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?

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