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

The Litigation The Pathway to Home-Based Services Implementing the Remedy

I: The Litigation The Rosie D case was filed in 2001 by the Center for Public Representation (CPR) and the firm of Wilmer Cutler Pickering Hale and Dorr (WilmerHale) The lawsuit was brought to force the State to provide mental health treatment to children in the community, so they would not have to be institutionalized or transferred to residential programs in order to obtain needed mental health services CPR is a public interest organization that has advocated for persons with disabilities for over thirty years For many years, CPR has had a children’s mental health project that assists children to obtain needed services so they can remain in their homes and home communities

The Litigation: Plaintiffs The plaintiffs include eight children who have serious emotional, behavioral, or psychiatric conditions The children all needed mental health services to be able to stay in their homes and home communities The case was brought by their parents or guardians who needed support to have their children remain at home

The Litigation: The Legal Claims The federal Medicaid program has a special provision for children called Early Periodic Screening Diagnosis and Treatment -- EPSDT Under EPSDT, children have a right to all needed treatment “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 enters sweeping decision finding Massachusetts in violation of EPSDT provisions of the Medicaid Act Orders State to develop in-home support services, including comprehensive assessments, case management, behavior supports, and mobile crisis services 8/22/06: Parties submit separate remedial plans after six months of negotiations fail to achieve agreement

The Litigation: The Remedy 2/22/07: Court decides to defer to the State’s plan at the outset, but requires that the final plan – Covers all children with serious emotional disturbance (SED) – Includes timelines for each implementation phase – Can only be modified by the Court – Is an enforceable order, overseen by the Court 4/27/07: Appoints Karen Snyder as the Court Monitor 7/16/07: Enters final judgment and adopts final remedial plan that requires home-based services for all children with SED who would benefit from them

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 Screening by Primary Care Physician or Nurse Under federal law (EPSDT), children visit a primary care doctor/nurse at least annually, and, when younger, even more frequently Primary care doctors/nurses must use one of six standardized screening instruments Primary care doctors/nurses must identify those children who have a behavioral health condition or may need mental health services Primary care doctors/nurses must either treat children or refer them to a specialist who will conduct a full mental health evaluation Children known to state agencies can bypass screening State (MassHealth) will maintain data on screenings, referrals, and treatment

Step 1 - Identification State agencies (DSS, DYS, DMR) and schools must identify children who may have a behavioral health condition or may need mental health services Schools, child care providers, and other child serving entities should identify children who may have a behavioral health condition or may need mental health services Emergency rooms, emergency services providers, and other health care professionals should identify children who may have a behavioral health condition or may need mental health services Families may identify their own children

Referral for Evaluation If a child is screened by a doctor or nurse as having a mental health condition, a referral is made for a mental health evaluation If a child is identified by anyone as having a mental health condition or needing mental health services, the child should be either: – Referred to a primary care doctor/nurse for a formal screening OR – Referred immediately for a mental health evaluation Referrals are to mental health professionals, mental health clinics and centers, and local mental health programs

Step 2 - Mental Health Evaluation Required for high risk children, children discharged from hospitals, intensive residential settings, or DMH facilities 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 – train professionals and clinics to use the CANS – improve mental health evaluation process by mental health providers Interim home-based services are available during the evaluation process

Eligibility for Home-Based Services Any Medicaid-eligible child 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: 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 General pervasive mood of unhappiness or depression A tendency to develop physical symptoms or fears associated with personal or school problems

Intensive Care Coordination If the child is determined to have SED, s/he is entitled to intensive care coordination. 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

Step 3 – Assignment of Single Care Manager A care manager is assigned promptly Child has one care manager responsible for overseeing and coordinating all home-based and other services Care manager convenes and oversees a single treatment team Care manager prepares, monitors, and reviews a single treatment plan Care manager works directly with family and child

Step 4 – Comprehensive Home-Based Assessment Care manager conducts comprehensive home-based assessment Assessment includes in-depth review of records and past treatment Assessment includes visit to home Assessment includes interview with family, teachers, and other involved persons Assessment focuses on strengths of child and family

Step 5 -Treatment Team Each child has a single child/family team that plans all home-based and other services Team includes all involved state and educational agencies, family and child, and other persons involved in the child’s life Team determines the type of home-based services that will benefit the child Team determines the amount, intensity, and duration of home-based services

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

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

Step 7 – Provide Home-Based Services In addition to existing Medicaid services and intensive care coordination, the five new home-based services are: Mobile crisis intervention and crisis stabilization In-Home Behavioral services In-Home Therapy services Mentor services Family Partners

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

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

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

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, develops strategies to address stressors, enhance problem solving and communication skills, identify community resources, risk and safety planning, offers some care coordination Therapist works with youth and the family on development of specific clinical treatment goals to improve youth’s functioning May be assisted by a paraprofessional who supports the child and family in day to day implementation of treatment goals

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 youth’s successful navigation of various social contexts, skill acquisition and functional progress towards identified treatment goals

Family Support and Training Available through CSA’s 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 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

Appeals Any disagreement with the decision on eligibility, need for a case manager, 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

III. Implementing the Remedy Design of Home-Based Services Developing the Service Delivery System Data Collection and Evaluation Monitoring Ongoing Court Involvement Implementation Timetables Challenges to Implementation

Design 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 with SED can access these services regardless of their eligibility category using the Commonhealth disability determination process All services can be provided separately or in combination, and delivered in any setting (natural or foster home, school, community)

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 All Managed Care Entities (MCEs) will contract with the CSA network, with some common UM strategies MCE’s are undertaking workforce and provider development activities now The Commonwealth will offer wrap-around training and ongoing coaching to CSA’s and in-home therapy providers Other trainings for schools and state agency staff

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

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

Implementation: Data 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 But no commitment to evaluation of child and family outcomes, integrity of team process, or family involvement

Implementation: Monitoring, Coordination 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

Implementation Timelines December 2007: Modifications to screening and informing completed November 2008: Assessment process developed and provider training completed November 2008: Data collection and evaluation processes completed July - November 2009: Services and services delivery system completed