ROSIE D. V. ROMNEY Transforming the Medicaid Children’s Mental Health System

Transforming the Children’s Mental Health System The Litigation – Purpose and Outcome The Pathway to Home-Based Services Status of Implementation

I: The Litigation 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 Litigation: 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 Litigation: 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 Litigation: The Decision 1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act Orders State to develop in-home services, including comprehensive assessments, case management, behavior supports, and mobile crisis services 8/22/06: Plaintiffs and the Commonwealth submit separate remedial plans after six months of negotiations fail to achieve complete agreement

The Litigation: The Remedy 2/22/07 Court orders the State’s plan, but requires – All Medicaid-eligible children with serious emotional disturbance (SED) be eligible for relief – Timelines for each implementation phase – Modification of plan only by the Court – An enforceable order, overseen by the Court 4/27/07 Appoints Karen Snyder as the Court Monitor 6/18/07 Plaintiffs and Commonwealth begin regular implementation meetings 7/16/07 Final judgment and final remedial plan

Eligibility for Home-Based Services Any Medicaid-eligible child (MassHealth Member) who is determined to have a serious emotional disturbance (SED) is eligible for care coordination and a comprehensive home-based assessment 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 for home-based services

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.

II.The Pathway to Home-Based Services Step 1: Screening or Identification Step 2: Mental Health Evaluation Step 3: Assign Care Manager Step 4: Conduct Comprehensive Assessment Step 5: Convene Treatment Team Step 6: Develop Treatment Plan Step 7: Provide Home-Based Services

Step 1 - Screening or Identification At routine well child visits, or when requested, primary care doctors/nurses will screen for behavioral health concerns, using one of six standardized screening instruments Parents, state agencies, and other child serving entities can refer children in need of screening Children with known conditions or state agency involvement can bypass screening MassHealth will maintain data on screenings, referrals, and treatment

Step 2 - Referral for Evaluation If a positive screen occurs, a referral is made for a mental health evaluation Parents can also seek specialized behavioral health evaluations directly if a need has otherwise been identified Evaluation can be conducted by mental health professionals in variety of settings

Step 2 - Mental Health Evaluation Evaluations will use the Child and Adolescent Needs and Strengths (CANS) survey as part of the assessment process The CANS is an established and reliable instrument used in many states to assess and child and family’s strengths and service needs State must – train professionals and clinics to use the CANS – Increase rates and timeframe for conducting evaluation

Step 3 Intensive Care Coordination If the child is determined to have SED, s/he is eligible to receive intensive care coordination, subject to a determination of medically necessary. A care manager is assigned promptly by the regional Community Service Agency (CSA) Intensive care coordination at the heart of wrap-around process

Step 3 – Role of Care Coordinator Working in partnership with family and child to ensure their meaningful involvement in all aspects of treatment planning, including Completion of a comprehensive assessment Convening and overseeing the treatment team Preparing, monitoring, and reviewing the treatment plan Overseeing and coordinating home-based and other mental health services

Step 4 – Comprehensive Home-Based Assessment Visit to home Interviews with parents, caregivers, teachers, and other persons identified by the family In-depth review of records and past treatment Collaboration with family to identify strengths and areas of need

Step 5 -Treatment Team A single team will works with the child and family to plan for and monitor implementation of necessary home-based services Team can also include state and educational agencies involved with the family and child, and other natural supports

Step 5 – Treatment Planning Process Core values of wrap-around process: – strength-based – individualized – child-centered – family-focused – community-based – multi-system – culturally competent

Step 6 - 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 and services

Step 7 – Home-Based Services In addition to existing Medicaid (MassHealth) services and intensive care coordination, the four new home-based services are: Mobile crisis intervention and crisis stabilization In-Home Behavioral services In-Home Therapy services Independent Living Skills training

Mobile Crisis & Stabilization Services Mobile crisis interventions will be available 24 hours day, seven days week. A short term response provided in the home or other community setting intended to evaluate and de-escalate a child in crisis Crisis stabilization will provide extended crisis management, staff support and treatment in the home or in another 24 hour community setting for up to 7 days

Behavior Management Therapy and Behavior Monitoring Designed to address challenging behaviors in the home and community which interfere with child’s functioning Therapist develops behavior management and crisis plan with the family, monitors effectiveness of the interventions Behavioral Aide helps to implement plan and re-enforce behavior management strategies in the home and community

Therapy Services In-home therapy services are designed to address treat mental health needs including social or emotional functioning Therapist works with child and the family on specific treatment goals May be assisted by an aide who supports the child in recognizing and addressing emotional/mental health needs in the home and other community-based settings

Therapeutic Mentoring Services Structured one-to-one relationship with child Paraprofessional under supervision of clinician Coaches child in development and practice of adaptive, social and communication skills Offer support and training in home, school, other community settings

Family Mentor Service Structured relationship with family/caregiver Works under supervision of clinician Assists caregiver in addressing child’s emotional and behavioral needs through education, coaching, support and training Paraprofessional or parent of child with disabilities

Appeals Any disagreement with MassHealth decisions on need for specific services, amount or duration of services, or termination of services can be appealed through the Medicaid fair hearing process Court will resolve current dispute concerning whether eligibility determinations (diagnosis of SED) are appealable.

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 All services can be provided separately or in combination, and delivered in any setting (natural or foster home, school, community) Service descriptions, billing rates, and utilization procedures are being developed

The Service Delivery System Regional Community Service Agencies (CSA) will be selected across the state to provide care coordination CSAs may also provide direct services All managed care organizations (MCOs) and the Partnership (MBHP) will contract with the CSA network State will establish criteria for CSA selection and performance

Data Collection and Evaluation Data must be collected on: Utilization of screening, assessment, care management, and service recommendations Claims data on service utilization Services may be evaluated: State may collect data on some outcomes and consumer satisfaction No formal commitment to evaluation of child & family outcomes, integrity of team process, or family involvement

Monitoring and Court Oversight Court Monitor meets regularly with parties, providers, professionals, and families Compliance Coordinator guides state efforts Parties meet monthly to discuss each element of new system Plaintiffs actively monitor all aspects of service design Court Monitor reports to Court about progress and compliance Court meets quarterly with parties and Monitor

Implementation Timelines November 2007: Initial report on service system and provider network development December 2007: Modifications to screening and informing completed November 2008: Assessment and evaluation process developed and provider training completed June 2009: Regional CSA’s in place, delivery system operational and home-based services available

Challenges to Implementation Workforce shortages Provider capacity Ongoing training / education Outcome measurement Network development Resources Effective coordination with child-serving agencies

Relevance of Rosie D. Reforms The new children’s behavioral health initiative will support the work of all professionals interacting with or serving Medicaid eligible children and adolescents – School Districts and Educational Programs – Clinicians and mental health providers – Juvenile Justice / DYS diversion programs – Benefits/Health Law Advocates – Family Law Practionners – CHINS and child welfare agencies

How Schools Can Benefit 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 and settings

How Schools Can Prepare 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 Offer outreach, 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 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

How You Can Help Consider where Rosie D. services could be useful in your work and share those ideas with us Help us identify 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 Make your voice heard in ongoing implementation

Additional Information For more information, go to the Rosie D. website, 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.