Transcript ROSIE D. V. ROMNEY

ROSIE D. V. ROMNEY
Transforming the
Medicaid Children’s
Mental Health System
Transforming the Children’s Mental
Health System
I. The Litigation – Purpose and Outcome
II. The Pathway to Home-Based Services
III. The Status of Implementation
IV. Realizing the Promise
of Rosie D. v. Romney
The Problem in Communities
Inadequate behavioral health services:
- Children stuck in ER’s or institutions
– Limited early identification of children in mental
health needs
– Services without sufficient intensity or duration to
meet children and families long term needs
– Fragmented and disorganized service system
with no single point of care coordination
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)
• Re-occurring hospital admissions creating interruptions in
educational services
• Students left considering more restrictive environments in order
to have their social, emotional and behavioral needs met
The Response
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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
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
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
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1/26/06: Court finds Massachusetts in violation of
EPSDT provisions of the Federal Medicaid Act
2/22/07 Court orders the State to develop in-home
services, including comprehensive care coordination,
screening, assessments, in–home supports and
crisis services
4/27/07 Appoints Karen Snyder as the Court Monitor
6/18/07 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
Family 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
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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.
Children who meet medical necessity criteria for the
remaining in-home services can be eligible without a
finding of SED.
II.
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
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
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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As of November 30, 2008, all diagnostic evaluations
will incorporate the Child and Adolescent Needs and
Strengths (CANS) survey
The CANS instrument includes a structured interview
used 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 timeframes for
conducting evaluation
Intensive Care Coordination
● Located within regional network of Community Service Agencies
(CSA)
● 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 development of a care planning team
including state agencies, schools and other providers
● Preparing and overseeing 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
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 plans
The Values of Wrap-Around
ICC team and in-home providers responsible for maintaining
fidelity to several core principals:
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strength-based
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individualized
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child-centered
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family-driven
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community-based
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multi-system
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culturally competent
Mobile Crisis Services
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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
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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
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 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, with focus on ensuring youth’s successful navigation
of various social contexts, skill acquisition and functional
progress towards identified treatment goals
Caregiver/Peer to Peer Support
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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
Appeals
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Any disagreements with the MassHealth agency or
Managed Care Entity regarding the need for
services, the amount or duration of services, or the
termination of services can be appealed through the
Medicaid fair hearing process
A dispute resolution process will be in place for Care
Planning Teams to utilize in the event there are
disagreements regarding service recommendations
and treatment planning needs
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 Center for Medicaid and
Medicare Services (CMS), services will be part of
Medicaid State Plan, receiving federal matching
money
Medicaid eligible youth can access these services
regardless of their eligibility category using the
MassHealth disability determination process
All services can be provided separately or in
combination, and delivered in any setting (natural or
foster home, school, community)
The Service Delivery System
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Regional Community Service Agencies (CSA) have
been selected across the state to provide care
coordination as well as family partner services
CSAs may also provide other direct services
All Managed Care Entities (MCEs) will contract with
the CSA network, but retain their own UM strategies
MCE’s are undertaking workforce and provider
development activities now
The Commonwealth will offer wrap-around training
and ongoing coaching to CSA’s and in-home therapy
providers
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 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
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
Challenges to Implementation
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Workforce shortages
Provider capacity
Ongoing training / education
Outcome measurement
Network development
Resources
Effective coordination with child-serving
agencies
IV. Realizing the Promise of
Rosie D. v. Romney
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The Relevance of CBHI reforms
The importance of Interagency Protocols
Community Involvement in Systems of Care
Benefits of Collaboration with Schools
Frameworks for Linking Schools and
Community Mental Health Services
How You Can Help
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
● Benefits/Health Law Advocates
● CHINS and child welfare agencies
Importance of Interagency Protocols
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MassHealth required by the Judgment to
develop protocols with all EOHHS agencies
Necessary to establish expectations,
procedures and communication strategies
across child serving systems
Intended to address issues like referrals, staff
training, Care Planning Team participation,
and dispute resolution
Community Involvement in
Systems of Care
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CSA’s are required to reach out to their
communities, including forming and
operating regional Systems of Care
Committees
Important opportunity for communication and
collaboration between various agency and
community stakeholders, review of systemlevel issues impacting delivery of care and
fostering of longstanding partnerships
Benefits of Collaboration with Schools
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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 through team and care
coordinator
Additional services to support children’s success in
integrated programs
Considerations for State and Local
Education Collaboration
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Provision of information and training on the scope of remedial
services, which students are eligible, how to facilitate referrals
and opportunities to coordinate educational supports with
community-based mental health services
Develop local and statewide guidance on Rosie D. system
reforms, including policies and procedures for effective
collaboration with parents and community-based behavioral
health providers
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
Yolanda’s Law: Section 19 Taskforce
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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
services…”
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
(6/30/2011)
Taskforce’s Framework
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Leadership
Professional Development
Access to clinically, linquistically and
culturally appropriate behavioral health
services
Effective academic and non-academic
activities
Policies and Protocols
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
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
Collaborate with Section 19 taskforce members and
the Children’s Mental Health Campaign
Additional Information
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For more information, go to the Rosie D. website,
www.rosied.org. The website contains:
– News updates on recent developments.
– An extensive library of documents from the case
including decisions, discovery documents, legal
memoranda, status reports, and much more.
– A training and events calendar.
– Other information designed for families, providers
or other professionals.