ROSIE D. V. ROMNEY
Transforming the
Children’s Mental
Health System
Transforming the Children’s Mental
Health System
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The Litigation
The Pathway to Home-Based Services
Implementing the Remedy
I: The Litigation
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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
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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
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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
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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
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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
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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
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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
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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
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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:
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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
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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
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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
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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
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If the child is determined to have SED, s/he
is entitled to intensive care coordination.
Intensive care coordination includes:
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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
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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
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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
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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
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Treatment planning will be based upon a wraparound process and the following core values:
– strength-based
– individualized
– child-centered
– family-focused
– community-based
– multi-system
– culturally competent
Step 6 - Treatment Plan
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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
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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
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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, skillbuilding, 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
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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
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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
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Structured one-to-one relationship between paraprofessional
and youth, addressing daily living, social and communication
skills in variety of home and community settings
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Includes coaching and training in age-appropriate behaviors,
problem-solving, conflict resolution and interpersonal
relationships using recreational and social activities
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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
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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 childserving systems and fostering empowerment
through education, coaching and training
Appeals
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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
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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
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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
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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
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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
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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
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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