Friday, May 16, 2008

Rosie D. and 5 Months of Screening: Access still takes time

I noticed that we have been mostly talking about S.B. 2518 lately, and not really addressing the changes that are now percolating through the system as a consequence of the implementation of the Rosie D. settlement.  This week has been a clinical one for me;  I have been seeing a lot of patients in the wake of my recent trip to the Pacific Ocean.  One from yesterday reminded me that while system changes are happening,  it is still difficult for families to engage the system and for the system to engage families.
Fred G. is a school-aged child in the 4th or 5th grade living with his/her grandparents, and who is having difficulty in social relationships and controlling anger.  (His/her?  Fred could be short for Frederica!)  Fighting at school, striking out at home, attacking friends physically for no good reason-  his/her  behaviors have escalated in the last year.  He/she was in for his/her annual physical back in January, and we talked about the family's struggle with these issues.  Our PSC screen scored a 33, and we had long discussions with the family regarding the need for mental health services to address the child's problems.  The problem didn't seem acute, so we didn't recommend an EMH evaluation-we gave out phone numbers and urged referral (school had done the same).   Problem identified;  problem addressed, right?  Score one of mental health screening.
Not really.
Fred came back this week, with his/her problems exacerbated and his/her family feeling at the end of their rope.  They have been working with our local "wraparound" agency-  he/she is signed up for "anger management" class starting in June, he/she has an intake assessment at a local mental health agency (with access to a  psychiatrist) starting in June and he/she hasn't been suspended from school.  The family, however, has seen his behaviors escalate, and they are worried that,  because of the family history of mental illness, this problem just can't wait until next month.  He/she pretty clearly didn't need to go through the EMH system, but this situation needs to be assessed for Serious Emotional Disturbance.  In the old days, this would be the classic dilemma:  too severe for the slow and plodding MH system, not severe enough for the "danger to self or others" standard set in the EMH system.  Still a problem in the new system:  soon we will be able to send them through the CSA either for an clinic based evaluation or a "mobile team" evaluation, but those bids have not gone out yet.  What can we do now?
I ended up called for a Family Stabilization Team, who seem quite willing to get involved with this family.  Turns out that pediatricians can call for an FST Team, even now.  In the past, FST required either DSS involvement or an EMH visit, but now families can be referred directly from the office.  They took the information, and I am hopeful that the family is being assessed as we speak.
Clearly, there is still many a slip twixt the screen and the evaluation (not to mention the effective evidence-based treatment).  We identified the problem, but we have not yet provided a smooth, family centered path to service.  The partners in this process (family, primary care, school, wraparound agency, mental health agency) are still engaged in "diadic" communication, with the family as the main conduit of information flow between the players.  We are beginning to have access to the tools (like FST) that we need to make this work, and this story is happier than it would have been five years ago.  We need tools: the rapidity of the assessment should match the family's perception of acuity, not ours,  the coordination of care still rests largely with the family who can be rapidly overrun by the problems, the diagnoses and the treatments are still not always as clear as they could be.  We have a long way to go.
By the way, the bidding for the CSA contracts begins now.  

To all interested parties:
Information has been posted on the MBHP web site regarding the procurement of the Community Service Agency (CSA) contracts, including a schedule for two upcoming bidders’ conferences. You can access this information from the home page at by clicking “CSA Procurement Information.
Additionally, all future communication regarding this procurement will be posted on this web site. MBHP will not be distributing updates via email.
Thank you for your interest in this important service.

Elizabeth O'Brien, LICSW
Regional Director
MBHP, Central Mass

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