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.