Thursday, January 10, 2008

The Devil is in the Details: A Conversation with Kathryn Rucker of the Center for Public Representation

This description of our recent session does not capture all of the richness of the discussion; these impressions are culled from my notes, and reflect my conscious and unconsious biases in this matter. The nice thing about a webblog is that I can edit it, to reflect your comments- PLEASE append your thoughts, corrections or disagreements as comments to enhance our discussion and understanding of this complex matter. David
About 25 people from a variety of agencies and advocacy groups came to the 3rd floor conference room of the old St. Vincent's Hospital building in Worcester MA (chops to the Department of Social Services and Kim Ferrucchia for the space and the fresh fruit and coffee) to hear and discuss the remedy in the case of Rosie D. v. Swift/Romney/Patrick, the landmark case that has driven the rapid pace of change in the processes of child mental health in the past few months. Kathryn Rucker spoke on behalf of the Center for Public Representation, which led the team that brought the lawsuit in 2001, working with the Mental Health Legal Advisors Committee and the firm of Wilmer Cutler Pickering Hale and Dorr. She tried to provide us with three things:
We provided a constant stream of questions and reflections that showed the importance of dialogue in this process, and really gave a sense of how complex this process is likely to be. I will try to fit the discussion in to the framework that she proposed, although the interactive process really had us jumping around quite a bit.


This was a class action brought on behalf of 8 named clients with amazing, real stories that illustrated a set of consistent problems in dealing with the mental health system as currently constructed within the Commonwealth of Massachusetts. The class is “children with Serious Emotional Disturbance” (a term not used by clinicians, but defined in law under IDEA and SAMSHA). She pointed out that, while the DOE and HHS define the term differently, the judge accepted EITHER definition for purposes of this suit and its remedy. Both definitions are a bit vague, meaning that we don't know exactly who is going to get these services. Anyway, the judge found that the state Medicaid program mandates Early and Periodic Screening, Diagnosis and Treatment, and that, under the current MassHealth guidelines, the state didn't didn’t tell parents about services to which their kids were entitled, and didn’t have the services accessible when the kids needed them. He told them to do better, and appointed Karen Snyder, former Chief of Program Operations for the Department of Children and Families in CT as the Court Monitor to ensure that it all happens.

The CPR and its allies seem to view the case as a pathway to home-based services for children with severe mental illness; they have worked hard during the remedy phase of the case to ensure that whatever is done is family-centered and community-based. After much discussion and disagreement, the judge felt that that the defendents plan was a realistic way to get to the goal of home-based services, and accepted their model. The idea was simple and the pace of change rapid; the judge set the following benchmarks:
1) Improved screening by Dec 31 2007
2) Improved evaluation process by Nov 30 2008
3) Improved treatment by 30 June 2008
Embedded in this plan is the notion of the treatment team; a group of professionals picked by the parents that will work with the family in ensure that services are right and that progress is being made.

It was at this point that the talk got interesting, as both our presenter and the group realized that scope of change that will be needed to make this happen. Many issues- full of devilish details were raised, discussed, resolved and not resolved- it was a lively time. "What about co-morbidity?" was one question. Turns that that co-morbidity will not interfere with your receipt of benefits, as long as your symptoms meet the criteria for one of the two definitions of Serious Emotional Disturbance. "What do you mean by home-based services?" This one was a look at the "wrap" of the "wraparound". Kathryn said that we hoped to cover some services like mentoring and community-based afterschool programs for these kids, but that the details are still being worked out. "Right now, families end up in the emergency room looking for this kind of help. Will there be changes in the way EMH and crisis intervention is done?". Ms. Rucker presented a vision of mobile evaluation teams, able to roll out to the places where the kids are, and reducing the need to go to the ER for emergency services. Much of these details, she said, are under discussion. She expressed hope that, by the time that Emily Sherwood comes to visit in February, many of these details will be resolved.

IMPLEMENTING THE REMEDY: Ms. Rucker then moved on to a discussion of how the implementation was proceeding so far.
STEP 1: Screening: Implementing it as we speak. And, as you heard in previous posts, proceeding with few hitches, although I must say that this is the easy part.
STEP 2: Assessing: Kids identified as positive need an assessment. At this point the mental health system to begin involvement, with an assessment using an assessment tool with unlikely name of CANS. THis led to a brief but intense discussion of the validity and utility of the instrument, until the many unanswered questions surged back to the surface.
"What about pediatrician filing a 51A for refusing referral?" M s. Rucker wasn't sure how that would work out, but both DDS folk and me (representing the pediartric community) though it unllikely. "Anyone talking about Medicaid’s level of reimbursement for behavioral health services?" Yes, they have, although everyone is acutely aware that the talk needs to translate into action. No specific targets or changes have been proposed. "Is any talking about training for the future? How are we developing the training for the next generation of mental health care providers? How are we going to have a more robust clinical field? This is an area for which there are no easy answers and the court monitor has asked to talk to providers to begin solving it. Right now, one is allowed 2 hours of diagnostic time per 6 months. What if they need a psychological evaluation? This actually led to a discussion of the role of the Intensive Care Coordinator. Their hope is that the care coordinator is the the person who may be able to override medical needs. What of this treatment team? She said that the treatment team needs an intensive care coordination model; and it needs to be tailored to the individuals, but that we need to figure out how much authority the treatment team has. Finally, how do we make this work across silos, and within families in which the parents are not able to navigate this system? There was no good answer- The need for confidentiality and the need for collaboration are both real and difficult. Although the family needs to drive the team, and the process, we need mechanisms to ensure that the child is the ultimate beneficiary. It is also clear that not everyone will get every service; we will need to watch how the regions are organized in order to be sure that the services are available all across the state.

If this reads like an active and fast moving discussion, it was, and I'll bet I missed half of the questions and answers. Please add comments; let me know what we missed. In the end, the group agreed on three things:
  • Ask Karen Snyder to talk with us.
  • Watch for the RFI to come out on evaluatin process to get input into the process as it is developed.
  • Keep talking about this.
So, please leave some comments, ask some questions and join us in February.

12 February 2008, 4:00 PM:
Conversation with Emily Sherwood,
Director of Children's Behavioral Health Interagency Initiatives,
Executive Office of Health and Human Services
DSS Conference Room, 25 Winthop St, Worcester MA

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