An Interview Conducted by Sera Davidow with Amy Morgan
One year ago, on July 1, 2018, the Massachusetts Department of Mental Health asked providers to implement a shift from Community Based Flexible Supports (CBFS) to Adult Community Clinical Services (ACCS). Also about a year ago, we published the results of a survey on how people felt about that shift. (Results available here: https://tiny.cc/ACCSSurvey).
In summary, the outlook wasn’t great from either people working within or receiving services from the state-funded mental health system. While some felt hopeful about the increased funds and numbers of employees available to offer support, many people worried about the lack of transparency, and the lack of transition time. One person said, “it just feels like a chaotic mess, which is not helpful for anyone’s mental health,” while another offered, “I’m told that not much will change but it seems to be moving backwards by becoming more clinical.”
Now, one year after implementation, we take a look back about the trip so far and hopes for the future with Amy Morgan, a seasoned clinician and administrator who’s been working in the system for 28 years.
How did you feel about the change when you first heard it was going to happen?: What was very hard to hear in the beginning of this process was the sense that DMH felt in many ways that CBFS was a failure. We benefited greatly from the flexibility. That’s how we – with a lot of thought and planning – [for example] were able to convert staff positions to peer positions. Which changed the quality and offerings to people. With the change to ACCS… right from the beginning, we saw that the flexibility was gone, and that the contracts would be managed in this very proscriptive way. That was disappointing.
I’ve actually heard a lot of people joke around about how CBFS had flexibility in its name, but wasn’t actually that flexible. Did you really experience it as flexible overall?: I think that based on the agency where I worked, the leadership at the agency, and the leadership of the area of DMH where I worked we got to experience flexibility. There were certainly areas that weren’t as flexible as we thought they were going to be. But, it felt a heck of a lot more flexible ACCS.
Last June, as you were approaching the start of ACCS, what did you feel most hopeful about?: What was hopeful about the model of ACCS as somebody that has been doing this same work for 28 years, was that it felt well-resourced in the way that things were back in the 90s when we were able to help people leave the state hospitals and go right into their apartments (rather than going into group living environments).
And during that same period, what were you most worried about?: There was no start-up time. No kind of laying out of where an organization should be at 3 months, 6 months, etc. Really the idea was that the entire model was supposed to be started up and implemented fully all as of July 1. The pressure and expectation coming out of central office of DMH was burdensome. The pressure around hiring, too. And what we saw in this was because of all these roles changing, the work force changed dramatically. There were suddenly many more positions across the state.
How did that transition period end up going?: The fact that Masshealth transformation was delayed, and that Behavioral Health Community Partners (BHCP) and ACCS started all at the same time… that was incredibly confusing not only to providers but to the people receiving services, too. It was very hard to articulate with any real competency what the new roles were going to be We were introducing Care Coordinators and asking people to sign up while also changing the model. It was a lot. People didn’t have the language – even providers and DMH – nobody had the language to describe what these different roles were now going to do. And with hiring, the competition was stiff. And the expectations and ratios of clinicians and licensing of clinicians resulted in providers losing long-time, incredibly talented employees.
Has the panic of hiring passed?: No, I think there’s still struggle across providers. There’s still significant vacancies with direct support staff. There are also different challenges in different geographical areas. Some have had a harder time hiring registered nurses for example, because the numbers don’t exist and the pay isn’t enough to pull them in. And, some areas have had a lot of difficulty hiring licensed substance abuse counselors because there isn’t a huge pool available. I think that varies provider to provider. And hiring in to the Licensed Practitioner of the Healing Arts (LPHA) positions… that was a huge lift across the state, because again, that many licensed clinicians don’t exist.
Hiring into each position once is one thing, but in order to be sustainable, there needs to not only be one person per role, but several as turn over happens or people get promoted. Are there enough people to fill these roles make sustainable for the long term?: I feel like I just don’t know. I think we’ve had the experience of, for example, not everybody wanting to do nursing in this kind of way. Community nursing requires flexibility that is sometimes challenging for nurses. It’s just not a role that is cut out for every RN. So, the sustainability for that, I just don’t know. And, while there was 90 million put in to create this model, and there was some attention to trying to adjust staff rates, the bottom line is we still pay direct care staff unconscionably low wages. And so there’s a genuine workforce crisis that we’re facing here.
How have things shifted in terms of quality of support received in first year?: As we’ve moved into year two, I think there are parts of the model that have been quite successful. My experience where I’ve worked is that the additional role of housing coordinator has been extraordinarily effective. Their desire to do this job, their belief in housing first principles, and being able to increase the numbers from having one housing coordinator to having a director and three housing coordinators… That has absolutely helped people get on housing lists, be much more knowledgeable about housing options, and move to settings that are more fitting for them. That’s been a huge success. Additionally, the infusion of thousands more dollars for vouchers has been a real positive.
I think that now that LPHAs have figured out how to balance the load of paperwork responsibilities and seeing people, they’ve gotten into their groove. I think there’s good qualities.
A challenge in the model in year one has been that we brought in very new, inexperienced (new to the field) licensed clinicians who in many ways were working side-by-side or supervising people who’d been doing this work for a very long time. And I think there’s been some tension between principles rooted in ‘psychiatric rehabilitation’ versus a ‘clinical lens’. So, helping someone with cleaning or managing money or learning how to shop for one’s on a truly limited income or taking people grocery shopping, providing transportation for people in areas where there were no transportation.. some more clinically oriented people have wrestled with how that qualifies as clinical work. Whereas people who came from a place of rolling your sleeves up and doing the work with people… they saw how it helps people to do well and move on. It is part of what paved the way out of the system.
If you could snap your fingers and go back to CBFS, would you?: No, I would want to take the best of both. The contracts have a lot more money in them, but they’re really expensive to run. There was this idea that there was going to be a ton of money – this huge infusion – but this model simply costs more. I would take the best of both: Some of the flexibility and the way we could be creative and innovative and combine it with the better resourced teams. In the organization where I worked, we also lost more than half of our peer specialist team because of the rigidity of that staffing pattern.
If you could keep money, but go back to the other approach would you do that?: Yeah, maybe. I don’t know. I can’t say definitively.
You mentioned peer support. A lot of people know it’s the ‘right thing to say’ nowadays that peer support is helpful. Did you really see it as helpful, and have you seen the reduction in availability of peer support have negative impact?: 100% yes to both things. It was something that we offered to people that they didn’t have access to before, and being able to have relationships with people that could say ‘I’ve been there’ or ‘I’ve had a similar experience’ or ‘I can relate because I was locked up against my will’ was truly transformative. And, by having a large peer support team supervised by someone in senior leadership who also had lived experience influenced and changed everybody in the organization. So, everybody was more willing to kind of be open, and say, “There really is this way that personal disclosure and sharing your story and being able to say I’ve been there was incredibly powerful, and just a tremendous change agent.”
In your experience, how has DMH responded to complaints about ACCS?: In the stakeholder meetings, one of the things we gave a lot of feedback on was the burdensomeness of the paperwork, and the interpretation of rehab options. There was a real belief and a promise that the paperwork would be lessened in ACCS and it in fact increased. That has been enormously burdensome. But, I am hopeful and excited about DMH’s willingness to embark on a pilot project to perhaps change the documentation, and a real willingness to change the compliance and auditing process for rehab options and try and get away from the interpretation that has been so tedious and really interfering with being able to just provide service and support.
Do you really believe that DMH is listening?: I have tremendous respect for our Commissioner [Joan Mikula]. I feel hopeful and optimistic about her. There are good people in DMH that are listening and are making changes even right now, this pilot project of documentation reduction, etc. In the last six months, that is actually one of the things that has sustained me. Being in those rooms, and seeing that there really is some willingness there.
Can you say more about your worries for ACCS moving forward?: I feel sad that this model has been created as a way to see people through a clinical approach, with such an emphasis on that ‘clinical’ piece. With that has come a huge de-emphasis on recovery. (I hate to use that language but I don’t know what the right word is.) I worry about moving away from this way of being with people that they actually want and find useful, and that allows them to take advantage of and try out different things. I’ve seen that what really helped people was flexibility, the use of peer support, and actually moving away from a clinical lens that is defined by a medical paradigm; This idea that there’s a problem and you necessarily treat a problem with a clinical approach. It just misses the mark on the fact that that’s not always been what’s been most helpful. I think there should be an array of pptions that people can choose from. Maybe someone wants a clinician in their life. Maybe they want a peer supporter. Or an array of holistic approaches.
Another aspect of ACCS that is uncertain at this time is the fact that employment supports and services were taken out of the model with expectation that these services will only be offered by the Mass Rehabilitation Commission (MRC). Adding another agency, and more team members outside of the model seems cumbersome. I fear that some people who have some interest in working, but are scared and questioning their ability to work will quickly get discouraged by the process of application acceptance necessary to gain access. I fear that there is now an added barrier to employment versus easy access, and quick response time when someone says they wish to work and need help to do so.
So, overall, how has this last year felt to you personally as a clinician trying to work in this new system?: It’s been very, very hard. The expectation from the Department around staffing up, and positive outcomes, and (at the central office level) wanting to demonstrate that this new model and this infusion of 90 million was the right thing to do brought about an enormous pressure without the model having start up time. And then DMH changed a number of things in the first three months… billing codes.. some of the paperwork… even getting to a point of really understanding some of the financial aspects that were changed by going to a unit rate… It was hard.
What have you heard from people receiving services?: I’ve heard that it’s confusing. I’ve heard from people who’ve appreciated more people in their life, more people available to offer support, different kinds of specialists. And I’ve heard people say there’s way too many people, and it’s way too confusing, and they don’t know who’s who or who works for whom.
Do you think DMH has gotten what they’ve wanted in this shift?: I think there are ways in which DMH feels the integrated team model has given them more of what they want. There’s success stories (for example) because of someone’s work with a licensed substance abuse counselor, or with housing. But for me, I have to wonder is it the new model, or is it just that more resources have been added. If instead an agency was given more resources to be creative – to say things like, you know, actually we could use three nurse instead of one, and we could reduce this other role – what different could be made then? Any time there are more resources there’s just more ability to meet people’s needs. But I don’t know if it’s specific to this particular clinical model.
What do you hope providers will keep in mind for moving forward?: I think year one was a mess. I think that it’s important to keep being skeptical and optimistic and be willing to really question what is it that we’re doing. We need to keep asking ourselves, “What is it that really helps people get their lives to the place where they want them to be?” And not just assume we know what it is. And, I think we need to be really be cautious about “care coordinating” people’s lives without them being present for all of those conversations.
Also, in my humble opinion and based on my years experience, if DMH wants to see ‘movement through the system’ (meaning people coming from continuing care settings [state hospitals] into Group Living Environments [GLE], and moving through GLEs into their own apartments), what they actually need to stop doing is putting this emphasis and this belief that GLEs are what are needed and are what is helpful to people. What I saw as most successful is when people could come out of continuing care and go straight into their own apartments. If they were then provided enough support people actually did better having some autonomy. If our provider system and DMH want to have an approach that says “you can get well and move on, and we believe in you,” then we cannot keep putting them in GLEs. To give the message to people that “we believe in your autonomy, and your ability to be well, and have a life” while simultaneously committing these microaggressions and sending these messages to people that “you have to live in a group home where we provide awake overnight staffing to monitor you”… It just doesn’t work.
I’m not sure what that does to an adult person’s sense of self. Even in our own homes with our children, we don’t stay awake at night to monitor them. We have a belief that, if our child needs us, they’ll wake us up. So, why aren’t we more aggressively questioning that? Why do we have GLEs with awake overnight staff? What’s the usefulness? What’s the purpose? Is it just to make ourselves feel like it’s safer? And do we ever stop to ask people, “What has that done to you in your belief in your own ability to maintain yourself?” I don’t think any of us would want somebody awake all night in our house ensuring our sense of safety.
It kind of blows me away that more people don’t ask that question. And, that’s not to say that we just switch it to an asleep model. We need to re-evaluate the whole model. If we could convert those dollars to community-based dollars and community-based living, I think DMH and providers would be much more successful. If we could take those dollars and provide more transportation, more access to peer support, the ability to see people if needed multiple times a day, multiple times per week, maybe mobile staff that could visit someone late at night if needed, or at least take a call… I think that that would transform the system. I get worried when I hear that there may be a wave of people thinking we need more GLEs, or more “beds.” It’s not what I’ve seen in my career as being what’s actually helpful. I think there’s a small percentage of people that may need assistance 24/7 for some period of time, but it really is a pretty small percentage. Overall, it’s more destructive. We are doing real damage to people.
Before we close, what three pieces of advice would you give to others in similar roles as the one you’ve held?: As a person working in these jobs, be open and expose yourself to all different kinds of ideas, and alternatives, and ways that to help people that are not always what we would think of as ‘traditional clinical approaches.’ That is really how you enrich the work and your own personal experience of it, along with what you’re able to offer people. I’d also say to continue with your advocacy. Continue to believe that there are people in DMH that want to make changes. Don’t give up on the messages about the paperwork or the other things that aren’t working well. Don’t believe that it’s just this bureaucracy that you can’t influence. Keep at it. Finally, I’d say to remain curious and questioning and skeptical. Question what is it that we are providing; What is most helpful.
Are you someone who works in or receives services from the ACCS system? Would you like to share your thoughts via an interview like this one? E-mail us at firstname.lastname@example.org and let’s connect. Stipends are available, and articles can be published with your name or anonymously to protect your privacy.