Rosie D.
Reforming the Mental Health System in Massachusetts

Service Design and Delivery Principles

The development, implementation, and evaluation of the system of home-based services described in the Rosie D. Remedial Plan conform to the well-established child-centered, family-driven principles.  These principles were originally developed in the 1980s by a federal consensus panel sponsored by SAMHSA, and form the basis for most federally-funded systems of care initiatives.  They are incorporated in a court-approved settlement of similar case in Arizona, J.K. v. Eden, as well as the MHSPY and CFFC demonstration programs in Massachusetts.

    1.        Collaboration with the child and family - Respect for and active collaboration with the child and parents is the cornerstone to achieving positive behavioral health outcomes. Parents and children are treated as partners in the assessment process and in the planning, delivery and evaluation of home-based services.


    2.        Functional outcomes - In-home support services are designed and implemented to aid children to achieve success in school, to remain with their families, to avoid delinquency, and to become stable and productive adults.  Implementation of the individual treatment plan stabilizes the child's condition and minimizes safety risks.


   3.        Collaboration with others - A comprehensive assessment is developed and an individual care plan is collaboratively implemented.  The care planning team plans and delivers needed services.  Each child's team includes the child and parents and any foster parents, and any individual important in the child's life who is invited to participate by the child or parents.  The team also includes all other persons needed to develop an effective plan, including, as appropriate, relevant service providers, the child's teacher, the child's DSS, DYS, DMH, or DMR case manager or worker, and the child's probation officer. The team develops an integrated care plan, monitors implementation of the plan, and makes adjustments in the plan if it is not succeeding.


    4.        Accessible services - Children have access to a comprehensive array of home-based and other behavioral health services, sufficient to ensure that they receive medically necessary treatment.  Care management is provided for all SED children who need services from more than one provider or agency, and would benefit from an integrated care plan.  The care plan identifies transportation the parents and child need to access in-home support services and how transportation assistance will be provided. 


    5.        Best practices - Home-based services are provided by competent individuals who are adequately trained and supervised.  Home-based services are delivered in accordance with guidelines that incorporate quality services.  The care plan addresses mental health conditions, substance abuse problems, the specialized behavioral health needs of children who have challenging behaviors, including abusive conduct and risky behavior, and the need for stability and the promotion of permanency in the child’s life, especially for children in foster care.  Home-based services are continuously evaluated and modified if ineffective in achieving desired outcomes.


    6.        Most appropriate setting - Children are provided home-based and other behavioral health services in their home and community to the extent possible, and in the most integrated setting appropriate to the child's needs. 


    7.        Timeliness - Children identified as needing home-based services are assessed and served promptly.


    8.        Services tailored to the child and family - The unique strengths and needs of children and their families dictate the type, mix, and intensity of home-based and other behavioral health services.  Parents and children are encouraged and assisted to articulate their own strengths and needs, the goals they are seeking, and the services they believe are required to meet these goals.


    9.        StabilityThe treatment team uses the care plan to minimize multiple placements.  Care plans identify whether a class member is at risk of experiencing a placement disruption and, if so, identify the steps to be taken to minimize or eliminate the risk.  The team anticipates crises that might develop and include specific strategies and services that will be employed if a crisis develops.  In responding to crises, the care plan incorporates all appropriate home-based and other behavioral health services to help the child remain at home, minimize placement disruptions, and avoid the inappropriate use of the police and the criminal justice system.  The care plan anticipates and appropriately plans for transitions in children's lives, including transitions to new schools and new placements, and transitions to adult services.


    10.      Respect for the child and family's unique cultural heritage - Home-based services are provided in a manner that respects the cultural tradition and heritage of the child and family. 


    11.      Independence - Home-based services include support and training for parents in meeting their child=s behavioral health needs and support and training for children in self-management.  The care plan identifies parents= and children=s need for training and support to participate as partners in the assessment process, and in the planning, delivery and evaluation of services, and provides that training and support, including transportation assistance and assistance in understanding written materials.


    12.      Connection to natural supports -The care plan identifies and appropriately utilizes natural supports available from the child and parents= own network of associates, including friends and neighbors, and from community organizations, including service and religious organizations.


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