Friday, July 31, 2009

Health Care Reform: The AMA Doesn't Speak for All of Us

80 years ago or thereabouts, my profession of Pediatrics separated from the AMA and supported the government in its efforts to improve the health of children through public interventions like immunizations and WIC. I was please to see us on the right side of this issue as well; check out or just watch the video.

Thursday, July 30, 2009

End of Month 1 of the New Mental Health Order: How Are We Doing?

So, my mini-vacation ended on Tuesday night, and, as you may have noticed, I did not rush in to post something. What is up, you may want to know?
First, there is the "back to work" shock: there really is a lot to do. Many small details of packing and moving and leaving needed attention, and I spent a good chunk of Wednesday attending to them. I may have been able to post, but I didn't have much to say.
Second, there is guilt- I missed the first Systems of Care Meeting for South Worcester County. That clearly would have been something to blog about-but I was in Worcester, and I needed to be in Douglas after that, and I couldn't figure out how to integrate a 4:30 PM meeting in Southbridge into that schedule. I hope that it went well, but I just couldn't get myself out there.
Third, there is the whole "national health insurance reform" thing going on- it is just a little distracting.
Still, these are excuses. The fact of the matter is that today was just not a major mental health sort of day. Or was it? I did get some records from a therapist about a child about whom I am quite worried. Child is a grader schooler, having outbursts of anger and rage, that have gotten him kicked off of the school bus and are really interfering with what he can do. That family saw a therapist who felt that it was all ADHD (and wanted us to medicate the lad). I am not so certain of the diagnosis, and, since mother is having trouble with rides to appointments, I sent them to the CSA in the hope of getting some care coordination. Guess there are always mental health issues, except when I am asleep.
Speaking of which, I must sleep now. Later.

Monday, July 27, 2009

Systems of Care Still Want You!

I'm still technically on vacation, so I haven't been as active the last few days. Apparently, the initial systems of care meetings are starting to happen. Anyone been to one yet? Another one is going on on Wednesday.

For the record, the Folk Festival was great.
This is a reminder that the YOU,Inc CSA in collaboration with Harrington Hospital will be hosting the initial System of Care meeting for the South Central area on Wednesday July 29th from 4:30 - 6:00 PM at Harrington Hospital in Southbridge in Conference Room 1-2. Light refreshments will be provided.

We are looking forward to this kickoff to provide you with updates on the start of the CSA and introduce you to the staff who have been hired. We will also talk about the wraparound model and the principles it is based upon. We hope to have representatives from the Mobile Crisis Teams to update you on the development of those new services. We will also share any new updates on the CBHI system and new services for the Fall.

We are hoping that you will help us to shape the SOC and identify other people that are key players that should be invited to participate.This is an exciting project and look forward to collaborating with many community partners to support our efforts to develop this model. We particularly need your input due to the large geographic area we are covering and the many individual communities that exist within the South Central Area. This needs to be a community effort and you are being invited as a key member of this community. Thanks again and if you haven't already RSVP, please send me an email. Thanks and see you next week.

Thursday, July 23, 2009

Obama's Press Conference: Watching the Fray at a Distance

OK, so in six weeks, I will be in the midst of Washington. There is, it seems, a small debate going on in Washington on the subject and our only President was talking about it today. So, while this is not exactly about children's mental health, it is relevant to our ongoing discussions. So, I figured that I would "live blog" tonight's press conference, thinking about how this will affect the lives of children.
Two observations from the opening salvos: First, he is carefully calling this debate one about "health insurance reform" rather than "health reform", casting this as primarily an economic issue instead of a moral one. Second, he is talking without teleprompters.
The press is asking the questions, but most of this seems to be a restating of things that he has said before:
1) Health insurance reform is needed now because people are being hurt.
2) We have made LOTs of progress toward an agreement within the Congress.
3) Paying for this is complicated, but doing it is possible.
20 minutes in: He is singing my song- he just said the words "single payer". But he has backed off a bit; he is going to allow Americans the right to refuse to get health care. Actually, he is saying that, in America, people should be able to get health care if they want it, even though he actually knows that single payer would be better. He sees some of the Republicans as helpful, even if they vote against the final bill. More than 100 Republican amendments were incorporated into the bill from the HELP committee. Overall, he is ably responding to the questions.
30 minutes: He just spoke about cost savings accumulated by improved primary care and better coordination of care. (Very exciting to this primary care doctor). This of course was in response to a question (really well put) about the nature of the sacrifices that Americans will need to make in order to reform the health care system.
35 minutes: Now we get to the nitty gritty: "How will this hit Medicare?" He is carefully nuancing his response, pointing out that Pharma is willing to help close the doughnut home in order to protect their profits, and that the AARP is endorsing his proposals.
Wait, the reporters have move on to the economy- not as interesting to readers of this blog. I'll stop here- I think that the President carefully maintained his position as a player in the discussion without "dissing" Congress. Now the discussions continue.

So what did we learn?
Obama wants to cover everyone, but he will settle for 97%.
Obama wants rich people to pay for it.

What else?
The news conference ran live on CBS, NBC and ABC. But not Fox. (Or PBS for that matter).

Tomorrow, I will be heading off to the Falcon Ridge Folk Festival for a few days- not sure what access will be like. I'll definitely be back in touch on Monday.

Wednesday, July 22, 2009

The Word is Getting Out There: At Least Among My Patients

Another summer day of physicals;  more positive screens on kids that I already knew had problems.  The difference this year, it seems, is that many of them have already been contacted by the CBHI and are in the process of getting into "wraparound".  

None of them called it that-  it seems that the "brand" of our particular kind of health reform has not been well marketed.  But as I talk to the families, it becomes clear that this is the CBHI that we are working with.  The family that was in crisis last week was in yesterday- things are moving along to get that child into a diagnosis.  Another family, one that has been through heck and back over the years, was in.  The boy, an articulate teenager with Asperger's and bipolar disorder,  spoke with remarkable frankness about his mental illness and is busy organizing their big team meeting.  I asked to be invited, and perhaps I will be able to go.  I got a call from DCF about a family that I wrote about in 2007; he is now doing OK, in a therapeutic day care setting,  with a psychiatrist and under treatment with only a few  psychotropics.  THe DCF worker is setting about getting that family hooked up with the CBHI.   I actually haven't seen them in a year- they will be coming back for a physical before I leave the practice.

Oh, I guess I hadn't written about that yet.  I will be leaving the practice in about 6 weeks, and heading off on a new adventure.  Each year, the Robert Wood Johnson Foundation selects up to 10 health professionals to be Health Policy Fellows at the Institute of Medicine, and to work directly with Congress on the implementation of health policy.  I mentioned last February that I had an interview in Washington- turns out that interview was successful, and that I am to be of the 10 in 2009-10.  This means that I have to leave my current practice, (South County Pediatrics in Webster) and many families with which I have worked for the last 18 years.  While all of my patients acknowledge that this is great for me and possibly even good for the country (they know what is going on down in DC right now), I am also having a hard time saying good-bye.  It is good to know that the work that we have all put into the mental health system over the past 3 years is benefitting a significant number of my patients;  it will be hard not to be here to find out what happens next.

I was worried when we started this whole thing that we would be making a system too complex for people to engage.  So far, that doesn't seem to be the case.  The larger issue is why should this system only be available to those on the "public plan"?  Why are the private insurers not engaged in supporting the establishment of systems of care?  That would be the next big thing.

Tuesday, July 21, 2009

Early and Periodic Screening: More Evidence of Change

Short post today-  I am continuing to see a lot of patients since the end of my Fellowship, and that leaves little time for writing or reflection.  Still, the roll-out of the CBHI is showing up here in my little corner of Massachusetts.

Summer physicals continue;  each one accompanied by a PSC or a PSC-Y.  I did at least 10 yesterday, and had at least 4 positives.  One was on brothers- a 7 year old with major behavior problems on 3 meds already and his 3 year old brother with speech problems who we have been trying to assess for PDD.  When I went to explain that they were eligible for the CBHI through MassHealth, she said "That sounds like the people who are coming to my house on Friday".  THe grandmother started to tell me about "wraparound".

The system seems to be embracing this family and their problems.

Called the family from Friday;  got voice-mail.  Hope that they are hooked in and doing OK.

The other two kids who screened positive were one teen with a cannibis-problem who seems uninterested in change and another kids with ADHD who thinks that he will make it through summer school OK and doesn't need more services at the present time.

The first of the Systems of Care Committee meetings happened last week-  I wonder if anyone can tell me how they went?

Sunday, July 19, 2009

Health Reform Moves On (and includes EPSDT)

All of this reform, the Mobile Crisis Intervention, the "Wraparound" Services, even the universal screening, stems from a quirky little piece of the Medicaid law, passed long ago, that has proven to be a tremendous tool for advocacy on behalf of children.  Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the basis of the Rosie D. case, because it established those services as a right of all Medicaid recipients.  So, this is extremely good news from the New England Alliance for Children's Health:

EPSDT Amendment

We recently received the great news that the House Education and Labor Committee passed an amendment that would guarantee children access to Early Periodic Screening, Diagnostic and Treatment (EPSDT) services the standard benefits package under Medicaid as part of any government-approved, Exchange-participating health plan. This is a priority that NEACH has been supporting throughout the health reform debate, and we are very happy to see that it will be included in the final House bill. 

Two moderate Republicans, Michael Castle (R DE) and Todd Platts (R PA), joined Democrats to approve the amendment by a vote of 31-17. The amendment was introduced by Robert Scott (D VA).  

Thanks to all, especially Representatives Tierney (MA), Courtney (CT) and Shea-Porter (NH) for their support.  This is an extremely solid basis on which to assure that children are not left out of the new health reform.

Saturday, July 18, 2009

A Well Deserved Honor

On our weekly new-e-mail today, I heard good news about a friend of ours:
Peter Metz, MD and the Communities of Care Project have been chosen to receive the American Academy of Child and Adolescent Psychiatry Rieger Service Award this year.  This award recognizes innovative programs that address prevention, diagnosis, or treatment of mental illnesses in children and adolescents, and serve as model programs to the community.  They will receive the award at the annual meeting in October, 2009.  Guess where the AACAP is meeting this year?  Honolulu, HI!  What a perfect year to receive this award.      Congratulations, Peter; well deserved.
I can only echo this sentiment;  well done, Peter.

Friday, July 17, 2009

Report from the Front Line: System Performed (with a few creaky bits)

Back when people were envisioning the implementation of the Rosie D settlement, or inventing the CBHI, primary care was envisioned as a key player in the process by some, and as a potential roadblock by others.  Who should screen for mental health problems?  Who should initiate the referrals into the CBHI?  Who would trigger the Emergency Crisis response system?  In many ways, it made sense for primary care providers to be integrated into the system.  Frequently, we are the place to which people turn when they don't know where else to go.  Often, we know the families, and can tell when someone is at the breaking point.  And sometimes, families with whom we have a relationship trust us just enough to let a system into their lives.

That happened today, in my office.

A mother came in, with a child with one problem, and in the course of our discussion, spoke of another child, a five year being treated for ADHD by a psychiatric nurse practitioner who my partner suspected had a more involved diagnosis.  She was at the end of her rope, and she was worried that this other child could harm the child in front of me in the exam room.  "No one is listening to me", she said, "I am not sure what else I can do.".  I explained the mobile emergency services to her, and she thought that was a good idea.  She spoke with her therapist, who also thought that this was a good idea.  Fortunately, the family had MassHealth.  So off I went to activate the system.

First problem:  who to call?  I knew the agency that had the contract for our area, but could not find a place that listed the contact information for the various mobile emergency service providers.  Finally, my nurse practitioner found the agency in one of our resource directories, and I put in the call.  The agency bounced me around a bit, but after about 10 minutes, I was talking to the program coordinator, who collected information efficiently and then asked to talk to the mother.  The mother was upset, and the coordinator did her job beautifully;  she offered options, she got a sense of how to enter the family's home respectfully and she developed a plan that allowed the husband to get home to be there for the assessment.  The family left my office nervous, but a little hopeful.

I called the family at the end of the day.  The EMH person had been to the house, assessed risk, developed plans with the mother for the weekend and hooked the family up with FST, all in collaboration with the child's therapist.  I will call Monday to check on them, but things seemed to work relatively smoothly.

How can it run better?  Well, we need clear access to a list of phone numbers for this service.  And, I need to learn something of family centered care for that coordinator-  she was great.  But overall, I think that the system did what it was supposed to, and saved us a trip to the psych emergency room.  

Good work, everyone.  Keep it up.

Wednesday, July 15, 2009

Massachusetts Mental Legal Advisors Committee on Mental Health Parity in Massachusetts

Effective July 1, 2009
Massachusetts Mental Health Parity Law 

1.      What is the Massachusetts Mental Health Parity Law?
The Massachusetts Mental Health Parity Law requires insurers who offer mental health benefits to cover the diagnosis and treatment of certain mental disorders  to the same extent that they cover the diagnosis and treatment of physical disorders.  The law makes it illegal for some health insurers to place stricter annual or lifetime dollar or unit of service limitations on coverage of qualifying mental disorders that differ from the limitations on coverage of physical conditions. The law also provides for minimum outpatient and inpatient benefits for those disorders not required to be treated the same as physical ailments.

2.       What mental disorders must be given unlimited medically necessary treatment?

The Mental Health Parity Law provides parity for these disorders:
“Biologically-based” mental disorders
·       Schizophrenia
·       Schizoaffective disorder
·       Major depressive disorder
·       Bipolar disorder
·       Paranoia and other psychotic disorders
·       Obsessive-compulsive disorder
·       Panic disorder
·       Delirium and dementia
·       Affective disorders
·       Any other "biologically-based" mental disorders appearing in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (the "DSM") that are scientifically recognized and approved by the Commissioner of Mental Health in consultation with the Commissioner of Insurance

Rape-related mental or emotional disorders
·       Mental or emotional disorders in victims of rape, or assault with intent to commit rape, to the extent the costs of diagnosis and treatment exceed the maximum compensation awarded to victims under the Massachusetts law regarding compensation to victims of violent crime.
There are special provisions for children.
NOTE: Showing the insurance company that the service you want is “medically necessary” is a must, even when the disorder or treatment is covered by the parity law.
3.       What special rights do children have?

        For children under the 19, the law provides additional safeguards with respect to "non-biologically-based " mental, behavioral, or emotional disorders. These are in addition to the protections for "biologically-based" disorders. Specifically, the law requires health plans to provide coverage to children:
·       For non-biologically-based mental, behavioral, or emotional disorders that
substantially interfere with or substantially limit functioning and social interactions, where:
·       The child’s primary care physician, pediatrician, or a licensed mental health professional has made the referral for diagnosis and treatment of the disorder,
and has documented the substantial interference or limitation,
·       The substantial interference or limitation is evidenced by conduct, including, but not limited to (1) an inability to attend school, (2) the need for hospitalization, or (3) a pattern of conduct or behavior that poses a serious danger to self or others.
·       If a child turns 19 while undergoing treatment, the health plan must continue to provide this coverage until the course of treatment is completed and while the benefits contract covering the adolescent remains in effect. The plan is allowed to charge a premium for these extended benefits, if the child's eligibility for coverage would otherwise end at 19.
4.       Does the law cover treatment for alcoholism or other chemical dependency?

        Massachusetts law requires that coverage of alcoholism and/or chemical dependency treatment include 30 days inpatient care and $500 worth of outpatient benefits. However, when treatment for these problems occurs in conjunction with treatment for mental disorders, the patient is entitled to broader coverage.  
5.       What is the minimum coverage for disorders that are not on the list of covered disorders?

For mental disorders that are not on the list of disorders eligible for parity, insurers must provide medically necessary coverage during each 12 month period for a minimum of 60 days inpatient treatment and 24 outpatient visits. Carriers cannot impose other limitations or cost-sharing (such as copayments) on treatment for these mental disorders, unless the same requirements apply to physical conditions.
Medication visits and neuropsychological testing are not subject to these limits, and must be covered on the same terms as medical services.

6.       What health plans must comply with the MHPL?

The Mental Health Parity Law applies to all of these health plans:
·       Group Insurance Commission ("GIC") plans for government employees and retirees
·       Plans issued by Massachusetts-licensed commercial health insurers
·       Blue Cross and Blue Shield of Massachusetts plans
·       Plans issued by Massachusetts-licensed HMOs
·       Small group health plans regulated by Massachusetts insurance authorities
·       Non-group health plans
·       Student health insurance plans (for higher educational institutions)
The following plans do
not have to comply with this law:
Self-insured employer group health plans.
An employer is self-insured when, instead of paying an insurance company or HMO to cover the health care costs of its employees, the employer itself covers these costs. For more information about your rights in a self-insured plan, call the Department of Labor (regional office) at 617-565-9600 or visit <> , or the Attorney General's Insurance Hotline at 1-888-830-6277.
·       MassHealth plans
·       Medicare plans

7.  Does the parity law cover outpatient as well as inpatient services?

        Yes.  The law states that a full range of inpatient, intermediate, and outpatient services shall be available for the treatment of mental disorders, so that treatment may take place in the least restrictive clinically appropriate setting.
8.       What is not covered by the parity law?

·       Insurers are not required to cover mental health services for persons incarcerated in jail, prison, Department of Youth Services facilities, or other correctional settings.
·       Insurers are not required to pay for those “educational services” that a school must provide as part of its special education program. Note: If there is a medical component to a special education plan, the insurer still should pay for those services which are medically necessary.
·       Insurers are not required to cover services provided by the Department of Mental Health.

If you have questions about the Mental Health Parity Law or you need help getting your insurer to pay for mental health services, please contact:


Mental Health Legal Advisors Committee

(617) 338-2345 or (800) 342-9092

ext. 29

Tuesday, July 14, 2009

From the Field: The Children's Mental Health Campaign Soldiers On

You would think that passing major omnibus health legislation would be enough, but the energy of the Campaign continues to make things happen, and, given the threats of the budget in the Commonwealth, it really needs to continue to do so. So what is happening around the Commonwealth?
Well, meetings of course:
  • NAMI:  Empowering our Community by DeMystifying Mental Illness and Treatment TONIGHT at 5 PM at the Boston Public Library (Lauri Martinelli for information)
  • Blue Cross Blue Shield is planning a big conference:  Improving Access to Children's Behavioral Health Services on Thursday 29 October 2009 at 8 AM at the Landmark Center. (Free but must preregister;  contact the Foundation for details)
And the budget:  We won some, lost some and then lost some more.  Preschool mental health consultations (3000-6075) started at $2.9 million and ended up with $1 million in the final budget.  Programs are planning a 60% cut across the board, and this is causing much loss in services.  People are very worried that this will be a major hit to this field, which is in the early stages of development.  Child and adolescent mental health services (5042-5000) took a 9.5% cut, which will likely impact some child mental health services.  The Children's Behavioral Health Initiative (4000-0950) did reasonably well until it got to the Governor's office;  as we have said in previous posts, they took a 3.5% hit.  The negotiation in this matter involves the Court, and the negotiation is going on at that level-  this money may be restored as the Judge and the Court monitor look into this matter.  The Campaign has made its concerns known, and that the legislature should override the veto.  Then we heard about something that we knew little:  Circuit Breaker (7061-0012):  an account to reimburse for collaborative, including schools, for the cost of special education costs of residential schools, many of whom have mental health issues.  This is a five year program, laying  the groundwork for section 19 of Chapter 321-  the "school climate" part of the Omnibus bill.  Cutting this would ultimately hurt our work in the future, and no one is championing this at the State level.  Interesting concept:  we clearly need to figure out how this plays in the future.

So, there is lots of advocacy still in play on the FY2010 budget, but we need to start thinking about the next year.  More to follow on that.

We moved on to a discussion of the words "collateral contacts";  legislators just weren't getting what we were talking about.  Even "coordination" of care was hard to understand.  The communication folks think that it would be easier to talk about stories than it would be to get caught up in the jargon of the clinical world.  They have some stories "You are a teacher; shouldn't you be able to talk to the child's psychiatrist", that put the bill into context, and they think that this will be more effective.  We also talked about the arguments made by the insurance companies; we all agreed that we need to focus on the messages of the insurers.  You all heard me talk about that before.  Anyway, the bill is moving through the committee structure and we will need to continue to work on this as it progresses through the legislature.

We did talk about Rosie D., things that we have mostly discussed in previous postings.  400,000 families have been notified; letters have been sent.  But the letter came in a plain envelope that looked like junk mail and wasn't opened by a lot of people.  The sense in the room is that the communication has not been heard yet by the people who need to hear it.  We discussed how to get the word out to people, and promised to get feedback to the CBHI on the success or lack thereof of their initial outreach effort.

Lots of good work needs doing.  Nice to know that there are lots of people out there doing the work.

Monday, July 13, 2009

Visiting Boystown: A Glimpse of a System of Care

Everyone remembers Spencer Tracy and his role as Father Flanagan in Boys Town, the 1938 Oscar-winning film about a crusading priest who worked with street youth in the early 20th century.  It turns out that the place is still there, outside of Omaha, NE, and that it has morphed into treatment facility for troubled youth of both genders, with a  strong emphasis on the need to create family atmosphere, teach social skills and provide a continuum of care ranging from a therapeutic school to an intensive inpatient unit that can work with children with violent self-destructive outbursts.  Tom Tonniges, the former chief of Community Pediatrics at the AAP, is now in charge of their "Institute for Child Health Improvement", which has a Health Tomorrows grant to develop a transitional program for youth aging out of their system, to insure that they are prepared to manage their own health issues when they leave the place.  Important idea, and it also let me see how a true "continuum of care" could work, and what the challenges are for such a thing in the modern environment.

Boys Town has changed a bit since the founding days when it was a place for street kids from Omaha-  for one thing, it has had girls since 1975.  The focus has changed, from a youth-leadership development model to a Family Home Model, in which the unit is a household of 8 kids (single gender) and a set of house parents (usually a married couple, it seems), living is a large brick house on the campus.  But, in addition to that, Boys Town now provides In-Home Services within Nebraska, an Intensive Residential Treatment milieu on the campus (4 kids with more staff to monitor and manage troubled behaviors) and the ICTU at the University of Nebraska Medical Center, a locked unit.  Oh, and a lot of traditional outpatient therapy.  A kid could theoretically go up and down this continuum of care as ones mental illness required it, getting consistent behavior management throughout, and minimizing that sense of shock and transititon that so complicates things for a lot of SED kids.

In talking to one of  the therapists, however, I learned that this model seldom works;  their managed care "carve-out" provider sees the different levels of care as interchangeable parts, and that, despite having a system that would allow communication and relationship building between agencies as well as with children and families, kids are moved between agencies in such a way as to make it really hard to maintain continuity.  It seems that it is never easy to make systems do what they should.

The transition program is, of course, magnificent;  they hope to hae a manuel of transition training that we can all use soon.  And steak in Omaha just tastes better.   I recommend 36 hours in Omaha, if you ever have the chance.

Sunday, July 12, 2009

Time to Organize: The Children's Mental Health Campaign is Alive and Well

I'm visiting Boystown in Omaha today;  more on that later.  For now, a reminder from the Children's Mental Health Campaign:

Please Join Us:
CMHC Supporters Meeting - Tues, July 14
Please join us for the next Children's Mental Health Campaign supporters meeting on Tuesday, July 14 from 9:30-11AM in the 9th floor conference room at 30 Winter Street.  
We have many things to discuss at this meeting, including the final FY 2010 State Budget, progress of the collateral contacts  bill, and the implementation of Rosie D.  services. If you have any questions or suggestions for agenda items, please contact Matt Noyes at or 617-275-2939.  

Action Needed:
Ask Legislature to Override Rosie D. Veto

Last week, Governor Patrick released his line item vetoes of the Legislature's FY 2010 State Budget.  
Among these vetoes was a $2.3 million reduction in funding for implementation of the Children's Behavioral Health Initiative (CBHI), also known as Rosie D.  This veto threatens the effectiveness of the community based services that were rolled out on July 1.  Please ask your networks to contact their State Representatives and State Senators and ask them to override Governor Patrick's veto of CBHI / Rosie D. funding.  

Friday, July 10, 2009

Lots of Kids Need the CBHI: I Wonder How the System is Doing.

As I have have said, I am mostly a primary care pediatrician.   That said,  I keep giving out information about the CBHI to families who come into the office for reasons not at all related to their mental health problems.  A grandmother today brought in her granddaughter for a cough, and in the course of our discussion, I discovered that the little girl was now on a third psychotropic medication for her difficult behaviors.  That grandmother left with treatment for her cold and with the words "Children's Behavioral Health Initiative" on a card to try to get Home-Based Behavioral Therapy for the child's mother.  Then there are the children who come in for annual physicals who, I think, would benefit from the new services.  Most of them have therapists and some even have psychologists;  the families could just use more.  Then, there are children like the one whose mother called today- he's three years old, his behaviors are out of control and he needs to be evaluated and his mother needs support.  I sent him into the system as well-  I think that he will end up in the CBHI.

So I am sending the patients into the system;  time will tell us how they end up.  Any stories from the CSAs?  How are you all doing at finding them all of the services that they need?

Thursday, July 9, 2009

Musing on a CATCH Visiting Professor

My Academy has some very cool parts to it; my personal favorite is the CATCH program, which actively promotes the interaction of pediatricians and communities to create things of beauty- partnerships that glow, radiating hope to families without ACCESS (that's the A in CATCH) who want to improve their child's health. One part of their program is the CATCH Visiting Professor Program, which brings accomplished Community Pediatricians to academic medical centers in an effort to broaden their horizons. (*FULL DISCLOSURE: I hosted one of these many years ago and , as the District 1 CATCH Facilitator for the AAP, I have reviewed these applications for many years since. I was selected to be a Visiting Professor in Austin next fall*) Today, my colleagues at Children's Hospital invited me to hear Dr. Angela Diaz, a Professor and advocate for adolescent services describe her program in New York City, at Mount Sinai Hospital. ( See Robin Hood - Heroes - Dr. Angela Diaz, Shared via AddThis) I was representing the Academy and promoting the CATCH program, mostly to the Residents.

Dr. Diaz had a lot to say, and at the end of it all, we were speechless. How does anyone do what she had done? She works with adolescents in the City. Initially, I wasn’t sure that this was going to be relevant to this blog, but it turns out to be incredibly relevant; she opened by pointing out that 20% of adolescents have mental health issues, but only 4% of those actually get those needs get addresses. Her program is focused on the uninsured youth, using a positive youth development model rather than a deficit model to assure long term growth. What’s that mean? A lot of programs focus on risk behaviors- she adds the “lens” of the consumer and the strength/asset to more fully understand what is going on with the teenager and to build a relationship that is therapeutic and the key to long term follow-up. She has found that it is really useful to form partnerships with “every organization in New York” that works with children, with has aided them tremendously in their fund-raising.

The core of her program is that they give the patients what they need regardless of ability to pay. She’s been creative at engaging subspecialists as well as getting funding for mental health services, health education services and the other ancillary services that are needed to address all of the needs of adolescents.

Sounds great, no? And yet there is very little evaluation data to support any of these “best practices”- they were recently funded to conduct an external evaluation to look at the impact of all of these services. Overall, her program serves 10,000 youth of color, from all over the metropolitan area, on a budget of $14 million per year, all of which is generated through fundraising.

To me, the most interesting (and relevant) part of her talk was her discussion of the distinction between her funding sources, which are focused on specific parts of the problem of adolescent health, and her care, which she described as wholistic. I am paraphrasing, but I think that she said something like: "I do what they ask of me, then I do what needs to be done" in the care of her high risk adolescent population. That strikes me as an appropriate lesson for the CSAs going forward: the funder (MassHealth) is required by law to cover a number of services; the agencies implementing the program (the CSAs) will need to decide how to use this funding to supply wholistic care.

Nice way to think about the process through which we are currently living.

Wednesday, July 8, 2009

Like the first crocus: It might be working.

Do you remember April?  We had a miserable winter in the Northeast, with much snow, ice and rain, unending coldness and gloom thoughout the land.  People kept speaking of this magical time called Spring, when it would all get better.  None of us believed it.  One day, in middle of April, I spotted a crocus, blooming in a sunny patch of grass.  THEN I believed in Spring, and the bloom of flowers and grass and weeds that has accompanied our joyous and wet Spring and early Summer.

That's what I felt like today.

I got a call from the mother/father of a 13 y/o girl/boy with bipolar disorder, who was being discharged from a respite facility, and who had lost her psychiatrist while in respite, and who needed some medication of which I had never heard in order to stay on an even keel.  A bridge prescription, they call it, to tide them over while they identify a new psychiatrist. (These "bridges" are sometimes far from temporary, as it can take months to get on a psychiatrist's list).  As per our routine, I asked for documentation of the medication and assured the guardian that I could handle it for a month. While waiting for the documentation to arrive, I read up on the medication, which really had only a little evidence in its favor.  The documentation arrived after about a week,  and I called the father/mother to tell him/her that it would be handled, using the opportunity to commiserate about how hard it was going to be to find a psychiatrist, and urging them to bear with me if we ran into problems with the medication.  "Oh, by the way" , she added nonchalantly,"I am enrolling him/her in that new program you have been talking about.  They are here right now doing the assessment".  

I smiled and laughed and cried just a little and my colleagues probably thought that I was crazy.  But that is the crocus, my friends, the first bloom of hope for a while.  This kid really needs this program;  the program people have found the family; I will bet that they will have them hooked up lickety-split.  I know intellectually that the folks from Community Healthlink with have just as much trouble finding a child psychiatrist as I would.  But emotionally, knowing that at least one family is engaging in the process, makes me feel a whole lot better. 

 It is nice to see the Spring come.  Bring it on.

Tuesday, July 7, 2009

Say It Ain't So, Deval!

I have a really hard time following the state budget, and I hadn't heard of any of the Governor's "line-item" vetos affecting children's mental health this year, so I left for my 4th of July weekend feeling like the budget debate was done for this year.  Boy, was I wrong.
According to the EOHHS Webpage,  Line Item 40000950, the Children's Behavioral Health Initiative will take a hit.  All it says on the webpage is 
Veto Explanation:  I am reducing this item by an amount not recommended in light of available revenues.
Now I could not find in that Veto anything about how much he was cutting from the item, which is:
For the purposes of administrative and program expenses associated with the children's behavioral health initiative, in accordance with the settlement agreement in the case of Rosie D. et al. v. Romney, United States District Court for the District of Massachusetts civil action No. 01-30199-MAP, to provide comprehensive, community-based behavioral health services to children suffering from severe emotional disturbances; provided, that the secretary of health and human services shall report quarterly to the house and senate committees on ways and means relative to implementation of the initiative; and provided further, that such quarterly reports shall include, but not be limited to, details of the implementation plan, results of the scheduled plan to date, including a schedule detailing commencement of services and associated costs by service type, and an analysis of compliance with the terms of the settlement agreement to date.
and is budgeted at $65,833,963 in the GAA for FY2010.  But in the reconciled budget,  it was  listed at $68,000,000, so that is a $2.1 million (or 3%) cut.  (Details of all of the cuts are available here.)  So now what?

Clearly we need to push for an override.  This is a penny-wise (perhaps) but pound-foolish idea.  According to Health Care for All in a recent e-mail:

This veto threatens the effectiveness of the community based services that were rolled out on July 1. 
Please ask your networks to contact their State Representatives and State Senators and ask them to override Governor Patrick's veto of CBHI / Rosie D. funding. 
Couldn't have said it better myself.  Time to man the phones, my friends.  Let the legislators know that implementing a new program as you are cutting its budget is a recipe for failure.

Monday, July 6, 2009

Systems of Care Want You!

I hope everyone had a great Fourth of July-  I certainly did, what with the fireworks and the ribs and the bicycling and the gorgeous (finally) weather in New England.  After re-rereading the Declaration of Independence (see previous post), though, I am reminded that the celebration of our freedom implies a need to engage in the systems of our governance.  For those of us interested in providing systems of care for families of children with serious emotional disturbance, there is a brand new opportunity to make a difference in the design of the system:  The Systems of Care Committee.


Already I can hear you running for the exits-  come back here and listen (or keep reading, which is the same thing).  To make this thing work, we need YOU to be on another committee.  Implicit in the structure of the CSAs is a feedback mechanism, called the Systems of Care Committee, through which the care coordination process is informed by a group of family members, community members, agency representatives and mental health care providers on what is working and what is not.  The groups will meet monthly, and their input into the process must be documented for the remedy to be effective.  They ALL will start meeting this month.  I know that is another meeting- but is an important one that you should try to build into your schedule.  Your mission is to transform it into a transformative event (I didn't say that this is going to be easy!)


I’ve posted the meetings for Central Massachusetts on the “Upcoming Events’ portion of the blog- I’ll try to keep it as current as I can.  If other CSAs want to send me their stuff, I will put it up there.  But it is incredibly important that as many of us as possible make it to these meetings.  They represent our chance to make a difference in this opportunity for real system change.

Remember, you can always find your CSA through the MBHP!

Saturday, July 4, 2009

Independence Day: The unanimous declaration of the thirteen United States of America

I love that the Globe still prints this, every year.  Read it.  You will learn things.

WHEN in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form as to them shall seem most likely to effect their Safety and Happiness.


We, therefore, the Representatives of the united States of America, in General Congress Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these United Colonies are, and of Right ought to be Free and Independent States; that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. And for the support of this Declaration, with a firm reliance on the Protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

Happy 233rd birthday, everybody!

Friday, July 3, 2009

Message from the Front Line: It Still Ain't Easy

So, I've have a couple more days on the front line, doing primary care.  Summertime in a pediatric practice  is mostly physicals and lyme disease, with a bit of coxsackie virus thrown in for good measure.  In our practice, however, the annual check-ups seem to involve a lot of kids who could well be friends of "Rosie D", families that would really benefit from the CBHI.   I have been singing the praises of the CBHI to many of those families, but I can already see soem of the roadblocks to enrollment in the new system.
1)  Fear:  Families of kids with serious emotional disturbance (SED) are used to being judged by others, but they still don't like it.  Is that child out of control because of biology or poor parenting?  Almost everyone has an opinion about what a family should do with a child who is behaving badly, and most of those opinions are formed without a full understanding of what is going on within the family.  A long history of being judged, however, makes it likely that you are not going to want to be judged in the future.  What happens if you go into this long and detailed assessment and you find out that it really is all your fault after all?
2)  Impatience:  Families of kids with SED often have a pretty sophisticated understanding of what makes their kid tick, and what would help them with behavioral management.  Now we want them to go through a 2 hour intake process, and a 4 hour CANS on the chance that they might get to sit in a 2 hour meeting to develop a plan over a 2 month period?  This does not sound terribly appealing, especially if the SED behaviors are slowly wearing down your spirit.    Saul Alinsky said that the key to successful community organizing (and this is community organizing, of a sort) is to have an early success, to give people hope.  Where is that "early success" in this approach?
3)  Hopelessness:  Some families of kids with SED have just given up;  they feel that they have exhausted the possibility of behavioral intervention, they have had therapists who didn't understand, they have seen psychiatrists on the 15 minute med check treadmill, and they don't see the possibility of something better than that.  It is hard work to build confidence in thos e families.
The key for us as primary care doctors is to walk with these families through the Valley, to see them past the fear and hopelessness and impatience, to convince that there is hope fo something better.
I saw families with all of these problems last week;  I am trying to walk them over to the CBHI.  One family, it turns out, had private insurance, even though they would be income eligible for SSI;  we are working with our legal aid attorneys to get that fixed.  Another wants psychopharmacology services, but no counseling.  Come to find out that her oldest son (not our patient) is now inpatient at a Psych Hospital, and she just can't deal with another system right now.  Another family has been a bit neglectful of check-ups and is about to move to another part of the state, to escape a domestic violence situation.  I am trying to assure some continuity of services, but am really not sure that will work.  None of these case have yet hit the CBHI;  I hope that the system is ready for them when they are ready for it.

Wednesday, July 1, 2009

Wait, I'm not done yet....we have not yet spoken about the impact of Swine Flu on Mental Health reform

While the Physician Advocacy Fellowship may be over, there is still a lot of work to do.  Today, I was at a really interesting "debriefing" session hosted by my good friend Lauren Smith at the Department of Public Health discussing how the issues of school exclusion and school closing were handled in the recent (and current) influenza epidemic.  (Wait- what can this possibly have to do with children's mental health services, you ask?  Bear with me).  We have folks from the Commonwealth, mostly public health and education folks, people with various health departments and school nurses, and me (a simple country pediatrician), talking about what went well, and what could be improved.  DPH did a lot of stuff right in the recent outbreak;  they quickly wrote up clear and effective handouts, they disseminated them through the web, e-mail, phone-conferences and personal appearances to a wide variety people and they responded quickly to feedback.  Around the table, people applauded the speed with which the DPH people worked, and the collaborative spirit that fueled the effort.  Problems seemed to happen, however, when the message (sick kids should be home, schools should close only if certain criteria are met, people at high risk for complications need treatment) became too complicated and had to move outside of the public health system.  Complications happens when the message changed, which, early in the outbreak, was almost daily.  The CDC spent the first few weeks of April trying to figure out what was going on, and whether or not this virus was the "son of 1918" or not.  In that process, the message became fuzzy- in fact, it resembled our actual level of knowledge about this thing- but still, it created some confusion about exactly who was to be excluded for how long from which activities, who was to get antivirals and whether prophylaxis should play a role.  Handwashing was still the most important thing, but it took us a few weeks to get straight on the rest of the details.
LESSON 1:  Everyone needs to stay on message during times of change.  Don't change the message too often, even as you are working out the details.  For the CBHI, the implication is that it is really important for them to control the message of change, especially during the "ramp-up" time, to keep things from taking on a life of their own.
Now the other problem was the way in which the message was interpreted in the 351 (or so) semi-autonomous school districts in the Commonwealth, a largely local option that depended on the strength of local health departments, the ability of the school nurses to have a voice in the systems, the sophistication of the parents, the relationship with the local medical community, and, most importantly,  the leadership style of the superintendent.  Ideally, this would be a collaborative relationship in which the DPH would bring information and plans that the other sectors of civil society would embrace and implement.  Not so, in many cases.  Implementing this should have been a discussion, but it more often reflected and amplified the local power imbalances that drive action at the local level.  We heard stories of excellent collaboration and stories of serious conflict, as the needs of the schools for high MCAS scores were balanced against the need of the community for school closure.  According to the office of the legal counsel, the health authorities should have had precedence in this matter.  In practice, they often did not.  This is the place where many saw a need for improvement.
LESSON 2:  Implementing change requires buy-in from all of the parties, and will build on the relationships that were established in the past.  Or not.  For the CBHI, the implication is that forming the multidisciplinary teams, especially with doctors and educators, is going to be difficult.  We need to invest in building relationships.

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