Chapter 257 of the Acts of 2008

Chapter 257 of the Acts of 2008 Provider Information & Dialogue Session:Family Stabilization Service Class June 30, 2010 www.mass.gov/hhs/chapter257

Session Objectives • In this session, EOHHS seeks to: • Provide an overview of chapter 257 • Outline the programs and services that DMH and DCF will purchase and for which DHCFP will regulate rates under the Family Stabilization Service Class. • Provide a forum to discuss the rate structures and methodologies that are in development for identified Family Stabilization services. • Elicit provider input regarding the similarity of services purchased by both DMH and DCF and reimbursable under the Children’s Behavioral Health Initiative. • Outline tentative timelines for the DMH procurement and the rate regulation process.

OUTLINE • Chapter 257 Overview • DMH & DCF Family Stabilization Services to be Rated • DCF Comprehensive and DMH Family Systems Intervention Programs • Service Definition • Unit of Service • Models by staff qualifications and intensity • Discrete Services • Alignment of rates for similar services • Timeline • DMH Procurement • Rate Regulation & Promulgation

Chapter 257 of the Acts of 2008 regulates pricing for the POS system. • Chapter 257 places authority for determination of Purchase of Service reimbursement rates with the Division of Health Care Finance and Policy. • Chapter 257 requires that DHCFP consider the following criteria when setting and reviewing human service reimbursement rates: • Reasonable costs incurred by efficiently and economically operated providers • Reasonable costs to providers of any existing or new governmental mandate • Changes in costs associated with the delivery of services (e.g. inflation) • Substantial geographical differences in the costs of service delivery • Some rates within the POS system do not reflect consideration of these factors. • Additional funding was not appropriated to finance any potential cost increases associated with the law. • The statute specifies a four year implementation timeframe.

Family Stabilization Overview Service Class Definition:Programs that provide supports to enrolled individuals and families with the purpose of promoting stability, whether this involves preventing out-of-home placement, supporting transition between placements, or independent living. Today’s discussion will focus on Family Stabilization services purchased by DCF and DMH because of the large number of shared providers between the two departments.

The HCFP-led cost analysis and rate setting effort has several objectives and challenges. Pricing Analysis, Rate Development, Approval, and Hearing Process • Objectives and Benefits • Development of uniform analysis for standard pricing of common services • Rate setting under Chapter 257 will enable: • Predictable, reimbursement models that reduce unexplainable variation in rates among comparable, economically operated providers • Incorporation of inflation adjusted prospective pricing methodologies • Standard and regulated approach to assessing the impact of new service requirements into reimbursement rates • Transition from “cost reimbursement” to “unit rate” • Challenges • (Extremely) fast paced timeline • Constrained resources for implementation • Cross system collaboration and communication • Data availability and integrity (complete/correct) • Coordination of procurement with rate development activities Data Sources Identified or Developed Provider Consultation Cost Analysis & Rate Option Development Provider Consultation Review/ Approval: Departments, Secretariat, and Admin & Finance Public Comment and Hearing Possible Revision / Promulgation

Chapter 257 will result in greater consistency and transparency within the Family Stabilization Service Class. • Future System: • There will be consistency for service names and definitions within, and where appropriate across, Departments. • Purchasing Departments will pay the same rate for delivery of the same service. • Wherever possible the unit of service will be consistent for the same service within and across Departments. • Current System: • Depending on the region/ area or Purchasing Department: • The same service may be referred to with different names • A provider may receive different rates for the same service in-house or compared to another provider • A provider may need to bill for the same service in different manners (cost reimbursement, hourly, daily, monthly etc.)

DMH & DCF Family Stabilization Rate Regulation and Service Definition • DMH has redefined the services it will purchase under 3066 Individual and Family Flexible Supports in its new procurement. These services will transition from cost reimbursement to unit rates regulated by DHCFP . • DCF does not intend to change the services that it purchases. DCF will NOT re-procure its Family Networks Support & Stabilization services at this time. DCF will reimburse providers with rates DHCFP has regulated for a range of comprehensive and individual services at identified levels of intensity.

DMH Individual and Family Flexible SupportsService Components • Family Systems Intervention: • Family focused therapeutic interventions in a child’s home or other natural environment to improve the capacity of the family to better meet the needs of the child and of the child to function successfully within the context of his or her family and community. • Staffed with a team of : • A master’s level clinician trained in home-based intervention • A paraprofessional who serves as a family partner • under the direct leadership of a licensed mental health clinician • Youth Group Support : • Social emotional skill building and community integrationthroughformally organized 6 to 8 week psych-educational groups of 6-12 youth. Family activity groups involving youth, their siblings and caretakers are also included in this category. • Staffing: Clinician and a trained paraprofessional with a staff to client ratio of 1:4. • Individual Youth Support: • Non-school hour mentoring to assist a youth to develop the emotional self-management abilities, social skills, communication skills, pre-vocational skills, and self-confidence that are a requisite for participation in age appropriate activities with peers. Mentoring usually takes place in the community, and may be activity based. Work with informal groups of two or 3 youth at a time is also included under this component. • Staffing: Mentors with training, clinical experience and behavior management skills working under the direction of a licensed mental health professional.

DMH Individual and Family Flexible SupportsService Components (continued) • Collateral Contact/Consultation: • Collateral contacts by a clinician treating a child or adolescent to assure that there is a clinically coherent approach taken to the services provided to the child/adolescent. Collateral contacts may be with school staff and staff from other agencies providing services to a child/adolescent. Contacts may include: • Meetings and telephone calls • One-on-one • Observation of a child in a classroom or other community setting • Participation in team meetings. • This component will not be authorized: • For Youth receiving DMH Family Systems Intervention • If care coordination is reimbursable through public or private insurance • If collateral contacts and consultation are reimbursable through the individual or family’s public or private insurance. • Flexible Funds/ Client Financial Assistance • Limited sum of money for purchase of services or supports to the youth and family that are not available as part of this contract, through other DMH contracts, through other state agencies, and that are not reimbursable through insurance. The DMH Area will authorize expenditures of these flexible pool dollars, based on the needs of the youth and family and available funds • Specialty consultations • Academic tutoring • Camperships • Transportation expenses

DCF does not intend to change the services that it purchases (continued). DCF will NOT re-procure its Family Networks Support & Stabilization services at this time. As a result of discussions with HCFP and EOHHS, DCF has realized that it may be necessary to re-categorize services for pricing purposes. • Individual Service program models • Services are classified under one of the following categories: • Parent Support • Youth Support • Family Stabilization • Placement Diversion • Reunification • Assessment • Currently: • Services are categorized based on the recipient of the services or the goal of the services. • As a result, the same services could be classified under different models based on different goals. • Different Areas may categorize the same service differently. • Proposal Going Forward: • Services will be grouped into categories for rate setting based on the nature and cost drivers of the service. • There will be consistency for service names and pricing across Areas.

DCF does not intend to change the services that it purchases. Comprehensive program models RFR definition: Programs “that use teams whose staffing, interventions, and funding are blended in a manner that allows for varying levels of intensity, duration, and capacity for building strengths and managing risk with complex families.” • Currently: • DCF Area Staff identified numerous programs that: • Serve varying levels of intensity but do not offer a range of interventions. • Are not identified as Comprehensive Programs but do offer a range of interventions. • ProposalGoing Forward: • These will be re-categorized as discrete services. • These will be re-categorized as Comprehensive Programs.

DCF Comprehensive and DMH Family Systems Intervention Program Definitions

DCF Comprehensive and DMH Family Systems Intervention Programs Rate Development Unit of service: Enrolled client day Staff positions were split into the following general Staff Categories:

DCF Comprehensive and DMH Family Systems Intervention Programs Rate Development (continued) • Rate Development Process: • DMH specified staffing model for Family Systems Intervention program. • DCF field staff identified contracts that provide a comprehensive array of services. • DHCFP grouped contracts together according to staff qualifications and relative staffing intensities. • There are currently 7 staffing models that fall under 3 main categories: • Direct Care Models • Non-management staff are non-Masters direct care staff only • 2 models with varying levels of staffing intensity • Blended & Clinical Models • The complement and intensity of staff vary, but the costs are constant. • Non-management staffing models: • 1:1 clinician to direct care staff • Mostly direct carewith some clinical • All clinical staff • Higher Intensity Blended Models • 2 models: both with intensive clinical staffing, each with a different level of direct care intensity. • HCFP derived percentages of staffing and non staffing expenses from the weighted average of contracts in each grouping. • The tax and fringe percentage was taken for FY09 UFR data for Activity codes 3066 and FNSS.

DRAFT Model Budgets for Direct Care Comprehensive Programs • Staffing ratios represent client per staff member. • Both models have 1 management FTE for every 48 consumers. • A-1 is a less intensive model with 7 consumers for every Direct Care FTE while Model A-2 has 4 consumers for every Direct Care FTE. • Models in this presentation are based on an 11 client capacity. Per client costs will remain constant for all programs regardless of capacity.

DRAFT Model Budgets for Blended & Clinical Comprehensive and Family Systems Intervention Models (2 of 3) • Model B relies on the same staffing pattern (1 clinical FTE to 1 DC FTE) as the DMH Family Systems Intervention Model. • DHCFP is considering splitting Model B out into 2 intensity levels. • Providers under Models A, B and C are able to offer different staffing patterns at a similar cost by “trading off” level of intensity and staff qualifications. For example, a provider that has a similar staffing intensity for both clinical and direct care staff can face the same costs as a provider that chooses more intensive direct care staffing paired with less intensive clinical staffing.

DRAFT Model Budgets for Blended & Clinical Comprehensive and Family Systems Intervention Models (3 of 3)

DRAFT Model Budgets for Higher Intensity Blended Comprehensive Models

Discrete Services • DMH is planning to purchase the following discrete services: • Individual Youth Support • Youth Support Groups • Collateral Contact/ Consultation • Flexible Funds • DHCFP, EOHHS and DCF are working together to identify the range of discrete services purchased under Support and Stabilization. We will reconvene providers at a future date to review the complete list of services and to discuss rate setting methodologies. For today’s session, we will discuss the following discrete services: • Mentoring • Parent Aide • Parent Coach • Psychological Evaluations • Psychological Assessments • For each individual service, DCF and DHCFP will identify any similar services with existing rates that may be appropriate. DHCFP will identify the range of staffing models and intensities within each service type to ascertain whether multiple rates will be necessary.

Discrete Services: Youth Mentoring • DMH’s Individual Youth Support component appears similar to the mentoring services DCF purchases. Both appear similar in definition to the Therapeutic Mentoring service covered under the Children’s Behavioral Health Initiative. • Questions for Providers: • In your experience, would these services be similar? • How may they differ? • Is DCF Youth Mentoring done on an individual or group basis, or both?

Discrete Services: DMH Youth Group Support DMH Youth Group Support Social emotional skill building and community integrationthroughformally organized 6 to 8 week psych-educational groups of 6-12 youth. • Questions for Providers: • Under the DMH component, youth engage in activities such as bowling, yoga, arts and crafts, karate, etc. • How should the cost of these activities be covered? • By building an allowance into the rate • Through Flex dollars, separate from the rate • Other? • Do DCF mentoring services include comparable activities? • DHCFP will build a model budget based on: • An average group size of 6-12 youth • A staff to client ratio of 1:4 • A staffing model that includes a clinician and a trained paraprofessional.

Discrete Services: DMHCollateral Contact/ Consultation • DMH Collateral Contact/Consultation • Collateral contacts by a clinician treating a child or adolescent to assure that there is a clinically coherent approach taken to the services provided to the child/adolescent. Collateral contacts may be with school staff and staff from other agencies providing services to a child/adolescent. Contacts may include: • Meetings and telephone calls • One-on-one • Observation of a child in a classroom or other community setting • Participation in team meetings. • This component will not be authorized: • For Youth receiving DMH Family Systems Intervention • If care coordination is reimbursable through public or private insurance • If collateral contacts and consultation are reimbursable through the individual or family’s public or private insurance. • Questions for Providers: • What services do youth receive for which these collateral activities are not covered?

Discrete Services: DMH Flexible funding/ Client Financial Assistance • Flexible Funds/ Client Financial Assistance • Limited sum of money for purchase of services or supports to the youth and family that are not available as part of this contract, through other DMH contracts, through other state agencies, and that are not reimbursable through insurance. The DMH Area will authorize expenditures of these flexible pool dollars, based on the needs of the youth and family and available funds • Specialty consultations • Academic tutoring • Camperships • Transportation expenses • DHCFP is currently working with DDS and DMH to develop a way to compensate providers for administering client funds. • Questions for Providers: • What kind of services and items are purchased utilizing flexible funds? • What is the dollar range for expenditures? • How much time does a staff person generally spend from identifying the family’s need to securing the product or service? • What staff position generally does the work to secure the product or service? • Are receipts always available for the product or service purchased?

Discrete Services: DCF Parent Aide and Parent Coach Programs • DCF Area Staff have identified Parent Aide and Parent Coach programs as discrete services currently provided under Support & Stabilization. These services appear similar in definition to the Family Support and Training/ Family Partner services covered under CBHI. • Questions for Providers: • How may Parent Aide and Parent Coach services differ? How are they similar? • How do they compare to the CBHI service?

Discrete Services: DCF Psychological Evaluations and Assessments • DHCFP has existing rates for psychological services. DHCFP and DCF are evaluating this regulation to determine if the rates are appropriate for the Psychological Evaluations and Assessments purchased by DCF under Support and Stabilization. • 114.3 CMR 29.00:PSYCHOLOGICAL SERVICES • 114.3 CMR 6.00: RATES OF PAYMENT FOR MENTAL HEALTH SERVICES PROVIDED IN COMMUNITY HEALTH CENTERS AND MENTAL HEALTH CENTERS

DRAFT Time Lines for DMH Procurement and Rate Promulgation Rate Development Provider Involvement DMH Procurement • DHCFP may modify this timeline and propose rates in stages in order to: • Enable DMH to reprocure services on their planned timeline • Allow sufficient time to develop rates for the full complement of DCF Support and Stabilization services

Chapter 257 of the Acts of 2008