ROSIE D. V. ROMNEY

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

2. Rosie D. Advocacy Training I. The Litigation – Purpose and Outcome II. The Pathway to Home-Based Services III. The Platform for Service Delivery IV. The New MassHealth Service Array V. Coordinating Child-Serving Systems VI. The Wraparound Process

3. Introduction: Rosie D. v. Romney

4. The Children’s Mental Health Crisis Inadequate behavioral health services leading to negative outcomes for children, youth and families: ● Children stuck in ER’s or institutions ●Limited early identification of mental health needs ● Services without sufficient intensity or duration ● Fragmented service system ● No single point of care coordination and treatment planning ● Inappropriate use of juvenile justice and child welfare systems to address conduct resulting from lack of behavioral health treatment resources

5. The Response: Rosie D. • Class Action lawsuit 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

6. The 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

7. 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

8. The Decision • 1/26/06: Court finds Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act • 8/22/06: Plaintiffs and the Commonwealth submit separate remedial plans after six months of negotiations fail to achieve complete agreement • 2/22/07 Court orders Defendant’s plan with Plaintiff’s requested modifications

9. The Remedy Judgment requires the State to develop a system for the provision of behavioral health screening, diagnostic evaluation and specific home-based services ● 4/27/07 Karen Snyder appointed Court Monitor • 6/18/07 Parties begin implementation • 7/16/07 Court enters judgment including detailed remedial plan with implementation timelines.

10. Implementing the Remedy • Designing Home-Based Services • Developing the Service Delivery System • Timetables for Service Availability • Monitoring Activities • Challenges to Implementation

11. Design of Home-based Services • Each service is defined by program specifications and medical necessity criteria • With federal (CMS) approval, services will be part of Medicaid State Plan and receive federal matching money • All services can be provided separately or in combination, and delivered in a variety of settings (natural or foster home, school, community)

12. The Service Delivery System • Regional Community Service Agencies (CSA) have been selected to provide care coordination and family support and training • All Managed Care Entities (MCEs) will contract with CSA network and use some common UM strategies • MCE’s are undertaking workforce and provider development activities now • Commonwealth will offer wrap-around training and coaching to CSA’s and in-home therapy providers • Other training for state agency staff and schools

13. Revised Implementation Timelines July 1, 2009: Intensive Care Coordination, Family Support and Training, & Mobile Crisis Services October 1, 2009: In-home Behavioral Services and Therapeutic Mentoring November 1, 2009: In-Home Therapy December 1, 2009: Crisis Stabilization Units

14. Implementation and Monitoring • Implementation activities ongoing since June 2007 • Court Monitor meets regularly with parties, providers, professionals, and families • Compliance Coordinator guides state efforts • Parties meet monthly to discuss implementation and service system design • Plaintiffs actively monitor all aspects of new system • Court Monitor reports to Court about implementation and overall compliance with the Judgment • Court meets quarterly with parties and Monitor

15. Challenges to Implementation • Provider capacity and network development • Ongoing training / coaching for Wrap fidelity • Education and outreach to members • Data and outcome measurement • Utilization Management • Effective coordination with child-serving agencies, courts, probation

16. The Pathway to Home-Based Services

17. Eligibility for Rosie D. Services • Medicaid-eligible members under 21 • For intensive Care coordination (ICC) children must have a serious emotional disturbance (SED) and be in MassHealth Standard or CommonHealth • Children with SED in other MassHealth categories can transfer to CommonHealth by completing a disability supplement • Two federal SED definitions apply. Any child who meets EITHER definition, as determined by the mental health evaluation, is eligible for ICC • Children without SED can obtain remedial services (other than ICC) if medically necessary, depending on MassHealth coverage type

18. 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.

19. 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…

20. 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 Federal IDEA Definition of SED

21. 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.

22. Pathways to Service Access ● Behavioral Health Screening ● Mental Health Evaluation ● Referral to Care Coordination Comprehensive In-Home Assessment Wrap-Around Team Process Delivery of Home-Based Services ● Referral to Discrete Remedial Services

23. 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 • State agencies and other child serving entities can recommend parents seek such a 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

24. Mental Health Evaluation • As of November 30, 2008, all diagnostic mental health evaluations will incorporate the Child and Adolescent Needs and Strengths (CANS) survey • The CANS uses a structured interview to assess the child and family’s strengths and identify their service needs • CANS can be provided by mental health clinicians in various settings (hospitals, clinics, private practices state agencies; CSAs) • If the clinician determines SED is present, a referral to intensive care coordination should usually result

25. Intensive Care Coordination ● Wraparound treatment planning process delivered by a regional network of 32 Community Service Agencies (CSAs) ● A Care coordinator is assigned to work in partnership with family and youth, ensuring family-driven care and meaningful involvement in all aspects of treatment planning ● ICC facilitates completion of a comprehensive home-based assessment and creation of a care planning team including natural supports, state agencies and other providers ● Prepares and monitors implementation of a single integrated treatment plan

26. 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 within parameters • Components of plan include: • Treatment goals and objectives • Identification and role of specific providers • Frequency, intensity and location of service delivery • Crisis plan

27. The Values of Wrap-Around ICC team and home-based providers responsible for maintaining fidelity to several core principals: • strength-based • individualized • child-centered • family-driven • community-based • multi-system • culturally competent

28. Speed of ICC Response ● Telephone contact within 24 hours of referral ● Face-to-face interview within 3 calendar days ● Upon consent to participate, immediate development of initial risk management and crisis plan ● Comprehensive home-based assessment within 10 days of consent ● Team meeting and plan development within 28 days of consent

29. Direct or Facilitated Self-Referral • All Medicaid behavioral health services can be requested in this way • If youth not interested in or eligible for ICC, may seek specific services instead, provided they are medically necessary • For Therapeutic Mentoring and Family Partner Services a clinical treatment plan must be in place to support the referral

30. The Platform for Delivering Children’s Mental Health Care

31. The EOHHS Infrastructure • EOHHS operates as the single State Medicaid Agency for Massachusetts • Office of Medicaid administers state and federal Medicaid dollars on behalf of EOHHS • Children’s Behavioral Health Initiative is an EOHHS interagency initiative whose mission is to strengthen, expand and integrate state services into a comprehensive, community-based system of care

32. The Managed Care Network • MassHealth Behavioral Health Unit oversees behavioral health services provided by MCO’s. • Four Managed Care Entities to which MassHealth and MCOs contract out behavioral health services • MBHP (serving PCC plan) 300,000 members statewide • Beacon Health Strategies (subcontractor NHP and Fallon) • BMC Health Net (MassHealth and Commonwealth Care) 250,000 members statewide • Network Health (MassHealth and Commonwealth Care) 160,000 members in 300 cities

33. The Special Role of MBHP • Serves the largest population of youth with behavioral health needs • Now serves youth whose behavioral health care was formerly under fee-for-service • Manages the behavioral health needs of youth in DCF or DYS custody • Took lead in CBHI network development and provider selection activities

34. The Role of Managed Care Entities • Develop, maintain and contract with the provider network • Set standards and monitor performance • Collect data and inform quality assurance • Maintain grievance/appeal procedures • Authorize care and payment of claims • Provide customer service and administration of benefits

35. Managed Care Reforms under CBHI • MCE’s contract with all Community Service Agencies and Emergency Service Providers • MCE’s all use same network of new MassHealth service providers • MCE’s all use agreed upon authorization parameters for new services • MCE’s will maintain distinct authorization processes when services are requested

36. The New MassHealth Service Array

37. 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 • Family Partners • Mobile Crisis and Crisis Stabilization Units

38. Mobile Crisis Services • Mobile, face-to-face response to youth in crisis, available 24/7 and for 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

39. 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

40. 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

41. In-Home Therapy Services • Delivered in the home or community setting • Includes 24/7 urgent response, flexibility in scheduling and frequency and duration of sessions • Fosters understanding of family dynamics, develop strategies to address stressors, enhance problem solving and communication skills, address risk and safety planning, identify community resources, offer care coordination • Therapist works with youth and the family on development of specific clinical treatment goals to improve youth’s functioning • Paraprofessional supports the child and family in day to day implementation of treatment goals

42. 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

43. Family Support and Training • Provided by Community Service Agencies (CSAs) • 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

44. Appeals • Any disagreements with the MassHealth agency or Managed Care decisions regarding the need, amount, duration or the termination of services can be appealed through the MCE grievance and Medicaid fair hearing process • A dispute resolution process will be in place for Care Planning Teams and state agencies to utilize

45. Coordinating Child-Serving Systems

46. Relevance of Reforms CBHI resources can support professionals and child-serving systems, while improving the experience of and outcomes for Medicaid eligible youth and families ● Schools and educational programs ● Juvenile Justice / DYS diversion programs ● CHINS and child welfare agencies ● Medical and Behavioral Health providers

47. Importance of Interagency Protocols • Commonwealth required by the Judgment to develop protocols with all EOHHS agencies • Necessary to establish consistent expectations, procedures and communication across systems • Address issues like referrals, staff training, Care Planning Team participation and dispute resolution • DCF, DYS and DMH protocols are now available with agency staff training underway; DMR and DEEC in development

48. Community Involvement in Systems of Care • CSA’s are required to convene regional Systems of Care Committees • Fosters communication and collaboration between regional state agency staff, courts, schools and other system stakeholders • Opportunity to review system-level issues impacting delivery of care, identify area resources and foster ongoing partnerships

49. Promoting Effective Collaboration With The JJ and Child Welfare Systems • Offer information/outreach to system stakeholders: attorneys, court clinics, clerk magistrates, judges, probation officers… • Encourage membership on CSA Systems of Care Committees • Consider use and impact of CBHI resources in existing or expanded diversion programs • Develop model motions or other practice aides for court appointed counsel seeking to access or present CBHI resources as part of alternative dispositions • Collect and review initial experiences with system interfaces • Identify strategies and infrastructure needed to establish successful linkages between community mental health services and children in the juvenile justice and child welfare systems

50. Potential Challenges in the Juvenile Justice and Child Welfare Context • Cooperation in the context of an adversarial proceeding • Protocols for early identification of children with behavioral health needs • Confidentiality issues • Stigma • Prompt access to clinically, linguistically and culturally appropriate behavioral health services • Medicaid eligibility determinations • Assessment of behavioral health status, determination of appropriate and medically necessary services • Delivery of services identified as medically necessary