Transcript Strategies for Success

The Promise and
Potential of Rosie D.
Empowering Parents and
Serving Children
The New Medicaid Behavioral
Health System
Summary of Rosie D. v. Patrick
 The Pathway to Home-Based Services
 The Remedial Services
 Wraparound Principles and Values
 Empowering Parents: Potential and
Promise
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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 Role of Parents in the
Litigation
The inspiration for the lawsuit
 The most patient participants in the
litigation process
 The most powerful witnesses at trial
 The most important players in the
implementation process
 The potential beneficiaries of the remedy
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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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Behavioral health screening
Comprehensive diagnostic assessments
Intensive Care Coordination
In-Home Therapy Services
In-Home Behavioral Services
Therapeutic Mentoring
Family Support Workers (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
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
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
WrapAround Priniciples and Values
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
The Potential of Wraparound to
Empower Families
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Families and children are the most important
participants in the process
Their vision and hopes are central to the
process
Their strengths, rather than needs, guide the
process
Their culture, style, and preferences must be
addressed by the process
They are in charge
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
A legal entitlement beyond special education