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.

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