1. Strategies for Success Using Educational and Medicaid Entitlements to Address Children’s Behavioral Health Needs

2. Topics for Discussion Preparing for the New Medicaid Behavioral Health System Accessing Educational Entitlements for Children with Serious Emotional Disturbance Opportunities for the Coordination of Community and School-Based Mental Health Supports

3. Part I: Preparing for the New Medicaid Behavioral Health System Summary of Rosie D. v. Romney The Pathway to Home-Based Services New Service Descriptions What this means for children and families What this means for the parent advocate

4. Rosie D. v. Romney 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

5. 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

6. The Remedy Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act Court orders the State to develop in-home services, including comprehensive care coordination, screening, assessments, in–home supports and crisis services Plaintiffs and Commonwealth begin regular implementation meetings

7. 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 Parent Partners Mobile Crisis and Crisis Stabilization Units

8. 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

9. 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.

10. 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…

11. 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

12. 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.

13. Pathway to Home-Based Services Screening or Identification Mental Health Evaluation Referral for Care Coordination Comprehensive Home-Based Assessment Wraparound Treatment Planning Delivery of Services

14. 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

15. Mental Health Evaluation If a positive screen occurs, a referral can be made for a mental health evaluation Parents can also seek behavioral health evaluations directly if a need has already been identified As of November 30, 2008, all diagnostic evaluations will incorporate the Child and Adolescent Needs and Strengths (CANS) survey The CANS includes a structured interview 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 time for conducting evaluations

16. Intensive Care Coordination  Provided by a regional network of Community Service Agencies (CSAs)  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  Prepares and oversees implementation of a single integrated treatment plan  Parents can self-refer or be referred by a mental health clinician or other professional

17. 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

18. The Value 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

19. Home-Based Service Descriptions Mobile Crisis Services Crisis Stabilization Units In-Home Behavioral Services In-Home Therapy Therapeutic Mentoring Parent Partners

20. 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

21. 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

22. 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

23. In-Home Therapy Services  Includes 24/7 urgent response, flexibility in scheduling, 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, coordinate care  Therapist works with youth and the family on development of specific clinical treatment goals to improve youth’s functioning  A paraprofessional may assist by supporting the youth and family in day-to-day implementation of treatment goals

24. 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

25. 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

26. What this means for children and their families A new array of home and community–based services Supports available with the length and intensity that youth with serious emotional disturbance need An approach which empowers families to direct their own care A process which coordinates all agencies and providers in one team and produces one unified treatment plan

27. What this means for parent advocates A new resource to help support children in their homes/communities and in the least restrictive educational environment A team of community experts available to work with/influence the school A need for familiarity with eligibility requirements, steps for referral, available services and the expectations of wrap-around An opportunity to help families successfully coordinate community-based mental health services with goals and services in the IEP A legal entitlement beyond special education

28. 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

29. Part II: Accessing Educational Entitlements for Children with SED Sources of legal entitlement Anatomy of the IEP Knowing What Can be Provided Using the Team Process Options for Dispute Resolution

30. Sources of Legal Entitlement Individuals with Disabilities Education Improvement Act (IDEA 2004) 20 USC Section 1400 et seq. Code Federal Regulations 34 CFR 300 Chapter 766, codified at M.G.L. c. 71B Code of Massachusetts Regulations 603 CMR 28.00 Bureau of Special Education Appeals, Hearing Rules and Decision Other State and Federal Case Law

31. The Broad Definition for Education State and Federal case law has interpreted ■Purely academic benefit is not the only measurement of educational progress ■ Educational, social and emotional problems are often intertwined and cannot be separated ■Where behavioral disturbance interferes with the student’s ability to learn and student needs highly structured activities during and after school to receive an appropriate education, the IEP must address such problems ■Education is to be broadly defined to include not only traditional academic skills but also basic functional life skills

32. The Range of “Related Services” Related services means transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education, and includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, early identification and assessment of disabilities in children, counseling services, including rehabilitation counseling, orientation and mobility services, and medical services for diagnostic or evaluation purposes. Related services also include school health services and school nurse services, social work services in schools, and parent counseling and training. 34 C.F.R. 300.34

33. Eligibility and Disability Definitions  Emotional Impairment: the student exhibits one or more of the following characteristics over a long period of time and to a marked degree that adversely affects educational performance: 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 types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; or a tendency to develop physical symptoms or fears associated with personal or school problems ( 34 CFR §300.8(c)(4))

34. Eligibility and Disability Definitions The determination of disability shall not be made solely because the student's behavior violates the school's discipline code, because the student is involved with a state court or social service agency, or because the student is socially maladjusted, unless the Team determines that the student has a serious emotional disturbance

35. The Importance of “ Effective Progress ” Massachusetts case law and regulations requires more of a Free and Appropriate Public Education than simply a student ’ s ability to benefit … First Circuit defines FAPE to require “[D]emonstrable improvement in the educational and personal skills identified as special needs – as a consequence of implementing the proposed IEP.” Town of Burlington v. Dep’t of Education 736 F.2d 773 (1 st Cir. 1984) Effective progress is defined as “ documented growth in the acquisition of knowledge and skills, including social/emotional development, within the general education program, with or without accommodations, according to chronological age and developmental expectations, the individual educational potential of the child, and the learning standards set forth in the Massachusetts Curriculum Frameworks and the curriculum of the district. 603 CMR 28.02(17)

36. SED and the Anatomy of An IEP Access to the Curriculum (A and B)  Are Necessary Accommodations, Modifications, and Instructional methods in Place? Individualized Goals  Are Social, Emotional and Behavioral Issues Addressed?  Are There Measurable and Objective Benchmarks The Service Delivery Grid  Are Parent Training and Consultation Included?  Are the Right Professionals Responsible? Extended Year/Day Services  Can FAPE be Delivered in a Regular School Day?  Is there a risk of regression?

37. Consider a Range of Educational Services and Program Options Home-based supports Consultation with parent, other faculty; providers Related services  Speech / PT  OT (sensory integration)  Counseling  Behavioral supports Extended day/year Specific accommodations Specific curricula or training programs Instructional methods  language-based  Discrete trial training Class size; ratios; teacher qualifications; peer groups Multi-disciplinary approaches across settings

38. IEP Requirements (603 CMR 28.05) The IEP shall include specially designed instruction to meet the needs of the individual student and related services that are necessary to allow the student to benefit from the specially designed instruction, or may consist solely of related services that are necessary to allow the student to access the general curriculum, consistent with federal and state requirements.

39. At the Heart of the IEP Process To develop an individualized education plan with the Team to address the child’s social, emotional, and behavioral needs in the least restrictive environment possible so that they may make effective progress consistent with their individual potential.

40. Knowing What Can be Provided BSEA Hearing Decisions: Eligibility  Student with anorexia nervosa and co-morbid disabilities did have serious emotional disturbance and need for special education; academic progress alone not a complete measure of effective progress, including progress towards independence Dighton-Rehoboth Reg’l School District #06-2145

41. Knowing What Can be Provided BSEA Hearing Decisions: Unmet Service Needs  Student with significant and continuing unmet deficits regarding emotional regulation, social skills and community/independent living skills which negatively impacted her learning – ordered curriculum-based social skills training, social skill group in the community, an assessment of independent living needs, a designated support person in school, and an mechanism to consult weekly with Student’s therapist In Re Boston Public Schools BSEA # 06-3610

42. Using the Team Process Effectively Knowing when to Convene  New evaluations  Repeated suspensions  Risk of absence for medical reasons  Change in circumstances; regression Comprehensive Educational Record Reviews  Past IEPs and progress reports  Report cards, MCAS testing  Incident reports, disciplinary records  Past educational testing; evaluations; observations

43. Using the Team Process Effectively Requesting Appropriate and Timely Evaluations  Three year evaluations (can request early)  Functional behavioral assessments (across settings)  Psychological/educational assessments  Related Services (OT, Speech) Identifying the Necessary School Staff  General education/special education/related service specialists Inviting the Right Experts / Providers  Independent evaluators, therapists, counselors, pediatricians Bringing State Agencies to the Table  Pooling knowledge and resources – applying joint pressure

44. Realizing Anticipated Educational and Therapeutic Benefits Regular communication with direct providers/school staff Exercising the right to parent/independent observation in schools Requesting consultation between school and community providers to assist in measuring progress Careful consideration of confidentiality concerns

45. Common IEP Disputes Finding of ineligibility Failure to Implement IEP Disputed Placement Inappropriate or insufficient services  Social, emotional, behavioral supports  Home based supports/training  Lack of measurable goals and objectives  Absence transitional goals/services

46. To Accept or Reject or Both Weigh last accepted IEP versus any new services within the proposed IEP A decision to reject, in part, allows for the application and enforcement of all other accepted portions of the proposed IEP After notice by school, BSEA will issue parent rights information to family

47. Options for Dispute Resolution Re-visit TEAM process  Issues not fully addressed or discussed  Independent or other evaluations not considered Program Quality Assurance (DESE)  For complaints or technical assistance BSEA mediation  Parties communicating well and in good faith  Mutual interest in less adversarial settlement process File formal BSEA hearing request  Exhaustion of other less formal options  Availability of legal representation

48. Part III: Opportunities for Coordinating Educational and Behavioral Health Services The Promise of the Children’s Behavioral Health Initiative How Schools and Students can Benefit Preparing for Effective Collaboration How You Can Help

49. Relevance of Rosie D. Reforms Supporting the work of advocates and professionals interacting with or serving Medicaid-eligible children and their families  School districts and educational programs  Clinicians and mental health providers  Juvenile justice / DYS diversion programs  Benefits/Health law advocates  CHINS and child welfare agencies

50. Benefits for Schools and Students 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 for School through ICC team and care coordinator Additional services to support children’s success in integrated programs and settings

51. How Schools Can Prepare Develop local guidance on Rosie D. system reforms, including model policies and procedures for effective collaboration with parents and community-based providers Partner with local CSA and participate in regional Systems of Care Committees 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

52. How Advocates Can Prepare Consider both entitlement systems when determining how best to support a youth and family Develop knowledge to assist with multi-system navigation (Education/Medicaid/State Agencies) Know where to seek additional information and consultation when questions or disputes arise

53. Other Ways 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

54. Additional Informationon CBHI For more information, Rosie D. website: www.rosied.org.www.rosied.org  News updates on recent developments.  An extensive library of documents from the case including decisions, discovery documents, legal memoranda, status reports, and much more.  Other information designed for families, providers or other professionals. MassHealth website: www.mass.govwww.mass.gov  Managed Care and Customer Service contacts  Relevant applications and Forms  Information on CBHI service system

55. Mental Health and Special Education Resources Boston Bar Association’s Updated Guide to Mental Health Services (www.bostonbar.org)www.bostonbar.org) Center for Law and Education (www.cleweb.org)www.cleweb.org Massachusetts Advocates for Children (www.massadvocates.org)www.massadvocates.org  Special Education Coalition Department of Education Website  www.doe.mass.edu Relevant statutes and regulations Mediation and BSEA hearing forms BSEA rules & hearing decisions Directory of legal/advocacy services