Saturday, May 30, 2009

New Director for CMS: Should be good for Implementing Rosie D.

From simutaneous NEACH and Community Catalyst e-mail blasts:

We wanted to pass along some great news to you: Cindy Mann, Director of Georgetown University Center for Children and Families, has been appointed by the Obama Administration to lead the Center for Medicaid and State Operations (CMSO) which oversees Medicaid and CHIP at the federal level.  Cindy will begin her new position on June 8.  Here is the statement from her blog:  

Last November, excitement over the prospects for real change swept a new President into office and gave hope to many who had long since lost hope that things could get better and that government could do good.  We all have our own criteria for what constitutes "real" or "good" change, but whatever change may mean, the majority of Americans soundly embraced it, even though we all know that change can sometimes be hard.  

For us at CCF, the promise of change has just taken on a new reality.  I am truly honored to have been selected by this Secretary, by this Administration, to lead the Centers for Medicaid and State Operations, otherwise known as "Medicaid" (though it also encompasses CHIP).  It is a great privilege to serve as a public servant in this Administration. The opportunity presented is enormously exciting and more than a little daunting.  Collectively, we have the chance of a lifetime to ensure that every person in America has access to affordable, quality coverage and to make Medicaid and CHIP the best programs they can be.  How can we do anything less?

Since all of the Rosie D. remedy services must pass through Medicaid, it is good to know that she favors a comprehensive approach to child health.

Thursday, May 28, 2009

Notes from the Hearing on H.3586

I am blogging live from the hearing room, although I am unable to post in realtime, so this will appear later. There will be a break in my notes when I go up to testify. The Committee meeting was attended by about half the Committtee as best I can tell. We led off with the stars: David DMaso from Children’s Hospital Lisa Scannell from MSPCC and Lisa Lambert from the Parent Advocacy League. Before our bill came up, Representative Provo spoke of the need to empower Social Workers to be able to make decisions on the children in crisis; licensed social workers on the front line not only make the initial assessment, but need to figure out who can provide the more definitive therapy and should be empowered to deal with it. Then our panel spoke about our bill. Ms. Scannell spoke about the details; the service is clearly defined, the costs are small and the benefits are high. In my view, this is one on the limitations of the bill; there is indeed more to care coordination than collateral contacts, but collateral contacts are part of the business. It is, however, a step in the right right direction. Lisa Lambert spoke of the needs of the families with children with mental illness in the Commonwealth. She spoke of how complicated the system is; how parents have to learn the alphabet soup of agencies and plans and how the service structure is not set up to facilitate communication between providers. Dr. DiMaso spoke of the support of Children’ Hospital for this bill; he spoke of an 8 year old boy in a classroom whose teacher doesn’t know what to do; the psychiatrist is treating the child, but the teacher doesn’t know what the psychiatrist is doing. Shouldn’t the mental health provider talk with the other significant providers in the children’s life? He pointed out the MCPAP program is a collaborative care program that has already started to change the culture in Massachusetts, and that, given the prevalence of the illness, we should really be doing this in cases of mental health care. We need to create capacity for systems to be able to handle the program. He also put in a plug for linguistically appropriate care.

Senator Tolman also stopped in to support the bill; he also found the cost to be very reasonable and he thought that this would support the needs of children. Then is was:

Matt Noyes videotaped our testimony and posted it on YouTube:

Our testimony went well- Catherine Apostoleris of Winchendon spoke of the need for collateral contacts to coordinate care in the context of her school based services, and Toni Poti of the Webster Boys and Girls Club spoke of the need for need to integrate services in the community and how collateral contacts were the first step in that direction. The opposition didn’t speak and the chairs asked remarkably gracious questions. Overall, our bill was well supported by all of this testimony. There may have been more but I stepped out of the room, because I ran into an old college classmate who I haven’t seen in 30 yrs, who is also working in the area of mental health advocacy. Small world. When I stepped back inside, I discovered that someone had taken my umbrella while. Is the moral of the story that you should watch your things while testifying? Still, that is a small price to pay when you are trying to get the system to better reflect the reality of treatment in the children's mental health world.

Matt Noyes wrote a nice summary here; he has pictures.

Wednesday, May 27, 2009

My Testimony on Collateral Contacts

This is what I presented today at the hearing:  comments and your stories are appreciated.

Madame Chairs, members of the Committee.  Thank you for this opportunity to testify in support of An Act Relative to the Coordination of Children’s Mental Health Care.  I am a general pediatrician, an Associate Professor on the clinical faculty of the University of Massachusetts Medical School and have practiced general pediatrics in Webster for the past 18 years.  I am here as a representative of the Worcester Mental Health Network and a member of the Legislative Committee of the Massachusetts Chapter of the American Academy of Pediatrics, both part of the Children’s Mental Health Campaign.

On the basis of my experience and the experiences of my colleagues, I urge you to support this legislation, which will help us to provide better care for our patients by requiring private insurance plans to pay mental health professionals for time spent in the collateral contacts that are essential to the coordination of care for children and families dealing with mental illness.

I know the benefits of collateral contacts because I have had a care coordinator in my office for the last 12 years, who has been able to support families working within our complex and multifaceted mental health system.  That position has been supported by our Maternal and Child Health Block Grant, because the current system of reimbursement only supports direct service delivery, not the collateral contacts needed for care coordination. With the help of our care coordinator, we have been able to assist many families effectively linking care between their homes, the mental health system, the schools, appropriate State agencies and the Medical Home.

 Let me share a story from my practice which will illustrate how collateral contacts allow us to coordinate care for children with mental illness in the context of a Medical Home.  Please note, I have changed the names and details of these stories to preserve patient confidentiality.

Kenny B., is a ten year old boy who came into to see me with his father last fall.  Ken had been diagnosed with ADHD several years ago, using the AAP protocols, and had actually done pretty well with treatment based on some classroom modifications (a 504 plan) and a low dose of stimulant medication. Last spring, however, he started having angry outbursts at school that were very different from the sorts of behaviors he had had earlier in his life- something seemed different.  We referred his family to a behavioral therapist and a child psychiatrist; six months later, he was on a combination of five psychotropic medications, was getting sent from school for Emergency Mental Health evaluations weekly and  had undergone a 7-day inpatient stay.  All of this with minimal discussion between school, psychiatrist, therapist, primary care doctor and inpatient treatment facility.  

We were able to straighten all of this out, with a substantial investment of time and energy by me and my care coordinator (mostly my care coordinator).  We got releases of information to talk to everyone, and spend a fair bit of time talking to his school, therapist, psychiatrist, place of hospitalization. DSS, DMH and his insurance company.  This took time;  while we were working on this, he ended up in EMH again. This time, the family contacted me, and I was able to provide the admitting hospital with a more complete picture of what was going on.    With this information, the mental health professionals were able to appropriately diagnose his psychosis, and began appropriate treatment.  When I last saw the family, things were substantially better.  Collateral contacts and care coordination was the key to unlocking this child’s problem and ensuring that appropriate therapeutic interventions were instituted.

Collateral contacts happen under the current system, in a haphazard way.  We need to begin to set up systems of care that make this the norm.  If this bill had been in effect, it is likely that one of the mental health workers involved in the case would have collated some of this information and therefore the child would have been diagnosed and treated quickly, with much less trauma to the family.

I could tell other stories; many working families with health insurance in Massachusetts have similar frustrating experiences in their struggle to coordinate services for their children, because the “treatment team” has little incentive to talk to one another. It takes a substantial amount of work to piece together information that allows proper treatment of children with behavioral and mental health issues.  Compensating mental health providers for this work will prevent morbidity, help to assure proper treatment, and likely prevent  unnecessary, counterproductive or duplicative services.  It will also encourage mental health professionals to contact us, the PCPs, who often vital information regarding the child and family.  Currently, the only payer supported this sort of service is the Commonwealth of Massachusetts; collateral contacts by mental health workers are covered under MassHealth.  It is time for the private sector to recognize and support the services that make it possible for mental health professionals to work with us to care for the children that they insure.

Tuesday, May 26, 2009

On Behalf of Children's Mental Health: Why We Need to Cover Collaterals?

Collateral contacts-  adults speaking to adults about a child- are a significant piece of the work of doctoring in all medical problems.  About 10 years ago, I saw a girl because she passed out in the lunch room.  She came in with her mother, who wasn't there, and the girl, of course remembered nothing.  In order to get some history, I called the school nurse, who also had not been present.  No history.  Hard to diagnose with no history, so I prepared to order a bunch of tests to "be sure" that the child was OK.  As the family was leaving to drive to the hospital for bloodwork, the school nurse called me back.  She had found the girls with whom my patient had been sitting, and they admitted to her that they had all been playing a game- they took turns hyperventilating to see who could do it the longest without passing out.  Needless to say, the history solved the mystery; I cancelled the tests, and the mother took the child home for a good "talking to".

That's a collateral contact.  Good clinicians and good doctors do it all of the time;  we take better care of patients when we do.  Right now, we don't get reimbursed for it, and most of us talk ourselves out of its necessity.    This is one of the things promoting the silos that are the mental health care system.  We need to make collateral contact a routine part of the practice.

SB 757/H 3586 would mean that mental health workers COULD get paid for what should be a routine part of practice.  It brings us one step closer to an integrated system of care for children with mental illness.

We will see how I do in my testimony tomorrow.  I'll try to blog about the hearing.

Monday, May 25, 2009

Memorial Day Weekend: A Bit of a Digression

As some of you saw, we spent a good part of the weekend in Annapolis and Washington, in which it is not uncommon to see folks in uniform.  Good people, who want to serve and to do their best.  Whenever I saw them, I thanked them for their service.  I don't always agree with what our country decides to do with our armed forces, but I respect those who wish to serve and appreciate the sacrifices that they and their families make on our behalf.  The Vietnam memorial was too crowded to visit; the Korean War memorial was too eery.  Between them, though, was President Lincoln, reminding us that war is ultimately the result of a failure of politics, and that we need to build infrastructure to make war obsolete.  Paradoxically, our servicemen and women are part of that infrastructure.

Thank you to all who have worn the uniform; your service is not forgotten.

(The picture is to remind us all of what a freshly minted Ensign looks like)

Saturday, May 23, 2009

Some Good News: Senate and House Restored Some Money

From the Children's Mental Health Campaign:

Children's Mental Health Successes in the Senate Budget


Thanks to the hard work by many advocates, as well as strong leadership by Senator Jen Flanagan and Senator Karen Spilka, the Senate restored more than $28 million for children's mental health. 

  • Behavioral Health Consultation for the Department of Early Education (3000-0675): line item restored, $1 million in funding provided.  
  • Child and Adolescent Mental Health Services (line item 5042-5000): $2.5 million in funding restored.  
  • Children's Behavioral Health Initative / Rosie D. (4000-0950): $25 million in funding restored.

Particularly in these difficult economic times, the restoration of this funding is something to celebrate.  

Moving forward, the House-Senate Conference Committee will have to decide on the appropriate funding level for Child and Adolescent Mental Health Services as the House level is $900,000 above the Senate.  

Please call (and ask your networks to call) your State Senator to thank them for restoring children's mental health funds and to ask them to support the higher House funding level for line item 5042-5000.  

You can find your State Senator by clicking here.  

If you have any questions, please contact Matt Noyes at 617-275-2939 or  

Friday, May 22, 2009

While I am away: Some Suggested Reading and a Request

A colleague (thanks, Rebecca) pointed out to me that this month's issue of Health Affairs is devoted to mental health, and it is indeed chock full of interesting articles on things like mental health parity and comparative effectiveness research.  Check out their blog here,  and take a look at the issue through your library.

Off to the graduation (and to hear the President give the graduation address) now-  it is a beautiful day in Annapolis.
Graduation was brilliant- the mids threw their hats into the air and the President gave a good speech (and shook every hand- my nephew has touched a President!).  After graduation,  I was thinking about next week;  I am supposed to be  one of three from Central Massachusetts testifying on Wednesday's hearing on the new mental health bill, which finishes last years work on reforming mental health care outside of the Medicaid system.  This is the notice we got from the campaign.

Collateral Contacts Hearing on Wednesday, May 27


Next Wednesday, the Mental Health and Substance Abuse Committee will hear testimony on H 3586, An Act Relative to the Coordination of Children's Mental Health Care.  

This bill is the Children's Mental Health Campaign's top legislative priority for the 2009-2010 session.  

Click here for more information about the bill.

The hearing will take place at 1:00 pm in Room A2 of the State House.  

The hearing is open to the public and all are welcome to come.  

If you are interested in submitting testimony, please contact Matt Noyes at 617-275-2939 or  

I can think of many reasons to pass this legislation, but the most important is to recognize that coordination of care is the most important part of dealing with children's mental health; without it, too many pieces of the system work at cross purposed.  If you have thought or insights on this that you would like me to share, leave a comment and I'll incorporate it into my testimony.

Thursday, May 21, 2009

From MCPAP: Useful information

From the folks at MCPAP:

According to a recent study published in the New England Journal of Medicine, both cognitive behavioral therapy (CBT) and sertraline (Zoloft) reduce the severity of anxiety in children diagnosed with anxiety disorder.  The study goes on to show that a combination of the two therapies show superior results.

How can a primary care clinician actually know whether the therapy that his/her patient is receiving is true CBT?  Many therapists state that they practice CBT techniques.  However, few have been formally trained and supervised to administer CBT.

Our newly designed website contains an article which illustrates the differences between CBT and other therapies.  This article written by Sara Brewer, MD, child psychiatrist at our Baystate MCPAP hub, can be found exclusively in the Spotlight section of our newly designed website at

If you missed our forums on the MassHealth mandated behavioral health screening tools, be sure to download a copy of our Primary Care Behavioral Health Toolkit available at our new website.  Also available on our website is the CRAFFT toolkit (acronym) for Car, Relax, Alone, Forget Friends, Trouble).  The CRAFFT screens for substance abuse

Our newly designed website also contains helpful information and many links to behavioral health resources.

 In our “Services” section, we explain what services MCPAP provides to primary care clinicians.  We also include information about our school pilot program and our screening tool consultation project. The “Find a Provider” directory contains links to MassHealth and commercial insurances.  We also included a form which primary care clinicians can fill out if they want more information about enrolling with MCPAP.  Our “Clinical Reference “ directory contains links to an extensive array of resources that a primary care clinician may need when treating children with behavioral health needs within the primary care setting.  These include medication guidelines, clinical practice guidelines, state agencies and more.  Our “Screening Tools” page contains resources and links for behavioral health screening within the primary care setting.  The “Diagnosis” section contains clinical guidelines, rating scales, and parent information and handouts for the following diagnoses: ADHDanxiety,  autism/PDD/ASDbipolar,  conduct disorderdepressioneating disordersobsessive compulsive disorderoppositional defiance disorder,post traumatic stress disorder,  schizophrenia, and substance abuse.  The “Behavioral Health Events” page currently provides information about the upcoming MCPAP Child Psychiatry in Primary Care Conference to be held in Holyoke on May 27, 2009.  Also you may find information about the upcoming forums titled How Primary Care Clinicians Can Help Patients Access the New Children’s Behavioral Health Initiative Services to be held on June 10, 2009 in West Springfield and on June 16, 2009 in Waltham at the Massachusetts Medical Society.

If you have feedback/comments/questions regarding our new website, please send them to

New website does look pretty!

Wednesday, May 20, 2009

The Sincerest Form of Flattery

If imitation is the sincerest from of flattery, then the Massachusetts Behavioral Health Partnership should be flattered.  This from Nationwide Children's Hospital sounds very familiar:
"To help empower pediatricians and family doctors, pediatric psychiatrists and mental health specialists at Nationwide Children’s have developed a program called the Telephone Decision Support Service which provides primary care doctors with a second opinion for diagnosing and managing mental health problems in children.

When presented with a patient whom general practice doctors feel may be suffering from a mental condition and could benefit from prescription medications, the doctor can contact an on-call psychiatrist or advanced practice nurse at Nationwide Children’s to discuss the case. After hearing the doctor’s findings and opinion, the decision support professionals offer insight as to course of treatment."
Sounds an awful like the MCPAP program.  While we in Massachusetts have our problems, it is nice to see others benefitting from our solutions.

I'm working on my talk for the upcoming "Rosie D" forums today, and planning a trip to the Naval Academy for my nephew's graduation on Friday- if I don't post, have a good Memorial Day weekend.

Tuesday, May 19, 2009

The Children's Mental Health Campaign continues to speak out!

Help Protect Children's Mental Health in the Senate Budget
Last week, the Senate Ways and Means Committee released its budget proposal for FY 2010. Unfortunately, there are significant cuts to programs that provide vital services to children with mental health needs. 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 three 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.
- Children's Behavioral Health Initative / Rosie D. (4000-0950): underfunded by $25 million.
You can help!Please call (and ask your networks to call) your State Senator to ask him or her to:
Please support Senator Jen Flanagan's amendment to restore the line item and $1 million in funding for Behavioral Health Consultations to DEEC (amendment EHS 617). 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 Senator Karen Spilka's amendment to restore $3.4 million for Child and Adolescent Mental Health Services (amendment EHS 500). 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.
Please support Senator Jen Flanagan's amendment to restore $25 million to the Children's Behavioral Health Initiative (Rosie D.) (amendment EHS 630). The full implementation of CBHI is key to ensure that Medicaid-eligible children with severe emotional disturbance are able to access community-based care.

Please activate your networks now! The Senate will debate the budget this week.

Give Your Input into DOI Regulations on Intermediary Care - Deadline 5/27

The Massachusetts Division of Insurance (DOI) is currently accepting comments on proposed regulations related to Intermediary Care for children with mental health needs. DOI has reached out to the Children's Mental Health Campaign and has asked for our input. If you are interested in giving your input, please contact Megan Mahle with Health Law Advocates at or 617-338-5241.

Monday, May 18, 2009

Connecting the dots: A Breakfast with the First Lady (of Massachusetts)

I had the opportunity this morning, amidst the budget cuts to Children's Mental Health and the roll-out of the CSAs, to join the Medical-Legal Partnership|Boston breakfast, in which advocates for  health in the Boston legal community were honored and the needs of the poor were highlighted.  It was wonderful to see the energy in the room;  Massachusetts now has medical-legal partnerships in Boston, Lowell, Lynn and Holyoke in addition to our site in Worcester, and many of those sites are connecting to the pro-bono community, to assure that patients have access to the care that they need to keep families healthy.

The keynote speaker was Diane Patrick (wife of Governor Deval Patrick) who, as a former schoolteacher and attorney, has an acute understanding of how, for the poor, small obstacles can become major problems.  She spoke of a number of cases:  a woman fleeing domestic violence who couldn't get health benefits for her child because of fears about unresolved immigration issues, a woman who didn't know how to defer a state hearing to attend her mother's funeral, a family working through the issues of transition to adulthood of a severely disabled youth- each presented a problem that required specialized legal knowledge in order for the law to fulfill its intent.  She sees the benefit of a little legal input early in the process, and how getting access early saves the family from a lot of grief and the Commonwealth from a lot of problems later in the process.  Her remarks were a fitting backdrop, reminding us all why it is not a good idea to let the edifice collapse under the weight of the state budget crisis.

And so it goes.  Mental health access is what this blog is all about, but mental health services are really just a small part of the fabric of services needed to allow children to be, and to become.  Ms. Patrick gave us the rationale;  her husband needs to help us to figure out the means.  Which , by the way, is why there is a "STOP THE CUTS" rally at the State House today.  Read about it HERE.

Saturday, May 16, 2009

Haven't We Been Here Before? The Budget AGAIN

Matt Noyes does such a great job of wording these alerts, I find it easier to cut and paste them.

Help Protect Children's Mental Health in the Senate Budget


On Wednesday, the Senate Ways and Means Committee released its budget proposal for FY 2010.  Unfortunately, there are significant cuts to programs that provide vital services to children with mental health needs.  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 three specific line items:

  • Behavioral Health Consultation for the Department of Early Education (3000-0675): line item eliminated.  
  • Child and Adolescent Mental Health Services (line item 5042-5000): funding reduced by $3.4 million.  
  • Children's Behavioral Health Initative / Rosie D. (4000-0950): underfunded by $25 million.

You can help!

Please call (and ask your networks to call) your State Senator to ask him or her to:

  • Please cosponsor and support Senator Jen Flanagan's amendment to restore the line item and $1 million in funding for Behavioral Health Consultations to DEEC.  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 cosponsor and support Senator Karen Spilka'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.
  • Please cosponsor and support Senator Jen Flanagan's amendment to restore $25 million to the Children's Behavioral Health Initiative (Rosie D.).  The full implementation of CBHI is key to ensure that Medicaid-eligible children with severe emotional disturbance are able to access community-based care.  

You can find your State Senator by clicking here.  

Please activate your networks now!  The Senate will take up budget amendments next week

Friday, May 15, 2009

Another Conference Call: Today

Reminder: CANS Conference Call Today at Noon

If you use the Child and Adolescent Needs and Strengths (CANS) tool, you are encouraged to join CBHI this Friday at noon for a conference call to discuss the newest version of the CANS on-line application. Jack Simons, Assistant CBHI Director, CBHI Business Analyst Mary Jane Iltz and Kirk MacAulay from the Virtual Gateway will be available to discuss using the newest version of the CANS on the Virtual Gateway, where to find instructional resources and how to get the most from the updated CANS. We hope you will join us for this informative hour.

CANS Conference Call Information
Date: Friday, May 15, 2009
Time: 12:00 pm - 1:00 pm
Phone: 866-565-6580
Passcode: 9593452

Please call at least 5 minutes before the conference call begins. In addition to asking questions "live" during the last 30 minutes of the call, questions can be forwarded in advance to .

Thursday, May 14, 2009

The meeting is on: What's up with the CBHI? (Updated)

This description of our recent session does not capture all of the richness of the discussion; these impressions are mine, and reflect my conscious and unconsious biases in this matter. The nice thing about a webblog is that I can edit it, to reflect your comments- PLEASE append your thoughts, corrections or disagreements as comments to enhance our discussion and understanding of this complex matter. David

The meeting was well attended-  clearly the cookies were the draw.  Jack Simon began by asking is the 15 or 20 attendees how much they knew about the lawsuit and what we would want to talk about;  the group all said that they were quite knowledgeable about the lawsuit and wanted to move to a discussion of what is going on.  We began with a disclaimer; everything is in flux, all of what we are doing is in response to a court order and many of the details are subject to that negotiation.
First, Jack reviewed the revised timeline:
1)  Intensive Care Coordination, Mobile Crisis Intervention and Family Partners are going into effect on June 30, 2009.
2)  The other services will be phased in over the next 5 months.  While the final Federal approval of the State Plan Amendment is not done, the folks at the CBHI believe that all of the other services are likely to be approved (maybe not  Crisis Stabilization Services, but the rest seem to be on track).  We will know for sure when the Federal government releases its response.
Intensive Care Coordination will require a determination of "SED" status.  Each of the other services will have a performance specification and a set of medical necessity criteria, which are currently being developed, negotiated, and  will all be publicly available.
Some of these "new services" are really new;  some will actually look like things that we already have:
  • In-Home Therapy looks a lot like our current FST program, but will last some of the "crisis" component of the current FST programs.  He thinks this will be very useful for troubled adolescents.
  • In-Home Behavioral Services is different.  It is conceptualized as specifically oriented at behaviors that have not responded to "center-based" behavioral therapy.  He sees this as working for kids with specific problems like head banging, that needs operant conditioning.
  • Therapeutic Mentoring Services:  This a new, different and not clear about how this will work.
****  I lost internet access for a while/ some text was lost in translation********
If memory service, my internet access failed during a discussion of how the new emergency services will work.  Jack expects that families will really value the way in which that 72 hour assessment will help them to avoid long delays in the emergency room.

As far as eligibility,  Jack told us that they have been collecting the CANS data from across the State, and they were surprised to see that 90% of the CANS done so far show a child meeting criteria for SED status.   It seems a pretty low bar to actually qualifying for all of these services, and suggests that there will be a whole lot of ICCing going on.

In Worcester County, Families and Communities Together (Community Healthlink (CHL) and LUK (I can't find an explanation for the abbreviation) are managing Worcester East, West and North CSA contracts.  Youth Opportunities Upheld (YOUInc) is handling South Worcester County.   These CSAs will be providing a “wraparound” model, developing a family centered plan that helps the family set and meet goals that they set over the course of the year.   CHL and LUK plan to start with 100 slots in Worcester (2 sites) and 30 slots in North County (3 sites in Fitchburg and .  They hope to subcontract with smaller, community-based organizations throughout the county.   YOUInc is planning to start with space in Southbridge, and looking of space in Webster.  Paul Carey is running the program, based on his experience in the Family Networks Program, a DCF based program that uses the CANS to support a strength-based approach to families.

CSA Trainings on "wraparound" are happening at present;  one of our participants was inspired by the degree of expertise that is already present in the State.   Jack thinks that Central Massachusetts actually has a leg up on the process, because of our experience with the COC program.  He also thinks that the CSAs with be working with   a population of kids with a broader spectrum of problems, not all of which will be as severe as the kids in the various pilot programs such as MSSPY and CFFC. 

Questions were raised about the “kids under 5”, many of whom don’t meet the SED criteria, and where we can send them for evaluation and treatment.  Several of us saw that as a gap in services.  Jack saw one of the functions of the CSA as trying to identify gaps in the services in the area, and that there will be a committee to interface the CSA with the community.  We had some discussion of the need for these committees to have some control over the local process.   We also spent some time discussing the process for getting informed consent for the sharing of CANS information, which is difficult and problematic.  Some families don't want to sign the consent to share information;  Jack reminded us that we should focus on getting the families services that they need even if they don't sign the release.

Jack remains optimistic;  he  thinks that the CSAs that will be successful are the ones that give their community partners and family partners a level of control within the system, and the ones that operate from an expert point of view will be less useful.

The impressive thing about the discussion was the degree of focus on the process, on the degree of cooperation that this going on within the State.  A lot of concern about “where all of the people are going to come from”.   They are doing career forums and other mechanisms for getting the word out about these services.

What does the system need?

1)  Referrals:  In Worcester and North Worcester County, referrals should go through the developing Families and Communities Together CSA at 508-856-5223

2)  Community Advisory Group:  Getting a group together to provide advisory services will be a challenge.

This whole thing is remarkably complicated;  the state is doing a great job of facilitating this complex process.


Right after I wrote this, I got my monthly (sort of) newsletter from the Center for Public Representation.  You can access it here.  They posted the definitions and specifications for the various kinds of services to to be offered, and the "medical necessity" criteria for each service.

All starts in 45 days.

Wednesday, May 13, 2009

General Membership Open Meeting Today

Greetings, Members of the Worcester Mental Health Network:

I am typing this e-mail on a beautiful spring day, thinking how am I going to convince people to come to our General Membership meeting at the Central Massachusetts AHEC on 37 Harvard St., Worcester MA on Wednesday, May 13th at 4 PM.  Our guest will be Jack Simon of the Children’s Behavioral Health Initiative, who will be filling us in on what is going to be going on when the next phase of reform hits in July, with the unrolling of the CSAa and the Wraparound services.  We have a number of questions that we are hoping he will address, most of which are outlined below.  If you have others, leave then on the blog.
  • - How is this going to work REALLY?  What are you hearing from different parts of the State?
  • - How are we going to get all of those people in the room?  Timing and transportation will be very challenging.
  • - Small caseloads- how do we keep it small? The caseloads planned are higher than what are usually seen in the Wraparound model.
  • - How is the training going to be done?  
  • The clinicians need to be able to work at various levels of service within the system, in order to assure continuity of care.  Staffing and supervision will also be remarkably tricky.  How can this be done within the budgeted resources?
  • - How can the ICC coordinate with the other teams (IEP, DCF, Court)?
  • - How does the CANS fit it into all of this?
If the strength of our speaker is not sufficient to bring you to the meeting, then I promise that, in addition, there will be cookies.  Hope to see you there.

I'll update this later, to see how our discussion goes.

Tuesday, May 12, 2009

Is half a "Wrap" better than none?

We will be chatting with Jack Simon tomorrow about the Rosie D. implementation, and I am certain that many issues will be raised.  One, however, was raised today in an e-mail, and I wanted to reflect on it a bit.  One of our colleagues, who cannot be at tomorrow's meeting, wrote:

As usual, I can’t attend – I’ll be at [away]...  but I want to make a couple of comments, just in case you might find them useful. ... I’ve been going to a lot of meetings about the CBHI.  In that process I’ve learned there really won’t be true wraparound services – not a full wrap program.  And as of a couple of weeks ago, the state still hadn’t completed negotiations with the feds about what services will be supported by Medicaid.  I believe that’s still up in the air.  The CBHI folks I’ve met with are optimistic, but it’s not a done deal.  As I understand it, the agreement with the plaintiffs is that the state won’t have to provide any service that isn’t covered by Medicaid.

My instant reply was "Isn't half a wrap better than none?"  (I considered "A half-wrap in hand is worth two in the bush", but it didn't flow).  Our colleague is correct:  what we have been authorized to do so far is to provide Intensive Care Coordination.   Family Partners and Mobile Crisis Services,  Behavior Management and Therapeutic Mentoring; In-Home Therapy; and Crisis Stabilization have not yet been approved as services by CMS, and can't really start until they have been.  So, how does an agency plan to implement these services without that approval?  And what does that do to the effectiveness of the wraparound model of care?

I think that the short answer is "We don't know".  The effectiveness of the model is not well established despite it's popularity.  In a recent article in the Journal of Behavioral Health Services and Research, Bruns, Sutor and Leverantz-Brady wrote:

"The wraparound research base is still “on the weak side” with respect to utilization of rigorous designs. Nonetheless, results of evaluation studies, success stories from individual communities, and clear popularity with communities and families have led to wraparound’s inclusion in two Surgeon General’s reports, and the discussion in the research literature of its integration with evidence-based practices."

Popularity with families and communities is the key to the political success of this program and the key to that success is the relationships built between the treatment team and the family.  So, as long as the program has the ICC situated to build those relationships, than I really do believe that half a wrap is better than none.  Way better.

Monday, May 11, 2009

Speak Now for Kids: A Note from a Colleague

By now you've likely heard of the Speak Now for Kids campaign, a movement to raise our voices for children's needs in health care reform.  It is a really well done campaign - very tech savy.  For those of you involved in residency training it makes a great AM or noon talk to - they even have slides you can use.  So please do this - we have until May 22nd.  I've drafted something here you can tailor/forward to your colleagues (and friends) asking them to do the same:  

I am writing with a great, EASY way to advocate for kids in the health care reform debate going on in Washington DC as I write.  Please join over 2,300 people who have raised their voice on this issue - pediatricians, moms, and kids themselves.  

Speak Now for Kids, is a campaign brought to you by National Association of Children's Hospitals, in partnership w/the Children's Defense Fund, American Academy of Pediatrics, March of Dimes, Children's Health Fund and First Focus.  Just go to  to make your voice heard, leave a testimonial, upload a video, find things to add to your FaceBook, ways to Twitter, etc.

If you are looking for inspiration and want to see what others have said go to for the "Dashboard" of this exciting movement where you can see state by state who is saying what. 

Best, Lisa

Lisa J. Chamberlain, MD, MPH
"An ounce of action is worth a ton of theory." Engels
Assistant Professor of Pediatrics
Stanford School of Medicine
Lucile Packard Children's Hospital

PS.  In case you have any doubt that the time is now, take a look at the NY Times Health Blog here.  The politics are lining up in a really interesting way.

Sunday, May 10, 2009

Sometimes Things Actually Work Out

The summer camp/ kindergarten/4th/7th/10th grade physical exams started up last week, bringing back a number of children that I don't see very often in for examination.  That is, of course, the very group of kids that we thought would be most in need of screening when this all began, right?  So, one morning last week, I went into to see a 10 year old boy in for his annual physical.  When I looked in his chart, I saw that we had last seen him in January 2008, when his PSC scored a 31 and he was noted in the chart to be in need of an ADHD evaluation due to poor school performance and high energy behaviors.  His mother had some troubles, as had his older siblings, and we did refer him to one of the local counseling agencies.  In the chart, it appeared, he had had one appointment with the therapists, but no more and he had had never made it back to us for a pschopharm evaluation.
My memory is sometimes faulty, but I quickly realized that the father in the room was the father on one of my other patients, and that this patient has been placed in foster care.  The father was a model foster parent; calm demeanor, clear rules, fair administration and- well, while to lad is still having some difficulties, he is now a 21 on the PSC and the school has finsihed an assessment that this young man needs help, but should be able to make it in the world.  He was a charming boy, talkative about everything, enjoying school, eager to see his mother and his biological family and really enjoying his life in foster care.  He had blossomed.  The problem behaviors of last year had responded well to a change in environment;  therapy and external rules thad obviated the immediate need for medication, although genetics and adolescence may bring us to reconsider those ideas.  He really likes is "foster brother", a patient of mine who, prior to this change had been an only child.
A cure- doubtful.  But a lot of times, a change in environment is as helpful as psychopharmocology.  I thanked the father for taking in this wayward soul, and his response was, while this may seem like altruism, in truth is was something that they could do relatively easily and that they were happy that their biological child had a "brother" with whom to play.
Nice when it works out, even if the CBHI can't claim full credit for the outcome.

Saturday, May 9, 2009

Speak Now for Kids

A group of pediatric advocacy organizations are collecting stories about about kids and how the system is going to affect them. Please click here to leave your testimony. This is what I wrote.

For the last 18 years, I have been privileged to work with parents and families in and around Webster MA to create a medical home for children, regardless of the ability of their parents to pay for care. What does that mean? For us, it meant understanding the needs of the communities that we serve, remaining focused on an ideal that is not fostered by our current systems of care and engaging in partnerships with parents, families, community agencies and always with the children. Our goal has been and continues to be to help our children to grow up healthy and that health is more than the absence of disease: emotional and developmental health is as important as physical and dental health. We have aggressively pursued that goal over the years, by engaging with parents in the office, on the telephone, in the schools and even sometimes in their homes. We have created teams and coordinated care, assuring that all those caring for a particular child are in communication with each other. We have started programs: adolescent clinics, Reach Out and Read programs, car seat loan programs, walking groups and school health programs. We have cared for more than 10,000 children and adolescents over my tenure in the practice, and we have helped many through some very difficult times. We want to be able to keep doing this good work. Health reform is an opportunity to address many of the barriers that we have encountered in our struggle to provide a medical home in South Worcester County Massachusetts. Here are a few things that we should do:
  1. The system should emphasize primary and secondary prevention, and that needs to be reflected in the way physicians are paid. Well care, immunizations, developmental screening, preventive mental health care, dental care and prophylaxis all need to be covered services, and the conditions that we find in our screening need to be addressed through treatment. 
  2. The system should encourage for coordination of care, whether through the payment of non-physician staff to coordinate care or incentives to establish electronic links among the referral teams. 
  3. The system should not intimidate parents who are seeking care, at the front desk, in the exam room, on the telephone or in the room with a physician. Parents have too much as stake to be forced to deal with an inpenetrable system. 
  4. The system should understand that parents need different things than do adults: time and reassurance on the phone, understanding of perception of pain, a EMR that can take the contact information for divorced parents. 
I've been blogging about these sorts of issues for the post 2 years. It will not be easy to build this new system. But we can do it. Yes we can.

Friday, May 8, 2009

Conference Upcoming

Full disclosure:  I am to be the speaker for this event.  Hope to see you there. 

Behavioral Health Screening in the Primary Care Office:

How Primary Care Clinicians Can Help Patients Access the New Children’s Behavioral Health Initiative Services

Sponsored by MBHP, UMass and MassHealth

A free training program for physicians,

physician assistants, nurse practitioners, nurse

midwives, and registered nurses

In December of 2007, MassHealth introduced a new mandate requiring primary care providers to use an age-appropriate, standardized behavioral health screening tool from the list of MassHealth-approved tools when completing the behavioral health component of EPSDT/PPHSD well-child care visits. Once a child has screened positive in the primary care setting, it is important for primary care providers to know about available behavioral health services for children and how to access these services. This training program is designed to introduce primary care providers (physicians, physician assistants, nurse practitioners, nurse midwives, and registered nurses) to the network of new Children’s Behavioral Health Initiative (CBHI) services for children, planned to be available 6/30/09.(* If approved by the Centers for Medicare and Medicaid Services) New services planned to be available* across the state include:

  • Intensive Care Coordination (ICC)
  • Care Giver Peer-to-Peer Support/Family Partner
  • Mobile Crisis Intervention (MCI)

Training Objectives

At the program’s conclusion, the participant will:

  • be able to describe the new Children’s Behavioral Health Initiative (CBHI) services planned to be available 6/30/09 (if they are approved by the Centers for Medicaid and Medicare Services) and how to refer to these services;
  • be familiar with the network of providers across Massachusetts available to provide these services to children who need them, particularly the new

Community Service Agencies (CSA) for your

practice area; andSpeaker

David Keller, MD, is Clinical Associate Professor of Pediatrics at the University of Massachusetts Medical School and Medical Director of Family Advocates of Central Massachusetts, an HRSA-funded, medical-legal partnership for children in Worcester County. Dr. Keller is a regional facilitator for the American Academy of Pediatrics’ CATCH (Community Access to Child Health) program and was recently elected Treasurer of the Board of the Ambulatory Pediatric Association. He served for eight years as the Pediatric Director of the Community Faculty Development Center, a 15-school collaborative program for the development of community-based clinical faculty in New York and New England, and he is currently serving as facilitator of the Community Pediatrics cohort of the Pediatric Academic Societies Educational Scholars program. His work in faculty development and advocacy training has been presented at national and international meetings and published in peer-reviewed journals. For the past two years, Dr. Keller has been working with Health Law Advocates and the Worcester Mental Health Network through a Physician Advocacy Fellowship by the Center for Medicine as a Profession to improve access to mental health care in Massachusetts. He has been blogging his experience on the web site “Rosie D. and Me” at

Training Dates and Locations

West Springfield - Wednesday, June 10, 2009:

Clarion Hotel and Conference Center of West Springfield

1080 Riverdale Street

West Springfield, MA 01089

Waltham - Tuesday, June 16, 2009:

Massachusetts Medical Society

The Conference Center at Waltham Woods

860 Winter Street

Waltham, MA 02451


To register for this free meeting please fax this form to Deborah Stark at (617) 350-1982.

If you have questions, call (617) 350-1956.

Please register no later than five days prior to each training date.

I (we) will attend:

  • June 10 - West Springfield *
  • June 16 - Waltham *

* Continental breakfast served 7 - 7:30 a.m.

Program 7:30 - 9 a.m.

Please print legibly.

Attendee name(s):  _______________________________



Practice name:  _______________________________




Phone number:  _______________________________

Fax number:  _______________________________

E-mail address:  _______________________________

Visit the Children’s Behavioral Health Initiative (CHBI)

web site:

understand the documents that primary care

clinicians will receive from certain behavioral health

providers, such as the Child and Adolescent Needs

and Strengths (CANS) tool and the Individualized

Care Plan (ICP).

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