1. 9/12/20151 Children’s Behavioral Health Initiative Vision and Implementation

2. 9/12/2015 2 CBHI Mission The Children’s Behavioral Health Initiative is an interagency initiative of the Commonwealth’s Executive Office of Health and Human Services. Executive Team:  MassHealth  Dept of Mental Health  Dept of Children and Families  Dept of Youth Services  Dept of Public Health

3. 9/12/2015 3 CBHI Mission To strengthen, expand and integrate Massachusetts state services into a comprehensive, community-based system of care To ensure that families and their children with significant behavioral, emotional and mental health needs obtain the services necessary for success in home, school and community

4. 9/12/2015 4 CBHI Values Family-Driven, Child-Centered and Youth Guided Strengths-Based Culturally Responsive Collaborative and Integrated Continuously Improving

5. 9/12/2015 5 CBHI Vision The Children’s Behavioral Health Initiative places the family and child at the center of our service delivery system. Policies, financing, management and delivery of publicly-funded behavioral health services will be integrated to make it easier for families to find and access appropriate services, and to ensure that families feel welcome, respected and receive services that meet their needs, as defined by the family.

6. 9/12/2015 6 CBHI Strategic Priorities 1.Establish an Integrated Behavioral Health System Across State Agencies 2.Increase Early Identification of Needs and Early Access to Appropriate Services 3.Expand Array of Community-based Services 4.Reduce Health Disparities

7. 9/12/2015 7 CBHI Strategic Priorities, con’t 5.Promote Clinical Best Practice and Innovation 6.Strengthen, Expand, and Diversify Workforce 7.Mutual Accountability, Transparency and Continuous Quality Improvement

8. 9/12/2015 8 Rosie D. v. Patrick Rosie D. v. Patrick (United States District Court, District of Massachusetts), Civil Action Number 01- 30199-MAP A class action lawsuit filed in 2001 on behalf of children and youth with serious emotional disturbance Alleged that the Massachusetts Medicaid program, MassHealth, had failed to meet the obligations of certain federal Medicaid laws, including the “Early Periodic Screening Diagnosis and Treatment” (EPSDT) statute

9. 9/12/2015 9 Rosie D. v. Patrick January, 2006, the Court found that MassHealth had not provided sufficient:  Behavioral Health Screening in primary care  Behavioral Health Assessments  Service Coordination  Home-based Behavioral Health Services Court’s final Order issued July 16, 2007

10. 9/12/2015 10 The Remedial Order Requires: 1. Standardized Behavioral Health Screening: 12/31/07 MassHealth has: Required primary care providers to offer all children and youth up to age 21 a standardized behavioral health screen at every “well-child” visit and refer members to further diagnosis and treatment, as needed Selected a menu of standardized screening tools and train providers to use tools Reported to the Court on screens delivered and screens indicating a behavioral health need

11. 9/12/2015 11 The Remedial Order Requires: 2. Educate Members, Providers, Public: 12/31/07 MassHealth: “Get the word out” to MassHealth members, providers and the public about the case, the new services and how to obtain them Will implement the educational campaign in phases, along with each phase of the remedy

12. 9/12/2015 12 The Remedial Order Requires, cont: 3. Implement Standardized Clinical Assessment: 11/30/08 All behavioral health clinicians treating youth under age 21 enrolled in MassHealth must use the Child and Adolescent Needs and Strengths (CANS) tool as part of clinical assessments. MA developed a Birth through Four CANS. Clinicians must be trained and certified to use the CANS. MassHealth has trained over 8,000 clinicians with over 7,000 certified. The CANS is NOT a clinical assessment tool, but is used to organize information gathered during the assessment process, and to guide treatment planning. It uses language accessible to families and asks questions about child and family strengths and needs. It is designed to support clear communication between families and clinicians, and among professionals working with the same child. MassHealth must report to Court on the number of CANS assessments performed and number of children identified with serious emotional disturbance.

13. 9/12/2015 13 The Remedial Order Requires, cont: Court-Ordered Reporting In Place by 11/30/08 New Services to be available state-wide: Intensive Care Coordination (ICC) - “Wraparound” model of service planning and delivery – July 1, 2009 Mobile Crisis Intervention – July 1, 2009 Family Partners – July 1, 2009 In-Home Behavioral Services – October 1, 2009 Therapeutic Mentors – October 1, 2009 In-Home Therapy Services – November 1, 2009 Crisis Stabilization Services – December 1, 2009

14. 9/12/2015 14 Remedy Services Design: Remedy services must be approved by the federal Medicaid program. Intensive Care Coordination has been approved; MassHealth is awaiting approval for the other services. All aspects of the new services are discussed with the lawyers for the Plaintiffs and overseen by the Court Monitor Karen Snyder. Expert and stakeholder input is being gathered through a Children’s Behavioral Health Advisory Council, meetings with families and providers, and “Requests for Information” (RFIs).

15. 9/12/2015 15 Service 1: Intensive Care Coordination What is Wraparound? Structured team-based process Plans & implements individualized care plans for children & families Based on an ecological understanding of the child and family Strong emphasis on cultural competence Especially appropriate for children and families with most complex and severe needs

16. 9/12/2015 16 “Why we think wraparound is important”* Wraparound was a response to overly professionalized and restrictive services Research has found poor outcomes for treatments (including “evidence-based practices”) delivered in “real world” settings Why?  Families don’t think treatments they get are relevant  Lack of “fit” between family needs and actual services/supports received  Lack of full engagement of families  Programs and systems are not engineered to support flexible, individualized care * The National Wraparound Initiative: Jane Adams, Eric Bruns, Trina Osher, Janet Walker, Jim Rast, Nancy Koroloff, Pat Miles, John VanDenBerg, and the National Wraparound Initiative advisory group. 11th Annual Building on Family Strengths Conference, Portland, Oregon, May 7, 2004

17. 9/12/2015 17 Plan for delivering Intensive Care Coordination: 32 Community Service Agencies (CSAs) will provide Intensive Care Coordination They’ve been selected by MA Behavioral Health Partnership and the MassHealth MCOs All MassHealth insurers will contract with the same network of providers Community Service Agencies: Deliver ICC services Convene and staff the local System of Care Committee

18. 9/12/2015 18 Service 2: Mobile Crisis Intervention Short-term, mobile, on-site, face-to-face. Therapeutic response to a child’s mental health crisis by trained crisis professionals. In community settings (including the child’s home), 24/7. Built on re-procured ESP system.

19. 9/12/2015 19 Service 3: Family Partners One-to-one relationship with parent or caregiver Coach, support caregiver to parent the child w/ serious emotional disturbance May include education, coaching, support and training In home and community settings

20. 9/12/2015 20 Service 4: Crisis Stabilization A stabilization bed for short-term stays (days) Evaluate and treat child, and teach, support & assist parent or caretaker Link child to other appropriate services

21. 9/12/2015 21 Service 5: In-Home Behavioral Services Behavior Management Therapy (MA or PhD) Behavior Management Monitoring (BA) Specialized service for children with persistent problem behaviors, who don’t benefit as much from talk-based therapies In any setting where the child is naturally located, including home, school, childcare centers, respite

22. 9/12/2015 22 Service 6: In-Home Therapy Services In-home, intensive, family-based treatment Goals: treat child’s mental health needs & promote healthy functioning of child in family Provided by a team: MA-level therapist and trained paraprofessional

23. 9/12/2015 23 Service 7: Therapeutic Mentoring Services Structured one-on-one mentoring relationship between therapeutic mentor and child or adolescent Addresses daily living, social & communication needs Set goals to support social functioning In home, school or social settings

24. 9/12/2015 24 The Remedial Order Requires Inter- Agency Care Coordination EOHHS must: Ensure that representatives of involved EOHHS agencies participate in child’s care planning team Establish interagency protocols to coordinate agency-specific planning processes with the ICC care planning process Establish a conflict-resolution process for resolving differences among members of care planning teams

25. 9/12/2015 25 Who will be eligible for services? The Order requires MassHealth to provide remedy services to any child or youth: eligible for EPSDT (MassHealth Standard and Commonhealth members ages 0 - 21) who meets either the SAMHSA or IDEA definitions of “emotional disturbance” for whom the service is “medically necessary”

26. 9/12/2015 26 SAMHSA Definitions of “SED” Child from birth to age 18 who currently or at any time during the past year, has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities.

27. 9/12/2015 27 IDEA definitions of “SED” Emotional disturbance means 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:  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 tendency to develop physical symptoms or fears associated with personal or school problems

28. 9/12/2015 28 Who will be eligible for services?, cont. However, MassHealth, according to its understanding of EPSDT, will provide remedy services to any EPSDT-eligible child who has a medical need for the service The exception is ICC, which, as a “Targeted Case Management” service, may be limited to a defined group – in this case, children who meet the SAMHSA or IDEA definitions

29. 9/12/2015 29 Percent of Well-Child Visits With a BH Screen: Quarter 4: Oct 1 – Dec 31, 2008

30. 9/12/2015 30 Resources: CBHI Website: www.mass.gov/masshealth/childbehavioralhealth www.mass.gov/masshealth/childbehavioralhealth National Wraparound Initiative website: www.rtc.pdx.edu/nwi www.rtc.pdx.edu/nwi