Thursday, February 14, 2008

Talking with the CBHII: Visions of the Systems Yet to Be

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
On Tuesday (12 February),  the Worcester Mental Health Network hosted a conversation with Jack Simon Ph.D, who joined Emily Sherwood one month ago as the Assistant Director of the Children's Behavioral Health Interagency Initiatives of the Executive Office of Health and Human Services. Jack and Emily are essentially in charge of assuring that the Commonwealth implements the remedy approved by Judge Ponsor in the Rosie D. case. Jack comes to the position after 25 years in the mental health field, and was the director of the CFFC program at Children's Friend and Family Services in the North Shore/ Merrimac Valley. He led a somewhat informal, but extremely fruitful conversation for 1.5 hours, that left many of us feeling quite hopeful despite the snow and sleet that was falling as we left.

He began by pointing out that, despite the fast timeline imposed in the settlement, "Rosie D" implementation is a process, that is continuing, and is still under discussion (In other words, some of what the state currently envisions may change). The priorities in MassHealth's initiative have been established in the "remedy" recommended by MassHealth and accepted (with a few revisions) by the judge. As part of MassHealth's mandate under the EPSDT guidelines, Massachusetts must do four things.  Briefly stated:

  • Institute a statewide education campaign to parents, providers and others
  • Institute a mental and behavioral screening program throughout the Commonwealth.
  • Provide more home based services and care coordination.
  • Develop a data system to track compliance.

In Dr. Simon's mind, the most ambitious part of the implementation will be the care coordination/ extensive home based services. Right now, there are a few hundred kids getting this high level care coordination; under the lawsuit, it is suspected that going to a class of 7000 to 12,000 children. Furthermore, the remedy is not just about scale (which would be remarkable enough).  This is about the way in which we work.  The judge's order  requires us to approach services in a different way than we have before, using the principles of "wraparound care planning", which is not the same the "case management" as it  has usually been practiced. One key point that he emphasized was that "wraparound care planning" is different than case management.  Wraparound is very intensive, and is suited to children and families with especially complex needs.
  • Case management is based on professional expertise.  The case manager, usually a clinician with mental health expertise, looks at the "case" and arranges for the services needed.
  • Wraparound care coordination is based on a structured team process and the  family voice.  It recognize ALL of the expertise in the room, especially the expertise that parents have about their own children.  It deliberately does not try to summarize the "case" into a "snapshot"diagnostic category, and does not try to answer every need with a one-time treatment plan.  Even the planning model is developmental;  the plan develops over time. Mental health expertise is not the sole determinant of what is appropriate.
This sort of planning will be available to all kids who meet the definition of "serious emotional disturbance", a determination that will be made by a mental health professional, using Federal guidelines.  This is one of the sticking points:  who is in the class?  Turns out to be one of two things (in my words:  or you can look at the actual definitions in the Federal Register under SAMSHA or IDEA)
  • Children and adolescents (eligible for EPSDT) with a psychiatric diagnosis and a significant level of impairment  OR 
  • Children and adolescents (eligible for EPSDT)  with "emotional impairments that impair learning" 
In addition to the intensive care coordination noted above,  folks in the class are going to be treated with "whatever it takes" that is medically necessary, including traditional office-based therapy,  in-home therapy and behavior management, treatment and monitoring by appropriately trained professionals and paraprofessionals.   The paraprofessionals can make a powerful contribution, as Dr. Simon found in the CFFC pilot program (and echoed in the experience of  "Communities of Care" in Worcester with Dr. Peter Metz)    "Family Partners", in the argot of wraparound program, are not part of the traditional mental health system. They are family members, people who have been caretakers of kids with SED or similar conditions, hired by programs for their understanding of the community in which the child or adolescent lives, and have a level of insight into the interaction between that community and the family that ultimately allows the therapy and medications to work better. Their training includes working with families, mentoring prarents and helping them to be full partners in the planning process.  While the state has a strong philosophical commitment to using Family Partners, Dr. Simons was clear we need to figure out how to do this within the Federal Medicaid regulations.  Family partners and Wraparound, if instituted in a meaningful way, will make this initiative into an oddessy;  moving from the traditional model of one-on-one expert driven care to a family-driven model, that uses the biologic cues of social interaction to reinforce both the "talk therapy", the behavioral therapy and, yes, even the medication.  

Question:  This sounds really labor intensive-  and all of the agencies have a really hard time hiring hire clinicians. How do we find the workforce to implement this bold new vision?

Dr. Simon agreed;  workforce will be a problem.  Wraparound is not therapy and doesn't replace traditional mental health services;  getting people trained in traditional therapy to learn how to be Wraparound facilitators will be a challenge.  Under the traditional model, all we needed to do an evaluation, find a diagnosis and propose a treatment plan.  Under the wraparound model,  the care planning agency will work with family over time to get the "team" up and running in a sustainable way, so that they are in the habit of working together: Under wraparound, the understanding of child and family needs and strengths can change over time,  and the team leaders goal is to facilitate a group process to move people through stages of understanding of the child and the problems.  Wraparound is the antithesis of a "one size fits all" model, that many in Central Massachusetts fear.  It involves cutting a different garment for each child in the class.  
The proposed system as described by Dr. Simon is a real break from the past, and has a number of hurdles that must be crossed to get us to where we want to be.  He list a few:
CATCH #1: We don’t yet have final Medicaid approval for all of these services.  CMS (the Federal one:  Center for Medicare/Medicaid Services) has to authorize the use of Medicaid dollars to pay for some of the wraparound services.  The Court order doesn't require Massachusetts to pay for services that CMS doesn't approve.
CATCH #2: The lawsuit is all about Medicaid, and kids and their mental health problems tend to oscillate between the public and private sectors.
CATCH #3: We (all of us) want interagency collaboration with the government, and  DYS, DSS, DOE, DMH,  DMR and others will need to weigh in on how this is all integrated into the system.
CATCH #4: Currently, MassHealth handles mental health services through five difference mental health providers (Mass Behavioral Health Partnership, Network Health, Neighborhood Health Plan, Fallon Community Health Plan, BMC Healthnet).  These changes will need to be rolled out through all of them quickly.
We all probably have come up with another 17 or 18 potential problems in implementing the wide-ranging reforms envisioned within the CBHII.  (CATCH 22, get it?)  It was clear that this process, however, means to offer real areal vehicle for moving the system in directions in which we want to go, and that, in fact, this will serve as a basis for delivering services in other insurance systems.

Our group, of course, had many questions.  First up, what about the conventional mental health center: Does this mean that we are not going to be doing the work that we are doing now?  Dr. Simon agreed that we will need "less than SED" services for many of the children identified within this process.  Concern was expressed for the severe SED kids who have multiple agency involvement. How do we keep from simply adding layers:  "Case managers to manage the case managers" was the phrase that was used? Dr. Simon responded that Wraparound is a different model and the main issue to decide on a case by case basis how the parts should interact effectively).  He suggested that we check out the  
NATIONAL WRAPAROUND INITIATIVE SITE  (I think that I found the right one)  for more information.  He also suggested looking at their publication: FOCAL POINT.  Lots of good information in those two publications.

Dr. Simon suggested that our organizations have an important opportunity to have input into the process through a Request for Information that will be coming out on COMM-PASS this week.  Agencies are invited to offer input into the process, on workforce issues, training, structure of the statewide centers to provide this.   is RFI coming out this week or next week.

We came back to a discussion of the needs of the vast majority of children with mental and behavioral health problems; how will we meet the needs of those working their way up to SED. Home-based services are clearly the most circumscribed of possible services. What can we do for the majority of kids? Screening and assessment, of course, but also early referral to the more traditional services, in an attempt to prevent the development of more serious problems. We discussed SED determination, and access to second opinions, when the assessing clinician doesn't feel that the child belongs in the class. Dr. Simon assured us that many of the services short of intensive care coordination would be available through more traditional channels. We discussed the impact of screening on the primary care provider, and the shortage of providers in Central Massachusetts, particularly in Family Medicine. While this is a bit outside the scope of the settlement, Dr. Simon agreed that MassHealth needs to be aware of the problem.

We seemed frequently to come back to the relationship between the new system and the old. MassHealth is proposing that there should be 27 CSAs throughout the system, but that "wraparound" is not therapy and the CSA is not there to provide traditional services to the services. CSA should help the clinician to do their jobs. Some thought that this sounded like "family networks" that were started within DSS several years ago, and have had some difficulties in implementation. That discussion went on for a while.

The final question was "What services are we going to pay for?" After all, true wraparound service include things like respite, after school programs and socialization services, none of which are considered the usual purview of Medicaid. How do we ensure that the other needs are met?  Dr. Simon sees that, while the reform of the system demanded by the Rosie D. case can open the door, it will not be enough to completely close the deal with services outside the scope of Medicaid.  Peter Metz of our group spoke to this at the end of our session:  "Access to flexible funds is key, but it has not yet been determined how all of this will hold together.  Family partners can serve as the bridge for people on the edge of services, but, in reality,  this is a lifetime endeavor.  After we do what is mandated, we will need to work with the legislature to create the kind of model system that children can access within the Commonwealth, one that transcends the various payment systems and provide children with a seamless continuum of services that support their growth into adulthood."  We all can dream, can't we?

As we came back to reality, our group had several thoughts regarding ways in which we could assist EOHHS with the implementation of the remedy to the problems identified in the Rosie D. case.  Shortly,  there will be a Request for Information from EOHHS regarding the next phase.  We agreed that we would watch for it, and plan a meeting in which agencies could discuss and share their responses to the questions.  The RFI will appear on COMM-PASS  when it does come out, and we agreed to set a date soon on which to have this discussion.  In the meantime,  stay tuned to the blog for further developments.

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