Haven't We Been Here Before? The Budget AGAIN

Matt Noyes does such a great job of wording these alerts, I find it easier to cut and paste them.

Help Protect Children's Mental Health in the Senate Budget

 

On Wednesday, the Senate Ways and Means Committee released its budget proposal for FY 2010.  Unfortunately, there are significant cuts to programs that provide vital services to children with mental health needs.  While we recognize the difficult economic and financial situation the state is faced with, it is important that we preserve the gains we have made for children with mental health needs.

In particular, the Children's Mental Health Campaign is concerned with three specific line items:

• Behavioral Health Consultation for the Department of Early Education (3000-0675): line item eliminated.  
  
• Child and Adolescent Mental Health Services (line item 5042-5000): funding reduced by $3.4 million.  
  
• Children's Behavioral Health Initative / Rosie D. (4000-0950): underfunded by $25 million.
  

You can help!

Please call (and ask your networks to call) your State Senator to ask him or her to:

• Please cosponsor and support Senator Jen Flanagan's amendment to restore the line item and $1 million in funding for Behavioral Health Consultations to DEEC.  These consultative services have been instrumental in reducing the number of suspensions and expulsions from preschools, and in dramatically reducing subsequent special education costs in elementary schools.
  
• Please cosponsor and support Senator Karen Spilka's amendment to restore $3.4 million for Child and Adolescent Mental Health Services.  These services are vital to facilitate the early identification and treatment of mental health needs of young people.  Early identification is vital for successful treatment.
  
• Please cosponsor and support Senator Jen Flanagan's amendment to restore $25 million to the Children's Behavioral Health Initiative (Rosie D.).  The full implementation of CBHI is key to ensure that Medicaid-eligible children with severe emotional disturbance are able to access community-based care.  
  

You can find your State Senator by clicking here.  

Please activate your networks now!  The Senate will take up budget amendments next week

Another Conference Call: Today

Reminder: CANS Conference Call Today at Noon

If you use the Child and Adolescent Needs and Strengths (CANS) tool, you are encouraged to join CBHI this Friday at noon 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 Kirk MacAulay 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: Friday, 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 last 30 minutes of the call, questions can be forwarded in advance to CBHI@state.ma.us .

The meeting is on: What's up with the CBHI? (Updated)

This description of our recent session does not capture all of the richness of the discussion; these impressions are mine, and reflect my conscious and unconsious biases in this matter. The nice thing about a webblog is that I can edit it, to reflect your comments- PLEASE append your thoughts, corrections or disagreements as comments to enhance our discussion and understanding of this complex matter. David

The meeting was well attended-  clearly the cookies were the draw.  Jack Simon began by asking is the 15 or 20 attendees how much they knew about the lawsuit and what we would want to talk about;  the group all said that they were quite knowledgeable about the lawsuit and wanted to move to a discussion of what is going on.  We began with a disclaimer; everything is in flux, all of what we are doing is in response to a court order and many of the details are subject to that negotiation.

First, Jack reviewed the revised timeline:

1)  Intensive Care Coordination, Mobile Crisis Intervention and Family Partners are going into effect on June 30, 2009.

2)  The other services will be phased in over the next 5 months.  While the final Federal approval of the State Plan Amendment is not done, the folks at the CBHI believe that all of the other services are likely to be approved (maybe not  Crisis Stabilization Services, but the rest seem to be on track).  We will know for sure when the Federal government releases its response.

Intensive Care Coordination will require a determination of "SED" status.  Each of the other services will have a performance specification and a set of medical necessity criteria, which are currently being developed, negotiated, and  will all be publicly available.

Some of these "new services" are really new;  some will actually look like things that we already have:

• In-Home Therapy looks a lot like our current FST program, but will last some of the "crisis" component of the current FST programs.  He thinks this will be very useful for troubled adolescents.
• In-Home Behavioral Services is different.  It is conceptualized as specifically oriented at behaviors that have not responded to "center-based" behavioral therapy.  He sees this as working for kids with specific problems like head banging, that needs operant conditioning.
• Therapeutic Mentoring Services:  This a new, different and not clear about how this will work.

****  I lost internet access for a while/ some text was lost in translation********

If memory service, my internet access failed during a discussion of how the new emergency services will work.  Jack expects that families will really value the way in which that 72 hour assessment will help them to avoid long delays in the emergency room.

As far as eligibility,  Jack told us that they have been collecting the CANS data from across the State, and they were surprised to see that 90% of the CANS done so far show a child meeting criteria for SED status.   It seems a pretty low bar to actually qualifying for all of these services, and suggests that there will be a whole lot of ICCing going on.

In Worcester County, Families and Communities Together (Community Healthlink (CHL) and LUK (I can't find an explanation for the abbreviation) are managing Worcester East, West and North CSA contracts.  Youth Opportunities Upheld (YOUInc) is handling South Worcester County.   These CSAs will be providing a “wraparound” model, developing a family centered plan that helps the family set and meet goals that they set over the course of the year.   CHL and LUK plan to start with 100 slots in Worcester (2 sites) and 30 slots in North County (3 sites in Fitchburg and .  They hope to subcontract with smaller, community-based organizations throughout the county.   YOUInc is planning to start with space in Southbridge, and looking of space in Webster.  Paul Carey is running the program, based on his experience in the Family Networks Program, a DCF based program that uses the CANS to support a strength-based approach to families.

CSA Trainings on "wraparound" are happening at present;  one of our participants was inspired by the degree of expertise that is already present in the State.   Jack thinks that Central Massachusetts actually has a leg up on the process, because of our experience with the COC program.  He also thinks that the CSAs with be working with   a population of kids with a broader spectrum of problems, not all of which will be as severe as the kids in the various pilot programs such as MSSPY and CFFC. 

Questions were raised about the “kids under 5”, many of whom don’t meet the SED criteria, and where we can send them for evaluation and treatment.  Several of us saw that as a gap in services.  Jack saw one of the functions of the CSA as trying to identify gaps in the services in the area, and that there will be a committee to interface the CSA with the community.  We had some discussion of the need for these committees to have some control over the local process.   We also spent some time discussing the process for getting informed consent for the sharing of CANS information, which is difficult and problematic.  Some families don't want to sign the consent to share information;  Jack reminded us that we should focus on getting the families services that they need even if they don't sign the release.

Jack remains optimistic;  he  thinks that the CSAs that will be successful are the ones that give their community partners and family partners a level of control within the system, and the ones that operate from an expert point of view will be less useful.

The impressive thing about the discussion was the degree of focus on the process, on the degree of cooperation that this going on within the State.  A lot of concern about “where all of the people are going to come from”.   They are doing career forums and other mechanisms for getting the word out about these services.

What does the system need?

1)  Referrals:  In Worcester and North Worcester County, referrals should go through the developing Families and Communities Together CSA at 508-856-5223

2)  Community Advisory Group:  Getting a group together to provide advisory services will be a challenge.

This whole thing is remarkably complicated;  the state is doing a great job of facilitating this complex process.

--------------

Right after I wrote this, I got my monthly (sort of) newsletter from the Center for Public Representation.  You can access it here.  They posted the definitions and specifications for the various kinds of services to to be offered, and the "medical necessity" criteria for each service.

All starts in 45 days.

General Membership Open Meeting Today

Greetings, Members of the Worcester Mental Health Network:

I am typing this e-mail on a beautiful spring day, thinking how am I going to convince people to come to our General Membership meeting at the Central Massachusetts AHEC on 37 Harvard St., Worcester MA on Wednesday, May 13th at 4 PM.  Our guest will be Jack Simon of the Children’s Behavioral Health Initiative, who will be filling us in on what is going to be going on when the next phase of reform hits in July, with the unrolling of the CSAa and the Wraparound services.  We have a number of questions that we are hoping he will address, most of which are outlined below.  If you have others, leave then on the blog.

• - How is this going to work REALLY?  What are you hearing from different parts of the State?
  
• - How are we going to get all of those people in the room?  Timing and transportation will be very challenging.
  
• - Small caseloads- how do we keep it small? The caseloads planned are higher than what are usually seen in the Wraparound model.
  
• - How is the training going to be done?  
• The clinicians need to be able to work at various levels of service within the system, in order to assure continuity of care.  Staffing and supervision will also be remarkably tricky.  How can this be done within the budgeted resources?
  
• - How can the ICC coordinate with the other teams (IEP, DCF, Court)?
  
• - How does the CANS fit it into all of this?
  

If the strength of our speaker is not sufficient to bring you to the meeting, then I promise that, in addition, there will be cookies.  Hope to see you there.

I'll update this later, to see how our discussion goes.

Is half a "Wrap" better than none?

We will be chatting with Jack Simon tomorrow about the Rosie D. implementation, and I am certain that many issues will be raised.  One, however, was raised today in an e-mail, and I wanted to reflect on it a bit.  One of our colleagues, who cannot be at tomorrow's meeting, wrote:

As usual, I can’t attend – I’ll be at [away]...  but I want to make a couple of comments, just in case you might find them useful. ... I’ve been going to a lot of meetings about the CBHI.  In that process I’ve learned there really won’t be true wraparound services – not a full wrap program.  And as of a couple of weeks ago, the state still hadn’t completed negotiations with the feds about what services will be supported by Medicaid.  I believe that’s still up in the air.  The CBHI folks I’ve met with are optimistic, but it’s not a done deal.  As I understand it, the agreement with the plaintiffs is that the state won’t have to provide any service that isn’t covered by Medicaid.

My instant reply was "Isn't half a wrap better than none?"  (I considered "A half-wrap in hand is worth two in the bush", but it didn't flow).  Our colleague is correct:  what we have been authorized to do so far is to provide Intensive Care Coordination.   Family Partners and Mobile Crisis Services,  Behavior Management and Therapeutic Mentoring; In-Home Therapy; and Crisis Stabilization have not yet been approved as services by CMS, and can't really start until they have been.  So, how does an agency plan to implement these services without that approval?  And what does that do to the effectiveness of the wraparound model of care?

I think that the short answer is "We don't know".  The effectiveness of the model is not well established despite it's popularity.  In a recent article in the Journal of Behavioral Health Services and Research, Bruns, Sutor and Leverantz-Brady wrote:

"The wraparound research base is still “on the weak side” with respect to utilization of rigorous designs. Nonetheless, results of evaluation studies, success stories from individual communities, and clear popularity with communities and families have led to wraparound’s inclusion in two Surgeon General’s reports, and the discussion in the research literature of its integration with evidence-based practices."

Popularity with families and communities is the key to the political success of this program and the key to that success is the relationships built between the treatment team and the family.  So, as long as the program has the ICC situated to build those relationships, than I really do believe that half a wrap is better than none.  Way better.

Speak Now for Kids: A Note from a Colleague

Hello!
By now you've likely heard of the Speak Now for Kids campaign, a movement to raise our voices for children's needs in health care reform.  It is a really well done campaign - very tech savy.  For those of you involved in residency training it makes a great AM or noon talk to - they even have slides you can use.  So please do this - we have until May 22nd.  I've drafted something here you can tailor/forward to your colleagues (and friends) asking them to do the same:  

I am writing with a great, EASY way to advocate for kids in the health care reform debate going on in Washington DC as I write.  Please join over 2,300 people who have raised their voice on this issue - pediatricians, moms, and kids themselves.  

Speak Now for Kids, is a campaign brought to you by National Association of Children's Hospitals, in partnership w/the Children's Defense Fund, American Academy of Pediatrics, March of Dimes, Children's Health Fund and First Focus.  Just go to http://www.speaknowforkids.org/  to make your voice heard, leave a testimonial, upload a video, find things to add to your FaceBook, ways to Twitter, etc.

If you are looking for inspiration and want to see what others have said go to for the "Dashboard" of this exciting movement where you can see state by state who is saying what. www.speaknowforkids.org/report.php 

Best, Lisa

Lisa J. Chamberlain, MD, MPH
"An ounce of action is worth a ton of theory." Engels
Assistant Professor of Pediatrics
Stanford School of Medicine
Lucile Packard Children's Hospital
PS.  In case you have any doubt that the time is now, take a look at the NY Times Health Blog here.  The politics are lining up in a really interesting way.

Sometimes Things Actually Work Out

The summer camp/ kindergarten/4th/7th/10th grade physical exams started up last week, bringing back a number of children that I don't see very often in for examination.  That is, of course, the very group of kids that we thought would be most in need of screening when this all began, right?  So, one morning last week, I went into to see a 10 year old boy in for his annual physical.  When I looked in his chart, I saw that we had last seen him in January 2008, when his PSC scored a 31 and he was noted in the chart to be in need of an ADHD evaluation due to poor school performance and high energy behaviors.  His mother had some troubles, as had his older siblings, and we did refer him to one of the local counseling agencies.  In the chart, it appeared, he had had one appointment with the therapists, but no more and he had had never made it back to us for a pschopharm evaluation.

My memory is sometimes faulty, but I quickly realized that the father in the room was the father on one of my other patients, and that this patient has been placed in foster care.  The father was a model foster parent; calm demeanor, clear rules, fair administration and- well, while to lad is still having some difficulties, he is now a 21 on the PSC and the school has finsihed an assessment that this young man needs help, but should be able to make it in the world.  He was a charming boy, talkative about everything, enjoying school, eager to see his mother and his biological family and really enjoying his life in foster care.  He had blossomed.  The problem behaviors of last year had responded well to a change in environment;  therapy and external rules thad obviated the immediate need for medication, although genetics and adolescence may bring us to reconsider those ideas.  He really likes is "foster brother", a patient of mine who, prior to this change had been an only child.

A cure- doubtful.  But a lot of times, a change in environment is as helpful as psychopharmocology.  I thanked the father for taking in this wayward soul, and his response was, while this may seem like altruism, in truth is was something that they could do relatively easily and that they were happy that their biological child had a "brother" with whom to play.

Nice when it works out, even if the CBHI can't claim full credit for the outcome.