Responding to the RFI- Part 2

The CSA's are an interesting component of the proposed Rose D remedy; they have some questions about them as well:

1. Do you have any comments or suggestions about the number or configuration of Service Areas?
Combining South Central Worcester County and the Blackstone Valley is a mistake; the distance from Wales to Bellingham is about 40 miles, over 2 lane roads, without public transportation. The large area includes 3 community hospitals, one of which is quite small, and only one local agency capable of performing the tasks requested in the settlement. Several aspects of service delivery, including rapid response team and home based therapy, will be very difficult to deliver over such a wide service area. We would recommend that the CSA be split into two separate regions.
2. Do you have any comments or suggestions about the proposed scope of CSA services?
The scope of services for the CSA is a little confusing; by specifying that the services be provided by an subcontractor, but delivered within the MCE (and subject to review by the MCE), it seems to me that you are setting up barrier to care. The CSA really needs to be empowered to authorize levels of service for this to work quickly, at least within MassHealth. For example:
A new patient (Rosie C) is found eligible for services for bipolar disorder. Her mental health provider MCE-A refers her to their subcontractor CSA-A, who works with the family and determines that her needs include family and individual therapy, therapeutic day-school, respite care and psychopharm services. The CSA-A sends this plan to the MCE-A for review, and convenes the team meeting. The school disagrees with their part of the plan, DMH has trouble with the respite portion of the plan, noone can find a child psychiatrist in plan and all beg the pediatrician to keep prescribing the meds while they sort this all out. The CSA-A then asks the MCE-A to go out of plan to find a psychopharmocologist. After 2 months of meetings, none of the needed services are authorized or running.
Unfortunately, the CSA can't have control over DMH or DOE resources; the least we can do is give them some authority over the MassHealth portion of the package. Otherwise, we are are just adding another layer of bureaucracy.

Responding to the RFI: What can the Commonwealth actually do?

So, here we are, moving into spring, and Children's Behavioral, Mental and Developmental Health in the Commonwealth is not yet fixed. What is wrong with us? As I mentioned in an earlier post, the Executive Office of the Health and Human Services (EOHHS) has offer us the opportunity to give them advice on how to fix a system that often seems clunky and unresponsive (and certainly seemed so to Judge Posner, in his recent ruling). Now is the time, it seems, to step up the plate, and let our opinions be know.
The Request for Information (which is still available on-line) has 68 specific questions, which have been carefully and thoughtfully written out for our review. We have until April 1 to give them a reply. After a few meetings with my colleagues in the Worcester Mental Health Network, I have been tasked with trying to formulate a reply that speaks to some of the unique characteristics of Central Massachusetts. They clearly have more confidence in my ability to do this than I do. On the other hand, it is our shot at getting some input into the process. So, I 'll give it a go.
First off, it is clear that the suggestions my Advocate Miller earlier in the blog are not terribly helpful. She has said on several occassions that the answer is to pay clinicians for no shows. The problem with that is that it encourages clincians to encourage no shows, to maximize revenue and minimize work. Bad idea, setting up a system ripe for abuse. As we move through the questions posed by MassHealth, I hope that we are able to help to create a system that is equitable, efficient and unlikely to engender fraud.
Let's look at the first set of questions:
(1) How would you recommend that MassHealth ensure that children and youth receive comprehensive assessments culminating in the completion of the Massachusetts CANS, at the times and places described above?
This is an interesting question. The CANS seems to be "a tool developed to assist in the management and planning of services to children and adolescents and their families with the primary objectives of permanency, safety, and improved quality in of life." which is used to assess the severity of a clinical problem, the impact on function, and the strengths that the child and family bring themselves to the table. It is not a functional status measure, yet many of us have concern that it will be used by agencies INSTEAD of the normed functional status measures that others are using.
The CANS assessments should be used as part of the diagnosis of psychiatric disorder, but as a means of determining whether or not the illness meets the threshold for a serious emotional disturbance. It should NOT replace the other functional status indicators such as the BASQ or the TOPS that are used in several of the "carve out" programs. Instead, the CANS should used sparingly, in order to document the need for a change in the level of care provided. Operationalizing this will be tricky, as the level of severity of mental illness can easily change over the course of a few days, but we wouldn't want to be repeating the CANS that frequently. The tool looks at performance over the past 30 days, and takes 2-4 hours to administer.
We are very troubled by one sentence in the RFI: "As a result, multiple clinicians may complete a Massachusetts CANS assessment for the same child within a short period of time. " Our concern is that will result in duplication of effort, focusing on lots of assessment and reassessment to the exclusion of treatment, and strongly urge the Commonwealth to allow multiple clinicians to work off of a single CANS assessment, especially if the number of clinicians able to perform the CANS is limited by the certification process.
Assuring access will require MassHealth to work with clinicians to develop criteria for the use of instrument, one of which should be parental desire for a more complete assessment.

(2) How would you recommend that MassHealth promote communication among multiple clinicians involved with the care of a child within the constraints of privacy and security laws?
Communication within a treatment team is paramount; the key to coordinating the flow of information has to be collaborative between the Intensive Care Coordinator and the parent; the parent needs to give or withhold consent, and the ICC has to have a handle on the flow of information. Many agencies have segregated information regarding mental health from the medical record of physicial health. This would be a mistake for these families- access to the full record is of the utmost importance.
To treat patients with SED requires free flow of information within the team. In developing the treatment plan, the ICC will need input from the clinician, the psychiatrist, the PCC and the school, as least in most cases. Add DMR, DYS, probation, and the court in another.  The family, working with the ICC, will need to manage a complex data system, one that, in most cases will allow the various parties to speak to each other in a timely fashion. This can be done within the Virtual Gateway, a clinic based EMR or frequent phone calls. The first two options require the support of a new level of computing skills within the program.  So, we are talking about an new and intimate relationship (family - ICC) that enables the members of the team to access some kind of "common record" that allows the family intimate contol over who sees what in this context.  Ultimately, that probably needs to be an incredibly secure on-line resource or "vault" with different "windows" that allow families to specify what level of information one is permitted to see.  One of the roles of the ICC would be to help families to ascertain who in the treatment team gets to see what part of the record.

(3) How would you recommend that MassHealth ensure coordination among clinicians assessing a child and not create the need for multiple assessments and reassessments?
Bingo. You have put your finger on the heart of the problem. How do you avoid multiple assessments, when your patients are tired of their problems and the creaky system. Early on in the process, MassHealth must encourage ALL parts of the treatment team to talk to each other, either by video conference or in person, and including at least the family (and the child, if the child is deemed sufficiently mature.  The team needs to discuss what is known about the child at this time, create a plan for intervention and further evaluation and generate a timetable for review and reassessment (sorry, but review and reassessment are essential because kids grow up and change as they grow).  MassHealth's tools:

1)  Higher rate of reimbursement for subsequent visits to those who show up to the meeting.

2)  Creation of a network of "meeting centers" that allow distant clinicians to be present in a virtual meeting.

3)  Major support for transportation for families to attend these sessions.

(4) What are the advantages and disadvantages of using an exclusively web-based CANS?

The big advantage that I see is that it would allow the CANS to be used collaboratively among the different providers, eliminating the need for repeated assessments by different agencies of the same tool.  The downside is that it requires access to the web, a problem particularly while doing home-based work.
(5) What are the advantages and disadvantages of using the Virtual Gateway to access the CANS application?   This one I need to take a "pass"on-  if others in the network have thoughts, please leave them here.  I have no personal experience in using the Virtual Gateway.
(6) If you are a provider, do you currently have internet access?  Most of the agencies in the Worcester Mental Health Network have internet access. That said, we have not yet figured out how to use that access forsecure  communication with patients or each other yet.  State support in this effort would be useful.

Also of Interest: My e-mail runneth over...

Still off running a conference:  I promise more substantive blogging soon.  But this came from an Academy Listserve that I am on, and seemed worth sharing:

Paper Highlights State and Local Innovation in Finance Policy for Child Behavioral Health Services
from MCH Alert, March 7, 2008
Towards Better Behavioral Health for Children, Youth and Their Families: Financing That Supports Knowledge provides an overview of sources of funding (and their policy roots) that underwrite children's behavioral health services, illuminating the flaws and prospects of various policy choices. The working paper is the third in a series titled Unclaimed Children Revisited produced by the National Center for Children in Poverty. Although the paper focuses on public funding for mental health and on substance abuse services within the behavioral health arena, it also addresses related funding in education, child welfare, and juvenile justice. Topics include an overview of children's behavioral services, an overview of federal behavioral health funding streams and their impact, fiscal innovation in states and local communities, and challenges and opportunities. The authors conclude the paper with recommendations for policy actions to create and sustain a supportive federal and state fiscal environment. The paper is available here.

Back to the frozen north soon!

Screening in Month 3: How's it going?

This came across my e-mail today, and seemed relevant:
"3. MANUAL PROVIDES GUIDANCE IN CHOOSING PEDIATRIC DEVELOPMENTAL SCREENING INSTRUMENTS:  Pediatric Developmental Screening: Understanding and Selecting Screening Instruments informs practitioners' selection and application of screening instruments in a range of practice settings. The Web-based manual, developed by the Commonwealth Fund, is based on a review of the scientific research on available developmental screening instruments.  Part 1 is designed to facilitate the selection of screening instruments by helping practitioners define their practice needs. Part 2 presents guides designed to facilitate practitioners' abilities to compare developmental screening instruments with respect to clinical utility in practice settings and validity, or sensitivity and specificity, in
different populations and at various ages. An interactive Web feature (flow chart) is also available to answer questions about screening needs and make instrument recommendations. The manual is available through the Commonwealth Fund"

Sat with a few providers the other day, pondering the current screening program and speculating about what to do next.  Only a few glitches identified:

1)  Screening kids under two years of age for behavioral problems makes no sense:  The parents understand the need to screen development, but find the behavioral questions irrelevant, especially at two weeks of age.  It would be better if Masshealth were to require fewer screens early in childhood for behavioral health problems, and let us focus on developmental issues at that time.  Also, the major behavioral health issue that affects the behavioral health of 2 week olds is maternal depression;  we need to be developing a system to deal with that.

2)  Billing remains complex:  Since most of us treat all of our patients the same, using the screening code and the modifiers has resulted in a some of our patients with "out of state" insurances getting billed for the screening, to their dismay.  Makes me long for the days of a single payer system (wait, we haven't had those days yet).

3)  U1 and U2 mean what?:  We all have found that the PSC doesn't identify a number of kids that we think have fairly significant problems, some of which are on-going and some of which are new, and think that the "yes/no" coding is too simplistic (don't capture the richness of what is actually going on.

4)  Teens and confidentiality:  We've had a couple cases now where parents looked at their kids PSC before it was collected, and argued with their kid about his "self-report".  Not sure that we have helped parent-child interaction in those cases.

Still, most folks were feeling pretty good about how things were going.  

I'm running a meeting in a faraway place this week, which is why the postings have been sparse.  More next week.

Rosie D. and US: implications for the “Medical Home”

Hello there, and thanks to David for letting me “blog” about this great topic. I’ve never “blogged” before (sounds like a trudge through a swamp), so here goes.

As you know, one great thing about the Rosie D. decision is that it mandates mental health screening for all children through their source of primary care. While this is great in that it identifies lots of kids who need mental health services and will hopefully make sure they are connected to those services, not much has been said about the ongoing parent-primary care-mental health provider partnership that such a system should create. For any of you new to the concept of the “medical home”, it has a long, drawn-out definition. However, in 25 words or less, its core is the partnership between parents, children and youth, and the child’s primary care practice as a center of coordination of care.

I’m co-leader with Dr. Rich Antonelli of the Central Massachusetts Medical Home Network Initiative (CMMHNI), a project to improve comprehensive, coordinated, continuous care for children and youth with special health care needs in a group of interested primary care pediatric practices (Medical Homes), and one of our major activities is to build and strengthen connections between Medical Homes and community-based service organizations. The Rosie D. decision represents a tremendous opportunity to strengthen coordination and collaboration between mental health service providers and primary care practices. We are committed to working toward ensuring that the recent court decision will be implemented in a way that benefits Medical Home-mental health service provider partnerships.

Working with our mental health partners in Central Mass. in our thoughts about responding to the recent RFI (Request for Input), we’ve come up with the following principles that, from our perspective, are critical for inclusion in the activities of the Rosie D. initiative as it moves forward:

• The need for bidirectional education between mental health service providers and Medical Homes about the needs of children and families under our care;
• The need for bidirectional discussion and idea sharing between mental health service providers and Medical Homes about how to best provide coordinated services to shared patients/clients and their families;
• The need for ongoing communication between mental health service providers and medical homes about mental health evaluation and services provided to children who are referred, to enable ongoing involvement of the medical home in care, high-quality coordination of these services with other health care and school-related services provided to the family, and more efficient care (including avoidance of duplication of care);
• The need for crisis plans and crisis teams to engage in communication and coordination with the child's ongoing medical and mental health service providers, as well as with their school. The goal of this process would be to help children and families transition smoothly between levels of care (both up and down the urgency/intensiveness ladder).
• The need for proactive designation of a person or small group of people as each child's crisis team, ideally determined BEFORE a crisis occurs. This would further enable well-planned, well-coordinated care.
  
  In a nutshell, we are interested in planning for “what happens after the referral, to make sure children receive the highest-quality coordinated care?”
  
  Thanks to Beth Pond, Barbara Donati, Rich Antonelli, Meri Viano, and Lisa Lambert for their help in putting this together. I’d be happy to hear any thoughts you might have about this. Feel free to contact me at stillec@ummhc.org, or post a reply. Thanks for your attention!
  
  Chris Stille, MD, MPH
  General Pediatrics, UMass
  Co-Principal Investigator, CMMHNI

How a Bill becomes Law: Update on the Children’s Mental Health Campaign

I hate driving to Boston. Even with GPS, I get lost. And GPS doesn’t find you a parking place. Still, on the day after the Rhode Island Primary, I hopped in my care to drive into Boston to hear Mary Lou Sudders (head of MSPCC) and David DeMaso MD (head of psychiatry at Children’s) talk about the Children’s Mental Health Initiative, a bill currently winding it’s way through the Massachusetts’ legislature that complements all of the work that we are doing with the Rosie D. case. As we have said repeatedly on this blog, Rosie D. is a tremendous opportunity for change in the system for kids on MassHealth. This bill offers the opportunity to bring similar changes to the rest of the kids in Massachusetts.
So, with my car carefully parked in a quasi-legal space, I arrived late to a brilliant session on the current state of the legislation. “An Act Relative to Children’s Mental Health” was introduced into the Massachusetts legislature on 1/10/2007, and it is currently clearing the committee hurdles.
The bill is based on a premise: that there is (and shouldn’t be) a single system for mental health care, but that the key to the process is to be building bridges between the various folks who work with the kids who do the work. Partnerships, with Health Care for All, with the Parent Professional Advocacy League and Health Law Advocates, are the key to moving this process along. All of these agencies are key to this process. To emphasize the point, the two presenters alternated sentences in the presentation of the material. This partnership has led to co-sponsorship by 96 legislators, as the coalition educates the legislature on what this bill is about and assures them that this is the right thing for the legislature to do.
The bill is HB4276 and has five key elements. First, the bill creates a single voice within the government for children’s mental health, the Commissioner of Mental Health. (like the Commissioner of Public Health handles hospitals). This will be a major step in breaking down the silos. Second, the bill calls for payment of primary care doctors are paid for early screening in practice. Third, it provides for payment for the provision of collateral mental health services and collaboration. Fourth, it requires coordination of care within public agencies. There was a fifth thing, but I missed it by not typing fast enough.
The original bill also had some mental health parity law language that has been moved out of the omnibus bill into its own bill. Strategically, mental health parity is likely to need more pushing to get it through.
It has been quite a process moving the Omnibus Bill through the process. Its first committee was the Joint Committee on Mental Health and Substance Abuse. After a tremendous hearing, the bill was sent on to the Joint Committee on Health Care Finance, a committee that often doesn’t let bills out for consideration. The Bill was then sent to the Senate Ways and Means committee (in order to avoid the logjam in the House over the budget). In so doing, it was renamed;  it is now called S.2518. When the bill makes it out of Senate Ways and Means, it needs to clear the House and to go to the Governor for signature. It is quite a process, and requires those of us on the ground to continue to support the bill to keep it moving through the process.
Children’s has been pushing this within the Children’s Hospital system. They have trained speakers, developed a website, sponsored a Mental Health Advocacy Day.  MSPCC has been working with their advocacy network. So far, only two groups have come out against this: the Church of Scientology and the Mass Association of Health Plans. To make this work, they need our help. So what can we do?
1) Give voice to the stories: The folks in the State House need to hear the stories that are happening in different parts of the state. This is probably the single most important thing.
2) Get into the media: Op-Eds, letters to the editor, interviews;  all of this is good. “The most important thing is not how well you are quoted, but how badly you are mis-quoted", to quote Ms. Sudders. While there is risk involved in talking to the media, there is benefit to getting this issue out and in the open. The media keeps the mission alive.
3) Talk to your legislators: They need to hear that this is their problem, not just a problem at Children’s.
Politically, the presenters thought that this was likely to be passed this year with the right support. A group of us are planning a series on events in Worcester County around mental health month to promote this initiative. Stay tuned for the details.
Oh, and if anyone wants to join the fight, give Matt Noyes (mnoyes@hcfama.org)  a holler. He’ll hook you up.

Rosie D. and You: MassHealth wants your ideas!

MassHealth has issued a Request for Information on the Rosie D. case. It was posted on Friday afternoon, and you can get it here or by going to COM-PASS and searching all solicitation for “behavioral health”. It’s called Children's Behavioral Health Initiative RFI and it is quite long, but I think asks some good questions. As we discussed, last month, I think that it is important for us to formulate a response that speaks for the needs of children in Worcester County.  (and for that matter, the rest of Massachusetts.)  Responses are due by April 1.

In Worcester, the Network will be meeting to discuss our responses:

Monday, March 17, 4 PM, Bowditch and Dewey:
Central Mass Responds: A discussion of possible responses to the RFI by the membership of the Network.

Look for more updates on this blog.