Tuesday, June 30, 2009
Monday, June 29, 2009
I was poking around the Massachusetts Behavioral Health Partnership's website, and would recommend those of you who want to see what happens next to the Massachusetts Behavioral Health Partnership website, which has assembled a lot of useful information in avery usable format. I particularly like the list of contracted providers (here) and the revised structural slide, which adds complexity to the already complex system. Good luck to the boots on the ground!
Sunday, June 28, 2009
In a little under 48 hours, the final phase of the Children’s Behavioral Health Initiative will be implemented with the start of the 32 CSA contracts across the Commonwealth. Personally, I don’t expect everything to change at once, but, having spoken with a number of the people doing this work, I do expect to see some changes in the way in which services are delivered in Massachusetts. It will not be easy- change never is. But it will be interesting.
I have heard a lot of people trying to frame the various new services in terms of what has gone before. If that is all that we are able to do after the massive political effort that has been mounted in the Commonwealth over the past 4 years, I will be disappointed. I thought that, at this juncture, I might put forth some ideas about how I will be looking at the CBHI to mark success.
1) Are families actually engaged in the process, and is that engagement strengthening their resilience? The bad stuff that we associate with mental illness, such as suicide, homicide, crime and homelessness, is all associated with people who live outside of the protective bonds of families. “Protective factors” such as strong families have been shown to help to prevent those outcomes. If we are not, at a bare minimum, strengthening families, then this effort has been in vain.
2) Are the interdisciplinary teams forming, communicating and collaborating in the care for children with SED, and does that collaboration affect the type and quality of the care delivered? It has been an article of faith among us that collaboration will lead to more efficient allocation of resources because of the avoidance of duplication of effort. We should test our faith; does it actually work in the real world?
3) Are children with SED better able to function in their communities? Whether school, daycare or the YMCA, this initiative needs to be about integrating children into the community. Our success should be measured by some sort of community integration metric; otherwise we are just creating a new set of institutions?
4) Have we created, in the hearts and minds of the Commonwealth, a sense of parity between children with physical handicaps and children with mental illness (and children without any of these things)? This is a truly long-term goal, to reduce the stigma of mental illness to the point where children enter treatment early and are well managed before they develop SED. I have watched with dismay that the word SPED (special education) is often thrown about the schoolyard as an epithet. We cannot allow the same to happen to SED.
So, perhaps I am setting the bar a bit higher than “compliance with the court order”, but we really should be looking at the data that rolls through the CBHI to see if these things are happening. Perhaps the Child Behavioral Health Research Institute envisioned under Yolanda’s Law can do this. When we have de-stimatized family-centered interdisciplinary care that allows children with serious emotional disturbances to function in the community, I will think that we have done something meaningful for the lives of children.
Thursday, June 25, 2009
A Community Service Agency (CSA) is a community-based organization whose function is to facilitate
access to, and ensure coordination of, care for youth with serious emotional disturbance (SED) who
require, or are already utilizing, multiple services or who require or are already involved with multiple
child-serving systems (e.g., child welfare, special education, juvenile justice, mental health) and their
families. In total, there are 32 CSAs across Massachusetts: 29 that provide services in the geographic
region consistent with the current 29 service areas for the Department of Children and Families (DCF)
and three culturally and linguistically specialized CSAs to address the needs of specific cultural or
linguistic groups in Massachusetts. Geographic CSAs and specialized CSAs working in overlapping
areas are expected to collaborate and partner in ways that strengthen services to youth and families.
The chart below is intended to assist potential referral sources, including families, in identifying and
selecting an appropriate CSA to meet their needs. Consistent with the Wraparound principle of family
voice and choice, families may choose from any CSA based on their needs and are not limited in using
the CSA in their geographic area. For the 29 geographically-based CSAs, towns are listed
alphabetically, followed by the (DCF) area, the CSA, the site(s) where services will be delivered, the
referral phone number, and other relevant information if available (i.e., contact person, e-mail address).
A town is assigned to a CSA based on the DCF area office that covers that particular town.
Additionally, the three specialized CSAs, which have tailored their services to engage and serve the
unique needs of their specialized populations, are listed separately at the bottom of the chart, identifying
the towns each covers, the specialty population, the site(s) where services will be delivered, the referral
phone number, and other relevant information if available (i.e., contact person, e-mail address). An
asterisk (*) next to a geographically based CSA town indicates the town is also covered by a specialized
If you have questions regarding this Alert, please contact our Community Relations Department at
1-800-495-0086 (press 1 for the English menu or 2 for the Spanish menu, then #3 then #1 to skip
prompts), Monday through Thursday, 8 a.m. to 5 p.m., and on Fridays from 9:30 a.m. to 5 p.m.
Wednesday, June 24, 2009
Are you or your staff interested in learning more about CBHI, screening and assessment improvements for MassHealth-enrolled children and youth or the new behavioral health services that will begin next month? Key CBHI staff members are scheduled to join other topic speakers at the upcoming Massachusetts Health Care Training Forum (MTF) series being held at different sites around the state in July. Click here for a list of dates, a registration link and to find a forum location near you.
Note: The Massachusetts Health Care Training Forum (MTF), formerly called the MassHealth Training Forum, is a partnership between MassHealth and UMass Medical School. Their quarterly meetings are designed to bring accurate and timely information related to MassHealth (as well as other public assistance programs) to health care and community agency staff serving MassHealth members, the uninsured, and underinsured. For more information about July’s forum, and others, call MTF at (508) 856-4306 or visit their website.
Tuesday, June 23, 2009
Got this on my e-mail today. Interesting, and possibly useful to our task.
ISSUE BRIEF EXAMINES FAMILY PERCEPTIONS OF MENTAL HEALTH NEEDS AMONG
Mental Health Needs of Low-Income Children with Special Health Care
Needs (CSCHN) summarizes a study that compared the prevalence of mental
health problems among CSHCN to family perceptions of mental health needs.
The issue brief focuses on what was learned from a Child Health Insurance
Research Initiative (CHIRI) survey of families of CSHCN enrolled in Medicaid
receiving services in six primary health care clinics in an urban Midwestern
city. Family perceptions of their child's mental health needs were compared
with the results of the Child Behavior Checklist, a standardized tool that
uses parent report to assess emotional, behavioral, and social problems in
children. Data on the percentage of health and mental health problems in
CSCHN in Medicaid and family perception and need for mental health treatment
by age are provided. Policy implications are also discussed. The brief is available at http://www.ahrq.gov/chiri/chiribrf9/chiribrf9.pdf.
Monday, June 22, 2009
You can hear the story here, I will sumarize it for you. Patients, particularly complex elderly patients, are finding that they need an advocate within the system, who understands their needs and desires and understands the multifaceted health care system well enough to guide you through the system. They highlighted two models- one was volunteer retired physicians and nurses who work with hospitalized patient and are able to ask the questions in such a way that the system would respond. The other was what I would call "concierge nurses" who coordinate care for folks in assisted living, helping to keep them out of the hospital. The story ends by pointing out that noone wants to pay to support these services, and suggested that we need data to justify this fairly self-evident cost to the system.
Both of these groups of people do what your primary care physician no longer has time to do; know you so that you can be known. The similarities to the impending ICC program seemed to suggest a similar trap lay ahead for us. As we roll out the CSAs, we need to be sure to collect the data to justify this cost, as we certainly believe that it is part of the cost of doing business.
Patients are here- got to go.
Sunday, June 21, 2009
So, unless my good friend Chris Stille wants to fill us in on the relationship between the Medical Home and the Children's Behavioral Health Initiative, you may see a dearth of postings over the next week- I'll be splitting my time between seeing patients in the office, and camping in the Berkshires. (We are little short-staffed this year, so I'll be in and out of the woods). I may post some things, but I will likely be in a hurry to get back to the woods. So, I wanted to post an image of our usual campsite, so that you all will understand my desire to get back to the woods.
Friday, June 19, 2009
Wednesday, June 17, 2009
In the larger group, others seemed to be more optimistic than were we; they spoke of successful diversion, a comfortable feeling, the strength of collaboration with those that have "walked the walk", PPAL and the strength of parent collaboration. The relationship with the Dudley Court and the availability of respite, the feeling of safety and the support of peers, parents and workers. The development of parents and youth as leaders works. All of these things work, and it is sad to see how our economic fallout will hurt so many families. There is an old saying: "When elephants dance, it is the grass that gets crushed, when the elephants fight it is also the grass that gets crushed". So what do I take from this?
Tuesday, June 16, 2009
Monday, June 15, 2009
Sunday, June 14, 2009
Friday, June 12, 2009
Thursday, June 11, 2009
Phase III of the Children’s Behavioral Health Initiative: What Do Primary Care Pediatricians Need to Know
To understand how this new system will work, you need to understand a couple of concepts key to the system. First is “wraparound”. To quote Bruce Kamradt of Wraparound Milwaukee, “Wraparound is an approach to implementing individualized, comprehensive services within a system of care. Wraparound is not a service or set of services. It is not a type of treatment like multi-system therapy (MST) or functional family therapy. It is a unique way of organizing services and supports individualized for a youth—it is more of a process that puts the family at the center of care”. In a sense, wraparound is remarkable like the system of care we pediatricians have proposed under the Medical Home model. Just look at the essential values of “wraparound” from the Milwaukee model:
- Build on youth and family strengths, not their deficits
- Care should be individualized—one size doesn’t fit all
- Youth are best served in the community
- Youth/families should have access to the services they need, not just what is available
- Services should be provided in the context of the family and families fully engaged in the planning and delivery of services
- Services and supports need to be culturally competent
- Care should be unconditional—plans fail--not youth!
This sounds an awful lot like the medical home to me. This model of care will not be foreign to pediatricians.So, how will this happen in Massachusetts? To understand this, you need to understand two other key concepts in the plan: the CANS and the CSA. The CANS is a tool, that allows the Behavioral Health providers to put the family at the center of the care plan, by focusing on their strengths and needs. Pediatricians don’t do CANS- it is administered at the Behavioral Health Agency to which you have referred your patient. With the CANS in hand, however, that agency is able to decide whether the child is “seriously emotionally disturbed” and qualifies for full “wraparound services”.
If they don’t, they may still benefit from either outpatient therapy or in-home therapy without wraparound services. If they do qualify, however, a care coordinator will work with the family to develop an individual care plan (ICP) that addresses ALL of the family needs. The care coordinator, working for one of 27 brand-new Community Service Agencies (CSA) around the State, will convene a meeting that includes ALL of the significant forces in the child’s life, including mental health workers, school personnel, community workers, DCF and, quite probably, the primary care pediatrician. The care coordinator’s job is to ensure that the family can maximize the effectiveness of these services, and help us to all work together for the benefit of the family. The CSA is the glue that facilitates communication between the various parts of the system, which, as we all know, sometimes do not speak with each other. In the end, this approach has the potential to create powerful synergies for some of our most difficult patients.
Starting on 30 June, we all get to put the pieces of this system together. What can pediatricians do to make sure that it works? Here are a few suggestions:
- Keep screening the children in your practice for behavioral health problems. Our screening efforts are the engine that will make the system work.
- Refer positive screens for evaluation, and learn the language of the CANS. It is the common language for the development of the treatment plans in the new CBHI.
- Comment on the Individual Care Plan that is developed,
- Know your CSA and the be part of the team, so that you can support families as they work through the new system.
For all of us who have wrestled with Behavioral Health issues in our practices, the CBHI represents a chance to help. The plan is complicated, it has a lot of acronyms and it risks becoming another impenetrable bureaucracy. If we can keep families at the center, however, it will allow us to offer hope to families that have had little hope in the past. That, as least, seems worth the risk.
For more information, try these websites:
1. Children’s Behavioral Health Initiative: www.mass.gov/masshealth/childbehavioralhealth
2. Rosie D: Reforming the Mental Health System in Massachusetts http://rosied.org/
3. Mass Behavioral Health Partnership Online: http://www.masspartnership.com/
4. Rosie D. and Me: A pediatrician reflects on the mental health of children and the systems that are trying to help them. http://olddockeller.blogspot.com/
Wednesday, June 10, 2009
- Acronym overload: The folks at the Massachusetts Behavioral Health Partnership put together a great packet of information about the program as it seems to be evolving and included a glossary of selected CBHI terms. 33 of them, starting with APRN and ending with SOC. (The Free Dictionary lists 123 possibilities for that one). There is a lot of detail in this proposed system, and it will be confusing to many. I tried to focus on 4 key bits of jargon: SED, CANS, CSA, and "wraparound" in an effort to keep it simple.
- Capacity underload: People get the model, people understood the sorts of patients that we are trying to manage, but it was very clear that they thought that we were opening Pandora's box, that the number of children eligible for services would quickly overload the new CSAs. Perhaps, but we have to start somewhere....
- Desire for change: This was a group of people like me, who have been banging their heads against the "wall" of mental health services for many years. They are eager to engage the new system, but wary of get getting their hopes up.
Tuesday, June 9, 2009
Monday, June 8, 2009
- The plan for the system is designed to address many of the concerns we have had in the management of children and adolescents with serious emotional disturbances as community-based care has replaced psychiatric hospitals as the standard of care.
- We are making a massive change in a really complicated system. We can predict a few of the places where it is likely to get messy, like identification, communication, coordination, and appropriate level of service
- The new systems will provide better service, but they will be new. Like a new car, it will take us a while to get used to the configuration of the controls.
- The most important thing we can do in the process is listen to the patients. That will keep us on track.
Sunday, June 7, 2009
So, this is my attempt to blog in realtime on iPhone, in a dining room in the west side of ProvIdence with 4 people in and out of the workforce (bank workers, a doctor from Kenya, a transplant from Chicago) We are listening to the Obama video, in which he really focuses on the three principles of his reform-controlling cost, picking your own doctor and getting everyone covered. They are planning a 27 June 'community' event. And he is aiming for the grassroots.In the end, our group decided to meet again next week, to work on using the website to call people and focus their thinking on health care and to work toward some sort of "volunteer" event in conjunction with one of the Farmer's Market's that seem so ubiquitous these days in Providence and Pawtucket.
Ideas included a health fair, maybe along with a farmer's market. People really want to do something. It is hard to type on this thing
People really didn't like the mandate (the Massachusetts plan), and many have had experiences with gaps in coverage, and people spoke of the need to make insurance universally available and accessible the folks on the margins. People liked the idea of Medicare for everyone. There was much concern about how much this was all going to cost and the notion of health care related bankrupcies was a bit scary. People are not sure what they want, but they want it to be easy.
Saturday, June 6, 2009
MassHealth Gets Approval for 5 More New Behavioral Health Services for Youths Under 21
The federal Medicaid agency known as the Centers for Medicare and Medicaid Services (CMS), recently gave its approval of the long-awaited State Plan Amendment necessary for MassHealth to pay for five additional behavioral health services. This follows the agency's previous approval of the new service "Intensive Care Coordination" last December, bringing the total number of approved new behavioral health services to six. Yesterday's approval now gives MassHealth the green light to provide Family Training and Support (“Family-Partners”), Mobile Crisis Intervention, In-Home Behavioral Services, Therapeutic Mentoring Services, and In Home Therapy Services for eligible MassHealth-enrolled children and youths under age 21. Currently, Crisis Stabilization remains the only service in need of CMS approval.
Last October, at CMS' request, MassHealth withdrew its written responses to the federal agency's formal requests for additional information. The withdrawal stopped the CMS 90-day review process, allowing more time for additional discussion and preventing a potential denial of the entire State Plan Amendment (SPA). For the next five months, a number of productive conversations and exchanges took place between CMS and MassHealth. When MassHealth formally resubmitted material in March, CMS requested that MassHealth remove Crisis Stabilization from the State Plan Amendment and re-submit it as a separate SPA. This was to allow continued discussion between CMS and MassHealth regarding outstanding issues on this services. A new SPA containing the Crisis Stabilization service was recently submitted to CMS. A decision should be reached by CMS prior to the service's planned start date on December 1, 2009. We will continue to keep you updated.
Friday, June 5, 2009
- A 10 year child with known mental illness, on three meds, currently doing well in school, whose mother is wondering how long to continue this "cocktail" of medication, which were finally finalized in 3 years ago. "Does he need to stay on the these forever?", she wondered,"When is it safe to change them?" She finds it hard to discuss these things with psychiatrist in the context of the 15 minute medication check; she feels guilty that her fabulous child requires this much medication; she feels safer talking about it with me.
- A 5 year old child with a normal PEDS but a heaping helpful of energy and a strong desire for attention, who has been adopted by an older couple who sort of understand my reluctance to medicate children before they start kindergarten. I've tried FST, but the family was unhappy with that in practice. I will try to refer them to MCPAP, in the hope of getting them hooked up with the CBHI.
- An 18 year old overweight boy with autism, on no meds at present, working with his mother to figure out what comes next. He is pretty well connected with the system, and his mother has opted to give him legal status as an adult.
Thursday, June 4, 2009
- Intensive Care Coordination
- Community Based Acute Treatment
- Family Consultation
- Day Treatment
- Crisis Stabilization
- Family Stabilization