ROSIE D. V. ROMNEY
description
Transcript of ROSIE D. V. ROMNEY
ROSIE D. V. ROMNEY
Transforming the Medicaid Children’s Mental Health System
Transforming the Children’s Mental Health System
I. The Litigation – Purpose and Outcome
II. The Pathway to Home-Based Services
III. The Status of Implementation
IV. Realizing the Promise
of Rosie D. v. Romney
The Problem in Communities
Inadequate behavioral health services:
- Children stuck in ER’s or institutions– Limited early identification of children in mental
health needs– Services without sufficient intensity or duration to
meet children and families long term needs– Fragmented and disorganized service system
with no single point of care coordination
The Problem in Schools
Unaddressed behavioral health needs underlying orexacerbating students’ struggles in school:
• Children suspended more than 10 days had average of three mental health diagnoses (Rappaport 2006)
• Students with mental health needs had a much higher rate of absenteesim, tardiness and lower grades (Gall et al., 2000)
• Re-occurring hospital admissions creating interruptions in educational services
• Students left considering more restrictive environments in order to have their social, emotional and behavioral needs met
The Response
The class action lawsuit filed in 2001 to compel provision of intensive mental health treatment to Medicaid eligible children in their homes and communities, thus avoiding unnecessary hospitalization, or extended out-of-home placement
Brought by the parents or guardians of eight children with serious emotional, behavioral, or psychiatric conditions representing a class of Medicaid-eligible children who needed home-based services to be successful in their communities
The Legal Claims
The federal Medicaid program mandates Early Periodic Screening Diagnosis and Treatment – EPSDT – for children under 21
EPSDT mandates screening and treatment necessary “to correct or ameliorate a physical or mental condition”
States must provide this treatment promptly and for as long as needed
The Remedy
1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act
2/22/07 Court orders the State to develop in-home services, including comprehensive care coordination, screening, assessments, in–home supports and crisis services
4/27/07 Appoints Karen Snyder as the Court Monitor 6/18/07 Plaintiffs and Commonwealth begin regular
implementation meetings
New Court-Ordered Services
Access to Behavioral Health Screening Comprehensive Diagnostic Assessments Intensive Care Coordination In-Home Therapy Services In-Home Behavioral Services Therapeutic Mentoring Family Partners Mobile Crisis and Crisis Stabilization Units
Eligibility for Services
Any Medicaid-eligible child (MassHealth Member) who is determined to have a serious emotional disturbance (SED) is eligible for intensive care coordination
SED is defined by two federal agencies which use slightly different definitions
Any child who meets EITHER definition, as determined by the mental health evaluation, is eligible
Federal SAMHSA Definition of SED
From birth up to age 18 Who currently or at any time during the past
year Has had a diagnosable mental, behavioral, or
emotional disorder That resulted in functional impairment which
substantially interferes with or limits the child's role or functioning in family, school, or community activities.
Federal IDEA Definition of SED
A condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance…
Federal IDEA Definition of SED
An inability to learn that cannot be explained by intellectual, sensory, or health factors
An inability to build or maintain satisfactory interpersonal relationships with peers and teachers
Inappropriate behaviors or feelings under normal circumstances
General pervasive mood of unhappiness or depression
A tendency to develop physical symptoms or fears associated with personal or school problems
Co-morbidity and Dual Diagnosis
Children with SED, in addition to any other disabling condition, such as autism spectrum disorders, developmental disability or substance abuse will be eligible for the Rosie D. remedy.
Children who meet medical necessity criteria for the remaining in-home services can be eligible without a finding of SED.
II. The Pathway to Medicaid Home-Based Services
Behavioral Health Screening
Mental Health Evaluation
Referral for Care Coordination
Comprehensive In-Home Assessment
Wrap-Around Team Process
Delivery of Home-Based Services
Screening or Identification
As of January 1, 2008, primary care doctors/nurses must offer voluntary screening for behavioral health concerns at well child visits or upon request, using one of several standardized screening instruments
Parents, state agencies, and other child serving entities can also refer children in need of screening
Children with known conditions can bypass screening and be referred directly to a mental health professional for evaluation
MassHealth will be maintaining data on screenings, referrals, and families ability to access treatment
Mental Health Evaluation
As of November 30, 2008, all diagnostic evaluations will incorporate the Child and Adolescent Needs and Strengths (CANS) survey
The CANS instrument includes a structured interview used to assess and child and family’s strengths and their service needs
State has trained mental health professionals in hospitals, clinics and state agencies to use the CANS, increasing rates and timeframes for conducting evaluation
Intensive Care Coordination
● Located within regional network of Community Service Agencies (CSA)
● Care coordinator works in partnership with family and youth to ensure meaningful involvement in all aspects of treatment
● Facilitates completion of a comprehensive home-based assessment and development of a care planning team including state agencies, schools and other providers
● Preparing and overseeing implementation of a single integrated treatment plan
Treatment Plan
Single plan that is child/family centered Integrates other agency/provider plans Team determines the type, amount, intensity and
duration of home-based services Components of plan include:
– Treatment goals and objectives– Identification and role of specific providers– Frequency, intensity and location of service delivery– Crisis plans
The Values of Wrap-Around
ICC team and in-home providers responsible for maintaining
fidelity to several core principals:– strength-based– individualized– child-centered– family-driven– community-based– multi-system– culturally competent
Mobile Crisis Services
Mobile, on-site, face-to-face response to youth in crisis, available up to 72 hours
Delivered by a clinical/paraprofessional team in the home or other community setting
Designed to assess, de-escalate and stabilize a child in crisis, offering safety planning, referrals and support to maintain the youth in their natural setting
Crisis Stabilization Units
A community-based, staff secure treatment setting offering short term crisis stabilization services for up to 7 days
Designed to facilitate immediate engagement of family/caretakers in problem solving, skill-building, crisis counseling, service linkages and coordination with existing providers
Focused on youth’s rapid return to the community, avoiding a higher level of care
Behavior Management Therapy and Behavior Monitoring
Clinical/paraprofessional team addresses challenging behaviors in the home and community which interfere with youth’s successful functioning
Therapist provides behavioral assessment, develops a behavior management plan with the family and reviews effectiveness of the interventions
Behavior Monitor helps implement the plan, modeling and re-enforcing behavior management strategies in the home and community
In-Home Therapy Services
Delivered in the home or community setting Includes 24/7 urgent response, flexibility in scheduling and
frequency and duration of sessions Works to foster understanding of family dynamics, develop
strategies to address stressors, enhance problem solving and communication skills, identify community resources, address risk and safety planning, offer care coordination
Therapist works with youth and the family on development of specific clinical treatment goals to improve youth’s functioning
May be assisted by a paraprofessional who supports the child and family in day to day implementation of treatment goals
Therapeutic Mentoring Services
Structured one-to-one relationship between paraprofessional and youth, addressing daily living, social and communication skills in variety of home and community settings
Includes coaching and training in age-appropriate behaviors, problem-solving, conflict resolution and interpersonal relationships using recreational and social activities
Delivered pursuant to plan of care and supervised by a clinician, with focus on ensuring youth’s successful navigation of various social contexts, skill acquisition and functional progress towards identified treatment goals
Caregiver/Peer to Peer Support
Available through CSA’s and stand alone providers Structured, one-to-one, strength-based relationship
with parent/caregiver of youth Delivered by a family partner with experience caring
for a child with special needs and utilizing child and family serving systems
Supports caregiver in addressing child’s behavioral health needs by identifying formal and informal supports, offering assistance in navigating child-serving systems and fostering empowerment through education, coaching and training
Appeals
Any disagreements with the MassHealth agency or Managed Care Entity regarding the need for services, the amount or duration of services, or the termination of services can be appealed through the Medicaid fair hearing process
A dispute resolution process will be in place for Care Planning Teams to utilize in the event there are disagreements regarding service recommendations and treatment planning needs
III. Implementing the Remedy
Delivery of Home-Based Services Developing the Service Delivery System Data Collection and Evaluation Monitoring Ongoing Court Involvement Implementation Timetables Challenges to Implementation
Delivery of Home-based Services
Once approved by Center for Medicaid and Medicare Services (CMS), services will be part of Medicaid State Plan, receiving federal matching money
Medicaid eligible youth can access these services regardless of their eligibility category using the MassHealth disability determination process
All services can be provided separately or in combination, and delivered in any setting (natural or foster home, school, community)
The Service Delivery System
Regional Community Service Agencies (CSA) have been selected across the state to provide care coordination as well as family partner services
CSAs may also provide other direct services All Managed Care Entities (MCEs) will contract with
the CSA network, but retain their own UM strategies MCE’s are undertaking workforce and provider
development activities now The Commonwealth will offer wrap-around training
and ongoing coaching to CSA’s and in-home therapy providers
Monitoring and Court Oversight
Court Monitor meets regularly with parties, providers, professionals, and families
Compliance Coordinator guides state efforts Parties meet regularly to discuss each element of
new system Plaintiffs actively monitor all aspects of
implementation Monitor reports to Court about progress and
compliance Court meets quarterly with parties and Monitor
Revised Implementation Timelines
July 1, 2009: Intensive Care Coordination, Family Partners & Mobile Crisis
October 1, 2009: In-home Behavioral Services and Therapeutic
Mentoring
November 1, 2009: In-Home Therapy
December 1, 2009: Crisis Stabilization Units
Challenges to Implementation
Workforce shortages Provider capacity Ongoing training / education Outcome measurement Network development Resources Effective coordination with child-serving
agencies
IV. Realizing the Promise of Rosie D. v. Romney
The Relevance of CBHI reforms The importance of Interagency Protocols Community Involvement in Systems of Care Benefits of Collaboration with Schools Frameworks for Linking Schools and
Community Mental Health Services How You Can Help
Relevance of Reforms
CBHI resources can support professionals and child-serving systems, while improving the experience of and outcomes for Medicaid eligible youth and families ● Schools and educational programs
● Juvenile Justice / DYS diversion programs ● Benefits/Health Law Advocates ● CHINS and child welfare agencies
Importance of Interagency Protocols
MassHealth required by the Judgment to develop protocols with all EOHHS agencies
Necessary to establish expectations, procedures and communication strategies across child serving systems
Intended to address issues like referrals, staff training, Care Planning Team participation, and dispute resolution
Community Involvement in Systems of Care
CSA’s are required to reach out to their communities, including forming and operating regional Systems of Care Committees
Important opportunity for communication and collaboration between various agency and community stakeholders, review of system-level issues impacting delivery of care and fostering of longstanding partnerships
Benefits of Collaboration with Schools
Increased access to mental health expertise and consultation to inform IEP development
Delivery of community-based services in school and after-school settings
Availability to coordinate services across settings and promote generalization of skills
Single point of contact through team and care coordinator
Additional services to support children’s success in integrated programs
Considerations for State and Local Education Collaboration
Provision of information and training on the scope of remedial services, which students are eligible, how to facilitate referrals and opportunities to coordinate educational supports with community-based mental health services
Develop local and statewide guidance on Rosie D. system reforms, including policies and procedures for effective collaboration with parents and community-based behavioral health providers
• Identify and fund infrastructure needed to establish successful linkages with community-based mental health providers and support increased communication and integration of services on behalf of students
Yolanda’s Law: Section 19 Taskforce
Created as part of the Children’s Mental Health Law of 2008
Intended to “…build a framework that promotes collaboration between schools and behavioral health services…”
Implementation plan involves piloting of framework in 10 schools, interim report (12/31/09), a statewide assessment of needs, and final report with recommendations to Governor/Child Advocate (6/30/2011)
Taskforce’s Framework
Leadership Professional Development Access to clinically, linquistically and
culturally appropriate behavioral health services
Effective academic and non-academic activities
Policies and Protocols
How You Can Help
Consider where Rosie D. services could be useful in your work and share those ideas with us
Help us identify best practices and address obstacles
Assist to development of materials/resources relevant to your field
Connect with other agencies/entities in your area who might be interested in training on Rosie D. implementation
Collaborate with Section 19 taskforce members and the Children’s Mental Health Campaign
Additional Information
For more information, go to the Rosie D. website, www.rosied.org. The website contains:– News updates on recent developments.– An extensive library of documents from the case
including decisions, discovery documents, legal memoranda, status reports, and much more.
– A training and events calendar.– Other information designed for families, providers
or other professionals.