September, 2002

I am pleased to share with you summaries of the Department’s Strategic Plan Implementation.  A few months ago, DMR senior staff conducted forums across the state in which they presented a status report on those objectives that have reached significant benchmarks.  At that time we promised to publish brief status reports of where we are on each of the objectives, which is the purpose of these summaries.

We are facing some critical challenges ahead of us in a climate in which dollars are particularly tight.  It is especially important in such times that we remain solidly committed to the effort of Strategic Planning to help define and guide our future.  As I have said many times, the Strategic Plan is not about money, although money is certainly a part of the process and outcome.  It is about who we are, who we want to be and about how we will best serve those who look to us for support.

I am pleased with the progress we have made and proud of our achievements.  I look forward to your continued support of the Department of Mental Retardation.

Sincerely,

Gerald J. Morrissey, Jr. Commissioner

WORK GROUP SUMMARY
OBJECTIVE 1.1

OBJECTIVE:  To develop a systemic plan to service the populations.

PROCESS: The group was comprised of a broad variety of DMR managers including area directors, family support directors, other key managers and external stakeholders. The group met frequently beginning in early February 2001 and worked through the early part of the summer.  The group did considerable research on the nature and prevalence of mental retardation and closely related conditions.  The group also surveyed and analyzed the current make-up of our child population in order to ascertain what type of developmental disabilities the children in our system had at initial intake.

CURRENT STATUS AND NEXT STEPS:  In considering the issue of DMR eligibility a number of issues were deeply explored and considered.  First of all, the workgroup had to examine who the Department was currently serving and whether all who were requesting services were receiving those services.  With this as a starting point, the impact of clarifying or changing, in some way, eligibility could be studied more seriously. Discussions included estimating the effect on all state disability agencies of broadening eligibility or narrowing eligibility.  Similarly, the impact of the differing childrens’ and adult eligibility requirements were assessed.  Prevalence rates for mental retardation and other disabilities were evaluated for their respective impacts as well.

The working group has made a set of recommendations to DMR that were forwarded to the Strategic Plan Steering Committee.  The Committee is in the process of evaluating the recommendations.  DMR will not change or modify its eligibility while this internal review takes place.  If any changes are proposed, DMR will follow the normal regulatory process that includes an opportunity for public comment.

In making its recommendations, this group has completed its work.  Future areas of planning and policy development will be part of the scope of work for DMR as it operationalizes approved recommendations.

WORK GROUP SUMMARY
OBJECTIVE 1.3

OBJECTIVE:   Create regional eligibility teams to complete intake and eligibility. PROCESS:  The group consisted of a broad cross section of departmental employees, individuals, family members, and providers.  The group met every other week for a period of six months.  It also focused on the question of eligibility as well as the process of creating eligibility teams.  The group did extensive research including a case review of all children registered in our consumer registry system, a workflow analysis, an extensive literature review about both eligibility and process.  This summary only includes the design of the regional teams.

PRODUCTS CREATED:  The group generated a report and plan recommending:
creation of 5 regional eligibility teams with central office supervision for both management and clinical coordination for a period of one year post implementation depending on the regional ability to absorb the managerial function
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clinical oversight remain at the central office
teams be staffed similarly with an increased focus on clinical skills

CURRENT STATUS AND NEXT STEPS: The recommendation of the work group has been extensively processed and accepted by the Commissioner. The plan is now in an active implementation framework and began in July, 2002.

The group has completed its work.

Public hearings on regulatory changes to the eligibility process have been scheduled for
September 26 and 30.  Further information regarding times and locations will be posted.

WORKGROUP SUMMARY OBJECTIVES 1.4 – 1.5

OBJECTIVES: (1.4) Create a standard assessment for consumers which generates a profile of support needs, assigns each consumer to an intensity of need level, and prioritizes access to available resources.  (1.5) Review and revise purchase of service mechanisms to fit the new system.

PROCESS:  As a result of feedback received from a variety of stakeholders concerning the issues of equity and fairness as they relate to resource distribution for consumers, objectives 1.4 and 1.5 were included in the Strategic Plan.  The “economics committee” was created with membership from DMR, provider agencies, family members and self advocates.
The work of the committee has focused on 4 major areas:
A standard clinical assessment, which can be related to a range of costs associated with meeting the intensity of need of the individual.
An individual resource allocation methodology based on the clinical assessment and other important factors.
A reformed P.O.S./contracting methodology based on a rate system e.g. cost corridor.
A revised prioritization methodology for use by DMR to decide who should receive available resources.

PRODUCTS CREATED:  With the assistance of a consultant, sub-committees have worked on all four of these areas to produce the following:
A recommendation to use the ICAP (Inventory For Client and Agency Planning)
as the standard clinical assessment tool to measure need intensity.
A Mass. Supplemental Assessment Tool to complement the ICAP to adjust the level of need as it relates to resources and also looks at available natural supports as well as clinical areas.
A draft prioritization methodology with back up criteria that will be sent on for proposed regulation changes.

CURRENT STATUS AND NEXT STEPS:  Analysis of DMR resource allocations for consumers in 24-hour settings is being completed to help determine rate ranges.  Our next major activity is to “test out” the correlation of the ICAP/Mass. Supplemental with rate ranges through a sampling of consumers receiving 24-hour residential supports. Much work will need to be done in the other service areas following this sample.  There

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are also many issues that have not yet been decided regarding how the new system will be phased in over time.

WORK GROUP SUMMARY
OBJECTIVES 1.6 - 1.7

OBJECTIVES: (1.6) Develop a plan to identify short and long term role for the facilities.
(1.7) Conduct study based on current community bed capacity as well as likely future bed expansion needs in order to develop a three to five year residential plan.

PROCESS:  The work group was charged with making recommendations regarding the current and future functions of the facilities, the appropriate number of facilities to meet capacity needs and the bed capacity needed to meet future needs.  The work group developed and followed a work plan that described the information to be collected, examined and analyzed, and the process for making projections and recommendations. The information used by the group came from various sources.
Information about the 6 DMR facilities (Monson, Glavin, Templeton, Hogan, Wrentham, Fernald) came primarily from the facilities, DMR Office of Management and Finance, Division of Capital Assets and Management.
Future need for facility beds was informed by historical information on referrals and admissions to facilities, results from a survey sent to offices in the DMR regional community service system, and a model developed by the National Association of State Directors of Developmental Disability Services that DMR used to project the number of residential beds needed in order for the Massachusetts residential system to have sufficient capacity to meet the residential needs of adults with mental retardation.
Information about other models or functions and the national trends in facility- based services came from a review of literature, publications, video, and work group members.
Much of the work was performed by the entire work group although there were three subgroups established to look at costs in a facility setting, costs in a community setting, and the current and changing needs of Ricci class members and people in nursing facilities.

PRODUCTS CREATED:  The Report of the DMR Facility Planning Working Group was completed in May 2002.  The Strategic Planning Steering Committee has reviewed the report and submitted its recommendations to the DMR Commissioner for decision and action.
The Report contained the following:
In April 2001, there were 1,209 facility beds.
The Methodology used to project facility bed capacity determined that:
By FY 2004 (short term):  A range between 971 beds to 1134 beds would be needed.
By FY 2011 (long term):  A range between 671 beds to 912 beds would be needed.
Although there was no consensus on the appropriate number of facilities to meet the projected range of bed capacity of 671 beds to 912 beds, the results of the vote by the working group ranged from no facility remaining open to all six remaining open. Approximately 46% of the voting members indicated that 3 to 4 facilities should remain open.

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The study conducted by the Department using the NASDDDS model projected that the
DMR residential system would require 12,030 beds (both facility and community beds)
in order to have sufficient capacity to meet the projected need for residential placements by adults with mental retardation.   In Fiscal Year 2001 when this study was done, there were 1,293 facility beds and 9,451 community beds.  To reach a capacity of 12,030 beds, the DMR residential system would have to grow by an additional 1,286 beds.

NEXT STEPS : The work group has completed its work.  The Commissioner has received the report and has solicited additional feedback from external stakeholders.  A final decision is expected in the fall.

WORK GROUP SUMMARY
OBJECTIVE 1.8

OBJECTIVE:  The Department will maintain an effective partnership with consumers and families.

PROCESS :  The work group looked at how the Department can effectively partner with people receiving services and their families.  This activity was facilitated by the strong family and consumer presence on the work group.  Of the 21 members, nearly half represented people with disabilities and family members and their contributions based on their personal experiences have been invaluable.  The work group developed a work plan that set forth the tasks and timelines.  There were two phases to the process.  The full committee participated in the first phase.  Five subcommittees were then established to tackle specific assignments identified by the full committee during the first phase.

PRODUCTS CREATED: Full Committee
Developed a set of Ground Rules for the work group.
Developed a definition of Partnership and Principles of Partnership
Determined effective communication strategies by:
1.  Identifying areas/topics where consumers and families want information from DMR and opportunities for input.
2.  Identifying areas/topics where DMR wants information, advice and feedback from consumers and families.
3.  Reviewing existing forms of communication.
4.  Identifying strategies to communicate respectfully to the diversity of culture, language and abilities of individuals and families receiving services.

Subcommittee on Publicly Funded Health Insurance and Benefits
Identified programs deemed critical and developed a process that provided essential information to DMR staff as they help families navigate the human services system.
Developed a master reference listing of publicly funded health insurance and benefits. (Web Based Format available through the Governor’s Commission on Mental Retardation web page linked to the DMR web site.)
Subcommittee on Spectrum of Services
Identified three tracks of service provision from DMR.

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1.  Spectrum of Services for Adults
2.  Spectrum of Services for Children
3.  Spectrum of Services for Elders
Identified questions most frequently asked by consumers and families.
1.  Who does DMR serve?
2.  How does someone apply for services?
3.  What services are available through DMR?
4.  How does DMR ensure quality services?
5.  What opportunities are available for citizen and family involvement?
6.  Looking for a support group? Developing responses to questions 3 and 4.
Developed format for putting information on DMR Web page. Subcommittee on Regulations
Identified and prioritized the 4 chapters of DMR regulations most likely to be used or referenced by consumers and families.
To date, drafts of ISP regulations and Human Rights regulations written in a condensed form in easy to understand terms.
Subcommittee on Web Page
Conducted a Department wide Web page survey for feedback
Working with DMR’s MIS staff with regards to systems capabilities
Working closely with all subcommittees who plan to put information on DMR Web
Page
Subcommittee on DMR Information Brochure
Presented second revision to Full Committee for review and comment. CURRENT STATUS AND NEXT STEPS:  Each subcommittee will continue to finalize its work.  A full report will be prepared for presentation to the Steering Committee along with actual products and recommendations to support the continuation of the efforts begun by the 1.8 work group.  The work group expects to complete its work in the Fall of 2002.

WORK GROUP SUMMARY
OBJECTIVE 2.1

OBJECTIVE:  Create a plan to address recruitment and retention, ensuring sufficient numbers of qualified staff and care providers at all levels, within the provider community, the Department, and family managed supports.

PROCESS:  The group initially met once every two weeks for a few months and then moved to a once per month meeting schedule to allow small group work to occur between meetings.  The group consists of a broad cross section of the Department’s managerial staff, both functionally and geographically.  The group has conducted surveys about both recruitment and retention and conducted demographic analyses on both a state and national level.

PRODUCTS CREATED: The group is in the process of completing 4 tasks:
1.  Analysis of demographics: The expansion of services for the Turning 22 population, the large number of Rolland and Boulet class members, the turnover rate, the vacancy rate, and the age of the current workforce were the variables

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used to calculate the workforce needs.  Upwards of 1200 new direct support workers will be necessary to meet our projected service increases.
2.  Creating an exit interview tool:  An exit interview tool has been designed and field tested in March and will be advanced.
3.  Creating an entrance interview tool:  An entrance interview has been designed and will be completed in July.  The group believes that both the entrance and exit interview tools will provide valuable data to managers to assist in recruitment and retention activities.
4.  Conducting a survey of recruitment and retention strategies:  A survey of recruitment and retention strategies of key staff across the state was completed and analyzed and will be used to create a guidance manual for staff about effective practices.

CURRENT STATUS AND NEXT STEPS:  Future steps include the following: Finalizing specific recruitment and retention strategies to be implemented statewide in the Department
Developing a manual to be distributed throughout the Department that describes effective strategies for recruitment and retention
Establishing forums to hear from employees about recruitment and retention issues
Integrating the work from the Training and Education Group, diversity council work and other work groups in orientation to support recruitment and retention efforts
Consideration of how to share practices with providers.

Given the nature of our workforce needs the groups will continue to meet to assess impact and implementation of the work group products.

WORK GROUP SUMMARY
OBJECTIVE 2.2

OBJECTIVE:  Develop an effective training and development program to enhance the competence, performance, role clarity, and satisfaction of staff.

PROCESS: The group was comprised of the regional training directors, state operated program directors, human resource directors, labor lawyer, individuals and family members and providers.  The group met on a monthly basis to focus on articulating the skills, knowledge, and competencies for all levels of DMR and provider employees including a supervisory model and the curricula and training methodologies to support them.  The group spent a good deal of time defining the categories of jobs within the system and specifying how they could be grouped.  The group developed a commitment to a competency-based system and agreed to a tentative work plan. However, one of the unique challenges for the work group was the awareness that both the final work plan and work products were dependent on input and work outcomes from the other work groups.  For example, Work Group #3 on Physical Health was in the process of developing tools for the direct support workers to recognize the signs and symptoms of illness.  Therefore, it was impossible for the Training workgroup to articulate and
develop competencies for direct support workers until the work from Group #3 was completed.

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CURRENT STATUS AND NEXT STEPS: The work group believes that the training plan has four basic elements: orientation, professional development, supervision and strategies. The group has articulated a four level orientation training plan.
Level 1 consists of generic information that all employees must know, such as the policy on workplace violence.
Level 2 includes content related to the issues around being a public employee, most specifically the concept of public stewardship.  The group has proposed that that these topics be included for all employees.
Level 3 will center on working with people with mental retardation.
Level 4 involves the specific knowledge and skill related to each job category. The paradigm is the Service Coordinator Institute.

The professional development track is designed to help employees continue to grow and develop in their jobs. This is a critical step because as the field evolves and the needs of people with disabilities change we will need to provide growth and learning opportunities for staff.  Supervision is another critical component of the plan. The group will seek to develop ways to enhance the supervisory skills of all supervisors and mangers.  We will also link training and development strategies with supervision. Finally, the plan will need to be cognizant of adult learning styles. A variety of strategies
and links with higher education and professional organizations will be developed.

Due to a number of issues, the membership of this group has changed over time.  A new group will be constituted to inform the training needs for the department based on the efforts and results of the various strategic plan workgroups.

WORK GROUP SUMMARY
OBJECTIVE 2.3.1

OBJECTIVE:  The work of this group is a part of the broader objective to develop organizational infrastructure and organizational development needs in support of the Strategic Plan.  Our specific group objective is to articulate the underlying assumptions and principles that guide organizational practice, i.e., to create a “Rulebook”.

PROCESS:  Following a work plan, the major work of the group was to examine how principles can affect organizational culture and to identify principles that should guide attitude, conduct and behavior of DMR staff; and standards to guide business practices. These principles and standards would apply to all DMR work areas and across all DMR functions.

After intensive discussions, the work organized around the five phrases to represent the DMR guiding principles: Stewardship, Respect, Professionalism, Commitment to Excellence, and Organizational Integrity.  Particular care and attention were given to the description and explanation of how these principles apply to the DMR organization.

Next nine standards were drafted to guide conduct and performance of all DMR staff regardless of their role or function.

Finally the group compiled listings of the current policies, protocols and procedures that govern or inform the work of DMR staff.  This listing would be available and easily accessible to all DMR staff to ensure that they have basic information to do their job.

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PRODUCTS CREATED: Two products have been created by the work group:
The set of principles and standards to guide the attitude, conduct and behavior of DMR staff.
The Index of Policies, Procedures and Protocols, which lists the current policies, procedures, and protocols in effect and where the document can be found. These two products will be contained in a new document, tentatively entitled, DMR Standards for Practice and Conduct: The Rulebook.

CURRENT STATUS AND NEXT STEPS:  This workgroup should complete its work this fall with the development of a roll-out strategy for embedding the principles and standards in to the fabric of DMR.

WORK GROUP SUMMARY
OBJECTIVE 2.3.5

OBJECTIVE:  Complete development of the Advanced Planning Document (APD) to provide an effective management information system and overall support for continual strategic management.

PROCESS:  A group was formed with representatives of the various technical, business and program arms of the agency to create a plan for the development or procurement of an information system that would achieve the above objective.   The federal government provided an opportunity to attach our planning needs to those of the Division of Medical Assistance and the Center for Medicaid and Medicare Services (formerly HCFA). Through an Advanced Planning Document (APD) and a subsequent Implementation Advanced Planning Document (I-APD), the Department has conducted extensive evaluation and proposal exploration for how best to achieve the objective.

PRODUCTS CREATED:  The APD was submitted to CMS for a new management information system in June 2001.  Based on questions from CMS, DMR and DMA began to prepare an amendment to the APD.  DMR also began to develop and RFR for procurement of the expertise to develop the system for DMR.  DMR was then asked to put the RFR on hold and to reexamine system advancements available through Meditech.  The APD amendment (I-APD) continues to be prepared with the Meditech proposal as a key component.

In preparation for a new system, the APD Workgroup accomplished the following: Completed an analysis of all data elements in CRS,
Developed a new draft of all updated program codes for all services, Drafted a new CRS Manual for users, and;
Developed a set of “business practices” for maintenance of data.

CURRENT STATUS AND NEXT STEPS:  The I-APD is in the final steps of work prior to being submitted to CMS.  Internal structures are beginning to be developed and a
contract with Meditech is being negotiated.  Next a Project Manager will be recruited (an internal one has already been appointed) and project teams will be created for the development and roll out phases.  Staffing needs have been identified and recruitment will commence once CMS approval is received.

WORK GROUP SUMMARY
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OBJECTIVE 3 (Physical Health Care)

OBJECTIVE:  To establish effective and consistent health, clinical, and behavioral supports for persons with mental retardation across the Department of Mental Retardation system.
Goal 3.1 Recognize and respond to each consumer’s needs for available health,
  clinical and behavioral supports
Goal 3.2 Ensure a coherent departmental approach for addressing health,
   behavioral, and clinical issues and concerns
Goal 3.3 Work with health care agencies and other funding sources to assert
  the needs of the overall population with mental retardation

PROCESS:  Due to the scope of issues that needed to be explored, Group #3 divided into 2 components - physical health care and clinical supports, and mental health and behavioral supports.

The physical health care group worked closely with CDDER (U/Mass/ Shriver Center) for purposes of research and background information.  U/Mass conducted several studies including a mapping project, preventive health standards, and health screening and assessment.  Surveys were conducted as part of the mapping project and current literature in the field was extensively reviewed.  The work group broke into several task related groups in order to more expeditiously complete its work.

PRODUCTS CREATED:
1)  Preventive health care standards
2)  Health status review checklist
3)  Medical history/record
4)  Protocol for communication for health care visits
5)  Resource recommendations and roles/responsibilities of DMR areas, regions
6)  Protocol for consultation on complex health care issues
7)  Signs and symptoms of illness

CURRENT STATUS AND NEXT STEPS:  A pilot of the above mentioned products will be conducted in late summer or early fall.  Results of the pilot will be incorporated into the final products.  A process for orienting providers and DMR to the processes will need to be developed.

Additional work includes finalizing resource recommendations, establishing regional and central office health care advisory committees, developing training recommendations, and incorporating changes into a new “pre-ISP package.”

It is anticipated that the group will sunset in the fall of 2002.  Future areas of planning and policy development will be part of the scope of work of the central office health care advisory committee.

WORK GROUP SUMMARY
OBJECTIVE 3 (Mental Health and Behavioral Supports)

OBJECTIVE:  Establish effective and consistent health, clinical, and behavioral supports for persons with mental retardation across the DMR system.
Goal 3.1 Recognize and respond to each consumer’s needs for available health,
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  clinical and behavioral supports
Goal 3.2 Ensure a coherent departmental approach for addressing health,
   behavioral, and clinical issues and concerns
Goal 3.3 Work with health care agencies and other funding sources to assert
  the needs of the overall population with mental retardation PROCESS:   This group has met for about a year.  Early in the process the group divided into halves, one half focusing on physical health, the other half focusing on mental health and behavioral supports. This is the report of the second half.

Early, this group focused on trying to understand roles of relevant specialties
(psychology, social work, psychiatry, nursing), processes (referral, assessment, treatment), specialty treatment (e.g., substance abuse treatment or parenting training) and whether there were applicable standards that pertain to individuals served by DMR. So, for instance, for individuals in developmental centers most standards are provided by Title XIX requirements.

This group developed an organizational framework for analyzing objective components
3.1 and 3.2 and a work plan for accomplishing major related tasks (Sept. 2001). PRODUCTS CREATED:  The group has provided input into the creation of a comprehensive health screening assessment, which will serve as a trigger for further mental health or behavioral support and assessment.  The group has also proposed a process of mental health mapping that represents a beginning analysis of supports available to community consumers.  The group has also begun to outline a potential process for mental health and behavioral care for individuals in the community, which may develop into standards.

In addition this group has done extensive work in assessing DMR’s utilization of behavior plans and peer review for these, two features of behavioral supports, which are specified in regulation.

CURRENT STATUS AND NEXT STEPS:  The work of the large group has come to an end.  Several small groups are being established to complete work in a number of key areas.  These small groups will build upon and complete the work started and move toward actual implementation.  The groups are:
Behavior Plan/Peer Review Medication use and review Public Safety/Risk Management
Processes/Protocols/Structures at area, regional, central (integrated with physical health)
Data base development
Regulation review

The large group will no longer meet.  The product of each small work group will be coordinated with the others and overseen by Strategic Plan Steering.  Each of the small groups will meet for a few months, completing their tasks within one year.

The large work group provided a good foundation for these new small groups to build upon.  The work so far has helped the Department to be able to know much about the

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needs of the people we serve, the systems that are in place, and gaps and deficiencies that require more attention.

WORK GROUP SUMMARY
OBJECTIVE 4

OBJECTIVE:  To develop an effective quality management system
Goal 4.1 - Measure key indicators and utilize information to promote service
     excellence.
Goal 4.2 - To strengthen, integrate, and utilize oversight and monitoring systems to ensure continuous improvement, quality outcomes and necessary
     safeguards for individuals

PROCESS:  The group jointly decided on key outcomes and process measures.  A survey was sent to the internal and external stakeholders to get input regarding priority areas to track over time.  A small sub-group met with staff responsible for key components of the quality assurance system to determine capabilities of databases.  A final QMIS design is almost complete, with a task list of activities that need to be completed in order to move design forward into implementation.  The key challenge for implementation will be the timing on implementation of the Advanced Planning Document (APD) which is the Department’s plan for development of an integrated data management system.

PRODUCTS CREATED;  A final report is in draft form and needs to be reviewed by the steering committee and Commissioner.

CURRENT STATUS AND NEXT STEPS
The report and QMIS design identified the high priority outcomes and process measures that will form the basis of the QMIS system.
Steps that need to be taken to enhance current data systems have been outlined.
Gaps, including the development of an incident reporting system, and evaluation mechanisms for individual and family supports have been identified.  Work groups will be established in each of these areas.
Existing databases will be modified and strengthened as identified by the work group.
Regional and Central Office Quality Councils will be established.

It is anticipated that the full work group will complete its design work by the beginning of July.  The group will be replaced by several discrete work groups to plan and develop recommendations for needed quality assurance components.

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