The Mississippi Department of Mental Health filed temporary Mississippi Youth Programs Around the Clock (MYPAC) standards on October 14, 2021. Due to the nature of a temporary filing, no public comment period is required prior to the temporary rules becoming effective. The Department will soon be submitting to the MS Secretary of State’s office a typical (i.e., permanent) filing of the proposed new MYPAC standards to become incorporated into the current (2020) Department’s Operational Standards document. Once these proposed permanent MYPAC standards are filed with the Secretary of State, there will be an approximate 25-day public comment period. Then, there will be a filing of the rules for final adoption, and there will be a 30-day period after this filing before the permanent rules are adopted.
This is the provider bulletin with policy changes about (MYPAC) and these are the MYPAC temporary standards to accompany the bulletin. The standards explain how the proposed policy will be implemented. We encourage families and others to review the provider bulletin and standards so that you can share your feedback when the comment period is opened.
There have been several changes made to MYPAC over the past few months, and at one point the program was stopped altogether. The issue that originally led to these changes is the need to separate wraparound, the care coordination process that is used by programs offering MYPAC, from the MYPAC services that children and families receive. If wraparound coordinators work for the same agencies that offer MYPAC services, they may feel obligated to offer services to families just from their own agencies. This prevents families from having all of the choices that they should have and it may make it hard for families to tell their care coordinators when they don’t like services or want to switch to a different provider.
It is important to understand the difference between wraparound and MYPAC in order to evaluate this policy, the standards that accompany it, and other changes that have been proposed since June. Wraparound is a care coordination process with nationally recognized standards for how it should be delivered that is driven by ten principles:
- Family Voice and Choice
- Natural Supports
- Unconditional Care
- Culturally Competent
There is growing evidence that Wraparound helps families and children achieve the goals that they want to achieve. The practice of Wraparound is consistent with the nationally accepted definition of family-driven practice in that both emphasize the driving force of family voice and choice, individualized service planning and a strengths-based approach. Wraparound is a key component of the Mississippi state law governing Mississippi’s system of care for children’s mental health as noted in lines 56-72 from the statute (emphasis added):
“The Mississippi Statewide System of Care shall be:
(a) Child-centered, family-focused, family-driven and youth guided;
(b) Community based;
(c) Culturally competent and responsive; and shall provide for:
(i) Service coordination or case management;
(ii) Prevention and early identification and intervention;
(iii) Smooth transitions among agencies and providers, and to the transition-age and adult service systems;
(iv) Human rights protection and advocacy;
(v) Nondiscrimination in access to services;
(vi) A comprehensive array of services composed of treatment and informal supports that are identified as best practices and/or evidence-based practices;
(vii) Individualized service planning that uses a strengths-based, wraparound process; “
There are also national wraparound standards to help agencies and states implement and provide wraparound in the way it was intended. One of these standards is that there should be a firewall between care coordination and services at the agency level and in the way the state sets up wraparound and mental health services. That is why Mississippi has made changes attempting to separate the wraparound process from services. There are different ways to set up firewalls. Sometimes agencies completely separate wraparound and services within one agency with different staff, supervision and locations. In other instances, wraparound is provided through organizations called Care Management Entities (CME) that do nothing but provide wraparound. Initial data indicate that the CMEs have better wraparound implementation than mental health centers that attempt to separate wraparound and services in one facility.
States should also have standards and processes to make sure that agencies have this separation. It does not appear that Mississippi has this process in place and it is not clear what agency will ensure that this happens. We believe the Interagency Coordinating Council on Children and Youth (ICCCY) can help provide guidance and support on this issue and others related to MYPAC and wraparound. The Mississippi Wraparound Institute gathers wraparound data and provides coaching on wraparound, including to MYPAC providers, but there is not a clear process for how this data can be used to make sure challenges with wraparound are accountably addressed and providers receive the ongoing support that they need when challenges are identified. Maximizing this resource and data is likely another area in which the Council can be of support.
MYPAC, in contrast to the process of wraparound care coordination, is a set of services that have changed over time and for which there is no current state, national or independent evidence of their effectiveness, although some of the agencies that offer MYPAC have internal data that indicates the services help children stay in their homes and communities. At a Division of Medicaid public hearing in June 2021, Pine Belt Mental Health Services shared data that children receiving MYPAC services were less likely to require hospitalization and Youth Villages Mississippishared that families reported better functioning of their children who were involved in MYPAC. The children and families from both of these organizations would have also been receiving wraparound care coordination in addition to MYPAC services.
MYPAC began in the mid-2000s. It was designed to provide intensive home and community-based services and supports to children and youth who would otherwise need admission to psychiatric residential treatment facilities. It was based on extensive focus group data from families throughout the state. The original proposal for MYPAC funding included comprehensive parent-to-parent support (including parents being the ones to initially introduce MYPAC to families), a wide array of informal and formal supports both within and outside of the mental health system and wraparound care planning. There was an objective evaluation process for MYPAC services. MYPAC was monitored by the Division of Medicaid and coordinated with councils and teams established in Mississippi law to oversee and facilitate Mississippi’s system of care for children’s mental health.
MYPAC has changed over the years, in part due to changes in the way it is funded. It was originally a Medicaid waiver service and is now a Medicaid state plan service. Families are now typically referred to MYPAC by mental health service providers, often providers from whom their child has received residential care. The service array is not as diverse or individualized as it was originally and usually includes weekly in-home visits for therapy, care coordination and parent peer support, with medication management provided separately. Wraparound coordination is offered but it is almost always offered by the same organization that is providing services. After its first few years of existence, MYPAC outcomes were not monitored by any external entity.
Services for MYPAC have traditionally been billed at a bundled daily rate for the days that they are delivered. So, if just one service is provided on a given day, the provider can bill for a higher rate than if that service were individually charged. Bundled rates can help providers provide flexible care because it cannot always be predicted what services might be most helpful to a family on any given day. Bundled rates can also help cover the cost of responding to complex and involved needs that youth and families may have. At the same time, bundled rates can make it easier for providers to repeatedly bill for the bundled rate when only one one-hour service per day is offered. Families as Allies has obtained some information about MYPAC billing patterns through public information requests to the Division of Medicaid and we have asked the Division for guidance on whether we can share this information more broadly.
MYPAC is not part of the state law that describes how Mississippi’s system of care shall be conducted, but it is important to evaluate any MYPAC proposals against the law to see if those proposals are consistent with family-driven practice and an individualized strengths-based approach and are coordinated using wraparound.
Our initial review of the Department of Mental Health’s MYPAC proposal and accompanying standards indicates features that are not consistent with Mississippi’s system-of-care statute. The policy and standards do not holistically incorporate wraparound, they do not appear to be strengths-based and they offer a restricted range of formal mental health services rather than the range of services and supports that families typically want. The policy does not require the use of evidence-based treatments.
It is concerning that there are no provisions in the policy or standards for how providers will be monitored to ensure that they refer to this intensive, high-end service only when indicated and that their billing patterns reflect that, especially since it appears they will be self-referring to the program. The policy makes it clear that other stakeholders, including families and family-run organizations, were not included in the development of the policy, but that the Department worked only with the Division of Medicaid to create it.
It is also puzzling that the policy refers to MYPAC as an “important service for Mississippi’s children, youth and their families” given MYPAC has changed and without explaining how or by whom the importance of a service is determined. We are not aware of families being part of this determination.
Families as Allies wants to help families understand policies and regulations when they are open for comment. That is why we share information such as this blog post. At the same time, remember that you do not have to agree with what Families as Allies or anyone else says about a policy or service. You also do not need to understand every detail of a policy in order to comment on it. As a parent, you already are an expert on two things that no one else is: your child and what you think would most help your child. What you think matters and can make a big difference in whether policies help our children. The definition of family-driven practice includes this principle: “Families and family-run organizations provide direction for policy decisions that impact funding, supports, and services, including the right of families and youth to have meaningful voice at the individual and policy level.”
We encourage you, especially if your family has participated in MYPAC and/or wraparound, to write down your feedback and ideas about this policy and its accompanying standards. You can comment about what the policy and standards say or share your ideas about how you think MYPAC and wraparound can be most helpful separate and apart from the proposed policy and standards.
These are some related points to keep in mind when thinking about comments about wraparound and MYPAC:
- Wraparound and MYPAC are both intended for children and youth who would otherwise need the level of care of a psychiatric residential treatment facility. If your child was referred to MYPAC or wraparound, were their needs intense enough to otherwise need out-of-home care?
- Both wraparound and MYPAC should be individualized to children and families. If your child and family participated in either or both, were the services and how often and where they were delivered set up in a way that worked for your family?
- Both wraparound and MYPAC should support choice in providers and other supports. If your family participated in either or both, were the providers that you were working with or wanted to work with part of your team? Were people who are important to your family (for example, friends, family, church members) included?
We also encourage everyone to consider if it makes more sense to strengthen high-fidelity wraparound in the state, given the promising evidence for it and the state and national resources already available to support it rather than to implement a new rendition of MYPAC that does not have fiscal accountability measures or an evidence-base.
We will update our website and our Facebook page when the public comment period is open.
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