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ROSIE D. V. ROMNEY

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ROSIE D. V. ROMNEY Transforming the Medicaid Children s Mental Health System Transforming the Children s Mental Health System I. The Litigation Purpose and ... – PowerPoint PPT presentation

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Title: ROSIE D. V. ROMNEY


1
ROSIE D. V. ROMNEY
  • Transforming the Medicaid Childrens Mental
    Health System

2
Transforming the Childrens Mental Health System
  • I. The Litigation Purpose and Outcome
  • II. The Pathway to Home-Based Services
  • III. The Status of Implementation
  • IV. Realizing the Promise
  • of Rosie D. v. Romney

3
The Problem in Communities
  • Inadequate behavioral health services
  • - Children stuck in ERs or institutions
  • Limited early identification of children in
    mental health needs
  • Services without sufficient intensity or duration
    to meet children and families long term needs
  • Fragmented and disorganized service system with
    no single point of care coordination

4
The Problem in Schools
  • Unaddressed behavioral health needs underlying or
  • exacerbating students struggles in school
  • Children suspended more than 10 days had
    average of three mental health diagnoses
    (Rappaport 2006)
  • Students with mental health needs had a much
    higher rate of absenteesim, tardiness and lower
    grades (Gall et al., 2000)
  • Re-occurring hospital admissions creating
    interruptions in educational services
  • Students left considering more restrictive
    environments in order to have their social,
    emotional and behavioral needs met

5
The Response
  • The class action lawsuit filed in 2001 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
  • Brought by the parents or guardians of eight
    children with serious emotional, behavioral, or
    psychiatric conditions representing a class of
    Medicaid-eligible children who needed home-based
    services to be successful in their communities

6
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

7
The Remedy
  • 1/26/06 Court finds Massachusetts in violation
    of EPSDT provisions of the Federal Medicaid Act
  • 2/22/07 Court orders the State to develop in-home
    services, including comprehensive care
    coordination, screening, assessments, inhome
    supports and crisis services
  • 4/27/07 Appoints Karen Snyder as the Court
    Monitor
  • 6/18/07 Plaintiffs and Commonwealth begin regular
    implementation meetings

8
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

9
Eligibility for Services
  • Any Medicaid-eligible child (MassHealth Member)
    who is determined to have a serious emotional
    disturbance (SED) is eligible for intensive care
    coordination
  • 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

10
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.

11
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 childs educational performance

12
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

13
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.
  • Children who meet medical necessity criteria for
    the remaining in-home services can be eligible
    without a finding of SED.

14
The Pathway to Medicaid Home-Based Services
  • Behavioral Health Screening
  • Mental Health Evaluation
  • Referral for Care Coordination
  • Comprehensive In-Home Assessment
  • Wrap-Around Team Process
  • Delivery of Home-Based Services

15
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
  • Parents, state agencies, and other child serving
    entities can also refer children in need of
    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

16
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
    and child and familys strengths and identify
    their home-based 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
    result

17
Intensive Care Coordination
  • ? Located within regional network of Community
    Service Agencies (CSA)
  • ? Care coordinator works in partnership with
    family and youth to ensure meaningful involvement
    in all aspects of treatment
  • ? Facilitates completion of a comprehensive
    home-based assessment and development of a care
    planning team including state agencies, schools
    and other providers
  • ? Preparing and overseeing implementation of a
    single integrated treatment plan

18
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

19
The Values of Wrap-Around
  • ICC team and in-home providers responsible for
    maintaining
  • fidelity to several core principals
  • strength-based
  • individualized
  • child-centered
  • family-driven
  • community-based
  • multi-system
  • culturally competent

20
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

21
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 youths rapid return to the community,
    avoiding a higher level of care

22
Behavior Management Therapy and Behavior
Monitoring
  • Clinical/paraprofessional team addresses
    challenging behaviors in the home and community
    which interfere with youths 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

23
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
  • Works to foster understanding of family dynamics,
    develop strategies to address stressors, enhance
    problem solving and communication skills,
    identify community resources, address risk and
    safety planning, offer care coordination
  • Therapist works with youth and the family on
    development of specific clinical treatment goals
    to improve youths functioning
  • May be assisted by a paraprofessional who
    supports the child and family in day to day
    implementation of treatment goals

24
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, with focus on ensuring youths
    successful navigation of various social contexts,
    skill acquisition and functional progress towards
    identified treatment goals

25
Caregiver/Peer to Peer Support
  • Available through CSAs and stand alone providers
  • 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 childs
    behavioral health needs by identifying formal and
    informal supports, offering assistance in
    navigating child-serving systems and fostering
    empowerment through education, coaching and
    training

26
Appeals
  • Any disagreements with the MassHealth agency or
    Managed Care Entity regarding the need for
    services, the amount or duration of services, or
    the termination of services can be appealed
    through the Medicaid fair hearing process
  • A dispute resolution process will be in place for
    Care Planning Teams to utilize in the event there
    are disagreements regarding service
    recommendations and treatment planning needs

27
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

28
Delivery of Home-based Services
  • Once approved by Center for Medicaid and Medicare
    Services (CMS), services will be part of Medicaid
    State Plan, receiving federal matching money
  • Medicaid eligible youth can access these services
    regardless of their eligibility category using
    the MassHealth disability determination process
  • All services can be provided separately or in
    combination, and delivered in any setting
    (natural or foster home, school, community)

29
The Service Delivery System
  • Regional Community Service Agencies (CSA) have
    been selected across the state to provide care
    coordination as well as family partner services
  • CSAs may also provide other direct services
  • All Managed Care Entities (MCEs) will contract
    with the CSA network, but retain their own UM
    strategies
  • MCEs are undertaking workforce and provider
    development activities now
  • The Commonwealth will offer wrap-around training
    and ongoing coaching to CSAs and in-home therapy
    providers

30
Monitoring and Court Oversight
  • Court Monitor meets regularly with parties,
    providers, professionals, and families
  • Compliance Coordinator guides state efforts
  • Parties meet regularly to discuss each element of
    new system
  • Plaintiffs actively monitor all aspects of
    implementation
  • Monitor reports to Court about progress and
    compliance
  • Court meets quarterly with parties and Monitor

31
Revised Implementation Timelines
  • July 1, 2009 Intensive Care Coordination,
    Family Partners Mobile Crisis
  • October 1, 2009 In-home Behavior Services
    Therapeutic Mentoring
  • November 1, 2009 In-Home Therapy
  • December 1, 2009 Crisis Stabilization Units

32
Challenges to Implementation
  • Workforce shortages
  • Provider capacity
  • Ongoing training / education
  • Outcome measurement
  • Network development
  • Resources
  • Effective coordination with child-serving agencies

33
Realizing the Promise of Rosie D. v. Romney
  • The Relevance of CBHI reforms
  • The Importance of Interagency Protocols
  • Community Involvement in Systems of Care
  • Benefits of Collaboration with Schools
  • Frameworks for Linking Schools and Community
    Mental Health Services
  • How You Can Help

34
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
  • ? Benefits/Health Law Advocates
  • ? CHINS and child welfare agencies

35
Importance of Interagency Protocols
  • MassHealth required by the Judgment to develop
    protocols with all EOHHS agencies
  • Necessary to establish expectations, procedures
    and communication strategies across child serving
    systems
  • Intended to address issues like referrals, staff
    training, Care Planning Team participation, and
    dispute resolution

36
Community Involvement in Systems of Care
  • CSAs are required to reach out to their
    communities, including forming and operating
    regional Systems of Care Committees
  • Important for communication and collaboration
    between various agencies, schools and other
    stakeholders,
  • Opportunity to review system-level issues
    impacting delivery of care and fostering of
    longstanding partnerships

37
Benefits of Collaboration with Schools
  • 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 childrens success
    in integrated programs

38
Promoting Effective State and Local Education
Collaboration
  • Provision of 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
  • 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
  • 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

39
Yolandas Law Section 19 Taskforce
  • Created as part of the Childrens Mental Health
    Law of 2008
  • Intended to build a framework that promotes
    collaboration between schools and behavioral
    health services
  • Implementation plan involves piloting of
    framework in 10 schools, interim report
    (12/31/09), a statewide assessment of needs, and
    final report with recommendations to
    Governor/Child Advocate (6/30/2011)

40
Taskforces Framework
  • Leadership
  • Professional Development
  • Access to clinically, linguistically and
    culturally appropriate behavioral health services
  • Effective academic and non-academic activities
  • Policies and Protocols

41
How You Can Help
  • Consider where Rosie D. services could be useful
    in your work and share those ideas with us
  • Help us identify best practices and address
    obstacles
  • Assist in 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
  • Collaborate with Section 19 taskforce members and
    the Childrens Mental Health Campaign

42
Additional Information
  • For more information, go to the Rosie D. website,
    www.rosied.org. The website contains
  • News updates on recent developments.
  • Feature descriptions of the service system
  • An extensive library of documents from the case
    including decisions, discovery documents, legal
    memoranda, status reports, and much more.
  • Information and resources for families, providers
    or other professionals.
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