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 I. The Litigation – Purpose and Outcome II. The Pathway to Home-Based Services III. The Status of Implementation IV. Issues in the Juvenile Justice and Child Welfare Case Contexts

3. 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

4. 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

5. 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 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.

7. 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

8. 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

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 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. The Values of Wrap-Around 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

20. 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

21. 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

22. 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

23. 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

24. 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, with focus on ensuring youth’s successful navigation of various social contexts, skill acquisition and functional progress towards identified treatment goals

25. 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

26. 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

27. III. Implementing the Remedy • Design of Home-Based Services • Developing the Service Delivery System • Monitoring • Ongoing Court Involvement • Implementation Timetables • Challenges to Implementation

28. 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)

29. 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

30. 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

31. Revised Implementation Timelines July 1, 2009: Intensive Care Coordination, Caregiver/Peer to Peer Support, & Mobile Crisis Services October 1, 2009: In-home Behavioral Services and Therapeutic Mentoring November 1, 2009: In-Home Therapy December 1, 2009: Crisis Stabilization Units

32. 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

33. Issues in the Juvenile Justice and Child Welfare Systems • The Relevance of CBHI reforms • The Importance of Interagency Protocols • Community Involvement in Systems of Care • Benefits of Participation/Collaboration • Challenges in the JJ/Child welfare context • Tips for Advocates

34. 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

35. 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 and DMH protocols are now available with agency staff training underway; DMR and DEEC in development

36. Community Involvement in Systems of Care • CSA’s are required to convene regional Systems of Care Committees • Important for communication and collaboration between various agencies, courts, schools, and other stakeholders, • Opportunity to review system-level issues impacting delivery of care, identify area resources and foster ongoing partnerships

37. Promoting Effective Collaboration With The JJ and Child Welfare Systems • Offer information/outreach to system stakeholders: attorneys, court clinics, clerk magistrates, judges, probation officers… • Encourage membership on CSA Systems of Care Committees • Consider use and impact of CBHI resources in existing or expanded diversion programs • Develop model motions or other practice aides for court appointed counsel seeking to access or present CBHI resources as part of alternative dispositions • Collect and review initial experiences with system interfaces • Identify strategies and infrastructure needed to establish successful linkages between community mental health services and children in the juvenile justice and child welfare systems

38. Yolanda’s Law: Behavioral Health Advisory Council • Created as part of the Children’s Mental Health Law of 2008 • Intended to develop proposals relating to best practices, inter-agency coordination of services, and extent of involvement of children with behavioral health issues within the JJ and child welfare systems • Also provides for inter-agency review teams to collaborate on complex cases. Specifically provides that juvenile probation may be invited to participate where appropriate. Team determines what services child should receive and who will provide them

39. Potential Benefits of CBHI Involvement • Increased access to mental health expertise to inform child’s service and placement decisions • Delivery of services in school, after-school and other community settings • Availability of resources to coordinate services across settings and promote generalization of skills • Single point of contact through ICC team and care coordinator • Additional services to avoid institutional care and support children’s success in more integrated community programs

40. Potential Challenges in the Juvenile Justice and Child Welfare Context • Cooperation in the context of an adversarial proceeding • Protocols for early identification of children with behavioral health needs • Confidentiality issues • Stigma • Prompt access to clinically, linguistically and culturally appropriate behavioral health services • Medicaid eligibility determinations • Assessment of behavioral health status, determination of appropriate and medically necessary services • Delivery of services identified as medically necessary

41. Tips for Advocates: Navigating the New CBHI System • Ask about insurance status; any existing disability or diagnosis • Get releases for client’s MCE and MassHealth (PSI) • Inquire about potential for SED determinations • Be aware of local CSA’s, contacts for referral and other resources for rapid clinical assessment • Take opportunities to educate court staff about voluntary diversion options using CBHI

42. Tips for Advocates: Navigating the New CBHI System • Have information about CBHI available to share with client’s/families • Ask to be included in the ICC Team and for permission to communicate with care coordinator • Monitor youth and families ICC participation for appropriate team development, access to necessary services, degree of state agency involvement and extent to which protected health information is shared with Team members orally or in writing

43. 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 Children’s Behavioral Health Advisory council members regarding issues unique to the child welfare and juvenile justice systems

44. 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