Executive Summary
In 1969 a small group of local citizens led by Carol Schmidt sponsored legislation that created the Worcester Juvenile Court. A year later, this tireless group incorporated Youth Opportunities Upheld, Inc. (Y.O.U., Inc.) as an arm of this court. “Intensive Juvenile Probation” was the first program offered. Every year since, YOU, Inc. has grown in direct response to the continuously changing needs of our community. From “deinstitutionalization” and “privatization” movements, to changes in local, state, and national trends, to ever-changing needs of children and families, YOU, Inc. has a record of well-managed, quality programs with high success rates and accreditation by the Council on Accreditation.
Today, YOU, Inc. is one of the leading behavioral health and education agencies in Central Massachusetts. We offer many different services: therapeutic, clinical, educational, or vocational, all of them stem from our mission to provide youth and families with bright and healthy futures. Our many services are grouped into 4 divisions: Community-Based, Outpatient Clinical, Out-of- Home, and Education & Transition. The YOU Inc. Community Service Agency provides Intensive Care Coordination and Family Partner support to the South Central region of Massachusetts. Due to the large geographic catchment area, the CSA has 2 sites operating out of Milford and Southbridge.
Over the next 5 years, the YOU, Inc. CSA aims to improve access to ICC services for enrolled members, strengthen the fidelity to the wraparound model through improved fidelity scores and develop strong partnerships and collaboration with our community providers, specifically Primary Care Providers and Accountable Care Organizations. The YOU, Inc. CSA has identified several organizational challenges that will be addressed in a 5-year business plan that align with the goals identified both in the CSA Development Plan and the goals within the DSRIP plan.
A priority challenge for the CSA is timely access to ICC services. The CSA has identified recruitment as the priority goal to address this challenge both on the Development Plan and through the DSRIP plan. Through a strong partnership with the agency’s Human Resources Department and Marketing departments and the development of the role of Clinical Talent Acquisition Specialist through DSRIP project #1, Workforce Recruitment Improves Timely Access, the CSA plans to increase the number of ICC staff which will then lead to an improvement in overall access to the service.
Another area of focus for the CSA is the ability to provide high fidelity wraparound to enrolled members. This is identified in the Development Plan as well as through DSRIP project #3, NWIC Wraparound Coaching "Boosters" and CSA Leadership Support & Training, through a focus on training of CSA staff and the sustainable support of supervisors to continue to maintain the fidelity of wraparound. The CSA Development plan shows how the CSA will focus training around the areas of need identified through wraparound fidelity scores. With its DSRIP investment funds, the CSA will contract with the National Wraparound Implementation Center (NWIC) to provide intensive training and supervisory support to specifically address the need for improvement in fidelity scores. Through the enhancement and development of our Wraparound training for the CSA program, this will also support our efforts in staff retention.
The CSA plans to focus on building and strengthening the collaboration and partnerships with community providers, specifically PCP’s and ACO’s. Although this is not directly linked to a goal in the Development Plan, this has been an area of focus of the CSA and an area that this CSA has shown strength in with regard to its ability to prioritize this level of collaboration.
Through the DSRIP project #2, the CSA will develop a part time position of Community Outreach Specialist that will be focused on the development of these relationships and building a sustainable collaboration between the CSA and Primary Care.
Description of how DSRIP investments will address challenges, support improvements on its Development Plan, and help the CSA meets its goals.
Through the use of DSRIP investments, the CSA will have the ability to address the challenges identified through the Development Plan and strengthen the CSA’s ability to provide timely, high quality, integrated care for our enrolled members.
The DSRIP investments will support the CSA in improving timely access to services through the use of a Clinical Talent Acquisition Specialist dedicated to the recruitment of ICC staff for the program. Investing in a strong training program with supervisory coaching will further support the CSA in providing high fidelity Wraparound and improve the areas of fidelity identified in the Development Plan. With DSRIP funding under project #3, the CSA will contract with National Wrap Around Implementation Center (NWIC) to tailor booster trainings and coaching sessions during Budget Period 1 that are specific to the strengths and needs of our CSA.
The DSRIP investments will support its goal to improve existing and develop new collaborations with ACO’s and PCP’s through the use of technology investments and through the development of the new role, Community Outreach Specialist. Under DSRIP project 4, we will leverage and expand technology to improve communication between our CSA and PCPs. Our agency currently uses CareLogic by Qualifacts as our electronic health record solution. We are connected to the MassHIway through our connection with MaxMD. It is through this interface that we are able to share Continuity of Care Documents (CCDs) with our behavioral health and primary care providers throughout the Commonwealth. These documents include information related to care plans, medications, discharge information, appointments and other key data points.
The Community Outreach Specialist (COS) will work to establish and further improve existing collaborations with PCPs but will educate both ACO and PCP providers on the role of care coordination for youth and their families. The COS will maintain regular contact with these providers through direct contact, phone, and email, and will be available to consult on cases as requested. Further, the COS will work with our Central Referral department in further developing protocols for triaging cases referred by and ACO or PCP directly to the COS so as to strengthen the bridge between ACO/PCP to the CSA. It is expected that such a practice will further develop the relationship between the providers.