Worcester Children’s Mental Health Issue Forum

Wednesday, October 15, 2008

9:30-11:00 AM

Please come to learn more about the recently passed Children’s Mental Health law, how you can be involved in its implementation, and tell the Children’s Mental Health Campaign what pressing issues remain unaddressed in your community.

MSPCC Worcester Office

335 Chandler Street 

Worcester, MA 01602

The time is now to:  Share your story • Speak out for reform • Learn about the new Children’s Mental Health law • Make children’s mental health care better together

Light refreshments will be served.

Mental Health in Washington: Mental Health Parity Almost Passed the Congress

Since Saturday, I have been in Washington, 5 blocks from the eye of the storm currently raging from Washington to Wall St.  While I have been following the current crisis closely, the reason for my visit was to attend the AAP's meeting of the Committee on Federal Government Affairs, as the representative of the APA.  We met with the staff from the AAP's Washington office, heard about the issues currently on the Hill that affect children, and spend a bit of time on Monday morning talking with our Representatives and Senators offices.  One issue that I knew was on the table was the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act of 2008, which the Academy has supported for a long time.  The key paragraph in the bill is this:  

"the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan, and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits;"

This would be an enormous relief for families with large co-pays or deductible requirements, and will compliment the changes being put in place in Massachusetts.  So what is the catch?

Like our bill in Massachusetts, this bill is widely supported and has no overt opposition.  It has passed the House, where it is engrossed, and is stalled in the Senate because it has been linked to a tax bill that the House finds unacceptable.  To get through, the bill must either be separated in the Senate or passed in the House.

People know that this can be passed.  The current disaster in finance and credit has refocused everyone's attention, and we need to ensure that Congress doesn't forget the Mental Health Parity bill in the sound and fury currently underway 10 blocks from where I am typing this.

Please let your Representative and Senator know that they should not let this bill die with the end of this Congress.

I'm off to catch my flight home.  More about this on this blog.

After the Party: Updates on Rosie D. Implementation

After the celebration, I (like the rest of America) got a little preoccupied with the imminent collapse of our economic system.  Sorry - its been a few days since my last posting.

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The Center for Public Representation recently issued a news bulletin, which is worth a look here.   They had four items:

1)  Final Medical Necessity Criteria:  It is good to hear that the criteria for determination of medical necessity are almost ready to be released;  we all knew that it would be a struggle to put that together and we fully expect that there will be controversy over them once that are released.  Their release, however, will be another landmark in this case.

2)  Response to CMA:  Folks should take a look at the forceful way that Secretary Bigby is arguing for the expansive and comprehensive services that will be needed to make wraparound services a reality in Massachusetts.  

3)  Revised State Plan Amendment:  This is also good to see;  an administration working to set policy that provides services for children and families.  We can only home that the Federal government sees the good in all of this as well.

4)  CSA:  Coming soon.  The Massachusetts Behavioral Health Partnership has put this on hold as well, trying to make this RFR consistent with the agreements that the Commonwealth is able to reach with the folks in Washington.

The last thing was a bit about screening.  I want to quote the article exactly, because I want my comments to be equally precise:

"The early data reports of the new behavioral health screening initiative indicate significant gaps remain in the Commonwealth. Although all children who visit their pediatrician or health care professional for a periodic EPSDT visit must now receive a behavioral health screening, only 25% did in the first six months since the new program was initiated on January 1, 2008. Of those who were properly screened, only 7% were identified as having a behavior health condition, even though national data indicates this figure is well over 10% and often approaching 20%. Finally, of those identified as having a behavior health condition, there was no data on the percentage who were referred for a mental health assessment, even though this figure should be approach 100%. Thus, despite the critical importance of behavioral health screening, as mandated by the Congress and ordered by the federal court, much remains to be done to ensure compliance with these mandates in Massachusetts."

In light of my experience in this area, I want make a couple of points:

1)  I am not troubled that MassHealth only found that 25% of EPSDT visits involved a behavioral health screen.  This program was implemented with almost no notice- it will take some practices more time than others to get up to speed.  Also, screening and billing may not match entirely.  Given that almost no-one was screened using a valid screening instrument prior to the Rosie D case,   getting to 25% is extraordinary.  That is at least a 100% increase.  Not bad for the first 6 months.  I suspect it will get to be a larger percentage of children over time.

2)  Billing and practice are not always in sync.  It is hard to change habits; it took me a while to remember to add the screening code to the billing sheets, and I know that some of my patients escaped without me billing for the screen that I did. 

3)  Rates of positive screens are low.  Research studies, where there is an interest in finding high rates of problems, almost invariably result in higher rates of case finding than we find in the real world.  For me, part of the problem is how to code the kids that we already knew had problems?  Are the "U2" referrals if they are already in treatment?  Or if they refuse treatment?  That happens in at least 50% of my positive screens-  that will look like underdiagnosis in the billing data.

4) No data on mental health referral:Here is where the "carve out" ideology gets in the way.  In our area, anyway, the act of making a referral is largely giving the phone numbers for several agencies to the mother.  The agencies won't let us book the appointment, as, in their experience, that leads to too many no shows.  And we often don't hear back regarding their their treatment plan.  So how can we tell who has been referred until we agree on what referral means?  The best that MassHealth can do is look at mental health billing records and compare them to the primary care record.

5)  Who were those patients? Please remember that the EPSDT visits during the school year (January to June) are likely to be younger, and the rates of mental illness are lower in that population.  I suspect that the number of screenings will increase in the summertime, when we are seeing all of the older kids for school and sports physicals.

Change is hard, whatever the system in which it is being promulgated.  I look forward to seeing the end of year numbers.

It Takes a Village to Raise a Bill: Celebrating Chapter 321

I should have brought a camera, because, as with everything else they have done, Health Care for All did a great job organizing today's celebration.  (Fortunately, I was able to scarf a picture from HCFA's website and post it here- I am sure that they won't mind).  There were a lot of people here and a lot of great pictures to be taken.  The people were really happy, as they gathered to celebrate a legislative accomplishment: the passage of Yolanda’s Law, An Act Relative to Children’s Mental Health, now Chapter 321 of the Acts of 2008.
The crowd began to clap at about 2:40 PM, and the officials arrived to begin the ceremony. We began with Secretary Bigby, who acknowledgd the critical role of the Children’s Mental Health Campaign, with Representative Balzer and Senator Tolman, and thanks to the leadership of Marilou Sudders and David Demasio. Governor Patrick took the stage, and thanked all of us for leading Massachusetts to a place where mental health and physical health are seen as equally important in the care of children in Massachusetts. He gave copies of the bill to Marilou Sudders and to the mother of Yolanda, a young woman who supported the bill and later succumbed to her psychiatric illness. His remarks were brief, and he passed the microphone to Senate President Murray, who further praised those who worked so hard to get this bill through. She pointed out that this bill’s high standard is the envy of all throughout the country. The microphone then passed to Speaker DiMasi, who was equally eloquent in his praise of those who worked so hard on this project.
From the Campaign, we heard from the CEO of Children’s Hospital, who reminded us that our work is not done- that we need now to finish the implementation of all aspects of the law, and Marilou Sudders, who spoke eloquently of the voices of families in the process of creating this law. She reminded us that parents and children, by sharing their stories, have given us the courage to go forward. Secretary Bigby echoed this sentiment, highlighting the story of Yolanda. Mrs. Tufts expressed gratitude that Yolanda’s voice was heard, and that her words had impact. She also reminded us that the real work now really begins, as we begin to fixc the broken system. She hoped that her family would be “last ones in” the system as it is currently configured.

Representatives of the various groups that had worked so hard to get this bill passed were on the steps behind all of the officials and speakers, and that was appropriate (and that was the picture that should have been taken).  It took all of them and all of us in the audience to get this done.  We really should be proud of ourselves-  we got a lot of work done last year.  But, as no good deed goes unpunished, we now have to embrace the task of implementation going forward.

Reflecting on a Reflection

It took a while to upload my slides, but I finally got my Grand Rounds  on the blog.  You could stop reading this, and drop down three posts to check it out.  Posting it made me think more about what I said- I think that it is mostly accurate (and of course, I would love it if folks would send me corrections), but I think that I spent too little time on the final reflections.  What has my modest participation in this fantastic process taught me?  My "lessons learned" seems a bit lean, and I wanted to think on this a bit, especially in the context of a talk I heard today by Michael Fine, a family doc from Rhode Island.  Michael has written a book, The Nature of Health in which he laws out a strong argument that our current healthcare mess (high cost, poor outcomes) is rooted in our social fabric, that has defined health in measurable terms (delay of death, alleviation of pain, personal function) that encourages us to think about medicine as a business, and that focusing our remedies on the payment system (national health insurance) will do little to change that unless we change the system from one focused on procedures and specialists to one focused on primary care and prevention.  All of which I agree with.  He points out that neither Obama or McCain want to fix this fundamental problem.  What he didn't do today was give us the blueprint for change;  how do we make this change happen?  

That's what was missing from my lessons learned slides:  What I have been learning for the last year or so (actually for the last 50 years, but I am a slow learner) is that actually bringing change to a system is really hard.  It requires a careful analysis of the forces holding the old system in place, a keen sense of timing to understand when the "Time is Now", incredible attention to details- an ear to ground, contacts at every level of the government, knowledge about how the levers of power are actually pushed, and finally a recognition that, in order to counter any political force, you need another political force to knock it sideways.  These are not things that one learns in medical school.  The are people- politicians and their aides- who have a keen sense of how this work.  When us medical people want something to change, we need to ally ourselves with these political chessplayers and let them show us how our knowledge can become political clout.  Sobering lesson, but really important if one wants to change actually systems.

Michael's talk, however, was right on target and brilliant.  He just needs to tell us more about the steps that we should take to make it all happen.

Bill signing tomorrow.  I'm looking forward to it.  I'll try to blog live.

More from the CBHI

To: All Minority Providers and Youth/Family-Serving Organizations in Communities of Color

You are cordially invited to a briefing and discussion about The Future of Public Children’s Mental Health Care in Massachusetts including opportunities to become a provider of new MassHealth services

The Massachusetts Executive Office of Health and Human Services (EOHHS) is in the midst of a major transformation of its children’s mental health system, sparked in part by the Rosie D. Medicaid lawsuit, and fueled by Governor Patrick’s commitment to the Children’s Behavioral Health Initiative(CBHI), whose goal is to develop an integrated system of care for children with serious emotional disturbance or behavioral health needs. As youth/family- serving organizations, your involvement and leadership is essential to the success of this initiative. This meeting is part of a series of provider and family meetings being held across the Commonwealth.

Wednesday, October 1st, 2008, 12:30pm-2:00pm

Ashburton Café Conference, in the lower level of 

the McCormack Building

1 Ashburton Place

Boston, MA 02108

Please rsvp to cbhi@state.ma.us. Attendance at this meeting is limited only by the space available.

Agenda
• Overview of the Children’s Behavioral Health Initiative and the Rosie D. lawsuit
• New MassHealth behavioral health services under development
• Process for becoming a provider of one or more of these new services
• Discussion of community needs
• Concerns, questions, and input

EOHHS welcomes input from all stakeholders and interested parties on the Children’s Behavioral Health Initiative. Individuals and organizations unable to attend this meeting are encouraged to e-mail questions or comments to: cbhi@state.ma.us

For updates and announcements relating to CBHI, please visit: mass.gov/masshealth/childbehavioralhealth

To request an accommodation, please call (617) 573-1832
or TTY: (800) 872-0166.

The Rubber is Getting Closer to the Road: Update on the CBHI

So, I arrive late to the update of the CBHI, and I am blogging live in Shrewsbury.  The senior leadership of the CBHI, the assistance commissioners and all of the major players were there, ready to answer questions.  We have made a lot of progress over the last few months, and, once again, they left themselves open to questions.   I am happy to report that the rubber is indeed getting closer to the road. I joined a conversation about the process of way in which this program is actually going to work, and was highly impressed with the thoughtful of the process in which this plan is evolving. Key ideas:

1. Care coordination is at the center of everything.
   
2. Families are at the center of care coordination.
   
3. The families get to determine the level of care needed in each level of services.
   

Let me try to summarize: The Core Clinical Services of the CBHI are

1. Intensive Care Coordination (ICC) as part of the wraparound process.
   
2. In home therapy
3. Outpatient therapy

Each of these will have access to the outside supports of Behavior Management, Family Partners and Therapeutic Monitoring, Mobile Crisis Intervention and Stabilization, and the care coordination will happen at the level of the the most intensive service being offered.  They had a great graphic that shows how this is supposed to work, which I may try to reproduce at some point.

Overall, the sense is that we are moving the WHOLE system, not just the Remedy services, to a family centered model.  It is all very exciting, very complex and a great challenge to us all moving forward.  In the ICC cases, this is the assembling of a team, selected by the family, to develop an individual care plan for the family that addressed the whole child.  In the In-Home and Outpatient levels, this translates into a care plan, but one that is still family focused and team implemented.

They have clearly recognized the difference between planning and therapeutic interventions, and seem to be offering a plan that both identified and values both sorts of services. It looks great on paper. 

So how are we going to do this:

1)  It will be a competitive RFR process.  One does not need to be a licensed clinic to be an ICC provider.

2) The RFR will be coming out in late October-mid  November, to correspond with the CBHI Institute.  MBHP will be selecting the CSAs with other managed care entities.

3)  In-home therapy will be provided agencies selected through a separate Network selection process.

4)  For outpatient services, that want to improve the capacity for core coordination over the next 3-5 years.  They are using the Performance Incentive projects within MBHP to move clinics in the right direction.  THis year, they are going to structure a pilot for paying outpatient clinics to provide crisis intervention for their clinics.

5)  This is going to be an iterative process:  they will convene provider and stakeholder meetings to identify action steps.

They have gotten so far as to begin defining the service elements of each of these components, and had some slides showing the relationship between Mobile Crisis Intervention, FST services, and In-Home Therapy.  The three are similar, but differ in the timelines (months, days, weeks) and scope of services vary in their scope.  FST will be morphed into the Mobile Crisis and In-Home Therapy programs.

The questions were focused and direct.  First question:  What about the "stuck kids"?  Several people responded that the remedy is focused on building community capacity and that, by doing so, the "stuck kids" will get better.  The second question was form someone who was not clear on where this all came from, prompting a brief summary of the history and a reference to the website for information about the CANS.  We then got down to the details:  Why were we going to a 72 hour crisis intervention?  The answer was that we are fortunate to have different levels of in-home care, and that the FST and home-based therapy teams will provide support to move families beyond the crisis.  They also pointed out the difference between referral and connection, a distinction that I found interesting.  They also discussed some of the details of how the contracts for home-based therapy providers, which is actually going to be a separate process from the CSA procurement process.  Who determines which level of service will be activated?  At first, it will be the families who pick the door on which to knock on, and after that it will become a dialogue, in which the CANS and the outcomes will drive the level of service provided.  One really practical question was the increased cost of in-home therapy versus office based therapy.  They are looking at the whole system, and the many different services can be provided in the in-home therapy.  How are they marketing the idea of who can be referred and how referrals happen?  They realize that they have a big educational task ahead of them.  How will this interact with the Family Network system (DCFs Wraparound services)?  They are in the process of making this happen.  How is his going to address the needs of cultural and linguistic communities?  They are actually looking for CSA providers with expertise in culturally diverse providers.  They are looking for ways to grow the workforce in diversity over the next 5 years.  There will be a provider meeting for culturally diverse providers to discuss this plan on Oct 1 in Boston.  What about the shortage of workforce?  We are going to need to expand the workforce that we have.  

The charts are getting more complex,  with lots of dense lines demonstrating service delivery for kids in  a variety different settings.  The process that has been established thoughtfully, with lots of feedback loops, of which we should take advantage.  Lots of work to do.  Go to the CBHI website for updates.