Tuesday, March 31, 2009

Churning in the Hinterlands: As the CSAs Roll Out, Existing Programs Roll In

South Worcester County is trying to get organized in advance of July 1. Others probably are as well.
Good afternoon,
It has been quite some time since our Advisory Council has come together, and there have been many changes over the past several months. In the climate of the Children’s Behavioral Health Initiative, it has become necessary for Central MA Communities of Care to examine all of our options for the remaining two years of our federal grant. We are committed to serving Southern Worcester County, although we acknowledge that our programming will be evolving and we are hoping to be developing new opportunities and partnerships in this area.

In May we are planning a regional, comprehensive strategic planning session to develop a workplan for the next two years. In order to ensure that the voices of the South Family Center, including our youth, families, and stakeholders, are well represented in this process, we would like to have a pre-planning meeting to hear from you. Please join us this Thursday, April 2nd from 3:30 to 5:00. Our Project Director, Suzanne Hannigan, will also be joining us. We will be looking at our projected budget, as well as asking our community what your vision is for our program.

I realize that some of you have not been able to be ongoing members of our Advisory Board, but I hope you will join us for this very important event.

Nicole A. Walker, LICSW
Youth and Family Center Director
Central MA Communities of Care
508-856-5760 (Webster)

Monday, March 30, 2009

Together for Kids: A National Model in our Backyard

I saw patients today, ranging from adolescents with depression and substance abuse problems to a baby with fever and an ear infection.  Busy day, with little time to reflect.  Then I saw think on an e-mail that went by.
Carole Upshur, Melodie Wenz Gross and George Reed published an article about the Together for Kids pilot work in Worcester that provides mental health consultation to child care programs. This work led to Carole’s current NIMH-funded study on primary prevention of behavior problems. The article, A pilot study of early childhood mental health consultation for children with behavioral problems in preschool, appears in the Early Childhood Research Quarterly. 2009, 24:29-45. This work was funded by the Health Foundation of Central Massachusetts, the United Way, and the Fred Harris Daniels Foundation.
This seems to me to be a practical and cost-effective approach to this problem, and worth replicating across the state.  Nice work.
Also heard about this:
You are cordially invited to participate with the U.S. Department of Health and Human Services as it presents an interactive Webcast:
Affordable Health Care for Kids: Moving Forward without Delay
Friday, April 3, 2009 - 2pm - 3pm ET

Share your experiences and ideas about how we can help millions of uninsured children get the health coverage they need...without delay.

Special Guests:
Rima Cohen, Counselor to the Secretary for Health Policy, Department of Health and Human Services (HHS)
Mary Wakefield, PhD, RN Administrator, Health Resources and Services Administration (HRSA)
Jackie Garner, Acting Director, Center for Medicaid and State Operations, Centers for Medicare & Medicaid Services (CMS)

Connect online at http://www.hhs.gov/childrenshealthinsurance

Questions and comments for the panel will be accepted in advance of and during the Webcast. To submit a question or comment, go to http://www.hhs.gov/childrenshealthinsurance/questions

Friday, March 27, 2009

Still in Cleveland: Social Determinants of Health (and the Behavior of the Harvard Faculty)

Last night, the Medical Advisory Board of the National Center for Medical-Legal Partnership
has a very nice dinner,  and today we opened with a tremendous talk by Rob Kahn on the intersection of social determinants of health and genomics.  Rob pointed to our haste of the medical profession to accept genetic determinism is a social, not a scientific phenomenon.  A couple thoughts:
Interesting quote:  “Few tragedies can be more extensive than the stunting of life, few injustices deeper than the denial of an opportunity to strive or even to hope, by a limit imposed from without, but falsely identified as lying within.”- Steven Jay Gould
Rob looked at the relationship of "hardships" and recurrent admissions for asthma.  Turns out that the folks with more hardship (money troubles, housing problems, lack of food) had more admissions, setting up the next question:  if we reduce hardship, can we improve health and create more wellness.  (Of course, there is another SJG quote that may relevant :  “The invalid assumption that correlation implies cause is probably among the two or three most serious and common errors of human reasoning”)  

Another thought:  applying QI methodologies to the medical-legal partnership makes a certain amount of sense, and Rob showed us how to make that happen.  Their electronic medical record has made it possible to look at individual performance in their site-  they are using the EMR to track the referral process.  EMR makes much of this stuff possible;  he presented some very exciting process data that shows how to monitor the process.

Ultimately, however this comes down to the need to find a common metric for the measurement of well-being.  He liked Sen, the Nobel-Prize winning economist and author of Development as Freedom, who defines well-being as living a life of genuine choice.
"Political rights, including freedom of expression and discussion, are not only pivotal in inducing social responses to economic needs, they are also central to the conceptualization of economic needs themselves."

Interesting guy.

Really interesting talk.  Rob did mention mental health, but only in the context of a consultative service that often provides us with little feedback.
Just to get back to Children's Mental Health, the New York Times has an article about Joseph Beiderman and his work with Johnson and Johnson in the past.  The article shows why you should never use irony in talking  to lawyers:
In a contentious Feb. 26 deposition between Dr. Biederman and lawyers for the states, he was asked what rank he held at Harvard. 
“Full professor,” he answered.
“What’s after that?” asked a lawyer, Fletch Trammell.
“God,” Dr. Biederman responded.
Did you say God?” Mr. Trammell asked. “Yeah,” Dr. Biederman said.
He continues to do our profession no favors.  I really wish that we could get beyond this discussion, but it seems that it will be with us for quite some time.

Thursday, March 26, 2009

Another Meeting: Cleveland and Medical-Legal Partnerships

As regular readers of this blog know (and we are setting a record for number of hits this month, so there seem to be more of them every month),  I have been working with public interest attorneys for the last few years, initially in a medical-legal partnership in Worcester called Family Advocates of Central Massachusetts and subsequently on the Children's Mental Health Campaign with Health Law Advocates of Boston.   Each year, there is a meeting of Medical-Legal Partnerships (this year in Cleveland) and this year, I am there.  The conference is all about advocacy; I am hoping to pick up some pointers that will help us in our advocacy efforts.  As goes along, I may pass along some of these tidbits for your perusal.  System change is hard:  we need all of the help we can get.
First speaker, Connie Schultz was brilliant.  She told stories, exhorting us to keep doing the good work with grace and a sense of humor.  She spoke of her experiences in shining light on injustice, and the power of a well written op-ed, reminding me that we need to write another one of those on children's mental health as the state is rolling out the Rosie D. initiative.
Then we got the report from the National Center (Megan Sandel, Ellen Lawton, Barry Zuckerman), from our national medical and legal leadership:  Medical-Legal Partnerships are everywhere:  81 around the country, working in 180 different kinds of health centers and practices in 37 cases.  The National Center has recognized that this practice model needs to include adults as well as children.  37 Law schools and 23 Medical schools have incorporated the partnership into some aspect of their training program.  The point was illustrated with cartoons-  worth looking at here without breaking the copyright laws. They closed by pointing out that we need to move the program into the sub-specialty programs to integrate Partnership into the medical system, and that the legal community should embrace the notion of preventive law.  Lots of potential for growth.
We then moved onto workshops:  more later.
First workshop was on "Environmental Health":  collaborations with Law Schools and Medical School to help families keep the heat on.  The students, of course, are amazed at how "real people" live, and find this a really interesting model of care.  Of note was a chance to meet Elizabeth Tobin Tyler, who wrote a marvelous account about of her experience in teaching law students and medical students together.
Then, we heard about "program advocacy"- how the medical "champion" can support the development of the program within the Medical Center.  Lots of ideas, all dependent on having passion and connection in equal measure.
Now we get eat lunch.
After lunch, I forgot that I was doing 2 workshops-  they went reasonably well, I suppose, but it is always hard to tell when you are the presenter.  We spoke of the trials of doing a multisite program, and the perils of evaluation.  Clearly the expertise in the room was tremendous.

I think that is all for today-  it is interesting that, among all of the services and needs of children in poverty that were mentioned today, mental health was not on the list.  I think that mental health is affected by social constraints, but I think that, when you are down and out, it does not rise to the top of your list.

Wednesday, March 25, 2009

From the CBHI: Need trainers for the ICC and stuff

Deadline Extension for Request for Responses (RFR) for Training, Coaching, and Ongoing Learning Support for Intensive Care Coordination and Caregiver Peer-to-Peer Services for the Children’s Behavioral Health Initiative (CBHI)


To: Interested Parties
Re: Training RFR Deadline Extension
This is to notify you that the Executive Office of Health and Human Services, Office of Medicaid (MassHealth), has extended the deadline for the Request for Responses (RFR) for Training, Coaching and On-going Learning Support for Intensive Care Coordination and Caregiver Peer-to-Peer Support Services for the Children’s Behavioral Health Initiative. 
The decision to lengthen the deadline for this RFR was made to allow bidders additional time to develop their submissions.  Key dates for this solicitation have been amended as follows:
Original Schedule Amended Schedule
FR Issued
3/11/2009 3/11/2009
Questions Due 3/18/2009 4/1/2009
Letters of Intent Due 3/25/2009 4/8/2009
Bids Close 4/8/2009 4/23/2009
Award Date 5/4/2009 5/18/2009
Contract Start 5/26/2009 6/8/2009
The RFR can be found at the
Commonwealth’s procurement website by browsing open solicitations from the Executive Office of Health and Human Services, searching by the solicitation number (9LCHHSTRAININGCBHIRFR), or by searching keyword “CBHI”.
Thank you for your continued interest in the Children’s Behavioral Health Initiative.

Children’s Behavioral Health Initiative

email us:cbhi@state.ma.us

Tuesday, March 24, 2009

Early Child Mental Health

Must be Spring;  much stuff is blooming around here.  From the American Academy of Pediatrics:

Partnering to Address Mental Health Concerns in Early Education and Child Care
The Recording is now available!
Thank you to those of you who participated in the American Academy of Pediatric's Webinar: Partnering to Address Mental Health Concerns in Early Education and Child Care. We would appreciate receiving your feedback by completing the survey:
If you were unable to attend the event, the recording has been posted, along with the PowerPoint and a complete resource list. We hope you find these helpful!
If you have any questions, please contact Renee Jarrett or Aldina Hovde.

 I am very sorry to have missed the first meeting of the Children's Behavioral Health Advisory Council on Monday morning (this is the oversight body created by Chapter 321, and will be a driving force in the coming system change);  I was seeing patients (which is also a good thing).  I haven't spotted anything in the news about the meeting- if someone was there, let me know how it went!

Monday, March 23, 2009

Academic Pediatrics and Children's Mental Health

 I couldn't be happier to see the this month's issue of Academic Pediatrics hit the 'stands' this week, with two important contributions to the literature on children's mental health. First, Guevera et al looked at the importance of co-location as a facilitator of mental health consultation.  It is a survey study, with all of the limitations of a survey, and yet found two really interesting things:  only 17% of those surveyed had on-site consultation available, but those folks were 6.58 times more likely to consult a mental health worker.  (They also found that the busier practitioners were less likely to refer)   This work implies that we need to encourage co-location if we want collaborative practices.  Next,  two important articles about health disparities.  Zuckerman et al  found looked at household language and parental perception of the risk of developmental delay-  they found that parents who spoke primarily Spanish were far less likely to perceive a developmental problem in their children (when adjusted for gender, age, family poverty status, insurance status, parental education of survey respondent).  The authors can't tell whether this means that there are fewer developmental problems in the Latino community, or if the parents in that community are less likely to be concerned about them;  clearly that distinction will have a major impact in how we design our systems.  Finally Coker et al looked at utilization of services in black and white-  African-American kids in the 5th grade were much less likely to use services than were whites, although the problems like ADHD, ODD, conduct disorder and depression were present in both groups in equal measure.  As stated in the accompanying editorial, 
Understanding the reasons for lack of engagement of certain groups that have been traditionally disenfranchised is not simple. Strengthening the therapeutic alliance in primary and specialty care may afford unique opportunities for recovery.
Nice job, Academic Pediatrics.

Full disclosure: As Treasurer of the Academic Pediatric Association, I chair the Journal Committee that provides oversight to Academic Pediatrics, a small but increasingly useful member of the Pediatric journal community.

Saturday, March 21, 2009

Nothing to Do with Mental Health, Really

The Webcomic XKCD has nothing to do with Children's Mental Health, but offers insight into how to think about numbers in budgets.  It is sometimes a little hard to keep the zeros straight.
Doesn't excuse a mistake, but does give it a bit of context.  As we have been thinking about budget cuts, it is appropriate in these troubled times to try to keep the systems going at full steam.  Sometimes one has to settle for minimizing the losses.

Also, my favorite political website (fivethirtyeight.com) says that health care reform is moving to the front of the political agenda while the AIG football is bouncing around the 24/7 News field.  Interesting times, that affect our work in a big way.

Finally, I am recommending that everyone read James K. Gailbraith Sr. classic book:  The Great Crash and his son's recent article in the Washington Monthly to have some understanding of what is happening at the macro-economic level.  We have to get a handle on the background to make health reform happen now- but it is ultimately part of the solution to the whole mess.

Tough times, tough budget.  Lots of work to do.

Wednesday, March 18, 2009

Budget Cuts and Early Intervention

My colleague Darshak Sanghavi has a very nice article in today's Globe, highlighting on of the downsides to the current budget cuts-  an increase in the level of deficit needed to qualify for services that went into effect on January 1st.  As Darshak points out, this is penny-wise and pound foolish.  Technically, this does not affect the "Rosie D" class of child, as "serious emotional disturbance" is really a mental health rather than a developmental problem, and we are supposed to screen for mental health problems.  But, in reality, any child with an SED at a young age may have a developmental problem as well, and merits a look by EI.  Given the paucity of other places where a young child can be sent,  it is likely that we would send such a child to EI for evaluation.  In fact, it probably makes sense to help EI to develop the capacity for early childhood mental health work, in order to be true to their mission (comprehensive services) and our intent (family-focused services).  I have never met a more family-centered program than Early Intervention.  When I started practicing in Massachusetts in the early 1990s, they would take kids with problems AND kids at risk for problems with no questions and no fee.  Now, families have pay cash up front, AND be behind the eight ball before they can get services.  Screening means nothing without the services to back it up.

This is progress?

Tuesday, March 17, 2009

Mental Health in Times of Scarcity: What's Up with the Campaign?

How goes the Children's Mental Health Campaign?  I attended the Children's Mental Health Campaign's meeting today, and heard some about the 9C cuts and the 2010 budget, but more about the new systems of care that are evolving throughout the Commonwealth.  There is lots going on;  let me try to summarize:
First, we hit the high points:
1)  Mental Health took a hit in 9C cuts, and we are advocating to bring this back to the funding levels "pre-9C".  People seem pretty optimistic that we can keep the budget in reasonable check.
2)  "Stuck Kids" are doing better.  The number of kids who are not moving through the child psych hospital system is currently running in the 70s (as opposed to the 140s two years ago), and people are reporting that the "back up" in the child psych emergency rooms is much better than it was two years ago.  The imminent concern is the Rosie D start-up;  the CAP program from DSS is no longer taking client, in anticipation of the start up of the CSAs and there may be some confusion in sorting out who is in charge with many of our most complicated kids.  We also heard of a new program to help move these kids with difficult mental illness out of the system, funded by the Blue Cross/Blue Shield Foundation;  things really are getting better all of the time.
3)  The last bit of the bill that is now Chapter 321 has been reintroduced into the legislature (we've blogged on this before, see here for the fact sheet).  There will be an Informational Meeting is on April 9 for the Joint Committee on Mental Health, and we are going to try to get children on the agenda for that hearing.

The big news was on the implementation of Chapter 321.  We heard reports on the  implementation of  the new bill:
Public Schools Work Group:  We are working to integrate the work of Chapter 321 implementation and the Rosie D. initiative, by working with the Department of Education's Task Force on Behavioral Health in the Schools.  (The difference between the work groups and the task force is a little confusing. One is monitoring the bill, one is actually doing the work and creating the reports)  Want to help?  The Work Group meets on the 4th Monday of the month at Mass Advocates for Children (25 Kingston St, 2nd Floor, Boston) and the Task Force is planning to meet on Wednesday, April 1 at 10 AM to discuss the Winchendon Project, a Health Foundation-funded project which some of us in Central Massachusetts know something about.
Work Group on Early Education:  Rather than start a new group, we have engaged with an existing group- the Infant and Early Childhood Mental Health Group that developed from a state initiative earlier in the decade.  They meet in Marlboro, and are scheduled for Friday, April 10 at 9:30 AM at Marlboro Hospital.
Interagency Work Group:  These folks have been refining the Interagency Review process, developing some of the "nitty gritty" of making these meetings parent centered and productive-  they have been writing regulation to help to make the process more clear.  DMH will be presented with these "draft regulations" soon, and DMH is going to be looking at how this meshes with the Rosie D. implementation.
Lots of activity:  lots of work to be done.
We also hear about "Integrated Comprehensive Resources In Schools", a program of the Department of Children's and Families and the Department of Education to challenge schools to integrate mental health and social services into the school systems.  They see the school as the unit of intervention.  As their starting point, they used the Educational Collaboratives, urban and rural districts, to look at programs already established to consolidate resources in a variety of school districts, and look at ways facilitate the development of the teams needed to care for the kids.  They are looking at the continuum of care, from co-located segregated services to well integrated services.  They found a range of districts where there were systems in place;  behavioral health, psychiatric care, counseling can be in place, but often they don't coordinate their care.  Most of the care is being provided on a traditional fee-for-service model, which does not encourage the networking needed to make this all happen.  Interestingly, it was the private payers that were least likely to participate in the networks.  Clearly, networking is the glue that holds the system together.
And we have a lot of work to do.

A philosophical digression:  In Rosie D, in many of the cases of which I have blogged over the course of the year, in this talk,  it seems that the weak link is "care coordination".  The is the key, and yet the system is set up to keep it from happening:
1)  We don't reward collaboration financially.
2)  We don't reward relationships (key to making a team work)
3)  We do reward efficiency (read:  shorter encounters are better)
4)  We see providers as interchangeable parts
5)  We don't allow time for the parts of the system to take with each other.
Whenever we do build it into a system, these meetings are seen as a frill, as non-essential, as not worthy of reimbursement.  When you take it away, the system degrades slowly- it is often the first thing cut when cuts need to be made.

So, as we move forward on the CBHI, we need to ask the question:  how can we build a politically-viable system that will allow us to collaborate in an way that meets the needs of the children and families that we are trying to serve.

Monday, March 16, 2009

From the Children's Mental Health Campaign

Please Join Us: CMHC Meeting: Tuesday, March 17 from 9:30-11 AM

Please join us for the next Children's Mental Health Campaign supporters meeting on Tuesday, March 17 from 9:30-11 AM in the 9th floor conference room at 30 Winter Street.  Even with the passage and enactment of Chapter 321 last session, the work of the Campaign has not slowed down. At this meeting, we will discuss the implementation of the new law, legislative and budget strategy for the next several months, and other issues to monitor related to children's mental health.  Also at this meeting, Susan Stelk, director of the EOHHS Integrated Comprehensive Resources in Schools project, will present on the Department's work on mental health resources for children in school settings.  Your involvement in these meetings is important. We have assembled a strong group of individuals and organizations, and our collective knowledge and experience will be key to making lasting systems reforms.
Please join us on Tuesday.

FY 2010 Budget and Children's Mental Health
These remain difficult economic times in Massachusetts and these difficulties were reflected in Governor Patrick's FY 2010 budget proposal.  Of particular concern for children's mental health is a proposed $3 million cut in the Child and Adolescent Mental Health Services line item (5042-5000).

According to analysis by the Mental Health and Substance Abuse Corporations of Massachusetts, this cut represents the annualization of the 9C cuts that were made to the line item last year. The Department of Mental Health does not expect to make additional cuts in community services for this population.

Especially in light of the current financial crisis, the Children's Mental Health Campaign will continue to advocate for adequate funding for children with mental health needs. Regardless of the budget situation, these young people continue to have needs that must be addressed.

CMHC State House Operations

As you know, there have been many changes at the State House in the past several weeks. In addition to a new Speaker, Representative Liz Malia and Senator Jen Flanagan have been tapped to lead the Mental Health and Substance Abuse Committee.

This session, the Campaign is supporting legislation sponsored by Representative Ruth Balser and Senator Steven Tolman that would establish reimbusement under private insurance for collateral contacts by mental health clinicians.
Click here for an updated fact sheet on the Collateral Contacts legislation.
Thanks to the work of the Campaign, we managed to secure 50 cosponsors on this bill.
Click here to see who signed on.

If you have any questions, please contact Matt Noyes, Children's Health Coordinator at Health Care For All.

Next CMHC Meetings:

Tuesday, March 17
9:30-11 AM
30 Winter Street, 9th Floor, Boston

Tuesday, May 19
9:30-11 AM
30 Winter Street, 9th Floor, Boston

Sunday, March 15, 2009

The problem with a positive screen.....and getting interpreters out into the community.

So, I was a little clinical last week-  three days in the office, with children vomiting and limping and needing their physicals all about me.  During that time, I saw three teens who were clearly having trouble with marijuana use.  Two were in for physicals and one had been taken to the ER for a medical condition over the weekend, where he was found to be using weed.  Interestingly, all had normal Psychosocial Checklists, but abnormal CRAFFTs.  All of them needed treatment.  None of them wanted it.  So none were actually "referrals", the only positive outcome allowed on the MassHealth billing form that is feeding into the data of which we look, and all were negative on the "usual screen" that we use for a first pass.  I couldn't refer;  I tried Motivational Interviewing.
I was sort of successful;  all agreed not to drive while stoned, none agreed to a trial of abstinence, one agreed that weed would hurt his chances of getting a scholarship to college, and all agreed to a follow up.  
But how will that count for Rosie D?  I could score the screening code for the PSC, not the CRAFFT and make it a negative.  Thats not right- the kids did have problems.  I could count the follow-up visit as a self-referral, although that seems a bit disingenuous.  I think, in the end, I scored them as positive screen with referral.  I am optimistic that I will be able to talk them through the process.
Many such stories lurk behind the simple numbers going to the CBHI and the Court, as Rosie D falls into place.  Those interpreting the billing data need to keep that in mind.
In a separate matter, I want to tell all of you who have not had access to interpreter services in the past, finally getting them is wonderful.  Our office in Webster doesn't have sufficient volume to support on-site interpreter services, and we have not had "phones in the rooms" to support telephonic interpretation.  Recently, however, we (UMass) got access to telephonic interpretor services, AND I got a cell phone with speaker capability, which would allow me to have the interpreter "in the room" in real time.  So, on Friday, I saw a Polish-speaking couple (who understand some English, but have trouble asking questions in Polish) with a young boy with frequent urination.  Now this is a potential medical problem, but more commonly is a behavioral habit;  one can distinguish the two pretty quickly, and, with some simple behavioral instruction, this can be handled without  much trouble.  I did the simple stuff to show that this was not diabetes, while thinking that this usually takes a bit of discussion (in English) to get parents to understand what is going on, and that this would be a challenge with this family.  Then I remembered my new phone, and got an interpreter on the speaker.  It was great- the family left happy, understanding what they were going to need to monitor over the next few weeks, and I felt that I was able to address their concerns in a complex situation.  If you don't have this service available in your office, find it.  It is great.
Complicated day.

Thursday, March 12, 2009

How does Children's Mental Health fit into the national push for Health Reform?

As a Board Member of the Academic Pediatric Association, I voted "yes" to endorse our organizational support for this letter to President Obama regarding children's mental health in the health reform process.   The letter came out of the National Center for Child in Poverty:  they seem to do really great work at translating data into policy.  It should have gone out today, with our endorsement. It also deserves wider distribution, hence the posting.

March 10, 2009

The White House
1600 Pennsylvania Avenue, NW
Washington, DC 20500

Dear President Obama:

As you and your colleagues begin to address health care reform, the undersigned organizations would like to urge your support for improving and enhancing the children’s mental health system. Over 25 years ago Jane Knitzer, Ed.D., in the report Unclaimed Children: The Failure of Public Responsibility to Children in Need of Mental Health Services, documented policy and program disconnects that meant children and youth with mental health needs and their families did not get the services they needed.

Last year, a follow-up report by Janice Cooper, Ph.D., titled Unclaimed Children Revisited illustrated how states are still struggling to respond appropriately to the needs of children and youth with mental health conditions, HIV/AIDS, and other disabilities. It also underscored the critical need to address the needs of children and youth at risk for those conditions. While it is clear that some progress has been made, the needs of children, youth, and families will not adequately be addressed without a comprehensive set of children’s mental health policies at the national level, and a focused strategy for attaining the same.

The report’s overarching goal is to provide guidance that will offer policy recommendations to move current care-delivery systems toward the vision of a comprehensive public health framework for children and adolescents’ mental health. Unclaimed Children Revisited recommends:

Family-centered Infant and Early Childhood Mental Health Services. There is an explosion of knowledge that calls attention to the importance of early relationships in setting the stage for a child’s social and emotional development and mental health. There is a need to support state efforts to infuse early childhood mental health services into early childhood settings, including child care and home visiting programs, as well as to address widespread parental depression that can have life long negative consequences for the children.
Comprehensive Financing Strategy. Develop and implement a comprehensive financing strategy that supports a public health focus to mental health. Place empirically-supported family-based treatment and supports at the center of financing children’s mental health care.
Public Health Approach to Children’s Mental Health. Incorporate a public health approach to children’s mental health services, which provide age and developmentally appropriate comprehensive services and on-going supports, and incorporate strategies of prevention, early intervention, and positive behavioral interventions and supports.
Service Delivery to Transition Age Youth. Transition youth with serious mental illness (SMI) encounter numerous obstacles as they transition from school and child welfare systems to their adult lives. Efforts to address the needs of this population require the provision of crucial programming to prepare them to address their own housing and independent living needs, increased collaboration across systems providing services to these young adults to facilitate access, and access to health insurance and social services for youth with mental health conditions up to age 25.
Eliminate Disparities in Mental Health Status and Mental Health Care. Overall, mental health services meet the needs of only 13 percent of minority children. Despite the fact that minorities are less likely to receive mental health services, when they do access services, those services tend to be ineffective and of low quality. Eliminating disparities in mental health status and mental health care and increasing the cultural competence of service programs and providers is essential to improving mental health services to racial and ethnic minority children because when a program is developed with consideration of the culture of the community being served, there is an increase in service utilization and decrease in early termination of treatment.
Health Professions Training and Education. Increase and enhance mental and behavioral health workforce education and training. As documented in the report of the Annapolis Coalition on the Behavioral Health Workforce (2007): There is substantial and alarming evidence that the current workforce lacks adequate support to function effectively and is largely unable to deliver care of proven effectiveness in partnership with the people who need services. The improvement of care and the transformation of systems of care depend entirely on a workforce that is adequate in size and effectively trained and supported.

Too few resources have been expended to develop and implement a compre¬hensive framework for addressing the needs of children and youth with mental health conditions HIV/AIDS, and other disabilities. We have an opportunity to improve the trajectory of children’s mental health policy, and improve the overall health, education, and future employability of children and adolescents in our country. Thank you for your thoughtful consideration and continued efforts on this important issue.

I will be interested to see how this gets translated into the new plans that come out.  Glad my professional organization had a chance to sign on.

Wednesday, March 11, 2009

Back the the Future: Training Primary Care Doctors to Do Mental Health Stuff

Back when I started delving into the issues of how to provide mental health services for my patients,  I invited Larry Wissow, a psychiatrist/pediatrician/genius to come to Worcester and provide us with some technical assistance on how to organize our services.  His focus is on communication, and one of the talks he gave up here has been refined and published on the AAP website
The 15 Minute Mental Health Visit
The AAP Task Force on Mental Health collaborated with the Committee on Psychosocial Aspects of Child and Family Health, Council on Children with Disabilities, Council on Community Pediatrics, Committee on Practice and Ambulatory Medicine, Section on Developmental and Behavioral Pediatrics, and Bright Futures to provide a Web-based teleconference for primary care pediatricians focused on educating pediatricians on how to approach mental health concerns with parents, children, and adolescents in the primary care setting.

Speakers Larry Wissow, MD, MPH and Anne Gadomski, MD, MPH discuss the "common factors" approach and present video clips of doctors interviewing simulated patients with mental health problems that are common in the pediatric primary care setting. A panel of experts respond to the video clips and assist in answering participant questions.

The 15 Minute Mental Health Visit Recording (Internet Explorer Only)
After viewing the recording, please complete the online evaluation to let us know your thoughts about this teleconference recording. Click Here to take survey
The link really does only work on Internet Explorer, which, as a Mac User, I cannot access. So someone will have to tell me if this is any good.  The Mental Health Task Force Education and Training website has a lot of other useful stuff-  you should check it out.

Tuesday, March 10, 2009

From the CHBI: FAQ

New CANS Frequently Asked Questions On-line
New and expanded CANS FAQs are now available on the CBHI website. The FAQs provide clear and easily accessible answers to questions about the CANS for administrators, behavioral health providers and others. Click here to the new CANS FAQs.

Mental Health and Homeless Children: A New Report

The National Center on Family Homelessness released an interesting report today:  America's Youngest Outcasts:  State Report Card on Child Homelessness.  Massachusetts did reasonably well-  overall ranking of 8th out of 50, with extensive state policies and planning in place.  Even so, Massachusetts ranked 18th in terms of "child well-being";  20% of families at less than 50% of the Federal poverty line (the new proxy for homelessness) reported children with health conditions that were "moderate or severe"; and 10% of those families reported "severe emotional disturbance" in at least one child in the family, language that should be familiar the readers of this blog. (Interestingly, kids under 100% of FPL have an almost 20% rate of SED, then it tapers off).  When one looks at the relationship between homelessness and SED at the National level,  Massachusetts is doing better.  While I not entirely sure how this information was gleaned, it does seem that our rate of 10% is better than many.  Not clear that this is not just the result of undercounting.  The link between mental health and children's social determinants is clear;  we need these kids to have better access to resources if we are going to address them. 

Monday, March 9, 2009

Care coordination makes the system work

A colleague today asked me if I thought that one of his/her client/patients has been sufficiently evaluated for mental health problems.  A teen, court-involved, DCF involved, dropping out of school kid, who had been seen by outpatient mental health, offered an IEP (declined), sent to a residential home (where she have neurological, psychiatric and medical evaluations suggesting ADHD, ODD and mood dosorder NOS.  She was responding a little to medication and the question was "does she need a neuropsychological evaluation?"

My question was, as always, "Who is following her?"  Here was this nice young lady, without primary care doctor, psychologist or psychiatrist, on mood stabilizers from an inpatient facility with no one in charge of her medication and they we asking me about more evaluation.  "He might need a neuropsych evaluation", I said, "but he really needs a bit more care coordination.  Someone needs to follow up on all of those recommendations from the earlier evaluations.".
He needs, in the end, SOMEONE to advocate and guide him or her through our system of care.   
I guess in the ideal world that would be the parent or guardian.  What happened in this case, i don't know.  Perhaps the parent tried, and hit a wall.  Perhaps the parent didn't try- didn't know that this was part of the job that we all approach with such trepidation.  Perhaps... well, the whole point of this exercise is to make it easier for parents confronting the system.  Will it happen under a CSA?  I suggested to my colleague that the child would benefit from getting a CANS now, so that this patient/client can be ready when the doors to the new system open.  He will clearly need all of the support that we can give her.

Oh, and I was deliberately changing genders in this story because it could have been either.  The point is that there are lots of children out there waiting for the CSAs to open.  I hope that they get up and running soon.

Sunday, March 8, 2009

CSAs are coming: What are they supposed to do?

The contracts are out there:  the CSAs are going to be developing over the next 4 months.  What are they supposed to do, anyway?  According to the RFR, the CSA should lead the way in the development of a faithful adaptation of the "Wraparound" model.  The four "core" functions are:
  • Actively engaging youth and families seeking Intensive Care Coordination (ICC) services and Caregiver Peer to Peer Support Services using the Wraparound care planning process
  • Providing infrastructure support for ICC and Caregiver Peer to Peer Support services
  • Actively participating in a quality improvement process to identify the “lessons learned” from youth, families, providers, and others. These “lessons learned” will continually shape the vision and functions of the CSA.
  • Developing and supporting a local Systems of Care Committee that will be charged with supporting the service area’s efforts to create and sustain collaborative partnerships among families, parent/family organizations, traditional and non-traditional service providers, community organizations, state agencies, faith-based groups, local schools, and other stakeholders.
That is a tall over of business, and it gets even more complex as we break down some of these broad and well intentioned goals. The CSA should provide:
  • A comprehensive home-based assessment of the youth’s and family’s strengths and needs inclusive of the Massachusetts Child and Adolescent Needs and Strengths (CANS) tool
  • Development and facilitation of a care planning team including a Family Partner if desired by the family
  • Creation of an individualized care plan
  • Monitoring and follow-up activities to ensure successful implementation of the individualized care plan]
So far, so good.  But who is going to provide all of this service?  The specifications of the Intensive Care Coordinator are 5 pages long,  but they suggest that "care coordinators who
have successfully completed skill- and competency-based training in the delivery of ICC consistent with Systems of Care philosophy and the Wraparound planning process
and have experience working with youth with SED and their families" are the ones that need to be in charge.  They might be  "bachelor’s level and master’s level care coordinators who work with a range of youth and their families who present with varying degrees of complexity and needs."  They could also be folks with "an associate’s degree or high school
diploma and a minimum of five (5) years of experience working with the target population; experience in navigating any of the child/family-serving systems; and experience advocating for family members who are involved with behavioral health systems."

Read the RFR.  This is going be hard to do, and, of course, that is what makes it worthwhile to try.

Friday, March 6, 2009

The Envelope Please: Announcing the CSAs

Right on schedule, the Massachusetts Behavioral Health Partnership has announced the contracts for the Community Service Agencies that will be providing intensive care coordination for children with serious emotional disturbances in July.  You can access the announcement here.  Looks like the State is covered.  It continues to get more interesting as this process keeps moving along.

Liveblogging CANS: Listening in on the CBHI

I have been wondering about the CANS instrument, so I listened in on today's call.  The training team is delightfully engaging, and quickly worked us through the logistics of the call.  They began by pointing out the the CANS is complicated, and their goal is to get people both at large practices and small practices to be comfortable using the instrument.  They pointed out that there are tutorials are available on the CBHI website, and they really want people to use the website to get information.   They reported that more and more providers are submitting their information through the Virtual Gateway, and are climbing up the learning curve pretty quickly.

Then they dug into the meat of the matter.  At the present time, providers are required to enter demographic information from the CANS assessment, including the determination of SED status  and to log the information into the Virtual Gateway.  Soon there will be an informed consent process that will allow all of the information from the CANS to be entered into the Virtual Gateway with the parent/guardians permission.   In order to do this, you need to register with the Virtual Gateway here.  Then you have to be trained in CANS-  that happens are UMass.  If you are a provider or a clinician who hasn't attended CANS training, they suggest calling the Massachusetts CANS Training Center at (508) 856-1016 or e-mail at MassCANS@umassmed.edu.  So far, about 7000 have been trained and 6000 have been certified in the system.   Listening to a description of the system, it sounds like there are a lot of "technical" components that make sense to computer people, but are confusing to us "mere mortals".  This sounds an awful lot like the process that I have to go through with my Electronic Medical Record.  I won't go into my long rant on the inefficiencies of our EMR, but listening to this talk, my sympathy for the Mental Health workers is greatly enhanced.   The system sounds quite complicated, and it sounds like it is changing pretty often.  On the call, both the providers and the CBHI folk have approached the process with good humor and a can-do attitude.

The questions were very practical:  Turns out that DCF has a CANS, that is subtly different.  So mental health providers can use the information from the DCF form, but it needs to be transferred into the MassHealth form and submitted separately at the present time.  They are working on developing ways to make that information transfer easier.  Several people had run into problems with the level of access that persons have on the system; the group reviewed the procedures for troubleshooting.

Again, I am impressed at the level of effort being made by the Commonwealth to support this transition.  At the same time, I understand why the agencies see this as an extra burden- mental health clinicians are traditionally not the sort of folks who spend lots of time navigating computerized record systems.  Needless to say, neither are doctors.  I suppose that they and we will need to get used to it.  The CANS is here to stay, and later today we will be hearing about the results of the RFP for CSAs, the next link in the process.  Stay tuned.

Thursday, March 5, 2009

From the Boston Bar Association

For Immediate Release
February 3, 2009

Contact: Bonnie Sashin, APR
Communications Director
(617) 778-1902

Boston Bar Updates Guide to Children’s Mental Health Services

BOSTON – Reaffirming its commitment to helping families gain access to the mental health services so desperately needed by many children in the Bay State, the Boston Bar Association (BBA) – in collaboration with Children’s Hospital Boston – today released the second edition of the Parents’ How-To-Guide to Children’s Mental Health Services in Massachusetts. The 2nd edition will debut as an
online publication available on web site of the BBA and also the web site for Psychiatry at Children’s Hospital Boston.

"This new edition incorporates significant developments that have occurred since the Guide was first published in December of 2004," said Michael L. Blau, Editor-in-Chief, a partner at Foley & Lardner LLP, who advocated tirelessly on behalf of the BBA for passage of Chapter 321, omnibus legislation relating to children’s mental health services in Massachusetts. "This Guide reflects the collective wisdom and experience of many families and stakeholders – all of whom helped us build a more complete and useful picture of available resources and system deficits as well as issues and potential solutions."

Among the new developments reflected in the second edition of the How-To-Guide are:

I. Enactment of Chapter 321: An Act Relative to Children’s Mental Health ("Yolanda’s Law"), which:
  • promotes early detection and treatment of mental illness 
  • requires Massachusetts state agencies to identify and adopt best behavioral health practices 
  • requires coordination of services where a child is receiving services from multiple Massachusetts state agencies 
  • promotes collaboration between public schools and behavioral health providers to improve learning environment for children with behavioral health needs 
  • requires timely discharge to the most appropriate clinical setting of children hospitalized for behavioral health reasons.
II. Enactment of Massachusetts Health Reform, which:
  • requires everyone in Massachusetts to have health insurance 
  • establishes The Connector, through which low-income individuals can get subsidized health insurance and others can get more affordable coverage.

III. The Children’s Behavioral Health Initiative ("Rosie D."), which:
  • requires the Commonwealth of Massachusetts to comply with requirements for early screening and treatment for children with serious emotional problems.
Sprinkled liberally throughout the How-to-Guide are specific advocacy tips to help parents overcome obstacles to obtaining needed care as they navigate the system.

"We recognize that it will take a sustained effort of many people to materially improve the availability and quality of child mental health services in Massachusetts," added Blau. "By updating the How-To-Guide and monitoring implementation of the Chapter 321, we are demonstrating that our commitment to the cause is unwavering."

Blogger's note:  This book is fabulous, useful and 170 pages long, with a Flesh-Kincaid Reading Level of 11.8.  We clearly make it way too hard to access services, even with the reforms that are in place.

Wednesday, March 4, 2009

Where Have I Been? Back in the land of Primary Care

I am tremendously flattered to note that, despite it being 3 days since my last post, people are still visiting the site, which means it must still be filling a need among those who have been diligently been working to improve children's mental health services in Massachusetts.  As I mentioned on Friday, I was away at the AAP's Future of Pediatrics meeting last weekend, and returned home to a blizzard and 90 minutes of shoveling to get the car into the driveway, and then a full day of clinical practice yesterday, ending in a Providence Singers rehearsal.  Concert coming up.  Get your tickets now!

I was an interesting day in the office-  we are at that point in the winter where it seems like every child in Massachusetts has been coughing for the last 3 months, and parents can't remember which child had a fever last night and which had a fever last month.  I saw 23 patients, but only 4 of them were well child visits (read EPSDT or the kind of visit in which we screen for behavioral health).  Those kids were fine- doing well in school, participating in sports, perhaps a bit on the overweight side- and their PEDS/M-CHAT/PSC screens were all fine.  Among the children who were sick, however, were several who were having difficulty in school.  

One stands out in my mind-  a young person in middle school, who needed a note to excuse an absence of 4 days for a cough.  Now, on examination, this person had a diagnosable condition, that would be amenable to treatment with an antibiotic.  I diagnosed the condition and gave the antibiotic, with my usual pronouncement that the youth should return to school tomorrow if afebrile.  This child, however, was being investigated for truancy (hence the need for the note) and on review was noted to have been referred for counseling back in the Fall, during a health maintenance visit in which school anxiety had been discussed.  We had screened, identified a problem, made a referral- all by the book.  It would have been easy to wash our hands of the situation, by saying that the family was "non-compliant".  Would have been accurate, except that in the eyes of the family, the child was having no problem.  We had a long conversation in which I advocated for school attendance, and the parent wanted to assure the youth that there were many people who made it in the world without graduating highs school.  Very different world views-  I cited Malcolm Gladwell's book Outliers, which points out how graduating from a "good enough" college gives one a leg up on the good life that being born brilliant really does not - the parent wanted to be clear that one simply cannot give up on oneself because of failure.  I am not sure that any minds were changed in the exchange.  It is pretty clear, however, that screening alone means little without the ability follow children longitudinally and follow-up on the recommendations that one makes.

The results of the CSA bids are supposed to be announced on Friday.  It will be interesting to see who will get the contracts.

Sunday, March 1, 2009

From the CBHI: Questions of the Week

So, I got this from the CBHI over the weekend, and tried to use the links-  but they wouldn't work.  When I looked at the HTML code, there were links to the EOHHS website, but they were all blocked -  not active.  What's up with that?  These certainly sound like they wopuld be useful tools.

"What support is available for end-users of the CBHI application? " 
Job Aids are available for end-users who use the application.  They were developed as on-the-job references for entering MassHealth member information into the application. The CBHI Job Aids, including their descriptions, are as follows:
·  Virtual Gateway Login Assistance: CANS is accessed through the Virtual Gateway. Review this job aid first to learn how to access and  log in to the Virtual Gateway.
·  CBHI Certified Assessor: This job aid explains to clinicians how to use and navigate the functionality of the CBHI application that is available to them.
·  CBHI Data Entry Operator: This job aid explains to data entry operators who enter information into the CBHI application on behalf of clinicians how to use and navigate the functionality of the application available to them. 
·  CBHI Organization: This job aid explains to case managers and provider organization supervisors/administrators how to view specific member details within the application that is available to them.
 ·  Virtual Gateway Customer Service: This job aid explains to all users how to reach Virtual Gateway Customer Service.

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