Children’s Behavioral Health Initiative MassHealth’s New Home- and Community-Based Behavioral Health Services for Youth

1. Children’s Behavioral Health InitiativeMassHealth’s New Home- and Community-Based Behavioral Health Services for Youth Autism Commission April 25, 2011

2. Rosie D. v Patrick Class Action Lawsuit • 2001: Suit filed alleging violation of Federal Medicaid EPSDT statute for a class of children with “serious emotional disturbance” • 2005: Case went to trial • January 2006: U.S. District Court Ruling: The Commonwealth violated 2 provisions of Medicaid law: EPSDT and “reasonable promptness” provisions • Specifically, the Court finds that the Commonwealth had not provided sufficient: • BEHAVIORAL HEALTH SCREENINGS • CLINICAL ASSESSMENTS • SERVICE COORDINATION • HOME-BASED BEHAVIORAL SUPPORT SERVICES • July 2007: Final Court Order defines the Remedy Plan

3. The Remedial Order: • December 2007: Standardized behavioral health screening during primary care visits • November 2008: Standardized mental health assessments using the Child and Adolescent Needs and Strengths (CANS) tool • July-November 2009: Six new home- and community-based services implemented statewide

4. How is the “class” defined? Any youth under 21 who: • is eligible MassHealth Standard or CommonHealth • meets either the SAMHSA or IDEA definition of “emotional disturbance” • However, MassHealth will pay for remedy services for any youth with a medical need for the service who is enrolled in MassHealth Standard or CommonHealth. ONLY Intensive Care Coordination is limited to youth who meet the SAMHSA or IDEA definitions of serious emotional disturbance.

5. SAMHSA definition of “Serious Emotional Disturbance” Child from birth to age 18 who currently or at any time during the past year, has had a diagnosable mental, behavioral, or emotional disorder* of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities. *”Developmental disorders, substance abuse disorders or V-codes are not included unless they co-occur with another DSM-IV or ICD-10 diagnosis.”

6. IDEA definition of “Emotional Disturbance” • Emotional disturbance means 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: • 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 tendency to develop physical symptoms or fears associated with personal or school problems • IF THESE CHARACTERISTICS ARE NOT SOLEY THE RESULT OF AUTISM, MENTAL RETARDATION, SPECIFIC LEARNING DISABILITY, HEARING IMPAIRMENT, VISUAL IMPAIRMENT, DEAF-BLINDNESS, SPEECH OR LANGUAGE IMPAIRMENT, ORTHOPEDIC IMPAIRMENT, TRAUMATIC BRAIN INJURY, OTHER HEALTH IMPAIRMENT, OR MULTIPLE DISABILITIES NOT INCLUDING A SERIOUS EMOTIONAL DISTURBANCE.

7. Additional information about MassHealth eligibility: • Youth under age 21 with a medical need for the service enrolled in other MassHealth “coverage types” such as Family Assistance, Basic or Essential may be able to access In-Home Therapy and Mobile Crisis Intervention. • These youth are NOT eligible to receive ICC, In-Home Behavioral Services, Therapeutic Mentoring or Family Support and Training

8. What is MassHealth CommonHealth?: • CommonHealth is MassHealth’s coverage for children and adults with disabilities. • THERE IS NO INCOME LIMIT for CommonHealth; there is a sliding scale premium, based on family income. • If a child’s condition meets the IDEA or SAMHSA definition of “emotional disturbance”, he or she may be eligible for “CommonHealth”. • Parents/guardians can either ask the MassHealth Enrollment Center to send them the “Disability Supplement” to the Medical Benefit Request form, or download both forms from the MassHealth website.

9. How to apply for MassHealth: • You can get information about applying for MassHealth at www.Mass.gov/masshealth or by calling the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997)

10. Children’s Behavioral Health Initiative Services • Intensive Care Coordination • Family Support and Training • In-Home Therapy Services • In-Home Behavioral Services • Therapeutic Mentoring Services • Mobile Crisis Intervention

11. Intensive Care Coordination – What is “Wraparound”? • A structured team-based process for developing and implementing individualized Care Plans • Process is facilitated by a Care Coordinator (MA or BA clinician) • Strong emphasis on working in partnership with family and youth: engagement, respect, collaboration, promoting youth and family “voice and choice” • Process must be culturally informed to be effective • A powerful approach to engaging families, and to making gains that can be sustained in the long run • Especially appropriate for youth/families with complex needs and/or multiple service providers/systems

12. Family voice and choice Team-based Natural supports (sustainability)‏ Collaborative Community-based Culturally competent Individualized Strengths-based Persistence Outcome-based 10 Principles of Wraparound

13. Family Support and Training – “Family Partners” • Family Partners have been caregivers of a child with mental health or other special needs and has received Family Partner training • Supports family, youth participation in the wraparound process • Supports caregiver in parenting the child w/ serious emotional disturbance – provides education, coaching, support and training • In home and community settings

14. In-Home Therapy Services • In-home, intensive, family-based treatment • Goals: treat child’s mental health needs & promote healthy functioning of child in family • Provided by a team: MA-level therapist and trained paraprofessional • Delivered by a network of community-based providers

15. In-Home Behavioral Services • Behavior Management Therapy (MA or PhD) • Behavior Management Monitoring (BA) • Specialized service for children with persistent problem behaviors, who don’t benefit as much from talk-based therapies • Addresses goals identified in a treatment plan written by an outpatient provider, In-Home Therapy provider or ICC provider. In other words, the child must also have either an outpatient provider, In-Home Therapy provider or ICC. • In any setting where the child is naturally located, including home, school, childcare centers, respite settings • Delivered by a network of community-based providers

16. New MassHealth Services:Therapeutic Mentoring • Structured one-on-one mentoring relationship between therapeutic mentor and child or youth • Addresses daily living, social & communication needs • Addresses social functioning goals identified in a treatment plan written by an outpatient provider, In-Home Therapy provider or ICC provider. • In home, school or social settings • Delivered by a network of community-based providers

17. Mobile Crisis Intervention • Provided by local Emergency Services Providers • Short-term (up to 72 hours), mobile, on-site, face-to-face crisis intervention • Therapeutic response to a MassHealth-enrolled student’s mental health crisis by trained crisis professionals • In any setting where the child is naturally located, including home, school, childcare centers, respite settings • Provides follow-up to other services • Statewide ESP/MCI Toll Free Number: 1-877-382-1609

18. At the Center: Care Coordination • Intensive Care Coordination • (Wraparound) • Clinical Assessment inc. CANS • SED determination for eligibility • Medical Necessity determination • Care coordination 1 Three Service “HUBS”: • In-Home Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available 2 • Outpatient Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available 3 Child may have 1,2, or all 3 services Care coordination provided by most intensive service received.

19. Accessing Service Hubs: • Intensive Care Coordination • (Wraparound) • Clinical Assessment inc. CANS • SED determination for eligibility • Medical Necessity determination • Care coordination • Families • decide on • most appropriate • initial service • independently • or in consultation with • helping professions such as: • primary care, • mental health clinicians • schools • case workers • community orgs • faith leaders • others • In-Home Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available • Outpatient Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available Child may have 1,2, or all 3 core services Care coordination provided by most intensive service received.

20. Accessing Additional Services • Intensive Care Coordination • (Wraparound) • Clinical Assessment inc. CANS • SED determination for eligibility • Medical Necessity determination • Care coordination • Additional • Services • (accessed • through • core clinical • services) • Behavior • Management • Therapy & • Monitoring • Family Partners • Therapeutic • Mentoring • In-Home Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available Families decide on most appropriate initial service • Outpatient Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available Emergency Services Mobile Crisis Intervention

21. Experience to date…. SCREENING RATES - July-Sept. 2010: • 38% of children under 6 mos. (1.4% possible BH need) • 71% of children 6 mos. through 2 (4.7% poss. need) • 74% of children ages 3 through 6 (9.4% poss. need) • 75% of children ages 7 through 12 (10.4% poss. need) • 70% of youth 13 through 17 (9.4% poss. need) • 35% of youth 18 through 21(10.3% poss. need)

22. Experience to date…. Youth served in FY2010 (July 1, 2009 – June 30, 2010): • BH Screens* 303,516 • Youth with potential BH need* 24,909 • CANS Assessments: 26,250 • Intensive Care Coordination 6,479 • Family Support and Training 5,281 • In-Home Therapy 7,492 • In-Home Behavioral Service 242 • Therapeutic Mentoring 2,735 • Mobile Crisis Intervention 9,727 * # of screens, not unduplicated # of youth

23. Experience to date: Youth on the Autism Spectrum served in MassHealth BH services: • From completed CANS records entered from Nov. 2008 through Nov. 2010: • Outpatient care 23,124 620 2.7% • SOAP* 65 3 4.6% • In Home Therapy 5,251 237 4.5% • ICC 6,337 437 6.9% • CBAT/ICBAT** 1,449 67 4.6% • Psychiatric Hosp. 615 19 3.1% * Structured Outpatient Addiction Program **Comm. Based Acute Treatment/Intensive CBAT

24. Resources: • CBHI website (information on screening, CANS and services, including Medical Necessity Criteria, links to CANS training and certification websites and more): www.mass.gov/masshealth/childbehavioralhealth • MassHealth website: www.mass.gov/masshealth • MBHP website (for lists of ESP providers, CSAs, and providers of other new MassHealth services under CBHI): http://www.masspartnership.com/ • National Wraparound Initiative website: www.rtc.pdx.edu/nwi