ROSIE D. V. ROMNEY
description
Transcript of ROSIE D. V. ROMNEY
Rosie D. Advocacy Training
I. The Litigation – Purpose and OutcomeII. The Pathway to Home-Based ServicesIII. The Platform for Service DeliveryIV. The New MassHealth Service ArrayV. Coordinating Child-Serving Systems VI. The Wraparound Process
The Children’s Mental Health Crisis
Inadequate behavioral health services leading to negativeoutcomes for children, youth and families:
● Children stuck in ER’s or institutions● Limited early identification of mental health needs● Services without sufficient intensity or duration ● Fragmented service system● No single point of care coordination and treatment planning● Inappropriate use of juvenile justice and child welfare systems
to address conduct resulting from lack of behavioral health treatment resources
The Response: Rosie D.
Class Action lawsuit filed in 2001 by the Center for Public Representation (CPR) the Mental Health Legal Advisors Committee (MHLAC) and the firm of Wilmer Cutler Pickering Hale and Dorr
The class action lawsuit sought 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
The Plaintiffs
Brought by the parents or guardians of eight children with serious emotional, behavioral, or psychiatric conditions
These plaintiffs represent a class of Medicaid-eligible children with serious emotional disturbance who need home-based mental health 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 Decision
1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act
8/22/06: Plaintiffs and the Commonwealth submit separate remedial plans after six months of negotiations fail to achieve complete agreement
2/22/07 Court orders Defendant’s plan with Plaintiff’s requested modifications
The Remedy
Judgment requires the State to develop a system forthe provision of behavioral health screening, diagnosticevaluation and specific home-based services ● 4/27/07 Karen Snyder appointed Court Monitor 6/18/07 Parties begin implementation 7/16/07 Court enters judgment including detailed
remedial plan with implementation timelines.
Implementing the Remedy
Designing Home-Based Services Developing the Service Delivery System Timetables for Service Availability Monitoring Activities Challenges to Implementation
Design of Home-based Services
Each service is defined by program specifications and medical necessity criteria
With federal (CMS) approval, services will be part of Medicaid State Plan and receive federal matching money
All services can be provided separately or in combination, and delivered in a variety of settings (natural or foster home, school, community)
The Service Delivery System
Regional Community Service Agencies (CSA) have been selected to provide care coordination and family support and training
All Managed Care Entities (MCEs) will contract with CSA network and use some common UM strategies
MCE’s are undertaking workforce and provider development activities now
Commonwealth will offer wrap-around training and coaching to CSA’s and in-home therapy providers
Other training for state agency staff and schools
Revised Implementation Timelines
July 1, 2009: Intensive Care Coordination, Family Support and
Training, & Mobile Crisis Services
October 1, 2009: In-home Behavioral Services
and Therapeutic Mentoring November 1, 2009: In-Home TherapyDecember 1, 2009: Crisis Stabilization Units
Implementation and Monitoring
Implementation activities ongoing since June 2007 Court Monitor meets regularly with parties, providers,
professionals, and families Compliance Coordinator guides state efforts Parties meet monthly to discuss implementation and
service system design Plaintiffs actively monitor all aspects of new system Court Monitor reports to Court about implementation
and overall compliance with the Judgment Court meets quarterly with parties and Monitor
Challenges to Implementation
Provider capacity and network development Ongoing training / coaching for Wrap fidelity Education and outreach to members Data and outcome measurement Utilization Management Effective coordination with child-serving
agencies, courts, probation
Eligibility for Rosie D. Services Medicaid-eligible members under 21 For intensive Care coordination (ICC) children must have a
serious emotional disturbance (SED) and be in MassHealth Standard or CommonHealth
Children with SED in other MassHealth categories can transfer to CommonHealth by completing a disability supplement
Two federal SED definitions apply. Any child who meets EITHER definition, as determined by the mental health evaluation, is eligible for ICC
Children without SED can obtain remedial services (other than ICC) if medically necessary, depending on MassHealth coverage type
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.
Pathways to Service Access
● Behavioral Health Screening● Mental Health Evaluation ● Referral to Care Coordination
Comprehensive In-Home AssessmentWrap-Around Team ProcessDelivery of Home-Based Services
● Referral to Discrete Remedial 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
State agencies and other child serving entities can recommend parents seek such a 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 mental health evaluations will incorporate the Child and Adolescent Needs and Strengths (CANS) survey
The CANS uses a structured interview to assess the child and family’s strengths and identify their service needs
CANS can be provided by mental health clinicians in various settings (hospitals, clinics, private practices state agencies; CSAs)
If the clinician determines SED is present, a referral to intensive care coordination should usually result
Intensive Care Coordination
● Wraparound treatment planning process delivered by a regional network of 32 Community Service Agencies (CSAs)
● A Care coordinator is assigned to work in partnership with family and youth, ensuring family-driven care and meaningful involvement in all aspects of treatment planning
● ICC facilitates completion of a comprehensive home-based assessment and creation of a care planning team including natural supports, state agencies and other providers
● Prepares and monitors 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 within parameters Components of plan include:
– Treatment goals and objectives– Identification and role of specific providers– Frequency, intensity and location of service delivery– Crisis plan
The Values of Wrap-Around
ICC team and home-based providers responsible formaintaining fidelity to several core principals:
– strength-based– individualized– child-centered– family-driven– community-based– multi-system– culturally competent
Speed of ICC Response
● Telephone contact within 24 hours of referral● Face-to-face interview within 3 calendar days● Upon consent to participate, immediate development
of initial risk management and crisis plan● Comprehensive home-based assessment within 10
days of consent● Team meeting and plan development within 28 days
of consent
Direct or Facilitated Self-Referral
All Medicaid behavioral health services can be requested in this way
If youth not interested in or eligible for ICC, may seek specific services instead, provided they are medically necessary
For Therapeutic Mentoring and Family Partner Services a clinical treatment plan must be in place to support the referral
The EOHHS Infrastructure
EOHHS operates as the single State Medicaid Agency for Massachusetts
Office of Medicaid administers state and federal Medicaid dollars on behalf of EOHHS
Children’s Behavioral Health Initiative is an EOHHS interagency initiative whose mission is to strengthen, expand and integrate state services into a comprehensive, community-based system of care
The Managed Care Network
MassHealth Behavioral Health Unit oversees behavioral health services provided by MCO’s.
Four Managed Care Entities to which MassHealth and MCOs contract out behavioral health services
– MBHP (serving PCC plan) 300,000 members statewide– Beacon Health Strategies (subcontractor NHP and Fallon) – BMC Health Net (MassHealth and Commonwealth Care)
250,000 members statewide– Network Health (MassHealth and Commonwealth Care)
160,000 members in 300 cities
The Special Role of MBHP
Serves the largest population of youth with behavioral health needs
Now serves youth whose behavioral health care was formerly under fee-for-service
Manages the behavioral health needs of youth in DCF or DYS custody
Took lead in CBHI network development and provider selection activities
The Role of Managed Care Entities
Develop, maintain and contract with the provider network
Set standards and monitor performance Collect data and inform quality assurance Maintain grievance/appeal procedures Authorize care and payment of claims Provide customer service and administration
of benefits
Managed Care Reforms under CBHI
MCE’s contract with all Community Service Agencies and Emergency Service Providers
MCE’s all use same network of new MassHealth service providers
MCE’s all use agreed upon authorization parameters for new services
MCE’s will maintain distinct authorization processes when services are requested
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
Mobile Crisis Services
Mobile, face-to-face response to youth in crisis, available 24/7 and for 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 Fosters understanding of family dynamics, develop
strategies to address stressors, enhance problem solving and communication skills, address risk and safety planning, identify community resources, offer care coordination
Therapist works with youth and the family on development of specific clinical treatment goals to improve youth’s functioning
Paraprofessional 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, focus on ensuring youth’s successful navigation of various social contexts, skill acquisition and functional progress towards treatment goals
Family Support and Training
Provided by Community Service Agencies (CSAs) 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 decisions regarding the need, amount, duration or the termination of services can be appealed through the MCE grievance and Medicaid fair hearing process
A dispute resolution process will be in place for Care Planning Teams and state agencies to utilize
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 ● CHINS and child welfare agencies
● Medical and Behavioral Health providers
Importance of Interagency Protocols
Commonwealth required by the Judgment to develop protocols with all EOHHS agencies
Necessary to establish consistent expectations, procedures and communication across systems
Address issues like referrals, staff training, Care Planning Team participation and dispute resolution
DCF, DYS and DMH protocols are now available with agency staff training underway; DMR and DEEC in development
Community Involvement in Systems of Care
CSA’s are required to convene regional Systems of Care Committees
Fosters communication and collaboration between regional state agency staff, courts, schools and other system stakeholders
Opportunity to review system-level issues impacting delivery of care, identify area resources and foster ongoing partnerships
Promoting Effective Collaboration With The JJ and Child Welfare Systems
Offer information/outreach to system stakeholders: attorneys, court clinics, clerk magistrates, judges, probation officers…
Encourage membership on CSA Systems of Care Committees Consider use and impact of CBHI resources in existing or
expanded diversion programs Develop model motions or other practice aides for court
appointed counsel seeking to access or present CBHI resources as part of alternative dispositions
Collect and review initial experiences with system interfaces Identify strategies and infrastructure needed to establish
successful linkages between community mental health services and children in the juvenile justice and child welfare systems
Potential Challenges in the Juvenile Justice and Child Welfare Context
Cooperation in the context of an adversarial proceeding
– Protocols for early identification of children with behavioral health needs
– Confidentiality issues– Stigma
Prompt access to clinically, linguistically and culturally appropriate behavioral health services
– Medicaid eligibility determinations– Assessment of behavioral health status, determination of
appropriate and medically necessary services– Delivery of services identified as medically necessary
Education: The Potential Benefits of CBHI Services
Increased access to mental health expertise to inform child’s service and placement decisions
Flexible delivery of services in school, after-school and other community settings
Availability of resources to coordinate services across settings and promote generalization of skills
Single point of contact through ICC team and care coordinator
Additional services to avoid institutional care and support children’s success in more integrated community programs and educational placements
Education: Challenges to Realizing Effective Coordination with CBHI
Providing meaningful information and outreach to school staff and parents
Identifying model policies and best practices for referral and service coordination by schools
Avoiding confusion regarding the interaction between two federal entitlement programs
Effectively integrating Individual Care Plans and Individual Education Plans
Limited school resources for coordination Appropriate access to MassHealth information for
eligible Students
Childrens’ Mental Health Law of 2008: How it Complements CBHI
Established the Behavioral Health Advisory Council by Statute
Convened Education Taskforce to inform statewide recommendations for improving coordination and delivery of mental health services in schools
Provided for regional inter-agency review teams to collaborate on and attempt to resolve service disputes in complex cases, including matters not successfully resolved through the ICC dispute resolution process. Implementing regulations now under development.
Ten Principals of the Wrap Process
Family voice and choice
Team based Natural Supports Collaboration Community based
Individualized Strengths based Persistence Outcome based Culturally competent
Understanding the Four Phases
Engagement (2-3 weeks) Family meets with facilitator; explore strengths, needs and culture; history; expectations for service; facilitator engages identified team members and prepares for first meeting
Planning Phase (1-2 weeks) Team learns about families strengths, needs and vision; together establish priorities; tasks and responsibilities; an integrated plan is developed
Understanding the Four Phases
Plan Implementation (9-18 months) Family and Team meet regularly to promote coordination of care; review progress towards goals, make adjustments in service provision
Transition (ongoing) As goals are achieved, preparations made for transition from formal wraparound; family and Team identify continuing needs and supports; plan for contingencies including how to “restart” wraparound if necessary in future
Ensuring Fidelity to Wrap Values
That caretakers, families and youth are well informed and empowered to direct care
That Team members seek and observe families perspective, goals and priorities for service provision
That Team shares responsibilities, services are effectively coordinated across settings and respects cultural identify of youth and families
Awareness of National Models and Wraparound Resources
● For users guide and process descriptionsNational Wraparound Initiativewww.rtc.pdx.edu/nwi
● For fidelity measurement and quality assessment tools
Wraparound Evaluation & Research Team WSU http://depts.washington.edu/wrapeval
Tips for Advocates: Navigating the New CBHI System
Ask about insurance status; any existing disability or diagnosis
Get releases for client’s MCE and MassHealth (PSI) Inquire about potential for SED determinations Be aware of local CSA’s, contacts for referral and
other resources for rapid clinical assessment Take opportunities to educate state agency and
court staff about voluntary diversion options using CBHI
Tips for Advocates: Navigating the New CBHI System
Have information about CBHI available to share with client’s/families
Ask to be included in the ICC Team and/or for permission to communicate with care coordinator
Monitor youth and families ICC participation for appropriate team development, access to necessary services, degree of state agency involvement and extent to which confidential information is shared with Team members orally or in writing
Rosie D. Advocacy Project at CPR
Available to class members needing short term advice on accessing services or direct representation based on service denials, terminations or state agency disputes
Available to attorneys and advocates seeking technical assistance and information on CBHI relevant to their practice and the representation of individual class members
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 class members may be confronting
Assist in the 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 stakeholders regarding issues unique to your practice
Additional Information
The Center’s website: www.rosied.org contains:– News updates and features on implementation– An extensive library of litigation documents – Information designed for families, providers and other
professionals Additional information on the Children’s Behavioral Health
Initiative, including program specifications, regional CSA’s and provider networks and information re: access to other MassHealth resources can be found at: www.mass.gov/masshealth/childbehavioralhealth