Speak Now for Kids

A group of pediatric advocacy organizations are collecting stories about about kids and how the system is going to affect them. Please click here to leave your testimony. This is what I wrote.

For the last 18 years, I have been privileged to work with parents and families in and around Webster MA to create a medical home for children, regardless of the ability of their parents to pay for care. What does that mean? For us, it meant understanding the needs of the communities that we serve, remaining focused on an ideal that is not fostered by our current systems of care and engaging in partnerships with parents, families, community agencies and always with the children. Our goal has been and continues to be to help our children to grow up healthy and that health is more than the absence of disease: emotional and developmental health is as important as physical and dental health. We have aggressively pursued that goal over the years, by engaging with parents in the office, on the telephone, in the schools and even sometimes in their homes. We have created teams and coordinated care, assuring that all those caring for a particular child are in communication with each other. We have started programs: adolescent clinics, Reach Out and Read programs, car seat loan programs, walking groups and school health programs. We have cared for more than 10,000 children and adolescents over my tenure in the practice, and we have helped many through some very difficult times. We want to be able to keep doing this good work. Health reform is an opportunity to address many of the barriers that we have encountered in our struggle to provide a medical home in South Worcester County Massachusetts. Here are a few things that we should do:

1. The system should emphasize primary and secondary prevention, and that needs to be reflected in the way physicians are paid. Well care, immunizations, developmental screening, preventive mental health care, dental care and prophylaxis all need to be covered services, and the conditions that we find in our screening need to be addressed through treatment. 
   
2. The system should encourage for coordination of care, whether through the payment of non-physician staff to coordinate care or incentives to establish electronic links among the referral teams. 
   
3. The system should not intimidate parents who are seeking care, at the front desk, in the exam room, on the telephone or in the room with a physician. Parents have too much as stake to be forced to deal with an inpenetrable system. 
   
4. The system should understand that parents need different things than do adults: time and reassurance on the phone, understanding of perception of pain, a EMR that can take the contact information for divorced parents. 
   

I've been blogging about these sorts of issues for the post 2 years. It will not be easy to build this new system. But we can do it. Yes we can.

Conference Upcoming

Full disclosure:  I am to be the speaker for this event.  Hope to see you there. 

Behavioral Health Screening in the Primary Care Office:

How Primary Care Clinicians Can Help Patients Access the New Children’s Behavioral Health Initiative Services

Sponsored by MBHP, UMass and MassHealth

A free training program for physicians,

physician assistants, nurse practitioners, nurse

midwives, and registered nurses

In December of 2007, MassHealth introduced a new mandate requiring primary care providers to use an age-appropriate, standardized behavioral health screening tool from the list of MassHealth-approved tools when completing the behavioral health component of EPSDT/PPHSD well-child care visits. Once a child has screened positive in the primary care setting, it is important for primary care providers to know about available behavioral health services for children and how to access these services. This training program is designed to introduce primary care providers (physicians, physician assistants, nurse practitioners, nurse midwives, and registered nurses) to the network of new Children’s Behavioral Health Initiative (CBHI) services for children, planned to be available 6/30/09.(* If approved by the Centers for Medicare and Medicaid Services) New services planned to be available* across the state include:

• Intensive Care Coordination (ICC)
  
• Care Giver Peer-to-Peer Support/Family Partner
  
• Mobile Crisis Intervention (MCI)
  

Training Objectives

At the program’s conclusion, the participant will:

• be able to describe the new Children’s Behavioral Health Initiative (CBHI) services planned to be available 6/30/09 (if they are approved by the Centers for Medicaid and Medicare Services) and how to refer to these services;
• be familiar with the network of providers across Massachusetts available to provide these services to children who need them, particularly the new

Community Service Agencies (CSA) for your

practice area; andSpeaker

David Keller, MD, is Clinical Associate Professor of Pediatrics at the University of Massachusetts Medical School and Medical Director of Family Advocates of Central Massachusetts, an HRSA-funded, medical-legal partnership for children in Worcester County. Dr. Keller is a regional facilitator for the American Academy of Pediatrics’ CATCH (Community Access to Child Health) program and was recently elected Treasurer of the Board of the Ambulatory Pediatric Association. He served for eight years as the Pediatric Director of the Community Faculty Development Center, a 15-school collaborative program for the development of community-based clinical faculty in New York and New England, and he is currently serving as facilitator of the Community Pediatrics cohort of the Pediatric Academic Societies Educational Scholars program. His work in faculty development and advocacy training has been presented at national and international meetings and published in peer-reviewed journals. For the past two years, Dr. Keller has been working with Health Law Advocates and the Worcester Mental Health Network through a Physician Advocacy Fellowship by the Center for Medicine as a Profession to improve access to mental health care in Massachusetts. He has been blogging his experience on the web site “Rosie D. and Me” at http://olddockeller.blogspot.com.

Training Dates and Locations

West Springfield - Wednesday, June 10, 2009:

Clarion Hotel and Conference Center of West Springfield

1080 Riverdale Street

West Springfield, MA 01089

www.wsclarionhotel.com

Waltham - Tuesday, June 16, 2009:

Massachusetts Medical Society

The Conference Center at Waltham Woods

860 Winter Street

Waltham, MA 02451

www.conferencecenteratwalthamwoods.com

TO REGISTER

To register for this free meeting please fax this form to Deborah Stark at (617) 350-1982.

If you have questions, call (617) 350-1956.

Please register no later than five days prior to each training date.

I (we) will attend:

• June 10 - West Springfield *
  
• June 16 - Waltham *
  

* Continental breakfast served 7 - 7:30 a.m.

Program 7:30 - 9 a.m.

Please print legibly.

Attendee name(s):  _______________________________

_______________________________

_______________________________

Practice name:  _______________________________

Address:_______________________________ 

 _______________________________

_______________________________

Phone number:  _______________________________

Fax number:  _______________________________

E-mail address:  _______________________________

Visit the Children’s Behavioral Health Initiative (CHBI)

web site:  www.mass.gov/masshealth/childbehavioralhealth

understand the documents that primary care

clinicians will receive from certain behavioral health

providers, such as the Child and Adolescent Needs

and Strengths (CANS) tool and the Individualized

Care Plan (ICP).

AHRQ Report Out Today

AHRQ released its reports on disparities and quality today.  My favorite tidbits included the finding that "Of people who needed treatment for illicit drug use in 2006, only 20.0% of adults ages 1844 and 11.2% of children ages 1217 received it. These rates remain significantly unchanged from 2002. " and that even using a "relatively low standard against which to assess quality of mental health care", few adults with major depressive episodes received adequate treatment.  I didn't see any markers of children's mental health care in the quality report, other than the substance abuse stuff.  Even with low standards, we aren't doing very well.

54 Days Until the New Order in Children's Mental Health

Lots going on in the world these days, and returning from Baltimore has found me with a full desk and many details to which to attend.  The CSAs are really getting ready to roll out; people are establishing their main offices and developing their wraparound teams all over the state.  I have been speaking with several of the people involved in that process;  we will have a chance to talk with Jack Simons next week in Worcester (see the events calendar).   The most interesting part of the process, it seems to me, is how we are going to engage families in this paradigm.  I suspect that many will not want "strangers" in their home.  My experience with patients in Family Stabilization is that about 50% of the time decline services when push comes to shove.  How do you get past that, to give the intervention a chance to work?

Many families of children with serious emotional disturbance has lived for a while with the notion that they are to blame for their child's behavioral outbursts.  Won't they be concerned that, with a bunch of professionals in their home, that the Department of Children and Families will be there too?  That notion runs completely against the central tenets of wraparound.  Family engagement is at the center of the process and that engagement in general has to be voluntary.  One therapist with whom I spoke assured me that there services were going to be voluntary and that it would take a lot more than simple refusal of services to get a family reported to the Department.  The hope is that the Care Coordinators and the Parent Partners (still not approved by HHS) will be able to make this all happen.  Clearly, this work will require families and providers to rethink the paradigm.

The Meeting: Mental Health is not as prominent this year

Meetings have a number of hot topics on which they focus on any given year.  Last year, I live blogged from the Pediatric Academic Societies meeting in Hawaii (OK, I vacationed a little bit afterwards).  There was a lot of talk and a lot of activity about Children's Mental Health.  This year, not as much.  The hot topics seem to be health reform, dealing the flu epidemic and overweight.  The debates spoke of health care reform and reimbursement; and, while everyone insists that access includes mental, dental and physical health, it is not clear to me that we parity is good enough.

Today, there were some posters on mental health, and this afternoon some platform sessions.  Let me tell you about them.

1)  Colocation of mental health workers with primary care:  Works great, when you can afford it.  They were grant-funded, and have yet to find the model that will let them carry on.

2)  TV and Behavior Issues:  A large cohort study of 2.5 - 6.0 y/o children from LA (many Latinos)  showed that attention and hyperactivity wasn't associated with TV exposure, but the conduct problems were associated with TV exposure, including "background" TV.  Comment from the floor:  Television is called a "medium" because it is neither rare or well done.

3)  The ethics of science:  One of my colleagues, Mark Schuster from Children's, gave a wonderful speech on the ways in which science has allowed itself to be politicized, leading to public mistrust of the analysis of data.  He mentioned the Biederman affair, discussed earlier on this blog.

So, this meeting was more about health reform than mental health reform.  Still worthwhile.

Going home tomorrow-  wonder what I have waiting for me.

More from the CBHI: Can you CANS?

Next CANS Conference Call

If you use the Child and Adolescent Needs and Strengths (CANS) tool, you are encouraged to join CBHI on Friday, May 15, 2009 for a conference call to discuss the newest version of the CANS on-line application.  Jack Simons, Assistant CBHI Director, CBHI Business Analyst Mary Jane Iltz and staff from the Virtual Gateway will be available to discuss using the newest version of the CANS on the Virtual Gateway, where to find instructional resources and how to get the most from the updated CANS.  We hope you will join us for this informative hour.

CANS Conference Call Information

Date:                May 15, 2009

Time:               12:00 pm - 1:00 pm

Phone:             866-565-6580

Passcode:        9593452  

Please call at least 5 minutes before the conference call begins.  In addition to asking questions "live" during the call, questions can be forwarded in advance to CBHI@state.ma.us.

Sharing the CANS: From the CBHI

   So, one of the potential problems in the new world order is one of the oldest problems in caring for children with mental health:  sharing information.   The CANS is a uniform system of data collection, a very rich source of information that should be shared among the various agencies working with the family, and the Virtual Gateway makes it possible for many people to look at information with killing trees to feed the copying machine.  You can share the information, according to the CBHI, with a simple consent form:

 

Important Info: Entering the Full CANS with MassHealth Member Consent on the Virtual Gateway 
Many providers are now entering the full CANS tool, with member consent, into the CBHI application on the Virtual Gateway.   Please remember that when you obtain consent, you need to do three things: 
1) Print a Consent Information Sheet from the application; it will automatically print the correct member name, member ID, provider agency name, and provider agency ID on the sheet.
2) Fax the two-page signed consent form using the Consent Information Sheet as your fax cover sheet (do not use your standard cover sheet). You can fax a batch of forms at once, if you want, as long as the batch consists only of three-page sets (the Consent Information Sheet followed by the two-page consent form). Fax to EOHHS at one of these numbers: 617-210-5565 or 617-210-5568.
3) Retain the signed consent form for your records.
If the member declines consent, you do not need to fax.
For more detailed instructions, see the CBHI Certified Assessor Reference Guide at the CANS page of the CBHI website.

 Works great, as long as you have parent who can give consent to share information.  But what about the parent who doesn't want the information shared? What if one agency knows about the abusive husband, but another doesn't?  What if the dangerous person actually can get to the Virtual Gateway?  One hopes that these scenarios don't come up too often.  Still, it is a great start to the sharing of information to help children do better.