Sunday, November 30, 2008

Opening Day: Conference report.

I wasn’t sure that I would have much to report from the conference as a whole, and my wandering of the Havana streets from yesterday are documented in my “personal” blog, with some pictures. One of our speakers today, however, merits comment, and is somewhat relevant to the issues with which we are grappling in the quest for improved children’s mental health. So, I blog.
This conference is quite eclectic; people from 22 countries all focused on the theme of Health Equity, a concept which I both like and fine hard to “sell”. The opening was full of ceremony that reminded me of how hierarchical Communist nationalism can be: we stood for the playing of what I am guessing was the Cuban National Anthem, a vigorous melody with much Revolutionary zeal, and we greeted in Spanish by Dra. Ileana del Rosario Morales Suarez, Chair of the Scientific Commission that put the conference together, who spoke of the need for medical education based on the needs of the people. She then introduced the Honorary Conference Chair, the Vice-Minister of Public Health for Medical Education, Dr. Roberto Gonzalez, who put this in the context of the Cuban Health Care system, of which he was justifiably broad. My Spanish was good enough to follow these “in principle”, but not good enough to capture the flavor of what they said. Hers was more lyrical, his was more of a recitation of the accomplishments of the Revolution in medicine. I realized halfway through the Spanish portion of the program that simultaneous interpretation was available; tomorrow I will try to get an earpiece.
The final speaker was in English: Dr. Charles Boelan, a Flemish doctor from the WHO, who spoke of “Social Accountability: A Mark of Excellence for Health Profession Educational Institutions”. I really liked the way in which he framed the discussion of health equity in the context of the role of the medical school in civic society. Let me try to capture a few of the high points.
1) Medical schools are really good at creating doctors who are well grounded in the science and art of medicine. He spoke of medical schools in the Middle East and South Asia, who were proud (and justifiably so) at the academic achievements of their students. One marker used to measure success was the number of graduates who ended up in the US system, which he pointed out was draining the best minds out of a third world country that would benefit from their expertise. When offered praise on the quality of the medical education offered in their system, the Nepalese dean despaired of the schism between the folks in the medical school and the folks who needed help.
2) He then framed it as an issue of partnership, quoting Desmond Tutu “Successful partnerships are built on trust, shared values and a clearly articulate vision of outcomes”. He felt that, in medical schools, we are often not clear on when the “product” is meant to be (everyone knows it, so why should we articulate it?) and that we don’t spend time developing a shared vision with the key stakeholders in the process (health managers, health policy makers, health professionals and civic society)
3) He saw as having an obligation to two levels of service, an HUMANISTIC one that addressed the needs of our individual patients and a SYSTEMIC one,, in which medical schools needed o t see themselves as part of the social fabric.
4) He saw the challenges to this as intrinsic to medicine: we are not always engaged in the civic process, our systems tend to be closed and unwelcoming and the system is not engaged with us.

All of this left him with a concept of the socially accountable medical school, in which medical educators actively engage with civic society to create doctors to meet social needs. I do not do it justice, but it was quite engaging. How does this relate to our work in Children’s Mental Health?
For one, the Children’s Mental Health Initiative has begun the process of engaging the Social Services educational system in developing a better “product”, a clinician who can fully utilize this new system that we are building. We need to do similar things in Medical Education, training doctors to think of Mental Health as something other than a default diagnosis to be raised when physical disease has been excluded. The second is that we need to remain focused on the outcome that we want from the Rosie D case: Family Centered Collaborative Mental Health Care based on wraparound principles (not just improved access to psychotropic medications), and not get overwhelmed by the details of the process by which we will get there. Third, we need to see the Children’s Mental Health Campaign as central to the process of improving the quality of care in the Commonwealth, not as a vehicle to a specific legislative end, although, in order to keep the Campaign alive, we will need pay attention to the specific needs of our members and generate some ongoing legislative successes.

Anyway, I’m looking forward to Day 2 of the conference. We present on Day 3. More later.

Saturday, November 29, 2008

How Do You Separate Science and Pharma?

In his novel Arrowsmith, Sinclair Lewis' fallen hero, Professor Gottlieb has his groundbreaking work on bacteriophages sucked into the PR driven world of the pharmaceutical industry, breaking his spirit.  Recent revelations that many of our smartest researchers are profiting from their discoveries in ways that put children at risk (today's NY Times, "Expert or Shill?") shouldn't surprise us-  it is what happens when we allow profit to drive the system with little regard for clinical relevance.  The answer in the short term is more disclosure and more transparency (I can't make a move in medical education without filling out 10 disclosure affirmations, and I keep wondering why I have nothing to disclose), but the long term answer is to create an academic culture that is less dependent on the pharmaceutical industry for the funding of research.  In my ideal world, pharmaceutical research funding to academic institutions needs to go through the NIH, cannot have ANY input from the industry and the results of the work CANNOT be patented.  Without patents to protect, the system of pharmaceutical privilege collapses.  Then, we can get back to the "Prayer of the Scientist" articulated by Professor Gottleib (one of my favorite parts of the book):
'God give me unclouded eyes and freedom from haste. God give me a quiet and relentless anger against all pretence and all pretentious work and all work left slack and unfinished. God give me a restlessness whereby I may neither sleep nor accept praise till my observed results equal my calculated results or in pious glee I discover and assault my error. God give me strength not to trust to God!'
Science has become business;  we need to draw the line between them more firmly again.

Friday, November 28, 2008

Off to a Meeting: May Not Post Much This Week

One of my other lives is to be the Associate National Medical Director of the National Center for Medical Legal Partnership.  As such, I am currently on my way to present a talk at the International Medical Education Conference called  Medical Education for the 21st Century: Teaching for Health Equity in Havana.   Our presentation is titled:
Teaching through Medical-Legal Partnership (M-LP): Impacting the Social Determinants of Health
David Keller MD, Valerie Zolezzi-Wyndham JD, Pat Flanagan MD, Rebecca Kislak JD, Pamela Tames JD, Kathleen Conroy MD Family Advocates of Central Massachusetts, UMass Medical School and Legal Assistance Corporation of Central Massachusetts, Worcester MA, Medical-Legal Partnership for Children of Rhode Island, Hasbro Childrend’s Hospital and Rhode Island Legal Services, Providence, RI, and Medical-Legal Partnership/Boston, Boston University Medical Center, Boston MA.
Children’s medical centers throughout the US have developed collaborative relationships with legal assistance attorneys to advocate for children and families on issues related to housing, education, immigration, domestic violence, financial support and access to services; social issues which are likely to affect child health. Attorneys and physicians involved in M-LPs are often used to teach medical students, residents, allied health students, faculty and clinical staff about the social determinants of health. Models of training include: 1) Medical students at the Warren Alpert Medical School at Brown University and law students at Roger Williams University School of Law in Rhode Island can enroll in a joint course on Poverty, Health and Law. Topics covered include the relationship between childhood asthma and poor housing; lead paint issues; and the impact of domestic violence on all members of the family. 2) Medical students and nursing students at UMass Medical School in Worcester, MA participate in a two week Community Clerkship in which they shadow doctors and attorneys in a variety of clinical settings and participate in court proceeding involving families served by the M-LP. 3) Residents at Boston University Medical Center and Hasbro Children's Hospital work with attorneys within their primary care continuity practice, as members of the interdisciplinary team addressing the social determinants of health in low income families. 4) Individual students at all three programs have conducted independent research projects under interdisciplinary supervision, resulting in local, regional and national presentations and publication in a peer-reviewed journal. 5) Participation in M-LPs by clinical faculty has led to the integration of health equity into the clinical teaching paradigms of all three institutions. In a society with growing social and health disparities, teaching through M-LP enables medical faculty to address the social determinants of health while addressing the needs of low income families.

I admit that part of the appeal of submitting the abstract was a desire to travel to Cuba (I was there in 1995, as part of a group of pediatricians looking at the impact of the Blockade/Embargo on the health of children after the collapse of the Soviet Union, and though that is was a fascinating place).  It was a beautiful country, with amazingly smart doctors and a truly wonderful health care system built with no access to Western resources, and I have been curious to see how they are faring in the waning days of the Castros.  Arranging this travel has made me realize that this really is one of the last Iron Curtains;  it will have to fall sometime.  I suspect that when it does, we will see some really creative collaborations in the areas of medicine.  
From a mental health perspective, however, I am curious to here more of their approach to mental illness.  When we were there last time, we got the sense that their approach to child development and mental illness was very different than ours, based a lot more on family taking care of family and less on pharmaceuticals (although, given the Embargo, that may have been making a virtue out of necessity)  
I am not sure how much I will be able to learn;  under US Law,  I am allowed to travel to Cuba because of my participation in the conference, and I may not have a lot of free time.  Still, I expect to meet some Cubans and hear about their child health system.  I'll try to blog it from the Island;  but I may need to wait until my return to post.  So stay tuned.

PS Interesting piece in the Milford Daily News this weekend, on early diagnosis.  See what you think-  it is hard to explain this stuff in lay language.

Thursday, November 27, 2008

Budget Cuts in Real Time: What Does It Mean in Worcester County?

I've been collecting a bit more information from the folks in Worcester County about the impact of the Governor's 9C cuts and what they mean to people.  Community Healthlink was in the T&G on Nov 3.  Of course, that was the day before election day, so I am not sure if it was widely read.  According to the article (now archived from the website), CHL is closing 4 programs and reducing the scope of others:
SIZE OF CUT:  $637,000, or 3.4 percent of the $19 million received from the EOHHS.  But, since the year is already half done, and the cuts are permanent, this translates to the loss of  40 of the nearly 1,000 Community Healthlink jobs and the reduction of a  $48 million budget to $46 million. 
  • Gateway Resources. Begun as The Gathering Tree about 30 years ago, the day program at 162 Chandler St. provides rehabilitation for 50 people with serious mental illness.   It is funded with $291,000 a year and will close at the end of this month.
  • Nuevos Horizontes, a Spanish-speaking version of Gateways that is open three days a week. Its yearly funding is $134, 445.   Nuveos’ 20 clients also have mental illnesses,  whose coping skills are limited by language barriers.
  • Vocational training programs for people with serious mental illness. The programs, called SEE, are located in Worcester ($356,276 a year) and Leominster ($263,983 a year). The programs help people with serious mental illness find and maintain jobs.  The programs support 60 people in Worcester and 51 in Leominster. 
  • Outpatient substance abuse programs in the Thayer Building at 12 Queen St. The Department of Public Health will cut $45,000 of the $55,000 it has been providing, which is about 15 percent of the program’s total funding.
  • Westwinds Clubhouse, 545 Westminster Road, Fitchburg, cut by $18,000. The clubhouse will continue to operate, but possibly with fewer than the 50 to 60 hours over six days per week that it is now open. 
  • Outpatient Mental Health Services:  Reductions in MassHealth rates will affect revenue from CHL’s 15,000-patient outpatient mental health services, two-thirds of whose clients are MassHealth clients; CHL’s 45-bed detoxification facility, which serves 3,800 people a year in the Thayer Building; and a two-week community-based acute treatment program for children at CHL’s 15-bed Burncoat Family Center, 227 Burncoat St. 
That is a big hit to a bunch of programs that are in bad shape already.  Much bigger than you would think when you hear the words "3%" cut.  Not that the cuts weren't equally severe in other areas, but it is important to bear witness.

Wednesday, November 26, 2008

Freedom of the Post: My thoughts on Robbin's post

Robbin is always provocative, and has put her finger on  the key dilemma in setting up a systematic approach to the mental health problems of children.  In order to approach something systematically with a multi-disciplinary team, you must all the sharing of information.  In that process, parents and the team members must have a degree of trust.  AND YET (as she has said in some of her posts), there are cases in which children's mental health problems are, at least in part, caused by family problems- domestic violence, child abuse and neglect and parental incapacity.  So those same team members, if they stumble on those things, are mandated reporters.  It creates an inherent conflict.  So, does how can a parent opt in to a system for help that could result in DCF involvement?
The answer proposed is that, in the new system of ICC, PARENTS have the power to select who is on the team, and that, with Parent Partners and Intensive Care Coordinators, that will create a balance of power.  In theory.  That is how it has worked out in the current models of wraparound that we have had in Worcester and Lowell and other parts of the state.  How that will work out around the state remains to be seen.
Parents do have the opportunity to give DIRECT feedback to the Children's Behavioral Health Initiative through a series of Parent Forums, the dates and times of which can be found here.  They happen about once a month, and the next one in Lakeville at the Public Library at 6 PM.
For more information about the CANS and how it applies to families, please look at the feature article on the ROSE D. website here.
As far as the other 3 questions posed by Advocate Miller, I would suggest that they are a little over the top:
1)  Parental right to refuse services:  That is inherent in the program, but poses difficulties as noted above.  Refusing any services, medical, psychiatric or otherwise, puts providers in an awkward position, as mandated reporters.  My hope is that, through the process of wraparound, it wouldn't be as confrontational as all that.
2)  Reported for declined services:  I have yet to be successful in reporting a parent for declining services, whether for immunizations or encopresis.  DCF won't accept the reports.  They will accept reports for "evidence of substantial harm", but that would be more than just declining services.  I really doubt that most providers would feel obliged to report a parental disagreement to DCF.
3)  Determination of SED status:  It is not clear to me yet that we entirely know what will qualify for SED services and what won't.  Hard to train people when you are still figuring it out.

Again, parents SHOULD educate themselves.  Follow the links, go to the talk back sessions, and give your input into the process.  This really is a work in progress.

Tuesday, November 25, 2008

Guest Spot: Parents Feedback on the CANS process

I am wondering if parents who read this blog can provide feedback on what their feelings are regarding the CANS (Children Adolescent Needs and Strength) assessment tool that will be administered starting on December 1st. Here are some questions and points of information to be aware of:

1) How do parents feel that certain information about their child/teen will be still transmitted to the virtual gateway for viewing by the Departments of Public and Mental Health and Mass Health after they decline to have the CANS assessment administered in a mental health agency?

2) Do parents have the right to decline intensive services if their child's SED (Serious Emotional Disturbance) score makes him/her eligible to receive this service?

3) Will parents be reported to the Department of Children and Families if they decline services for the above mentioned?

4) Clinicians were trained to pass the CANS test to be certified only. They were not trained to interpret a SED score. It is quite mind boggling that some clinicians trained and certified to administer the CANS do not even know what the CANS's purpose is.

What can you do? Do your homework on what the CANS assessment tool is and ask questions on why and how the scores from this tool will be useful, and who will be reviewing this information.

Robbin Miller
Advocate/Private Practitioner

Sunday, November 23, 2008

MassHealth (and the CBHI) want you. Again.

I am impressed at the effort being made by the MassHealth to solicit input as these new systems of care go into place.  Got this on my e-mail last week:

Request for Information (RFI) Issued
The Executive Office of Health and Human Services has issued a Request for Information (RFI) to solicit information from training organizations, providers of mental health care services, community stakeholders and other interested parties that will inform the drafting of a Request for Responses to procure training contracts for Intensive Care Coordination (ICC) and In-Home Therapy. We invite you to reply to any or all questions. Succinct commentary is appreciated. The RFI is available on Comm-pass, the Commonwealth’s procurement access and solicitation site (document # 9LCEHSICCIHT-RFI) and is also located above as an e-mail attachment. 
Unfortunately, I can't give you a link to the RFI;  you must go to COM-PASS and log in to get it.  And 10 pages is not much space for responses.  Still, it is something.  I hope that you all take advantage of the opportunity.  Oh, and if you can't get to COM-PASS, drop me an e-mail and I'll send you a copy. 

Saturday, November 22, 2008

A Poll from PAL

PAL Wants to Hear From You! 

There has been a lot of interest lately in what parents consider to be priorities for their children with emotional, behavioral and mental health needs.  While each family's story or experience is important, it's also important to get the data and numbers.  PAL has designed and posted a short, 16 question survey.  
Click Here to Take the Survey.
 (Or You can copy and paste the link below.
Please forward this to as many interested people as you can!
We will keep the survey open until December 3. 
Thanks in advance!
Lisa Lambert, Executive Director
Parent/Professional Advocacy League
The Massachusetts Family Voice for Children's Mental Health
45 Bromfield Street, 10th Floor
Boston, MA 02108
617.542.7860 x203

Friday, November 21, 2008

Post for the Road: Happy Thanksgiving, Y'all

Next week, I am going to be on the Left coast with my wife's family for Thanksgiving (been a while and all of that), so the posts may be a bit sparse, although I will try to keep abreast of the changes in Massachusetts.  It is an interesting time:  the Mental Health Campaign is doing some real policy development work, the CANS is about to take center stage in the Virtual Gateway and the 9C cuts are hitting the Commonwealth, making it harder to get the work done.  I got this the other day, and leave with this thought from the Mental Health and Substance Abuse Coalition of Massachusetts the other day:

Re: Contact Governor Patrick about Cuts to Behavioral Health Services
As you know, MHSACM has been working with our various coalition partners to ensure that our community responds to the FY 2009 9C budget cuts with one voice. If you have not done so already, please contact Governor Patrick and urge him to restore the cuts to DMH-funded community-based services.

On the other hand, the Children's Behavioral Health Initiative hosted a summit the other day, with the faculty of the various schools of social work and psychology, to help develop the curricula needed to teach "wraparound"  and some of the other concepts unique to the impending settlement.  Sure, cuts are hard, but it seems so obvious to me that the folks within the Patrick Administration are trying so hard to do the right thing that I really don't want to call them up and give them a hard time.

It seems a good time to gather with family, give thanks for the turkey in whatever way you deem appropriate, and prepare yourself for the work yet to come.  We've done a lot, but there is much more left to do.

PS.  Many of us in the Pediatric world have been arguing that the behavioral health screening for young children should be dropped.  Nice to see this on the CBHI website:
Behavioral health screening in the primary care setting for children less than 6 months of age.  In response to continuing concerns raised by the primary care provider community about the suitability of behavioral health screening for children less than 6 months of age, MassHealth asked the Massachusetts Chapter of the American Academy of Pediatrics (MCAAP) to provide an assessment of the screening periodicity schedule. MCAAP recently offered its recommendations, which MassHealth is currently reviewing.
One hopes that my Academy recommended that the screening focus on maternal depression rather than childhood depression.  We shall see.

Thursday, November 20, 2008

Upcoming DataSpeak on Health Behaviors of School-Age Children (HBSC)

This looked interesting.  I can't attend, but I thought that others might wish to do so.

The MCH Information Resource Center, funded by the Maternal and Child Health Bureau at the Health Resources and Services Administration (HRSA), is pleased to announce the next program in the DataSpeak Series:  "New Findings on Health Behaviors of School-Age Children (HBSC)." Dr.Ronald Iannotti and Dr. Bruce Simons-Morton from the National Institute of Child Health and Human Development will present new international findings from the 2005/2006 HBSC survey. They will highlight findings onU.S. school-age children's behaviors related to obesity and physical activity, bullying, and substance use, comparing their prevalence in this country to that in other nations. They will also discuss international differences in health policies related to these behaviors.

This program will take place on 
Wednesday, December 3, 2008, 
at 2:00 p.m., EST (1pm Central, 12noon Mountain, 11am Pacific).

For full program details, please visit the MCHIRC Web site
To register for this event, please go to DataSpeak registration
When you register, you will receive the details on how to participate in the Web conference.

Wednesday, November 19, 2008


Beginning November 30, 2008, MassHealth and the MassHealth Managed Care Entities (MCEs) will require a uniform behavioral health assessment process for members under the age of 21 that includes a comprehensive needs assessment using the Child and Adolescent Needs and Strengths (CANS) tool.

The Executive Office of Health and Human Services (EOHHS) invites behavioral health providers and other interested parties to join a statewide conference call on the Massachusetts CANS tool on Friday, November 21, 2008, from 12:00 p.m. to 1:00 p.m. Registration is not necessary. Conference seats are limited.

During this conference call, Jack Simons, Assistant Director of the Children's Behavioral Health Initiative, Carol Gyurina, Director of Analyst and Contracting, MassHealth Behavioral Health, and other Commonwealth staff will provide key information about the CANS tool, including steps clinicians must take to complete CANS training and certification and activities provider organizations must undertake in order to enroll in the Virtual Gateway. New and clarifying information regarding CANS requirements and release of the IT application on the Virtual Gateway will also be provided. Questions will be taken during this call.
CBHI CANS Conference Call Information

Date: November 21, 2008
Time: 12:00 p.m. - 1:00 p.m.
Phone: 866-565-6580
Passcode: 9593452 (then press #)

EOHHS welcomes continued input from all stakeholders and interested parties on the Children's Behavioral Health Initiative (CBHI). Individuals and organizations unable to participate in this teleconference are encouraged to e-mail questions and comments to:

Tuesday, November 18, 2008

The Children's Mental Health Campaign: Moving Forward in a Time of Scarcity

The Children's Mental Health Coalition met today.  As usually, I learned a few things:
  1. 9C Cuts.  The conversation opened with discussion of the impact of 9C cuts on the governor's budget.    As reported here the line item that supported the expansion of MCPAP was cut.  Early Childhood Mental Health lines were not cut, which seems a good idea, given the "return on investment" from early intervention.  Several people spoke of the cuts to the Collaborative Assessment Program, a DCF/DMH(?) program,  has sustained major cuts, resulting in some loss of personnel.  This was seen as a "bridge program" for the Rosie D. population, which has been seen as one of the major bridge items.  In addition to this, there were cuts in the DMH line that supported mental health services in the schools, a large cut from the "circuit breaker" (funding to match local funding for out of district placements for kids in special education funding, many of whom have mental illness problems.) And over all, funding for providers was cut throughout the system.  There are stressors to the care of children, but are really hard to follow and to figure out exactly how things filter through the system. So,  the Children's Mental Health Campaign is working on a rubric  to track the impact of these 9C cuts on the formation of policy and or tracking the way in which the state budget can be restructured to better achieve our goals while not spending a lot more money.
  2. Chapter 321 Implementation:  The good news is that implementing many of pieces of the new law will not cost much money, and we can still plan to make progress in tight economic times.   How do you look at the entirety of Chapter 321, and find the places where we can make a difference?  Watch carefully.  To watch carefully, we are going to watch topic areas and deadlines, to be sure that what happens is what is supposed to happen.  Within the Campaign, three or five working groups seem to be forming, around these issues.
  • Schools:  There are two parts of this task.  The Task Force on Behavioral Health on the Public Schools is supposed to be established and convened by 12/31/08, so this is where the work starts.  Some of the issues already identified:  How will the entitlements of Rosie D. and Special Ed mesh/clash/synergize in the context of Chapter 321?  Will there be separate team meetings or can they be integrated?  How will confidentiality be handled?  How will you build trust with parents?  Big questions;  this working group will have lots of work to do, to help to inform the discussion of this Task Force.  Early Education will be another focus of the group;  the group will work with the DEEC to make sure that the Early Childhood report (due 2/15/09) is equally substantive.  They will have a lot of input for that process, based on the pioneering work done in Worcester over the last few years.
  • Behavioral Health Advisory Council and Research Council:  There is many parts about this work that we don't understand, this is a really important one for us to pay attention to- the Advisory Council and Research Center have reporting deadlines, but no direct funding, so that the work is going to involve ways to maximize the use of "private" resources to accomplish these goals.  There are reports due on 10/1/09 and 2/1/09 on the Advisory Council and the Research Council.    Lots of work to do.
  • Private Markets:  HLA and the Boston Bar Association have taken the lead on this, but one of the first tasks of this Working Group will be to introduce the legislation needed to get the "Payment for Collaterals" part of the original legislation.  They will also be reaching out to the provider community and the community at large to see how this looks in practice.
Want to join a Working Group?  Contact Matt Noyes, and he will direct you to the appropriate Working Group chair.  The Campaign was successful last year, but we still have a lot of work to do.  It will just be a different kind of work.  Last year, the Campaign was all about legislation;  this year, the focus will be on implementing.  We will of course be paying attention to the 9C cuts, and we will be finishing the collateral contact legislation.  Implementing last year's success will take up lots of time.  

As Barack learned on Nov 4, this is what winning feels like.  We have a lot of work to do.

Sunday, November 16, 2008

Culture in the New World of CSAs.

The stories are endless:
- A grandmother can no longer cope with her grandchild’s impulsive and uncontrollable behavior; she moved from Puerto Rico to Massachusetts, seeking help from her extended family. How can we find a Spanish-speaking psychiatrist to decide if he needs the medications prescribed him before moving here?
- A family of recent immigrants from Eastern Europe, needs help with their child’s severe toileting issues, but the concepts of “encopresis” and “behavioral therapy” don’t translate well into their native language. How can we find common ground on which to discuss this problem?
- A naturalized family of South Asian origin, loses a child to cancer. How can we help to parents, whose English fails them when they try to discuss their loss?

We practice pediatrics and provide mental health services in Worcester County,
where an increasingly diverse population arrives at our doors, expecting treatment that is “accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective”. New initiatives, such as the Commonwealth’s Child Behavioral Health Initiative should help us do a better job. Screening will allow families and pediatricians to begin a conversation about the complex behavioral and mental health issues that affect and increasingly large number of our children. For families like those described above, however, the conversation can be somewhat one-sided.
The good news is that the language of the Community Service Agency (CSA) RFP really requires the agencies to ponder the extent to which they are are able to handle families with linguistic and cultural barriers to care.  The RFP, for example, calls on the agency to provide "Services are relevant to the culture, values, beliefs, and norms of the family and their community."  It also sets as one its strategic priorities to "Strengthen, Expand and Diversify Workforce", which has been identified by most in the field as one of the major challenges in doing this work.  20% of the points awards in the contract evaluation are for "Cultural and Linguistic Capacity and Responsiveness to Underserved Populations", which involves looking at both the client interface and the organization's commitment to cultural competence and institutional development of a diverse workforce.  Many of the leaders of the agencies in Worcester County have found this to be a useful to in identifying the strengths and weaknesses in their own organizations.  Certainly, the CBHI is to be commended for putting cultural and diversity in the center of the initiative.
That said, it is not clear where the workforce is supposed to come from.  We need therapists who speak various languages, and who understand how behaviors fit into the cultural mileau at home and in other venues.  We need to hear how families from diverse background understand what we in the "Western World" call mental illness.  
As with so many things we have a lot of work to do.

Thursday, November 13, 2008

Upcoming Children's Mental Health Campaign

Please join us for the next Children's Mental Health Campaign Supporters' Meeting on Tuesday, November 18 from 9:30-11 AM in the 9th floor conference room at 30 Winter Street.
In the two years of the Campaign, we have accomplished a great deal.  We have established a formidable coalition of advocates, families, and policy makers.  The passage and enactment of Chapter 321 in August is a testament to everyone's hard work and dedication.
With the passage of An Act Relative To Children's Mental Health, the Campaign enters a new phase - implementation of Chapter 321.  At the meeting on the 18th, we will discuss a work plan to monitor implementation including opportunities for greater campaign involvement. 
In addition, we will discuss last month's 9c cuts and potential CMHC responses, as well as legislation to file during the upcoming session.

Wednesday, November 12, 2008

Bearing Witness: What do the Budget Cuts Look Like on the Ground

Last month, Governor Patrick announce the first round of budget cuts to the State budget, in response to the fall in revenues thought the Commonwealth.  You heard in an earlier post that the fees to mental providers were rolled back.  Turns out that the cuts are starting to be felt throughout the Commonwealth.  The cuts are probably as fair as is possible, but the axe is starting to fall on some important strands of the community safety net for folks with mental health problems.  At our Steering Committee meeting yesterday, I heard some stories, so I sent out an e-mail to our larger group to see what was up.
Minutes will be forthcoming, but, at the Steering Committee meeting yesterday, we decided that one of the ways in which we could be useful would be to collect information about reductions in service or losses in service due to the current rollback in state funding, as a way of bearing witness, and knowing what needs to be restored when the hard times are over.

Please send me items that I can integrate into a blog entry, that can be updated on regular basis. What has your agency had to cut? What have you lost as a service recipient? What have you heard about cuts in the community?

David Keller MD
Clinical Associate Professor of Pediatrics,
UMass Medical School
Physician Advocacy Fellow,
Center on Medicine as a Profession, Columbia University
Check out “Rosie D. and Me”

New E-mail address:
So far, I have heard about a few concrete examples:
Currently LUK is having to shut down our community based CEDAR group
home, which
we have run for over 20 years. This represents 6 DMH funded
slots, and 3 DSS slots for youth with behavioral health issues. We were
devastated, many of us put blood, sweat and tears into that program. We
have had limited referrals to some support and stablization services
through DCF and DMH, and others put on hold. DCF is only making emergency
referrals at this point. Cases are not being extended except in dire
circumstances. As a result, case loads are shrinking, and you know what
that could mean. We fear that we will not have DMR funding for our
adventure-based vacation bridge programs for kids with ASD. For some
families it was the only service they recieved. We will keep folks posted.
I also heard about some cuts to the CAP program- I am waiting for some of the details, and I will add them to the post.  We may have to cut some things, but we need to aware that these cuts are not "pork" or "fat".  They represent real losses to real people, and we have to figure out we are going to fill the gap created.

Friday, November 7, 2008

Change amidst the Ruins: The Economy Meets Rosie D.

As we have dreamed of building a new system for children's mental health care, we have heard over and over that, without mental health providers who are adequately reimbursed, we can do little.  With the budget being cut at the state level, it was only a matter of time before reimbursement was affected on the ground.  This came from MBHP the other day:
Alert #47:  This Alert is to inform providers within the MBHP network that, as of December 5, 2008 provider rates will revert back to those in place as of July 31, 2008.

In response to the current economic crisis affecting the Commonwealth, on October 15, 2008, Governor Deval Patrick announced a plan that will reduce spending within state government during the remainder of FY 2009. As part of this plan, MassHealth has established a savings target that will necessitate that MBHP’s earnings and administrative resources be cut and that total medical expenditures also are reduced.

Since the announcement of the budget cuts by Governor Patrick, MBHP has met with, and solicited input and ideas from, many stakeholders, including consumers, families, advocates, and providers, in an effort to devise a spending reduction plan that will minimize the negative impact on MBHP Members, the Commonwealth’s behavioral health delivery system, and the providers of services.

As part of the specific budget cuts, MBHP will roll back provider rates, effective December 5, 2008 to those levels that were in place as of July 31, 2008. To clarify, providers will be reimbursed at the current rates as announced in Alert #40, inclusive of dates of service from August 1, 2008 through December 4, 2008. Effective with dates of service thereafter, all providers will receive the rates that they were receiving as of July 31, 2008.
So, how can we talk of CSAs and better services in this era of shrinking resources?  MBHP and the other providers are doing what it can to preserve the provider network, but mental health reform is clearly getting tangled up very quickly in the morass of economic decay.  

Tuesday, November 4, 2008

CHADIS is cool, but not compatible with our EMR

A few weeks ago, an old teacher of mine from Maryland invited me to look at their system for integrating behavioral health into a primary care setting.  (I posted the invitation  here).  So I went to check it out a few weeks ago, and I have been slow to post my comments.  In part, that was because I wasn't completely blown away.  The system is a bit too text based for the visual learner in me, and I thought that the screening questionnaires were too wordy and that parents wouldn't like them.  Their data would suggest otherwise- they put a lot of work into this thing, and it has LOTS of potential as a source of information for our families.

The real problem, though, is that it would be one more system.  In our hospital's computers, we book appointments on IDX, we check labs on MEDITECH, we look at X-rays on IMAGECAST, we sign records on WEBESA, and our e-mail is on EXCHANGE.  Last spring, we added TOUCHSCAN as the source of our electronic medical record and soon we will be typing our noted directly into the system.  And MassHealth wants us to be passed our mental health information through the VIRTUAL GATEWAY.  Each of these systems has a login and a password.  Our computers don't allow them to easily transfer information between themselves and we are spending more and more time looking at the screen.  Can this be the way to better care for children with mental health problems?

CHADIS is a good system, developed by good people who are more interested in children's mental health than most.  But I cannot recommend to anyone that they add one more system into their lives at the present time.  Someone needs to start some serious work at integrating all of there things, so that we can return our focus to the child and the family, where it belongs.

Monday, November 3, 2008

Report from the Field: It is Getting Any Easier?

So, here we are, 10 months into "universal" screening for behavioral health problems, on the cusp of implementing a new and uniform system for evaluation of children who screen positive for mental health services, and a mere 8 months from the promised land of coordinated care, wraparound services and family-centered care.  How does it look from the front-line of the primary care practice?  This week, I came back from vacation to a fairly heavy clinical schedule, and this afforded me, in the dark of the night on Thursday, the opportunity (but not the time) to reflect on that.  Keep in mind that, on top of the screening tests, my practice has recently gone over to an electronic medical record system that I find makes my days in the office quite long (adds about 5% additional time to each encounter, as best we can tell)
Day 1:  It is "winter" now in the office:  many children with colds, coughs, pneumonias, asthma- acute illnesses that we don't see in the spring and summer.  In the summer, about 50% of my patients are scheduled for Well Visits (about 10-14 screens/day);  in the winter, I will typically have about 30% for Well Visits (6-9 screens/day).  On the other hand, it is now two months into the school year, and families are starting to hear about school problems- behavior problems, multiple absences, discipline issues.  A lot of these get raised as what we call "doorknob questions"- a child is brought in for a cough, and, after addressing the cough, and as we are reaching for the doorknob, the parent will say, "By the way, the school asked me to ask you about Joe's attention span."  Also, a lot of my patients on medication for ADHD are coming in for their first quarterly "medication check", another time when concerns are frequently raised.  All of this means that Mental Health issues often present at times when we don't expect them; it is their irregularity that make them tricky.
Monday:  My Well Visits went well;  screens were all negative, and those kids were relatively healthy.  My ADHD rechecks generated a few questions, but none that required a query to MCPAP.   My most complicated questions were from football players- I saw several boys who had suffered concussions or other injuries during play, and who were interesting in returning to play (and whose mother's were interested in their safety).  This involves a bit of psychology, but anxiety is largely parental, and the challenge is adhering to the guidelines that tell us to keep the young men out of play for a while.  I was starting to wonder if Mental Health had magically vanished from my practice.  Turns out that that was not the case.  Left the office at 7 PM- not a bad day.
Tuesday:  Tuesday was a busier day, with a few more kids with overt mental health problems and some with unexplained abdominal pains and headache that may represent mental health problems.  Only 5 physicals, and 5 screens done, none positive.  My challenges came in the physical realm-  a child with pneumonia, some more football injuries and some folks with fevers of questionable origin.  My patients with mental health issues had established diagnoses, and were stable on their medications.  I was a little late out of the office (7:15 AM), but I was starting to think that this was getting easier.
Thursday:  On Thursday, I got to remember why this is still so hard.  I opened with a school age child with some learning issues who may also have ADHD; we've diagnosed him as such, and started treating him with medications a few weeks ago.  It is working, but his family is worried a bit. Are we over-diagnosing him?  Does he need the medication?  Will it help or harm him?  Lots of questions and I hope that I answered them all.  Then I saw brothers, teenagers, one of whom is having a rough time of adolescence.  His PSC was positive, and he clearly identified the things that were bothering him.  I thought that he would be a great candidate for cognitive-behavioral therapy, so I strongly urged him and his parent to get into some therapy.  Will they go?  Did they believe me?  Will he get therapy?  I hope so, and I hope it helps.  But now I am 40 minutes behind schedule (this stuff takes time).  More children with illness, more with mental health issues.  I made it to lunch, only 30 minutes behind and no time for phone calls.  Then the afternoon began, with a young man with bipolar disorder and a series of  complex decisions with which his family is struggling.  Medications, psychiatrists, schools- all hard calls for a school-aged child with  bipolar disorder.  And how sure are we about that diagnosis, if we are not sure what is happening with a child with ADHD?  If my morning conversation made me uncertain, this conversation made me realize in what difficult waters we are treading.  It was a productive visit.   I gave advice, we established some systems for communication and we continued that long walk that begins when you realize that your child is developing down a different path.  And now I am 40 minutes behind.  The day continued- more physicals, but no more positive screens.  More physical illnesses of various kinds.  Many phone calls.  I was 45 minutes behind schedule by the end of the day.  I finished the calls late, and went home to a really late dinner.
Is it getting easier?  Well, the screenings were smooth, but we identified several families today that really needed my help, answering questions, coordinating care, writing prescriptions.  It didn't fit into the day-  our appointments and the frenetic pace of our days really don't make primary care the optimal environment for mental health work.  And yet, I have a relationship with these families, and that relationship is important for them that are undertaking this most important work.  At least, this time, they all had psychiatrists, they had evaluations, they were being treated.  I don't know that it is easier, but it is starting to seem possible.

Everyone go vote, now.  We have much work that needs to be done.

Sunday, November 2, 2008

More Opportunities to Get Better at This Mental Health Stuff

I am actually working on something in my own voice, but the meantime, I will keep posting other people's stuff.  Here's an opportunity to improve your communication skills and get paid for it from Liz Rider MSW, MD, an excellent teacher at Harvard.  Beside, I am a sucker for impressionist paintings (anyone identify the artist?)

We are pleased to invite your participation in a skills training program and study, "Emotional and Psychosocial Issues in Children and Families: Pediatrics for the New Millennium," that evidence shows will enhance your ability to evaluate and manage emotional and psychosocial problems commonly seen in pediatric practice with children, adolescents and their families.

Program benefits:
  • Enhance your skills with pediatric patients and their families 
  • Learn the art of the mental health referral and develop resource materials 
  • An opportunity to interact and to discuss difficult cases with colleagues 
  • A stipend of $1400.00 to those who complete the program 
  • 35.5 CME credits (AMA Category 1, including 5.5 risk management credits) applied for 
  • Monthly dinner and seminar

Faculty: Elizabeth A. Rider, MSW, MD, FAAP; Howard S. King, MD, MPH, FAAP; Julia Swartz, MSW, LICSW, CEIS; David Robinson, EdD

Deadline for applications is November 15, 2008. The course starts January 28, 2009.

For more information and to apply online, click here 
To see the announcement, click here
If you have questions, please contact Howard King, MD, MPH

*I think it is Mary Cassatt's work, isn't it?

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