Rosie D. and Me

The more things change....

2012-01-09T19:41:00.000-08:00

Massachusetts has lots to be proud of in the approach that the Commonwealth has taken to the implementation of the CBHI, with the acceptance of behavioral health screening in the pediatric office to the establishment of mobile EMH services throughout the state (nobody else is even thinking about that one!). We are innovators, on the cutting edge of high quality services for children with serious emotional disturbances.

And yet....

Why do I get a call from an intensive treatment program about one of my patients, telling me that the child's psychiatrist left in October, that they have not identified a new one for this patient, and ask that I write prescriptions for his/her three psychotropic medications. Why have I heard nothing about this patient for 8 months, while his/her psychiatrist manages his/her meds, and, upon leaving, assumes that I will continue the meds? How do I monitor the effectiveness of therapy, when I have no evidence of this child's current diagnoses? How do I monitor side effects, when I have never heard of one of the medications? This is the sort of thing that intensive case management is supposed to prevent; why did it fail my patient?

We build systems that are supposed to work. We hope that this sort of thing is happening less frequently than before. And we recognize that there are likely still a few bugs in the system.

Happy New Year!

Teen Screen is quoting me now.

2011-12-21T07:52:00.000-08:00

Kind of cool to be quoted. Thanks, TeenScreen.
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From the Boston Globe : Kinda wish I had been there.

2011-12-15T08:52:00.000-08:00

Yesterday in the Globe- reminded me how long it takes to get anything done.

Summit focuses on children’s mental health By Patricia Wen
December 13, 2011

It was billed as the Children’s Mental Health Summit, the second in a decade, and its organizers hoped it would inspire as much passion for reform as the debut gathering did in 2001. Among the issues addressed by top officials in Boston yesterday were the high rate of psychotropic drugs consumed by the state’s foster children, poor insurance coverage of family-based services, and the relatively high percentage of substance abuse among Massachusetts teens. The keynote speaker, Pamela Hyde, an Obama appointee who heads the Substance Abuse and Mental Health Services Administration, also spoke about the growing awareness that trauma -- including domestic strife, neighborhood violence, and bullying -- undermines children’s mental well-being.…The closing talk came from US District Court Judge Michael Ponsor, who issued the 2006 landmark ruling, referred to as the Rosie D. case, which required the state to offer intensive home-based mental health services for children on Medicaid with serious emotional disturbances. “Serving the needs of children with mental health problems, especially poor children, is not for the faint of heart, or for people overly fond of cheap thrills and immediate gratification,” Ponsor said in his written remarks. “It is a very long-term commitment.”

Larry's Webinar is on the Web

2011-12-14T18:23:00.000-08:00

As primary care providers incorporate adolescent mental health care into practice, Common Factors may hold solutions to successfully taking on the challenge. An approach that emphasizes provider/parent interaction over the need for diagnoses and specific treatments, Common Factors can have a powerful impact on provider training, confidence and outcomes.

Common Factors focuses on the process of care, and emphasizes the characteristics and interactions of providers, parents and others -- nurse practitioners, office staff, school health personnel -- in influencing patient behavior and improving outcomes. It challenges the need for a diagnosis and specific treatment for each patient, and instead maintains that therapies can be designed to help broad classes of people.

Common Factors expert Larry Wissow, MD, Professor, Johns Hopkins Bloomberg School of Public Health, discussed incorporating Common Factors principals into adolescent mental health care. Click here if you want to hear it.

Rethinking Adolescent Mental Health Care: Using Common Factors to Improve Your Practice Potential

2011-11-29T21:00:00.000-08:00

A TeenScreen National Center Webinar Event

With

Larry Wissow, MD, MPH

Professor, Johns Hopkins Bloomberg School of Public Health

Principal Investigator, NIMH-funded Center for Mental Health in Pediatric Primary Care

December 8, 2011

1:00-2:00 ET

Register

As primary care providers incorporate adolescent mental health care into practice, Common Factors may hold solutions to successfully taking on the challenge. An approach that emphasizes provider/parent interaction over the need for diagnoses and specific treatments, Common Factors can have a powerful impact on provider training, confidence and outcomes.

Common Factors focuses on the process of care, and emphasizes the characteristics and interactions of providers, parents and others -- nurse practitioners, office staff, school health personnel -- in influencing patient behavior and improving outcomes. It challenges the need for a diagnosis and specific treatment for each patient, and instead maintains that therapies can be designed to help broad classes of people.

Join Common Factors expert Larry Wissow, MD, Professor, Johns Hopkins Bloomberg School of Public Health, for a practical discussion on incorporating Common Factors principals into adolescent mental health care.

Experts Convene on Capitol Hill to Discuss Models of Integrated Care for Youth: Massachusetts Child Psychiatry Access Project Highlighted

2011-11-23T07:42:00.000-08:00

From TeenScreen (love to be quoted)
Washington, D.C. - National experts in delivering integrated behavioral and physical health care to adolescents presented three different models of service delivery to this vulnerable population in a Capitol Hill forum. The Massachusetts Child Psychiatry Access Project (MCPAP) was highlighted as one national model that bridges the significant gap between the need for specialty mental health services and access to those services.
The TeenScreen National Center for Mental Health Checkups at Columbia University convened the forum, “Bridging the Gap through Innovation: Expanding Access to Mental Health Services,” on Nov. 16. This was the third annual Eric Trendell Health Policy Forum. Dr. David Keller described how he and his colleagues in Massachusetts have filled the behavioral health service gap through MCPAP, providing vital services to over 6,000 children in the state. “Before we started MCPAP in 2005, I had few, if any, resources for dealing with these issues. As a general pediatrician practicing in Worchester, MA, I saw perhaps 30 or 40 patients per day,” said Dr. Keller. “At least 30 percent of these children had mental health problems. Like so many of my colleagues trained in pediatrics, I was not trained extensively in child psychiatry.”

“MCPAP has changed all that,” he said. “It is comprised of six centers throughout Massachusetts led by a psychiatrist and each linked to an academic health center. Individual primary care doctors and pediatricians are able to enhance their services through MCPAP tutorials in child psychiatry and consultation with specialists,” Dr. Keller said.

Through MCPAP, doctors are assured of a telephone consultation with a psychiatrist about a specific patient, usually within an hour, or immediately, if the situation demands. Dr. Keller said that 26 other states are exploring establishing a MCPAP like system to meet the growing demand for mental health care for children and adolescents.
“We have created virtual, integrated care teams so that all of the children and adolescents in Massachusetts have access to the behavioral and mental health care they may require,” said Dr. Keller.
“Integrating behavioral health into primary care is a game changer,” said A. Seiji Hayashi, MD, MPH, and Chief Medical Officer, Bureau of Primary Health Care at the Health Resources and Services Administration, and a panelist. The Centers for Medicare and Medicaid Services is working to strengthen the Medicaid and Medicare programs by looking to innovative forms of service delivery. Barbara Edwards, a director at the Centers for Medicare and Medicaid Services, and a panelist said, “The models of integrated care discussed today present important ways forward as we look to design and support methods of bringing health and mental care to children.”
TeenScreen Executive Director Laurie Flynn, said: “The movement to integrate behavioral health into primary care brings a vital benefit to adolescents. We know that up to half of all visits to pediatricians involve a behavioral, emotional or mental issue. We also know that half of all mental disorders begin by age fourteen. Innovative, integrated care models have demonstrated that we can expand mental health care to youth, bringing this vital dimension of medicine to their medical homes.”
Other forum panelists detailed their unique experiences with leading innovations such as co-located care; telepsychiatry; fostering collaboration between primary care physicians and child psychiatrists; the development of patient-centered medical homes; and the adoption of electronic medical health records.
The 2011 Eric Trendell Health Policy Forum Panel:
- Greg V. Jensen, LSCW, ACSW, Vice President for Behavioral Health Services at Lone Star Circle of Care
- Steven Adelsheim, MD, Director, Center for Rural and Community Behavioral Health and Professor of Psychiatry, Pediatrics, & Family/Community Medicine at the University of New Mexico, Department of Psychiatry
- David Keller, MD, Clinical Associate Professor of Pediatrics and Senior Analyst, Center for Health Policy and Research at the University of Massachusetts Medical School
- A.Seiji Hayashi, MD, MPH, Chief Medical Officer, Bureau of Primary Health Care at the Health Resources and Services Administration
- Barbara Edwards, Director, Disabled and Elderly Health Programs Group, Center for Medicaid, CHIP and Survey and Certification at the Centers for Medicare and Medicaid Services.
Senator Scott Brown (R-MA), a sponsor of the forum, said, “I’m proud to support the cause of improving mental health services for our children and teens. From my own childhood, I recognize how critical it is to help our youth weather the tough circumstances that can come early in life.”
Senator Tom Udall (D-NM), a sponsor of the forum, said, “We have a moral obligation to help young people from every background and ethnicity with the support they need to overcome and deal with depression and suicidal tendencies.”

To view videos of remarks by the panelist, please visit:

http://www.teenscreen.org/policy/policy-events/trendell-forum-2011/

The TeenScreen National Center for Mental Health Checkups at Columbia University is a

non-profit public health initiative and national policy center devoted to increasing youth

access to regular mental health checkups.

More Webinars: We're famous, you know...

2011-04-15T07:47:00.000-07:00

TeenScreen National Center Upcoming Webinar
High-Performance Model: How One State Improved Youth Mental Health Care By Helping Providers

Thursday, April 27, 2011
2 p.m. - 3 p.m. Eastern Daylight Time

The issues were familiar: Mental health challenges in youth on the rise, a limited number of specialists, and a primary care community working to fill the gap.
Click here for the full event details and description.

John Straus, MD and Barry Sarvet, MD of the Massachusetts Behavioral Health Partnership will describe the MCPAP program, its role in supporting providers following the Rosie D decision, and how building and sustaining a partnership between primary care and mental health clinicians can help transform youth mental health care.

Please click here to register or copy and paste the below link:

https://event.on24.com/eventRegistration/EventLobbyServlet?target=registration.jsp&eventid=302803&sessionid=1&key=A1D6E523085B441CAFA921B2E21E113A&sourcepage=register

From the Children's Mental Health Campaign

2011-04-15T02:03:00.000-07:00

From my INBOX this morning:

As you know, the House Ways and Means Committee released their budget recommendations yesterday. Children’s mental health services faired well and many line items were level funded:

The CBHI line item was funded at $214.7 million which is the same level as the Governor’s budget.
The language on reporting requirements for the CBHI line item was included but not in the Governor’s budget.
The DMH child and adolescent mental health services line item was level funded at $71.4 million from FY11, this is a $2 million increase over the Governor’s budget.
The mental health consultative services line item under EEC was level funded from FY11 at $750K which also matched the Governor’s budget.

Our recommendation to include the MCPAP bill as an Outside Section was not included.
Representative Ruth Balser will file the Massachusetts Child Psychiatry Access Project (MCPAP) legislation as an outside section to the budget at the request of the CMHC.
This would act as a revenue stream for the Commonwealth during these difficult financial times as well as a workforce development program.
MCPAP is run as an “insurance blind” program and is currently funded solely by the Commonwealth. However data collected on participants includes insurance coverage. This data reveals that more than half of those served have commercial coverage.
The goal of MCPAP is to make child psychiatry services universally accessible to primary care providers (PCPs) throughout the Commonwealth who can access a team of child psychiatrists, psychologists and/or social workers via telephone consultation in order to diagnose and treat mental health disorders.
This outside section would requires commercial health insurance companies to proportionally contribute to the funding of the MCPAP at a rate equal to the participation of their membership. This will generate nearly $1.8 million per year to contribute to the cost of the program. Surplus revenue will be directed toward implementation of MCPAP in schools where administrators and teachers struggle daily to deal appropriately and effectively with children showing signs of mental health conditions.

Please CLICK HERE for more information and ask your State Representative today to sign on as a co-sponsor here.

Thank you,
Erin G. Bradley
Coordinator, CMHC

Webinars today

2011-04-14T07:29:00.000-07:00

Why does all of the good stuff happen at once?

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From the Patient Center Primary Care Collaborative:
Please join us for a free webinar on Thursday, April 14, from 1:00 - 2:30pm, entitled: "Behavioral Health Integration in the Medical Home and Its Facilitation by Health Information Technology." This informative presentation is co-sponsored by the PCPCC Center for eHealth Information Adoption and Exchange and the Behavioral Health Task Force and will feature Drs. Rodger Kessler and Timothy Burdick from Fletcher Allen Health Care at the University of Vermont.

More info here.

From the Center for Mental Health Services in Primary Care:
"The Scope of a Federal Mandate for Providing Behavioral Health Services to Children: The Rosie D. Case"
Are children entitled under the law to mental health services?

Please join us for a free webinar on Thursday, April 14, from 1:00 - 2:30pm. Deborah Agus, JD, will discuss the Rosie D. Case and the subsequent mandate for behavioral health care for children in Massachusetts as well as the implications for other states.

Connect on the web at: http://connect.johnshopkins.edu/pediatricmentalhealth/

Contact slongway@jhsph.edu for dial-in information

A request from SAMSHA

2011-04-13T07:22:00.000-07:00

Here's an opportunity to have input into Federal policy on mental health. Go for it.
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SAMHSA Is Seeking Comments on a New Unified Application for Mental Health and Substance Abuse Block Grants

SAMHSA announces a new approach for the Substance Abuse Prevention and Treatment Block Grant (SAPTBG) and the Community Mental Health Services Block Grant (MHSBG). Under this new approach, the grant applications will merge, providing states and territories the opportunity to use block grant dollars for prevention, recovery supports, and other services that supplement services covered by Medicaid, Medicare, and private insurance.
The block grant funds will be directed to four purposes:

Fund priority treatment and support services for individuals without insurance or for whom coverage is terminated for short periods of time.
Fund those priority treatment and support services that demonstrate success in improving outcomes and/or supporting recovery for low-income individuals and are not covered by Medicaid, Medicare, or private insurance.
Fund primary prevention—universal, selective, and indicated prevention activities and services for persons not yet identified as needing treatment.
Collect performance and outcome data to determine the ongoing effectiveness of behavioral health promotion, treatment, and recovery support services and plan the implementation of new services on a nationwide basis.

SAMHSA will work with states and territories to plan for and transition the block grants to these four purposes. In redesigning their plans, states will consider new factors: conducting a needs assessment of their behavioral health system, developing collaborative plans for health information systems, forming strategic partnerships to provide individuals better access to behavioral health services, and redesigning systems and services to increase accountability and improve the performance of services funded. SAMHSA invites your comments on the proposed grant application.

Click here to find out more.

AHRQ has much cool stuff:ASD review

2011-04-04T16:26:00.000-07:00

Given that this is the month to think on autism, this message from AHRQ seemed worth reposting:

--------------------------------------------------

The Agency for Healthcare Research and Quality (AHRQ) Effective Health Care (EHC) Program is pleased to announce that the following research review is now available:

Therapies for Children With Autism Spectrum Disorders.

To access the research review and associated products, please visit: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=651.

An article on this report has been published in the journal Pediatrics. The abstract for this article can be accessed at:http://pediatrics.aappublications.org/cgi/content/abstract/peds.2011-0426v1.

Learn how you can personalize your interactions with and share what you learn on the EHC Program Web site. Visit:http://www.effectivehealthcare.ahrq.gov/index.cfm/personalization-and-social-media-tools/.

We welcome your comments on the EHC Program Web site! Please use our “Contact Us” form available at:h ttp://www.effectivehealthcare.ahrq.gov/index.cfm/contact-the-effective-health-care-program/.

Thank you,
Effective Health Care Program
www.effectivehealthcare.ahrq.gov

Upcoming Conference for folks interested in System Change

2011-03-24T11:30:00.000-07:00

Future of Pediatrics Conference
Embracing Change: Improving the Health of ALL Children
Chicago, Illinois
July 29-31, 2011
http://www.pedialink.org/cmefinder/search-detail.cfm?key=65511D4A-EB04-46D9-BFCD-ECA9E84F4A7C&type=event&grp=1&task=details
Register by June 29, 2011 for Early Bird Rates!

What is the Future of Pediatrics Conference?
With the overall goal of improving child and adolescent health, this conference blends cutting-edge updates on clinical and practice management topics with strategies for advancing medical homes and building partnerships within communities. Learners will apply principles of team-based care, change management, and co-management between pediatric specialists and primary care, to achieve a goal of improving the health of all children. A variety of educational formats will be utilized, including interactive, roundtable, and networking sessions, to provide learners with opportunities to develop innovative, enduring partnerships and transform their practices.

Who Should Attend?
• Pediatricians in Primary Care Practice
• Community Pediatricians
• Faculty in General and Community Pediatrics
• Pediatric Residents
• Family Advocacy and Maternal and Child Health Leaders
• Pediatric Nurse Practitioners
• Practice Administrators
• Other Pediatric Health Care Professionals

Earn a Maximum of 17.5 AMA PRA Category 1 CreditsTM

Register online at www.pedialink.org/cmefinder or call 866/THE-AAP1 (866/843-2271).

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAP designates this live activity for a maximum of 17.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Attend the Mental Health Preconference -

Embracing Mental Health Care: Lessons Learned for Success
Thursday, July 28
10:00 am-5:15 pm

Plan to arrive early and participate in this opportunity designed to empower pediatricians with innovative best practice models for addressing mental health concerns and practical tools for clinical care. Advance registration is required, and seating is limited. A limited number of travel stipends will be available. For more information, visit www.aap.org/mentalhealth.

This preconference is supported by the Child, Adolescent and Family Branch (CAFB), Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA). The content of this preconference does not necessarily reflect the views, opinions or policies of CAFB, CMHS, SAMHSA or the Department of Health and Human Services.

Child Services in the Commonwealth: Making it Better

2011-03-19T08:07:00.000-07:00

Secretary Bigby is committed to changing the way in which children's services are organized in the Commonwealth (see her letter, posted last month) Now, several of the groups that advocate for children have weighed in, with a letter and some organizing around upcoming hearings (read it here) To join up, contact Barbara at the Children's League.

A letter from MCPAP

2011-03-18T09:58:00.000-07:00

A letter from MCPAP:

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Dr. Keller,
Behavioral Health Emergency Services (ESP) are available to people of all ages who are uninsured or covered by MassHealth (Medicaid plans). These services are also covered by some commercial insurance companies.
A statewide toll-free telephone number is available to help individuals reach their local Emergency Service Program/Mobile Crisis Intervention provider (ESP/MCI). By dialing 877-382-1609 and entering their zip code, callers will hear a recorded message containing the phone number of the ESP/MCI program in their area. If the zip code is unknown, the caller will be given a number of an ESP/MCI provider to call for the information.
Mobile Crisis Intervention is the youth (under the age of 21) -serving component of an emergency service program (ESP) provider. Mobile Crisis Intervention will provide a short-term service that is a mobile, on-site, face-to-face therapeutic response to a youth experiencing a behavioral health crisis for the purpose of identifying, assessing, treating, and stabilizing the situation and reducing immediate risk of danger to the youth or others consistent with the youth’s risk management/safety plan, if any. This service is provided 24 hours a day, 7 days a week
Click here for a handy flyer for providers. Click here for a handy flyer for families.
If you have a patient who is in crisis, please remember that this resource is available. This is an alternative to hospital emergency departments.
Thank you.
Sincerely,
John Straus, MD
VP Medical Affairs
Massachusetts Child Psychiatry Access Project

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Pretty cool. Good to link MCPAP and CBHI.

Anxious? Click here

2011-03-12T09:35:00.000-08:00

From TEENSCREEN:

------------------------------------------

Anxiety & Adolescents: Recognizing and Managing Teen Anxiety in the
Primary Care Office

Thursday, March 31, 2011
1 p.m. - 2:30 p.m. Eastern Daylight Time

While adolescence is known as a time of normal stress and transition, clinical anxiety disorders can impair a teen’s life and contribute to distress, academic failure and social dysfunction. Left untreated, these disorders often lead to major depression or substance abuse.

Anxiety disorders are among the most common of mental illnesses in teens, but only 18% of adolescents with clinical anxiety ever receive treatment. Identifying and managing adolescent anxiety can be challenging. Symptoms and the focus of anxiety are varied and are often misidentified in primary care as somatic complaints due to “normal” teenage stress.

Anne Marie Albano, PhD, ABPP is a leading expert on child, adolescent and young adult anxiety and mood disorders. She is associate professor of clinical psychology in psychiatry in the Division of Child and Adolescent Psychiatry at the Columbia University College of Physicians and Surgeons, and director of the Columbia University Clinic for Anxiety and Related Disorders. She is also President of the Society of Clinical Child and Adolescent Psychology of the American Psychological Association and is Past President of the Association for Behavioral and Cognitive Therapies (ABCT).

Dr. Albano will discuss ways to effectively identify anxiety disorders, available evidence-based treatments, strategies primary care providers can use with teens who suffer from anxiety disorders, and helpful resources that can be accessed for providers and parents.

Please click here to register.

From SAMSHA: A reminder that policies have consequences.

2011-02-28T09:46:00.000-08:00

SAMSHA sent me a reminder today, that, in two months, it will with be Children's Mental Health Month. They included this graph, from some research out of ASPE in the last administration. In the accompanying report, it was pointed out that the way to prevent this from happening was to strengthen the social network around parents and children. So why are budget cuts in the current House Continuing Resolution targeting programs that support that very network? Full report available here.

"Young children exposed to five or more significant adversities in the first 3 years of childhood face a 76 percent likelihood of having one or more delays in their cognitive, language, or emotional development. The likelihood of delay increases in nearly a straight line with the number of risks.¹

However, research has shown that caregivers can buffer the impact of stress and promote better outcomes for children even under stressful times when the following Strengthening Families Protective Factors² are present:

Parental resilience
Social connections
Knowledge of parenting and child development
Concrete support in times of need
Social and emotional competence of children

Need help navigating the system? Sometimes a kid needs a lawyer.

2011-02-25T13:30:00.000-08:00

50 years ago, Leonard Bernstein captured the essential dilemma of the juvenile justice system in the song "Office Krupke", where a youth on the street goes from police officer to social worker to psychiatrist to judge in an eternal circle of ineffective care. Health Law Advocates has been trying to break that circle through the Mental Health Guardian Ad Litum program. Can be useful sometimes to have someone looking for a way out. (By the way, doesn't Lenny look great on YouTube? Really miss having him around...)

---------------------------------------------

HLA and Children's Mental Health

One of HLA's leading initiatives is our Children's Mental Health Access Project (CMHAP). Since we launched this initiative, HLA's work in this area has helped scores of families to overcome obstacles to securing diagnoses, treatment, and follow-up care for their children with unmet mental health needs.

A major component of HLA's CMHAP is our Mental Health Guardian Ad Litem (GAL) program which focuses on helping juvenile court-involved children who need mental health care. HLA attorneys are appointed by Juvenile Court Justices in select locations as Mental Health GAL for children in court who are falling through the cracks of the mental health system. The Mental Health GAL's role is to identify the child's unmet mental health needs, advocate on behalf of the child's interests and recommend judicial actions.

Numerous studies have measured a high incidence of mental illness among children in the juvenile justice system. The enormous cost of not diagnosing and treating mental illness in these children is apparent. Children who do not get the care they need are at greater risk of entering and remaining in the juvenile detention system and eventually the adult justice system, resulting in substantial social and economic costs to families, communities, and public agencies.

HLA's Mental Health GAL Project is currently supported by the Klarman Family Foundation and has received past support from the Jesse B. Cox Charitable Lead Trust, the Health Foundation of Central Massachusetts, the Nord Family Foundation and the Massachusetts Bar Foundation.

Reforming CHINS is not easy

2011-02-24T14:39:00.001-08:00

I guess it is harder to reform CHINS than it looked. Secretary Bigby sent this out today.

----------------------

Letter from Secretary Bigby

Sent:Wednesday, February 23, 2011 7:50 PM

Subject: A Message from Secretary Bigby

Dear Colleagues,

I am writing to keep you informed and engaged in an exciting effort to strengthen the many services and supports we provide to children, youth and families. Since I became Secretary, I have heard from a diverse range of stakeholders - including families we serve, agency staff and advocates - about the need for a more integrated and coordinated system of services. I have also heard the need for services that strengthen families through a respectful approach that is holistic, responsive to each family's unique needs, and community-focused. In numerous forums, including the Human Service forums hosted by Governor Patrick in 2009 and 2010 and the recent Children's League Advocacy Day at the State House, advocates and stakeholders encouraged the Patrick- Murray Administration to address the "current maze of agencies" to make the service delivery system more closely coordinated and with a single access point for families seeking services.

Governor Patrick has heard the repeated requests from numerous sectors of the child-serving community to strengthen service access and coordination and has asked EOHHS to engage with a broad range of stakeholders to define how to reform the Commonwealth's services for children and families. We began discussions with agencies and with some stakeholders. In the coming weeks we will continue our discussion about how we can together streamline and strengthen the services and supports we offer to children, youth and families. We look forward to engaging in a thorough and thoughtful series of discussions about our ideas for improving service delivery. State employees, so many of whom are on the "front lines" of service delivery, will play an integral role as we refine our plans and we plan to engage Union leadership throughout this process. I welcome your input and feedback and will be in touch with you again soon with more information about this process.

In the meantime, thank you for the work you do each and every day on behalf of all of our consumers and for your commitment to working with us to strengthen the services and supports we offer.

JudyAnn Bigby, M.D.

Secretary

JudyAnn Bigby, M.D.

Secretary, Executive Office of Health and Human Services

One Ashburton Place, Suite 1109

Boston, MA 02108

617 573-1800

Assistant: Mary Skahen (mary.skahen@state.ma.us)

Family Perspective is Worthwhile.

2011-02-18T01:26:00.000-08:00

Too much interesting stuff going on in the world.

-----------------

FEB. 18TH CHILDREN’S CONFERENCE CALL WITH DR. KEN DUCKWORTH

Save the Date: Friday, February 18th, 2011, from 11:00a.m. to 12:30p.m. Eastern Time.

Topic: The Integration of Mental Health and Primary Care ~ The Family Perspective

NAMI will be on the February Children’s Conference Call with Dr. Duckworth to discuss the integration of primary care and mental health from the perspective of families. We conducted a national survey on the family experience with primary care physicians and staff and will share some of the survey results during the call. We will also discuss the role primary care physicians can play in the early identification and intervention of mental illness.

Friday children’s conference calls with Dr. Ken Duckworth, NAMI’s medical director and a child and adolescent psychiatrist, take place on the third Friday of every month. The calls are toll free and are scheduled from 11:00 a.m. – 12:30 p.m. E.T. To access the toll-free call, please dial 1-888-858-6021; access number 309918#. We hope that you will join us!

This is not good for children.

2011-02-17T12:51:00.000-08:00

Wraparound requires that you have services to network with. The current Federal budget debate puts that at risk, as outlined in the letter I got today from Michael Petit:

---

Dear David,

This has been a major week for the future of children’s programs. We want to give you a breakdown of what is being debated and tell you what you can do to fight the wrong decisions many in Congress want to make.

Background

On October 1st of last year, the federal fiscal year 2011 began. The Congress did not pass a budget funding government programs. Instead they passed what is known as a “continuing resolution” that funds programs at essentially the same level they were in 2010. This resolution will expire on March 4th. Congress needs to pass final legislation that will fund the government until September 30th of this year or at some point government could "shutdown.' The fiscal year for 2012 will begin on October 1st of this year.

What the Congress is Currently Considering

The House of Representatives recently proposed a series of cuts to the budget for this year. Last week we told you about how they proposed $32 billion in cuts – including to the Maternal and Child Health Block Grant, the Women, Infants, and Children (WIC) program, community health centers, poison control centers, and other children’s programs. This was not enough for some members of the House, particularly those who associate with the “Tea Party” movement. On Friday night, a day and time known by government officials as the best to release information that they know will get the least amount of media coverage, the Appropriations Committee offered an additional $42 billion in cuts. These include

Head Start - $1 billion (15%) cut

Community Health Centers - $1 billion cut

Community Services Block Grant - $341 million cut

Low Income Home Energy Assistance contingency fund - $390 million cut

Title I (K-12 education for low-income students) - $693.5 million cut

IDEA (special education) grants to states - $560 million cut

Special Supplemental Nutrition Program for Women, Infants, & Children (WIC) - $747 million cut

21st Century Community Learning Centers (after school programs) - $100 million cut

Maternal and Child Health Block Grant - $50 million cut

Child Care Development Block Grant - $39 million cut

Many other children's programs will be eliminated entirely. Some examples include:

Teen Pregnancy Prevention Grants

Mentoring Children of Prisoners

Even Start

Striving Readers

High School Graduation Initiative

Student Aid – for higher education

LEAP program (for low-income college students)

The House could include even more cuts as they debate this resolution.

These cuts are wrong on many levels. They harm children at a vulnerable time in their development. The economy remains in recession, and an all-time record number of children (14,567,000) currently live in poverty. Cuts like this would mean that 368,000 low income 3-and 4-year olds would lose the education and nutrition program they receive at their Head Start center. The education cuts, along with others being made in states, would leave thousands of teachers out of jobs this year. Many in Washington say these cuts are needed to reduce the deficit. However, these cuts would take only 2% off this year’s projected deficit. So essentially, these cuts harm children and don’t solve America’s fiscal challenges.

What You Can Do

Contact your member of the House and Senators and tell them you oppose these cuts and why. They will listen to you. The original House proposal included a $210 million cut to the Maternal and Child Block Grant. When they heard from people opposed to this, the Republicans reduced their cut to $50 million. Many lawmakers are not fully supportive of all these cuts. When they reduce these cuts, they are showing just how much discomfort they have. Click here to contact your representatives. Some suggestions when you get hold of someone in their office:

Tell them that Congress needs to start budgeting like real families and put our nation's kids first! Please stop these harmful proposed cuts to programs that are essential for our nation's economic future.

Remind them that scientific research and leading economists have said for years that investing in children is one of the smartest investments we can make. We need more investments in the health, safety, and education of children, not mindless cuts.

Ask them what they would say to the 4-year-old in their district or state who is forced out from his or her Head Start program.

Let us know what they say.

What Happens Next

Even if the House of Representatives passes all of these cuts to the budget for this year, the Senate has their say as well. Senator Daniel Inouye of Hawaii, the chairman of the Senate Appropriations Committee, has slammed these cuts, saying “they would impede the federal government from completing even its most core functions.” President Obama has threatened to veto these cuts. This debate will continue throughout the year.

At some point, Congress will begin debating the budget for next year. This week, President Obama released his budget for 2012. Overall, it contains a small increase to children’s programs. Not all programs receive an increase. The President proposed cuts in juvenile justice, heating assistance for low-income families, and community service programs. He makes up for this somewhat with increases in Head Start, afterschool programs, child nutrition, child health, and education programs. We will let you know much more about this proposal for next year, but the main business in Washington is to fight the cuts House members want to make to children’s programs, right now.

Michael Petit

President

Every Child Matters Education Fund

Mental Health Parity is Still Confusing

2011-02-16T03:25:00.001-08:00

Still trying to understand Mental Health Parity? Me too. These might help:

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Free Webinars for Consumers: The Mental Health Parity and Addiction Equity Act (MHPAEA)

SAMHSA's Partners for Recovery Initiativ e invites you to two free webinars on the new Federal parity law.

Parity 101 | February 17, 2011 | 1 to 2 p.m. Eastern Time

The webinar will provide a general overview of MHPAEA and the recently released Interim Final Rule. The webinar, which is directed to consumers, will be presented by health policy experts from the Legal Action Center.

Parity 201 | March 10, 2011 | 1 to 2 p.m. Eastern Time

The webinar, designed for states and providers, includes a detailed discussion about implementation of MHPAEA. This discussion will provide details on state-level implementation efforts, interplay between the Federal parity law and state parity laws, and anticipated additional pieces of regulatory guidance.

2011-02-15T02:53:00.000-08:00

This looked interesting. Wish I had time to listen in.

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TeenScreen National Center Webinar
Managing ADHD in Children and Adolescents:A Clinical Update
Wednesday, February 23, 2011

ADHD remains the most prevalent and challenging of behavioral disorders in school-aged children. With research showing that children with ADHD face increased risks of major depression and suicidal ideation in adolescence, clinicians are confronting both the immediate and potentially long-term burdens of a disease that can impact a patient’s emotional, social and academic life.

Lawrence Greenhill, MD, is a child and adolescent psychiatrist and a leading researcher on the treatment of ADHD. The Ruane Professor of Clinical Psychiatry at Columbia University and current President of the American Academy of Child and Adolescent Psychiatry, Dr. Greenhill will discuss the latest research and clinical advances in the treatment and management of ADHD.

Click here to register

Click here for event details.

Comments on the WBUR series.

2011-02-07T07:25:00.000-08:00

I promised comments, but, like most of America, I watched the Super Bowl and ate chilli last night (good vegetarian chilli with a nice sourdough bread and cheddar cheese atop, Moosewood recipe). This morning, I woke up to WBUR's comments and though that I might start by reflecting on those, which you can read here.

A few thoughts:

1) Stigma really does exist. Lots and lots of people do not seem to believe that mental illness is as common as it seems to be, and that there is value in blaming parents, Ben Spock, liberals, modern society, the internet, vaccines, toxins and all manner of things for its existence. Their conclusion is that, if we just took those things away, it would get better. Much more likely is that mental illness does exist (the brain is the most complicated organ we've got; why should that work better than our heart or liver?) and that we are seeing more problems now because people are surviving childhood diseases that may have been harder on those with mental illness in the past, and that we are asking the brain to function in a way that we have not asked it to do in the past. In any event, how a brain gets messed up is useful in prevention work; what to do after the fact is actually a separate issue. People should be kind to those trying to cope with the aftermath, many of them are, but a lot of the ones that aren't wrote into WBUR last week (and perhaps went back to their Scientology meetings afterwards). The fight is not over, just because we have mental health parity now.

2) There is a disparity between care for the poor and the middle class (and the rich): But it is not what you think. The rich can pay cash for a child psychiatrist like Dr. Edna in Mad Men, who will talk with there child, develop a plan for treatment that involves therapy with the judicious use of medication, and sometimes treatment in ranches in New Mexico. The poor are locked into Medicaid, which is held to an EPSDT standard for children: If we find it, it must be treated. This allows the poor in States with good advocates to do things like the Rosie D. lawsuit, and to get Medicaid to cover a variety of what are called "wraparound" services, things that do more for kids than give them medications with reckless abandon. Granted, they still do: there are several studies showing that rates of medication in Medicaid patients are high. But it is usually the case that meds in Medicaid, at least in Massachusetts, are tied to some sort of therapy and the CBHI is working hard to get the children with serious emotional disturbances into some sort of coordinated care. The vast majority of us, however, are in commercial plans, which are not held to the EPSDT standard. Those kids often find it easier to get medications than to get therapy, and may actually be getting care that is less comprehensive than either the rich or the poor, a problem that is augmented because the parents are working, and don't that the time or resources to advocate for their child that are available to those who are either rich or poor.

3) What to do about this is a political decision. So, do you upgrade the middle class to at least the level of support given through Medicaid? Or to do take down the poor to the level of the middle class? That is a classic politic dilemma, and fits well into the current discussions about the appropriate role of government. I would argue that to cut services to the poor guarantees increase cost in unemployment, disability and incarceration in the future, and is a "penny-wise, pound-foolish" strategy, but others would certainly disagree.

4) Treatment of mental health problems in childhood is complicated. While the new services offered by the CBHI are great, they reflect that complexity, and will require much care coordination if they are to be used effectively.

Good series. You should listen to it.

Good chilli. You should eat it.

Back to the Legislature: Making it Better

2011-02-05T07:09:00.000-08:00

I meant to listen to the WBUR series, I really did. I will do so this weekend, and pour forth a spate of commentary. In the meantime, the Campaign does have some good ideas going forward:

As the 2011-2012 legislative session commences, the Children’s Mental Health Campaign (CMHC) continues advocating to improve the system of care for children with mental illness and their families. Please click HERE today to contact your State Senator and State Representative and ask them to sign-on as co-sponsors of CMHC’s 2011-2012 legislative session priorities:

Coordination of Children’s Mental Health Care

Lead Sponsors: Senator Steven A. Tolman and Representative Ruth B. Balser

This provision requires commercial insurance companies to reimburse licensed children’s mental health clinicians for time spent in consultation with families, teachers, pediatricians, day-care providers and other adults who regularly interact with the child in order to make a diagnosis or to formulate or implement a treatment plan.

Families and Children Engaged in Services (FACES)

Lead Sponsors: Senator Karen E. Spilka and Representative Paul J. Donato

The Child in Need of Services (CHINS) system is intended to provide assistance to children and families when the child is habitually truant, runs away from home or refuses to obey the lawful and reasonable rules of their parents or their school. This provision transforms the current juvenile justice based system in to one which is community based.

Proportional Payments of the MA Child Psychiatric Access Project

Lead Sponsors: Senator Jennifer L. Flanagan and Representative Ruth B. Balser

The MA Child Psychiatric Access Project (MCPAP) provides primary care providers, who are on the front lines in diagnosing and treating mental health disorders, access to mental health consultations with a team comprised of child psychiatrists, psychologists and/or social workers. This provision requires commercial insurers to contribute to the funding of this program at a rate equal to the participation of their membership.

For more information about these bills please visit the CMHC's legislative priorities page at www.childrensmentalhealthcampaign.org/legislation.

We need your help turning these important bills into laws. Thank you for your continued support and advocacy on behalf of the Commonwealth's most vulnerable children!

Thank you,

Erin G. Bradley

CMHC Coordinator

Reflecting on Part 1: WBUR's series on Mental Health Treatment

2011-02-02T12:08:00.000-08:00

First, this is really well done, in depth, radio journalism. You should listen to this here, if you haven't already. It tells the story of a young man who has a story similar to many that I have seen over the years, who has had some sort of mental health problem, has accessed our system (in a manner, to be clear, that most of the country cannot) and is entering adulthood confused about his diagnosis, his need for treatment and his prognosis going forward. He (and implicitly the reporter) imply that it really shouldn't be so hard. What is it about? A few themes, that you may have heard before.

1) Behavioral/psychiatric problems are hard to diagnose, in part because diagnosis is based on clinical impression. This family had many reports; with many diagnoses and many recommendations and it made them confused.

2) Stigma lives. A youth with mental health, who develops substance abuse problems suddenly has to find a whole new treatment system. Why? Read the comments that people have left on the website. The obsession with blame and fault is impressive.

3) Primary care wasn't helpful. This family really would have benefited from a primary care doc who stayed with them throughout the journey. Kind of sad that they had to keep looking.

4) Treatment works. Sort of. Sometimes. The young man in the story was not a big fan of the many medications that he has taken over the years, although, in the end, he conceded that they may have been helpful. A long term relationship with a consistent provider may have been helpful.

More tomorrow.

WBUR Investigates Children's Mental Health in Massachusetts:

2011-01-28T15:02:00.001-08:00

Weeklong News Series Begins Mon., Jan. 31

WHO: WBUR, 90.9 FM, WBUR.ORG, Boston's NPR News Station, examines the children's mental health system in a special series titled, "ARE THE KIDS ALL RIGHT?"

WHAT: An estimated 300,000 Massachusetts children have a diagnosable mental health disorder, but many of them don't receive care or don't receive appropriate care. That's despite the lawsuit known as "Rosie D," that mandates adequate mental health care for children on state subsidized insurance in Massachusetts. Described as a "lightning rod of change" by Children's Hospital and other child advocates, the lawsuit has had broad implications for the diagnosis and treatment of ALL Massachusetts children. WBUR Reporters Deborah Becker and Monica Brady-Myerov explore this subject in a special WBUR news series.

WHEN: "ARE THE KIDS ALL RIGHT?" airs Jan. 31 - Feb. 4 during Morning Edition from 5 a.m. - 9 a.m. and All Things Considered from 4 p.m. - 6:30 p.m., only on WBUR and wbur.org (segments scheduled to air at 6:35 a.m., 8:35 a.m. and 5:50 p.m.).

Monday, Jan. 31: ONE LOCAL FAMILY'S JOURNEY

WBUR explores the Cadogan family's struggle with son, Will, age 17, who has tried several medications, psychiatrists, therapists, hospitalizations, outpatient programs, special schools and even self-medication over the years.

Tuesday, Feb. 1: THE MEDICATE DEBATE

As psychopharmaceutical drugs become more sophisticated, and more parents demand treatment, WBUR looks at the debate over when and how to medicate children for mental health issues such as depression, ADHD and more.

Wedneday, Feb. 2: SCREENING ALL KIDS EARLY FOR MENTAL HEALTH ISSUES

Because of "Rosie D," Massachusetts has become a national model for pediatricians to regularly screen ALL kids for mental health issues during routine exams. WBUR looks at how screening has worked and whether pediatricians are equipped to do it.

Thursday, Feb. 3: ACCESS: WHERE ARE ALL THE DOCTORS?

Massachusetts has one of the best doctor-to-child mental health patient ratios in the nation, yet many families can't get the services they need. Complicating matters, a recent study estimates that half of the state's mental health providers will leave in the next five years. WBUR talks to families and doctors about the challenges around access.

Friday, Feb. 4: HOW DO WE IMPROVE?

Roundtable discussion moderated by WBUR's Bob Oakes with guests including a local parent, a doctor, the Department of Mental Health Commissioner Barbara Leadholm, and Lisa Lambert, executive director of the Parent/Professional Advocacy League.

We extend our sincere gratitude to all of the families whose personal stories will be reflected in this series and to our friends at PPAL for their work to make this series happen. This promises to be a significant milestone in our efforts to educate the public about what happens in families when a child is mentally ill.

Meeting Notice (and Free Gift Cards)

2010-12-06T18:57:00.001-08:00

The Massachusetts Behavioral Health Partnership (MBHP)

The Partnership that Works

Please join us for an open forum about current mental health and addictions services and new directions in Massachusetts.

MBHP continues to develop and implement many innovative supports so that people with lived experience can lead lives of safety, stability, community, and accomplishment. This forum is an opportunity for us to hear from you about what is working and to hear your suggestions for improvements.

We value the lived experience and the contributions of our many stakeholder partners, including consumers, families, providers, advocacy groups, human service agencies, and legislators. MBHP would like to strengthen these partnerships by hearing from those who use services, provide services, and/or provide advocacy for our public behavioral health system.

Please let your voice be heard by attending and sharing your ideas at one of the sessions listed below.

Sessions: (Please click each location for directions.)

Tuesday, December 14, 2010: Marriott, Springfield

Wednesday, December 15, 2010: Marriott Courtyard on Tremont, Boston

Thursday, December 16, 2010: Hilton Garden Inn, Worcester

10:30 a.m. to 12:30 p.m.

Lunch will be provided. Parking is complimentary.

Gift cards will be distributed to all attendees.

To help us plan for space and lunch, please let us know which session you will be attending by e-mailing MBHPforum@valueoptions.com or leaving a message at (617) 350-1942.

If you require Spanish interpretation or American Sign Language (ASL) services, please notify us by Thursday, December 9th.

Welcome and Introductions:

Nancy Lane

Chief Executive Officer, MBHP

Facilitators:

Richard Sheola

ValueOptions® Senior Leadership Team

Clarence Jordan

Director, Recovery & Resiliency, ValueOptions® of Tennessee

Clara Carr

Director, Rehabilitation and Recovery, MBHP

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

2010-12-05T09:23:00.001-08:00

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.

Keynoting a System for a Medical Home: Some Joy Out There in Muddville

2010-10-26T20:02:00.000-07:00

Today, I had the privilege of keynoting the kickoff of a learning collaborative for pediatric practices that want to enhance the care that they provide for children with mental illness. The Boston Public Health Commission led a consortium that successfully got 2 grants from SAMSHA to address issues of early childhood mental health problems in the context of a community health care. It is a noble effort. One program, Boston LAUNCH, is targeting children from 0-8 with an assortment of mental health prevention approaches and the other, a Systems of Care effort that really focuses on younger children with more severe behavioral problems. What's really cool is that the BPHC convinced HRSA to allow the programs to integrate, and that they are "braiding" the funding, which be allow both programs the opportunity to work off of each other in very different circumstances. Very cool initiative. Maybe they will be able to tell us how to "fill in the blanks" in health reform.

So what did I say to them, you may ask? Really three things:

States have much say in how health reform plays out, and they are in various degrees of understanding their role in the process. All of them will need to implement new programs that intertwine behavioral services with routine primary care.
You can do the coolest program in the world, but if is not well evaluated, it will not change policy.
With Massachusetts health reform, CHIPRA and the Affordable Care all mean that the system is vulnerable to change. These programs, properly evaluated, will be what informs the choices that lawmakers have to make over the next few years.

After that, we team built, talked, laughed and bonded. Overall, a good use of my time.

Save the Date: CMHC Supporters Meeting

2010-10-25T19:51:00.000-07:00

November 23, 9:30-11am

The next CMHC Supporters Group Meeting will be on Tuesday, November 23 from 9:30-11am in the 9th Floor Conference Room at 30 Winter Street in Boston.

This will be an important meeting where we will finalize the Campaign's policy and advocacy agenda for the upcoming legislative session.

We need everyone's input and help to be successful.

Also, if you or your organization have legislative priorities or upcoming events you would like to share with the group, the November meeting is a great chance for this.

See you on November 23!

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Show the world your support of Children's Mental Health

Cut and paste the html code below into your website for a button that will direct users to the CMHC website.

When you put it on your organization's website, let Matt know at mnoyes@hcfama.org.

Thought on Returning from Sabbatical

2010-10-09T06:16:00.000-07:00

It is both wonderful and weird to be back.

Wonderful because I really enjoy working with patients. For those of you who don't want to go back into ancient blogging history, I left Massachusetts last September to go to Washington and work in the Federal Government as a Robert Wood Johnson Health Policy Fellow. As part of that deal, I too a year off of patient care, and left my practice, where I had worked for 18 years. One of the things that surprised me in DC was that I didn't seem to miss the day-to-day doings of seeing patients. So I was concerned that, when I got back to Massachusetts, I wouldn't either remember how or enjoy doing that anymore.

Turns out I needn't have worried. The give and take of the clinical encounter really grounds me in reality, in a way that detached policy discussions don't. Now, I am not back in my old practice in Webster- South County has continued to flourish in my absence and has recently added a third doctor to its group. I couldn't ask those patients to put their lives on hold while I was away. Since I am now working on policy stuff within UMass Medical School's Commonwealth Medicine, a great organization that lets us bring clinical and analytic expertise to the service of state government, I need to be in Worcester more. So I am working in another practice within our clinical system. And, it turns out, I really do like seeing patients.

In my new role, mental health has not been as large a part as it was in my old practice. We are screening for behavioral health issues, as one would expect from in these days of the Rosie D rollout. I am still not finding the screening terribly useful. Most of the kids I've been seeing are pretty well plugged into services, and have already been diagnosed. The system continues to work for them in its own creaky way, and I am incredibly conscious that we in Massachusetts have a lot more in our system than does any other State in the Union. Despite all that we do, it is not yet enough to calm the feeling of dread that course through a parent's heart whenever they take one step forward and two steps back. Much work to do.

What is weird about being back is that I have now travelled over the whole landscape of 90,000 foot high grand policy decisions (like mental health parity and children's mental health reform) at the Federal and State levels, seen the agencies where they are implemented (like HHS and SAMSHA and the CBHI) and been to the meetings where decisions are made that affect the lives of millions of children (no, I didn't make any of the decisions, and I don't think that I influenced them much- but I have seen the process). So now, when I am seeing a patient, and trying to figure out how to make that system work for them, I sometimes visualize it as the end of a long web of decisions that stretch from the halls of Congress to my examining room. It is an odd and vertiginous perspective, but I am getting used to it.

I did manage to attend the MCAAP Mental Health Task Force meeting a few weeks back. There is still much energy in that group, and they continue to focus on early childhood mental health. There was talk of aligning that work with the push for early childhood education, which I think is important. More on that in another post.

Not sure how often I will post in the future, but I will try to post things that are useful.

Cater to Your Inner Wonk

2010-09-17T19:44:00.000-07:00

Louise Norris of Colorado Health Insurance Insider hosts the Politics,
Money and Health edition of Health Wonk Review....

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http://www.healthwonkreview.com/mt/2010/09/new_health_wonk_review_at_colo.html

THe Affordable Care Act and Behavioral Health: A Webcast

2010-09-16T08:02:00.000-07:00

HealthCare.gov sent this bulletin on September 15, 2010 08:48 AM

There are many important benefits for you and your family in the Affordable Care Act, but one area that you may not be aware of is behavioral health. The new law contains important new programs that will help improve and expand coverage for those with behavioral health disorders. Unfortunately, many Americans do not have access to the mental health and substance use treatment services they need. Quality, affordable coverage can be hard to find and insurance companies can arbitrarily limit care for behavioral health disorders.

You can check it out here.

Antipsychotics and the Kids

2010-09-14T18:07:00.000-07:00

A long time ago, I posted a set of rules that I used to help me to navigate the treacherous roads of children's mental illness. (Note to new readers- I am a pediatrician, not a child psychiatrist, and am a bit humbled by the new medications now at our disposal.) One of those rules was pretty straightforward:

There is little evidence to support using two psychotropic medications to treat AD/HD in children, and none to support using three.

According to the New York Times a few weeks ago, I was pretty close to the mark. Young children have been overprescribed medications for no good reasons. Often. What was interesting to me is why this was suddenly front page news? Anyway, I was not surprised and unhappy at the line taken by the pediatrician in the story: You have to do something when people come in desperate for help. Unfortunately, the right answer, frequently, is to do hold back on the big guns, and use focus on the hard stuff, like behavior management and family supports.

Nice article, with a nice "shout out" for Mary-Margaret Gleason, a triple boarded child psychiatrist who I have not seen in too long.

I'm back to seeing patients today, screening away for mental health and behavioral health problems. So far, not much. But I've only been back for 2 weeks. More later.

The Parent-Professional Advocacy League

2010-09-13T12:37:00.000-07:00

Always nice to hear good things about nice people. This came in on my listserve from Meri Viano. Nice work, Mary.

I wanted to welcome and congratulate Mary Lambert as the Full time Lead Family Support Specialist for PAL ( Parent/ Professional Advocacy League). ( Mlambert@ppal.net, 508-767-9725).

As many of you are aware, Mary has been with PAL for over 3 years and has dedicated herself to helping , advocating, teaching and empowering families all across the state.

Mary has a passion to teach families their rights, and educate them to help support their child and themselves. Mary has begun working full time for PAL and will continue to bring families, communities, and providers valuable information. Mary is a parent of 4 wonderful , amazing children and brings her own heartfelt stories, strategies, and tools to her job daily. Mary is in charge of getting families information/referrals and options of supports and needs for help in our state.
PAL is excited to welcome Mary Full time !!

Also from the Children's Mental Health Campaign

2010-09-10T06:57:00.000-07:00

If you can't make the meeting on the 14th, consider this meeting on the 16th:

CMHC Legislative Committee
Thurs., Sept. 16
3-5 PM
9th Floor Conference Room
30 Winter Street, Boston
As the legislature goes into informal session - likely for the remainder of the 2009-2010 legislative session - it's time to look toward setting our agenda for the 2011-2012 session.
The Legislative Committee will be reconvening to begin that work on Thursday September 16th from 3:00-5:00 in the 9th floor conference room at Health Care for All.

The goals for the meeting will be to

Agree on legislation which we will seek to have filed on behalf of the campaign,
Establish a process for drafting and filing new legislation and
Discuss a proposed process by which the CMHC will support legislation filed by others. (this will be sent to you prior to the meeting)
The issues we are currently considering are below. If there are other legislative issues that you would like considered please feel free to contact me to discuss them. In addition, we welcome receiving any information which would inform our work that you would like to have distributed to members ahead of time.
Please respond directly to Nancy Allen Scannell at
Nscannell@mspcc.org or 617-587-1510.
Legislation:
Refiles:
Coordination of Care: Discussion of options for refilling the coordination of care bill.
CHINS: Discussion of ongoing support for the CHINS bill.
New:
Based on the input we have received to date we are currently considering new legislation to address the following issues
1. Establish a uniform definition of "out of school time." Time out of school has a profound negative impact on children. However, the ability to get a complete picture of 'out of school time" is hampered by the existence of an array of terms used to describe time that children are excluded from school. The intent of creating a uniform overarching definition of out of school time to apply to early, elementary and secondary settings is to facilitate the collection of information and data to inform strategies for increasing the amount of time that children are in school.
2. Mandated attendance State Agencies and LEAs at meetings to Coordinate Care
The lack of a forum where parents can expect the attendance of all state and local authorities who are involved in providing care to their child creates tremendous issues in coordinating care for the child. The delays and mixed messages that result from multiple separate meetings between and among the parties are harmful to the child's well being, put an enormous burden for advocacy on parents and are a waste of precious human and financial resources. Solutions under consideration are mandating LEA participation in the Unified Planning Teams established under Ch.321 of the Acts of 2008 or mandating State Agency participation in IEP meetings.
3. Payment Reform
The CMHC is very concerned about the absence of any focus on systems of care for children and especially children with mental and behavioral health issues in the larger discussions of payment reform. We hope to establish a strategy for ensuring that these issues are given due consideration in any proposal that begins to move toward becoming law.

The More Things Change: Back in New England

2010-09-06T12:49:00.000-07:00

Been away for a while, and it is good to be able to breathe the New England air again. Also good to see this in my Inbox, from the Children's Mental Health Campaign.

Please Join Us: CMHC Supporters Meeting

Tuesday, September 14 from 9:30-11am

30 Winter Street, 9th Floor Conf. Room

Please join us for the next Children's Mental Health Campaign Supporters' Meeting Tuesday, September 14 from 9:30-11am in the 9th Floor Conference Room at 30 Winter Street.

One of the major issues facing the Legislature during the 2011-12 session will be examining the way that health care is paid for.

Payment Reform has significant implications for the delivery of children's mental health services.

On September 14, we will be discussing Payment Reform and how the Campaign can work to make sure that the children with mental health needs are considered in any policy changes.

Additionally, we will discuss new legislative priorities for the Campaign, grassroots development work, and potential larger public events around children's mental health.

If you have any questions or would like more information, please contact Matt Noyes, Campaign Coordinator, at 617-275-2939 or mnoyes@hcfama.org.

Thank you again, and please save September 14 for the next CMHC supporters' group meeting.

Good to know that someone has been fighting the good fight while I've been gone. Perhaps I'll see you there.

A New Blog for the New Year:http://holdonitsnotover.wordpress.com/

2010-01-03T12:36:00.000-08:00

Hi, all. Happy New Year.

It's been a while since I've posted, and those of you who have been checking have probably noticed that I haven't updated the meeting times and dates since October. Oh, and I am have closed off the comments function. What's up with all of that?

Let me take the last thing first: I was getting SPAMMED to death be Chinese comment-bots that wanted me to post viagra ads in the comment section. Rather than constantly rejecting the postings, I figured I would stop taking comments.

Now, the meeting times: I've just fallen off the lists, and, being in Washington now, I just don't know when the meetings are. I'll try to find out.

What about the lack of posting? Well, I've been busy, learning about the Federal Government and finding a "placement" where I will be spending the next 8 months as a very junior part of the process. I have not been following things back in Massachusetts nearly as closely as I might have been. As a consequence, I just haven't had very much to say.

Today, however, I got an e-mail for Lisa Lambert, the head of PAL, the Parent-Professional Advocacy League, in Massachusetts- well, let me just let her speak for herself:

Hi David,

I also wanted to let you know that PAL (me) just started a new blog. When I write "just started" I mean it is days old. Wrote the first entry on New years eve and am about to post #2. I have wanted to write something about childrern's mental health from the perspective of families for a while, and with you gone, there is no one around to hold the state accountable in print. The first few entries will be avout the parent perspective and then I'll write a bit about Rosie D, cuts, the shift in services and on and on. There sure is no shortage of topics.

So, having said all that, here's the link:
http://holdonitsnotover.wordpress.com/

If you like it as you read it, maybe you could post a link? I would be happy to do the same!

Have a great 2010!

Lisa

Folks, I have read it, and I like it, and I recommend it to you all. There is still lots of work to be done, so lets all get to it, shall we?

Children and Antipsychotics

2009-12-15T08:00:00.000-08:00

From the New York Times:

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Not sure why this came out right now, as the research seems to have been published earlier in the fall. I wonder how this will impact actual practice.

The Worcester Mental Health Network Goes On!

2009-11-25T20:03:00.000-08:00

Greetings:

Please join the WMHN on Wednesday, December 2nd at the MSPCC offices at 335 Chandler Street as it hosts Mary Bartholomew of Lutheran Social Services of New England. Mary will be speaking about the mental health needs of refugee children in the greater Worcester area. The program will begin at 4:30 p.m. and we hope to see as many as can make it.

Thank you,

Samuel Leadholm, Esq.
Health Law Advocates
30 Winter Street, Suite 1004
Boston, MA 02108

Caring Across Communities Briefing Kit: Addressing Mental Health Needs of Diverse Children and Youth

2009-11-18T19:55:00.000-08:00

from Robert Wood Johnson Foundation

Recognizing the unique mental health challenges facing growing numbers of immigrant and refugee children, the Robert Wood Johnson Foundation launched a national program to reduce emotional and behavioral health problems among school children in low-income, immigrant and refugee families. The program, Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth, includes $4.5 million in grants awarded to 15 projects across the country that will work to bring school connected mental health services to children in need, particularly those from immigrant and refugee families. The 15 projects are operated by a partnership involving schools, families, students, mental health agencies and other community organizations to build effective, easily-accessed services for children and youth. To access the briefing kit visit, http://www.rwjf.org/pr/product.jsp?id=49488.

From the CHildren's Mental Health Campaign: Progress.

2009-11-10T16:57:00.000-08:00

Save The Date:

CMHC Supporters' Meeting 11/17

Please join us on Tuesday, November 17 from 9:30-11am in the 9th floor conference room at 30 Winter Street for the next CMHC supporters' meeting.

At this meeting, we will hear from Vic DiGravio, President of the Association for Behavioral Health (formerly the Mental Health and Substance Abuse Corporations of MA) who will talk about implementation of CBHI from his agency's perspective.

We will also be discussing legislative and budget strategies for FY 2011.

If you have any questions or suggestions, please contact Matt Noyes at mnoyes@hcfama.org.

CMHC Sign-On Letter:

Ask Commercial Insurers To Pay Their Fair Share of MCPAP

The CMHC Executive Committee has prepared a letter to commercial insurers in Massachusetts, asking them to pay their fair share of the cost of the Massachusetts Child Psychiatric Access Project (MCPAP).

MCPAP is a fully state-funded program that provides telephonic mental health consultations to pediatricians, regardless of their insurance status. Since 2004, 63% of children served by MCPAP are on private insurance.

In the current budget crisis, it is imperative that commercial insurance companies pay their fair share for the benefits they get from the program.

Click here to read the letter.

To add your organization to the list of singers, please contact Matt Noyes at mnoyes@hcfama.org or 617-275-2939.

The deadline to sign on to the letter is noon on Friday, November 20.

Hey. It's November.

2009-11-07T08:08:00.000-08:00

Full disclosure: I am sitting in a barbershop in Charleston SC, waiting for a haircut and wondering if Speaker Pelosi and her team will successful navigate the House rules to pass the House version of health reform today. I am not actively involved in the process, but the process in play in Washington this year will affect the way in which the CBHI is implemented in a big way. I am hopeful that it will work to the benefit of children, but I see many ways in which it could work against our efforts. So I am apprehensive. I am excited. I am nervous. I am hopeful.

With that mix of emotions, I don't want to do anything that could conceivable disrupt the process. Hence the silence of the last week.

There have been a few interesting things on the Massachusetts Children's Mental Health front.

Blue Cross/ Blue Shield put out a paper on the status of the mental health workforce in Massachusetts that is worth reading here.
Lesley Alderman had a nice piece in the New York Times on how patients should think about mental health parity, which kicks into play on January 1.
All of the "Rosie D" remedy services under the CBHI have now kicked into play, except for Crisis Management Services, which has not been approved by CMS. The new CMS Administrator is likely to be appointed after the health reform debate is done; one wonders how this is affecting the negotiations on this point.

Progress seems steady, as the Massachusetts State budget continues to present challenges.

Back to health reform now.

Clinical Hub or Medical Home?

2009-10-26T11:59:00.000-07:00

Boy, you can tell I am no longer "on the ground" in Massachusetts. I am on break this week from my Fellowship, and going through my e-mails, when I spied this one, highlighting Provider Alert #78 from the Massachusetts Behavioral Health Partnership :

Beginning October 1, 2009, as part of the Children’s Behavioral Health Initiative (CBHI), outpatient providers serving youth under the age of 21 who are enrolled in MassHealth Standard and CommonHealth will be responsible for assuming the role of “clinical hub,” and will play a key role in the coordination of three new “hub dependent” services for their clients.

Therapeutic Mentoring, In-Home Behavioral Services, and Family Support and Training are new services available to youth under age 21 with behavioral health needs who are enrolled in MassHealth Standard and CommonHealth. As with all CBHI services, these services are designed to promote Systems of Care values and ensure that the care provided is:

• Family-Driven, Child-Centered, and Youth Guided

• Strengths-Based

• Culturally Responsive

• Collaborative and Integrated

• Continuously Improving

This Alert includes information on all six CBHI services so that outpatient providers are aware of the entire CBHI continuum.

Role of the Clinical Hub

Clinical Hub providers are responsible for coordinating care and collaborating with other service providers (e.g., making regular phone calls to collaterals, holding meetings with the family and other treatment providers, or convening care planning teams for ICC). Clinical Hub services in order of intensity are: Intensive Care Coordination (ICC), In-Home Therapy (beginning November 1, 2009), and Outpatient Therapy. When more than one Clinical Hub service provider is involved with a family, care coordination is provided by the most intensive service. Clinical Hub providers may refer for services that require a hub (i.e., “hub dependent” services). These services include: Therapeutic Mentoring, In-Home Behavioral Services, and Family Support and Training. Hub dependent services require a referral from one of the three Clinical Hubs (i.e., outpatient, In-Home Therapy, Intensive Care Coordination) and will not be authorized as a “stand-alone” service. There must be a goal identified on the existing outpatient or IHT treatment plan, or on the individual care plan (ICP) for youth in ICC, which corresponds directly with the need for a “hub dependent” service. It is the responsibility of the Clinical Hub provider to regularly connect with those “hub dependent” service providers to which you make referrals in order to coordinate care and obtain and provide updates on the youth’s progress.

Outpatient providers will be reimbursed for coordination activities related to their Clinical Hub responsibilities including participation in care plan team meetings and collateral contacts. Providers can be reimbursed by billing for Case Consultation or Collateral Contacts. See Provider Alert #74, dated August 20, 2009, on MBHP expanding the parameters for case consultations.

Now that sounds an awful lot like the kind of care coordination that we want to see in the Medical Home. If we can do it for kids with SED, why not for the rest of them? How will this mesh with the various Medical Home projects under development within the Commonwealth and throughout the nation? When the Medical Home comes, we will have a good model off of which to work.

Progress. More progress is always a good thing.

A Note from Sam Leadholm, HLA

2009-10-22T07:35:00.000-07:00

INTERAGENCY REVIEW TEAMS Under Chapter 321 of the Acts of 2008

Prepared by Samuel Leadholm, Staff Attorney at Health Law Advocates – October 2009

*****************************************

Landmark legislation passed in August of 2008 entitled “An Act Relative to Children’s Mental Health” (“Act”) restructures how the Commonwealth oversees, provides and coordinates children’s behavioral health services. Among other things, the Act creates Interagency Review Teams (“Interagency Teams”) and a hearing process to improve coordination of services for children with complex needs. The Act defines children with complex needs as those individuals under age 22 who are disabled or have special needs and may qualify for services from multiple state agencies, i.e., DMH, DCF or DDS.

These Interagency Teams must be geographically-based and consist of necessary state agency representatives from departments within the Commonwealth’s Executive Office of Health and Human Services, the Department of Early Education and Care, and the Department of Elementary and Secondary Education according to the needs of the child. If appropriate and where consent is provided, the Interagency Teams may include representatives from schools. An Interagency Team may be convened upon the request of a state agency, the juvenile court, or a parent or legal guardian.

The role of the Interagency Team is to determine what services are appropriate to the child. In doing so, the Interagency Team may evaluate whether the current services are sufficient and whether case management is needed. However, the Act does not create any new services provided by the agencies. If you are seeking a service that the agencies do not already provide, the Interagency Teams may not be helpful. The Interagency Team must listen to parents and other treatment providers before reaching any decision, which must be reached by consensus.

The Act provides that where an Interagency Team cannot reach a decision by consensus or where parents or legal guardians disagree with a decision, those decisions must be reviewed by regional directors of the respective agencies for resolution. Those regional directors must convene within 10 business days of the referral and arrive at a decision within 3 business days thereafter.

The Act also provides a right of appeal with the state’s Division of Administrative Law Appeals and that nothing in the Act limits the rights of parents or children under state and federal special education laws and regulations.

If you need additional assistance accessing these multi-agency teams, please contact: Samuel Leadholm at (617) 275-2982 or sleadholm@hla-inc.org, Jennifer Honig, Staff Attorney at Mental Health Legal Advisors Committee (“MHLAC”) at (617) 338-2345 x. 25 or jhonig@mhlac.org, or MHLAC’s intake line on M.W.F between 8:30-1 p.m. at (617) 338 2345 x. 20.

A Meeting in Worcester

2009-10-16T12:13:00.000-07:00

You Are Cordially Invited

to Attend

The Department of Children and Families

REGIONAL FORUM

With Commissioner Angelo McClain

Date: Tuesday, November 3, 2009

Time: 2:30pm to 4:30pm for DCF Providers

Location: Regional Conference Room

Central Regional Office

121 Providence Street, Suite 300

Worcester, MA 01604

Come hear about:

*The Integrated Casework Practice Model and What it Means for You

*A Current Status Report on the Department’s Budget

RSVP by October 28, 2009

by contacting:

Lani Geselius at 508-929-2132 or

at Lani.Geselius@state.ma.us

So much going on: Update from the CBHI

2009-10-09T17:39:00.000-07:00

Got this in the mail: Sounds like progress.

---------------------------------------------------

MassHealth Rolls Out Two More Community-Based Services: In-Home Behavioral Services and Therapeutic Mentoring

Two new community-based behavioral health services for MassHealth-enrolled children and youth under age 21 began on October 1, 2009. In-Home Behavioral Services provides support to children and youth with challenging behaviors. Therapeutic Mentoring Services provides a therapeutic mentor to work one-on-one with a child. The mentor supports and coaches the child or youth learn social skills, such as better ways to communicate with other children and adults, how to deal with different opinions and how to get along with others.

How to Access These Services:

To access In-Home Behavioral Services or Therapeutic Mentoring, a child or youth must be receiving services from a “clinical hub”, either: outpatient therapy, In-Home Therapy, or Intensive Care Coordination (ICC). The child’s treatment plan, developed by one of these “clinical hub” providers, must include a goal which requires one of the new services to address. Families should talk to their child’s behavioral health provider about these services, or they can call the customer service department of their MassHealth Health Plan. (These numbers are listed at the end of this notice.) Lists of providers of the new services can be found on any of the MassHealth Health Plan’s websites.

In-Home Therapy Will Become Available Nov. 1, 2009

In-Home Therapy (IHT) provides intensive therapy for a child and family to treat the child’s behavioral health needs and help the family support the child in the home. Contact information for In-Home Therapy providers may be found on any of the MassHealth Health Plan’s websites. Families may contact IHT providers directly, or they may call the customer service department of their MassHealth Health Plan for assistance.

CSAs Serving Over 1,600 Children and Youth

The MassHealth Managed Care Entities (MCEs) have reported over 1,691children and youth are currently being served by the 32 Community Service Agencies (CSAs) located across the state. The CSAs began delivering services to MassHealth-enrolled children and youth under age 21 on June 30, 2009. They provide two of the five new MassHealth behavioral health services, Intensive Care Coordination (ICC) and Family Support and Training (Family Partners), to children and youth with serious emotional disturbance (SED). Referrals to the CSAs have remained steady at approximately 200 per week.

Mobile Crisis Intervention Teams Delivering Needed Services

Emergency Service Providers (ESPs) began delivering round-the-clock Mobile Crisis Intervention services on June 30, 2009. Since that time, Mobile Crisis Intervention Teams have recorded over 2,040 mobile crisis interventions or “encounters” with MassHealth-enrolled children and youth under age 21. The MassHealth Managed Care Entities (MCE) and Mobile Crisis Intervention providers are presently working within their communities to educate families, caregivers and others about the availability of crisis services in the home and community. Many people are still accustomed to the previous practice of crisis service delivery through the hospital emergency room.

MCEs Continue to Support Provider Implementation

The MassHealth Managed Care Entities (MCEs) continue to work closely with Intensive Care Coordination (ICC) and Mobile Crisis Intervention providers to implement these two new services. Upcoming MCE plans call for a regional meeting structure that will initially consist of ICC and Mobile Crisis providers and eventually include other service providers to support regional practice. The Massachusetts Behavioral Health Partnership (MBHP) also continues to provide technical assistance to Mobile Crisis Intervention providers through a contract with a leading national expert on this service. Last month, the MCEs hosted a conference for In-Home Behavioral Services, Therapeutic Mentoring and In-Home Therapy providers. The day-long conference included presentations by MCE staff on program specifications and medical necessity criteria as well as presentations by nationally known clinical leaders with expertise in each new service.

Mental Health Alphabet Soup

2009-10-07T05:53:00.000-07:00

Busy down here, but I wanted to share this:

ABC soup for Children’s Mental Health- www.ppal.net

CAFAS Child & Adolescent Functional Assessment

CANS Child and Adolescent Needs and Strengths

CASPP Child and Adolescent Services Planning Principles

CBAT Community Based Acute Treatment

CFFC Coordinated Family-Focused Care

CHBI Children’s Behavioral Health Initiative

CHINS Children in Need of Services

CMS Centers for Medicare & Medicaid Services

CPT Care Planning Team

CSA Community Service Agency

CSP Community Support Program

DCF Department of Children and Families

DMH Department of Mental Health

DDS Department of Disability Services

DOE Department of Education

DYS Department of Youth Services

DSM IV Diagnostic and Statistical Manual, Version IV

EMH Emergency Mental Health

EOHHS Executive Office of Health & Human Services

EPSDT Early, Periodic Screening, Diagnosis and Treatment

ESP Emergency Services Program / Provider

FST Family Stabilization Team

FS & T Family Support and Training

IAP Individual Action Plan

ICC Intensive Care Coordination

ICP Individual Care Plan

IDEA Individuals with Disabilities Education Act

IEP Individualized Education Program

IVR Interactive Voice Registration

IT Information Technology

IHBT In Home Behavior Therapy

LEA Local Educational Agency

LOC Level of Care

MBHP Massachusetts Behavioral Health Partnership

MCPAP Massachusetts Child Psychiatry Access Project

MCE Managed Care Entity

MCI Mobile Crisis Intervention

MCT Mobile Crisis Team

MCO Managed Care Organization

M-CHAT Modified Checklist for Autism in Toddlers

MHSPY Mental Health Services Program for Youth

MYR Motivating Youth Recovery

PCC Primary Care Clinician

PCP Primary Care Physician / Provider

PHP Partial Hospital Program

PEDS Parents’ Evaluation of Developmental Status

PSC Pediatric Symptom Checklist

RESC Regional Emergency Service Center

SAMHSA Substance Abuse & Mental Health Services Administration

SED Serious Emotional Disturbance

SOC System of Care

TM Therapeutic Mentoring

TTS Therapeutic Training and Support

UCC Urgent Care Center

____________________________________________________________________________________
Federation of Children with Special Needs- FCSN

NAMI- National Alliance of the Mentally Ill

PAL- Parent/ Professional Advocacy League

A Note from the Worcester Mental Health Network

2009-09-25T00:09:00.000-07:00

Hello to all:

The WMHN has scheduled a planning meeting on Wednesday October 21st at 4:30 at Bowditch and Dewey to draw up a short list of the people WMHN members would like to invite to come and speak on various topics of interest. Suggestions have touched on inviting someone to speak to about the implementation of CBHI. Other suggestions entail finding someone to speak about incorporating the provision of crisis stabilization and hospital diversion services in the public schools.

Please come and weigh in on the topics you are interested in hearing more about. The WMHN wants to hear your suggestions.

Best,
Samuel Leadholm, Esq.
HealthLawAdvocates
30 Winter Street, Suite 1004
Boston, MA 02108

Technology Makes All Things Possible: Listening In on the Children's Mental Health Task Force

2009-09-23T00:03:00.000-07:00

As I have mentioned, I am currently in Washington DC, training with the Institute of Medicine in the practical aspects of the creation of health policy (there's some active work in that area right now) through the RWJ Health Policy Fellowship. Sometimes, however, I am able to keep up on the state of Children's Mental Health in Massachusetts, and so I phoned into the Massachusetts' Chapter of the AAP's Mental Health Task Force meeting today. Sounds like the work is still going on: Today's meeting was focused on how to get services for the really young kids who are being discovered in the screening system.

The meeting opened with a presentation by the the Center for Early Relationship Support, a program of Jewish Family and Children's Services, which is an early childhood mental health program (a rare beast within the Children's Behavioral Health Initiative). They do things via home visiting, a relationship based treatment program that is very different fro the usual mental health paradigm. The cool thing is that they run an Institute to train others to do this work, and they could help expand this model so that, when we find children who "screen positive" on our behavioral screening, we would have someplace to which to send them. There is some evidence (here as well) to support this approach, and clearly it needs to be expanded to meet the needs that we are identifying in the CBHI. Training can also be found within Connected Beginnings, a program started by the United Way that trains folks in various agencies to work with families on similar issues. Both of these programs have started working with the Massachusetts Early Intervention folks (within the Department of Public Health) For their part, EI is planning to do more screening for early mental health problems. So, with the CBHI and screening within EI, we are going to be creating more demand for these services.

Progress, but slow work. Both programs spoke of the need to do the training in small groups. I suspect that this stuff will take some time to work its way out into the hinterlands like Webster. Several people spoke to the need to bring this stuff out through the Early Intervention programs, which are already understaffed and dealing with a lot of these kids, especially out in the hinterlands. Much of this work is currently funded by soft money, which makes it hard to roll this out throughout the state.

People spoke out in favor of other models; co-location/collaboration/integrated models of care seem to be more popular in other states and it is not clear why that model has not caught on in Massachusetts. It ended with more discussion of the lost of funding for MCPAP, and the need to get support from the insurance industry if we are to keep this model going.

It was fun to hear the voices of so many old friends and colleagues, continuing to do the right thing for children. Hope I can phone in again sometime.

What is up with the CBHI?

2009-09-22T00:00:00.000-07:00

Not being on the ground in Massachusetts, I rely on others to keep me abreast of our progress in implementing the CBHI. According to the Center for Public Representation:

Community Service Agencies Engage Over 1,200 Families

During the first two months of implementation of Community Service Agencies (CSAs) and Intensive Care Coordination services (ICC), more than 1,200 children have applied and are being actively assessed for ICC. Many have been provided Family Partners to assist them in the assessment process. By the end of August, referrals to ICC had increased to over 200 per week.

CSAs have approached staffing decisions quite differently. Some have only hired the minimal number of staff: three service coordinators and one family partner. Others have hired many more coordinators and partners. Overall, as of the end of August, there were 127 care coordinators, 33 senior care coordinators, 74 family partners, and 27 senior family partners. Despite pre-implementation concerns about workforce challenges, CSAs have had a significant number of applications for each ICC position.

All service coordinators have caseloads at or below the maximum number of eighteen. The Court will consider and decide on the defendants' challenge to the Monitor's recommendation on caseload limits, data collection, and monitoring at the next status conference, scheduled for September 28, 2009.

Training and coaching for ICC teams by the new wraparound training provider, VandenBerg and Associates, begins this month.

According to the Center for Public Representation, progress is being made:

MA CANS Facts: August 2009

Number of: May June July August

MA CANS trained clinicians 7,639 8,067 8,282 8,328

MA CANS trained certified clinicians

7,123 7,322 7,780 7,827

MA CANS records in CANS data base

4,555 7,322 10,008 13,038

Organizations submitting CANS records

136 169 188 199

Progress indeed. But how are the kids doing? Only time will tell.

Interesting Piece in Slate This Week

2009-09-21T03:30:00.000-07:00

Some of us in practice live through the "black box" era describe in Arthur Allen's recent piece in Slate , when we realized that, while SSRIs were a lot easier on our patients that the tricylic antidepressants of an earlier era, they were not without side effects. His point, that the rate of prescription dropped dramatically, was certainly the case in our office. In Massachusetts, of course, we had the benefit of the MCPAP program to help us through that time, and perhaps we we able to find a middle road a bit faster than most. The article, however, asks the more interesting question. Aside from the posturing, and the ideological issue of whether or not it is acceptable to pharmacologically manipulate our children, was the public health affected by this "black box" intervention? A quick look at the data says "I don't know". Adolescent suicide is uncommon enough that we can't tell through the noise whether or not this made a difference. So where does that leave us in practice? As always, doing the best we can, with the information that we have at hand.

Interesting article.

Other useful information.

2009-09-18T06:50:00.000-07:00

From the Center for Health Care Strategies:

Youth with serious emotional disorders are a high-utilizing and high-cost Medicaid population that is not well served by traditional approaches to care. Managed care organizations (MCOs) are uniquely positioned to deliver more appropriate and cost-effective care that addresses the complex needs of these children and young adults.

The Collaborative on Improving Managed Care Quality for Youth with Serious Behavioral Health Needs, an initiative designed by CHCS and made possible by the Annie E. Casey Foundation, worked with nine health plans to test a number of approaches to better serve this population. This toolkit, which summarizes the participating plans' experiences, presents:

Promising practices implemented by the plans, and the resulting impact on access, care, and avoidance of unnecessary services and costs;
Challenges identified and addressed by the plans, and lessons learned; and
Opportunities for continued innovations in care for children and youth with serious behavioral health needs.

The toolkit is a valuable resource for MCOs, policymakers, state agencies, families, and others interested in innovative approaches to improve behavioral health care for youth.

Where Have I Been? Busy, I'm Afraid.

2009-09-17T20:30:00.000-07:00

It turns out that they really keep you busy as an RWJ Health Policy Fellow, meeting lots of people, traveling around the city, reading lots of books and- well, really, just too busy to blog much. Especially since, in general, we are not spending a lot of time discussing children's mental health care in the current environment. I've been learning about ERISA and "paygo" rules and all of the minutia that is going into the current health reform debate. I have seen a member of the President's Cabinet and the First Lady in person. But I haven't really had time to keep up on the progress of Children's Mental Health reform in Massachusetts. Sorry.

So, from my e-mail, three tidbits:

1) Agency capacity in Massachusetts seems stretched. Intake evaluations for children seem to be delayed 4-6 weeks, which is worse than in previous years, and suggests to me that the screenings are yielding and that we are flooding the system.

2) Systems of care committees are meeting. Go to them.

3) The Tri-Committee (House) and the Senate Finance Committee's Chairman's mark both require mental health benefits of the insurance companies.

Stay tuned. I really don't know when I will have time for this again.

Please join us on 9/23/09: Learn about Wraparound!

2009-09-10T00:40:00.000-07:00

WRAPAROUND IS HERE!

Wraparound Care planning is now available for children & youth with complex behavioral health needs who have MassHealth Standard and CommonHealth. This new offering will be provided by a network of local agencies called Community Service Agencies (CSAs)

WRAPAROUND HELPS: Wraparound is based on the youth’s and family’s strengths, and develops a team to help the youth and family reach their goals, no matter how tough things become

WRAPAROUND INCLUDES: Wraparound builds families who are the foundations of our communities and draws on the strengths of many helpers in the community: doctors, educators, therapists, family members, faith communities, neighborhood and community organizations

JOIN US Crowne Plaza Worcester Hotel

Wednesday - September 23, 2009

6:00 pm – 8:00 pm

10 Lincoln Square, Worcester, MA

LEARN MORE ABOUT WRAPAROUND: If you’re interested in learning about how Wraparound can help children and families who have MassHealth in your region, come join us for a public presentation by a national expert Michele Stewart-Copes, MSW.

You will need to RSVP by September 15th to Susan Whitaker, VVDB Administrative Assistant, who is based in the Boston area. Her her email address is: sue@vroontraining.com and phone is 617-827-7300.

What is happening to Senate 757/H. 3586: Does a bill becomes law? (Updated)

2009-09-09T00:01:00.000-07:00

Some of you may remember that last year, we got an omnibus children's mental health bill through the State legislature, at a fairly high cost: in order to get the bill passed, we withdrew a section that would have mandated payments for collateral contacts (ie your child's therapist could get paid a bit to talk to your child's teacher). This year, we have S. 757 (An Act Relative to Children's Mental Health Clinicians) and H. 3586 (An Act Relative to the Coordination of Children's Mental Health Services), both of which had their day of hearings before the Joint Committee on Mental Health and Substance Abuse back in May. (I testified in support, as you may recall). Well, that Committee has a hearing again tomorrow, and, while neither of these bills are currently on the agenda, many of us hope that the Committee wil choose to send this onto the Committee on Health Care Financing, so that it can come over to Ways and Means. That is the way that these things go. It feels a little like the introduction to Casablanca; now, we are all waiting, waiting for the other shoe to drop.

*****According to my friends at "A Healthy Blog", the bill has been favorably reported out, and should be moving over to Health Care Financing. Cool beans*****

Meanwhile, the "nibbling around the edges" of our new system has commences with the 20% cut to the funding for MCPAP. Latest plan I heard calls for them to shut down on Fridays, and then to try to get the insurer's to chip in a piece of the action. Makes sense, but we will see.

On arriving in Washington at an interesting time.

2009-09-08T11:06:00.000-07:00

"It's always going to be the POTUS when you see three helicopters coming in toward the WAMO", the nice park ranger told us, "They always come in threes". They love acronyms in Washington; POTUS is "President of the United States" and WAMO is "Washington Monument". I've been here a week, and seen it twice already, when he came back from Camp David and when he came back from Cincinnati. There is a lot of activity going on around me, and yet the life of DC just keeps on flowing. My mattress arrived today, signaling the completion of the furnishing of the apartment.

My Fellowship starts tomorrow, 9 o'clock, at the Institute of Medicine, where we will be filling out forms and learning more about what we will be doing for the next couple of months. A few of us who were in the District for Labor Day Weekend got together for a picnic near Constitution Garden on the Mall, amid some subtle rainfall. We are all nervous, excited, thrilled and hopeful that we can make a difference in this time of change. This is not just an academic exercise. We definitely have some work to do. I'll keep blogging, but probably not as frequently.

Save this Date: Great Conference in November

2009-09-03T03:52:00.000-07:00

The District 1 Connecticut, Massachusetts& Rhode Island American Academy of Pediatrics’ (AAP) Chapters

presents

“Navigating the Mental Health System from the Pediatrician’s Office”

Friday, November 13and Saturday, November 14,2009to be held at the Biltmore Hotel, Providence, Rhode Island

Friday, November 13^th

10:00 am - 12:45 pm – Registration

12:00 pm – 12:40 pm – Lunch

12:40 pm – 12:45 pm - Welcome – Elizabeth Lange, M.D., FAAP – AAP Rhode Island Chapter President

12:45 am – 2:00 pm – General Session #1 - Panel Discussion - “How to Discuss Issues on Sexuality with GLBT Youth in the Pediatrician’s Office” - Moderator - Carole Allen, M.D., FAAP, AAP Massachusetts Chapter President

2:00 pm – 3:00 pm – Concurrent Workshops

Workshop #1 - “Early Identification of Emotional and Behavioral Problems in Primary Care Settings”– Mary Margaret Gleason, M.D., FAAP, - Assistant Professor, Tulane University School of Medicine, Departments of Psychiatry and Neurology of Pediatrics, Associate Training Director, Child Psychiatry and Triple Board Program
Workshop #2 – “Mental Health Care in the Pediatric Office: Integrating a Co-Location Model” –

Jean Marconi, M.D., FAAP, Private Practice Pediatrician, Center for Advanced Pediatrics, Norwalk, CT and Andrew Lustbader, M.D., FAAP, Pediatrician and Child and Adolescent Psychiatrist, Medical Director, Child Guidance Center of Mid-Fairfield County, Norwalk CT

3:00 pm – 4:00 pm – Break – Exhibit Hall

4:00 pm – 5:00 pm - General Session #2 - “The Little Black (Pill) Box: A Comprehensive Approach to Pharmacology in Child and Adolescent Psychiatry” – Dr. Andrew Lustbader, M.D., FAAP

5:00 pm – 6:00 pm – Concurrent Workshops

Workshop #3 – “The World is Not Flat: Mechanisms of Social Development in Two-Year-Olds and the Absence Thereof in Autism”– Warren Jones, Ph.D., Co-Director, Laboratory of Social Neuroscience, Yale Child Study Center, Yale University School of Medicine

Workshop #4 –“Sleepy, Dopey, and Grumpy: Sleep and Sleep Disorders in Adolescents”– Judith Owens, M.D., MPH, FAAP, Director of the Pediatric Sleep Disorders Clinic at Hasbro Children’s Hospital and Associate Professor of Pediatrics at Brown Medical School

6:00 pm – 7:15 pm –Reception - AAP Community Access to Child Health (CATCH) Grant Presentations and Updates on Health Care Reform – Invited guests include Representative Patrick Kennedy and Senator Jack Reed (both of Rhode Island) and AAP President Judy Palfrey, M.D., FAAP

7:15 pm – Dinner on your own

Saturday, November 14^th

7:30 am – 8:30 am – Breakfast - Regional Chapter Highlights

8:30 am – 9:30 am – General Session #3 – “The (Inter) Active Child: Facebooking, Sexting and the Electronic Bully”– Michael Rich, M.D., MPH, FAAP, Director, Center on Media and Child Health (CMCH), Director, Video Intervention/Prevention Assessment (VIA), Children’s Hospital Boston, Associate Professor of Pediatrics, Harvard Medical School, Associate Professor of Society, Human Development, and Health, Harvard School of Public Health

9:45 am – 10:45 am – Concurrent Workshops

Workshop #5 –“ABC’s for the Primary Care Pediatrician”– Mary Margaret Gleason, M.D., FAAP
Workshop #6 – “Preventive Interventions for Disruptive Behavior Disorders in the Office” – Ellen Perrin, M.D., MA, FAAP, Professor of Pediatrics, Director, Developmental-Behavioral Pediatrics, Floating Hospital for Children at Tufts Medical Center

10:45 am – 11:00 am - Break

11:00 pm – 12:00 pm - General Session #4 – “The Invisible Casualties of War at Home” – Elizabeth Slater, Ph.D., Psychologist, Strategic Outreach to Families of All Reservists (SOFAR) Program, Cambridge, MA

12:00 pm – 1:00 pm – Concurrent Workshops

Workshop #7 - “GHB the prototypical ‘Date Rape’ Drug and Ecstasy” – Angela Anderson, M.D., FAAP, Associate Professor of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University
Workshop #8 - “Maternal Depression. The Why and How of Screening in Primary Care” – Ardis Lee Olsen, M.D., FAAP, Associate Professor of Pediatrics and of Community and Family Medicine, Dartmouth Medical School

1:00 pm – Conference ends

The Massachusetts Chapter of the American Academy of Pediatrics designates this educational activity for a maximum of 8.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This program meets the criteria of the Massachusetts Board of Registration in Medicine for risk management study for 3 credits.

The MCAAP is accredited by the Massachusetts Medical Society to provide continuing education for physicians.

Moving into my DC digs: I can't believe I am here.

2009-09-02T03:58:00.000-07:00

Got up on Tuesday, picked up the U-Haul truck, loaded it with some furniture and boxes (with a bit of help from my brother Peter) and traveled the Northeast Corridor until arriving at our one-bedroom flat in SW DC. We spent the better part of Wednesday unpacking- the kitchen is almost set up, the flaws of the apartment are becoming apparent (the leak under the sink, for example), but it is starting to feel like home. Then, hungry and tired, we stumbled down 6th St. to Cantina Marina, a little pub on the water just off of the Potomac. We were definitely in DC; helicopters flew up and down the river, looking very important, planes landed at National (aka Reagan) airport, and the cicadas were chirping loudly in the trees. Then we stopped at the neighborhood Safeway to pick up some groceries, and were told to "Be Safe" by the woman checking us out. Perhaps there are some things about the neighborhood that I still need to learn.

So, for the next year, I will be commenting on Children's Mental Health reform in Massachusetts from a distance. It's good to be here.

Thoughts on a Sabbatical: My Last Day in Webster

2009-08-31T20:00:00.001-07:00

Today was my last day in Webster. It was a quiet day, mostly annual physicals with patients I have known for many years. All are very excited to hear that I am going to Washington, most have somewhat overblown ideas about what I am going to do, all are proud that "their" doctor was selected to go and many are sad that I won't be there to hear where they are going to college. Sad, and yet wonderful, to think that I have been privileged to be part of the lives of so many children and families for the last 18 years. If any of my Webster folks are reading this, I just want to thank you for making me a better doctor.

As I said earlier, I intend to keep the blog going, at least for a while, so I wanted to mention one last thing about the CBHI. One of the last families I saw were sisters, 10 and 18, members of the family who meeting I missed last week. I asked the mother how she was liking the work with the CSA so far, and she was incredibly effusive in her praise:

"They focus on the whole situation, the whole family, not just the child in front of you".
"They have be really helpful in sorting out the services that my sons need"
"For single mothers especially those without much of an outside support system, they are wonderful"

The mother works in the early childhood capacity, and she told me that her Center was planning to screen for kids with behavior problems.

Progress. Keep it up, CSAs.

I'll blog again after we get to DC.

"How's Clare?" Why this work is important.

2009-08-29T06:14:00.000-07:00

The U-Haul is coming on Tuesday, and my house is a mess, and the news is all about Health Reform and the Ted Kennedy. Then there is work: Thursday was frustrating. A 13 year old patient of ours had his Daytrana denied by MassHealth. Daytrana is a patch form of Ritalin, one that is quite expensive, and MassHealth rightfully wants us to us it after we have tried other things first. This kid had tried Methylphenidate and Concerta, without much success; Daytrana worked for the last 1.5 years and, as best I can tell, was paid for by MassHealth without a problem. Suddenly, it's a problem. Apparently, there is a written, but not publicly available policy that says that you have to have failed 3 forms of long acting stimulant before you can get Daytrana.

The family is one of the "working poor", with MassHealth as a supplement to private insurance. Their private insurance would pay 50% of the cost of the medication, leaving them with a $179/month out of pocket to stay on the medication. It had been paid for over the past 1.5 years out of their "spend down", which has something to do with their being employed. But $179 per month? They can't afford it. So, on the day before the kid starts 8th grade, I have to switch a marginal student off of the medication that works to a new medication that may not work to "try it out"- if he fails Adderall and Focalin, THEN we can get him back on the medicine that works.

The family sighed, and agreed to the change, but I was frustrated: if we had known of the problem in June, we could have done the required "trials" over the summer and not disrupted school. The needs of the system were served, but it is hardly personal. And mental illness is nothing if not personal.

In pondering the meaning of this incident, I came across this about the Senator in the Globe, and thought is appropriate to quote here at length. Although the Wellstone-Domenici bill was Patrick Kennedy's baby, the Senator's fingerprints were all over it. This is from an article by Kevin Cullen, that was in the Globe:

About 20 years ago, Senator Pete Domenici, a Republican from New Mexico, found out that his daughter Clare was schizophrenic. Domenici and his wife, Nancy, struggled to get help for Clare, and Domenici became an advocate for families of children and adults with mental illness.
Thirteen years ago, Domenici and Paul Wellstone, the liberal senator from Minnesota, teamed up to sponsor a mental health parity bill, so that people with a mental illness would be treated the same as those with a physical illness. After Wellstone was killed in a plane crash, Domenici asked Kennedy to step in as the bill’s cosponsor. Because of his sister Rosemary’s condition, Kennedy was always empathetic to those with mental disabilities, and he quickly agreed.
As the legislation’s progress waxed and waned, whenever Ted Kennedy saw Pete Domenici, he would ask one question: “How’s Clare?’’ And then they would talk about getting the bill through. Last year, when President Bush signed the bill into law, Ted Kennedy called his old friend Pete Domenici. Kennedy was in Hyannis Port, four months after being diagnosed with brain cancer, and Domenici was in Washington, about to retire from the Senate because he has a progressive form of brain disease.
The two old senators reminisced a bit and thanked each other for getting the law passed, and then Ted Kennedy said, almost apologetically because he had almost forgotten: “How’s Clare?’’

In the end, that's what the work is all about- building a system so that when you ask people "How's Clare?", they have something good to say about it. Connecting the policy to the personal is hard; Kennedy was the master at it, and we need to get better at it.

CBHI is a Process: Thoughts on a Systems of Care Meeting

2009-08-26T11:05:00.001-07:00

Building the CBHI is a process, and the key to that process is the collaboration that will happen in the Systems of Care Committee meetings (times and dates for Worcester County are listed to the right)

Please note that this is my take on this meeting, and I bring my own biases and thoughts to this process. If you were there, and thought that I got something wrong, let me know and I will change it.

I went to a Systems of Care Committee meeting today. It was crowded in the Conference Room, with people from Worcester, Southbridge, Webster and Milford congregated in a room, to see how the South Central CSA is doing. It is a big district, stretching from Ware to Franklin across Massachusetts’ southern border with Eastern Connecticut and Rhode Island, and it is great that they were able to get this many people in one place. We introduced each other; there were parents, providers and even a school district represented at the table. Then we got down to business.

Initially, it was mundane; time and place of meeting, can we get phone access to the meeting, who else do we need to be here? The group is in the “forming” stage and we were all trying to understand what each of us are trying to do. The programs are in place, both emergency mobile services and intensive care coordination and family partners are up and running. Several community agencies (schools, practices, parents) expressed confusion about when to call the different types of services and asked for more guidance in organizing themselves to address the services. We also spoke of the upcoming “change in initials” for programs like FST, which is morphing into In-home behavioral health therapy. Change is hard, and at least part of it is that it is new.

The group was very interested in the process, and people had concrete suggestions for ways in which this can work. First was getting the information out: Make the literature more clear. Create multiple ways of disseminating the message. Clarify the roles that all of the players are clear as to their names, agencies and roles. Then was communication: There are overlapping roles with DCF, DMH, the school, the FST program have sometimes created logjams, with parents confused as to who is involved in various specific cases. All of this is complicated by the need for releases from the family to allow inter agency communication.

The South Central CSA got 60 referrals in the first month; they reported fewer referrals in August to date. Some of this reflected the level of staffing; the CSA is hiring the people and it is hard to find folks with the right skill set who are willing to travel as much as is required in this area. Some of this, however, reflects the culture of the area. Folk down here don’t like to air their family problems in public, and they don’t trust outsiders in their homes. It will take time to build trust, that this program is really going to be responsive to their needs and not to the needs of DCF or some other government agency. Finally, some of this reflects the newness of the program- people are going to need to hear about this program over and over again before the implications actually sink in.

So what is our vision? Collaborative care, creating a system that families can understand? We kicked it around for a while, but it came down to struggling with the central question of the CBHI: How do we fit this model of wraparound into the culture of South Worcester County? This group is actively engaged in that process. I hope that the other meetings are going as well.

Statement from The Kennedy Family

2009-08-25T23:59:00.000-07:00

Hyannisport, August 26, 2009

"Edward M. Kennedy -- the husband, father, grandfather, brother and uncle we loved so deeply -- died late Tuesday night at home in Hyannis Port.

"We've lost the irreplaceable center of our family and joyous light in our lives, but the inspiration of his faith, optimism, and perseverance will live on in our hearts forever.

"We thank everyone who gave him care and support over this last year, and everyone who stood with him for so many years in his tireless march for progress toward justice, fairness and opportunity for all.

"He loved this country and devoted his life to serving it.

"He always believed that our best days were still ahead, but it's hard to imagine any of them without him."

Hard to add anything to this. All of those dedicated to improving the health care system are in mourning. Of course, we need to keep doing the next thing, in his memory.

MCPAP Needs Our Help (and our Stories)

2009-08-24T20:17:00.000-07:00

Adapted from a recent e-mail blast:

The various MCPAP programs need help to negotiate with the medical insurers who provide behavioral health and medical coverage to your patients. In the State’s FY 2010 budget, the MCPAP received a 20% cut in funding with the State’s intention of having the private insurers make up this shortfall. Presently all of the money supporting MCPAP comes fully from state dollars. This is in spite of the fact that more than half of the calls and families evaluated by MCPAP have private insurance with a behavioral health benefit. It will be difficult for any program to take a 20% cut in support without decreasing services.

MCPAP is asking our involved primary care clinicians to write a brief letter describing the value of MCPAP to your practice and the patients you treat. If appropriate, you could note your understanding of the limited access that you have to mental health services in the community. MCPAP will use these letters in our negotiations with the private insurers to both demonstrate the value of our state-wide service as well as to show the important (albeit invisible) role we play in the insurer’s delivery system, filling some of the gaps that we know are there.

If you are willing to write a letter, you use the MCPAP “Tell Us Your Story” link here, which may result in your comments being published on the MCPAP website . We are hoping to receive supporting letters by early September.

From the Maternal and Child Health Bureau

2009-08-23T05:59:00.000-07:00

PAPER DELINEATES BENEFITS OF AN INTEGRATED APPROACH TO SUPPORT CHILDREN'S EMOTIONAL WELL-BEING

Strategies to Support the Integration of Mental Health into Pediatric Primary Care provides an overview of research advances and policy trends that support integration of mental health into primary care and explores strategies that can be employed by primary care health professionals, with support of health plans, to achieve coordinated and integrated mental health care in the pediatric primary care setting. The issue paper was published by the National Institute for Health Care Management with support from the Maternal and Child Health Bureau. Topics include the prevalence of and risk and protective factors for children's mental health problems; the current state of mental health in pediatric primary care, including the relationships between primary care and mental health services; public and private sector financing of mental health services for children and the implications for integrative approaches; federal, organizational, and foundation initiatives supporting integrative care; and considerations and strategies for health professionals and health plans to improve the delivery of mental health care in pediatric primary care.

Conclusions and selected resources on children's mental health care are provided. The paper is available at http://nihcm.org/pdf/PediatricMH-FINAL.pdf.

A thought from a reader

2009-08-22T14:25:00.000-07:00

It is nice to know that folks are still reading this blog; being in the office, packing up my office and furnishing an apartment in DC has cut into my blogging time.

Hi David,

I was just catching up on your blog and saw that you are leaving for DC in less than 2 weeks. Last time I talked to you, you were awaiting a "call" on whether you were keeping your blog. So what happened with that?

I am really glad you are commenting on CBHI. I am realizing more and more that there is very little critical observation and even less advocacy (except for rates). At times like these, I really miss Walter!

At any rate, I am wondering about the blog and want to wish you well on your sojourn in DC. Please stay in touch!!! We wade in on national health policy stuff from time to time (as you might guess).

Best,

***********

-------------------

In case you were wondering, authors LOVE it when someone asks them to keep writing. This sort of e-mail just makes me want to get out there and write more. Thanks, **********. This means a lot. Let me try to answer as best I can.

1) I will try to keep this blog both alive and focused on the Children's Mental Health Reform process on which we have spent so much time and energy. That may be tricky, as I will no longer have direct contact with my patients, who have always been my best source of information about the CBHI, and the mental health system in general. But I will try.

2) Over the next few months, I will be undergoing a training process in Washington, organized through the Institute of Medicine, that will give me access to many of the folks setting the policies that drive what we do. I mostly can't talk about that, especially on an open blog. By January 1, I will be an aide in a Congressional or Senatorial office. At that point, I may or may not be able to blog at all. So, stay tuned.

But what of the CBHI in the lazy days of summer? I actually had two folks from the Worcester CSA (their new name escapes me at present) join me in discussing the CBHI process with our Housestaff at UMass Medical Center last week. They told us that they have enrolled the first 90 or so families in the program and that they are working on the second hundred now, doing CANS, hiring staff, convening meetings (like the one I couldn't make last week) and the like. They were surprise at how few of their referrals are coming from pediatricians and other primary care providers. I wasn't. Traditionally, there has been so little communication between primary care and behavioral health providers that I would have been surprised if they were contacting the CSA themselves. Most of us give parents a list of counselors and agencies and have them get to it. So the CSA would likely not know that the primary care doc had sent the patient.

So it is churning, and movement is happening. If I can make it to the next community meeting in Webster, I will have much more to say on that.

Anyone else got any stories? Put them in a comment, send them in an e-mail. It is out there, percolating now. Look at CBHI on Google News here.

On a personal note, I still can't believe that in 8 days I'll be on my way to Washington. It is simply too cool to be real.

Pictures from a Town Hall Meeting.

2009-08-21T14:50:00.000-07:00

I went to the Town Hall (literally) in Warwick on Wednesday night to try to hear Representative Langevin speak on the prospects of health reform, and instead found a wild group of LaRouchites (with Obama as Hitler posters), "Government can't do anything" folks, Democrats, Union supporters, medical students and the odd pediatrician standing around, outside the Hall, trying to convince the the media of their importance. It was an interesting scene; I met few there who had not yet already made up their minds and many who enjoyed shouting and chanting. As a singer, I sort of get that- their is value in the human cameraderie that goes along with a good chant. In this case, however, it made it difficult to engage in a meaningful discussion with the folks who had serious doubts about the legislation, which is why I was there. But I tried.

I would say that the folks who were present broke down

into three groups. First were the supporters of reform; largely professionals, Obama supporters and union folk. Tended to be younger, tended to be less loud- these folks were often single-payor supporters, and were very much in favor of the inclusion of the public plan in the mix of things to come out of this process. In talking to them, I was concerned that they were too focused on the public plan; for many, the loss of the public plan would mean that we had failed in our effort, even if more people were covered and the insurance industry is dragged into a process other than ruthless competition to fund the care that people need. You all have probably guessed that I think that this process is essential; the "free" market as currently structured is likely to oscillate and collapse unless we are able to realign the structure in which it operates. Kind of like the stock market, except this bubble really does kill people directly. So "our side" needs to convince its own people that 3/4 of a loaf is an acceptable outcome.

Second were the ideologues, the folks who think that the government is simultaneously incompetent and unable to accomplish anything AND evil, conspiratorial and able to focus in and ruin their lives in a really personal way. It is interesting to talk to them; the arguments tend to be circular and to focus back on personal attributes of the one that they are trying to convince. I was asked over and over again, "Have you read the bill?" Well, yes, but, unless you are an attorney, reading the bill doesn't really tell you very much. The language is there, but the meaning of the language is steeped in prior legislation, numerous Court decisions and the policies and procedures of the Department of Health and Human Services. We are all, in many ways, dependent on our colleagues in the legal professions to tell us what this bloody thing means, and sometimes they don't even know until it is passed. Smart people think that this thing will get more people covered, support the move to quality improvement and allow me to take care of children without worrying about their coverage all of the time- that is actually good enough for me. The bill is hundreds of pages long (double spaced, though), and is worth a look through.

The biggie for me is that it extends EPSDT to children on the Children's Medical Security Plan- that is a huge boon to families of children with special needs and I am absolutely for it.

Third were the critics with ideas, and there were a lot of them. People who think that things need to change, but that this bill (the House Bill being the only one on the table at the present time), is not good enough. I spoke with one IT guy who was worried that the system would be too permeated with politics- he favored removing this from the political process. Another person was a hospice worker, concerned that they would mess up the regulation of the transition from treatment to end of life care. A couple with seven kids gets their health care through a Christian health cooperative- they were concerned that they wouldn't be able to continue in this form of insurance that worked so well for them. These are folks that we can talk to- they may never support the reform, but they won't blow up the country to keep it from happening.

The one thing that was clear that evening was that people on all sides of this debate care deeply about how this thing happens- inside the room, the session went on for several hours, and we stood out there without a speaker, talking and yelling and arguing and waving signs and engaging in the political process that makes us who we are: Americans. My side has not yet closed the deal on this thing, but neither has the opposition run it off of the cliff. It is time, though, for all of us to weigh in and figure out which side we are on.

A Busy Day: I missed my chance to see the Team in Action

2009-08-18T20:25:00.001-07:00

Got this from the CBHI today:

August 18, 2009
Over 1,000 Families Enrolled in ICC Services!
On June 30th, Community Service Agencies (CSAs), the organizations that deliver Intensive Care Coordination and Family Support and Training, began providing services to children, youth and their families. Since that time, the MassHealth Health Plans have reported over 1,000 families are in the beginning stages of working with Intensive Care Coordination services. During the beginning “engagement” phase of this service, families work with Care Coordinators and Family Partners to complete a “strengths and needs” discovery and start building their child’s ICC Team. In the experience of Wraparound programs nationally, as well as CFFC and MHSPY in Massachusetts, some number of families will decide during this process that ICC is not for their family. CBHI will begin to have data in September on the number of families that enroll beyond the engagement phase. Intensive Care Coordination (ICC) is a care-coordination service for children and youths with serious emotional disturbance (SED). Children, teens and young people most likely to benefit from ICC services may include: those with complex needs involving many providers or state agencies; families of children or youth who have frequent behavioral health crises; and children or youth in families that have been “difficult to engage” in other services.

I know this to be true- as I mentioned last week, I got invited to one of those meetings myself. During the day. When I had patients. So I couldn't go.
Mental health figured prominently into today's patients: a young man with ADHD and an untreated substance abuse problem heading off to college; we had a long talk about weed and apathy and the possibilities of drinking and drugs in teh big city (I won't say which one!). Another youth, repeating 9th grade, whose ADHD is unresponsive to medication because it doesn't work ("I don't feel any different") or because he doesn't take it very often (last Rx was in December, although he claims to be on the stuff). Neither of them is seeing a therapist; both have one parent in MA and one in CT, making it tricky to sort out which mental health system to access. These kids are hard to manage, and I truly look forward to having a CSA with whom to work.

Back from the Mountains: The Cost of Children's Health

2009-08-17T19:40:00.000-07:00

I saw patients today, 9 physicals with negative behavioral health screens, a bunch of kids with acute medical problems, a few behavioral/mental health follow-ups and no contact with the CBHI. It is really odd to think that I will be leaving the practice in a mere 14 days, and that I only have 6 more days of clinical pediatrics before I descend into the maelstrom of Washington politics.

One of the reasons that children are often absent from the discussion of health reform is that, in general, child health is a small percentage of the cost of health care (some colleagues refer to the cost of "child health" as a rounding area when compared to the cost of care for the elderly). My AAP News today, however, suggested that we should be looking at this in a different way. According to a recent study by AHRQ, $98.8 billion was spent on children's medical care in 2006. Please note that this is in the context of $2 - $3 trillion of total expenditure on health care, so that is a mere 5% of the healthcare pie. 5 conditions account for 30 % of that spending, and mental health costs led the way in terms of expected outlay. As the same time, it turns out that the insurers have managed to turn this one into a massive cost shifting to the consumers. When one looks at the percentage of that cost that is paid out of pocket by parents, 21% of the bills are shouldered by parents, in the context of a system that most would consider to be woefully inadequate, compared to 11 % of the bills in the case of infectious disease. These data confirm what we already knew- that a substantial part of the problem of access to health care for children is access to mental health services, and that the system is designed to restrict access as a means of cost control. Clearly, for children, this message needs to be heard in the discussion on Capital Hill.

Of Interest: From the National Institute of Health Care Management

2009-08-14T10:26:00.000-07:00

FROM MY COUNCIL ON COMMUNITY PEDIATRICS NEWSLETTER:

Report - Strategies to Support the Integration of Mental Health into Pediatric Primary Care

The National Institute for Health Care Management (NIHCM) Foundation is pleased to release an issue paper, Strategies to Support the Integration of Mental Health into Pediatric Primary Care, examining the landscape for mental health service delivery to children, including a discussion of the role of federal and state agencies, as well as public and private insurance. With the aim of informing and facilitating discussions on how mental health care can be fully integrated into pediatric primary care, the issue brief reviews information on mental health programs, practices and guidelines and discusses strategies health plans can utilize to improve early identification and treatment for children in primary care. To view the report visit here.

Mountains are great, but there is work to be done

2009-08-13T05:17:00.000-07:00

There is nothing like three days in the White Mountains to give one perspective on life. The Whites are crowded, meaning that, while hiking on a popular trail, you will run into someone every 20 minutes or so. The Whites are treacherous, meaning when you see the thunderhead on the horizon, you have about 20 minutes to get off the Ridgeline or you will become a intimate acquaintance of the lightning. The Whites are magnificent, because when you are sitting on top of Mount Lafayette (5260 ft- not quite a mile high), you can not hear the roads in the valleys below. The silence is deafening (and the ascent does good things for your leg muscles). It is worth breaking from the internet to hear that silence.

*******************

My inbox is full of Health Insurance Reform, with little to offer in the area of Children's Mental Health. I will direct you all to MCPAP website today; it is a useful place, and they ran an article that I wrote about the CBHI that you might find useful. I'm visiting some Congressional and Senatorial offices over the next few days, working this Insurance reform plan through Congress. I'll keep you posted on how that is going.

Off for a Walk in the Woods

2009-08-09T06:08:00.000-07:00

So, I'm heading off for 3 day walk on the Appalachian Trail with my family and a few friends- more on that later. I have just finished a solid week of primary care with little time to blog; mostly well child visits for boys in early and late adolescence. My screens have mostly been negative; several young men have needed referral for standard mental health services (counseling for outbursts or depression). I've had one family that I sent to the CSA for care coordination. The family from last week (the boy who was acting out here) had two kids in for a well child check- the CSA seems to be working out pretty well for them.

And I got this e-mail:

David,
Kim RXXXXX-SXXXX - a clinician from Counseling and Assessment Clinic of Worcester called regarding XXXXXXX. Meeting is on August XXth at XX:30 - location at their office which is at 51 Union Street, Suite 104, Worcester, MA (over by Maxwell Silverman's). Work Cell # : XX-XXX-XXXX.

My first invitation to an CSA Meeting to coordinate care. I can't go, of course- patients are scheduled, and, if I still had a care coordinator, I would send her in my stead. But I was invited!!

It's a start.

See you after we get back from the mountains.

The Center Can Hold, If We Let It

2009-08-08T09:14:00.000-07:00

Check out today's post on Health Care for All's blog. This is an appropriate response, folks. Let's get out there and do it.

Hello From Niki Tsongas’ Community Meeting at the Chelmsford Town Hall. The meeting was scheduled to begin at 10 a.m. but the place was packed to capacity at 9:30 a.m. Hundreds of people were in the overflow of the parking lot, with signs, songs and slogans, and a good dose of respect-filled conversation. The radicals from the right handed out some very scary materials, and there were a smattering of single payer advocates, and an equal number holding signs in favor of reform, but mostly there were people in the middle interested in telling their stories and learning more about what health reform will mean for them. These were the folks asking questions, and very disappointed not to be in the auditorium. At the very beginning I thought that the majority of the crowd opposed reform, but eventually, by about 10:15 the sides were even, and groups were beginning to congregate together, mostly with their backs to the hateful signs and chanting. I talked to plenty of national reform opponents who did not want to be associated with the sad fringe.

From the Center for Public Representation: Progress is Being Made

2009-08-06T19:05:00.000-07:00

Court Holds Status Conference on New Services

On July 28, 2009, the Court held another periodic conference to review the status of implementation. Prior to the hearing, the defendants filed a detailed semi-annual report on the status of all of their activities under the Judgment. The plaintiffs submitted their status report, which included comments on the accomplishments and challenges of the implementation process and which identified several pending disputes concerning care coordinator caseload limits, authorization procedures by managed care entities (MCEs), inclusion of children in Medicaid expansion populations, and the availability of a meaningful appeal process for families. The parties discussed their respective views on the status of implementation, and the Court asked many questions concerning screening, assessments, the new Community Service Agencies (CSAs), the new remedial services, and the approval process for these services.

I Know it is not Mental Health, but....

2009-08-05T16:27:00.001-07:00

I should stay focused on children's mental health, but it is hard not be excited about this:

FOR IMMEDIATE RELEASE

Contact:

Aug. 5, 2009

Quentin Young, M.D., (312) 782-6006, info@pnhp.org

Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

David Lerner or Karmen Ross, Riptide Communications,

(212) 260-5000

House vote on single payer will be historic first, doctors' group says

Physicians call on lawmakers to 'do the right thing' on health reform

Hailing last week's pledge by House Speaker Nancy Pelosi to hold a floor debate and vote on single-payer health reform this fall, a group of 16,000 physicians is launching an intensified campaign to educate lawmakers about the urgency of a "Medicare-for-All" solution to the nation's health care crisis.

Leaders of Physicians for a National Health Program (PNHP) say their campaign includes a stepped-up program of visits by doctors to House members in their home districts during the August recess.

Last Friday's commitment by Pelosi (D-Calif.) to Rep. Anthony Weiner (D-N.Y.) to put his single-payer amendment to H.R. 3200, the House leadership's health reform bill, to an up-or-down vote before the full House has set the stage for first-ever floor vote of its kind. The House debate on the amendment could begin as early as September.

"Single payer has gone from being 'off the table' to 'on the floor,'" said Dr. Quentin Young, national coordinator of PNHP. "This dramatic turn of events is a striking indicator of our success. It shows the House leadership recognizes the strong public support - including among doctors - for removing the wasteful insurance company middlemen from our health system and redirecting the resultant savings into care."

Weiner's amendment would delete most of the language of in the House bill and instead substitute language from H.R. 676, the single-payer bill introduced by Reps. John Conyers Jr. (D-Mich.) and Dennis Kucinich (D-Ohio).

The Weiner amendment, unlike the House leadership's bill, assures universal, comprehensive, and high-quality coverage, free choice of doctor and hospital, and no co-pays or deductibles through a publicly financed system similar to Medicare. Young said that because of massive savings on private insurance overhead and paperwork, the amendment would entail no increase in U.S. health spending, in contrast to the House bill's $1 trillion price tag over 10 years.

"By recapturing the administrative waste associated with our present multi-payer, for-profit private insurance system, estimated to be $400 billion annually, a single-payer program would have more than enough resources to cover everyone who lacks insurance now and to upgrade everyone else's," he said.

"A single-payer system would also possess strong cost-control tools like bulk purchasing of drugs, negotiation of fees and global budgeting, controls that are notably absent in the House bill," he said.

Young says many union, civic and faith-based groups will be watching how lawmakers vote with an eye to the 2010 election cycle. "Lawmakers now have a golden opportunity to stand up for the best interests of their constituents, to rebuff the private, for-profit health insurance industry, and assure the health of our nation," he said.

He continued: "Many members of Congress - including Speaker Pelosi - have told constituents that they personally support a single-payer, Medicare-for-all approach, but claim they can't vote for it because it's not politically feasible. Yet polls that show they would have the public's support for such a stand. Now we'll be watching to see whether their votes match their words."

Single-payer bills have been introduced in Congress repeatedly over the past 60 years - starting with the Wagner-Murray-Dingell bill in the 1940s, and including the Kennedy-Griffiths bill of the 1970s and the Wellstone, McDermott and Russo bills of the 1990s - but none has ever reached the floor of the House or Senate.

It only seems fair; if the opposition wants to accuse us of creeping socialism, we might as well actual put something radical on the table. This isn't quite socialism, any more than arms procurement is socialism- just makes the Federal government as the sole purchaser, while allowing us all to compete to be the vender.

We do live in interesting times.

An Approach to Destroying Health Insurance Reform: If You Can't Win the Argument, Make It Impossible to Have One

2009-08-04T18:53:00.000-07:00

I could not attend today's "Town Hall Meeting" in Worcester, in which our Congressman tried to lay out the case for health reform. My wife was there (and in the picture in the Telegram and Gazette); she was appalled by the tactics used to stifle discussion. There is a story about the tactics on the NPR blog that I commend to all to read here and another story in the NY Times here. Also, our friend and sometime poster Robbin Miller posted her thoughts:

I attended a Health Insurance Reform in Worcester today that was co-sponsored by Congressmen Neil and McGovern.
You can be my post at www.therapistsforchange.blogspot.com
I would be interested in hearing your comments.

Robbin Miller, LMHC
Facilitator
www.robbinmiller.vpweb.com

It is a little worrisome, but not unexpected, to find those opposed to health reform are using a bit of guerrilla theater. Logic dictates change- so to fight change, one must drown out logical thought. We will see how it plays in the rest of the world.

Meanwhile, the President visited a Children's Hospital today. Check out the speech here. Not a bad thing.

Guess It Is Official Now: RWJ Health Policy Fellowship Announcement

2009-08-03T14:20:00.000-07:00

So, the word is officially out now. Check it out here. Sounds awesome, no?

RWJF Health Policy Fellows have unique opportunity to influence health reform
10 health professionals selected to participate in competitive fellowship
Princeton, N.J. — Ten exceptional health professionals have been selected as Robert Wood Johnson Foundation Health Policy Fellows for 2009-2010. The ten fellows will utilize their wide range of academic, public health, clinical and community-based experience to provide health policy leadership on Capitol Hill to improve health and health care.
Each year, fellows are selected through a competitive selection process. They leave their academic settings and professional practices to spend a year in the nation's capital. A three-month orientation program is followed by a nine-month assignment in which fellows work in a congressional office or the executive branch. Work assignments are supplemented throughout the year with health policy leadership development activities and media training.
"This is a particularly remarkable year to contribute much-needed practical knowledge of health and health care to Washington, D.C. Our fellows will have the chance to impact health reform directly," said Michael Painter, J.D., M.D., RWJF senior program officer and 2003-2004 Robert Wood Johnson Health Policy Fellow. "The 'hands-on' health and health care experience of our fellows provides a critical perspective to the reform debate."
In September, following the one-year experience, fellows can choose to extend their Washington stay past the fellowship period through the end of the legislative session. Once they've completed the program, fellows return to their respective institutions or take another appropriate position where they further develop their health policy leadership skills. They become part of a nationwide alumni network and typically return to Washington yearly to attend the Institute of Medicine's annual meeting and get an update on issues and trends in health and health care policy.

From the Children's Mental Health Campaign: Still Some Work to Do!

2009-08-01T00:27:00.000-07:00

Action Needed: Blue Cross Foundation Provider Capacity Survey

The Blue Cross Blue Shield Foundation is conducting a survey to determine provider capacity in Massachusetts and potential barriers to children's behavioral health services.

Click here for information on how to participate in the survey.

Please forward this information to your networks.

State House Ops Committee Meeting: September 9 @ 11:30am

The next CMHC State House Operations Committee meeting will be on Wednesday, September 9 from 11:30am - 12:30pm at MSPCC (99 Summer Street, Boston).

At this meeting, we will discuss legislative advocacy work in support of passage of the Collateral Contacts legislation.

If you are planning to attend or to have your name added to the email distribution list for this group, please contact Nancy Scannell at nscannell@mspcc.org.

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

2009-07-31T03:33:00.000-07:00

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 http://www.healhealthcarenow.org or just watch the video.

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

2009-07-30T20:34:00.000-07:00

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.

Systems of Care Still Want You!

2009-07-27T03:45:00.000-07:00

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.

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

2009-07-23T01:09:00.000-07:00

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.

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

2009-07-22T02:46:00.000-07:00

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.

Early and Periodic Screening: More Evidence of Change

2009-07-21T03:32:00.000-07:00

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?

Health Reform Moves On (and includes EPSDT)

2009-07-19T06:26:00.000-07:00

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.

A Well Deserved Honor

2009-07-18T05:29:00.001-07:00

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.

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

2009-07-17T15:48:00.001-07:00

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.

Massachusetts Mental Legal Advisors Committee on Mental Health Parity in Massachusetts

2009-07-15T00:03:00.000-07:00

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,
or

·       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 www.dol.gov <http://www.dol.gov/> , 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

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

2009-07-14T06:35:00.000-07:00

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.

Visiting Boystown: A Glimpse of a System of Care

2009-07-13T03:21:00.000-07:00

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.

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

2009-07-12T04:14:00.000-07:00

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 mnoyes@hcfama.org 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.

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

2009-07-10T00:02:00.000-07:00

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?

Musing on a CATCH Visiting Professor

2009-07-09T00:01:00.000-07:00

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.

Like the first crocus: It might be working.

2009-07-08T00:05:00.000-07:00

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.

Say It Ain't So, Deval!

2009-07-07T00:01:00.000-07:00

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.

Systems of Care Want You!

2009-07-06T05:48:00.001-07:00

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!

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

2009-07-04T03:40:00.000-07:00

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.
CLICK HERE FOR THE REST
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!