Thursday, August 28, 2008

My Notes from Today's Hearing at EOHHS!

NOTICE OF PUBLIC HEARINGS
________________________________________________________________________

The Executive Office of Health and Human Services will be conducting two public hearings. Secretary JudyAnn Bigby, M.D., and the Assistant Secretaries at EOHHS are looking forward to hearing the views of members of the community regarding the agencies under their purview.

Wednesday, August 27, 2008 Reggie Lewis Center
1350 Tremont Street
Roxbury, MA
1 p.m. – 5 p.m.


THERE WERE A LOT OF PEOPLE THERE, AS WERE ALL OF THE COMMISSIONERS AND THE SECRETARY. CLEARLY ALL SAW THIS AS AN OPPORTUNITY TO MAKE SURE THAT THE POLICY-MAKERS UNDERSTAND HOW THEIR BUDGETS AFFECT THE WORLD.

1:00 to 2:00 Veterans, Elder Affairs, Soldiers’ Homes  

SIGN IN LIST SHOWED MORE THAN 30 PEOPLE SIGNED UP TO TESTIFY. I MISSED THIS PART OF THE MEETING, AS I HAD A CONFERENCE CALL THAT I HAD. IT WAS REPORTEDLY VERY ORDERLY.

2:00 to 3:00 Disabilities & Community Services – MCDHH, MCB, MRC, DMR DDS

THE SIGN IN LIST HERE WAS HUGE, MORE THAN 50 PEOPLE; I WALKED IN AS THIS PART WAS UNDERWAY, AS A NUMBER OF REPRESENTATIVES OF THE DEAF AND HARD OF HEARING COMMUNITY MADE THE CASE FOR ENHANCED SERVICES FOR COMMUNICATION ACCESS IN THE COMMONWEALTH. SEVERAL MEMBERS OF A REALLY LARGE GROUP TESTIFIED, USING SIGNED INTERPRETATORS AND TELEPROMPTERS TO MAKE THEIR POINT. AFTER THAT LARGE GROUP, PEOPLE WERE MORE TERSE AND FOCUSED. WE HEARD THAT SPECIFIC LINE ITEMS FOR TRAINING OF PERSONAL CARE ATTENDENTS, AS THE DEMAND IS RISING WITHIN THE COMMONWEALTH. THE CARROLL CENTER SPOKE TO SOME VERY SPECIFIC NEEDS OF THE BLIND COMMUNITY: TECHNOLOGY FOR CHILDREN TO CONTINUE THEIR SCHOOLWORK AT HOME, AND THE TRANSITION FROM SCHOOL TO UNIVERSITY OR WORK OR ADULT LIFE. THEY DISCUSSED THEIR “EARLY INTERVENTION” PROGRAM FOR TRANSITION AND FELT THAT IT WAS, IN GENERAL, QUITE SUCCESSFUL FOR THE 13 STUDENTS WHO WERE INVOLVED. WE ALSO HEARD FROM A STUDENT FROM THE PROGRAM (WITH RETINITIS PIGMENTOSA). WE ALSO HEARD FROM A LARGE GROUP OF “MASSACHUSETTS ADVOCATES STANDING STRONG” (MASS), REPRESENTING THOSE SERVED BY THE DEPARTMENT OF DEVELOPMENTAL SERVICES, WHO WERE LOOKING FOR INCREASED SUPPORT FOR TRANSITION, FAMILY CENTERED CARE AND CARE COORDINATORS. THEY HAD A SIZABLE CONSTITUENCY THAT REALLY ADDRESSED THE NEEDS OF THE COMMUNITY AT LARGE. THEY WERE LOOKING FOR MORE CONTROL IN THEIR LIVES, AND MANY OF THE STORIES TOLD WERE QUITE POIGNANT, WORKING HARD TO BRING A HUMAN FACE TO THE HEARING, AND EMPHASIZING THE RANGE OF CAPABILITIES OF THE PEOPLE SERVED BY THE DEPARTMENT. I LIKED ONE OF THEIR LINES “INVEST IN THE PEOPLE, NOT IN THE PAPER”. WE ALSO HEARD A LOT MORE ABOUT THE NEED FOR SUPPORT FOR “TRANSITION” SERVICES, AS CHILDREN WITH DOWN’S SYNDROME AND OTHER PROBLEMS “AGE OUT” OF THE SCHOOL SYSTEM. FINALLY, MANY SERVICE PROVIDERS SPOKE OF THE NEED PROVIDE HOUSING AND INDEPENDENT LIVING CENTERS TO HELP MOVE PEOPLE OUT INTO THE COMMUNITY. THIS GROUP WENT ON FOR 1.75 HOURS; CLEARLY THIS IS A MATTER THAT GENERATES A LOT OF PASSION. THIS IS WHAT MAKES IT SO DIFFICULT. ALL OF THESE SERVICES MERIT OUR SUPPORT, AND THE SECRETARY HAS TO DECIDE WHICH OF THESE THINGS MERIT HER SUPPORT.

3:00 to 4:00 Health Services - DMH, DPH, DHCFP, MassHealth

ANOTHER 30 OR SO SIGNED UP HERE, BUT MATT NOYES FROM HCFA GOT US ON THE DOCKET REASONABLY EARLY. PEOPLE TALKED ABOUT SUBSTANCE ABUSE SERVICES, COMMUNITY MENTAL HEALTH SERVICES AND HEALTH CARE REFORM. WE HAD TWO MINUTES TO TALK ABOUT CHILDREN”S MENTAL HEALTH, AND WE COMPRESSED OUR DISCUSSION DRAMATICALLY; AND I THINK EFFECTIVELY. MATT THANKED THEM FOR SUPPORT FOR THE BILL, AND URGED THEM TO SUPPORT IMPLEMENTATION IN THE BUDGET. I SPOKE OF THE WORK DONE IN THE CHILD BEHAVIORAL HEALTH INITIATIVE TO DATE, AND URGED INNOVATION TO BE SURE THAT THE INITIATIVE IS IMPLEMENTED BOTH IN BOSTON IAND IN THE REST OF THE STATE. IT WAS SHORT, SWEET, AND HOPEFULLY HEARD. AFTER US, THE TESTIMONY WENT ON.
THE FEDERATION FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS CALLED FOR MEDICAL HOMES FOR CSHCN. (APPARENTLY, MASSACHUSETTS IN NOT LEADING ON THIS). THE CONSUMER COUNCIL CALLED FOR THE ESTABLISHMEN OF COUNCILS. AND SO IT WENT. AT 4:40 PM, THERE WERE STILL LOTS OF PEOPLE WAITING TO TALK. I DECIDED TO CALL IT A DAY- 2.75 HOURS IS ALL I COULD HANDLE.

WHAT DID I LEARN FROM ALL OF THIS? FIRST, MY RESPECT FOR THE COMMISSIONER AND THE SECRETARY IS EXTRAORDINARY- THE WAY IN WHICH THEY LISTENED TO THE VAST ARRAY OF FOLKS IN ATTENDENCE WAS CARING AND CAREFUL, AND THEY WERE EXTREMELY POLITE IN THEIR EFFORTS TO MOVE THE PROCESS ALONG. SECOND, THE COMMONWEALTH IS FULL OF EXTRAORDINARY PEOPLE DOING EXTRAORDINARY THINGS, AND THEY ALL DESERVE FUNDING. I KNOW THAT THERE MUST BE A PROCESS FOR SORTING OUT ALL OF THESE NEEDS, BUT I CANNOT IMAGINE WHAT IT IS. THIRD, IT IS WORTHWHILE WAITING YOUR TURN TO SPEAK, AND THEN HAVING SOMETHING TO SAY. WE WILL SEE HOW THIS GOES FORWARD.


4:00 to 5:00 Children, Youth and Families - DCF, DYS, ORI, DTA

NOT TOO LATE TO HAVE YOUR SAY!
Due to the numbers of persons anticipated to attend, oral testimony will be limited to two minutes. In the interest of time, representative panels are welcome. In addition, written testimony is strongly encouraged and may be mailed to:
Secretary JudyAnn Bigby, EOHHS
One Ashburton Place, Room 1109, Boston, MA 02108
Or emailed to: eohhshearings@massmail.state.ma.us


Wednesday, August 27, 2008

Testimony from the Worcester Mental Health Network: Delivered at EOHHS Budget Hearing 8/27/08

The Worcester Mental Health Network identifies communities underserved by existing mental health services and, through advocacy, seeks to remove barriers to care.”
Affiliated Organizations:
Central Mass AHEC, Central MA Communities of Care, Central Massachusetts Medical Home Network, Children and Family Law, Community Healthlink, Court and Family Law, Great Brook Valley HC, Health Law Advocates,Legal Assistance Corporation of Central Mass, MSPCC/ Central Mass, Parent Professional Advocacy League/ Central MA, South County Pediatrics/UMMHC, The Health Foundation, The Willis Center, Youth Opportunities Upheld INC
Please note:  Affiliation with the Network does not mean that this statement was formally approved by each of these organizations.

August 27, 2008

Secretary JudyAnn Bigby, MD
Executive Office Of Health and Human Services
One Ashuburton Place, Room 1109
Boston, MA 02108

Dear Secretary Bigby:

Thank you for the opportunity to speak today, as you begin the development of the FY2010 budget. I am a pediatrician, who has practiced for the past 17 years at South County Pediatrics in Webster. For the last 4 years, I have been working with the Worcester Mental Health Network, a group of 15 provider, consumer and advocacy organizations in Worcester County working to identify communities underserved by existing mental health services and, through advocacy, seeks to remove barriers to care.

On behalf of the Network, I first wanted to thank EOHHS for the Child Behavioral Health Initiative. Emily Sherwood and her colleagues have brought that effort to life, breaking down many of the traditional silos that have confronted families with a system so complex that even the most highly educated parents have trouble navigating it.

Over the past 10 years, we in the Pediatric community have witnessed an explosion in the need for mental health services for children, ranging from the need for Behavioral Management for out-of-control toddlers to adolescents with depression, anxiety and bipolar disorder. While this is a problem in Worcester and Boston, where services are overwhelmed, it is worse in Webster and throughout most of the small towns of the Commonwealth, where services are fragmented and hard to reach without a car. This year, we began to build a system, though the implementation of the Rosie D. settlement, and the passage of An Act Relative to Children’s Mental Health (Chapter 321) Next year’s budget needs to build on this year’s success, if we are to serve all of the children of the Commonwealth.

What do I mean? Families of children with mental illness need support. From care coordination within a primary care setting to wraparound services like Communities of Care and MSSBY, we can make a difference for families. Let me talk about a few patients from my practice:

• A 6 year old with a serious chronic medical condition, ADHD and possibly bipolar disorder, who receives care from specialists in Springfield, Worcester, Boston and Southbridge. He is involved with DCF, DDD, DTA and the public schools, all of which must coordinate their efforts through the parents. There are no child psychologists in South Worcester County who can work with the family to develop and implement to the behavior plan that this child needs. This family needs support; ensuring adequate funding for the CBHI will help us help them.

• A 10 year old hospitalized last fall with acute psychosis after being taken from school out of school for “meltdowns” on a weekly basis. His parents both work in towns 30 miles from his school; coordinating care from a psychiatrist and a therapist means time off from work and more miles on the car. This family needs support; ensuring adequate funding for the CBHI will help us help them.

I could name others, but I want to stop here, because the message is clear. Funding services that bring together the resources of the community and the resources of the family will go a long way to reducing the burdens on our courts and the children stuck in the mental health system.

What is adequate support? It’s complicated; we certainly endorse the proposals of the Children’s Mental Health Campaign (see below), but we want to be sure that those initiatives reach past the urban centers to Worcester County and beyond. It seems to us in the service delivery system that the children of the Commonwealth would benefit from policies that encourage co-location of mental health and primary care providers; this model works well within Community Health Centers, but could be expanded to many of the private offices that treat our MassHealth patients. We know that the diverse population of the Commonwealth demands the development of a multi-cultural and multi-lingual workforce; we need pilot programs to develop a pipeline from within and outside of the Commonwealth to address those needs.

We hope to continue this conversation; we invite you to join us sometime in Worcester or perhaps even Webster to discuss ways in which EOHHS can leverage its dollars to support the family-centered multi-disciplinary approach at the center of the CBHI. If you have any questions or would like more information, please contact David Keller MD, Facilitator of the Worcester Mental Health Network at david.keller@umassmemorial.org.

Sincerely,

David Keller MD
Facilitator
Worcester Mental Health Network

Clinical Associate Professor of Pediatrics
UMass Medical School


From the Children’s Mental Health Campaign- specific budgetary requests:
• Mental Health Consultative Services To Schools (line item 5042-5000) – an increase of $2.75 million.
• Behavioral Health Consultation for the Department of Early Education (3000-6075) - an increase of $1.1 million.
• Children’s Behavioral Health Advisory Council and Children’s Behavioral Health Research Center (4000-0300) – an increase of $500,000.
• School Capacity Pilot and Evaluation (4590-0250) – an increase of $500,000.

Tuesday, August 26, 2008

ANNOUNCEMENT!

PROVIDER FOCUSED MEETING ON CHILDREN’S BEHAVIORAL HEALTH INITIATIVE (CBHI) IMPLEMENTATION ACTIVITIES

The Executive Office of Health and Human Services (EOHHS) announces the second in a series of provider-focused meetings to communicate current information about the Children’s Behavioral Health Initiative (CBHI) and to provide stakeholders and interested parties an opportunity to share their views on activities related to CBHI. 
Topic “CBHI System Overview: How it All Connects” *
The meeting will be held on Friday, September 19, 2008 at the University of Massachusetts Medical School, Hoagland-Pincus Conference Center, 222 Maple Avenue, Shrewsbury, MA. The meeting will begin at 1:00 p.m. and conclude at 3:00 p.m. No registration is necessary. Attendance at this meeting is limited only by the space available. 
The EOHHS welcomes input from all stakeholders and interested parties on the Children’s Behavioral Health Initiative. Individuals and organizations unable to attend this meeting are encouraged to mail comments to:
Children’s Behavioral Health Initiative 
Executive Office of Health and Human Services
1 Ashburton Place – 5th floor
Boston, MA 02108
To request an accommodation, please call (617) 573-1799
or TTY: (800) 872-0166.
* Meeting agenda will be available at the door or to view on-line go to www.mass.gov/masshealth/childbehavioralhealth and click “Attachments” one day prior to the event.

Monday, August 25, 2008

A bit more on Mental Health Parity

So, in conversations with folks at Health Care for All, I have obtained a deeper understanding of the Parity issue.  Two additional comments to my posting:

1)  Children in general are not affected much by this legislation.  Turns out that the section of the bill allowing "children with non-biologically based diagnoses" to get parity with additional documentation means that kids have always gotten more.  The issue for kids revolves around different issues (what is "medical necessity"?  How many different levels of care are needed in mental health services in order to achieve "parity"?)  The Commissioner of Insurance is in charge of those decisions, and the insurance industry has sought for years to keep that all very limited.
2)  Parity doesn't always mean high quality.  If your insurance has high deductables and limited panels of specialist,  it will likely be the same for mental health.

The one place where parity will be of great utility is in late adolescents/ young adults who are transitioning out  of the pediatric age group.  Many of them loose services as they grow up-  now, we can hold insurances to the task.

Still a victory.  But, as one of my HLA colleagues says, there is only so much that you can do with legislation.  

Coming soon:  What does the An Act Relative to Children's Mental Health mean for us?

Friday, August 22, 2008

Yolanda's Bill Becomes Law

Governor Patrick signed the bill yesterday, so it is now the law of the Commonwealth.  Instead of the S.B. 2518,  it is now Chapter 321 of the Acts of 2008.  I'll be back later, with more about what it all means.  For now,  let's all just enjoy the day.

Thursday, August 21, 2008

A Chance to Speak Up for Children: What do you want to say?

DRAFT
NOTICE OF PUBLIC HEARINGS
_____________________________________________________________

The Executive Office of Health and Human Services will be conducting two public hearings. Secretary JudyAnn Bigby, M.D., and the Assistant Secretaries at EOHHS are looking forward to hearing the views of members of the community regarding the agencies under their purview.

Wednesday, August 27, 2008 Reggie Lewis Center
1350 Tremont Street
Roxbury, MA
1 p.m. – 5 p.m.


The hearing will tentatively be divided as follows:
1:00 to 2:00 Veterans, Elder Affairs, Soldiers’ Homes
2:00 to 3:00 Disabilities & Community Services – MCDHH, MCB, MRC, DMR
3:00 to 4:00 Health Services - DMH, DPH, DHCFP, MassHealth
4:00 to 5:00 Children, Youth and Families - DSS, DYS, ORI, DTA

Thursday, August 28, 2008 Basketball Hall of Fame
1000 West Columbus Avenue
Springfield, MA 01105
10 a.m. – 2 p.m.


The hearing will tentatively be divided as follows:
10:00 to 10:45 Veterans, Elder Affairs, Soldiers’ Homes
10:45 to 12:30 Disabilities and Community Services – MCDHH, MCB, MRC, DMR
12:30 to 1:15 Health Services – DMH, DPH, DHCFP, MassHealth
1:15 to 2:00 Children, Youth and Families – DSS, DYS, ORI, DTA

Due to the numbers of persons anticipated to attend, oral testimony will be limited to two minutes. In the interest of time, representative panels are welcome. In addition, written testimony is strongly encouraged and may be mailed to:

Secretary JudyAnn Bigby, EOHHS
One Ashburton Place, Room 1109, Boston, MA 02108

Or emailed to: eohhshearings@massmail.state.ma.us

Wednesday, August 20, 2008

So What Did We Win?: Legislation and Children's Mental Health

It's all over but the shouting.  The Children's Mental Health Omnibus Bill has passed, albeit in two pieces:  "An Act Relative to Mental Health Parity" and "An Act Relative to Children's Mental Health".  As one would expect, we did not get everything that went out in the original "ask".  It probably makes sense to spend a little time thinking about what we did get, and what work still needs to be done.  I hope that others who better understand how the system actually works will correct my misunderstandings, and that through this process, we can better understand the path that stretches before us.

Today, let's look at Mental Health Parity;  that seems more straightforward.  Mental Health Parity seems a simple concept: illness is illness, and the brain gets sick as frequently as the body.  So, it makes little sense to treat mental illness differently than physical illness.  Since treatment seems to follow payment, and we don't let insurance companies opt out of treating particular "physical illnesses" (i.e. you are insured for all illnesses except diabetes- not allowed), why should we allow them to say that they won't pay for mental illnesses. Why is this complex?

The complexity, it seems, comes from the definition of "illness".  In 2000, Masachusetts passed a law that created Mental Health Parity for nine "biologically-based" illnesses:   Schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, delirium and dementia, and affective disorders (note to self:  all mental health takes place in the brain, which is a biological computer.  Why only those nine disorders?).  There was a way to add to the list, but involved the intervention of the Commissioner of Mental Health AND the Commissioner of Insurance.  Two Commissioners makes it hard to do.  For children, there was one extra clause:  
For non-biologically-based mental, behavioral, or emotional disorders that substantially interfere with or substantially limit functioning and social interactions, where:
  1. The child’s primary care physician, pediatrician, or a licensed mental health professional has made the referral for diagnosis and treatment of the disorder, and has documented the substantial interference or limitation,
or
  1. The substantial interference or limitation is evidenced by conduct, including, but not limited to (1) an inability to attend school, (2) the need for hospitalization, or (3) a pattern of conduct or behavior that poses a serious danger to self or others.
This language, in practice, led to the widespread exclusion of treatment for children with eating disorders, Asperger's syndrome, conduct disorder, oppositional defiant disorder and anxiety disorder until they became "end-stage" conditions, such as Kenny, of whom I blogged earlier in the year.  So, what did we win?

First, we won a new list:  
(1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorders; (12) substance abuse disorders; and (13) autism.
This is a victory for children, because of the inclusion of eating disorders and autism on the list.  There is room for improvement:  ADHD, ODD and anxiety disorder, the three most prevalent forms of mental illness in children, are not on the list.  In our original bill, we, like Patrick Kennedy, asked to have the whole DSM-IV added to the list.  We didn't get that.  But this is definitely an improvement.
Second, we won an easier process to add to the list.  Under the new Bill, the Commissioner of Mental Health can expand the list.  I see no language about the Commissioner of Insurance (please correct me, someone, if I have missed something).   Given that the Omnibus bill calls for the formation of a Behavioral Health Council to advise the Commissioner on Children's Behavioral Health issues, this power may prove more useful than having to go back to the legislature every time we change the bill.

What didn't we win?  For kids, I see a few things:  First, language that recognizes that kids don't always fit diagnostic boxes, and that we can do a lot for families BEFORE a diagnosis is finalized.  EI has shown us that, and we need to make that part of the future.  I think that the restrictive "medical necessity" language regarding children is still in play, which means that children will still have to wait for intensive intervention until they are really badly off.  We should think about changing the standard for requiring coverage:  for example, why wait until they are "substantially unable to attend school", when intensive intervention earlier on could prevent that breakdown in a child's life.  And, if we are still working off of a list, anxiety disorder and oppositional defiant disorder should be on it.  So we still have some work to do.

On the other hand, not a bad change.  Not bad at all.  I'll keep working on understanding the longer and more complicated bill in the future.

Monday, August 18, 2008

Screening in our office: How is it going eight months on?

So, how goes the screening you ask? Turns out, at least in my office, we have some information about how that is going, from some ongoing reporting that we are doing to the Dpeartment of Public Health through another project. Last month, we screened 98 adolescent patients (about 8% of our adolesent patient panel) with the Y-PSC and the CRAFFT. The Y-PSC was completed by 95 of them; of those, 9 or 10% screened positive. We CRAFFTed all of them (we are doing the CRAFFT verbally, as part of the routine well child visit, identified 6 as positive (6%). There was, as you would expect, some overlap between the two groups. Our success at referral was less impressive; of the 12 kids identified as troubled, 1 was already in treatment and 2 made it into treatment. The rest will be back; in primary care, they always come back.

By the way, this group of adolescents mostly had private insurance (15% Medicaid, which is lower than our usual case mix). Not sure why. But we do see a lot of sports physicals in the summer.

What does this tell us? First, that the screening instruments work reasonably well, at least in adolescents, finding about what we thought they would find. Second, that,even with screening, we can’t get our patients into treatment. This is not a consequence of MassHeath. To us, it seems a consequence of motivation (both parent and youth don’t like the idea of treatment for substance abuse and mental health problems), time (hard to make the schedules work, especially when all of parents, both single and partnered, have jobs) and mindset (a lot of people still think that you can stop mental illness through force of will). Third, if we were ever successful in referring everthing that we found, we would swamp the system. 12 teens per month adds up to 144 teens per year, multiply by 1700 pediatricians around the state and you have 28,000 intakes waiting to happen. Again, only 25% of those are MassHealth patients (maybe more), but that’s a lot of work waiting to be done. Surely there are a lack of resources, but, in order to improve them, we need to use the ones that we already have.

Sunday, August 17, 2008

More Ideas: Lots of Ways to Spin Mental Health Care.

I am just back from Chicago on Saturday, where I got to deliver 2 workshops, 2 roundtables and an introduction at the semi-annual (by which I mean every other year-did I get that right?) meeting of the CATCH facilitators of the AAP and the Healthy Tomorrows grant recipients, sponsored by the AAP's Community Pediatrics program.  I met people from Idaho and Montana and Texas and North Carolina, all trying to develop systems through which they are able to care for children with mental illness.  The good and the bad news is that they are ALL experiencing the problems with we have, such as stigma, poor morale, lack of child psychiatrists and poor follow-up.  Here are a few of the many solutions that have been proposed.

Connecting The Dots
City, State: Chapel Hill, NC
Year (start of the project): 2005 (5 Year Grant Period)
Program Description: Connecting the Dots takes advantage of existing relationships among the Local Health Departments, community-based out-of-home childcare providers, and the local childcare health consultant. Connecting the Dots will establish a hierarchy of services to prevent problem behaviors among children in out-of-home childcare from becoming behavioral and psychosocial health conditions. Child Care Health Consultants will offer consultation and technical assistance to out-of-home childcare providers to improve their response to challenging behaviors. Children needing medical services will be screened and referred to their medical homes for primary health services, and those with more serious needs will be referred on to pediatric mental health services.
Projects Goals & Objectives: The goals of the project are (1) to implement and integrated community-wide, pyshcosocial/behavioral health system for young children that will link child care, primary health care, and mental health providers, (2) to create a well-trained cultrually diverse workforce trained to prevent minor behavioral issues from escalating into major behavioral problems, and (3) to assure that all children in out of home child care have medical coverage and a medical home to address their psychosocial/behavioral health needs.
Project Title: Project EAGLE - Central Intake and Referral System
Grant ID: 727
City, State: Kansas City, KS
Year (start of the project): 2004 (5 Year Grant Period)
Program Description: The Project EAGLE Central Intake and Referral System is a mechanism for screening multiple risks in families with children zero to 5 years of age and for providing referrals to address multiple needs. The Central Intake and Referral System is based on the idea that early identification and timely access to appropriate services leads to healthy development and children entering school ready to succeed. The goals of CIRS are to identify immediate family needs via a collaborative relationship that includes multiple risks screening; to provide appropriate referrals and problem-solving support to improve parents' self-advocacy in accessing services; and to improve utilization of community resources.
Projects Goals & Objectives: The goals of this project are: 1) To identify immediate family needs via a collaborative relationship that includes multiple risks screening, 2) To provide appropriate referrals and problem-solving support to improve parents

Project Title: West Virginia CARES (Coordinating Access to Resources and Emergency Services) Project
City, State: Huntington, WV
Year (start of the project): 2007 (5 Year Grant Period)

Program Description: Homeless and foster care children are a complex and especially vulnerable group of children with special health care needs. The West Virginia CARES project will improve access to a medical home for Appalachian children who are homeless or in foster care. The project will select and train two parents of children with special health care needs to serve as parent care coordinators. These coordinators will become an integral part of the medical home improvement team and will create a Medical Passport and Education Passport for all families in the program. The coordinators will also be responsible for screening for developmental delays and school issues, including ADHD.
Projects Goals & Objectives: The overall goal of this project is to improve the health status of homeless and foster care children by establishing a model for coordination of health care and improvement of the medical home led by trained parent care coordinators.

So, are you noticing that the core of all of these initiatives is care coordination, either through trained parent advocates, a professional care coordinator or co-location?  Really drove home two points, in my mind:
1)  It will take more than access to make this work.  After we open access, whether through insurance mandates or the Rosie D. remedy, families won't use the system unless we help them to do so.  We can build it, but they won't come unless we walk with them through our new system of care.
2)  Communication between the various members of the team is even more important that I thought.  I understand that there are barriers, including time, compensation, HIPPA and fear that keep that from happening, but we need to address it square on or we are just spinning our wheels.

Thursday, August 14, 2008

We Won: Now a Bill Becomes Law.

I've been quiet the last few days.  As I mentioned before, I didn't want to upset the apple cart.  Didn't think that I could upset the apple cart, but I just couldn't be sure.  Besides, it was nice out and managed to fit two long bike rides into my schedule.  And then....


It actually is an amazing feat of legislative prowess.  We owe tons to Ruth Balzer and Steve Tolman, for championing the bill, and President Murray and Speaker DiMasi for keeping in play when we thought it was gone, and the 5 founding organizations for pulling together the coalition to make it all happen.  (A Health Blogs summary of the process can be found here.) We should jump up and sing, we should hug a child, we should raise a joyful noise, we should be very proud of ourselves.  Well done, all.

So, I'll let you all listen to the Providence Singer's do "My Lord, What a Morning", which has, to me the right degree of joy and mournfulness.  We got the bill through, but we still have a lot of work to do.  In the meantime:

1)  Thank your State Rep and State Senator for their support.
2)  Urge the Governor to sign the bill.
3)  Come to the party in September.  Should be a blow out.

Monday, August 11, 2008

An Act Relative to Children's Mental Health: On to the Senate.

Our bill, S.B. 2518, (AKA SB 2804), passed the House today in informal session.  It was interesting to watch the process, which began at 11 AM today, and was over at 11:08.  I went over with some colleagues from Health Care for All and MSPCC, two of the leaders in the Children's Mental Health Coalition.   It was so quiet and understated that you might have missed it, if you didn't know what to look for.  The bill is in a grey box, that sat to the side of the podium, from which the Clerk intoned the words that brought it to consideration.  It passed unanimously, without discussion, and the Clerk walked the box over to the Senate clerk's office, where it will wait for the Senate's next informal session.  Almost there.  A simple vote in the Senate and then on to the Governor's office for signature.  The Coalition will have passed an Omnibus bill in one session.

I've decided that one of the hardest things of advocacy in the policy arena is to know when to speak and when to be quiet.  This is a time to be quiet, to allow the tides of the Senate sweep this bill into law.  We who have been working for its passage over the past two years need to be watching, to know when it has happened, so that we can move onto the process of making the law into actual practice.  There is still a lot of work to do, and the Children's Mental Health Coalition isn't done yet, but the work must wait until the process washes the bill up onto the Governor's desk for a signature.  Stay tuned.

Sunday, August 10, 2008

Pediatricians and CANS: You can, but you don't have to.

There has been some confusion in the Pediatric community regarding the Child Behavioral Health Initiative and the CANS, stemming from the word "screening".  Let me try to clarify, and suggest some language that may avoid confusion in the future.
1)  PRIMARY SCREENING:  Last January, MassHealth Primary Care providers were asked to initiate Behavioral Health Screening, using one of nine State-approved screening instruments. (See this blog from last December here for the details)  We've been screening, which means dividing our patients into two groups:  those who need further evaluation and those who don't.  The assumption was that many of those who need further evaluation would be referred into the Mental Health system.  That would lead to:
2)  SECONDARY SCREENING:  As of November, 30, 2008, the children who are referred for further evaluation will need to be screened/evaluated with the CANS.  This is a secondary screening, which is going to form the basis of the determination of whether or not the family is part of the class of families eligible for Intensive Care Coordination services.  Now, there is no reason that a pediatrician couldn't learn to do this, if they planned to offer intensive mental health or behavioral health services.  But this is NOT required of you as a primary care provider.  It is required of MENTAL HEALTH WORKERS who are planning to work with these children and families.
The confusion seems to be about the word "screening", and would be clarified by using the terms primary and secondary as modifiers.   The Mass Chapter sent out a clarification last weekend, that we hope will make all clear.

Saturday, August 9, 2008

Children's Mental Heath in America: What's Going on in Other Places.

As the AAPs District 1 CATCH Facilitator, I get to attend the AAP District meeting,  which this year, was health in Montreal.  Mental health was most certainly on the agenda.  Some observations:
1)  Canada is having a mental health crisis as well.  We heard from our Canadian brethren that, despite the many advantages of Universal Health Care, they had poor access to mental health workers and child psychiatrists, similar to many of the issue we are trying to address in the United States.
2)  Other states are working on mental health system issues, and they are all fascinated by MCPAP.  Connecticut has not yet been able to put our model in place, Virginia is planning to do so and Tennessee is doing similar sorts of things.
3)  States have differing degrees of public-private collaboration.  The Vermont Departments of Health and  Mental Health  are developing statewide protocols for management of common behavioral health problems of children by primary care providers through a series of learning collaboratives.
4)  Carve outs can be more collaborative:  In North Carolina, the primary care provider can authorize the first 26 visits to a mental health worker without oversight,  and the mental health worker can see them for 6 visits without a diagnosis.  They've also established laws to allow LCSWs (not independent) to work under the supervision of a pediatrician, and allow mental health providers who don't work for community mental health agencies to see Medicaid patients, two major barriers to care in Massachusetts. 
North Carolina has also taken pro-active action to encourage co-location of mental health workers and physicians working with children.  They are giving out small grants to encourage the start up, and I believe are also reimbursing at a preferential rate.
We are doing OK, as I said below, but we can learn things from our colleagues throughout the US.  And Canada.  

Friday, August 8, 2008

Keeping Massachusetts in Perspective: Look at the Map


For those frustrated with how hard it is to change things, it can pe useful to take the "long" view, as the Commonwealth Fund in this map. Overall, Massachusetts ranks fourth in the country in "Child Health Systems".  Sounds pretty good, doesn't it?   But the nice thing about the map is that, if you click on the state, it gives you the details.  Remember the details?  Where the devil lives?  This allows you to see that the fact that we are doing well doesn't mean that there isn't still work to do.
So when you click on the "printable version of the Massachusetts data, you get a table with the indicators that the are using.  Our infant mortality is #7 in the country (not bad), but we have a high percentage of children at risk of developmental delay.  What's that about?  Are we saving preemies, or do our services attract families with high levels of need?  Don't know.  We do well on access:  only 5.6 percent of our children are uninsured, and 93% of family below 200% of FPL are insured.  The big one, to me, is our access to specialists:  We were the best in the country, with 86.5 % over children with special needs able to access speciality care.   All of these thing bode well for children in Massachusetts.

And yet.....

We are THE most expensive health care market in America at $6,683 per captita, and we have one of the the highest costs of insurance in the country ($11,435 per year).  It is sad to see that, at best, 22.8% of families report that they cannot access needed behavioral health services (32.4% in Massachusetts, making us #8 in the country).   Only 60% of our families (#3 in the country) report that they have a medical home.  Our needs reflect national needs-  we need access to medical homes, behavioral health services and we need to do something about the everrising costs of health care.  This suggests that our efforts to improve, in these areas represent the right focus for our state. 

When you are number 4, you have to try harder.

Thursday, August 7, 2008

One Down, One to Go: Mental Health Parity Bill Signed

According to my friends at Health Care for All, Mental Health Parity has just been expanded in Massachusetts (check out "A Healthy Blog") and "An Act Relative to Mental Health has been fully engrossed by the Senate.  It now goes back to the House for final passage and signature.  Step at a time;  it seems that the wheels of lawmaking do grind slowly, but they are still grinding.  Thanks and credit to the Leadership and Representative Balzer for keeping her eye on this prize so intently.

The Cost of SB 2518: Report from EOHHS

SN 2518 is still moving through the legislative process;  I was encouraged to see that EOHHS's Division of Health Care Finance and Policy released their analysis of the bill's impact on the Commonwealth recently (click here to see the report)  The report bodes well for the future of collateral services. To wit:
After reviewing the literature and other available sources of information, the only payer identified currently covering collateral services for children was MassHealth managed care. (MassHealth is the name for the Medicaid program in the Commonwealth.). In order to estimate the impact of mandating collateral services on the commercial population, the ratio of per member collateral services spending to per member children’s behavioral health spending in the MassHealth population was applied to the per member spending on children’s behavioral health in the commercial population. This estimate was adjusted upward to reflect higher fees in the commercial sector. Low, middle, and high scenarios were computed to address the uncertainty stemming from the application of Medicaid utilization to the commercial population.
Exhibit 1 displays the projected impacts for the years 2008-2012 for three scenarios. Over the five year period, the mid-scenario impact averages approximately $1.5 million per year, which is 5 ½ cents per member per month, or about 0.01% of premium.
I hope that this sort of positive report makes our legislators even more willing to get this bill through the legislature and to the governor's desk for signature.  It may not solve all of the problems, but it is a really good start.

Wednesday, August 6, 2008

Gains in the FST Process: Will It Be Enough?

News flash:  "Enhanced FST now available statewide
SPRINGFIELD [July 31] – Children across the Commonwealth who have mental health needs can now receive home-based supports to enable them to avoid hospitalization or other out-of-home placements through enhancements to an existing program known as Family Stabilization Team services or FST.
U.S. District Court Judge Michael A. Ponsor today signed off on a proposal, submitted by the Commonwealth, to expand the utilization, intensity and duration of FST services. FST, which includes flexible supports such as in-home therapy, behavioral aides and mentoring services, is designed to help families and caregivers stabilize a child with psychiatric disabilities."
--From the Rosie D website.


I found this interesting; as regular readers of the blog know, I was tickled last fall to discover that I was allowed to make referrals to the FST program, and I have used the service on several occasions.  In my somewhat limited experience (5 referrals since they made it OK to refer from the primary care office), the main problem with FST has not been limitations imposed by the State contract.   Rather, it has been limitations imposed by the families.  One family that came into the office begging for me to "do something" about their "out of control" toddler agreed to the FST program in the office, then refused to make an appointment with the program back in their home.  Another family told me they were in crisis, then left town for 2 weeks of planned vacation;  the FST program finally gave up trying to reach them, and I had to re-refer after the vacation.  That's been a problem for 2/5 of the families I have referred to the program.  What's up with this?

Part of the problem is that the families that need the FST program are not families that are working well.  Mental illness in the child may co-mingle with adult mental illness, financial worries, unstable housing, failing marriage, three jobs, inadequate daycare or any number of social stressors that make it hard for families to meld with systems.  Engaging with families undergoing these kinds of stresses is an art form; not everyone can do it.

Another issue is the nature of the intervention.  FST is a pretty invasive program;  the workers are in your home, working with you to do "whatever it takes" to get your child under control.  It doesn't surprise me that they make families nervous.  Having a social worker or psychologist in your home is a major deal.  Families worry that they are being scrutinized, too much or too little.  Many of the families conflate the FST program with the surveillance of DSS.  That is a lot of baggage.

Finally, there is the tyranny of high expectations.  The families referred to the program are the ones with intractable problems.  If they were easy to solve, they would have been solved already.  Some families may think that this is like the calvary coming to the rescue and be disappointed when the problems don't disappear after a day or two.  I try to put it into perspective by saying that the problems will take at least as long to solve as they took to develop.  Still, people who are already frustrated are likely to get more frustrated, and sometimes they fire the FST worker before the job is done.  

In this context, it is good that FST can function with fewer administrative restraints.  It makes them more likely to get the work done.   It is still a shame that most private insurers won't support this essential part of the "system of care" that we are trying to build in Massachusetts.  
We shouldn't, however, expect miracles.

Tuesday, August 5, 2008

Teleconference for Primary Care Docs

A Message from the AAP
Please find the following link to the recording of The 15 Minute Mental Health Visit Web-based teleconference: Go here and look under Children's Mental Health News . If you are viewing the teleconference for the first time, please take a moment to complete the online evaluation linked to on the teleconferences Web page or click on here to complete our SurveyMonkey evaluation   Should you wish to join the teleconference email listserv to further discuss the "common factors" approach, please email me at  and I will add you to the email listserve.  Let me know if you have any questions. Have a great day!
Aldina M. Hovde, MSW
Manager, Mental Health Initiatives
Division of Developmental Pediatrics & Preventive Services
American Academy of Pediatrics

Folks from Worcester will recognize this as the descendent of the talk that Dr. Wissow presented in Worcester last fall as part of our Technical Assistance Visit.

Monday, August 4, 2008

Who's in the class?: What an appeal process means for families.

I mentioned last week that the Judge issued a ruling last month on the eligibility process for the Rosie D settlement on which we should reflect.  So, I figured that it was worth spending time thinking about this. Let me start by putting in context.
As it relates to the Rosie D settlement, the Child Behavioral Health Initiative MUST meet the needs of the CLASS of children represented by the 8 named plaintiffs in the case (one of whom is Rosie D. herself).  So, for any individual child, membership in the CLASS is determined by whether or not you have "Serious Emotional Disturbance", which has two definitions specified in the settlement.  The settlement says that mental health clinicians will determine your status in the CLASS by using the CANS (hence all of this talk of CANS training).  Those in the CLASS with get intensive care coordination(ICC), the whole wraparound "team" thing.  Those not in the CLASS will still get appropriate services, but not the ICC.

But what if the parents/family disagrees with the mental health clinicians findings on the CANS?  Can the family appeal the decision of CLASS status to a higher authority, or is mental health clinician the last word?  Last month, the Judge said, "For now, no appeal process", although he apparently left the door open to change his mind later.  On the face of it, this sounds like a bad deal for families.  I would argue, however, that it may not be as bad as it sounds.
1)  We don't know how the CANS is going to work yet.  Maybe the instrument does does a great job of identifying the class, and disagreements are few.
2)  We have limited resources to access for the kids who are eligible.  An appeal process would divert attention from our need to build more service-provision  infrastructure into the system.
3)  The judge wants to hear about the problems of CLASS status before imposing a solution on a system that hasn't been built yet.
4)  It is difficult to ask 7000 mental health clinicians from around the State to use a new intrument in their systems of care AND tell them you are going to frequently second guess their professional judgement on a regular basis.
So, pragmatics won the day, at least in the short term.   Judge Posner, however, will be watching as we move forward over the next year, and reserves the right to change his mind.

Sunday, August 3, 2008

Courts and Kids: Will the CBHI make the process easier?

I seem to have spent a lot of time lately on the rituals of government, as evidenced in yesterday's screed about the legislative engrossment of our marvelous Children's Mental Health bill last week.   Last week, I was also privileged to observe the Juvenile Court in action;  usually a sobering experience- last time I was there, I watched a 13 y/o "tough" burst into tears as he was shackled and taken off into DYS custody.  Sometimes I think that the images on "Law and Order" make us forget that these are kids, and, despite the bravado and "in your face" gangsta thing, they really don't want to screw up their lives.  This week, I was struck by how difficult the task of the court was in trying to straighten out the lives of children, and how the ritual makes it, if not doable, at least palatable.  Here is what I wrote at the time, appropriately edited.

Court is ritual. The family, the judge, the attorney, the interpreter, the social worker: all elements must be in place for the ritual to occur. We waited for all to arrive, then it began. It proceeds like a ritual, with the judge at the head. He called on the Department of Children and Families, on the guardian ad litum, on mother. This was a happy story; the brother and sister were being reunited with their mother. I have no idea what sort of behavior resulted in their separation, but it was clear that their mother wanted them back and that she felt that the State had made no positive contribution to her children's welfare. Her anger was visceral; it seemed directed at this systems that cared for her children. The Judge tried to understand her anger; she had much difficulty in stating her grievances in words. After hearing her out, the judge let them go home together with stiff admonitions to the children that they should not cause their mother such problems in the future. He might as well have said, “Go and sin no more”.
LESSON: Don't expect thanks when circumstances require you to intervene on behalf of children. And, as is continually stated at our "Rosie D" forums, how does one practice "family centered" care when the family is a part of the problem?  It was interesting to watch a judge wrestle with that issue- it is hard work.

We them moved to plea bargains. Three girls at a local hight school were caught on videotape stealing from a locker and plead guilty. They all had their cases continued without finding after giving up all of their rights. The Judge carefully made sure that the facts were all in place, and impressed on the girls how close to the edge they were. He asked them about his dreams. Then he was appropriately merciful.
LESSON: Mandatory sentencing, automatic suspensions and the like do not allow for the complexity of human interactions.  Some humans do learn from experience;  I recall an 11 y/o of my acquaintance who once lit a field on fire while playing with matches, and "went straight" after a stern talking-to by the Fire Chief.  Humans make mistakes; one hopes that they continue to learn and grow from them.  And, in terms of our response, one size is unlikely to fit all.  As we build the Children's Behavioral Health Initiative, with the screening and the CANS and the ICC and the wraparound, we need to remember that:  the human experience requires a flexible response.  We need to give those working in the system enough room to provide it.

We moved on to the ritual of CHINS. Here I must be circumspect due to confidentiality:  the cases were complex, and involved petitions files by parents and by the schools.  In each case, the Judge tried to recognize that the CHINS is a culmination of a series of events, and that the history often helped him understand the future direction of the case.  His response to the child varied, depending on the nature of the case.  
LESSON:  Each case begged the question:  could a better designed and more family centered mental health system address some of these issues so that the court didn't need to be involved?

As the morning moved on (the Judge is just back from vacation, and had quite the docket).  Two cases stick in my mind:  One was a  restraining order, through which the mother of a younger girl was trying to keep her from talking to an older boy.  Violations involving the telephone and texting were alleged;  it is not clear who was calling whom.
THOUGHT:  Why don't the parents just take away their cell phones?
The other one was a CHINS case: a young man with severe psychiatric problems who is not currently getting psychiatric treatment. He is hearing voices, he tells a court ordered evaluation, but his mother doesn’t agree.  They are installing FST program, to try to get him some services-  if that doesn't work, his options are foster care, lock up or maybe an alternative school.  What can we do with this?
THOUGHT:  All of which leads me to wonder why we can’t handle these things without a court.  I guess we need the court when the family is not making the creaky and overburdened system work well for themselves.
OBSERVATION:  It is interesting that, in all of the continuance cases, the judge asks “Are you under the care of psychiatrist’”, I presume as a screen for serious mental illness. Given the shortage of child psychiatrists in the Commonwealth, I wonder if that is sufficient screen.  Also, there are lots of folks with mental illness who see psychologists and social workers, not psychiatrists.
I alway learn things sitting in the Juvenile Court, in part because that is where the kids that we haven't helped often end up.  This time, I saw the need for options, so that the Judge, in his wisdom and compassion and common sense, has something to offer the families that come to him seeking help.  We have to be able to make that work.

Saturday, August 2, 2008

Children's Mental Health Campaign: What is "engrossment"?

As I briefly mentioned on Friday, the Children's Mental Health Bill (SB 2804) survives despite the end of the legislative session through the mechanism of "engrossment".  Engrossment is  "the process of preparing a bill for Final Reading by incorporating all adopted amendments."  Apparently this dates back to the days of pretty parchment paper, when the bills had to be scribed before they can be finally approved.  So the Children's Mental Health Bill (SB 2804) wasn't passed, but it was reported out of the Ways and Means Committee with an amendment, and has been sent back to the Senate (which already passed it unanimously) to be sure they agree with the final amendments.  Once the Senate "engrosses" the bill, it comes back to the House for approval, then back to the Senate and then to the Governor.  Complex, no?

Really, it is a beautifully designed system, that allows the members of the Legislature to juggle the wide variety of issues that are competing for attention.  The Legislature had many major issues with which to deal before the end of the session;  fixing the health care reform, bond stuff, fixing mental health and many other things.  Too much to do. Several of the issues needed to be done with public debate.  ALL of the land bills required a full vote of the House (including something to do with Community Healthlink in our little town of Worcester) People who felt strongly needed to have their say on the floor;  that uses up floor time.  So how do you get through the process and still close at midnight?  You pass some things, you engross some things, you get some things out of committee, you literally alter time and you run the whole think through a complex whirling spree that is the end of the session.  I watched them debate; I watched them pass some things, and I watched them "engross" a whole bunch of bills, not knowing what it meant.  To a bill, "engrossment" means survival, a chance to pass in one of the "informal" sessions that will happen over the next few months.  Amazing process;  not at all the way they described it on "Schoolhouse Rock".  Apparently the Federal government doesn't believe in parchment, although I am certain that they have their own set of interesting and arcane rules.

Why is all of this a good thing?  All of these convolutions allow those interested in this legislation to ensure that a consensus is reached that incorporates the interests of all concerns. 
It clearly requires people who have a deep understanding of the process.  Fortunately for our bill, Speaker Dimasi and Representative Balser have that understanding and were able to shepard this bill past the midnight deadline.  And we still have a shot.

The Speaker closed the session by having everyone give themselves a round of applause.   They earned it, and I hope that they had a good party in the Berkshires (Governor Patrick hosted a party in the Berkshires).   Despite the end of the session, they still have some work to do.  We will keep you posted.

Friday, August 1, 2008

Secretary Leavitt has a blog

Since I am a major believer in dialogue, I was excited to learn that Secretary Leavitt has a blog on HHS.  It makes fascinating reading-  he is clearly a more regular contributor to it than am I.  Here's the link.  I haven't found much on mental health care yet, but I am sure that I will.
*******
I know, I should be reflecting on the Legislative session that just ended.  The Mental Health bill did not go through;  Health Care for All tells us not to give up hope, so I haven't yet.  Read about it on "A Healthy Blog".  Since I am not reflecting on that, I should be reflecting on the Judge's ruling in the Rosie D. settlement that the evaluation of a child's mental health condition to determine if he or she is part of the class of "seriously emotionally disturbed" children will not be a "disability-like" process.  You can read about that here.  
Instead, I have been contemplating the storms that swept through the Falcon Ridge folk festival last weekend, creating a almost-tornado in a field full of campers.  I was there, but didn't have my camera out; stuff is starting to appear on YOUTUBE-  it's a little scary when the folks with their ear to the Weather Service say "Run to your cars, now".  Kind of puts all of this in perspective. (Note the tent collapsing in the background).
Hope we have better weather this weekend.  Be well, all.

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