Good morning, everyone. I have the pleasure of introducing our very own doctor Kate Sig Ford, a pete Pyschiatrist at our U CS F Children's Hospital Oakland. They attended medical school at U C Davis and then completed a physical medicine and rehabilitation residency at Stanford. Then they returned to their hometown of Saint Paul Minnesota for a fellowship in pediatric rehabilitation medicine at Gillette. And then afterwards, uh stayed in the Midwest for several more years working at uh the Stanford Health System. Um And then afterwards, it's been almost 2.5 years that they joined our team at U CS F in September of 2020. In addition to their uh clinical work. Um here they are chair elect of the American Academy of um cerebral palsy and developmental medicines membership committee and for fun. They compete in triathlons and play with their cat and I know that I always enjoy when another cat joins us on our Zoom division meetings. And personally, I have really benefited from all of their knowledge and experience from having worked at so many places over the years. So take it away, Kate. Well, thank you so much for those kind words in the introduction. Unfortunately, I'm presenting from work this morning, so Anna will not show up except you will get a, you will get a picture at the very end. Um, my topic today is going to be on M T U Regional Center and school. Um, these are, and I have, I guess I'm, I'm supposed to tell you that I have no disclosures, no relevant financial relationships. Um, the, these are three systems through which Children with disabilities can get services. And it is a confusing and complicated system that I think can lead to folks not getting all the services that they're eligible for. And so my goal today is to try to demystify this a little bit. Um First to describe the eligibility criteria for the regional Center, the CCS Medical Therapy program, um which sometimes is also called the M T, which is more commonly called the M T U. Uh and the school based services to differentiate qualifying versus non qualifying diagnosis for the CCS M T P services. Since that's a question that I answer a lot and then to identify barriers that families might face in receiving services for which they are eligible. Um There are multiple overlapping service providers for Children with physical and developmental disabilities, California children's services has both an administrative program and a medical therapy program and we'll talk about the difference there in just a minute. There's the regional center system and then there's the school districts. These, this is of course, on top of any services that Children get through their private health insurance and their, and their health care providers. Uh These are simply the uh state sponsored or required programs. First, California children's services is, was uh created by law in 1927. It is still governed by, by legislation makes it difficult to change anything. Um Which is good and bad. It is an expensive program and so it's maybe good. They can't change it easily, but it's also bad because we're working under still some uh in some cases, some antiquated definitions and ways of doing things. Um the medical therapy program then was established in 1945 to provide therapy services in a school setting. This is however not a program of the schools. Uh First off the administrative program serves Children from birth. Actually CCS in general serves Children from birth to their 21st birthday. Administrative and M T P. The administrative program provides medical coverage for Children who are residents of California have a qualifying medical condition and this is a pretty wide variety. This is a pretty wide scope definition of a qualifying medical condition and are low income. These folks are on full scope medic And with the family's adjusted gross income of less than $40,000 a year and expenses related to the medical condition are expected to exceed 20% of the adjusted gross income. So it's a it's not just any, it's so it's expensive medical conditions, particularly. Um The second part is the medical therapy program. This enrolls Children from their birth, from birth to 21st birthday, just like the administrative program. And for this, you also have to have a medically eligible condition, but the definition is far, far more narrow. Um here, the, here you can see the entirety of the definitions. I edited a little bit for brevity to fit it on one slide, but this is pretty much it. Um The There's a slightly different set of things that are required under the age of three. The most. The key of which that I want to call attention to today is that you don't necessarily have to have finalized any of these diagnoses but have a certain set of two or more out of five characteristics that might be pointing towards any of these diagnoses. Um And uh particularly important is that after the age of one hypotonia has to be accompanied by increased wheat reflexes to count as qualifying uh under cerebral palsy or anything else for the M T P under the age of one hypotonia with normal reflexes does also does also count. So my advice would be to have a low index of suspicion and look as early as possible. While the criteria are a little bit more generous kids can always get disenrolled, but that's a little bit kids can always get disenrolled, but better to have them have services for a while at the age of three, then they have to meet the full scope qualifying conditions. Um So what's so to compare the differences between the administrative and the M T P eligibility? Only a subset of the CCS eligible administrative conditions are eligible for the M T P services. Uh Administrative eligibility depends on financial status and M T P eligibility does not depend on financial status. The other. And the other important point about uh f financially is that medical therapy program services, therapy services are free to the family regardless of their insurance. So if somebody is on medical, it's free. If somebody is on private insurance and getting their therapy through the M T P, they cannot be charged the copay that their insurance would otherwise demand. So who can refer anyone can refer in theory, a parent can phone, can phone up and ask the school district can refer any physician. But documentation beyond the initial referral may be required to demonstrate that there is a proper qualifying condition um from a parent or from a physician if the parent refers sometimes from a relevant subspecialist if eligibility is unclear from a primary care note. Um here getting supporting documentation I would say is sometimes one of the barriers. I just as an example, I saw a kid last week um seven, eightish year old with a very clear uh with a very clear spastic hemiplegia. This had been the case probably since birth though he was adopted with very poor, adopted from overseas with very poor birth records. And so now at seven or 8, every doctor he had ever seen in the United States agreed he'd have had cerebral palsy. But he got, when he got referred to CCS, they denied him said he was ineligible until a psychiatrist or a neurologist said he had cerebral palsy. Um so he turned up in my office so I could say he had cerebral palsy just like everybody already thought. Um So required. So to open a case with CCS again, to review, you need to have an eligible diagnosis, a medical report clearly documenting the eligible diagnosis and a current prescription for P T and or O T services depending on which one, all of these then get sent to the relevant county's CCS office. Um Here's Alameda County's page on how to enroll it walks it through pretty easily step by step. We've got one of the, we've got uh a good county web page. It's very clear, easy to follow. So where are services provided? They're in dedicated spaces called the Medical Therapy Units which are located at selected schools. This is one of the places that confusion comes up um in that there is not always a clear differentiation in parents' minds between services provided at the school and services provided by the school. Um in trying to make sure that kids get everything there entitled to. You have to be very careful in talking with the families and make sure that if they're getting physical therapy at the school, are they getting it from the school or from the M T P or both? Because if they're eligible for both, you want to make sure they're getting both and don't just assume that, uh, and don't just assume that they're getting both or only getting one, um, I periodically have a patient whose parents would are pretty sure that they might have heard of the M T U once. Uh But nobody's talked to them from there for a long, long, long time. And so we call them up to get records and have notes from within the last two months. And the parents say, oh, I thought that was the school. So there's another barrier is understanding the difference between in the school and at the or you know, part of the school and just happens to be at the school. Um uh So here test your knowledge is the CCS medical therapy program part of the school system that should be obvious by now. No, it's not. Um what services can be provided by the M T P physical therapy, occupational therapy, case management, social work assessment of need for durable medical equipment, like bracing, like wheelchairs, like other special equipment that may include standard walkers, gate trainers, bath chairs, uh specialized car seats for kids who need more support than a commercial car seat for their uh size and weight would provide. These may also be um as a side note, those may also be called A O P DS or uh adapt uh adaptive orthoped uh automobile orthopedic positioning device. Got it. Um And then they have, but they don't provide the D M E themselves though. They may as though they assess for it and then they often may provide coordination with the vendor who's going to, who's going to provide the D M E. Um Many of the ones, many of ours here in Alameda and Contra Costa counties will have the brace. The orthotic vendor come to the clinic a day or a couple days a month so that the families can go where they're familiar and get their braces made, may have the may have wheelchair clinic a day or a couple days a month at their location again so that the families can go where they're familiar and get their wheelchair worked on. Finally, there are multidisciplinary medical conferences attended by the patient family, uh case manager P T O T and physician that provide recommendations on management of a CCS of the CCS eligible condition. So for physician services, Children enrolled in the medical therapy program and covered by C C S's primary insurance for their qualifying condition must be followed by a doctor and paneled by CCS in the relevant specialty. Um In many cases, then CCS also requires uh folks who are just in the administrative program to follow as well with a doctor in the relevant specialty and all of these should occur at a, at one of their designated care centers. CCS has decided certain that a hospital taking care of their medical conditions should have certain expertise, should have certain personnel to make sure that the kids are getting standard of care, uh type care, children's Oakland has a number of CCS, has a number of CCS clinics housed here in a number of different specialties for the medical therapy program. However, to be part of those multidisciplinary case conferences, the doctor goes out to the medical therapy unit and we see the patients there. Um Many of the Alameda County and Contra Costa County M T us are staffed by Children's Oakland physicians. We also through uh through both sides of the bay, hit some of the North Bay and the large number of outlying counties as well. Um This actually brings up, this actually leads into another problem though, which is that I think that none of the count, no county right now uses an epic based E M R if any E M R at all, Santa Clara County, I hear rumors is heading that way but no one is on. Um but no one is there right now, which means that there is no integration of what happens at the M T U with a child's record here at Children's Oakland or in fact, probably any other epic based care system that means that it is hard for you all. And in fact, us when we're sitting in our desks at Children's Oakland to know what physiatry did when we were out at the M T U. Um, and so it often looks, I think to a lot of other providers like where there are, like, there are many, many kids who should have rehab services and aren't getting them where in reality, we're seeing them quite regularly. And at the M T U, um we're trying, we try to work around that a couple of ways, either getting the final reports and scanning them into the chart here. But then you have to dig through all the scans or writing a 56 sentence uh documentation only encounter when we see him out there. But it's uh unfortunately a system that's not perfect and leads to things, leads to things slipping through the cracks. Um Our Alameda County sites are, are listed here. Um There's a little bit of a problem with West Oakland right now because their site, well, it's basically uh their traditional site is well, basically unfit for human habitation at the moment. So they're operating out of San Leandra, but that's left that part of the city without uh without a site as close as uh as close as it should be to the consumers. So next question, this one actually goes back a while. What age does a child age out of the medical therapy program. Uh and that is age 21. Next. The is the regional center system, the regional center system provides services for people with developmental disabilities. A regional center catchment area may be more than one county. So it's not exactly county by county like CCS. Uh For example, here we're served by the regional center of the East Bay which covers Alameda and Contra Costa counties. Again, anyone may refer to the regional Center but depending on where the referral comes from, there may be supporting documentation needed. Regional center eligibility is Based on a developmental disability. This is something that started before 18 uh continues or is expected to continue indefinitely and causes a substantial disability by definition. This includes intellectual disability, cerebral palsy, epilepsy and autism. It also includes closely related conditions but excludes solely physical disabilities. The definition possibly has a little bit of a difficulty in it. At least to me as a psychiatrist because it implies that everyone with cerebral palsy has a developmental disability and therefore an intellectual disability, which is not at all true. You can have um you can have normal intelligence with cerebral palsy. Um that aside, I think it's good that they have the service that aside, I think it's good they have the services. This provides the regional Center system provides services for all ages infants through older adults. Um eligibility wise at Uh there are again some exceptions in the infant toddler and preschool range from the what we saw in the previous slide, you can qualify under the standard criteria and as an infant up to 36 months, uh 25% delay in making developmental milestones is what is what substantial is defined as or you can qualify based on high risk of developmental disability. So if you see a kid with something in their, you know, in their birth history, in their uh prenatal history that suggests they are very likely to have a developmental disability. Go ahead uh and think about a referral to the regional center. You don't necessarily have to have proved it yet. You just have to up to up to the age of three, you just have to have a reasonable suspicion or believe that there's a high risk of a developmental disability. Um and then in preschool, again, the standard criteria or um you can still qualify based on having significant functional limitations in at least two major life activities without the diagnosis of developmental disability having to be finalized quite yet. uh a few months before the third and the 5th birthday, provisionally eligible Children should be as are assessed for the definitive diagnosis and eligibility and may be discharged if they don't, if they no longer meet criteria. So a child who is say admitted as high risk at the age of a year but goes on to make, make and exceed all their milestones may be discharged at the age of three or the, or the age of five. Um So I've said a lot about major areas and the major area, the five major areas that you have to be, that they look for delays in our self-care, receptive and expressive language. That's one together, learning, mobility and self direction. And again, all of these things have to be limited by uh cannot only be limited by a physical disability. There must be an intellectual or developmental component. OK. Next question, which of the following conditions is not a developmental disability as defined for the purposes of the Regional Center system? Uh Arthrogryposis is not um though you probably ought to refer that that child with arthrogryposis to hi to uh their local medical therapy program because they probably would qualify there. Um At what age does a child age out of the regional center? Um never or They transition from child to adult services at 18 or 21. But the answer is they can get regional center services for the rest of their lives. Um what does the regional center do? Lots and lots and lots of stuff, too much on this page to read it all? So next page is kind of a pullout of the things that I think are most relevant to us as pediatric providers. Um They provide early start and infant developmental services. They provide behavior management services. They provide P T O T and speech language pathology services. Um So in general, Since these are provided up, only up to the age three. In the regional center service system, many kids will get their initial three years of therapy at the regional center, particularly since um at least locally regional center of the East Bay is able to do some level of in-home therapies. It's not as much as it was before the pandemic, but there is still greater ability for the therapists to go in home than there is through the M T P. And it's just super convenient to have your therapists come to you as opposed to having to go to them. What happens at the 3rd birthday after the 3rd birthday though therapy services transition to the school district and the mt and the MTU. Um the retinal center also provides case management services. And then in terms of things, in terms of helping get things paid for, they may cover diapers for Children age 5 to 18. So that's after the uh after the expected age of continence who are in con who are still incontinent and at risk of skin breakdown. Now, technically, in the definition, it says at risk of skin breakdown, I'm not entirely convinced there's any child that isn't at risk of skin breakdown from where uh if they're incontinent. And I don't think that I've had anybody denied because they weren't at risk of skin breakdown. Um sec other thing is that they're, they are the payer of last resort for durable medical equipment. So um a piece of durable medical equipment that will be beneficial to the child is supported by a doctor and generally also by uh one of the child's therapists, but is not covered under any of the insurance plans may be paid for by the regional center. One example I think particularly of because it comes up a lot is um is a medical stroller. The distinction between a medical stroller and a standard manual wheelchair is a little bit esoteric. But for the, but for, for our purposes here, a manual wheelchair is probably is probably heavier, harder to fold up and throw in the back of your car, but also provides more support and is propelled by the kid. So there are benefits to both. A lot of families want, one of one of each insurance will pay for one, you get one wheeled mobility device. So in a lot of cases, they will get one probably the wheelchair through insurance. And then the second, probably the stroller through the regional center. Um Our local regional center is the, as I said, a couple slides ago is the regional center of the East Bay which serves Alameda and Contra Costa counties. Here's their, here's their web page. Um Then lastly, the school system, federal and state law require that students with disabilities must be provided with a free and appropriate public education, which is often abbreviated and which is often uh distilled to its acronym. This includes the requirement that education must be provided in the least restrictive environment and includes requirement that students make progress in the general education curriculum and towards achieving their I E P goals. Um So entry to special education for um the referral for assessment can be made by anyone again, but it must be legally, it's required to be made in writing to the school district. Um if it's made verbally, the law also says that the district personnel are supposed to help put it in writing. Will they always, I suppose it depends, It may depend on what kind of day they're having. I don't know. Um, but it's, it's required legally to be made in writing. The district must respond to the referral with a plan for assessment within 15 days and the parent has at least 15 days to respond to that plan. Once the parent signs the plan for assessment, the school then has 60 school days to complete the assessment and develop the IEP or individualized education plan. If the child is eligible, um, that can wrap from one end of the school year to the beginning of the next. So if the request is made, you know, within the last week or two of the school year, the district doesn't, isn't required to finish it over the summer unless it's a year round school, they're allowed to defer until the next until after summer break. Um I didn't get the age, I didn't get the age in here. The age is uh the age of entry to the school system for Children who may have need is three when they age out of the Regional Center System of Systems Therapy and they are transferred to the school district. The regional center is supposed to work on with this local school on a transition plan to ensure that there is no uh that there is no interruption in smooth providing and smooth provision of services. Um Under the idea, the individuals with disabilities education act uh originally passed in October of 1990 and uh modified several times. Since then, the qualifying conditions are visual impairment, including blindness, hearing impairment, including deafness, deaf blindness, orthopedic impairment, language or speech impairment, intellectual disability, autism, emotional disturbance, specific learning disability, traumatic brain injury, multiple disabilities and other health impairment. Other health impairment is a very broad and vague category. Um And they go on to say further about that, that it, that this could include any chronic or acute health problem that limits strength vitality or alertness. There's some discussion over whether A DH D can fit under health, other health impairment as something that limits alertness. Um So once this child is, is once it is decided that a child is eligible, I just lost my word. Um The school system is required in conjunction with the parent for developing an I E P and indi visualized education plan that lays out the student's current performance learning goals, what school they would be placed in and what services they need to be in that school and to achieve their learning goals. These goals must reflect meaningful educational progress for the child. Um They should be achievable but they should also be, but they should also be challenging and move the child forward. There is no one size fits all in writing the goals for some Children, an appropriate I E P goal will be passing grade equivalent classes. Um For others, you will have to spend a lot of time thinking about what is the current functional level and what can we achieve here. But you can't just write a goal. That's you can't just write a goal that is super easy and say, look, they have a goal, they made it, the goal has to represent meaningful progress. Um There was a lot, a lot of this, a lot of this question about making the goals comes from a lawsuit that's slipping in the name of it was slipping my mind, slipping my mind right now. Um in which uh parents of a student with an I E P in Colorado noticed that they were writing pretty much exactly the same goals into the I E P every year and, and with maybe, you know, marginal changes and claiming that the student was making progress, but these goals weren't leading towards anything useful or meaningful and so the parents wanted to dis enroll the ST the child in public school and enroll them in a private school and they did and the private school wrote meaningful goals. The students started making progress and I was never gonna, not necessarily, ever gonna pass all of his classes at grade level, but the progress but his progress accelerated quite dramatic, accelerated in a meaningful way. And so the parents went to court and said, look, you all got to pay for our private school because you weren't making any progress in the public school. And this is now a better free and appropriate education. Um Every lower level of court ruled against the parents, the Supreme Court ruled in favor of the parents saying yes, the school district's goals were, were not meaningful. They didn't represent a true appropriate education. Um Y'all either sort out your school district or pay for this private school. Supreme Court probably didn't say y'all. Um What does the school have to do in support of this? They actually have a pretty wide ranging, uh pretty wide ranging scope of responsibilities. Uh First, they're required to provide school health services. So this include, can include any service that does not have to be performed by a licensed physician. Um They have to provide gastrostomy tube feedings, they have to provide catheterizations or two of the things that I think that I often hear about folks getting stuck on. Um, they have to provide the, they have to provide medication administration. Anything that doesn't take a licensed physician to do the school may not depend on parents to perform this service. They can't say, oh, well, we can't do tube feedings. You have to come in and feed your child. Yes, I have heard that. Um, however, they don't have to do any medical service. The parent asks, the service has to be necessary for the child to benefit from special education. Um I have a hard time thinking of a medical service that would be necessary for the child's health but not necessary for education. Um However, that exception is there, the the school must provide a pair for professional aid if an aid is needed to benefit from education, this includes that if the student could be in a special or resource classroom without an aid or could go to a regular classroom without an aid, the aid is required the school district is required by law to provide the aid to meet the least restrictive environment criterion because being in a class with uh other typically developing Children or Children who are less a who are less affected by their disabilities is less restrictive than being in a classroom with uh kids who are more. Now again, this is another place that is sometimes an area of contention. How much does a child need an aid? Does a child need a personal aid? Does, is one or is it a 1-2 aid do enough. Um, in addition, the school is required to have a backup plan for if the aid is absent, it's not legally acceptable for the school to say. Oh, sorry, your aide called out sick. You can't go to school today. Does that happen? Yeah, absolutely. Um, but the school is supposed to have a backup plan then also the school is required to provide mental health services if they're required to benefit from education and likewise behavioral support services. Um Coming back around to coming back around to uh my profession as a physi uh as a psychiatrist, schools provide physical therapy, occupational therapy and speech therapy. Um School districts are responsible providing these therapy services if they are needed to benefit from special education. Even if an outside payer is not identified, the school district can ask the parent for permission to build their insurance. The parent does not have to grant this permission. And even if the parent doesn't grant permission or if there is no insurance, the school district still must provide these services. Um Now the law only requires the therapy in school to be necessary to benefit from special education. So the scope may be limited. Um for instance, a child may be able to get around school adequately by walking or using a wheelchair but not be able to run outside and play soccer on the playground and do the monkey bars. Is it necessary for an education? To do the monkey bars. Probably not. Yeah. Yeah. It's good for socialization. Yeah. It's good for health but it probably does not advance your actual learning, um, your actual academic learning. And so there are things that can be carved and so there are things that can be carved out because they are not necessary to benefit from special education. Um, if you think back to the, if you think back to the list of qualifying conditions I gave for an I for an I E P under idea it was relatively limited. So there's this other, there's this other law section five oh four, which is technically section five oh four of the Rehabilitation Act of 1973 which offers protections and the possibility for special services to Children who need them but do not qualify under idea anybody who has a physical or mental impairment, which substantially limits a major life activity is eligible. And it also covers students with a record of impairment and those regarded as having an impairment, whether or not they have that have an impairment. Um This is much broader in scope. So it covers a much broader range of uh so it covers a much broader range of impairments than idea does. It's also much less well defined legally. So where I could give you the exact timeline. If a parent asked for an I E P assessment, you have 15 days and 15 days and 60 days I section five oh four says a reasonable period of time. What's a reasonable period of time? And uh not entirely clear, probably not, probably not four months based on some court cases. Um But what exactly it is not defined likewise, what exactly impairments r um to a certain extent, the difference is a, to a certain extent as well. Um The five of section 504 has a little bit more of a focus on equitable access to services so the kids can get in to the school and get to their programs. Whereas the uh idea through the I E P focuses more on uh on the educational component but and a student can have one or can actually qualify for both. But honestly, the difference is a little bit murky. It's always been murky to me. I hoped I'd understand it better after uh after all the work I did on this talk and maybe it's a little bit better, but it's still a little but still murky. Um just I think know that Children could qualify, Children are eligible for school services could qualify, under idea could qualify under section 504. And your section 504 criteria are much broader. Um Looks like I didn't get in the last question slide that I intended to. So this one is gonna be verbal and it is um of the services I discussed today, the school based services, the Regional Center Services and the uh CCS program, how many of them can any child, can a single child be enrolled in? Um And the answer to that is all of them, as many as qual, as many as the, as many as the child qualifies for. Uh And there I think is where things sometimes tend to fall down because understanding that all these programs are there, understanding the differences and the eligibility requirements is tough getting through the amount of paperwork it takes to get enrolled in three bureaucratic in three bureaucratic programs is tough. Um And so help, help your families through it. Use your, use your social worker to help your families through it. They do mostly uh they do have resources to help with these things and make sure that every child gets the chance that they gets the chance that they need. Um Here as promised is the cat as the placeholder for uh for the questions. Thank you so much, Doctor Sigurd. Um If Maya is still with us, we can have doctor. No. Um maybe direct some questions. Looks like we have a lot of questions and comments. We do. A lot of them were fired off by our very own drazi this morning. Um I'm just gonna try to organize them a little bit here for you, Doctor Sig Ford. So um a lot of the questions had to do with like the differentiators between the programs, CCS regional centers school. So, well, let's see, one of the first ones was for someone younger than one with hypotonia and normal or low reflexes. Um Do they get to continue with the M T P until just one or until three? And then how do you select or counsel families on deciding between, um, the M T P versus Regional Center? Um, someone who qu someone who uses hypotonia with normal reflexes as one of their qualifying conditions under the age of one can continue, can continue through the age of three definitive diagnosis. Meeting the um meeting the standard childhood criteria needs to be made at the age of three. Um How do you coach on which one on which one to do? Um Children may be enrolled in the regional center and the M T P simultaneously. They probably can only get therapy services from one or the other. Otherwise it qualifies as duplication of services. Um So which one do you do? Many, many, many parents do regional center until the age of three, if the therapist will come to their home, just because it just because it gets um so much more convenient for the therapist to come to you than for you to have to go to them. Does it make a lot of difference in terms of quality of therapy? I don't think so. I think that both both can be very quality. Uh Regional center was slower at least locally to get back to in person therapy as we got to this point in the pandemic than the M T U was. So there was quite a while in there that I was saying more often get into the M T P so that you can be seen in person. Um There was another question down the line about like if somebody's getting Regional Center and then they age out at three, do you have to then get a new referral for the M T P? If regional center and M T P have separate referral pro processes. Um If they age out of therapy services at three, they do need a referral to the M T P but please start it before three so that it's in place at three. Great. And let's see. Another one of no Amy's questions is um some families have complained that the I E P and the M T U won't both duplicate like therapy services. So like how do you can coach the families on um how to navigate that and try to get as many services as possible? They are not allowed to. Yeah, you're, you're absol you're absolutely right. No, I mean, um there's this huge, huge deal about duplication of services and that's also, and it also comes into why we, a lot of kids we see as psychiatrists out at the M T U sites and not at show because that would be duplication of services. Um Children who have academic uh to get services in both places. The child must have academic therapy needs and outside of academic therapy needs. And then the M T P therapists and the school therapists work together and say, all right, M T P therapist, I'm gonna do these goals, school therapist, I'm gonna do these goals. So if they have enough goals to split up into school, academic goals and outside of school goals, so that everybody has a job, everybody is working on something and there is no duplication of services. You may still be able to get both. Um, and I think that's also gonna, I, I've got this open, I think that's also gonna, and I also gonna go jump off from there into another one. I know him. These questions. The answer is, um, the answer to the question of, uh, is it true that we can't manage medications at the M T US? Yes. Uh, it is, it is absolutely true. So, the vast majority of the, so the vast majority of kids who are enrolled in the M T P. But then also seen here at Children's Oakland Biop psychiatrists are one who are, uh, are ones who are on medications that we're managing. Um, and that is because we're not allowed to prescribe medications out of the M T US. And so it is, ah, you may, you may benefit from medication, come up to my office in Oakland. Um, let's see, there was a comment from Doctor Salzberg just lamenting that there's no interconnectivity in documentation between our systems, which is very true. Um She mentioned that school health clinics are connected to Epic, but outcome M T us can't be, well, they, they could be, they'd have to, the state would have to give them, the state would have to give them enough funding to buy. Epic. Um Oh, somebody asked when you were talking about a regional center covering behavior management, can you clarify about that? Um They are required to provide, they're supposed to provide behavioral management. So they do some of the assessment. So they do some of the assessments for things like autism, for things like a DH D they're supposed to provide um services. It's not something that I've had a whole lot of success with families, with families getting. Um There's a push now too. I feel like we learned recently where before I used to rely on Regional Center to try to at least work on getting the A B A for kids who have the diagnosis of A S D. But now they're like putting it back in the family's laps to try to find those services in the community somehow, which is extra hard. Yeah, I know. I mean, just added sorry to about the behavior. They do not do that insurance first. I still do have an occasional family that gets, that gets help and advice. It's not the long, it's not the long term treatment but help and advice. Um Somebody else asked about how, you know, there's the big drop in services through Regional Center at three. Is there any way we can help kind of smooth out that transition? The Regional Center is supposed to ensure that there is a smooth transition to school. So the first thing to do is to make sure that the the first thing to do is make sure that the parents know that regional centers should be transitioning them to the school district. Um because like a lot of other things that should be happening, it's not, it's not always something that gets talked about early enough that the families are ready for that, the families hear about a plan for. So first make sure that your families know that this, that this is going to happen, that they need to be asking questions about it. Um Second is, uh, see that you've got, make sure that you've gotten all other, make sure that you've gotten all other services that are possible in place. So is this a child who's also going to be eligible for the M T P? Get that referral made early enough that it can be that it can be in place and set by That, it can be in place and set by the time the child turns three. and last, I guess the last, I guess last is more of the second makes about uh about additional services, the uh making sure that if you need to send them on if the school is not gonna, is not gonna pick up enough. Make sure that, uh, if you need to send them on to therapy at a private center, you're, you're working with the family on that. Um, there's a question about, do you know of any publication that community docs can have in their offices to, um, help educate families on these services and how to access them. I don't know one that covers, I don't know one that covers all of them. Yeah. All right. Let's see. Oh, Doctor Hallberg asked, can Children do Children get N T U services during their school day? Yes. The school, the M T U therapists run on a typical, typical business day schedule, eight or 98 or nine to five o'clock. So some Children get, are able to get those prized slots after school. But the majority of the, the majority of the therapy appointments are doing are during school. And what's the typical frequency of therapies like for the M T P? It varies. It varies a lot, depending on where the child is and what their needs and what their needs are. Um, someone who the legally, there are three categories of, uh, of therapy need. There are those who have and there's a lot, there's a lot I could say about whether this is really a good, a good system, a good way to do it. But this is what we're working with legally right now. Um, there is every child is classified as being, having a good rehabilitation potential, meaning they have the possibility to rapidly make progress towards their goals. So these are the kids who, um, are young, still making a lot of developmental progress and need help getting along. These are the kids who are, you know, post surgery, you need to get back on their feet and then are, are kind of two of the big categories also other reasons. But those are two of the big categories. They're gonna move along really, really, they're gonna move a long way really fast. And those folks can get services um easily once a week, every once in a while, twice a week. Um fair means the child is going to make progress but is gonna make progress. But at a slower pace and so they don't get services, they don't get services quite as often. They depend more on having the, uh, on having period, on having therapy services to advance a home exercise program, uh that the families then keep reinforcing until there's ready for the next step. And then the last category is limited where either because of the child's medical condition, um developmental stage being about equal to what they've achieved at this at the moment or a number of other reasons. There is not a possibility to progress at this, at this moment. They need uh medical improved or they need, uh you know, they need their medical situation improved. They need to just develop a little more maturity, whatever. Um And those kids will just get periodic check in to see if whatever they're whatever is keeping them from progressing has resolved to allow them to get along far. Great. Ok, let's see. Um Somebody asks, how do like pediatricians get the documentation um about what's going on at the M T US? Um When the family is seen for one of the medical therapy conferences, the uh case manager or the, uh, the case manager, whoever is running, whoever is running that clinic visit in, in her uh in place to the case manager. Has the family signed a release of information form says, who can we send this? Who can we send today's report to? Um, or who do you want us to send this report to? And that could include, and that could include any doctor you could also request from them through the standard release of information process. OK. Um two minutes, Romina. OK. Let's see. Somebody asked for clarification about the, um ID A, the I DEA law. Hm. Um, idea is that individually in individuals with disabilities Education Act and that is the law that sets forth the, and that is the law that sets forth all the criteria that ultimately end up in, uh, getting I E P and getting services there. Ok. Um Kelly Jackman, one of the supervisors from Alameda County CCS wanted everyone to make sure to refer early, like 4 to 6 months before their third birthday if they're transitioning from Regional Center to the M T U. Um, and then in general, how do you just refer to the medical therapy program again? Um, every county will have, every county will have an office. Um, and you can find, and you can find that through the Department of Health at CAL of California's website. Um, or you may just, or you may find it just by, uh googling up the CCS and then whatever county you're interested in. Ok. That brings us to nine o'clock. So we're gonna close the meeting. Thank you so much for attending. Thank you to doctor. No, for guiding us through the plentiful questions and comments. And lastly, thank you so much, Doctor Sigurd for the talk today. Hope everyone has a great week. Thank you.