Rosie D.
Reforming the Mental Health System in Massachusetts

News Stories & Feature Article

Periodically, news of important implementation activities will be described, together with a short feature article on a topic relevant to the reform of the mental health system in Massachusetts.

Court Holds Status Conference on Access  

At its January 16th status conference, the Court raised concerns over continued delays in access to Intensive Care Coordination and In-Home Therapy, two services it identified as central to the 2007 Judgment.  The Court also expressed frustration with the State’s lack of specific, concrete actions to improve timely access to ICC and IHT.  It directed Defendants to submit a more detailed filing on this subject by February 22, 2018, and signaled the need for more frequent hearings to monitor implementation of those actions.  The parties next Status Conference is scheduled for March 1, 2018.

In November of 2017, the parties filed reports on the subject of access, including proposed actions to reduce waiting lists for ICC and IHT.  See Defendants’ Status Report On ICC and IHT; Plaintiffs’ Supplemental Report on Access Plaintiffs’ Report called for state-wide implementation of the ICC day rate, IHT rate increases, targeted quality assurance efforts, and an expansion of ICC and IHT provider capacity.

The parties established specific access standards as part of the Joint Disengagement Criteria. However, they were unable to agree on the final, numerical measure of compliance for calendar year 2018.  As a result, Plaintiffs’ asked that the Court establish this access standard, as contemplated in the parties’ Joint Disengagement Criteria.  Plaintiffs’ proposed standard would require a 7.5% improvement in access during calendar year 2018, for a total of 15% improvement over the two year disengagement period.  Plaintiffs expect the Court to take up this issue, and the implementation of specific actions to improve timely access to remedial services, at the upcoming Status Conference.

2017 Massachusetts Practice Review Shows Progress, Concerns 

The State has released its Massachusetts Practice Review (MPR) Practice Summary Report for fiscal year 2017. This report describes the findings from 121 individual reviews conducted in the fall of 2016 and the spring of 2017.  MPR results from this time period showed mixed findings with regard to the quality of practice in both IHT and ICC.  It is important to note that while IHT scores improved in several areas since June of 2016, ICC scores declined, including in those MPR areas discussed below. 

The FY2017 Report finds relative strengths the areas of accessibility of services, service responsiveness, cultural competence and youth/family engagement. However, problems with the quality of clinical assessments and service planning persist.  Only 30% of ICC assessments, and resulting service planning, received practice scores of good or better.  IHT assessments and service planning were scored good or better in 36% of cases reviewed.  While this represents an improvement in IHT practice, the quality of clinical assessments, and the resulting impact on individual service planning, remains a serious implementation concern.  Team formation scores for both services also remain low, at 35% for ICC and 36% for IHT. This area measures the extent to which providers actively engage formal and informal supports in the service planning and delivery process. ICC and IHT practice in the area of transition planning was found to be good or better in 38% and 39% of cases, respectively.  In the area of care coordination, practice was found to be good or better in 50% of ICC cases and 42% of IHT cases.

Overall, ICC and IHT practice both received a mean practice score of 3.3 percent.  According to the MPR rating system, this means the service “does not consistently meet established standards and best practices.” Recommendations for continuing practice improvement focus on workforce development and coaching, wider dissemination of training tools, and ongoing quality improvement initiatives addressing supervision, assessment and clinical understanding.

For a more detailed discussion of the MPR and its implications for ongoing disengagement efforts, see this month’s feature: The Massachusetts Practice Review: Measuring Compliance with Joint Disengagement Criteria.

Defendants Prepare To Release Report On Outpatient Services

Outpatient therapists are expected to provide care coordination for youth and families who are not receiving Intensive Care Coordination (ICC) or In-Home Therapy (IHT). As a result, the parties’ Joint Disengagement Criteria measure the adequacy of care coordination for class members who rely on outpatient therapists for this function.  The first report on outpatient care coordination is expected in early February, 2018. Its findings will provide a baseline for measuring improvements in the delivery of care coordination.

During the summer of 2017, the State’s Managed Care Entities (MCEs) were asked review a sample of outpatient provider charts.  The review was intended to evaluate care coordination occurring in outpatient therapy. After receiving the review protocol in September 2017, Plaintiffs expressed concerns regarding its design. The review did not included youth who had declined referrals to ICC or IHT in the prior 12 months.  Nor did it examine care coordination in cases where youth and families had transitioned from ICC or IHT in the previous year.

These and other methodological issues were resolved through subsequent negotiations, but occurred too late to impact the 2017 Report results.  Future changes to the 2018 outpatient chart review are described in the parties’ November 17, 2017 Joint Report on Disengagement.      

Feature Article 

The Massachusetts Practice Review:
Measuring Compliance with Joint Disengagement Criteria

The Massachusetts Practice Review (MPR) is the State’s primary mechanism for evaluating the quality and effectiveness of home-based services at the individual client level.  These reviews are focused on two remedial services central to the Court’s 2007 Judgment: Intensive Care Coordination (ICC) and In-Home Therapy (IHT).  Given its unique focus on the quality of individual service delivery, the MPR has an important role to play in measuring overall compliance with the Rosie D. remedial order.

As part of the MPR process, a random sample of youth and families is drawn from across the state, based on their participation in either ICC or IHT.  Once consent is obtained, trained reviewers examine relevant medical records and conduct interviews with multiple informants, including the youth, the caregiver and the IHT or ICC provider. The MPR examines service system performance across multiple domains, including youth and family progress.  Reviewers rate the quality of provider practice using a scale from 1 to 5, with 1 being adverse and 5 being exemplary. Individual scores are totaled together to determine what percentage of clinical practice experienced by youth and families in the review is adverse, poor, fair, good or exemplary.

Several compliance measures within the parties’ Joint Disengagement Criteria are based on results from the MPR, including the adequacy of care coordination, clinical assessments, service delivery, treatment planning, team formation and team participation.  In order to satisfy the annual Disengagement Measures, there must be a ten percent increase in the number of services considered “good or better” by the MPR.  This formula for incremental change uses baseline data from ICC and IHT system performance gathered in 2016.  Additionally, the Joint Disengagement Criteria require that no youth should experience “adverse practice” (a rating of 1 on the MPR scale) except in rare circumstances. 

A new set of MPR data on ICC practice, gathered during the fall of 2017, was released in mid-January, 2018. This new data has been designated as the measure of compliance for calendar year 2017 of the Disengagement Criteria. These scores show mixed results in the delivery of ICC.  Relative areas of strength (accessibility of services in the community, service responsiveness, cultural competence and youth/family engagement) are consistent with prior reviews. However, concerns remains regarding the quality of clinical assessments, as well as the effectiveness of care coordination and transition planning.

Data from the fall 2017 ICC review show practice exceeded the Joint Disengagement Criteria’s incremental progress requirements in two areas: team formation and team participation. However, ICC practice scores failed to meet the remaining 2017 Disengagement measures.  Only 45% of ICC practice scored good or better in service planning, falling 3% points short of the relevant disengagement measure. MPR results in other disengagement categories ranged from 5 to 10 percentage points below established disengagement standards.  The largest deficit was in the area of care coordination, where only 55% of practice was rated good or better.  Only 39% of ICC clinical assessments were rated good or better, 8% below the 2017 compliance measure. Across all MPR domains, there were seven findings of adverse practice.  Overall youth progress remains disappointing - with only 27% of those reviewed experiencing good or better progress as a result of services.

The FY2017 IHT practice review (the agreed upon measure for IHT compliance in calendar year 2017) met incremental disengagement measures for team formation, team participation and care coordination. However, it failed to meet benchmarks for assessment, service delivery, and service planning.

The MPR concluded that 42% of youth reviewed received care coordination that was rated good or better, a 13% improvement over FY 2016 MPR results.  Clinical assessments also improved over 2016. Practice in this area was rated good or better 36% of the time, but missed the 2017 disengagement measure by 3 points. Practice also improved slightly in the area of service delivery, but not enough to meet established disengagement benchmarks. Service planning scores were down 2% points from 2016, at 36%. Across all IHT categories, there were fifteen findings of adverse practice, six of which occurred in the area of care coordination. MPR progress ratings showed 36% of youth making good or better progress.

As the Joint Disengagement Criteria move into their second year, there is some measurable progress in certain MPR areas. However, more work needs to be done to ensure that youth in ICC and IHT have access to clinically appropriate assessments, treatment planning, service delivery, and care coordination.  

Read previous news and features.

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