ROSIE D' V' ROMNEY

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ROSIE D. V. ROMNEY

• Transforming the Medicaid Childrens Mental
  Health System

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Transforming the Childrens Mental Health System

• The Litigation Purpose and Outcome
• The Pathway to Home-Based Services
• Status of Implementation

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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

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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

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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

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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

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The Litigation The Remedy

• 2/22/07 Court orders the States 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
  Monitor
• 6/18/07 Plaintiffs and Commonwealth begin regular
  implementation meetings
• 7/16/07 Final judgment and final remedial plan

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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

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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.

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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

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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

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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.

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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

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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

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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

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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 familys strengths and service needs
• State must
• train professionals and clinics to use the CANS
• Increase rates and timeframe for conducting
  evaluation

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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

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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

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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

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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

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Step 5 Treatment Planning Process

• Core values of wrap-around process
• strength-based
• individualized
• child-centered
• family-focused
• community-based
• multi-system
• culturally competent

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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

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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

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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

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Behavior Management Therapy and Behavior
Monitoring

• Designed to address challenging behaviors in the
  home and community which interfere with childs
  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

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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

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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

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Family Mentor Service

• Structured relationship with family/caregiver
• Works under supervision of clinician
• Assists caregiver in addressing childs emotional
  and behavioral needs through education, coaching,
  support and training
• Paraprofessional or parent of child with
  disabilities

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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.

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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

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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

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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

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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

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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

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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 CSAs in place, delivery
  system operational and home-based services
  available

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Challenges to Implementation

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

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Relevance of Rosie D. Reforms

• The new childrens 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

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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 childrens success
  in integrated programs and settings

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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

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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

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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.