EXPERT CLIENT REVIEW REPORT
by Marci White
Corrected – November 19, 2004
I.INTRODUCTION
I have been retained by the Center for Public Representation as an expert witness in a class action lawsuit that challenges the lack of intensive home-based services for Medicaid-eligible children in Massachusetts who have serious emotional and behavioral disabilities. The lawsuit was filed on behalf of such children who need mental health treatment and interventions that will enable them to remain in their home communities.
I was asked by the Center for Public Representation to coordinate and conduct a “client review” of a sample of children (approximately 40) who received certain Medicaid mental health services during the timeframe of late 2002 and early 2003. The purpose of the review was to examine and analyze the history, needs and services of the clients in the review, including their need for intensive home-based services in recent years.
II.BACKGROUND AND EXPERIENCE
I have more than twenty-five years of experience in the field of child mental health, child welfare, and juvenile justice services. I have held several positions with organizations providing services to children with significant mental health needs. My current position is Vice President of Early Childhood Services at the Methodist Home for Children in Raleigh, North Carolina. The Methodist Home for Children provides community-based services, including services through 13 therapeutic group homes and 150 therapeutic foster homes, family preservation in-home services, residential and community outreach substance abuse services, and inclusive childcare and community-based early intervention services. The Methodist Home for Children serves more than 500 children through its residential services, approximately 250 additional children through its home and community-based services, and approximately 180 children through its childcare and early intervention services. My work at the Methodist Home for Children focuses on providing administrative and programmatic management for all early childhood services.
Previously (1981-1998), I was involved with the implementation of the Consent Decree in the matter of Willie M., et al. v. James B. Hunt, Jr., et al. Willie M. was a lawsuit filed on behalf of a class of more than 1,650 children in whose lives the State of North Carolina had already intervened; who suffer with severe emotional, neurological, or mental handicaps; who are also violent and aggressive; and who are or will be in need of residential or other treatment and educational services. From February 1981 through December 1991, I was Administrator of the Willie M. Review Panel. This Review Panel was an independent body that reported to the federal court and reviewed defendants’ development of services for class members, monitored the provision of services, reviewed procedures for identifying and evaluating class members, and made recommendations to the court.
From January 1992 through June 1998, at which time the court determined that the State of North Carolina had complied with the Consent Decree and closed the case, I served as the Chief of the Willie M. Section of the North Carolina Department of Human Resources, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. I was responsible for ensuring that all Willie M. class members statewide received the mental health and substance abuse services to which they were entitled under the Consent Decree.
The lawsuit class size was approximately 1,650 children. My responsibilities as Chief of the Willie M. Section included managing, overseeing and administering the service design, service implementation, individual client and service system monitoring and quality improvement, advocacy, budget planning, legislative liaison, interagency coordination, and allocation processes necessary to ensure appropriate service provision through a statewide system of 40 locally managed systems and two secure, non-medical institutional treatment programs. A significant piece of the service system includes an information system that was implemented in July 1996, to which all 40 local programs are directly connected and which tracks individual client data (clinical, services provided, service costs, other activities, and client outcomes).
The State developed an extensive array of services for members of this lawsuit class. Key among that array were case management and clinical assessments to determine and then coordinate the range of services each child needed. Despite the criteria of serious emotional, mental or neurological handicapping conditions, which were accompanied by assaultive and violent behaviors, approximately 80% of the class live in community settings, 50% of them in their own homes or substitute family home settings (e.g., foster care or therapeutic foster care). Approximately 30% are served in community-based group homes near their families, attending local schools, day treatment/education programs, or vocational programs. The vast majority of this class is able to be served in such community-based settings because they also receive intensive home-based services that were designed and delivered with the goal of enabling them to develop the skills and supports necessary for living successfully at home or in the community.
In addition to my work with the services developed as a result of the Willie M. Consent Decree, I have also been involved with other class action lawsuits brought on behalf of children with similar needs. In all of those cases, my work included extensive client case reviews, and, on occasion, testimony by deposition and in federal court. Specifically, during 1994-95, as part of an enforcement action in Wyatt v. Hardin (M.D. Ala.), I conducted an extensive review of mental health services provided to more than 70 individual class members at Alabama’s Eufaula Treatment Center. This included record reviews and on-site interviews and observations with children placed at Eufaula. I also coordinated and conducted similar case reviews for class members in M.E. v. Bush (S.D. Fla.) during 1998-2003. Children reviewed in this lawsuit included children in state custody and children in need of mental health services who were placed in programs as a result of a delinquency adjudication. I have also conducted individual client reviews in Arizona as part of a federal lawsuit alleging EPSDT violations. Currently, I am serving as an expert to the Special Master in John B. v. Goetz (Tennessee) regarding Medicaid-eligible children who have behavioral health needs and/or are in state custody. During my twenty-five years of experience in this field, I would estimate that I have conducted case reviews for several thousand children for purposes of examining their histories and their mental health needs and services.
III.STRUCTURE AND PROCESS OF THE CLIENT REVIEW
The plaintiffs decided to conduct a review of the histories, needs, and services of a number of Medicaid-eligible children, in order to determine whether they needed home-based services. The plaintiffs asked me and Marty Beyer to design and implement this review. Over the course of a year, we developed and implemented a plan for the review, directing the plaintiffs’ counsel in the tasks we felt necessary to gather clinically useful information that we needed to make informed judgments concerning home-based services. Together with Marty Beyer, I developed a strategic approach for the review; determined the characteristics of the children to be reviewed; relied upon an independent research expert to advise us on the methods of selecting a random and reliable sample, and then to actually select the sample; decided on what provider information, family data, medical records, and interviews were needed; made adjustments to the plan when unforeseen obstacles arose; and then recruited a team of reviewers to assist us in conducting the review.
A.Sample
In order to conduct a review of a sample of Medicaid-eligible children, the plaintiffs asked the defendants to provide a list of children who had received certain Medicaid behavioral services, based on the most recent service encounter data available to the defendants.
In order to obtain a cross-section of children, based on advice from Marty Beyer and myself, the plaintiffs requested lists of children from four different categories of services provided to Medicaid-eligible children under the age of 22. For the four categories, the defendants reported that the most recent service encounter data they had were either November 2002 or April 2003. Therefore, the sample that was ultimately reviewed was selected from children who had received certain Medicaid services as of November 2002 or April 2003, depending on the most recent defendant data.
In consultation with other experts involved with the case, and based on my own professional experience, we selected four different groups from which the ultimate client review sample would be taken. We did this to obtain a wider scope of children with a broader range of mental health treatment needs. The November 2002 and April 2003 dates were only significant for purposes of having a “point-in-time” for gathering information. We did not anticipate that those dates would have any particular significance in the lives of the children selected in the sample.
Included below are the four categories of services for which we asked the defendants to provide lists of children, along with the corresponding services to include within each category. The specific services codes were taken from the Massachusetts Behavioral Health Partnership’s provider manual, data dictionary, and service code lists, although they are generally applicable to other managed care organizations and state agencies.
1. Inpatient: administrative approval - youth - full rate
post-acute administratively necessary days
sub-pay post cute administratively necessary days
inpatient administratively necessary days
inpatient DMR
inpatient psychiatric
administrative necessary days awaiting DMH hospital
2. Residential: residential psychiatric - administratively necessary days
residential stabilization services
residential psychiatric
enhanced residential care
ICI case management
3. Crisis: child and adolescent ESP encounter over 72 hours
child and adolescent ESP encounter under 72 hours
crisis stabilization bed under 24 hours
crisis stabilization bed under 72 hours
community crisis stabilization over 72 hours
mobile crisis intervention
4. Home: therapeutic foster care
family stabilization phase 1
family stabilization phase 2
family stabilization phase 3
family stabilization - step down - professional staff
family stabilization - diversion - professional staff
family stabilization - step down - paraprofessional staff
family stabilization - diversion - paraprofessional staff
placement stabilization services
community support per (15 minute unit)
shelter plus community support per (15 minute unit)
For persons receiving any of the listed inpatient services, the requested list of children was further limited to persons who had been previously hospitalized at least once in the past twelve months prior to receiving the listed inpatient services during April 2003. For persons receiving any of the listed crisis services, the requested list of children was further limited to persons who previously received any of the listed crisis services at least once in the past twelve months prior to receiving them again in April 2003.
For all persons identified in each of the four categories, the following data were subsequently requested:
(1) child's name;
(2) address;
(3) Medicaid eligibility category;
(4) DSS, DMH, DMR, or DYS involvement;
(5)all services provided during the past twelve months (April 1 – March 31, 2003), including the date of such service, the provider of such service, the provider's address, and the cost (claims paid) of such service; and
(6)total cost of all services provided to that person during the past year.
Given the time frame available for obtaining consents for record releases, requesting provider records, reviewing available records and conducting client and provider interviews and reviews on site, there was a realistic limit to the number of clients for whom reviews could be conducted. Using four reviewers, we estimated that they would be able to review a total of 40 to 50 clients. Once we had determined the service categories from which the sample would be selected and the total number of cases that could be reviewed, we relied on the statistical expertise of Dr. Jim Conroy, director of the Center for Outcome Analysis in Pennsylvania, and former director of Temple University’s Institute on Disabilities. We asked Dr. Conroy to confirm whether this total sample size would be adequate. In addition, we relied on his expertise to determine the number of clients to be reviewed within each identified service category. Based on his expertise and recommendations, the total sample was to include the following number of cases from each category: Inpatient services, 10 children; Residential services, 15 children; Crisis services, 10 children; and Home with other mental health services, 10 children.
Once we determined the size of the sample and its different subparts, we asked Dr. Conroy to actually draw the sample from the computer lists provided by the defendants and different managed care organizations. We decided that it would be best to obtain consent from the families, guardians, or legal representatives of each child in the sample. Therefore, we realized that a much larger pool of children had to be drawn than the number we actually would review, since some families or guardians would not consent, other children would have moved, and addresses would not be correct for others. We asked Dr. Conroy to determine how many children to select for the sample. When we subsequently learned that only a small number of children who were in the crisis cohort had consented to participate in the review, we asked Dr. Conroy how to proceed. He decided to draw another sample of children from this cohort. Finally, before actually beginning the review, we again sought the opinion of Dr. Conroy to confirm that the number of children who agreed to participate in the review, and those in each subgroup, were sufficient to generate reliable information. He informed us that they were.
For each child whose name was randomly selected in the sampling process, the plaintiffs attempted to obtain authorizations for access to all relevant records from guardians, parents or DSS. Because of significant difficulties in obtaining consent from DSS for children in its custody, a guardian ad litem had to be appointed. The GAL allowed access to the clinical records of most of these children. However, DSS refused to provide access to all of the records in its possession, thereby limiting the information available to the reviewers for DSS children. Moreover, only a few DSS caseworkers agreed to meet with or discuss the children in their care with the reviewers, which further limited information on these children.
B.The Review Process
1.Goal and Focus - The purpose of the review was to examine and analyze the history, mental health treatment needs and the services received by the clients in the review, with a particular focus on their need for intensive home-based services. We examined both their current mental health treatment needs (as of September 2004), as well as any other past significant time period(s) when they had mental health treatment needs. The primary question was to form an opinion, if possible, as to whether the child now needs or has needed intensive home-based treatment services at a significant point in his/her life.
2.Activities – Together with Marty Beyer, I determined the key steps, information, and process for the review. We determined that this review would be multi-faceted (not merely a paper review) and multi-modal (not merely one point in time). We decided that the review would include a review of available records from mental health providers for each child in the sample for the past three years; face-to-face meetings with children in the sample in their home, school, residential/hospital placement or other setting; face-to-face meetings with parents or guardians of sample children whenever possible; face-to-face meetings and phone conversations with key individual providers for an individual child (e.g., individual and/or family therapist, psychiatrist, school personnel, case manager, behavior specialist, family support worker, social worker, front-line staff in a child’s residential program, DSS worker). We determined which providers or staff would be interviewed, based upon availability and apparent knowledge of the child, as reflected in providers’ records.
3.Materials reviewed – Plaintiffs’ counsel attempted to obtain all available records for the past three years from service providers and state agencies for whom signed releases were obtained from the parent or guardian. Copies of records were obtained by the plaintiffs’ counsel and then forwarded to each reviewer for all clients she would be reviewing. In addition, plaintiffs provided the reviewers with copies of other materials that might be relevant, such as Medicaid service definitions, program descriptions prepared by the defendants or provider agencies of various programs throughout the state, service encounter data for the children included in the sample, and copies of the program review reports of Marty Beyer and Bruce Kamradt to provide an overview of available home-based services in Massachusetts.
4.Schedule – The on-site reviews were conducted between September 18, 2004 and September 30, 2004. Plaintiffs’ counsel were responsible for the logistics of the review, including scheduling appointments and making other arrangements.
5.Reviewers – I recruited two other professionals to participate in the review. I selected them based upon their knowledge of home-based services, their experience in conducting similar reviews in other states and cases, and the reliability of their professional judgment. The expert reviewers for the client review were Marty Beyer; Narell Joyner, Beth Whitaker and myself. I served as the coordinator of the expert reviews, with logical assistance from staff at the Center for Public Representation.
6.Psychiatric consultant – Dr. James Greer, a child psychiatrist from Rhode Island who works with children with serious emotional disturbance and provides home-based services funded by Medicaid to many of these children, was available to consult with me and the other reviewers and reviewed at least one case from each expert as well as seeing a few children in the sample.
7.Review guidelines –
Taking into consideration the limitations of the available records, I provided the reviewers with the guidelines included below for reviewing the available records, conducting interviews, and forming their opinions for inclusion in their reports. These guidelines were initially circulated to the other reviewers prior to being finalized. These guidelines were developed to ensure that opinions reached by the four expert reviewers were based on consistent data and information.