Community Counseling of Bristol County Executive Summary
Community Counseling of Bristol County (CCBC) is pleased to submit this proposal to MassHealth to strengthen our Community Service Agency (CSA) program and enhance our role in MassHealth’s innovative DSRIP and ACO initiatives. We believe that we are well positioned to engage children with Severe Emotional Disturbance (SED) and their families in a strength-based, family-centered approach to behavioral health problems and primary care conditions such as diabetes, asthma, and obesity that frequently co-occur with our population in the Attleboro-Taunton area.
We are fully confident that careful management of the DSRIP resources over five years for our CSA will support CCBC as an active partner with area ACOs in improving health outcomes, expanding the culture of a strength-based and family-centered approach with area pediatricians, specialty providers and hospitals. At the same time, CCBC will also maintain timely access report on quality metrics and enhanced and efficient information sharing through our electronic health record (EHR) eHana via the Mass HIway. The EHR is currently being updated to contain the necessary fields and data sets to handle the care management reporting requirements within the CSA EHR.
The CSA was selected by MassHealth as one of the original 32 CSAs and began operating on June 30, 2009. The program has enjoyed strong reviews from MassHealth, the MCO contract managers and above average score on the annual Wraparound Fidelity Index (WFI) evaluations conducted by independent researchers. The program has established a leadership role among CSA for its commitment to family voice and choice through the integral role of Family Partners on the CSA team. CCBC’s strengths as a CSA include:
- Timely access to Intensive Care Coordination (ICC) services; there are no families on our waiting list.
- A high rate of engagement and retention of families in the Wraparound process as measured by improved scores on Strength-based approach to families.
- Expanded networking into the community by the CSA Program Director.
- Networking with local police departments.
CCBC’s CSA is working on improving the Team Observation Measure score (TOM) related to Individualizing Care and Persistence. Another need is to increase the capacity to share information on the aggregate CSA population and the associated total costs of care from a population health perspective.
CCBC maintains an agency-wide commitment to timely access to services. We are one of the few outpatient mental health clinics that has an “Open Access” policy where any client – child or adult – can come to the agency and receive a clinical evaluation the same day. This policy applies to the ICC services where we have no families on our waiting list.
CCBC is very excited about our plan to improve care coordination, care planning and care management for ICC-engaged children with SED and their families. In our proposal, we list three projects that will strengthen our ability in these areas and align the agency’s ICC activities more closely with the activities of the ACO-affiliated pediatricians. These projects include:
- Installation and Implementation of the eHana EHR and Mass HIway connection to improve data sharing functionality with PCCs, ACOs, MCOs and MassHealth, and reporting on quality measures per Appendix A’s Quality Slate;
- Training of CSA staff on improving skills overall, addressing the needs of children and families from diverse cultures, and engaging PCCs in the Care Planning Process; and
- Strengthening CCBC’s technology infrastructure to share information via the Mass HIway and through installation of a HIPAA compliant secure video conferencing capacity to encourage remote participation by PCCs in the Care Planning process.
CCBC is well-positioned to implement this plan. In addition to providing timely access to care and scoring high on the WFI and TOM measures, CCBC has established strong working relationships with over 20 pediatric offices in the Attleboro-Taunton area. Our relationships extend beyond sharing information on treatment plans and results of physicals. ICC’s have conducted care planning meetings at the offices of pediatricians when requested by the family. We have also expanded care planning teams to include specialty medical providers and Emergency Room staff for children and families with complex co-occurring medical and behavioral health conditions. All of these efforts have been built on a foundation of collaboration with Steward Health Care through four Infrastructure Capacity Building (ICB) contracts that includes data sharing and collaborative treatment planning. There is a joint commitment to continue as Steward Transitions from a pilot ACO to a fully operating ACO on January 1, 2018, including real-time notification of ED or inpatient admissions of shared clients.
CCBC continues to work on the two Goals established in our CSA Development Plan:
- Increase staff knowledge regarding various cultures and how culture impacts the many aspects of a family’s life; translate the knowledge of that culture to the Wraparound process to enrich and inform the Care Planning Teams process; and
- Increase skill sets within the phase of transition for families and youth engaged in ICC Services.
The activities related to Goals 1 and 2 are ongoing within the CSA and across CCBC as a whole. Interventions include facilitated open discussion among CSA staff to solicit individual definitions of culture and translate that definition to the clients we serve. CSA staff focuses on improving their skills and competency to align individual care coordination to the background in which the individualized Care Plan is developed. Staff continues to improve their skills at helping families articulate the influence of their culture as a resource or an obstacle to achieving the goals of the Care Plan. Staff then revisits the cultural context in subsequent care planning meetings.
Another activity of Goal #1 will be to supplement the internal discussions with regional trainings on engaging families from diverse cultures into the Wraparound planning process. The region has diverse populations, including Cape Verdeans, Portuguese, and Asians. Each culture has its own unique context in which behavioral health needs are identified, accepted and addressed. Finally, supervisors will review staff assessments to make sure that the cultural component is addressed, and indicates that the staff explored the family’s cultural orientation in initial meetings.
Goal #2 represents a more focused challenge in improving the Wraparound process. One element is for increased supervisory oversight of the transitions out of ICC to outpatient counseling and natural community supports, transitions from higher levels of care back to
community-based services, and transition to adult services for clients who are turning 21. The ICC supervisors will enhance the process by reviewing documentation on care planning to ensure a strength-based approach at the time of transition. Supervisors will be trained to track staff documentation and follow up to make sure any gaps are addressed by staff, especially around transition.