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 or exacerbating 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 mental health evaluations will incorporate the Child and Adolescent Needs and Strengths (CANS) survey The CANS uses a structured interview to assess and child and family’s strengths and identify their home- based 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 result

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, 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 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 Behavior Services 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 for communication and collaboration between various agencies, schools and other stakeholders, Opportunity to review 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

Promoting Effective 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, linguistically 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 in 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, The website contains: – News updates on recent developments. – Feature descriptions of the service system – An extensive library of documents from the case including decisions, discovery documents, legal memoranda, status reports, and much more. – Information and resources for families, providers or other professionals.