ROSIE D. V. PATRICK

1. ROSIE D. V. PATRICK Transforming the Medicaid Children’s Mental Health System

2. Transforming the Children’s Mental Health System I. Litigation – Purpose and Outcome II. Pathway to Home-Based Services III. Implementation & Monitoring IV. Opportunities and Benefits Across Child Serving Systems

3. The Litigation – Purpose and Outcome

4. The Problem in Communities Inadequate behavioral health services leading to negative outcomes for children, youth and families: ● 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

5. 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) • Hospital admissions interrupting educational services • Students left considering more restrictive environments in order to have their social, emotional and behavioral needs met

6. The Response • 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

7. The Legal Claims • 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

8. The Remedy • 1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act • 2/22/07 Court orders development of in-home services, including comprehensive care coordination, screening, assessments and crisis services • 4/27/07Appoints Karen Snyder as the Court Monitor • 6/18/07 Parties begin implementation meetings • 7/16/07 Court enters judgment including detailed remedial plan with implementation timelines.

9. New Court-Ordered Services • 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

10. Eligibility for Rosie D. Services • 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 the remedial services (other than ICC) if medically necessary

11. 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.

12. 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…

13. 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 General pervasive mood of unhappiness or depression A tendency to develop physical symptoms or fears associated with personal or school problems Federal IDEA Definition of SED

14. 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.

15. The Pathway to Home-Based Services

16. Accessing a Continuum of Care Behavioral Health Screening Mental Health Evaluation Referral for Care Coordination / Other Services Comprehensive In-Home Assessment Wrap-Around Team Process Delivery of Home-Based Services

17. 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 • 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

18. Mental Health Evaluation • 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

19. Intensive Care Coordination ● Delivered by 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 home-based assessment and creation of a care planning team including state agencies, schools and other providers ● Prepares and monitors implementation of a single integrated treatment plan

20. 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 within parameters • Components of plan include: • Treatment goals and objectives • Identification and role of specific providers • Frequency, intensity and location of service delivery • Crisis plan

21. 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

22. The Values of Wraparound 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

23. The New MassHealth Service Array

24. Mobile Crisis Services • 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

25. 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, skill-building, crisis counseling, service linkages and coordination with existing providers • Focused on youth’s rapid return to the community, avoiding a higher level of care

26. In-Home Behavior Services • 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

27. In-Home Therapy Services • 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

28. Therapeutic Mentoring • 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

29. Family Support and Training • 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 child-serving systems and fostering empowerment through education, coaching and training

30. Appeals • 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

31. Implementation and Monitoring

32. Design of Home-based Services • 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)

33. The Service Delivery System • 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

34. Monitoring and Court Oversight • 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

35. Revised Implementation Timelines July 1, 2009: Intensive Care Coordination, Family Support and Training, & Mobile Crisis Services October 1, 2009: In-Home Behavior Services and Therapeutic Mentoring November 1, 2009: In-Home Therapy December 1, 2009: Crisis Stabilization Units

36. Challenges to Implementation • 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

37. Opportunities and Benefits Across Child-Serving Systems

38. 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

39. Benefits of Coordination with Schools • Increased access to mental health expertise to inform service and placement decisions • Flexible delivery of services in school, after-school and other community settings • Ability to coordinate interventions across settings and promote generalization of skills • For youth in ICC a single treatment plan and point of contact through the Care Coordinator • Additional services to avoid unnecessary institutionalization and support success in more integrated community and educational programs

40. Challenges to Effective Coordination • Avoiding confusion regarding the interaction between two federal entitlement programs • Effectively integrating Individual Care Plans and Individual Education Plans • Limited school/staff resources for coordination • Navigating confidentiality requirements including students’ MassHealth eligibility

41. Promoting Effective State and Local Collaboration ● Provide meaningful information and outreach to staff / parents • Offer training on the scope of remedial services, which students are eligible, how to facilitate referrals and opportunities to coordinate educational and community-based services • Develop local and statewide guidance on MassHealth system Identify model policies and best practices for referral and service coordination for effective collaboration with parents and 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

42. Community Involvement in Systems of Care • 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

43. Yolanda’s Law: Section 19 Taskforce • 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)

44. Importance of Interagency Protocols • MassHealth required by the Judgment to develop protocols with all EOHHS agencies • Necessary to establish consistent expectations, procedures and communication across systems • Will address issues like referrals, staff training, Care Planning Team participation and dispute resolution • DCF, DYS, DMH and DPH protocols are now available with agency staff training underway; DDS and DEEC in development

45. Tips for Educators and School Staff • Have information about the new MassHealth available to share with eligible students and families • Maintain contacts for local CSA’s, service providers and mobile crisis intervention/ESP programs • Consider mechanisms for assisting interested families with the referral process • Participate in the ICC Wraparound Team process and communicate with care coordinator if requested • Discuss school/district wide policies and procedures needed to support access and effective collaboration

46. How You Can Help • 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 confront • 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 DESE Taskforce and participate in the School Assessment Tool

47. Additional Information • The Center’s website: www.rosied.org contains: • News updates and features on implementation • An extensive library of litigation documents • Other information designed for families, providers and 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