www.mass.gov/hhs/chapter257 eohhspospolicyoffice@state.ma.us Chapter 257 of the Acts of 2008 Provider Information and Dialogue Session: DCF/DMH Youth Residential Joint Procurement Program and Pricing June 3, 2011 www.mass.gov/hhs/chapter257 eohhspospolicyoffice@state.ma.us

Agenda Chapter 257 Implementation and Status Update Impact of Governor’s FY12 Supplemental Budget Filing Updated Implementation Timeline and Key Milestones Comparison of Current and Future Approach to Residential Services Continuum Wrap Model Program Design Draft Pricing Structure Follow Along and Stepping Out Models Procurement and Rate Setting Regulatory Timeline

Impact of Chapter 9 of the Acts of 2011 On April 11, 2011, the Governor signed into law Chapter 9 of the Acts of 2011, which amends the implementation timeline for Chapter 257 of the Acts of 2008. As amended, Chapter 257 will now require that a prospective rate setting process be implemented for not less than 40 percent of contracts with social service providers by January 1, 2012, 70 percent of such contracts by January 1, 2013, and for all contracts no later than January 1, 2014. EOHHS is developing communication to be posted on the Chapter 257 website and disseminated to departments and providers regarding the legislation, implementation plan, and activities that will be undertaken.

How will this legislation impact planned implementation? New implementation dates require meeting the current work schedule so that 40% of the POS system will have rates adopted by January 1, 2012. Delay reflects the amount of time needed to not only develop rate proposals, but to also plan for effective implementation. Allows for better alignment with the Commonwealth’s budget cycle; fiscal and client impact of proposed rates will be incorporated into Department spending plans and Governor’s budget proposal. Section 48 requires that departments not procure services, where procurement is necessary to implement regulated rates, prior to rate setting. New procurements may only be issued with the written approval of the Secretary based on a documented finding that the procurement is necessary to assure: Continuity of consumer health, safety, or access, Program integrity, where a new contract is necessary to replace an existing contract that terminated early due to unanticipated circumstances, or Compliance with a court order, settlement agreement, or statutory requirement.

Today and Tomorrow Current residential POS contracts are structured so that: Services end with discharge from the residential facility Community services post discharge are purchased separately, presenting a challenge for continuity Providers serving both DCF and DMH are held to different standards and requirements The planned contracting mechanism: Allows for integration of residential and community services within the same contract Allows for continuity of service post residential to promote successful transitions Creates consistent standards and expectations for both purchasing Agencies.

Highlights of New Expectations contained in Joint Standards (Required for All Models) Family Focus Increased family engagement and utilization of family partners in care planning and delivery. The family is the focus of the intervention and treatment: Voice and Choice Increased use of peer leaders with older adolescents: Voice and Choice Focus on School Achievement Requirement for Board Members with “lived experience” Family part of CQI process Quality Continuous Quality Improvement: Supporting positive outcomes in education, permanency, health and wellness Outcomes measured will reflect post discharge success in community tenure and school participation Performance Based Contracting: Develop performance contracts with financial incentives to leverage performance relative to client and system outcomes. Financial Incentives and reimbursement methodologies that support improved client outcomes. Performance measures that align with principles and reflect the primary desired outcomes. Records and Documentation: Includes joint reporting requirements and documentation

Continuum Wrap Model Child/youth at risk for residential placement and family identified as able to care for child at home (or work toward return home) with intensive supports Services delivered by a wrap-team across levels of care Services designed to support youth in their homes and families in their care-giving roles, including: Care planning and coordination In-home family treatment Parent support, Peer mentoring Youth and family outreach Crisis support Flex Funds Long-term and short-term out-of-home care if needed (e.g. group home, pre-independent living, foster care, respite) The Continuum emphasizes service integration and care continuity. The service can be provided by a community provider, a residential provider, or through subcontract as long as service continuity requirement is met.

Continuum Wrap Model __A_____B_______C________D__________E_____ Events during Continuum Wrap Program __A_____B_______C________D__________E_____ Child may utilize out-of-home or respite service Child leaves Residential Component of Program, (if ever utilized) Child/Fam assessed for community or residential Wrap Team works with child and family regardless of whether child is in the home or in a placement Child/Fam Discharged from entire program Continuum Wrap Services include: Care Coordination, Flexible Funds In -Home Family Treatment Parent Support, Peer Mentoring Crisis Support Youth and Family Outreach Long and short term out-of-home care if needed

DRAFT Continuum Model Budget: Community Wrap Slots: 30 Slot Days: 10,950   FTE Expense Management 2.00 11% Medical and Clinical Physician & Psychiatrist 0.10 2% Occupational Therapy 0.50 3% Social Worker - L.I.C.S.W. 1.00 5% Direct Care Peer Mentor Clinical Care Manager (MA) 4.00 18% Direct Care Staff 6.50 25% Relief 0.49 Support Prog Secretarial / Clerical Total Program Staff 16.09 64% Expenses Factor Tax and Fringe 23.42% 15% Total Compensation 79% Flex Funds $ 1,000 Occupancy 4% Other Expenses Additional Travel 1% Total Reimb excl M&G 89% Admin. Allocation 11.85% TOTAL 100% CAF: 5.39% UNIT RATE: TBD FTEs reflect staffing models recommended by the joint program design teams. Relief calculated at 7.5% of Direct Care Staff FTEs. Tax & Fringe, Admin Allocation percentages are consistent with other community residential models. Flex funds calculated as $1000 per slot. An estimated cost adjustment factor (Source: HIS Global Insights Massachusetts CPI Forecast-Spring 2011) is applied to account for inflation between the FY09 base year through the prospective rate period FY12-FY14.

CONTINUUM Model Budget - Group Home Intensive 1:3 DRAFT Continuum Model Budget: Residential GH 1:3 Adjusted for Continuum CONTINUUM Model Budget - Group Home Intensive 1:3 Beds: 12 Bed Days: 4,380   FTE Expense Management 1.75 10% Medical and Clinical Physician & Psychiatrist 0.10 2% Nursing (RN non-masters) 0.25 Occupational Therapy 0.50 3% Social Worker - L.I.C.S.W. 1.00 5% Direct Care Clinical Care Manager (MA) Direct Care Staff 13.20 40% Relief 1.98 6% Support Prog Secretarial / Clerical 1% Total Program Staff 19.53 70% Expenses Factor Tax and Fringe 23.42% 16% Total Compensation 86% Occupancy Other Expenses Nutrition Offset -1% Total Reimb excl M&G 89% Admin. Allocation 11.85% TOTAL 100% CAF: 5.39% UNIT RATE: TBD This model budget starts with the Group Home 1:3 and adjusts various resources considered included in the Community Wrap pricing to avoid double payment. The following adjustments include: Clinical Care Manager FTE reduced from 1.00 Direct Care Staff reduced from 15.00 Relief calculated accordingly at 15% of Direct Care FTEs Travel reduced to reflect reduced staffing

CONTINUUM Model Budget - Group Home 1:4 DRAFT Continuum Model Budget: Residential GH 1:4 Adjusted for Continuum CONTINUUM Model Budget - Group Home 1:4 Beds: 12 Bed Days: 4,380   FTE Expense Management 1.75 12% Medical and Clinical Nursing (RN non-masters) 0.25 2% Social Worker - L.I.C.S.W. 0.50 3% Direct Care Clinical Care Manager (MA) 1.00 5% Direct Care Staff 11.20 41% Relief 1.68 6% Support Prog Secretarial / Clerical 1% Total Program Staff 16.63 70% Expenses Factor Tax and Fringe 23.42% 16% Total Compensation 86% Occupancy Other Expenses Nutrition Offset -1% Total Reimb excl M&G 89% Admin. Allocation 11.85% 11% TOTAL 100% CAF: 5.39% UNIT RATE: TBD This model budget starts with the Group Home 1:4 and adjusts various resources considered included in the Community Wrap pricing to avoid double payment. The following adjustments include: Direct Care Staff reduced from 13.00 Relief calculated accordingly at 15% of Direct Care FTEs Travel reduced to reflect reduced staffing Additional residential models can be paired with the Community Wrap piece using the standard pricing model.

DRAFT Continuum Pricing: Sample Blended Per Diem Rate Program Community Wrap GH1 Adjusted IFC Total Served in Continuum # of Slots 30 12 1 Unit Rate Community Wrap Unit Rate $100 Total Cost Cost1 = Wrap Unit Rate x 30 Cost2 = GH Adj Unit Rate x 12 $100 x 1 Sum of Costs Blended Unit Rate: Sum of Costs/ 30 Slots The example above is based on a model for 30 children that includes the Community Wrap and assumes on a typical day 12 children are in a Group Home 1:3 residential program and 1 child is in Intensive Foster Care (rate set under 114.4 CMR 11.00). Blended rate is calculated by taking the sum of the total costs (Cost1+Cost2+$100) for each component and dividing by the total number of slots (30).

Introduction to Follow Along & Stepping Out

Community Reintegration Follow Along Follow Along – Residential Schools and Group Homes Services begin when family ( including kin, foster, etc) resource is ready to begin visitations Home based reintegration work 1 to 3 sessions per week After return home – sessions continue along with on-going access to groups and activities at res program 24/7 consultation to family Respite as needed at program Follow Along services emphasize service integration and care continuity. They can be provided by the residential provider, by a network of providers, or through subcontract as long as service continuity requirement is met.

__A_____B_______C________D__________E_____ Residential School, Intensive Group Home and Group Home Services with Follow Along Events during Residential Component of Program Events during Follow Along Component of Program __A_____B_______C________D__________E_____ Child enters Residential Component of Program Family Identified (if not identified at intake) Child/Fam ready to begin reunification Child leaves Residential Component of Program Child/Fam Discharged from entire program Follow Along Services include: Home Based Treatment, ~ 2 sessions/week (more during “peak” times) Continued access to groups/activities at residential program Respite as needed at residential program 24/7 access for consultation Joint Planning with school

DRAFT Follow Along Model Budget: Home-Based Services Slots: 3 Slot Days: 1,095   FTE Expense Management 0.25 19% Medical and Clinical Social Worker - L.I.C.S.W. 17% Direct Care Direct Care Staff 10% Relief 0.02 1% Support Prog Secretarial / Clerical 0.08 3% Total Program Staff 0.84 51% Expenses Factor Tax and Fringe 23.42% 12% Total Compensation 63% Flex Funds $ 1,000 4% Additional Travel $ 1,872 8% Other Expenses 14% Total Reimb excl M&G 89% Admin. Allocation 11.85% 11% TOTAL 100% CAF: 5.39% UNIT RATE: TBD Follow Along developed for children in Residential Schools, Group Home 1:3, and Group Home 1:4. FTEs reflect staffing models recommended by the joint program design teams. Relief calculated at 7.5% of Direct Care Staff FTEs. Tax & Fringe, Admin Allocation percentages are consistent with other community residential models. Flex funds calculated as $1000 per slot. Travel calculated from 90 miles per child per week, reimbursed at $0.40 per mile. A cost adjustment factor is applied to account for inflation between the FY09 base year through the prospective rate period FY12-FY14.

Community Reintegration Stepping Out Stepping Out – Pre-Independent and Independent Living Provides continuation of residential casework/manager function through the transition period in order to assist youth Stepping Out provides service integration and care continuity. They can be provided by the residential provider, by a network of providers, or through subcontract as long as service continuity requirement is met.

Pre IL and IL Services with Stepping Out Events during Residential Component of Program Events during Stepping Out Component of Program __A_________B_________C___________D_____________E___ Child enters Residential Component of Program Family / Lifelong Connection Identified (if not identified at intake) Youth ready to begin transition to independence Youth leaves Residential Component of Program Youth Discharged from entire program Stepping Out Services Include: Continuation of Casework Management Function Continued access to groups/activities at residential program 24/7 access to consultation

DRAFT Stepping Out Model Budget: Home-Based Services Slots: 6 Slot Days: 2,190   FTE Expense Management 0.25 14% Direct Care Case Worker Manager 0.60 23% Support Prog Secretarial / Clerical 0.13 4% Total Program Staff 0.98 41% Expenses Factor Tax and Fringe 23.42% 10% Total Compensation 51% Flex Funds $ 1,000 6% Additional Travel $ 1,872 12% Other Expenses 20% Total Reimb excl M&G 89% Admin. Allocation 11.85% 11% TOTAL 100% CAF: 5.39% UNIT RATE: TBD Stepping Out, a less intensive model, developed for children in Pre-Independent Living and Independent Living. FTEs reflect staffing models recommended by the joint program design teams. Tax & Fringe, Admin Allocation percentages are consistent with other community residential models. Flex funds calculated as $1000 per slot. Travel calculated from 90 miles per child per week, reimbursed at $0.40 per mile. A cost adjustment factor is applied to account for inflation between the FY09 base year through the prospective rate period FY12-FY14.

Implementation Timeline and Key Milestones for DCF Family Stabilization Services Service Design Finalized: All service components, staffing ratios, staff qualifications, other program inputs have been decided by the purchasing departments and approved by Commissioners. Executive Sign-Off: Commissioner and C257 Executive Committee sign-off on draft rates and implementation plan. EO485 Submitted to ANF: Draft rate regulation to ANF; Will better align the rate regulation proposal with budget planning. Procurement: DCF/DMH issue RFR and conduct procurement activities. Rates Effective: July 1, 2012.