Thank for your help: My Fellowship is over.

The woods were dark and deep (and wet),

And I must have some sleep (you bet).

Last week was my reintroduction to clinical practice- as I mentioned when I started this thing, I am a primary care pediatrician who has been given an extraordinary opportunity by the Center on Medicine as a Profession to spend a significant chunk of my time exploring ways in which a primary care pediatrician can advocate for improvements in the children's mental health system. I have worked with coalitions, written articles and op-ed pieces, given testimony, organized "events", hosted meetings, given talks on children's mental health, all with the intention of building a better system in Massachusetts (and eventually the world). Along the way, I have come to understand a few things:

1) There is a lot about children and mental health that we don't know.

2) Families are the key to managing children with mental health issues.

3) Medications are useful, but not an answer without the rest of the system.

4) This is going to be difficult, and take many years to get right.

In my work, I've gotten to work with advocacy groups like HLA and PAL, clinical groups with the UMass MCPAP team and the WMHN and state-sponsored groups like CBHI and MBP. All have been helpful. I have watch a bill make it through the State Legislature, another go through the Federal one, and watched as dedicated public servant drew up the blueprints for a new system out of whole cloth. I think that, on the whole, I have contributed positively to the process.

Tomorrow, my funding is done; as of July 1, I am back to being a full-time pediatrician, cranking through the patients and trying to do right by them. Of the 25 kids I see most days, 3or 4 will have serious emotional disturbance. Half of those will already be in some sort of treatment; the rest will need help getting there. I'll be trying to work with CSA on this; in the long run, however, that is not going to be good enough. We need the promise of the CBHI to be fulfilled and that requires that each of us think hard about how to help the CBHI achieve its maximal potential. With that thought, I close. Thanks for your help; now the real work begins.

Oh, don't think that you've heard the last of me- I will keep posting. Probably not as frequently, but there is still much to do.

Tomorrow

I was poking around the Massachusetts Behavioral Health Partnership's website, and would recommend those of you who want to see what happens next to the Massachusetts Behavioral Health Partnership website, which has assembled a lot of useful information in avery usable format.  I particularly like the list of contracted providers (here) and the revised structural slide, which adds complexity to the already complex system.  Good luck to the boots on the ground!

A respite of sort: Two days until CBHI

So, I just typed in a blog entry on my i-phone, because I wanted to see if it work, and when I pushed the publish button- blip- it disappeared.  Frustrating.  Let me try again:

In a little under 48 hours, the final phase of the Children’s Behavioral Health Initiative will be implemented with the start of the 32 CSA contracts across the Commonwealth.  Personally, I don’t expect everything to change at once, but, having spoken with a number of the people doing this work, I do expect to see some changes in the way in which services are delivered in Massachusetts.   It will not be easy- change never is.  But it will be interesting.

I have heard a lot of people trying to frame the various new services in terms of what has gone before.  If that is all that we are able to do after the massive political effort that has been mounted in the Commonwealth over the past 4 years, I will be disappointed.  I thought that, at this juncture, I might put forth some ideas about how I will be looking at the CBHI to mark success.

1)  Are families actually engaged in the process, and is that engagement strengthening their resilience?  The bad stuff that we associate with mental illness, such as  suicide, homicide, crime and homelessness, is all associated with people who live outside of the protective bonds of families.  “Protective factors” such as strong families have been shown to help to prevent those outcomes.  If we are not, at a bare minimum, strengthening families, then this effort has been in vain.

2)  Are the interdisciplinary teams forming, communicating and collaborating in the care for children with SED, and does that collaboration affect the type and quality of the care delivered?  It has been an article of faith among us that collaboration will lead to more efficient allocation of resources because of the avoidance of duplication of effort.  We should test our faith;  does it actually work in the real world?

3)  Are children with SED better able to function in their communities?  Whether school, daycare or the YMCA, this initiative needs to be about integrating children into the community.  Our success should be measured by some sort of community integration metric;  otherwise we are just creating a new set of institutions?

4)  Have we created, in the hearts and minds of the Commonwealth, a sense of parity between children with physical handicaps and children with mental illness (and children without any of these things)?  This is a truly long-term goal, to reduce the stigma of mental illness to the point where children enter treatment early and are well managed before they develop SED.  I have watched with dismay that the word SPED (special education) is often thrown about the schoolyard as an epithet.  We cannot allow the same to happen to SED.

So, perhaps I am setting the bar a bit higher than “compliance with the court order”, but we really should be looking at the data that rolls through the CBHI to see if these things are happening.  Perhaps the Child Behavioral Health Research Institute envisioned under Yolanda’s Law can do this.  When we have de-stimatized family-centered interdisciplinary care that allows children with serious emotional disturbances to function in the community, I will think that we have done something meaningful for the lives of children.

They are coming: A word from the Partnership.

I've been in the office 3 days this week, and in the Berkshires 3 days;  I've identified at least 6 families that have Masshealth, a child with SED and a need for ICC.  One has already told me that they can't get in to their local agency for the intial CANS evaluation.  In other words, it begins.   Here is what the CSAs are going to look like, according to the MBHP folks.

A Community Service Agency (CSA) is a community-based organization whose function is to facilitate

access to, and ensure coordination of, care for youth with serious emotional disturbance (SED) who

require, or are already utilizing, multiple services or who require or are already involved with multiple

child-serving systems (e.g., child welfare, special education, juvenile justice, mental health) and their

families. In total, there are 32 CSAs across Massachusetts: 29 that provide services in the geographic

region consistent with the current 29 service areas for the Department of Children and Families (DCF)

and three culturally and linguistically specialized CSAs to address the needs of specific cultural or

linguistic groups in Massachusetts. Geographic CSAs and specialized CSAs working in overlapping

areas are expected to collaborate and partner in ways that strengthen services to youth and families.

The chart below is intended to assist potential referral sources, including families, in identifying and

selecting an appropriate CSA to meet their needs. Consistent with the Wraparound principle of family

voice and choice, families may choose from any CSA based on their needs and are not limited in using

the CSA in their geographic area. For the 29 geographically-based CSAs, towns are listed

alphabetically, followed by the (DCF) area, the CSA, the site(s) where services will be delivered, the

referral phone number, and other relevant information if available (i.e., contact person, e-mail address).

A town is assigned to a CSA based on the DCF area office that covers that particular town.

Additionally, the three specialized CSAs, which have tailored their services to engage and serve the

unique needs of their specialized populations, are listed separately at the bottom of the chart, identifying

the towns each covers, the specialty population, the site(s) where services will be delivered, the referral

phone number, and other relevant information if available (i.e., contact person, e-mail address). An

asterisk (*) next to a geographically based CSA town indicates the town is also covered by a specialized

CSA.

If you have questions regarding this Alert, please contact our Community Relations Department at

1-800-495-0086 (press 1 for the English menu or 2 for the Spanish menu, then #3 then #1 to skip

prompts), Monday through Thursday, 8 a.m. to 5 p.m., and on Fridays from 9:30 a.m. to 5 p.m.

Learning About Change: CBHI to Present at 5 Massachusetts Health Care Training Forums in July

From the CBHI:  

Are you or your staff interested in learning more about CBHI, screening and assessment improvements for MassHealth-enrolled children and youth or the new behavioral health services that will begin next month?  Key CBHI staff members are scheduled to join other topic speakers at the upcoming Massachusetts Health Care Training Forum (MTF) series being held at different sites around the state in July.  Click here  for a list of dates, a registration link and to find a forum location near you.
Note: The Massachusetts Health Care Training Forum (MTF), formerly called the MassHealth Training Forum, is a partnership between MassHealth and UMass Medical School. Their quarterly meetings are designed to bring accurate and timely information related to MassHealth (as well as other public assistance programs) to health care and community agency staff serving MassHealth members, the uninsured, and underinsured. For more information about July’s forum, and others, call MTF at (508) 856-4306 or visit their website.

From the MCHB newsletter

Got this on my e-mail today. Interesting, and possibly useful to our task.

ISSUE BRIEF EXAMINES FAMILY PERCEPTIONS OF MENTAL HEALTH NEEDS AMONG
CSHCN
Mental Health Needs of Low-Income Children with Special Health Care
Needs (CSCHN) summarizes a study that compared the prevalence of mental
health problems among CSHCN to family perceptions of mental health needs.
The issue brief focuses on what was learned from a Child Health Insurance
Research Initiative (CHIRI) survey of families of CSHCN enrolled in Medicaid
receiving services in six primary health care clinics in an urban Midwestern
city. Family perceptions of their child's mental health needs were compared
with the results of the Child Behavior Checklist, a standardized tool that
uses parent report to assess emotional, behavioral, and social problems in
children. Data on the percentage of health and mental health problems in
CSCHN in Medicaid and family perception and need for mental health treatment
by age are provided. Policy implications are also discussed. The brief is available at http://www.ahrq.gov/chiri/chiribrf9/chiribrf9.pdf.

Pondering NPR While Commuting from the Woods

An odd schedule this week; I am seeing patients while camping near that beautiful view you all saw in yesterday's post. My first 3 patients did not come in for their appointments, and I have time for a quick blog entry on one of the stroies that I heard on NPR which cruising (at the speed limit) down the Massachusetts turnpike morning.

You can hear the story here, I will sumarize it for you. Patients, particularly complex elderly patients, are finding that they need an advocate within the system, who understands their needs and desires and understands the multifaceted health care system well enough to guide you through the system. They highlighted two models- one was volunteer retired physicians and nurses who work with hospitalized patient and are able to ask the questions in such a way that the system would respond. The other was what I would call "concierge nurses" who coordinate care for folks in assisted living, helping to keep them out of the hospital. The story ends by pointing out that noone wants to pay to support these services, and suggested that we need data to justify this fairly self-evident cost to the system.

Both of these groups of people do what your primary care physician no longer has time to do; know you so that you can be known. The similarities to the impending ICC program seemed to suggest a similar trap lay ahead for us. As we roll out the CSAs, we need to be sure to collect the data to justify this cost, as we certainly believe that it is part of the cost of doing business.

Patients are here- got to go.

(And I just added a picture of the swollen stream near our campsite. )