Thursday, April 30, 2009

Yippee! From the Children's Mental Health Campaign!

Children's Mental Health Victories!


Yesterday, the House took significant steps to protect children's mental health services by restoring funds to three important line items.  

In the Mental Health consolidated amendment, the House restored $3.4 million to the Child and Adolescent Mental Health Services line item (5042-5000) and $25 million to Rosie D.  

Special thanks goes to Representative Malia for her strong advocacy on the floor and behind the scenes to secure these funds.

Additionally, the Early Education consolidated amendment restored the Mental Health Consultative Services to Early Education Settings line item (3000-6075) and allocated $1 million for these consultations.

Representative Pedone was the lead sponsor for this line item and was the driving force in the State House to preserve these services.

Although we are pleased that the Early Education Mental Health Consultations were restored to the budget, the funding allocated is a significant cut from last year's funding level.  

The Campaign will discuss Senate strategy for this line item at the May 19 supporters meeting.  

Thank you for your hard work on the House budget.  If you have the opportunity, please contact your State Representative and thank them for their support of children's mental health.  

You can find your State Representative by clicking here.  

Wednesday, April 29, 2009

Going to Baltimore for the Pediatric Academic Society meetings

On Thursday, I leave to 6 days of meetings in Baltimore, the Pediatric Academic Societies meetings, an annual gathering of 5,000 pediatricians who talk about all that is happening in our field.  I may be able to post from the meetings.  There certainly will be a lot of discussions about Children's Mental Health and system change.  The titles alone are intriguing;  many of the questions we have all seen in our quest to build a better system in Massachusetts will be discussed by leading researchers from around the country.  This is what I saw on a "quick scan" of what is going on:

Title: [2115.6] Evaluation of the PHQ-2 Depression Screener among Adolescents

Title: [2809.83] Racial/Ethnic Disparities among US Adolescents in Medical and Oral Health, Access to Care, and Use of Health Services

Title: [2809.85] An Educational Intervention for Optimizing Adolescent Mental Health Screening Skills and Treatment

Title: [4322.33] Impact of Integrated Mental Health Services on Residents' Perceptions and Practices in Continuity Clinic

Title: [4329.104] California Children with Mental Disorder: Predictors of Emergency Department Disposition

Title: [4329.105] Detection and Referral of Mental Health Problems in the Primary Care Setting: One University-Based Center's Experience

Title: [4329.106] Effects of Primary Care Provider Communication Training That Predict Child and Youth Mental Health Outcomes

Title: [4329.107] Psychological Distress and Mental Health Care Utilization among Asian Adolescents in California

Title: [4750.5] Differences between Parent and Teen Reported Mental Health (MH) Problems among Those in Foster Care

Title: [4740.7] Collaborative Care Interventions for ADHD in Pediatric Primary Care

Title: A Practical Approach to Mental Health Care Treatment in the Pediatric Primary Care Setting.

Title: [5140.6] Mental Health, Physical Health, and Home Environments of In-Home, Foster, and Kin Caregivers of Children Investigated by Child Protective Services

Title: [5514.226] Physical Health and Mental Health Services Utilization among US Children — 2008

Title: [5514.256] Self-Efficacy as a Mediator between Child Hospitalizations and Maternal Depression

Title: [5516.314] Culturally Effective Shared Decision Making (SDM) in ADHD

Title: [5521.392] Needs Assessment: Creating a Mental Health Home for Latino Children

Title: [5521.401] Factors Affecting Parental Mental Health Treatment Initiation in Children and Adolescents

If I make it to half of these, I will learn much.  And I will try to blog about it.

Tuesday, April 28, 2009

Linking and Aligning Medical Home and Mental Health

We Need Your Help!
Parent Professional Advocacy League (PAL) and Central Mass Medical Home Network Initiative (CMMHNI)invite you to participate in an important survey.   

The purpose of  survey is to:
  • Identify services that are currently offered to parents and caregivers of children/youth with behavioral and mental health issues, as well as,
  • Identify additional services needed to insure that an integrated behavioral and mental health care plan is in place that is facilitated by their community based Primary Care Provider (Medical home).

You responses will be kept anonymous.  We will not ask you to give us your name or any other identifying information.  To access the survey please click here.
The survey is also in the process of being translated into Spanish and should be available on our websites May 5th.  We appreciate your time! 

If you have any questions, please contact: 

Beth Pond, CMMHNI, 978-928-3388                                   

Meri Viano or Mary Lambert, PAL, 508-767-9737

Monday, April 27, 2009

In Our New Systems, Relationships are the Key.

Claudia Meininger Gold has an op-ed in the Globe today, highlighting the reasons why caring for mental health problems  requires relationship.  Patients and parents hold tightly to their stories, and the insight of the story is really needed to guide their care.  Otherwise, we are just ameliorating the symptoms.  I remember many similar cases:  I am working with a family of a school aged child right now who clearly meets criteria for ADHD in the context of a divorce;  I am being somewhat slow to medicate, and hoping that, with some work on the trauma of divorce, we can manage this without medication.
The system lesson from all of this, however, is that systems of care need to allow and encourage the development of relationships, between patient and primary care doctor, between parent and doctor, between patient and doctor and therapist-  these relationships need to be encouraged to thrive.  This doesn't happen when the systems teat "providers" as interchangeable components on an assembly line.
I may have more to say later-  I will be going over the State House to observe the reaction to the budget.
It's later.

A packed room (I crouched in the back with the folks from Health Care for All), lots of people, one message:  the people in the room were gathered to raise revenue and invest in the future of the Commonwealth.  We heard speeches from a variety of political leaders:  the mayor of Somerville spoke of the need for partnership that preserves services at the local level.  He thinks that people are smart enough to want to keep critical services in place, but he knows that we cannot put this all onto the property owners, and that other forms of revenue are needed.  A nurse from the Worcester Public Health Department spoke of the impact of local aid cuts on the City of Worcester;  the city of Worcester will essentially cut out the Public Health Department on May 1st, after which there are only a few people left to do the work.  A member of the Coalition for Social Justice spoke of the cuts in Substance Abuse services, which would have affected her personally had they happened 3 years ago.  She is three years sober, but still subsidized by the Department of Substance Abuse.  While typing, it got really crowded.  Labor was there as well, framing this as an issue for working families.  Working families are not responsible for this crisis;  the bankers are and that we need to hold them accountable for this.  We closed with Youth, the voice of the future, telling us to go out there and make sure that there is something for them to grow up for.

So, what’s the down side?  Really, it comes down to who you are going to raise the revenue from.   Proposals currently out there seem to focus on raising the regressive taxes like the sales tax, and not the income tax, which would  allow us to target the cost to many of the folks that caused it.  Still, without these additional revenues, mental health reform is not going to happen.  As the group went off to visit the members, it was with a single message:  “Raise Revenues, Reduce Cuts”.  It will be interesting to see if it sells.

Friday, April 24, 2009

From the Children's Mental Health Campaign

Children's Mental Health Gains Threatened


The House Ways and Means budget for Fiscal Year 2010 contains significant funding reductions that will have a devastating impact on children with mental health needs.


Last session, the Legislature took a major step forward in addressing the ongoing crisis of the children's mental health system in Massachusetts by enacting Chapter 321 of the Acts of 2008: An Act Relative to Children's Mental Health. 

Unfortunately, the budget proposal before the House would squander many of the gains made by this law.

While we recognize the difficult economic and financial situation the state is faced with, it is important that we preserve the gains we have made for children with mental health needs.

In particular, the Children's Mental Health Campaign is concerned with cuts to two specific line items:

Behavioral Health Consultation for the Department of Early Education (3000-6075): line item eliminated.  

Child and Adolescent Mental Health Services (line item 5042-5000): funding reduced by $3.4 million.  

You can help!

Please call your State Representative (as well as ask your networks to call) and ask him or her to:

Please support Representative Pedone's amendment to restore the line item and to restore funding to Behavioral Health Consultations for DEEC (amendment number 688) These consultative services have been instrumental in reducing the number of suspensions and expulsions from preschools, and in dramatically reducing subsequent special education costs in elementary schools.

Please support Representative Malia's amendment to restore $3.4 million for Child and Adolescent Mental Health Services (amendment number 580).  These services are vital to facilitate the early identification and treatment of mental health needs of young people.  Early identification is vital for successful treatment.

You can find your State Representative by clicking here.  

Please activate your networks now!  The House is expected to take up health care amendments early next week.  

Thursday, April 23, 2009

For all of those worried that the proposed budget goes too far....

Invest in Our Future: Stop Budget Cuts! 

What: Event & Lobby Day

When: Monday, April 27th 12:00-1:00pm

Where: State House Room 437

The House Budget makes well over a billion dollars in cuts to essential services for our communities!

We need to stop these cuts so we can invest in our schools, infrastructure and social programs to rebuild our economy. 

The debate on the budget starts on April 27th! 

Be there to tell the House:

“We need to raise new revenue to invest in our future and stop these cuts!”

 For More Info Contact:

Harris Gruman SEIU state Council  617-316-0443

Carl Nilsson Neighbor to Neighbor  617-470-5664

Wednesday, April 22, 2009

Follow-up from our friends in the UMass Child Psychiatry Department

The Department of Psychiatry have different Academic Interest Groups, and the Autism/Autism Spectrum Interest Group has created a survey and would like to get it out to as many people as possible to help them.   Please only complete the "survey" if you practice in Worcester County, Massachusetts.
Dear Colleagues:
The Autism / Autism Spectrum AIG would like your participation in the survey listed below.  The group is interested in collecting data that will help them learn where people are located and the types of patients that are seen.  If you have any questions or need more information, please let us know.
Laurie Charlot, LICSW, Ph.D.
Teresa Mitchell, Ph.D.

Tuesday, April 21, 2009

What is Happening Out there: Trolling the News Briefs

As we all meet, and ponder, and discuss the future of the children's mental health system, change is happening out there.  I linked in some articles about the restructuring of the service delivery system at MSPCC the other day:  look what I found today:
  1. The CSA contract is leading one Cambridge-Somerville agency to expand services. "Nonprofit organizations are often the first casualties during difficult economic times, floundering or closing their doors due to the lack of federal and private funds. Not The Guidance Center, however. The 50 year-old nonprofit organization that provides comprehensive developmental, mental health and family services to residents of both Somerville and Cambridge, is thriving. "  The article goes on to say that the agency will be hiring 25-30 new staff to meet the needs of the CSA contract.
  2. Another agency in Pittsfield seems to be picking up the slack in Western Massachusetts, where services are being cut by MSPCC.  "We're working very closely together. There's a lot of details to work out, but I'm fairly confident that we'll do well by all the clients," said Mucia [of the Brian Center. "We're extremely willing to take on the full 450." The center met with representatives from the Massachusetts Society for the Prevention of Cruelty to Children on Thursday to begin negotiations, which will carry over to Monday with a site visit of the MSPCC's office at 53 Eagle St. That site, as well as locations in Greenfield and Brockton, are slated for closure.  
  3. Wareham and New Bedford Schools were recently honored for establishing better linkages with DCF and mental health providers.  "Wareham has provided professional development for all middle and alternative school staff, group and individual counseling and crisis management for trauma-affected students, and adventure-based counseling. The district has also increased communication with collaterals such as the Department of Children and Families, area mental health providers, the juvenile justice system and community-based agencies such as the Boys and Girls Club. Services to parents have also increased and include parent conferences, mental health referrals, and consultations for the family system. The creation of a school and community-based Trauma Advisory Council assists the district in assessing needs and creating strategies to work with trauma-affected students across the district."
So, while there is plenty over which to be distressed in the current environment, there does still seem to be a statewide commitment to making this happen.  Change is happening, and today's news makes some it sound good.

Monday, April 20, 2009

Another Day in the Life: Practice in a Time of Transition

Last week, we had news of new systems of mental health care, of cuts in the state budgets for mental health and other children's services, of CSAs building up and outreach offices closing down.  Today, I was an old-fashioned pediatrician, seeing kids and families with a variety of illnesses at the start of Massachusetts Spring vacation.  It is an interesting time;  the wave of illness that consumes us each winter breaks on the shore of spring (is that what Chaucer meant by "shores soote"?)  I saw croup today, and strep throat,  urinary tract infections and hematochezia (there's a word you don't get to use every day).  In the midst of sorting through some really interesting clinical problems, however, I still found myself wrestling with issues of mental health.  We screened, a little, with 5/5 screens negative.  A girl with poor school performance screened negative on the Y-PSC, but she is already receiving counseling (in home, actually, but not at the SED level).  A toddler boy seems a little slow of speech, an elementary school student meets criteria for anxiety disorder and needs a letter to qualify her for SPED services, brother with depression and substance abuse issues come in for follow-up (both are doing better after initiating regular exercise, and really don't want to go on SSRIs.  So I didn't start them, despite my initial plan).  My SED patients continue to lurk in the background, some getting FST, some unable to reach their therapist or their psychiatrist.  For my patients, the events of last week wash up against the reality of their complex mix of mental and physical health problems.
In the midst of all of that, I have doubts;  doubts about how to choose a treatment plan when the eidence is murky, doubts that we can build a new system in the culture of a shrinking pie, doubts that, even if we build a decent system, we can get our families to navigate it.  I think these things, and then, I get over it.  I remember that, it isn't just about me and my clinical (or political) sense of how to manage this patient or that system issue.  I work with a great group of families and professionals;  together we may actually develop something useful.
More patients tomorrow.

Friday, April 17, 2009

From the CBHI: What's New in Behavioral Health Screening:

My e-mail today had this from the CBHI:
Primary care providers from throughout the Commonwealth recently attended the provider training forums co-sponsored by Boston Medical Center HealthNet Plan, Neighborhood Health Plan, Network Health Plan, and the Massachusetts Behavioral Health Partnership (MBHP), the behavioral health contractor for the PCC Plan.

Speakers Robin Adair MD, Betsy Brooks MD, Karen Hacker MD, and Alison Schonwald MD, experts in the area of pediatric behavioral health screening, presented information on how to implement behavioral health screening in the primary care practice and introduced the newly developed screening tool toolkits, which provide information on 5 of the more commonly used behavioral health screening tools.

The CRAFFT toolkit, developed by the Department of Public Health in conjunction with MBHP and the Center for Adolescent Substance Abuse Research (CeASAR), provides an overview of how to use of the CRAFFT screening tool in the pediatric primary care setting, what to do if the screen is positive, and guidance on how to bill for the administration of the screening tool and any necessary follow-up counseling. The CRAFFT screening tool is currently available on the MBHP website at: under the “For PCCs/Support Materials section.”

The Primary Care Behavioral Health Toolkit, developed for the Children’s Behavioral Health Initiative and the PCC Plan by the Massachusetts Behavioral Health Partnership (MBHP) and the Massachusetts Child Psychiatry Access Project (MCPAP), focuses on how to implement behavioral health screening in the primary care setting and how to use the following four MassHealth-approved screening tools: M-CHAT, PEDS, PSC, and PHQ-9. A section of the toolkit is dedicated to each tool and, like the CRAFFT toolkit, information is provided on how to use the tool and what to do when a screen indicates a member has a potential behavioral health need. The Primary Care Behavioral Health Toolkit can be found at the MBHP website at: under the “For PCCs/Support Materials section.”

Additional information on the requirement to use a standardized behavioral health screening tool when completing the behavioral health component of all EPSDT/PPHSD well child care visits can be found at the CBHI website at
Screening is the easy part, but we might as well do it properly.

Thursday, April 16, 2009

Children's Mental Health Funding in Danger:Call Your Legislator Today!

From the Children's Mental Health Campaign:

The House Ways and Means budget for Fiscal Year 2010 contains significant funding reductions that will have a devastating impact on children with mental health needs.  In particular, the Children's Mental Health Campaign is concerned with cuts to two specific line items:
  • Behavioral Health Consultation for the Department of Early Education (3000-6075): line item eliminated.  
  • Child and Adolescent Mental Health Services (line item 5042-5000): funding reduced by $3.4 million.  
You can help!
Please call your State Representative and ask him or her to:
  • Please cosponsor Representative Pedone's amendment to restore the line item and to restore funding to Behavioral Health Consultations for DEEC (line item 3000-6075).  These consultations have been instrumental in reducing the number of suspensions and expulsions from preschools, and in dramatically reducing special education costs for elementary schools.
  • Please cosponsor Representative Malia's amendment to restore $3.4 million for Child and Adolescent Mental Health Services.  These services are vital to facilitate the early identification and treatment of mental health needs of young people.  Early identification is vital for successful treatment.
You can find your State Representative by clicking here
The deadline for Representatives to be listed as cosponsors is 5:00 pm on Friday, April 17. 
Last session, the Legislature took a major step forward in addressing the ongoing crisis of the children's mental health system in Massachusetts.   Unfortunately, the budget proposal before the House would squander many of the gains made by Chapter 321 of the Acts of 2008: An Act Relative to Children's Mental Health.  While we recognize the difficult economic and financial situation the state is faced with, it is important that we preserve the gains we have made for children with mental health needs.
If you have any questions or feedback from your calls, contact
Matt Noyes  at 617-275-2939. 
And, in a related posting, some other Children's programs are in jeopardy:

Yesterday, the House Ways and Means Committee released its proposed budget for FY 2010.  Unfortunately, the budget contained significant cuts to several children's programs, including Healthy Start and Early Intervention.  You can help by calling your State Representative and asking him or her to:

  • Please cosponsor and support Representative Katherine Clark's amendment to restore $4 million to Healthy Start (line item 4000-0895).  Healthy Start helps low income women access health care during pregnancy and has been instrumental in reducing infant mortality and low birth weight.  Funding reductions to Healthy Start have a profound effect: every dollar cut from Healthy Start adds $8 to the future costs of caring for low birth weight and premature infants, and forfeits the immediate return of 65 cents in federal revenue.
  • Please cosponsor and support Representative Lou Kafka's amendment to restore funding to Early Intervention (line item 4513-1020).  Each year, Early Intervention serves 30,000 children from birth to age three with developmental delays.  9c funding cuts last year have already forced changes in eligibility standards for the program..  The proposed 21% cut in the Ways and Means budget would necessitate further eligibility barriers and the elimination of important programs for extremely vulnerable children.  
Please call your State Representative today - the deadline for them to be listed as a cosponsor is 5:00 pm on Friday, April 17.  You can find your Representative's contact information by clicking here.  If you have any questions or feedback from your calls, please contact Matt Noyes 617-275-2939. 

Wednesday, April 15, 2009

From the Latest Issue of Health Affairs

I love it when a study confirms that what I already knew:

Primary Care Physicians Struggle to Get Patients Mental Health Services
About two-thirds of U.S. primary care physicians reported in 2004–05 that they could not get outpatient mental health services for their patients—a rate that was at least twice as high as for other services, according to a Commonwealth Fund–supported study published by Health Affairs.

Conducted by Peter J. Cunningham, Ph.D., a senior fellow at the Center for Studying Health System Change (HSC), the national study found that more than half of the primary care physicians reporting problems getting mental health services for their patients cited lack of or inadequate insurance coverage, health plan barriers, and shortages of mental health providers as "very important" reasons for the difficulty in accessing this care.

"From the perspective of primary care physicians, the study findings suggest that lack of access to mental health services is a serious problem—much more serious than for other commonly used medical services," Cunningham said.
My favorite finding, of course, was when they looked at pediatricians:
PCP specialty. Pediatricians were more likely than other PCPs to report not getting outpatient mental health services because of health plan barriers (9.2 percentage points higher) and because of a shortage of providers (15 percentage points higher), but not as a result of lack of or inadequate coverage.
So, the bottom line is, coverage isn't enough, when you don't have a system.  Sounds too simple, doesn't it.  That was before I got a little involved with the creation of a new system.  It is bloody hard work.

Tuesday, April 14, 2009

Working Differently in the Mental Health World: What Does It Mean?

A couple of posts last week dealt with closures of offices, and reduction in staff at various locations around the Commonwealth.  While these changes are happening in the context of a generalized economic downturn with a simultaneous drop in State revenues (aka The Great Recession), they may not simply represent a decline in State revenue.  Perhaps, it is the beginning of the realignment of services needed to deliver on the promise of Rosie D, in the context of the a practice environment in which we don't have enough providers to go around.  In that context:
  • Smart organizations are going to need to realign their resources to be able to provide home-based services in a wraparound model.  It makes sense to close satellite offices when we are about to open up CSAs and the provide much service "in the home".  
  • The finding in the Rosie D case requires us to focus attention on the "high-intensity, high need" kids for a while, and, without additional mental health providers, that will require agencies to focus on those services, probably at the expense of those not so severely affected.
  • Re-training people to do wraparound means that there will be fewer "boots on the ground" while we are getting things in place.  That will look like things are getting worse for a while;  our hope is that they get better.
All of this is not to excuse low rates and the administrative snafus that interfere with the provision of mental health services to children.  It does mean, however, that we need to acknowledge that change carries with it a certain cost in "activation energy", and that that cost is not nothing.  We need to hope that, at the end of it all, we are doing things better.  So, as we hear of the changes in the system, think hard with our agency partners about how from the chaos of our current system we can build a system that allows up to effectively address the needs of those that we have been unable to serve in the past.  We need to break down the silos to build up the systems, and the acting of breaking silos is painful.  

Monday, April 13, 2009

Preventing Childhood Mental Illness: Starting Early

I didn't make it to the Massachusetts Chapter AAP's Mental Health Task Force meeting last week; I rehearse on Tuesday nights, and we have a concert coming up.  I apparently missed a great presentation from Early Education for All, an advocacy group trying to operationalize our new understanding of childhood neurodevelopment, that most of our brain growth happens early, and that early traumas are the hardest to erase.  They pointed out that the American Recovery and Reinvestment Act (ARRA) provides an unprecedented opportunity for strategic investments in our state educational system.
Of key importance is investing in evidence-based strategies with proven benefits for children and families. Research demonstrates that high-quality early education improves school readiness and increases academic achievement, thereby lowering educational costs. Low-income children are 40% less likely to need special education or be held back a grade, 30% more likely to graduate from high school, and twice as likely to go to college. These benefits have been shown to carry on into adulthood, and the Minneapolis Federal Reserve Bank has estimated that high-quality early education produces a 16% return on investment.

April 19-25, the 38th annual Week of the Young Child, marks a wonderful opportunity to share this message. This week-long celebration highlights the importance of families, early childhood professionals, and communities working together to support every child’s healthy development and learning. Please join in celebrating this week by urging Governor Deval Patrick and our state legislators to continue to support high-quality early education and early educators in the FY10 state budget. It’s time to ensure that each and every child gets the start they deserve.
I didn't know that Patriot's Day kicks off the "Week of the Young Child".  In any event, check out their website;  it has much good stuff.

Saturday, April 11, 2009

AAP and AACAP Joint Paper on Mental Health Services is Released

From my Academy:

The AAP and the AACAP would like to announce the release of Improving Mental Health Services in Primary Care: Reducing the Administrative and Financial Barriers to Access and Collaboration.  This article should be helpful to advocacy efforts at the local, regional, and national levels. This paper was supported though the Improving Mental Health in Primary Care Through Access, Collaboration, and Training (IMPACT) grant to the AAP from the Maternal and Child Health Bureau. Please click here to learn more about the effort, and here to read the paper.
Also, those of you who missed the Healthy Child Care Consultant Network Support Center (NSC) webinar Integrating Mental Health and Child Care Health Consultation on March 24th can now find it archived in the
NSC website's resources.  Following an introduction by Dr. Phyllis Stubbs-Wynn, state leaders from Illinois and Oregon shared their expertise and experience, and answered questions from participant Watch and listen to the webinar or download the PowerPoint slides and other resources that accompanied the event, including resources from Oregon's CCHC program.   And remember to visit the website often to check for new resources and other information about CCHC initiatives across the country! 

Thursday, April 9, 2009

The Great Recession and Access to Services: What Will Our Capacity Be?

Robbin Miller, a frequent cross-poster on this site, reports that several agencies in Massachusetts have recently closed their doors:   I am interested in knowing more.  Which agencies, how many people?  .  I am not surprised to hear these reports; the economic situation nationwide is dire, and many mental health agencies operate on a very narrow margin.  Details?  This is what I have so far:
Child abuse office to close
By David Pepose, Berkshire Eagle Staff
Updated: 04/01/2009 08:33:16 AM EDT
Wednesday, April 01
PITTSFIELD — The Massachusetts Society for the Prevention of Cruelty to Children is closing three of its statewide facilities — including its lone Berkshire County office in Pittsfield — by July.
According to MSPCC spokeswoman Mary McGeown, the recession is forcing the nonprofit organization to phase out its offices in Pittsfield, Greenfield and Brockton. The Pittsfield office, which primarily treats children with mental health and behavioral issues, has a caseload of 450.

Child abuse nonprofit to close 3 sites
By Marc Larocque
Globe Correspondent / April 1, 2009
The Massachusetts Society for the Prevention of Cruelty to Children is planning to close its offices in Pittsfield, Brockton, and Greenfield.
The organization informed its staffs from those locations last week.
"These sites provide only outpatient services," said Mary McGeown, communications manager for the MSPCC. "We made the decision that we really need to close those facilities and focus our efforts and energies on other locations. We made a decision to close those sites that offer one single service type: mental health services" for outpatients.

I have heard that there was a hearing at the State House yesterday about this;  several people from the Children's Mental Health Campaign spoke, although they didn't seem to directly address this issue, at least in the blog entry on "A Healthy Blog"

Wednesday, April 8, 2009

Looks Like a Good Conference

Got this in the mail the other day:

On behalf of the Baystate Children’s Hospital and the Massachusetts Child Psychiatry Access Project (MCPAP), I would like to encourage you to attend our full-day 5th Annual Conference on Child Psychiatry in Primary Care. This conference will be held at the Log Cabin in Holyoke, MA on May 27, 2009.

This conference is designed for primary care physicians and advanced practice nurses and the mental health professionals who collaborate with them.

This continuing education program will cover a variety of practical topics in children’s mental health and child psychiatry. Topics include services for children with acute mental health problems, a clinical update on pediatric bipolar disorder, the mental health/school interface, living with Asperger's syndrome, sorting out severe behavior problems in very young children, treatments for post-traumatic stress disorder, and ADHD in adolescents.

CME/CEUs will be offered.

For more information about the conference, or to register, please click here.
Please register early because space will be limited.

I hope to see you there.


Barry Sarvet, MD
Medical Director
Massachusetts Child Psychiatry Access Project
Western Massachusetts – Baystate Medical Center

Too bad we have to go to Springfield, rather than Worcester.  The Heart of the Commonwealth was just named the #9 small city in America by Forbes Magazine,  behind Tulsa  and Oklahoma City!

Tuesday, April 7, 2009

A Day in the Life: Making the Squeaky System Work

Our office is down two providers right now, so I have been "in the office" a lot over the last few weeks (and not posting as much as I have been- sorry about that).  It has been instructive, however, to see how the system has evolved over the past two years, when I really started working on the policy changes embodied in the CBHI/Chapter 321/Rosie D reforms still unwinding through the system.  I alluded to these observations in a previous post;  let me try to be more explicit.
1)  Screening and identifying mental health problems is routine, but still not easy.  We hand out our questionnaires, they are mostly completed, we are coding our 96110 codes with the MassHealth required modifiers, but still-  well, I saw a teen yesterday for a check-up, with a PSC that scored around 20 (negative), but who, it turns out, has some alcohol/weed issues, an underaged partying arrest last month, and some issues with anger management (with evidence of trauma on his physical examination) that suggest adjustment disorder or depression.  These details came after a lot of intense conversation, soAfter teasing this information out of him, and as he was walking out the door, he turned to me and said "Oh, and I had my first panic attack last week".  He wasn't interested in a counselor, but did say he would come back and talk with me some more next week.  How am I to get him the treatment he needs, after I talk him into it?  This stuff is really hard (and doesn't really fit into the 20 minute time slot allowed for such things).
2)  Multidisciplinary teams are starting to exist, but no one knows what to do with the CANS yet.  One of my patients is part of the DCF Family Networks program, which has been using the CANS for the past 3 or 4 years to develop strength-based approaches to family support (some information about the project can be found here)  He was in last week, a 5 year old with major problems in functioning in his kindergarten classroom, and his mother told me that there would be a meeting of the team on the next day.   I couldn't make it, but managed to get our care coordinator to go to the meeting.  The team is working together, but having trouble meeting their treatment goals because of the scattering of the services.  There are only 24 hours in a day, and services in South Worcester County are scattered all over the map.  Psychiatrist in Milford, pediatrician in Webster, psychologist in Auburn, behavioral therapist in Worcester, workplace in Marlboro and home someplace else-  by the time that you try to truck the kid to all of those places, you are averaging 200 miles a day on the road.  The child is on MassHealth, so would qualify for Rosie D. services, and has already had a CANS assessment, but no one is sure exactly what the process will be for getting an ICC on the case.  Not clear where this one is going to go;  we will be at the next meeting.
3)  And then, there is the private sector....  with its inadequate provider lists and notion that people can call a psychiatrist and get an appointment.  I have a child with ADHD on stimulant medication, who is giving me an air of having bipolar disorder.  I have not gotten a therapist to see him yet through his insurance, but have engaged MCPAP to at least take a first look.  In the meantime, I have spend several evenings chatting with the family about his behavioral health issues.
Please remember,  in addition to this stuff, my partners ad I still see kids with flu and ear infections and the like-  it is not entirely a psychiatric practice in my office.  Knowing that the reforms are in process, however, has not yet translated into "making my life easier".  Wonder if it ever will?

Monday, April 6, 2009

Rosie D Roll-Out: Mobile Crisis Contracts Announced

I got my monthly Rosie D newsletter yesterday-  if you are not on their list, I strongly suggest that you go to the Plaintiff's Rosie D. website and sign up now - and learned that the contracts for the Mobile Crisis Teams have been awarded.  The list is posted here ;  in three months, these folks are supposed to mobile crisis teams ready to move in response to parent calls for intervention with their "out of control" child.   The interesting part of this is how the word "crisis" is interpreted, and exactly how much intervention will be done by the crisis team.  In my part of Worcester County, the Mobile Crisis Team will be run through Riverside Community Care while the Intensive Care Coordination Services will be run through YOUInc.  The interface between those two services, it seems to me, will be critical to making this whole thing work.

So, congratulations to the all who have stepped forward to serve, and I look forward to working with you to see how these services are implemented in real life!

Sunday, April 5, 2009

April is Here: Three Months Until the New Mental Health Order, and We are Still Trying to Get Screening Right

One thing that has been ongoing is the controversy over screening of newborns in the first six months of life.  The Court, in it's desire to enforce the EPSDT standard, has asked (and when a Court asks, it is not actually a question) that the provider's screen for SED at ALL EPSDT visits.  The problem is that 4 of those visits occur in the first 6 months of life, an age for which we have no tools that y predict a child's future risk of development of SED with any diagnostic certainty.  On the MassHealth approved list of screening tools, in fact, we are given the option of the PEDS at the 1 week, 2 month and 4 month visit.  Bad choice.  So bad, in fact, that the Primary Care doctors just aren't doing it.  Looking at the screening data,  it seems that only 20% of children at those visits are getting bills for screening (as opposed to something approaching 50-60% in older kids.
Our subcommittee met last week,  to try to formulate an alternative for the docs who are just trying to make this work.  Seemed to us we had three options:
1)  Status quo:  Let it stay the way is is now.  Parents unhappy, doctors unhappy, insurance providers unhappy and the judge unhappy.  Not an option.  
2)  Screen for something useful:  Caregiver depression is the obvious candidate;  we have good evidence that parental mood affects child development.
3)  Hold off on screening until we have a decent screener to use.  Ellen Perrin at Tufts is working on it.
There was a lot of discussion, and the verdict is in:  we want to do number 2.  If I can quote our elegant statement:

 [O]ur recommendations for mental health screening of infants under 6 months of age [reflect] the dissatisfaction of both providers and parents regarding the current choice of screening measures for infants of 1,2 and 4 months of age. We agree that the current infant screening measures are an inadequate screen for mental health problems in this age group and should be considered optional rather than mandated. On the other hand, there is substantial evidence that screening for caregiver depression is an effective way to improve the mental health of young infants..Therefore, we recommend that two validated instruments (the Edinburgh and the PHQ2) should be approved for use at the 1,2 and 4 month well child visits in accordance with the mandate currently in place to screen infants and children at every well child visit. Of note, a similar mandate has been implemented successfully in Illinois with Medicaid reimbursement.
Several committee members wanted to skip screening altogether in the "under six month olds", but the group as a whole felt that the opportunity to screen should not be squandered.   We also felt that, at the present time, the best evidence was for screening of caretaker depression (rather than infnat behavior)   Hopefully, they are listening to our recommendations.  Kudos to Mike Yogman for the great language and his leadership on this one.

Thursday, April 2, 2009

From the CBHI: "Help Wanted" or "Someone has to staff this thing"

Sign Up for CBHI Career Forum 

Are you interested in learning about career opportunities in children’s behavioral health in Massachusetts?  The Executive Office of Health and Human Services and CBHI invite behavioral health clinicians to attend
“An Exploration of Careers in a Strength-Based, Family-Driven System of Care”
Monday, April 27, 2009 from 9:00 am – 12:00 pm
 Holy Cross College Campus, Worcester, MA
 Hogan Campus Center Ballroom
Join us to learn more about CBHI and the innovative services that will become available between June 30 – December 1, 2009 for MassHealth eligible children and youth under 21, along with their families/caregivers.  These services are leading to the creation of hundreds of new employment opportunities for behavioral health clinicians who are interested in providing strength-based and family-driven care.  To register, please send an e-mail to with your name and professional association, if applicable.  Please include the words “CBHI Career Forum” in the subject line of your e-mail. Space is limited

I haven't been posting as much lately, because we have had some turnover in the office, and I have been doing a bit more clinical work.  Some interesting observations, on which I might elaborate later:
1)  It is still hard to access mental health services for children in Massachusetts, even through the EMH system.
2)  My families who have been through the CANS still don't know what it means, and the agencies don't seem to know what to do with the information yet.
3)  Mental health and physical health in children are closely intertwined;  it is still not always easy to know which system a family should access.
4)  Sometimes you actually can make a difference.
It has been a busy and interesting time down in Webster.  Hope someone comes to the "career forum"-  you are badly needed.

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