Children and Antipsychotics

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!

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

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.

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.

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?

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

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

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

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

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

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

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?

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

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.

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.

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!

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)

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.

"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

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 13 and 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.

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

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.

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

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.