Lots of Kids Need the CBHI: I Wonder How the System is Doing.

As I have have said, I am mostly a primary care pediatrician.   That said,  I keep giving out information about the CBHI to families who come into the office for reasons not at all related to their mental health problems.  A grandmother today brought in her granddaughter for a cough, and in the course of our discussion, I discovered that the little girl was now on a third psychotropic medication for her difficult behaviors.  That grandmother left with treatment for her cold and with the words "Children's Behavioral Health Initiative" on a card to try to get Home-Based Behavioral Therapy for the child's mother.  Then there are the children who come in for annual physicals who, I think, would benefit from the new services.  Most of them have therapists and some even have psychologists;  the families could just use more.  Then, there are children like the one whose mother called today- he's three years old, his behaviors are out of control and he needs to be evaluated and his mother needs support.  I sent him into the system as well-  I think that he will end up in the CBHI.

So I am sending the patients into the system;  time will tell us how they end us.  Any stories from the CSAs?  How are you all doing at finding them all of the services that they need?

Musing on a CATCH Visiting Professor

My Academy has some very cool parts to it; my personal favorite is the CATCH program, which actively promotes the interaction of pediatricians and communities to create things of beauty- partnerships that glow, radiating hope to families without ACCESS (that's the A in CATCH) who want to improve their child's health. One part of their program is the CATCH Visiting Professor Program, which brings accomplished Community Pediatricians to academic medical centers in an effort to broaden their horizons. (*FULL DISCLOSURE: I hosted one of these many years ago and , as the District 1 CATCH Facilitator for the AAP, I have reviewed these applications for many years since. I was selected to be a Visiting Professor in Austin next fall*) Today, my colleagues at Children's Hospital invited me to hear Dr. Angela Diaz, a Professor and advocate for adolescent services describe her program in New York City, at Mount Sinai Hospital. ( See Robin Hood - Heroes - Dr. Angela Diaz, Shared via AddThis) I was representing the Academy and promoting the CATCH program, mostly to the Residents.

Dr. Diaz had a lot to say, and at the end of it all, we were speechless. How does anyone do what she had done? She works with adolescents in the City. Initially, I wasn’t sure that this was going to be relevant to this blog, but it turns out to be incredibly relevant; she opened by pointing out that 20% of adolescents have mental health issues, but only 4% of those actually get those needs get addresses. Her program is focused on the uninsured youth, using a positive youth development model rather than a deficit model to assure long term growth. What’s that mean? A lot of programs focus on risk behaviors- she adds the “lens” of the consumer and the strength/asset to more fully understand what is going on with the teenager and to build a relationship that is therapeutic and the key to long term follow-up. She has found that it is really useful to form partnerships with “every organization in New York” that works with children, with has aided them tremendously in their fund-raising.

The core of her program is that they give the patients what they need regardless of ability to pay. She’s been creative at engaging subspecialists as well as getting funding for mental health services, health education services and the other ancillary services that are needed to address all of the needs of adolescents.

Sounds great, no? And yet there is very little evaluation data to support any of these “best practices”- they were recently funded to conduct an external evaluation to look at the impact of all of these services. Overall, her program serves 10,000 youth of color, from all over the metropolitan area, on a budget of $14 million per year, all of which is generated through fundraising.

To me, the most interesting (and relevant) part of her talk was her discussion of the distinction between her funding sources, which are focused on specific parts of the problem of adolescent health, and her care, which she described as wholistic. I am paraphrasing, but I think that she said something like: "I do what they ask of me, then I do what needs to be done" in the care of her high risk adolescent population. That strikes me as an appropriate lesson for the CSAs going forward: the funder (MassHealth) is required by law to cover a number of services; the agencies implementing the program (the CSAs) will need to decide how to use this funding to supply wholistic care.

Nice way to think about the process through which we are currently living.

Like the first crocus: It might be working.

Do you remember April?  We had a miserable winter in the Northeast, with much snow, ice and rain, unending coldness and gloom thoughout the land.  People kept speaking of this magical time called Spring, when it would all get better.  None of us believed it.  One day, in middle of April, I spotted a crocus, blooming in a sunny patch of grass.  THEN I believed in Spring, and the bloom of flowers and grass and weeds that has accompanied our joyous and wet Spring and early Summer.

That's what I felt like today.

I got a call from the mother/father of a 13 y/o girl/boy with bipolar disorder, who was being discharged from a respite facility, and who had lost her psychiatrist while in respite, and who needed some medication of which I had never heard in order to stay on an even keel.  A bridge prescription, they call it, to tide them over while they identify a new psychiatrist. (These "bridges" are sometimes far from temporary, as it can take months to get on a psychiatrist's list).  As per our routine, I asked for documentation of the medication and assured the guardian that I could handle it for a month. While waiting for the documentation to arrive, I read up on the medication, which really had only a little evidence in its favor.  The documentation arrived after about a week,  and I called the father/mother to tell him/her that it would be handled, using the opportunity to commiserate about how hard it was going to be to find a psychiatrist, and urging them to bear with me if we ran into problems with the medication.  "Oh, by the way" , she added nonchalantly,"I am enrolling him/her in that new program you have been talking about.  They are here right now doing the assessment".  

I smiled and laughed and cried just a little and my colleagues probably thought that I was crazy.  But that is the crocus, my friends, the first bloom of hope for a while.  This kid really needs this program;  the program people have found the family; I will bet that they will have them hooked up lickety-split.  I know intellectually that the folks from Community Healthlink with have just as much trouble finding a child psychiatrist as I would.  But emotionally, knowing that at least one family is engaging in the process, makes me feel a whole lot better. 

 It is nice to see the Spring come.  Bring it on.

Say It Ain't So, Deval!

I have a really hard time following the state budget, and I hadn't heard of any of the Governor's "line-item" vetos affecting children's mental health this year, so I left for my 4th of July weekend feeling like the budget debate was done for this year.  Boy, was I wrong.

According to the EOHHS Webpage,  Line Item 40000950, the Children's Behavioral Health Initiative will take a hit.  All it says on the webpage is 

Veto Explanation:  I am reducing this item by an amount not recommended in light of available revenues.

Now I could not find in that Veto anything about how much he was cutting from the item, which is:

For the purposes of administrative and program expenses associated with the children's behavioral health initiative, in accordance with the settlement agreement in the case of Rosie D. et al. v. Romney, United States District Court for the District of Massachusetts civil action No. 01-30199-MAP, to provide comprehensive, community-based behavioral health services to children suffering from severe emotional disturbances; provided, that the secretary of health and human services shall report quarterly to the house and senate committees on ways and means relative to implementation of the initiative; and provided further, that such quarterly reports shall include, but not be limited to, details of the implementation plan, results of the scheduled plan to date, including a schedule detailing commencement of services and associated costs by service type, and an analysis of compliance with the terms of the settlement agreement to date.

and is budgeted at $65,833,963 in the GAA for FY2010.  But in the reconciled budget,  it was  listed at $68,000,000, so that is a $2.1 million (or 3%) cut.  (Details of all of the cuts are available here.)  So now what?

Clearly we need to push for an override.  This is a penny-wise (perhaps) but pound-foolish idea.  According to Health Care for All in a recent e-mail:

This veto threatens the effectiveness of the community based services that were rolled out on July 1. 
Please ask your networks to contact their State Representatives and State Senators and ask them to override Governor Patrick's veto of CBHI / Rosie D. funding. 

Couldn't have said it better myself.  Time to man the phones, my friends.  Let the legislators know that implementing a new program as you are cutting its budget is a recipe for failure.

Systems of Care Want You!

I hope everyone had a great Fourth of July-  I certainly did, what with the fireworks and the ribs and the bicycling and the gorgeous (finally) weather in New England.  After re-rereading the Declaration of Independence (see previous post), though, I am reminded that the celebration of our freedom implies a need to engage in the systems of our governance.  For those of us interested in providing systems of care for families of children with serious emotional disturbance, there is a brand new opportunity to make a difference in the design of the system:  The Systems of Care Committee.

 

Already I can hear you running for the exits-  come back here and listen (or keep reading, which is the same thing).  To make this thing work, we need YOU to be on another committee.  Implicit in the structure of the CSAs is a feedback mechanism, called the Systems of Care Committee, through which the care coordination process is informed by a group of family members, community members, agency representatives and mental health care providers on what is working and what is not.  The groups will meet monthly, and their input into the process must be documented for the remedy to be effective.  They ALL will start meeting this month.  I know that is another meeting- but is an important one that you should try to build into your schedule.  Your mission is to transform it into a transformative event (I didn't say that this is going to be easy!)

 

I’ve posted the meetings for Central Massachusetts on the “Upcoming Events’ portion of the blog- I’ll try to keep it as current as I can.  If other CSAs want to send me their stuff, I will put it up there.  But it is incredibly important that as many of us as possible make it to these meetings.  They represent our chance to make a difference in this opportunity for real system change.

Remember, you can always find your CSA through the MBHP!

Independence Day: The unanimous declaration of the thirteen United States of America

I love that the Globe still prints this, every year.  Read it.  You will learn things.

WHEN in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form as to them shall seem most likely to effect their Safety and Happiness.

CLICK HERE FOR THE REST

We, therefore, the Representatives of the united States of America, in General Congress Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these United Colonies are, and of Right ought to be Free and Independent States; that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. And for the support of this Declaration, with a firm reliance on the Protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

Happy 233rd birthday, everybody!

Message from the Front Line: It Still Ain't Easy

So, I've have a couple more days on the front line, doing primary care.  Summertime in a pediatric practice  is mostly physicals and lyme disease, with a bit of coxsackie virus thrown in for good measure.  In our practice, however, the annual check-ups seem to involve a lot of kids who could well be friends of "Rosie D", families that would really benefit from the CBHI.   I have been singing the praises of the CBHI to many of those families, but I can already see soem of the roadblocks to enrollment in the new system.

1)  Fear:  Families of kids with serious emotional disturbance (SED) are used to being judged by others, but they still don't like it.  Is that child out of control because of biology or poor parenting?  Almost everyone has an opinion about what a family should do with a child who is behaving badly, and most of those opinions are formed without a full understanding of what is going on within the family.  A long history of being judged, however, makes it likely that you are not going to want to be judged in the future.  What happens if you go into this long and detailed assessment and you find out that it really is all your fault after all?

2)  Impatience:  Families of kids with SED often have a pretty sophisticated understanding of what makes their kid tick, and what would help them with behavioral management.  Now we want them to go through a 2 hour intake process, and a 4 hour CANS on the chance that they might get to sit in a 2 hour meeting to develop a plan over a 2 month period?  This does not sound terribly appealing, especially if the SED behaviors are slowly wearing down your spirit.    Saul Alinsky said that the key to successful community organizing (and this is community organizing, of a sort) is to have an early success, to give people hope.  Where is that "early success" in this approach?

3)  Hopelessness:  Some families of kids with SED have just given up;  they feel that they have exhausted the possibility of behavioral intervention, they have had therapists who didn't understand, they have seen psychiatrists on the 15 minute med check treadmill, and they don't see the possibility of something better than that.  It is hard work to build confidence in thos e families.

The key for us as primary care doctors is to walk with these families through the Valley, to see them past the fear and hopelessness and impatience, to convince that there is hope fo something better.

I saw families with all of these problems last week;  I am trying to walk them over to the CBHI.  One family, it turns out, had private insurance, even though they would be income eligible for SSI;  we are working with our legal aid attorneys to get that fixed.  Another wants psychopharmacology services, but no counseling.  Come to find out that her oldest son (not our patient) is now inpatient at a Psych Hospital, and she just can't deal with another system right now.  Another family has been a bit neglectful of check-ups and is about to move to another part of the state, to escape a domestic violence situation.  I am trying to assure some continuity of services, but am really not sure that will work.  None of these case have yet hit the CBHI;  I hope that the system is ready for them when they are ready for it.