News Stories & Feature Article
Every month, news of important implementation activities will be described, together with a short feature article on a topic relevant to the reform of the mental health system in Massachusetts.
Monitor’s Case Review Process Allowed to Proceed, But Legal
Proceedings Loom
SPRINGFIELD
- At a status conference July 20, 2010, U.S. District Court Judge Michael A. Ponsor rejected
a last-minute attempt by the Commonwealth to derail the Rosie D. Court Monitor’s imminent performance review of
the remedial services that is scheduled to begin in September. But the Court agreed to consider the
defendants’ motion to halt further reviews at a hearing set for September 30,
2010. As a result, at least the first
component, planned for next month in the western region, will proceed and may
be followed by other regional reviews after the Court renders a decision on the
defendants’ motion.
Judge Ponsor called the case review process a “significant
if not essential” mechanism to provide a window into the implementation of the
new remedial services and their impact on the children and families. “I don’t feel like I know how this system is
working,” he said. Stressing his “particular responsibility to this very vulnerable
population,” he added, “I feel I’m losing touch with what’s going on out there.”
For several months, the Court Monitor, Karen Snyder, has
worked with both the defendants and the plaintiffs to develop the case review
protocol. Nationally-renowned consultants
helped draft the protocol, using models successfully implemented in several
other states. The Monitor did a pilot
review in April, and revised the instrument to incorporate suggestions from a
range of stakeholders, including many from the defendants. Since then, Snyder has selected a random
sample of cases to review in September, has obtained records from the relevant
service providers, has identified and scheduled reviewers, and has invested
considerable time and resources into this process.
But hours before the status conference, the defendants
informed Snyder they wanted to halt the process. Lead plaintiffs’ attorney Steven Schwartz
said he was not apprised of the Commonwealth’s intent until he arrived at the
courthouse. He likened the defendants’
request to a petition seeking “a temporary restraining order to enjoin the
monitor to stop the process.” He added, “We
strongly object to halting this process at the last minute.”
The defendants said the case reviews would exceed the scope
of the Monitor’s authority. Asst. Atty.
Gen. Daniel Hammond said state officials are “at an impasse with the monitor” about
the protocol which may “expose [them] to negative reviews.” Emily Sherwood, director of the Children’s
Behavioral Health Interagency Initiatives, said officials are concerned with the breadth
of the review. But Schwartz told the
Court, “Your Judgment has invested her with that authority.”
Sherwood also cited the cost of the statewide review,
estimated at $200,000, which she said is not in her budget, due to recent
cutbacks. She suggested that CBHI can use
its own data to provide a picture of the system. But Judge Ponsor questioned the reliability
of an internal review that might “look at the system to see if the components
exist,” rather than focusing on whether children are getting the services and
benefitting from them.
Crisis Stabilization Services Still A Year Away
In response to the suggestions of national Medicaid experts,
the Court Monitor, and the plaintiffs, the defendants have finally agreed to
include the final remaining remedial service – Crisis Stabilization – in its
1115 Demonstration Project. But the
state has decided to wait until the program is renewed next July before
offering children this critical service.
Despite the Court’s concerns about a gap in the Rosie D. service system -- “a smile with a tooth missing” -- the
Commonwealth has rejected the suggestion that it seek to amend the program
now. Instead, the Commonwealth will
include Crisis Stabilization Services in its renewal application, which, once
negotiated with the Centers for Medicare & Medicaid Services, will be
effective on July 1, 2011.
At the July 20th status conference, Judge Michael A. Ponsor
called the lack of crisis stabilization services “a bit of a heartache” due to
the projected year-long delay. “I’m
concerned about what’s happening for people when that’s not on-line,” he said.
Emily Sherwood, CBHI director, said youth in need of
stabilization services are being served through the current community-based
acute treatment (CBAT) programs that already are funded through the
waiver. She also said that providers of
Mobile Crisis Intervention – another Rosie
D. service – have stepped up and are engaging with youth in crisis and
their families for 72 hours, as required under program specifications. She said there was “no desperate hole in the
system” due to the lack of Crisis Stabilization Services, despite the Court’s
finding that this service is essential.
Steven Schwartz, the plaintiffs’ attorney, praised the
defendants for taking the “best possible course” by incorporating crisis
stabilization in the demonstration waiver.
He suggested that the Commonwealth should submit an amendment to the
existing waiver to get the service on-line sooner. “We want to both applaud and thank the
defendants – and we want it earlier,” he said.
Court Delays Action on Wait Lists
The Court did not act, as anticipated, at its July 20th status
conference on the plaintiffs’ proposed court order
to reduce and eliminate the waiting lists for ICC and other remedial services. Instead, Judge Michael A. Ponsor said he will
revisit the issue at the next hearing on September 30.
The plaintiffs’ proposed order, filed at the Court’s
directive in June, set forth data collection requirements to ascertain how many
youth and their families with identified behavioral health needs forgo needed
care – and for how long. The defendants,
who acknowledge long waiting lists, disputed the need for judicial intervention
in their response.
The defendants told the Court at the July 20th status
conference they have initiated plans and actions to address the wait lists and
they are moving ahead on gathering accurate data. The plaintiffs reiterated that waiting lists
are contrary to the preventive goals and requirements of the EPSDT provisions
of the Medicaid Act, and stressed that no action effectively sanctions an
ongoing violation of federal law.
Data Indicates Strong Demand for Services
More than 4,000 youth enrolled in Intensive Care Coordination – the core remedial service – in the seven-month period following the July 2009 roll-out of the Rosie D. services. State reports, based on claims data and utilization data, offer an insight into the number of children who receive each service and the average amount of services rendered per month from July 1, 2009 through Jan. 31, 2010. Based on the Commonwealth’s data, 4,135 youth received ICC; 3,206 received Family Support Services; 4,029 received In-Home Therapy; 64 received In-Home Behavior Services; 1,176 received Therapeutic Mentoring; and 5,504 received Mobile Crisis Intervention.
The state’s reports also describe the average number of service hours that were provided to each child per month during the same period. In-Home Therapy services were the highest, with an average of 17 hours per child, per month or approximately 4 hours per week. In successive order, the others were: In-Home Behavior Services, 10.4 hours per month; Therapeutic Mentoring, 9 hours per month; ICC, 7 hours per month; Mobile Crisis Intervention, 5.9 hours per month; and Family Support, 5.8 hours per month. Surprising, children and families are receiving considerably less than 2 hours per week of Intensive Care Coordination.
Feature Article
Community
Service Review:
Assessing
Implementation of Home-Based Services
Theo is a 15-year-old
African American youth who is in the eighth grade at a fully self-contained
therapeutic school. Theo was born drug-exposed
and has had severe behavioral challenges throughout his life. Theo has been diagnosed with severe ADHD, and
has a history of fire setting, school expulsion, and involvement in outpatient
services. Theo currently receives
individual therapy, intensive care coordination, and medication management
services through the Children First Agency.
However, Theo frequently misses appointments with his therapist and does
not consistently take his medication.
Theo is also involved with the juvenile courts and is on probation.1
The Rosie D.
remedial plan provides a blueprint for the reform of the children’s mental
health system in Massachusetts
to better serve youth like Theo. It
requires the development of an integrated system of coordinated services,
including home-based services for Medicaid-eligible children with serious
emotional disturbance (SED). These youth
must have timely access to necessary services through effective screening,
assessment, coordination, treatment planning, and pathways to care. A primary goal of the new children’s mental
health service system is to allow youth like Theo to live with his family, to
return to his home community, attend his local school, and participate in
community activities.
Karen Snyder, the Rosie
D. Court Monitor, oversees the implementation of, and compliance with, the
remedial plan. She is responsible for
assessing how well the new services are serving youth with SED and their
families, and whether they are implemented consistent with national
professional standards. One method that
has been used successfully in several other states and lawsuits for evaluating
services and systems is a client review process. The process is based upon an in-depth review
of a sample of children in a system of care. The review assesses both whether
the wraparound process for planning and delivering services is consistent with
accepted standards, whether the services actually provided to the youth and
family are appropriate, coordinated, and effective, and whether the overall
system is functioning effectively.
Beginning in September, the Court Monitor will initiate a
statewide client review process, called the Community Service Review (CSR). Using a framework of questions which guide
expert judgments about the child and service system, the CSR will
systematically assess the delivery of care across the new children’s mental
health service system. The CSR will
include an in-depth assessment of a sample of youth who receive either
Intensive Care Coordination (ICC) or In-Home Therapy in each geographic region
of the Commonwealth. The process is
designed to evaluate how well locally-coordinated services are working for
youth and families. Trained reviewers
will be able to offer an independent, professional assessment of the status and
progress of individual youth and parent/caregivers. It also will evaluate the adequacy of
assessments, treatment plans and related system performance.
Ms. Snyder and a team of reviewers will conduct two cycles
of case reviews in each of the Commonwealth’s six regions between September
2010 and April 2012. Each cycle will
include approximately 150 youth and families, selected equally from each
region. The team will spend five days in
each area. Each reviewer will analyze
services for three youth who have been randomly selected. Participation by the selected youth and their
families is completely voluntary. The
CSR includes a document review of the youth’s assessments, treatment plans,
intake forms, and medical records.
Reviewers will meet with all of the members of the treatment team and
those who work with the youth. For example,
in Theo’s case, the reviewer would meet with Theo, his adoptive family, his
care coordinator, his therapist, his psychiatrist, his probation officer, his
teacher, and his school therapist.
Once the process is completed in each region, the review
team will meet with the service providers and state officials to share results,
patterns, findings, and recommendations.
Ms. Snyder will generate a report for each region, and then aggregate
the findings and recommendations into a statewide report.
The reviewers are qualified practitioners who are certified
in the use of the CSR protocol. Each
will conduct an independent, competent, accurate and fair appraisal of the
quality and consistency of individual services and system practices. They will
use sound professional judgment, based upon evidence and information gathered
during each client review, in assessing youth status, recent progress, and
practice performance findings. Their
reports will offer a fair, objective, and well supported assessment of the
service planning and delivery for each youth and family.
The results of the CSR will provide an important source of
information for system assessment and improvement. For example, the CSR will gather detailed
individual stories of practice and results which will reveal the degree to
which important requirements are being met.
Thus, the CSR will provide a close-up view of how individual youth and
families are doing in the areas that matter most and how well the service
system is performing necessary functions that impact youth well-being. Similar review processes have been used in
many communities throughout the nation to measure changes in behavioral health
services and to evaluate system development.
The results of such reviews have helped agencies to improve the consistency
and quality of practice and performance.
Here, the results of the CSR will be invaluable in assessing the quality
and adequacy of home-based services provided under the Rosie D. remedial plan, and in determining what improvements are
necessary to better support youth and families.
__________________________________
1 Abridged
hypothetical case study from A CSR
Simulation for Reviewer Training and Rating Practice.
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