Transcript ROSIE D. V. ROMNEY

ROSIE D. V. ROMNEY
Transforming the
Medicaid Children’s
Mental Health System
Rosie D. Advocacy Training
I. The Litigation – Purpose and Outcome
II. The Pathway to Home-Based Services
III. The Platform for Service Delivery
IV. The New MassHealth Service Array
V. Coordinating Child-Serving Systems
VI. The Wraparound Process
Introduction: Rosie D. v. Romney
The Children’s Mental Health Crisis
Inadequate behavioral health services leading to negative
outcomes for children, youth and families:
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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 Response: Rosie D.
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Class Action lawsuit filed in 2001 by the Center for
Public Representation (CPR) the Mental Health
Legal Advisors Committee (MHLAC) 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 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 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 Decision
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1/26/06: Court finds Massachusetts in
violation of EPSDT provisions of the Federal
Medicaid Act
8/22/06: Plaintiffs and the Commonwealth
submit separate remedial plans after six
months of negotiations fail to achieve
complete agreement
2/22/07 Court orders Defendant’s plan with
Plaintiff’s requested modifications
The Remedy
Judgment requires the State to develop a system for
the provision of behavioral health screening, diagnostic
evaluation and specific home-based services
● 4/27/07 Karen Snyder appointed Court Monitor
 6/18/07 Parties begin implementation
 7/16/07 Court enters judgment including detailed
remedial plan with implementation timelines.
Implementing the Remedy
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Designing Home-Based Services
Developing the Service Delivery System
Timetables for Service Availability
Monitoring Activities
Challenges to Implementation
Design of Home-based Services
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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
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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
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
Implementation and Monitoring
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Implementation activities ongoing since June 2007
Court Monitor meets regularly with parties, providers,
professionals, and families
Compliance Coordinator guides state efforts
Parties meet monthly to discuss implementation and
service system design
Plaintiffs actively monitor all aspects of new system
Court Monitor reports to Court about implementation
and overall compliance with the Judgment
Court meets quarterly with parties and Monitor
Challenges to Implementation
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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
The Pathway to Home-Based Services
Eligibility for Rosie D. Services
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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 remedial services
(other than ICC) if medically necessary, depending
on MassHealth coverage type
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.
Pathways to Service Access
● Behavioral Health Screening
● Mental Health Evaluation
● Referral to Care Coordination
Comprehensive In-Home Assessment
Wrap-Around Team Process
Delivery of Home-Based Services
● Referral to Discrete Remedial Services
Screening or Identification
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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
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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
● Wraparound treatment planning process delivered by a
regional network of 32 Community Service Agencies (CSAs)
● A Care coordinator is assigned to work in partnership with
family and youth, ensuring family-driven care and meaningful
involvement in all aspects of treatment planning
● ICC facilitates completion of a comprehensive home-based
assessment and creation of a care planning team including
natural supports, state agencies and other providers
● Prepares and monitors implementation of a single integrated
treatment plan
Treatment Plan
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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:
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Treatment goals and objectives
Identification and role of specific providers
Frequency, intensity and location of service delivery
Crisis plan
The Values of Wrap-Around
ICC team and home-based providers responsible for
maintaining fidelity to several core principals:
– strength-based
– individualized
– child-centered
– family-driven
– community-based
– multi-system
– culturally competent
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
Direct or Facilitated Self-Referral
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All Medicaid behavioral health services can
be requested in this way
If youth not interested in or eligible for ICC,
may seek specific services instead, provided
they are medically necessary
For Therapeutic Mentoring and Family
Partner Services a clinical treatment plan
must be in place to support the referral
The Platform for Delivering
Children’s Mental Health Care
The EOHHS Infrastructure
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EOHHS operates as the single State
Medicaid Agency for Massachusetts
Office of Medicaid administers state and
federal Medicaid dollars on behalf of EOHHS
Children’s Behavioral Health Initiative is an
EOHHS interagency initiative whose mission
is to strengthen, expand and integrate state
services into a comprehensive, communitybased system of care
The Managed Care Network
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MassHealth Behavioral Health Unit oversees behavioral health
services provided by MCO’s.
Four Managed Care Entities to which MassHealth and MCOs
contract out behavioral health services
– MBHP (serving PCC plan) 300,000 members statewide
– Beacon Health Strategies (subcontractor NHP and Fallon)
– BMC Health Net (MassHealth and Commonwealth Care)
250,000 members statewide
– Network Health (MassHealth and Commonwealth Care)
160,000 members in 300 cities
The Special Role of MBHP
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Serves the largest population of youth with
behavioral health needs
Now serves youth whose behavioral health
care was formerly under fee-for-service
Manages the behavioral health needs of
youth in DCF or DYS custody
Took lead in CBHI network development and
provider selection activities
The Role of Managed Care Entities
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Develop, maintain and contract with the
provider network
Set standards and monitor performance
Collect data and inform quality assurance
Maintain grievance/appeal procedures
Authorize care and payment of claims
Provide customer service and administration
of benefits
Managed Care Reforms under CBHI
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MCE’s contract with all Community Service
Agencies and Emergency Service Providers
MCE’s all use same network of new
MassHealth service providers
MCE’s all use agreed upon authorization
parameters for new services
MCE’s will maintain distinct authorization
processes when services are requested
The New MassHealth Service Array
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
Family Partners
Mobile Crisis and Crisis Stabilization Units
Mobile Crisis Services
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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
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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
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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
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Delivered in the home or community setting
Includes 24/7 urgent response, flexibility in
scheduling and frequency and duration of sessions
Fosters understanding of family dynamics, develop
strategies to address stressors, enhance problem
solving and communication skills, address risk and
safety planning, identify community resources, offer
care coordination
Therapist works with youth and the family on
development of specific clinical treatment goals to
improve youth’s functioning
Paraprofessional supports the child and family in day
to day implementation of treatment goals
Therapeutic Mentoring Services
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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
Family Support and Training
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Provided by Community Service Agencies (CSAs)
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
Appeals
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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
Coordinating 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
Importance of Interagency Protocols
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Commonwealth required by the Judgment to develop
protocols with all EOHHS agencies
Necessary to establish consistent expectations,
procedures and communication across systems
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
Community Involvement
in Systems of Care
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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
Promoting Effective Collaboration With
The JJ and Child Welfare Systems
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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
Potential Challenges in the Juvenile
Justice and Child Welfare Context
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Cooperation in the context of an adversarial
proceeding
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Protocols for early identification of children with behavioral
health needs
Confidentiality issues
Stigma
Prompt access to clinically, linguistically and
culturally appropriate behavioral health services
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Medicaid eligibility determinations
Assessment of behavioral health status, determination of
appropriate and medically necessary services
Delivery of services identified as medically necessary
Education: The Potential Benefits of
CBHI Services
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Increased access to mental health expertise to
inform child’s service and placement decisions
Flexible 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 children’s success in more integrated
community programs and educational placements
Education: Challenges to Realizing
Effective Coordination with CBHI
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Providing meaningful information and outreach to
school staff and parents
Identifying model policies and best practices for
referral and service coordination by schools
Avoiding confusion regarding the interaction
between two federal entitlement programs
Effectively integrating Individual Care Plans and
Individual Education Plans
Limited school resources for coordination
Appropriate access to MassHealth information for
eligible Students
Childrens’ Mental Health Law of 2008:
How it Complements CBHI
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Established the Behavioral Health Advisory Council
by Statute
Convened Education Taskforce to inform statewide
recommendations for improving coordination and
delivery of mental health services in schools
Provided for regional inter-agency review teams to
collaborate on and attempt to resolve service
disputes in complex cases, including matters not
successfully resolved through the ICC dispute
resolution process. Implementing regulations now
under development.
Supporting the Wraparound Process
Ten Principals of the Wrap Process
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Family voice and
choice
Team based
Natural Supports
Collaboration
Community based
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Individualized
Strengths based
Persistence
Outcome based
Culturally
competent
Understanding the Four Phases
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Engagement (2-3 weeks) Family meets with
facilitator; explore strengths, needs and culture;
history; expectations for service; facilitator engages
identified team members and prepares for first
meeting
Planning Phase (1-2 weeks) Team learns about
families strengths, needs and vision; together
establish priorities; tasks and responsibilities; an
integrated plan is developed
Understanding the Four Phases
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Plan Implementation (9-18 months) Family and Team
meet regularly to promote coordination of care;
review progress towards goals, make adjustments in
service provision
Transition (ongoing) As goals are achieved,
preparations made for transition from formal
wraparound; family and Team identify continuing
needs and supports; plan for contingencies including
how to “restart” wraparound if necessary in future
Ensuring Fidelity to Wrap Values
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That caretakers, families and youth are well
informed and empowered to direct care
That Team members seek and observe
families perspective, goals and priorities for
service provision
That Team shares responsibilities, services
are effectively coordinated across settings
and respects cultural identify of youth and
families
Awareness of National Models and
Wraparound Resources
● For users guide and process descriptions
National Wraparound Initiative
www.rtc.pdx.edu/nwi
● For fidelity measurement and quality
assessment tools
Wraparound Evaluation & Research Team
WSU http://depts.washington.edu/wrapeval
Next Steps for Advocates
Tips for Advocates: Navigating the
New CBHI System
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Ask about insurance status; any existing disability or
diagnosis
Get releases for client’s MCE and MassHealth (PSI)
Inquire about potential for SED determinations
Be aware of local CSA’s, contacts for referral and
other resources for rapid clinical assessment
Take opportunities to educate state agency and court
staff about voluntary diversion options using CBHI
Tips for Advocates: Navigating the
New CBHI System
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Have information about CBHI available to share with
client’s/families
Ask to be included in the ICC Team and/or 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 confidential information is shared
with Team members orally or in writing
Rosie D. Advocacy Project at CPR
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Available to class members needing short
term advice on accessing services or direct
representation based on service denials,
terminations or state agency disputes
Available to attorneys and advocates seeking
technical assistance and information on
CBHI relevant to their practice and the
representation of individual class members
How 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 best practices and address
obstacles class members may be confronting
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 stakeholders regarding issues
unique to your practice
Additional Information
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The Center’s website: www.rosied.org contains:
– News updates and features on implementation
– An extensive library of litigation documents
– Information designed for families, providers and
other 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