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ROSIE D. V. ROMNEY . Transforming the Medicaid Children’s Mental Health System . Transforming the Children’s Mental Health System. The Litigation – Purpose and Outcome The Pathway to Home-Based Services Status of Implementation. I: The Litigation. - PowerPoint PPT Presentation
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ROSIE D. V. ROMNEY
Transforming the Medicaid Children’s Mental Health System
Transforming the Children’s Mental Health System
The Litigation – Purpose and Outcome The Pathway to Home-Based Services Status of Implementation
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
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
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
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 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 Monitor6/18/07 Plaintiffs and Commonwealth begin regular
implementation meetings7/16/07 Final judgment and final remedial plan
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
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.
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…
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
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.
II. 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
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 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
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 in variety of settings
Step 2 - Mental Health Evaluation
Evaluations will use the Child and Adolescent Needs and Strengths (CANS) survey as part of the assessment process
The CANS is an established and reliable instrument used in many states to assess and child and family’s strengths and service needs
State must – train professionals and clinics to use the CANS– Increase rates and timeframe for conducting
evaluation
Step 3 Intensive Care Coordination
If the child is determined to have SED, s/he is eligible to receive intensive care coordination, subject to a determination of medically necessary.
A care manager is assigned promptly by the regional Community Service Agency (CSA)
Intensive care coordination at the heart of wrap-around process
Step 3 – Role of Care Coordinator
Working in partnership with family and child to ensure their meaningful involvement in all aspects of treatment planning, including
Completion of a comprehensive assessment Convening and overseeing the treatment team Preparing, monitoring, and reviewing the treatment plan Overseeing and coordinating home-based and other
mental health services
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
Step 5 -Treatment Team
A single team will works with the child and family to plan for and monitor implementation of necessary home-based services
Team can also include state and educational agencies involved with the family and child, and other natural supports
Step 5 – Treatment Planning Process
Core values of wrap-around process: – strength-based– individualized– child-centered– family-focused– community-based– multi-system– culturally competent
Step 6 - 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 and services
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
Mobile Crisis & Stabilization Services
Mobile crisis interventions will be available 24 hours day, seven days week. A short term response provided in the home or other community setting intended to evaluate and de-escalate a child in crisis
Crisis stabilization will provide extended crisis management, staff support and treatment in the home or in another 24 hour community setting for up to 7 days
Behavior Management Therapy and Behavior Monitoring
Designed to address challenging behaviors in the home and community which interfere with child’s functioning
Therapist develops behavior management and crisis plan with the family, monitors effectiveness of the interventions
Behavioral Aide helps to implement plan and re-enforce behavior management strategies in the home and community
Therapy Services
In-home therapy services are designed to address treat mental health needs including social or emotional functioning
Therapist works with child and the family on specific treatment goals
May be assisted by an aide who supports the child in recognizing and addressing emotional/mental health needs in the home and other community-based settings
Therapeutic Mentoring Services
Structured one-to-one relationship with child Paraprofessional under supervision of
clinician Coaches child in development and practice
of adaptive, social and communication skills Offer support and training in home, school,
other community settings
Family Mentor Service
Structured relationship with family/caregiver Works under supervision of clinician Assists caregiver in addressing child’s
emotional and behavioral needs through education, coaching, support and training
Paraprofessional or parent of child with disabilities
Appeals
Any disagreement with MassHealth decisions on need for specific services, amount or duration of services, or termination of services can be appealed through the Medicaid fair hearing process
Court will resolve current dispute concerning whether eligibility determinations (diagnosis of SED) are appealable.
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
Delivery of Home-based Services
Once approved by Center for Medicaid and Medicare Services (CMS), services will be part of Medicaid State Plan
All services can be provided separately or in combination, and delivered in any setting (natural or foster home, school, community)
Service descriptions, billing rates, and utilization procedures are being developed
The Service Delivery System
Regional Community Service Agencies (CSA) will be selected across the state to provide care coordination
CSAs may also provide direct services All managed care organizations (MCOs) and the
Partnership (MBHP) will contract with the CSA network
State will establish criteria for CSA selection and performance
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
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 service
design Court Monitor reports to Court about progress and
compliance Court meets quarterly with parties and Monitor
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
Challenges to Implementation
Workforce shortages Provider capacity Ongoing training / education Outcome measurement Network development Resources Effective coordination with child-serving
agencies
Relevance of Rosie D. Reforms
The new children’s behavioral health initiativewill support the work of all professionals interacting with or serving Medicaid eligible children and adolescents
– School Districts and Educational Programs – Clinicians and mental health providers – Juvenile Justice / DYS diversion programs– Benefits/Health Law Advocates– Family Law Practionners– CHINS and child welfare agencies
How Schools Can Benefit
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 through team and care coordinator
Additional services to support children’s success in integrated programs and settings
How Schools Can Prepare
Develop local and statewide guidance on Rosie D. system reforms, including policies and procedures for effective collaboration with parents and community-based behavioral health providers
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
How 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
Additional Information
For more information, go to the Rosie D. website, www.rosied.org. The website contains:– News updates on recent developments.– An extensive library of documents from the case
including decisions, discovery documents, legal memoranda, status reports, and much more.
– A training and events calendar.– Other information designed for families, providers
or other professionals.