“I never heard from my outreach workers and DMH worker about this change until last week because they were told not to talk about it to clients.”

– Person receiving DMH services on June 21, 2018 (10 days before ACCS went into effect)

A few weeks ago, we sent out a special e-newsletter inviting people to give feedback on the new Adult Community Clinical Services (ACCS) program that replaced Community-Based Flexible Supports (CBFS) as of July 1. ACCS is the largest Department of Mental Health-funded (DMH) service across Massachusetts, and is essentially what used to more simply be thought of as DMH residential and outreach services.

Since releasing the survey, we’ve received 72 responses. 5 responses came in from people receiving DMH services. 23 were received from people working in peer roles in what is now ACCS. There were also a handful (8) of responses from parents and interested citizens who are watching the process unfold. However, the largest number of responses came from providers (primarily those directly providing services through ACCS, but also a few who were losing their jobs with the end of CBFS or who worked in clinics and other settings that interfaced with these services). There were 36 provider responses, to be exact. The bulk of these responses (40) were from Western Massachusetts, but another 31 were from other parts of the state (with one from out of area).

What follows is a summary of what people had to say.

Do you feel like you fully understand what ACCS is and what it will look like once fully implemented?

Most popular response: “No.”

A selection of other responses:

• I have been following the development and contracting of ACCS closely, so I feel like I have some idea of what to expect from ACCS. I wouldn’t say that I fully understand what ACCS will look like when it is implemented, and I doubt that anyone really does.
• Not at all, and not a single one of the overwhelming Powerpoints helps.
• No, I think it will take some time to fully understand what it will look like and I hope that participants, providers, and peers can collaborate to make it as effective as possible.
• No, I have been through contract changes in the past and it will take easily 6 months before I know more information and what to do in my role.
• Not really. I’m told that not much will change but it seems to be moving backwards by becoming more clinical.
• It’s much too early to know what it actually will look like.
• No, I don’t. From the looks of the articles presented here, it seems more like a farce.
• No, it just feels like a chaotic mess, which is not helpful for anyone’s mental health.
• No one can “fully understand” what ACCS will look like once it gets operationalized. There are 27 different organizations that have been awarded ACCS contracts from DMH.
• No, the entire process does not feel very transparent. As a provider I am concerned that we still do not know who will be transitioning out of services. It’s a very important conversation to have with our persons served well before July 1st. (Submitted on June 18.)

There were a handful of people who said they did feel they at least mostly thought they had an idea of what to expect. Here are some of those comments:

• For the most part, I do understand the basic concepts yes. My job title, job description and entire role as I knew it in CBFS is changing. Staff and people served are understanding the program as “unknown changes” is bottom line.
• .
• Not entirely, but I have a pretty solid working knowledge of how my agency will use peer role, family connector, LPHA roles and how we will link with care coordination.
• I feel I have a good idea what it looks like and how it should be implemented. Whether that happens in every organization is to be seen.
• As much as is possible at this point considering the State isn’t fully clear in many things yet.

Why do you think the state decided to change from CBFS to ACCS?

Most popular response: Financially related. For example:

• If I’m to assume no ill intent on the part of DMH, then it simply must root back to funding streams.
• To save the state money. Period.
• To work in collaboration with the MassHealth changes.
• It was likely to satisfy the agencies funding this new program. It sounds great overall, the idea of saving funds, lessened, ER and hospital visits, etc.. but its implementation might be a whole other story.

Second most popular answer: I don’t know. For example:

• I have no idea, I think it is the worst restructure I have ever seen in my 25+ years working in mental health
• I’m unsure, as I disagree with much of it.

A selection of other responses:

• Increase clinical services, expanded coverage, uniformity across state. Clinicians will have lower caseloads (currently 35, going down to 21).
• Because they think they know how to provide services better than the providers do. And they want a “clinical” focus.
• My understanding is the CBFS contract was expiring and the state used the opportunity to update outreach and group home services. I think the the state chose ACCS to replace it because they wanted to make changes for the services based partly on feedback they received from providers and the community. I also think that they wanted to promote integrated care (so they created the BHCPs) and create an incentive structure that emphasizes outcomes over treatment (so they created the ACOs).
• CBFS was ineffectual
• New EOHHS Secretary felt pressure and had a fundamentally different, more clinically based perspective – likely pressures include Globe Spotlight series and public embarrassment, NAMI-MA unhappy related to access and scope of service, RLCs unhappy with role of peers, Governor concerned with 50% of state budget going to Mass Health.
• So it will look better on paper.
• I think the state is always assessing what they do and trying to improve it . I’ve noticed this in quarterly file audits, that they seem to be interested anew in various things, that there are always new trends in their recommendations.
• “To increase movement within and through the system” to decrease the number of people that require services.
• I feel adding the word clinical in a clinical world always looks better. Also, adding more supports offers services to those who are not receiving them, billable hours, clinical again, adds more money.
• CBFS varied greatly depending on who the individual staff people were in terms of the quality and the ability to actually connect with me and the ways that I needed and wanted help. Some people were fabulous others had no clue. Too often staff were busy putting out fires instead of being able to meaningfully engage and work on meaningful life matters. Everything took forever – even stupid stuff. Because time was allocated in bits and pieces rather thank focusing on getting the task done too often I heard ‘times up’!!!
• because what they are doing is -not providing results -because they don’t pay people an adequate wage to fully show up for work not stressed about their living situations, the health or their finances and few can afford to take a vacation and take care of themselves, how can they expect good service when they don’t pay and support their workers
• The demands of the the Affordable Care Act for states that have bought into the Medicaid Expansion requires the integration of primary care and behavioral health services. MassHealth and CMS initiated a demonstration called One Care that serves as a precursor for dual eligibles in what ACCS is trying to provide for the majority of MassHealth individuals receiving services from DMH. Unlike CBFS, care coordination will be assisted in ACCS by Accountable Care Organizations (ACO’s) and Behavioral Health Care Partners (BH CP’s). The so called triple aim of Integrated Health Care is (1.) improved care coordination (2.) increased participation of the individual in their overall health care; and (3.) be cost effective.
• They needed to put it out to bid since it hadn’t been in 10+ years, and chapter 257 needed to be incorporated.
• It is an attempt to improve and expand services through integrating modalities and specify accountability for services.
• To give the appearance that it is doing something to improve mental health services.
• More focus on Clinical Case Management and care.

In what ways do you think ACCS might be better or worse than Community Based Flexible Supports? (CBFS)

People approached this question from a number of directions. The most common answer for what would be ‘better’ (as noted below) was the additional peer support that would become available in most organizations. On the other hand, the most popular response for what would be ‘worse’ was the renewed clinical focus. Also of note, many people seemed very clear on what was worse, while people frequently spoke to what they thought was better as “hopes”.

A selection of responses from both perspectives:

Better:

• I do like that counselors are working later hours (the time more people have difficulty). 
•  Increased peer support and adherence to CPS code of ethics. Increased accountability and lower case loads for people in clinical roles.
• Lower case loads, multidisciplinary team (nurse, peers, LADC), service recipients will have more time with a range of staff in addition to one-to-one work with counselor, increased office hours including weekend and holiday coverage, clinicians serving as leaders of outreach teams will hopefully serve to move away from care model, direct care staff will be supervised by clinicians who will be able to offer an enhanced clinical perspective. 
• I think ACCS will be an improvement in several ways. I think the statements in the RFR on maintaining the integrity of peer roles is crucial to providing more humane services and improving outcomes. I feel that the requirement that there be three peer specialists per team will be an improvement at many organizations (though I do worry about conflating peers with family partners and recovery coaches and for organizations that already exceed this standard). 
• More peer supports.
• It will be theoretically be better for DMH and the state government funders to have more evidence based data, with new scales, surveys and factual based research to evaluate whether the program is working or not.
• Access to other services (Family Partner, Recovery Coach). Adhering to the Peer Specialist Code of Ethics.
• I hope more accountability and actually supporting folks.
• Increase supportive housing. Staff client ratios better.
• Better potentially in coordinating physical health needs and reducing overall disease burden. Better potentially in focusing clinical intervention toward remediation of symptoms as an aggregate outcome. Better potentially at reducing strain on service delivery staff (assuming rates allow positions to be filled). 
• I think that having more clinical supervision opportunities will allow staff to process the work we do rather than come from a reactive place.
• We will have more Peer Specialists, but I also am aware that there will be some cuts to Peer positions in bigger agencies. That is tragic. 
• Higher level of staff to individual ratio, some increase in clinical services, including housing, substance use, nursing. All providers will have peer roles that are more toward fidelity of that position. 
• As far as “better,” I like the “team ” approach and how providers bring their strengths to the table and focus on that rather than expecting to be a jack of all trades and be able to help with substance abuse, administering meds, finding housing, writing treatment plans, teaching life skills, etc. I think staff excel at various things and this will give us an opportunity to give clients our “best” meanwhile probably enjoying our jobs more.
• Hopefully- more services for the folks we are working with and better/more case management
• + increased peer specialist FTEs + at least attempt to work of peer code of ethics
• ACCS requires contracted organizations to be person centered, recovery focused and trauma informed. It creates opportunities of peer support that did not exist in prior models.
•  increased clinical capacity; increase in overall budgets; utilization of evidence based practices (i.e. housing first, SBIRT, MI, CBT, DBT, etc.); increase in peer workforce; inclusion of LADAC’s in integrated teams.
• Hopefully, the integrated model will attend to areas previously neglected, like substance use issues.

Worse:

• Over reliance on license requirements – MANY MANY qualified people with long standing relationships. Too many clinicians not enough “direct” care staff to offer practical support and intervention. Highly structured 100 person teams has meant a lot of transitioning to new providers, putting housing subsidies at risk. All smaller “non CBFS” DMH programs have lost funding and are now “rolled into” ACCS. Employment is no longer a funded service and MRC is not equipped to work effectively with those receiving DMH services.
• Tension as staff adjust to their new roles
• “Clinical” is often over stated as a response to challenging situations in service providing.
• We lose the flexibility we had before. Also, staff with tons of experience are considered less valuable than staff with licenses and barely any experience. The pay rates are worse than before. CPRPs and LSWs area worthless now.
• More clinical focus.
• More clinical focus. Less flexibility in agency to custom design services based on need of people supported.
• Less friendly. More militarized.
• It’s worse in all the ways.
• I think ACCS will be worse in many ways as well. I think most glaring is the removal of the employment specialist role. There is currently no other service that comes even close to providing the same level of support. Given how our society is set-up, employment is important to many people’s well-being as it relates to resources (such as money), purpose, and social connectedness. Also, I have spoken with many people receiving services who are being arbitrarily moved from outreach services to case management because of mandated enrollment caps. I also have observed that ACCS has not done anything to motivate providers to improve the abysmal compensation for peers and group home direct care staff.
• It will theoretically be worse for people served because there will now be less people served, less staff and less intensive outreach services for those receiving ACCS staff assistance. It will be worse for ACCS staff because it is more workload, more people served per staff caseload, more forms to complete with people served. Higher rate of burnout with higher caseload and lower rate of quality care.
• I really can’t think of any way it will be better. Worse, on the other hand… The article the RLC wrote was right on target about the potential problems.
• I’m worry a lot about those people who have services now and are losing them. I don’t see built in steps down so that people don’t feel dropped. I think that it will cause resentment, bad feelings, and renewed mental difficulties for people who are managing now.
• In becoming more “clinical” it seems to neglect engagement and health needs – both have a major impact on outcomes. It doesn’t seem to give much weight to the engagement process, which is crucial for setting the groundwork for future change and for some can take months or even years. Health “coverage” is included, but not the health NEEDS of the person, which can often interfere with their other goals.
• Likely worse in providing access to and coordination with employment. Potentially worse, depending upon provider orientation, at ensuring a focus upon the goals and interests of the person receiving services, in the face of increased emphasis on clinicians calling the shots: completing assessment and plans.
• You are severing relationships with clients /outreach workers and this is detrimental.
• It might turn out to be more supportive, but also standardized and clinically focused instead of self-determined. The Finland example should be looked at.
• More clinical services and more oversight of people’s lives. It is a step backwards.
• Worse because less continuity of support. People were discharged to DMH who should not have been. Punished for their success.
• More clinical cannot be for the good of people.
• In no way do I think it will be better. All of the specialized services are being cut and the care is going to be the responsibility of workers being paid pennies. The quality of care is going to drastically change for the worse and I truly worry about the folks I have supported and their future.
• Reduced choices as many areas now only have one provider. Rigid system. Less flexibility in placement of people as they need approval from DMH to move or go into a program even if already served by an agency. Loss of staff who have long history serving people. Lack of credentialed staff to do roles that do not need credentials.
• I feel like we are losing the “flexible” part of CBFS the most, which I find concerning. I think the expectations regarding housing the homeless quickly are unrealistic – it takes months and sometimes years to obtain affordable housing, especially when there are barriers such as a poor housing history, bad CORI’s , etc.
• It sounds like the reality is that a clinical model is being pushed and accepted more so than the much needed peer role.
• I don’t have a clear vision of what will happen or what my boss’s interpretation of the expectations will look like. I feel like different vendors have different interpretations of what they expect. (Put that under “drawbacks”).
• – kicking out employment and wellness support – spending way too much funds on expensive (required) clinical staff (LMHC, LICSW, LCSW, OT, LN, …) – selling service as inclusive to people living with substance use challenges yet forcing MRC on people as vocational support (has exclusions for people who are using substances)
• It is just insane, that people are having to go thru all this change. it is hard to feel good about the increase in peer staff because they just turned everything upside down. I’m not sure having more clinical support is a good thing. I’d like to believe so but I don’t see them likely to pay, appropriately to invite good clinicians to apply
• disrupts important relationships within teams, disadvantages workers, creates a more complicated matrix of services that will likely not help anyone
• Too clinical. Not human experience based
• increase in regimentation and data driven service delivery; duration in time to prepare for the model – contracts were awarded in March/April and the go live date is July 1, 2018;
•  I am concerned about those being transitioned out of services and if they are really ready to leave the program. The fact that ACCS reduced the number of persons served as compared to CBFS is frustrating.
• i think it will take away staff that cares and replace them with “therapists” who’s roles will be so not personal or person centered
• The total lack of relationships that have been built with people served is very disturbing. Discharge this one, move teams, lay off those not “qualified” because of a licence, etc! This is destructive, lacks empathy, and is breaking hearts of people served.

What are you most hopeful about regarding the change to ACCS?

Most popular response:

• Additional peer support/integrity of peer role; and
• Nothing/I am not hopeful.

A selection of other responses:

• I hope that organizations will embrace DMH’s guidance towards more person-driven, trauma-informed support. I am also hopeful that the increased level of peer staffing will help educate providers and non-peer staff on how to generate those qualities in the services they provide. I am hopeful that DMH is serious about partnering with the peer community to achieve this vision.
• Better services for people in DMH residential treatment. Am remaining hopeful that as the state realizes people living independently in the community are the people served who need regular staff outreach services THE MOST, more funding will be allocated to human service agency/providers in communities to take more people served who live independently in the community.
• Team based approach with primary care.
• That we will find a way to survive it without losing connections and the ability to do what is actually useful.
• Lower caseloads could allow for more intensive attention to developing the clinical relationship, though that doesn’t seem to be a focus.
• Hopeful that people in services will get to know staff better, have greater access to face-to-face interventions, have plans that attends to different phases of recovery/stages of change, and have access to hopeful messages from other people in recovery/peer staff. Hopeful about the possible impact of better connecting people with family members when there is a rift, helping families to get basic support and feel better connected to the care of loved ones.
• We can work with a Housing First Model and take time to develop relationships through the model of engagement.
• Im hopeful that clinical supervision will staff will allow them to feel more supported leading to less turnover and more consistent services in the long run.
• Hoping to not have to do things I don’t do very well , that things will be delegated effectively throughout each client’s team. (which leads to the largest hope:) Hoping that providers can focus on one or two areas of expertise and deliver stronger services to the clients.
• Hopefully less staff turnover particularly of the really good ones. Better able to help me in the ways that I need help.
• That contracted organizations will better educate integrated teams on improved engagement skills for direct care staff.
• I’m hopeful that the inclusion of LADAC’s, increased peer support, and increased clinical services will meet the needs of the people we serve.
• Working more as a team.
• That the state will find it is too costly and not as effective as what they once had therefore doing away with it.

What are you most worried about regarding the change to ACCS?

Most popular response: People will continue to be/will be lost in the shuffle.

A selection of other responses:

• Too many clinicians and not enough staff to provide meaningful and practical support (Clinicians will not be teaching people how to access public transportation, balance a checkbook, build community ties, etc.) Also Clubhouses and MRC are not equipped to provide appropriate employment support.
• Changing everyone I’m working with at one time
• That the system is still deciding for the individual the type and amount of services they need. Also some people I work with who need their services are being cut. I’m not clear about what my own job will look like in the new system. I don’t think it’s being communicated adequately.
• Not being able to continue working with some people with whom I’ve only just started to develop important relationships.
• Outcome reporting.
• I’m worried about how sudden of a change this will be without any real transition time.
• Micro management. Lack of seasoned supervision. Less opportunities for clients to get together and speak up and feel part of the organization.
• DMH has high expectations for “movement” through, but a prime enabler of recovery – access to integrated employment supports – has been abandoned, and outreach/efforts greared toward community participation in other area could easily take a back seat to efforts to deliver clinically based interventions. DMH both narrowed the scope of peers roles and significantly increased the numbers of peers, but also did the same with clinicians, potentially putting competing perspectives on a collision course.
• The severing of relationships built between clients and outreach workers. These workers are often the only people clients trust. You are making a severe error in cutting these most important relationships.
• Too much involvement in people’s lives when the focus of peer support is to offer mutual support and understand that people have a right to live a life of personal choice without being hindered, questioned and experiencing a sense of being controlled. I am hoping that people have gained their own sense of self and empowerment and will hold their own if they begin to feel any kind of an overload from clinical services.
• System will get stuck. Funding structure will lead to pressures on agencies. The mantra of not being paid until “head hits the bed” will lead to less safe practices due to impact of funding. People being discharged to get to certain numbers and not being able to have the right support in place to follow up with them. If a person does not like the agency they get services from, there is no other option.
• People losing jobs. Maybe another fear is that it will wind up simply being something on paper but not in practice (I’m sensing my boss is going to have me doing what I always did plus more intensive work with substance abuse. I’m already spread horribly thin. If clients have a lot of doctors’ appointments in a week and there’s a staff meeting, I’m working late and not eating lunch and not quite caught up).
• Who’s agenda will it be? Mine or medical model?
• Heavy clinical approach. Forced weekly contact (weight on contact and not what works for person) Being more “engaged” with services can’t be the best outcome
• That the effectiveness of the recovery model within mental health and addiction recovery peer support will be coerced by the economic power and sheer number of health care workers trained and practicing with the medical model.
• Disruption of existing services, removing clients from relationships with trusted workers
• Referrals to our residential programs, and how will we be (or if we will be) paid for a bed we are holding for a person served. DMH may intend on placing someone, but they may not actually move in for months. Also, tracking FTE vacancies is going to be very difficult. Given the turnover percentage at the direct care level it feels like it’s going to be a lot of work, and providers are not clear on what will be done with the information.
• That people in the programs will initially experience worsening symptoms because they have lost long term provider relationships.
• DMH will work to enforce the most rigid and visible of the new requirements. It will discourage innovation and creativity on the part of organizations and individual staff.

Do you feel like the state did a good job of involving and listening to providers and people receiving services when developing the ACCS model?

Most popular answer: No.

A selection of other responses:

• I was a member of the “Stakeholder” workgroup meetings and essentially none of the feedback DMH received was incorporated into the RFR. Many people who did not have the opportunity to attend those meetings (especially those people receiving CBFS services) were never heard.
• I was not aware that these conversations were going on, so no. I don’t know what was done to include a variety of voices in this new model.
• It appears there were efforts to involve management at providers. I feel like the state did not do a good job of getting input from people receiving CBFS services or people working in peer roles. I feel like the community was somewhat heard regarding expanding and improving peer supports through the RFI, but I don’t feel that DMH made an active effort to obtain this input or that DMH’s response was proportionate to the community passion on this matter. More importantly, it seems that there was unanimous support from stakeholders regarding the importance of the employment specialist role. There has been no explanation for why this role was cut given such overwhelming support.
• Hahahahahahahahaha! No.
• Somewhat.
• I feel like the state decided on their own.
• I attended a final meeting where providers who’d sat on feedback committees were told how their input impacted the model. However, the ‘last revised’ date on the presentation preceded much of the feedback given. That seems to say it all.
• I don’t know anyone at my level (clinician) or below that had any input, nor any people we support.
• It’s hard to say. I’m unsure.
• It appears that this was completely lacking.
• Very little of the feedback providers gave was incorporated.
• I have no idea. I don’t know who they talked to or where they obtained their data.
• I realize a lot of effort went into it. I am hopeful but cautious
• NO, the lack of time to transition is criminal
• Better than it has done on previous occasions.
• Not as much as they should have.

 

What has been most difficult about the implementation process so far?

Most popular response: Loss of services and or staff.

A selection of other responses:

• The chaos of the sudden change with providers losing their jobs.
• Not knowing or getting conflicting messages.
• Cannot get any answers from providers.
• The lack of communication from DMH. As a provider we did not learn who would be receiving ACCS services and who would not be until early-mid June. We weren’t able to communicate with the people we are serving about significant changes to their services until last week. Many of the people we are serving today are being discharged from services entirely or are being transitioned to a new provider.
• All the staff we have to lose because they don’t fit into the new model. Plus the state doesn’t even have the paperwork details worked out yet.
• The uncertainty regarding many of the changes seems to have many people very concerned. This seems like it could be solved with more transparency and stakeholder involvement, along with a more realistic timetable for implementation.
• The catastrophic loss of relationships of individuals receiving services. Individuals speak of suicide, receive ESP services, and are hospitalized due to these devastating losses. This transition is unthinkably absurd: an overarching focus of ACCS is building relationships, yet it begins by destroying all relationships.
• The “Unknown”, constant talk of “changes” with very little communication or training on the “unknown changes”. Me as master level clinician had two hour long webinar trainings from DMH and lots of anxious talk from co-workers who are merely speculating what could or could not happen and aren’t really anticipating the new changes.
• Figuring out how to talk to and support both employees and persons served that they’re losing their job/services.
• Not knowing who we’d be continuing to work with and who would be transferred. We still don’t know when any major moves will take place, so we have very little information to provide our clients, who are understandably concerned and stressed by the impending changes. It has also been very difficult seeing our most seasoned Outreach staff be lured away to the new behavioral health program. We’re also supposed to get 4 more LPHA’s. Great, except we’ve been operating with 3 vacancies for the past 3 years because the salaries are so low. We’re going to have to train a whole new staff with very few seasoned ones. (Written on June 21)
• Lack of leadership by Department on promises they could not ultimately fulfill: “paperwork reduction” and general inability of DMH Leadership to properly orient site office and operational staff to the changes. Short turnaround time from contract awards to service delivery date (3 months) given the scope of changes to staff role, disenrollment and transition/support needs of some CBFS clients, development of new care coord entities and processes for coordinating between services
• Misinformation and the unnecessary stress you placed on clients.
• Trying to impliment this new model with the ACO and BH CP at the same time.
• Losing employees who were absolutely person centered. Concerns for people who will lose services or have diminished services who have been affected by so many changes during their lives. Concerns about staying true to our peer values and being center in all supports of people to validate their experiences and voice.
• I’ve seen many people be discharged from supporting agencies with questionable evidence of their increased ability to move on.
• Letting go of staff who were good at their positions but no longer qualify. Telling individuals that they no longer will have services without enough time to do go transitions.
• Staff all having varied opinions about what it will look like, what the expectations really are, and the programatic changes being uniformly implemented statewide. I sense someone could have services in Pittsfield and have a different experience than someone in Boston – – even if they had the same caliber of staff, same experience level & expertise. I just feel like we all have wildly varying visions of this.
• Not enough information for our folks who are transferring from one agency to another- lots of unanswered question.
• Still don’t get how those community behavioral health partners work or why we need a whole separate layer of people to do stuff it’s always better when fewer people are involved and Fewer systems.
• Discharging lots of people not because the person wanted to, but because they were on a DMH list. Lots and lots of lives got very interrupted. It shouldn’t require a recontracting, implement a new model if n Ed be but don’t disrupt people’s lives unnecessary.
• Providers are struggling to find qualified clinical and peer personnel. It is unclear how communication will take place between providers, BH CPs and ACO’s. It is unclear if BH CP’s and ACO’s will have peers at senior level administrative positions.
• Understanding the rationale.
• Not knowing which participants will no longer be served. Having to let go of long time staff that are not licensed, but are very capable in their job and have established relationships with people we’ve been serving for years.
• Finding enough “qualified licensed” people to fill the teams. Losing veteran management due to not having a license.

If you could change three things about the ACCS contracts, what would they be?

Most popular response: Don’t let go of qualified providers/change licensing requirements.

A selection of other responses:

• Three changes I think would improve ACCS contracts are: 1. Require contract recipients to be governed as consumer, employee, community cooperatives. This would re-align incentives so that services are consistent with the needs of the people receiving services and community, while balancing it with the perspective of staff. I anticipate this will increase engagement among all three of these groups. 2. Create or partner with an independent peer organization with which all ACCS providers must contract their peer labor. This will give peers more autonomy to implement peer support and flexibility to provide peer support independently of other services (for example, someone can maintain their peer specialist relationship even through changes in services, providers, locations, teams, etc). This will also allow peers to set wages to eliminate pay discrimination between peer roles and comparable non-peer roles. 3. Restore the employment specialist role for the entirety of the ACCS contracts.
• Realistic, living salaries for peer support workers. The wages that have been allotted are deeply insulting. More peer support workers. Intentional Peer Support training mandated for all ACCS staff.
• There would be space to plan out transitions; There would be less rigid expectations related to licenses and staffing patterns; There wouldn’t be an ask to implement something that doesn’t even seem to be fully understood by the individuals who issued the RFPs.
• People wouldn’t be losing their jobs or services in any sort of abrupt way; There’d be a clear and reasonable transition plan for any changes that do need to be made; Rigidity would not get in the way of creativity and flexibility.
• Make surveys of providers inclusive of program visits and interviews with people served by the programs (rather than just reviews of policies and paperwork). Create mechanism for ACCS providers to maintain integrated access to employment supports and high quality benefits counseling.
• I would have to be more supports then clinical.
• Allowing providers to develop staffing models based on needs instead of a set standard. More peer trainings offered, defining a standard for family partner role.
• Less intensive clinical supports. More Peer supports…much more. Transparency and ensuring the rights of people we support.
• Supervisors of Peer Supporters should be working in a primarily Peer role. (This should be written clearly) Give grace periods for required training to keep your job. Give the folks who receive services have an opportunity to voice what THEY feel might be helpful in their services and what changes they might like to see.
• Keep the jobs they are cutting and pay people what they are worth. Listen to the CLIENTS feedback, they are the ones receiving the services!
• Every area should have at least 2 providers. Only LPHA roles should be required to be clinicians, other roles should only recommend. Funding should be adequate to pay direct care staff a starting wage of $15/hour with appropriate pay scale above that, and rate should be paid based on capacity not utilization which puts the pressure on DMH to make sure openings are filled.
• -LADC 2 positions would be acceptable, not just LADC 1 -Recovery Specialist/ Recovery Coaches would be supervised by peer supervisors -look at the peer ratios
• Mandated educational training for all ACCS integrated team leaders on the role and purpose of peer supports. (2.) Increased compensation for peer support workers. (3.) Forensic peer support specialists.
• Return to old model.
• More regular staff who care.
• Grandfather people into positions.

Do you believe that providers will ultimately be able to successfully implement these contracts as they were envisioned?

Most popular response: No.

A selection of other responses:

• I do believe that providers will be able to implement the broad strokes of ACCS. I think that just like CBFS, the quality of implementations will vary greatly between providers.
• Well I don’t know? We aren’t there yet. But we will have to try, whether we like it or not! I am trying to remain positive since we can’t really predict until its put into practice. Change is hard for most so right now it doesn’t feel good or comfortable. Please follow up with us 1-2 years from now.
• Yes, I have faith that the new model will work out after a rocky start.
• I don’t know. I am an optimist. I believe in the best of people. I am going to keep helping.
• No, the vacancies are already making life stressful.
• Some will be more successful than others.
• Too many people going to do business as usual. Name changed but not attitudes.
• I believe providers will be able to provide services only as the work force is able – I suspect that providers will experience a short fall in the number of qualified LPHA candidates and to some extent certified peer specialists who can be recruited. There are only so many people who can go through the certification process and universities only graduate so many LPHA’s.
• I do not feel there has been adequate communication to make this successful.
• If enough senior people stay and educate the new staff about why we do this work! And if we find quality peers to work in the model.
• No more successful than CBFS. The measures of success (e.g., fewer hospitalizations, emergency room visits, more independent living) will not actually be monitored so there will be no way of knowing.

If you are someone working in the ACCS system, do you think this new model will make your job easier or harder? How?

There was no ‘most popular’ answer in this category. A selection of responses include:

• I think it depends on the role. Supposedly documentation requirements are less than CBFS, though the required record set contains more assessments in ACCS than it did in CBFS so although caseloads for clinicians are smaller, I don’t see a reduced workload. With less “non clinical” staff I imagine we will not be able to see people as frequently or for as much time.
• I think this new model will make work easier for most peer support staff through increased numbers and lower levels of isolation.
• It’s hard to say what things will look like, but ‘easier’ seems unlikely.
• Hopefully easier since collaboration is anticipated.
• After the initial transition period, I think that things will get easier. I anticipate having a better understanding of the people I serve and what there needs are. Through having more time to develop therapeutic relationships I believe we will be able to avoid acute crises.
• Too early to tell. I don’t anticipate much change unless the state suddenly gives Deaf Services money for interpreters for equal access.
• I think my organization is rapidly making changes to improve their delivery of outreach services and group home supports, making my work much easier. Beyond that, I think my agency is cultivating a trauma-informed work place in which staff can thrive, which will result in better services. I do not anticipate that all, or even many, providers will be as enthusiastic about making their organizations trauma-informed or embracing the peer perspective.
• Definitely doesn’t sound easier in any way. We’ve already been given a series of new job tasks, mostly master level clinical paperwork, scales, forms, questionnaires, surveys, etc. to complete with people served in ACCS. This seems helpful for staff, DMH and state funders, but don’t know how helpful or useful an influx of forms will be for people served who just want real hands on people centered, goal oriented care. People served don’t care about what “risk category” or their scaling rate of suicide. They care about staff working with them in a human, compassionate, every day life kind of way! They care about staff teaching them skills and implementing treatment plans with them. More required forms for staff means less time for the real human good work!
• Easier or harder doesn’t matter people should be doing this type of work because they actually want to see people getting powered and make their own decisions and not being treated like clients. People should be readily available to do support of work for those they serve.
• I think it will be fairly similar in difficulty to how it is now. Some things may be harder while others will get easier. I’m hopeful for improvements and increased efficiency.
• Harder, due to challenges in finding correct staffing, working with people who otherwise might chose to be with another agency but have no other choice, reporting requirements though vague in most places, the ones that are clear feel micromanaging.
• I can’t tell. I feel like there will be housing specialists in the picture and that will make my job easier. There is a stronger emphasis on peers, so maybe we’ll have another set of hands? There will be a substance abuse provider on the team who can work with clients on that (but what if they don’t want to work on it???? It feels potentially less client-centered). But harder because of the deadlines and expectations around time.
• Initially harder, there will be a lot of explaining to our folks. We will be picking up a lot of slack to help our people not get lost in the system. Adding Recovery coaches will need job/role clarity and strong advocating for the fidelity of the peer role in general!
• Harder, so much change for people to deal with, insurance have more control which means less choice for the people we are working for, I think it will be harder for people to keep their psyche history private from other medical providers, like their eye doctor or dentist, or someone else who doesn’t need to know.
• I have been reassigned after 24 years at the job because I lack a license. I will be fine. The people Inserve however do not understand why this license is so important! What is important to them is that they have trusting relationships with people that have shown they care.
• ACCS adds needed clinical services into the team structure in a more clearly defined way – historically LPHA’s, while working with the teams, have not been embedded in team structure to the extent that the ACCS contract requires – this will make my job easier.
• This will make my job infinitely harder if for no other reason than in order to do a good job, I need to believe in what I’m doing.

If you are someone receiving services in the ACCS system, do you think this will make the support you receive better or worse? How?

• I’m hopeful that the (unfortunate) lower client ratio opens up better support.
• I think the increased clinical focus could lead to deeper oppression of individuals using services.
• I am not a people receiving ACCS services. But my younger brother is. He is being uprooted from his residential program home in Westfield. He was first told he “had to go to Belchertown” on July 1st or become homeless. Now he is being told he has 2 weeks to find a temporary place to go until his name comes up on the subsidized housing list he’s been on for 4 months. This knowledge alone has caused him a lot of new psychosocial stress as you can well imagine.
• Not sure, but I’m trying to be hopeful.

Anything else you want to share?

Most popular response: Thank you for collecting this feedback.

A selection of other responses:

• Given DMH’s insistence on consistency across the state I am astounded how differently implementation seems to be happening. Western MA seems to be very much behind other parts of the state in implementation and communication with people being served.
• The state did not think this through well and it is certainly not recovery oriented. I feel like we’ve taken steps back to the 1990s.
• The dramatically lower pay of peer support workers in comparison to traditional staff erodes the potential gains of increased peer support numbers.
• Even though initially the new ACCS contract might sound like it is going to create a lot of new issues for mainly people served, I am hoping we can all work together. At the end of the day, its not money that matters the most, its people’s lives. Its about people helping people. And I’m grateful to know for the most part, staff really do know this. And the people served who receive whether the name is called CBFS, ACCS, ZZZZ, or ABCD its the people helping people that people served will remember the most!
• Lets see how it goes but we need a way to quickly change the system if it’s not working.
• We were asked to notify people who were losing services by sending them letters that were not written by us in cold and impersonal language even though it was not our decision that they’d be losing services in the first place. It was terrible.
• I hope there’s a process for people receiving the services so they can register complaints and maltreatment.
• I think it’s unprofessional and disgraceful that you are severing relationships that are beneficial, even life saving.
• Fixing problems doesn’t always mean reinventing the wheel.
• I’m baffled. I hope for more clarity.
• I plan on doing the best I can for the folks I work with as I have a code of ethics to do no harm. Being in the system not of the system!
• Community based organizations like the Recovery Learning Communities and Recovery Service Centers have the opportunity to collaborate with one another in new ways. They can reach out to ACO’s and BH CP’s and play a major role in integrating peer supports into a cooperative partnership with contracted organizations and work for system transformation.
• I think I have said enough.

Thank you to everyone who took the time to give this feedback! We believe that giving voice to what is happening in the state is absolutely critical on many levels.

If you would like to add your feedback to this data, you can still do so by filling out this survey: https://www.surveymonkey.com/r/ACCS_SURVEY