Monday, March 17, 2008

Responding to the RFI: What can the Commonwealth actually do?

So, here we are, moving into spring, and Children's Behavioral, Mental and Developmental Health in the Commonwealth is not yet fixed. What is wrong with us? As I mentioned in an earlier post, the Executive Office of the Health and Human Services (EOHHS) has offer us the opportunity to give them advice on how to fix a system that often seems clunky and unresponsive (and certainly seemed so to Judge Posner, in his recent ruling). Now is the time, it seems, to step up the plate, and let our opinions be know.
The Request for Information (which is still available on-line) has 68 specific questions, which have been carefully and thoughtfully written out for our review. We have until April 1 to give them a reply. After a few meetings with my colleagues in the Worcester Mental Health Network, I have been tasked with trying to formulate a reply that speaks to some of the unique characteristics of Central Massachusetts. They clearly have more confidence in my ability to do this than I do. On the other hand, it is our shot at getting some input into the process. So, I 'll give it a go.
First off, it is clear that the suggestions my Advocate Miller earlier in the blog are not terribly helpful. She has said on several occassions that the answer is to pay clinicians for no shows. The problem with that is that it encourages clincians to encourage no shows, to maximize revenue and minimize work. Bad idea, setting up a system ripe for abuse. As we move through the questions posed by MassHealth, I hope that we are able to help to create a system that is equitable, efficient and unlikely to engender fraud.
Let's look at the first set of questions:
(1) How would you recommend that MassHealth ensure that children and youth receive comprehensive assessments culminating in the completion of the Massachusetts CANS, at the times and places described above?
This is an interesting question. The CANS seems to be "a tool developed to assist in the management and planning of services to children and adolescents and their families with the primary objectives of permanency, safety, and improved quality in of life." which is used to assess the severity of a clinical problem, the impact on function, and the strengths that the child and family bring themselves to the table. It is not a functional status measure, yet many of us have concern that it will be used by agencies INSTEAD of the normed functional status measures that others are using.
The CANS assessments should be used as part of the diagnosis of psychiatric disorder, but as a means of determining whether or not the illness meets the threshold for a serious emotional disturbance. It should NOT replace the other functional status indicators such as the BASQ or the TOPS that are used in several of the "carve out" programs. Instead, the CANS should used sparingly, in order to document the need for a change in the level of care provided. Operationalizing this will be tricky, as the level of severity of mental illness can easily change over the course of a few days, but we wouldn't want to be repeating the CANS that frequently. The tool looks at performance over the past 30 days, and takes 2-4 hours to administer.
We are very troubled by one sentence in the RFI:
"As a result, multiple clinicians may complete a Massachusetts CANS assessment for the same child within a short period of time. " Our concern is that will result in duplication of effort, focusing on lots of assessment and reassessment to the exclusion of treatment, and strongly urge the Commonwealth to allow multiple clinicians to work off of a single CANS assessment, especially if the number of clinicians able to perform the CANS is limited by the certification process.
Assuring access will require MassHealth to work with clinicians to develop criteria for the use of instrument, one of which should be parental desire for a more complete assessment.

(2) How would you recommend that MassHealth promote communication among multiple clinicians involved with the care of a child within the constraints of privacy and security laws?
Communication within a treatment team is paramount; the key to coordinating the flow of information has to be collaborative between the Intensive Care Coordinator and the parent; the parent needs to give or withhold consent, and the ICC has to have a handle on the flow of information. Many agencies have segregated information regarding mental health from the medical record of physicial health. This would be a mistake for these families- access to the full record is of the utmost importance.
To treat patients with SED requires free flow of information within the team. In developing the treatment plan, the ICC will need input from the clinician, the psychiatrist, the PCC and the school, as least in most cases. Add DMR, DYS, probation, and the court in another.  The family, working with the ICC, will need to manage a complex data system, one that, in most cases will allow the various parties to speak to each other in a timely fashion. This can be done within the Virtual Gateway, a clinic based EMR or frequent phone calls. The first two options require the support of a new level of computing skills within the program.  So, we are talking about an new and intimate relationship (family - ICC) that enables the members of the team to access some kind of "common record" that allows the family intimate contol over who sees what in this context.  Ultimately, that probably needs to be an incredibly secure on-line resource or "vault" with different "windows" that allow families to specify what level of information one is permitted to see.  One of the roles of the ICC would be to help families to ascertain who in the treatment team gets to see what part of the record.

(3) How would you recommend that MassHealth ensure coordination among clinicians assessing a child and not create the need for multiple assessments and reassessments?
Bingo. You have put your finger on the heart of the problem. How do you avoid multiple assessments, when your patients are tired of their problems and the creaky system. Early on in the process, MassHealth must encourage ALL parts of the treatment team to talk to each other, either by video conference or in person, and including at least the family (and the child, if the child is deemed sufficiently mature.  The team needs to discuss what is known about the child at this time, create a plan for intervention and further evaluation and generate a timetable for review and reassessment (sorry, but review and reassessment are essential because kids grow up and change as they grow).  MassHealth's tools:
1)  Higher rate of reimbursement for subsequent visits to those who show up to the meeting.
2)  Creation of a network of "meeting centers" that allow distant clinicians to be present in a virtual meeting.
3)  Major support for transportation for families to attend these sessions.

(4) What are the advantages and disadvantages of using an exclusively web-based CANS?
The big advantage that I see is that it would allow the CANS to be used collaboratively among the different providers, eliminating the need for repeated assessments by different agencies of the same tool.  The downside is that it requires access to the web, a problem particularly while doing home-based work.
(5) What are the advantages and disadvantages of using the Virtual Gateway to access the CANS application?   This one I need to take a "pass"on-  if others in the network have thoughts, please leave them here.  I have no personal experience in using the Virtual Gateway.
(6) If you are a provider, do you currently have internet access?  Most of the agencies in the Worcester Mental Health Network have internet access. That said, we have not yet figured out how to use that access forsecure  communication with patients or each other yet.  State support in this effort would be useful.

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