ROSIE D. V. ROMNEY

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

2. Transforming the Children’s Mental Health System • The Litigation • The Pathway to Home-Based Services • Implementing the Remedy

3. I: The Litigation • 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

4. The Litigation: Plaintiffs • 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 home-based mental health services to be successful in their communities

5. The Litigation: 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

6. The Litigation: The Decision • 1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act • Orders State to develop in-home services, including comprehensive assessments, case management, behavior supports, and mobile crisis services • 8/22/06: Plaintiffs and the Commonwealth submit separate remedial plans after six months of negotiations fail to achieve complete agreement

7. The Litigation: The Remedy 2/22/07 Court orders the State’s plan, but requires • All Medicaid-eligible children with serious emotional disturbance (SED) be eligible for relief • Timelines for each implementation phase • Modification of plan only by the Court • An enforceable order, overseen by the Court 4/27/07Appoints Karen Snyder as the Court Monitor 6/18/07 Plaintiffs and Commonwealth begin regular implementation meetings 7/16/07Final judgment and final remedial plan

8. Eligibility for Home-Based Services • Any Medicaid-eligible child (MassHealth Member) who is determined to have a serious emotional disturbance (SED) is eligible for care coordination and a comprehensive home-based assessment • 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 for home-based services

9. 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.

10. 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…

11. 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

12. 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.

13. The Pathway to Home-Based Services • Step 1: Screening or Identification • Step 2: Mental Health Evaluation • Step 3: Assign Care Manager • Step 4: Conduct Comprehensive Assessment • Step 5: Convene Treatment Team • Step 6: Develop Treatment Plan • Step 7: Provide Home-Based Services

14. Step 1 - Screening or Identification • At routine well child visits, or when requested, primary care doctors/nurses will screen for behavioral health concerns, using one of six standardized screening instruments • Parents, state agencies, and other child serving entities can also refer children in need of screening • Children with known conditions or state agency involvement can bypass screening • MassHealth will maintain data on screenings, referrals, and treatment

15. Step 2 - Referral for Evaluation • If a positive screen occurs, a referral is made for a mental health evaluation • Parents can also seek specialized behavioral health evaluations directly if a need has otherwise been identified • Evaluation can be conducted by mental health professionals at clinics, centers or local programs

16. Step 2 - Mental Health Evaluation • Evaluations will use the Child and Adolescent Needs and Strengths (CANS) as part of the assessment process • The CANS is an established and reliable instrument that is used in many states to determine whether a child needs mental health services • State must • improve mental health evaluation process • train professionals and clinics to use the CANS

17. Step 3 Intensive Care Coordination • If the child is determined to have SED, s/he is eligible to receive intensive care coordination. • A care manager is assigned promptly by the regional Community Service Agency (CSA) • Intensive care coordination includes: • A comprehensive home-based assessment • A single care coordinator for all services • A single treatment team for all services • A single treatment plan for all services

18. Step 3 – Role of Care Manager Care managers will be responsible for: • Working in partnership with family and child to ensure their meaningful involvement in all aspects of treatment planning, including • Completion of a comprehensive assessment • Overseeing and coordinating home-based and other mental health services • Convening and overseeing the treatment team • Preparing, monitoring, and reviewing the treatment plan

19. Step 4 – Comprehensive Home-Based Assessment • Visit to home • Interviews with parents, caregivers, teachers, and other persons identified by the family • In-depth review of records and past treatment • Collaboration with family to identify strengths and areas of need

20. Step 5 -Treatment Team • A single child/family team will work with families to plan home-based and other services • Team can also include all involved state and educational agencies, family and child, and other persons involved in the child’s life • Team determines the type, amount, intensity, and duration of home-based services

21. Step 5 – Treatment Planning Process • Treatment planning will be based upon a wrap-around process and the following core values: • strength-based • individualized • child-centered • family-focused • community-based • multi-system • culturally competent

22. Step 6 - Treatment Plan • Team develops single plan that focuses on strengths of child and family • Single plan integrates any other agency plans • Components of the Plan include: • treatment goals and timetables • home-based services provided, including frequency and intensity • specific providers identified • crisis plans and services

23. Step 7 – Home-Based Services In addition to existing Medicaid (MassHealth) services and intensive care coordination, the four new home-based services are: • Mobile crisis intervention and crisis stabilization • In-Home Behavioral services • In-Home Therapy services • Independent Living Skills training

24. Mobile Crisis Services • Mobile crisis intervention will include short term emergency care in the home to evaluate and treat a child in crisis • Mobile crisis intervention will be available 24 hours/day, 7 days/week • Crisis stabilization will provide staff and treatment in the home or in another community setting for up to 7 days

25. Behavioral Services • In-home behavioral services are designed to address challenging behaviors in the home and community • Behavioral therapist writes and monitors behavior management plan with the family • Behavioral Aide implements the plan in the home and community

26. Therapy Services • In-home therapy services are designed to address social or emotional issues • Therapist works with child and the family on specific issues • May be assisted by an aide who supports the child in the home, school, and recreational settings

27. Mentor Services • Independent Living Skills Mentors help child with adaptive, social and communication skills • Child/Family Support is offered to help families address child’s needs, including education, support and training • Services provided by qualified paraprofessionals working under the supervision of the treatment professional or treatment team

28. Appeals • Any disagreement with decisions on eligibility, need for a care coordination, need for services, amount or duration of services, or termination of services can be appealed through the Medicaid fair hearing process • Advocates are available to assist families in these appeals

29. III. Implementing the Remedy • Delivery of Home-Based Services • Developing the Service Delivery System • Data Collection and Evaluation • Monitoring • Ongoing Court Involvement • Implementation Timetables • Challenges to Implementation

30. Delivery of Home-based Services • Once approved by federal Center for Medicaid Services (CMS), services will be part of the Medicaid State Plan • All services can be provided separately or in combination, and delivered in any setting (natural home, foster home, community) • Service descriptions, billing rates, and utilization procedures will be developed but cannot further restrict eligibility

31. The Service Delivery System • Community service agencies (CSA) selected for each geographic area • CSAs provide care management, oversee teams, and coordinate services • CSAs may provide direct services • Children in all managed care organizations (MCOs) and the Partnership (MBHP) are entitled to home-based services though the same CSA • State to establish criteria for CSA selection and performance

32. Data Collection and Evaluation Data must be collected on: • Utilization of screening, assessment, care management, and service recommendations • Claims data on service utilization Services may be evaluated: • State may collect data on some outcomes and consumer satisfaction • No formal commitment to evaluation of child & family outcomes, integrity of team process, or family involvement

33. Monitoring and Court Oversight • Court Monitor meets regularly with parties, providers, professionals, and families • Compliance Coordinator guides state efforts • Parties meet monthly to discuss each element of new system • Plaintiffs actively monitor all aspects of new system • Court Monitor reports to Court about progress • Court meets quarterly with parties and Monitor

34. Implementation Timelines • November 2007: Initial report on service system and provider network development • December 2007: Modifications to screening and informing completed • November 2008: Assessment and evaluation process developed and provider training completed • June 2009: Regional CSA’s in place, delivery system operational and home-based services available

35. Challenges to Implementation • Workforce shortages • Provider capacity • Ongoing training / education • Outcome measurement • Network development • Resources