Thursday, June 11, 2009

Phase III of the Children’s Behavioral Health Initiative: What Do Primary Care Pediatricians Need to Know

Submitted to the Massachusetts AAP  Forum:

As most primary care pediatricians know, Massachusett’s Medicaid program (AKA MassHealth) in in the midst of a massive reform of the systems of care for EPSDT-eligible children and adolescents with “serious emotional disturbance”.
  Last year, we began screening for behavioral health problems in our practices, and referring those children to behavioral health providers throughout the Commonwealth for assessment and treatment.  For the last 8 months, that system has been assessing those children with a single tool (the Child and Adolescent Needs and Strengths instrument or CANS) to establish a common language for a new kind of treatment paradigm, called “wraparound”, that will be practiced throughout the Commonwealth.  On June 30, the final phase of the Children’s Behavioral Health Initiative begins, as new forms of Mobile Emergency Mental Health Services and Intensive Care Coordination are instituted around the State.  The new system in complicated;  detailed descriptions are available at several websites around the state.  In this article, I want to talk about how this new system will work with you to provide family-centered care for families with children with serious emotional disturbances.

            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:

2. Rosie D:  Reforming the Mental Health System in Massachusetts

3.  Mass Behavioral Health Partnership Online:

4.  Rosie D. and Me: A pediatrician reflects on the mental health of children and the systems that are trying to help them.

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