By:    Massachusetts Inter-Agency Disability Services Coordinating Council
          One Ashburton Place, Room 1305, Boston, MA 02108
          [617] 727-7440 (V/TTY), [800] 322-2020 (V/TTY), [617] 727-0965 (FAX)                                                    Revised January 2000

References

Bibliography

INTRODUCTION
The purpose of this report is to provide information regarding the service system for people with disabilities in the Commonwealth. It includes recommendations to the Governor and the Legislature on ways to improve the accessibility and delivery of services.

The report is divided into four sections. Each section includes Findings and Recommendations. The first looks at disability services for infants and toddlers from birth through age 2. It is followed by services for children from 3 to age 5, adolescents and young adults from 5 to 22 years of age, and concludes with the fourth section which focuses on adults.

Appendixes A (Ages 0-5), B (Ages 5-22) and C (Adults) are a series of tables which apply to each of the sections. (Appendix A includes infants and children to age 5.) They identify programs/services from a cross-agency perspective. The tables contain basic information on the various agencies that provide services, the methods by which services are accessed, eligibility criteria, funding sources, barriers and comments. Accompanying footnotes elaborate particular aspects of a chart's text where appropriate.

This report is the result of three individual studies. Its information has been updated and accurately reflects the disability service system as of January 1998. It is a project of the Inter-Agency Disability Services Coordinating Council (Executive Order 352) which has been meeting since late 1994.

The Council's goal is to better serve recipients of state disability services by increased coordination of services, information and communication. Its members consist of representatives from the following agencies and departments which deliver services to people with disabilities in the Commonwealth: the Director of the Massachusetts Office on Disability (MOD) who chairs the Council; Massachusetts Rehabilitation Commission (MRC); the Massachusetts Commission for the Blind (MCB); the Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH); the Department of Mental Health (DMH); the Department of Mental Retardation (DMR); the Department of Transitional Assistance (DTA); the Massachusetts Commission Against Discrimination (MCAD); the Disabled Persons Protection Commission (DPPC); the Governor's Commission on Mental Retardation; the Architectural Access Board (AAB); the Massachusetts Developmental Disabilities Council(MDDC); the Department of Special Education; the Division of Medical Assistance (DMA); the Executive Office of Elder Affairs (EOEA); the Department of Public Health (DPH) and the Executive Office of Transportation and Construction (EOTC).

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Information for this report was obtained from members of the Council, and numerous other sources. On behalf of the Inter-Agency Disability Services Coordinating Council, thank you to everyone who contributed.

The Inter-Agency Disability Services Coordinating Council sought information for this report from a variety of resources. It began with:

A questionnaire was sent to all Inter-agency Disability Services Coordinating Council representatives. It requested information on: agency function, target population, services provided (programs and their descriptions), method of accessing services (direct self-referral or indirect), eligibility criteria, providers of services (public or private), funding sources (state, federal, private, or other), service gaps, numbers on waiting lists and average time waited, unmet need for services including an explanation of the way that need is computed, percentage of dollars allocated to service delivery, and administrative costs vis-a-vis direct service costs. A similar questionnaire was also sent to a group of community non-profit agencies which represented and worked with people with disabilities.

Follow-up phone calls and interviews were made to program heads in both state agencies and community-based non-profits. In addition, numerous phone and in-person interviews were conducted with consumers, family members, and advocates in both the state system and the community. These interviews addressed the individual's personal experience in seeking services through the public system including its community-based contractors. Interviews focused on issues which were perceived as barriers to, or gaps in service, and recommendations for reforms which would facilitate improvements in service delivery.

Further documentation was provided through reports which focused on specific issues and services, and documents which explicated eligibility guidelines and regulations.

The information gathered originally was compiled into three reports and distributed for comments before being produced. The first report was issued in December 1995, the second in May 1996, and the third in June 1997.

This report is a compilation of those that preceded it. It has been updated by the appropriate agencies to reflect the current status of the various programs identified within.

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Early Intervention (EI) is the primary program that provides services for children (from birth through age 2) with disabilities, or children who are at risk, biologically or environmentally, of developmental delay. EI is housed in the Department of Public Health's Children with Special Health Care Needs Division. The program focuses on including and empowering families - i.e. the service environment adapts to the family, it is supportive of care givers, and it trains parents to provide needed skills. Services after age 2 are not provided through a single program.

FINDINGS:

1. Early Intervention should strive to serve children more frequently in natural settings such as integrated toddler groups in day care rather than groups that focus on a particular disability need. Integrated groups should not preclude the need for day care workers to be trained in working with children who have specific disabilities, nor should day care be considered a substitute for training parents in how to care for a child's disability.
2. The voluntary aspect of the EI program can be a problem for some children who are considered to be at risk - (some parents may be unaware or unwilling to admit that there is a potential environmental risk^1/ to a child's development.
3. Services specific to certain severe or low incidence^2/ disabilities such as autism or hearing loss, are not yet fully in place with ready access and complete training, to interface with specialty providers.
4. Children who age out of EI (3 year olds) who do not have a diagnosed disability which meets the Chapter 766 eligibility criteria^3/ (most likely the at-risk child, such as one who is HIV positive), may experience some service gaps.^4/ This is due to the fact that the broad eligibility requirements for EI and Chapter 766 differ. In some cases a child may be eligible through an LEA-funded program which is not part of special education, or s/he may qualify for a state subsidized child care program.
5. There are generally no dollars for providing respite care services.
6. A shortage of in-home nursing staff exists for families of children with special health care needs.^5/
7. Providers of special services are limited.
8. Housing resources for families, including home adaptations such as wheelchair ramps or an accessible bathroom, are extremely limited.^6/
9. A smooth transition process is needed for families moving from EI, which is family focused, to Special Education which is child focused.
10. Funding is not a barrier because it is an entitlement, but adequate funding for services for children with disabilities or at risk of developmental delay is not necessarily assured.

RECOMMENDATIONS: (Some recommendations reflect more than one Finding)

1. Expand outreach and education to professionals who are involved in the diagnosis and treatment of children with disabilities.
2. Implement universal screening for hearing loss to make an early diagnosis.
3. Increase training in parenting programs to prepare parents in responsible child-rearing skills. These programs are inherently preventive in that they help mitigate burn-out, abuse and neglect among parents of a child with a disability or at risk of developmental delay, who are unprepared for the task of raising a child.
4. Fund respite services; they are cost effective, and may preclude the need for expensive, intensive, family support services when a crisis occurs.
5. The potential for expanding child care services in the under 3 population should be increased. EI should not be the only source.
6. Work with home health and other nursing agencies to promote in-home nursing services. Providing services, such as shuttle buses or escorts, may encourage health care workers to provide nursing services in areas considered hazardous.

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Footnotes for Birth to 3:

^1/    "...Environmental risk infants are those who are biologically sound but whose early life experience, including maternal and family care, health care, nutrition, opportunities for expression od adaptive behaviors, and patterns of physical and social stimulation are sufficiently limited to the extent that they impart high probability of delayed development." (Early Intervention Operational Standards 5/94.)

^2/    Low incidence disabilities are severe disabilities which have a low prevalence rate in the general population.  Each low incidence disability has unique needs and requires special knowlegde of professionals and parents in order to effect maximum development.

^3/    "Eligibility Guidelines for Special Education," Massachusetts Department of Education, October 1994, pp. 11-19.

^4/    A child's continued need for services does not assume that the issues which made that child eligible for the EI program have been successfully addressed within the limits of that program.

^5/    "There's No Place Like Home, Meeting the Housing Needs of Families of Children with Special Health Care Needs," A Report for Franciscan Children's Hospital and Rehabilitation Center, Boston, Massachusetts, December 1994, p. 3.

^6/    "There's No Place Like Home, Meeting the Housing Needs of Families of Children with Special Health Care Needs," pp. 20-25.

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FINDINGS:

1. The system is fragmented; it requires frequent transitions (particularly for children who are continually aging out of systems) and is disruptive to families. This is due to the fact that the system is driven by separate funding streams, different eligibility criteria and agency focus rather than individual need. For example, a child with special health care needs might enter the system through Medicaid, the reimbursement agency; her case would be managed by DPH and actual services would be provided by a contracting agency in the community. If she is in the Early Intervention Program she ages out when she is 3. The family is then faced with entering another system (preschool, if eligible or day care, if affordable) until that child is 5; she then leaves that system to enter school.
2. Case management services are duplicated from agency to agency. This is not cost effective.
3. Outreach is limited by limited budgets and funding caps.
4. No accurate numbers exist on the "unmet" need for services. Waiting lists only identify those people who are in the system. Current projections of the unmet need are extrapolations based on national disability prevalence rates.
5. There is considerable expertise on specific disabilities in the existing agency structure which could be more effectively utilized through inter-agency collaboration.
6. Access to specialized programs may be impeded by a lack of transportation.
7. Early childhood programs (pre-kindergarten) are not affordable or accessible to all 3 and 4 year olds.^7/

RECOMMENDATIONS: (Some recommendations reflect more than one Finding)

1. Establish a central information and referral system to provide up-to-date, reliable information. This would be effective in not only directing consumers but in providing specialized information about types of services as well as eligibility criteria for those services. This will cut down on the number of calls placed directly to agencies and provide more comprehensive information to the public.
2. Multiple agencies are often involved in providing services to an individual. Inter-agency service coordination can be improved by: (a) utilizing inter-agency service agreements (ISAs), (b) implementing appropriate legislative and regulatory changes and (c) seeking federal waivers
3. Remove rigid category definitions. They create barriers to access and service delivery at both the state and federal levels. However, the particular needs of people who are blind or deaf must be recognized.
4. A functional assessment tool to determine mental illness in very young children should be utilized. Mental illness in children under 3 is identified under Early Intervention; however, it is rarely recognized as such in this age group. Children from 3 - 6 years old fall into a huge gap because, (a) there is no standard process for screening and assessment (a) the public mental health system is oriented towards treatment of severe emotional disturbance (SED). As a result, children who may have a mental illness but do not meet the disability definition fall into a huge gap.
5. Itinerant consultants with expertise in specific disabilities could be utilized to provide joint training and assist with Individualized Family Support Plans (IFSPs) for Early Intervention, Preschool and HeadStart teachers.
6. Actively promote utilization of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to ensure good, preventive health care for children, and to maximize federal Medicaid dollars in the Commonwealth.
7. Establish a funding pool for transportation to programs and services for low income children with disabilities and their parents.
8. Implement a funding plan which ensures that all pre-school children have the opportunity to participate in early education programs in their communities.

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Footnotes for Age 3 to 5:

^7/    "Children First: A Plan for an Early Care and Education System for Masssachusetts," A Report for the Special Commission on Early Childhood, December 1995, p. 9.

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FINDINGS:

1. Special Education is the focus of most services which are provided for children and adolescents with disabilities once they reach school age.^8/ Linkages between Special Education and the human service agencies that have expertise in particular disabilities vary significantly across the state. Collaborative relationships are strong in some places, but in most they are weak.^9/
2. Age eligibility standards are inconsistent throughout agencies with the result that adolescents (around 18 years old) often fall into gaps when they age out of one system and are too young to enter the adult system (age 22).^10/
3. The present system of contracting for residential programs limits agencies and their clients (i.e. agencies must commit dollars prior to actual need and they are bound to the programs with which they contract). However, related to deaf children, it may be expedient to contract for this type of service in order to ensure the ready availability of staff in a residential facility who can fully communicate with children who use American Sign Language (ASL) or a manually coded English Sign System.
4. Lack of accessible transportation is pervasive in the Commonwealth and creates major barriers for individuals who are dependent on it to receive services and avoid social isolation.^11/
5. There is a need for more recreational and social programs which include children with disabilities.
6. The Department of Social Service's (DSS) important priority of protecting children from abuse has inadvertently diverted attention from serving the needs of families in which a disability exists.
7. No regulations exist that specifically require licensees of after-school programs to be accessible. (Note: regulations do exist requiring licensees of infant and pre-school programs to hold those programs in accessible places).

RECOMMENDATIONS: (Some recommendations reflect more than one Finding)

1. Provide sensitivity trainings for DSS workers in issues specific to children with disabilities and their families and collaborate, through Interagency Service Agreements (ISAs) with disability service agencies, on programs and services which would pre-empt crisis situations for families with a disabled child.
2. Delegate responsibility for an individual client to a lead case manager (when dual or multi agency service provisions) and define agency links so that families do not have to deal with more than one case manager at a time, unless it is determined that a co-case manager is appropriate to provide assistance to the lead regarding technical assistance in a specialty area. In most other cases, when more than one agency is involved, the services of each should be defined in a service plan and should be complimentary. This would preclude duplication of services, including case management, which is burdensome for an individual, and not cost ineffective.
3. A more flexible system for purchasing residential services would enable agencies to buy program slots based on need and client-appropriateness; currently agencies contract for them.
4. Develop stronger linkages through inter-agency service agreements (ISAs) that support more effective coordination of programs and initiatives (such as School to Work), and job-skills training of consumers among DOE, MRC, DMR and other relevant agencies. This would be cost effective and result in increasing job opportunities for people with disabilities who experience high unemployment (nearly 70%^12/).
5. Redirect funds that support sheltered workshops to supported/competitive employment.
6. Coordinate age-eligibility standards among the various agencies delivering services to children and adolescents and fund services that are identified in Chapter 688 and individualized transition plans when students age out of school or graduate.^13/  Currently there is no age consistency among systems with the result that persons aging out of one, who are still too young for the adult system, fall into a gap. The ramifications of systemic interstices are often costly to society as well as to the individual who gets stuck in the gaps (see footnote #3 under the table for Residential Treatment Services).
7. Expand programs and increase intensive family supports so that residential care can be limited. It is often far more cost effective to increase intensive family supports when a child with a disability lives at home than to provide residential treatment.
8. Use collaborative staff as itinerant consultants to assist local education agencies (LEAs) in developing programs for challenging special education students. This may alleviate the need for out-of-district placements.
9. Establish a mechanism for transferring funds between institutions and community based services, and between agency programs.
10. Support transition planning, as part of a student's special education program, that effectively addresses a student's career needs and life experience. Assessments should be conducted early enough to establish a student's vocational aptitude and interests, in order to preclude a break between school and employment training.
11. Require state agencies that license after-school programs, to articulate the specific compliance requirements regarding program accessibility in their regulations.

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Footnotes for Age 5 to 22:

^8/    Efforts are underway to reform the Special Education system.  This report does not address specific findings and recommendations in that system.

^9/    Chapter 688 "Turning 22" Program, A Report to the Legislature,"  Executive Office of Health and Human Services, October 1997, Executive Summary.

^10/    Chapter 688 "Turning 22" Program, A Report to the Legislature,"  Executive Office of Health and Human Services, October 1997, Executive Summary, #1, Streamline the Eligibility and Referral Process.

^11/    "RTA Transit Needs and Funding Analysis, Final Report," KKO & Associates, May 1996, pp. xix-xxi.

^12/    Statistic is derived from a 1994 survey conducted by Louis Harris and Associates for the National Organization on Disability.  See N.O.D. Survey of Americans with Disabilities, Employment-Related Highlights," May 30, 1994, Special Advertising Section.

^13/    See Chapter 688 "Turning 22" Program, A Report to the Legislature,"  Executive Office of Health and Human Services, William D. O'Leary, Secretary, October 30, 1997, Executive Summary, Conclusions and Recommendations, #1.

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FINDINGS

1. Information and Referral (I&R) systems, as the linchpin of disability services, are fragmented and limited, thus creating barriers to services for consumers whose needs go beyond the immediate agency through which they entered the system. Existing systems are not multilingual and as such impede access for individuals for whom English is not the primary language.
2. Transportation services are essential to people with disabilities who live in the community or in facilities such as nursing homes. These services are defined by their funding source, or they may be tied to programs with which agencies have contracts. These facts result in a system that is piecemeal, uncoordinated, and, in some cases, duplicated. Under such conditions, delivery of transportation services is neither cost effective, nor user friendly.  Individuals with disabilities rely heavily on public transportation. Some metropolitan areas in the Commonwealth have vast public transportation systems which frequently do not meet the accessibility standards mandated in the American with Disabilities Act (ADA) and other laws. In contrast, rural transportation services are both inadequate and extremely limited, if they exist at all. In addition, the Regional Transit Authorities (RTAs) must contend with an expanding customer base - the result of an aging population, federal laws, and lack of full accessibility in public transportation systems - and a lack of new dollars to meet this growth. All of these facts create barriers for customers and would-be customers.^14/
3. Protective services and abuse investigations exist within five state agencies (e.g. DPPC, DMR, DPH, MRC, and DMH), all of which provide services for people with disabilities. Services are duplicated, lack uniformity, and are too narrowly restricted by the statutory definition of abuse which is limited to that perpetrated by a caretaker. As a result, people with disabilities may be vulnerable to abuse from other individuals, including, in some cases, family members who do not provide care or who exploit them financially. Investigations are usually internal which may result in limited objectivity.
4. Case management/Service coordination eligibility criteria preclude some consumers with less common disability diagnoses or with complex service needs from receiving these services.
5. Funding constraints and high case loads limit case management. This may have the result of providing less effective and, in the long run, more costly care for consumers who would benefit from a coordinated service plan.
6. Personal Care Attendant (PCA) services enable individuals with disabilities to live maximally independent lives in the community. The existing system is bogged down in administrative problems (e.g. issues of eligibility, accountability, prior authorization, etc.), unresolved tax issues (in most cases, there is no responsible party or mechanism in place for payroll deductions), and PCAs who have not had a rate increase in 8 years.^15/
7. Individuals with developmental disabilities are ineligible for certain DMR residential and day services when they reach the age of 22. While they continue to receive services from DMR, the age and categorical ineligibility criteria results in service gaps.^16/
8. Consumers with low incidence and/or multiple disabilities, often fall into gaps because they do not meet the specific eligibility criteria of service-providing agencies. For example, deaf individuals who have serious mental health problems, or a person whose traumatic brain injury results in a behavior disorder, may not qualify for DMH services. In some of those cases, agencies with no funds for purchasing services, attempt to provide vital services.
9. In some cases, managed care has created confusion for consumers. It most often requires additional paperwork, prior authorization forms, and dependence on others to complete procedural tasks before services can be received. (Providers also must comply with excessively complicated administrative procedures.)
10. Major federal programs, such as SSI/SSDI create disincentives to work for people with disabilities by focusing on one's general inability to work as proof of total disability. Reforms are needed to encourage, rather than discourage, both full and part-time employment, without jeopardizing the financial supports provided by these programs.^17/
11. Medicaid payment mechanisms perpetuate an institutional bias and foster expansion of private mental health hospitals and locked wards.

RECOMMENDATIONS (Some recommendations reflect more than one Finding.)

1. Eliminate eligibility criteria for receiving public transportation services between the systems which serve the elderly and individuals with disabilities. Coordinate funding streams, transportation routes, and schedules. Increase outreach and training on existing rural transportation services. Some agencies have begun to use Regional Transit Authorities extensively to gain service efficiencies and reduce fragmentation. This effort should be encouraged on a cross-agency basis.
2. Establish a task force to: (a) study the cost effectiveness and impact on consumers of eliminating the brokerage system currently utilized by the Regional Transit Authorities (RTAs) and (b) identify potential revenue sources for expanding fixed route service which is currently limited, and transportation to rural communities.
3. Expand the existing disability Information and Referral Program in the Massachusetts Office on Disability (MOD) to provide a broad range of information through a single source which is available to all people with disabilities, agencies, and individuals outside the system. This program is already accessible statewide through an 800 number and by TDD (telecommunication device for the deaf). It also provides cross-disability information. Enhancements would include making information readily available to individuals for whom English is not the primary language and to those needing alternative formats such as braille or large print.  The expansion should result in a seamless web which includes the Massachusetts Network of Information Providers and the New England Index.
4. Consolidate abuse investigations into a single, independent agency and expand its jurisdiction to include neglect and abuse by individuals other than caretakers, financial exploitation, and people with disabilities 60 years of age and older who are living in DMH and DMR funded facilities. Provide adequate resources to cover the expanded legal and practical capacity including forensic experts.
5. Increase outreach and education to consumers at "transitions" and when systems and procedures change to avoid confusion and frustration, interruption and termination of services.
6. Develop a strategy around waiting lists for vital services (e.g. Turning 22, DMR, Brain Injury, etc.).^18/
7. Develop a strategy around gap consumers who are not receiving vital services due to eligibility criteria. Consider allocating funds to non-service providing agencies that have expertise in those disabilities.

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Footnotes for Adults from Age 22:

^14/    "RTA Transit Needs and Funding Analysis, pp. 1-13 - 1-21.

^15/    A Memorandum of Understanding Concerning the Personal Care Attendant (PCA) Program between the Division of Medical Assistance, the Governor's Commission on Disability Policy, the Massachusetts Office on Disability and the Statewide Independent Living Council was signed on May 8, 1997.  Its aim is to resolve various policy issues associated with the PCA program.

^16/    "Family Support Guidelines," Massachusetts Department of Mental Retardation, July 1995, p. 3.

^17/    "Removing Barriers to Work: Action Proposals for the 105th Congress and Beyond, 'Executive Summary, Barrier: Many People Would Be Worse Off Financially If They Worked and Earned to Their Potential Than if They Did Not Work,'" p. 2, National Council on Disability, September 24, 1997.

^18/    See Chapter 688 "Turning 22" Program, A Report to the legislature,"  Executive Office of Health and Human Services, William D. O'Leary, Secretary, October 30, 1997.

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• Case Management
• Child Care
• Information & Referral
• Personal Care Attendants
• Preschool & Early Education
• Respite Care

^19/    "At risk" applies to children who do not have a diagnosed/identified disability, but who, because of environmental limitations or biological conditiona in their early life, have the potential for developmental delay.

^20/    Massachusetts eligibility criteria for EI is broader than Special Ed's preschool in most LEA's; this caeses the gap for some 3 year olds.   Children who are at risk of developmental delay experience the most significant impact which results from this difference.  For example, any asymptomatic HIV positive 3 year old whose parents live at poverty's edge may not meet the special ed eligibility criteria or Head Start's Financial eligibility criteria.  This creates a gap in Day care because the child's parents probably cannot afford the costs associated with programs in the community.

^21/    The Kaileigh Mulligan Program provides an entree into the Medicaid system.  The child's Medicaid eligibility is not based on the parent's income; intensive ongoing medical needs which put the child at risk of institutionalization can be provided at home if the child is determined eligible.   Cost of home care may not exceed that of institutional care.  Care equal to the level provided in an institution must also be provided at home.

^22/    DMR uses 1.5% to determine the incidence of mental retardation in the general population.  Massachusetts' population is 5,993,739; 1.5% of that is 89,906.  DMR currently serves 22,00 people.  The difference between those two figures equals the number assumed to be unserved.  However, having the presnece of MR does not necesaryily equate to being unserved by DMR because not all people with MR seek services through the Department.

^23/    MCDHH's case management includes such functions as: cross-agency case coordination, crisis intervention, life needs assessment and service plan development, personal counseling, intensive case work and certification services.

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^24/    The Child Care Resource and Referral Network (CCRR) is a program that consists of 13 resource and referral agencies statewide which match parents and their children to community-based child care programs.  Each agency has its own catchman area; these do not match the Office for Child Care Services (OCCS) 5 regional licensing areas.  Child care programs register, voluntarily, with the R&R agencies in their catchman area.  The 13 agencies also administer a voucher system which sussidizes AFDC families who meet certain requirements.  The program consists of community education, support for parents on choosing appropriate child care, training and assistance for child care providers and services for employers.  Currently, there are a limited number of vouchers targeted specifically for income-eligible families of children with disabilities.

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^25/    "Child Find" is a comprehensive statewide system that coordinates the various State agencies responsible for administering services (education, health and social) to identify all infants and toddlers in the COmmonwealth who are eligible for services under the Early Intervention Program.   

^26/    While the Early Intervention Program does provide I & R as part of services coordination, the bulk of the program's dollars pay for services.

^27/    Developmental Disability (DD) is defined in Section 102 (8) of the Developmental Disabilities Act of 1994, as a severe, chronic disability (mental, physical or a combination) which is manifested between the ages of 5 and 22.   It is likely to continue indefinitely, results in substantial limitations of 3 or more major life activities and reflects an individual's need for interdisciplinary supports.

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^28/    Each School Committee is required to make an effort to identify children who need special education by examining annual registration forms which request information about recent medical examinations and other information that would be relevant to a need for special education.  (Registration and relevant information are optional.)  Services are also addressed by outreach through orientation sessions; kindergarten screening at a parent's request; physical exams required by DPH for entry into the public school system.

^29/    See "766 Regulations, Massachusetts Department of Education, September 1992," Chapter 3, Section 304.1-307.3.

^30/    The evaluation process may determine an at risk 3 year old ineligible because s/he has no identified disability which qualifies for special education services in preschool programs.  While there are state subsidied child care programs, parents may not know how to access them after leaving the EI system (or if they have never been in the EI program), or they may not be able to afford a co-pay if eligibility in those programs is based on financial criteria.

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• Abuse Investigations & Protective Services
• Case Management
• Crisis Intervention
• Day Programs
• Out Patient Rehabilitation
• Residential Treatment
• Supported Employment

^31/    Children, people in nursing homes, and individuals in the elder care system are covered under other systems.

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^32/   Traumatic Brain Injury (TBI) is defined as an externally (such as a blow or violent shaking) caused head injury which results in significant physical, cognitive and/or behavioral deficits.  It is distinguished from Acquired Brain Injury (ABI) which may result from smoke, organic brain disease, etc. (See "Traumatic Brain Injury in Massachusetts, Incidence and Prevention," Massachusetts Department of Public Health, Bureau of Family and Community Health, Injury Prevention and Control Program, 1994).

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