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.

At its June 13th status conference, the Court confronted the long standing and undisputed issue of waiting lists for home-based services, and specifically the lack of timely access to Intensive Care Coordination and In-Home Therapy, two services central to the Court’s Judgment.

After repeated requests for a concrete plan of action from Defendants to ensure timely access to remedial services, the Court concluded that it had no confidence such a plan was in place or would be forthcoming.  At the Court’s urging, Plaintiffs submitted a Motion and Proposed Order to Improve Access to Remedial Services, seeking specific actions designed to reduce waiting lists, and increase provider capacity.  Plaintiffs’ Memorandum in Support of Proposed Order to Improve Access, describes the rationale for these remedial actions.  

Defendants argued that no additional actions were necessary to improve timely access to services, since lengthy waiting lists and insufficient provider capacity were driven by workforce issues outside the Commonwealth’s control.  Defendants then renewed past assertions of compliance with the 2007 Judgment, and claimed that the Court had no authority to modify or enforce its Judgment, absent an evidentiary hearing and finding of noncompliance.

In light of these arguments, and in order to resolve disputes about the Court’s authority to order additional actions, Judge Ponsor directed Defendants to file a Motion Regarding Substantial Compliance, describing how they have substantially complied with the Court's remedial order of July 16, 2007. The Court also directed Plaintiffs to refile their Motion to Approve Joint Disengagement Measures and Motion to Modify the Judgment to Incorporate Provisions on Outpatient Therapy. Hearing on these motions is set for September 27, 2018, at which time U.S. District Judge Richard G. Stearns also will be present, since Judge Ponsor is retiring.

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.  

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