Tuesday, September 30, 2008

Worcester Children’s Mental Health Issue Forum
Wednesday, October 15, 2008
9:30-11:00 AM

Please come to learn more about the recently passed Children’s Mental Health law, how you can be involved in its implementation, and tell the Children’s Mental Health Campaign what pressing issues remain unaddressed in your community.

MSPCC Worcester Office
335 Chandler Street 
Worcester, MA 01602

The time is now to:  Share your story • Speak out for reform • Learn about the new Children’s Mental Health law • Make children’s mental health care better together

Light refreshments will be served.

Monday, September 29, 2008

Mental Health in Washington: Mental Health Parity Almost Passed the Congress

Since Saturday, I have been in Washington, 5 blocks from the eye of the storm currently raging from Washington to Wall St.  While I have been following the current crisis closely, the reason for my visit was to attend the AAP's meeting of the Committee on Federal Government Affairs, as the representative of the APA.  We met with the staff from the AAP's Washington office, heard about the issues currently on the Hill that affect children, and spend a bit of time on Monday morning talking with our Representatives and Senators offices.  One issue that I knew was on the table was the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act of 2008, which the Academy has supported for a long time.  The key paragraph in the bill is this:  
"the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan, and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits;"
This would be an enormous relief for families with large co-pays or deductible requirements, and will compliment the changes being put in place in Massachusetts.  So what is the catch?

Like our bill in Massachusetts, this bill is widely supported and has no overt opposition.  It has passed the House, where it is engrossed, and is stalled in the Senate because it has been linked to a tax bill that the House finds unacceptable.  To get through, the bill must either be separated in the Senate or passed in the House.

People know that this can be passed.  The current disaster in finance and credit has refocused everyone's attention, and we need to ensure that Congress doesn't forget the Mental Health Parity bill in the sound and fury currently underway 10 blocks from where I am typing this.

Please let your Representative and Senator know that they should not let this bill die with the end of this Congress.

I'm off to catch my flight home.  More about this on this blog.

Saturday, September 27, 2008

After the Party: Updates on Rosie D. Implementation

After the celebration, I (like the rest of America) got a little preoccupied with the imminent collapse of our economic system.  Sorry - its been a few days since my last posting.
The Center for Public Representation recently issued a news bulletin, which is worth a look here.   They had four items:
1)  Final Medical Necessity Criteria:  It is good to hear that the criteria for determination of medical necessity are almost ready to be released;  we all knew that it would be a struggle to put that together and we fully expect that there will be controversy over them once that are released.  Their release, however, will be another landmark in this case.
2)  Response to CMA:  Folks should take a look at the forceful way that Secretary Bigby is arguing for the expansive and comprehensive services that will be needed to make wraparound services a reality in Massachusetts.  
3)  Revised State Plan Amendment:  This is also good to see;  an administration working to set policy that provides services for children and families.  We can only home that the Federal government sees the good in all of this as well.
4)  CSA:  Coming soon.  The Massachusetts Behavioral Health Partnership has put this on hold as well, trying to make this RFR consistent with the agreements that the Commonwealth is able to reach with the folks in Washington.
The last thing was a bit about screening.  I want to quote the article exactly, because I want my comments to be equally precise:
"The early data reports of the new behavioral health screening initiative indicate significant gaps remain in the Commonwealth. Although all children who visit their pediatrician or health care professional for a periodic EPSDT visit must now receive a behavioral health screening, only 25% did in the first six months since the new program was initiated on January 1, 2008. Of those who were properly screened, only 7% were identified as having a behavior health condition, even though national data indicates this figure is well over 10% and often approaching 20%. Finally, of those identified as having a behavior health condition, there was no data on the percentage who were referred for a mental health assessment, even though this figure should be approach 100%. Thus, despite the critical importance of behavioral health screening, as mandated by the Congress and ordered by the federal court, much remains to be done to ensure compliance with these mandates in Massachusetts."
In light of my experience in this area, I want make a couple of points:
1)  I am not troubled that MassHealth only found that 25% of EPSDT visits involved a behavioral health screen.  This program was implemented with almost no notice- it will take some practices more time than others to get up to speed.  Also, screening and billing may not match entirely.  Given that almost no-one was screened using a valid screening instrument prior to the Rosie D case,   getting to 25% is extraordinary.  That is at least a 100% increase.  Not bad for the first 6 months.  I suspect it will get to be a larger percentage of children over time.
2)  Billing and practice are not always in sync.  It is hard to change habits; it took me a while to remember to add the screening code to the billing sheets, and I know that some of my patients escaped without me billing for the screen that I did. 
3)  Rates of positive screens are low.  Research studies, where there is an interest in finding high rates of problems, almost invariably result in higher rates of case finding than we find in the real world.  For me, part of the problem is how to code the kids that we already knew had problems?  Are the "U2" referrals if they are already in treatment?  Or if they refuse treatment?  That happens in at least 50% of my positive screens-  that will look like underdiagnosis in the billing data.
4) No data on mental health referral:Here is where the "carve out" ideology gets in the way.  In our area, anyway, the act of making a referral is largely giving the phone numbers for several agencies to the mother.  The agencies won't let us book the appointment, as, in their experience, that leads to too many no shows.  And we often don't hear back regarding their their treatment plan.  So how can we tell who has been referred until we agree on what referral means?  The best that MassHealth can do is look at mental health billing records and compare them to the primary care record.
5)  Who were those patients? Please remember that the EPSDT visits during the school year (January to June) are likely to be younger, and the rates of mental illness are lower in that population.  I suspect that the number of screenings will increase in the summertime, when we are seeing all of the older kids for school and sports physicals.

Change is hard, whatever the system in which it is being promulgated.  I look forward to seeing the end of year numbers.

Wednesday, September 24, 2008

It Takes a Village to Raise a Bill: Celebrating Chapter 321

I should have brought a camera, because, as with everything else they have done, Health Care for All did a great job organizing today's celebration.  (Fortunately, I was able to scarf a picture from HCFA's website and post it here- I am sure that they won't mind).  There were a lot of people here and a lot of great pictures to be taken.  The people were really happy, as they gathered to celebrate a legislative accomplishment: the passage of Yolanda’s Law, An Act Relative to Children’s Mental Health, now Chapter 321 of the Acts of 2008.
The crowd began to clap at about 2:40 PM, and the officials arrived to begin the ceremony. We began with Secretary Bigby, who acknowledgd the critical role of the Children’s Mental Health Campaign, with Representative Balzer and Senator Tolman, and thanks to the leadership of Marilou Sudders and David Demasio. Governor Patrick took the stage, and thanked all of us for leading Massachusetts to a place where mental health and physical health are seen as equally important in the care of children in Massachusetts. He gave copies of the bill to Marilou Sudders and to the mother of Yolanda, a young woman who supported the bill and later succumbed to her psychiatric illness. His remarks were brief, and he passed the microphone to Senate President Murray, who further praised those who worked so hard to get this bill through. She pointed out that this bill’s high standard is the envy of all throughout the country. The microphone then passed to Speaker DiMasi, who was equally eloquent in his praise of those who worked so hard on this project.
From the Campaign, we heard from the CEO of Children’s Hospital, who reminded us that our work is not done- that we need now to finish the implementation of all aspects of the law, and Marilou Sudders, who spoke eloquently of the voices of families in the process of creating this law. She reminded us that parents and children, by sharing their stories, have given us the courage to go forward. Secretary Bigby echoed this sentiment, highlighting the story of Yolanda. Mrs. Tufts expressed gratitude that Yolanda’s voice was heard, and that her words had impact. She also reminded us that the real work now really begins, as we begin to fixc the broken system. She hoped that her family would be “last ones in” the system as it is currently configured.
Representatives of the various groups that had worked so hard to get this bill passed were on the steps behind all of the officials and speakers, and that was appropriate (and that was the picture that should have been taken).  It took all of them and all of us in the audience to get this done.  We really should be proud of ourselves-  we got a lot of work done last year.  But, as no good deed goes unpunished, we now have to embrace the task of implementation going forward.

Tuesday, September 23, 2008

Reflecting on a Reflection

It took a while to upload my slides, but I finally got my Grand Rounds  on the blog.  You could stop reading this, and drop down three posts to check it out.  Posting it made me think more about what I said- I think that it is mostly accurate (and of course, I would love it if folks would send me corrections), but I think that I spent too little time on the final reflections.  What has my modest participation in this fantastic process taught me?  My "lessons learned" seems a bit lean, and I wanted to think on this a bit, especially in the context of a talk I heard today by Michael Fine, a family doc from Rhode Island.  Michael has written a book, The Nature of Health in which he laws out a strong argument that our current healthcare mess (high cost, poor outcomes) is rooted in our social fabric, that has defined health in measurable terms (delay of death, alleviation of pain, personal function) that encourages us to think about medicine as a business, and that focusing our remedies on the payment system (national health insurance) will do little to change that unless we change the system from one focused on procedures and specialists to one focused on primary care and prevention.  All of which I agree with.  He points out that neither Obama or McCain want to fix this fundamental problem.  What he didn't do today was give us the blueprint for change;  how do we make this change happen?  
That's what was missing from my lessons learned slides:  What I have been learning for the last year or so (actually for the last 50 years, but I am a slow learner) is that actually bringing change to a system is really hard.  It requires a careful analysis of the forces holding the old system in place, a keen sense of timing to understand when the "Time is Now", incredible attention to details- an ear to ground, contacts at every level of the government, knowledge about how the levers of power are actually pushed, and finally a recognition that, in order to counter any political force, you need another political force to knock it sideways.  These are not things that one learns in medical school.  The are people- politicians and their aides- who have a keen sense of how this work.  When us medical people want something to change, we need to ally ourselves with these political chessplayers and let them show us how our knowledge can become political clout.  Sobering lesson, but really important if one wants to change actually systems.
Michael's talk, however, was right on target and brilliant.  He just needs to tell us more about the steps that we should take to make it all happen.
Bill signing tomorrow.  I'm looking forward to it.  I'll try to blog live.

Monday, September 22, 2008

More from the CBHI

To: All Minority Providers and Youth/Family-Serving Organizations in Communities of Color

You are cordially invited to a briefing and discussion about The Future of Public Children’s Mental Health Care in Massachusetts including opportunities to become a provider of new MassHealth services

The Massachusetts Executive Office of Health and Human Services (EOHHS) is in the midst of a major transformation of its children’s mental health system, sparked in part by the Rosie D. Medicaid lawsuit, and fueled by Governor Patrick’s commitment to the Children’s Behavioral Health Initiative(CBHI), whose goal is to develop an integrated system of care for children with serious emotional disturbance or behavioral health needs. As youth/family- serving organizations, your involvement and leadership is essential to the success of this initiative. This meeting is part of a series of provider and family meetings being held across the Commonwealth.

Wednesday, October 1st, 2008, 12:30pm-2:00pm
Ashburton CafĂ© Conference, in the lower level of 
the McCormack Building
1 Ashburton Place
Boston, MA 02108
Please rsvp to cbhi@state.ma.us. Attendance at this meeting is limited only by the space available.

• Overview of the Children’s Behavioral Health Initiative and the Rosie D. lawsuit
• New MassHealth behavioral health services under development
• Process for becoming a provider of one or more of these new services
• Discussion of community needs
• Concerns, questions, and input

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 e-mail questions or comments to: cbhi@state.ma.us

For updates and announcements relating to CBHI, please visit: mass.gov/masshealth/childbehavioralhealth

To request an accommodation, please call (617) 573-1832
or TTY: (800) 872-0166.

Friday, September 19, 2008

The Rubber is Getting Closer to the Road: Update on the CBHI

So, I arrive late to the update of the CBHI, and I am blogging live in Shrewsbury.  The senior leadership of the CBHI, the assistance commissioners and all of the major players were there, ready to answer questions.  We have made a lot of progress over the last few months, and, once again, they left themselves open to questions.   I am happy to report that the rubber is indeed getting closer to the road. I joined a conversation about the process of way in which this program is actually going to work, and was highly impressed with the thoughtful of the process in which this plan is evolving. Key ideas:

  1. Care coordination is at the center of everything.
  2. Families are at the center of care coordination.
  3. The families get to determine the level of care needed in each level of services.

Let me try to summarize: The Core Clinical Services of the CBHI are
  1. Intensive Care Coordination (ICC) as part of the wraparound process.
  2. In home therapy
  3. Outpatient therapy
Each of these will have access to the outside supports of Behavior Management, Family Partners and Therapeutic Monitoring, Mobile Crisis Intervention and Stabilization, and the care coordination will happen at the level of the the most intensive service being offered.  They had a great graphic that shows how this is supposed to work, which I may try to reproduce at some point.
Overall, the sense is that we are moving the WHOLE system, not just the Remedy services, to a family centered model.  It is all very exciting, very complex and a great challenge to us all moving forward.  In the ICC cases, this is the assembling of a team, selected by the family, to develop an individual care plan for the family that addressed the whole child.  In the In-Home and Outpatient levels, this translates into a care plan, but one that is still family focused and team implemented.
They have clearly recognized the difference between planning and therapeutic interventions, and seem to be offering a plan that both identified and values both sorts of services. It looks great on paper. 
So how are we going to do this:
1)  It will be a competitive RFR process.  One does not need to be a licensed clinic to be an ICC provider.
2) The RFR will be coming out in late October-mid  November, to correspond with the CBHI Institute.  MBHP will be selecting the CSAs with other managed care entities.
3)  In-home therapy will be provided agencies selected through a separate Network selection process.
4)  For outpatient services, that want to improve the capacity for core coordination over the next 3-5 years.  They are using the Performance Incentive projects within MBHP to move clinics in the right direction.  THis year, they are going to structure a pilot for paying outpatient clinics to provide crisis intervention for their clinics.
5)  This is going to be an iterative process:  they will convene provider and stakeholder meetings to identify action steps.
They have gotten so far as to begin defining the service elements of each of these components, and had some slides showing the relationship between Mobile Crisis Intervention, FST services, and In-Home Therapy.  The three are similar, but differ in the timelines (months, days, weeks) and scope of services vary in their scope.  FST will be morphed into the Mobile Crisis and In-Home Therapy programs.
The questions were focused and direct.  First question:  What about the "stuck kids"?  Several people responded that the remedy is focused on building community capacity and that, by doing so, the "stuck kids" will get better.  The second question was form someone who was not clear on where this all came from, prompting a brief summary of the history and a reference to the website for information about the CANS.  We then got down to the details:  Why were we going to a 72 hour crisis intervention?  The answer was that we are fortunate to have different levels of in-home care, and that the FST and home-based therapy teams will provide support to move families beyond the crisis.  They also pointed out the difference between referral and connection, a distinction that I found interesting.  They also discussed some of the details of how the contracts for home-based therapy providers, which is actually going to be a separate process from the CSA procurement process.  Who determines which level of service will be activated?  At first, it will be the families who pick the door on which to knock on, and after that it will become a dialogue, in which the CANS and the outcomes will drive the level of service provided.  One really practical question was the increased cost of in-home therapy versus office based therapy.  They are looking at the whole system, and the many different services can be provided in the in-home therapy.  How are they marketing the idea of who can be referred and how referrals happen?  They realize that they have a big educational task ahead of them.  How will this interact with the Family Network system (DCFs Wraparound services)?  They are in the process of making this happen.  How is his going to address the needs of cultural and linguistic communities?  They are actually looking for CSA providers with expertise in culturally diverse providers.  They are looking for ways to grow the workforce in diversity over the next 5 years.  There will be a provider meeting for culturally diverse providers to discuss this plan on Oct 1 in Boston.  What about the shortage of workforce?  We are going to need to expand the workforce that we have.  
The charts are getting more complex,  with lots of dense lines demonstrating service delivery for kids in  a variety different settings.  The process that has been established thoughtfully, with lots of feedback loops, of which we should take advantage.  Lots of work to do.  Go to the CBHI website for updates.

Wednesday, September 17, 2008

Notice from the CBHI: For parents and families

TO: Family Organizations and Interested Parties
FROM: Children’s Behavioral Health Initiative (CBHI)
DATE: September 17, 2008
SUBJECT: CBHI Family Forums
Recently, several parents and family organizations have contacted us with questions about future CBHI Family Forums scheduled for their area. As you may recall, these meetings were developed to provide families with information on upcoming CBHI services, solicit family feedback on how to measure success of this new effort, and answer questions about CBHI and how it may affect their family. While exact dates and locations for future Family Forums have not been finalized, we are happy to share the following general information with you:

Locations Dates
Springfield Week of Oct 13
Lawrence Week of Nov 17
Southeast Week of Dec 8
Boston Week of Jan 12

Additional 2009 CBHI Family Forum locations and dates will be announced. Dates and locations are subject to change. More specific information will be sent to you and can be found on our web site as we approach each meeting date. We hope you find this information helpful.

Children’s Behavioral Health Initiative

Monday, September 15, 2008

Me and “Rosie D”: Text of a Grand Rounds Presentation

The following is a close approximation of the text of my Grand Rounds presentation at Cornell on 9/16.  Feedback is more than welcome.  This is a one hour talk, so it is a bit longer than my usual post.  Read at your own risk.
Slide 1:  Thank you very much for that introduction, and for the opportunity to talk with you today. You are probably wondering,“Why is a general pediatrician talking to me about advocating for children’s mental health care? Shouldn’t this talk be from a psychiatrist, or a DBP specialist?” Of course, those of you who provide primary care for children know why I am giving this talk; over the past 30 years, our practices have included more and more  behavior and mental health issues. My frustration with the current state of things led to my involvement in a movement that may actually be able to help me to do my job, which is to care for the children and families of South Worcester County.
Slide 2:  Oh, yes, the disclosures. I have had the time to get involved in the movement through funding provided to me as a Physician Advocacy Fellow at Health Law Advocates through the Center on Medicine as a Profession at Columbia University. As part of that project, I am Chair of the Worcester Mental Health Network and a member of the Massachusetts Chapter of the AAP’s Mental Health Task Force. I also blog at olddockeller.blogspot.com and am a citizen of the United Stated (which means that making the system work is part of my job). I really do have a vested interest in this project, although the monetary reward is mostly through the Fellowship. 
Slide 3: So today, I want to take you on my journey, which began with a problem with my patients and ended with my understanding of the current state of the system that cares for children’s mental health in Massachusetts. Then I want to talk a bit about the process of changing systems, in so doing, I will describe a lawsuit, an election and a bill that our coalition  have used as vehicles for change. In this course of this description, I will try to highlight the role of the pediatrician in the process, and talk a bit about how one goes about finding a place in the process. Finally, I’ll close by discussing “lessons learned” about the “science” of advocacy. 

Slide 4: Before we begin this journey, however, I would like to give you a framework through which I have learned to think strategically about system change. They suggest that change happens when three streams converge: the problem stream (We should change this), the policy stream (We know how we want to change this) and the political stream (changing this will benefit enough of the right people to make it worthwhile). These streams represent the “activation energy” (if you will pardon a former Chemistry major) that is takes to upset the “steady state” equilibrium that tends to keep systems where they are. Keep this in mind as I talk about the last decade of children’s mental health policy in Massachusetts.

Slide 5:  For me, the problem stream begins in my practice. I work in Webster, a small town of 17,000 people located 20 miles SSW of Worcester. For the residents in the audience, small town practice is great. We are the only pediatricians for miles around, we teach residents and medical students, we have about 3500 patients and see 12,000 visits per year. Payor mix is about 25% Medicaid, and we have a number of innovative collaborations with various community agencies. (Oh, and we are hiring!- talk to me later). Several years ago, we began a registry for Children with Special Health Care Needs, and we realized that 20% of our patients had a DSM-IV diagnosis of mental illness. In fact, that was our major “special health care” need. We also realized that we were not doing a great job of caring for these kids- the nearest therapy was 30 minutes away, and they only had a child psychiatrist 2 days per week. Worcester City had some resources, but Webster people really don’t like to go to “the big city”, so that only helped a little.

Slide 6: This picture, by the way, is our office. And these are some of the actual cases from that office over the past year. A 4 year old with poor impulse control who is actively injuring animals- to whom can he go? A nine year old with ADHD and violent behavioral outbursts what is his diagnosis REALLY? A 17 year old in juvenile detention with depression and  anxiety- what does she need? How can we help? These are pretty representative of the common problems that we face daily in primary care; without a system, there is little we can do to help them. 
Slide 7:  I work with a bunch of “can do” people- that is us at one of our annual practice retreats, where we try to address these sorts of issues on a regular basis. Over the years, we had responded to our inability to treat mental health problem in a variety of ways. We  developed protocols for common behavioral health issues (ADHD and adolescent depression). We developed partnerships with local psychiatrists (the 2 day/week psychiatrist from Southbridge gave me her beeper number so that we could talk, and I took back some of the “routine” drug management cases to free up her schedule.) We had agency lists, and got a grant to fund a care coordinator position to help families access the few resources that we had in South Worcester County. My partners and I did CME and Collaborative Office Rounds to build up our skills in managing behavioral health issues. One does what one can. But we always realized that we were working on the edge-chipping away on the fringes of a much bigger problem. 
Slide 8:  As we looked out into the wider community, there was a lot of activity going on in the area of children’s mental health. Nationally, the AAP had convened a Mental Health Task Force, and our State chapter had followed suit. I joined at the State level, to stay in the loop. We heard of the opening of an advocacy agency called the Parent Professional Advocacy League in Worcester, and invited them over to meet our parent advisory group and to help them in their advocacy. And, fortuitously, I was invited to sit on the Worcester Mental Health  Network by the head of Health Law Advocates, a public interest law firm specializing in access to health care in Massachusetts. I learned that this wasn’t just a problem in my practice-it is a state and national problem.
Slide 9:  I’m a small town doctor- I’ll stick to the State problem. 1.46 million children in the Commonwealth of Massachusetts, and the Department of Mental Health estimated that 10% of them need mental health services (guess our practice is above average). Only 30% of them are currently getting services (that seems consistent with our experience.) Multiple blue ribbon commission reports over the past 20 years in education, foster care, child protection, corrections had all identified the problem; no one had a solution that was politically viable.
Slide 10:  The problems, at a system level, seemed to fall into three areas. First was fragmentation of care. This afflicts health care in general, and is worse in the mental health arena. We have, in America, separate but equal systems of public and private health care and within those systems, mental health care was often “carved out” to behavioral health management companies that are even less responsive to the needs of families. This separation of the finances of mental and physical health care is reflected in the lack of  communication between the providers in those areas. In Massachusetts, we had tried to address this through a Mental Health Parity bill- unfortunately, the Parity was only for  “biologically based diagnoses”- nine  of them which further divided mental health into covered  and uncovered areas. Finally, for those with “serious emotional disturbances” (a federal term not part of my clinical lexicon), there were up to six separate State agencies that were supposed to address their needs, each of which attended to only a part of the child in front of them.   There was no incentive for these fragments to come together to make things better.
Slide 11:  When one spoke with health care (and mental health care) providers around the State, this fragmentation had led to a real erosion of quality. The carve-outs all had limited provider panels, often based on geography, that did not acknowledge the difference between adult and child therapy. There was a major lack of child psychiatrists, resulting in long delays. For many families, Emergency Mental Health Services were seen as the first resort in a crisis- calling their therapist was unlikely to elicit a response as providers had no time to make phone calls. This chaotic non-system kept so many families out of the loop that the Boston Bar Association prepared a 148 page manual to help them understand the process- one  clearly needed a college degree to make sense of it all. Finally, as a last resort, the State created the “Child in Need of Services” or CHINS process, where a parent could ask the State to intervene to get their child the services that they needed. Almost a Zen concept- to get control over the process, one needed to give up control. And there was no plan to make it easier.
Slide 12:  We had model programs to address most of these concerns: Children’s and Cambridge Hospitals had piloted screening programs in Primary Care settings that showed that the PEDS and the PSC could be used successfully as part of a comprehensive solution. At my shop, Ron Steingard and Dan Connor established Targeted Child Psychiatry Services, initially a co-location model that grew to include telephone consultation and rapid assessments in collaboration with primary care doctors, leveraging the short supply of child  psychiatrists through partnership. For the “seriously emotionally disturbed” children clogging our EMH services, there were Wraparound programs in Communities of Care in Worcester and Coordinated Family Focused Care in Lowell. We had lots of ideas on how to fix the system; we lacked a method to scale them statewide.
Slide 13:  The first hint that change was coming really came from a public-private partnership, and involved the “scaling up” of the TCPS program into MCPAP. The disseminated version of this program is a consult liaison model: the PCP is the point of contact, the psychiatrist promises a response by phone within 30 minutes and offers a single psychiatric consultation  within a couple of weeks, as well as care coordination to assure follow-up. The version that was rolled out statewide had more emphasis on supporting primary care doctors as prescribers and ongoing care managers than the original program, which had included up to 4 visits with the psychiatrist for stabilization. The nicest thing about this program was that, although the State funded the program, it was the open to all children regardless of insurance (although the program was housed in the Massachusetts Behavioral Health Partnership, one of the Medicaid behavioral Health carve-outs). The program is wildly successful- pediatricians and patients are very happy, and it survived it’s first challenge in the State budget this year, always a sign of a successful program.
Slide 14:  With the successful scaling up of MCPAP, you might say “dayenu”- “it is enough”. But the problem with the response at that point was the “Rube Goldberg”-like machine that we had created, similar to the potato peeler shown here. We addressed fragmentation by creating pockets of collaboration, we addressed quality by creating pockets of quality and family engagement, and we had multiple small models of care around the state creating pockets of sustainability. This all is change, but it is slow change, and, as the parents in my practice like to remind me, children can’t wait.
Slide 15:  The problem stream is a waterfall, the policy stream is a small cataract and the political stream is still dammed up. Something has to give, before this metaphor implodes.

Slide 16:  Let’s take a look at the political stream. Our politics is organized into three branches, in order to maintain stability. To change it radically, you need to create a politics that works at all three levels. That is, more or less, what happened in Massachusetts. A lawsuit (“Rose D” vs variously Swift, Romney and Patrick), a major reorganization of the executive branch in response ot an election and sweeping new legislation have broken the dam and created the somewhat chaotic environment for change that is Children’s Mental Health care in Massachusetts right now. Let me tell you about it.
Slide 17: The lawsuit Rosie D v. Swift was filed in Springfield in 2001 by the Center for Public Representation and a private firm on behalf of the parents or guardians of eight children with serious emotional, behavioral or psychiatric conditions (these slides are from lawyers- many words, few graphics). They sought to compel provision of intensive mental health treatments to Medicaid-eligible children in their homes and communities, and they based the suit on the EPSDT section of the Federal Medicaid act. What impressed me as I read through their cases was that these kids had gotten a lot of services- but they were fragmented, of variable quality and always tried to get the child to fit the program, rather than trying to design a program to fit the child.
Slide 18: The good news was that the children won (took a while, though- note the change in Governor) In early 2006 (shortly after MCPAP was rolled out state-wide), the court found Massachusetts in violation of the EPSDT provisions of the Federal Medicaid Act and ordered them to fix it. 6 months later, the plaintiffs and the Commonwealth submitted separate remedial plans. The remedial plans before the Judge contained many similar or overlapping concepts and approaches to services, but also contained very substantive differences. They  were  probably most similar in regards to use of the wrap-around model and the agreed upon  services.
Slide 19: In early 2007, the Court order was finalized. The Court accepted most of the State’s proposal, with a few caveats as noted. The key changes were that the Court insisted on active involvement in assuring the remedy, through the appointment of a Court monitor and a really aggressive timeline. On July 1, 2007, the final judgment went into effect.
Slide 20: This pathway to accessing services closely mirrors elements of the Federal EPSDT law (Early, Periodic Screening, Diagnosis and Treatment.) Screening came first, and is the part of 
the system now in place. As of July 1, 2008, mental health screening using an approved instrument is part of every EPSDT encounter in the Commonwealth. By Nov 1, all of our Mental Health providers are supposed to be using a family-centered, asset-based evaluation system (the CANS) to determine diagnosis, level of need and to drive the level of services provided in the system. By next July, we are beginning to assess the service teams that will faciliate care coordination and the team planning process which ultimately determine which home-based services are needed. This last bit depends on Federal approval of the Massachusetts Medicaid waiver, a process that is currently taking way too long in Washington.
Slide 21: As you heard earlier, I had identified this as an important area of advocacy for my patients in 2004 or 2005, so I was looking for a way to make a difference when the lawsuit was won in 2006. I had joined a couple of task forces, and, when the Center for Public Representation was looking for a primary care doctor to take about what a good screening system would look like, I participated in the discussions of the Rosie D Advisory group. I actually submitted testimony to the Judge on screening, and I testified at the State House on the need for expanded mental health services for children, drawing on some of the stories from my practice to inform the policy discussion.
Slide 22: Rosie D. made the political stream into a river. Change was going to happen. Dayenu? Was it enough? Did we have a happy ending? Do you get to leave Grand Rounds with a feeling of satisfaction? Not yet.  The settlement didn’t address families without MassHEalth, doesn’t address children’s mental health until they are “severely emotionally disturbed”, doesn’t integrate change into the system and doesn’t ensure a process of continuing input into the system as the system evolves. But it is a start.

Slide 23: Rosie D brought the policies needed for change into the fore, creating a cataract of change in the Masshealth system. It remained to stoke the other branches of the political stream to finish the task.

Slide 24: In November of 2006, Deval Patrick was elected Governor of Massachusetts, just as the Rosie D order was being finalized. His administration was interested in creating change, which fit the directives coming out of the Court. In order to implement the Rosie D. decision, EOHHS created the Child Behavioral Health Initiative, with a mandate to coordinate all activity within the State government relevant to the remedy of the case. Within the Executive branch, there was now a change agent, working within the State machinery to bring this policy to life. The rest of the Executive branch was reorganized, with a particular emphasis on children. In addition, the Office of Child Advocate was created to give children a voice in the Administration.
Slide 25: At this point, I have to introduce the “small group of informed citizen’s” that Margaret Meade said was the only thing that ever changed the world. David DiMaso from Children’s Hospital, Steven Rosenfeld from Health Law Advocates, Lisa Lambert from the Parent Advocacy League, MaryLou Sudders from MSPCC and John McDonough from Health Care for all looked at the coming change and saw the golden opportunity to kick things up a notch. They thought that, through careful policy analysis informed by Science, Law, Families, Service Providers and Politics, we could engrave in law some of the policy ideas that we have recommended in the various blue ribbon reports cited earlier. In particular, they wanted to bring to the private sector of insurance some of the incentives to collaborate would be present in the new Medicaid funded system. And the Children’s Mental Health Campaign, not to be confused with the Children’s Behavioral Health Initiative, was born.
Slide 26:  The group recruited members, reviewed the work of the past 10 years and issued a report with 27 specific recommendations (integrated mostly from past reports.) With 35 co-sponsors, from many sectors of Massachusetts society, it was a hard report to ignore. AND they issued on the Tuesday after Thanksgiving, 20 days after Governor Patrick was elected. 
Slide 27:  The report was quickly codified into An Act Relative to Children’s Mental Health, an Omnibus bill that would address many of the areas and recommendations raised in the report. It is really hard to summarize what was in this legislative behemoth: Screenings, “Stuck Kids”, improved insurance coverage, collateral services, school access to psychiatric consultation and improved coordination were all on the table. I was told at the time that it would be very difficult to get part of the bill through; getting the whole thing through would take years.
Slide 28:  Absent a political miracle. A political miracle is when the problem stream, the policy stream and the political stream all come together. Like this. (This slide, in real life, involved a growing wave and the theme from Hawaii-50)

Slide 29:  It was an interesting time to get my Physician Advocacy Fellowship in July 2007, just in time to ride the wave. I became chair of the Worcester Mental Health Network, and after a bit of negotiation, we agreed that our main tasks over the next few years were to ensure that plans include “outside of Boston” families and practices, provide feedback for CBHI to make the system workable and work to educate legislature on need for “Act Relevant to Children’s Mental Health”. I am happy to report that it has been one really interesting and very wild ride.
Slide 30:  Let’s start with the basics: The Children’s Behavioral Health Initiative is underway, starting with screening. MassHealth provided trainings for providers, approved tools for them to use, and provided additional reimbursement for them to receive when they did it. The list of “approved” instruments was pretty good,and they weren’t hard to use. As one would predict, many of us reported identifying children with mental Illness for whom treatment was sub-optimal; there are not yet adequate treatment options.. The tools presently available are good, but we are not currently allowed to screen parents of young children for maternal depression, which many of us feel would be more valuable than the current strategy. In many practices, this screening is done on all of the children in the practice, not just the MassHealth kids, which has led to billing issues with the private insurers. But, despite the problems, it is happening, without too much of a hitch.
Slide 31:  In our office, we elected to screen kids 5 years of age and younger with the PEDS (except for a single MCHAT at 18 months per AAP recc), and older kids with the PSC and Y-PSC. Our teens are also screened with the CRAFFT for substance abuse, as part of a grant driven project of which we are a part. We are collecting data on teenagers was part of the other grant, and I am happy to report that, among our first 498 screenings, 10% had a positive PSC and 4% had a positive CRAFFT. Of interest to us is that we are finding little that we don’t already know- most of the teens with troubles refuse or can’t get an appointment and many of the kids that we know have problems score negative on the self-report questionnaires.
Slide 32:  Now we are gearing up for the next phase of the CBHI, by actively engaging the players and asserting our need to be part of the implementation loop. Last fall, we got an AAP sponsored mentoring and technical assistance visit from Larry Wissow, a triple boarded Professor from Hopkins who helped us to frame some of the questions around collaboration in the initiative. We hosted meetings with the plaintiffs attorneys and the CBHI folks from Boston, to discuss some of the problems around implementation. I started my blog, Rosie D and Me, to document and underscore some of the issues with the implementation of the settlement. And, in March, when the CBHI issued a Request for Information to all interested parties, we pulled together a response from Central Massachusetts, that helped to assue that we wouldn’t be forgotten as implementation moves forward.
Slide 33: Meanwhile, on the Legislative front, there was also a lot to do. The legislative process is complex: HR 1872 was introduced in January 2007 and then, before 31 July 2008, it must be approved by the Joint Committee on Mental Health and Substance Abuse, the Committee on Health Care Financing, the Ways and Means Committees of both houses, both Houses of the Massachusetts General Court, an then the Governor has to sign it! The flow chart makes this process look neat- it is anything but. 
Slide 34:  In October 2007, there was a hearing at the Joint Committee on Mental Health and Substance Abuse. They liked it, they passed it and they merged it with 5 other bills, stretching the beautiful language in odd ways to meet many needs. From there, it went in February 2008 to the Committee on Health Care Financing who also passed it (without a hearing) and sent it one to Senate Ways and Means. The expansion of Mental Health Parity was split out at this point, and was introduced as a separate bill.
Slide 35:  By April, nothing was happening, despite lots of pushing in Boston. So, what did we do in Worcester? We pushed more. We organized events throughout the county, met with legislators and gained co-sponsors and wrote letters; all of which kept the bill in the spotlight throughout the ferocious budget battle that was now in full swing.
Slide 36:  We got feedback: it was still in Senate Ways and Means, there was no opposition and it should pass after the budget is done. In July, it passed, short one key provision: Collaterals (payment for providers to work on a case without the patient in the room). I will be happy to tell that story over a beer at the train station, but it passed with all of the other  provisions intact. And, despite a few more procedural bumps, it was passed unamimously and signed by the governor in August 2008.
Slide 37:  What do we do now? First, we should celebrate: It is really hard to get this much done in two years. We are having a party at the State House next week- y’all are invited. Second, we still need to implement the “Rosie D.” settlement: the hard part is still to come. Third, we need to implement Chapter 321: Omnibus bills are the most complex to make happen, and this one has a lot of little bits that could fall by the wayside. Finally, we need to go back to the legislature to change the reimbursement system to cover “collaterals”: It turns out that it won’t cost too much, and collaboration is the name of the game. Oh, and once we have build the new children’s mental health system, we have to get our practice to fit into it.
Slide 38:  How has any of this filtered back to our practice? Well, screening is now routine. We’ve facilitated the location of a branch of one of our local behavioral health providers in our building (business is booming). The Communities of Care folk have opened a branch office in town, and help some of our families coordinate services. And it is getting easier to get home based services: Primary care doctors can refer for home-based team assessments without emergency mental health screening.
Slide 39:  So, what have I learned? First, that focused advocacy can health you take better care of your patients. In the course of do this work, it is important to think carefully about partnerships: Who can you work with to move your agenda along? It is also important to think strategically: What are the missing pieces to bring the plan together? In the end, it is important to think longitudinally: What are the steps going forward, and how far can I ride this wave? Oh, and one last bit of advice: when the wave comes, ride it.Thank you for your attention.
Slide 40:  Credits.

Sunday, September 14, 2008

A Busy Week Ahead: Talking Mental Health Reform in the Big Apple

I'm a little nervous this week:  I am traveling to Weill-Cornell Pediatrics in Manhattan tomorrow, where I am presenting Pediatric Grand Rounds on mental health reform in Massachusetts,  we have our first meeting of the academic year for the Worcester Mental Health Network and there is a Rosie D forum on Friday.  This in addition to the usual seeing of patients and teaching and Medical School interviewing and- well, you get the idea.  It has proven to be quite challenging to capture the breadth of what has happened in Massachusetts over the past 4 years in a one hour talk.  I thought that I might lay out some of my reflections here, so see what you all thought-  it is not too late to change it before Tuesday, after all.
I was impressed by a talk I heard at Judge Baker a few months ago, in which Marylou Sudders of MSPCC and David DeMaso of Children's outlined a way to look at changing systems, which I have shamelessly adapted into my talk.  As a model, it fit with my view of the last few years, which is that the problem is quite apparent, the policies that we
 need are reasonable well understood and that current "Rube Goldbergian" system has been held in place only by the lack of political pressure.  In Massachusetts, we sort of had the perfect storm of political happenings in all three branches of government:  the Rosie D case, the change in administration and the Act Relative to Mental Health as depicted in the this other slide (the model is from the US Government's website, but I figured that it was still relevant). I've tried to weave the story to go between policy and the kids that I see in my practice.  It is hard to integrate the timelines- they are related, but it can be very confusing for the outsider.
What this contemplation has made me realize that systems in general live in equilibrium; in order to get them to change, you have to be willing to risk a bit of chaos, and that the art lies in not using more force than is necessary in upsetting the apple-cart.  There are those who think that Rosie D. was overkill, that we could have gotten change without the overwhelming force of a court order.  Most parents are still not convinced that the current political change will result in better services for their children.
Turns out this is a reasonable way to think of conflict in general.  The task before us is, now that we have established these areas of change, can we actually implement the changes that we have planned and come up with a better (likely not perfect, but better) system?
I think that that the talk will go well; my nervousness stems from the realization that I intend to discuss the politics of medicine in front of an audience that is usually more focused on the science.  Anyone who wants to look at the slides, drop me an e-mail and I'll send them out for you to look at.  

Wednesday, September 10, 2008

Statewide Family Forum on the Children's Behavioral Health Initiative

The Executive Office of Health and Human Services (EOHHS) is holding a series of statewide Family Forums on the Children’s Behavioral Health Initiative (“Rosie D”). The first of these forums will be held on:

Wednesday, Sept 24th
6:30-8:30 PM
Blessed Sacrament Church,
Phelan Center (the yellow brick building behind the Rectory)
551 Pleasant St
Worcester, MA 01602

The Children’s Behavioral Health Initiative (CBHI) is an undertaking by EOHHS to implement the Court Order in a lawsuit known as Rosie D. vs. Romney. Representatives from EOHHS, MassHealth, and the MA Department of Mental Health (DMH) will provide information on upcoming CBHI services; solicit family feedback on how to measure the success of this new effort, and answer your questions about CBHI and how it may affect your family.

Registration is not required but seating may be limited

Light refreshments will be served

A list of the upcoming CBHI Family Forum dates and locations around the state will be available soon.

To request an accommodation, please call 617-573-1832 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.

Tuesday, September 9, 2008

Chapter 321 of the Acts of 2008: What did we win with An Act Relative to Children's Mental Health?

I have many patients who are proud that their doctor is taking this "semi-sabbatical" to work on improving the system for providing mental health services for children and adolescents in Massachusetts.  (There are also some who are annoyed that I am not always available around the office when I am off "advocating" in Boston).  If their child has a mental illness, however, many want to know how my work is going to benefit their child.  For example, what will this new law, Chapter 321 of the Acts of 2008,  actually do for children and families?  
If you  just go and look it up here, you will get text that is quite lawyer-like and full of legislative jargon.  It is confusing and sometime difficult to understand.  After a while, you will likely be scratching your head and saying to yourself, "What does this thing actually do?"
For one thing, the new bill requires a lot of meetings (Interagency meetings, a mental health advisory council meeting, regional meetings) and a large number of reports (a monthly report from the Secretary, an annual council reports, an annual report from the Department, a report on early education and expulsions, a monthly report on "stuck kids", a report from the Research wing of the program)- lots of paper.  The new law doesn't put psychiatrists into clinics in our town, but it clarifies lines of authority within State government, placing to the responsibility for providing "clinically-appropriate" behavioral health services on the Secretary of HHS, and ensuring that the commissioner of mental health is "in the loop" when other agencies change their systems in ways "substantially affecting the design and implementation of behavioral health services for children".  Finally, it creates systems, several different systems in fact.  One to coordinate care for kids, another to mandate collaboration between inpatient and outpatient facilities, another to establish a child behavioral health research center, a task force on the interaction of schools and mental health services, and a project aimed at providing behavioral health consultation to school systems.  Oh, and by the way, it establishes the office of the Children's Behavioral Health Initiative in response to the Rosie D. case.  Making meetings, generating reports, ensuring collaboration, creating systems-this bill does a lot of things, but, to my parents and their children, it may all seem to be theoretically helpful, without creating a real change in the level of services provided in the Commonwealth.  
What I have come to realize is that, before you can change to way in which mental health services are provided in the field, you have to change the way in which they are organized at an administrative level.  One of my colleagues put it in terms of the IEP process: you can write the best IEP in the world, but if the team that needs to carry it out doesn't have a long-term and compassionate view of the process, you will likely get nowhere with it.  The needs to function in the context of a system that allows the team to do it's job, by keeping the child and the family at the center of a process that will ultimately provide excellent high quality care.  This legislation is about fixing systems;  our challenge will remain.  We need people of high quality and good heart to bring the system to life.
Let's think about some of the things that are in this bill.  (This is not the order in which these appear in the bill; I'm borrowing these categories from my good friends at Health Care for All, and you can look at their take on this site  for their take on the bill.) 
EARLY IDENTIFICATION:  Traditionally the system waits for you to come in because of a problem, and based the intensity of treatment on how bad the problem is at the time of "presentation".  This bill takes the "screening" portion of the Rosie D settlement (see our blog in December) and extends it to other places in the community.  In addition to primary care settings, who will continue to screen as they have done since the Rosie D settlement went into effect, we will be looking at schools and daycare centers as places where professionals often have contact with children and families BEFORE they are in crisis.  We won't be screening in those settings,  rather will will approach the problem through statewide task forces and direct consultations with child behavioral health specialist.
MOST APPROPRIATE SETTING:  Kids get stuck in hospitals for a variety of reasons, most commonly because because we can't find a bed.  We can't force beds into existence, but we can encourage the State to find them, in or out of state, but creating a performance standard and charging them when they don't meet it.
INSURANCE COMPANIES:  This one almost snuck by me; they have improved the ways in which families can complain about shoddy treatment at the hands of insurers.   "Carve outs" allow "behavioral health management companies" to avoid state regulation by putting themselves an arms length away from the Division of Insurance.  Now they are held to the same standards as the insurance companies that hired them.  One tends not to cut corners when there is a chance that you will be caught.
STATE SERVICES:  Some may see this as rearranging the deck chairs on the Titanic, but one of the common complaints of families in my practice and in the Rosie D case was the lack of clarity about who is in charge.  Now, it IS the Commission of Mental Health.  And she has a broad-based advisory council and a Children's Behavioral Health Research Center to help her.  This multiagency collaborative approach, incidently, is extended down to the local level, through the Child Behavioral  Health Initiative (Rosie D Compliance) office and regional multi-agency teams (which will warm the cockles of some of our more senior colleagues hearts, as these were once commonplace in the Commonwealth).

So how does this help my patients?  First, problems should enter the system earlier.  You will see active screening in my office, in the day care and in your child's school.  Second, if you are in crisis, and there is no community placement for your child, let us know and we will work on activating the multi-disciplinary team to get your child out of the ER or hospital.  Third, if your behavioral health provider is giving you the runaround, complain and we have the authority to try to make it better.  Fourth, make your observations, positive and negative, to the Commissioner of Mental Health.  The buck stops with in her office,  which is virtually here.

Will this fix all of our problems?  Well, not immediately.  It does something better- it gives us a structure in which we can work together to fix our own problems.  How we use it is up to us?
Hope that puts it in some perspective.  Comments and feedback are much appreciated.

Monday, September 8, 2008

Children's Mental Health Bill Signing Event Sept. 24

On Wednesday, September 24 at 2:00 pm in the Governor's Council Chamber, Governor Patrick will host an event to recognize the signing of Chapter 321 of the Acts of 2008 - An Act Relative To Children's Mental Health. 
The event will recognize the hard work of the Children's Mental Health Campaign and reaffirm the Commonwealth's commitment to addressing the needs of children living with mental illness. 
All are invited, but because of space limitations in the Governor's Council Chamber, please contact Matt Noyes at 617-275-2939 or mnoyes@hcfama.org if you are planning to attend. 
The Children's Mental Health Campaign will host a reception following the bill signing.  Details to follow. 

Sunday, September 7, 2008

Wait times: A difficult question.

Robbin Miller, also known as "Advocate" on this blog, asked some difficult questions on the comment section below, that I thought merited some discussion:
What is the average wait list for your clients to receive counseling services in their area? I am wondering if the new law will be monitoring wait times and assessing what the reasons are for these waiting lists.

I know in the Worcester area, the waiting list for counseling services are between one to three months. I know some agencies have a 30 day waiting period for Family Stabilization Services (FST).

Do counseling agencies have to report their waiting lists to the state on a monthly basis? For private practitioners, some take Mass Health Clients while others don't for a variety of reasons.

I was glad to hear that Fallon is now paying for coordinated/collateral services their clients on Mass Health. However, Network Health has not stepped up to the plate yet.

How come commercial insurances such as Blue Cross and Fallon won't be pay for the above services?

Robbin Miller
Advocate/Private Practitioner
The answer to the "waiting question" is difficult, because of my uncertainty as to when to start the count.  Does the wait time start from when I suggest the referral (ie Day of the Annual Physical?)  If so, I would say 1 to 3 months is accurate.  Or does it start from the day that the parent makes the initial phone call, which may be up to 3-4 weeks after we see the child in the office (and actually may never happen?  Or is it from when the agency calls back?  (Which may be days, weeks or never after the initial call)  Agencies to report this stuff monthly and I was getting reports from Elizabeth O'Brien, LICSW, the Regional Director of MBHP, Central Mass for a long time.   Last one I got last winter reported that the wait times for an initial evaluation were 0-5 weeks, with additional times for initiation of therapy and initial consultation with a psychiatrist.  The data apparently is from agency information, and is not verified independently.

I'd post one of the reports, but it is 18 pages long and would fill the blogosphere.

FST, I haven't had long waits with, on the 5 or so patients that I have referred.  My biggest problem has been families that don't want FST in the house.

As to why insurers don't cover collaterals and FST, the answer is always "money" and "because they don't have to".

I am interested if others have thoughts on this.

Saturday, September 6, 2008

Oh, and by the way....

Good morning everyone,

I would like to bring to your attention that the paper version of the Child and Adolescent Needs and Strengths (CANS) tool is now online. It can be found at: www.mass.gov/masshealth/childbehavioralhealth

Once at that website, choose Information for Providers, and then click on CANS tools.

As you will see, there are two Massachusetts versions of the CANS – Birth through Four, and Five through Twenty. A CANS Glossary for Five through Twenty is also available (the CANS Glossary for Birth through Four will be available shortly).

We are currently working on posting a link to this Mass Health web site on the Partnership web site. Once this is completed, all staff will be notified. Providers will then be able to access the link directly from our web site. Thanks very much. Elizabeth

Elizabeth O'Brien, LICSW
Regional Director
MBHP, Central Mass
120 Front Street, Suite 315
Worcester, MA 01608
Office: 508-890-6406
Fax: 508-890-6410
Cell: 617-645-6219

Friday, September 5, 2008

Labor Day is Over: Time to Get Back to the Blog

I think that this is the longest gap in this blog since I started back in December;  a little vacation, a bunch of school physicals, abstract writing for the Pediatric Academic Societies meeting and close observation of the political conventions seem to have interfered with my muse.  Also, I have been reluctant to begin a close reading of the final product of Yolanda's bill-  I know that we got a lot done, but I fear that I will become obsessed with the things that we didn't get done.  So, in resuming my writings, I thought that I would start by revisiting an old topic:  mental health screening.
I have a bit of information on the results of screening 12-18 year old children in our practice in Webster.  We are having each kid fill out the Y-PSC, and asking the CRAFFT questions verbally at each annual physical examination.  (We're collecting information on 12-18 year olds as part of our DPH contract for care coordination)  Last month, I told you about the results for July (here).  Now, I have the data for the first 9 months of 2008.
We have 1211 adolescent patients currently in our practice (as best we can tell).  We've managed to get about 40% of them in for physicals this year so far.  Here is the data:
Well visits done: 489 unique teens
Y-PSCs done: 482 (98 %)
CRAFFT done: 474 (97 %)
The screenings missed were usually because of lack of time or inability to separate parent and child (I don't usually ask the CRAFFT with the parent in the room).

Positive Y-PSC: 49 (10 %)
All were either already in treatment or referred for evaluation.  Many of the referrals didn't happen, for a variety of reasons already mentioned in this blog.
Positive CRAFFT:  17 ( 4%)
Most denied that they had a problem and only 40 % accepted referral for further evaluation.

Oh, and we should point out that only about 15% of our adolescent patients are on MassHealth.
Our practice seems to have integrated screening into the routine without too much disruption.  Patients and families have accepted the screens for the most part without incident.    It seems to have increased our rate of referral a bit, and our teens don't like to be referred for the treatment of substance abuse issues.
Do others have similar information?  Are we typical?  Post your comments on the blog.

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