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

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

Introduction: Rosie D. v. Romney

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

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

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

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 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

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.

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

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)

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

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

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

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

The Pathway to Home-Based Services

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

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.

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

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

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

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

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

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

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

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

The Platform for Delivering Children’s Mental Health Care

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

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

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

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

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

The New MassHealth Service Array

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

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

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, 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

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

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

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

Coordinating Child-Serving Systems

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

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

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

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

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

Education: The Potential Benefits of CBHI Services Increased access to mental health expertise to inform child’s service and placement decisions Flexible delivery of services in school, after-school and other community settings Availability of resources to coordinate services across settings and promote generalization of skills Single point of contact through ICC team and care coordinator Additional services to avoid institutional care and support children’s success in more integrated community programs and educational placements

Education: Challenges to Realizing Effective Coordination with CBHI Providing meaningful information and outreach to school staff and parents Identifying model policies and best practices for referral and service coordination by schools Avoiding confusion regarding the interaction between two federal entitlement programs Effectively integrating Individual Care Plans and Individual Education Plans Limited school resources for coordination Appropriate access to MassHealth information for eligible Students

Childrens’ Mental Health Law of 2008: How it Complements CBHI Established the Behavioral Health Advisory Council by Statute Convened Education Taskforce to inform statewide recommendations for improving coordination and delivery of mental health services in schools Provided for regional inter-agency review teams to collaborate on and attempt to resolve service disputes in complex cases, including matters not successfully resolved through the ICC dispute resolution process. Implementing regulations now under development.

Supporting the Wraparound Process

Ten Principals of the Wrap Process Family voice and choice Team based Natural Supports Collaboration Community based Individualized Strengths based Persistence Outcome based Culturally competent

Understanding the Four Phases Engagement (2-3 weeks) Family meets with facilitator; explore strengths, needs and culture; history; expectations for service; facilitator engages identified team members and prepares for first meeting Planning Phase (1-2 weeks) Team learns about families strengths, needs and vision; together establish priorities; tasks and responsibilities; an integrated plan is developed

Understanding the Four Phases Plan Implementation (9-18 months) Family and Team meet regularly to promote coordination of care; review progress towards goals, make adjustments in service provision Transition (ongoing) As goals are achieved, preparations made for transition from formal wraparound; family and Team identify continuing needs and supports; plan for contingencies including how to “restart” wraparound if necessary in future

Ensuring Fidelity to Wrap Values That caretakers, families and youth are well informed and empowered to direct care That Team members seek and observe families perspective, goals and priorities for service provision That Team shares responsibilities, services are effectively coordinated across settings and respects cultural identify of youth and families

Awareness of National Models and Wraparound Resources ● For users guide and process descriptions National Wraparound Initiative ● For fidelity measurement and quality assessment tools Wraparound Evaluation & Research Team WSU

Next Steps for Advocates

Tips for Advocates: Navigating the New CBHI System Ask about insurance status; any existing disability or diagnosis Get releases for client’s MCE and MassHealth (PSI) Inquire about potential for SED determinations Be aware of local CSA’s, contacts for referral and other resources for rapid clinical assessment Take opportunities to educate state agency and court staff about voluntary diversion options using CBHI

Tips for Advocates: Navigating the New CBHI System Have information about CBHI available to share with client’s/families Ask to be included in the ICC Team and/or for permission to communicate with care coordinator Monitor youth and families ICC participation for appropriate team development, access to necessary services, degree of state agency involvement and extent to which confidential information is shared with Team members orally or in writing

Rosie D. Advocacy Project at CPR Available to class members needing short term advice on accessing services or direct representation based on service denials, terminations or state agency disputes Available to attorneys and advocates seeking technical assistance and information on CBHI relevant to their practice and the representation of individual class members

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 class members may be confronting Assist in the 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 stakeholders regarding issues unique to your practice

Additional Information The Center’s website: contains: – News updates and features on implementation – An extensive library of litigation documents – Information designed for families, providers and other professionals Additional information on the Children’s Behavioral Health Initiative, including program specifications, regional CSA’s and provider networks and information re: access to other MassHealth resources can be found at: