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

2. Transforming the Children’s Mental Health System
The Litigation
The Pathway to Home-Based Services
Implementing the Remedy

3. 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

4. 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
These parents and families were the real heros of this litigation. They invited us into their lives, shared their struggles to care for their children, their frustrations regarding available services and supports, and the pain and trauma of hospitalization and out-of-home placement. They endured with us through years of court proceedings, knowing that the remedy they were fighting for might be a decade away. While some of those children have aged out of the class, manu are still at home and fighting to stay there.
Class projections – commissioned an epidemiological study which found that there were approximately 50,000 children on Medicaid with serious emotional disturbance. Some of those children will be well and appropriately served by traditional out-patient services (perhaps 20%). Many will need more intensive, in-home services at some point in time.
Remedy currently includes MassHealth members in the standard category and in the expansion population known as Commonhealth – together represent approximately 87 percent of all children on Medicaid (approxiamtely 460,000)
One issue currently before the court is whether this Rosie D. remedy, and the rights to medically necessary services under federal law, will apply to other expansion populations covered under the state’s 1115 Medicaid demonstration waiver. Essential (19,20 year olds) and Family Assistance (varies by age of children) are the two groups most likely to contain children who could be eligible for relief in this case. Generally represent persons who are above 300 percent of poverty.

5. 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
Found in federal statue at 42 USC Section 1396(a) et seq. is a comprehensive sets of entitlements for children, mandating medically necessary treatment which meet broad definitions of medical assistance, including the category of rehabilitative services, which encompasses behavioral health care.

6. 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 remedial plans before the Judge contained many similar or overlapping concepts and approaches to services, but also contained very substantive differences.
They were probably most similar in regards to use of the wrap-around model and the agreed upon services.
Key differences included
level of detail (criteria for providers, policies, programs)
outcome evaluations and (compliance assessments, surveys and client reviews vs. data collection only)
how and to whom services delivered (managed care environment/ approach PCP screening and all SED kids vs only those most at risk).

7. 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

8. 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
These two definitions operate within two different staturoty schemes, and are subject to different interpretation, but generally speaking both consider the duration of a child’s illness, some diagnostic standards, and severity or level of functional impairment, meaning how and to what extent the condition interferes with the child’s role in family, school, community, or in developing appropriate social, behavioral, cognitive or other adaptive skills

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.
Substance Abuse and Mental Health Services Administration
Found at 58 FR of the federal register
The Public Health Act gives the Secretary of HHS the authority to “establish definitions for the term[…] serious emotional disturbance.” USCA 300x-1
Purpose creation in 1993 for determining incidence and prevalence of emotional disorders under the PHA.

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…
Individuals with Disabilities in Education Act
Definition, although reference in statute, is defined in federal special education regulations at 34 CFR 300.8(c)(4)
Not defined in IDEA

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.
Of the two definitions, the IDEA is more flexible in several ways, including duration and diagnosis. Its contextual reference to co-ocurring conditions , speciifically ASD, is that … Autism does not apply if child’s educational performance is primarily affected by an emotional disturbance. This makes sense within the construct of the federal special education call, which requires the designation of a particular category of eligibility over another, but it is less clear to what extent that construct will govern eligibility decisions for purposes of the relief in this case.

13. 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
This pathway to accessing services closely mirrors elements of the Federal EPSDT law (Early, Periodic Screening, Diagnosis and Treatment.)
It also follows both chronology and process of ongoing implementation of the Rosie D remedy:
screening / evaluation / team process and service delivery
For better or worse, in building this system, there first needs to be a way to identify and screen children who may need the services, to specifically evaluate them for diagnosis, eligibility or level of need, and then to refer them to the appropriate service options, including regional agency who will faciliate care coordination and the team planning process which ultimately determines which home-based services are needed.
Unfortunately what this means for implementation is there will be a period of time when children are identified or evaluated as being in need of the service, before it is actually on the ground being delivered. For this reason, we want to ensure that families and providers 1) are aware of what to expect and when new services should be rolled out; 2) what existing services exist; and 3) what are their ongoing rights to receive medically necessary services, whether covered or uncovered, using state EPSDT regulations. One caveat is that this regulatory process, to be effective, generally requires that a provider be identified who is willing and able to deliver the service sought.

14. 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 also 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
Early detection and prevention of illness is a corner stone of Early Periodic Screening, Diagnosis and Treatment. So is trying to intervene for children before medical concerns place them at risk of more debilitating conditions.
The plan does not mandate or track the identification of children with potential behavioral health needs by anyone other that primary care clinicians. There will be planned education and outreach to other child serving professionals, both by the Commonwealth and CPR, including day care, early intervention and school-based providers, like school nurses.
As mentioned above, there will be a group of children who are already receiving some mental health services, either by private clinicians or state agencies or both. These children should be able to jump into this pathway where ever makes the most sense for them, either at evaluation or directly to a referral for a comprehensive home-based service assessment.

15. 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 at clinics, centers or local programs
It is important to note that while providers will be required to offer screening, parents can opt out of this process. Similarly, they can chose to accept, or not, whatever referrals might be generated as a result of a positive screen. This process is designed to provide them with those options, to hopefully intervene early and effective for children, and is designed to keep at least the initial burden on parents relatively low. There are a number of screens pediatricians will be able to choose from. The all involve direct feedback from the parent and I am told most do not exceed one page. They simply serve to flag an issue or concern for further discussion or review.

16. Step 2 - Mental Health Evaluation
Evaluations will use the Child and Adolescent Needs and Strengths (CANS) as part of the assessment process
The CANS is an established and reliable instrument that is used in many states to determine whether a child needs mental health services
State must
improve mental health evaluation process
train professionals and clinics to use the CANS
Developed by John Lyons, it is a series of topics for discussion and review by parents and clinicians to help better understand a child’s strengths, functioning in a variety of environments and potential service needs.
A standardized, short version of this evaluation is being developed by the Commonwealth for use by evaluators as part of an overall clinical determination regarding diagnosis and intensity of need. This is designed to provide a common language for evaluators to discuss and consider children who present at their practices.

17. Step 3 Intensive Care Coordination
If the child is determined to have SED, s/he is eligible to receive intensive care coordination.
A care manager is assigned promptly by the regional Community Service Agency (CSA)
Intensive care coordination includes:
A comprehensive home-based assessment
A single care coordinator for all services
A single treatment team for all services
A single treatment plan for all services

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

19. 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
Comprehensive assessment is intended to be a thoughtful and inclusive process, including time spent with the child and family at home, in –depth record reviews, and interview will all relevant parties identified by the family. Again it is conducted in partnership with the family, focused on assessing their strengths and needs and providing the basis for informing Team recommendations regarding necessary home-based services.

20. Step 5 -Treatment Team
A single child/family team will work with families to plan home-based and other services
Team can also include all involved state and educational agencies, family and child, and other persons involved in the child’s life
Team determines the type, amount, intensity, and duration of home-based services

21. Step 5 – Treatment Planning Process
Treatment planning will be based upon a wrap-around process and the following core values:
strength-based
individualized
child-centered
family-focused
community-based
multi-system
culturally competent
This basically means that parent and family’s voices are central to this process, not just as consultants to a room full of professionals but as partners in the design and construct of services, to maximize their utility and effectiveness for that family and child. The composition of Teams should also be determined together with the family and child, including individuals from the community, friends, clergy, or others who provide natural supports and whom the family want to be involved in ongoing treatment planning.
This is a signifigant departure from a typical medical model approach and one that will certainly require ongoing training and education for providers and families to work effectively, consistently, and with fidelity to these core values

22. Step 6 - Treatment Plan
Team develops single plan that focuses on strengths of child and family
Single plan integrates any other agency plans
Components of the Plan include:
treatment goals and timetables
home-based services provided, including frequency and intensity
specific providers identified
crisis plans and services

23. 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
All these home-based services will be delivered and their effectiveness monitored under the auspices of the individual child and family’s treatment plan.

24. Mobile Crisis Services
Mobile crisis intervention will include short term emergency care in the home to evaluate and treat a child in crisis
Mobile crisis intervention will be available 24 hours/day, 7 days/week
Crisis stabilization will provide staff and treatment in the home or in another community setting for up to 7 days

25. Behavioral Services
In-home behavioral services are designed to address challenging behaviors in the home and community
Behavioral therapist writes and monitors behavior management plan with the family
Behavioral Aide implements the plan in the home and community

26. Therapy Services
In-home therapy services are designed to address social or emotional issues
Therapist works with child and the family on specific issues
May be assisted by an aide who supports the child in the home, school, and recreational settings

27. Mentor Services
Independent Living Skills Mentors help child with adaptive, social and communication skills
Child/Family Support is offered to help families address child’s needs, including education, support and training
Services provided by qualified paraprofessionals working under the supervision of the treatment professional or treatment team

28. Appeals
Any disagreement with decisions on eligibility, need for a care coordination, need for services, amount or duration of services, or termination of services can be appealed through the Medicaid fair hearing process
Advocates are available to assist families in these appeals

29. 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
Because of nature of the legal claims in this case, federal Medicaid law, both the relief and its implementation is driven almost entirely by EOHHS and specifically MassHealth as the single state Medicaid agency. Its managed care network therefore represents the state’s vision for service delivery.
Some risks come along with this approach to service delivery. One is that it may marginalize the roles of other state human service agencies who have a history of providing community services and supports to children with serious emotional disturbance, like DMH.
A second risk is that various MCO’s would operate their own network of of home-based service providers, rather than all being made to contract with a single service network. This is an area in which the Commonwealth has discretion under the order and we should know more about these delivery system decisions in the next 6 months. Our goal is to try and ensure that children and families will have access to the same services or providers networks, regardless of the MCO they choose, and that providers, in turn, will be able to receive the same rates, across managed care entities.

30. Delivery of Home-based Services
Once approved by federal Center for Medicaid Services (CMS), services will be part of the Medicaid State Plan
All services can be provided separately or in combination, and delivered in any setting (natural home, foster home, community)
Service descriptions, billing rates, and utilization procedures will be developed but cannot further restrict eligibility
Commonwealth’s federal medicaid obligations include notice and informing provisions under which they need to make MassHealth members aware of the services available to them. The Commonwealth has also agreed to undertake in a limited way, outreach to family groups and to providers, in order to make people aware of the implementation process and to obtain feedback on certain select issues.
The Center is embarking on its own outreach and educational campaign as well, with partner organizations in the family, provider and legal communities. We hope this process can augment and further inform key stakeholders about these developments and prepare them for how the system is expected to change over the next two years.

31. The Service Delivery System
Community service agencies (CSA) selected for each geographic area
CSAs provide care management, oversee teams, and coordinate services
CSAs may provide direct services
Children in all managed care organizations (MCOs) and the Partnership (MBHP) are entitled to home-based services though the same CSA
State to establish criteria for CSA selection and performance
We anticipate there being anywhere from regional CSA’s delivering and coordinating home-based services.
MassHealth and DMH will establish qualifications, standards and performance measures for each CSA. Their will then be a drafting of contract and procurement documents and the actual negotiations with potential CSA providers. It also intends for MBHP to assist in selection of these CSA’s.
The Commonwealth’s intention is for providers in the MassHea;th managed care network to contract with these CSA’s for delivery of home-based services.
This process will be unfolding over the next 12 months and certainly much more will be known about its development by the middle of next year.

32. 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

33. 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 new system
Court Monitor reports to Court about progress
Court meets quarterly with parties and Monitor
Although the state has a fair amount of discretion to fill in parts of the remedial plan that were not highly prescriptive in their details, this is a process which is closely monitored by the Commwealth’s compliance officer, the Plaintiffs, the Court monitor and the judge himself.

34. 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
While two years seems like a lifetime when you have a child in need now, this is actually a very aggressive and ambitious timetable, and the good news is that the Commonwealth has given every indication that they are committed to sticking with these deadlines. One variable which they will be confronting soon is the amount of time it will take for CMS to indicate clearly is position on approval for and federal funding of these home-based services.

35. Challenges to Implementation
Workforce shortages
Provider capacity
Ongoing training / education
Outcome measurement
Network development
Resources
Number of challenges to implementation process, and their level of priority depend on whether you are a family member, a provider, of a managed care organization…
Workforce shortage – number of qualified professionals in/entering field
Provider capacity (volume, expertise, geography, cultural competence)
Ongoing training and fidelity to the wrap-around model
Licensure requirements for MassHealth
Orienting familes to the services and empowering them to use them
Assessing outcomes and effectiveness
Federal approval and financial participation in service delivery
Cost – dependant on number of children actually eligible for and making use of system – in FY 2005 MassHealth’s behavioral health expenditures for children under 21 was 202 million dollars. (Court’s estimate 459 million?)
Supplemental budget approved October 11th – means 7.8 million for screening rate adjustments and other staff for EOHHS implementation.