Rosie D. Meeting of the Parties
Updated February 7, 2013
Updated February 13, 2013
Updated February 25, 2013
Updated February 28, 2013
Updated March 4, 2013
Updated March 27, 2013
Updated April 25, 2013
Updated May 13, 2013
Updated May 23, 2013
Updated May 27, 2013
Updated June 6, 2013
Updated June 10, 2013
Plaintiffs’ Proposed Criteria for Disengagement
I. Access
Focus: Plaintiffs are concerned that certain class members are not receiving medically
necessary remedial services. Plaintiffs propose the following outcome measures for
determining compliance with access standards under EPSDT, as well as suggested methods
for data collection:
1. Medicaid eligible youth involved with DMH and/or receiving DMH funded services
also receive all medically necessary remedial services
a. the number of youth in a DMH funded community program who also used remedial
services over the past year, and the number that used each remedial service.
EOHHS can produce the report described above by June 30, 2013, using the
following analytic steps:
 DMH will provide MassHealth with a list of MassHealth Members under the
age of 21 who, during the period April 1 2011 through March 31, 2012, used
services from a DMH-funded community program.
 DMH will separate the list into two groups: youth receiving high-intensity
services such as Family Systems Intervention and youth receiving lowintensity services such as respite and camperships (as defined by DMH.)
 MassHealth will run an eligibility report for this list of youth and select those
youth with continuous1MassHealth eligibility during this period. MassHealth
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Since members often cycle on and off MassHealth, Plaintiffs agree to consider members to
have continuous eligibility so long as they have not been ineligible for a gap of more than 45
continuous days during a 12 month time period, provided this does not result in the exclusion of
significant numbers of youth from the relevant data sets. In each data set using continuous
MassHealth eligibility, defendants will report the percentage of youth who are removed after the
application of this eligibility test. This note pertains to all uses of the word “continuous” in this
document.
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will report the percentage of youth eliminated by the continuous eligibility
screen.
For the DMH-reported youth who have been continuously eligible for
MassHealth, MassHealth will analyze claims and encounter data and report
the number of youth using, (during the study period): 1) each of the following
individual services: Intensive Care Coordination (ICC;, In-Home Therapy
(IHT); In-Home Behavioral Services (IHBS); Therapeutic Mentoring (TM);
Family Support and Training (FS&T); Mobile Crisis Intervention (MCI);
psychiatric hospitalization; outpatient therapy; and Community-Based Acute
Treatment and Intensive Community-Based Acute Treatment (CBAT/ICBAT);
2) the number of unduplicated youth with any utilization of ICC or IHT; 3) the
number of youth with any utilization of outpatient therapy and no utilization of
either ICC or IHT; 4) the number of unduplicated youth receiving any of the
remedy services other than MCI2; 5) the number of unduplicated youth with
utilization of MCI, Inpatient psychiatric care or CBAT/ICBAT, without any
utilization of outpatient therapy, ICC or IHT; and 6) the number of youth with
no utilization of behavioral health services in the study period.
Plaintiffs’ Expectations: The data sample above will capture virtually all Medicaid
members who also are in receipt of DMH community-based services. There should be a
significant overlap between these youth and youth who need/could benefit from homebased services. As a result, plaintiffs expect to see the following:
that the vast majority of youth receiving low intensity services (as defined above) used
one or more remedial services in conjunction with DMH community supports;
that a majority of youth receiving high intensity services (as defined above) used at least
one remedial service in conjunction with DMH community supports.
b. the number of youth who used remedial services within a year of being admitted to or
discharged from a DMH inpatient, residential or IRTP program, and the number that
used each remedial service.
EOHHS can produce the report described above by July 15, 2013, using the
following analytic steps:
 DMH will prepare two lists of MassHealth Members under the age of 21 who ,
used services from DMH inpatient, residential or IRTP programs. DMH List #1
will consist of Members who used DMH residential services during the period
April 1, 2010 through March 31, 2011. List #2 will consist of Members who used
DMH residential services during the period April 1, 2011 through March 31,
2012. These lists will contain starting and ending dates for each episode of
DMH residential care for each youth.
 The Defendants will provide the Plaintiffs with a report containing four numbers:
1) the total number of unduplicated youth who were discharged from DMH
residential services in the target year; 2)the number of youth with only one
2
ICC, IHT, IHBS, TM, FS&T
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residential stay in the target year; 3) the number of youth with more than one
residential stay, but with no gap greater than 30 days between stays; and 4) the
number of youth with more than one residential stay and at least one gap greater
than 30 days between residential stays.
MassHealth will run eligibility reports for each youth on DMH List #1 for the
twelve months following the end of each youth’s last episode of residential
services in the sample period and for each youth on DMH List #2 for the twelve
months prior to the start of each youth’s first episode of residential services in the
sample period.
For the list of eligible Members in these periods, MassHealth will report the
numbers of youth using community-based services, as defined in Item I.1.a above.
Defendants’ Expectations: There will be relatively little overlap between the children
and youth using intensive community services and residential services from DMH and
those using intensive home and community based BH services through MassHealth
because both systems offer similar services. We expect higher rates of overlap between
children and youth using low-intensity services from DMH and those using intensive
home and community based BH services through MassHealth.
Plaintiffs’ Expectations: The data sample above will capture virtually all Medicaid
members who, during the relevant time period, were found to meet DMH’s clinical
criteria for inpatient or other hospital-based continuing care services, or who required
residential services as a step-down from hospital level of care or in lieu of home-based
services. Among these youth, plaintiffs expect to see the following:
1) that the vast majority of youth received one or more remedial services in order to
prevent more restrictive placements;
2) that the vast majority of youth received one or more remedial services in order to
facilitate discharge from a higher level of care; and
3) that youth who received home-based services were more likely to avoid readmission to
acute care settings or other out-of-home placements.
2. Youth adjudicated delinquent and committed to the custody of DYS receive all
medically necessary remedial services
The number of youth who used remedial services in the year prior to being detained in a
DYS detention facility or the year following release from a DYS contracted or operated
hardware or staff secure residential program and the number that used each remedial
service.
EOHHS can produce the report described above by July 15, 2013, using the following
analytic steps:
 DYS will prepare and convey to MassHealth two lists of MassHealth Members
under the age of 21: DYS list #1 will consist of Members who were released from
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a DYS contracted or operated hardware or staff secure residential program
during the period April 1, 2010 through March 31, 2011. DYS list #2 will consist
of Members who were held in DYS detention during the period April 1, 2011
through March 31, 2012. These lists will contain start and end dates for each
episode of DYS detention or secure treatment for each youth.
The Defendants will provide the Plaintiffs with a report containing four numbers:
1) the total number of unduplicated youth who were discharged from DYS
residential services in the target year; 2)the number of youth with only one
residential stay in the target year; 3) the number of youth with more than one
residential stay, but with no gap greater than 30 days between stays; and 4) the
number of youth with more than one residential stay and at least one gap greater
than 30 days between residential stays.
MassHealth will run eligibility reports for each youth on DYS list #1 for the
twelve months following each youth’s last release in the sample period and for
each youth on DYS list #2 for the twelve months prior to each youth’s first
episode of detention in the sample period.
For the list of eligible Members in these periods, MassHealth will produce a
report of the numbers of youth using community-based services, as defined in
Item I.1.a above.
Defendants’ Expectations: Generally, youth involved in the juvenile justice system are
harder to engage in BH services than other youth. Sometimes parents will engage despite
a youth’s resistance; other times families are discouraged by the youth’s unwillingness to
engage, and give up on services themselves. We would hope to see use of BH services
by younger youth, in the pre-detention period, as Court Clinics and Probation recommend
BH services to try to prevent the youth’s deeper involvement in the juvenile justice
system.
For youth adjudicated delinquent who are leaving DYS secure treatment, DYS staff
report more interest by youth and families in outpatient therapy and IHT, than in ICC.
Plaintiffs’ Expectations: The data sample above will capture virtually all Medicaid
members who, during the relevant time period, were at risk of DYS commitment or
eligible for release from DYS secure settings. A significant number of these youth are
anticipated to have behavioral health conditions such that they would need/benefit from
home-based services in the community. As a result, plaintiffs expect to see the
following:
1) that the majority of detained youth received one or more remedial services in order to
avoid DYS commitment;
2) that the majority of youth received one or more remedial services in order to facilitate
discharge from a DYS secure care setting and to promote community stability;
3) that youth who received home-based services were more likely to avoid repeated or
prolonged detention;
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4) that youth who received home-based services upon discharge from DYS secure
settings were more likely to avoid revocation and to have longer periods of community
tenure.
3. Youth who are in out-of-home placement in psychiatric inpatient units or
Community Based Acute Treatment (CBAT) programs, or who are at risk of such
placement, receive all medically necessary remedial services
Number of Medicaid eligible youth who used certain behavioral health services within
twelve months, and 30 days, of starting inpatient, CBAT or ICBAT services, or twelve
months, and 30 days, of after the end of an inpatient, CBAT or ICBAT services..
EOHHS can produce the report described above by July 15, 2013, using the following
analytic steps:
 MassHealth will prepare a list of MassHealth Members under the age of 21 who,
during the period January 1, 2012 through March 31, 2012, used inpatient
psychiatric or CBAT or ICBAT services.
 MassHealth will prepare two lists of MassHealth Members under the age of 21
who used services from inpatient psychiatric, CBAT or ICBAT programs.
MassHealth list #1 will consist of Members who used these acute services during
the period April 1, 2010 through March 31, 2011. MassHealth list #2 will consist
of Members who used acute services during the period April 1, 2011 through
March 31, 2012. These lists will contain start and end dates for each episode of
inpatient, CBAT or ICBAT service for each youth.
 The Defendants will provide the Plaintiffs with a report containing four numbers:
1) the total number of unduplicated youth who were discharged from CBAT,
ICBAT or psychiatric inpatient services in the target year; 2)the number of youth
with only one residential stay in the target year; 3) the number of youth with more
than one residential stay, but with no gap greater than 30 days between stays;
and 4) the number of youth with more than one residential stay and at least one
gap greater than 30 days between residential stays.
 MassHealth will run eligibility reports for each youth on MassHealth list #1 for
two periods: the 30 days and the twelve months following the end of each youth’s
last episode of inpatient, CBAT or ICBAT services in the sample period and, for
each youth on MassHealth list #2, for the thirty days and the twelve months
before the start date of each youth’s first episode of these services in the sample
period.
 For the list of eligible Members in these periods, MassHealth will produce a
report of the numbers of youth using community-based services, as defined in
Item I.1.a above.
Defendants’ Expectations: We expect to see significant utilization of remedy services
by children and youth leaving psychiatric hospitals or ICBAT/CBAT stays. We expect to
see somewhat less utilization of remedy services by children and youth prior to an
inpatient/ICBAT/CBAT stay because youth may have used remedy services more than a
year prior to the acute stay, and been stable, but experienced a difficult life event or
episodic worsening of their condition, prompting an acute stay.
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Plaintiffs’ Expectations: The data sample above will capture virtually all Medicaid
members who, during the relevant time period, were at risk of out-of-home placement
and eventually met clinical criteria for acute inpatient or CBAT level of care.
Anticipating a very significant overlap between youth who need/could benefit from
home-based services and youth receiving acute inpatient or CBAT services, plaintiffs
expect to see the following:
1) that the majority of these youth received one or more remedial services in order to
prevent/reduce risk of out-of-home placements;
2) that the vast majority of these youth received one or more remedial services in order to
facilitate discharge from a higher level of care and avoid subsequent re-admission;
3) That youth who received home-based services were more likely to avoid readmission
to acute care settings or other out-of-home placements
4. Medicaid eligible youth involved with DCF and receiving DCF residential services
also receive all medically necessary remedial services
Number of Medicaid eligible youth who used remedial services within a year of being
admitted to, or discharged from a DCF residential program, and the number that used
each remedial service.
EOHHS can produce the report described above by July 15, 2013, using the following
analytic steps:
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DCF will prepare two lists of MassHealth Members under the age of 21 who,
used services from DCF residential programs. DCF list #1 will consist of
Members who used DCF residential services during the period April 1, 2010
through March 31, 2011. DCF list #2 will consist of Members who used DCF
residential services during the period April 1, 2011 through March 31, 2012.
These lists will contain start and end each episode of DCF residential care for
each youth.
Using list #1, DCF will prepare a report of utilization of DCF-purchased
community-based services by this group of youth during the period April 1, 2011
through March 31, 2012. The report will group these services into two categories:
clinical and non-clinical and will report on whether the services were associated
with the youth or with the parent or caregiver.
Using list #2, DCF will prepare a report of utilization of DCF-purchased
community-based services by this group of youth during the period April 1, 2010
through March 31, 2011. The report will group these services into two categories:
clinical and non-clinical and will report on whether the services were associated
with the youth or with the parent or caregiver.
The Defendants will provide the Plaintiffs with a report containing four numbers:
1) the total number of unduplicated youth who were discharged from DCF
residential services in the target year; 2)the number of youth with only one
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residential stay in the target year; 3) the number of youth with more than one
residential stay, but with no gap greater than 30 days between stays; and 4) the
number of youth with more than one residential stay and at least one gap greater
than 30 days between residential stays.
MassHealth will run eligibility reports for each youth on DCF list #1 for the
twelve months following the end date for each youth’s last episode of residential
services in the sample period and for each youth on DCF list #2 for the twelve
months prior to the start date for each youth’s first episode of residential services
in the sample period.
For the list of eligible Members in these periods, MassHealth will produce a
report of the numbers of youth using community-based services, as defined in
Item I.1.a above.
Defendants’ Expectations: We expect to see significant utilization of remedy services
by children and youth using DCF-funded residential services, offset by intensive home
and community based services provided by DCF.
Plaintiffs’ Expectations: The data sample above will capture virtually all Medicaid
members who, during the relevant time period, were at risk of and eventually found to
require, out-of-home placement in a DCF operated or funded residential treatment
program. There should be a significant overlap between youth who need/could benefit
from home-based services and youth whose conditions/symptoms require access to a
residential treatment program. Among these youth, plaintiffs expect to see the following:
1) that the majority of these youth have received one or more remedial services in order
to prevent out-of-home placement:
2) that the majority of these youth have received one or more remedial services in order
to facilitate discharge from a residential level of care.
5. Youth with SED who have IHT as their hub receive all medically necessary
remedial services, including appropriate care coordination
Employ the SOCPR sampling process to evaluate and answer the following questions for
youth with IHT as their hub:
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Is the youth also eligible to receive ICC?
If so, was the youth/family offered ICC?
Why is the youth/family not receiving ICC at this time?
Does the youth need or receive services from multiple providers/state agencies?
Does the youth need providers to coordinate/collaborate with school personnel?
Is the IHT in regular contact with other providers, state agencies and school personnel
involved with the youth and family? What form does this contact take (i.e. meetings,
phone calls)?
Do providers, school personnel or other state agencies involved with the youth
participate in care planning?
What other remedial services are supported by the IHT?
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Is the youth/family receiving the level of care coordination
his/her situation requires?
EOHHS can make these questions part of the FY13 and 14 System of Care Practice
Review (SOCPR) of IHT providers. Defendants anticipate that preliminary reports will
be available approximately two months after every cycle of reviews. MassHealth plans
the following schedule of reviews:
 IHT in June, 2013; and
 IHT and ICC in October 2013 and January, March and May 2014.
Defendants’ Expectations: We expect that the majority of children and youth using IHT
services are receiving the medically necessary services they seek and appropriate care
coordination of those services by the IHT provider staff.
Plaintiff’s Expectations: Youth with SED who have IHT as their hub receive all
medically necessary remedial services, including appropriate care coordination
6. Youth with SED who have out-patient therapy as their hub receive all medically
remedial services including care coordination
EOHHS can produce a report on this topic by June 30, 2013, using the following
analytic steps:
a. Gather a random sample of 50 youth with SED enrolled in MBHP3 currently
receiving outpatient therapy as their only “hub” service and conduct a review of the
clinical record and interviews of the youth’s therapist and caregiver to answer the
following questions:
i. Is the youth eligible to receive ICC or IHT;
ii. Does the youth have an IEP and need providers to coordinate/collaborate with
school personnel?
iii. How often does the out-patient therapist have contacts with other providers, state
agencies and school personnel? What form does this contact take (i.e. meetings,
phone calls)?
iv. Is the youth/family receiving the level of care coordination
his/her situation requires?
b. For the sample of 50 youth, analyze claims data to determine:
i. Are these youth receiving one or more remedial services?
ii. How many are receiving each remedial service (IHBT, TM, MCI, FS&T) over a
one year period?
iii. During a one year period how many youth have used MCI, and for how many
encounters?
iv. During a one year period how many youth have used inpatient psychiatric care,
and for how many admissions?
3
To perform this task, the Defendants will need to amend a health plan contract to define and pay for this study. It
would be most cost-effective to contract with one health plan to perform this task.
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Defendants’ Expectations: We have no particular assumptions or expectations for this
report and look forward to seeing the data.
Plaintiffs’ Expectations: Youth with SED who have out-patient therapy as their hub
receive all medically remedial services including care coordination
II. Utilization
Focus: Plaintiffs are concerned that certain class members are not receiving remedial services
with the frequency, intensity and duration required to correct or ameliorate their conditions.
1. Youth who are in ICC and/or IHT receive appropriate assessments and treatment
plans coordinating delivery of all medically necessary services
The Plaintiffs wish to review the results of upcoming SOCPRs to assess practice in these
areas. Defendants anticipate that preliminary reports will be available approximately
two months after every cycle of reviews. MassHealth plans the following schedule of
reviews:
 IHT in June, 2013; and
 IHT and ICC in September and November of 2013 and January, March and
May of 2014.
Defendants’ Expectations: We expect that the majority of children and youth using ICC
and IHT will be using these services with the frequency, intensity and duration their
families’ desire.
Plaintiffs’ Expectations: Youth who are in ICC and/or IHT receive appropriate
assessments and treatment plans coordinating delivery of all medically necessary services
2. Youth receive other remedial services with the intensity and duration their
conditions require
Defendants have shared with the Plaintiffs a report on length of stay in IHT during the
period April through June, 2012, prepared by MBHP. The Plaintiffs have requested the
Defendants to share additional quarterly MBHP IHT length of stay reports as they
become available and quarterly reports on length of stay in TM and IHBS.
Defendants can share additional quarterly reports prepared by MBHP on length of
stay in IHT, IHBS and TM as they become available. MBHP expects to put the IHBS
and TM reports into production by the end of May.
Defendants’ Expectations: This data will show variation in the average length of stay in
these services across providers, but will not answer the question of optimal intensity or
duration for a particular child or youth.
Plaintiffs’ Expectations: Data on length of stay or duration of service, when combined
with utilization data, should reflect a range of individualized treatment decisions on
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behalf of members. However, average lengths of service (by provider) should not fall
below a minimum expectation of 3 months in duration.
Average lengths of stay also should reflect key variables impacting service delivery,
including whether the service is delivered alone or in combination, whether the service
includes a care coordination function, and the diversity/needs of the population served.
For youth in IHT, plaintiffs have the following expectations regarding average length and
intensity of service:
1)
Youth who are otherwise eligible for ICC (who need or have received multiple
services/have multiple provider/agency involvement) have significant needs and
will require both service coordination and treatment provided by IHT, resulting in
average lengths of stay from 9-12 months and an average of 5-6 hours of service
per week.
2)
Youth who receive IHT in combination with ICC have significant needs but
require no care coordination from IHT, resulting with average lengths of stay
from 6-9 months and an average of 4-5 hours of service per week.
3)
Youth who are not eligible for ICC (those without multiple providers/agencies or
without SED), but who use IHT as a hub for one or more remedial services, have
less significant needs but require some care coordination, resulting in average
lengths of stay from 6-9 months in duration and an average of 4-5 hours of service
per week.
4)
Youth who receive only IHT and no other remedial service have less intense
needs and require no care coordination, resulting in lengths of stay averaging 4-6
months and an average of 2-3 hours of service per week.
For youth in IHBT, Plaintiffs have the following expectations regarding average length
and intensity of service:
1)
Youth with psychiatric disabilities and challenging behaviors can be expected to
require significant periods of behavioral therapy in order to learn pro-social,
adaptive behaviors and to reduce or extinguish negative, harmful behaviors,
averaging 9-12 months in duration and 5-6 hours per week.
2)
Youth with cognitive or developmental disabilities, alone or in combination with
psychiatric diagnoses can be expected to require even more intensive
interventions delivered over a longer period of time, averaging 12-18 months in
duration and 7-8 hours per week.
III. Effectiveness
Focus: Plaintiffs believe there must be child outcome data which demonstrates whether
remedial services have been effective in correcting or ameliorating youths’ mental health
conditions.
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Youth receive remedial services that result in improved functioning in families, home,
community and school
Defendants have shared a report of CANS data on a cohort of 1600+ youth who have used, or
are receiving ICC for enough time to accumulate four CANS prepared by the ICC provider.
In order to generate additional and more nuanced data with which to understand youth
outcomes, and to assess available evidence of effective progress, the plaintiffs are requesting,
and the defendants have agreed to produce by June 30, 2013, the following:
CANS outcomes reports, by individual CANS item, for six cohorts of youth, those:
 with exactly two CANS in ICC
 with exactly four CANS in ICC
 with six or more CANS in ICC
 with exactly two CANS in IHT
 with exactly three CANS in IHT
 with four or more CANS in IHT
For each cohort:
 The number of youth who improved from a 3 to a 2
 The number of youth who improved from a 3 to a 1
 The number of youth who improved from a 2 to a 1
 The number of youth who showed no change
 The number of youth who went from a 2 to a 3
By September 13, 2013, for each of the six cohorts, the Defendants will produce counts of
youth with increases, decreases and no change, using the reliable change index, by domain,
for Life Functioning, Risk Behaviors, and Behavioral/Emotional Needs domains.
Defendants’ Expectations: Within the limit of data reliability present in our services
system, and taking into account the fact that children and youth using remedy services may
have used other BH services prior to ICC and IHT, we expect to see modest gains in areas
pertaining to BH conditions.
Plaintiffs’ Expectations: Given that most youth demonstrate at least modest gains following
traditional, out-patient interventions, plaintiffs expect the following with regard to the
provision of intensive home-based services:
1) that among youth with three or more CANS, the vast majority of items will demonstrate
significant improvements in functioning and corresponding reductions in symptoms;
2) that the vast majority of youth with three or more CANS will demonstrate overall
progress in the domain areas of life functioning, risk behaviors and behavioral/emotional
needs; and
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3) that the majority of youth with two CANs will demonstrate no change or worsening
across domain areas.
IV. Quality Standards/Practice Guidelines
Focus: Plaintiffs believe that the current program specifications for services other than ICC
are inadequate, and that the Judgment requires the creation of quality standards designed to
ensure that providers are delivering consistent, quality services in accordance with the
Court’s order.
Plaintiffs request EOHHS to develop and implement Practice Guidelines for the
following remedial services: MCI, IHT, IHBT and TM, with the specific items for each
service included in materials shared by the Plaintiffs with the Defendants.
The Defendants will work with their contracted health plans, providers and, if necessary,
consultants to develop Practice Guidelines for MCI, IHT, IHBT and TM. Drafts will be
available for review by the Plaintiffs in early June. If, after their review, the Plaintiffs
have concerns, the parties agree to bring in mutually agreed upon expert consultants to
help resolve concerns with the documents.
V. Continued Monitoring and Reporting
Focus: Plaintiffs want to receive existing, periodic data reports through June 2013, as well as
data/reports concerning:
1. Data on the percentage of youth with a positive screen who receive follow-up behavioral
health services within 90 days of the screening.
Plaintiffs’ Expectations: Based on MBHP’s methodology for measuring “follow-up”
(pediatric visits for behavioral health reasons or subsequent claims by behavioral health
providers), screening follow-up rates will increase from 50% to 75%.
2. CANS compliance data
Plaintiffs’ Expectations: Out-patient therapists’ compliance with CANs administration will
improve from 50% to 75%.
3. WIFI
Plaintiffs’ Expectations: Plaintiffs expect that: 1) as compared to baseline data collected
over one year ago, significantly more youth will have claims for home-based services prior to
their receipt of MCI; and 2) that the vast majority of youth who entered an episode of crisis
without home-based services will have remedial service claims in the period following crisis
intervention.
4. SOCPR reports on ICC and IHT
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5. MCI pre-/post- report
6. Data on average length of stay for youth receiving services from Community-Based
Acute Treatment (CBAT) programs
Plaintiffs’ Expectations: Plaintiffs expect that youth referred to CBAT level of care for
continued stabilization of a behavioral health crisis will remain for an average of seven days
of less, excluding youth in the custody of DCF.
7. Data on the number and percentage of youth who receive MCI services for more than
three days.
Plaintiffs’ Expectations: Plaintiffs expect that there will be a significant increase in
utilization of the expanded MCI service period one year after implementation.
EOHHS can provide updated reports in these areas as part of the May 30, 2013 Report to the
Court.
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