Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Children and Families

Department of Mental Health
Community–Based Residential Services Initiative

REQUEST FOR INFORMATION

&

NOTICE OF PUBLIC FORUMS

Document Number: 0LCEHSYOUTHRESIDENTIAL

July 2010
 Table of Contents
Section 1. OVERVIEW......................................................................................................1
Section 2. RFI INFORMATION.........................................................................................5
Section 3. RFI RESPONSE INSTRUCTIONS................................................................12
Section 4. PUBLIC FORUMS..........................................................................................14
APPENDIX I.....................................................................................................................15
APPENDIX II....................................................................................................................17
APPENDIX III...................................................................................................................21

RFI – Community-Based Residential Services Initiative ii

 Section 1. OVERVIEW

The Executive Office of Health and Human Services, the Department of Mental Health
(DMH) and the Department of Children and Families (DCF; together referred to as the
Agencies) are committed to the development of a fully integrated behavioral health
system for children and families. A major step in this direction was taken with the
implementation of the Children’s Behavioral Health Initiative (CBHI) in 2009, which
made major improvements to services paid for by MassHealth to screen for, assess and
treat behavioral health conditions in MassHealth-enrolled children and youth up to age
21. Primary care providers are now required to offer to screen these children and youth
using standardized behavioral health screening tools during well-child visits. Behavioral
health providers are required to use a standardized tool, the Child and Adolescent Needs
and Strengths (CANS) tool, to record information gathered during the clinical assessment
process. Finally, six home- and community-based services have been added or improved:
Intensive Care Coordination, Family Support and Training, Mobile Crisis Intervention,
In-Home Therapy, In-Home Behavioral Services and Therapeutic Mentoring. Intensive
Care Coordination implements the Wraparound Process of care planning and delivery
consistent with the model described by the National Wraparound Initiative.

The Agencies have been systematically, and separately, procuring services over the past
decade with a System of Care lens. The DCF procurement of Family Networks services
included a Shared Roles and Responsibilities section that required bidders to describe
how they would participate as a partner with the DCF and with other providers in a
cohesive service delivery system. Prior to the procurement residential providers were
offered opportunities to learn from their colleagues in other states, such as EMQ Families
First in Santa Clara County, California about how they had re-engineered their programs
to be a “residential service without walls”. DMH has procured models of community
residential services that offer services flexibly both in placement and in the community,
providing continuity of care and relationships for the child and family. The Agencies
have embraced family voice in all aspects of their work, from the individual case level to
the highest levels of administration and governance. All of this is consistent with an
emerging national consensus on the delivery of residential services that is articulated in
the Building Bridges Initiative. We now have an opportunity through a joint procurement
of residential services categorized as “Youth Intermediate Term Stabilization Services” in
the EOHHS Chapter 257 Implementation Plan to support the further evolution of the
system.

Our goal in this Community-Based Residential Services initiative is to achieve better and
more sustainable positive outcomes for children and families. This requires full family
engagement during the course of the residential service in all aspects of a child’s care and
treatment. The objective is to prepare families to manage successfully their children at
home. School transitions will be facilitated to maximize likelihood of academic success,
and social supports will be in place. The Agencies are interested in 1) procuring program
models that provide trauma-informed care environments and are focused on
strengthening connections to family and community, 2) embedding evidence-based

RFI – Community-Based Residential Services Initiative 1

clinical practices in those programs that are responsive to the complex social, emotional,
educational and psychological needs of children and families, 3) unifying the Agencies’
administrative and management structures and processes in order to improve efficiencies,
4) supporting stronger integration and continuity of out-of-home behavioral health
services with those that are delivered in the home, 5) providing a fair rate of
reimbursement for these services, and 6) rewarding providers that consistently deliver
positive outcomes.

This RFI is intended as one of several strategies the Agencies are employing to obtain
stakeholder input and invite commentary on discrete elements of the initiative. Some
questions are asked in order to understand the operational challenges of implementing
new program models, and some are asked in order to obtain information about innovative
strategies that have already been implemented in the provider community, and some are
asked to generate your ideas and thoughts for how a re-engineered out-of-home system
should be designed. You are welcome to answer as many of the questions in the RFI as
you wish, and you do not have to answer all of them for your responses to be considered.
If we have not thought of a question to which you would like to respond, or you have
information that you want the Agencies to take into consideration in the design work,
please submit them to us as well.

Definitions

Building Bridges Initiative: Building Bridges is a national initiative working to identify

and promote practice and policy that will create strong and closely coordinated
partnerships. These collaborations occur between families, youth, community- and
residentially based treatment and service providers, advocates and policy makers to
ensure that comprehensive mental health services and supports are available to improve
the lives of young people and their families. (www.buildingbridges4youth.org)

Class Rates: A payment method that establishes a schedule of rates in which providers
receive the same rate for equivalent services. Rates may be differentiated based on levels
of intensity, size or location of program, qualifications of required staff or other
documentable cost-influencing features.

CBHI (Children’s Behavioral Health Initiative): An interagency initiative of the

Commonwealth’s Executive Office of Health and Human Services (EOHHS) whose
mission is strengthen, expand and integrate Massachusetts state services into a
comprehensive, community-based system of care, to ensure that families and their
children with significant behavioral, emotional and mental health needs obtain the
services necessary for success in home, school and community. The first project of the
Initiative was to implement the program improvements described in the judgment in
Rosie D. v. Patrick. (Civil Action No. 01-30199-MAP).

Community-Based Residential Services: Current programs for the RFI and RFR
include:

• Intensive Residential Treatment Program (IRTP),

RFI – Community-Based Residential Services Initiative 2

 • Clinically Intensive Residential Treatment (CIRT)
• Behavioral Intensive Residential Treatment (BIRT)
• 766 Approved Residential Programs
• Behavioral Treatment Residence (BTR)
• Group Home
• Short-Term Assessment & Rapid Reintegration (STARR)
• Transition to Independent Living Programs
• Teen Living Programs

Family: broadly defined as biological, kin, guardian, foster, pre-adoptive or adoptive

person(s).

Five Fundamental Rights: Persons served in Department of Mental Health licensed,

operated or contracted facilities or programs (including Residential Programs, IRTPs,
BIRTs, and the CIRT) are guaranteed certain rights according to G. L. c. 123, § 23. These
rights include: living in a humane environment, access to making/receiving telephone
calls, sending/receiving mail, receiving visitors, and visiting with legal advocates, clergy
and their social worker. Only some of these rights can be restricted, and only in
circumstances that meet a specific standard of harm criteria that is clearly stated in the
Department of Mental Health regulations. See Appendix II.

Five Protective Factors: The Five Protective Factors are the foundation of the
Strengthening Families approach. Extensive research supports the common-sense notion
that when these Protective Factors are present and robust in a family, the likelihood of
child abuse and neglect diminish. The factors are Parental resilience; Social connections;
Knowledge of parenting and child development: Concrete support in times of need; and
Children’s social and emotional development.

Foster Child Bill of Rights: See Appendix III.

Performance-Based Contracting: A Performance-Based Contract is one that focuses on

the outputs, quality and outcomes of service provision and may tie at least a portion of a
contractor’s payment as well as any contract extensions to their accomplishment (Martin,
1997:1 & 8).

Promoting Positive Youth Development: Children who are connected to caring adults
are more likely to be emotionally healthy and engaged in school, and less likely to
participate in delinquent or destructive behavior. EOHHS agencies that engage with
youth support their positive development; our efforts range from rehabilitating youth in
residential facilities to offering youth violence and teen pregnancy prevention programs
in communities across the Commonwealth.

RFI – Community-Based Residential Services Initiative 3

Regional Interagency Team: Clinical and program specialists drawn from both agencies
to perform utilization and quality management functions.

Residential Program: For the purposes of this RFI the Agencies use this term broadly
to include all congregate care programs along the continuum of services from
community-based group homes to campus-based residential schools and locked secure
settings.

Six Core Strategies©: The Six Core Strategies© were developed by national experts
working through the Office of Technical Assistance at the National Association of State
Mental Health Program Directors (NASMHPD, the organization that represents public
mental health systems throughout the United States). The Core Strategies are a public-
domain curriculum and model designed to create organizational culture change. They
have been successfully applied to reduce and prevent the use of restraint, seclusion and
violence in care settings. The Six Core Strategies© have been used in child/adolescent
and adult settings including schools, residential, inpatient, juvenile justice and
correctional facilities. See Appendix I.

System of Care: “A comprehensive spectrum of mental health and other necessary

services which are organized into a coordinated network to meet the multiple and
changing needs of children and their families”. (Stroul, B., & Friedman, R. 1986) “A
System of Care incorporates a broad array of services and supports that is organized into
a coordinated network, integrates care planning and management across multiple levels,
is culturally and linguistically competent, and builds meaningful partnerships with
families and youth at service delivery and policy levels”. (Pires, S. 2002)

Utilization Management: The process of managing service use and costs through
effective planning and decision-making to ensure that services provided are appropriate,
meet the intended goals and are cost-effective.

Wraparound: A definable planning process involving the youth and family that results
in a unique set of community services and natural supports individualized for that youth
and family to achieve a positive set of outcomes. See also National Wraparound
Initiative (http://www.nwi.pdx.edu) for further description of Wraparound.

Youth Intermediate-Term Stabilization Services: Under the Chapter 257

Implementation Plan, EOHHS has created a consistent Purchase of Service (POS)
Classification System comprised of service classes defined by target population,
general program purpose, service setting, and scope and bundling of service
elements. Youth Intermediate-Term Stabilization Services are defined as programs that
provide a child, adolescent, or young adult a place of overnight housing in a specialized
residential or hospital setting for a limited period of time to promote stabilization and
transition to a less restrictive setting, to a permanent family home, to independence, or to
another adult serving program.

RFI – Community-Based Residential Services Initiative 4

 Section 2. RFI INFORMATION

2.1 Program Requirements

The Agencies have assessed the performance of the current system and conducted
research into new and promising practices in residential care. We are considering
including the following requirements for all programs in order to ensure alignment with
our common values for how best to serve children and families in these settings.
• All programs embrace the concept of family-driven and youth-guided care. The
Agencies want to strengthen efforts that support youth and families as integral
partners and ensure that they have a primary decision-making role in service delivery
decisions and provider agency functioning, including having roles of significance on
agency boards and committees.
• All programs have a strategic plan to reduce and prevent the use of restraint and
seclusion that is informed by the Six Core Strategies and is reviewed and updated
annually.
• All programs have a strategic plan to improve their family engagement practices
that includes at minimum:
o Assessment of current family engagement practices, utilizing the Building
Bridges standardized tool, updated annually
(www.buildingbridges4youth.org/sites/default/files/BB-SAT.pdf);
o A plan for identifying a caring adult who can support youth who have an
alternative permanent plan of living independently in the community;
o A plan for pro-actively engaging both parents, including the non-resident
parent, in the lives of their children in care.
• All programs will have a strategic plan, which is updated bi-annually, to improve
their capacity to provide culturally and linguistically competent services that includes
at minimum
o A workforce development strategy;
o Affiliation and/or sub-contracting strategies.
• All programs serving adolescents and young adults age 14 and above provide
education and training in skills needed to be self-sufficient adults, including
assistance with job placement and support, based on a positive youth development
model.
• All programs will align their clinical, managerial and systemic practices with the
System of Care philosophy, principles and values. See Building System of Care: A
Primer, Sheila A.Pires, 2002. Available from Georgetown University Child
Development Center at:
https://gushare.georgetown.edu/ChildHumanDevelopment/CENTER
%20PROJECTS/WebSite/PRIMER_ChildWelfare.pdf

RFI – Community-Based Residential Services Initiative 5

 • All programs implement the requirements of G. L. c. 123, § 23. Rights and
Privileges of Patients (see Appendix II) also known as the Five Fundamental Rights.
• All programs will have credible mechanisms for self-assessment and reporting on
demonstrating their adherence to the principles.

Questions:
1. What are the challenges, if any, of implementing each requirement in Residential
Programs?
2. Please define other requirements you believe should be added that would drive
toward improvements in the existing system.

2.2 Community and Family Engagement

The Agencies have processes in place that engage formal and informal community-based
services to facilitate successful integration of youth within community life. Some
residential providers also will help to connect families and youth to these resources in
their own community. These resources will offer additional supports to families and
youth during the placement as well as after discharge.

Questions:
1. The national Building Bridges Initiative recommends the incorporation of family
partners/parent support specialists and youth peer mentors as part of the residential
services workforce. What recommendations do you have regarding how to translate
this recommendation into requirements in the proposed procurement in order to
ensure the programs can successfully adopt the change?
2. What are the training needs associated with the new paradigm? Identify what
training, if any, should be offered by state agencies? What training(s) is best
conducted by the provider?
3. List effective solutions you have employed to support a family’s and youth’s
connection to formal and informal resources in their community of origin. What
barriers have you found particularly challenging?
4. Identify key areas and/or issues that must be in the future procurement to ensure
that the initiative will meet the unique needs of transitional age youth.
5. What solutions should be employed to partner successfully with support services
to ensure they are in place before a youth’s transition from residential to community-
based care? What barriers have you found particularly challenging?
6. What community-based services are most readily integrated into residential
treatment models/programs, and how would this integration be best achieved?
7. What suggestions do you have to support, or improve, collaborative practice
between providers and schools? Are there specific actions the Agencies should do to
support these recommendations?

RFI – Community-Based Residential Services Initiative 6

 8. What suggestions do you have to ensure the voices of youth and family are fully
and meaningfully incorporated into Community-Based Residential Services?
9. As a parent, or family member, what have you found to be most helpful and what
has been an obstacle to your child's success both in a Residential Program and post
discharge? How would you like to be involved/engaged with the Residential Program
while your child is there? Other recommendations?
10. As a youth in a residential setting, or a youth’s sibling, what have you found to be
most helpful and what has been an obstacle to your success both in the Residential
Program and post-discharge? How would you like to be involved with/engaged with
Residential Program while there? Other recommendations?
11. What are the challenges of providing services to children with a parent who has
severe mental illness, and what solutions could be employed for successful family
reunification when a parent has mental illness?

2.3 Program Models

In addition to existing program models the Agencies are interested in developing capacity
in each region for an integrated continuum of services within a single contract with a
residential provider. This expanded model would include both placement and in-home
services provided flexibly as determined by the needs of the child and family. Family in
this sense is defined broadly as person(s) with a biological, kin, guardian, foster, pre-
adoptive or adoptive relationship. Service elements would include residential care,
respite care, transitional-care services and community-based services that supplement a
care plan developed as part of DMH, DCF or MassHealth-covered services.

Questions:
1. As providers, identify the challenges you face in implementing this program
model. Offer recommendations to address these challenges.
2. List the essential components of a program of this type.
3. What are the implications of providing access to short-term, long-term and part-
time residential treatment within this program?
4. Identify the clinical challenges and opportunities serving both DMH and DCF
youth in this program, and offer recommendations to mitigate those challenges.
5. Should a provider of this program model be required to deliver all of the
contracted services or should sub-contracting to other vendors be permitted? What
are the advantages and disadvantages of each strategy?
6. What delegated decision-making authority do we need to give providers for a
Performance-Based Contract for this program to be considered when the successful
outcome is defined as stable residence in a community setting?
The Agencies will continue to purchase existing program models and are also seeking
input on potential enhancements to some of these models.
7. Do IRTP/BIRT/CIRT programs need to adopt specific models of care?

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 8. There is a set of clinical services normally associated with the BIRT level of care,
which includes, among other things, enhanced levels of Psychiatry, Medical/Nursing
staff, and LCSW Social Work staff. To what extent would providers be able to make
this level of clinical programming available to BTR level programs on an as-needed
basis when indicated for specific youth for a specific period of time, for example
when transitioning a youth to a BTR from a IRTP/BIRT or hospital setting? What
challenges would providers face in implementing this kind of flexible programming?
9. What are the unique populations that need specialized approaches, and what do
the Agencies need to be aware of prior to establishing new program requirements?
10. List issues in transitioning youth with unique needs, such as those with substantial
cognitive impairments or chronic medical conditions to the next stage in their
treatment.

2.4 Purchasing and Pricing Methodologies

Chapter 257 of the Acts of 2008 (Chapter 257) places authority for the determination of
reimbursement rates for social service programs with the Division of Health Care Finance
and Policy (DHCFP). Chapter 257 requires that rates be adequate to meet the costs of an
efficient and economically operated provider, take into account the costs to providers of
any existing or new governmental mandates, are regularly reviewed for adequacy, and
reflect any meaningful geographical differences in the costs of service delivery.
The intention is to establish a series of Class Rates that will support DCF and DMH
purchase of these services under the new service models currently being developed
within the Youth Intermediate-Term Stabilization Service Class. In developing these
rates, DHCFP will use existing information on costs and expenditures and will likely
supplement this information by surveying providers for additional data. Payment systems
employed by other states will be examined for features and methods that could be
applicable for replication. Pricing options to be explored can include a single case rate, a
tiered rate that is adjusted based on client status and functioning (i.e., no longer meets
criteria for placement, meets transitional criteria, meets aftercare criteria) or pricing of
service components according to type, frequency and intensity. It may prove difficult to
move the payment system directly to a performance-based model that remunerates solely
on outcomes and quality, so it is likely that the rate setting process will be a staged
endeavor.

Questions:
1. Staffing intensity is likely to be the greatest determinant of variability in rates.
What other major programmatic inputs should be evaluated for their effect on cost?
2. How does type of physical facility affect the pricing structure? Should rates
reflect variation in how the provider acquired the physical structure (Rent? Purchase?
Donated?)
3. Historically bed/day has been the unit of service employed for residential
services. Should the Division consider other types of unit rates such as a per-case over

RFI – Community-Based Residential Services Initiative 8

 a pre-determined period of time, such as an episode, bed/day plus a follow-up rate of
some type for post residential services? Other types?
4. Should rates be case-mix adjusted? In your experience have you encountered
valid tools that would support efforts to adjust rates by case-mix?
5. There has been discussion of a performance-based payment system. What
additional data would need to be collected to develop and evaluate such a system?
6. Would additional data collection for pricing be perceived as burdensome? Would
your agency be willing to assist with the development of such a tool?
7. Do you have recommendations on how to involve providers in the development of
rate options?

2.5 Performance-Based Contracts

The Agencies intend to move toward a Performance-Based Contracting system for a
portion of these services. It is intended that contracts implemented pursuant to a future
RFR for the implementation of this initiative will describe what outcomes are desired and
expected relative to contractor service specifications and will include incentives for
providers to achieve the desired youth and family outcomes. Such a system requires that
we first identify the outcomes we want to achieve, core components of the services, the
populations that are most likely to benefit, a way to reliably and validly measure when
those outcomes have been achieved, and reasonable rewards for high performing
programs.
The Agencies are considering the following outcomes for programs entering into a
performance contract.
• Improved rates of successful discharge to a home or stable and enduring
community placement;
• Improved placement stability;
• Improved safety through prevention and reduction of restraint and
seclusion
• Improved child/youth functioning (as measured by CANS or similar
outcomes measurement tool).

Questions:

1. Identify the key service components of a Residential Program that offer the
greatest likelihood that children and families will succeed in achieving these
outcomes.
2. Define possible performance rewards the Agencies should consider. Are there
rewards other than financial ones that would incentivize performance to desired
outcomes?
3. What process would you recommend for obtaining consensus on outcomes,
measures, service components, eligible populations and performance rewards for a
performance contract?

RFI – Community-Based Residential Services Initiative 9

 4. Are there other outcome measures that should be included in a performance
contract?

2.6 Management Structures

The Agencies currently have separate structures and processes for service authorization,
Utilization Management, and quality monitoring for Community-Based Residential
Services. Yet many of the providers under contract to DMH and DCF are the same, and
the needs of the children being placed in these programs are similar. We believe that
consolidating these functions and establishing common processes will improve access to
the right service at the right time for the right duration, will better serve the needs of
children and families, and will simplify procedures for both the purchasers and the
providers. Most importantly, this shared system will establish a foundation for the future
integration of the out-of-home System of Care with community-based child welfare
services and community-based behavioral health services, into fully integrated local
systems of care.
The core managerial elements of this system for improving youth and family outcomes
and system performance are as follows:

1. A unified entry point utilizing common protocols to determine eligibility/

service authorization. The new system will have a “virtual” front door to residential
and group home services. This “door” will be managed by a Team that will receive
requests for placement from the Agencies’ respective field offices. The Team will
apply level-of-service criteria in determining the appropriate program in the service
continuum. The level-of-service criteria will take into consideration the social,
educational, permanency and behavioral health needs of the child and family.

2. Technology-enabled provider census information to quickly and efficiently

locate services. Agencies currently send referrals to multiple providers for their
consideration. Each provider in turn has its own internal process for reviewing
referrals and making acceptance or rejection decisions based on current or projected
vacancies and clinical presentation. This can delay entry and result in children
waiting in hospitals or transitional placement settings, creating uncertainty and
instability for the child, and creating back-ups in the system. It is anticipated that the
Agencies will use an existing Census Tracking system to identify providers who can
meet the child and families needs, are located closest to the child’s community of
origin or most significant ties, and have a vacancy. This will shorten the referral –
placement process and result in better outcomes for children.

3. A single approach to Utilization Management that will eliminate duplication

of administrative processes between the Departments. The Agencies currently
have separate and distinct Utilization Management structures and processes for the
same programs. This requires that providers submit separate documentation
regarding discharge readiness or on-going need for service and participate in separate
and different review processes. It is anticipated that the new system will operate on
one integrated set of requirements for continuing care assessment, and that these
requirements will reflect the imperatives and mandates of the Agencies.

RFI – Community-Based Residential Services Initiative 10

 4. A single system of quality monitoring and quality improvement that is data-
driven, transparent and consistent. There are well-established key indicators of
program quality that are currently reported electronically to the Agencies that will be
integrated into a single set of reporting elements and process. There are other
indicators of quality that can be assessed by the Utilization Managers in the course of
their documentation reviews and conversations with program Clinical Directors and
state agency social workers. When the data from these sources indicate that an
intervention is required, a Regional Interagency Team will meet with the provider to
review the concerns and assist in developing a plan for improvement. When a child
presents exceptional clinical challenges, an Agency Child Psychiatrist will be
available to provide consultation.

Questions:
1. Please comment on what you see as the benefits and/or the potential
challenges with these management structures and processes. Should the state consider
alternative solutions?
2. Is there an impact of maintaining the Agencies different payment
processes, and would you recommend any changes?
3. Please identify the key indicators of program quality that should be
tracked.
4. What process would you recommend that the Agencies use in establishing
level-of- service criteria for each level of care?
5. What are the criteria that are most important to consider when determining
the need for continuing care?
6. What standards would you recommend the Agencies establish related to
discharge planning and decision-making?

RFI – Community-Based Residential Services Initiative 11

 Section 3. RFI RESPONSE INSTRUCTIONS

3.1 RFI Response Instructions

To be reviewed and considered, RFI responses must be received by August 13, 2010, by
4:00 p.m. Eastern Time. Responses may be submitted in one of the following ways:

• By SurveyMonkey: http://www.surveymonkey.com/s/5WPT6H2

• By e-mail to: perry.trilling@state.ma.us

• In writing to:
Perry Trilling, DMH and DCF Project Manager
Department of Children and Families
24 Farnsworth Street, 5th Floor
Boston, MA 02210

Parties interested in responding to this RFI should prepare a typewritten response that
includes a cover sheet that states the respondent’s name, organization, address, telephone
number, email address, and affiliation or interest (e.g., family member, current or
potential contractor, community member, provider, advocacy organization). Responses
may be submitted either electronically or in hard-copy format, with double-sided, single-
spaced pages, using Microsoft Word 2003, 12-point font. Parties responding in hard copy
should submit one original and three copies of their response and an electronic copy on
CD.

Questions should be answered in order of appearance and numbered according to the RFI
question number. Respondents are invited to respond to any or all of the RFI questions;
please respond to as many as you feel are appropriate. Responses, including any
attachments thereto, should be clearly labeled and referenced by name in the RFI
response. No part of the response can be returned. Receipt of RFI responses will not be
acknowledged.

3.2 Additional Information

A. Electronic Distribution

This RFI has been distributed electronically using the Commonwealth

Procurement Access and Solicitation System (Comm-PASS). Comm-PASS is an
electronic mechanism used for advertising and distributing the Commonwealth of
Massachusetts’ procurements and related files. No individual may alter (manually
or electronically) the RFI or its components except those portions intended to
collect the respondent’s response. Interested parties may access Comm-PASS at
the following address: http://www.comm-pass.com.

RFI – Community-Based Residential Services Initiative 12

 Questions specific to Comm-PASS should be made to the Comm-PASS Help
Desk comm-pass@osd.state.ma.us or by telephone at (888) 627-8283 (MA-
STATE).

B. RFI Amendments

Interested parties are solely responsible for checking Comm-PASS for any
addenda or modifications that are subsequently made to this RFI. The
Commonwealth and its subdivisions accept no liability and will provide no
accommodation to interested parties who fail to check for amended RFIs.

3.3 Use of RFI Information

Information is being solicited in the RFI to assist EOHHS, DCF and DMH in the
development and implementation of the DCF/DMH Initiative. The Agencies reserve the
right to accept or reject, in part or in full, any information contained in or submitted in
response to this RFI. The RFI is not binding on the Agencies and shall not obligate the
Agencies to issue a procurement that incorporates any RFI provisions or responses.
Responding to this RFI is entirely voluntary, will in no way affect the Agencies’
consideration of any proposal submitted in response to any subsequent procurement, and
will not serve as an advantage or disadvantage to the respondent in the course of any
procurement that may be issued. Responses to this RFI become the property of the
Commonwealth of Massachusetts and are public records under the Massachusetts
Freedom of Information Law, M.G.L. c.66, and c.4, regarding access to such documents.
However, information provided in response to this RFI and identified by the respondent
as trade secrets or commercial or financial information shall be deemed confidential and
shall be exempt from disclosure as a public record (see M.G.L. c.4). This exemption may
not apply to information submitted in response to any subsequent procurement.

RFI – Community-Based Residential Services Initiative 13

 Section 4. PUBLIC FORUMS

DMH and DCF are holding five (5) public forums to receive information on the redesign
of Community-Based Residential Services. The forums will focus on the questions posed
in this RFI.

The forums will be held as follows:

Date and Time Location

Family and Youth Forum Shrewsbury, MA
July 13, 2010 Hoagland Pincus Conference Center
10:00 – 12:30 222 Maple Avenue

Provider Forum Taunton, MA

July 20, 2010 Taunton State Hospital
9:30 - 12:00 Ricky Silvia Rec Center (Gym)

Provider Forum Worcester, MA

July 27, 2010 Worcester Public Library
9:30 – 12:00 3 Salem Square
Main Library - Saxe Room

Provider Forum Bedford, MA

August 4, 2010 Middlesex Community College
9:30 – 12:00 591 Springs Road
Cafe East - Building #8

Provider Forum Boston, MA

August 5, 2010 John Adams Courthouse
9:30 – 12:00 Second Floor Conference Suite

RFI – Community-Based Residential Services Initiative 14

 APPENDIX I
Guiding Principles for Successful Restraint and Seclusion Reduction
Reform

The National Technical Assistance Center and NASMHPD have identified six "core
strategies", based on literature reviews and on "lessons learned" from successful
restraint/seclusion reduction efforts, which can serve as guiding principles for similar
initiatives. In brief, those are:

1) Leadership toward Organizational Change:

Leadership must define and articulate the vision for reduction and elimination of
seclusion and restraint; clarify the values and philosophy on which new practice
strategies will be based; and establish accountability for implementing those practices.
Development of multi-disciplinary teams to lead the change effort has proven helpful in
many successful restraint/seclusion reduction and elimination efforts.

2) Use of Data to Inform Practice:

Collection of restraint/seclusion data at the unit, facility, and agency levels is needed in
order to establish pre-change-effort baselines of restraint and seclusion events; to identify
patterns in restraint/seclusion use; to establish accountability through setting and tracking
progress toward reduction and elimination goals; and for tracking injuries related to
restraint/seclusion use.

3) Workforce Development:

Building the skill and knowledge of program staff is at the heart of efforts to supplant the
use of restraints/seclusions with a trauma-informed, recovery-oriented treatment milieu.
Ability to utilize alternatives to restraint and seclusion; to safely implement least
restrictive interventions when necessary; and to accurately record required data elements
are among the fundamental skills needed by staff of a quality residential treatment
program. Both intensive and ongoing trainings which engage and challenge staff are
necessary in order to develop needed skills and knowledge, to update staff with new
information, and to prevent "drift" and regression to undesired practices.

4) Use of Seclusion/Restraint Prevention Tools:

These include an understanding of and attunement to the emotional impact and

behavioral sequelae of traumatic events, including experiences of restraint and seclusion;
the use of individualized assessments to document histories of trauma, violence or self-
harmful behavior, the situations or events which may trigger behavioral crises, and
strategies for calming and de-escalation; linking that information to individualized

RFI – Community-Based Residential Services Initiative 15

treatment and recovery plans which staff actively utilize; and the teaching of self-
soothing and self-management skills.

5) Consumer Roles in Care Settings:

Consumers, families, and other advocates have contributed significantly to successful

restraint/seclusion reduction and elimination efforts by providing compelling first-hand
testimony to the impact of coercive interventions; through participation in the planning
and monitoring of change initiatives; and by serving on debriefing teams and as peer
support advocates. Full and formal involvement of consumers, families and other
advocates at all stages of restraint/seclusion reduction efforts has proven fundamental to
the success of these initiatives.

6) Debriefing Techniques:

Two types of debriefings are recommended after a seclusion/restraint event has occurred.
The first involves an immediate review of antecedents, behaviors, non-coercive
interventions that were attempted, and possible missed opportunities to implement safe
alternatives. Not for external distribution 4
restraint/seclusion. The second is a more formal review involving staff, supervisor(s), the
resident, advocate(s), and the treatment team. Purposes of debriefing are both to learn
from negative events and reduce the likelihood of future restraints/seclusions, and to
ameliorate to the extent possible the emotional impact of coercive interventions on the
resident, staff, and any witnesses involved.

Huckshorn, K.A. (2006). "A Snapshot of Six Core Strategies for the Reduction of S/R". National Technical
Assistance Center and National Association of State Mental Health Program Directors.

RFI – Community-Based Residential Services Initiative 16

 APPENDIX II

FIVE FUNDAMENTAL RIGHTS

G. L. c. 123, § 23

§ 23. Rights and Privileges of Patients.

This section sets forth the statutory rights of all persons regardless of age receiving
services from any program or facility, or part thereof, operated by, licensed by or
contracting with the department of mental health, including persons who are in state
hospitals or community mental health centers or who are in Residential Programs or
inpatient facilities operated by, licensed by or contracting with said department. Such
persons may exercise the rights described in this section without harassment or reprisal,
including reprisal in the form of denial of appropriate, available treatment. The rights
contained herein shall be in addition to and not in derogation of any other statutory or
constitutional rights accorded such persons.

Any such person shall have the following rights:

(a) reasonable access to a telephone to make and receive confidential telephone calls
and to assistance when desired and necessary to implement such right; provided, that
such calls do not constitute a criminal act or represent an unreasonable infringement
of another person's right to make and receive telephone calls;

(b) to send and receive sealed, unopened, uncensored mail; provided, however, that the
superintendent or director or designee of an inpatient facility may direct, for good
cause and with documentation of specific facts in such person's record, that a
particular person's mail be opened and inspected in front of such person, without it
being read by staff, for the sole purpose of preventing the transmission of contraband.
Writing materials and postage stamps in reasonable quantities shall be made available
for use by such person. Reasonable assistance shall be provided to such person in
writing, addressing and posting letters and other documents upon request;

(c) to receive visitors of such person's own choosing daily and in private, at reasonable
times. Hours during which visitors may be received may be limited only to protect the
privacy of other persons and to avoid serious disruptions in the normal functioning of
the facility or program and shall be sufficiently flexible as to accommodate individual
needs and desires of such person and the visitors of such person.

(d) to a humane psychological and physical environment. Each such person shall be
provided living quarters and accommodations which afford privacy and security in
resting, sleeping, dressing, bathing and personal hygiene, reading and writing and in
toileting. Nothing in this section shall be construed to require individual sleeping
quarters.

RFI – Community-Based Residential Services Initiative 17

(e) to receive at any reasonable time as defined in department regulations, or refuse to
receive, visits and telephone calls from a client's attorney or legal advocate,
physician, psychologist, clergy member or social worker, even if not during normal
visiting hours and regardless of whether such person initiated or requested the visit or
telephone call. An attorney or legal advocate working under an attorney's supervision
and who represents a client shall have access to the client and, with such client's
consent, the client's record, the hospital staff responsible for the client's care and
treatment and any meetings concerning treatment planning or discharge planning
where the client would be or has the right to be present. Any program or facility, or
part thereof, operated by, licensed by or contracting with the department shall ensure
reasonable access by attorneys and legal advocates of the Massachusetts Mental
Health Protection and Advocacy Project, the Mental Health Legal Advisors
Committee, the committee for public counsel services and any other legal service
agencies funded by the Massachusetts Legal Assistance Corporation under the
provisions of chapter 221A, to provide free legal services. Upon admission, and upon
request at any time thereafter, persons shall be provided with the name, address and
telephone number of such organizations and shall be provided with reasonable
assistance in contacting and receiving visits or telephone calls from attorneys or legal
advocates from such organizations; provided, however, that the facility shall
designate reasonable times for unsolicited visits and for the dissemination of
educational materials to persons by such attorneys or legal advocates. The department
shall promulgate rules and regulations further defining such access. Nothing in this
paragraph shall be construed to limit the ability of attorneys or legal advocates to
access clients records or staff as provided by any other state or federal law.

Any dispute or disagreement concerning the exercise of the aforementioned rights in

clauses (a) to (e), inclusive, and the reasons therefore shall be documented with specific
facts in the client's record and subject to timely appeal.

Any right set forth in clauses (a) and (c) may be temporarily suspended, but only for a
person in an inpatient facility and only by the superintendent, director, acting
superintendent or acting director of such facility upon such person; concluding, pursuant
to standards and procedures set forth in department regulations that, based on experience
of such person's exercise of such right, further such exercise of it in the immediate future
would present a substantial risk of serious harm to such person or others and that less
restrictive alternatives have either been tried and failed or would be futile to attempt. The
suspension shall last no longer than the time necessary to prevent the harm and its
imposition shall be documented with specific facts in such person's record.

A notice of the rights provided in this section shall be posted in appropriate and
conspicuous places in the program or facility and shall be available to any such person
upon request. The notice shall be in language understandable by such persons and
translated for any such person who cannot read or understand English.

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 The department, after notice and public hearing pursuant to section 2 of chapter 30A,
shall promulgate regulations to implement the provisions of this section.

In addition to the rights specified above and any other rights guaranteed by law, a
mentally ill person in the care of the department shall have the following legal and civil
rights: to wear his own clothes, to keep and use his own personal possessions including
toilet articles, to keep and be allowed to spend a reasonable sum of his own money for
canteen expenses and small purchases, to have access to individual storage space for his
private use, to refuse shock treatment, to refuse lobotomy, and any other rights specified
in the regulations of the department; provided, however, that any of these rights may be
denied for good cause by the superintendent or his designee and a statement of the
reasons for any such denial entered in the treatment record of such person.

FIVE FUNDAMENTAL RIGHTS, G. L. c. 123, § 23

RIGHTS INPATIENT FACILITY COMMUNITY PROGRAM

MAIL right to send and receive sealed, unopened, right to send and receive sealed,
uncensored mail with the exception that: if unopened, uncensored mail
"good cause" exists, the facility director or
designee can authorize staff to open and
inspect an individual's mail in the presence of
the individual for the sole purpose of
preventing the transmission of contraband.
Staff must document the specific facts
justifying the mail inspection in the
individual's record and staff may not read the
mail.
TELEPHONE right to reasonable access to make and to right to reasonable access to make
receive confidential phone calls, with the and to receive confidential phone
exceptions that: calls, with the exceptions that:
(a) the calls cannot constitute a criminal act; (a) the calls cannot constitute a
(b) the calls cannot unreasonably infringe on criminal act; and
another person's access to the telephone; and (b) the calls cannot unreasonably
(c) this right may be temporarily suspended infringe on another person's
by the facility director or designee only if there access to the telephone
is a determination that, based on the person’s
exercise of such right, further exercise of the
right in the immediate future would present a
substantial risk of serious harm to the person or
others, and less restrictive alternatives have
been tried and failed or would be futile to try.
Any suspension must be documented, and the
suspension can last only as long as necessary
to prevent the harm.

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 RIGHTS INPATIENT FACILITY
GENERAL right to receive visitors of one's own choosing,
VISITORS daily and in private, at reasonable times.
"Reasonable times" means that the hours
during which visits can occur must be
sufficiently flexible to accommodate an
individual's needs and desires, and that the
hours may be limited only to protect the
privacy of other clients and to avoid serious
disruptions in the functioning of the facility.
This right may be temporarily suspended by
the facility director or designee only if there is
a determination that, based on the person’s
exercise of such right, further exercise of the
right in the immediate future would present a
substantial risk of serious harm to the person or
others, and less restrictive alternatives have
been tried and failed or would be futile to try.
Any suspension must be documented, and the
suspension can last only as long as necessary
to prevent the harm.
VISITS OR PHONE right at any reasonable time to receive or to
CALLS WITH refuse to receive visits and telephone calls
ATTORNEY, from one's attorney, legal advocate, physician,
LEGAL psychologist, clergy, or social worker, even if
ADVOCATE, not during normal visiting hours.
PHYSICIAN,
SOCIAL
WORKER,
PSYCHOLOGIST
OR CLERGY
HUMANE right to a humane psychological and physical
ENVIRONMENT environment, including living quarters which
provide privacy and security in resting,
sleeping, dressing, bathing, personal hygiene,
reading, writing and toileting. However, this
right does not require that there be individual
sleeping quarters.
RFI – Community-Based Residential Services Initiative
COMMUNITY PROGRAM
right to receive visitors of one's
own choosing, daily and in
private, at reasonable times.
"Reasonable times" means that
the hours during which visits can
occur must be sufficiently flexible
to accommodate an individual's
needs and desires, and that the
hours may be limited only to
protect the privacy of other clients
and to avoid serious disruptions in
the functioning of the program.
right at any reasonable time to
receive or to refuse to receive
visits and telephone calls from
one's attorney, legal advocate,
physician, psychologist, clergy, or
social worker, even if not during
normal visiting hours.
right to a humane psychological
and physical environment,
including living quarters which
provide privacy and security in
resting, sleeping, dressing,
bathing, personal hygiene,
reading, writing and toileting.
However, this right does not
require that there be individual
sleeping quarters.
20
 APPENDIX III
FOSTER CHILD BILL OF RIGHTS

(see the attached document which follows)

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RFI – Community-Based Residential Services Initiative 22