youth with serious emotional disturbance
need
An approach which empowers families to direct
their own care
A process which coordinates all agencies and
providers in one team and produces one unified
treatment plan
What this means for parent
advocates
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A new resource to help support children in their
homes/communities and in the least restrictive
educational environment
A team of community experts available to work
with/influence the school
A need for familiarity with eligibility requirements, steps
for referral, available services and the expectations of
wrap-around
An opportunity to help families successfully coordinate
community-based mental health services with goals and
services in the IEP
A legal entitlement beyond special education
Revised Implementation Timelines
July 1, 2009: Intensive Care Coordination,
Family Partners & Mobile Crisis
October 1, 2009: In-home Behavioral
Services and Therapeutic
Mentoring
November 1, 2009: In-Home Therapy
December 1, 2009: Crisis Stabilization Units
Part II: Accessing Educational
Entitlements for Children with SED
Sources of legal entitlement
 Anatomy of the IEP
 Knowing What Can be Provided
 Using the Team Process
 Options for Dispute Resolution
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Sources of Legal Entitlement
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Individuals with Disabilities Education
Improvement Act (IDEA 2004) 20 USC
Section 1400 et seq.
Code Federal Regulations 34 CFR 300
Chapter 766, codified at M.G.L. c. 71B
Code of Massachusetts Regulations
603 CMR 28.00
Bureau of Special Education Appeals,
Hearing Rules and Decision
Other State and Federal Case Law
The Broad Definition for Education
State and Federal case law has interpreted
■ Purely academic benefit is not the only measurement of
educational progress
■ Educational, social and emotional problems are often intertwined
and cannot be separated
■ Where behavioral disturbance interferes with the student’s ability
to learn and student needs highly structured activities during and
after school to receive an appropriate education, the IEP must
address such problems
■ Education is to be broadly defined to include not only traditional
academic skills but also basic functional life skills
The Range of “Related Services”
Related services means transportation and such developmental,
corrective, and other supportive services as are required to assist a
child with a disability to benefit from special education, and includes
speech-language pathology and audiology services, interpreting
services, psychological services, physical and occupational therapy,
recreation, including therapeutic recreation, early identification and
assessment of disabilities in children, counseling services, including
rehabilitation counseling, orientation and mobility services, and
medical services for diagnostic or evaluation purposes. Related
services also include school health services and school nurse
services, social work services in schools, and parent counseling and
training.
34 C.F.R. 300.34
Eligibility and Disability Definitions
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Emotional Impairment: the student exhibits one or more of the
following characteristics over a long period of time and to a
marked degree that adversely affects educational performance:
 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 types of behavior or feelings under normal
circumstances;
 a general pervasive mood of unhappiness or depression; or a
tendency to develop physical symptoms or fears associated
with personal or school problems (34 CFR §300.8(c)(4))
Eligibility and Disability Definitions
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The determination of disability shall not be made
solely because the student's behavior violates
the school's discipline code, because the
student is involved with a state court or social
service agency, or because the student is
socially maladjusted, unless the Team
determines that the student has a serious
emotional disturbance
The Importance of “Effective Progress”
Massachusetts case law and regulations requires more
of a Free and Appropriate Public Education than simply a
student’s ability to benefit…
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First Circuit defines FAPE to require “[D]emonstrable improvement
in the educational and personal skills identified as special needs –
as a consequence of implementing the proposed IEP.” Town of
Burlington v. Dep’t of Education 736 F.2d 773 (1st Cir. 1984)
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Effective progress is defined as “documented growth in the
acquisition of knowledge and skills, including social/emotional
development, within the general education program, with or without
accommodations, according to chronological age and
developmental expectations, the individual educational potential
of the child, and the learning standards set forth in the
Massachusetts Curriculum Frameworks and the curriculum of the
district. 603 CMR 28.02(17)
SED and the Anatomy of An IEP
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Access to the Curriculum (A and B)
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Individualized Goals
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Are Social, Emotional and Behavioral Issues Addressed?
Are There Measurable and Objective Benchmarks
The Service Delivery Grid
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Are Necessary Accommodations, Modifications, and Instructional
methods in Place?
Are Parent Training and Consultation Included?
Are the Right Professionals Responsible?
Extended Year/Day Services
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Can FAPE be Delivered in a Regular School Day?
Is there a risk of regression?
Consider a Range of Educational
Services and Program Options
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Home-based supports
Consultation with parent,
other faculty; providers
Related services
 Speech / PT
 OT (sensory
integration)
 Counseling
 Behavioral supports
Extended day/year
Specific accommodations
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Specific curricula or
training programs
Instructional methods
 language-based
 Discrete trial training
Class size; ratios;
teacher qualifications;
peer groups
Multi-disciplinary
approaches across
settings
IEP Requirements (603 CMR 28.05)
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The IEP shall include specially designed
instruction to meet the needs of the individual
student and related services that are necessary
to allow the student to benefit from the specially
designed instruction, or may consist solely of
related services that are necessary to allow the
student to access the general curriculum,
consistent with federal and state requirements.
At the Heart of the IEP Process
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To develop an individualized education
plan with the Team to address the child’s
social, emotional, and behavioral needs in
the least restrictive environment possible
so that they may make effective progress
consistent with their individual potential.
Knowing What Can be Provided
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BSEA Hearing Decisions: Eligibility
 Student
with anorexia nervosa and co-morbid
disabilities did have serious emotional
disturbance and need for special education;
academic progress alone not a complete
measure of effective progress, including
progress towards independence
 Dighton-Rehoboth Reg’l School District
#06-2145
Knowing What Can be Provided
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BSEA Hearing Decisions: Unmet Service Needs
 Student
with significant and continuing unmet deficits
regarding emotional regulation, social skills and
community/independent living skills which negatively
impacted her learning – ordered curriculum-based
social skills training, social skill group in the
community, an assessment of independent living
needs, a designated support person in school, and an
mechanism to consult weekly with Student’s therapist
In Re Boston Public Schools BSEA # 06-3610
Using the Team Process Effectively
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Knowing when to Convene
 New evaluations
 Repeated suspensions
 Risk of absence for medical reasons
 Change in circumstances; regression
Comprehensive Educational Record Reviews
 Past IEPs and progress reports
 Report cards, MCAS testing
 Incident reports, disciplinary records
 Past educational testing; evaluations; observations
Using the Team Process Effectively
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Requesting Appropriate and Timely Evaluations
 Three year evaluations (can request early)
 Functional behavioral assessments (across settings)
 Psychological/educational assessments
 Related Services (OT, Speech)
Identifying the Necessary School Staff
 General education/special education/related service specialists
Inviting the Right Experts / Providers
 Independent evaluators, therapists, counselors, pediatricians
Bringing State Agencies to the Table
 Pooling knowledge and resources – applying joint pressure
Realizing Anticipated Educational and
Therapeutic Benefits
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Regular communication with direct
providers/school staff
Exercising the right to parent/independent
observation in schools
Requesting consultation between school and
community providers to assist in measuring
progress
Careful consideration of confidentiality concerns
Common IEP Disputes
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Finding of ineligibility
Failure to Implement IEP
Disputed Placement
Inappropriate or insufficient services
 Social,
emotional, behavioral supports
 Home based supports/training
 Lack of measurable goals and objectives
 Absence transitional goals/services
To Accept or Reject or Both
Weigh last accepted IEP versus any new
services within the proposed IEP
 A decision to reject, in part, allows for the
application and enforcement of all other
accepted portions of the proposed IEP
 After notice by school, BSEA will issue
parent rights information to family
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Options for Dispute Resolution
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Re-visit TEAM process
 Issues not fully addressed or discussed
 Independent or other evaluations not considered
Program Quality Assurance (DESE)
 For complaints or technical assistance
BSEA mediation
 Parties communicating well and in good faith
 Mutual interest in less adversarial settlement process
File formal BSEA hearing request
 Exhaustion of other less formal options
 Availability of legal representation
Part III: Opportunities for
Coordinating Educational and
Behavioral Health Services
The Promise of the Children’s Behavioral
Health Initiative
 How Schools and Students can Benefit
 Preparing for Effective Collaboration
 How You Can Help
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Relevance of Rosie D. Reforms
Supporting the work of advocates and
professionals interacting with or serving
Medicaid-eligible children and their families
 School districts and educational programs
 Clinicians and mental health providers
 Juvenile justice / DYS diversion programs
 Benefits/Health law advocates
 CHINS and child welfare agencies
Benefits for Schools and Students
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Increased access to mental health expertise and
consultation to inform IEP development
Delivery of community-based services in school and
after-school settings
Availability to coordinate services across settings and
promote generalization of skills
Single point of contact for School through ICC team and
care coordinator
Additional services to support children’s success in
integrated programs and settings
How Schools Can Prepare
Develop local guidance on Rosie D. system reforms, including
model policies and procedures for effective collaboration with
parents and community-based providers
 Partner with local CSA and participate in regional Systems of Care
Committees
 Offer outreach, information and training on the scope of remedial
services, which students are eligible, how to facilitate referrals and
opportunities to coordinate educational supports with communitybased mental health services
■ 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
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How Advocates Can Prepare
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Consider both entitlement systems when
determining how best to support a youth and
family
Develop knowledge to assist with multi-system
navigation (Education/Medicaid/State Agencies)
Know where to seek additional information and
consultation when questions or disputes arise
Other Ways You Can Help
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Consider where Rosie D. services could be useful in
your work and share those ideas with us
Help us identify and address obstacles
Assist to 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
Make your voice heard in ongoing implementation
Additional Information on CBHI
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For more information, Rosie D. website: www.rosied.org.
 News updates on recent developments.
 An extensive library of documents from the case including
decisions, discovery documents, legal memoranda, status
reports, and much more.
 Other information designed for families, providers or other
professionals.
MassHealth website: www.mass.gov
 Managed Care and Customer Service contacts
 Relevant applications and Forms
 Information on CBHI service system
Mental Health and Special
Education Resources
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Boston Bar Association’s Updated Guide to Mental
Health Services (www.bostonbar.org)
Center for Law and Education (www.cleweb.org)
Massachusetts Advocates for Children
(www.massadvocates.org)
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Special Education Coalition
Department of Education Website
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www.doe.mass.edu
 Relevant statutes and regulations
 Mediation and BSEA hearing forms
 BSEA rules & hearing decisions
 Directory of legal/advocacy services