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Wednesday, 12 December 2018

A New Model Begins: Adult Community Clinical Services

ACCS replaces CBFS in July in Massachusetts, but what on earth does that mean? Some years back mental health residential services were reconfigured and became Community Based Flexible Services (CBFS). Now, CBFS is ending, and in its place, Adult Community Clinical Services (ACCS) has moved in.

But what is ACCS?: According to the Massachusetts Department of Mental Health (DMH), ACCS will “deliver evidence based interventions within the context of a standardized, clinically focused model to promote:

  • Active engagement and assertive outreach to prevent homelessness; 
  • Clinical coverage 24/7/365 days a year 
  • Consistent assessment and treatment planning 
  • Risk assessment, crisis planning and prevention 
  • Skill building and symptom management, 
  • Behavioral and physical health monitoring and support 
  • Addiction treatment support;  
  • Family engagement; 
  • Peer support and recovery coaching  

Reduced reliance on emergency departments, hospitals and other institutional levels of care.

How is it different than CBFS?: Well, some of that remains to be seen, but some of the differences highlighted by DMH include:

  • A standardized staffing model for teams providing services
  • A clinician is assigned and accountable to each person receiving services at all times (as opposed to simply for therapy, or at the point of assessment and treatment planning)
  • Increased focus on involving and centering the family
  • Increased focus on the integration of and access to peer support
  • Standardization of assessment for problems with substances and access to relevant supports
  • Standardization and increased clarity around determinations for rates paid to providers for services
  • Standardization of contract monitoring, outcome measures, and criteria for enrollment

There are some clear positives that are born of ACCS. For example, this new contract represents the first time that DMH has made a strong commitment to the integrity of the peer role. This includes writing in requirements that people in peer roles not be responsible for administration of psychiatric drugs, and that providers implement these roles in a way that is consistent with the Massachusetts Peer Specialist Code of Ethics. (You can learn more about ACCS directly from DMH by clicking HERE.)

However, ACCS also brings with it a number of question marks and problems, as well. A summary of some of these concerns follows:

1. Experienced People are Losing Their Jobs: Historically, licensure has not been required to lead a program or team. As a result, there are many very experienced people who are passionate about their work but who don’t have clinical licenses (or don’t have the right clinical licenses) and who are being required to take a demotion or lose their jobs altogether. This could mean (and almost certainly will in at least some instances) that a young, inexperienced clinician will head up a team in place of someone with far more experience and knowledge of the actual systems and needs of people being supported.

2. There May Not Be Enough Licensed Clinicians to Go Around: Not only has the new requirement for a licensed clinical lead led to other people losing their jobs, it’s not terribly clear whether or not there are enough licensed clinicians (or nurses, or Licensed Alcohol and Drug Addiction Counselors, etc.) around to truly fill the need. Historically, it’s been very difficult for most providers of DMH’s core residential services (including CBFS and, now, ACCS) to hire (and/or retain) licensed clinicians onto teams. Licensed clinicians often prefer to work in private practice or fee-for-service clinics where they’re able to focus on one-on-one therapy (or similar). This new requirement could end up being a set-up that does little more than ensure that providers are involved in a (even more than usual) never ending cycle of hiring for key roles, and that program leads are frequently new and unfamiliar with the programs they are heading up. Additionally, while the new structure increases staffing levels, if providers are forced to carry vacancies due to inability to fill positions, will the increase be a reality or an illusion? And, could the plan to increase available support actually lead to a decrease due to all these vacancies?

3. ACCS Doubles Down On a Clinical Focus In Spite of the Fact that It Doesn’t Appear That That’s What’s Wanted or Needed: CBFS was certainly a clinical service, but ACCS has increased the clinical emphasis by a stretch. Meanwhile, when we look at international outcomes, it would appear that services that have a more connection-focused approach that makes space for individual meaning making of distress (such as Open Dialogue in Finland) are getting the best results, while outcomes have failed to improved or even declined for anything considered ‘mental health’ in most westernized nations that prioritize more rigid clinical approaches. A rigid clinical approach is also inconsistent with both person-centered and trauma-informed approaches (both of which are also named as desired elements of ACCS), as well as so much feedback that already exists in the state from people who say that it’s the connection and support to figure out their own path that is truly needed.

4. The Rigid Formula Regarding Roles On Teams is a Mixed Bag: On the one hand, it’s wonderful that DMH has required three people in peer roles for every one hundred individuals in services. But that ‘wonderful’ only applies to providers who weren’t already at or over that threshold. Unfortunately, for some providers, the new rigid formula is actually requiring that they undo some of their progress, and reduce the number of peer supporters available within their organization. Overall, many providers have made some of their most progressive steps based on the flexibility to be creative. Much of that flexibility is being lost with the implementation of ACCS. Will creativity and progress be sacrificed as a result?

5. The ‘Evidence-Based’ Focus is Misguided: Unfortunately, evidence-based is often defined more by who has the money to pay for the research to convey their outcomes in a positive light than anything else. In an April, 2018 article, “The Corruption of Evidence Based Medicine”, Dr. Marcia Angell (former editor in chief of the New England Journal of Medicine) was quoted as saying the following:

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor”

What this ultimately means is that sometimes (too often) systems get stuck with ineffective strategies, while more affective approaches get overlooked for their lack of status.

6. It Appears That Providers May Be Encouraged to Misuse some ‘Evidence-Based’ Approaches: There is a heavy emphasis on Motivational Interviewing in the new ACCS contract. While the problems with Motivational Interviewing are many (enough to merit a separate article), it is at its heart designed to be an approach used without an agenda and toward simply building energy to take action toward change. However, the original Request for Response (RFR, the document that outlines what is required from providers interested in submitting a proposal to implement a service) had this to say about Motivational Interviewing:

“Contractors utilize Motivational Interviewing and other engagement techniques to help Persons resolve any ambivalence about receiving the service and address barriers to engagement.”

This at least appears to suggest that providers use Motivational Interviewing with the agenda of engagement in services. Will evidence-based practices be used for genuine support or manipulation?

7. So Much is Unknown: The ACCS RFR openly acknowledged that certain parts of the plan were unknown at the time it was written, and providers have since raised many other questions including:

  • How will ACCS providers and Behavioral Health Community Partners (another new part of the picture being contracted out through Masshealth) ensure that they are clear who is supposed to be doing what? (For more on Community Partners, click here!)
  • How will DMH ensure fidelity to the new requirements to support the integrity of peer roles?
  • How will the new system be ready to go in July, including new supervision, certification, and licensure requirements that leave no room for grandfathering in or grace periods?
  • How will providers support the effective discharge of so many people who’ve been receiving services? (ACCS has a lower capacity than CBFS did, and a large number of people—as many as 15 to 20% of those served prior to July 1— are relatively abruptly losing the services with which they are most familiar)

For the first time in many years, Massachusetts is experiencing a substantial bump in its mental health budget; An increase of over 80 million. (For a little perspective, 80 million could fund about 150 peer respites and 5 Soteria Houses.) The bulk of that new money is going into ACCS (largely to support requirements like the hiring of  licensed clinicians), a service that will have a reduced capacity for the number of people with whom it can work, and will not be giving any raises to individuals offering most of the direct support. Overall, the state seems to be stepping forward into this new ACCS territory amidst a great deal of uncertainty. Either way, ACCS is here and only time will tell how it really works out.

 

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