CANS: Driving Greater Improve- ments in Daily Practice Pages 1 CANS: Driving Greater Improve- ments in Daily Practice Pages 1 Improvements to CANS Domain: Cultural Considerations to Replace Acculturation Page 4 CBHI Website to Unveil a New Look! Page 5 With each issue of the CANS Newsletter, CBHI strives to offer relevant and meaningful information. In this issue, CBHI is pleased to enhance the CANS Newsletter with provider perspectives. We are excited to introduce articles written by clinicians that share implementation solutions and CANS activity from across the provider community. We hope you will find this occasional feature helpful in considering how to make implementation improvements as we move forward. Also, in this edition we are pleased to provide a preview of an upcoming improvement to the CANS Acculturation domain. Over the past year, various stakeholders have been working to improve the domain to reflect a more culturally competent and useful understanding of cultural considerations in practice. Each of these efforts is aimed at moving CANS in daily practice forward in Massachusetts. At the Wayside Community Serv- ice Agency (CSA), the Child and Adolescent Needs and Strengths (CANS) Tool is seen as a roadmap that assists our clinicians, families, and others in guiding a youth to improved overall functioning within the community. Cli- nicians use the CANS to point the way to a clearer diagnosis, to guide the care/ treatment planning process, and to pro- vide us with feedback as to when goals and needs of youth are met. As a hub for the CBHI services, our CSA also relies on the CANS to communicate together as a Care Planning Team (CPT) about the varied perspectives that each team member brings to the work ahead. The Assessment Conversation The work that the Wayside Intensive Care Coordination (ICC) Care Coordinators do to complete the CANS is essentially the same work that goes into any comprehensive as- sessment. It is an extended, sensitive con- versation with the family, which maps the territory into which we are venturing. In conversation with the family, the ICC Care Coordinator learns about the strengths and needs of the youth in order to embark on a course of action to help meet the youth and family’s needs. The difference from other assessment tools is that the CANS simplifies informa- tion gathering, organizes the information in a very useful manner, ensures that all domains of the youth and family’s life are considered, and provides a common language for the CPT that will evolve as the ICC service gets under way. The CANS covers all the relevant do- mains of a youth and family’s life, and CANS questions are designed to elicit un- derstanding of behavioral health functioning and symptoms of emotional disturbance as CANS: Driving Greater Improvements in Daily Practice continued on page 2 Moving Forward Submitted by: Bonny Saulnier, MA, Vice President Wayside Community Service Agency May 2011 | 1 “News for the CANS Community” Volume 2 Number 1 May 2011 CBHI Mission The Children’s Behavioral Health Initiative (CBHI) is an interagency initiative of the Commonwealth’s Executive Office of Health and Human Services. Our mission is to strengthen, expand and integrate Massachusetts state services into a comprehensive community-based system of care to ensure that families and their children with significant behavioral, emotional and mental health needs obtain the services necessary for success in home, school and community. The CANS allows everyone to use the same language. For example, under “Sanc- tion Seeking Behavior,” a rating of ‘3’ means that a youth engages in “frequent serious in- stigating behavior that forces adults to seri- ously and/or repeatedly sanction the child.” This description is common to everyone who has seen the CANS. From it, a specific, measurable goal emerges on the Action Plan, such as “de- crease Sanc- tion Seeking Behavior from a ‘3’ (severe) to a ‘2’ (moder- ate) level over the next four weeks.” The Action Plan “pre- scription” links back to a documented need. Going forward, progress notes maintain the “golden thread” of medical necessity by carrying out the prescription (treatment goal). Table of Contents well as the strengths and supports that can help to overcome mental health challenges. Wayside’s initial assessment conversation is most often one conversation with two staff – the ICC Care Coordinator who will complete the CANS as part of the compre- hensive assessment, and the Family Partner who will use the exact same information to complete the Strength, Needs and Culture Discovery document. Using a set of open-ended, respectful questions that reflect the focus of each CANS section, such as, “How does your child show his/her emotions?” and “How does your child get along with other mem- bers of your family?”, the two staff members engage the family in much the same way that good clinicians have always done. From that conversation, the ICC Care Coordinator is able to both complete the CANS ratings and provide sufficient narrative to support the ratings. The CANS narrative and ratings supply all the evidence that the ICC Care Coordinator needs to formulate a working diagnosis and establish medical necessity for the service. As with any assessment, follow up discus- sion with the family and input gathered with the family’s consent from other stakeholders relative to the family’s well-being, can be added, as needed, either at the time of the initial assessment or in subsequent revi- sions. The assessment is a living document that evolves as new information becomes available or different life situations develop. CANS reassessments at 90-day intervals help keep the assessment up-to-date. The comprehensive assessment, inclu- sive of the CANS, leads to a well-supported diagnosis, including a description of how the diagnosis affects the youth’s function- ing. The “prescription” for the diagnosed behavioral health disorder is the Treatment or Action or Care plan. This is the same planning stage that follows any assessment and diagnosis. However, with the CANS, the prescription (treatment planning) is more focused and measurable, since items of con- cern are clearly highlighted by each CANS rating. The CANS organizes information so that no important item is left out and full attention falls on items that carry actionable ratings (‘2’s and ‘3’s). CANS: Driving Greater Improvements in Daily Practice continued from page 1 The “Golde Thread” The CANS allows everyone to use the same language. For example, under “Sanc- tion Seeking Behavior,” a rating of ‘3’ means that a youth engages in “frequent serious in- stigating behavior that forces adults to seri- ously and/or repeatedly sanction the child.” This description is common to everyone who has seen the CANS. From it, a specific, measurable goal emerges on the Action Plan, such as “de- crease Sanc- tion Seeking Behavior from a ‘3’ (severe) to a ‘2’ (moder- ate) level over the next four weeks.” The Action Plan “pre- scription” links back to a documented need. Going forward, progress notes maintain the “golden thread” of medical necessity by carrying out the prescription (treatment goal). Table of Contents well as the strengths and supports that can help to overcome mental health challenges. Wayside’s initial assessment conversation is most often one conversation with two staff – the ICC Care Coordinator who will complete the CANS as part of the compre- hensive assessment, and the Family Partner who will use the exact same information to complete the Strength, Needs and Culture Discovery document. Using a set of open-ended, respectful questions that reflect the focus of each CANS section, such as, “How does your child show his/her emotions?” and “How does your child get along with other mem- bers of your family?”, the two staff members engage the family in much the same way that good clinicians have always done. From that conversation, the ICC Care Coordinator is able to both complete the CANS ratings and provide sufficient narrative to support the ratings. The CANS narrative and ratings supply all the evidence that the ICC Care Coordinator needs to formulate a working diagnosis and establish medical necessity for the service. As with any assessment, follow up discus- sion with the family and input gathered with the family’s consent from other stakeholders relative to the family’s well-being, can be added, as needed, either at the time of the initial assessment or in subsequent revi- sions. The assessment is a living document that evolves as new information becomes available or different life situations develop. CANS reassessments at 90-day intervals help keep the assessment up-to-date. The comprehensive assessment, inclu- sive of the CANS, leads to a well-supported diagnosis, including a description of how the diagnosis affects the youth’s function- ing. The “prescription” for the diagnosed behavioral health disorder is the Treatment or Action or Care plan. This is the same planning stage that follows any assessment and diagnosis. However, with the CANS, the prescription (treatment planning) is more focused and measurable, since items of con- cern are clearly highlighted by each CANS rating. The CANS organizes information so that no important item is left out and full attention falls on items that carry actionable ratings (‘2’s and ‘3’s). CANS: Driving Greater Improvements in Daily Practice continued from page 1 The “Golde Thread” CANS:DrivingGreaterImprovementsinDailyPractice1ImprovementstoCANSDomain:CulturalConsiderationstoReplaceAcculturation4CBHIWebsitetoUnveilaNewLook!5ImportantReminderforClinicAccessAdministrators5Using“IncompletebutFinal”StatusintheCANSApplication5May 2011 | 2 A collaborative effort of CBHI, Virtual Gateway & UMass Medical School Send your comments and suggestions about this newsletter to: CANSnews@state.ma.usNewsletterCoordinationDeborah McDonagh & Gretchen Hall Design,Layout&ProductionRanjana Verma EditorsDeborah McDonagh Rose Reith CommunicationThe CANS provides a common language for members of the CPT. The Wayside team of ICC Care Coordinator and Family Part- ner share the completed CANS with every family. For some, this confirms that the ICC Care Coordinator “got it right” when translating the family conversation into an assessment. For others, it serves as a point of departure for further discussion. For exam- ple, additional information from collaterals may have influenced the assessment after the conversation with the family. Sharing the completed CANS assessment means sharing that new or different information with the family in a transparent, respectful manner. The CANS language also promotes ac- curacy during the initial assessment conver- sation. One Wayside ICC Care Coordina- tor had the experience of asking a mother about any fire setting behavior engaged in by her son. The mother indicated there was no concern (a ‘0’ on the CANS). Later in the conversation, the mother described an incident in which she was driving with her son to an activity and he lit a match under the car seat while they were in transit. The ICC Care Coordinator was able in the moment to go back to the fire setting section on the CANS and revisit the ‘0’ score. Reading the definitions together, they agreed that the best fit was a ‘2’ (“recent fire setting behavior . . . not of the type that endangered the lives of others”), which helped to inform accurate diagnosis and treatment/care planning. Sharing the CANS with families has the added benefit of giving them a tool for communication with others of the families’ choice, others who may not yet be part of the CPT – for example, if a youth requires emergency placement in an acute treatment facility or STARR program that was not pre- viously involved. Providers using the CANS can compare their clinical impressions of a youth using the same items and scale. In this way, they can identify differences, double check as- sumptions and biases, and arrive at more fully informed assessments. The CANS drives the process in CPT meetings. The shared language and “golden thread” (medical necessity) of connections bring areas of concern into focus more quickly, consensus is readily achievable, and progress is measurable. When a ‘3’ drops to a ‘2’, you can clearly see that progress has been made. When the ‘2’ is finally a ‘1’, you’ve made further progress. If a CANS revision alerts the CPT to a new actionable concern, they can see the evidence for ad- dressing an emergent need. SummaryThe CANS provides a clear map for gath- ering the information needed for an informed diagnosis, an effective treatment/care plan, and documentation of medical necessity. The identified needs of the youth translate directly into measurable goals for treatment. The CANS ratings are a quantitative meas- ure of travel toward these goals. With all members of a CPT sharing the same infor- mation in the same format with a common language for discussion, communication stays on course even when there are de- tours from the original plan. And, the CPT members all have greater confidence with the outcomes – that the goals and needs of the youth are being met. CANS: Driving Greater Improvements in Daily Practicecontinued from page 2 May 2011 | 3 CommunicationThe CANS provides a common language for members of the CPT. The Wayside team of ICC Care Coordinator and Family Part- ner share the completed CANS with every family. For some, this confirms that the ICC Care Coordinator “got it right” when translating the family conversation into an assessment. For others, it serves as a point of departure for further discussion. For exam- ple, additional information from collaterals may have influenced the assessment after the conversation with the family. Sharing the completed CANS assessment means sharing that new or different information with the family in a transparent, respectful manner. The CANS language also promotes ac- curacy during the initial assessment conver- sation. One Wayside ICC Care Coordina- tor had the experience of asking a mother about any fire setting behavior engaged in by her son. The mother indicated there was no concern (a ‘0’ on the CANS). Later in the conversation, the mother described an incident in which she was driving with her son to an activity and he lit a match under the car seat while they were in transit. The ICC Care Coordinator was able in the moment to go back to the fire setting section on the CANS and revisit the ‘0’ score. Reading the definitions together, they agreed that the best fit was a ‘2’ (“recent fire setting behavior . . . not of the type that endangered the lives of others”), which helped to inform accurate diagnosis and treatment/care planning. Sharing the CANS with families has the added benefit of giving them a tool for communication with others of the families’ choice, others who may not yet be part of the CPT – for example, if a youth requires emergency placement in an acute treatment facility or STARR program that was not pre- viously involved. Providers using the CANS can compare their clinical impressions of a youth using the same items and scale. In this way, they can identify differences, double check as- sumptions and biases, and arrive at more fully informed assessments. The CANS drives the process in CPT meetings. The shared language and “golden thread” (medical necessity) of connections bring areas of concern into focus more quickly, consensus is readily achievable, and progress is measurable. When a ‘3’ drops to a ‘2’, you can clearly see that progress has been made. When the ‘2’ is finally a ‘1’, you’ve made further progress. If a CANS revision alerts the CPT to a new actionable concern, they can see the evidence for ad- dressing an emergent need. SummaryThe CANS provides a clear map for gath- ering the information needed for an informed diagnosis, an effective treatment/care plan, and documentation of medical necessity. The identified needs of the youth translate directly into measurable goals for treatment. The CANS ratings are a quantitative meas- ure of travel toward these goals. With all members of a CPT sharing the same infor- mation in the same format with a common language for discussion, communication stays on course even when there are de- tours from the original plan. And, the CPT members all have greater confidence with the outcomes – that the goals and needs of the youth are being met. CANS: Driving Greater Improvements in Daily Practicecontinued from page 2 May 2011 | 3 The Children’s Behavioral Health Initiative (CBHI) has been work- ing to update the CANS domain, Acculturation, and its accompanying items, to more accurately capture and understand the individual, group and family cultural considerations of the children and families who are served by CANS assessors. The data collected in the newly revised Cultural Considerations domain can be used at the individual level to inform treatment planning and service provision, at the program level to under- stand the children and families served and the necessary support that providers require to offer services to their clients, and at the systems level to inform policy development and the future direction of behavioral health care services in Massa- chusetts. Transforming the Acculturation domain to the Cultural Considerations domain demonstrates CBHI’s ongoing effort to ensure that the CANS is a cul- turally informed tool that may help in addressing some aspects of health care disparities.* The domain revisions are still underway with the rollout of the new Cultural Con- sideration domain expected in late 2011. CBHI would like to acknowledge that the revised domain is the result of a collective effort and reflects input and ideas garnered through a collaborative process that included members of the CBHI Advisory Committee for Health Care Disparities Sub-committee, UMMS Training Program and CBHI staff who participated in the development of both the goal and specific items included in the re- vised Cultural Considerations domain. CBHI looks forward to sharing more details about the revised domain in the coming months. Please stay tuned for more information about these upcoming changes. Improvements to CANS Domain: Cultural Considerations to Replace Acculturation YourFeedback... ACANSNewsletterboxhasbeenestablishedtoreceiveyourfeedbackregardingtheCANSNewsletter.SendyourMassCANSNewslettercomments,suggestions,andcontributionstoYourFeedback... ACANSNewsletterboxhasbeenestablishedtoreceiveyourfeedbackregardingtheCANSNewsletter.SendyourMassCANSNewslettercomments,suggestions,andcontributionstoCANSnews@state.ma.us*For more information on health care disparities go to: National Association of Chronic Disease Directors (NACDD). Definition of Health Disparities. Retrieved February 17, 2011 from http://www.diseasechronic.org/i4a/pages/index.cfm?pageid=3447“Transforming the Acculturation Domain to the Cultural Considerations domain demonstrates CBHI’s ongoing effort to ensure that the CANS is a culturally informed tool that may help in addressing some aspects of health care disparities.” May 2011 | 4 Important Reminder for Clinic Access Administrators Managing Users that Leave Your Organization When a CANS user is no longer employed by a provider organization, the Access Administrator needs to be notified immediately so he/she can remove (deactivate) the CANS user’s access to the CBHI CANS Application for that organization. If a CANS user works for more than one provider organization, the CANS user has a single VG Username, but when logging in, he/she must indicate the or- ganization for which assessments need to be entered. Removing the CANS user’s access from one organization will not remove his/her access from the other organization(s). You will soon notice significant changes to the CBHI website. While most of the content will be familiar to veteran users, the website will be reorganized to allow for easier access to needed information. It also includes some new features: Quick Links: On each page of the website, users will be able access links to the CBHI Brochure and Companion Guide, information on applying for MassHealth, and contact information for plans and providers. Users will also be able to sign up for the CBHI list serv. A Streamlined CANS Page: Previously, users had to scroll through a very long list of items. The new CANS webpage will be divided into sections so that users CBHI Website to Unveil a New Look! can easily find what they are looking for, from CANS forms to reference guides. More improvements are planned for this section— we will keep you posted of the changes as they occur. Publications and Reports: Users will be able to access reports on screening, services and utilization that CBHI will now post to the website on a regular basis. Information for Early Education and Care, Pre K-12 School Personnel and Information for Higher Education: These sections are works in progress. Both sections aim to provide resources to edu- cators who work with students who have behavioral health needs. CBHI hopes the Using “Incomplete but Final” Status in the CANS ApplicationIncomplete information is a fact of clinical life. Generally a rating of ‘0’ on a CANS item indicates either no concern or no information. This ambi- guity is built into the CANS tool and is usually not a problem. A skilled clinical inquiry will usually lead you to those areas where you need to focus your in- formation gathering effort so that you will have needed information about those items that need to be rated higher than ‘0’. Therefore “no information” really will correlate with “no concern”. Higher Education section will also be a resource to educators preparing the next generation of practitioners working with children and families. CBHI will send out an email alert to inform you when the website is live. If you have bookmarked any individual pages on the website, those links may have broken in the website redesign. You will need to update those bookmarks in your “Favorites”. Your feedback is important to us so please let us know what you think. You can send an email to: Managing Users that Leave Your Organization When a CANS user is no longer employed by a provider organization, the Access Administrator needs to be notified immediately so he/she can remove (deactivate) the CANS user’s access to the CBHI CANS Application for that organization. If a CANS user works for more than one provider organization, the CANS user has a single VG Username, but when logging in, he/she must indicate the or- ganization for which assessments need to be entered. Removing the CANS user’s access from one organization will not remove his/her access from the other organization(s). You will soon notice significant changes to the CBHI website. While most of the content will be familiar to veteran users, the website will be reorganized to allow for easier access to needed information. It also includes some new features: Quick Links: On each page of the website, users will be able access links to the CBHI Brochure and Companion Guide, information on applying for MassHealth, and contact information for plans and providers. Users will also be able to sign up for the CBHI list serv. A Streamlined CANS Page: Previously, users had to scroll through a very long list of items. The new CANS webpage will be divided into sections so that users CBHI Website to Unveil a New Look! can easily find what they are looking for, from CANS forms to reference guides. More improvements are planned for this section— we will keep you posted of the changes as they occur. Publications and Reports: Users will be able to access reports on screening, services and utilization that CBHI will now post to the website on a regular basis. Information for Early Education and Care, Pre K-12 School Personnel and Information for Higher Education: These sections are works in progress. Both sections aim to provide resources to edu- cators who work with students who have behavioral health needs. CBHI hopes the Using “Incomplete but Final” Status in the CANS ApplicationIncomplete information is a fact of clinical life. Generally a rating of ‘0’ on a CANS item indicates either no concern or no information. This ambi- guity is built into the CANS tool and is usually not a problem. A skilled clinical inquiry will usually lead you to those areas where you need to focus your in- formation gathering effort so that you will have needed information about those items that need to be rated higher than ‘0’. Therefore “no information” really will correlate with “no concern”. Higher Education section will also be a resource to educators preparing the next generation of practitioners working with children and families. CBHI will send out an email alert to inform you when the website is live. If you have bookmarked any individual pages on the website, those links may have broken in the website redesign. You will need to update those bookmarks in your “Favorites”. Your feedback is important to us so please let us know what you think. You can send an email to: cbhi@state.ma.usBut sometimes the assessment process is seriously derailed. For example, an inform- ant does not return for a second interview or leaves a 24-hour setting unexpectedly. In cases where large amounts of information are missing, it is appropriate to finalize the record as “Incomplete but Final”. ‘Incom- plete but Final’ is available as an option when there is not enough information available to complete the CANS. For more information on using ‘Incom- plete but Final’ status clickhereor see page 10 of Virtual Gateway Guidelines. CBHI encourages outpatient clinicians to take adequate time for the assessment. Note that MassHealth and MCEs allow up to two 90801-HA sessions for assessments done in outpatient. May 2011 | 5 CANSCalendar CANSContact Children’s Behavioral Health Initiative (CBHI) Mailbox: CBHI@state.ma.us Website: www.mass.gov/masshealth Click on CBHI link Virtual Gateway Virtual Gateway Customer Service Executive Office of Health and Human Services 100 Hancock Street, 5th floor, Quincy, MA 02171 Phone: (617) 984-1425 Fax: (617) 847-6575 Customer Service 800-421-0938 TTY: 617-988-3301 MassHealth Customer Service Center 800-841-2900 TTY: 800-497-4648 UMMS CANS Training Program 508-856 -1016 Mailbox: mass.cans@umassmed.edu Training Website: https://masscans.ehs.state.ma.us The University of Massachusetts Medical School is the contracted provider for MASS CANS Training and Certification for the Children’s Behavioral Health Initiative (CBHI) of the Massachusetts Executive Office of Health and Human Services