Churning in the Hinterlands: As the CSAs Roll Out, Existing Programs Roll In

South Worcester County is trying to get organized in advance of July 1. Others probably are as well.

Good afternoon,

It has been quite some time since our Advisory Council has come together, and there have been many changes over the past several months. In the climate of the Children’s Behavioral Health Initiative, it has become necessary for Central MA Communities of Care to examine all of our options for the remaining two years of our federal grant. We are committed to serving Southern Worcester County, although we acknowledge that our programming will be evolving and we are hoping to be developing new opportunities and partnerships in this area.

In May we are planning a regional, comprehensive strategic planning session to develop a workplan for the next two years. In order to ensure that the voices of the South Family Center, including our youth, families, and stakeholders, are well represented in this process, we would like to have a pre-planning meeting to hear from you. Please join us this Thursday, April 2nd from 3:30 to 5:00. Our Project Director, Suzanne Hannigan, will also be joining us. We will be looking at our projected budget, as well as asking our community what your vision is for our program.

I realize that some of you have not been able to be ongoing members of our Advisory Board, but I hope you will join us for this very important event.

Sincerely,
Nicole A. Walker, LICSW
Youth and Family Center Director
Central MA Communities of Care
508-856-5760 (Webster)

Together for Kids: A National Model in our Backyard

I saw patients today, ranging from adolescents with depression and substance abuse problems to a baby with fever and an ear infection.  Busy day, with little time to reflect.  Then I saw think on an e-mail that went by.

Carole Upshur, Melodie Wenz Gross and George Reed published an article about the Together for Kids pilot work in Worcester that provides mental health consultation to child care programs. This work led to Carole’s current NIMH-funded study on primary prevention of behavior problems. The article, A pilot study of early childhood mental health consultation for children with behavioral problems in preschool, appears in the Early Childhood Research Quarterly. 2009, 24:29-45. This work was funded by the Health Foundation of Central Massachusetts, the United Way, and the Fred Harris Daniels Foundation.

This seems to me to be a practical and cost-effective approach to this problem, and worth replicating across the state.  Nice work.

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Also heard about this:

You are cordially invited to participate with the U.S. Department of Health and Human Services as it presents an interactive Webcast:
Affordable Health Care for Kids: Moving Forward without Delay
Friday, April 3, 2009 - 2pm - 3pm ET

Share your experiences and ideas about how we can help millions of uninsured children get the health coverage they need...without delay.

Special Guests:
Rima Cohen, Counselor to the Secretary for Health Policy, Department of Health and Human Services (HHS)
Mary Wakefield, PhD, RN Administrator, Health Resources and Services Administration (HRSA)
Jackie Garner, Acting Director, Center for Medicaid and State Operations, Centers for Medicare & Medicaid Services (CMS)

Connect online at http://www.hhs.gov/childrenshealthinsurance

Questions and comments for the panel will be accepted in advance of and during the Webcast. To submit a question or comment, go to http://www.hhs.gov/childrenshealthinsurance/questions

Still in Cleveland: Social Determinants of Health (and the Behavior of the Harvard Faculty)

Last night, the Medical Advisory Board of the National Center for Medical-Legal Partnership

has a very nice dinner,  and today we opened with a tremendous talk by Rob Kahn on the intersection of social determinants of health and genomics.  Rob pointed to our haste of the medical profession to accept genetic determinism is a social, not a scientific phenomenon.  A couple thoughts:

Interesting quote:  “Few tragedies can be more extensive than the stunting of life, few injustices deeper than the denial of an opportunity to strive or even to hope, by a limit imposed from without, but falsely identified as lying within.”- Steven Jay Gould

Rob looked at the relationship of "hardships" and recurrent admissions for asthma.  Turns out that the folks with more hardship (money troubles, housing problems, lack of food) had more admissions, setting up the next question:  if we reduce hardship, can we improve health and create more wellness.  (Of course, there is another SJG quote that may relevant :  “The invalid assumption that correlation implies cause is probably among the two or three most serious and common errors of human reasoning”)  

Another thought:  applying QI methodologies to the medical-legal partnership makes a certain amount of sense, and Rob showed us how to make that happen.  Their electronic medical record has made it possible to look at individual performance in their site-  they are using the EMR to track the referral process.  EMR makes much of this stuff possible;  he presented some very exciting process data that shows how to monitor the process.

Ultimately, however this comes down to the need to find a common metric for the measurement of well-being.  He liked Sen, the Nobel-Prize winning economist and author of Development as Freedom, who defines well-being as living a life of genuine choice.

"Political rights, including freedom of expression and discussion, are not only pivotal in inducing social responses to economic needs, they are also central to the conceptualization of economic needs themselves."

Interesting guy.

Really interesting talk.  Rob did mention mental health, but only in the context of a consultative service that often provides us with little feedback.

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Just to get back to Children's Mental Health, the New York Times has an article about Joseph Beiderman and his work with Johnson and Johnson in the past.  The article shows why you should never use irony in talking  to lawyers:

In a contentious Feb. 26 deposition between Dr. Biederman and lawyers for the states, he was asked what rank he held at Harvard. 

“Full professor,” he answered.

“What’s after that?” asked a lawyer, Fletch Trammell.
“God,” Dr. Biederman responded.
“Did you say God?” Mr. Trammell asked. “Yeah,” Dr. Biederman said.

He continues to do our profession no favors.  I really wish that we could get beyond this discussion, but it seems that it will be with us for quite some time.

Another Meeting: Cleveland and Medical-Legal Partnerships

As regular readers of this blog know (and we are setting a record for number of hits this month, so there seem to be more of them every month),  I have been working with public interest attorneys for the last few years, initially in a medical-legal partnership in Worcester called Family Advocates of Central Massachusetts and subsequently on the Children's Mental Health Campaign with Health Law Advocates of Boston.   Each year, there is a meeting of Medical-Legal Partnerships (this year in Cleveland) and this year, I am there.  The conference is all about advocacy; I am hoping to pick up some pointers that will help us in our advocacy efforts.  As goes along, I may pass along some of these tidbits for your perusal.  System change is hard:  we need all of the help we can get.

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First speaker, Connie Schultz was brilliant.  She told stories, exhorting us to keep doing the good work with grace and a sense of humor.  She spoke of her experiences in shining light on injustice, and the power of a well written op-ed, reminding me that we need to write another one of those on children's mental health as the state is rolling out the Rosie D. initiative.

Then we got the report from the National Center (Megan Sandel, Ellen Lawton, Barry Zuckerman), from our national medical and legal leadership:  Medical-Legal Partnerships are everywhere:  81 around the country, working in 180 different kinds of health centers and practices in 37 cases.  The National Center has recognized that this practice model needs to include adults as well as children.  37 Law schools and 23 Medical schools have incorporated the partnership into some aspect of their training program.  The point was illustrated with cartoons-  worth looking at here without breaking the copyright laws. They closed by pointing out that we need to move the program into the sub-specialty programs to integrate Partnership into the medical system, and that the legal community should embrace the notion of preventive law.  Lots of potential for growth.

We then moved onto workshops:  more later.

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First workshop was on "Environmental Health":  collaborations with Law Schools and Medical School to help families keep the heat on.  The students, of course, are amazed at how "real people" live, and find this a really interesting model of care.  Of note was a chance to meet Elizabeth Tobin Tyler, who wrote a marvelous account about of her experience in teaching law students and medical students together.

Then, we heard about "program advocacy"- how the medical "champion" can support the development of the program within the Medical Center.  Lots of ideas, all dependent on having passion and connection in equal measure.

Now we get eat lunch.

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After lunch, I forgot that I was doing 2 workshops-  they went reasonably well, I suppose, but it is always hard to tell when you are the presenter.  We spoke of the trials of doing a multisite program, and the perils of evaluation.  Clearly the expertise in the room was tremendous.

I think that is all for today-  it is interesting that, among all of the services and needs of children in poverty that were mentioned today, mental health was not on the list.  I think that mental health is affected by social constraints, but I think that, when you are down and out, it does not rise to the top of your list.

From the CBHI: Need trainers for the ICC and stuff

Announcement:
Deadline Extension for Request for Responses (RFR) for Training, Coaching, and Ongoing Learning Support for Intensive Care Coordination and Caregiver Peer-to-Peer Services for the Children’s Behavioral Health Initiative (CBHI)
 
To: Interested Parties
Re: Training RFR Deadline Extension
_______________________________________________________________________________
 
This is to notify you that the Executive Office of Health and Human Services, Office of Medicaid (MassHealth), has extended the deadline for the Request for Responses (RFR) for Training, Coaching and On-going Learning Support for Intensive Care Coordination and Caregiver Peer-to-Peer Support Services for the Children’s Behavioral Health Initiative. 
 
The decision to lengthen the deadline for this RFR was made to allow bidders additional time to develop their submissions.  Key dates for this solicitation have been amended as follows:
                       
Original Schedule Amended Schedule
RFR Issued 3/11/2009 3/11/2009

Questions Due 3/18/2009 4/1/2009

Letters of Intent Due 3/25/2009 4/8/2009

Bids Close 4/8/2009 4/23/2009

Award Date 5/4/2009 5/18/2009

Contract Start 5/26/2009 6/8/2009

                                               
The RFR can be found at the Commonwealth’s procurement website by browsing open solicitations from the Executive Office of Health and Human Services, searching by the solicitation number (9LCHHSTRAININGCBHIRFR), or by searching keyword “CBHI”.
 
Thank you for your continued interest in the Children’s Behavioral Health Initiative.
   
CBHI
Children’s Behavioral Health Initiative
www.mass.gov/masshealth/childbehavioralhealth
email us:cbhi@state.ma.us

Early Child Mental Health

Must be Spring;  much stuff is blooming around here.  From the American Academy of Pediatrics:

Partnering to Address Mental Health Concerns in Early Education and Child Care
The Recording is now available!
Thank you to those of you who participated in the American Academy of Pediatric's Webinar: Partnering to Address Mental Health Concerns in Early Education and Child Care. We would appreciate receiving your feedback by completing the survey:
If you were unable to attend the event, the recording has been posted, along with the PowerPoint and a complete resource list. We hope you find these helpful!
 
If you have any questions, please contact Renee Jarrett or Aldina Hovde.

 I am very sorry to have missed the first meeting of the Children's Behavioral Health Advisory Council on Monday morning (this is the oversight body created by Chapter 321, and will be a driving force in the coming system change);  I was seeing patients (which is also a good thing).  I haven't spotted anything in the news about the meeting- if someone was there, let me know how it went!
 

Academic Pediatrics and Children's Mental Health

 I couldn't be happier to see the this month's issue of Academic Pediatrics hit the 'stands' this week, with two important contributions to the literature on children's mental health. First, Guevera et al looked at the importance of co-location as a facilitator of mental health consultation.  It is a survey study, with all of the limitations of a survey, and yet found two really interesting things:  only 17% of those surveyed had on-site consultation available, but those folks were 6.58 times more likely to consult a mental health worker.  (They also found that the busier practitioners were less likely to refer)   This work implies that we need to encourage co-location if we want collaborative practices.  Next,  two important articles about health disparities.  Zuckerman et al  found looked at household language and parental perception of the risk of developmental delay-  they found that parents who spoke primarily Spanish were far less likely to perceive a developmental problem in their children (when adjusted for gender, age, family poverty status, insurance status, parental education of survey respondent).  The authors can't tell whether this means that there are fewer developmental problems in the Latino community, or if the parents in that community are less likely to be concerned about them;  clearly that distinction will have a major impact in how we design our systems.  Finally Coker et al looked at utilization of services in black and white-  African-American kids in the 5th grade were much less likely to use services than were whites, although the problems like ADHD, ODD, conduct disorder and depression were present in both groups in equal measure.  As stated in the accompanying editorial, 

Understanding the reasons for lack of engagement of certain groups that have been traditionally disenfranchised is not simple. Strengthening the therapeutic alliance in primary and specialty care may afford unique opportunities for recovery.

Nice job, Academic Pediatrics.

Full disclosure: As Treasurer of the Academic Pediatric Association, I chair the Journal Committee that provides oversight to Academic Pediatrics, a small but increasingly useful member of the Pediatric journal community.