1. ROSIE D. V. ROMNEY Implementing the Court Order

2. The Court Decision 1/26/06: Court enters sweeping decision finding Massachusetts in violation of EPSDT provisions of the Medicaid Act Orders State to develop in-home support services, including comprehensive assessments, case management, behavior supports, and mobile crisis services 8/22/06: Parties submit separate remedial plans after 6 months of negotiations fail to achieve agreement

3. The Remedy Many elements of both plans are similar: (1)Improvements to EPSDT screening; (2)Outreach and education to families, professionals and providers; (3)Use of CANS for preliminary assessment; (4)Single team, single plan, and single case manager with participation by all key agencies, providers, and families; (5)Most covered services; (6)Framework of delivery system using lead entity/provider for each area; (7)Data collection (8)Court monitor

4. Fundamental Differences There were four arching differences between the plans: (1) Eligibility: all SED kids v. high end kids (1)Deadlines: tight timelines v. flexible goals (2)Modification: by court v. by defendants (3)Enforceability: all provisions v. only those required by the Medicaid Act

5. Specific Differences There also were several specific differences: (1)Screening by any health professional v. only by a pediatrician (2)Comprehensive, home-based assessments for all kids who need more than outpatient services v. only high end kids (3)Covered services include after-school, therapeutic foster care, MST, and other therapies (4)Detailed description of delivery system, provider qualifications, performance standards, and rates (5)Significant role for families, professionals and local experts in designing and developing system (6)Outcomes (7)Level of detail

6. Resolving the Differences Court asks for briefs on the significance of the differences Plaintiffs submit 10 affidavits and detailed justification for their plan Defendants generally argue for deference to their plan 2/22/07: Court decides to defer to the State’s plan at the outset, with four caveats Requires that the final plan include the plaintiffs’ proposal on the four overarching differences Makes clear that it will impose far stricter requirements if the plan is not fully implemented as proposed

7. The Remedy: The Pathway to Home-Based Services Step 1: Screening Require standardized screening instruments Require referral to pediatricians by state agencies Require pediatricians to refer identified children for mental health assessment Allow children known to system to bypass screening Train pediatricians Collect data on screens, findings, and referrals

8. Assessment Step 2: Intake assessment Require use of CANS as part of mental health intake process Improve mental health assessment process by MH providers Require assessments for high risk children Require assessment for children discharged from hospitals and intensive residential settings Step 3: Comprehensive assessment Assign intensive case manager Conduct comprehensive home-based assessment for eligible children

9. Treatment Planning Step 4:Child/family team Case manager assembles family-centered team Team includes all involved state and educational agencies, family and child, and other persons involved in the child’s life Step 5:Single treatment plan Team develops single plan that integrates any other agency plans But agencies retain authority over eligibility for their services, commitment of their resources, and compliance with their statutory duties (child welfare – protection and placement; juvenile justice – safety and court supervision)

10. Step 6: Home-based Services Basic elements: All services will be part of State Plan All services must first be approved by CMS All services can be provided separately or in combination –Effectively allows therapeutic foster care All services can be provided in any setting (family, natural home, foster home) Service descriptions, billing rates, and utilization procedures to be developed but cannot further restrict eligibility

11. Covered Services Mobile crisis intervention Crisis stabilization Behavioral services Therapy services Mentor services

12. Informing, education and outreach The State must: Revise EPSDT notices, regulations, provider manuals Develop educational materials on home- based services for families, providers, and professionals Train pediatricians, mental health professionals, and providers Conduct outreach for families

13. Delivery System Basic elements: Community service agencies (CSA) selected for each geographic area CSAs provide case management, oversee teams, and coordinate services CSAs may provide direct services Hopefully, all MCOs contract with the same CSA for the same area Medicaid to establish criteria for CSA selection and performance Mental health (DMH) has role in, but not control over, system development and operation decisions Much left to State’s discretion and experimentation

14. Data and Evaluation Data Collection Utilization data on screening, assessment, case management, and service recommendations Claims data on service utilization Evaluation May collect data on a few outcomes and consumer satisfaction No commitment to evaluation of child and family outcomes, integrity of team process, or family involvement

15. Timelines December 2007: Modifications to screening and informing completed November 2008: Modifications to intake, assessment, and referral processes completed November 2008: Data collection and evaluation processes completed June 2009: Services and services delivery system completed

16. Next Steps Court Monitor just appointed: Karen Snyder, former assistant commissioner for Children and Families in Connecticut Monitor’s role, authority, and budget approved Final judgment entered: June 2007? First report due: June 30, 2007 Plaintiffs’ attorney’s fees