Been a While: Thoughts on Children's Mental Health in the Commonwealth

One might think that I have been reluctant to post since the November elections because I was overwhelmingly depressed by the outcome. After all, the composition of the Congress has swung back toward the Right, and many of the Tea Party supported candidates have views on the role of government that would not support interventions like the Children's Behavioral Health initiative. For the record, that's not it. While the 111th Congress has accomplished much, including the passage of CHIPRA, one has to remember that it was a bipartisan effort in the 105th Congress that got us SCHIP in the first place (the same House that voted to impeach President Clinton later in the session). Congress is a wonderful and bizarre place, where much unexpected can happen. While current rhetoric calls for repeal of the Affordable Care Act, the dynamic for change triggered by the passage of CHIPRA, ARRA and PPACA is in motion, and the results of the next rounds of Congressional action are likely to surprise us all. In the end, it about building systems of care that are family-centered, evidence-based and outcomes oriented. The devilish details will provide those of us engaged in the process with lots to do. Sure, I might prefer Speaker Pelosi than Speaker Boehner, but either one will need input from those of us in the field doing the work. The recent election changes the terrain in which we work, but not the work itself. So, no, that not why I haven't written.

Truth is, I've been busy. Gave a keynote on Health reform to the Vermont Council for Quality last month that was well received, attended the annual gathering of the Physician Advocacy Fellows in New York, taught classes for medical students on health policy, saw patients in my new practice within UMass Memorial Healthcare, went to the Fall Board meeting of the Academic Pediatric Association (my last as Treasurer) and started working as faculty on the Massachusetts Patient Centered Medical Home Initiative. All of which might suggest that I haven't had time to think about children's mental health over the past month.

Wrong answer. Thought about it a lot. Three thoughts:

1) The discussions within the settlement are continuing and the system is evolving. It is instructive to read comments from both sides on the progress we have made. From the Commonwealth, there has been an enormous effort to develop wraparound services throughout the state. From the Plaintiffs come concerns about waiting lists and a paucity of resources. I am certain that both are true. In my months back in practice, I have met several families who have benefited from the the Home-Based services and the Family Partner programs that are integral to the CBHI. I have heard praise for the new level of care coordination available to families that are in the system. I have also met families churning through the system who have not found the right therapist, or who have not been comfortable with the notion of in-home services, or whose teens with mental illness are not able to engage in the system. We have lots of anecdotes of success and problems. What is clear in the discussions within the settlement is that we need better metrics for assessing progress and success in this complex endeavor.

We have some ways to make that happen. The National Quality Forum has recognized the need for the development of those metrics as has the AHRQ/CMS Quality Initiative of CHIPRA. Section 23 of the Yolanda's Law authorized the Commonwealth to designate a Children's Behavioral Health Research Center:

the primary mission of which shall be to ensure that the workforce of clinicians and direct care staff providing children’s behavioral health services are highly skilled and well trained, the services provided to children in the commonwealth are cost-effective and evidence-based, and that the commonwealth continues to develop and evaluate new models of service delivery.

Pretty clear that we need that; how can we make it happen?

2) Nationally, the system is evolving too. Much of what what we are doing in Massachusetts is of great interest to the rest of the country. One thing in particular that has generated much interest is the Massachusetts Child Psychiatry Access Program (MCPAP), highlighted in a case study by the Commonwealth Fund and a recent article in Pediatrics, led by Barry Sarvet out in Springfield. Other states are starting to work to emulate this model, such as Arkansas and Ohio. Sure, we need to work to make our system better, but shouldn't we also be highlighting our successes and "taking the system to scale" on a national level? How do we make that happen?

3) Medications are not all bad: There's a lot on the net about the overtreatment of children with psychotropic medications, and sometimes we forget that there is a risk of undertreatment as well. Lisa Lambert, in her recent post at "It's Not Over" makes that point beautifully. I recently struggled with a mother whose teen had been dropped from treatment (he didn't want to talk any more) and whose prescriber of 4 psychotropic medications had stopped prescribing because the boy wouldn't go to therapy. I tried to stick to the party line, of not prescribing multiple meds to kids disengaged from the system, but eventually wrote the scripts to restart the pharmacotherapy. It worked, at least in terms of preventing a dropout. In the course of worrying about the overuse of psychotropic drugs, it is really important to remember that, for many patients, the medications actually work. Makes building the system and making it family-centered even more complicated.

Lots of work going on. Don't always have time to write about it.