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.

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