Dear Commissioner Fowler

June 12, 2012

Marsha Fowler, MA, JD, Commissioner

Mass. Department of Mental Health

25 Staniford St.

BostonMA02114

Dear Commissioner Fowler:

The board of directors of the Mass. Psychiatric Rehabilitation Association is writing to express deep concern about the rate structure and RFR recently issued for clubhouse programs by DHCFP and DMH. A careful review of these documents by our board members representing current providers of clubhouse services suggests that the rates, billing mechanism and other policies spelled out would do great damage to clubhouse services, and degrade overall services to people in recovery. Our concerns can be summarized as follows:

Rates represent a decrease in funding while the RFR requires services to more individuals. Added administrative and other burdens would add significant expenses, and as a result our members who operate clubhouses are convinced that they could not remain in operation under this structure.
Other provisions of both documents contradict clubhouse standards, which codify an evidence-based practice. Resulting programs would not be recognizable as clubhouses, and would not be nearly as effective in supporting recovery of their members.
Administrative requirements also would contribute little to support recovery of members while greatly adding to costs. An immediate result would be to pull staff away from work with members into activities not at all consistent with clubhouse principles or standards. There is no provision to add funds to pay for these services, but we also see them as a waste of critically needed resources.

MassPRA represents educators, researchers, and people in recovery. [State staff members on our board have recused themselves from these deliberations.] We do not promote any single model or approach, but support access to sound psychiatric rehabilitation services in support of recovery. Clubhouses have been a critical part of Massachusetts’ psychiatric rehabilitation services for many years, and Massachusetts clubhouses are recognized as some of the best in the world. The current rate and RFR threatens to dismantle that network, denying many people in recovery access to critically needed services. We ask you and the department to reconsider this step, and withdraw the pending RFR. The attached information sheet provides further detail regarding our concerns. Representatives from our board would like to discuss these issues further with you and members of your staff. Please feel free to contact me at any time.

Sincerely yours,

Stephen C. LaMaster, MS, CPRP

President

Details of MassPRA concerns with DHCFO Clubhouse Specifications and DMH RFR

Rate structure and details:

Unit is defined as a day member attends when activities are consistent with their IAP goals
Clubhouses would have to spend considerable time and staff resources developing IAPs, at significant expense
Billing would require backup, which would have to document member activities on a daily basis.
Not all members wish to have IAPs that imply that their behavior should change, or that they want anyone’s direct assistance.
While rates are apparently set on average daily attendance, they don’t take into account the percentage of attendance that might fall outside of an individuals IAP, including critical crisis-oriented services the clubhouses provide.
Rates are set on a 6 day week, while most clubhouses had operated on weekdays only because of resource shortages. These rates don’t take into account reduced attendance expected on weekend days, effectively making it impossible to bill out the full contract amount, even at the unfairly low rate.
Clubhouses have been essentially level funded for more than 12 years, with no allowance for most increases in expenses. The current rate structure is far costlier to administer than the current accommodations rate, with no increase in funding to pay for it. Rates set on 2009 expenses are based on services without the greatly increased costs from mostly administrative expenses, but are now proposed to fund these more expensive services, for at least as many individuals. This is anything but a fair and reasonable rate-setting process on its face.

RFR Details:

IAP requirements violate the fundamental relationship between the clubhouse and its members, which is based on a supportive and accepting community that allows great flexibility in the way its members relate to it. While IAPs would be useful to many members as an option, they are not the primary engine of rehabilitation and recovery in the clubhouse. Acceptance, the use of everyone’s talents and interests, progressive responsibility and moves into employment opportunities often happen in response to the perceived needs of the community and the value it places on each individual as they are, on their own terms. This social, community model balances the introspective, self-centered focus of other services, and works best for a sizable percentage of the population. Requiring IAP goals will drive away many members who, especially at the initial stages of their engagement, find the process intrusive and unhelpful.
The RFR specifies discharge criteria in violation of the clubhouse principle of indefinite availability of services. In practice, members in advanced recovery may attend very little, so the cost of their participation is very low, but they represent a critical resource to other members who are earlier in their recovery as a model for what can be accomplished. As pressures build to discharge people early in their recovery from CBFS services to make room for others coming in to the system, clubhouse membership represents one of a very few remaining lifelines for them. Their occasional participation can support their continued recovery, but can also provide a resource during times of relapse or other challenges, when early intervention can make the difference between timely targeted services at modest expense and highly expensive services when problems aren’t attended to until life conditions worsen. This indefinite membership commitment may seem extravagant, but it actually represents a very modest investment that pays for itself many times over in preventing emergency room visits and hospitalizations.
Controlling eligibility to services, and effectively restricting them to DMH clients, would deny services to significant numbers of people. The fact that clubhouses can accept people for membership without their having to sign up with the larger system has represented a front door to services for many individuals who may be homeless and feel alienated from clinical or government services. Others feel with some justification that they are sufficiently advanced in their recovery to have graduated from services, but still feel they can contribute to others as peers at the same time that they can experience occasional supports. The RFR requires that members who establish their eligibility for services by documenting their disability, even if they can avoid the formal eligibility process as implied by the RFR, still are required to give DMH access to any and all personal details they might share with the clubhouse, including their personal goals and the monitoring, through progress notes, of their activities. This will drive away still more individuals.