Brewster v. Commw. of Mass
IllIllllIII MH-MA-001-002

f i , Jr.

NORTHAMPTON

,•«?-•";-

CONSENT DECREE

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MASSACHOSETTS

DAVID BREWSTER HECTOR SANTIAGO RICHARD SCHNEIDER DONALD GABOURY MARTIN WEINBERG ALBERT POTTER ELLA BAILEY THONNIE ROWELL, by his next friend
STEPHEN FERRARONE MARY MCGUILLICUDDY, by her next friend
CAROL BOOTH
in behalf of themselves and all other similarly situated Plaintiffs

MASSACHUSETTS ASSOCIATION FOR MENTAL

HEALTH, INC.

MASSACHUSETTS ASSOCIATION FOR RETARDED *

CITIZENS, INC.

*

Plaintfiffs-Intervenors

v.

MICHAEL S. DUKAKIS Governor, Commonwealth of Massachusetts

DR. ROBERT L. .OKIN Commissioner, Department of Mental Health

MARY JANE JBjGLAND

Associate Commissioner for

Programs, Department of Mental

*

Health

*

*

CIVIL ACTION NO. 76-4423-F

Assistant Commissioner for Mental Retardation Services, Department of Mental Health
ROBERT W. MURPHY Assistant Commissioner for Mental Health Services, Department of Mental Health
RAYMOND BRIEN Regional Administrator of Region I, Department of Mental Health
JSVCJUYN MCLEAN Acting Area director of the Franklin-Hampshire Area, Department of Mental Health
ANpREW_PHILLXES Area Director of the Holyoke Area Department of Mental Health
FRANK ROBINSON Acting Area Director of the Springfield Area, Department of Mental Health
KERRY HOLLAND Area Director of the Westfield Area, Department of Mental Health
JOSEPH VANHOE^ACKER Area Director of the Berkshire Area, Department of Mental Health
IRVING A. JACOBS Superintendent, Northampton State HospJLtal
DR. JONATHAN Commissioner, Department of Public Health
JOHN _R_._BQG£LEY Commissioner, Executive Office for Administration and Finance
All individually and in their official capacities. Defendants
FINAL CONSENT DECREE

A. General 1. Plaintiffs are all mentally disabled persons who
were as of December 15, 1976, are, or may be hospitalized at the Northampton State Hospital. They bring this action pursuant to, inter alia, 42 U.S.C. §1983, claiming violations of their constitutional and statutory rights to be treated in appropriate, less restrictive alternatives suitable to their needs.
2. This Court has jurisdiction of the subject matter, pursuant to, inter alia, 28 D.S.C. §1343 and 42 D.S.C. §1983. On October 27, 1977, this Court certified this matter as a class action.
3. Based upon the record and consideration of submissions filed by all the parties in conjunction with the case, this Decree is entered by the Court and consented to_J>y the parties for the purpose of establishing a comprehensive system of appropriate, less restrictive treatment, training, and support services for each member of the plaintiff class which will meet, without necessarily defining, federal and state constitutional and statutory standards.
4. This Decree, including the attachments hereto subject to the provisions of paragraphs 9 through 11, shall be as binding on the defendants' successors, officers, agents, employees, and attorneys as on the defendants themselves. Defendants and their successors will take actions necessary to
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secure full implementation of this Decree, including coordinating with other agencies and officials of the Commonwealth of Massachusetts and delegating among themselves and their subordinates the appropriate responsibilities.
5. In order to address the issues the parties and the Court deem pertinent for final settlement of the case, this Decree, including the attachments hereto subject to the provisions of paragraphs 9 through 11, sets forth the defendants' commitments towards the plaintiff class. This Decree includes a final, substantive resolution of most of the issues raised by this litigation. To the extent that current information renders final, substantive settlement of an issue impracticable, the parties have agreed upon a schedule and process for collaboration and/or negotiation, supervised by the Court, which the parties believe can lead to a final resolution of the issue in a fair and reasonable manner.
6. Jurisdiction is retained by the Court until further order, to enable any party to apply at any time for such further orders as may be necessary or appropriate for the interpretation, implementation, enforcement, or modification of the terms of this Decree and for supervision and approval of the resolution of issues left for further planning and negotiation.
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B. Definitions 7. As used in this Decree, the following terms shall
have the following meanings: "Department" means the Department of Mental Health of
Massachusetts. "Commissioner" means the Commissioner of the
Department of Mental Health. "Region I" means the geographical area designated in
Section 3.2 of the Code of Human Services Regulations, Title 4 - Mental Health and Mental Retardation, in force as of the date of this Decree, including the four counties of Franklin, Hampshire, Berkshire, and Hampden.
"Regional Office" means the principal administcative office for Region I or its successor.
"Regional Services Administrator" means the director and chief administrator of Region I or its successor.
"Areas" means the geographical divisions designated in Section 3.2 of the Department Regulations, in force as of the date of this Decree.
"Area Office" means the principal administrative office for each of the five Areas, or their successors, in Reg ion I.
"Hospital" means the Northampton State Hospital, Northampton, Massachusetts.
"Resident" means a member of the class who resides at the Northampton State Hospital or is not otherwise discharged
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from the Hospital while residing in another facility or environment.
"Client" means a member of the plaintiff class who does not presently reside at the Northampton State Hospital.
"The plaintiff class" means all persons who were, as of December 15, 1976, are, or may be hospitalized at the Northampton State Hospital, including those persons on indefinite visit or conditional discharge during that period.
"Community residence or residential alternative" means any mental health or retardation program providing residential services, other than a state hospital or state school for the retarded, including, but not limited to, a supervised residence or apartment, transitional residence or apartment, specialized residence or apartment for persons with behavior or physical problems, group home, halfway house, foster home, specialized home care, rest home, nursing home, or any other type of environment providing care or treatment for mentally disabled persons.
"Nonresidential program" means any mental health or retardation service provided in other than a residential setting, including, but not limited to, individual needs assessment and service planning, case management, counseling and psychotherapy, respite care, family therapy, medication clinic, crisis intervention, day treatment, day activity, prevocational training and sheltered workshop, transitional
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employment and job placement, supervised recreation, or any other type of nonresidential service providing care or treatment for mentally disabled persons.
"Individual Service Plan or ISP" means an individualized written plan describing the individual's capabilities and needs for treatment, training, and support services, including the methods to be utilized and the person(s) responsible for providing such services.
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C. Principles for Creating and Maintaining Community Programs 8. The following principles form the basis for
creating and maintaining the comprehensive system of community mental health and retardation services suitable to meet the needs of all members of the plaintiff class:
a. A comprehensive community mental health and retardation system consists of three distinct components: (1) residential environments which are the least restrictive and most normal settings appropriate for each resident or client; (2) nonresidential treatment, training, and support programs which are geographically separate from community residences and which provide the major daily activity for those clients whose residential environment does not provide the total treatment program, as well as for other members of the plaintiff class who live independently in the community; and (3) management services to adequately develop, coordinate, administer, monitor, and evaluate this network of environments and programs.
b. Residents and clients are entitled to live in the least restrictive, most normal residential alternative and to receive appropriate treatment, training, and support suited to their individual needs.
c. There are approximately 2135 mentally disabled plaintiffs in Region I who have been, since the initiation of the lawsuit, are, or will be
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hospitali'zed within any two year period at the Northampton State Hospital. The lack of appropriate treatment in less restrictive community alternatives can result in their unnecessary institutionalization. These plaintiffs constitute the population to be served by the development of new and the expansion of existing programs and services, as is more fully described in Attachme_n_t__A.
d. There are approximately 3588 other mentally disabled plaintiffs, as described in Attachment A, who are presently receiving community residential and nonresidential services, but who may be hospitalized if such services are eliminated, reduced or otherwise diluted. To the extent these existing services remain adequate, these clients are not part of the population to be served by the development of new programs and services.
e. The provision of appropriate treatment, training, and support services to residents and clients will not deprive other persons currently receiving mental health or retardation services from the defendants from continuing to receive such services for as long as they are determined to be necessary, according to professionally accepted standards.
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f. The determination of client service needs will occur through an individualized screening, evaluation, and service planning process, including annual reviews of Individual Service Plans.
g. The determination of the appropriate residential and nonresidential placement for each resident and client will be made so as to guarantee that all persons are placed in the least restrictive alternative which will provide them with appropriate treatment, training, and support.
h. In light of the profound effects of the long term institutionalization of many of the plaintiffs, and the practical problems in making available the most suitable setting, some residents and clients may be placed initially in the more structured alternatives; however, they will be provided with the necessary treatment, training, and support to enable them to move, as quickly as possible and in accordance with their capabilities, into less restrictive, more open settings and programs.
i. Since the residential models are designed to be the most normal and least restrictive environments appropriate for the residents and clients, smaller apartment units are preferred to larger group homes, although either may be appropriate depending on the particular circumstances.
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j. Community residential and nonresidential services will be offered, to the maximum extent feasible and entirely if possible, on a voluntary basis and with due regard for the client's dignity and personal autonomy.
k. All residential and nonresidential services will be offered by providers of services on a nondiscriminatory basis, without regard to a resident's or client's degree of handicap or ability to pay, subject to the provisions of G.L. c. 123, SS32 and 37.
1. Community residential alternatives and nonresidential programs will be integrated in the community and operated in the most normal manner appropriate to the needs of their clients.
m. Standards^ for all residential alternatives and nonresidential program models are necessary to insure the health, welfare, and dignity of all clients of such programs. Licensing procedures are necessary to enforce these standards and serve as the primary monitoring device to insure program adequacy.
n. An evaluation process is required to assess a program's quality and effectiveness in meeting the needs of its clients.
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o. Adequate residential and nonresidential services will be provided in appropriate, less restrictive alternatives to all residents and clients for as long as determined necessary to meet their individual needs, according to professionally acceptable standards.
II
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D. Development of Community Programs 9. The community residential alternatives and
nonresidential programs, set forth in Attachments B and C respectively, represent appropriate program models designed to meet the needs of all residents and clients. These models are based on current information and experience and may be modified, to the extent that new knowledge discloses more appropriate alternatives, provided that the plaintiffs' attorneys are given notice and an opportunity to object reasonably in advance of any budgetary or programmatic action to implement any modification.
10. The number of residential and nonresidential placements in each program model, set forth in Attachments D and E respectively, represent the number of placements which the parties deem appropriate to .meet the needs of all residents and clients. The number of placements in each program model which will be created may be modified to the extent necessary to meet the individual needs of all residents and clients as determined by their Individual Service Plans.
11. The parties recognize that administrative and management services are necessary and appropriate to develop, coordinate, manage, monitor, and evaluate the diverse system of community programs. A proposed design for such administrative and management services is set forth in Attachment F. This design is subject to further review and modification by J:he
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defendants' normal budgetary and programmatic processes, provided that plaintiffs are informed of and allowed to participate in and have the opportunity to object to any budgetary or programmatic decision. The design set forth in Attachment F does not imply any conclusion as to whether the proposed positions are to be newly created or reallocated from the Hospital. Such management services insure that all residents and clients receive appropriate treatment, training, and support in the least restrictive alternative suitable to their individual needs.
12. The defendants will create and maintain appropriate community residential alternatives and nonresidential programs, including necessary management services, for all members of the plaintiff class adequate to meet their individual needs as recommended in their Individual Service Plans.
13. The defendants will create and fund appropriate community residential alternatives and nonresidential programs and will maintain and continue to fund all new and existing programs unless the needs of the residents and clients, as determined by their Individual Service Plans, no longer require such programs.
14. The defendants will not place residents or clients in residential alternatives or nonresidential programs which fail to meet the environmental, care, and programming standards included in this Decree and the attachments hereto, subject to the provisions of paragraphs 9 through 11.
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15. With respect to residents at the Northampton

State Hospital, the defendants will create and maintain

residential and nonresidential programs which will reduce the

census of the Hospital to 250 residents by June 30, 1979, to

150 residents by June 30, 1980, and to no more than 50

residents by June 30, 1981. As to this remaining population,

the defendants will, by June 30, 1931, create and maintain

appropriate community residential and non residential programs

suitable to the individual needs of those residents for__whom

the community program models set forth in Attachments B-E are

appropriate, and will place those residents in such

^alternatives.

/"

16. To the extent that the community program models

set forth in Attachments B-E do not adequately meet the needs

\of a portion of this remaining population, the defendants

agree, during the formulation of the budget for fiscal year

1981, to seek a resolution of outstanding issues relevant to

the need for a secure treatment setting at an appropriate

location. If the parties cannot agree on a resolution of these

issues, they will report to the Court by November 15, 1979.

17. The; defendants will use their best efforts to insure the development of an inpatient capacity of additional

acute psychiatric beds in community general hospitals in Region

I, as deemed necessary to meet the needs of members of the

plaintiff class described in Attachments C, D and E. To the

extent that factors outside the defendants' control inhibit or

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, .!
M
IN

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prevent the creation of this inpatient capacity in community hospitals, the parties recognize the need to modify the projected number, type, and timing of community residential alternatives necessary to meet the needs of these members of the plaintiff class.
18. The defendants will take all necessary action to maximize the reallocation of funds from the Hospital to the community. Reallocation will proceed so that by June 30, 1981, the unit cost will not exceed $40,000 per resident at the Hospital.
19. With respect to clients who have been or may be institutionalized at the Hospital and who are presently receiving some but not all of the residential and nonresidential services appropriate to their needs, the defendants will upgrade existing community programs- and create new programs and services to meet their individual!needs. The defendants agree that sixty percent of the deficiency in existing services, as described in Attchment G, will be eliminated by June 30, 1980, and the remainder will be eliminated by June 30, 1981.
20. By June 30, 1979 the defendants will place forty mentally retarded residents currently at the Hospital in appropriate, less restrictive residential alternatives and provide them with treatment, training, and support services suitable to their individual needs. The projected cost of these placements for six months is $412,000, of which $260,000

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will be allocated from the Comnonwealth's 5C22-0100 account and the remaining $152,000 will be reallocated from the Hospital budget for the 1979 fiscal year.
21. By June 30, 198C the defendants will place all remaining mentally retarded residents at the Hospital in appropriate, less restrictive residential alternatives and provide them with treatment, training, and support services suitable to their individual needs.
22. The defendants will insure that Department personnel experienced in mental retardation will assume predischarge planning and community placement responsibility for all mentally retarded residents and clients in order that there is no distinction in Department aftercare responsibilities for any mentally retarded client based on prior residency in the Northampton State Hospital as opposed to state schools for the retarded. All mentally retarded clients will be considered within the scope, and will receive the protections of, all mental retardation regulations, standards, and procedures.
23. The defendants will make their best^efforts to insure that residents and clients of community residential alternatives and nonresidential programs are provided equal access to all generic services, such as education, transportation, recreation, and medical care, and will develop appropriate links between the community mental health delivery system and such services.
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24. The defendants will use their best efforts to

overcome all obstacles and barriers to the creation of

coamunity residential and nonresidential programs, as required

by this Decree, including, but not limited to, the actions set

forth in Attachment H.

25. As soon as it is practicable and to the extent

not inconsistent with existing contracts, the defendants will

reach a written agreement with the operator of the community

residence or nonresidential program to include the following:

a. require the residence or program to comply

with the applicable terms of this Decree and with all

applicable statutes, rules, and regulations

promulgated by the United States, the Commonwealth of

Massachusetts, and the Department;

b. reserve the right of employees and

•

contractees of the Department to have reasonable

access to the residence or program and to audit its

records, to supervise services to its clients, and to

operate, or make appropriate provision for the

operation of, the residence until clients are

appropriately placed elsewhere in the event the

provider substantially fails to fulfill the terms of

its contract;

c. specify all charges and the sources of

payment of a client's program, room and board, and any other expenses;

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d. require the participation of the residence or program director, or appropriate representative, in the Individual Service Plan process for each of their clients;
e. require substantial fulfillment of the applicable portions of each client's Individual Service Plan. Sanctions foe failure to comply with the provisions of the agreement will be included in the agreement and will include, but will not be limited to, the termination of the agreement and the removal of the client from the placement. Prior to the renewal of an agreement, the defendants will monitor the service provider's compliance with the terms of the agreement.
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E. Individual Service Plan 26. The defendants will furnish or continue to
furnish all residents and clients with a written Individual Service Plan which specifies in detail the individual's capabilities and needs for services, including the methods to be utilized to provide such services. The Individual Service Plan will address the individual's residential and nonresidential program needs, with particular emphasis on the determination of the least restrictive residential environment and suitable nonresidential treatment, training, and support services appropriate to meet those needs. Such residential alternatives and nonresidential services will include, but not be limited to, those programs set forth in Attachments B and C. The Individual Service Plan will describe short-term and long-term program goals and timetables for the attainment of these goals. The Individual Service Plan will identify by name the person or persons who are primarily responsible for implementing, and overseeing implementation of, service goals.
27. The Individual Service Plan will be developed under the direction of a qualified professional and will be reviewed at least annually by an interdisciplinary team which is appropriately constituted in accordance with professionally acceptable standards and which includes the person or persons primarily responsible for the daily care and support of the resident or client, as well as the community service coordinator responsible for the client. Each resident or
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client, and the individual's guardian, advocate or other representative will be notified of and invited to participate in the interdisciplinary team meeting, unless the resident or client objects to such attendance. Notification of team meetings will be provided as far in advance as practicable, and in no event less than two weeks prior to the meeting. As of September 1, 1979, a resident or client, either individually or with the assistance of a representative, may challenge the Individual Service Plan pursuant to procedures to be agreed upon by the parties by June 1, 1979, which will be substantially similar to those to be promulgated .le Department regulations.
28. The resident's or client's community service coordinator will be responsible for reviewing andLsupervising the client's progress, for ascertaining that appropriate services are being delivered, and for coordinationthe input of other professionals and staff in the Individual Service Plan process.
29. Recommendations as to residential and nonresidential program placements will be based on an evaluation of the actual needs of the resident or client rather than on what programs are currently available. In cases where the services needed by a client are unavailable, the Individual Service Plan will recommend an interim program based on available services which meet, as nearly as possible, the actual needs of the client. The number of clients in need of a service or program which is not currently available and the
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type of residential alternatives or nonresidential programs which they need will be compiled in order to plan for the further development of programs.
30. For all residents who do not presently have an Individual Service Plan in conformity with the provisions of paragraph 26 of this Decree, an ISP will be developed by January 1, 1980.
31. A uniform system of records will be established by the Department for Area offices and residential and nonresidential programs to the extent necessary to insure the proper delivery of services and in accordance with Department regulations. A complete copy of the resident's or client's record will be kept at a single, appropriate location and updated regularly.
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p. Standards 32. In order- to protect the legal and civil rights of
all residents and clients, including their rights to personal dignity/^individual autonomy, adequate treatment, and freedom from abuse, the Department will draft and promulgate regulations, to be incorporated by reference in this Decree, governing residential alternatives, nonresidential programs, Individual Service Flans, and due process procedures for residents moving from the Hospital to a community setting. These regulations will substantially parallel similar regulations promulgated or drafted by the Department of Mental Health for mentally retarded persons and will be promulgated pursuant to the following schedule, unless an extension is agreed upon by the parties:
a. Community residential regulations'by Juno 1, 1979;
b. Nonresidential program regulations, including provisions for all relevant program models.described in Attachment C, by March 1, 1980; and
c. Individual Service Plan and Due Process regulations by April 1, 1980. 33. The Department will include the plaintiffs in reviewing and revising drafts of these regulations and all other standards affecting clients1 rights and the quality of life in community programs. If the standards as promulgated differ substantially from those regulations applicable to mentally retarded persons, separate standards for community
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residential and nonresidential programs serving Members of the plaintiff class will be jointly drafted through a negotiation process between the plaintiffs and the Department and subsequent1 included in this Decree.

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i

G. Personnel and Training

34. The defendants will either directly or indirectly

recruit qualified personnel to staff community residential

alternatives and nonresidential programs. Such recruitment

efforts" and hiring practices will be designed to insure that

personnel working in community programs are sensitive to

clients' needs and their right to be treated in the least

restrictive, most normal setting possible. Every effort will

be made to screen out those applicants for employment who might

pose a danger to clients or who fail to work in their best

interests.

35. The defendants wili provide all new employees

with appropriate orientation and training programs to increase

their skills and interest in achieving service goals for

clients. The defendants agree-to provide staff persons

employed in new residential and nonresidential programs with

training appropriate to their tasks as set forth in Attachments

B and C. Those (Hospital employees^; for whom employment in

community settings is both desired and suitable will be offered

retraining to permit them to serve appropriately the needs of

clients in these community programs. The parties will prepare

by October 1, 1979, a plan for orientation, retraining, and

ongoing development of Hospital staff and employees of

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\

community programs. This plan will be incorporated Jby_

reference in this Decree after review_and_appr_ova 1 by all v

parties

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36. Personnel policies will he designed to maximize use of individual employee skills and to enhance effective services for clients and working conditions for employees. Personnel policies will include provisions, consistent with state law, for suspending or terminating employees whose job performance is determined, after appropriate review, to be substantially unsatisfactory or to violate the rights of clients as set forth in relevant statutes, regulations or the provisions of this Decree.
37. The defendants agree to use their best efforts to secure federal funds, through Title XX of the Social Security Act, 42 U.S.C. S1397a{2) (A), and other -sources, .tec train and retrain individuals working in community programs. To the extent federal funds are inadequate for this purpose, the defendants agree to provide by other means or tar^eek adequate funding for training personnel.
j '!
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H. Monitoring and Evaluation 38. The defendants will, through the Department's
Area and Regional offices, monitor compliance with contract requirements and the provisions of this Decree by local vendors, agencies, and other providers of service to residents and clients. To fulfill this responsibility, the defendants will use the licensing procedures for residential and nonresidential programs included in the Department regulations described in paragraph 32.
39. The defendants will, thiough program standards and evaluation mechanisms to be established by the Department, seek to insure that residential alternatives and nonresidential programs provide appropriate services which provide a high quality of life for their clients and which are effective in promoting their clients' early movement to less restrictive, more independent living environments.
40. The defendants will develop and maintain a management information system to better understand clients' use of residential and nonresidential programs and to generate data for planning and evaluation purposes.
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I. Hospital and Placement Procedures 41. The defendants will make all reasonable efforts
to substantially reduce new admissions to the Hospital through the creation of residential alternatives and nonresidential programs designed to prevent the unnecessary hospitalization of clients. No mentally retarded client will be admitted to the Hospital except upon criteria developed by and with the express approval of the Regional Services Administrator. No resident will be transferred to another state hospital or school unless and until the Regional Services Administrator or the Commissioner determines that such transfer will offer the resident more appropriate services and a more suitable, less restrictive environment than the Hospital.
42. The defendants will provide all residents of the Hospital with appropriate planning and preparation for discharge from the Hospital through the Individual Service Plan process. The Department will seek to insure, through the assignment of a community service coordinator to each resident, appropriate links between Hospital based and community services
43. The parties will review all issues relevant to the phasing down of the Hospital, including administrative, personnel, programmatic, and fiscal considerations, and will produce, through a negotiation process, a reorganization and phase-down plan by November 15, l?2i_wni<?h_J?.irAL.be_ini*Il1<led_ ?y reference in this Decree. The.plan will include specific timetables for reallocation of Hospital funds and may include a
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proposal for the use of the Hospital grounds and buildings, which plan shall keep at an absolute minimum maintenance costs for the Hospital grounds and buildincs net used by residents. The plan will be designed to insure that no resident is provided with less treatment or a more restrictive environment during this transition period than presently exists at the Hospital.
44. The procedures for the reallocation of Hospital funds, which will be set forth in detail in the reorganization plan, will be done in such a manner as to insure a staff-patient ratio appropriate to meet the basic needs of the residents. No funds will be reallocated from existing community programs serving members of the plaintiff class, except to the extent that the parties agree that such programs jare inappropriate to or inefficient in meeting the needs of (their clients.
45. After a placement in an appropriate residential alternative and/or nonresidential program has been located, the Area Director will inform the resident or client of the proposed placement. Notification will also be given to the plaintiffs' attorneys, pursuant to an agreement between the parties set forth in Attachment I. If the resident or client finds acceptable and consents to the proposed placement, it will be accomplished without undue delay. If the resident or client rejects the proposed placement, the Department will make an effort to locate an alternative residential and/or
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nonresidential program more suitable to the wishes of the resident or client and appropriate to his/her needs. The Department will draft, in consultation with the plaintiffs, detailed regulations governing placement and transfer procedures and will issue such regulations, pursuant to paragraph 32 (c).
46. The resident or client may at any time initiate a request for transfer to a more appropriate, less restrictive setting. The Area director will respond within 30 days, either accepting or rejecting the request and stating the reasons for any rejection. A request for such a transfer will be rejected only because continuation in the current residence offers the individual a better opportunity for personal development in a more suitable, less restrictive environment, because of statutory restrictions on the resident's os; client's freedom of movement, or because a placement is not currently available elsewhere. In this third situation the resident or client will be transferred as soon as an appropriate placement can be found or developed.
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J. Implementation and Monitoring 47. The defendants will use their best efforts to
insure the full and timely financing of this Decree, including: submission of appropriate budget requests to the Massachusetts General Court; allocation of sufficient funds to "insure that all existing and new programs meet the minimum standards herein; full allocation of funds appropriated for services during the fiscal year; allotments of appropriated funds as needed; prompt release of scheduled positions and processing of conversion and transfer requests; use of an appropriate voucher system by the comptroller's office to insure the prompt availability of necessary funds; use of a timely payment system to insure adequate cash flow to providers of services, so long as the providers have in place an auditing system and comply with.reasonable auditing procedures to be established by the defendants which do not restrict the appropriate provision of services to clients. In order to finance the obligations of this Decree, the defendants agree not to transfer funds among accounts in such a way as to reduce the level of services presently being provided to mentally disabled persons at the Hospital or elsewhere in Region I of the Department of Mental Health.
48. The defendants will include in every future contract requiring an agent or independent contractor to perform duties, standards, and procedures which would otherwise
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be performed by the defendants or their employees, a clause requiring the agent or contractor to meet the relevant obligations of this Decree and the attachments hereto.
49. The parties agree that Regional and Area administrative personnel should have reasonable flexibility to implement residential and nonresidential programs.
50. The defendants agree to take all necessary action ! to insure full and timely compliance with the provisions of
this Decree. The parties recognize that there may arise, during the implementation of this Decree, difficulties beyond the control of the defendants which may inhibit timely accomplishment of certain of its terms. Whenever the parties or the Monitor determine that such difficulties have arisen and significantly threaten implementation, the problem may be brought to the Court.for its attention.
51. By January 1, 1979, an independent Monitor will be appointed by the Court from a list of proposed candidates jointly prepared by-the plaintiffs and defendants. The Monitor will be responsible solely to the Court and will serve the Court and the interests of justice for as long as necessary. The Monitor will review and report to the Court and the parties on the progress towards implementation of this Decree, in accordance with procedures and schedules to be agreed upon by the parties. The Monitor's first term of appointment will be for eighteen months., which may be extended by agreement of the parties and the Court. The parties' attorneys will consult

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with each other prior to the reappointment or replacement of the Monitor, and exchange proposals regarding the Monitor's position at least three we~ks prior to submittal to the Court for approval. The defendants will pay the salary and expenses of the Monitor and will provide necessary clerical support. The defendants will pay the costs and expenses of those consultants which the Monitor finds necessary to fulfill its responsibilities as set forth in this Decree, provided that either the parties agree or the Court, after a hearing, finds that such consultation is appropriate.
52. The Monitor will be allowed access to all information, records, residential environments, and program areas, and will be permitted to interview any person affected by or involved in the implementation of this Decree to the extent necessary to discharge .the Monitor's duties under this Decree.
53. The Monitor will evaluate residential, nonresidential, and management services in the community, including their costs and effectiveness, as well as services at the Northampton State Hospital which relate to placement in community programs, pursuant to the standards set forth in this Decree and the attachments hereto.
54. The Monitor may make informal suggestions to the defendants in whatever form the Monitor deems appropriate in order to facilitate compliance with the Decree.

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55. If an individual complaint or problem is not or cannot be resolved through existing procedures of the Department, any employee or agent of the defendants, any resident or client, or any guardian, advocate, or other representative of a resident or client, may bring a situation or disagreement related to the provisions of this Decree to the attention of the Monitor for appropriate action. The Monitor will provide written notice of such matter to the parties1 attorneys. The Monitor may make a recommendation to the defendants to promptly address or resolve such problem. The Monitor's action on individual complaints or problems will be considered final, and inappropriate for review by this Court, except to the extent provided in paragraph 61.
56. The Monitor will have the authority to make recommendations with: regard to implementation of the Decree if: (1) the Monitor believes that the defendants are not in compliance with the .Decree; (2) this judgment is accompanied by written findings of fact which indicate the source of the evidence upon which each finding is based; and (3) the recommendations are consistent with and can be implemented within the framework of the Decree. Such recommendations will include, where necessary, timetables for implementation of steps or measures necessary to bring the defendants into compliance.
a. Copies of each recommendation accompanied by the findings of fact required by this paragraph will
- 34 -

be filed with the Court and sent to counsel for the parties. All parties shall be bound by the recommendation unless, within fifteen business days, any party files an objection with the Court and requests a hearing. Objections may be made on the basis that (1) the findings of fact relied upon by the Monitor are erroneous, (2) the Monitor's judgment of noncompliance is erroneous, or (3) the Monitor's recommendations are beyond the provisions of or inconsistent with the Decree.
b. The hearing on the objections will be held at the earliest convenient time after notice to all parties. 57. The Monitor will submit written reports to the Court and the parties every six months: on li<« progress achieved in complying with the provisions of this Decree, including a description of all problems and disputes which have arisen and suggestions for appropriate action to- remedy such problems. The reports will also make recommendations on unresolved issues and propose modifications or revisions in the Decree to facilitate compliance with its fundamental purposes. Before filing its report the Monitor will submit a draft thereof to the parties for comment. The Monitor may submit special reports to the Court and the parties at any time. 58. Any party may submit a written request to the Monitor for a specific action or recommendation. A copy of such request will be filed with the Court and served upon the parties' attorneys. The Monitor will prepare and file a
- 35 -

response with the Court in 30 days, a copy of which will be sent to all parties. Any party objecting to the Monitor's response may request a hearing before the Court.
59. The Monitor will investigate and determine the necessity for trained. independent advocate^ to assist clients in the protection of their rights as set forth in relevant statutes, regulations, and the provisions of this Decree, including the attachments hereto. The Monitor will submit its recommendation to the parties and the Court by January 1, 1980, on the appropriate role of and funding for such independent advocacy. The plaintiffs and defendants agree to cooperate in investigating sources of funding and in seeking federal funds to establish and maintain an advocacy system, to the extent such is determined to be appropriate.
60. The plaintiffs and the defendants will cooperate, with the Monitor in his/her efforts to facilitate compliance with this Decree. For this purpose, the Governor's office, the Secretary of Administration and Finance, the Executive Office of Human Services, the Department of Public Health, and the Department of Mental Health will designate staff persons responsible for coordinating implementation of this Decree and will furnish the names of such persons to the Court, the Monitor, and the plaintiffs' attorneys.
61. Plaintiffs' counsel may apply to the Court for appropriate relief on matters of significant concern to the class. Nothing herein shall be construed to prevent a resident
- 36 -

or client or his/her legal representative from bringing an independent enforcement action in the event that the individual's grievances have not been remedied through the procedures specified in this Decree or other procedures existing within the Department.
62. Defendants will post in each building at the Horthampton State Hospital, and will either post in or send to each community program where members of the plaintiff class receive services, a notice that the Court has issued a judgment setting forth standards and procedures to be applicable to all the plaintiffs. The defendants will insure that a copy of that judgment is available for inspection at Area and Regional offices of the Department of Mental Health during regular business hours by employees and agents of defendants, vendors and service providers, residents, clients and--theit parents, relatives, and legal guardians, and all other interested members of the public. Defendants are committed to providing copies of this Decree to all providers of mental health services in Region I. Defendants agree to make available to concerned individuals, local agencies, and consumer organizations copies of the Decree and the attachments hereto at a reasonable cost.
- 37 -

Assented to this 6th day of December, 1978 For the Plaintiffs:

Stevenl J.. STcS<hwartz Attorney for the Plaintif and the Massachusetts Association for Mental Health
William C. Newman Attorney for the Plaintiffs
Boisfeuillet Jones, Jr. Attorney for the Massachusetts Association for Retarded Citizens
Elizabeth B. Bawlxns President, Massachusetts Association for Mental Health, Inc.
Raymond NicJterson President, Massachusetts Association for Mental Retardation, Inc.

en Rosenfeld Assistant Attorney Gent
Catherine A T White Attorney Gem
rz. gut.
Joton R. Buckley Secretary of Administrs And
'Dolores L. Mxtc Secretary of Human Serv
Robert L. OkYn Commissioner of the Def of Mental Health

"33 -

s

,

- -_

Jonathan E. Fielding

//Commissioner of Departm

' of Public Health

f Raymbnd P. Br ien Regional Services
Administrator

Approved at Springfield, Massachusetts, this seventh day of December, 1978.
> rf j
Frank H. Freedman United States District Court Judge
i

- 39 "

SCHEDULE OF ATTACHMENTS Population Analysis Residential Alternative Models Nonresidential Program Models Residential Placement Recommendations Nonresidential Placement Recommendations Management Component Deficit in Existing Programs Defendants' Obligations to Overcome Obstacles to Implementation Notification of Discharge Agreement
(40)

ATTACHMENT A FINAL DRAFT

Analysis of the Mentally Disabled Population Presently Hospitalized and at Risk of Hospitalization in Region I

I. Introduction

In order to plan a system of community treatment programs

and residences for mentally disabled persons, it is necessary to

identify the population within the parameters of the planning

process and then to subdivide this population into relatively

homogeneous groups or clusters according to individual character-

istics and corresponding mental health needs. The total population,

defined as all persons who have been, are now, or will be hospital-

ized in the Northampton State Hospital (the Hospital), can be

viewed as composed of five distinct subpopulations: (1) Acute

patients admitted for the first time and who remain in the Hospital

for a brief period; (2) Recidivist patients who have been admitted

more than once and who remain in the Hospital for varying lengths

i

of time; (3^ Long-term patients who have been hospitalized for

more than three months and usually for more than a year; (4) Non-

acute patients who were hospitalized on or after December 15, 1976,

who have been discharged as of a given planning date, and who

are not likely to return to the Hospital; and (5) Persons never

admitted to the Hospital but at substantial risk of being hos-

pitalized unless alternative services are available. For planning

purposes, the grouping of each of these subpopulations was

(41)

undertaken on the basis of the Final Draft of the Index Construction jointly prepared by the plaintiffs and defendants. This document identifies the number of persons in each subpopulation and analyzes that subpopulation according to relevant clusters. The data set forth within will form the basis for determining the appropriate number and type of community programs and residences necessary to meet the needs of the mentally disabled population subject to this planning process.
II. Methodology for Identifying Subpopulations Although no formula or statistical design has been created
to precisely identify the number of persons who have been or may be hospitalized, there is remarkable similarity in the results produced by several different approaches that have been devised after an exhaustive review of hospital data and results of the assessment survey. It is recognized that all of these approaches attempt essentially to approximate a dynamic model of client "flow" into and out of the hospital, without actually relying upon a dynamic—simulation methodology. The development of a fully dynamic model of patient flow would have required the retrieval of a substantial amount of additional data, and require' considerable delays in the planning process. As noted, the distinctive methodologies employed here do show a remarkable convergence, results of which are described below:
i I
(42)

A. Acute Subpopulation - 525

There are an average of more than five hundred and twenty-

five new admissions to the Hospital each year who have never

been previously admitted to a mental hospital. Alternatively,

a total of 32 persons in the Hospital on September 17, 1977

were identified on the assessment survey as either acute or

adolescent with not more than one previous admission, and
t

V

hospitalized for less than three months. Similarly, there

were 29 persons with no previous admissions. Given the

average length of stay at the Hospital for this subpopulation

of approximately 20 days, these persons represent an acute

population of approximately 550 (29 x 18 - 532; 32 x 18 - 576)

B. Recidivist Subpopulation - 1076 In order to determine the unduplicated count of persons
admitted to the Hospital over a two year period who had previously been hospitalized, an extensive review of Hospital records was undertaken. This review included examining the admission history of every person admitted during the six month period from October 1, 1977 - March 31, 1978. This individual analysis allows for an exact determination of the number and frequency of persons entering the Hospital in a given time period, in addition to precisely identifying who those persons are and the source of their referral.
On the basis of this data (see especially Appendix C, Tables 1 to 3), a total of 1300 annual admissions to the
(43)

Hospital were identified, 736 of which were readmissions. When this figure was adjusted for repeated readmissions of the same client, there were 680 unduplicated individuals identified for a single year. In order to determine for a 2 year planning period how many unduplicated recidivist clients would re-enter the Hospital, a number of databased assumptions were made (see Appendix C, Table 4). Basically, four'separate recidivist subgroups were identified:

Group A: Consisting of 46 persons, each of whom are readmitted two to three times each year, and 4 to 6 times over a two year planning period;

Group B: Consisting of 318 persons, each of whom are readmitted once each year, and twice over a two year planning period;

Group C: Consisting of 121 persons, each of whom are

readmitted about every 18 months, 80_ of whom

could be expected to show up within a single

ii

year, and all of whom could be expected to

show up at least once during the two year

planning period, and;

Group D: Consisting of 590 persons, each of whom are readmitted about every 30 months, 236 of whom could be expected to show up within a single year, and 472 of whom could be expected

(44)

to show up at least once during the two year planning period.

Thus, for a one year planning period we would expect 680

unduplicated clients

(46 +318 + 80 + 236) in the

recidivist subpopulation. For a two year planning period

there would be 957 unduplicated recidivist clients (46 + 318 +

121 + 472*) admitted to the Hospital.

In addition to this total, there are 119 other clients

released form the Hospital on an indefinite visit status,

who returned to the Hospital one or more times during the

year (See Appendix C, Table 3). Although pursuant to

Department procedures these persons are not formally re-

admitted, they clearly must be considered as part of the

recidivist subpopulation for planning purposes. Thus this

methodology suggests the total unduplicated recidivist

subpopulation that will be admitted to the Hospital in a

two year period is 1076 persons (957 + 119).

C. Long-Term Subpopulation - 362 A total of 362 persons at the Hospital on September 17,
1977 had been there longer than three months. Of this group more than three hundred had been hospitalized for more than a year.

*While Group D (the infrequent readmit group) consists of an estimated 590 individuals at risk of readmission, only 472 could be expected to show up during the two year planning period.
(45)

i 1 '. t

D. Nursing Home Discharged Subpopulation - 172 As of June 30, 1977 there were 178 persons on convalescen
leave status. These people, although not residing in the Hospital, are still considered clients of the Department. Alternatively a total of 172 persons were discharged from the Hospital to either a nursing home, rest home, or boarding home during FY 1977. Given the exceedingly low readmission rate from nursing and rest homes, there is little likelihood this subpopulation is included in the recidivist subpopulation above. Finally, 1980 former Hospital patients were discharged to nursing or rest homes between 1969 and 1977; of this number 1240 left between 1969 and 1974. Thus in years 1975 to 1977, slightly more than 200 persons per year were discharged to these type of facilities, with only a slight risk of their returning to the Hospital (1980 --1240).
E. At Risk Subpopulation - 3588 Based on an October 1977 Department inventory of all
community facilities in Region I, there are 3588 persons presently being served that were identified as being at risk of hospitalization in the absence of these programs. Although it is difficult to determine with precision the size of this group, it is clear that existing community mental health services presently being used by this subpopulation should be maintained at their current levels and not be considered available to other persons not presently
(46)

receiving such services. Any decrease or dilution of these services for this subpopulation would create a substantial risk that members of this group would be hospitalized. However, Department staff should retain the discretion to decide whether a given program is operating below capacity and is therefore able to serve additional clients without decreasing existing services to, or creating a risk of hospitalization for, this subpopulation. Given these
'•4
programmatic principles, the calculation of this subpopulation represents the best available figure and is supported by recently collected information in the Region. Combining these subpopulations, the community mental health system should be designed to serve 2135 persons through a variety of programs and residences. While some portion of this, population, particularly the long-term and discharged subpopulation (C and D ) , may require continuous residential services and programming, a substantial percent of this group, especially the acute subpopulation (A) , will require intensive services for only limited time. Moreover, the subpopulation of persons never hospitalized but at risk of institutionalization (E) should be considered to be receiving appropriate services at the present time, provided none of these services are reduced or otherwise altered. By grouping each subpopulation into homogeneous clusters, it is possible to determine the number of persons needing each type of program or residence. Clustering of Subpopulations Using the Final Revision of the Index Construction, a total of 47 clusters were created. The assessment survey of all
(47)

persons in the Hospital on September 17, 1977 generated data indicating that much of the resident population fell within a' relatively small number of clusters. Almost half of the cluj ters were void. The frequency distribution of all the clust< for that population, which includes the entire long-term sub-' population and a portion (approximately 1/12) of the acute at recidivist subpopulations is attached as Appendix A followed a summary list of all the clusters that were not void (Appenc B).
Each relevant cluster was then cross-tabulated with the number of prior admissions and length of stay in the Hopsital order to determine which clusters related to the acute, recic and long-term subpopulations. Appendix D sets forth the results of that cross tabulation, including the percentage of each subpopulation in each cluster. That table also describe*] the percentage of each cluster that, on the basis of clinical and practical experience, would be expected to fall within eac subpopulation. Thus, although three persons in poor health were admitted for the first time and were at the Hospital less than three months, thereby falling in the acute subpopu-
lation, it is highly likely that they will remain at the Hospi indefinitely and thereby soon become part of the long-term
I •
subpopulation. Appendix E sets forth the results of the crosJ tabulation adjusted for these clinical considerations, includ-J ing the percentage of each adjusted subpopulation in each
(48)

cluster. It should be noted that the adjustments were only made in obvious cases and technically resulted in an insignificant net change in each subpopulation.
On the basis of this adjusted cross-tabulation, the following projections emerge for each subpopulation:

A. Acute Subpopulation -

Total Number - 525 per year or 31 for a 20-day period

Frequency Distribution in Relevant Clusters:

Cluster

Percent

Number

N (27.29)

28

9

0 (34)

9

3

P (35)

63

20

B. Recidivist Subpopulation

Total Number - 1076 per year

Frequency Distribution in Relevant Clusters:

Cluster
B (4) C (5) F (11) M (21) N (27.29) T (41) V (45) W (47)

Percent
5
10 16 10
7 10 37
5

Numb er
54 108 172 108
75 108 398
54

(49)

10

C. Long-Term Subpopulation

Total Number - 362

Frequency Distribution in Relevant Clusters:

Cluster

Percent

Number

A (1,2)

9

33

B (4)

4

15

C (5)

2

8

D (9)

2.6

9

E (10)

2

8

F (11)

13

49

G (14.15)

1

4

H (17)

5

17

J.L (18.20)

2

8

K (19)

5

20

M (21)

12

45

Q (36.37)

1.4

5

R (39)

1

• 4

S (40)

1.6

6

T (41)

10

37

U (44)

1.4

5

V (45)

27

94

D. Discharged Subpopulation Total Number - 172

Although it is not possible to determine the distribu-

tion of these persons amongst the clusters, it is clear that

i f

psychiatric supportive services for the entire subpopulation

should be provided in the nursing and rest homes in which

they reside.
(50)

F

11
E. At Risk Subpopulation Total Number - 3588
An analysis of this population and the current services they are now receiving is set forth in Appendix F. This data, drawn from the Region I Inventory Survey conducted in October - November 1977, represents the best information available on,-this subpopulation, and appears generally reliable for the limited purpose of an assessment and planning tool. Assuming a continuation of existing treatment programs serving this subpopulation, no planning of additional services is required.
n

t
(51)

12 APPENDIX A
IV. Clusters NOTE: Clusters 6 - 4 7 not designated as high on ADL include only persons who score low on the ADL index.

1. High on Hlth., high on Beh.

2. High on Hlth., medium on Beh.

!!i

3. High on Hlth., low on Beh.

:

4. High on Hlth., Chronic Brain Syndrome.

5. High on Assaultive Behavior.

6. Mentally Retarded, high on Beh., medium or high on Psych.

7. Mentally Retarded, high on Beh., low on Psych., medium or high on CAP.

8. Mentally Retarded, high on Beh., low on Psych., low on CAP.

9. Mentally Retarded, high on ADL.

10. Mentally Retarded, medium on Beh., medium or high on CAP.

11. Mentally Retarded, low on Beh., medium or high on CAP.

12. Mentally Retarded, medium on Beh., low on CAP.

13. Mentally Retarded, low on Beh., low on CAP.

14. Over 60, high on Beh., medium or high on Psych., medium or high on CAP.

15. Over 60, high on Beh., medium or high on Psych., low on CAP: OR Over 60, high on Beh., low on Psych., medium or high on CAP. I

16. Over 60, high on Beh., low on Psych., low on CAP.

?

17. Over 60, high on ADL.

*

18. Over 60, medium on Beh., medium or high on Psych., medium or hig" •

on CAP.

i

V
19. Over 60, low on Beh. , medium or high on Psych. , medium or hign ?

on CAP.

1

20. Over 60, medium on Beh. , medium or high on Psych. , low on CAP-"- j Over 60, medium on Beh., low on Psych., medium or high on CAP- 1

(52)

13

21. Over 60, low on Beh., medium or high on Psych., low on CAP: OR

5Z

Over 60, low on Beh., low on Psych., medium or high on CAP.

22. Over 60, medium on Beh., low on Psych., low on CAP.

O

23. Over 60, low on Beh., low on Psych., low on CAP.

O

24. Adolescent, high on Beh., medium or high on Psych.

O

25. Adolescent, high on Beh., low on Psych.

O

26. Adolescent, medium on Beh., medium or high on Psych.

27. Adolescent, low on^.Beh., medium or high on Psych.

2L

28. Adolescent, medium on Beh., low on Psych.

O

29. Adolescent, low on Beh., low on Psych.

'2-

30. Acute, high on Beh., medium or high on Psych.

31. Acute, high on Beh., low on Psych.

32. Acute, medium on Beh., medium or high on Psych.

O

33. Acute, medium on Beh., low on Psych.

O

34. Acute, low on Beh. , medium or high on Psych.

35. Acute, low .on Beh. , low on Psych.

Z.O

36. Chronic, high on Beh., medium or high on Psych., medium or high 2.
on CAP.

37. Chronic, high on Beh., medium or high on Psych., low on CAP: OR ' Chronic, high on Beh., low on Psych., medium or high on CAP.

38. Chronic, high on Beh., low on Psych., low on CAP.

O

39. Chronic, high on ADL.

4

40. Chronic, medium on Beh., medium or high on Psych., medium or high on CAP.

41. Chronic, low on Beh., medium or high on Psych., medium or high on CAP.

42. Chronic, medium on Beh., medium or high on Psych,, low on CAP.

^3. Chronic, low on Beh., medium or high on Psych., low on CAP.

(53)

14 44. Chronic, medium on Ben.,-low on Psych., medium or high on CAP. 45. Chronic, low on Beh., low on Psych., medium or high on CAP. 46. Chronic, medium on Beh., low on Psych., low on CAP. 47. Chronic, low on Beh., low on Psych., low on CAP.
(54)

15 APPENDIX B
SUMMARY OF CLUSTERS FOR NORTHAMPTON STATE HOSPITAL
An asterisk (*) indicates that the index was not considered in determining the cluster.)

Composed of

rBee? Cluster No. 2.3 4

5

i

[D

9

a

10

[F

11

FG

14.15

Characteristic
High Hlth.
Chronic Brain Synd. Assaultive Behavior
MR MR. MR
Elderly

[H

17

Elderly

J

18

Elderly

IK

19

Elderly

L

20

Elderly

Beh. Low Med.
*
*
Med.
Low
High
*
Med. Low Med.

Psych.
*
*
*
* * *
High-Med. Low
*
High-Med. High-Med.
Low

M

21

Elderly

Low Low

N

27.29 - Adoles.

Low High-Med.

Low

0

34

Acute

Low High-Med.

P

35

Acute

Low Low

Q

36,37

Chronic

High High-Med.

Low

R

39

Chronic

*

S

40

Chronic

Med. High-Med.

T

41

Chronic

Low High-Med.

U

44

Chronic

Med. Low

V

45

Chronic

Low Low

W

47

Chronic

Low Low

CAP *
*
*
*
High-Med. High-Med. High-Med. Low
*
High-Med. High-Med. High-Med. Low^ High-Med. Low
*
* *
High-Med. Low
*
High-Med. High-Med. High-Med. High-Med. Low

ADL NO. * 33
* 19

* 15

High 9 Low 8 Low 61 Low 4

High 17
Low 6 Low 20 Low 2

Low 52

Low 14

Low 3

Low 20

Low

5

High 4

Low

6

Low 44

Low

5

Low 121

Low 4

Clusters 1.6.7,8,12,13.16,22,23,24,25,26,28,30,31,32,33,38,42,43,46 had no members (N = 0)
(55)

16
APPENDIX C
TABLE 1
RECIDIVIST PATIENTS WHO HAVE RETURNED TO NORTHAMPTON STATE HOSPITAL WITHIN ONE YEAR SINCE LAST ADMISSION
OCTOBER 1, 1977 - MARCH 31, 1978*

Number of Readmissions
One Two
Three More Total

U it

I II III. IV

16 40 29 55

3

,3

5

4

1

2

1

1

0

0

0

0

• 2 0 45

35

60

Northampton State Hospital

Six-Month One-Ye

V

Total

Tota

19

159

318

3

' 18

36

0

5

10

0

0

_ q

22

182

364

*These figures do not include readmissions of persons on indefinite visit status. See Table 3, following.

17
APPENDIX C
TABLE 2
ANALYSIS OF RECIDIVISM FOR NORTHAMPTON STATE HOSPITAL PATIENTS
OCTOBER 1, 1977 - MARCH 31, 1978*

Total admissions to Northampton State Hospital
Number of first admissions
Readmissions within 12 months since previous admission (unduplicated patient count)
Readmissions 12 to 24 months since previous admission (unduplicated patient count)
Readmissions after more than 2 years since previous admission (unduplicated count)
Total readmission episodes during 6 month period
Unduplicated count of all persons readmitted

Six Month Total 650 283
182
40
118 368 340

One Year Total 1300 566
364
80
236 736 680

*These figures do not include readmissions of persons on indefinite visit status. See Table 3, following.
'4
(57)

18

APPENDIX C
TABLE 3
ANALYSIS OF RECIDIVISM FOR NORTHAMPTON STATE HOSPITAL PATIENTS
PLACED ON INDEFINITE VISIT STATUS OCTOBER 1, 1977 - MARCH 31, 1978

Placed on Visit Discharged (at end of 6 months) Returned from Visit (within 6 months)

Number of Persons 270 151 119

RATE OF RETURN FROM VISIT

Number of Returns Within 6 Months

Number of Persons

1

97

15-

2

10

3

7

4

4

5

1

(58)

APPENDIX C TABLE 4
RECIDIVIST POPULATION: A 2 - YEAR PLANNING PERIOD ESTIMATE

# Clients at Risk of Readtnission

A.

46

B.

318

C.

121

D.

590

TOTAL 1075

Average Annual Readmissions for
This Group

# of Clients at Risk Who Will Be
Readmitted During 1 Yr. Period 2 Yr. Period

2.21

46

46

1.00

318

318

•66 (every 18

80

121

months)

•4 (every 30 236

472

months)

680

957

# of Readmission Episodes that Are Attributed to Group During
1 Yr. Period 2 Yr. Period

102

204

318

632

80

121

236

472

736

1,429

Assumptions:

Group A: The n of 46 is based on TABLE 1, Appendix C; the average readmit rate is a weighted average based on 36 clients having 2 readmissions 1 year and 10 having 3 readmissions 1 year.

Group B: The n of 318 is based ..on TABLE 1, Appendix C.

Group C:

The n of 121 is derived from TABLE 2, Appendix C; 80 unduplicated clients with an average readmit rate of .66 (or once every 18 months) were identified in this group. It is assumed that this group of 80 derives from a larger subpopulation, given an average admit rate of .66 which characterizes this group, the total population at risk would have to be 121 in order for 80 individuals to show up within a one year period.

Group D:

The n of 590 individuals at risk is derived from TABLE 2, Appendix C; 236 unduplicated clients in that table are identified with a risk of readmission somewhat less than once every 2 years. Assuming that the average readmit rate for this group is about once every 30 months (or .4 readmits 1 year), then the total class at risk would have to be 590, in order to find 236 individuals showing up in a single year. Note however, that for a two year planning period, only 472 of these 590 individuals will show up at the Hospital.

APPENDIX D

Acute

Recidivist

Long Term

Clusters

Under 3 Mos.

NofPrior Adm.

Projected Actual

% of

7. of

No. Cluster Sub-Pop.

A 1,2 High Health

3

10

B 4 Chronic Brain 1

3

C 5 Assaultive

2

7

D 9 MR - ADL

0

E 10 MR

1

3

F 11 MR

1

3

G 14,15 Elderly

0

H 17 Elderly-ADL

0

318,20 Elderly

0

K 19 Elderly

0

M 21 Elderly

1

3

N 27,29 Adolescent

5

75

18

0 34 Acute

3

100

10

P 35 Acute

11

100

40

Q 36,37 Chronic

0

R 39 Chronic-ADL

1

3

S 40 Chronic

0

T 41 Chronic

0

U 44 Chronic

0

V 45 Chronic

0

VI m Chronic

0

IfeaU

29

Under 3 Mos.

Under 3 Mos.r 2 or More 1 Prior Adm. w Prior Adms.

Projected

Actual

7. of

7. of

No. Cluster

Sub-Pop.

0

3

25

4

5

40

6

0

0

11

20

14

0

1

1

1

1

Over 3 Mos

Projected Actual

% of

% of

No. Cluster Sub-Pop

30

100

15

75

8

60

9

100

7

100

49

80

4

100

16

100

12 4 2 2.2 1.8 15 1 4

7

100

1.8

0

6

13

6

25

0

9

0

-

0

2

7

20

0

27

20

3

100

20

100

7

45

87

7

3

0

11

0

5

100

3

100

2

4

100

9

37

80

5

100

34

94

80

4

1

6 11
.8
1.2 .8
1 9 1.2 25
.2

Acute

Clusters

Under 3 Mos.

No ,Prior Adm.

Projected Actual

7. of

7. of

No. Cluster Sub-Pop.

A 1,2 High Health

0

B 4 Chronic Brain 0

C 5 Assaultive

0

D 9 MR - ADL

0

E 10 MR

0

F 11 MR

0

G 14,15 Elderly

0

H 17 Elderly-ADL

0

L[18,20 Elderly
K 19 Elderly M 21 Elderly N 27,29 Adolescent
0 34 Acute
P 35 Acute Q 36,37 Chronic
R 39 Chronic~ADL S 40 Chronic T 41 Chronic U 44 Chronic
V 45 Chronic W 47 Chronic
TOTALS

0
0 0 9 3 20 0 0 i0 0 0 0 0
32

75

28

100

9

100

63

••

1007.

o\
M

Recidivist

Under 3 Mos.

Under 3 Mos. , 2 or More

1 Prior Adm. Prior Adms.

Projected

Actual

7. of No. Cluster

7. of Sub-Pop.

0

4

25

5

7

40

10

0

0

12

20

16

0

0

No.
33 15
8 9 8 49 4 17

mmmmmtm

Long Term

.s

Over 3 Mos

Projected Actual

7. of

7. of

Cluster Sub-Pop

100

9

75

4

60

2

100

2.6

100

2

80

13

100

1

100

5

0

8

100

2

0

7

13

5

25

0

0

0

0

0

7

20

0

27

20

4

100

20

100

10

45

87

7

0

0

0

5

100

4

100

6

100

10

37

80

5

100

37

94

80

5

0

5 12
1.4 1 1.6 10 1.4 27

73

1007o

67

1007o

Ml
1
I11
1
iViii'j
!
IIK
11i "'
If
1
I11f
1!

22
APPENDIX F

ANALYSIS 01' REGION I INVENTORY DATA

Code: A - Emergency/Prevention Service B - Outpatient Therapy C - Day Treatment/Activities

Average Length of
A - 3 days B - 7 months C -10 months

Program Hampshire Franklin East Spoke F.C.P.H.
it
Outreach (N'ton) Outreach (Gfld) Frank. Cty. M.H.C.
"
it
Hampshire Day House ••

Code
B A C A A A
B
C B C

# of Clients Per 2 Wks.
7 17
1 2 1 4 29 10 26 3

Multiplication Factor
1.7 26
1.2 26 26 26
1.7 1.2 1.7 1.2

4i of Per
11 442
1 52 26 104 49. 12 44.
3.

Westfield

Westfield A.M.H.C. A

4

26

104

it

B

6

1.7

10.

Northampton St. Hosp . C

1

1.2

l.;

Berkshire

Main St. Human Res. A

5

26

130

B

13

1.7

22.1

B.M.H.C.

A

2

26

52

it

B

14

1.7

23.8

it

C

22

1.2

26.4

No. Berk. M.H.C.

B

4

1.7

6.8

••

C

16

1.2

19.2

(62)

23 APPENDIX F (Cont.)

,gram
Springfield
faystate
If
jB.CC.
Holvoke-Chicopee Haple House H.C.M.H.C.
Crossroads Wing Mem. Hosp.
ii
TOTALS

Code
A B B C
A A B B A B

# of Clients Per 2 Wks.
57 84 98 6
1 1 23 36 11 123 627

Multiplication # of Clients

Factor

Per Year

26 1.7 1.7 1.2
26 26
1.7 1.7 26 1.7

1482 142.8 166.6
9.2
26 26
39.1 61.2
286
209.1 3588
i!

t:it
(63)

ATTACHMENT B

COMMUNITY RESIDENTIAL ALTERNATIVES FOR MENTAL HEALTH CLIENTS PROGRAM MODELS

•4

Prepared for the Massachusetts Department of Mental Health

Region I Planning Process

1:1

By Marlene Ross, Cornhili Associates

Principal Planner

i

fey Brian,, O.M.H. Region I &ej£jj£ff, O.M.H. Central Office

Stgye,, Schwartz. Mental Patients

Advocacy Project

with the Northampton Plannins.Ie.am

-

T

Date: June, 1973

8 I
it

1

(64)

TABLE OF CONTENTS

Page

Introduction

1

Program Definitions

5

II. Start-up Costs

7

I* Staff and Other Operating Costs

A. Support Services to Clients Residing in Non-DMH

provided or funded housing

9

B. Specialized Home Care'Program

12

C. Supervised Apartment Program

14

D. Supervised Group Home

17

E. Transitional Apartment Program

20

E l . Transitional Community Residence

23

F. Apartment program with Physical Care Component

26

F 1. Group Home with Physical Care Component

29

G. Apartment Program with Behavioral Emphasis

32

G 1. Group Home with Behavioral Emphasis

36

H. Apartment Program with 3ehavioral Emphasis and Physical Care Component

40

H 1. Group Home with Behavioral Emphasis and Physical Care Component

43

V. Comparison of ?&r Oiem and Per Annum Costs

46

VI. Sample Job Descriptions for Residence Program Staff

47

MlI

(65)

COMMUNITY-BASED RESIDENTIAL SERVICES FOR MENTAL HEALTH CLIENTS

I. INTRODUCTION

l\

The following program descriptions, compositions and cost breakdowns are

meant to serve as a guideline for regional and area planning in the development

of community residential alternative programs. The matching of client and

residential alternatives as described for each program is based on the Region

I Client Evaluation Survey. Approaches to staffing and start up program

costs will require modification depending on such factors as the support

services provided, client level of functioning, location of the facility

and condition of the building.

Program Considerations

An underlying principle in the development of program models should be the maximizing of individual client growth and the development of individualized service plans to assist and teach clients to live as normal a 1ife as possible in the mainstream of the community. This can be facilitated by incorporating the developmental model when designing Individual Service Plans, recognizing the capability of each person to learn, grow and develop, no matter how severely disabled.

Many clients in need of a community residential placement require assistance in gaining self-help skills, socialization skills, and use of community resources. For some clients training may be quite basic; for others, more sophisticated, depending on the individual level of functioning upon entry into the community program. In addition, some clients may require an individualized program to eliminate problemmatic behaviors and/or supervision of basic physical care needs.

The following programs describe staffing and cost figures for either eight bed residences or 4 bed apartments. Although each apartment is described for a maximum of four persons, two separate apartments might be clustered together in one large building or adjacent buildings. In no event, however, should programs be located in such geographical proximity as to create an undue concentration of clients in one area or neighborhood.

Many of the attached program descriptions include the alternative of operating programs in either houses or apartments. As many programs can be implemented in either type of housing, facility decisions should be based on the programmatic flexibility as well as on the barriers to implementation and operation presented > by each type of facility. These may include the relative social advantages of a small apartment for four persons over a larger home for eight residents; tMe ability to design and implement service plans on a more individualized basis in smaller settings; the reality that small apartments are more normative than larger homes; considerations of the types of housing available in an area; the availability of start-up monies (minimal for an apartment program which r e c ! u 1 [ e * tJ ' no mortgage); cost of alternative staffing requirements (often higher in aoart^e .,; than in homes); renovation or time delays caused by the need to meet tne 5ta:3 Building Code for Group Residences; and issues related to community acceptance and integration and local zoning ordinances.
(66)

-2-
Finally, some of the residential alternatives are described as specialized programs for persons with severe behavioral problems and/or physical care needs. Staffing in these programs has been designed to provide the additional coverage required by the added program responsibilities. Programmatically, however, it is important for any one facility to have a mixed population with regard to level of severity of disability, as an important aspect of residential programming is peer role modeling, interaction and support. It is recommended that no more than half the residents in any specialized program require intensive behavioral intervention or physical care. Special subpopulations, such as programs for adolescents, may require alternative staffing configurations. With some modifications, however, the range of specialized programming needs should fit within the alternative residential programs described herein.
Satellite Model of Organizing Network of Community Residential Services
When planning an area network of community residential programs one concept to consider is the Satellite Model of Organizational structure. This consists of a core residential unit which, in addition to providing services and training to clients who live there, also provides managerial support and program coordination for each program in the area's network of residential services. Professional staff as needed by the residential network are maintained by the unit and are responsible for providing programmatic coordination and management for clients within the network. Some clients receiving services in the satellite netowrk may never live in the core unit itself but may move into a satellite setting directly. Others may live in the core unit during an evaluation period, so that an individual service plan may be developed and appropriate satellite program identified. Some clients may come to the core unit intermittently for respite or emergency care. Satellite programs may consist of specialized group home or apartment programs, specialized home care and support services to clients residing in non-OMH provided or funded housing (see following descriptions). Utilization of this model'would necessitate modification of the enclosed program and staffing descriptions to accommodate a centralized and consolidated administrative and program coordination.
Staffing Considerations
Full time staff positions are based on a non-residential forty hour week rather than a live-in staff approach. Programs utilizing live-in staff will require modification of the staffing pattern described here. The annual salary for mental health workers is estimated at $9500 with the recommendation that each program establish two levels of salary, with entry level workers without experience in community mental health work (MHW I) beginning at S3500 and those with greater expertise and/or experience (MHW II) beginning at $10,500.
In addition, it is important that new staff participate in a comprehensive training program designed to orient them to the larger community mental health system, other generic community services, the goals, objectives and behavioral techniques of the particular residential program and a range of skills necessary to :neet client needs.
(67)

ii
i Mr ' r
J4

-3-
On the enclosed charts the nubmer of positions indicated in the "Direct Care Personnel" column reflect the number of persons on duty on a particular shift. The Full Time Equivalent (F.T.E.) column indicates the number of forty hour week positions necessary to provide the coverage. The "Cover Factor" column reflects staff necessary to cover vacation and sick leave time. Recommended staffing patterns should be viewed from the standpoint of overall need rather than rigid adherence to shift. For example, if a director is at a residence at scheduled times during the day shift she/he may be able to provide the minimal coverage required when the majority of clients are engaging in day activities outside the home. It might then be advantageous for some of the day shift mental health- workers1 hours to be reassigned to the evening shift when more clients are in the residence. Additionally, it may be important to staff understanding of client functioning,inter-staff communication and program implementation for staff to rotate shifts so that all staff have the opportunity to be with clients engaging in a variety of daily living and social experiences. Actual staff scheduling should also include time for all staff to meet weekly to discuss general concerns of the program and individual client progress, as well as a time for house meetings with all staff and residents present.
Staffing for each program with a minimum of eight clients includes a half time Oirector/Administrator. Responsibilities of this position should include hiring and supervising direct care staff, coordinating and managing the residential aspect of the Individual Service Plans (ISP), arranging for support services as needed, facilitating the use of generic community services, representing the program in community relation efforts, providing or arranging for pre-service and in-service training of direct care staff, managing the fiscal aspects of the operation and maintaining data as required. Organizational structure and staff composition of the residential program will affect the responsibilities and time needed for "Oirector/Administrator" duties. For example, an agency operating more than one residential program may require a full time director with funding partially provided by each program. A small agency operating a single program may want to combine the half-time director and float time into one position to include both direct care and administrative duties and/or may require night staff to handle a portion of the paper administrative duties such as completion of statistical reports, etc.
The duties of mental health workers include assisting and teaching clients in learning to live independently, providing counselling and support to clients as necessary, implementing the program's goals and responsibilities and sharing with the director and other staff the daily operational tasks of the residence. Weekday staff are expected to facilitate clients' involvement in non-residential programs,activities and employment, but must be available to clients who, for whatever reason, do not participate in such activities.
Budget Considerations
When calculating the amount cf DMH resources needed for operating expenses, c income should be deducted from the total cost. Many clients are eligible for Supplementary Security Income (S.S.I.) which is presently 5215.93 per month. Subtract the amount the client keeps for personal needs. Multiply the remainder by 12 (months). Reduce this figure by 5% as most facilities average a 5% vacancy rate over a year's time. This will provide you with an estimated non-OMH house income.
(68)

-4Provider Considerations It is generally beneficial for providers of these programs to be private, non-profit organizations experienced in operating residences for mentally disabled clients. Such providers should have the professional skills necessary to design, establish and coordinate quality programs, including the ability to recruit and train dedicated staff. They should also possess the administrative capability and flexibility to manage such programs and integrate their goals with the larger community alternative system. To the extent that small, inexperienced private corporations or public agencies are used as providers, some modification of these program models may be necessary to account for the lack of flexibility or other resultant constraints. Providers also have the flexibility to rent or purchase homes or apartments as well as the discretion to combine rent, maintenance and some insurance costs to cover variable rental prices.
I!
M
(69)

\i\ PR06RAM DEFINITIONS
(70)

PROGRAM DEFINITIONS

A.
C.
0.
E. 1
r. r. 1

Support Services to Clients Residing in Non-DMH Provided or Funded Housing - Staff support and consultation consisting of regular visits to clients' to assist in their adjustment to their living environment and the community at large, as well as assisting facility providers, when appropriate, in their work with clients.
•Specialized Home Care Program - Supervised living of one to three adults in a private home in the community. Home care providers supervise and assist in activities of daily living, home management skills, utilization of community resources, etc. Each home may serve 1-3 clients.
Supervised Apartment Program - A community-based residential program providing structure and supervision to adults living in apartments. Supervision and teaching of daily living skills are provided to assist clients to move to less restrictive settings.
Supervised Group Home - A small community based group living facility providing room, board and supervision in daily living skills for persons in need of long term maintenance.
Transitional Apartment Program - A community based transitional apartment program with a maximum of four persons per apartment, operating 24 hours a day providing room, board, and supportive services including supervision and intensive training in daily living skills. Residents are usually expected to move to a more independent and/or less intensive living situation within one year.
Transitional Community Residence - A community based living facility operating 24 hours a day providing room, board and supportive services including supervision and intensive training in daily living skills. Residents are usually expected to move to a more independent and/or less intensive living siutation within one year.
Apartment Program with Physical Care Comoonent-A community based apartment program with a maximum of four persons per apartment -hat provides daily assistance and training in basic activities of daily living and physical care for clients with high A.D.I, needs.
Group Home with Physical Care Component - A community based living racility providing room, board and daily assistance and training in basic activities of daily living and physical care for clients with minimal behavioral problems and high A.O.I, needs.
Apartment Program with Behavioral Emphasis'' - A community basea apartment program with a maximum of four persons per apartment providing room, board and intensive services within the apartment for persons with serious behavioral problems. The program is designed to rspiaca Droblemmatic behaviors with appropriate living skills sc the individual may move to a less restrictive, more normalized environment. Residents will have low physical care needs.

(71)
i.?
I!1.

G. 1 H. H. 1

Group Home with Behavioral Emphasis* - A community based living . facility providing room, obard and intensive services within the
home for persons with serious behavior problems. The programs are designed to replace problemmatic behaviors with appropriate living skills so the individual may move to a less restrictive, more normalized environment. Residents will have low physical care needs.
Apartment Program with Physical Care Component and Behavioral Emphasis - A community based apartment program with a maximum of •four persons per apartment that provides both intensive behavioral program intervention as well as physical care and help with activities of daily living.
.Group Home with Physical Care Component and Behavioral Emphasis A small community based group living facility that provides both intensive behavioral program intervention as well as physical care and help with.activities of daily living.

• A Group Home and Apartment Program with Intensive Behavioral Emphasis to the needs of persons with severe self-destructive or other destructive behaviors is included by increasing the staffing in this model. In all otherregards, including the purpose and programming of these residences, the radals are the same.
(72)

START-UP COSTS
(73)
I

-7-
Ill'
III. START-UP COSTS

Start-Up Costs will vary considerably depending on such factors as location and condition of facility, whether facility is to be purchased or rented; whether there are legal complications; the particular building code specifications to be met, etc.

a. House Purhcase/Oown Payment: Conventional mortgages from banks

-t

usually require a 20% down payment. Thus a $15,000 down payment would be sufficient to obtain a $75,000 conventional mortgage.

With liberal bank and/or employment of a state/federal mortgage

assistance/guarantee program this amount could vary.

b. Legal Services: Generally such services might include title transfer, zoning advice and legal counseling. In some instances, these services might be obtained on a pro bona basis, in which case there would be no cost.

c. Real Estate Taxes: This varies depending on the time of year the property is purchased. If the sale is closed in January, taxes for the entire year must be paid before an exception is granted. Conversely, if the closing occurs in December, little or no taxes need be paid. To date no way has been found to obtain an. exemption on the first year's taxes short of a legislative act.

d. Meeting Building Code Specifications: These requirements include total smoke and heat detector systems (approximately $5000) and special fire resistant paint. Depending on the structure, other expenses could include widening stairs, adding rear fire escapes, changing the direction for opening doors, adding fire doors, installing emergency lighting, etc.

e. Staff: Prior to beginning program operation staff must be available to write proposals, perform need studies, make referral contacts, hire and train staff, purchase supplies and equipment, deal with banks, lawyers, contractors, etc.

f. Contingency Fund: Clients generally move into a new residence a few

I

at a time over the first few months of operation. Ouring tnis rime

the majority of expenses are fixed costs that have to be met, in spite

of a lower income from client fees.

g. Staff Training: New staff should participate in a comprehensive training program prior to beginning to work with clients. Ongoing training should be provided through consultation funds.

§
(70

ESTIMATED START-UP COSTS

X. Residence or Home
•

Mtnumum

Down Payment

0

b. Legal Services
c. Real Estate Taxes 4. Suildinej Code Specifications

0 0
5,000

t. Staff f. Furnishings

2.000 8.000

9- Vehicle h. Insurance (Care and House)

4.500 700

1. Miscellaneous

300

J. Contingencies

1,000

k. Delay of Payments

4,500

1. Staff Training

1.000 Z7.000

Average
7.500 400 400
6,500 3,000 11,000 5,000
800 400 1,200 8,000 2,000 46.200

Maximum
15,000 800 800
a, 000 4,000 14,000 5,500 1,000
500 1,400 8,000 3s000 52,000

II. Apartment
Items (a-d). would not l i k e l y be applicable to apartment programs Die other costs (e-1) would be the same.

(75)

STAFF AND OTHER OPERATING COSTS
(76)

A. Support Services to Clients Residing in Non-DMH Provided or Funded Houalng - Staff support" si sting of regular visits to clients to assist In their adjustment to their living envlroment and the community at large, as well as assisting facility providers, when appropriate, in their work with clients. This service may be provided to persons residing in varied residential settings, including nursing/rest homes, boarding houses, cooperative apartments and private homes. Clients include: A small number of elderly and chronically handicapped clients (54) presently at the hospital with minimal needs other than assistance in adjusting to their new living envlroment; an additional large group of clients (528) with a history of recurring hospitalizations who require these support services to live in their own home or apartment and the (198) clients presently residing in nursing/ rest homes where their mental health needs are minimally met.
1
Alternative approaches to providing this service include:

a. The provision of consultation and follow-up to Facility Staff and Clients in Nursing/Rest/Boarding Homes

STAFflNG/COST SCHEDULE

i. Program providing minimum support service ( 4 hours per week ) .

Direct Care Personnel

Equivalent

Staff

Cover

Full/Time

Actual

Fringe G&A

Costs

Factor

ID

Salary

Salary

18%

10%

Subtotal

(x.10)

I

1 MENTAL HEALTH WORKER

9.500

950

171 95

1,216

N.A.

ii. Program providing maximum support service ( 12 hours per week ) .

Equivalent

Full/Time

Actual

Fringe G&A

Direct Care Personnel Shift FTE's Salary

Salary

18%

10%

Staff Costs Subtotal

1 MENTAL HEALTH WORKER N.A

N.A

9,500

2,850

513 285 3,648

Cover Factor (x.10)
N.A.

TOTAL
3.648

Support Services to Clients Residing in Non-DMH Provided or Funded Housing ( Continued )

b. The provision of mental health staff to supplement staff of nursing/rest homes for the purpose of providing specialized services required by mentally disabled population.

I. Direct Care Personnel

STAFFING/COST SCHEDULE (to supplement a facility for 16 mental health clients)

Shift FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe GsA 10*

Staff Costs Subtotal

1 MENTAL HEALTH WORKER M-F DAYS 1.0 1 MENTAL HEALTH WORKER S&S DAYS .4 1 MENTAL HEALTH WORKER M-F EVE1si.0 1 MENTAL HEALTH WORKER S&S EVE's .4

9,500 9,500 9,500 9,500

9,500 3,800 9.500 3,800

1.710 950 12,160

684 380

4,864

1,710 950 12,160

684 380

'.,86 A

Cover Factor (x.10)
1,216 486.4
1,216

TOTAL
13,376 5,350 13,376
1
5,350 ?

Sub-Totals:

II. Administrative Personnel

1 MH SUPERVISOR

N.A.

III.

TOTALS:

2.8

38,000

.25 12,000 l.Zi 50,000

26,600

4,788 2,660 34,048

3,000 29.600

540 300

3,840

5,328 2,960 37.888

3,404.8
384
3,788.8

37,452.8
4,224 41,676.8

Support Services to CHents Residing In Non-PHH Provided or Funded Homing ( Continued

c. The provision of consultation and follow-up to clients residing in cooperative apartments or homes to assist with obtaining and maintaining apartments, employment, budgeting, etc.

i. Direct Care Personnel Shift FTE's

STAFFING/COST SCHEDULE

Equivalent

Full/Time

Actual

Salary

Salary

Fringe G6A 10%

Staff Costs Subtotal

Cover Factor (x.10)

(Program providing 4 hours per week of support service.)

1 MENTAL HEALTH WORKER N.A. J O

9,500

950

(Program providing 12 hours per week of support service.)3

1 MENTAL HEALTH WORKER N.A. .3

9,500

2,850

95

1,216

513

285

3.648

12* 364.8

II. Admimistrative Personnel

1 Supervisor

N.A. .125

12,000

1,500

270

150

1,920

192

TOTAL 1,337.6 4,012.8 2,112

III. TOTALS:

Program

pjroyjdjn<j 4 hf/Wk support

J

Vrogram

fy

providing 12hr/wk support

2,450 4,350

441

245 3,136

783

435 5,568

There are no costs other than staffing for this service

One hour supervision per week to each oi" four clients residing in apartment or home. ^Three hour supervision per week to each of four clients residing in apartment or home.

313 556.8

3,449.6 6,124.8

B. Specialized Home Care Program - Supervised living of one to three clients .in a private home in the community. Home care providers supervise and assist in activities of daily living, home management skills, utilization of community resources, etc. Each home may serve 1-3 clients. Specialized home care servi-.es will be required for a small number of clients (31) presently at the state hospital, who require residential supervision and some assistance in community adjustment. They include: a few mentally retarded adults; adolescents with minimal needs other than adult supervision in other than their natural home; and some chronically handicapped persons. These services are also planned for some clients (13) presently residing in the community, but with a history of recurring hospitalizations.

Essential to the success of the Specialized Home Care program, are the selection of families and the provision of on-going consultation and back-up support staff.

A Start-up budget for a maximum of four homes should include:

1 Full-time Coordinator (for six months) Consultation (training families)

7,500 4,500

Total

12,000

Program Consisting of Four Homes Serving a Maximum of 12 Clients
( Figures based on 4.2 family members at 2.65@hr.) • STAFFING/COST SCHEDULE

Direct Care Personnel Shift FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe G&A 10%

Staff Costs Subtotals

FAMILY MEMBER,providing Two

in-home training

Hrs/Day 4.2

per client

(6 hrs per home,per day 4 homes,3 c l i e n t s , per
home)

5,512 (2.65/hr, for 40 hr
week)

23,150

4,167

2,315 29,632

II. Mm\n\straUve Personnel ^

i

Cover Factor (x.10)

TOTAL

N.A. 29,632

17,700

III. Operating S9*X Room and Board $5.00/Day/Client
Shift IV. Program Total: NA

Actual Salary
38,150

Fringe G&A

18%

10%

Staff Costs Subtotal

TOTAL

6,867 2,315

47,332

N.A.

47,332

V. Unit Cost: 10JH per Day

Average Annual per Client Cost $ 3.944.33

This, as other full time equivalent figures is based on a 40 hour week. Family members providing two hours supervision per day per client for a 12 client program (4 homes, 3 clients per home) will require a total of 168 hours or 4.2 forty hour work weeks.

SUPERVISED APARTMENT PROGRAM - A community-based residential program providing structure and supervision to adults living in apartments. Supervision and teaching o f daily living skills are provided to assist clients to move to less restrictive settings. Either a supervised apartment or supervised group home setting will be necessary for the majority of the clients (255) presently at the state hospital. These include the majority of the mentally retarded population;elderly clients with psychiatric symptomatology and need for assistance with community adjustment; and some chronically handicapped clients with psychiatric symptomatology and/or need for assistance with community adjustment.

These settings are also planned for a few (12) clients presently residing in the community but with a history o f recurring hospitalizations.

The following staffing and cost estimates are for a program consisting of one apartment, housing four clients.

1. Direct Care Personnel Shift

FTE's

STAFFING/COST SCHEDULE

Equivalent

Full/Time

Actual

Fringe

Salary

Salary

183

G £A

Staff Costs Subtotal

Cove »Factor (x.!0)

TOTAL

1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER

M-F DAYS .5
(7-H a.m.)
S6S DAYS .4

1 MENTAL HEALTH WORKER M-F EVE's 1.0

1 MENTAL HEALTH WORKER SfcS EVE's .4

1 MENTAL HEALTH WORKER FLOAT

.35

1 MENTAL HEALTH WORKER, 7 NIGHTS N.A.

(on call)

CONSULTATION

AS NEEDED N.A.

9500 9500 9500 9500 9500 N.A. N.A.

4,750 3.800 9,500 3.800 3.325 5,000 1,300

855 684 1 .710
684
598.5 900 N.A.

475 380 950 380 332.5 500 N.A.

6.080 4,864 12,160 1.864 4,256 6,400 1,300

608 486.4 1,216 486.4 N.A. N.A. N.A.

6,688
5,35O.4f
13.376 5.350.4 4.256 6,400 1,300

Sub-Totals -

II. Administrative Personne 1

1 DIRECTOR

N.A.

I SECRETARY/BOOKKEEPER N.A.

Sub-Tolat-i :

?M 47,500

.25 .125 .375

15,000 7,200
22,200

31,^75
3,750 900
4,650

5 ,431.5 3,017.5

39.924

2,796.8 42,720.8

675

375

4,300

N.A.

4,800

162

90

1,«52

N.A.

1.152

837

465

5.952

N.A

5.952

III. Operating Costs
Rent and Utilities Haintenance Telephone Insurance Food Transportation Other

Shift

Sub-Totals:

»«ITV

'* A
•' ' • <*#,. • **

11.100

IV. Program Total

3.025

69.700

6.268.5 3,^82.5

*5,876

2.796.8

59.772.8
in i

V. Unit Cost: $40.9*1 per DAY
Average Annua! per Client Cost: $ l*»,3'i3.1O
NOTES:
Apartment programs serving more or less than four clients will require appropriate modifications in staffing patterns.
Float position provides extra staff coverage whenever most needed, i.e., in emergencies, client illness, to attend meetings, to provide extra coverage during special activities, etc. See recommended breakdown following page.
Coverage during sleeping hours may be either provided by staff sleeping at apartment on a rotating basis or by additional staff-provided room in exchange for availability in case of emergency. Staff paid at minimum wage for four hours if disturbed during sleeping hours for emergency duty. If two apartments are in same building coverage may be provided by one staff person with intercom between apartments. Cost based on estimate of coverage needed.
Consultation is based on $25/per hour for one hour per week.
CD
u>

PROGRAM TYPE Supervised Apartment - 4 Clients

WEEK DAYS

DAY

On
Hours per day Hours per week No. of staff Total F.T.E.s

'•• 7 - 1 1 ain.
4
' 20.
- J__
5

EVE
= 3-11 p.m.
» 8
« 40 - 1 = 1

NJr.HT
Staff will sleep 1n apartment and be available In emergency situation

FLOAT
= As Needed 2
- 10 1
- .25

TOTAL
1.75

•

=..3 p.m

^ - 11 p.m. Staff will sleep

= As Needed

WEEK

Hours per day

.a.

Hours per week

s 16

In apartment and be

2

available In

4

ENDS

No. of staff

emergency

K

|

Total F.T.E.s

4

- .4

situations

.1

en
i
.9

D. Superviaed Group Home - A small community .baaed group living facility providing room, boar* . „ * •up.cvl.Lou i» da Iv Hvlng sk.lls for persons in need of long term maintenance. Supervision and te.chIng of da«W 1WPno sk,ns.-are prov,ded to assist clients to move to less restrictive settings. Either a supervised apartment or supervised group home setting will be necessary for the majority of clients (255) presently at the state hospital. These include the majority of the mentally retarded population; elderly clients with psychiatric symptomatology and need for assistance with community adjustment; and some chronically handicapped clients with psychiatric symptomatology and/or need for assistance with community adjustment.

STAFFING/COST SCHEDULE

I. Direct Care Personnel Shift

FTE's

Equivalent Full/Time Salary

Actual Salary

I MENTAL HEALTH WORKER I MENTAL HEALTH WORKER

M-F DAYS (7-11 a.mi..))
S-S DAYS .4

1 MENTAL HEALTH WORKER M-F EVES. 1

1 MENTAL HEALTH WORKER S-S EVES, ..44

9.500 9.500 9.500 9.500

9.500 3.800 9.500 3.800

I MENTAL HEALTH WORKER FLOAT

.87 9.500

8.265

I MENTAL HEALTH WORKER
I CONSULTANT Sub-Totals:

7 NIGHTS
ON CALL NA

NA

NA

3.67

NA NA
47,500

5.000 2,600
42,465

Fringe G&A

18%

lot

Staff Costs Subtotal

1.710
684

950 12,160 380 4,864

1.710
634

950 12,160 380 4.864

1.487.7 826.5 10,579.2

900 500 6,400

NA

NA 2,600

7.175.7 3 .986.5 53,627.2

Cover Factor (x.10)
1,216
486.4
1,216
486.4 NA
NA NA
3.404.3

TOTAL
13.376 5,350.4 13,376 5,350.4 10,579.2
6,400 2,600 57.032

I I . Administrative Personnel

I DIRECTOR

NA

I BOOKKEEPER/SECRETARY NA Sub-Totals:
Oo

.5 15.000

.25 7.200

n. .75

,200

7.500
1.800 9,300

1,350
324 1,674

750 9,600 180 2,304 930 11,904

NA

9.600

NA

2,304

NA

11.904

III. Operating Costs
Rent and UtiIities Maintenance Telephone Insurance Food Transportation Other

Equivalent Full/Time Salary

Actual Salary

FrInge CfiA 18%

Staff Costs Subtotal

Cover Factor (x-10)

TOTAL

Sub-Totals: IV. Program Total:

51.765 8,849.7 4,916.5 65,531.2 3,40<t.8

V. Unit Cost: 3).21 Per Day

Average Annual per Client Cost: 11,392

NOTES:

t

Float position provides extra staff coverage whenever most needed, i.e., in emergencies, client or staff illness, to attend meetings, to provide extra coverage during special house activities, etc. See recommended breakdown fol lowing page.

Coverage during steeping hours may be either provided by staff sleepi.ng at home on a rotating basis or by additional staff - provided room in exchange for availability in case of emergency. Staff paid at minimum wage for four hours if disturbed durinq sleeping hours fnr emergency duty.

Consultation is based on $25/psr hour for two hours per week.

WEEK DAYS

PROGRAM TYPE Supervised Group Home - 8 C11ents_

DAY

loiir.q p e r d a y
lourn per week to. of staff Totnl F.T.K.B

= 4
- 40 " _.Z_. = .1

EVE
- _U1 9M-
= _4Q_
- __J_. - 1.

MIGHT
Staff will sleep In apartment and be available In emergency
situations.

FLOAT
As Needed * b
25
1 .62

TOTAL 2.62

WEEK ENDS

on Hours per day
Hniirif per wpflc No, of «Miff
To m l F.T.R.s

= 7 a.m.-3 p.m. - 8
= 16
•- 1
c ,4

= 3-11 p.m.
= 8
= 16
= 1
= .4

Staff will sleep
In apartment and be available 1n emergency situations.

= As Needed
5
- 10
1
- .25

I
1.0b

00
1

E. Transitional Apartment Program - A community based transitional apartment program with a maximum of four persons per apartment, operating 24 hours a day providing room, board, and supportive services including supervision and intensive training in daily living skills. Residents are usually expected to move to a more independent and/or less intensive living situation within one year. Either a transitional apartment or transitional community residence is required for a small number of clients (29) as they leave the state hospital setting. They include: mentally retarded clients with some behavioral problems and the need for assistance with community adjustment; elderly clients with some behavioral problems, psychiatric symptomatology and community adjustment needs; adolescents with psychiatric symptomatology; and chronically handicapped persons with some behavioral problems, psychiatric symploiikjlolocjy and the need for assistance with community adjustment.

The following staffing and cost estimates are for a program consisting of one apartment housing four clients.

STAFFING/COST SCHEDULE

1. Direct Care Personnel Shift

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe G£A

18%

10%

Staff Costs Subtotal

Cover Factor
(*.to)

TOTAL

1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER
1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER
1 MENTAL HEALTH WORKER
1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER
CONSULTATION Sub-Totals:

M-F DAYS

.5

(7-11 a.m.

S-S DAYS

.4

M-F EVES.

1

S-S EVES.

.4

M-F NIGHTS

1

S-S NIGHTS .4

FLOAT

.43

AS NEEDED NA

4.13

9,500 9,500 9,500 9,500 9.500 9,500 9.500 NA 66,500

4,750 3,800 9,500 3,800 9,500 3,800 4,085 1,300 40,535

855

475 6.080

684

380 4,864

1,710

950 12,160

684

380 4,864

1,710

950 12,160

684

380 4,864

735-30 408. 50 |i,22fl.H

NA

NA

1,300

7,028.3 3,923. 51,520.8

608
406. 4
1,216
486. 4
1,216
486. 4
NA NA 4,499• 2

6,688
5,350.4 13,3/6 ^
1
5,350.4
13,376 5,350.4 •,,?A\.n 1 , JOO
•>6, o?o.o

II . Administrative Personnel

I DIRECTOR

NA

\ SECRETARY/ttOOKKEEPER HA

.25 .125

15,000 7.200

3,750 900

675. 162

375 4.800
90 I.152

NA

4,800

NA

1.152

Shift
I I I . Operating Costs
Rent and U t i I i t i e s Maintenance Telephone Insurance Food Transportation Other

FTE's

Equlvalent Full/Time Salary

• *• '-ft*•40' t^?:::

Actual Salary

Fringe GtA 18%

Staff Costs Subtotal

Cover
Factor (x.10)

MHMMMMMM
TOTAL

4,200 1,000 *~~300
500 4,500
500
0_

Sub-Totals: IV. Program T o t a l ;

4.505 88,700

45,185 7.865.3 4.388 57,472.8

4,499.2

11,100 73.072.0

V. Unit Cost: $50.05 per Day

Average Annual per Client Cost: 18,268

NOTES:

Transitional apartment programs serving more or less than four clients will require appropriate modifications in staffing patterns.

Float position provides extra staff coverage whenever most needed, i.e., in emergencies, client illness, to attend meetings, to provide extra coverage during special house activities, etc. See recommended breakdown following page.

If two apartments are in same building coverage during sleep hours may be provided by one staff person with intercom between apartments.

Consultation is based on $25/per hour for one hour per week.

00
J

-11-

\
Si
1
cu c;

i!

1

F 7

bo

1i i£>• 1w

-

i

i1

!l :i 1 II

i i
1
et. .1 :i 'I

>» 4)

a

•ao >a> ««-«i •«•

u

u

ucd

•
H

4ai. 4ai. a fa.

4-1

u0) CuO O <m~i e 3o o3 o• uo O SS X Z H

u: en

i i i i

a 41 <M •

•O » «a-i W•

h b uH

a) a) m •

a. a (>4

«0 03 O f - l

I J V4

CS

3 3 • *J

C O O OO

O IS SS Z H

(90)

%'tyi
rrmhtltlonal Communityfimnldmncm- A cowwuolty bated irvfngffaetllty operating th hours a day providing room, board, and supportive services Including supervision and Intensive training In dally living skills. Res/dents are "isually expected to move to a more Independent and/or less intensive living situation within one year. Either a transitional apartment or transitional community residence is required for a small number o f clients (23) as they leave the state hospital setting. They include: mentally retarded clients with some behavioral problems and the need for assistance with community adjustment; elderly clients with som« behavioral problems, psychiatric symptomatology and community adjustment needs; adolescents with psychiatric symptomatology; and chronically handicapped persons with some behavioral problems, psychiatric symptomatology and the need for assistance with community adjustment.

STAFFING/COST SCHEDULE

1. Direct Care Personne_l Shift

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe G6A

Staff Costs Subtotal

Cover Factor (x.lO)

TOTAL

1 MENTAL HEALTH V/ORKER MM--FF DDAAYYSS 1.0

9,500

9,500

1,710

950 12,160

1,216

13,376

2 MENTAL HEALTH WORKERS S-S DAYS .8

9.500

7,600

1,368

760 9,728

972.8

10,700.8

2 MENTAL HEALTH WORKERS M-F EVES. 2.0 2 MENTAL HEALTH WORKERS S-S EVES. .8

9,500 9,500

19,000 7,600

3,420 1,900 24,320

1,368

760 9,728

2,432 972.8

26,752 ro CO 1
10,700.8

I MENTAL HEALTH WORKER M-F NIGHTS 1

9,500

9,500

1,710

950 12,160

1,216

13,376

1 MENTAL HEALTH WORKER S-S NIGHTS .4

9,500

3,800

684

380 4,864

486.4

5,350.4

CONSULTATION

NA

NA

NA

2,600

NA

NA

2,600

NA

2,600

Sub-Totals:

5.2 57,000

59,600 10,260 5,700 75,560

7,296

82,856

II . Administrative Personnel

DIRECTOR

NA

SECRETARY/BOOKKEEPER

NA

.5 15,000

7,500

1,350

750 9,600

NA

.25 7,200

1,800

324

180 2,304

NA

Sub-Tota1s:

•/5 22,200

9,300

i.674 930 11,904

NA

9,600 2,304
li.904

- -Kzrrx.—xxt

III. Operating Costs

Shift

Rent and Utilities Maintenance Te 1ephone Insurance Food Transportation Other

Sub-Totals: IV. Proyram Total:

V. Unit Cost: $*i0.05 per DAY NOTES:

Equivalent Full/Time
FTE's Salary

Actual Salary

Fringe G&A

182

lot

Staff Costs
Subtotal

Cover Factor
(x.10)

5*95 79,200

68f 900 11,93*1 6,630 07,fr6't

7., 296

Average Annual per Client Cost: $|l»,620

TOTAL
8,400 2,000
600 1,000 9,000 1,200
22,200 116,960

Consultation is based on $25/per hour for two hours per week.

WEEK DAYS

PROGRAM TYPE T. 'r. la. n_ _si_tional Community Itesidence - 8 Clients

DAY
On loura per day lours per week Mo. of staff total F.T.E.8

- 3 p.m.

EVE
=3-11 p.m.
» ~~4D"
z
2

MI (HIT
= 11 p . m . - / a.m
ft
„ 40
1 1

I II

FLOAT
=
=2

TOTAL 4

WEEK

On

= 7 a.m.-3p.m.

= 3-11 p.m.

ENDS

Hours per day •=' 8

8

Hours per week

= 16

No. of staff

2

Total F.T.E.s

- .8

= Up.m.-7a.m.

8

=

16

1

S3

-

.4

SE

I
?

Apartment Program with Physical Care Component - A community based apartment program with a maximum of four p e r s o n s per apartment that provides daily a s s i s t a n c e and training in basic a c t i v i t i e s of daily living a n d physical care for clients with high A.D.L. needs. Either an apartment program or group home with a physical care component will be necessary for a small number of clients (42) leaving the state hospital. They include: persons whose primary problem is poor physical h e a l t h ; mentally retarded, elderly and chronically handicapped clients w h o only need assistance with basic activities of daily living such as feeding, toileting and dressing. The following staffing andcost estimates are for a program consisting of one apartment housing four clients.

STAFFING/COST SCHEDULE

1. Direct Care Personnel Shift

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe GSA

18*

10%

Staff Costs Subtotal

2 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 LPN 1 LPN 1 MENTAL HEALTH V/ORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER CONSULTANT: R.N. CONSULTANT: M.H. PROFESSIONAL

M-F DAYS* S£S DAYS S£S DAYS M-F EVES. M-F EVES. S£S EVES. S£S EVES. M-F NIGHTS StS NIGHTS FLOAT
NA
NA

• 75 .4 .1 1 1 .4
.2
1 .4 .25 NA
NA

19,000 9.500 9,500 9.500 9.500 9.500 9,500 9.500 9.500 9.500
NA
NA

7.125 3,800
950
9.500 9,500 3,800 1,900 9.500 3,800 2,375 1,950
1,300

1,282.5
684 171
1,710 1,710
684 342
1,710
684
427.50
NA
NA

713 9,120 380 4,864 95 1,216 950 12,160 950 12,160 380 4,864 190 2,432 950 12,160 380 4,864
237. 503.040
NA 1,950
NA 1,300

Sub-Totals:

5.5 104,500

53,550 9.405 5,224 70,130

Cover Factor (x.10)
912 4,864
121.6
1,216 1,216
486.4 243.2
1,216. 486.4 NA NA
NA
10,761.6

TOTAL
10,032
5,350.4 1.337.6 13.376 13,376 5.350.4 2,675.2 13,376 5,350.4 3,040 1,950
1,300
76,514

l|. Administrative Personnel

1 DIRECTOR

NA

1 SECRETARY/BOOKKEEPER NA

.25

15,000

3.750

675.

375 4,600

NA

• 125 7.200

900

162

90 1,152

NA

Sub-Totals:

.375 22,200

4,650

037

465 5,952

NA

* See page 28 for recommended hour* on duty.

4,300 1,152
5,952

Shift
III. Operating Costs
Rent and Uti1i ties Maintenance Telephone Insurance Food Transportat ion Other

FTC't

Sub-Totals: IV. Program T o t a I :

5,875

126,700 53,200

V. Unit Cost: 6^.60 Per Day NOTES:

Average Annual per Client Cost: 23,579
i

Apartment programs serving more or less than four clients will require appropriate modifications in staffing patterns

Float position provides extra staff coverage whenever most needed, i.e., in emergencies, client illness, to attend meetings, to provide extra coverage during special house activities, etc. See recommended breakdown following page.

Consultation by Registered Nurse for 2.5 hours per week at $15 per hour. Consultation by Mental Health Professional for 1 hour per week at $25 per hour.

PROGRAM T Y P E Apt. Program with Physical Care Component - 4 Clients

DAY

EVE

WEEK

On

- iJla...m /7-9a.n

DAYS

Hours per day = 4

2

a

Hours per week - 26 10

= 40

Ho. of staff

- 1

1

2

Total F.T.E.s = .5

.25

2

NIGHT

" 1 lp.m.-7a.in.

=

0

40

^' 1

1

FLOAT
= As Needed 2
= 10
J

TOTAL
4.0

WEEK

On

, 7a.nur3p.n)./S-ll a.n

/6-I0 p.m. =llp.m.-7a.m.

S3

ENDS

Houre per day ^

Q2

= a

8

=

Hours per week ^ ]6 4

Ib

=

No. of staff

«

\1

= 1 ~T

1

=

Total F.T.E.s =

4 .1

= .4 .2

.1

I
CO
1.5

vo
ON

F. I Group Home with I'ltyaic.nl Cara Component - A community baa«d living; faolllty p m v l d l m TOOW.,-1lO>md
daily assfsiance and training in basic activities o f dally living and physical care for cttantt wttti minimum behavioral problems and high A.O.L. needs. Either an apartment program or group home with a physical care component will be necessary for a small number of clients (42) leaving the state hospital They include: persons w h o s e primary problem is poor physical h e a l t h ; mentally retarded, elderly and chronically handicapped clients who only need assistance with basic activities of daily living such as feeding, toileting and dressing.

STAFFING/COST SCHEDULE

1 Direct Care Personnel Shift FTE's

1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER* 2 MENTAL HEALTH WORKERS 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 LPN 1 LPN 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER CONSULTATION, RN CONSULTATION, MENTAL HEALTH PROFESSIONAL

M-F DAYS M-F DAYS S-S DAYS M-F EVES. S-S EVES. M-F EVES. S-S EVES. M-F EVES. S-S EVES. M-F NIGHTS S-S NIGHTS
NA

1.0
.37 .8
1.0
.4 .5
.2
1.0
.4
1.0
.4
NA

NA

NA

Equivalent FulI/Time Salary
9,500 9.500 9,500 9,500 9,500 9,500 9,500 9.500 9.500 9.500 9.500 NA
NA

Actual Salary
9,500 3,515 7,600 9,500 3,800 4,750 1,900 9,500 3,800 9,500 3,800 3.900
2,600

Fringe GfcA

18*

10*

Staff Costs Subtotal

1.710
632.7 1.368
1,710 68*.
855 342 1.710
684
1.710
684
NA

950
351-5 760 950 380
475
190 950 380 950 380 NA

12,160
4, ^99.2 9.728 12,160
4,864
6,030 2.1O2 12,160 i»,86^» 12,160
4,86*. 3.900

NA

NA

2,600

Sub-Totals:

8.07 104,500

73.665 12,089.7 6 ,716.5 92,^71-2

Cover Factor (x.10)
1,216 449-92 972.8
1,216 486.4 608. 243.2
1,216. '18 6.'!
1,216. 486.4
NA
NA
8,597.12

TOTAL
13.376 4,949.12 10,700.8 13,376 5,350.4 I
6,683 1
2,675.2 13.376
5,350.4 13,376 5,350.4 3,900
2,600
101,068.32

II . Administrative Personnel

I DIRECTOR

NA

I SECRETARY/BOOKKEEPER NA

S ub-Tot a I s :

.5

15,000

7,500 1,350

750 9,600

NA

.25

7,200

1,800

324 ' 180

2 ,304

NA

.75 22,200

9,300 1,674

930 1),904

NA

9,600 2,304 11,904

See page 31 for recommended hours on duty.

Shift
III. Operating Costs
Rent and Uti1ities Maintenance Telephone Insurance Food Transportation Other

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe G£A

18%

10%

Staff Costs Subtotal

Cover Factor (x.10)

TOTAL
8,400 3,000
600 1,500 9,000 1,200
0

Sub-Totals: IV. Program Total:

8.82

126,700

82,965 13,763.7 76,465 10*1,375.2 8,597.12

23,700 136,672.32

V. Unit Cost: 46.80 Per Day NOTES:

Average Annual per Client Cost: 17,084.04
1 CO
?

Consultation by Registered Nurse for five hours per week at $l5/per hour.

Consultation by Mental Health Professional for 2 hours per week at $25 per hour.

WEEK DAYS

PROGRAM TYPE G r O U P H o m e w 1 t h P n y s 1 c a l C a r e

DAY

On

7a.in.-3p_JiL/LJOa.in.

lours per day

;t

lours per week - 4fl IS

to. of staff

.1

Total F.T.E.B - 1 .37

EVE
=3-Vlp.m./6-10p.m _8 40 20
2.0 1 75

Hir.iiT
= Up.m.-7a.in.

= T

«

1

FLOAT

TOTAL
4.87

WEEK

Oil

-- 7a.m.-3p.iw.

3-llp.m./6-10p.u lip. in. -7a.m.

ENDS

Hours per day

~8 y~4

8

Hours per week.

76

No. of staff

2.0

2.2

Total F.T.E.8

.8

.8 ~.2

i

G. Apartment Program with Behavioral Emphasis^- A community based apartment program with a maximum of four persons, per apartment providing room, board and" TrTtensive services within the apartment for persons with serious behavior problems. The program is designed to replace problemmatic behaviors with appropriate living skills so the individual may move to a less restrictive, more normalized environment. Residents will have low physical care needs. Either an apartment program or group home with behavioral emphasis will be necessary for a small number of clients (21) presently at the state hospital. They include some persons with chronic brain syndrome who do not need nursing home care; elderly and chronically handicapped clients with behavioral problems, psychiatric symptomatology and assistance with communItyadjustment skills.

The following staffing and cost estimates are for a program consisting of one apartment, housing four clients. STAFFING/COST SCHEDULE

1. Direct Care Personnel Shift

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe G£A

18*

10*

Staff Costs Subtotal

Cover Factor (x.10)

TOTAL

1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 2 MENTAL HEALTH WORKERS

M-F DAYS

.5

(7-11 a.m.)

M-F DAYS

.2

(7-9 a.m.)

S6S DAYS

.8

2 MENTAL HEALTH WORKERS M-F EVES. 2.0

2 MENTAL HEALTH WORKERS S6S EVES. .8

1 MENTAL HEALTH WORKER M-F NIGHTS 1.0

1 MENTAL HEALTH WORKER S6S NIGHTS .4

1 MENTAL HEALTH WORKER FLOAT

.35

CONSULTATION

AS NEEDED NA

Sub-Totals:

6.05

9.500 9,500 9.500 9,500 9,500 9.500 9,500 9.500
NA
76,000

4,750

855

475

6,080

1.900

342

190

2.432

7.600 1,368

760

9,728

19,000 3,420 |,900 24,320

7,600 1,368

760 9,728

9.500 3,800

1.710
684

950 12,160
380 4,864

3.325 1,950

598.5
NA

332.5
NA

4,256 1.950

59.425 10,345.5 5 .7*7.5 75,5)8.0

608 243.2 972.8 2,432 972.8 1,216
486.4 NA NA
6,931.2

6,688
2,675 .2
10,700.8 u1>
ISO 1
26,752
10,700.8
13.376
5,350 .4
4.256
1.950
82,449 .2

II. Administrative Personnel

\ DIRECTOR \ SECRETARY/BOOKKEEPER

.25 18,000

4.500

810

450

5.760

NA

.125 7.200

900

162

90

1,152

NA

S.4O0

MA

III. Operating Costs

Shift

Rent and UtiIities Maintenance Telephone Insurance Food Transportation Other

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe GsA

18*

10*

st«rr
Costs Subtotal

TOTAL

Sub-Totals: IV. Program T o t a l ;

6.^25 101,200

64,825 11.317-5 6,287.5 82,^30

11,100
6,931-2 100,^61.2

V. Unit Cost: NOTES:

68.80 Per Day

Average Annual per Client Cost: 25,115-30
• CO

An Apartment Program with Intensive Behavioral Emphasis to meet the needs of persons with severe self destructive or other destructive behaviors should provide two mental health workers per apartment for each weekday (7 a.m. 3 p.m.) shift as it is anticipated that it will be necessary for residence workers to accompany clients to their day programs. A small number of clients (15) at the state hospital will require an apartment or group home with intensive behavioral emphasis.
Program serving more or less than four clients will require appropriate modifications in staffing patterns.
It is recommended that the program director be a psychologist or other mental health professional knowledgeable in behavior modification techniques.
Float position provides extra staff coverage whenever most deeded, i.e., in emergencies, client or staff illness, to attend meetings, to provide extra coverage during special house activities, etc. See recommended breakdown following page.
Consultation is based on $25/per hour for 1.5 hours per week.

WEEK DAYS

PROGRAM TYPE APfc- Pr°9rani with Behavioral Emphasis-4 Clients

DAY

EVE

On

7-ila.in./7-9a~.m.

Hours per day = 4

Hours per week -2Q

No. of staff -

Total F.T.E.e .-

T2

WEEK

On

" 7a.m.-3p.m.

ENDS

Hours per day

Hours per week

:—1— No. of staff
Total F.T.E.s

TCTAL

,*-.. ;;

C ] i«.MU

14.8:1

Total D.c. staff -

X 1.23

=

If Apt. X 2 =

- "15.3

%*• r

WEEK DAYS

PROGRAM T Y P E APl- Program with Intensive Behavioral Emphasis - 4 Clients

DAY

On

Hours per day

Hours per week

40

No. of staff

2.

Total F.T.E.B

2

EVE
=3p. m.-llp.nl. » ~8

Nir.iiT
"fl p.m. -II p. in. 8 40
1

FLOAT
~Rs~Neea*elI*'

TOTAL
5.5

WEEK

On

ENDS

Hours per day

a

Hours per week

16

No. of staff

Total F.T.E.8

.8

= 3p.m.-lip.m.
"nre8
.8

= As Needed*

4-

2.2

* Backup for nighttime staff

G.I Groap Home with Behavioral Emphasis - A community based living facility providing room, board, and intensive services w i t h i n the home for persons with serious b e h a v i o r p r o b l e m s . T h e p r o g r a m Is designed to replace problemmatic behaviors with appropriate living skills so the individual may move to a less restrictive, more normalized environment. Resident will have low physical care needs. Either an apartment program or group home with behavioral emphasis will be necessaiy for a small number o f clients (21) p r e s e n t l y at th,e state h o s p i t a l . They include some persons w i t h chronic brain s y n drome who do not need nursing home care; elderly and chronically handicapped clients with behavioral problems, psychiatric symptomatology and assistance with community adjustment.

I. Direct Care Personnel Shift 1FTE's

1 MENTAL HEALTH WORKER M-F DAYS 1.0

1 MENTAL HEALTH WORKER M-F DAYS (7-10 a.m,. ) • "
3 MENTAL HEALTH WORKERS StS DAYS 1.2

3 MENTAL HEALTH WORKERS M-F EVE's 3.0

3 MENTAL HEALTH WORKERS S&S EVE's 1.2

1 MENTAL HEALTH WORKER M-F NIGHT!51.0

1 MENTAL HEALTH WORKER S&S NIGHT!> . 4

1 MENTAL HEALTH WORKER 7 NIGHTS N.A.

(on cal1)

CONSULTATION

AS NEEDED N.A.

STAFFIMG/COST SCHEDULE

Equivalent Full/Time Salary

Actual Salary

Fringe G&A

18%

10%

Staff Costs Subtotal

9500

9.500 1.710 950 12,160

9500

3,515

632.7 351.5 4,499.2

9500

11,400 2,052 1,140 14,592

9500

28,500 5,130 2,850 36,480

9500

11,400 2,052 1,140 14,592

9500

9.500

1,170

950 12,160

9500

3,800

684 380 4,864

N.A.

5,000

N.A. N.A. 5,000

N.A.

3,900

N.A. N.A. 3,900

Cover Factor (x.10)
1,216 449.92
1.459.2
3,648 1,459
1,216 486.4 N.A. N.A.

TOTAL

13,376

4,949.12

16,051.2

40,128

I

CO

16,051

13,376

5.350.4

5,000

3,900

Sub-Totals:

11. Administrative Personnel

1 DIRECTOR

N.A.

\ SECRETARY/BOOKKEEPER N.A.

JLJ2 66.son
.5 18,000 .25 7,200
?< Tftfl

AA SIS

15.140.7 7,761 .5 108,247.2

9,000 1.800

1,620 900 11.520 324 180 2,304

9,934.72 118,181.7;

N.A. N.A.

11,520 2,30k

III. Operating Costs
Rent and U l t i l i t i e s Maintenance TeIephone Insurance Food Transportation Other
Sub-Totals:

FCottii

factor

10*

Subtotal

TOTAL

8,400
1,000 9,000 1,200
22,200

IV. Program Total:

g

91,700

97,315

17,084.7 8,841.5 122,071.2 9,934.72 154,205.72

V. Unit Cost: NOTES:

$52.81 per DAY

Average Annual per Client Cost: $ 19,275.73

It is recommended that the program Director be a psychologist o r other mental health professional, knowledgeable in behavior modification techniques.

In addition to one M/H Worker awake and on duty, staff will provide on call back up by sleeping at house on rotating basis, or by additional staff-provided room in exchange for availability in case o f emergency. Staff paid at minimum wage for four hours if disturbed durning sleeping hours for emergency duty. Cost is based on estimated duty time.

A Group Home with Intensive-Behavioral Emphasis to meet the needs of persons with severe, self destructive behaviors should provide two additional M/H Workers on the weekday (7 a.m.-3 p.m.) shift as it is anticipated that it will be necessary for residence workers to accompany clients to their day programs. A small number of clients (15) at the state hospital will reqire an apartment or group home with intensive behavioral emphasis.

Consultation is based on $25/per hour for 3 hours per week.

o

WEEK [JAYS

PROGRAM TYPE

Hnmfl with BahavJuwal Bnphasle - 8 Clienta

DAY
On Hours per day Hours per week m. of Staff •total F.T.E.s

i
i
= '/nnw-^pn 7pm-10

=• ft

» Jjfj

1*)

" 1

1

» •)

."57

EVE
ft

NIGHT
= 11rm-7ftm » o
40 1 1 Additional back up provided by second peraon sleeping at house.

FLOAT
m
SI

TOTAL

WEEK ENDS

Jn
lours per day lours per week to. of Staff Total K.T.E.s

= 7am-3pn»

-

8

= 16

» 3

»

1.2

« 3-11pm H 16
3
1.2

= 11pm-7an>

IS

U

S3

if.

»

m

'I

m

Additional back up

provided by seoond

peraon sleeping at

liouae

i
2.8

•*,.

WEEK DAYS

PROGRAM TVPE Group Home with Intensive Behavioral Emphasis 8 Clients

DAY
On Hours per day Hours per week l*>. of Staff IDtal F.T.E.s

= 7am-3pni = Q = 40 » 3
» 3

EVE
• 3pni-llpm ft
= . 40 3 3

NIGHT
• llpm-7am
a
40 2 2

FLOAT
m
SB 9 .
m

TOTAL
8

WEEK ENDS

)n lours per day lours per week 4o. of Staff Total F.T.E.s

= 7am-3pm

= 8

s

16

= 3

= 1.2

=» 3pni-llpm

- 11pm-/am

8

8

a

16

40

a

3

2

a

1.2

2

m

I
4.4

H. Apartment Program with Physical Care Component and Behavioral Emphasis - A community based apartment program with a maximum of four persons per apartment that provides both intensive behavioral program intervention as well are physical care and help with activities of daily living. According to the Region I Client Evaluation Survey no persons have been Identified as requiring this kind of program at the present time.
The following staffing and cost estimates are for a program consisting of one apartment, housing four clients.

I. Direct Care Personnel Shift

FTE's

STAFFING/COST SCHEDULE

Equivalent Full/Time Salary

Actual Salary

Fringe G&A 10*

Staff Costs Subtotal

1 MENTAL HEALTH WORKER M-F DAYS 1

1 MENTAL HEALTH WORKER M-F DAYS .5 (7-11 a.m.)
2 MENTAL HEALTH WORKERS S-S DAYS .8

1 MENTAL HEALTH WORKER M-F EVES. 1

I MENTAL HEALTH WORKER S-S EVES. .4

I LPN

M-F EVES. I

1 LPN

S-S EVES. .4

I MENTAL HEALTH WORKER M-F NIGHTS 1

1 MENTAL HEALTH WORKER S-S NIGHTS .4

1 MENTAL HEALTH WORKER FLOAT

.7

CNSULTATIOH(R.N.RM.H. NA

NA

Sub-Totals: Professional)

^

II. Administrative Personnel

9,500 9,500 9,500 9,500 9.500 9,500
9,500 9.500 9,500 9,500 NA 95.000

9.500 4.750 7,600 9,500 3,800 9,500 3,800 9,500 3,800 6,650
71,650

1,710

950 12,160

855

475 6,080

1,368

760 9,728

1,710

950 12,160

684

380 4,864

1,710

950 12,160

684 1,710
684 1,197 NA 12,312

380 950 330 665
NA 6,840

4,864 12,160 4,864 8,512 3,250 90,802

DIRECTOR

NA

SECRETARY/BOOKKEEPER

MA

4,500 900

810

450 5.760

162

90 1.152

Cover Factor (x.10)
NA NA

TOTAL
13,376 6,688
10,700.8 **
13,376 5,350.4 13.376 5.350.4 13,376 5.350.4 8,512 1,250 98,706
5,760 1,152

I I I . Operating Costs

Shift

Rent and U t i l i t i e s
Maintenance
Telephone Insurance Food Transportation Other

FTE's

q Full/Time Salary

Sub-Totals: IV. Program Total:
V. Unit Cost: 3o.^»6 Per Day NOTES:

7.575 120,200

77t050

13.28A 7,380 97.714

Average Annual per Client Cost: 29,367

Program serving more or less than four clients will require appropriate modifications in staffing patterns.
It is recommended that the Program Director be a psychologist or other mental health professional knowledgeable in behavior modification techniques.
Float position provides extra staff coverage whenever most needed, i.e., in emergencies, client illness, to attend meetings, to provide extra coverage during special house activities, etc. See recommended breakdown following page.
Consultation by Registered Nurse for 2.5 hours per week at^$15/per hour.
Consultation by Mental Health Professional for 2 hours per week at $25/per hour.

o

IT)
CvJ
II I I

CM
"S
ai i i

u» i n«

s ni i I

cv it a a a a
1
1cc c
i
iiit u » n it •a x <*- a M M 0 <-• 3 3 .u
3 a

as u u « a
> a)
-a t
S.S. Cfl
a a
M Z 2 W

1. Direct Care Personnel Shift FTE's

2 MENTAL HEALTH WORKERS M-F DAYS 2.0
3 MENTAL HEALTH WORKERS S-S DAYS 1.2 2 MENTAL HEALTH WORKERS M-F EVES. 2.0
2 MENTAL HEALTH WORKERS S-S EVES. .8

I LrN 1 LPN I MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER 1 MENTAL HEALTH WORKER
CONSULTATION (R.N. £ M.H.

M-F EVES. 1.0

S-S EVES. .4

M-F NIGHTS 1.0

S-S NIGHTS .4

7 NIGHTS

(On Call) NA

NA

NA

Professional)

Sub-Totals:

8.8

Equivalent Full/Time Salary
9,500 9,500 9,500 9,500 9,500 9,500 9,500 9,500
NA NA
76,000

Actual Salary
19,000 II, 'tOO 19,000 7.600 9,500 3,800 9,500 3,800
5,000 5,200

Fringe
3,420 2,052 3.420 1,368 1,710
684 1,710
68't
NA NA

Staff GCA Costs 10* Subtotal

1,900 1,140 1.900
760 950 380 950 380

2*1,320 14,592 24,320 9,728 12,160 4,364 12,160
4,864

NA

5,000

NA

5,200

88,800 15,048 8,360 117.208

Cover Factor (x.10)
2,432.0 1,^59.2 2,432
972.8 1,216
406.4 1216
486.4
NA NA
10,700.8

TOTAL
26,752 16,051.2 26,752.
10,700 8
13 376 5,350.
1 3,J/O
5,350. 4
5,000 5,200
127.908.8

11. AdminIstratlve Personnel

I DIRECTOR

NA

I SECRETARY/BOOKKEEPER NA

Sub-Totals:

.5 18,000 .25 7,200

9,000 1,800

1,620 324.

900 11,520 180 2,304

NA NA

75 25,200

10,800

1,944 1,080 13,824

11,520 2,304
13,824

III. Operating Costs

Shift

FTE's

Equivalent Full/Time Salary

Actual Salary

Fringe GtA

18*

10%

Staff Costs Subtotal

TOTAL

Rent and UtiIities Maintenance Telephone Insurance Food Transportation Other

8,400
I ,000 "5oo
1,500
9,000
T,200
0

Sub-Totals: IV. Program T o t a l ;

9.5 101,200

99,600 16.992 9,^0 131.032

23 ,700
10,700-8 165 ,432.8

V. Unit Cost: $56.65 Per Day

Average Annual per Client Cost: 20,679.10

NOTES:

It is recommended that the program director be a psychologist or other mental health professional knowledgeable in behavior modification techniques.
In addition to one M/H worker awake and on duty, staff will provide on call back-up by sleeping at house on rotating basis, or by additional staff - provided room in exchange for.availabiIIty in case of emergency. Staff paid at minimum wage for four hours if disturbed during sleeping hours for emergency duty.

Consultation by Registered Nurse for 5 hours per week at $15/per hour. Consultation by Mental Health Professional for 4 hours per week at $25/per hour.

WEEK DAYS

PROGRAM TYPE Qroup Home with Phyaioal Care and Behavi6ral Bnphaala Component

DAY
On Hours per day Hours per week W. of Staff iota}. F.T-E.s

= 7Bp-^p|n

=

ft

•

UQ

«

2

•

j>

EVE •
fl •» Un ™ 3
• 3

NIGHT

" 1 'ljTO-7f|«J|

ft

" Un

•

1

•

1

FLOAT
B
a • >

TOTAL
6.0

WEEK ENDS

in lours per day lours per week to. of Staff Total F,T.E.a

« fam-^l**

=

8

=

16

»

3

=

1.2

= 3-11PfQ
8 16 3
* 1.2

• 11pm-7am

8

a

16

a

1

a

,k

81

in
2.8

COMPARISON OF PER DIEM AND PER ANNUM COSTS
I
(114)

-46-

Comparison of Per Diem and Per Annum Costs

The following costs are based on eight client programming
Support Services to Clients Residing in Non-DMH Provided or Funded Housing a. Consultation to Nursing/Rest/Boarding Homes b. Consultation to Persons residing in Cooperative Apartments or Homes
Specialized Home Care Program
Supervised Apartment Program Supervised Group Home Transitional Apartment Program Transitional Community Residence Apartment Program with Physical Care Component Group Home with Physical Care Component Apartment Program with Behavioral Emphasis
Apartment Program with Intensive Behavioral Emphasis Group Home with Behavioral Emphasis Group Home with Intensive Behavioral Emphasis Apartment Program with Physical Care Component
and Behavioral Emphasis Group Home with Physical Care Component and
Behavioral Emphasis

Per Diem
15.81 40.94 31.21 50.05 40.05 64.60 46.12 68.80 80.70 52.81 61.97 80.46 56.65

Per Annum
5,769.33 14,943.10 11,392.00 18,268.00 14,620.00 23,579.00 16,834.04 25,115.30 29,462.50 19,275.73 22,619.05 29,367.00 20,679.10

(115)

-47-
Staff Responsibilities
Irector/Administrator vera responsibility and authority for management of residential program, including supervision of direct care staff. »rsee liaison and coordination of services with community mental health [network:. Represent the residential program in community relations efforts.
ft
Eprovide or arrange for pre-service and in-service training of direct care staff, nagement of fiscal aspects of program operation and maintenance of data as
[required. evelop and implement ongoing program evaluation methods.
Irect Care Staff skdays: Day Shift ^Assist with a.m. routine including breakfast, dressing, medication supervision, etc. [in preparation for day time activity. Attend residence and interagency staff meetings related to residents. ^Transport residents to non-routine appointments, when appropriate. ssist clients who are at home during day because of sickness, malingering, [between day programs, etc.
part in prospective resident screening and evaluations, available to meet with repairmen, inspectors, prospective residents, etc. household errands. •Perform daily record keeping and exchange information with evening shift.
akdays: Evening Shift Be available to greet residents returning from day time activity. ^Coordinate/supervise dinner preparations and clean up. [•Assist residents engaging in daily chores. |*Hold house meetings and informal discussion groups with residents.
with residents on individual basis to discuss concerns, problems, etc. of the day/week.
(116)

1

-48-

-Assist residents, as necessary, in pursuing community recreational activities. -Perform daily record keeping and exchange information with night staff.

Direct Care Staff
Weekends: Day and Evening Shifts
-Assist with a.m. routine including breakfast, dressing, medication supervision,
-Supervise, with with and teach residents as they engage in weekly household maintenance chores, menu planning, weekly shopping, etc.
-Meet individually with residents as they define and pursue individual goals for the coming week and review goals for previous week.
-Assist residents when necessary and appropriate to plan and engage in weekend social/recreational activities.
-Perform daily record keeping and exchange information between shifts.
-Coordinate/supervise luncn and dinner preparations and clean up.
-Assist with p.m. routine, including personal hygiene activities, medication supervision, etc.

Direct Care Staff

Weekend and weekday: Night Shift

-Be available in case of any nighttime emergency and see that residents are hoar from any evening activity in community.

?!•>

-Do any household maintenance or repairs residents unable to do.

-Do all major record keeping activities, such as Title XX form completion, etc. *|

-Assist with a.m. ADL activities and nighttime medication taking.

f

ATTACHMENT C

NON RESIDENTIAL TREATMENT AND SUPPORT SERVICES PROGRAM MODELS

Prepared for the Massachusetts Department of Mental Health Region I Planning Process

By: tjRay Brien, DMH Region I

|ISMnEjyeilvfJel"lLtellfP.£-5f-5»DMHC

Centra ornhill

l

Office

Associates, Principal

Planner

i Steve__S_chwart_z, Mental Patients

I Advocacy Project

ManageUmppesnhtu, rI.In

Providers c.

Consultant for Mental Patients

Advocacy Project

With the Northampton Planning Team

(118)

AMENDED FINAL DRAFT
NONRESIDENTIAL TREATMENT AND SUPPORT SERVICES

TABLE OF CONTENTS

Page

Introduction

I. Assessment Team

8

II. Community Service Coordination Program

12

III. Psychotherapy Counseling Program

16

IV. Respite Care Services

20

V. Family Support Services

24

VI. Medication Unit/Nursing Support

28

VII. Crisis Intervention Unit

32

VIII. Inpatient Programs

38

IX. Day Treatment Programs

40

X. Day Activity Programs

44

XI. Vocational Rehabilitation

48

A. Prevocational Training/Sheltered Workshops 51

8. Transitional Employment/Job Placement

53

XII. Recreational/Socialization Program

58

XIII. Transportation

62

XIV. Educational Programs

63

(119)

INTRODUCTION

A. The Program Models

The program models described herein are designed to provide mentally

disabled persons living in the community with those treatment and support

services appropriate to their neeas. Taken together, they represent a

continuum of programs that vary in structure and intensity but which

should enable clients to progress towards independent, productive lives

in the community. Seme programs are primarily clinical and offer a range

of treatment modalities in a radically oriented environment; some ire

distinctively nonclinical and provide training in various social, physical,

vocational, and educational skills to assist clients in gaining such in-

dependence; and finally others are chiefly supportive, giving clients

help, when necessary, in responding to the demands of community living.

Although available to all mentally disabled persons Iving in the com-

munity, these models are principally intended to complement ccrmiunity

residential alternatives yj serving the nonresidential program needs of

clients living in those settings. It is the expectation that such clients

will participate in these nonresidential programs or other activities

such as employment or schooling five days per week. Thus these programs

are but one piece of a comprehensive network of a conmunity mental health

system.

The separate models :re$=n*ed below are designed to be unified in

multiple ways. First, zr.s assessment unit draws into the evaluation

and treatment planning pr;cass reoresantatives from those services thac

Ii1'

clients are to receive. In :.iis way even before client treatment clans

i!

il

ii-

(120)

are implemented, key caregivers meet to discuss a client's needs and total program.
This initial unification is carried forward by community service coordinators who assume primary responsibility for the whole client, and insure that the client is not treated atomistically. It would be a mistake, however, to view the community service coordination function as merely a "liaison" one. Community service coordinators will establish "supportive human relationships" with their clients, providing counseling aimed at bolstering clients' coping skills and self esteem. Through these relationships community service coordinators will develop a multi-level knowledge of their clients' service needs and how these needs fit together.
Another dynamic for unification provided for in this plan is that the various programs can share staff, so that persons employed part time by one program might also be employed part time by another. This coemployment will be facilitated by the fact that many programs, in particular the

It should be noted that the community service "coordinators functions are

ones that are sometimes assigned to aftercare workers or psychotherapists n

other systems. The model of community service coordination.Proposed here s

designed to emphasize several aspects of these functions which become problem-

atic in systems that rely on aftercare or psychotherapy.

. In^ontrast to ?he concept of aftercare community service coordinat on

as proposed here is not restricted to discharged clients and a post-hospital

ization period. Instead i t is a service designed for a spectrum of clients

ranging from those who are recently discharged to those who have never been

in the hospital but are at risk and those who are currently hospitalized.

Moreover, i t is explicitly designed to be available to such clients as long

as

they are in need of any mental health services • Community Service coordination also assumes

that

jost

rUant<. clients

wwiiinlnl

need a variety of services which must be coordinated to b ^ ' ^ ^

clients to obtain these servicas involves working with clients on

and insuring that they a variety OT problems,

ar« «?rdina many or rfjich

are

neither psychological nor psychiatric, in a variety or settings tor

flexible amounts of time. Psychotherapy provided in an or.ica ^ a

fixed amount of time is i l l suited to ^ e s e functions. Moreover, only

a minority of clients are appropriate ror the specialized behav ° r

d

modification or intrapsychically oriented treatments soeci.icaU/ as.ociat.a

with psychotnerapy.

(121)

"clinical" ones: assessment, community service coordination, crisis intervention, psychotherapy, family therapy, respite care and medication/nursing are intended to be co-located in and an integral part of a community mental health center.
Finally, other mental health and generic social services that may be physically separate from a mental health center will be integrated into the care system by means of affiliation agreements maintained by coordination staff in area offices, by umbrella activities of community service coordinators and assessment team members and by day to day working interactions among other program staff.
In conformity with the principles of normalization, these models specifically exclude all generic services that are otherwise available in the community. Clients should be encouraged to use generic educational, transportation, health, legal and other services; mental health staff shouTd assist generic service providers in making their services accessible to mental health clients. To the extent that mental health clients are denied such services, Area based advocates should assist clients in gaining access to those agencies and organizations.
Given the dearth of existing, generally accepted nonresidential prototypes, the attached models set forth the overall purpose and particular elements of each program and include a reasonably accurate projection of the range of costs for serving clients with intensive and moderate needs. As new data and information are generated through the implementation of these programs, refinements and adjustments will necessarily be made.
(122)

B. Population to Be Served
It is recognized that some of the treatment and support services described in the attached models are presently being offered in some form, although there is a considerable variance between Areas. Moreover, certain nonresidential services such as prescreening, crisis, intervention, and community service coordination are not available anywhere in the Region. These program models are designed to supplement existing services in order to meet the needs of persons who are or may be hospitalized due to the inadequacy or total unavailability of appropriate community treatment and support programs. Based on a thorough review of data supplied by the Northampton State Hospital, the Regional Office, and the client assessment survey, this population includes approximately 2100 mentally disabled persons in Region 1. (See Analysis of Population in Region 1.) In addition, there are approximately 4000 other persons now receiving partially adequate mental health services from existing programs which are essential in preventing their hospitalization. For purposes of the planning process, it is assumed that the attached models must be integrated with existing Area programs in a manner that does not decrease or dilute the services presently being provided to persons Irving in the community. C. Staffing and Costs
1. Staffing The attached models include only a staffing pattern and projection
of costs. Staffing is in terms of full time equivalents (FTE's) and not actual persons. One FTE may be one person working 40 hours, two
(123)

people working 20 hours, etc. No detailed employment objectives, lines of authority, hiring procedures, or staff training element is included. Standards for nonresidential programs should be developed that address these issues by establishing guidelines for service providers in their development of clear personnel policies.
Regular training is essential to the viability of the entire community care system and participation in ongoing training programs is included as a portion of each person's nondirect care responsibilities. In addition, time is allocated for staff meetings, client conferences, record keeping, consultation, eduction, liaison with other agencies, and travel. It is assumed that most staff would spend 70% of their time in direct care tasks and only 30% in nondirect care responsibilities. The latter figure is significantly less than that used by the National Institute of Mental Health in computing similar staffing requirements and is estimated to be somewhat less than that presently being practiced in community mental health centers in the Commonwealth.
Provided with each program model is a service analysis. These analyses quantify the work to be done by a program and the staff time available for performing it. These and certain other statistics are used to check the appropriateness of the programs' projected utilization, direct and non-direct care staffing and unit costs.
Although the models do not include separate components or staffing patterns for different client subpopulations such as elderly, mentally retarded or adolescent, it is clearly recognized that "he actual imDlementation of the models, particularly day treatment, day
(124)

6 activity and sheltered workshop, may differ. The special needs of each subpopulation would affect both the content of a client's program and the qualifications of the individual staff person, but not the actual model or staffing pattern. 2. Costs
In light of the current cost of medical insurance, social security, and other employee benefits, the models adopt a standard fringe of 18%. Similarly a figure of 20% of direct care salaries is regularly used to compute the cost of overhead, which includes equipment maintenance and replacement, supplies, postage, travel, office rental, telephone, auditing costs, and legal expenses.
For those services open 50 weeks a year (i.e. offering staff a 2 week vacation) approximately 11% of staff time was estimated to be necessary to cover sick days, accidents and other types of legitimate absences. This figure was computed as follows:
250 working days per year to cover (= 50 weeks x 5 days per week) 15 sick days 3 personal days 7 other (average number per year, due to: industrial accidents,
maternity/education leave, extended vacation, death days, etc.) 25 Total lost days 225 Average number of days worked per year 1.11 Factor to cover lost days = 225 * 250
No reference is made in program elements to expected start-up costs, including office equipment and initial training. Approximately S600 should be added for each staff person to every program model, 20" of which is allocated to training and the remainder to
(125)

equipment. A portion of these expenses may be reduced through the use of certain equipment from other state f a c i l i t i e s and institutions. In addition, $5,000 should be allocated for the purchase of a vehicle for each program that provides transportation (day treatment, day a c t i v i t y and pre-vocational training/sheltered workshops). A summary of start-up costs is shown in Table 1.

D. Administration

I t is the expectation that each Area w i l l have the administrative

capacity to coordinate the delivery of services between residential

and nonresidential programs pursuant to individual service plans (ISP).

However, these models also locate within services the clerical personnel

necessary to meet their secretarial, receptionist, record keeping and

bookkeeping needs. Along with overhead, these administrative costs amount

to an average of 202 of the total program cost. The quality control and

monitoring functions of the system w i l l be performed by the Regional Offict

Although the program models set forth a standard staffing pattern to be
•IIP
for every Area, the Regional Services Administrator would retain the m.

w discretion to shift and distribute resources between areas in order to *:

ensure an equitable per c l i e n t a l l o c a t i o n . F i n a l l y , eaich c l i e n t w i l l

^'

have a community service c o o r d i n a t o r and each Area a cljient advocate

^>>

to facilitate the delivery of appropriate services in t|he least restrictive J-

environment.

^

(126)

8 I. ASSESSMENT TEAM
The Assessment Team will provide a major coordinating, evaluation, assessment and individual treatment planning function for the 427 at risk persons in each OMH area in Region I. The Team will provide a core interdisciplinary staff and will draw upon professionals from the Medication, Conmunity Service, Crisis Intervention, and Psychotherapy Programs to provide an individual interdisciplinary team for each client. The individual client's team will be responsible for drafting and annually reviewing individual service plans for the client. More frequent than annual reviews may be requested by the community service coordinator, may be planned by the client's team or may be required because of a crisis incident. The Team ideally should be based in a community mental health center.
A. Definition A program designed to provide initial screening, assessment and
service planning for all at risk persons in the DMH service system and to annually or more frequently review and update the initial service plan. B. Program Elements
ij
Program will 1. Provide initial screening, assessment and individual
service plans for persons seeking DMH services who have been previously hospitalized or would be at the risk of hospitalization if comprehensive community services were not available. 2. Receive referrals from public and private agencies as well as self-referrals. 3. Utilize staff from the Medication, Crisis, Psychotherapy Counseling and Community Service Programs to create
(127)

interdisciplinary teams to:carry out screening, assessment, and individual service planning. 4. Determine the range of appropriate OMH services and services of other public and private agencies for each client. 5. Refer clients for placement and ongoing service monitoring the Community Service Coordination Program. 6. Periodically, but at least annually, reevaluate all individual service plans and reevaluate upon request of any service program or community service coordinator. 7. Provide screening, assessment, and individual service plans for clients referred from the Crisis Unit after initial crisis resolution. 8. Reevaluate individual service plans upon requests of Medication, Community Service Coordination, Crisis and/or Psychotherapy Programs.
C. Clients (427) area clients could be assessed at least once annualy
by this program model. Some clients, such as those who become acutely disturbed, behave in unexpected and dangerous ways, appear ready for less restrictive services or whose progress appears blocked, might be re-evaluated more frequently. The average number of assessments per client is projected to be one and one half. The annual program capacity is 640 evaluations.
(128)

Staffing/Cost Schedule

p,gg»ssment Team

Direct Care Personnel

FTE's

*. Clin. Director/Sr. Clinician 0.5

8. Psychiatrist

1.0

C. PhD Psychologist

1.0

p. MSW Psychiatric

1.0

Full Sala
25,000 4S,000 22,000 16,000

Proqram Salary
12,500
33,750
22,000 16,000

10

Fringe 18%
2250 6075
3960 2880

Overhead 20%
2500
5750
4400 3200

TOTAL
172S0
45,575
30360 20030

r

Sub-Totals:
Administrative Personnel
f
L Program Administrator I. Secretaries § 7,500

I. 3.25 j

184.250J

o.
2.

3
0

25, 000 15, 000

12 ,500 15 ,000

M5.165J M6.85QJ i l U . 2 6 §

2250 2700

17250 20700

Sub-Totals:

1 2.-.S 1

Program Supplies & Eauip.

*. Client Supplies & Eauip.

I 27.5OCJ I 4Q50 I

Misc. ISnaci fy)

l6Cast:

S2 38 per assessm

Average Episode C:sc: Avarage Annual per Clianr asz

Service Analysis

T-T

s ERVICS .- Assessment, Team

program Content Analysis

Client Service

Client Hrs.

Client Hrs.

per ctexAssess. oer week

A. Intake, screening, ass-

essment, indiv. service

plans & referral to

Community serv. workers

6.0

N.A.

B. Periodic reevaluation

-at least annually

c. Raevaluations upon req.

Utilization Analysis

Staff Hrs. per Client oer wk. Comments

1) psych.eval. - 2

2) psychoi.eval. .

3) fain, fc'social

6.0

serv. eval. «• 2.

Annual Prog. Capacity/^ of Clients
427

Average # Episodes per Client
1.5

Average # weeks per Episode
N.A.

* Direct Serv. Staff Hrs. per Client per Wk.
6.0

Total Staff Direct Serv. Hrs. Clients

% Direct Serv. Hrs. of D. Serv. Hrs. Avail.

3843 1

3843 ; 3347 = 1008

i Dir. Care Staff B. avail, for Dir. Serv.
3.25

Hrs./Wk. # Weeks

40

50

Total Hrs. Avail. Total Hrs. Avail. for Direct Serv (x.~)

6760

4732 i 1.23 = 3847

Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead £ Administration

.Ratio: OSA to Total Cost

752,216

99,415

Total Cost per Unit of Service
$ 39.60 per client hour 237.60 per assessment

Admin. * 37950 O.H. = 16850

54800 -. 152216 =

Total Cost per Episode

Total Cost per Client

$237.60

$356.40

Staffing Pattern Analysis Direct Cara Staff/Program Census .Ratio: 1.5 : 427 - .008 : 1 Administrative Staff/Direct Care Staff .Ratio: 2.5 i * 25 -
Commants Tota client hours = total staff direct service nours

(130)

12 II. COMMUNITY SERVICE COORDINATION PROGRAM
Community service coordinators should be closely related to the Assessment Team which will serve as the intake point for at risk clients in an Area. They should be assigned after the Assessment Team screening and once it is determined that DMH services will be made available to the client through an individual community service plan. Each service coordinator should have a caseload which reflects a range of client difficulties since long term ability to constantly handle the clients most disorganized and frequently in crisis is limited.
A. Definition Community service coordination involves responsibility for
establishing a supportive human relationship with each client; providing itermittent supportive'counseling with respect to problems in daily living; coordinating, monitoring and initiating changes in the agreed upon service plan for a client; providing continuity for clients as they move through various services of the system; and advocating for client vis a vis the mental health and generic service systems. 8. Program Elements
Program ^wi 11 1. Work closely with Assessment Team to receive referrals of clients for whom DMH services are being planned. 2. Establish a primary support relationship with the client through periodic individual meetings at a clinic location and in the field (e.g., in a client's home, residential program or day program). 3. Meet periodically with the program staff or individuals providing services for the client to monitor client's progress
(131)

13 and services and to assure linkages and communication among
services when a client is receiving more than one service.

4. Aid client's transition from one service or program to

another.

5. Assist clients in meeting demands of community living,

including advocating for the client's needs with community

agencies and other service providers.

S. Act as resource for referral and assistance of clients in

obtaining generic education, employment and recreation services.

7. Arrange for periodic revaluations of client by the

m

Assessment Team and referral to other services when appropriate

or discharge planning and recommendations when appropriate.

8. Receive consultations from the Assessment Team, Crisis

Unit, and Medication Unit.

9. Casework supervisors will assist in staffing individual

service planning teams drawn up by the Assessment Team and

will provide direct care two days per week.

C. Clients

This program model will provide Community Service coordination

to 427 clients at any one time. The caseload for an individual

community service worker- will he between 30 and 35 clients.

No worker will have more than 5 acute severely disturbed clients.

Clients are projected to need Community Service coordination

for 50 weeks annually.

(132)

Staffing/Cost Schedule

ICE: Community Service Coordination

Full

reet Care Personnel

FTE's Salary

Program Salary

Community Service Coordinators 9 lO.OOOea.

140,000 140,000

Case Work Supervisors <a 15,000 ea.

3.0 45,000 45,000

Fringe Overhead

181

20* TOTAL

25,200 28,000 -193,2:c

8,100 9,000 62,IOC

t

Sub-Totals: 1. Administrative Personnel

I 17-0 1

A. Director

1.0

B, Secretaries <? 7,500ea.

4.0

T185T00I

18,000 30,000

18,000 30,000

133,300 I
3,240 5,400

Sub-Totals:

\ 5.0

~. Program Supplies & Equip.

77' Client Supplies S Squio.

'• Transportation '**• Misc. (Specify)

21,240 35,400
56,D40|

Program Total

22.0 !

'-'nit Cost: 17.3U

per nour oer

!223,0Q0i 1^1,940 1 1377000
Average Episode Cost: mod.= 921
sev.= 1363
Average Annual per Client Co5t^3
(133)

Service Analysis

SERVICE; Community Sprvirp P.nnrrh'nation

?rcaram Content'Analysis

Client Service

Client Hrs. per day

Client Hrs. per week

A,. Commun. Serv. Coord, j

meetings with clientsC

5. Client advocacy

I

-)

- mild. dist. clients (43%). . . .25
- mod. dist. clients (43%). . .1.0
- severely dist
clients (14%). . .2.0

Staff Hrs. per Client per Wk. Comments
.25 . . . Clients seen. 1 hr. 1.0 . . . Clients seem 1 hr. p 2.0 . . . Clients seen I hrs/«

Utilization Analysis

3.25

3.25

Annual Prog. Capacity/* A. of Clients

Average # Episodes per Client

Average # weeks per Episode

# Direct Serv. Staff Hrs. per Client per Wk'.

Total Staff Direct Serv. Hrs. Clients

% Direct Serv. Hrs. of D. Serv. Hrs. Avail.

184

1

184

1

60

1

* Dir. Care Staff B. avail, for Dir. Serv.

50 50 50
# Hrs-Afc. * Weeks

.25

23001

17480 *?20432 •

1.0

9180

2.0

6000

86%.

17480 Total Hrs. Avail.

Total Hrs. Avail. for Diract Serv (x.7)

16.2'

40

50

32400

22680 * 1.11-= 20432

Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead & Administration

Ratio: OSA to Total Cost

325740

230100

Total Cost per Unit of Service
$ 1 7 - 8 i | Per c l i e n t hour per
Staffing Pattern Analysis

Admin. O.H.
Total Cost per Episode
mild = 232.87 mod. = 968 sev. =• 1937

56640 39000 95640

95640 t 325740 = 292

Total Cost per Client

232.87 931.50 1863.00

Direct Care Staff/Program Census Ratio: 15.2 : 427 = .036 ; 1

Administrative Staff/Direct Care Staff Ratio: 5 r 1?' = , ~B : 1

Total client hours = total staff direct service hours
Includes 3 supervisors available for direct service 2 days per week = 48 * 4u
(134)

16 I I I . PSYCHOTHERAPY COUNSELING PROGRAM
Access to regular psychotherapy, in addition to that provided through DMH residential or day programs, w i l l be provided through r e f e r r a l by the Assessment Team or the community service coordinator. The therapists w i l l work closely with the Assessment Team and the Community Service Coordination Program and w i l l aid in s t a f f i n g i n d i v i dual service planning teams structured by the Assessment Program. Since i t is expected that support f o r problems of daily l i v i n g would be offered by the community service coordinators and residential or day program s t a f f , therapy should be considered a supplementary service available to those c l i e n t s where day-to-day supportive help is not suff i c i e n t and individual therapy is recommended.

A. Definition

Family and individual psychotherapy services will provide

regular supportive therapy oriented to short term needs and goals

of clients and families as a supplement to DMH residential or day

services, or as the sole service for some DMH clients.

B. Program Elements

Program will

1. Recieve referrals of potential clients from the

Assessment Team or Community Service Coordinator

as part of client's overall service plan.

4

2. Meet periodically (ranging from several times weekly

to once or twice a month) with the client and/or

family for one hour supportive therapy sessions

directed to short term needs and goals of client.

3. Reoort to the Community Service Coordinator progress

or problems with the client.

(135)

17 4. Make recommendations to Community Service Coordinator
on changes in the client's service plan as may become apparent. 5. Aid in staffing individual service planning teams structured by the Assessment Team. 6. Receive consultation from the Assessment Team, Medication Unit and Crisis Unit. C. Clients Psychotherapy/counseling will be available for those clients who require intense, specialized assistance in modifying behaviors which they experience as problematic, resolving intrapsychic conflicts which interfere with their functioning and/or acquiring the skills and attitudes necessary to making and maintaining close interpersonal relationships. Therapy and counseling may be individual, group, or family, depending on client needs. This program model will serve 44 clients per area (10 per cent) annually providing approximately one hour per week of psychotherapy for 50 weeks per year. Each therapist would carry a caseload of 22 clients.
(136)

Staffing/Cost Scheduls , . Psychotherapy/Counseling -.

-•1. Direct Care Personnel
^. psychotherapists 2] ,000 ea.

Full FTS's Salary

Program Salary

2

42000 42000

Fringe

18

Overhead

20%

TOTAL

7560

3400

57960

Sub-Totals:
Administrative Personnel
A secretary 9 $7,500

|I 2 !1
.5 7,500

|42000| [ 7 5 6 0 j | «34uu |

3,750

675

NA

4425

2385

Sub-Totals: Program Supplies S Equip.
"• Client Supplies & Equip.
Transportation Misc. (Specify!

3.75CJ 1 675 I

4425

ar. Total

ZJ

t Cost: S28.26 per c l i e n t hour

ser

l45,750j IS235 I I 3400 | i 623351 Average Episcda Cos-: 1418 Average Anr.uai ?er Client Cost '418
(137)

Service Analysis

19

SERVICE t Psychotherapy

L Program Content Analysis

Client Service

Client Hrs. per day

Client Hrs. per week

Staff Hrs. per Client per >flc.

A. Intake and hourly

sessions directed

N.A.

1.0

1.0

it-

towards short term

needs

II. Utilization Analysis

Annual Prog. Capacity/* A. of Clients
44

Average S Episodes per Client

Average # weeks per Episode
50

S Direct Serv. Staff Hrs. per. Client per Wk.

Total Staff Direct Serv. Hrs. Clients
22001

% Direct T Serv. Bri. of D. i Hrs.
2200-252>«l
-4

4 Dir. Care Staff a v a i l , for Dir. Serv. 3 Hrs./VTk. ? Weeks

Total Hrs. Avail. Total Hrs. Avail. for Direct Serv te

40

50

4000

2S00il.11=1523

III. Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead & Administration

Ratio: 0SA to Total Cost

62385

49560

Total Cost per Unit of Service
28.36 per clienthour
per

O.H. =• 8400
Admin. = 4425 12825
Total Cost per Eoisode
$1418

12825 T 62385 = 215
Total Cost per Client
$1418

IV. Staffing gattarn Analysis Direct Care Staff/Program Census Patio: -.. 44 = .045:1 Adninistrative Staff/Dirsct Cara Staff ?.atio: .5-7 = pc-i
V. Corjnents 1. Total client hours = to total staff direct service hours.

(138)

1

20

IV. RESPITE CARE SERVICES

For those clients who are l i v i n g at home with immediate family or

relatives, or in specialized home care, or those adolescents who are placed in foster care, some r e l i e f (consistent with.Department policies) from constant supervision and care by the family, relative and/or foster family should be provided. Respite care services which would allow such a family or foster family to take a t r i p or vacation (or r e l i e f , required for emergency reasons such as the primary family member is hospitalized) are vital components in the a b i l i t y of families to main-

tain some chronically handicapped persons at home on a long term basis. Respite care can involve day time and evening (less than overnight), and overnight care of varying lengths, either in the c l i e n t ' s home while the family is absent, in the home of a trained provider, or in an apartment program or community residence.

A. Definition Respite care provides r e l i e f for a family from daily care and
supervision of a DMH client who is residing in a family setting, whether natural family, relative, foster family, or other types of specialized home care. Respite care may extend from a few hours up to 30 days of care provided in the c l i e n t ' s home, in the home of a trained community provider or in DMH community-based housing.
8. Program Elements Program w i l l 1. Receive referrals from the family and/or client's community service coordinator but provide service only after consulting with the community service coordinator. (139)

21 2. Provide day time/evening r e l i e f for a fe* ncurs on
a regular or intermittent basis or ovemicn: cars for up to 30 days a year on a regular or intarmittant basis in the c l i e n t ' s home, trained ccnrunity provider's home or DMH community-based housing. 3. Continue as much as possible client's c'ai'y routine. C. Clients For any clients l i v i n g with imnediata fairily ^emoers, friends or relatives or in specialized home care, who reouira constant supervision. This program w i l l provide respite an services to 75 clients annually for an average of 2 weeks.
(140)
m

3ta;fir.?/Cost Schedule • •Respite Care Coordinator :

Direct Care Personnel

FTS's

i. Respite Care Coord.

0.75

I. Training Coord./Comnun. Provider Recruiter 0.25

Full Salary J4000
]2000

Program Salary 10500
3000

Fringe
18%
]890

22
Overhead
20%
2]00

TOTAL
] 4490

540

600

4] 40

Sub-Totals:

11.o !

Administrative Personnel A. Administrative Coord. 0.25

: B'. Training S Recruit. Admin.

0 .25

C. Secretary
Sub-Totals:

0 .5
Li J1_J

Program Supplies & Eouip.

Client Supplies & Eauip.

1 3500| | 2430 | | 1 70U j j ] 36 30

14000

3500

630

n.a.

4]30

12000

3000

7500

3750

li0250' 1

540 675 1 "T845 1

n . a . 3540

n.a.

4425

fT2095"1

1 01

' v - Transportation

Misc. (Specify)
a. Fees for s e r v i c e 53. per hour for

= 14 days

o v e r n i g h t s o r 12 days d a . c a r e §a o r $ 2 0 . p e r n i g h t : S 2 8 0 x 75 c l i eents

20900

Program Total 2.0-

51525^1

'-nit Cost:

S6.15
_J9.20

per r i • a P t hour

Average Episode Cose: 689

?er s, v,r . d a . or night

Annual per C l i e n t Cost 589
(141)

Service Analysis

23

SERVICE; Respite Care I. Program Content Analysis
Client Service A. Day and/or Night
Residential Care

Client Hrs. per day

Client Hrs. per week

Staff Hrs. per Client per Wk.

IX. Utilization Analysis

Annual Prog. Capacity/t A-. of Client3
75

Average # Episodes per Client

Average # weeks per Episode

# Direct Serv. Staff Hrs. per Client per Wk.
56

Total Staff Direct Serv. Hrs. Clients

% Dix« Serv. of 0. Hrs. A

840CT

N.A.

# Dir. Care Staff B. avail, for Dir. Serv. ft Hrs./Wk. ft Weeks

40

50

Total Hrs. AT. Total Hrs. Avail. for Direct Sei

2000

1400 7 1..11-U

III. Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead & Administration

Hatio: O&A to Total Cost

51625

15930

Total Cost per Onit of Service

$6.15 S49.20

P « client hour per 3 hr. day or
nighr

O.H. » 2700 Admin. =12095
14795 Total Cost per Episode
688.30

H795 -• 51625 = 295
Total Cost per Cliant
688.80

IV. Staffing Pattern Analysis

Direct Care Staff/Procram Census Hatio •.

Adr.ir.isrrative Staff/Direct Care Staff 2atio:

1-1. = i n

V. Comments

1. Total client hours = total staff direct service hours

(142)

24 V. FAMILY SUPPORT SERVICES
In addition to Respite Care and Psychotherapy Counseling Programs, natural families, foster families and specialized home care programs who maintain a client at home may need some additional specialized training and direction to help them with their DMH family member. Rather than creating an entirely separate component, such programs should be contracted, via a family and individual psychotherapy counseling program or a respite care program, with the addition of a staff member in each area who focuses primarily on family management help. This person would be responsible for meeting with family members on issues relating to maintaining clients at home in addition to traditional family counseling. The services should be directed to specific short term goals and not be designed as a long term maintenance program. Maintenance should be provided through periodic family and individual psychotherapy and the Community Service Coordination Program.
A. Definition Family support services consist of specific, short term training
and behavior management skills help which is provided to families of DMH clients who are living at home, with a relative, foster family or in specialized home care.
8. Program Elements Program will 1. Receive referrals from the Assessment Team and/or community service coordinators. 2. Meet with family members to identify and provide help in resolving training and behavior management needs of clients where family, as opposed to pro-
(143)

25 fessional intervention, is necessary and appropriate. 3. Keep community service coordinator informed of family's progress and skill attainment. 4. In consultation with community service coordinator and family, terminate services when goals are achieved. C. Clients
For families with clients at home who need assistance to help them cope with and aid the clients. This program will provide services to a total of 40. families annually for an average of 15 weeks. A therapists' weekly caseload is projected to be 12 families, each family to be seen on the average once a week for approximately 2 hours.
(144)

Staffing/Coat Schedule

Support Services
Direct Care Personnel

Full FTE's Salar\

Salary

\, Family Therapy Specialist

1.0

20,000 20,000

Fringe IB\

26
Overhead 20%

TOTAL

3,600

4,000 27,600

Sub-Totals: t."Administrative Personnel

I 1.0 I

i 20,OOOl | 3,6001 ' 4,000 \ 27.S0~cl

Sub-Totals:

•3

OX. Program Supplies s Eauip.

**. Client Supplies & Equip.
v. Trannsportation
H
Misc. (Specify)

Program Total

Unit Cost:

S23

per client hour

546

t-.o r sessica

1 20,DCO 1 3,,-jogJ I * . wCO 1 127 n H
Avcraac Episcdo C.nsz-. (145)

Service Analysis

27

SERVICE; Family Support Service

I. PTogram Content Analysis

Client Service
A. Short term family support

Client Krs. per day

Client Hrs. oer week

Staff Hrs. J>er Client per Wk.

II. Otilization Analysis

Annual Prog. Capacity/* A. of Clients
40

Average 4 Episodes per Client
1

Average # weeks par Episode
15

# Direct Serv. Staff Hrs. per Client oer Wk.

% Dire

Total Staff Serv. ;

Direct Serv. of D. :

Hrs. Clients Hrs. A'

1200J

1200-126

# Dir. Care Staff 8.. avail, for Dir. Serv. $ Hrs./Wk. = KaeJcs

40

50

Total Hrs. Ave Total Hrs. Avail. for Direct Sei

2000

14000 - 1.11 - I

III. Cost Analysis
Total Cost 27600

Direct Care Personnel Cost
23600

Overhead s Aininistration
O.H. 4000

Ratio: OSA to Total Cost
4000:27600 = 14%

Total Cost per Unit of Service

$23

per client

$46

per session

Total Cos: per Esiso:
$690

IV. Staffing Pattern Analysis

Direct Care Staff/Program Cansus Hario:

1-4Q =

Administrative Staff/Direct Care Staff ?.= ti.3:

Total Cost per Client
$690

1. Total client hours • Total s-caff direct service hours

(146)

28 VI. MEDICATION UNIT/NURSING SUPPORT
All clients in each Area will need an initial evaluation to determine the need for and .type of medication. In addition, all clients who receive medication will need professional monitoring of the medication. Some DMH clients will need monitoring of physical health care needs that relate to the use of medication, and which cannot be obtained from generic services such as the V.N.A. Non-medical supervision of administration of medication - when necessary - should be a responsibility of residential and day program staff. This program should be based in close physical proximity to the Assessment Team. Staff of this program will work closely with the Assessment Team and will aid in staffing individual service planning teams for all at risk DMH clients in the area.
A. Definition A program designed to evaluate, in conjunction with the
Assessment Team, the need for medication for all at risk DMH clients in the Area, to prescribe and monitor medication for those clients who require it, and to provide supplementary home nursing visits for those persons having physical health care needs related to medication.
B. Program Elements Program will 1. Aid in staffing individual service planning taams structured by the Assessment Team. 2. In conjunction with the Assessment Team, evaluate the need for medication for all clients and for those requiring medication, determine aDpropriate
(147)

29 medication type, dosage and frequency. 3. Periodically monitor medication effects of clients through client appointments at a clinic or home visits (75% clinic visits; 25% home visits). 4. Provide consultation to OMH residential and day programs on medication issues. 5. Provide periodic home visits designed to deliver or monitor general health care in conjunction with medication needs through coordination with V.N.A.'s and when V.N.A. services are not adequate. 6. Provide regular weekday coverage for determining medication needs and administering medication for Crisis Unit clients.
C. Clients Assessment will be provided aTl clients. Medication will
be provided to clients requiring it to control mental or somatic symptoms not amenable to less restrictive treatments. Medication for physical illnesses will only be given to clients who do not have access to generic health services. This model can provide medication assessments to 427 clients annually. It car) also provide medication monitoring and medication related services to 256 persons of the 427. The average client would be seen once per 2 weeks.
(148)

Staffins/Coat Schedule

Support

Direct Care Personnel

Full FTE's Salary

Program Salary

A. Clinical Director (RN)

.5

15,000

7,500

B. Psychiatrist

.75 45,000 33,750

C. RN's 9 12,000 ea.

2.0

24,000 24,000

Fringe 13%
1,350

30

Overhead

20%

TOTAL

1,500

10,350

6,075

6,750

46,575

4,320

4,800

33,120

Sub-Totals:
Administrative Personnel A. Administrator B. Billing/Appts. Secy.

I 55.250! 1 11,745i

.5

15,000 7,500

1.0

7,500 7,500

1,350 1,350

8,350 8,850

Sub-Totals:

1 1.5|

Program Supplies-& Equip.

!• Client Supplies & Equip.

Transportation Misc. (Specify)

27UU \

17.7001

0!

Program Total

•unit cost:

10.39 21 . 73

?er client hr. ?er assessmt.

n3,Q'5"G"|

Average Episode Cost:

m med mn-

Average Annual par Client Cost ^07.32 :Tied-

monitoring plus assessment ( U 9 )

Service Analysis

31

SERVICE: Medication/Nursing Support

I Prograa Content Analysis
Client Service
A. Medication Group B. Medication Review C. Physical health care
(limited) 0. Medical Assess, for
all clients

Client Hrs. per day

II. Utilization Analysis

Client Hrs. per week
1.0 .25 .2
1.45

Staff Hrs. per Client ner WJc.

.12 .25 .2 .57 .28 2 hrs per assess.

8 clients »1

Annual Prog. Capacity/* A. of Clients

Average # Episodes per Client

Average $ weeks per Episode

# Direct Serv. Staff Hrs. per Client per Wk.

. % Direct Total Staff Serv. Brj Direct Serr. of D. s«i Hrs. Clients Hra.

427

1

1

2

954

2818 z 331

256

1

26

.28

'1864

735

2818

4 Dir. Care Staff B. avail, for Dir. Serv. 3 Hrs.Afo-

V7eeks

Total Hrs. Avail Total Hrs. Avail. for Direct Serv

3.25

40

52

6760

4732 f 1.23 »

III. Cost Analysis

Total Cost
107745

Direct Care Personnel Cost
76995

Overhead & Administration O.H. » 15,300 Admin. - ]7,7QQ
33,000

Ratio: O&A to Total Cost
33000 :• 107745 • 318

Total Cost per Unit of Service
<;in-.?f; per client hour l ? per Assess

Total Cost per Episode $386.80-

Total Cost per Client
$407.32

IV. Staffing Pattern Analysis

Direct Care Staff/Program Cansus Ratio: 3.5:427 = 008:1

Administrative Staff/Direct Care Staff Ratio: 1:3.5=.29:1

V.
i Total Client hours Assessments 427 x 2=854 client hours
Medication monitoring 256 x 1.45 x 26 = 3651.2 hours
Total client hours = 10505.2

25% of staff rime to.be soenz i support of crisis intervention unit and assessment team
(150)

32
VII. CRISIS INTERVENTION UNIT This program will respond to crises in homes, DMH residences or
day programs and will act as the intake point for all clients in crisis. It will work closely with the Assessment Team to initiate revaluation of clients in crisis if they are already in the DMH service system or to initiate an assessment and individual service plan if the client is new to the DMH service system. The program will receive referrals from a community service coordinator, a DMH contracted program (day or residential), other public and private agencies, the client or any citizen. It will have the capacity to respond to a crisis through visits to the client's home, bringing the client to a clinic location or providing temporary residential services in a small residential setting exclusively reserved for clients in crisis but preferably operated by a nonprofit community agency which is also providing other residential services for DMH. In all cases there must be adequate staff to be with, support and follow the client fhrough the crisis for up to five days. The Crisis Intervention Program will receive back up support from the Assessment Team. For clients not capable of returning to some residential setting or their home after five days, for highly assaultive persons, or those needing medical attention, voluntary or involuntary inpatient services in general hospitals will have to be considered.
A. Definition A program designed to provide crisis intervention on a 24 hour
a day, 7 days a week basis for up to five days, 24 hours a day, to clients both new to the DMH system and those already receiving DMH services.
(151)

33
B. Program Elements Program wi11: 1. Be available on a 24 hour, 7 day a week basis to respond to mental health crises of new, former or current DMH c l i e n t s . 2. Provide crisis intervention services of a short term nature (1-5 days), including residential services. 3. Provide consultation in crisis intervention to DMH contracted programs, hospitals, police-departments and other public and private agencies. 4. Receive referrals from any DMH program, from public or private agencies or individuals, and from clients and fami 1i es. 5. Make arrangements for revaluation of the client's individual service plan or i n i t i a t e assessment and service planning for clients new to the DMH system with the Assessment Team. 6. Utilize the Medication Unit and Assessment Team professionals as back-up during regular working hours for providing prescriptions and recommendations in handling crisis situations. Utilize on-call psychiatrist(s) and psychoiogist(s) for evenings, nights and weekends. 7. Along with the Assessment Team, i n i t i a t e plans to be implemented for the client at the end of the 5 day crisis intervention period.
(152)

34 C. Clients
This service will be available for clients who are acutely and severely disturbed Including those who may be dangerous to themselves or others, extremely psychotic, intoxicated, or experiencing some severe life crises. This model 1s designed to provide emergency services to- 16V. clients. . 89 of these are projected to require regular emergency service and 72 the intensive services. These clients will generate 411 emergency episodes p^r year.
(153)

Staffing/Cost Schedule

I. Direct Care Personnel

FTE's

A. Prog. Dir. s Sr. Clinician 0.75

B. MSW, Psychiatric

(Fam. Treatment Background) 1.0

C. RNs Psychiatric @ 13,000 ea.

(rotating shifts or on call) 3.0

0. Mental Health Workers

@ $12,000 ea. (rotating

shifts or on call)

6.0

E. Psychiatric Consultation

7 da. 24 hr.

0.5

F. Crisis Man. Consult. 7 da.

24 hr.

0.5

Full Salary 25,000 15,000 39,000
72,000 53,100 25,960

Program Salary 18,750 16,000 39,000
72,000 26,550 12,980

35

Fringe Overhead

18%

20%

TO]

3,375

3,750 25.375

2,880 7,020

3,200 7,800

22 » .*»

12,960 N. A. N. A.

14,,400 N., A. N.. A.

99'3«Q
26,550 12,980

Sub-Totals:
II. Administrative Personnel
A. Adiainistrator B. Sect's. @ 7,500 ea.

f 11.75!

i]85 .280

0.25 2.0

25,000 15,000

6,250 15,000

! 262,3S| ! 29I,SO (240

1,125 2, 700

N. A. N. A.

7,37S 17 .700

Sub-Totals:

| 2.25

III. Program Supplies & Equip.

IV. Client Supplies & Equip.

1 21,250| I 3,3251

CZ3

V. Transportation
VI. Misc. (Specify) Residential Costs - Retainer fee plus $20 per night for 432 nights per yea

VII. Program Totai

.206.530 , 30,360J I 29.:5o! wti—• -

VIII. fJnit Cost:

S23.24ger

f o r Average Episodo Cost: 1733.00 iar l*

reg. emergenciies

,q

$24.07 =er intensive care Average Annual per Client Cost•r^J

^ '

hour

JlSo

577.68 per day

WEEK DAYS
WEEK ENDS
01

PROGRAM TYPE 24 Hour, 7 Day Emergency and C r i s i s Intervention

DAY

On

7AM - 3PM

Hours per day

p

Hours per week

4Q

tto. of Staff

2 .75

it>tal F.T.E.s

2.75

.75 c l i n i c a l director

1.0 s o c i a l worker

1.0 MIIA

(1 RN from medic, grp on

call)

EVE = 3-
40
) .0 RN ].0 MHA

Jit

7- 3

lours p e r day

8

lours per week

16

lo. of Staff

2

l'otal F . T E . s

•8

1 RN
1 MIIA

3 - UPM 8
I6
2 •8
1 RN 1 MIIA

NIGHT
" I 1PM - 7AM
32
1
.8 (Mon. - Thurs.)
].0 MUA

(Fri.- Sun.

= 11PM -7AM 8

«

24

m

2

ss

i.i

1 RN 1 MUA

FLOAT
As Needed

m PlOMr.

MD Crisis

3

3

15 )5

Flex.

.4 .4

•As Needed -fttJ ^MHA .10

-.5

MD Cris

Spec

3

3

6 15

Flex.

.2 .4

TOTAL
8.0S 75 Clin. U r . 1.0 Soc. Wprk 4.1 MHAs .8 MD & Crisis
>ecial
4. 1 1.6 RNs 1.9 MIIAs
.6 MD S Crisis Spec.

Staff: Client Ratio

Total D.C. Staff «= X 1.23 If Apt. X 2
+ Dir.

12.15 Included in Float

o>

Service Analysis

SERVICE: Emergency/Crisis I. Program Content Analysis
Client Service A. 24 hrs, 7 day avail,
intake & referral B. Intensive care
(24 hr. specialing)

Client Hrs. per day N.A.
24

Client Hrs. per week
72

II. Utilization Analysis

37

Staff Hrs. per Client per Wk.

CoGunentg

72

... Extra staffing

for average episodet

IMHA per shift per -

day

Annual Prog. Capacity/* A. of Clients
1. Reg.Emerg. s-89 2. Intens.Smergs-72
161

Average # Episodes per Client
3 2

Average # weeks per Episode
N.A. N.A.

# Direct Serv. Staff Hrs. per Client per Wk.
6 72

Total Staff Direct Serv. Hrs. Clients
1602 10368 11970

* Direct Serv. Hrs. of D. Sez^r. Hrs. Avail.
11970^13909

*. Dir. Care scarf B. avail, for Dir. Serv. # Hrs./Wk. # Weeks

Total Hrs. Avail. Total Hrs. Avail. for Direct Serv (x.V,

1U75

40

52

24,440

17108 T 1-23 = 13909

til. Cost Analysis

Total Cost
A. Regular- 24,817 B. Intern.-249,563
274,380

Direct Care Personnel Cost
208385

Overhead & Administration
Admin.-25072 O.H. -29150
54222

Ratio: OSA to Total Cost
54222* 274380 =

Total Cost per Unit of Service
A._Res_$23..2>4 P e r client hour B.Int.$7d r)7 per hr
577.68 per day

Total Cost per Episode
A.Reg •' 92.96. B.lnt '•1733.00

Total Cost per Client
A.Reg. - 278.88 B.lnt. - 3466.00

Staffing Pattern Analvsis

Direct Care Staff/Program Census Ratio:12.15;161 » .075: 1

Administrative Staff/Direct Care Staff 3atio; 2.25:.11.75 - .19:1 V. CoerceHE3

Total Client hours: Reg emergency clients » 89x3x4 » 1063 client hours Int. emergency clients - 72x2x72 • 10368 Total client hours - 11436

(156)

38 VIII. INPATIENT PROGRAMS
Treatment will be provided in general hospitals with psychiatric capacity. Referrals will be made from the Crisis Intervention Program and directly from the community. Depending on the length of stay of the client, the Inpatient Program will perform assessment, evaluation and treatment planning functions and initiate on-site treatment. If the stay 1s less than four days, assessment and treatment planning will be referred to the Assessment Team. The Inpatient Unit will work cooperatively with the Assessment Team and Crisis Unit and referral to other OMH services will take place only through the Assessment Team.
A. Definition To provide short term involuntary or emergency hospitalization
(under 30 days) for assaultive persons who are in crisis and who cannot be served at the time 1n other DMH residential, day, or crisis intervention programs.
B. Program Elements Program will 1. Receive referrals from the community or the Crisis Unit. 2. Provide short term crisis intervention, assessment, treatment planning and initiate treatment programs for clients. 3. Refer to and coordinate with Area Crisis Unit and Assessment Team.
Program could 1. Provide shelter and treatment in the evenings for clients
who participate in Day Treatment, Day Activity, Vocational
(157)

39 Training, or other programs during the day. 2. Provide shelter and treatment on the weekends for clients who participate in Day Treatment, Day Activity, Vocational Training, or other programs during the weekdays. C. Staffing/Costs Approximately 4 beds should be provided in a general hospital located in each Area. The costs of care in the hospital should be paid through insurance or Medicaid. D. Clients For those clients needing constant or specialized medical supervision in a medical environment including those requiring involuntary care. Approximately 4 beds annually are estimated to be necessary. The costs of care in the hospital should be paid through private insurance or Medicaid.
(158)

40

IX. DAY TREATMENT PROGRAMS

These programs will be utilized primarily by clients requiring

OMH housing but not exclusively so. They should be viewed as rela-

tively intensive therapeutic programs which should serve clients

for an average of 16 weeks with treatment directed toward specific

goals. Clients should then be able to move to less intensive ser-

vices such as supportive psychotherapy counseling, day activity,

employment, or educational programs. Referrals, along with individual

service plans, will be received from the Assessment Team and monitor-

ing of individual service plans will be conducted by a community

•I?

service coordinator.

A. Definition

Day treatment programs provide a structured, five day a week,

day time program including psychiatric services, individual and

group therapy, milieu therapy, medical services, educational ser-

vices, and social and vocational rehabilitation on irrelatively

short-term basis directed to individual treatment goals.

B. Program Elements Program w i l l 1. Receive referrals from Assessment Team. 2. Implement individualized service plans directed toward movement of client into less intensive services. 3. Provide a range of medical, therapeutic, educational, social and vocational services. 4. Regularly consult with each client's community service coordinator and together with community service coordinator plan for client leaving program when client reaches goals
(159)

•ftf

originally agreed upon or when for other reasons, termination of program seems appropriate. 5. Provide for transportation of clients to and from program. 6. Meet periodically with client's family and/or residential placement staff to discuss client progress.

"9*
41

C. Clients For acutely disturbed clients who need intensive supervision
for severe psychosis, medical disorders or behavioral problems.
The annual number of clients to be served by this model is 60. The average client is estimated to need 16 weeks of care. The census capacity of the program at any one time is 20.

(160)

X. Direct Care Personnel
;. psychiatric MSW l, - Oecyvoe Therapist 3. N H? worker 9 9500 ea j. Psychologist T. Psychiatrist (consult)

Staffing/Cost Schedule :

Full FTE's Salary

Program Salary

42

Fringe Overhead

13%

20%

TOTAL

.5 1
.5 3
.5 .25

17,000 16,000 14,000 28,500 11,000
53,100

8,500 16,000
7,000 28,500
5,500
13,275

1530 2880 1260 5130
990
n.a.

1700 3200 1400 5700 1100
n.a.

11,730 22,080
9.660 39,330
7,590
13,275

Sub-Totals:

5.75

XI. Administrative Personnel

7ft, 77* 1U.790I 1 13,10q

director Secretary

0.5 17,000

1.0

7,500

8,500 7,500

1,530 1,350

Sub-Totals: III. Brogram Supplies & Eauip.

J"5 1

| 16,00CJ 1 23,80

IV. Client Supplies S Equip.

N.A. N .A.

10 ,030 3,850
1 13,38CJ
|0

V. Transportation VI. Misc. (Specify)

5,00C 7,000

VIZ. Srogram Total

7.251

Unit Cost:

A.67 per slienr hr 29.02 ?er da

I" 94.7751 i 14,6701 1 13,100|
Average Episode Cost: Average Annual per Client Cost gg^T.50
(161)

Service Analysis
43

SERVICE: Day Treatment

I- Program Content Analysis

Client Hrs.

Client Service

per day

A. Intake,Treatment Plan

N.A.

B. Brief psycho therapy

N.A.

C. Voc. Counsel.

N.A.

:

D. Group ther.

1

E. O.T.

3

F. Meetings with fam/resid staff N.A.

Recreation

N.A

II.' Utilization Analysis

Client Hrs. per week
N.A. 1.0 1.0 5.0 15.0
.5
7.5
30

Staff Hrs. per

Client per W7c. Commtsnts

N.A.

—=i

1.0

1.0

1.0

10 clients: 2 sti

2.0

15 clients: 2 st*

.5

2 staff spend to*

1 hr per mo.

1.0

15 clients: 2 sta:

6.5

Annual Prog. Capacity/* A. of Clients

Average # Episodes per Client

Average % weeks per Episode

# Direct Serv. Staff Hrs. per Client per Wk.

% Direct Total Staff Serv . Hrs. Direct Serv. of D . Sen Hrs. Clients Hrs. Avail

60

1

16

6.5

624C

6240-J72S2-8

V '

#. Dir. Care Staff »• avail, for Dir. Serv. # Hrs • AHc- # Weeks

Total H r s . Avail. Total Hrs. Avail. for Direct Serv I

5.75

40

50

11500

8050*1.11 - 7252

III. Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead & Administration

Ratio: O&A to Total Cost

34465

90565

Total Cost per Unit of Service
4.67 per client h o u r 1 28.02 per day

Admin O.H.
Total Cost per Episode
2241.60

18,800 13,100 31,100

31100 * 134465 » 23S

Total Cost per Client

2241.60

IV. Staffing Pattern Analysis Direct Care Staff/Program Census ?.atio: 5.75:20 * .29:1 Administrative Staff/Direct Care Staff 3atio: 1.5:5.75 * .26:1
V. Conffisnts Total Client hours = 60x16x30 * 28600

(162)

X. DAY ACTIVITY TREATMENT PROGRAMS
*
The major distinction'between day activity and day treatment programs is that some clients may utilize day activity programs on a long term basis whereas day treatment programs should be designed as more Intensive and limited to a short term. Day activity programs will be oriented for chronic or stable clients (including MR) who may be preparing for sheltered workshops or some supervised employment setting but who have limited potential for independent employment and self-support. They will include a prevocational training component similar to, but separate from, the sheltered workshop serving more independent clients.
A. Definition Day activity programs consist of a daily, five day a week,
structured program of social, educational, vocational, rehabilitation and activities of dally living training oriented to individual services plans and goals of clients, including both those requiring a short term transitional service and others requiring a longer term maintenance service.
B. Program Elements Program will 1. Receive referrals from Assessment Team, Day Treatment, and Community Service Coordinator. 2. Implement individualized service and training plans directed either to movement of clients on to sheltered workshops or other vocational programs or to maintenance of clients who cannot move to less structured settings. 3. Provide training in social, educational, vocational,
(163)

45 rehabilitation and activities of daily living s k i l l s . 4. Regularly consult with each c l i e n t ' s community service coordinator and together with the community service coordinator, plan for c l i e n t ' s leaving the program or any necessary adjustments for long term clients, including placement in sheltered workshop. 5. Meet periodically with family and/or residential placement staff to discuss c l i e n t ' s progress. 6. Provide for transportation of clients to and from program. C. Clients For clients who are not acutely disturbed but who need long term support and supervision to assist them in dealing with chronic and/or ^ry debilitating problems. The program model would serve 30 clients at any one time. The expected length of service for an average client is 50 weeks. Consequently"the number of clients one program can serve annually is 30.
(164)

Staffing/Cost Schedule

»rvi<set*

n»y a^t-iv-it-y Treatment m

I. Direct Care Personnel

Full FTE's Salary

Program Salary

A. Pronram Director

.5

16,000 8,000

B. MS*i Psychiatric

.5

16,000 8,000

C. Psychologist

.5

20,000 10,000

D. Education Specialist

.5

14,000 7,000

E. Occupational Therapist
r. Mental Health Workers
S 9500 ea

1.

14,000 14,000

3.

28,500 28,500

G. Vocational Counselor Consult

.2

20,700 4,140

Fringe 18%

46
Overhead 20%

TOTAL

1440 1440 1800 1260 2520

1600 1600 2000 1400 2800

11,040 11,040 13,800
9,660 19,320

5130

5700

N.A. N.A.

'39,330 4,140

Sub-Totals: II Administrative Personnel
A Administrator B Secretary

[ 6.2 |

(79,640 j |13,590 j I is,ioq |108,33q

.5

16,000 8,000

.5

7,500 3,750

1,440 675

9,440 4,425

Sub-Totals:

[ 1. |

IXI Program Suoolies & Eauip.

|ll,750 | 1 2,115 |

IV. Client Supplies & Equip.

V. Transaortation (Bus Driver, Insurance, Maintenance)
VI. Misc. (Specify)

| 13,363
! o
7,000 7,000

VII. Program Total

Unit Cost:

oer

aer

75,5001 i 15.705J I 15-lQol
Average Episode Cost:_ Average Annual per Cl-ar.t Ccs:
(165)

SERVICE: Day Activity Treatment

Service Analysis
-

i 47 4

X- Program Content Analysis

Client Hrs.

Client Service

per dav

A. Intake, service plan

N .A.

B. Counseling (Supportive)

N .A.

C. Voc. Counseling

N .A.

D. Voc. Training/O.T.

3

E. AOL Group

1

F. Meet with Family/Resid. staff N .A.

C. Recreation II. Utilization Analysis

N .A.

Client Hrs. per week
N.A. .33 .25 15.0 5.0 .5
7.5 28.58

Staff Hrs. per

Client oer

Carwiei-

N.A.

.33

.25

2.0

15 clients: 2 tt,

1.0

10 clients: 2 at

.5

2 staff spend

total l h r s u ,

1.0 5.08

15 clients:2 tta

Annual Prog. Capacity/3 A. of Clients
30

Average £ Episodes per Client
1

Average # weeks per Episode
50

w Direct Serv. Staff Hrs. per Client oer Wk.
5.08

% Direct Total Staff Serv. Hr*. Direct Serv • of D. s«r». Hrs. Cliants Hrs. Av»4t

7620

7620^-7320 «f

#. Dir. Care Staff B. avail, for Dir. Serv. # Hrs.AJk- * Weeks

6.2

40

50

Total Hrs. Avail. Total Hrs. Avail. for Direct Serv {a

12400

8630-1.11 = 7820

III. Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead & Administration

Ratio: OSA to Total Cost

13619S

93230

Total Cost

per Unit of Service

3.18
ISL1S

per client hour1
Per day

Admin. » 13865

28965 - 136195= 21%

O.H. » 15100

2S965

Total Cost

Total Ccst

per Episode

per Client

$4540

$4540

IV. Staffing Pattern Analysis Direct Care Staff/Program Census Ratio:6.2:30 = .21 Administrative Staff/Direct Cara Staff 3atio: 1:6.2 = .16
V. Cotrjr.ents Total client hours = 30x50x28.53 = 42870

(166)

48
XI. VOCATIONAL REHABILITATION Vocational services should, wherever possible, be utilized in the
community, rather than creating special programs for OMH clients. Clients who do not require intensive supervision in Day Treatment or Day Activity Programs would presumably be able to participate in a CETA, WIN, NYC, OIC, or other privately financed job training program with the supportive help of their family and/or residential placement counselor or their community service coordinators. For those persons needing additional support and assistance in locating employment, a transitional employment and job placement program is necessary. For persons not yet capable of working in regular employment settings, a prevocational and sheltered workshop program would be created.
While a number of vocational rehabilitation services and program models are being proposed, we realize that there are many other types of programs that can and should be encouraged to develop- The absence of such programs from this model is not to imply that new, creative, and innovative approaches to vocational rehabilitation should not be encouraged. Some specific models that are valuable for different client ability levels and interests include client managed businesses, outdoor work programs, and cottage industries.

• -'•!>:.

(167)

49
A. PREVOCATIONAL TRAINING/SHELTERED WORKSHOPS Prevocational training and sheltered workshops should be
established with the primary goal of teaching basic work skills and providing employment opportunity in a supervised and structured setting which will also meet the client's social and rehabilitation needs. It is expected that some percentage of the clients will eventually move on to other employment settings. The capacity to provide such movement must be included, in addition to the provision of long term useful employment on a maintenance basis for a number of clients.
1. Definition Prevocational training provides a structured employment
setting for the teaching of basic work skills to persons not yet able to perform independently in a sheltered workshop. A sheltered workshop provides vocational training and rehabilitation services, and work activity acquired through contracts with private industry. This training is designed primarily as an intermediate step for clients capable of moving on to independent employment, but also serves as a long term setting for clients with limited potential to obtain independent employment.
2. Program Elements Program will a. Receive referrals from Assessment Team, Day ~reiz~erz, and Community Service Coordinator. b. Implement individualized vocational plans, as oreoarec by program staff, directed toward ,-novment of clients to independent emcioyment or to productive -aintenanca
(168)

50 of sheltered employmentc. Provide supportive counseling related to employment and employment related problems. d. Regularly consult with each client's community service coordinator and together with the community service coordinator, plan for any changes in the client's service plan. e. Meet periodically with client's family and/or residential placement counselor to discuss client's progress or status. f. Provide transportation to and from program.
'£.:
C. Clients For clients with severe or multiple disabilities who lack
basic work and social skills, "his program model will serve 38 clients annually, and 30 clients at any one time. The average length of service per client is 39 weeks.
(169)
Jl

I. Direct Care Personnel

Staffing/Cost Schedule

ltered Workshop

Full FTE1 s Salary

Program Salary

51

Fringe Overhead

18%

20%

A. Program Director

.5

18,000

9,000

B. Voc?/Rehab.Specialist

1.

15,000 15,000

C. LPN

.5

8,000

4,000

0. WorK Supervisors @ 10,000 ea

3.

30,000 30,000

1620 2700
720 5400

1800 3000
800 6000

1242 2070
552 4140

Sub-Totals:

1 5. I

II. Administrative Personnel

iA. Administrator

.5

^j. Secretary

.5

L. Bookkeeper

.5

Sub-Totals:

1 1.5 1

III. Srogram Suaalies & Equip.

I 53,000| I io ,,4444001| i 11,9241 1 30,04

18,000 9,000

1 ,620

7,500 3,750

675

8,000 4,000

•720

1 If? .750! I 3,01 Si!

10,62t 4,423 4,720

IV. Client Supplies & Equip. -«
Manufacturing Materials
V. Transportation Bus driver, insurance, maintenance
VI. Mx5C. (Specify) A. Employee (client) wages @ $40 per week, 30 clients, 50 weeks B. Employee (client) fringe 1 10%

60,000 6,000

VII. Jrogram Tocal Minus 5100,000 received Program Income

vizi, unit Cost: 2.02 2.52

oer client hour s e r client day

Average Episode Cose: 244L.JIQ—• Average Annual per Ciier.t.

(170)

Service Analysis

SERVICE; Prevocational/Sheltered Workshop

I. Program Content Analysis

Client Service

Client Hrs. per day

\. Provide structured employment £ related services

3. Voc. Counseling

N.A.

Client Hrs. per week
30
31"

52

Staff Hrs. Jper Client per Wk. Comments

• 3

30 clients:3 staf

' 1
7

II. utilization Analysis

Annual Prog. Capacity/ft A. of Clients

Average * Episodes per Client

Average ? weeks per Episode

# Direct Serv. Staff Hrs. per Client per Wk.

% Direct Total Staff Serv. Hrs. Direct Serv. of D. Serv. Hrs. Clients Hrs. Avail.

38

39

#. Dir. Care Staff B. avail- for Dir. Serv. # Hrs./Wfe. # Kaeks

5923

5928-6306 93%

Total Hrs. Avail. Total Hrs. Avail. for Direct Serv (x.7)

40

SO

10.000

7.000*1.11 - 6306

!. Cost Analysis

Direct Care Total Net .Co3t Personnel Cost

Overhead & Administration

Satio: OSA to Total Cost

Net 92805 Gross 92805

68440

Total Net Cost per Unit of Service
2.0? per client hour L 12.52 per day

Admin » 20165

32089 * 192805 = 17S

O.H. - 11924

32089

Total Cost per Episode

Total Cost per Client

2441.40

2441.40

Staffi.-.o Pattern Analysis "act Care Staff/Program Cansus Ratio: 5:30».17:l
Adainiscrative Staff/Diract Care Staff -ji-io: i .

c l i s n t hours = 38x38x31 • 45942

(171)

53 B. TRANSITIONAL EMPLOYMENT/JOB PLACEMENT

1. Definition Transitional employment programs assist clients capable of
engaging in gainful employment if provided with necessary counseling, support, and training. Job placements help clients locate and continue in independent/competitive employment.

2. Program Elements Program w i l l a. Receive referrals from Assessment Team, Day Treatment, Day A c t i v i t y , and Sheltered Workshop Programs. b. Implement vocational service plans to promote client's moving to independent employment. c. Provide on-job t r a i n i n g , counseling, and supervision. d. Pay subsidies to private industry or public employer. e. Assist clients in locating competitive employment.

3. Clients

For clients high in community adjustment potential with

sufficient work and social skills for engaging in independent/

competitive employment given support. This program liiodel v/i 11 ^

serve 30 clients at any one time. Clients will receive, on the_.

average, service for 26 weeks. The number of clients served

annually by this program will be 60.

"^

(172)

Staffiii'i/Cost Schedule

Transitional Employment/Job Placement:
tile-I.

Direct Caru Personnel

Full FTE's Salary

Program Salary

^Support/Placement Specialists @ 12,000 ea
Counselor

1.5 .5

l8,000 15,000

1 8 ,000 7,500

Fringe
t o •>

54
Overhead
cJ 5

TOTAL

3240 1350

3600 1500

24,840 10,350

Sub-Totals: Administrative Personnel £. Secretary

|~2".O I .5

[5*500] \A,59Qi (LlOQj 135.190 1

7,500 3,750

675

4,425

Sub-Totals: Broqram Supplies & Eouip.

3,750

675

I 4,425

Client Supplies S Eauip.

Transportation
•Misc. (Specify) £• Pay subsidies @ minimum wage -25% weekly salary for 15 clients, i.e., $26.50 per week x 52 weeks

p*ograa» Total
Cost:

1275 1

5,265f

|60 , 2£g

client hour for T s P w/subsidy per

Average Episode Cost: 367.20 for T&P w/sub 1745.20 for T&P w/sub
Average Annual per Client Cost 1734657.2.200wf/orsuTb&P(173) 431.05 job placement

Service Analysis

SERVICE: Transitional ^molovment/Job Placement

I . Program Content Analysis

Client Service
A. Vocational counseling B. OJT Counselingfisupport
C. Job placement

Client Hrs. per day N.A. N.A.

Client Hrs. per week
.25 .5 .75

Staff Hrs. per Client oer VJk. Cor ..25 .5
23 hours, per wk. (70 %)

II• Utilization Analysis

Annual Prog Capacity/* A. of Clients

Average # Episodes per Client

Average # weeJcs per Eoisode

# Direct Serv. Staff Hrs. per Client perWk.

% D Total iStaff Ser Direct Serv. of Hrs. Clients Hrs

TEP 60

1

26

Placement:

#. Dir. Care Staff B. avail, forDir. Serv. # Hrs.AJ5t. * Weeks

.75 Total Hrs.

1170 1400 2570
Avail.

;25704-
8
Total Hrs. for Direct

2.5

5000

3500-rl.ll

III. Cost Analysis

Total Cost

Direct Care Personnel Cost

Overhead & Administration

Ratio: OSA to Total Cost

TEP

35038.5

Placement 33526.5

68565

37170

Admin. O.H.

4425 5300 9725

9725-63565 *> 44%

Total Cost per Unit of Service

Total Cost per Episode

Total Cost per Client

12.28

per client hour2 239.46 TEP with subsidy Per TEP w/o subsidy 1617.46 with subsidy

IV. Staffing Pattern Analysis

239.46 TEP. without subsidy
1617.46 TE? with sibsidy 553.77 per client job for 60 clients

Direct Care Staff/Program Census

2.5 60 .04:1

Administrative Staff/Direct Cara Staff ?.atio: 15;2.5 .20:1

V. Co.~r.3r.t5

TEP Cast = 14363.5 = personnel,overhead

^

20670 = subsidy

"Total client hours = 50x.75x26 = 1170

(174)

/ice

tslope

I. direct Care Personnel

. Job Developer

Staffing/Cost Schedule

Full FTE's Salarv

Program Salary

Fringe 18S

56
Overhead 201

TOTAL

1. ' 16,000 16,000

2380

3200

22,080

Sub-Totals: jidministrative Personnel

I 1.

1 16,000) | 2880 j f~17UT~\ {22,08

Sub-Totals:

|

[

Program Supplies & Equip.

tjlient Supplies s EquiD.

Misc. (Specify)

(ZZI

Tocal Cost:

.J
oer rser

->.->nr) ! (22,080|
Averacc Episode Cost: Average Annual r c r Client Cost
(175)

SERVICE: Job Developer I. Program Content Analysis
Client Service \. Job development

Service Analysis

Client Krs. oer dav

Client Hrs. oer week

Staff Hrs. per Client per v«!c.

57
-ents 1 per A:

II. Utilization Analysis

Annual Prog. Capacity/# A- of Clients

Average # Episodes per Client

Average # weeks per Eaisode

# Direct Serv. Staff Hrs. per Client oer Wk.

Total Staff Direct Serv. Hrs. Clients

% Direct Serv. Kr: of D. Se. Hrs. Ava

90

S. Dir. Care Staff B. avail, for Dir. Serv. f Hrs./Wk. # Weeks

Total Hrs. Aval Total Hrs. Avail. for Direct: Serv

40

50

2000

14000-1.II = 12!

'II. Cost Analysis
Total Cost 22080

Direct Care Personnel Cost
18.880

Overhead & Administration
3200

Ratio.- O&A to Total Cost
3200T22080 =14.6

Total Cost cer Unit of Service

N.A.

per client hour per

Total Cost per Episode
N.A.

Total Cost per Client
$245.33

IV. Staffing Pattern Analysis Direct Care Staff/Program Census ?.atio: 1:90 = .01:1 Administrative Staff/Direct Care Staff ?.atio:
V. Coru-er.ts

(176)

58 X I I . RECREATIONAL/SOCIALIZATION PROGRAM
In general, c l i e n t s should use regular conmunity programs at adult education centers, the YMCA-YWCA, and other recreational locations. Segregating c l i e n t s f o r special programs o f a general recreational nature is not conducive to n o r m a l i z a t i o n . To the maximum extent poss i b l e they should be encouraged to go on t h e i r own or i n small groups o f 2-3 to generic programs f o r a d d i t i o n a l a c t i v i t i e s . To f a c i l i t a t e use o f generic programs and i n t e g r a t i o n o f c l i e n t s i n t o adult education programs, community centers or YMCA-YWCA programs, there should be funding for a part-time liaison s t a f f person at the generic program, and regular membership or t u i t i o n fees f o r the a c t i v i t i e s . The role of the l i a i s o n person would be merely to be f a m i l i a r w i t h DMH c l i e n t s using the program and to respond to any problems that might a r i s e . Other r e c r e a t i o n / s o c i a l i z a t i o n services such as social clubs and s e l f - h e l p groups should be f a c i l i t a t e d by the community service coordinators and r e s i d e n t i a l s t a f f .

A. Definition Funds should be provided to community centers, YMCA, YWCA or
adult education programs u t i l i z e d regularly by 10 or more DMH c l i e n t s l i v i n g in DMH housing or in non-DMH housing, to provide cne extra part-time s t a f f l i a i s o n and necessary membership or t u i t i o n fees.

B. Program Elements

Program w i l 1

1. Receive names of DMH c l i e n t s wno plan to u t i l i z e the

program from DMH residences and community service

coordinators.

(177)

59 2. Aid in assuring that clients can participate in
regular ongoing activities which interest them. 3. Communicate periodically with referral person as to
involvement of clients. 4. Communicate, when necessary, with referral person as
to any problems that arise with DMH clients. C. Clients
For clients high in community adjustment potential with sufficient social skills to participate in generic social and recreational activities, This model will provide service for up to 30 clients at any one time.
(178)

Service: 2 I. Direct Cara Personnel
A. Liaison Specialist:

Staffing/Cost Schedule

Full FTE's Salary

Program Salary

Frincje in'.

60
Overhcjer ::o". 3 •

TOTAL

.5

9,000

4,500

310.

900

6,210

Sub-Totals: ri. Administrative Personnel

j .5

4,300 1 | 810 j 1 900 .-3|- |6,21Q

Sub-To Ciils: III. Program Supplies a Equip.

Vi. Client Supplies & u

Y. Transportation
vt. Misc. (Specify) Ar, Client memberships and t u i t i o n

VII. Program Total rJiiit Cost:

1 -5 i
uer •oer

• 4.500; ; 310 '. i 500 \ |7,71O

Average Episode Cost:

A'/era'ja Annual per Ciienc Cost : 257

(179)

I !

1

I

Service Analysis

'61

SER ZE-. Recreation/Sncializat.inn

Procram Content Analysis

I. Client Service
Facilitate client involvement in generic social & recreational activities

Client Hrs. Der dav

Client Hrs. per week

Staff Hrs. per Client oer Wk. Comment!

II. Utilization Analysis

Annual Prog. Capacity/* A. of Clients
30

Average # Episodes cer Client

Average * weeks per Eoisode

•f Direct Serv. Staff Hrs. per Client oer Wk.

Total Staff Direct Serv. Hrs. Clients

% Direct Serv. Hrs.j of 0. Ser»l Hrs. Avail)

i Dir. Care Staff B. avail., for Dir. Serv. = Hrs./Wk. 3 Keeks

.5

40

50

Total Hrs. Avail; Total Hrs. Avail. for Direct Serv

1000

700 + 1.11 -U

til. Cost Analysis
Total Cost
7,710

Direct Care Personnel Cost
5,310

Overhead & Administration
900

Ra-io: CSA to Total Cast
900 * 5310 = 175

Total Cost per Unit of Service
N.A. per client hour oer

Total Cost per Episode
N.A.

Total Cost per Client
$257

VI. Staffino Pattern Analvsis Direct Care Staff /'Procram Census ?.atic: . b : 20 = . 0 2 : 1 .Administrative Staff/Direct d r a Staff ".atio:
V.

62 XIII. TRANSPORTATION
Transportation of clients to and from programs and appointments is an ongoing problem for all mental health and social service providers. Creating separate transportation systems, however, is not cost effective or manageable, given the varying needs of clients and the fact that for some clients transportation needs will change periodically, and in some cases, frequently. For this reason transportation should be included in full time Day Activity, Day Treatment and Sheltered Workshop Programs. In addition, most residential programs will find that staff have to provide transportation for clients' appointments or other special needs, as well as for social and recreational group activities. Funding for these programs should include the purchase of a vehicle and ongoing transportation costs. Individual transportation to clinics, counseling, jobs, higher education and non-DMH training for those not in DMH residences would be arranged by the client with assistance from the community services coordinator if necessary.
(181)

63 XIV. EDUCATIONAL PROGRAMS
Educational needs of clients who require intensive DMH services should be met in the context of Day Treatment and Day Activity Programs. Clients who are then able to move into adult education programs or college courses should be encouraged and aided to do so. All youth (age 22 and under) should receive CORE evaluations and be provided services via their local board of education. For adolescents, these services should include a comprehensive day treatment/educational program specifically designed to meet their needs as identified in the CORE evaluation. Pursuant to Chapter 766, it is the responsibility of local school boards to implement such programs.
(182)

ATTACHMENT D
AMENDED FINAL DRAFT
RESIDENTIAL PLACEMENT RECOMMENDATIONS FOR MENTALLY DISABLED PERSONS IN REGION I
I. INTRODUCTION
This document sets forth the number and type of residential placements that must be designed and created for the mentally disabled population in Region I. Having drafted a general description of 12 residential models, including staffing patterns and costs (see Community Residential Alternatives), and having grouped the disabled population into 22 clusters representing different client needs (see Summary of Clusters for Northampton State Hospital), it was then necessary to match each cluster with a primary and, if appropriate, secondary placement recommendation. The conclusions of the matching process are set forth in Part II.
While most clusters are assigned only one primary placement recommendation, in certain cases several primary placement recommendations are suggested. Wherever an apartment placement is recommended as a first choice, it is always coupled with a group home or transitional community residence. This reflects the fact that both placements are programmatically approximately the same, and that the determination of which should be created and funded is primarily an administrative choice best left to the implementation phase of this planning process. In certain other cases two or more placements are suggested as first choices with percentages assigned to each. In these cases it is recognized that the least restrictive alternative is most desirable, but given the institutionalization of some persons in that cluster, immediate placement in that alternative may not be appropriate for all clients in that cluster. It is clearly intended, however, that such clients will be provided necessary training and support as to enable them to move into the less restrictive placement shown as soon as possible. Secondary placements are considered to be less desirable than the primary placements for most clients; however, they are to be considered as options for certain clients in clusters with documented special needs.
The Summary of Clusters and the Analysis of the Mentally Disabled Population (Appendix E) describe the number of persons , in each cluster for both the Hospital and community populations.
It should be noted that, pursuant to the precedental rules described in the Summary of Clusters, adolescent, mentally retarded, chronic, and acute clients with serious behavioral problems were initially factored out and placed in the assaultive cluster (c).
(183)

Given this frequency distribution and the matching of clusters

and residential models, it is possible to determine the number

of placements for each subpopulation that must be created in

I-

each type of residential program. The residential needs of the Hospital subpopulations and the community subpopulations

I1.;

are set forth in Parts III and IV, respectively. A table des-

cribing the total number of placements in each residential

alternative for all mentally disabled persons in Region I is

in Part V.

(184)

II. CLUSTER-?-MODEL MATCHING

Cluster

Characteristic High Health

Residential Placement Recommendation

First
Supervised Apt. or Group Home w/ Physical Care

Second
Nursing Home (II) w/ Support Services

B

Chronic

Supervised Apt. or

Nursing Home w/

Brain Syndrome

Group Home w/

Support Services

Behavioral Emphasis

C

Assaultive

Behavior

Supervised Apt. or Group Home w/ Additional Behavioral Emphasis

D

MR

Supervised Apt. or Group Home w/ Physical Care

MR

Transitional Apt. or

Community Residence

MR

Home Care (15%);

Supervised Apt. or

Group Home (857.)

Third

II. CLUSTER - MODEL MATCHING (Continued)

Cluster

Characteristic Elderly

H

Elderly

J

Elderly

K

Elderly

L

Elderly

M

Elderly

N

Adolescent

0

Acute

P

Acute

Q

Chronic

First

Residential Placement Recommendation Second

Supervised Apt. or Group Home w/ Behavioral Emphasis

Supervised Apt. or Group Home w/ Physical Care

Transitional Apt. or Community Residence

Supervised Apt. or Group Home

Transitional Apt. or Community Residence

Non-DMH Housing w/ Support (157.); Supervised Apt. or Group Home (85%)

Home Care (507.) ; Transitional Apt. (507.)

(Crisis Intervention)

(General Hospital)

(Crisis Intervention) (General Hospital)

Supervised Apt. or Group Home w/ Behavioral Emphasis

Third

Cluster
R

Characteristic Chronic

S

Chronic

T

Chronic

U

Chronic

V

Chronic

Chronic

First
Supervised Apt. or Group Home w/ Physical Care
Transitional Apt. or Community Residence
Supervised Apt. or Group Home
Supervised Apt. or Group Home
Non-DMH Housing (15%); Home Care (10%); Supervised Apt. or Group Home (75%)
Non-DMH Housing w/ Support (507.); Home Care (50%)

III. FREQUENCY DISTRIBUTION OF RESIDENTIAL PLACEMENTS FOR HOSPITAL POPULATION
The following distribution shows the residential placements for all persons in the Hospital on a given day. It is based on the data gathered from the client assessment survey with respect to the Hospital population as of September 17, 1977. Thus it includes an average daily census of persons within the acute and recidivist subpopulations, as well as all persons in the long-term hospitalization group.

Model Code
A B CD E, E-, F. F
H,
G, G,

Model Type

No. of Primary Placements

Non-DMH Housing w/Support

28

Specialized Home Care

31

Supervised Apartment/Group Home 255

Transitional Apartment/

Community Residence

29

Supervised Apartment/Group Home

with Physical Care

36

Supervised Apartment/Group Home

with Behavioral Emphasis

15

Supervised Apartment/Group Home

with Physical Care and

Behavioral Emphasis

0

Supervised Apartment/Group Home

with Intensive Behavioral

Emphasis

15

Nonresidential Crisis Inter-

vention/General Hospital*

23

Non-DMH Housing w/Support

Services (Nursing Home)

26

No. of Secondary Placements

*To the extent nonresidential crisis intervention is not avaiiatu or not appropriate, beds in general hospitals will be necessary (see Part IVA, following).
(188)

IV. FREQUENCY DISTRIBUTION FOR NON-HOSPITAL SUBPOPULATIONS

A. • Acute Subpopulations

A significant portion of the thirty-two persons in this subpopulation who are hospitalized at any given time could best be served by non-residential crisis intervention services. (See Nonresidential Treatment and Support Models--Crisis Intervention). Although this subpopulation is comprised only of persons with no prior admissions to the Hospital, a portion of this subpopulation may have been receiving mental health services through outpatient clinics and support programs, while the remainder of this group had no previous contact with the mental health system. For both components of this subpopulation, however, a nonresidential crisis intervention program is appropriate and has already been included in Part III, above.

Because a non-residential program does not have the

capability of responding to the security needs of highly

assaultive or committed persons, a limited number of general

hospital psychiatric beds will be necessary. Given the

small number and rapid turnover of such cases, tw_en£.y

hospital beds should meet the needs of the Region. These

placements would be created in private hospitals located

in each DMH ARea, and would include the capacity to accept

involuntary clients. An additional twenty voluntary psy-

chiatric beds should be created in these hospitals, thus

,

providing a toj:a,l_of forty beds in the Region. It is

interesting to note that a detailed study of general

hospital resource allocations by the Western Massachusetts

..Health Planning Council indicated that, beyond the eighty

beds specifically designated for psychiatric services, an

additional forty beds were often used to meet the needs of

psychiatric patients. Although any new hospital beds may

have to go through the Determination of Need procedure,

it is clear that the failure to create the necessary hospital

placements would significantly undermine the other residen-

tial placement distributions.

B. Recidivist Subpopulation

Although almost all of the 1076 persons in this subpopulation will require some form of mental health services to prevent their rehospitalization, only a small percentage (150 persons) will need a residential placement. Most of the residential needs of this subpopulation should be reflected in the 81 placements for this group, included in Part III (see also Appendix E of the Final Draft of the Population Analysis)'. Given the size of this subpopulation, however, it is somewhat difficult to determine the precise

(189)

number of persons who will need residential placement at any given time. It is reasonable to assume that a small number of additional placements will be needed to meet the need of individuals in this subpopulation who are in acute crisis or need extensive support subsequent to such crisis. The needs of this group for non-residential crisis services and general hospital beds have already been included in the placements set forth in Part III and Part IVA. Many others, however, may require intensive support to live in their own apartment or home. On the basis of data on the recidivist population of the Northampton State, approximately 500 persons per year must be provided this level of support.

Model Code
A B C, D

Model Type Non-DMH Housing with Support Specialized Home Care Supervised Apartment/Group Home

No. of Primary Placements
500
13
12

C. Long Term Subpopulation

All of the 362 persons in this subpopulation who will need residential placement have already been included in Part III

D. Discharged Subpopulation

Since all 172 persons in this subpopulation presently reside in nursing or rest homes, they will only need psychiatric support services in their residences. Given the lack of adequate staff or other resources of almost all nursing and rest homes to address the needs of former Hospital patients, additional support services are necessary to avoid having the nursing home become a mini-institution with inadequate treatment.

Model Code

Model Type

No. of Primary Placements

Non-DMH Housing with Support

172

(Nursing Home)

(190)

IV. FREQUENCY DISTRIBUTION OF RESIDENTIAL PLACEMENTS FOR ALL MENTALLY DISABLED PERSONS IN REGION I
!

Model Type Non-DMH Housing with Support Specialized Home Care Supervised Apartment/Group Home

No. of Placements 528 44 267

Transitional Apartment/Community Residence

29

Supervised Apartment/Group Home

with Physical Care

36

Supervised Apartment/Group Home

with Behavioral Emphasis

15

Supervised Apartment/Group Home

with Physical Care and

Behavioral Emphasis

0

Supervised Apartment/Group Home

with Intensive Behavioral Emphasis

15

Nonresidential Crisis Intervention/

General Hospital

Z3

Non-DMH Housing w/Support Services

(Nursing Home)

198

No residential support needed

Subtotal

Total

1155 980
2135

(191)

ATTACHMENT E

NONRESIDENTIAL PROGRAM RECOMMENDATIONS FOR MENTALLY DISABLED PERSONS IN REGION I

FINAL DRAFT

I

I. Introduction
This document sets forth the number and type of nonresidential placements that must be designed and created for the mentally disabled population in Region I. Having drafted a general description of 15 nonresidential models, including staffing patterns and costs (see Nonresidential Treatment and Support Programs) and having grouped the disabled population into 22 clusters representing different client needs (see Summary of Clusters for Northampton State Hospital), it was then necessary to match each cluster with the program(s) appropriate to the needs of those clients. The conclusions of the matching process are set forth in Part II.
A comprehensive nonresidential system must have the capacity to assist approximately 2100 persons in Region I or roughly 427 persons in each of the five Areas. While some models, such as the assessment and community service coordination programs, are designed to serve all persons, others, such as day treatment, day activity, prevocational/sheltered workshop, and transitional employment/job placement represent a continuum along which clients should progress as they move towards full integration in the community. Thus only a percentage of any one cluster will need a particular program on this continuum at a given time. The percentages used for these program models reflect the clients' present needs, as determined by the client assessment survey data, with due weight given to the institutionalization that most of the Hospital population has experienced.
A few models, such as counseling, respite care, and family support, are limited programs that should be available for a relatively small number of persons. Although it is possible to determine which clusters are likely to require these services, as well as the total number of persons in each Area who would participate in these programs, it is not possible to calculate the precise percentage of each cluster appropriate for each model; therefore, an x is used to indicate the general conclusion that some portion of the cluster needs that program.
The Summary of Clusters and the Analysis of the Mentally Disabled Population (Appendix E) describe the number of persons in each cluster for both the Hospital and community populations. Given this frequency distribution and the matching of clusters

(192)

and residential models, it is possible to determine the number of placements in each program that must be created for each subpopulation The nonresidential needs of the Hospital and community subpopulations are set forth in Part III. A tabulation of the total number of placements in each program for all mentally disabled persons in Region I is presented in Part IV.
It is recognized that each of the five Areas vary considerably in size and need for new programs; for the ease of computation, however, each Area is considered to have an average of 1/5 of the client population.
(193)

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P HH

Day Activity

c
CO
rr
Q
rt

Treatment

o

3

XXX

S~S S-3 ff-S

Pre Voc./ Sheltered Workshop

I I

Transitional

Emplov'ment/

Placement

III. CLUSTER NONRESIDENTIAL MODEL MATCHING: Number of Persons in Each Program A. Hospital Subpopulation - 4 7 2

NONRESIDENTIAL TREATMENT OR SUPPORT PROGRAMS

u
0)
u u
C O <n n» o
•H U -H u nl u
a) £i to fX, O -M
High Health Chronic Brain Syndrome Assaultive
Mentally Retarded
Mentally Retarded
Mentally Retarded
Elderly
Elderly
Elderly
Elderly
Elderly
Elderly

CJ
33

B 19

C 15

D

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F 61

G

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49

'"'Approximately 57o (5 Dersons) of the elderly subpopulation will need day treatment.
^Remainder of clients in this cluster receive no day or vocational services from DMH

(.3 3*

(.a

>n

> o

O 3

O 3

i-t O 3

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Patient Characteristic

ro

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I-1 to to

Cluster
# of Persons in Cluster
Intake/ Assessment
Coram. Service Coordinator Psychotherapy /Counseling
Respite Care
Family Support
Medication/ Nursing
Prescreen./ Crisis Interven.
Day Treatment
Day Activity Treatment Pre Voc./ Sheltered WorkshoD

n r en oH
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rtro z

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CA

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Employment/
Placement

8" o o
crt rr
to m
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vO vO
00 vO
ho i_n 00
xxx

CO 00

01

Ln oo

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Patient Characteristic
Cluster
# of Persons in Cluster
Intake/ Assessment
Coinm. Service Coordinator Psycho therapy Counseling
Respite Care
Family Support
Medication/ Nursing
Prescreen./ Crisis Interven.
Day Treatment
Day Activity Treatment Pre Voc./ Sheltered Workshop

C

> n

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-
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vo

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W

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# of Persons in Cluster
Intake/ Assessment
Comm. Service Coordinator Psychotherapy /Counseling

[X

XXX

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XX

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170

Ul

to I-1

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vO O

0 - J Ul 00O

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Nursing

100

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0

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^.

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0

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Treatment

£

Ul to

ON

Ul 0

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ro

*
ON

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Activity Treatment

vo ON

vO

to 0

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Pre Voc./ Sheltered Workshop

Ul

10

to to

U)

N3 VO

0

to

Transirional Employment/
Placement

c:

re

a

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5

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OH

3onr

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H
O

ozM

(D
it
CO
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3
CO
n
3* 1 O
it
I

CO

[II. CLUSTER NONRESIDENTIAL MODEL MATCHING: Number of Persons in Each Program D. Discharged to Nursing Home - 172
NONRESIDENTIAL TREATMENT OR SUPPORT PROGRAMS

ui
CU 4J U
C o
•rl U d
Elderly

G-M 172

4J
C
0)
B co CO
U
CO
w
172

u
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w c
B O
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172

0)

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•rl

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IS*

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at V-i ca O-rl U co ca cu
CU i H 4J
rl rl C

cu
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b to

£2;

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172

4-1

4-i ai

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5

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(CUM

• 4) (X CJ M O
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CU CU r .
UXO
CL, CO ^

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O <U O
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8

10

IV. FREQUENCY DISTRIBUTION OF NONRESIDENTIAL PLACEMENTS FOR
ALL MENTALLY DISABLED PERSONS IN REGION I.

Average Area
Total

Regional Total

Intake/Ass e ssment

427

2135

Community Service Coordination

427

2135

Psychotherapy/Counseling Respite Care

44

220

75

375

Family Support

40

200

Medication/Nursing Prescreening/Crisis Intervention Day Treatment Day Activity Treatment Pre Vocational/Sheltered Workshop

255 1501
572 73
69

1277 752 285 366 347

Transitional Employment/Job Placement

71

356

Recreation/Socialization

903

450

Because of the short length of stay (1-5 days) in the crisis intervention program, one placement is capable of meeting the needs of a large number of persons (approximately 80-100). Therefore, the Area and Regional figures do not accurately reflect the number of placements needed but rather the unduplicated number of persons needing such services. As set forth in the Nonresidential Treatment and Support Programs, it is reasonable to assume that four placements is sufficient to meet the needs of approximately 400 persons in each Area.
2 The average client stay in the day treatment programs is 16
weeks; one placement is thus capable of serving approximately 3 persons. As set forth in the Nonresidential Treatment and Support Program, it is reasonable to assume that a program with 20 placements can meet the needs of each Area.
Participation in this program is not related to client cluster and therefore is not included in the preceding tables. None of the persons in the day treatment (20) or day activity treatment (73)
(201)

11 programs or clients in the acute (100) or discharged to nursing hor.e (35) subpopulations will need a separate recreation program. Of the remaining 200 clients in each Area, most of whom are in the recidivist subpopulation, approximately one-half would participate in this program.
(202)
J

ATTACHMENT F
-FINAL DRAFT
MANAGEMENT COMPONENT
I. Introduction The Department of Mental Health has the primary and ultimate
responsibility for creating and maintaining a comprehensive system of community treatment and support programs appropriate to the needs of mentally disabled persons. This responsibility is undertaken on a local level through Regional and Area Offices which develop, fund, manage, coordinate, and monitor these programs. To the extent that services are delivered through many independent providers, the Department's responsibilities can only be fulfilled If it has the management capacity to oversee a diverse delivery system. Moreover, given the clinical advantages of providing much treatment and training outside of the residential environment, the task of ensuring that its clients regularly receive appropriate services makes the Department's management responsibilities especially complex. The Regional and Area Offices presently lack adequate mental health resources to fulfill those responsibilities, since they are primarily geared to an institution based service system. In order to develop and manage quality community programs, a management component must be included in the planning design. Portions of this component like the direct care components, should be purchased through contract mechanisms. An outline of such a component, vith a specific description of the organizational structure, is attached.
(203)

Page 2
II. The Providers
It is expected that the actual provision of services will be done chiefly through private nonprofit corporations experienced In designing and implementing residential and non-residential programs for mentally disabled persons. The Department will contract with these Independent providers pursuant to standard RFP procedures and regulations established by the Office of Administration and Finance. It is estimated that there are on the average, 40 contracts per area and 200 contracts regios-wide. in Region I, totalling roughly $8 million dollars. Implementation of this plan might double their number and/or size. This increase in Area and Regional responsibility cannot be over emphasized. Area and Regional Offices provide technical assistance to vendors in developing their proposals and monitor contract operations In order to ensure that all programs are compliant with State regulations and are an integral part of a comprehensive system. If an Area elects to become a primary service provider for some of its clients, the management component must be modified accordingly. In certain cases, the Regional Office may also provide services for high risk/low incidence clients in inter-area programs. This should be reflected in Regional Office structure and staffing.
(204)

Page 3
III. General Description of Functions, Management Areas and Activities
Although Regional and Area Offices address very different levels of operations, both must have the ability to perform two types of functions: planning and development and monitoring and coordination. These functions must be performed in three management areas: program management, fiscal and personnel management, and information management. Table I shows the matrix of functions by management areas and lists the major types of activities associated with each combination of function and management area. A general description of these activities follows which does not detail the difference between regional and area activities. However in sections 17 and V Area and Regional Office activities are specified separately.
A. Program Management Within the program management area three activities re-
flect the planning and development funtion. System and program development refers to planning a community care system, including residential and non-residential programs and linkages to generic services. This activity also includes developing vendors and agencies and providing technical assistance in drafting proposals. Staff training and development involves insuring that adequately trained manpower is available to meet program needs. Community development consists of working with citizen boards and councils to facilitate community acceptance and client integration. This is done by educating citizens and developing local leadership.
(205)

Table I. Matrix of Functions by Services showing Major Management Activities
Management Areas

Functions

Program Management

Fiscal and Personnel Management Information Management

Planning and Develop.

1. System and Program development
2. Training 3. Community Develop.

1. Budget Development
2. Spending Plans 3. Contracting

4. Revenue Planning

1. Long range Planning
2. Annual Planning 3. Research for Program
Development

Monitoring and Coordination

1. System and program Coordination
2. Legal services
3. Program monitoring 4. Quality Assurance

1. Expenditure/Revenue Monitoring
2. Auditing 3. Personnel management

Client, Fiscal, Personnel and Service management information Program evaluation and evaluation research

Page 5
Four activities are associated with the monitoring and coordination function within program management. System and program coordination includes developing functional linkages between programs, facilitating the sharing of information when appropriate, supervising the transition of services from institutions to communities and ensuring that clients continue to move through community programs towards less restricitve, more independent living with appropriate continuity of care. Legal services differ from the area to the regional level.

At the regional level

legal services consist of legal counsel to the Regional and Area offices.

Program monitoring occurs primarily at the area level. It involves over-

seeing the community care system. This includes reviewing and approving

vendor contracts, ensuring contract compliance through periodic reviews

of programs and technical assistance in the implementation of "plans of

correction" in cases of non-compliance. Prograa monitoring also includes

reviewing and resolving any complaints by clients or advocates against

il

programs.1 Quality assurance is primarily a regional function although

Area Office staff will participate. This activity involves annual re-

views of programs to assure compliance with program and professional

standards. It is a crucial activity in setting the staff for program

monitoring.

^This document does not address but recognizes an important role for consumers in program evaluation.

(207)

Page 6

B. Fiscal and Personnel Management

there are four activities associated with the planning and development function within the area of fiscal and personnel management. Budget development and contracting refer to the process by which dollars are assigned to accounts and vendors in compliance with state laws and regulations. Contract development can extend to assisting providers in writing contracts. Spending and revenue planning involves establishing expenditure schedules and strategies for generating revenues so that programs can operate uninterrupted by issues of fiscal solvency.
The monitoring and coordination function is reflected in three activities in the fiscal and personnel management area. Expenditure and revenue monitoring refer to tracking spending and revenues to ensure compliance with spending and revenue plans. A goal of such monitoring is to uncover variances from plans while there is time to correct them. Auditing involves monitoring contracts to ensure that vendors are operating in compliance with state fiscal regulations and laws. Personnel management and affirmative action involves facilitating the recruitment, hiring, development and maintenance of an appropriately skilled and motivated workforce composed of minority employees to a degree consistent with affirmative action guidelines.

C. Information Management

In the information management area there are three planning

and development related functions. Long range planning consists of the

development of explicit goals for clients and programs within a 3 to5

year planning horizon. This goal setting is a key area of citizen in-

volvement.

(208)

Page 7
It is also a component reguixed in most federal grant proposals and increasingly in state health and social service planning. Annual planning involves devising strategies for allocating dollars to programs. These plans are the basis for budget development. Research for program development includes needs assessment and evaluation research designed to provide information as to what client needs are and what programs most successfully meet them. This information is necessary for deciding what programs to develop, and/or fund, it also provides back up for federal grants, determination of need procedures, etc.
Finally, within the information management area two activities relate to monitoring and coordination. The first is developing and maintaining client, personnel, fiscal and service management information systems. These systems information as to: types and quantities of services provided; numbers and types of clients served; staffing patterns and activities; costs. Such information is basic to most management activities. The second is program evaluation and research. This activity provides information as how well different services work for different clients. This information is the key to system and program planning.
(209)

Page 8

IV. The Area Office

The primary responsibility for designing and supervising the community care delivery system lies with the Area Office. Table II shows how the activities just described translate into specific Area Office staffing and activities in support of programs for clients in the Northampton class. The number of area staff required for management support

of programs for all area clients would be between 2 and 2?j times the

number shown (e.g.: mentally retarded persons, children and adolescents,

substance abusers, adults with mental health problems, but not at risk of state hospitalization, etc.). This table also shows which of the positions required exist and which do noC. Table III depicts the organization chart for the area positions listed in Table II.

Table IV summarizes the Information on Area Office staffing and

presides cost information. This cost Information includes salaries, fringe benefits at 18%, support costs at 15%, and 40% of electronic data processing costs of $10,000.00 per area. The support costs are set at 15% rather than 20% (the figure used for direct care programs), because Area Offices already exist and have certain support equipment and supplies.

The data processing costs cover terminal rental at $250.00 per month

to permit decentralized data entry and report generation, at $585.00

per month for computer time and telephone costs. The information on costs

may be summarized as follows:

Positions (Poa.):

6.9

Salaries: 94 ,450-

Fringe benefits § 13%: 15 ,921

Support costs 0 15%:

17 ,267

Total : $ 127 ,638

x 5 Areas : $ 638 ,190

(210)

AKEA STAFF AHO ACTIVITIES

Orgaiiir.ntion.il Unit

Tonition

I. Area D i r e c t o r ' s Off. A. Area Dir.

flFTE's ([Exist.

0.4

0.4

D. Asnoc. AD

0.4

0.4

P.. Trogram Services

A. Pys/Frogram Devel. flpec.

1.0

D. Syntem/l'rograen 1.0

0

Coordinator

C. System/Program 1.0

0

Monitor

POK. A c t i v i t i e s

0

1 . D e v e l o p s I..ong r a n g e p l a n s f o r Area w/Area IV>ru d

2. Develop.-. Annual Plans with Area floord

3 . P a r t i c i p a t o r ; iei p e r s o n n e l . engine/., i etc 1ml i ii'i l a l m r r e l a t i o n s

4 . R e v i e w s p l a n s o f p r o g r a m s , v e n d o r s , a<i"ee<rion

5 . J n t e r a g c n c y c o o r d i e i - i t i o n - r\rc<~\ s l r a t o < t y

G. S o l e l i n o a u t h o r i t y t o d i r e c t , n n r v i o * i«n)<ie;im

7 . S u p e r v i s e s F. c o o r d i n a t e s Area O f f i r . o s t a f f

0

1 . S t a f f t o AD; f u n c t i o n s do 1 ece;it r-d l>y AH.

P.. Community d e v e l o p e n e n t ; q o n o r i c s e r v i c e dove lopnwiil .

3 . P r o v i d e s s t a f f work t o Area Uoard

1.0 1 . Develops program models, vpeidorn, au«in:ir.i 2. Develops c o n t r a c t s , plans and n c t i v i t i n n that a i e c o n s i s t e n t w i t h A r e a g o a l s a n d oh joel i v<-v. 3. Provides t e c h n i c a l assistneece to pro'itamr; wirhing t o expand 4 . S t a f f t r a i n i n g aeid d e v e l o p m e n t

1.0

1 . D e v e l o p s l i n k a g e s b e t w o e n inrU i I tit ionr. r. corunmn i t i <••:

2 . D e v e l o p s l i n k a g e s among community pmrit nut.s

3 . F a c i l i t a t e s communicatioei aeiK>eig pro'ii.Tm"

4 . I n s u r e s c l i e e i t inovemeeit from mcire t o ) rr.r. i rr.\.t I <;t 1 ve

settings

5. Insures continuity of care for r l i e n t s

6 . I n v e s t i g a t e s a n d r e s p o n d s t o c l i e n t , complae nl r-

1.0 1 . O n g o i n g , o n - r i t o m o n i t o r i n g of progenm rnenp I I n i n o with j>rogr.nm a n d / o r c o n t r a c t ol<joct.ives s i p-|iei i rmiMit.'S
2. Monitors iTrplemontation of planr: of r o i n v l i»n^ 3. Works with regional q u a l i t y assietaeice I ••am 4. Keeps Area Hoard infoimr-d

1
SABLE II (cont.)

AREA STAFF AND ACTIVITIES DEVOTED TO CLIENTS IN THE NORTHAMPTON CLASS

Organizational Unit

Position

IFTE'3 tBxlst. Pos. Activities

Fiscal & Personnel Services

D'i Secretary
A Bus/Contzact Manager

Information Serv.

B Bookkeeper C Secretary A Infor. Spec.

B Data Coord. C Secretary

.5
0.4

0. H 0

0 .4

0

0 .4

0

0.4

0

0.4

0

.5 1. Standard secretarial duties
1. Prepares area line item budget 2. Prepares area spending plan 3. Develops area contracts to meet accounting requirement 4. Revenue planning 5. Expenditure and revenue monitoring 6. Auditing 7. Supervises bookkeeper
8. Personnel management and labor relations
0.4
1. Supports Bus/Contract Manager in above activities
0.4
1. Standard secretarial duties
0.4
1. Long range planning 2. Annual planning 3. Reviews and summarizes research bearing on program
development 4. Prepares reports for AD, Area Board, RSA, Central
Office and others 5. Designs and implements program evaluation research
for program development applications
0.4 1. Maintains and coordinates client, fiscal, personnel
and service maangement information systems. Input?, and Outputs data. 2. Supports activities of Information Specialist
0.4 1. Standard secretarial duties

I
Program Management

System and System and System and

Program Dev. Program

Program

Specialist Coordination Monitor

Specialist

Secretary

Area Director

Associate Area Director

Secretary
I
Area Programs

T
Fiscal and Personnel
~T Management
Business/Contract Manager
I
Bookkeeper
Secretary

I
Information Management Information Specialist
I
Data Coord.
Secretary

H

1
I Organizational Unit

Table IV
Area office staffing and to provide Management Support for Programs for Northampton Clients

Position

i

#

#

Total Fringe Support

FTEs Exist. l'OB. Salaries Salaries 618%

9 15X

Total $

All Costs

11 Area Direct. Office 1 . AD

.4

2. Assoc. AD .4

.4 .4

0 0

0 0

3. Secy.

.4

.4

0

0

12 ,000

N.A.

N.A.

0

68 ,000

N.A.

N.A.

0

3 ,000

N.A.

N.A.

0

12 ,000 68 ,000
3 ,000

Total

1 ° 1 1 1.5 1.5

1 o EL ,800 | 1 o ( r™o i r~o \ \ 21,800 ]

System/Prog. Develop.

Management

1. Sys/Prog.

Devel.

Spec.

l

0

2. Sys/Prog

1

Coord. 1

0

3. Sys/Prog

Monitor. l

0

1

16 ,000 16 ,000

2,880 2,400 21 ,280

21 ,280

1

16 ,000 16 ,000

2,880 2,400 21 ,280

21 ,280

1

16 ,000 16 ,000

2,880 2,400 21 ,280

21 ,280

1

V- Secy.

.5 0

.5

3 ,750 3 ,750

675

562

4 ,987

4 .987

Fiscal Mgmt.
Information Mgmt.
•

Total

3.5 0

1. Bus/Contr .4 0

Managemr.

2. Bookkeep. .4 0

3. Secy.

.4 0

Total

12

0

1. Info.Spec. .4 0

2. Data Coord • 4 0

3. Secy-

4

0

4 . EDP Support N.A. N.A.

Total

12

0

1 3.5 \ 51.750J 1 5J

.4

6 ,400 6 ,400

.4 .4
ra I

3 ,600 3 ,000

3, 600 3, 000

13tflflo/J 13, 000/

.4

6 ,400 6 , 4 0 0

.4

4 ,800 4 , 8 0 0

.4

3 ,000 3, 0 0 0

N.fl

1I . A .

N .A.

,200/ 14.

I 1,152

7.762J | 6 8 , 827 |

960

8 ,512

I 68,8 2 7 f 8 .512

648

540

4 ,788

540

450

3, 990

\ 2,340/ { l,950j 1 17,J!90]

1,152 864
540 N.A.
I 2.55CJ I

960

8, 512

720

6, 384

450

3, 990

4,000

4, 000

6,130] | 22,806]

4 ,788 3 ,990
I 17<lio~|
8,
6 , 384 3 , 990 4 , ODD
886~]

•

8

\ .s

7"5fT) 114,211 / N.5.H42.J |

<; '

1 1
1
1 1 1 1
M

V. The Regional Office

89e

The ultimate responsibility for the proper design and functioning

of a quality system of community programs rests with the Regional office.

In the abstract, the Regional Office must have capacities that are timi-

lar to the areas. However, concretely regional activities deal with diff-

erent levels of operation than do Area Offices. For example, Regional

and Area Offices both monitor programs. However, the Area Office does

"hands-on" day to day monitoring while the Regional' Office does quality

assurance once per year.

Table V shows the concrete activities performed in the Regional

Office and how these translate into regional staffing needs for the

purposes of the suit. Once again management support for programs for

all regional clients would require approximately 2-2*1 times the numbers

regional staff shown. Table VI depicts the Regional Table of Organization.

Table VII summarizes this information and shows staffing costs. The cost

information in Table VI is the same as in Table IV. These costs aggre-

gate as follows:

Positions:

2.5

Salaries: 36,600 Fringe 9 18%t 6588

Support 9 15%: 9490

TOTXL.2 52,678

(215)

TABLE V

Regional Offlea STAFF AND ACTIVITIES

organizational "nit ~RSAfs Office

Position A. RSA

iPTB's tExiat. tPos. .4

Activities 1. Supervises and coordinates other 3 units 2. Sole line authority to Area directors 3. Reviews and approves Area & Regional Plans &
Budgets 4. Policy development 5. Sets regional goals and objectives 6. Long and short run regional planning 7. Area strategy & other inberagency coordination 8. Regional resource allocation 9. Marks with regional Council

B. Administrative

Asst. & Sect. .4

.4

1. Works under supervision of RSA

C. Regional Oper-

tions Coord. .4

.4

1. Plans & monitors Regional activities.

Program Develop. Unit A. Regional Prog.

Coord.

2.0

2.0

1. lech. Assist to areas in developing service programs, goals objectives.
2. Monitoring & approving Area work 3. Develop Regional/inter-Area programs

fi. Quality Assur.

Team

3.1

C. Lawyer

.4

1.0

1. Visit all programs yearly

0

.4

1. Legal Counsel to Regions and Areas

D. Sect.

1.0

1.0

0

1

Fiscal Management

Unit

A. Business

Manager

.4

1

0

1. Prepares regional Budget (211)

2. Reviews Area Budget (211)

3. Prepares regional account spending plan (212)

4. Technical assistance to Areas

5. Monitors Area spending & revpnues

6. Monitors Area spending & revenues

7. Regional auditing

Organizational Unit fiscal Mgmt. cont.
Information Management

V (Oont.)

Position

ICTB'8 fBXJBt. |?os, Activities

B. Accounts

i Bockkeepei

.4

0

1* Marks under supervision regional Bus. Man. 2. Prepares budgets for specific 3. Reviews and approves Area & Regional Plans &
Budgets 4. Policy development

C. Personnel

Clerk

.4

1. Monitors personnel changes 2. Reviews 6 approves 3. Provide tech. assististance

D. Affirm. Act.

Coord.

.4

.4

E. Contracts Mgr. .4

.4

1. Monitors Affirmative Action compliance' 2. Plans & implements.,affirm action initiatives
1. Prepare inter-Area contracts 2. Tech. assist, on contracts to Areas * venders 3. Review « sign off Aaea

6. Vbucherlng

Clerk

.4

.4

1. Narks under contracts mgr.

H. Executive

Secretary

.4

I. Secy.

.4

A. Info, special .4

0

.4

.4

e

.4

o 1. Conduct research for Prograro Development

2. Oversee collection of multiple types of data:

Area plan. Client component, CAS, Personnel, etc.

3. Train Area Information personnel

B. Data Coord. & info. spec. .4

C. Sect.

.4

.4

0 1. Works under Info. Spec.

0

.4 1. Standard secretarial duties

Table VI. Regional Office Organization Chart> Staffing Shown for entire office. RSA (1) - Regional operational Coordinator (1) - Administrative Assistant and Secretary (1)

r
Regional

Program Management

Quality

I

Program

Assurance

Lawyer

Coordinators Team

Secretaries

Catchment Areas

Fiscal and Personnel Management
Business Manager
RYPPIIUBB
Sect.

Information Management
I
Information Spec.
I
Data Coord.

Affirmative Contracts Action Coord- Manager inator

I Accounts Personnel Book- voucher-

Bookkeeper Clerk

keeper ing

clerk

Sect.

00

Regional Office Staffing and Costs to Provide Management Support to Programs for Northampton Clients.

Organizational Unit

Position

9

H

9

Total Fringe Support Total

FTEs Exist. Pos. Salaries S a l a r i e s @ 1 8 %

<? 152

$

All Costs

RSA's O f f i c e
Syst/Program Develop. Mgmt.

1 . RSA

.4

.4

0

o

12,000

N.A.

N.A.

0

2. Admin.Asst •

Secy

.4

.4

0

0

5,600

N.A.

N.A.

0

3. Reg. Opera

Coord.

.4

.4

0

o

8,000

N.A.

N.A.

0

12,000 5,600 8,000

Total

1.2

1.2

\ o ] 1 u ( \ 25.600) f 0 1 T 0 ) I 0 \ ( 7t; finn j

1 . Reg. Progr. 2

2

Coord.

2. Qual. Assur .3.1

2.1

Team

3. Atty

.4

0

4. Secy

1

1

0

0

1

18,000

.4 8,000

0

0

24,000
47,625
8,000 7,500

N.A.
3,240
1,440 N.A.

N.A.
2,700
1,200 N.A.

0
23,910
10,640 0

24,000
53,565
10,640 7,500

Fiscal Mgmt.
I n f o . Mgmt. ~
ro —'TflTAI S

Total

6.5

6.1

1 . Bus. Mgr. .4

.4

2. Accts. Book-

keeper

.4

0

3. Personnel

Clerk

.4

.4

4. EEO/AA Coord..4

.4

5. Contract Mgr..4

.4

6. Bookkeeper .4

.4

7. Vouchering Clk. .4 .4

8. Exec. Secy .4 0

9. Secy

.4

.4

Total

h.!k—

1. Info Spec. .4

2. Data Coord. .4

3 Secy 4. BUP

:4 N.A.

Total

J_-2._

.4 .4 0 N.A.

12.r>

9.9

U.4j | [26,O00| f 87.1251 /iiiiSO | ULSflOj

0

N.A.

8,000

N.A.

N.A.

.4 4 , OOO

4,000

720

600

0

0

0

0

0

0

0

0

0

0

.4

3,600

0

0

3,600 5,600 6,800 3,20O 3,200 3.600 3,000

N.A. N.A. N.A. N.A. N.A.
648 N.A.

N.A. N.A. N.A. N.A. N.A.
540 N.A.

tLi600J Ul.£O.oJ

CL.140J

0
0 .4
N.A.

0
0 3, OOO
N.A.

5,600
4,800 3,000
N.A.

l2-.fi]

[36, 001)!

L-

J

'167,1251

N.A. N.A.
540 H.A.
L540J

N.A. N.A.
450 4,000
|4.450/

|91_4jK):

I J 4 , 5 O Q J I^5.l/fl5 1

N.A.

8,000

5,320

5,320

N.A. N.A. N.A. N.A. N.A. 4,7RB N.A.

3,600 5,600 6,800 3,200 3,200 4.78B 3,000

bo.jonl 1.4.1,508-.-. 1

N.A.

5,600

N.A.

4,800

3,990

.1,990

•1,000

.», 000

(~7.990 I lj.8.390 1

jjfi J,20)|

y. Summary

Page 18

On the basis of the above analysis of the responsibilities

I

and activities, resources and needs of both area and regional

officer, the management component to a comprehensive community

care system 1n all of Region will cost S690,868" annually In

addition to existing administrative personnel. A breakdown of

this figure is as follows:

Salaries Fringe Support TOTAL

Personnel Costs

5 Area Office s 472,250 79,605 86,335

638,190

i

1 Regional

36,600

6,588

9,490

52,678

j

Office

Total for Region

706,500 105,975 105,975

690,868

Although this figure theoretically assumes an equal distribution of

administrative resources to each area, the actual allocation of funds

should be modified to reflect individual area needs and population.

(220)

ATTACHMENT G
SURVEY OF EXISTING COMMUNITY MENTAL HEALTH SERVICES FINAL DRAFT
I. Introduction
. The documents in Phase I of the planning process designed a. range of residential and nonresidential program models and determined the actual number of placements which must be created in each of those models to meet the needs of the members of the -plaintiff class. The Summary of Principles and Conclusions of ; Phase I correlated all planning documents and estimated the total I cost for creating and maintaining a system of community mental health services for a specific portion of the plaintiff class who were hospitalized in a given two year period (planning population). Given the fact that some of the programs needed by the planning population already existed, although not necessarily in a form comparable to the relevant model, it thus was necessary to assess the capacity and adequacy of existing programs to serve this planning population. The resultant information could then be used to determine the actual number of new residential and nonresidential placements which must be created and the extent to which existing programs must be upgraded to satisfy the plaintiffs' needs as set forth in the Phase I planning documents.
(221)

II. The Process
After extensive discussion of various assessment techniques, a process was developed over several months to generate and analyze relevant data on the capacity and adequacy of existing programs. It was recognized at the outset that even an extensive research project using sophisticated computer methodologies would not be significantly more reliable than information gathered through individual interviews and analysis of existing contracts due to the limits on the type and accessibility of information maintained by community service providers. Therefore, a two step process was adopted which initially determined the capacity of existing programs to serve members of the planning population and which subsequently analyzed this data in light of the program models to assess their adequacy.
The data gathering phase of this process began with a review of all mental health programs funded in whole or in part by. the Department of Mental Health. Through a series of questions addressed to each Area Director in separate interviews (see Appendix A ) , the programs in each Area which significantly serve members of the planning population were delineated and their actual client capacity determined. A list of all relevant programs, by Area, and their capacity to serve the planning population was then compiled for review and certification by the Regional Services Administrator. It was recognized that this approach not only provided a reliable measure of the extent of services
(222)

offered by existing programs to the most disabled population, but also created a standard against which all programs and Area managers could be held accountable in the future.
An adequacy assessment instrument to collect information as to each program's personnel and fiscal resources was then carefully drafted, discussed, and finalized (see Appendix B ) . For each program determined to significantly serve the planning population a separate staff and funding survey form was completed, either by the 'Area Director based on a review of contracts and other Department statistics or through a formal site visit to the service provider by the Area Director, Regional Office staff person, and a representative of the plaintiffs. Using this survey instrument, accurate information was generated as to the staff and fiscal resources of existing community programs which are available to deliver each of the model residential and nonresidential services described in the planning documents.
To summarize and analyze this data, two formats were created (see Appendix C). The first described all available resources in Region I for each residential and nonresidential service and then assessed the adequacy of existing programs providing that service by comparing the available resources with the standards set forth in the planning documents. This comparison was done not only for present resources, but also for anticipated program resources included in the new FY'79 budget, as approved, and the FY'80 budget, as requested by che Department. The second format compiled the adequacy conclusions for each
(223)

service and presented a composite description of the adequacy of all existing residential and nonresidential services. This summary was again done for present resources, approved FY*79 programs, and requested FY'80 programs. The resultant data analysis, a summary of which is attached as Appendix D, provides a clear picture of which program models exist in Region I, and the capacity and adequacy of those programs to serve members of the planning population.
III. Conclusion
Based on the carefully devised process for gathering and analyzing information with respect to the capacity and adequacy of existing community programs, several conclusions emerge:
1. There is no unused capacity in existing programs to serve the present residents of the Hospital. Therefore, further census reduction in conformity with the residential and nonresidential placement recommendations set forth in the planning documents, can only be accomplished through the creation of new programs or the expansion of existing programs to serve these members of the planning population.
2. There are several residential and nonresidential programs which have the capacity to serve a specific portion of the planning population but which are inadequate, as compared to the planning documents,
(224)

to meet the needs of the members of the planning population living in the community who participate in these programs. The projected cost of upgrading these programs for community clients is $2,801,506.
3. There are other residential and nonresidential programs which are entirely absent or only minimally available in most Areas in Region I, and which therefore must be newly created to serve the members of the planning population living in the community who need such programs. The projected cost of creating or expanding these programs for community clients is $3,812,077.
Thus these conclusions indicate that the residential and nonresidential programs which now exist in Region I are substantially inadequate to serve the 1755 members of the planning population not presently institutionalized at the Northampton State Hospital. The total cost of upgrading these programs to provide adequate treatment in appropriate less restrictive alternatives for these persons is $6,613,583. Some but not all of these costs include federal reimbursements under Titles XIX and XX of the Social Security Act, which would be significant for many nonresidential programs.
Therefore, in order to reduce 607. of this inadequacy in existing programs during FY'80, it will require $2,933,421 during that year (see Appendix E). A significant portion of
(225)

this cost ($1,404,341) is already included in and has been approved as part of the Region I budget request for FY'80. To eliminate the remaining inadequacy during FY'8l, it will cost $1,772,440 during that year.
(226)

FOR MEETING OF 9/8/78

APPENDIX A

Methodology for identifying existing community mental health services funded fully or partially by D.M.H. and for determining the extent to which these programs meet the needs of the plaintiffs' class members as set forth in the summary and documents of Phase I of the planning process.

FILTERING QUESTIONS

1. Does the reporting unit or agency operate at more than a minimum level at least one program described in the residential or non-residential program models? If so, uhich program (use Appendix A ) .

Yes

2. Is the program significantly designed and funded, pursuant to State Plan, policy, or assurances made in other litigation to serve a client population other than the members of the class as defined in the planning documents? No
3. Is the program designed and funded to significantly serve members of the planning population, as opposed to other members of the plaintiff class (See Appendix B for description of the planning population). Yes
Repeat above procedure for all RUs corresponding to F.Y.'79 for funding. New programs funded for F.Y.'79, new programs requested for F.Y.'SO.
ADEQUACY QUESTIONS *». What is the full capacity of the program and what percentage is designed
and funded to service the planning population? (See Appendix C for capacity format).
5. What is the level of D.M.H. and non-D.H.H. funding?
6. Uhat is the total number of staff and hou are they assigned to the program under consideration. Uhat is the resultant staff/client ratio?

(227)

DIRECTIOWS

APPENDIX B

This packet includes this coversheet, a Staffing Form, a Funding Form and an Appendix of Staff Discipline Codes. All programs being surveyed are assumed to fall into one of four Qeneral categories.
Category 1
The program is equal to the agency for budget and staffing.
Category 2
The program is not equal to the total agency, but staff and budget are distinct in all but administrative overhead.
Category 3
The program is not equal to the agency. There is staff sharing but allocation of staff time to each program is clearly predetermined by agency policy and procedure.
Category *»
The program is not equal to the agency. There is a staff and/or budget sharing that is not administratively predetermined. This category would include all cases that do not fall into any of categories 1, 2 or 3 above.

The rules for applying the Funding and Staffing Forms to the four (k) categories are presented belou:

Catecorv Number
1

Staffino
Columns 1 through 3
and 6

Funding
Columns 1 through *»

2

Columns 1 through 3

Columns 1 through 5

and 6

3

. Columns 1 through 3

Columns 1 through 5

and S

I*

Columns 1 through 6

Columns 1 through 9

In general, there are only a feu general rules that apply to the Staffing Form and the Funding Form:
Staffino Form
1. Column 2 - FTE - is mandatory for computing Column 6 (Cost of Staff Person to Program) S = 2 x 3(salary)
2. If 2 is not available, than Columns k and 5 in regard to assigned hours must be computed. Thus 4 + 5 = 2 , Then 2 x 3 = 6

DIRECTIONS CONT'D

PAGE 2

Funding Form 1. Columns 3, *» and 5 should be equal to Column 1
2. Columns 8 and 9 should be equal to Column 6
3. For Categories 2, 3 and k the figure for Column 5 is computed by the formula

1 PROGRAM BUDGET 6 TOTAL BUDGET

9 == 5 THE AMOUNT OF ADMINISTRATIVE OVERHEAD THAT BELONGS TO THE PROGRAM

GENERAL RULE: Past experience has illustrated that uhile advanced planning is invaluable, no amount of foresight uill allow for prediction of the occasional "special case" that may not fall into any of the four categories. In the event of any of these "special cases" being encountered, they will be so noted and all raw data mill be collected on both forms. This uill allou for later re-evaluation of the handling of that particular situation.
Collection of Data for the four categories uill be completed by the following persons:
Categories 1, 2 and 3: The Consultant (Paul Gerson, LJMTC) uill explain the forms to the Area Directors and they or their designee uill complete them uith the consultant available for input.
Category fr: The Area Directors (possibly including other area office staff), the Consultant and Steve Ferrarons (MPAP) uill meet uith the program director (possibly including other agsncy stafF) to complete th» forms.

'229)

APPENDIX S T A F F I N G FOR M
D e p a r t i n g U n i t Number/HraQrnm Cade

ISCIPLIf.'E DP STAFF PER3QN (GEE APFEND1X " A " )

F.T.E.

TOTi'il. GROSS SALARY HOURS ASSIGNED TO TO ANCPJCY, INCLUDING PROGRAM

FRUJCJI:

(X c Ualunteers,

Direct All Other

Placements, etc Contact Hours

tilth

clients

it

COST OF STAFF PERSON TO PROGRAM

O

I I

I I

FUNDING FORM

NONE CF THE rIGUHES ENTERED OELOW GHUULD INCLUDE THE VALUE OF NON-PAID PERSONNEL OH ANY IN-KINO COKTf! IOUTIGNS.

PROGRAM BUDGET FOR:

/

REPORTING UNIT NUMOER/PRUGIIAM CODE

AGENCY OUDGET FOR:

TOTAL 1

D.H.H. 2

PERSONNEL 3

riorjPEUSCNtCL

PROGRAM*S AMOUNT OF OHAREO Ol/EIUEAD
5

it

TOTAL 6

D.K..H. PERSONNEL KCN-FERncrjf.'EL

7

8

9

(231)

APPENDIX D Revised Summary of Data for All Residential and Nonresldential Program Models

COLUMN 3 RESOURCES NEEDED

COLUMN 5 FY'79 EXISTING RESOURCES

COLUMN 6 RESOURCES LACKING— COMMUNITY CLIENTS IN EXISTING PROCRAMS

COLUMN 9 TOTAL RESOURCES LACKINGCOMMUNITY CLIENTS

COLUMN 9 TOTAL RESOURCES LACKINGHOSPITAL CLIENTS

COLUMN 11 FY'80 EXISTING RESOURCES

COLUMN 15 RESOURCES LACKINGCOMMUNITY CLIENTS

COLUMN IS RESOURCES LACKINGHOSPITAL CLIENTS

Residential 6,585,102 2,677,209

488,298

936,388 3,022,585 4,494,371

414,939

1,681,273

NonResidential

9,755,791

2,515,535

2,313,208

5,677,195

1,559,936

4,378,296

4,660,365

714,912

Total

16,340,893 5,192,744

2,801,506 6,613,583 4,582,521

8,872,667

5,075,304

2,396,185

Copies of all data are available at the Region I Office In Northanpton. This data Includes completed funding and staffing forms for all relevant existing programs, as well as aggregated data, by Area and program model, which sets forth the deficits in client capacity and fiscal resources for both FY'79 and PY'80.

Summary of Costs of Upgrading of Programs in FY'80 and FY'81

Funding for Brewster vs. Dukakis Consent Decree

stions:

1. Program Models developed in planning process 2. Timetable for census reduction as in draft decree 3. Funding 3/5 of resources lacking for community clients in
FY'80 and 2/5 in FT'81.

of FY'79

Jiting resources for planning population (incl. SSI, Title XIX)

3,508,282

pital Budget minus reallocation

9,801,521

(Programs - FY '79 (already appropriated)

FY'79 - Part Year Funding

Annualized - FY'80

Funds llocation al

793,861 151,790 945,651

New Rollover Reallocation Total

796,809 831,440 1,684,462

of FY'79 - Start of FY'80

Bting Resources (incl. SSI, Title XIX) urces lacking for Community Clients urces lacking for Hospital Clients pital Budget minus reallocation

Programs - FY'80 - DMH Budget Request

FY'80 - Part Year Funding

mminity Clients - New Funds -.JReallocation Total

737,137 667,204 1,404,341

bspital Clients - New Funds Reallocation Total

765,986 595,530 1,361,516

d Total

2,765,857

5,192,744 6,613,303 4,582,321 7,814,005
Annualized - FY'8l
250,000 1,435,940 1,685,940
250,000 1,837,074 2,087,074
3,773,014

Above funding will permit the following:
Appropriate residential and day programs for 100 hospital clients. Case Management services for 100 hospital and 590 community clients. Medication aftercare services for 100 hospital and 80 community clients. Funds for 150 respite care and 480 crisis intervention episodes. Improving the funding inadequacies of 10 existing residential programs. Improving the adequacy of regional-area office staff.
(233)

New Programs - Added to FY'80 Request (due to 3/5 provision)

FY'80 Part-Year Funding (8 months)

New Funds

1,529,080

Annualized - FY'81 2,282,209

This added funding v;ill permit the following:

Increase the capacity of day activity programs for 100 community clients. Increase the capacity of case management services for 300 community clients. Establish 5 area assessment teams to do Individual Service Plans for all clients. Funds for additional 210 respite care and 470 crisis intervention episodes.

Total New Programs in FY'80

FY'80 Part-Year Funding

New Reallocation Total

3,032,203 1,262,734 4,294,937

End of FY'80 and Start of FY'81

Annualized - FY'81
2,782,209 3,273,014 6,055,223

Existing Resources (including SSI, Title XIX) Resources lacking for Community Clients Resources lacking for Hospital Clients Hospital Budget minus reallocation

11,247,967 2,645,434 2,495,447 3,735,707

New Programs - FY'81

FY'81 Part-Year Funding
Community Clients - New Funds - Reallocation Total

1,772,440 1,772,440

Annuali2ed - FY'81
1,777,581 867,953
2,645,534

Hospital Clients - New Funds Reallocation Total

972,723 375,000 1,347,723

877,494 1,617,953 2,495,447

Grand Total

3,120,163

5,140,881

These funds will, permit the following:
Appropriate residential, day and case management servicas for 100 hospital clients. Remaining missing capacities:
Respite Care - 15; Family Support - 19; Medication Aftercare - 372; Case Management - 478; Prevorational - 473; Transitional Employment - 240; RecreationSocialization - 283. Remaining adequacy of existing programs: Counseling, Family Support, Medication Aftercare, Day Activity, Residential Programs, and Regional-Area Management.

(234)

End of FY'81 - Start of FY'82
Existing Resources (including SSI, Title XIX) Resources lacking for Community Clients Resources lacking for Hospital Clients ^Hospital Budget minus reallocation

16,388,848
0 0 4,000,000

*To be used for secure treatment for 50 remaining hospital clients if option is to use building on hospital grounds. Remainder is savings as physical plant is phased out and remaining support staff is reassigned.
**Maximum SSI funding is built into FYf79 through FY'81 projections; but Title XIX projections are conservative. The latter will possibly be higher than projected in FY'80 and '81 as clinics and day treatment programs qualify for free-standing Title XIX certification.

(235)
I

FY 79- New Community Resources DM11, BSI, TITLE XIX

l'Y 79 3,508,282.

New Programs KY 79 NKW PROGRAM KUNDS
Roallo.a Lion, SSI, XIX
TOTAL

793,881. 151,790. 945,651.

New Programs FY 80 NKW PROGRAM I'UNDS
Reallointlon.-SSl, XIX
TOTAL

New Programs l'Y 81 NEW PROGRAM I'UNDS Koallocation, SSI, XIX TOTAL
TOTAL COMMUNITY RKSOURCES
HoH|ill .1 1 1111(1^1*1
to

4,453,933. 9,801,521.

l'Y 80
3,508,282.
796,809. 831,440.
1,684,462.

I'Y 81 3,508,282.
796,809. 831,440. 1,684,462.

3,032,203. 1,262,734. 4,294,937.

2,782,209. 3,273,014. 6,055,223.

9,487,681. 7,814,005.

2,745,163. 375,000.
3,120,163.
14,368,130. 5,735,707.

KY (12 3,508,282.
796,809. 831,440. . 1,684,462.
2,782,209. 3,273,014. 6,055,223.
2,655,175. 2,485,706. 5,140,881. 16,388,848. 4 ,000,000.

Attachment H
Defendants' Obligations to Overcome Potential Obstacles* to Implementation

The defendants will take the following actions to overcome potential obstacles and barriers to the full implementation of this Decree:
1. Educating communities, citizens, and the general public as to the appropriateness and advantages of residents and clients living in less restrictive) more normal residential alternatives;

2. Working with local cities and towns to assist them in integrating residents and clients into the community and insuring clients equal access to generic services;

3. Opposing restrictive zoning measures and actions designed to frustrate the right of residents and clients to live in less restrictive community residences;

4. Securing the approval of determination of need applications;

5. Reviewing relevant labor contracts and collective

bargaining agreements to determine methods for addressing con-

cerns of Hospital employees;

(237)

6. Assisting service providers and vendors in increasing their capacity and efficiency to operate residential alternatives and nonresidential programs;
7. Reviewing and, where appropriate, modifying the present contracting process to eliminate burdensome administrative procedures which may be found to unduly delay reimbursement to service providers and vendors or which may be, found to unnecessarily limit administrative flexibility; and
8. Working cooperatively with persons, agencies, departments, programs, or organizations not a party, to this Decree and not within the direct or indirect control of the defendants to insure full compliance with the provisions of this Decree.
(238)

ATTACHMENT I
REVISED NOTIFICATION OF DISCHARGE AGREEMENT
The parties involved ir. the lawsuit, Brewster v, Dukakis, agree to the following:
1. As soon as possible, but in no event less th.in two weeks prior to the discharge, referral to a community treatment program, or placement in an alternative community facility of any member of the plaintiff class who has been at. Northampton State Hospital (the Hospital) for more than thirty days, the defendants will give written notice to the plaintiffs' counsel, Steven J. Schwartz, at the Mental Patients Advocacy Project, Northampton State Hospital, of the name of the resident being discharged, referred, or placed, the proposed date for such discharge, referral, or placement, and the name and address of the community facility or program to which placement or referral will be made; and whether the resident or his guardian consents to such placement.
2. With respect to any member cf the plaintiff class who has been at the Hospital for less than thirty days, the defendants will give written notice on a weekly basis to the plaintiffs' counsel, Steven J. Schwartz, at the Mental Patients Advocacy Project, Northampton State Hospital, of the name of all residents who were discharged during that week, the actual date of such discharge, and the name and address of the community facility or program to which placement or referral was r^ade.
(239)

3. For all mentally retarded residents, copies of such notices will be sent to Boisfeuillet Jones, Hill and Barlow, 225 Franklin Street, Boston, Massachusetts 02110.
4. The Regional Services Administrator shall designate one person responsible for all such notifications of discharges, referrals, or'placements.
5. Upon execution of an authorization, signed by the resident, permitting Steven J. Schwartz or Boisfeuillet Jones or their designated-in-writing representative, to examine the clients' records (G.L. c. 123, §36), the Regional Services Administrator or the director of medical records of the Hospital will permit the records and files to be examined. In the event a resident is incompetent and has no guardian, the Commissioner or his designee shall approve the release of the medical records pursuant to §7.03(c)(l) of the Regulations of the Department of Mental Health.
6. The Department of Mental Health will cooperate with plaintiffs' attorneys in their desire to examine the proposed community referral or placement and to discuss its program with staff of both DMH and the community facility.
7. No part of this agreement or notification orocedure shall be construed to cause a person to remain in the Hospital any longer than he/she otherwise would in the absence of such agreements or procedure.
(240)

' A L-3- -' -. ~<-r?~P w^—- > \

Raymond Briefi

•

Regional Services Administrator

DMH, Region I

Steven J. 'Schwartz Attorney for Plaintiffs ^ O

Catherine A. White Assistant Attorney General Attorney for Defendants

Boisfeuillet: Jorfes, Jr.
Attorney for Plaintiffs Massachusetts Association for Retarded Citizens

(241)

TABLE OF CONTENTS

A. General Description of Suit (par. 1-6)

3

B. Definitions (par. 7)

5

c. Principles for Creating and Maintaining Community

Programs (par. 8)

8

D. Development of Community Programs (par. 9-25)

13

E. Individual Service Plan

(par. 26-31)

20

F. Standards

(par. 32-33)

23

G. Personnel and Training

(par. 34-37)

25

H. Monitoring and Evaluation

(par. 38-40)

27

I. Hospital and Placement Procedures (par. 41-46)

28

J. Implementation and Monitoring

(par. 47-62)

31

SCHEDULE OF ATTACHMENTS

40

ATTACHMENT A - Analysis of the mentally disabled population

presently hospitalized and at risk of

hospitalization in Region I

41

ATTACHMENT B - Community residential alternatives for

Mental Health Clients program models

64

ATTACHMENT C - Non-Residential treatment and support

services program models

U8

ATTACHMENT D - Residential Placement recommendations for

mentally disabled persons in Region I

183

ATTACHMENT E - Non-Residential program recommendations

for mentally disabled persons in Region I 192

ATTACHMENT F - Management component

203

ATTACHMENT G - Survey of existing Community Mental

Health Services

221

ATTACHMENT H - Defendant's obligations to overcome

potential obstacles to implementation

237

ATTACHMENT I - Brewster v. Dukakis

Notification of discharge, referral

239

or placement

(242)

 
 Brewster v. Commw. of Mass.
—— —— — — —__v H m •• •• •• • p •• •• BV • • • •
MH-MA-001-001 IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS

DAVID BREWSTER

•k

HECTOR SANTIAGO

k

RICHARD SCHNEIDER

*

DONALD GABOURY

V-

MARTIN WEINBERG

ALBERT POTTER

ELLA BAILEY

THONNIE ROWELL, by his next friend

*

STEPHEN FERRARONE

*

MARY MC GUILLICUDDY, by her next friend

CAROL BOOTH

in behalf of themselves and

*

all others similarly situated *

*

MASSACHUSETTS ASSOCIATION FOR MENTAL

•k

HEALTH, INC.

•k

MASSACHUSETTS ASSOCIATION FOR RETARDED

•k

CITIZENS, INC.

*

it

•k

Plaintiffs

•k

•k

•k

•k

•k

v.

k

•k

MICHAEL S. DUKAKIS

Governor, Commonwealth of Massachusetts
•k

DR. ROBERT L. OKIN

Commissioner, Department of Mental Health*
-k

DR. MARY JANE ENGLAND

-k

Associate Commissioner for Programs,

•k

Department of Mental Health

•k

CIVIL ACTION No. 76-4423-F

LINDA GLENN

Assistant. Commissioner for Mental

-k

Retardation Services, Department of

Mental Health

ROBERT W. MURPHY

*

Assistant Commissioner for Mental Health

*

Services, Department of Mental Health

*

*

RAYMOND BRIEN

*

Regional Administrator of Region I,

*

Department of Mental Health

*

*

EVELYN MC LEAN

*

Area Director of the Franklin-Hampshire

*

Area, Department of Mental Health

*

ANDREW PHILLIPS

*

Area Director of the Holyoke Area,

*

Department of Mental Health

*

FRANK ROBINSON

*

Area Director of the Springfield Area,

*

Department of Mental Health

*

KERRY HOLLAND

*

Area Director of the Westfield Area,

*

Department of Mental Health

*

JOSEPH VAN HOENACKER

*

Area Director of the Berkshire Area,

*

Department of Mental Health

*

IRVING A. JACOBS

*

Superintendent, Northampton State Hospital *

DR. JONATHAN FIELDING

*

Commissioner, Department of Public Health

*

•k

JOHN R. BUCKLEY

*

Commissioner, Executive Office for

*

Administration and Finance

*

*

All individually and in their

*

official capacities,

*

Defendants

*

THIRD AMENDED COMPLAINT

I. NATURE OF THE ACTION
1. The Northampton State Hospital (hereinafter the Hospital) presently involuntarily confines more than 500 mentally disabled persons and admits more than 1500 involuntary patients annually. Of both this fixed and revolving patient population, a significant number did not and do not belong in the Hospital and would benefit by being placed in alternative care facilities, including community mental health clinics, halfway houses, nursing homes, rest homes, group homes and other residential environments. However, only a tiny fraction of these patients have been or can be placed in such alternative facilities, either because there are not enough places in existing alternatives to handle the number of patients who are appropriate for placement or because the quality of treatment and supervision provided in many of the existing alternatives is inadequate and would harm rather than benefit patients placed there or because the Hospital has neglected to locate suitable placements. The absence of adequate and appropriate community placements is the result of a pattern and practice on the part of the defendants in failing to create such alternatives.
The term "mentally disabled," as used throughout this Complaint, refers to persons who are mentally ill or mentally retarded, or who have a combination of these handicaps

4
2. The involuntary confinement of mentally disabled persons in a total institution such as the Northampton State Hospital results in a serious deprivation of liberty. Moreover, patients' constitutional rights of association, assembly, and travel as well as their freedom of speech and freedom of belief are seriously restricted if not fully curtailed in the Hospital. The abridgement of individuals' liberty and other fundamental rights must be accomplished by the least drastic means possible. Since placement in a less restrictive community setting or facility is appropriate and would benefit a significant number of patients at the Hospital, retention in the Hospital is unnecessary and unconstitutional.
3. The sole legitimate purpose for the confinement of persons at the Hospital is treatment. The limited treatment offered at the Hospital can be and routinely is administered in community clinics, halfway houses, nursing homes, rest homes, group homes, and other residential environments. This continuum of less restrictive alternatives also offers other modes of treatment which are not available in the Hospital and which would greatly further the patients' rehabilitation and their integration into the community. Where the treatment of a significant number of patients at the Hospital can be undertaken in a less restrictive setting or facility, and where the treatment provided at the Hospital often harms rather than benefits their mental condition, retention at the Hospital is inappropriate and unconstitutional.

4. The desirability of providing treatment in less restrictive community alternatives in order to avoid the resultant harm of institutionalization is now clearly a national policy incorporated in several recent Congressional enactments. The mandate to maintain a continuum of community treatment programs has been incorporated in every recent federal statutory scheme affecting the mentally disabled. Specifically, Congress has enacted five interrelated programs that provide the major portion of federal funds for mentally disabled persons and has conditioned receipt of such funds on the care, treatment, and rehabilitation of disabled persons in less restrictive alternatives. These programs include the Developmentally Disabled Assistance and Bill of Rights Act, 42 U.S.C. §6001 et seq.; the Community Mental Health Center Amendments, 42 U.S.C. §2689; the Special Health Revenue Sharing Act, 42 U.S.C. §246; the Rehabilitation Act of 1973, 29 U.S.C. §794; and Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq. Taken together they reflect a clear federal policy to treat mentally disabled persons in appropriate, less restrictive alternatives and not to discriminate in the allocation of federal funds against any subgroup of such persons by virtue of their unnecessary institutionalization. Massachusetts has violated and continues to violate this policy by accepting federal monies pursuant to these programs but failing to place the plaintiffs and members of their class in such less restrictive alternatives

5. All of the patients in the Hospital are confined there pursuant to Stat. 1970, c. 888, codified as M.G.L. c. 123. The fundamental goal of that statute is to return the mentally ill, through suitable rehabilitation and treatment, to a full, productive, and autonomous life in the community as soon as possible and insofar as possible. In revising this statute, the legislature was particularly concerned with the rights of mental patients and mentally retarded residents after they were confined in institutions. Among the most important of those rights to which mental patients are entitled after confinement are the rights to be confined and treated in the least restrictive environment. Therefore, the legislature was aware that many mental patients stagnated in large mental institutions and did not receive suitable treatment in an often inhumane environment that impeded the person's physical or psychological recovery. The legislature was also especially sensitive to the reality that confinement in a mental hospital often impaired the basic constitutional rights to liberty, to travel, to privacy and to association. In order to minimize any infringement on these constitutional rights, the legislature provided that persons confined under M.G.L. c. 123 be placed in the least restrictive setting consistent with suitable treatment. It contemplated that persons confined in the Hospital should have available to them a continuum of phased treatment settings ranging from large

institutions such as the Hospital to smaller, less restrictive facilities that would promote the patients' early reintegration to a normal life in the community. As the need for any restriction on a person's liberty decreased and the patient's level of function improved, the legislature intended that they should move along that continuum of alternatives.
6. This class action, arising under the United States Constitution and its statutes and the laws of the Commonwealth of Massachusetts, is brought by patients confined under the control of the Department of Mental Health at the Northampton State Hospital and other facilities in Region I of the Commonwealth of Massachusetts established to provide treatment to the mentally ill and mentally retarded of that area. The plaintiffs seek to compel the defendants not to deprive them of their liberty, their rights of association, assembly, speech, belief, travel, and privacy, and their right to treatment and rehabilitation, except under the least restrictive conditions necessary, as guaranteed by the First, Eighth, Ninth, and Fourteenth Amendments to the United States Constitution, 42 U.S.C. §6010, 42 U.S.C. §2689, 42 U.S.C. §246, 42 U.S.C. §1396 et seq., 29 U.S.C. §794, and M.G.L. cc. 19 and 123. Specifically this action seeks to compel the defendants to create sufficient and adequate treatment settings or facilities which are less restrictive than the Hospital as

presently constituted, and to place the plaintiffs therein. Such settings or facilities include but are not limited to community clinics, halfway houses, nursing homes, rest homes, group homes, and other residential environments.
II. JURISDICTION
7. This action arises under the Civil Rights Act, 42 U.S.C. 1983, the First, Eighth, Ninth; and Fourteenth Amendments to the United States Constitution, Developmentally Disabled Assistance and Bill of Rights Act, 42 U.S.C. §6010; Community Mental Health Center Amendments, 42 U.S.C. §2689; Special Health Revenue Sharing Act, 42 U.S.C. §246; Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., Rehabilitation Act, 29 U.S.C. §794, and, pursuant to the Court's pendent jurisdiction, under M.G.L. cc. 19 and 123. The jurisdiction of this Court is based upon 28 U.S.C. §§1331, 1343(3) and (4). Declaratory relief is sought pursuant to 28 U.S.C. §§2201-2. The amount in controversy exceeds Ten Thousand Dollars ($10,000) exclusive of interest and costs, for each plaintiff.
III. PLAINTIFFS
8. David Brewster is a 24 year-old resident of the Northampton State Hospital. Mr. Brewster was brought to the

Hospital in 1968 at the age of sixteen and has remained there without interruption. He has spent the greater part of the last eight years locked on his ward with virtually no treatment, recreation, or exercise, despite the absence of evidence in the medical records of any violent or disruptive behavior. No education has ever been provided for Mr. Brewster, despite numerous requests by him for reading instruction. At the most recent judicial review of his confinement in September 1976, the staff determined that placement in a less restrictive alternative setting or facility was necessary for Mr. Brewster's treatment needs, that he had in fact regressed during his confinement at the Hospital, but that no setting or facility existed appropriate for Mr. Brewster. Therefore, no effort at placement has been made or is reasonably expected to be made.
9. Hector Santiago is a 29 year-old Puerto Rican resident at the Northampton State Hospital. Mr. Santiago has been confined intermittently since 1973. Mr. Santiago speaks primarily Spanish and has great difficulty in communicating with any Hospital employee on his ward or unit because no staff member is able to converse in Spanish. Furthermore, no psychological tests or psychotherapy has been administered because of this language barrier. His most recent psychiatric evaluation, completed in June 1976, recommends placement in a community setting, with appropriate treatment and supervision.

10
Mr. Santiago has been recommended for this placement since 1973. There is no evidence in his records that the Hospital has ever taken any action to secure a suitable community placement for Mr. Santiago. Instead he has been released periodically to his home, which lacks any suitable support, supervision, or treatment. Due to the absence of a suitable community facility, and the inadequacies of existing community settings, Mr. Santiago has been involuntarily returned to the Hospital, each time in a regressed condition.
10. Richard Schneider is a 26 year-old resident of the Northampton State Hospital. Mr. Schneider has been confined since 1973. He was once released on convalescent leave status from the Hospital to a boarding house that did not have any support, supervision, or treatment. Mr. Schneider was returned in eighteen days from this placement in a deteriorated and regressed condition. Due to the absence of suitable community facilities and the inadequacies of existing alternative facilities, no effort has been made to place Mr. Schneider in a community setting, although he would benefit by placement in a suitable community alternative.
11. Donald Gaboury is a 25 year-old resident of the Northampton State Hospital. Mr. Gaboury was confined at the age of five at the Belchertown State School for the Retarded

LI
from which he was transferred in 1970 to the Hospital along with 200 other retarded persons after the filing of a lawsuit in the United States District Court challenging the conditions of confinement and the overcrowding at the School. There is absolutely no evidence in the records that he is mentally ill. Mr. Gaboury was locked in seclusion from July 9, 1971 to February 9, 1973, every evening without interruption, although there is no evidence in the records of any serious threats of violence or significantly disruptive behavior during the time he has been confined at the Hospital. A social services report, completed in 1974, recommends that Mr. Gaboury be placed in a group home for retarded persons since the Hospital has no staff or facilities to devise or implement any treatment program for such persons. No such placement has ever been effected due primarily to the absence of a suitable community facility available to patients at the Hospital.
12. Martin Weinberg is a 34 year-old resident of the Northampton State Hospital. Mr. Weinberg was confined in 1959 at the Paul A. Dever State School for the Retarded from which he was transferred in 1967 to the Hospital. There is absolutely no evidence in the records that he is mentally ill. Mr. Weinberg has continually regressed during this eighteen years of confinement due to the lack of treatment for his condition. At the most recent periodic review in August 1976, placement

12
in a community facility for the retarded was recommended since the Hospital has no staff or facilities to devise or implement any treatment program for such persons. No such placement has ever been effected, due primarily to the absence of a suitable community facility available to patients at the Hospital.
13. Albert Potter is a 34 year-old resident of the Northampton State Hospital. Mr. Potter has been confined since 1962. He has been released periodically from the Hospital, but has been involuntarily returned on seventeen separate occasions. On each occasion, Mr. Potter has been released to live in an apartment by himself, with no provision for suitable support, supervision, or treatment. Within the past two years, he has been readmitted to the Hospital six times, always in a regressed condition. During each hospitalization and prior to discharge, the Hospital staff recommended a placement in a supervised community setting where Mr. Potter can receive suitable treatment. At no time has such placement ever been effected. Due to the absence of suitable community facilities and the inadequacies of existing alternative facilities, no effort is presently being made or can reasonably be expected to be made to place Mr. Potter in a less restrictive alternative.
14. Ella Bailey is a 73 year-old resident of the Northampton State Hospital. Ms. Bailey has been confined since

13
1950. During the past seven years, Ms. Bailey has been permitted to live outside the Hospital in a nursing home. She has, however, been returned to the Hospital due to the inadequacies in existing alternative facilities. In September 1976, the social service staff recommended placement in an appropriate nursing home. The Hospital has not effected this placement, due primarily to the absence of a suitable community facility.
15. Thonnie Rowell is a 62 year-old resident of the Northampton State Hospital. Mr. Rowell has been confined since 1940. The medical notes in his record comprise only eight pages for the entire 36 years of his hospitalization. In a psychiatric evaluation in July 1974, placement in a rest home was recommended. No effort was made to accomplish this placement at that time. In a subsequent psychiatric evaluation in July 1976, placement in a community setting was again recommended but deemed impossible because of the lack of a birth certificate for Mr. Rowell. The lack of suitable treatment within the Hospital and the failure of the Hospital to place him in an appropriate less restrictive alternative have resulted in a serious regression of Mr. Rowell's condition. Due to the absence of an appropriate community facility and the inadequacies of existing community settings, Mr. Rowell continues to be confined at the Hospital. Stephen Ferrarone,

14
his next friend, is a paralegal with the Mental Patients Advocacy Project at the Northampton State Hospital and has assisted Mr. Rowell in other matters. Mr. Rowell has no other family or friends.
16. Mary McGuillicuddy is a 70 year-old resident of the Northampton State Hospital. Ms. McGuillicuddy has been confined without interruption since 1935. Immediately after her transfer from the Foxboro State Hospital to Northampton in August 1975, placement in a nursing home was recommended by the Hospital staff. No effort was made to accomplish this placement. At her most recent psychiatric review in February 1977, such placement was again recommended. Despite repeated notations in her medical records suggesting the need for nursing care, no effort has yet been made to locate a suitable nursing home for Ms. McGuillicuddy. Due to the absence of suitable community facility and the inadequacies of existing alternative facilities, Ms. McGuillicuddy remains confined to her ward at the Hospital. Carol Booth, her next friend, is a paralegal with the Mental Patients Advocacy Project at the Northampton State Hospital and has assisted Mr. McGuillicuddy in other matters. Ms. McGuillicuddy has no other family or friends.
17. The Massachusetts Association for Mental Health, which sues on its own behalf and on behalf of its members, is

15
an organization concerned with the care and general welfare of mentally ill citizens of the Commonwealth of Massachusetts. The Association has twenty-six affiliated chapters throughout Massachusetts with a combined membership of approximately ten thousand persons. Two of its affiliated chapters, the Springfield Mental Health Association and the Hampshire-Franklin Mental Health Association, serve the geographic areas in which patients at Northampton State Hospital resided before their institutionalization. These affiliates also provide or seek to provide community mental health services to former Hospital patients by managing or seeking to manage halfway houses in their respective areas. The Association members are citizens concerned with the issue of mental health, including former mental patients, relatives, and friends of mentally ill persons, lay mental health volunteers, and mental health professionals in the areas of psychiatry, psychology, social work, law and other specialties. The Association advocates on behalf of the approximately four thousand persons in state mental health institutions, the approximately eighty thousand persons who annually use community mental health services in Massachusetts, and those other persons in the general community who may at some time need such services. The Association's activities include dissemination of information about state and federal programs for the mentally ill, participation in public policy through its evaluation of state and federal agencies for the

16
mentally ill, review of pending and enacted state mental health legislation, and independent citizen review of the conditions at various mental health institutions in Massachusetts. The nature, purpose, and activities of the Association make it a proper party to vigorously represent the interests of the mentally ill persons presently confined in Northampton State Hospital. The Association is a nonprofit corporation organized pursuant to the laws of Massachusetts with its principal office in Boston, Massachusetts.
18. The Massachusetts Association for Retarded Citizens, which sues on its own behalf and on behalf of its members, is an organization concerned with the care and general welfare of mentally retarded citizens of the Commonwealth of Massachusetts. The Association has twenty-six affiliated chapters throughout Massachusetts with a combined membership of approximately eleven thousand persons. Three of its affiliated chapters, the Franklin Association for Retarded Citizens, the Hampshire Association for Retarded Citizens, and the Berkshire Association for Retarded Citizens, serve the geographic areas in which retarded residents at the Northampton State Hospital resided before the institutionalization. The Association members are citizens concerned with the issue of mental retardation, including parents, relatives, and friends of mentally retarded persons, lay mental retardation volunteers, and mental retardation professionals in the areas of psychiatry, psychology, social work, law, and other specialties. The Association advocates on behalf of approximately five-

17
thousand persons in state mental retardation and mental health institutions and the approximately one-hundred and fiftythousand persons who annually use community mental retardation services. The Association's activities include dissemination of information about state and federal programs for the mentally retarded, participation in public policy through its evaluation of state and federal agencies for the mentally retarded, review of pending and enacted state mental retardation legislation, and independent citizen review of the conditions at various mental retardation institutions in Massachusetts. The nature, purpose, and activities of the Association make it a proper party to vigorously represent the interests of the mentally retarded persons presently confined at the Northampton State Hospital. The Association is a nonprofit corporation organized pursuant to the laws of Massachusetts, with its principal office in Newton, Massachusetts.
IV. CLASS ACTION ALLEGATIONS
17. Plaintiffs David Brewster, Hector Santiago, Richard Schneider, Donald Gaboury, Martin Weinberg, Albert Potter, Ella Bailey, Thonnie Rowell, and Mary McGuillicuddy sue on their own behalf and pursuant to Rules 23(a), 23(b)(l) and 23(b)(2) of the Federal Rules of Civil Procedure, on behalf

18
of that class of persons who are or who may be hospitalized in the Northampton State Hospital pursuant to M.G.L. c. 123, and who now or may, in the future, need placement in a least restrictive setting, consistent with suitable care and treatment, and including those who now or may be placed on leave status by the Hospital. As persons confined in the Northampton State Hospital who need placement in a least restrictive setting, plaintiffs David Brewster, Hector Santiago, Richard Schneider, Donald Gaboury, Martin Weinberg, Albert Potter, Ella Bailey, Thonnie Rowell, and Mary McGuillicuddy can fairly and adequately represent and protect the interests of this class. The class represented by the named plaintiffs is so numerous that joinder of all members is impractical. The questions of law and fact presented in this action are common to members of the class. The claims of the representative parties are typical of the claims of the class. Prosecution of separate actions by individual members of the class would create a risk of inconsistent or varying adjudications with respect to individual members of the class which would establish incompatible standards of conduct for the defendants. The prosecution of separate actions would also create a risk of adjudications with respect to individual members of the class which would, as a practical matter, be dispositive of the interests of the other members not parties to the adjudications or substantially impair or impede their ability to protect their interests.

19
18. The defendants have refused to act on grounds generally applicable to the class, thereby making appropriate final injunctive relief or corresponding declaratory relief with respect to the class as a whole; that is, the defendants have refused to provide the class with suitable treatment in the least restrictive setting as required by the United States Constitution, 42 U.S.C. §6010, 42 U.S.C. §2689, 42 U.S.C. §246, 42 U.S.C. §1396 et seq., 29 U.S.C. §794, and M.G.L. cc. 19 and 123.
V. DEFENDANTS
19. Michael S. Dukakis is Governor of the Commonwealth of Massachusetts and as such has overall responsibility for the operation of the government of the Commonwealth of Massachusetts and the administration of its laws. Pursuant to M.G.L. c. 19, §1, he appoints the Commissioner of Mental Health and has final approval of the site of any new mental health facility and of any land to be taken for such facility. Pursuant to M.G.L. c. 17, §2, he appoints the Commissioner of Public Health and has final approval of all funds to be spent on licensing and enforcing standards of care in facilities under the jurisdiction of the Department of Public Health. Pursuant to M.G.L. c. 7, §4, he appoints the Commissioner of

20
Administration and Finance, and has final approval of all funds to be spent on the construction and operation of mental health facilities, including community residences and programs.
20. Dr. Robert L. Okin is the Commissioner of the Department of Mental Health of the Commonwealth of Massachusetts Pursuant to M.G.L. c. 19, §2, he has exclusive supervision and control of the Department and its facilities, including responsibility for all persons received into any of the facilities of the Department. In his capacity as Commissioner, he has the power to develop additional mental health facilities and/or to contract with private institutions, organizations or agencies to furnish mental health services to those persons who need such care and treatment.
21. Dr. Mary Jane England is the Associate Commissioner for Programs of the Department of Mental Health. Pursuant to M.G.L. c. 19, §4, she has the duty to assist the Commissioner in the establishment and supervision of all mental health services in the Commonwealth. Until November 1, 1976 she was chiefly responsible for the planning and development of community programs within the Department.
22. Linda L. Glenn is the Assistant Commissioner for Mental Retardation Services for the Department of Mental Health.

21
Pursuant to M.G.L. c. 19, §4, she is responsible for assisting the Commissioner in the supervision and planning of mental retardation programs and services.
23. Robert W. Murphy is the Assistant Commissioner for Mental Health Services of the Department of Mental Health. Pursuant to M.G.L. c. 123, §4, he has the duty to assist the Commissioner in the establishment and supervision of all mental health services in the Commonwealth. Until November 1, 1976, he was directly responsible for the licensing and quality review of community programs within the department.
24. Raymond Brien is the Regional Mental Health Administrator for Region I, an administrative subdivision of the Department of Mental Health consisting of five separate Areas: Franklin-Hampshire, Berkshire, Holyoke, Springfield, and Westfield. In his capacity he is responsible for the administration of all mental health services within Region I, including development of community programs and the review and approval of all Area budgets for the Region, as authorized by M.G.L. c. 123, §§19, 20.
25. Evelyn McLean is the Area Director for the FranklinHampshire Area of the Department of Mental Health. Pursuant to M.G.L. c. 19, §18, she is charged with the duty of preparing an

22
annual plan and budget for the operation and development of all mental health programs within the Franklin-Hampshire Area. That statutory provision further requires that "such a plan shall provide, as far as practicable, a comprehensive community program in mental health and retardation services."
26. Andrew Phillips is the Area Director for the Holyoke Area of the Department of Mental Health. Pursuant to M.G.L. c. 19, §18, he is charged with the duty of preparing an annual plan and budget for the operation and development of all mental health programs within the Holyoke Area. That statutory provision further requires that "such a plan shall provide, as far as practicable, a comprehensive community program in mental health and retardation services."
27. Frank Robinson is the Area Director for the Springfield Area of the Department of Mental Health. Pursuant to M.G.L. c. 19, §18, he is charged with the duty of preparing an annual plan and budget for the operation and development of all mental health programs within the Springfield Area. That statutory provision further requires that "such a plan shall provide, as far as practicable, a comprehensive community program in mental health and retardation services."
28. Kerry Holland is the Area Director for the Westfield Area of the Department of Mental Health. Pursuant to

23
M.G.L. c. 19, §18, he is charged with the duty of preparing an annual plan and budget for the operation and development of all mental health programs wtihin the Westfield Area. That statutory provision further requires that "such a plan shall provide, as far as practicable, a comprehensive community program in mental health and retardation services."
29. Joseph Van Hoenacker is the Area Director for the Berkshire Area of the Department of Mental Health. Pursuant to M.G.L. c. 19, §18, he is charged with the duty of preparing an annual plan and budget for the operation and development of all mental health programs within the Berkshire Area. That statutory provision further requires that "such a plan shall provide, as far as practicable, a comprehensive community program in mental health and retardation services."
30. Irving A. Jacobs is the Superintendent of the Northampton State Hospital. The Hospital is the only state mental hospital for persons residing within the geographical boundaries of Region I of the Department of Mental Health. In this capacity he is responsible for the supervision and operation of the Hospital and, pursuant to M.G.L. c. 123 and the Regulations enacted thereunder, for the admission, release, and administration of suitable treatment to all persons admitted or committed to the Hospital.

24
31. Dr. Jonathan Fielding is the Commissioner of the Department of Public Health. Pursuant to M.G.L. c. Ill, §2, he is responsible for administering all laws relative to the general health of the Commonwealth and the regulations of the Department, including but not limited to the licensing of nursing homes and rest homes and the establishments of standards for the operation of such facilities, as required by M.G.L. c. Ill, §§71, 72.
32. John R. Buckley is the Commissioner of the Executive Office for Administration and Finance. Pursuant to M.G.L. c. 7, §4, he represents the Governor in the financial, planning, and policy coordination between all Departments of the Commonwealth, including the approval of all budget requests of each Department. In this capacity he is also responsible for the promulgation of rules, regulations, and procedures governing all state contracts, pursuant to M.G.L. c. 7, §22. Such rules, regulations, and procedures apply to all contracts with private mental health facilities, including community clinics, halfway houses, nursing homes, rest homes, group homes, and other residential environments.
VI..' DUTIES
33. Under the Fourteenth Amendment to the United States Constitution, the defendants have the duty not to deprive the

25
patient plaintiffs of their liberty in other than the least restrictive setting.
34. Under the Fourteenth Amendment to the United States Constitution, the defendants have the duty to provide the patient plaintiffs with suitable treatment under the least restrictive conditions.
35. Under the First Amendment to the United States Constitution, the defendants have the duty not to abridge the patient plaintiffs' rights of association, assembly, speech, belief, and travel except with the least drastic means available and in the least restrictive setting appropriate for the plaintiffs' condition.
36. Under the First, Ninth, and Fourteenth Amendments to the United States Constitution, the defendants have the duty not to infringe upon the patient plaintiffs' right of privacy by confining them in other than the least restrictive setting.
37. Under the Eighth Amendment to the United States Constitution, the defendants have the duty not to confine the patient plaintiffs in a setting more restrictive than is necessary to provide them with suitable treatment consistent with their needs.

26
38. Under the Fourteenth Amendment to the United States Constitution, the defendants have the duty not to deny the patient plaintiffs or any subclass of the patient plaintiffs the equal protection of the law by discriminating against them in the allocation of benefits pursuant to federal statutory programs.
39. Under the Developmental Disabilities Act, 42 U.S.C. §6010, the defendants have a duty to use any federal funds received under the Act to provide the plaintiffs with appropriate treatment under the least restrictive conditions.
40. Under the Community Mental Health Center Amendments of 1975, 42 U.S.C. §2689, the defendants have a duty to provide a complete continuum of mental health services for the patient plaintiffs that is designed to avoid unnecessary institutionalization and to provide treatment in alternative community facilities.
41. Under the Special Health Revenue Sharing Act, 42 U.S.C. §246, the defendants have a duty to eliminate the inappropriate institutionalization of the patient plaintiffs and to insure the availability of appropriate community programs
42. Under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., the defendants have a duty to insure

27
that funds appropriated pursuant to the Act are expended to provide care and treatment in noninstitutional facilities whenever appropriate for the needs of the patient plaintiffs.
43. Under the Rehabilitation Act, 29 U.S.C. §794, the defendants have the duty not to discriminate against any handicapped person or class of persons in the provision of federally assisted programs.
44. Under M.G.L. c. 123, the defendants have the duty to return the mentally ill to a full, productive, and autonomous life in the community as soon as possible and insofar as possible.
45. Specifically, M.G.L. c. 123, §4, requires the defendants to periodically review the condition of every person within the care of the Department to determine whether placement in a community setting is appropriate or whether continued hospitalization is required.
46. In addition, M.G.L. c. 123, §2, and the Regulations enacted thereunder provide that the defendants must establish the highest practicable professional standards for the treatment of mentally ill persons including, but not limited to the provision of treatment in halfway houses, family care,

28
aftercare and home treatment settings. The treatment which the defendants have a duty to provide must be suitable to the rehabilitation of the patient plaintiffs as to result in their earliest possible return to the community or to the highest level of function which the plaintiffs can reasonably attain.
47. To fulfill its constitutional and statutory responsibilities, the defendants must explore all alternative treatment settings or facilities and promptly place the patient plaintiffs in the alternatives reasonably suited to their needs. Records must be kept of all consideration given at periodic reviews to alternative placements and the reason why any alternative was rejected.
48. Pursuant to M.G.L. c. 19, §24, the defendants are mandated to develop and maintain comprehensive mental health and mental retardation services including, but not limited to, inpatient, outpatient, and partial hospitalization services. Such services must be established to provide preventive, precare and aftercare treatment consistent with the treatment needs of persons residing in Region I which include the patient plaintiffs and members of the plaintiff class.
49. Therefore, the defendants are constitutionally and statutorily required to provide, as alternatives to the

29
Northampton State Hospital as presently constituted, smaller, more suitable, and less restrictive treatment settings or facilities such as community clinics, halfway houses, nursing homes, rest homes, group homes, day houses, night houses, and other appropriate residential environments. To the extent that such least restrictive alternatives do not presently exist, the defendants have the duty to create new alternative facilities or to upgrade and restructure existing but inadequate alternative facilities so that all the patient plaintiffs may be placed in alternative facilities to their benefit.
VII. STATEMENT OF FACTS
50. Plaintiffs David Brewster, Hector Santiago, R.ichard Schneider, Donald Gaboury, Martin Weinberg, Albert Potter, Ella Bailey, Thonnie Rowell, and Mary McGuillicuddy should no longer be confined in the Hospital but instead should be placed in lesser restrictive settings where suitable treatment can be provided and where there is significantly less abridgement of their rights of association, assembly, speech, travel, and privacy. According to M.G.L. c. 123 and the Regulations of the Department of Mental such less restrictive alternatives include, but are not limited to, community mental health clinics, halfway houses, nursing homes, rest homes, group homes,

30
and other residential environments. The named plaintiffs have not been placed by the defendants in such alternative facilities which will provide suitable treatment and instead have continually been confined at the Hospital, in violation of the First, Eighth, Ninth, and Fourteenth Amendments to the United States Constitution, 42 U.S.C. §6010, 42 U.S.C. §2689, 42 U.S.C. §246, 42 U.S.C. §1396, 29 U.S.C. §794, and M.G.L. cc. 19 and 123.
51. A significant portion of the present and annual population of the Hospital, including the named plaintiffs and constituting the plaintiff class, should no longer be confined in the Hospital but instead should be placed in lesser restrictive settings where suitable treatment can be provided and where there is significantly less abridgement of their rights of association, assembly, speech, travel, and privacy. Such alternatives include, but are not limited to, community mental health clinics, halfway houses, nursing homes, rest homes, group homes, and other residential environments. In violation of the guarantees of the First, Eighth, Ninth, and Fourteenth Amendments to the United States Constitution and M.G.L. cc. 19 and 123, the members of the plaintiff class have not, however, been placed by the defendants in suitable, less restrictive alternative facilities.

31
52. Inappropriate and unnecessary institutionalization of mentally disabled persons often results in their intellectual, emotional, physical, and social regression as well as the loss of those skills necessary to regain their self-sufficiency. Plaintiffs David Brewster, Hector Santiago, Richard Schneider, Donald Gaboury, Martin Weinberg, Albert Potter, Ella Bailey, Thonnie Rowell, and Mary McGuillicuddy have suffered such regression and loss of self-sufficiency as a consequence of their prolonged and unnecessary institutionalization. Their ties and communication with their families and friends have become weaker, thereby fostering further dependence. Because they are denied any opportunity to reintegrate into the mainstream of society through placement in a residential community treatment program, their mental conditions continue to deteriorate while they remain confined in an institution.
53. Several community mental health centers presently serve mentally ill persons residing in certain areas of Region I in Western Massachusetts. Pursuant to the provisions of the Community Mental Health Center Amendments, 42 U.S.C. §2689 and its predecessor, these centers are mandated to provide preventive services to persons who otherwise would be hospitalized and aftercare services to discharged hospital patients who might otherwise be forced to return to a hospital. In addition, the centers are required to provide a continuum of mental health services including the creation of community residential

32
treatment programs, in order to avoid or eliminate inappropriate institutionalization. The centers are further required to assist local courts in the evaluation of individuals within their jurisdiction for the purpose of assessing whether inpatient hospitalization is necessary.
54. Plaintiffs David Brewster, Richard Schneider, Albert Potter, Mary McGuillicuddy, and other members of the plaintiff class are entitled to receive services from these community mental health centers and could benefit from such services, including placement in a less restrictive community setting. None of the patient plaintiffs have ever received the services offered by these centers Tior benefited by the federal funds expended pursuant to the Community Mental Health Center Amendments, due primarily to their inappropriate confinement at the Northampton State Hospital. Many members of the plaintiff class, although otherwise eligible for such services, have never been evaluated by these centers as to the necessity for hospitalization and have therefore been needlessly institutionalized when treatment in a less restrictive setting was more appropriate for the individual's treatment needs.
55. Several of the named plaintiffs and members of the plaintiff class are developmentally disabled and reside at the Northampton State Hospital solely as a result of being

33
transferred from the Belchertown State School. Pursuant to the provisions of the Developmentally Disabled Assistance and Bill of Rights Act, 42 U.S.C. §6010, they are entitled to adequate treatment that is designed to maximize their developmental potential and that is administered in the least restrictive alternative. The named plaintiffs and members of the plaintiff class should no longer be confined in the Hospital, which provides no treatment, no specialized services, no rehabilitation program, and no vocational training for developmentally disabled persons, but instead should be placed in lesser restrictive settings where suitable treatment can be provided and where there is significantly less abridgement of their rights of liberty, association, assembly, speech, travel, and privacy. Other developmentally disabled persons do receive such treatment, services, and training in less restrictive environments, but no federal funds pursuant to this Act are expended for those persons residing at the Hospital. Such alternatives include, but are not limited to, halfway houses, group homes, rest homes, shared apartments, and other residential environments. In violation of the guarantees of the First, Eighth, Ninth, and Fourteenth Amendments to the United States Constitution, the Developmental Disabilities Act, 42 U.S.C. §6010, the Rehabilitation Act, 29 U.S.C. §794, and M.G.L. cc. 19 and 123, the plaintiffs and members of the plaintiff class have not, however, been placed by the defendants in suitable less restrictive alternative facilities.

34
56. The named patient plaintiffs and the members of the plaintiff class have not been and cannot reasonably expect to be placed in less restrictive alternatives where suitable treatment is provided, because, inter alia:
a. There is poor record keeping at the Northampton State Hospital, which impedes a determination of whether a patient should be placed in a less restrictive setting and includes no documentation of the consideration given to placement in a community setting or facility;
b. The defendants regularly fail to explore and investigate less restrictive alternative settings;
c. The defendants have not established adequate placement procedures for patients at the Hospital;
d. The defendants have no procedures for referring prospective patients to less restrictive alternative settings prior to admission;
e. There is not adequate deployment of staff by the defendants to effect proper placements;
f. There is not adequate deployment of staff to monitor and supervise existing placements and to facilitate the transition from the Hospital to a less restrictive setting;

35
g. The defendants have not provided enough places in existing alternative facilities in Region I to give the named plaintiffs and the plaintiff class suitable treatment in the least restrictive setting. For instance, there is not one supervised residential halfway house in the entire Springfield Area, although the city of Springfield is the second largest city in Massachusetts;
h. The quality of care provided or approved by the defendants in the few existing alternative facilities in Region I is so low that the patient plaintiffs and the plaintiff class would be harmed and not benefited if placed in such alternative facilities;
i. The defendants have failed to establish or enforce minimum standards for alternative facilities that will insure that persons placed in such facilities are benefited and not harmed;
j. The defendants have failed to allocate the necessary resources and to supervise the establishment of a continuum of less restrictive alternatives that will provide suitable treatment for a broad range of patients' conditions;

36
k. The defendants have failed to make full use of the evaluation, preventive care, and aftercare services of community mental health centers and to coordinate its admission and discharge policies with the practices of these facilities;
1. The defendants have failed to allocate any places in existing less restrictive alternative facilities for retarded persons or to establish any new less restrictive alternatives in order to provide suitable treatment for retarded persons confined in the Hospital;
m. The defendants have failed to coordinate and implement any comprehensive plan for the establishment and maintenance of an adequate number of suitable, less restrictive alternative settings.
57. The defendants' failure to provide an adequate number of appropriate community placements consistent with the treatment needs of the patient plaintiffs results from a pattern and practice of disregarding their duty to develop and establish a continuum of less restrictive alternatives, all in violation of the United States Constitution, 42 U.S.C. §6010, 42 U.S.C. §2689, 42 U.S.C. §246, 42 U.S.C. §1396, 29 U.S.C. §794, and M.G.L. cc. 19 and 123.

37
VIII. CAUSES OF ACTION
58. The defendants have, in violation of their duty under the Fourteenth Amendment to the United States Constitution, deprived the named plaintiffs and members of the plaintiffs class of their liberty by failing to place them in the least restrictive alternative settings.
59. The defendants have, in violation of their duty under the Fourteenth Amendment to the United States Constitution, failed to provide the named plaintiffs and the members of the plaintiff class with suitable treatment, under the least restrictive conditions consistent with the patients' treatment needs.
60. The defendants have, in violation of their duty under the First Amendment to the United States Constitution, abridged the patient plaintiffs' rights of association, assembly, speech, belief, and travel by not placing the named plaintiffs and members of the plaintiff class in less restrictive alternative settings.
61. The defendants have, in violation of their duties under the First, Ninth, and Fourteenth Amendments to the United States Constitution, abridged the plaintiffs' right of privacy

38
by not placing the named plaintiffs and members of the plaintiff class in less restrictive, alternative settings.
62. The defendants have, in violation of their duty under the Eighth Amendment to the United States Constitution, confined the named plaintiffs and members of the plaintiff class under conditions which are more restrictive than necessary to provide suitable treatment and which have harmed rather than benefited the plaintiffs.
63. The defendants have, in violation of their duty under the Fourteenth Amendment, deprived the named plaintiffs and members of the plaintiff class of their right to the equal protection of the laws by denying them the benefits of several federal statutory programs for the mentally disabled solely because of their confinement at the Northampton State Hospital.
64. The defendants have, in violation of their duty under the Community Mental Health Center Amendments of 1975, 42 U.S.C. §2689, received federal funds or otherwise endorsed the receipt of federal funds by other nonprofit corporations operating under the Amendments, but failed to provide the named plaintiffs and members of the plaintiff class with appropriate evaluation, preventive care, and aftercare services designed to eliminate unnecessary institutionalization.

39
65. The defendants have, in violation of their duty under the Special Health Revenue Sharing Act, 42 U.S.C. §246, received federal funds but failed to eliminate inappropriate institutionalization and to insure the availability of less restrictive community treatment programs for the named plaintiffs and members of the plaintiff class.
66. The defendants have, in violation of their duty under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., received federal funds pursuant to the Medicaid program but failed to determine, both upon admission and regularly throughout the period of hospitalization, whether treatment could be provided in a less restrictive, noninstitutional setting and to place the named plaintiffs and members of the plaintiff class in such alternative programs.
67. The defendants have, in violation of their duty under the Developmental Disabilities Act, 42 U.S.C. §6010, received federal funds appropriated pursuant to the Act but failed to provide the named plaintiffs and members of the plaintiff class with adequate treatment, under the least restrictive conditions consistent with the patients' treatment needs.
68. The defendants have, in violation of their duty under the Rehabilitation Act, 29 U.S.C. §794, discriminated in

40
the provision and administration of treatment, rehabilitation, and vocational training programs receiving federal financial assistance, by failing to create and maintain such programs for the named plaintiffs and members of the plaintiff class.
69. The defendants have, in violation of their constitutional and statutory duties, failed to provide an adequate number of places in alternative settings where the named plaintiffs and the members of the plaintiff class could receive suitable treatment.
70. The defendants have violated their constitutional and statutory duties by failing to establish, maintain, and enforce minimum standards governing the administration of alternative treatment settings or facilities which would insure that the named plaintiffs and members of the plaintiff class would be benefited and not harmed by their placement in such least restrictive settings or facilities.
71. The defendants have violated their constitutional and statutory duties by failing to develop a comprehensive plan for community mental health services, which includes the establishment of a sufficient number of less restrictive alternative placements to provide suitable treatment consistent with the needs of the patient plaintiffs and members of their class.

41
IX. PRAYERS FOR RELIEF
WHEREFORE, Plaintiffs respectfully pray that this Court:
1. Determine that this action may be properly maintained as a class action and make such orders for notice as the Court may deem just and proper.
2. Declare, adjudge and hold that the defendants have, by acts of commission and omission, violated the United States Constitution, 42 U.S.C. §6010, 42 U.S.C. §2689, 42 U.S.C. §246, 42 U.S.C. §1396, 29 U.S.C. §794, and M.6.L. cc. 19 and 123 by failing:
a. to place the patient plaintiffs and members of the plaintiff class in the least restrictive alternative settings or facilities suitable to their needs;
b. to create and to maintain an adequate number of such alternative settings or facilities;
c. to establish, maintain, and enforce minimum standards to insure that the patient plaintiffs and members of the plaintiff class are benefited by their placement in such alternative settings or facilities;

42
d. to provide the patient plaintiffs and members of the plaintiff class with suitable treatment, under the least restrictive conditions consistent with their treatment needs;
e. to carry out their legal obligations in other particulars as described above.
3. Issue a preliminary and permanent injunction enjoining the defendants from violating their duties in the particulars described above and directing the defendants to assist in the drafting, submission, and implementation of a plan that satisfies the requirements of the Constitution, 42 U.S.C. §6010, 42 U.S.C. §2689, 42 U.S.C. §246, 42 U.S.C. §1396, 29 U.S.C. §794, and M.G.L. cc. 19 and 123 by securing the right of the patient plaintiffs and members of the plaintiff class to placement in less restrictive alternative settings and facilities which provide suitable treatment consistent with the patients' treatment needs. Such plan should include, inter alia:
a. a complete medical and psychiatric evaluation of each patient plaintiff and member of the plaintiffs' class to determine the appropriateness of placement in a less restrictive setting or facility and the particular type of alternative consistent with his/her treatment needs;

43
b. a full description of each type of alternative setting or facility, including staffing, degree of supervision, activities, treatment modalities, and desirable patient population necessary for the patient plaintiffs and members of the plaintiff class;
c. the number, type, and location of alternative settings or facilities necessary to accommodate the patient plaintiffs and members of the plaintiff class;
d. the measures to be taken to create such necessary settings or facilities;
e. minimum standards for maintenance of suitable treatment in such settings or facilities;
f. the deployment of staff and procedures for insuring placement and follow-up of the plaintiffs in proper alternative settings or facilities;
g. the precise responsibilities of various officials of the Department of Mental Health, the Northampton State Hospital, the respective Area Boards, and other governmental agencies and organizations in implementing such plan;
h. a timetable for prompt implementation.

44
4. Appoint, or supervise the appointment of a Review Panel charged with the responsibility for drafting and overseeing the implementation of the above described plan. The Review Panel should be given the appropriate authority necessary to satisfy its responsibilities, including the necessary funding to be provided by the defendants for permanent staff, consulting fees, and administrative expenses.
5. Retain jurisdiction over this matter until the above plan has been completely implemented.
6. Grant such other and further relief as shall be deemed necessary and appropriate, including but not limited to an award of attorneys' fees and costs to the plaintiffs.
Respectfully submitted,

Dated: July 12, 1977

Steven J.Schwartz Mental Patients Advocacy Western Massachusetts Legal Services Northampton State Hospital Northampton, Massachusetts 01060 413-584-1644, ext. 265
JgtfC. Costello Mental Patients Advocacy Project Western Massachusetts Legal Services Northampton State Hospital Northampton, Massachusetts 01060 413-584-1644, ext. 265
Thomas B. Lesser Lesser and Newman 39 Main Street Northampton, Massachusetts 01060 413-584-7331

 
 Brewster v. Commw. of Mass
•HIIllI

UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS

DAVID BREWSTER, e t a l . , )

Plaintiffs

)

)

v.

)

)

MICHAEL S. DUKAKIS, et al.,)

Defendants

)

CIVIL ACTION NO. 76-4423-F

FINDINGS AND ORDER March 19, 1981

FREEDMAN, D.J. Based on the hearing held on March 16, 1981, this
Court makes the following findings: 1. The defendants have failed to comply with
Paragraphs 24 and 47 of the Consent Decree entered in this matter, due to their failure to take effective measures to secure timely release of funds for programs required by the Decree. The absence of effective coordination among the defendants in assembling documentation required by the legislature has resulted in substantial delays in release of funds held in certain legislative supplementary accounts and targeted for Consent Decree programs.
2. The efforts made by the defendants to access these funds were drastically complicated by vague and unnecessarily restrictive language imposed by legislative committees limiting access to Consent Decree supplementary accounts.
3. Although staff members connected with the House Ways and Means Committee were requested, by Order of this Court, to attend the hearing to provide the Court with necessary information regarding the processes of the House Ways and Means Committee, no representative staff members for that Committee appeared. Staff members and counsel from the Senate Ways and Means Committee did appear.

n

4. The delays in coordinating submission of documentation to the legislature by the defendants resulted in late release of funds contained in the 5 OJ. 1^9.006 account, earmarked for improvement in the existing community mental health system and specifically required by Paragraph 19 of the Decree. As a result of delays in release of funds from this account, members of the plaintiff class were unnecessarily hospitalized and denied their right to placement in less restrictive community settings, as required by the Decree.
5. As a result of the lack of coordination by the defendants, and the unnecessarily restrictive language imposed by the legislature limiting access, approximately $2.6 million contained in the 5100-0101 supplementary account is currently being withheld from the community mental health system.
6. Without these funds, the local Department of Mental Health administrators will be unable to pay community mental health providers through the end of this fiscal year. In addition, a number of providers with short funded contracts, or with personnel transferred from state slots to contract positions, will begin running out of money as early as April 30, 1981.
7. The plan proposed by the defendant Executive Office of Human Services to avoid the destructive ramifications of the failure to obtain release of the 5100-0101 funds is wholly inadequate to prevent harm to the plaintiff class. The use of so-called reversions from one account to absorb shortages in another account requires a protracted process of contract amendment, negotiation with and active cooperation from private mental health agencies and processing of dozens of such amendments through the elaborate state bureaucracy. Representatives of several agencies whose cooperation would be critical to the amendment process necessary to generate reversions indicated
an unwillingness to be involved in this process. Dependency
- 2-

on reversions for program funding has, in addition, caused considerable delay and harm to members of the plaintiff class when used in the past. Finally, the use of the reversion process will not generate sufficient funds to offset existing shortages.
8. The defendants have violated Paragraph 20 of the Consent Decree, and the subsequent agreed upon recommendations of the Monitor to implement this Paragraph, by failing to approve in a timely manner contracts for several mentally retarded persons currently at Northampton State Hospital and to be served by the Franklin/Hampshire Area Office of Region One of the Department of Mental Health.
9. The delays in accessing funds from the 5011-9006 account intended to upgrade existing community programs and create necessary new programmatic services may without prompt action result in an inability by the Department of Mental Health to spend these monies in an effective, timely and positive manner.
10. The additional requirements for numerous administrative reports both to the legislature and to the Central Office of the Department of Mental Health has placed demands on the Office of Region One of the Department of Mental Health that cannot be met by current personnel resources without harm to members of the plaintiff class. Reporting requirements are forcing regional administrative personnel to abbreviate their programmatic efforts.
Based on the preceding findings of fact, the Court hereby ORDERS:
1. That the defendants submit no later than April 17, 1981 a plan for productive and effective expenditure of all funds contained in the 5011-9006 account, assuring that no portion of these funds is reverted tojthe^ general funds but
is invested effectively in improving existing community mental
- 3-

health services as required by Paragraph 19 of theJDecree. 2. That the defendants submit to this Court no
later than July 31, 1981 an accounting specifying details regarding all expenditures out of the 5011-9006 account.
3. That the defendants take all action legally permitted to insure retroactive payment to private contract agencies who have incurred expenses for members of the plaintiff class subject to reimbursement from the 5011-9006 account.
4. That the defendants, no later than April 3, 1981, approve all contracts submitted prior to the date of this Order for programs to serve members of the plaintiff class in Region One of the Department of Mental Health,v or .report to the Court in writing as to each contract not approved the legal or administrative reasons which require denial of approval.
5. That the defendants submit to the Court in writing no later than April 10, 1981 a plan for increasing the administrative staff of Region One of the Department of Mental Health to carry out the reporting and statistical demands of the legislature and the Central Office of the Department of Mental Health, to insure that no member of the plaintiff class is harmed by ^draining of resources away from program development.
6. That the defendants are hereby enjoined forthwith from employing contract reversions to make up for funding shortages caused by their failure to obtain timely release of funds in the 5100-0101 supplementary budget account.
7. That the defendants, no later than April 10, 1981, resubmit a request to the appropriate legislative committees for release of the necessary funds from the 5100-0101 account. The defendants will, prior to that date, meet with the legislative committees and ascertain precisely what documentation is required by the committees to obtain release of these funds.
The defendants will further communicate to the legislature the - 4-

findings of this Court related to the effect of the vague and restrictive language attached to this account and the Order of this Court preventing use by the defendants of any reversions to make up for funding shortages caused by the failure to release funds from the 5100-0101 account. The defendants will further communicate to the legislative committees the willingness of this Court, and of this Court's appointed Monitor, to assure the legislative committees of oversight and accounting requirements to prevent any waste of released funds.
8. That the defendants, no later than fourteen (14) days after release of funds from the 5100-0101 account, submit to this Court a written plan specifying all expected expenditures to be made from this account. The defendants will also provide this Court, no later than July 31, 1981, with an accounting of all expenditures made from this account.
All until further Order of this Court.
United States District Judge
- 5-

 
 ..7
UNITED STATES COURT OF APPEALS FOR THE FIRST CIRCUIT

No. 81-1688

DAVID BREWSTER, ET AL., Plaintiffs, Appellees,
v.
MICHAEL S. DUKAKIS, ET AL., Defendants, Appellants.

Before Campbell, Bownes and Breyer,
Circuit Judges.

MEMORANDUM AND ORDER
Entered November 16, 1981
This matter came on to be hear,d upon appellants' motion for stay of preliminary injunction pending appeal. The stay is hereby granted with respect to paragraphs 1-9 only of the injunction, and the appeal placed on the January list for argument.
The injunction in issue directs defendant officials, pursuant to a 1978 consent decree, to disregard the budgetary constraints which they believe (and the district court nowhere denies) are necessary if defendants are to live within the means presently appropriated by the state legislature for the mental health programs here in question. In its decision, the district court seemingly justifies these commands upon the grounds that (1) the legislature is under a legal duty to fund the consent decree, and (2) that the court is constitutionally empowered to enforce that duty. In a case such as this, where the existence of a constitutional violation has never been adjudicated and where the legislature is neither a party nor has agreed to fund the consent decree, we are compelled to entertain serious doubts as to the correctness of the district court's premise that the legislature is under any such absolute, judicially enforceable duty. See New York State Association for Retarded Children v. Carey, 631 F.2d 162 (2d Cir. 1980).

Brewster v. Commw. of Mass.

•J

pj I P B I • H i t * • • • • • • * w

MH-MA-001-004

Moreover, if these doubts should grove well founded', and the injunction should meanwhile remain in full effect, irreparable harm could ensue not only to defendants, who may be compelled to act in derogation of valid state laws, but to the recipients of mental health services, whose programs might altogether cease when existing funding runs out. We accordingly believe that appellants have made a sufficient showing of probable success, irreparable harm and a claim upon the public interest, to warrant issuance of a stay at this time pending resolution of the appeal. Virginia Petroleum Jobbers Association v. Federal Power Commission, 259 F.2d 921 (D.C. Cir. 1958). In reaching this conclusion we take into account the deference properly owed by federal courts to a state's management and control over its financial affairs. Welsh v. Likins, 550 F.2d 1122, 1131-32 (8th Cir. 1975). Given the considerable uncertainty of the law, the officials of Massachusetts should not be subject to these judicial commands pending final determination of the appeal.
We recognize that as the district court did not cite the Carey case, supra, it may not have had the issues therein brought to its attention. We also note possible confusion over the extent to which the court's order is actually meant to apply to the legislature and to require defendants to violate state budgetary restrictions. Because of these factors, and because time may be of the essence to secure for the plaintiffs the maximum level of assistance to which they are entitled, we provide that prior to our January sitting the district court is free to reconsider and to modify its injunction notwithstanding the pendancy of this appeal, provided we are given timely advance notice Of such action which might, of course, moot this appeal.
While this court reserved the right to decide the merits following the briefing and argument permitted on the motion for stay, we now believe that opportunity for further argument and briefing of the merits should be provided, hence, as noted, the case has been placed on the January list. If either party wishes to file briefs in addition to those already submitted, they may do so on or before December 14, 1981.
So ordered.
By the Court,
DANA H. GALLUP, CLEJRK
/s/ Fmntis t. By
Chief Deputy Clerk
[Cert, c , Hon. Frank HJFreedman; Clerk, U.S.D.C., Mass.; cc: Messrs. Mohl, Fleischner and Ponsor and Ms. Burnes.]

 
 iiiil MH-MA-001-005 B l "

UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS

DAVID BREtSTER, ET AL. , )

Plaintiffs )

)

v.

)

)

MICHAEL S. DUKAKIS, ET AL.,)

Defendants )

CIVIL ACTION NO. 76-4423 -F

MEMORANDUM December 23, 1981

FREEDMAN, D.J. I. INTRODUCTION
On December 7, 1978 the Court received a Consent Decree in the above-entitled matter, signed by representatives of the plaintiff class and by virtually all the senior executive offi cers of the Commonwealth of Massachusetts. In this Decree, the defendants bound themselves and their successors in office to establish "a comprehensive system of appropriate, less restrictive treatment, training, and support services" for mentally disabled persons in the western part of the Commonwealth of Massachusetts. Consent Decree, 1 3. The Decree's explicit goal is to replace, or virtually replace, Northampton State Hospital with this comprehensive system.
As in the fast with other Decrees, the rosy atmosphere of cooperation and consensus existing when the Consent Decree was filed has grown murkier during the years of implementation. A previous opinion of this Court in the same case, at 520 F.Supp. 882 (D. Mass. 1981) gives the flavor of the difficulties encountered by the Court in overseeing the process of implementation.
The current round of hearings and memoranda is Dronroted by the defendants' massive reductions in mandated orograraming for mentally disabled class members. The defendants do not deny that the services being reduced or eliminated and the new programming being cancelled are required by the Consent Decree. They justify

the reductions, eliminations and cancellations—which amount in
effect virtually to a dismantling of large components of the
community mental health system—by pointing to the Legislature.
The Legislature, according to the defendants, is to blame for
these reductions because of its failure to appropriate adequate
funds to support programming mandated by the Decree.
On August 4, 1981, the Court issued a temporary re-
straining order, and after hearing on September 9, 1981, the
Court on September 15, 1981 issued a preliminary injunction
barring the defendants from eliminating or reducing existing
required programming, or cancelling plans for prospective
programs required by the Decree. A final paragraph of the
Court's injunction required the defendants to report in writing
on their efforts to secure the additional funding which they
claimed was necessary to comply with the Decree.
A Motion to Suspend Injunction Pending Appeal was filed
before this Court and denied; this denial was subsequently
appealed by the defendants to the United States Court of Appeals
for the First Circuit and on November 16, 1981 the Court of
Appeals stayed all the provisions of the injunction, except for
the paragraph requiring the defendants to report on their efforts
to secure funding. The Court of Appeals stated in its memorandum,
however:
We recognize that as the District Court did not cite the Carey case, supra [New York State Association for Retarded Children v. Carey"! 6Tl F.Zd 162 (ZncTCir. 1980)], it may not have had the issues therein brought to its attention. We also note possible confusion over the extent to which the court's order is actually meant to apply to the Legislature and to require defen dants to violate state budgetary restrictions. Because of these factors, and because time may be of the essence to secure for the plaintiffs the maximum level of assistance to which they are entitled, we provide that prior to our January sitting the District Court is free to reconsider and to modify its Injunction notwithstanding the pendancy of this appeal, provided we are given timely advance notice of such action which might, of course, moot this appeal.
In response to this language, this Court is today issuing
- 2-

a revised preliminary injunction, along with this Memorandum, in order to eliminate any possible confusion as to the intent and target of its orders. In formulating the revised order, the Court has reviewed additional affidavits, depositions, and other discovery material submitted by the plaintiffs and defendants. In addition, the plaintiffs have filed a Motion to Revise the Injunction; the Court received oral argument on this motion on December 17, 1981.
The defendants have attempted to cast the current controversy as a dispute between this Court and the Legislature over appropriation of funds, inflating the issue to unmanagable constitutional proportions. It is apparent now that certain ambiguous language in this Court's Memorandum of September 15, _1981 has added to rather than decreased the confusion. In fact, as will be demonstrated below, it is the defendants who have failed to perform their obligations under the Decree and under existing authority. It is the defendants, and only the defendants, whose conduct is the target of the Court's orders. The Court well recognizes that the Legislature is not a defendant.

II. FACTUAL BACKGROUND The 1982 fiscal year ("FY '82") in the Commonwealth of

Massachusetts runs from July 1, 1981 through June 30, 1982. Overall planning within the Department of Mental Health ("DMH")

for programming to operate during FY '82 obviously takes place many months prior to July 1, 1981. This planning is translated into a budget proposal which is passed up through the Executive

Branch eventually to the Legislature.

f

Insofar as the programming required by the Consent

Decree is concerned, with some minor exceptions, the proposed

scope of services for FY '82 — including old, expanded and new

programming—was deemed sufficient by the Court and plaintiffs / to satisfy generally all applicable provisions of the Decree.

It is important to note, however, that neither the court-appointed

- 3-

Monitor nor the plaintiffs are in a position to ."judge competently the reasonableness of the defendants' translation of programming into dollars. Putting this issue another way, the focus of the Court's attention is on the development of appropriate programming; the determination as to the amounts and source of funds for this programming is entirely within the discretion of the defendants, though they may keep the Court_j1nformed of their decisions. The overall budget request made by the defendants to the Legislature for FY '82 to support Consent Decree programming in the community was slightly in excess of 53 million dollars.
In July of 1981, the Court was informed through the Monitor of the fact that the Legislature had apprppriated approximately 5 million dollars less than the defendants' budget request. Later that month the plaintiffs filed their Motions for Temporary Restraining Order and Preliminary Injunction, alleging that the defendants' planned wholesale cancellations and reductions of programming, justifying these reductions and cancellations by pointing to the reduced appropriation. The planning for these reductions and cancellations was apparently underway, without any prior notification to Jthe Court or motion to revj.g_e the Consent Decree. In fact, the Court was noj^ even. programs to be reduced or eliminated until just prior to the hearing on plaintiffs' motion for preliminary injunction, on September 9, 1981.
The destructive impact of these cuts is not disputed. Over 100 persons ready for community placement will be indefinitely retained at Northampton State Hospital. Current census is approximately 225. Court clinic programs, badly needed adolescent services, the only Hispanic residential program and a large segment of programming for the elderly will be eliminated. Substantial reductions are slated for service coordination, assessment, and individual service planning, throughout the Region.
In framing its preliminary injunction, the Court took
- 4-

into consideration the foregoing facts and these additional considerations:
''First,xthe defendants began the process of reducing and eliminating programming while a request for supplemental appropriation was still pending before the Legislature. This supplemental appropriation, if approved, would be more than adequate to replace the funding which defendants deemed necessary for all required services.
^ S e c o n d , the defendants began the reduction of programming, without"~at any point filing any motion pursuant to F.R.Civ.P. 60 (b) (6) to amend the Consent Decree. In other words, the defendants, faced with what they felt were barriers to implementation of the Decree, began independently choosing which provisions of the Decree would be complied with, which would be partially complied with, and which would be ignored.
/Third,,, the defendants apparently assumed the reduction in appropriation warranted immediate proportionate reductions in programming. However, the DMH has been notoriously imprecise in its estimations of the amounts of money needed by it for Consent Decree programming. For example, the DMH reverted to the Commonwealth's general fund in FY '81 at least $11 million in funds requested and appropriated but unspent. It was not clear that the reductions in programming were fully justified by the decreased appropriation.
^Fourth, the cancellations and program reductions would have gone into effect without the defendants attempting first to transfer funds which may have been available in other accounts within the Department of Mental Health or under the control of the Executive Office of Human Services. It is not clear to what extent these transfers are within the discretion of the defendants, or require Legislative approval. In any case, mechanisms exist to effect such transfers and they are not uncommon.
, the Court recognized that the budgetary and
- 5-

spending mechanisms in the Commonwealth are somewhat unclear, and subject to various informal pressures. Even the scope of the defendants' formal power to obtain access to funds is in dispute in regard to, for example, the defendants' power to shift monies from the institutional to the community account. Funding projections themselves have a will-of-the-wisp quality. For example, the additional amount of funds required to insure compliance with all provisions of the Consent Decree was estimated at the hearings in September before this Court as more than $5 million. By November 19, 1981, the projected shortfall was down to slightly more than $3 million.
In consideration of all these factors, the Court concluded on September 15, 1981, that the wisest course was to enjoin the defendants' proposed reductions, at least long enough to permit the Legislature to act on the supjalemental budget request. The Court did not, therefore, enter into a thorough examination of the defendants' overall good faith in using all the means at their disposal to secure funding. Likewise, the Court did ;no£ comment upon the appropriateness of instituting programmatic reductions without first moving to revise the Consent Decree. Since the Legislature has chosen not to act, favorably or unfavorably, on the supplemental budget request, and since the defendants have proceeded to implement various programmatic reductions and cutbacks, it is now appropriate for the Court to examine carefully the defendants' efforts to secure what they conceive to be adequate funding to support Consent Decree programs.
III. THE OBLIGATIONS OF THE DEFENDANTS IN IMPLEMENTING THE CONSENT DECREE
The question before the Court on the facts described above is very simple: What are the responsibilities of defendants charged with the inrolementation of a consent decree, when an initial budget appropriation appears to be insufficient to support mandated
- 6-

consent decree programming?

The Court holds that the defendants have^minimally,

two responsibilities under the terms of the Decree in thi_s

situation. f First,, before reducing any programming required

by the Decree, defendants have an obligation to exhaust all

efforts to obtain necessary funds, (^econdy when these efforts

are exhausted, or when defendants conclude that failure to

make revisions in the Consent Decree would create a risk of

substantial harm to plaintiff class members, defendants have

an obligation--prior to any reduction in programming that would

violate the Consent Decree--to present the Court with an

appropriate motion to revise the Consent Decree pursuant to

F.R.Civ.P. 60(b)(6). Morris v. Travisono, 509 F.2d 1358, 1361

(1st Cir. 1975).

The defendants have failed to perform either of these

obligations.

/Tirsty the defendants have not made best efforts to

locate funds required to support the Consent Decree. The affi-

davits of Bruce Bullen and George Hertz make it clear that, at

least prior to December 16, 1981, the Legislature x\/as never

informed that the funding shortage for Consent Decree programs

was in fact approximately half of the amount originally projected

'

"' 2

" ""~"~ ~~

~"

by the defendants. It is inconceivable that this change would

have been irrelevant to the Legislature. Further, the defendants

have not made efforts to effect the transfer of funds from

Layered beneath this question is a second question, of

far more profound constitutional significance: What are the powers

of a district court in relation to a legislative body which, by its

failure to appropriate adequate funds, renders it impossible for

defendants to comply with a consent decree? As__noted in Section

it_jLs unnecessary to .address, this difficult questTon_ in_j>jrder Jto

resolve the issue before the Court.

~

2 By letter of December 16, 1981, Governor King has

apparently informed Chairman Michael C. Creedon, of the House Ways

and Means Committee, for the first time of the decreased need

for supplemental funds. This letter was first presented to the

Court at oral argument on plaintiffs' Motion to Revise Preliminary
Injunction on December 17, 1981.

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existing accounts to £Over_,Cons^nt Decree Programs,^despite the

fact that a significant budget surplus is projected for the

Commonwealth of Massachusetts during the current fiscal year.

No effort has been made to access emergency funds available to

the Governor. No efforts have been made to transfer funds from

the Northampton State Hospital account to the community account

to cover community programming.

In conclusion, the Court is not satisfied that the

defendants have made their best efforts to obtain funding

necessary for Consent Decree programs. In particular, the Court

^_

-

is not satisfied that the defendants have made all necessary

efforts to shift funds already appropriated by the Legislature
3 to Consent Decree accounts. The defendants have, at a minimum,

the obligation to make these efforts before dismantling the

community mental health system required by the Decree.

In the event that the defendants are unsuccessful in

effecting transfers or locating funds by taking actions within

their own control, the defendants are ordered to return to this

Court with an appropriately drafted motion to revise the Consent 4
Decree with full justification for each requested revision.

•'These justifications will be specifically and carefully scrutinized.

i The Court of Appeals has recently suggested that one rationale for

service cutbacks — "the state's bar to payment of funds without a

j current appropriation"--may be inadequate where the degree of

resulting harm is severe. Coalition for Basic Human Needs v. King,

654 F.2d 838, 843 (1st Cir. 1981).

IV. THE COURT'S POWERS IN OVERSEEING IMPLEMENTATION OF THE CONSENT DECREE
It appears undisputed that the Court has at least the

3

f

It is important to emphasize that this resolution of the

defendants' funding problem would not require any new Legislative appropriation, only movement of funds already approved, a far less substantial intrusion on state government functions.

4

It is now clear that additional or different cuts are now contemplated beyond those described at the hearing on September 9, 1981.

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powers described above in relation to the Consent Decree: the power to require best efforts and the power to require an appropriate motion where these efforts are ^^vaxli^ig,.
Additional powers of the Court appear to be less clear. The Court assumed in its opinion of September 15, 1981, and still assumes, that it retains in supervising the implementation of this Consent Decree all powers afforded a court after an adjudicated finding of unconstitutionality. Considerable authority exists for this position. In the case of United States v. Board o_f Education ojf Naterbury Connecticut, 560 F. 2d 1103 (2nd Cir. 1977), the Court of Appeals stated:
Had the case gone to trial, the school board might have proved that the school system was not intentionally segregated. However, the posture of this litigation now prevents such an inquiry since the Consent Order operates as a litigated finding of unconstitutional segregation. Id., at 1104. See also, Brown v. Neeb, 644 F.2d 551 (6th Cir. 1981); United States v. Board of Ed o_f City o_f Chicago, 88 F.R.D. 769 (1981); Inmates of_ Boys' Training School v. Southworth, 76 F.R.D. 115 (D. R.I. 1977). It is axiomatic that a Consent Decree ratified by a court, becomes an order carrying the same force and effect as any order entered after a contested trial. United States v. Swift, 286 U.S. 106, 114-15 (1932). The defendants argue that exercise of the Court's broad remedial powers requires a prior finding of violation of constitutional rights, citing Milliken v. Bradley, 433 U.S. 267 (1974), Swann v. Charlott-Mechlenburg Board p_f_ Education, 402 U.S. 1 (1971), and other Supreme Court cases involving adjudicated findings of unconstitutionality. The Court of Appeals has suggested in its memorandum that the absence of an adjudicated finding of unconstitutionality may be a factor in determining the extent of the Court's I remedial powers.
In this Court's opinion, such a limitation of a district
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The plaintiffs have requested that this Court exercise its remedial powers by moving to close admissions at Northampton State Hospital. Since the Court has declined to do this, or exercise any other remedial option at this time, the question of the precise scope of the Court's powers does not arise.
V. THE DISTRICT COURT'S POWERS IN RELATION TO THE LEGISLATURE
Clearly, district courts retain the power to issue orders that have fiscal ramifications, at least where the exercise of these powers is based on an adjudicated finding of unconstitutionally. Milliken v. Bradley, supra at 289. It is not clear to what extent, if any, the Court's powers to issue orders having fiscal ramifications are limited by the absence of an explicit adjudication of violations of constitutional rights.
In any case, by now__it should be^absoj^u^ly__c_lear that the Court has no intention of ordering the Legislature., .directly or indirectly, to do anything. Any language in the Court's prior opinion that appeared to suggest the contrary is regrettable. In fact, the Court did not, on September 15, 1981, and does not now make any order applicable to the Legislature.
The Court was aware of the case of New York State Association for Retarded Children v. Carey, 631 F.2d 162 (2nd Cir. 1980), but did not cite it because of its view that the case is inapposite, That case involved an "express Legislative disapproval" of certain monies required for consent decree implementation. Such was not the case here. Significantly, the court affirmed in that decision the defendants' obligation to use all available discretionary efforts to obtain necessary funds. In addition, the Court in that, decision did not examine the defendants' responsibility to file a
fn. 5 (cont'd) court's powers would eliminate the jConsent Decree as_ a means for resolution of cases where constitution^T]TTg]jtJ3-^s~ involved*": This disappearance would have serious ramifications.. f~ar .litigant s. and QQUrtLS..
- 10 -

motion to revise--perhaps because the _fa_ilure to fund related
only to the ancillary Review Panel and not to programming a_t the
heart of the Decree, as in the present case.
This case is much more in line with a prior decision,
in the Carey line, at 596 F.2d 27 (2nd Cir. 1979). There, the
Court of Appeals reviewed the district court's orders requiring
the hiring of certain staff for the so-called Consumer Advisory
Board (CAB). The Court stated:
The State's second objection on appeal is that the district court's order is vague and unenforceable and lacks compliance with F.R.Civ. P. 65(d). See also, Pasadena City Board of Education v. Spangler, 427 U.S. 424 (197617 The State officials are concerned, they allege, because the district court has provided no guidance as to what specific actions they are to take after their request to the Legislature for appropriations and whether, if the request is unsuccessful, what further action would be sufficient. But at the same time the State points out that a number of options appear to be available to comply with the order, including requests to the supplemental budget under New York Constitution Article 7, Sees. 3 and 4. Moreover, the state claims that there are only three potential sources of funds available that it may use to fund CAB staff; budgets of the other twenty-one developmental centers in the State, funds already designated for programs for the developmentally disabled, or funds from the executive management budget.
We do not think the order lacks specificity. It compels appellants to assure approval and funding for four full-time professional staff positions and one full-time secretarial position for the CAB. The order leaves it to the state officials themselves to determine the exact means by which to implement the order, appropriately wary of superseding state officials in the proper performance of their governmental functions. Newman v. Alabama, 559 F.2d 283 (5th Cir. 1977, rev'd on other grounds, sub nom.); Alabama v. Pugh, 438 U.S. 781 (1978).
New York Association for Retarded Children v. Carey, 596 F.2d 27,
38 (2nd Cir. 1979).
This Memorandum and Order stand only for the proposition
that the defendants must make good faith efforts--meaning they must
exhaust all available mechanisms--to secure adequate_^funding^for
the Decree before abandoning efforts to maintain and initiate a
mandated services. Where this effort is not successful through no
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fault of the defendants, they_have_an obligation to provide this Court with a detailed motion__to revise the Consent Decree.
VI. CONCLUSION Based on the foregoing, the Court concludes that the irreparable harm to the plaintiff class members, their likelihood of success on the merits and considerations of public interest all warrant reissuance of this Court's prior preliminary injunction, with the following revisions and additions: Paragraph 2: October 1, 1981 will be revised to January 15, 1982. Paragraphs 3, 4, 6, 7, 9, and 10: October 15, 1981 will be revised to February 1, 1982. In addition, the Court will add the following paragraphs: Paragraph 11: Undertake any and all actions within their discretion to obtain, by accessing funds under their discretionary control, by transferring funds under their discretion, by seeking approval from the Legislature of transfers of funds, by obtaining supplemental or deficiency appropriations, or by whatever mechanism may be available to the defendants sufficient funding to comply with all provisions of the Consent Decree. Submit, no later than January 15, 1982, a report to this Court on all actions taken pursuant to this paragraph and their effect. Paragraph 12: Submit to this Court in the event that the actions under the foregoing paragraph are ineffective, a motion for relief from this Order accompanied by an appropriate motion under F.R.Civ.P. 60(b)(6) to revise this Consent Decree. An appropriate Order shall issue.
United States District Judge
- 12 -

 
 Brewster v. Commw. of Mass.

UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS

DAVID BREWSTER, ET AL.,

)

Plaintiffs )

V.

) CIVIL ACTION NO. 76-4423-F

MICHAEL S. DUKAKIS, ET AL., ) Defendants )

MEMORANDUM AND ORDER

March 12, 1987

FREEDMAN, C.J.

The history of this litigation has been recounted too

many times to require still another repetition here. In the

interest of expeditiously resolving the few areas of con-

troversy remaining between the parties, therefore, the Court

will proceed directly to the heart of the matter.

Pursuant to Paragraph 57 of the Final Consent Decree

entered into by the parties and approved by this Court on

December 7, 1978, the court-appointed Monitor has submitted a

Recommended Order providing for the Court's disengagement

from the Consent Decree. On March 2, 1987 the Court held a

hearing on this recommendation at which counsel for plain-

tiffs and defendants presented oral arguments. The Monitor

was also present and addressed some comments to the
Court.1 Having carefully considered the briefs and oral
1At the hearing, the Court expressed its willingness to receive comments from interested community organizations within ten days. Two such comments were received and have been reviewed by the Court.

argument of the parties and the further comments of the Monitor, the Court will, with some adjustments, adopt the Recommended Order of the Monitor.
The parties are in full agreement with nearly every aspect of the Recommended Order. What is in contention, though, is the final section. This section sets forth a three-year timetable for the Court's disengagement. At the conclusion of this period, the Monitor is to report to the Court and a hearing will be held as to whether "the defendants have made significant good faith efforts and progress. . . . " If this is found,
the Court will make a finding that the defendants are in compliance with the Consent Decree and will /end its jurisdiction over the case and the mental / health system in Western Massachusetts and the Decree will be terminated and notwithstanding said termination of the Consent Decree, the maintenance of effort provisions in Section VII herein shall remain in effect. Recommended Order, Paragraph 53. Defendants are in full agreement with this language. Plaintiffs agree that it is appropriate to conclude this case and to permit the gradual withdrawal of active supervision of the Court. Nevertheless, plaintiffs fear the Monitor's proposed language could lead in the future to a wholesale return to pre-Decree conditions. In the words of their counsel, plaintiffs fear that "a fundamental undermining of the whole purpose of the case" could occur and plaintiffs would be powerless to return to Court to stop it. Transcript of February 6, 1987 Hearing at 14.
- 2-

Though the Court deems this contingency highly unlikely to happen, it does seem to be in everyone's interest for this Court to state at this juncture that plaintiffs would not be without a remedy should the highly unlikely come to pass. The Court,/therefore, shall add to the final paragraph of the Recommended Order the following sentence:
Court notes that said maintenance of effort provisions, in addition to the stated principles therein, are designed to prevent a virtual undermining of the Decree's accomplishments or a dismantling of the mental health system created in Western Massachusetts by the Decree.
At the hearing, the parties also expressed some disagreement about one clause contained in the maintenance of efforts section. The paragraph at issue now reads:
Notwithstanding the Court's Disengagement Orders and subject to available resources and appropriations. the community mental health system of services established under the Decree shall be maintained at appropriation levels and annualized appropriations. . . .
Recommended Order, Paragraph 39 (emphasis added). The Court
agrees with the position of plaintiffs' counsel that the
inclusion of "available resources" gives the appearance of
according too much authority to the Department for the
allocation of appropriated revenue among the areas of the
Commonwealth. Hearing Transcript at 12. The Court will,
therefore, eliminate the words "available resources," to
clarify this point.
In light of one of the public comments received, see
supra n. 1, the Court wishes to clarify one further aspect of
the disengagement section. At every occasion at which the
- 3-

Monitor is to report to the Court about progress in the implementation of the Decree during the next three years, representatives of interested community organizations will have the opportunity to make their feelings known to the Monitor and the Court..
As so modified, the Court hereby ADOPTS the Monitor's Recommended Order. An Order of Disengagement embracing the modifications contained herein shall issue.'2
The Court also wishes to add its voice to those of the parties in expressing its thanks to the tireless efforts of the Monitor who enabled the parties to accomplish so much for the citizens of Western Massachusetts and for bringing into sight the conclusion of this case.
It is So Ordered.
r/ ?suu~-
_ Chief United States District Judge
Court has also reorganized the Recommended Order somewhat and made some grammatical and stylistic corrections.
- 4-

 
 Brewster v. Commw. of Mass.

MH-MA-001-008 UNITED STATES DISTRICT COURT
DISTRICT OF MASSACHUSETTS

DAVID BREWSTER, ET AL.,

)

Plaintiffs )

)

V.

)

)

MICHAEL S. DUKAKIS, ET AL., )

CIVIL ACTION NO. 76-4423-F

Defendants )

ORDER OF DISENGAGEMENT

March 12, 1987

FREEDMAN, C.J.

I.PRELIMINARY STATEMENT

A. INTRODUCTION

1. On December 6, 1978, the parties entered into an

agreement with each other for the purpose of establishing a

comprehensive system of appropriate, less restrictive treat-

ment, training, and support services for each member of the

plaintiff class, which agreement, upon the approval of the

Court, was entered as the Final Consent Decree ("Decree") in

this action on December 7, 1978 and which Decree has been

amended from time to time.

2. The parties have diligently pursued the goals of the

Decree and, with the assistance of the Court and its Monitor,

much has been accomplished and the purposes of the Decree are

nearing completion.

B. ACCOMPLISHMENTS

3. The Decree provided for the establishment of a com-

prehensive community-based mental health system. Community-

based services were to be designed and developed to enable Brewster class members "to live in the least restrictive, most normal residential alternative and to receive appropriate treatment, training, and support suited to their individual needs." Decree, Paragraph 8.b. The parties are in agreement that there have been substantial accomplishments regarding this objective. Specifically the parties note the following achievements:
(1) Residential Services 4. Approximately 500 beds have been developed during the term of the Decree for mentally ill and mentally retarded Brewster class clients. 5. These community residential beds are provided to Brewster clients through a wide range of program types, maximizing the likelihood of finding a placement for each individual that is least restrictive and most appropriate in light of that individual's needs. 6. The range of community residential programs now available includes programs offering services within each of the program types defined in Attachment B of the Decree, specifically including: specialized home care programs, supervised apartment programs or group homes, transitional apartment programs or group homes with physical care components, apartment programs or group homes with behavioral emphasis, and apartment programs or group homes with physical care components and behavioral emphasis. 7. Innovations in community residential programming have
- 2-

occurred throughout the course of defendants• implementation of the Decree, allowing many individual class members to be appropriately served in programs specially designed to meet their unique needs.
8. Mentally retarded class members, more than eighty of whom were at Northampton State Hospital in 1978, have benefitted from successful placements in community residential programs. These residential placements and related day or nonresidential programs have effectively minimized acute hospitalization and have almost completely substituted for long-term hospitalization at Northampton State Hospital of mentally retarded class members.
9. Elderly class members, about one hundred of whom were at Northampton State Hospital in 1978, have similarly benefitted from successful placements in community residential programs. As with the mentally retarded class members, these residential programs have effectively minimized acute hospitalization and have almost completely substituted for long-term hospitalization at Northampton State Hospital.
10. The establishment of short-term respite beds in association with crisis intervention programs in each community mental health service area has enabled thousands of Brewster class members to receive effective care and treatment services in the community without the need for institutionalization in the more restrictive environment of Northampton State Hospital.
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(2) Nonresidential Services 11. Nonresidential community-based treatment and support programs are now available to serve the mentally ill and mentally retarded Brevster class clients who have been placed in community residential programs as well as to serve many other Brewster class members, who with this support, are capable of living independently. Prior to the Decree most of these services either were not available or were provided in association with long-term hospitalization at Northampton State Hospital. 12. The nonresidential programs are provided through a wide range of program types, maximizing the likelihood of effectively assisting each individual client to acquire and maintain those physical, mental and social skills that will enable the client to cope most effectively with the demands of his or her environment. 13. The range of nonresidential programs now available includes programs offering services within each of the program types defined in Attachment C of the Decree, specifically including: assessment teams, community service coordination, psychotherapy/counseling, respite care, family support, medication unit/nursing support, crisis intervention units, day treatment, day activity, vocational rehabilitation (including prevocational training/sheltered workshops and transitional employment/job placement), and recreational, socialization and support services. 14. New innovative community nonresidential programs
- 4-

have been developed during the course of defendants1 implementation of the Decree, with particular emphasis on vocational and work support programming, intensive case management services, specialized support programs for adolescents, citizen advocacy and family support programs and mobile crisis intervention services.
(2) Client Rights, Service Planning, Human Resources and Licensing
15. Comprehensive regulations for the community-based mental health service system regarding client rights, individual service plans, program standards and licensing requirements have been promulgated by the Department of Mental Health ("the Department"). No comparable regulations existed prior to the signing of the Decree.
16. Activities beneficial to Brewster class clients that have occurred pursuant to the community mental health regulations have included: development and implementation of comprehensive individual service plans for hundreds of clients; independent reviews of some disputed service plans pursuant to a formal appeals system wherein fundamental differences of opinion regarding appropriate services may be fairly and definitively resolved; independent surveys and licensing of community residential and nonresidential programs to ensure that established program standards are met; and enforcement of clear regulatory standards governing such basic client rights issues as the use of restraint, consent to treatment, and the management of client records,
- .5 -

client possessions and client funds. 17. Training to maximize staff understanding of and
capacity to respond to client needs is now occurring on a continuous cycle for all staff of community residential and nonresidential programs.
II. DEFENDANTS1 UNDERTAKINGS 18. NOW THEREFORE, the Court hereby ORDERS defendants as part of this Order of Disengagement to undertake to accomplish the following: A. MANAGEMENT AND QUALITY ASSURANCE 19. A Field Operations Manager will be established for mental health services in District I, with direct supervisory authority over the Area Directors. The Field Operations Manager will be fully responsible for the overall operation, development and quality of all community-based mental health services in the District. A position has been authorized and funded for this purpose in the Fiscal Year ("FY") 1987 budget. Sufficient staff will be assigned to support the Field Operations Manager in carrying out these responsibilities. 20. At the direction of an appropriate central office manager, the Field Operations Manager will have authority over the expenditure of community mental health resources allocated to the District. The Field Operations Manager will periodically review expenditures within the community program accounts throughout the fiscal year. The Field Operations Manager will review and approve all purchase of service
- 6-

changes and any other significant reallocation of resources within an area's community mental health system.
21. The Field Operations Manager will monitor utilization of community mental health resources. As is the current practice the Field Operations Manager will approve long-term vacancies from residential programs. The Field Operations Manager will also review and approve all justifications relating to delays in program development or underutilization.
22. The Field Operations Manager will have authority over issues that arise between areas. Specifically, the Field Operations Manager will have responsibility for settling all disputes between areas within the District regarding area of meaningful tie designations. The Field Operations Manager will have the authority to order the treatment of a client from one area in another area's program when necessary.
23. The Field Operations Manager will serve as the Commissioner's designee for many regulatory and contractual functions. The Field Operations Manager will ordinarily be the hearing officer for all contract award appeals. The District Manager's role in departmental investigations, 104 C.M.R. 24.06, will be taken over by the Field Operations Manager when the complaint involves community mental health services. The Field Operations Manager will assume the responsibilities given the Regional Services Administrator in mental health Individual Service Plan appeals, see 104 c.M.R.
- 7-

16.11(4). 24. The Field Operations Manager will continue the
District Manager's role in the licensing process. Specifically, the Field Operations Manager will review and sign all deficiency statements/plans of compliance, review and sign all licensing waiver petitions and review and monitor all deficiency correction orders.
25. The Field Operations Manager will regularly review utilization by the areas of institutional mental health resources. In conjunction with the Chief Operating Officer of Northampton State Hospital, staff from the area office and said state hospital, the Field Operations Manager will regularly review the current patients at this state hospital. This review will center on the circumstances of the client's admission, the client's clinical condition, the plan for discharge, barriers to discharge and any other relevant issues regarding the client or utilization of the state hospital and community systems.
26. The Field Operations Manager will continue to have oversight of the training of staff in community mental health programs. The Field Operations Manager in conjunction with the area personnel will develop a system to insure that staff in community programs are adequately trained.
27. The Field Operations Manager will develop and implement systems for utilization review within the community mental health system. Part of this community utilization review will result from the amendment and strengthening of
- 8-

the Individual Service Plan process which is discussed infra. The Field Operations Manager will preside over the standardization of the Individual Service Plan process in District I. The Field Operations Manager will also develop other utilization review procedures in the community mental health system. While implementation of this system will primarily rest with the areas, the Field Operations Manager will have an independent capacity in this process to conduct quality assurance client audits or as an ex officio member of treatment or assessment teams. Each area will be required to submit regular reports to the Field Operations Manager on its utilization review process.
28. The Field Operations Manager will periodically review the performance of the Area Directors in regards to their management of the community mental health system.
29. The Field Operations Manager shall be responsible for working with the Chief Operating Officer of Northampton State Hospital to insure the integration of the hospital•s operations with the community mental health system and shall have access to the central office manager responsible for hospitals to resolve any differences.
30. For a period of three years from the effective date of this Order of Disengagement, the defendants shall comply with present Court orders regarding human resource training. B. INDIVIDUAL SERVICE PLANS
31. Mental Health Individual Service Plan regulations were issued by the Department in 1980 pursuant to Decree
- 9-

requirements. The regulations are limited in scope to District I in Western Massachusetts. They are presently codified at 104 C.M.R. 16.00.
32. The Department will develop a plan thoroughly to assess, revitalize and standardize the District I mental health Individual Service Plan system. This plan shall be completed within three months from the Court's approval of this recommendation. The goals of this plan will be (1) to conduct training and to establish enforcement mechanisms sufficient to ensure full and timely implementation as mandated by the Individual Service Plan regulations, and (2) to identify and then make whatever revisions of the regulations may be necessary to ensure that they will promote their purposes to the maximum extent possible. The Department plans to initiate the Individual Service Plan regulatory revision and implementation activities concurrently during FY •87.
33. The defendants shall complete all required Individual Service Plans for those persons who are hospitalized at Northampton State Hospital within six months of the date of this Order of Disengagement. Individual Service Plans shall be implemented thereafter within a reasonable time subject to available resources. C. RESIDENTIAL PLACEMENTS
34. With respect to the Governor's 1986 mental health initiative which presently provides that there be 230 new residential placements for District I, the defendants shall,
- 10 -

for FY '88, seek funding for twenty-five high-intensity residential placements for class members. Preferences for these twenty-five placements will be given to those class members who are hospitalized at Northampton State Hospital on the date of this Order and shall apply on a seniority basis to those residents with the longest length of hospitalization.
35. With respect to other placements that may be developed pursuant to the Governor's initiative, it is understood that preference shall be given for one-half of these additional placements to persons now or hereafter hospitalized at Northampton State Hospital. Defendants shall plan for these additional placements but, do not commit themselves for their funding. These placements shall be allocated on the basis of seniority favoring those residents with the longest length of hospitalization. With respect to the presently planned eighty additional placements of the moderate or high-intensity type that may be developed, preference will be given for one-half of these placements to persons presently or hereafter hospitalized at Northampton State Hospital. These placements are also to be allocated on the basis of seniority favoring those residents with the longest length of hopsitalization. D. INPATIENT FACILITIES
36. The defendants will develop a plan for the providing of inpatient services for class members. The plan will identify the location(s) and projected capacity of inpatient
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services to be provided by the Department in District I. The plan will utilize regional, emergency and/or backup facilities and area inpatient facilities. This plan shall be completed within eight months of the date of this Order of Disengagement and submitted to the Monitor and plaintiffs' counsel.
37. It is recognized that the capacity of such regional \ and area inpatient facilities may be increased or decreased
in the future, depending upon the needs of persons in ^ District I. The Department shall nonetheless prepare and
implement a plan providing for a capacity of no more than 120 persons in three to five area facilities. Defendants have exercised reasonable good faith efforts during the last two years to prevent inappropriate hospitalization and shall continue to make such efforts in order to attempt to achieve the goal of a census of 120. The defendants agree the Memorial Complex Building will be closed at the earliest possible date permitted by the development of the three-tofive area inpatient facilities. Thereafter, the Haskell Building shall be utilized and maintained as an emergency or backup inpatient facility.
38. The defendants may eventually close the Haskell Building if the defendants determine that it is no longer necessary to serve class members or if the defendants decide another facility is more suitable as an emergency or backup inpatient facility.
39. These inpatient facilities should be operated
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consistent with existing policies and state law to screen out

inappropriate admissions of the mentally retarded, those with

organic brain syndrome, alcoholics and adolescents.

III. MAINTENANCE OF EFFORT

40. Notwithstanding the Court's Disengagement Order and

subject to avairiiible appropriations, and community mental

health system of services established under the Decree shall

be maintained at present appropriation levels and annualized

'V.

•

'

-

'•"-"

appropriations for the twenty-five new residential placements

referred to in Section II, supra. pursuant to the following

principles:

(a) Residents and clients are entitled to live in the

least restrictive, most normal residential alternative and to

receive appropriate treatment, training, and support suited

to their individual needs.

(b) The determination of client service needs will occur

through an individualized screening, evaluation, and service

planning process, including annual reviews of Individual

Service Plans.

(c) The determination of appropriate residential and

nonresidential placements for each resident and client will

be made so as to guarantee that all persons are placed in the

least restrictive alternative which will provide them with

appropriate treatment, training and support.

(d) Since the residential models are designed to be the

most normal and least restrictive environments appropriate

for the residents and clients, smaller apartment units are

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preferred to larger group homes, although either may be appropriate depending on the particular circumstances.
(e) Community residential and nonresidential services will be offered, to the maximum extent feasible, on a voluntary basis and with due regard for the client's dignity and personal autonomy.
(f) Community residential alternatives and nonresidential programs will be integrated in the community and operated in the most normal manner appropriate to the needs of their clients.
(g) If new information and a clear change in circumstances indicate a more appropriate way to maintain existing services than required by these principles, the defendants may modify a program or programs. For purposes of this subparagraph (g) only, notice of any such change which is proposed within a period of three years from the effective date of this Order of Disengagement, and an opportunity to object, shall be given to plaintiffs' counsel.
IV. COURT DISENGAGEMENT 41. In consideration of the foregoing, the Court hereby relinquishes active supervision over the Consent Decree but retains supervision over this case subject to the following qualifications: (a) For a period of one year, the defendants will file bimonthly written reports with the Monitor and also oral reports at least monthly describing their efforts and progress in planning and implementation of Section II. The
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Monitor shall retain the authority specified in the Decree to investigate and propose action by the defendants sua sponte or on request by a party. Defendants will provide copies of their written reports to plaintiff's counsel.
(b) At the end of one year, the defendants shall file a one-year progress report with the Monitor describing the status of the several initiatives and plans identified herein. The Monitor shall afford the plaintiffs and representatives of interested community organizations an opportunity to comment upon the defendants' report, and shall thereafter file the report with his own comments thereon with the Court. The plaintiffs and interested community representatives may file comments with the Court, to which the defendants may respond.
(c) If it shall appear to the Court, based upon the defendants' report, the Monitor's comments, and the comments of plaintiffs and representatives of interested community organizations, if any, that the^defendants have exercised .good faith efforts iand have Imade reasonable progress1* in developing and implementing the initiatives and plans identified above, the Court shall find reasonable progress is being achieved and therefore the terms of the Order of Disengagement will continue to be recognized by the Court and the parties will continue to be bound thereby for an additional two-year period.
42. (a) The defendants shall for an additional two-year period file quarterly written reports with the Monitor and
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such other oral reports as the Monitor may require outlining their continued efforts and progress with the planning and implementation of Section II herein.
(b) The Monitor shall retain authority to investigate and propose action sua sponte or on request of a party. Defendants will provide copies of their written reports to plaintiffs' counsel.
43. At the end of the two years of said quarterly reports, the Monitor shall report to the Court as to whether the defendants during said additional two-year period have made reasonable good faith efforts to bring about significant progress toward implementation of the initiatives in Section II. Plaintiffs, defendants and representatives of interested community organizations may submit their own comments to the Court with regard to the degree of effort and progress achieved in this two-year period. The Court shall hold a hearing and if it determines that the defendants have made significant(good faith efforts and progress, the Court will make a finding that the defendants are in compliance with the Consent Decree and will end its jurisdiction over the case and the mental health system in Western Massachusetts. The Decree will then be terminated and notwithstanding said termination of the Decree, the maintenance of effort provisions in Section III herein shall remain in effect. The Court notes that said maintenance of effort provisions, in addition to the stated principles therein, are designed to prevent a virtual undermining of the Decree's accomplishments
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or a dismantling of the mental health system created in Western Massachusetts by the Decree.
It is So Ordered. Chief United States District Judge
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United States District Court District of Massachusetts (Springfield) CIVIL DOCKET FOR CASE #: 3:76-cv-04423-FHF

CLOSED

Brewster, et al v. Comm of Mass, et al Assigned to: Judge Frank H. Freedman Demand: $0 Cause: 28:1983 Civil Rights Plaintiff David Brewster
Plaintiff Hector Santiago
Plaintiff Thonnie Rowell
Plaintiff Adeline Stark
Plaintiff Richard Schneider
Plaintiff Donald Gaboury
Plaintiff Martin Weinberg
Plaintiff Albert Potter
Plaintiff Ella Bailey
V. Defendant Commonwealth of Massachusetts
Defendant Dr. Robert L. Okin
Defendant

Date Filed: 12/15/1976 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: Federal Question

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Dr. Mary Jane England Defendant Robert W. Murphy Defendant Rudolph Magnone Defendant Nancy MacGillvray

Date Filed 01/02/1991 01/04/1991
01/31/1991 01/31/1991
02/11/1991 02/11/1991
02/14/1991
02/14/1991
03/04/1991 03/04/1991 05/07/1991 05/17/1991

#

Docket Text

Ps' Response in opposition to Ds' Motion to Enlarge Time to Resp. to Ps' motion for attorney's fees. (mef) (Entered: 01/04/1991)

Chief Judge Frank H. Freedman . Endorsed Order entered ALLOWING Ds' motion to ext. time to resp. to Ps' motion for attorney's fees to 2/01/91. (mef) (Entered: 01/04/1991)

Ds' Motion to extend time to 2/08/91 to Resp. to Ps' motion for attorneys' fees. (mef) (Entered: 02/01/1991)

Chief Judge Frank H. Freedman . Endorsed Order granting [0-1] motion to extend time to 2/08/91 to Resp. to Ps' motion for attorneys' fees. (mef) (Entered: 02/01/1991)

Ds' Motion to Bar Further Attorney's Fee Awards (fmr) (Entered: 02/11/1991)

Ds' Memorandum in opposition to Motion for Attorneys' Fees and in support of Motion to Bar Further Fee Awards (fmr) (Entered: 02/11/1991)

Chief Judge Frank H. Freedman . Endorsed Order granting [0-1] motion to extend time to resp. to Ds' motion to bar fees and for leave to file reply brief to Ds' oppos. to motion for fees. (Both due 3/01/91) (mef) (Entered: 02/20/1991)

Ps' Motion to extend time to resp. to Ds' motion to bar fees and for leave to file reply brief to Ds' oppos. to motion for fees (fmr) (Entered: 02/14/1991)

Ps' Reply Memorandum in support of their Motion for an Interim Award of Attorney's Fees. (mef) (Entered: 03/04/1991)

Ps' Memorandum in opposition to [0-1] Ds' motion to Bar Further Attorney's Fee Awards (mef) (Entered: 03/04/1991)

Ps' Motion for status conf. re cuts to community mental health services (fmr) (Entered: 05/07/1991)

Ds' Response motion for status conf. re cuts to community mental health

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06/10/1991
06/28/1991 06/28/1991 06/28/1991
08/30/1991 09/11/1991 11/19/1991
12/04/1991 12/04/1991 12/13/1991 12/17/1991
12/17/1991 12/17/1991 12/20/1991 01/06/1992

(fmr) (Entered: 05/17/1991)
Chief Judge Frank H. Freedman . Memorandum and Order entered. The Court hereby ORDERS defendants to pay to plaintiffs the sum of $24,915.00 for reasonable attorneys' fees incurred in the case. The Court DENIES defendants' motion to bar attorney fee awards in the future. (mef) (Entered: 06/10/1991)
Joint Motion for entry of final judgment for fees to Chief Judge Frank H. Freedman (fmr) Modified on 07/01/1991 (Entered: 07/01/1991)
Chief Judge Frank H. Freedman . Endorsed Order granting [0-1] motion for entry of final judgment for fees (mef) (Entered: 07/01/1991)
Chief Judge Frank H. Freedman . Final Judgment entered as to Interim Award of Attorney's Fees from 4/01/89 - 10/31/90 by the Court. (mef) (Entered: 07/01/1991)
Ds' Notice of Amendment to Inpatient Facilities Plan (fmr) (Entered: 08/30/1991)
Ps' Response in opposition to Ds' Amendments to Inpatient Facility Plan (fmr) (Entered: 09/11/1991)
Notice of Hearing: Hearing re: Court Disengagement from Consent Decree on 12/17/91 at 10:00 A.M. before Chief Judge Freedman. (mef) (Entered: 11/20/1991)
Ds' Notice of Substitute Amendment to Inpatient Facilities Plan. (mef) (Entered: 12/04/1991)
Ds' Substitute Amendment to Inpatient Facilities Plan filed. (mef) (Entered: 12/17/1991)
Ps' Memorandum in Support of Proposed Orders of Disengagement filed. (mef) (Entered: 12/17/1991)
Chief Judge Frank H. Freedman . Clerk's Notes: Hearing on final disengagement. Arguments of counsel, court monitor, and statement of the Alliance. The Court takes the matter under advisement. (mef) (Entered: 12/17/1991)
Statement of the ALLIANCE filed. (mef) (Entered: 12/17/1991)
Case taken under advisement with Chief Judge Freedman. (mef) (Entered: 12/17/1991)
Monitor's Report (fmr) (Entered: 12/20/1991)
Chief Judge Frank H. Freedman . Order of Dismissal entered. The Consent Decree entered on December 7, 1978 is VACATED, the Court's active jurisdiction over the case and the mental health system in Western Massachusetts is ENDED, and this action is DISMISSED; and Ordered that notwithstanding the foregoing order, the defendants are enjoined from violating Section III and Paragraph 43 of the Disengagement Order

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01/06/1992
01/06/1992 01/17/1992 01/17/1992 03/02/1992 03/02/1992 03/03/1992
04/07/1992 04/07/1992 04/20/1992 04/21/1992
05/18/1992 05/18/1992
05/27/1992 05/27/1992 05/27/1992 11/06/1992

which shall remain in effect. (mef) (Entered: 01/06/1992)
Chief Judge Frank H. Freedman . JUDGMENT OF DISMISSAL entered pursuant to the Order of the Court entered this date. (mef) (Entered: 01/06/1992)
Case closed (mef) (Entered: 01/06/1992)
Joint Motion to ext. time to 3/01/92 to file P's req. for attorney's fees. to Senior Judge Frank H. Freedman (mef) (Entered: 01/17/1992)
Senior Judge Frank H. Freedman . Endorsed Order granting [0-1]. P's req. for attorney's fees due by 3/01/92. (mef) (Entered: 01/17/1992)
Joint motion to ext. time to 4/10/92 for the Pltfs. to file Req. for Attorney's Fees. (mef) (Entered: 03/02/1992)
Transcript dated 2/24/92 of hearing re: Disengagement held before Senior Judge Freedman on 12/17/91 filed. (mef) (Entered: 03/02/1992)
Senior Judge Frank H. Freedman . Endorsed Order granting [0-1] joint motion to ext. time to 4/10/92 for the Pltfs. to file Req. for Attorney's Fees. (mef) (Entered: 03/03/1992)
Ps' Motion for attorney fees for the period from 11/01/90 to 4/10/92. (mef) (Entered: 04/07/1992)
Ps' Memorandum in support of [0-1] motion for attorney fees for the period from 11/01/90 to 4/10/92. (mef) (Entered: 04/07/1992)
Ds' Motion to ext. to 5/15/92 to resp. to Ps' motion for attorney's fees. (mef) (Entered: 04/20/1992)
Senior Judge Frank H. Freedman . Endorsed Order granting [0-1] motion. D's resp. to motion reset to 5/15/92 for [0-1] motion for attorney fees. (mef) (Entered: 04/21/1992)
Ds' Motion to Bar Further Attorneys' Fee Awards. (mef) (Entered: 05/18/1992)
Ds' Memorandum in opposition to [0-1] motion for attorney fees and in support of its motion to bar further fee award. (mef) (Entered: 05/18/1992)
Ps' Suppl. Motion for attorneys' fee award. (mef) (Entered: 05/27/1992)
Ps' Memorandum in support of [0-1] suppl. motion for attorneys' fee award. (mef) (Entered: 05/27/1992)
Ps' response in opposition to [0-1] motion to Bar Further Attorneys' Fee Awards. (mef) (Entered: 05/27/1992)
Senior Judge Frank H. Freedman. Order entered. The Court GRANTS Ps' motion for attorney's fees, and ORDERS Defts. to pay Pltfs. the sum of $12,766.00 for reasonable fees incurred in the case. The Court also GRANTS Ds' motion to bar attorney's fee award from this date forward.

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11/06/1992 11/18/1992 12/01/1992
12/04/1992 12/08/1992 12/23/1992
12/30/1992 01/07/1993 01/15/1993 01/15/1993
02/22/1993 02/22/1993 03/04/1993 09/16/1993 09/16/1993
10/21/1993 10/22/1993

(mef) (Entered: 11/18/1992)
Senior Judge Frank H. Freedman. JUDGMENT ON ATTORNEY'S FEES entered. (mef) (Entered: 11/18/1992)
Ds' Offer of Judgment (copy) filed. (mef) (Entered: 11/18/1992)
Ps' Notice of appeal filed. Filing fee of $105.00 paid. Copy sent to All Counsel. Original docket sheet and pleadings related to attorneys' fees filed between 4/07/92 - 12/01/92 sent to the Appeals Clerk. Appeal record due on 12/31/92. (mef) (Entered: 12/01/1992)
Certified copy of docket and record on appeal forwarded to U.S. Court of Appeals: [0-1] appeal (fmr) (Entered: 12/09/1992)
Notice of Docketing ROA from USCA Re: [0-1] appeal USCA NUMBER: 92-2399 (fmr) (Entered: 12/09/1992)
Ps' Notice of appeal filed. Filing fee of $105.00 not paid. Copy sent to all counsel. Original notice of appeal sent to the Appeals Clerk. (mef) (Entered: 12/23/1992)
Certified copy of docket and record on appeal forwarded to U.S. Court of Appeals: [0-1] appeal (fmr) (Entered: 01/04/1993)
Notice of Docketing ROA from USCA Re: [0-1] appeal USCA NUMBER: 93-1013 (fmr) (Entered: 01/07/1993)
Ps' Motion to extend time to file new notice of appeal to 1/18/93 (fmr) (Entered: 01/15/1993)
Senior Judge Frank H. Freedman . Endorsed Order granting [0-1] motion to extend time to file new notice of appeal to 1/18/93 (mef) (Entered: 01/15/1993)
Filing fee of $105.00 paid for Notice of Appeal filed on 12/23/92. (mef) Modified on 02/22/1993 (Entered: 02/22/1993)
USCA appeal fees received $ 105.00 (eaf) (Entered: 02/24/1993)
Terminated document(s) terminating [0-1] motion to Bar Further Attorneys' Fee Awards. Requested by jcs. (jcs) (Entered: 03/04/1993)
Closed flag. (fmr) (Entered: 10/23/1997)
Mandate of USCA Re: entered AFFIRMING in PART and VACATING in PART Order of the District Court. The case is REMANDED for entry of revised fee award for the period of 6/1/92, increasing the amount of attorney's fees from $12,766.00 to $16,524.00. Costs in favor of the Appellee are taxed at nothing ($0.00) appellee filed no itemized bill of costs. (mef) Modified on 10/25/1993 (Entered: 10/22/1993)
Joint motion for entry of judgment filed. (mef) (Entered: 10/22/1993)
Senior Judge Frank H. Freedman . Endorsed Order granting [0-1] joint motion for entry of judgment. (mef) (Entered: 10/22/1993)

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10/22/1993 10/22/1993

Senior Judge Frank H. Freedman . Judgment for Attorneys' Fees in the amount of $20,124.00 entered for the Pltfs. (mef) (Entered: 10/22/1993)
(mef) (Entered: 10/22/1993)

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 UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS

DAVID BREWSTER, ET AL., ) Plaintiffs )

)

v.

)

)

MICHAEL S. DUKAKIS, ET AL.,)

Defendants )

CIVIL ACTION NO. 76-4423-F

ORDER December 23, 1981

FREEDMAN, D.J. This matter came before me upon Motion for Temporary
Restraining Order and Preliminary Injunction by the defendants related to implementation of the Consent Decree previously entered in this case. After considering all the evidence presented by the parties, and for the reasons set forth in the Memorandum of even date, I hereby Order the defendants to do as follows:
1. Take no action—other than act^ions__that defendants would take in the normal course unrelated to insufficient funds in the FY '82 budget--to freeze, terminate, or otherwise not fully fund for the xsma_inde_r of this fiscal year all programs serving p^:aant^ff_cla:s£ members. Such programs include all services to class members for which FY '82 contracts currently are signed and dated by the Comptroller as well as services staffed by state employees and funded through the Department's 01/02 subsidiaries in Region I.
\
2. Notify in writing all providers serving class members who currently have an FY '82 contract with the Department of Mental Health or who have state positions in their programs of this Order. The defendants shall instruct and assist programs to perform all activities and provide all services required by such contracts or affiliation agreements, including the spending of funds necessary to develop promptly and maintain specified services

to class members. The Court Monitor will be supplied with a copy of said written notification along with a list of all providers notified with the date of notification by January 15, 1982.
3. Pror.ptly develop, submit for bids, contract, and fund all new community programs which x<7ere planned to begin during this fiscal year under the defendants' original budget request (House I) and its pending supplemental budget. Supply the Court Monitor, no later than February 1, 1982, with a plan for development and implementation of these programs.
4. Immediately halt the freeze of state employment positions allocated to community residential, nonresidential, and administrative services required by Paragraph 11 and Attachment F, and promptly fill and maintain all positions currently authorized in community services, including partnership clinics and DMH Area Offices. Supply the Court Monitor, no later than February 1, 1982 with a list of all state employment positions frozen as of the date of this Order and a report on action taken to fill these positions.
5. Take no action to reduce the availability to class members of services at the Hill Adolescent Program.
6. Within fifteen days of this Order, take all necessary steps to restore full, annualized funding to every contract providing services to class members which is presently funded for less than this entire fiscal year, unless the defendants determine that such full funding cannot reasonably be spent due to constraints unrelated to deficiencies in the FY "82 budget. Submit a report to the Court Monitor, no later than February 1, 1982, describing in detail all steps taken to comply with this paragraph.
7. Within fifteen days of this Order, take all necessary steps to fully implement the procedures for funding the conversion of state employment positions into contract staff, as set forth in the memorandum of May 29, 1981 from Martha McCahill to the Monitor.
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Such steps shall include the timely allocation of sufficient funds in the community account of DMH Region I (account number 5145) to implement these procedures so as to insure continuity of all services to class members. Submit a report to the Court Monitor, no later than February 1, 1982, describing in detail all steps taken to comply with this paragraph.
8. Take no action to reduce other contracts in Region I to satisfy this Order, except where savings accrue and are not needed to operate such program.
9. Within fifteen days of this Order, prepare and finally approve new spending plans and other fiscal documents which are necessary to fully implement this Order. Submit, no later than February 1, 1982, a report to the Court Monitor describing in detail all steps taken to comply with this paragraph.
10. Submit a report to the Court Monitor, no later than February 1, 1982, describing in detail all efforts made by the defendants, including the Governor's Office, to inform the Legislature of the necessity for approval of the appropriation of sufficient funds to permit compliance with the Consent Decree, including the names of all persons contacting the Legislature, the dates of said contacts, the substance of said contacts, copies of all written material submitted to the Legislature, and any and all information related to communications between any member of the defendants or any employee of any defendant and the Legislature, related to funding of the Consent Decree.
11. Undertake any and all actions within the defendants' discretion to obtain, by accessing funds under their discretionary control, by transferring funds under their discretion, by seeking approval from the Legislature of transfers of funds, by obtaining supplemental or deficiency appropriations, or by whatever mechanism may be available to the defendants, sufficient funding to comply with all provisions of the Consent Decree. Submit, no
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later than January 15, 1982, a report to this Court on all
actions taken pursuant to this paragraph and their effect. 12. Submit to this Court in the event that the actions
under the foregoing paragraph are ineffective, a motion for relief from this Order accompanied by an appropriate motion under F.R.Civ.P. 60(b)(6) to revise this Consent Decree.
It is so Ordered. United States District Judge
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 687 F.2d 495 (1982)
David BREWSTER, et al., Plaintiffs, Appellees, v.
Michael S. DUKAKIS, et al., Defendants, Appellants.
No. 81-1687.
United States Court of Appeals, First Circuit.
Argued February 12, 1982. Decided June 28, 1982.
Rehearing Denied August 23, 1982.
Bruce E. Mohl, Asst. Atty. Gen., Government Bureau, Boston, Mass., with whom Francis X. Bellotti, Atty. Gen., Boston, Mass., was on brief, for defendants, appellants.
Steven J. Schwartz, Springfield, Mass., with whom Robert D. Fleischner, Nonnie S. Burnes, and Hill & Barlow, Boston, Mass., were on brief, for plaintiffs, appellees.
Before ALDRICH and BREYER, Circuit Judges, and TORRUELLA,[*] District Judge.
BREYER, Circuit Judge.
Appellants, representing the Commonwealth of Massachusetts, seek to overturn a district court order requiring them to develop, and to pay for, a program of legal assistance for mentally ill and retarded people. The district court, in connection with its ongoing supervision of a consent decree, ordered the Commonwealth to create an independent legal advocacy program that would represent mentally ill or retarded clients on issues arising out of a client's "disability," "prior ... institutionalization," or "current institutionalization." After examining the language of the decree, its background, its purposes, and other relevant law, we agree with appellants that the court has no legal authority to require the Commonwealth over its objection to pay for a broad legal services program. We therefore vacate the district court's order.
I
The consent decree in this case represents the negotiated settlement of a suit filed in 1976 as a class action in federal district court by nine residents of Northampton State Hospital in Western Massachusetts. The plaintiffs, appellees here, claimed that the Commonwealth's programs for treating mentally ill and retarded people violated state and federal law (constitutional and statutory) which, in their view, required treatment in less restrictive, more normal surroundings. After two years of negotiation, the parties agreed to enter a consent decree. The Commonwealth 0907 represented by the Governor, the Attorney General, the Secretary of Administration and Finance, the Secretary of Human Services, and the Commissioner of the Department of Mental Health 0907 did not admit any violation of law. But in the decree it promises to provide a "less restrictive" system of mental health 496 care. It undertakes to provide community *496 mental health services, offering less restrictive residential facilities and nonresidential treatment programs, with the aim of allowing hospitalized patients to leave Northampton State Hospital and find a place to live, and to obtain treatment, in their communities. The decree is lengthy and detailed; it explicitly leaves some issues undecided and open to future resolution. It provides for ongoing court supervision with the assistance of a court-appointed monitor. It has been the subject of previous litigation in this court, see, e.g., Brewster v. Dukakis, 675 F.2d 1 (1st Cir. 1982).
This particular appeal arises out of the decree's arrangements for resolving one of the controversies explicitly left undecided, namely, the appropriate type, role, and financing of a system of legal advocacy for the mentally ill and retarded. Although the parties could not agree about these matters in 1978, they wrote into the decree a provision that dealt with the issue as follows:

¶ 59. The Monitor will investigate and determine the necessity for trained, independent advocates to assist clients in the protection of their rights as set forth in relevant statutes, regulations, and the provisions of this Decree, including the attachments hereto. The Monitor will submit its recommendation to the parties and the Court by January 1, 1980, on the appropriate role of and funding for such independent advocacy. The plaintiffs and defendants agree to cooperate in investigating sources of funding and in seeking federal funds to establish and maintain an advocacy system, to the extent such is determined to be appropriate.
Pursuant to this paragraph, the Monitor asked an expert consultant, a lawyer with special qualifications and experience in this area, to undertake a study of the problem. The consultant prepared a lengthy report, and submitted it to the Monitor in September 1980. This report appears to constitute the basis for the order under challenge.
The report begins by setting out many rights that the author believes are conferred upon mentally ill people by law, including the decree, administrative regulations, statutes and constitutions. Some of these rights are highly general, such as rights to treatment, to a nonrestrictive environment, to decent facilities, to fair procedural rules. Others involve nondiscrimination, such as the right of equal access to educational, recreational, transportation, and medical services. Still others are detailed and specific, such as rights to stationery, postage, storage space, and access to a telephone. As these examples suggest, the list of rights is extensive, ranging from practical issues, such as a decent diet, to individual rights, such as treatment with dignity. The report goes on to make a powerful case that the 13 pages of specific rights which it lists as those of the mentally ill may remain only paper promises, unless the mentally ill are also provided with independent advocates who can represent them individually. The report's 200 pages argue clearly and strongly for a general, state-financed, system of independent advocates to secure these rights for the mentally ill and retarded.
In January 1981, the Monitor, acting pursuant to ¶ 59, made recommendations more modest, but roughly similar to those that the consultant suggested. He noted that independent legal advocates are needed and that, after June 1982, it will be difficult for many existing advocacy organizations to find funding. He concluded that the state should pay for at least a few lawyers to act as the nucleus of a general, independent legal advocacy system.
Subsequently, the Commonwealth asked the court to declare that it had no legal obligation to pay for such a program. The court held an evidentiary hearing. The consultant and others testified. Appellees submitted affidavits, for example, from patients whom legal advocates had helped to obtain such benefits as better treatment and vocational training. Appellants submitted evidence that their existing program of "service coordinators" meets those needs for which the Monitor recommended independent legal advocates. But, the 497 Commonwealth's main argument was a legal *497 one 0907 that it could not be required to pay for the legal advocacy program, because the law imposes no such obligation.
The district court, on August 19, 1981, rejected the Commonwealth's argument and accepted the Monitor's recommendations. It ordered the Commonwealth to present a specific detailed plan for carrying out those recommendations. Appellants appeal from that order.
II
Although appellants argued in the district court that the Commonwealth's "service coordinator" program was adequate to secure the rights of the mentally ill, they will concede for purposes of this appeal that an independent legal advocacy program is highly desirable. They do not take issue with the soundness of the recommendations of the expert consultant or the Monitor. They argue only that, as a matter of law, the district court lacks the power to force the Commonwealth to pay for the recommended program. And that question 0907 not the desirability of the program 0907 is the sole issue that we consider.
The district court found the source of its power in the decree itself. We have examined the decree and the record in detail, keeping in mind that the district court is more familiar with the background of the litigation than are we. Cf. Brown v. Neeb, 644 F.2d 551, 558 n.12 (6th Cir. 1981). Nonetheless, we have been unable to find adequate

authority in the decree for the court's order. Nor can we find adequate authority elsewhere in the law. If the decree provides this authority, it must be found in some combination of language, structure or purpose. A discussion of each of these aspects of the decree, in turn, should indicate why we are unable to find the requisite authority.
1. Language. The language of the decree, if given its ordinary meaning, does not authorize the court to order the Commonwealth to fund a general legal advocacy program for the mentally ill. Paragraph 59, which deals specifically with legal advocacy, instructs the Monitor to "investigate and determine" the need for "trained, independent advocates." He is to "submit" his "recommendation to the parties and the Court." (Emphasis added.) The paragraph goes on to state that the parties will "cooperate in investigating sources of funding and in seeking federal funds." But it says no more. It does not specifically authorize the court to order the parties to accept the Monitor's recommendations. Cf. New York State Association for Retarded Children, Inc. v. Carey, 596 F.2d 27, 33, 37 (2d Cir.), cert. denied, 444 U.S. 836, 100 S.Ct. 70, 62 L.Ed.2d 46 (1979).
The court relied for its power upon ¶ 59 in combination with ¶¶ 5 and 6 of the decree. Yet, the language of these paragraphs, if given its ordinary meaning, also seems inadequate. The relevant sentences of ¶ 5 (which appears in the "general" section of the decree) read as follows:
This Decree includes a final, substantive resolution of most of the issues raised by this litigation. To the extent that current information renders final, substantive settlement of an issue impracticable, the parties have agreed upon a schedule and process for collaboration and/or negotiation, supervised by the Court, which the parties believe can lead to a final resolution of the issue in a fair and reasonable manner.
This language suggests that the parties intended to resolve through negotiation or collaboration certain issues that the decree left open. This expectation seems reasonable given the fact (as the briefs point out) that relations between the parties were good: both sides believed in, and were working to achieve, "deinstitutionalization" (the main object of the decree); and negotiation has led to resolution of most of the other undecided issues. Moreover, this language says only that the court shall "supervise" the "process for collaboration and/or negotiation." It does not say that the court shall "resolve" the issues subject to that process. Courts, as well as administrative bodies, are familiar with the difference between encouraging parties to settle a dispute (or supervising a settlement 498 process) *498 and deciding a dispute over objection. There is not here any evidence of "bad faith" by a party that could transform the one power into the other.
Paragraph 6 (also contained in the "general" section of the decree) reads as follows:
Jurisdiction is retained by the Court until further order, to enable any party to apply at any time for such further orders as may be necessary or appropriate for the interpretation, implementation, enforcement, or modification of the terms of this Decree and for supervision and approval of the resolution of issues left for further planning and negotiation.
The first part of this sentence does not grant the needed authority. Even if one viewed this order as one "appropriate for the ... implementation ... of the terms" of the decree, one would still have to find elsewhere in the decree specific "terms" that the order implements. Nor does the order purport to be one of "modification" of terms. The last clause of the sentence gives the court the power of "supervision and approval of the resolution of issues left for further planning and negotiation...." (Emphasis added.) It does not speak of the court's powers of "supervision and approval and resolution" of issues left for future settlement. Thus, it is most naturally read as specifying the court's authority to incorporate into the decree, and to implement, the results of negotiations on open issues, not as granting the court authority to resolve those issues itself.
Paragraph 50, to which appellees also point, states that if unforeseen difficulties arise which "significantly threaten implementation, the problem may be brought to the Court for its attention." There is no indication that we are dealing here with an "unforeseen difficulty." But, even if this paragraph were relevant, its language does not confer the power at issue.
In sum, the language of the decree's "general" provisions, while recognizing the existence of major open issues, cannot, without straining, be read automatically to grant the court a general power to resolve all open issues,

other than in conformity with procedures specified elsewhere. And, the more specific provision relevant here (¶ 59) allows the Monitor to investigate and to recommend, but it does not state that the Monitor or the court shall resolve the matter of a broad, general, independent, legal services program for the mentally ill.
Nonetheless, these clauses do not forbid court resolution. And, there is, at least arguably, some ambiguity in some of the language. We therefore go on to see whether there are special reasons, arising out of the decree's structure or purposes, or out of the parties' likely intent, for allowing the district court, nonetheless, to read the needed authority into this language.
2. Structure. The "structural" argument rests on an analogy to three other sets of provisions that concern issues deliberately left open. These other provisions arguably bear upon the proper interpretation of the language just discussed. The first set of these provisions concerns the powers of the Monitor. Paragraph 55, for example, states that "an individual complaint or problem" of a client or resident may be brought to the attention of the Monitor "for appropriate action." He may make "a recommendation to the defendants" to resolve the problem. His "action on individual complaints or problems will be considered final." Paragraph 56 gives the Monitor "authority to make recommendations with regard to implementation of the Decree if ... the Monitor believes that the defendants are not in compliance with the Decree [and certain other conditions are fulfilled]...." The "recommendations" are binding on the parties unless they file an objection with the court and request a hearing. Paragraph 57 allows the monitor to "make recommendations on unresolved issues and propose modifications or revisions in the Decree to facilitate compliance with its fundamental purposes." Paragraph 58 allows a party to ask the Monitor "for a specific action or recommendation," and a party objecting to the "Monitor's response may request a hearing before the Court."
499 These provisions do not shed much light on the present problem. Paragraphs 55 and *499 56 provide for binding recommendations. But they deal with specific circumstances (such as "individual" grievances) which the parties apparently agree are not present here. And, since they use specific language to make a recommendation binding where they do apply, they are of little help in deciding how to treat a "recommendation" where they do not apply. The last two paragraphs 0907 ¶¶ 57 and 58 0907 also speak of a Monitor's "recommendation" but they do not suggest that a "recommendation" is binding or that the court has power to make it so.
Second, appellees point to several provisions that both deal with issues left open and also seem to foresee the court's having the power, if necessary, to resolve them. Paragraphs 32 and 33 state that appellant Department "will draft and promulgate regulations, ... governing residential alternatives, nonresidential programs, Individual Service Plans, and due process procedures for residents moving from the Hospital to a community setting." The regulations "will be promulgated," they "will ... be incorporated by reference" in the decree, and they "will be jointly drafted through a negotiation process between the plaintiffs and the Department." Similarly, ¶ 35 provides that "the parties" (presumably acting together) "will prepare ... a plan for orientation, retraining, and ongoing development of Hospital staff and employees of community programs ... [which] plan will be incorporated by reference in this Decree after review and approval by all parties." Paragraph 43 provides that "[t]he parties ... will produce, through a negotiation process, a reorganization and phase-down plan" for the Northampton State Hospital, which plan "will be included by reference in this Decree." Appellees argue that these provisions 0907 dealing with regulations, personnel training, and hospital reorganization 0907 do not expressly grant the court authority to resolve the issue; yet, it is reasonable to imply such authority despite silence. Thus, one might imply an intent to grant the court authority to resolve other issues 0907 indeed all issues left open for future resolution.
This argument, however, is weak. If these provisions bestow upon the court the power to impose solutions, they do so in virtue of 1) their rather specific language (the regulations, the training plan, the phase-down plan, all "will be" written and incorporated), and 2) the need to resolve these details of "deinstitutionalization" (regulations, personnel training, reorganization of the hospital) to achieve the decree's agreed upon, major, "deinstitutionalization" objective. Yet, it is as to these two key points that the relation of these paragraphs to the legal services paragraph (¶ 59) breaks down. An inspection of the language of ¶ 59 reveals that it is far less specific in foreseeing a resolution of the issue than are ¶¶ 32, 33, 35 and 43. And, as will be elaborated below, the legal services program at issue in ¶ 59 is not a "deinstitutionalization" detail, logically implied by a commitment to the objective. Rather, it constitutes a major, separable program which could in good faith be opposed (or favored) by one committed to achieving "deinstitutionalization."

Third, appellees point to ¶ 16, which provides the closest analogy to ¶ 59. It concerns the problem of what to do with the "remaining" population at Northampton State Hospital 0907 those who appear to need "a secure treatment setting at an appropriate location." It states that, "[i]f the parties cannot agree on a resolution of" this issue, "they will report to the Court." This paragraph is very much like ¶ 59, because it does not say what the court can or cannot do. The matter is simply to be referred to the court. Moreover, like a general legal services program, resolution of issues related to those who cannot be "deinstitutionalized" is not obviously essential to the success of deinstitutionalization. The problem with pointing to ¶ 16, however, is that ¶ 16 raises exactly the same question at issue here. It is no more clear than ¶ 59 that the court is to have the power to resolve differences if the parties fail to agree. Nothing in the record before us shows that it gives this power to the court; thus, it is an analogy that shows little.
500 *500 In sum, the "structural" argument by analogy to other provisions in the decree fails to show the necessary delegation of power. Those provisions that appear to grant the power at issue in respect of their own particular subject matter (¶¶ 55, 56, 32, 33, 35, 36, 43) are not similar enough to ¶ 59 to be convincing. The provision that seems most similar (¶ 16) does not clearly delegate the necessary power.
3. Purpose. The key question is whether the main purpose of the decree 0907 deinstitutionalization 0907 requires a general legal services program for the mentally ill or at least requires that the court have the power to create such a program. If so, one might argue that the parties intended to give the court this power on the principle that he who wills the end must will the means. After examining the record, however, we do not believe the court power here at issue can be implied from the basic purposes of the consent decree.
As described in the decree itself, in letters written by appellees' counsel, and in court opinions, the decree's basic purpose is "deinstitutionalization" 0907 that is to say, removing patients from Northampton State Hospital and providing for their care in less restrictive, more normal, surroundings. The aim of the system described in the court's order, in the Monitor's recommendation, and in the consultant's report, however, is different. It is to provide legal representation on legal issues arising generally out of the "clients' disability" as well as their "prior or current institutionalization." The opinion, recommendations, and report make clear that the relevant range of legal issues on which representation is sought is vast, encompassing everything from job discrimination to surgical treatment. Clearly, legal representation and "deinstitutionalization" are related; the former can help achieve the latter. But, the relationship between a general legal advocacy program and deinstitutionalization is neither close enough nor special enough to conclude that parties intending the latter must have intended the former, or must have intended to allow the court to order it in the event of disagreement.
We reach this conclusion primarily for the reason just stated. The legal services program described summarily in the court's order extends well beyond problems arising out of "deinstitutionalization;" it is not a program tailored to decree enforcement; it is a program for general representation of the mentally ill; it thus could not constitute a necessary part of the decree's basic deinstitutionalization objective. Moreover, it does not seem inevitable to us to infer an intent to resolve definitively the "legal services" issue (unlike the "regulations," "training" or "hospital reorganization" issues) from the basic deinstitutionalization commitment. At least one of the parties, the Commonwealth, has never believed (given its own "service coordinators") that independent legal advocacy is an absolute necessity. It still argues that, even if independent legal advocacy is desirable, as a practical matter funds are limited, and whatever money is available is better spent on treatment, or other patient needs. Cf. Brewster v. Dukakis, supra. Whether or not its arguments are correct, the fact that they are made, and that they are reasonable, suggests that the Commonwealth did not intend, and that it need not have intended, that the legal services issue be resolved, as part of its commitment to deinstitutionalization. Thus, even if we interpret the language of the decree flexibly "in light of the need to achieve ... [its] basic purposes," Massachusetts Association for Retarded Citizens, Inc. v. King, 668 F.2d 602, 607-08 (1st Cir. 1981), those purposes do not imply a grant by the parties to the court of the power to order the Commonwealth, over its objection, to pay for a general legal services program in Western Massachusetts to represent mentally ill and retarded persons on all issues related to their disabilities.
We specifically confine our holding to the general legal services program referred to in the district court's order. Some of the statements made at oral argument suggest that the order's program might also cover the legal cost 501 of representing plaintiffs in this and other proceedings directly related *501 to the implementation and

enforcement of the decree. But we are not considering an order that deals specifically with these costs. The order before us is broader. An order narrowly aimed at legal representation in this case itself would raise quite different issues from those argued here, in terms of both expectations and needs. And, by vacating this order, we do not intend to prejudge the determination of the lawfulness of a more narrow order aimed at legal representation in this case itself.
4. Other sources of law. Finally, we do not see how the court's powers can be augmented by references to "general equitable," or to other, powers, to cure violations of the Constitution, for the simple reason that there has been no finding of any such violation. The appellees' legal claims were not adjudicated; the Commonwealth did not concede they were valid; nor has it been persuasively shown that the requisite findings can be inferred from the circumstances. Cf. NAACP v. Beecher, 679 F.2d 965 (1st Cir. 1982); Brown v. Neeb, 644 F.2d at 561-63. See Youngberg v. Romeo, 457 U.S. 307, ___ n.25, 102 S.Ct. 2452, 2460 n.25, 73 L.Ed.2d 28 (1982) ("A federal court, of course, must identify a constitutional predicate for the imposition of any affirmative duty on a state."). Thus, we cannot here accept as controlling authority, cases such as Halderman v. Pennhurst State School and Hospital, 446 F.Supp. 1295, 1325, 1327 (E.D.Pa.1977), aff'd on federal statutory grounds, 612 F.2d 84, 113 (3d Cir. 1979), rev'd, 451 U.S. 1, 101 S.Ct. 1531, 67 L.Ed.2d 694 (1981), where violations of law were found.
For these reasons, we vacate the order of the district court and remand for proceedings consistent with this decision.
Vacated and remanded.
[*] Of the District of Puerto Rico, sitting by designation.
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 520 F.Supp. 882 (1981)
David BREWSTER, et al., Plaintiffs v.
Michael S. DUKAKIS, et al., Defendants.
Civ. A. No. 76-4423-F.
United States District Court, D. Massachusetts.
August 19, 1981.
883 *883 Mental Patients Advocacy Project, Western Mass. Legal Services, Northampton State Hospital, Steven J. Schwartz, William C. Newman, Northampton, Mass., for plaintiffs.
Nonnie S. Burnes & Robert G. Bone, Hill & Barlow, Boston, Mass., for Mass. Assn. for Retarded Citizens.
Michael Broad, Catherine A. White, Asst. Attys. Gen., Boston, Mass., for Evelyn McLean-Linda Glenn.
Michael Ponsor, Brown, Hart & Ponsor, Amherst, Mass., for monitor for consent decree.
MEMORANDUM
FREEDMAN, District Judge.
I. INTRODUCTION
The disputes before this Court arise from differences in interpretation of the Consent Decree entered in this case on December 7, 1978.
In order to understand the position of the Court, a brief summary of the history and contents of the Decree is necessary.
The Complaint in this matter was filed in December 1976. The Decree was born out of two years of intense negotiation between the parties. The Court was completely neutral in this process, in no way compelling agreement; every substantive or procedural obligation contained in the Decree has been voluntarily assumed by the parties, with the full knowledge that their agreement as ratified by this Court would constitute a binding order. Paragraph 4 of the Decree binds not only the Decree's signors but their successors and employees as well.
884 The target of this Decree is one of the most vulnerable and chronically abused segments *884 of our society: those labelled mentally ill and mentally retarded.[1] Specifically, the plaintiff class is defined in Paragraph 7 of the Decree as "all persons who were, as of December 15, 1976, are, or may be hospitalized at the Northampton State Hospital, including those persons on indefinite visit or conditional discharge during that period."
The catchment area of Northampton State Hospital is Region One of the State Department of Mental Health (DMH). It includes all of Hampshire, Franklin, Hampden, and Berkshire counties, and a small portion of Worcester County. A shorthand definition of the plaintiff class then might be: all persons in the western third of the Commonwealth of Massachusetts with mental health needs severe enough to qualify them for potential hospitalization.
The Decree estimates that this group comprises approximately 2,135 persons during any two-year planning period.[2] A further group of 3,588 persons is designated the "at-risk subpopulation" 0907those persons who might find themselves in need of hospitalization if services available in December 1978 were cut back. See Attachment A of the Decree, and paragraphs 8c and 8d.

As might be expected with such a large group spread over such a broad and diverse geographic area, a wide range of disabilities is exhibited. Some class members suffer from chronic mental illness, having been hospitalized for thirty, forty, or in some cases in excess of fifty years. Others are suffering an acute episode which may respond quickly to treatment and never be repeated. Still others are "revolving door" clients whose illness may lead them to multiple, short admissions in any two-year period. Juveniles are treated in this system as well as geriatrics, whites as well as minorities. A few class members have histories of violence; the overwhelming majority offer a risk only to themselves, if anyone.
The body of the Decree and its attachments describe0907and require a 0907 dramatic transformation in the method of care for plaintiff class members. The defendants bind themselves to create no less than "a comprehensive system of appropriate, less restrictive treatment, training and support services for each member of the plaintiff class ...." Decree at paragraph 3.
The distinctive quality of the Decree lies in the commitment to treatment in a "comprehensive community mental health and retardation system," with three components: residential environments which are "the least restrictive and most normal setting appropriate for each resident or client"; non-residential programs designed to provide "the major daily activity for those clients whose residential environment does not provide the total treatment program, as well as for other members of the plaintiff class who live independently in the community"; and management services to oversee residential and non-residential programming. See Decree at Paragraph 8a.
Probably the most concrete ramification of the Consent Decree from the point of view of the service recipient or "client," is the transfer of mental health services from a large, state-run centralized institution to scores of much smaller, private community-based service facilities, spread out over the Region. These non-profit organizations vary widely in their size, experience, funding, administrative structure, staffing patterns and theories of treatment. Although some state personnel work in these programs, most personnel in the community system is private and therefore not subject to civil service regulations.
These agencies administer a wide variety of programs. Twelve distinct types of residential programs are 885 described in Attachment B to the Decree. At least fourteen *885 types of non-residential services are described in
Attachment C.
The Decree, in addition, makes heavy demands on DMH's administrative structure. Specific provisions are made in the Decree for the development of Individual Service Plans (ISPs) to insure the complete evaluation and appropriate treatment of clients (paragraphs 26 to 31); for the drafting of governing regulations (paragraphs 32 and 33); for monitoring and evaluation of the system (paragraphs 38 to 40); and for the reorganization and phase-down of the Hospital (paragraphs 41 to 46).
The parties bind themselves in signing the Decree to the ongoing supervision of the Court both in the general implementation process and with regard to specific outstanding issues not finally resolved by the parties in the negotiation process. Paragraph 6 of the Decree states:
Jurisdiction is retained by the Court until further order, to enable any party to apply at any time for such further orders as may be necessary or appropriate for the interpretation, implementation, enforcement or modification of the terms of this Decree and for supervision and approval of the resolution of issues left for further planning and negotiation.
As will be seen, the issues left for further planning and negotiation 0907with supervision and approval of the Court0907include some of the most crucial features of the Decree.
Finally, the plaintiffs and defendants have agreed to the appointment of an independent Monitor, responsible only to the Court, with a right of access to all information, records, residential environments, and program areas. The parties bind themselves to the proposition that, with certain limitations, the Monitor has the final word with regard to individual complaints and the power to make recommendations to the Court on any issue related to implementation of the Consent Decree. These recommendations become final and binding unless a Court hearing is requested by a party. See paragraphs 51-60.

Realizing perhaps that disagreements would arise during the implementation process the parties have given the Court in paragraph 50 extremely broad powers. This paragraph states:
The defendants agree to take all necessary actions to insure full and timely compliance with the provisions of this Decree. The parties recognize that there may arise during the implementation of this Decree, difficulties beyond the control of the defendants which may inhibit timely accomplishment of certain of its terms. Whenever the parties or the Monitor determine that such difficulties have arisen and significantly threaten implementation, the problem may be brought to the Court for its attention.
Over the past three years progress has been made in establishing the community mental health system. Nonresidential and residential programming in the community has greatly expanded. Census at the Hospital has gone down. The administrative capacity of the Department of Mental Health has increased.
On the other hand, the concrete problems of implementation have to some extent undermined the ambitious promises of the Decree. The development of residential, non-residential and administrative components has often occurred only after long delays. Hospital census, which was originally intended to be at 50 by June 30, 1981, is still well over 200. Regulations have emerged tardily. The drafting of Individual Service Plans is at least eighteen months behind schedule.
Obviously, the creation of a community mental health system that provides treatment in settings that are more tailored to the client, more homelike and less restrictive can have enormous advantages. These settings can provide more appropriate care, with fewer of the dangers of long-term institutionalization and an enhanced enjoyment of basic civil liberties. It is equally obvious that a poorly designed or poorly implemented community mental health system leaves the client isolated, less visible and even more vulnerable to neglect and abuse. It is 886 against this backdrop that the *886 controversy before the Court should be seen.
The current disputes between the parties center on the interpretation and application of two paragraphs of the Decree: paragraph 59, which addresses the subject of trained, independent advocates for clients; and paragraph 35, which addresses the subject of appropriate orientation, retraining and ongoing development of Hospital staff and employees of community programs. Both these issues were left unresolved in the negotiation process leading to the Decree. An evidentiary hearing was held on the question of advocacy on July 16, 1981 and on the subject of training on August 4, 1981.
II. POWERS AND RESPONSIBILITIES OF THE COURT
A consent decree, speaking generally, has the quality of a contract between or among the parties entering into it; at the same time a decree, when ratified by the court, is a court order and calls into play the exercise of the court's equitable powers.
The Supreme Court has stated:
Because the defendant has, by the decree, waived his right to litigate the issues raised, a right guaranteed to him by the Due Process Clause, the conditions upon which he has given that waiver must be respected, and the instrument must be construed as it is written and not as it might have been written had the plaintiff established his factual claims and legal theories in litigation.
United States v. Armour and Company, 402 U.S. 673, 681, 91 S.Ct. 1752, 1757, 29 L.Ed.2d 256 (1971).
Thus, a court would not be justified in imposing some additional burden on the defendants, or substantially changing the terms, to justify some inferred "purpose" of a consent decree. United States v. ITT Continental Banking Company, 420 U.S. 223, 235, 95 S.Ct. 926, 933, 43 L.Ed.2d 148 (1974).
At the same time, the agreement of the parties does not extinguish the equitable or supervisory powers of the court. It is settled that the court retains the authority to resolve ambiguities in the language of a decree. United

States v. Armour, supra, at 681, 91 S.Ct. at 1757; EEOC v. Safeway Stores, Inc., 611 F.2d 795, 798 (10th Cir. 1979), cert. denied, 446 U.S. 952, 100 S.Ct. 2918, 64 L.Ed.2d 809 (1980). Where changed legal or factual situations make it necessary, courts even retain the power to make modifications of a decree. United States v. Swift and Company, 286 U.S. 106, 114, 52 S.Ct. 460, 462, 76 L.Ed. 999 (1932); Gomes v. Moran, 605 F.2d 27, 30 (1st Cir. 1979).
In the Swift case, Justice Cardozo stated:
The result is all one whether the decree has been entered after litigation or by consent .... In either event, a court does not abdicate its mandate if satisfied that what it has been doing has been turned through changing circumstances into an instrument of wrong.
286 U.S. at 114-115, 52 S.Ct. at 462.
To summarize, the parties to a decree may rest confident that they bind themselves only to what is agreed upon, provided that they are aware of the court's inherent supervisory role. The court, in the act of transforming a simple agreement between two parties into a court order0907and inevitably placing the dignity of the court and its full range of sanctions behind the decree0907 may be confident that it retains some equitable powers of supervision, provided that these powers are exercised in a way that is sensitive to the parameters of the parties' original agreement.
Turning specifically to this Consent Decree, the Court finds its inherent powers ratified and dramatically expanded by the Decree's very provisions. Paragraphs 5 and 6 explicitly recognize that certain issues have evaded "final, substantive settlement" and that the Court's supervision and approval of the resolution of these issues is necessary. These unresolved issues are not trivial. They include: determination of need for and design 887 of a secure treatment setting for those clients not appropriate for community placements (paragraph 16); the *887 content of a plan for orientation, retraining and ongoing development of Hospital staff and employees of community programs (paragraph 35); the content of a reorganization and phasedown plan for the Hospital (paragraph 43); the need for, role of and funding for trained, independent advocates for clients (paragraph 59). The failure to resolve definitively any one of these issues would create a gap in the Consent Decree and render its full implementation almost impossible.
Paragraph 6 of the Decree also confers on the Court not only ongoing jurisdiction but also the power to render "such further orders as may be necessary and appropriate for the interpretation, implementation, enforcement or modification of the terms of this Decree ...." Paragraphs 50 through 61 of the Decree establish in broad terms the powers of the Court and of the court-appointed Monitor.
In short, the Court's supervisory authority permeates the Decree, not only through its inherent equitable powers, but also by the express choice of the parties.
III. LEGAL ADVOCACY
A. The Interpretation of Paragraph 59
Paragraph 59 of the Decree states as follows:
The Monitor will investigate and determine the necessity for trained, independent advocates to assist clients in the protection of their rights as set forth in relevant statutes, regulations, and the provisions of this Decree, including the attachments hereto. The Monitor will submit his recommendation to the parties and the Court by January 1, 1980, on the appropriate role of and funding for such independent advocacy. The plaintiffs and defendants agree to cooperate in investigating sources of funding and in seeking federal funds to establish and maintain an advocacy system, to the extent such is determined to be appropriate.
In compliance with the first sentence of this paragraph, the court-appointed Monitor submitted his report and recommendations to this Court. A copy of the report is appended to this Memorandum as Appendix A.

In summary, the report finds that trained, independent advocates are necessary, and that effective advocacy services will disappear after June 1982. The report makes additional recommendations regarding the general composition of the advocacy apparatus: that it must be paid and fulltime, include attorneys and lay advocates, have access to records, include clients themselves to the extent possible and be free from undue outside influence. Finally, the report recommends that the defendants be required to fund the advocacy system and report to the Court with a timetable and budget "that will assure no discontinuity of advocacy services within the Region."
With the permission of the Court and the parties, the Monitor's report was submitted over a year later than was originally required by the Decree. The delay permitted the employment of an expert consultant, Dr. Stanley S. Herr, who prepared and submitted an extensive report on the need for advocacy services, advocacy models, and potential funding sources. The Herr Report, which was also prepared for the assistance of the Court, Tauro, J., in Massachusetts Association for Retarded Citizens v. Dukakis (Nos. 75-5023-T and 75-5210-T), is part of the record of this case. The Herr report fully supports the findings and recommendations of the Monitor.
The Monitor's report to the Court was circulated to the parties and they were asked to respond to each of the report's seven recommendations, indicating support or disagreement. The plaintiffs' response generally supported the recommendations. The defendants' initial response, after a month delay, was to oppose the final two recommendations0907which placed the responsibility for funding advocacy on the defendants 0907and to decline to agree or disagree with the other five recommendations. The defendants were not willing to take a position on the need for advocacy, only denied their responsibility to fund it.
888 *888 More recently, the defendants appear to have altered their position, now contesting the need for advocacy services beyond those currently provided. They have continued to assert vigorously that the Decree neither imposes an obligation to fund advocacy services, nor gives the Court the power to impose such an obligation on them.
Certainly the defendants are right that the Decree does not explicitly impose on them the responsibility to fund advocacy services.
It is equally clear that the defendants are wrong about the powers conferred by the Decree on the Court. As noted, the question of advocacy services is one of the issues in the Decree left open, whose resolution is left subject to the supervision and approval of the Court, under paragraph 6 of the Decree. Moreover, as to this issue, the Court's Monitor is given important responsibilities. He is to "determine the necessity" for advocates and make a recommendation to the Court "on the appropriate role of and funding for such independent advocacy."
The Court holds that this paragraph along with the other enabling provisions of the Decree gives to the Court the power to accept or reject the Monitor's recommendations and, if the recommendations are accepted, order them to be carried out. To the extent that the paragraph contains any ambiguity on this point, the Court hereby exercises its supervisory power to remove the ambiguity. Any other interpretation of the Decree would leave the Court without the power to intervene where the inability of the parties to negotiate a resolution of an outstanding issue would undermine the expeditious implementation of the Decree and render it an incomplete document.
The defendants argue that their responsibilities are confined to those set out in the third sentence of the paragraph: "to cooperate in investigating sources of funding and in seeking federal funds to establish and maintain an advocacy system ...." It is their position that, even after making appropriate findings, no power would lie in the Court to place responsibility to provide advocacy on the defendants.
It flows from this argument that the recommendations of the Monitor to the Court would have no significance if they were rejected by the defendants. It also follows that the Court's role in providing supervision and approval of the resolution of outstanding issues would be entirely passive: the Court would have no power to order a resolution and the defendants would have the power to permanently block resolution of this and other critical areas of the Decree simply by refusing to agree.
This interpretation of the Decree is both dangerous and incorrect. It belies both the obvious intent of paragraph 59 and the other provisions of the Decree. Moreover, it derogates from the inherent equity power of the Court in

supervising the implementation of the Decree. Clearly, the final sentence of paragraph 59 was intended to impose an additional task on the defendants, not define their exclusive responsibility.
The Court holds that it has the power within the four corners of the Decree as interpreted, as well as in the exercise of its general equitable and supervisory powers, to order the defendant to design and fund a system of advocacy for the plaintiff class members0907provided that it supports this exercise of power with appropriate findings of fact determined after hearing at which the defendants are given full opportunity to argue and present evidence, as was done in this case.
B. Factual Findings
The plaintiff class members involved in this lawsuit are particularly vulnerable to invasions of their legal rights.
First, they suffer the normal handicap of all economically disadvantaged persons 0907 the inability to purchase legal representation.
Second, they suffer from the stigma of association with a State mental hospital, which renders them uniquely exposed to prejudice in housing, employment, access to generic services and in many other areas.
889 *889 Third, this group has unique problems in recognizing and asserting its legal rights due to cognitive limitations or impaired ability to communicate. Many chronically hospitalized clients may become either so passive as a result of decades of confinement or medication, or become so fearful of authority, that they may lose the ability either to protect themselves or obtain protection.
Fourth, the sheer variety of the clients puts unique demands on any advocacy system: old and young, white and minority, chronic and acute, mentally ill and retarded are all contained within the class served under the Decree.
Fifth, the geographic spread of the clients, from the urban areas of Springfield to the rural areas of Berkshire County makes it extremely difficult to keep track of clients. Clients have the tendency to 0907 use a phrase frequently heard during the implementation of this Decree to 0907 "fall through the cracks" as they move from a large, centralized, State-run treatment setting like Northampton State Hospital, into small, atomized, privately administered treatment programs.
The plaintiff class members possess a wide variety of rights arising by virtue of their disabling condition or from their past or present institutionalized status. These rights are complex and multitudinous. They are defined under consent decrees, including this one, and under federal and state constitutions, statutes and regulations. With no mechanism for assisting mentally disabled persons in enforcing them, these rights might as well not exist.
By way of example, the rights conferred upon the plaintiff class by this Consent Decree alone include at least the following:
... to live in the least restrictive, most normal residential alternative suited to their individual needs;
to have their residential and non-residential needs determined and reviewed according to individualized planning processes;
to participate and be represented in those processes;
to be free from admission to the Hospital, if a mentally retarded client, unless by special exception of the RSA;
to due process in connection with transfers from the Hospital to the community; to receive residential and non-residential services on a voluntary basis to the maximum extent feasible;
to be notified and given an opportunity to object to any proposed residential or non-residential placement;

to request a transfer at any time to a more appropriate, less restrictive setting, and to have such requests considered and acted upon in accordance with specified standards and procedures;

to file complaints with the Court Monitor; and

to initiate independent enforcement actions.

Herr Report, 20-21.

To cite just one segment of the Department of Mental Health's regulations, specifically promulgated pursuant to paragraph 32 of this Decree, the plaintiff class members have the following rights:

1. The right to be free from unlawful discrimination by the DMH or by programs licensed or regulated by DMH;

2. The right to religious freedom and practice without compulsion according to the client's preference;

3. The right to vote, including reasonable assistance when desired in registering and voting;

4. The right to communicate including the right to have access to a telephone for confidential calls and the right to receive unopened mail;

5. The right to representation by an attorney or advocate;

6. The right to be protected from commercial exploitation;

7. The free right of association, including the right to call meetings and receive guests in community programs;

8. The right to enjoy basic goods and services without threat of denial or delay, including a sound

890

diet, clean and appropriate clothing, medical care, social contact, *890 daily activities, personal

possessions, access to storage space;

9. The right to control provision of medical treatment;

10. The right to be free from specific forms of abuse including corporal punishment, verbal abuse, threat of transfer, inappropriate restraint.

See 104 C.M.R. 15.03(3) and (4).

Other regulations govern the use of restraint and seclusion (104 C.M.R. 15.03(5)), medication (104 C.M.R. 15.03 (6)), labor (104 C.M.R. 15.03(7)), possessions and funds (104 C.M.R. 15.03(8)), access to records and record privacy (104 C.M.R. 15.03(9)).

104 C.M.R. 16.01 et seq. describes the complex process of individual service planning and the rights of clients in this process. This includes initial screening, comprehensive assessment, ISP development, the drafting of program specific plans to carry out the ISP, periodic reviews of the ISP, possible modifications of the ISP, and elaborate procedures for client appeals through administrative hearing and ultimately through judicial review under Mass.Gen. Laws c. 30A, § 14. See 104 C.M.R. 16.11(4)(d).

Specific statutes give clients additional rights. See Mass.Gen.Laws c. 123, § 23 and c. 111, § 70E.

This enumeration is intended as an example merely, not exhaustive, of those rights possessed by clients because of their status as disabled persons, or as former or current residents of the Northampton State Hospital.

Persuasive testimony was offered at hearing, and the Court finds, that without trained advocates clients would suffer chronic and substantial deprivation of the rights afforded them under this Decree, under existing regulations and under State statutes.

Familiarity with the nature of the plaintiff class, the community mental health system and the applicable statutes, regulations and provisions of this Decree makes it possible to define more exactly what sort of advocate is needed if the Decree is to be fully implemented.
First, advocates must be legally trained. The Herr Report and the testimony of Dr. Herr demonstrate clearly that without legal training, and without the power to go to court for redress if necessary, advocates would lack the necessary knowledge, skills, and "clout" to function effectively. The advocacy system must include lawyers.
Second, advocates must be independent. Permitting DMH administrators or employees of direct care agencies sole responsibility for advocacy would, in the words of one witness, be like "letting the fox guard the henhouse." Promoting the interests of clients must inevitably mean conflict with DMH administrators and private vendor agencies.
Third, the advocacy system must have sufficient resources to permit representation of institutionalized clients and outreach efforts to community programs. To do this, advocates cannot be donating their time. The advocacy apparatus must have the financial and professional stability to permit comprehensive planning and reasonably sophisticated coordination of its efforts.
Fourth, advocates must have access to clients themselves and, with appropriate safeguards, client records. Giving an administrator or an agency the power to close off this access would quickly cripple an advocacy system.
The foregoing analysis permits the following findings: a need for advocacy services for plaintiff class members exists; these advocacy services must be sufficient to protect the rights of clients stemming from their condition of disability or status as currently or previously institutionalized persons; the advocacy system must include lawyers and others with legal training, must be independent, must have stable resources and must have access to clients and their records.
Two questions remain: are existing advocacy services adequate to meet the needs of plaintiff class members? If not, how is such advocacy to be obtained?
891 *891 The Herr Report thoroughly reviews existing advocacy services, public and private, and finds them inadequate to meet even the minimal needs of clients. The Mental Health Legal Advisors Committee, established by the Supreme Judicial Court, is largely not engaged in advocacy for individual clients. The Developmental Disabilities Law Center concentrates its efforts solely on clients labelled retarded, who make up a tiny fraction of the plaintiff class. The Mental Patients' Advocacy Project, currently serving as counsel for the plaintiff class and offering comprehensive legal advocacy both at the institution and in the community, operates on a federal grant that will terminate on June 30, 1982 and will not be renewed.[3] The affidavit of the executive director of the Western Massachusetts Legal Services, funded under the Legal Services Corporation, confirms that organization's inability to provide comprehensive legal advocacy for the plaintiff class. Charitable efforts by members of the private bar have an ad hoc value at best. The courageous efforts of fledgling self advocacy groups, such as "On Our Own" are insufficient without the support of lawyers.
The defendants' testimony attempting to prove the sufficiency of advocacy efforts within DMH only demonstrated the contrary. The Department's Regional counsel testified it was not part of his function to offer individual representation to clients. The head of the Region's quality assurance team indicated the same. Further, he testified that one-day preannounced quality assurance visits to community programs occurred only once every two to three years. An attorney working for DMH in the Westfield Area testified to her efforts to set up voluntary human rights committees in Westfield's community programs. But she testified, first, that the committees, when constituted would have no enforcement powers. Second, she testified that no human rights committee was actually in operation in Westfield as of the date she testified. Finally, she stated that, to the best of her knowledge, none of the other four Areas in the Region employed an attorney in her role or had established any human rights committees. An appeals mediator working for the DMH in the Franklin/Hampshire area testified that: "I just try to mediate and if mediation does not appear possible, I clarify ... I in no way represent clients."

To the extent that defendants have offered service coordinators, or other care givers, as "advocates" for clients, the Court finds that these individuals lack the expertise, independence and capacity, given their other responsibilities, to perform in the manner required.
The Court finds that after June 30, 1982, no comprehensive or effective advocacy services will exist within Region One to protect the legal rights of plaintiff class members.
The last question is by far the most difficult and the one most hotly pressed by the defendants. Who shall be responsible for the advocacy system?
On the one hand, the Court cannot help taking note of, and sympathizing with, the State's fiscal problems. More importantly, the Court has no desire to involve itself in the administration of the State's mental health system.[4]
On the other hand, at least three considerations press the Court to require advocacy.
First, unless the State takes responsibility for establishing the advocacy apparatus, there will be none. Put differently, the choice is not between a State-supported advocacy system or one supported by some other stable sponsor; it is rather between a State-supported system or none at all.
892 *892 Second, the cost is not great. The sample budget for an advocacy system, proposed by the Monitor and appended to his report, suggests costs amounting to well less than one-half of one per cent of the annual operating budget of Region One of the Department of Mental Health.
Third, the Court finds the need to be critical, and inherent in the very scheme of the Decree. A system of advocacy is not a luxury for the plaintiff class but, given the Decree's other requirements, an absolute necessity.
The Decree calls for the dispersal of client services into privately run programs from one end of the four-county Region to the other. The Monitor's reports submitted to this Court after review by the parties have alerted the Court to the risk that this Decree might become0907through incompetence, inadequate funding, or for some other reason0907a justification for "dumping" clients out of the institution into poor quality treatment programs, or pushing them from the institution without any program at all. Already the Court has been warned of a large number of clients "falling through the cracks" in the community mental health system, and winding up in substandard housing or, homeless, on the streets. The Court is not willing, personally or institutionally, to provide through this Decree a sanction and a disguise for the continued neglect and abuse of persons labelled mentally ill. Without some minimal system of legal advocacy, members of the plaintiff class will be in the words of Dr. Herr, falling into "chasms, not cracks."
It is worth noting, in addition, that at least one other court has placed the responsibility for providing advocacy services on defendants in a similar case. See Halderman v. Pennshurst State School and Hospital, 612 F.2d 84, 113 (3rd Cir. 1979), reversed on other grounds, ___ U.S. ___, 101 S.Ct. 1531, 67 L.Ed.2d 694 (1981).
Finally, the Court finds that the vigorous involvement of plaintiffs' counsel in the implementation of this Decree has substantially reduced the need for judicial oversight. The disappearance of active counsel will inevitably require Court involvement in the minutiae of implementation.
With regard to the question of advocacy, then, the Court hereby orders the defendants to submit, no later than October 1, 1981, a plan for a system of independent, legally trained advocates, capable of representing clients in connection with legal issues arising from the clients' disability or status of prior or current institutionalization. A timetable and budget must be submitted with the plan that will insure that the system is fully operational no later than June 1, 1982. The Court is requiring this date to permit thirty days of overlap with the Mental Patients Advocacy Project and insure no discontinuity of services. The advocates must be independent of the Department of Mental Health, and must be paid and full-time. A sufficient number of lawyers must be employed by the system to insure adequate supervision of lay advocates and court representation where necessary.

IV. HUMAN RESOURCES
The second issue grows out of the Consent Decree's human resource requirements. Again, the Court must both construe the meaning of a paragraph of the Decree and make findings of fact regarding compliance with the paragraph.
In paragraph 35 of the Decree, the defendants placed upon themselves four obligations. These obligations have endured through various amendments of the paragraph.
First, they agreed to "provide all new employees with appropriate orientation and training programs to increase their skills and interest in achieving service goals for clients." Second, the Decree states "the defendants agree to provide staff persons employed in new residential and non-residential programs with training appropriate to their tasks as set forth in Attachments B and C." Third, the defendants stated that "those Hospital employees for whom 893 employment in community settings is both desired and suitable will be offered retraining *893 to permit them to serve appropriately the needs of clients in these community programs." Finally, to accomplish and report to the Court on these efforts the defendants agreed to work with the plaintiffs so that "[t]he parties will prepare by October 1, 1979, a plan for orientation, retraining, and ongoing development of Hospital staff and employees of community programs."
The history of paragraph 35 of the Consent Decree is illustrative of the frustrations encountered in implementation. As originally drafted it is a relatively simple provision containing the elements described above.
A few days prior to October 1, 1979 a motion to amend paragraph 35 was submitted, assented to by all parties, which extended the date for submission of a final human resources plan to January 1, 1980. Elaborate provisions for substitution of a draft plan by October 1, 1979 were added to the paragraph, but are not relevant here.
The rationale for the extension to January 1, 1980 was the need to undertake a manpower survey of hospital employees to determine their interest in and fitness for employment in community programs.
A second motion to amend paragraph 35 was submitted on January 15, 1980. The rationale for this requested extension was the need to collect information on salaries to be incorporated in the final plan. Again, the defendants received the extension, this time to May 15, 1980.
On May 14, 1980 the Monitor was notified in writing that a further extension was needed because of the "enormous magnitude" of the final plan. An informal extension was granted.
By July 1980 a 145-page draft plan comprehensively addressing a broad range of troublesome personnel issues, and fully satisfying the provisions of paragraph 35, was submitted by the Regional Office to the DMH Central Office and shared with the plaintiffs and the Monitor.
On August 25 and September 16, 1980 the Monitor held conferences in Boston regarding obstacles to implementation of the Decree, with a stenographer present. At these conferences the Monitor was informed by various representatives of the defendants that the Regional DMH plan was being reviewed at other levels of the Executive and that a final plan would shortly be submitted to the Court which would address not only training but other broader personnel issues such as salary adequacy and career ladders. It was informally agreed that the final plan of the defendants would be submitted on September 30, 1980.
On September 25, 1980, the defendants again moved for an extension of time to submit their final plan. The motion cited the magnitude of the draft under consideration and the "complexity and scope" of their efforts. It sought an extension of time to submit the final plan to December 1, 1980. The extension was allowed but only until November 1, 1980.
On October 31, 1980, after a delay of more than a year (during which time no comprehensive training efforts were being made either with regard to hospital or community staff), after repeated protestations regarding the magnitude of the plan and the need to gather extensive data, the defendants submitted a six-page document

which they represented as their final plan. As will be seen, this plan is no more than a collection of generalities that pay lip service to the wording of paragraph 35 without beginning to satisfy its provisions substantively.[5]
A non-evidentiary hearing was held before this Court on December 18, 1980, with the Secretaries of Administration and Finance and the Executive Office of Human Services, present. The Court requested that the defendants develop an amended plan to satisfy what the Court and the Monitor felt were some of the clear 894 inadequacies *894 of the six-page final plan as submitted. The deficiencies of the plan were spelled out in writing by the Monitor in a letter to the defendants.
In response to the listing of deficiencies the defendants submitted, in January of 1981, their "Administrative Plan" for implementation of the six-page human resources plan. The "Administrative Plan" was intended to give the Court some notion of the defendants' specific intentions with regard to human resources. However, the defendants insisted that the plan was entirely discretionary and that none of its terms should be considered binding or incorporated in the Decree.
The "Administrative Plan" is an ambitious scheme for a schedule of orientation sessions and the development of a core curriculum to form the basis of intensive training. As of August 1981 virtually none of its provisions has been carried out.
Thus, nearly two years after the original date required for submission of a final plan for "orientation, retraining, and ongoing development of Hospital staff and employees of community programs," next to nothing has been done. The plan before the Court is still the six-page document which the defendants insist satisfies paragraph 35 and the plaintiffs condemn as inadequate.
This long summary of the history behind implementation of paragraph 35 is offered for two reasons. First, it gives the lie to any accusation that the Court has acted hastily or impatiently with regard to defendants' efforts to satisfy this paragraph. Second, it demonstrates what the Court believes to be conduct amounting to outright bad faith on the part of the defendants.
It is no consolation that this bad faith cannot be laid at the feet of any one individual. It can be described as the bad faith of the defendants collectively, or perhaps as systemic bad faith. Nevertheless, specific representations were made to this Court through the Monitor as to the magnitude and content of the final plan being drafted by the defendants. The representations were not vindicated by subsequent events. A discretionary "Administrative Plan" was offered to the Court purporting to show the intentions of the defendants; few if any of the elements of this plan were actually carried out.
When delays and misrepresentations occur to this degree, the Court has forced upon it only two options: intervene or abdicate.
Turning to the plan as submitted under paragraph 35, the Court finds it inadequate for the following reasons. First, the sections describing the orientation effort lack any proposed budget, lack specification of a person or persons to be responsible for coordinating orientation, lack a timetable for orientation sessions and lack details of the content of orientation.
Second, the sections describing the defendants' proposed training efforts are inadequate for the following reasons: no details of training content are offered, no persons responsible for coordinating training are identified, no timetable for provision of necessary training is established, no budget is offered for the training effort, no procedures are established to insure that all employees of private contract agencies are properly trained.
Third, the six-page plan completely lacks any details regarding ongoing development of Hospital and community staff. Minimally, procedures must be established to insure that new staff are pulled into training programs and that the professional expertise of program staff is monitored and upgraded.
Putting aside the plan and looking directly at the training efforts actually made, the progress can be described simply and emphatically. Virtually no training has been done, except on an ad hoc basis by individual vendors or particular Area staff.

The Executive Director of the Western Massachusetts Training Consortium, the agency whose contracts with the DMH provide most of the resources for developing a comprehensive training effort, testified that, as far as 895 orientation sessions, only one pilot session has occurred. None further *895 was planned. Due to delays in contract approval, only a little over one month's work was done in developing the core curriculum for training. No training sessions are scheduled.
Dr. David Specht, also of the Western Massachusetts Training Consortium, testified as to the results of his manpower turnover study. According to his study, there is a 54.8% turnover in direct care staff in the average community program annually. Only one-third of community employees have worked in their agency for more than a year. There is a 40% turnover of residential supervisory staff. Specht found that in most community programs staff were placed on the job without any training whatsoever. He also found that during a six-month study of 13 agencies and 192 staff, no agency reported any dismissal of staff. Specht cited lack of adequate salaries, lack of appropriate orientation and training programs and absence of career ladders as the main reasons for the high turnover of staff.
The defendants' evidence only confirmed the impression made by the plaintiffs' witnesses. Elaine Ostroff, the DMH person responsible for training admitted on direct examination that a statewide system for training "really does not exist at this time .... Very little training is provided in a consistent, ongoing way." Ms. Ostroff described the beginning of an effort at development of the core training curriculum, orientation programs and supervisor training; while encouraging, these beginnings have as yet produced little in the way of concrete results.
Based on the foregoing the Court finds that the defendants have not only failed to submit an adequate plan as required by paragraph 35, but have failed to satisfy the substantive provisions of that paragraph requiring provision of appropriate orientation, training programs and ongoing development for community and Hospital personnel.
It was for good reason that the personnel and training provisions formed a central feature of the Decree. The decentralized nature of the proposed community system means that, if treatment is to be consistent and adequate, a comprehensive supervisory and planning role must be played by the DMH in the area of training. This is particularly true in an isolated community program which, unlike a large medical facility, lacks a concentration of trained medical personnel to oversee, to at least some extent, the direct care staff. The fear remains 0907 and clearly has been realized to some extent 0907 that underpaid persons with little or no training or supervision will be given responsibility in community programs for the day-to-day treatment of class members. Concrete, comprehensive steps by the defendants to confront this problem have been practically non-existent.
With regard to human resources, the Court makes the following orders:
1. The defendants will submit to this Court, no later than October 1, 1981, a comprehensive plan for training, orientation and ongoing development of community and Hospital staff. The plan will satisfy all the deficiencies enumerated in this Memorandum.
2. The plan will insure that a final draft of a core curriculum for training of supervisory and direct care staff is approved and submitted to this Court by all defendants no later than November 1, 1981.
3. The plan will insure that appropriate retraining programs are available for interested Hospital staff no later than February 1, 1982.
4. The plan will insure the orientation of all community and Hospital staff no later than April 1, 1982.
5. The plan will insure that all supervisory and direct care staff receive training under the core curriculum no later than June 30, 1982.
6. Any requests for extensions of the timelines in this Order will be filed prior to the expiration of the date to be extended and will be supported by affidavit setting forth the reasons for the request.
896 *896 APPENDIX A

MONITOR'S REPORT REGARDING NECESSITY FOR TRAINED ADVOCATES
This Report is submitted pursuant to Paragraph 59 of the Consent Decree, which requires the Monitor to "investigate and determine the necessity for trained, independent advocates to assist clients in the protection of their rights ..." and "to submit its recommendation ... on the appropriate role of and funding for such independent advocacy."
Two sources provide the foundation for this Report. First, and primarily, close experience with implementation of this Decree over two years and thousands of hours has provided the Monitor with direct knowledge of the concrete realities and needs of mentally disabled persons living in the community. Second, the comprehensive report of Dr. Stanley S. Herr, of Harvard Law School, commissioned by this Court for use in the Brewster Decree and other Decrees, has afforded the Monitor and this Court an excellent summary of thought on advocacy nationally. This lengthy report is appended.
On the question of the necessity for advocates, the Court Monitor determines that independent, trained legal advocates are necessary to protect adequately the rights of the plaintiff class in the coming years. This conclusion is supported unanimously by the literature and court decisions on the subject.
The most obvious justification for this conclusion lies in the extreme vulnerability of the group to be protected. The abuse and neglect suffered by mentally disabled persons in institutions and in the community, historically and to the present, is too glaring to require particularized support. While fledgling self-advocacy groups composed of ex-hospital clients have some power to articulate their own needs and desires, even these groups would be the first to admit that without training and support their voices may have little impact.
In addition, the extreme complexity of the evolving law expressing or related to the rights of the mentally disabled demands trained legal advocacy. The Herr Report details some 20 pages of specific areas where regulations, court decisions, statutes or other sources of law are found applicable to mentally disabled persons. The advocacy of these rights is often literally a matter of life and death. No untrained lay person could be expected to comprehend the various sources of applicable law, let alone fluently argue from them in support of mentally disabled persons. See Herr, pp. 10-31.
Third, existing mechanisms for advocacy are clearly inadequate, either in terms of their current capacity or their long-term ability to provide services. The Herr Report carefully analyzes the capacity of existing advocacy services in the Commonwealth and finds that, with one exception, the services are not able to meet the advocacy needs of this client group. The one exception is the Mental Patients' Advocacy Project, a nationally recognized advocacy group currently representing the plaintiff class in the implementation of this Consent Decree and operating under a grant from the National Institute of Mental Health (NIMH). The funding grant for this organization, however, will terminate in June of 1982. Thus, unless preparations are made within the next few months, current advocacy resources will expire on this date. See Herr, pp. 39-57.
Finally, the disappearance of adequate advocacy services may force this Court to act, as a practical matter, as the permanent advocate or protector of the plaintiff class. A well established advocacy system reduces or eliminates the need for constant recourse to the federal court and avoids the possibility of this lawsuit becoming an open book in perpetuity.
Having determined the necessity for trained, independent advocates, the Monitor is required then by the Decree to make recommendations as to the appropriate role of and funding for these advocates. While the theoretical 897 role of an advocacy system *897 could be discussed indefinitely, the necessary features of an independent legal advocacy system for mentally disabled persons in this Region are easy to summarize.
First, advocates must have thorough legal training. They must be familiar with the evolving law as expressed in regulation, statutes and court decisions. They must have minimal training in both informal negotiation and formal

trial practice. This requires that the system contain attorneys, though they may be supported by legally trained advocates.
Second, the advocacy system must have a capacity to respond and assist clients in their relationships with state agencies, with private non-profit agencies and with a society at large. This means that the advocacy system must have the potential to do both individual client advocacy and systemic litigation. In short, the advocacy system must have a high degree of flexibility and expertise to confront a wide variety of problems.
Third, the advocacy system must be capable of making contact with its clients. Since the Brewster population will be scattered in various residences and treatment sites throughout the Region, this will require considerable outreach efforts and availability at a variety of locations. It will also require that, within established limits, advocates have access to client records and that defendants insure that no private agency prevents advocates from contacting clients. To increase the likelihood of fruitful contact, the advocacy system should make efforts to include ex-hospital patients or other clients within the system.
Fourth, advocates must be free from any undue influence from the agencies or persons with whom they may have an adversarial relationship.
In order to play the role described above, the advocacy system must be full-time, must be paid, must contain a mixture of attorneys and legal paraprofessional advocates and be capable of performing on-going training for its staff. The Herr Report describes in detail the general role of the advocacy system at pages 59 through 99.
The practical feasibility of this proposed system is demonstrated by the fact that the system really exists and is currently functioning in this Region. The Mental Patients' Advocacy Project comprises three attorneys and five paralegal advocates performing a broad spectrum of advocacy across the four counties of Western Massachusetts, both at Northampton State Hospital and at a wide variety of community programs in the Region's five Areas.
The final topic of this Report is the question of funding for the independent legal advocacy system. On this issue, two principles must be observed. First, the funding source must be stable and reliable. Second, the funding source cannot compromise the independence of the advocacy system.
Many potential sources of funding for legal advocacy are set out in the Herr Report at page 100 and following. One of the most promising external sources of funds may be the federal government itself. Section 502 of the recently enacted Mental Health Systems Act empowers the Secretary of Health and Human Services to make grants to providers of advocacy services. It is worth noting that these grants may be made only if the entity:
(A) has the authority and ability to pursue legal, administrative, and other appropriate remedies to ensure the protection of the rights of mentally ill individuals, and
(B) is independent of any entity which provides treatment or services to mentally ill individuals.
While many sources of funds potentially exist, the locus of responsibility for assuring adequate funding of the advocacy system can only be with the defendants. Federal grants, private foundations, and local universities and law schools may help, and may even assume the bulk of cost, but they do not have the long-term stability and reliability to assure continued existence of an advocacy system. It will therefore be the recommendation of this Report that the responsibility for assuring and, if necessary, supplying adequate funding of the advocacy system lies with the state.
898 *898 This recommendation is not inconsistent with the independence of legal advocates. The defendants currently provide substantial funding for civil and criminal legal assistance to indigent persons without compromising the independence of that advocacy system.
As an example of an advocacy program which would be adequate to safeguard minimally the various legal rights of the plaintiff class for the indefinite future, a sample administrative structure and proposed budget is appended. This information is based on the current budget for the Mental Patients' Advocacy Project. Please note that the annual proposed budget represents less than one-half of one percent of the current operating budget for the defendants' services in the four counties of Western Massachusetts.

In summary, the finding and recommendation of the Monitor in this matter are as follows:
1. There is a necessity for trained, independent legal advocates to assist all class members in the protection of their rights as set forth in relevant statutes, regulations, and the provisions of this Decree.
2. Without action, adequate legal advocacy services for the plaintiff class will disappear after June, 1982.
3. The advocacy system must be capable of intervening through legal means in the relationship of clients with agencies of state government, with private non-profit agencies providing direct service, and with the society at large.
4. The advocacy system must include attorneys, though it may also incorporate legally trained paraprofessionals. Advocates must be trained, paid and full-time. Advocates must have access to client records through appropriate procedures and access to clients themselves in community programs. Clients should be encouraged to work with the advocacy system.
5. The advocacy system must be free of undue influence by the agencies with whom they are likely to have an adversarial relationship.
6. The defendants must adequately fund the legal advocacy system, though federal or other sources may generate some or all of the needed monies.
7. Defendants must provide the Court by March 16, 1981 with a timetable and proposed budget that will insure no discontinuity of advocacy services within the Region.
Plaintiffs and defendants will submit their responses to these recommendations by February 27, 1981. As to each recommendation, plaintiffs and defendants should indicate whether they agree or disagree. As to each point where there is disagreement, plaintiffs or defendants should indicate the grounds or reasons for disagreement and suggest alternatives to the proposed recommendation.
Respectfully submitted, /s/ Michael A. Ponsor MICHAEL A. PONSOR, Court Monitor BROWN, HART & PONSOR 35 South Pleasant Street P. O. Box 63 Amherst, MA 01004 (413) 256-8125

PROPOSED ADMINISTRATIVE STRUCTURE AND BUDGET

I. ANNUAL (FY '83)

A. Personnel

Salary Fringe Total

Director Attorney Attorney/Training
Director Advocate Advocate Advocate Advocate Advocate Office Manager Secretary
Sub-totals:

$25,500 23,800
16,600 13,000 12,200 10,600
9,800 9,800 12,000 10,800 ________ $144,100

$2,550 2,280

$28,050 26,080

1,660 1,820 1,710 1,484 1,372 1,372 1,680 1,512 _______ $17,440

18,260 14,820 13,910 12,084 11,172 11,172 13,680 12,312 ________ $161,540

B. Non-personnel Costs

Rent Utilities Telephone Copying Insurance Travel Consumables Postage Equipment Library Service Contracts

$ 11,340 342
9,720 1,129 1,512 9,720 2,322 1,296 2,160 1,080
540

899 *899 Miscellaneous Litigation Expense
Sub-total: Personnel and Fringe: Consultants:
TOTAL:

540 3,240 ______

II. PHASE-IN COSTS (FY '82)
April (1/24 total cost) May (1/24 of cost) June (1/12 of cost)
TOTAL:

$ 44,941 161,540 5,000
________ $211,481 ========
$ 8,662 8,662
17,624 ________ $ 34,948 ========

[1] Although Northampton State Hospital was intended to treat only mentally ill persons, a group of retarded persons was apparently transferred to the Hospital several years ago. In recognition of their inappropriateness at the Hospital, the Decree lays down special requirements for retarded persons. See paragraphs 20 to 22, and 46.
[2] Only a fraction of this group actually resides at the Hospital at any one time. The current census at Northampton State Hospital is approximately 230 patients.
[3] According to testimony, the Project handled over 1,500 cases for class members in one twelve-month period, 1980-81. No replacement of these services is currently planned by the defendants.
[4] For a helpful discussion of the general issues this Court is grappling with, see Note, "Implementation Problems in Institutional Reform Litigation" 91 Harv.L.Rev. 428 (1977).
[5] Although the Decree requires "the parties" to prepare a plan, the defendants have always assumed responsibility for drafting the plan, because of their expertise and responsibility for implementation. The plaintiffs have never accepted the defendants' plan, creating the current deadlock.

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 544 F.Supp. 1069 (1982)
David BREWSTER, et al., Plaintiffs, v.
Michael S. DUKAKIS, et al., Defendants.
Civ. A. No. 76-4423-F.
United States District Court, D. Massachusetts.
July 16, 1982.
1070 *1070 Steven J. Schwartz, Mental Patients Advocacy Project, Western Mass. Legal Services, Northampton State Hosp., William C. Newman, Northampton, Mass., for plaintiffs.
Nonnie S. Burnes and Robert G. Bone, Hill & Barlow, Boston, Mass., for Mass. Ass'n for Retarded Citizens.
Michael Broad and Catherine A. White, Asst. Attys. Gen., Boston, Mass., for Evelyn McLean and Linda Glenn.
Michael Ponsor, Brown, Hart & Ponsor, Amherst, Mass., monitor for consent decree.
MEMORANDUM
FREEDMAN, District Judge.
This case is before the Court on plaintiffs' application for an interim award of attorneys' fees pursuant to 42 U.S.C. § 1988. This statute provides that:
In any action or proceeding to enforce a provision of [42 U.S.C. § 1983], the court, in its discretion, may allow the prevailing party ... a reasonable attorney's fees as a part of costs.
1071 The plaintiffs' attorneys have submitted extensive material purporting to summarize *1071 their efforts for the years 1976 to 1981.[1] Their total fee claim for these years exceeds 1.2 million. The defendants oppose the award of any attorneys' fees. Alternatively, they argue on a variety of grounds that plaintiffs' fee claim should be reduced. The Court agrees with defendants that a substantial reduction of the fee claim is warranted. For reasons detailed below, the Court finds that plaintiffs are entitled to $386,204.01 in attorneys' fees and costs.
I. The Decree
On December 15, 1976 plaintiffs filed this suit as a class action under 42 U.S.C. § 1983 and other federal and state statutes against various officials of the Commonwealth of Massachusetts. The essence of the action was plaintiffs' demand that the defendants create and maintain appropriate community programs for persons institutionalized at Northampton State Hospital. On August 22, 1977, the Massachusetts Association for Mental Health, Inc. ("MAMH") and the Massachusetts Association for Retarded Citizens, Inc. ("MARC") were permitted to intervene as plaintiff-intervenors.
The plaintiff class, defined as all persons who were, as of December 15, 1976, are, or may be hospitalized at the Northampton State Hospital, was certified by this Court on October 27, 1977. Between October 1977 and October 1978, the plaintiffs and defendants engaged in a "planning process" at 0907 the request of the Court in 0907 an attempt to negotiate a plan for community mental health services for class members in Western Massachusetts and, if possible, to resolve the issues presented by the litigation without a trial.
On October 23, 1978, plaintiffs and defendants agreed, again at the suggestion of the Court, to incorporate the result of their planning process into a Consent Decree. After approximately six weeks of drafting, all parties

signed the Consent Decree on December 6, 1978, and the Court approved the Decree after hearing on December 7, 1978.
At the time of its signing, this Decree was to 0907 the best of the Court's knowledge 0907 the most comprehensive, judicially enforceable plan for the provision of community mental health services in the country. It was a direct product of the year-long cooperative planning efforts of plaintiffs and defendants. The Decree itself contains sixtytwo paragraphs setting forth in broad outline the jurisdiction of the Court, definition of terms, principles for creating and maintaining community programs, models for the development of these programs, individual service planning, standards and regulations, personnel and training, evaluation of compliance, and placement procedures. The appointment of a Monitor to oversee implementation, and a description of his or her powers, is included. The Decree also contains over 200 pages of attachments, analyzing the sub-populations to be served, describing in great detail twelve different residential program models and thirteen non-residential models to serve clients with varying levels of need, and mandating various other responsibilities for defendants including development of needed management services.
Although the Consent Decree is an extensive document, it explicitly fails to wrap up definitively all issues related to implementation. The development of a secure treatment center for the residual Northampton State Hospital population inappropriate for community placement (Paragraph 16), the processes for retraining and transfer of hospital staff (Paragraph 35), the creation and maintenance of an adequate training system for community mental health staff (Paragraph 35), the necessity for and design of legal advocacy services for community mental health 1072 clients (Paragraph 59), the reorganization and phase-down of the Hospital (Paragraph 43) and the drafting of *1072 Regulations (Paragraphs 32 and 33) exemplify issues left by the Decree to further negotiation between the plaintiffs and the defendants. All of these paragraphs mandate active plaintiff involvement in resolution of outstanding issues.
Beyond this, the Decree itself reaches years into the future with its provisions for community placements (Paragraph 15), upgrading of existing programs (Paragraph 19), development of psychiatric beds in general hospitals (Paragraph 17), program licensing (Paragraph 38), funding (Paragraph 47), individual service planning (Paragraphs 26 and 27), management information services (Paragraph 40), and programming for persons denominated as mentally retarded (Paragraph 20).
Since 1978 the efforts of defendants and plaintiffs have gradually resulted in the emergence of a community mental health system in Western Massachusetts. Hospital census has been reduced by one-third. Plaintiff class members have been assessed and individual service plans drafted to reflect each client's needs and strengths. Crisis intervention programs now function to reduce or entirely eliminate the necessity for institutionalization for many individuals. Both residential and non-residential, including vocational, programming have been expanded and enriched. Appropriations for services for class members have more than quadrupled.
While the full implementation of the Decree has been delayed, significant progress has been made towards providing every plaintiff class member adequate and appropriate treatment in the environment most respectful of his or her freedom and dignity.
Plaintiffs' counsel have played a vigorous and necessary role in implementation. They have assisted in the drafting of regulations, negotiated myriad administrative disputes with the defendants without the necessity of court intervention, consulted with the court-appointed Monitor and participated in mediation with the Monitor regarding disputes not subject to administrative resolution, evaluated the progress towards implementation of the Decree through frequent meetings with Department of Mental Health personnel, reported and vigorously pressed charges of client abuse or neglect both in the community and in the hospital, represented clients during hearings on the drafting of individual service plans called for in the Decree, negotiated several amendments to various paragraphs of the Decree and participated in final negotiations around issues left open by the Decree itself. Several evidentiary hearings on issues such as human resources, legal advocacy and budgetary matters have taken place before this Court, particularly in the past two years. Plaintiffs' counsel have represented the class in three hearings before the First Circuit Court of Appeals.
As in other institutional reform litigation, the entry of the Court's judgment has not terminated the role of the plaintiffs' counsel. In important respects, entry of judgment has represented only a beginning. Without

determined, competent and dedicated representation, the provisions of this Consent Decree might have had little practical significance for the class members.

II. Attorneys' Fees: General

Although 42 U.S.C. § 1988 provides for the award of attorneys' fees in the court's discretion, the Supreme Court has held that a successful plaintiff "should ordinarily recover an attorney's fee unless special circumstances would render such an award unjust." Newman v. Piggie Park Enterprises, 390 U.S. 400, 402, 88 S.Ct. 964, 966, 19 L.Ed.2d 1263 (1968). (Action for attorneys' fees under Title II of the Civil Rights Act of 1964 § 204(b), 42 U.S.C. § 2000a-3(b)).

The First Circuit has stated: "Parties may be considered to have prevailed when they vindicate rights through a consent judgment." Nadeau v. Helgemoe, 581 F.2d 275, 279 (1st Cir. 1978).

There is no bar to fees for post-judgment remedial work.

1073

Services devoted to reasonable monitoring of the court's decrees, both to insure *1073 full compliance and to ensure that the plan is indeed working ... are compensable services. They are essential to the long-term success of the plaintiff's suit.

Northcross v. Board of Education, 611 F.2d 624, 637 (6th Cir. 1979), cert. denied, 447 U.S. 911, 100 S.Ct. 2999, 64 L.Ed.2d 862 (1980).

It is clear that, in an appropriate case, an interim award of attorney's fees may be ordered. Hanrahan v. Hampton, 446 U.S. 754, 757-58, 100 S.Ct. 1987, 1989, 64 L.Ed.2d 670 (1980). Given that judgment has entered pursuant to the Consent Decree and given further that implementation of the Decree has been protracted, the Court finds consideration of an interim award at this time reasonable.

Defendants do not apparently contest any of these propositions. They insist, however, that the plaintiffs are not entitled to any attorneys' fees for two reasons. First, they say that the application for fees is not timely, second, they allege that the plaintiffs are not "prevailing parties," as that term is to be understood under the doctrine of Nadeau v. Helgemoe, supra.

Defendants note that plaintiffs first filed their application for attorneys' fees on March 21, 1981, more than two years after the entry of the Consent Decree and judgment. Acknowledging that White v. New Hampshire Department of Social Security, ___ U.S. ___, 102 S.Ct. 1162, 71 L.Ed.2d 325 (1982) permits the District Courts to exercise discretion and award attorney's fees in these circumstances, they nevertheless argue that the court should use its discretion to deny fees on the ground that the defendants have been unfairly prejudiced by the delay.

This argument might carry weight if the litigation had indeed ended on December 7, 1978. However, the plaintiffs and defendants have had an intimate and unbroken relationship since 1976. Despite the Consent Decree, in essential respects, the negotiation, monitoring and litigation have unfolded continuously from the initiation of the suit to the present. Moreover, the defendants' complaint that individuals critical to an assessment of the attorneys' fees application have moved on to other employment is substantially undercut by the fact that all of these individuals are still employed in eastern Massachusetts and are readily available for discussion and consultation. In fact, some former state employees have filed affidavits or made themselves available for depositions in connection with this application. See, Affidavit of Catherine A. White and Deposition of S. Stephen Rosenfeld. The First Circuit has recently held that, in the absence of a local rule, "the determination of timeliness rested within the sound discretion of the District Court." White v. New Hampshire Department of Employment Security, 679 F.2d 283, at 285 (1st Cir. 1982), on remand from ___ U.S. ___, 102 S.Ct. 1162, 71 L.Ed.2d 325 (1982). The Court finds that the defendants have not suffered any significant prejudice as a result of the timing of filing the attorneys' application. This factor, therefore, will not bar payment of fees.

The issue of whether plaintiffs were "prevailing parties" is somewhat more complicated.

In Nadeau v. Helgemoe, supra, the First Circuit established two criteria for determining when a party will be considered to have "prevailed" for purposes of the attorneys' fees statute. First, the plaintiffs must demonstrate that the lawsuit was factually the "catalyst" which prompted the defendants to take particular action. Second, even if the lawsuit were the catalyst, defendants' action must not be "gratuitous," but must flow from some legal compulsion.
Defendants point to the declining populations of other institutions for the mentally ill and mentally retarded throughout the state as evidence that census reduction at Northampton State Hospital constitutes part of a voluntary state-wide policy, and has not been compelled or catalyzed by the lawsuit.
The defendants' emphasis on mere census reduction, however, entirely avoids the central theme of the Brewster 1074 litigation. The *1074 goal of this action has never been census reduction alone; this may be a euphemism for
what has been more pungently described as "dumping" or 0907 placing clients into the community without adequate services. On the contrary, the goal of this litigation has been the creation of "a comprehensive system of appropriate, less restrictive treatment, training and support services ...." Consent Decree, Paragraph 3.
On this score, the Decree has been an agent for progress. Millions of new dollars have been committed by the state in recent fiscal years to press forward with the development of a community mental health system in the Western third of the Commonwealth. Defendants do not allege that the exponential growth of this system in the geographic area covered by the Decree has been duplicated elsewhere in the State. Recognizing the unique growth of community mental health services subject to this Decree, the Department of Mental Health's Individual Service Plan and Non-Residential Regulations have been made applicable only to Brewster class members. Prior to the promulgation of the Consent Decree, the expenditures for community mental health programs for Region I were the lowest in the state; subsequent to the Decree, they became the highest.
Moreover, a "policy" favoring movement of clients from institutional to community settings apparently dates back at least to 1966, when the Legislature made community mental health treatment the preferred alternative. But policy commitments by themselves do not necessarily garner hard results. By 1978, when this Decree was signed, little more than the barest skeleton of a community mental health system existed in this part of the Commonwealth. The Court finds that this lawsuit was a catalyst which led to the remedies described in the Decree.[2]
The assertion that the actions of the state defendants were gratuitous, and not incited by any constitutional or statutory considerations is similarly groundless. The First Circuit has carefully articulated the method for assessing the validity of a fee claim against this criterion.
Even if plaintiffs can establish that their suit was causally related to the defendants' actions which improved their condition, this is only half of their battle. The test they must pass is legal as well as factual. If it has been judicially determined that defendants' conduct, however beneficial it may be to plaintiffs' interests, is not required by law, then defendants must be held to have acted gratuitously and plaintiffs have not prevailed in a legal sense. See Taylor v. Safeway Stores, Inc. [524 F.2d 263, 273 (10th Cir. 1975) ]. In the present case ... there has not yet been a judicial determination of whether plaintiffs' rights were violated under traditional standards of analysis. In such circumstances, one might argue that the district court cannot meaningfully decide the legal requirements that govern defendants' conduct without conducting the very trial the consent decree was signed to avoid. However, we believe the court has had sufficient exposure to the facts and law of this case to determine, whether if plaintiffs had continued to press their claims under traditional constitutional theory, their action could be considered "frivolous, unreasonable, or groundless, or that the plaintiff continued to litigate after it clearly became so." Christianburg Garment Co. v. E.E.O.C., 434 U.S. 412, 422, 98 S.Ct. 694, 701, 54 L.Ed.2d 648 (1978) (the standard under which defendants may be entitled to attorney's fees under the 1964 Civil Rights Act).
Nadeau v. Helgemoe, supra at 281.

No court has determined that defendant's conduct is not required by law. The recent Supreme Court decision in 1075 Youngberg v. Romeo, ___ U.S. ___, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982), offers general support *1075 for the
position taken by plaintiffs in their lawsuit. By 1978, lower courts had supported the requirement of treatment in the least restrictive environment. Dixon v. Weinberger, 405 F.Supp. 974 (D.D.C.1975); Lessard v. Schmidt, 349 F.Supp. 1078 (E.D. Wis.1972), vacated and remanded on other grounds, 414 U.S. 473, 94 S.Ct. 713, 38 L.Ed.2d 661 (1974). More recently, of course, the concept has received additional support. See, e.g., Commonwealth v. Nassar, 380 Mass. 908, 406 N.E.2d 1286 (1980).
Moreover, the fact that plaintiffs' original complaint lacked definitive constitutional support does not bar fees. The purpose of § 1988 is to encourage civil rights actions that may press the boundaries of black-letter doctrine. Furtado v. Bishop, 635 F.2d 915, 918-19 (1st Cir. 1980). Certainly, plaintiffs' action is not frivolous, unreasonable or groundless.
The Court finds that plaintiffs have sufficiently "prevailed" in both the legal and the factual sense within the meaning of § 1988, to warrant payment of attorneys' fees.[3]
III. Calculation of the "Lodestar"
Having determined that neither of defendants' arguments would bar completely payment of attorneys' fees, the Court turns to analysis of the proper method for calculating the amount of fees to be paid.
The method for calculating appropriate attorneys' fees under § 1988 has been clearly described in Furtado v. Bishop, 635 F.2d 915 (1st Cir. 1980), which refined the previous decision in King v. Greenblatt, 560 F.2d 1024 (1st Cir. 1977), cert. denied 438 U.S. 916, 98 S.Ct. 3146, 57 L.Ed.2d 1161 (1978). In Furtado, the First Circuit approved the "lodestar" approach to fee calculation and cited with approval Copeland v. Marshall, 641 F.2d 880 (D.C.Cir.1980) (en banc). See also, Lindy Bros. Builders, Inc. v. American Standard Radiator & Sanitary Corp., 540 F.2d 102 (3rd Cir. 1976) (en banc). More recently, in Miles v. Sampson, 675 F.2d 5 (1st Cir. 1982), the Court of Appeals has summarized the procedure for making the calculation.
Under this method, there are two principal steps to computing an award of fees. First, a "lodestar" fee is determined by multiplying a reasonable hourly rate by the number of hours reasonably expended on the lawsuit. Second, the "lodestar" is adjusted up or down to reflect factors, such as the contingent nature of success in the lawsuit or the quality of legal representation which have not already been taken into account in computing the "lodestar" and which are shown to warrant the adjustment by the party proposing it.
Id., at 8.
The Court's analysis in this case will begin with a calculation of reasonable hourly rates for each of the attorneys involved. The Court will then determine the reasonable number of hours expended on the lawsuit, making certain reductions in consideration of factors to be detailed below. Finally, the Court will address the issue of whether the "lodestar" should be adjusted upward or downward, as urged by the plaintiffs and defendants respectively.
A. Reasonable Hourly Rates
STEVEN J. SCHWARTZ
Steven J. Schwartz, the lead counsel for the plaintiffs, is a 1971 cum laude graduate of Harvard Law School. Attorney Schwartz practiced as staff attorney of the Western Massachusetts Legal Services, staffing their Greenfield, Northampton, and Northampton State Hospital offices; he has specialized in poverty law cases and represented institutionalized persons at Northampton State Hospital. In 1976, Attorney Schwartz established, through a grant from the National Institute for Mental Health ("NIMH") the Mental Patients' Advocacy Project, a 1076 program designed to train lay advocates to represent mentally *1076 disabled persons. Attorney Schwartz is a

nationally recognized expert who has contributed to securing the rights of institutionalized mentally disabled persons through litigation, legislative and regulatory development, consultation and publications.
The lodestar rate requested for Attorney Schwartz is $80.00 per hour for 1976, $90.00 per hour for 1977, $100.00 per hour for 1978, $110.00 per hour for 1979 and $120.00 per hour for 1980.
The Court believes that this fee range is somewhat above the level generally demanded by others with Attorney Schwartz's background and above rates awarded in similar cases. Defendants have suggested rates of $50.00 to $80.00 per hour and the Court finds a fee of $80.00 for Attorney Schwartz's "core" litigation services to be reasonable. In this district fees for similar work have ranged from $50.00 to $100.00 per hour. See Ingerson v. Hogan, No. 76-3255-S (D.Mass. Order entered April 6, 1982) slip op. at 5, n. 2. To compensate plaintiffs for delay in payment, the Court will use the same hourly rate for all years claimed.
Slightly lesser rates should be paid for activities in the nature of support and preparation. Thus, the Court will award Attorney Schwartz the full hourly rate for the time spent during meetings directly related to litigation, during direct meetings with the Attorney General, for court appearances and for activity directly related to court appearances including the preparation of briefs and memoranda. Monitoring and implementation of the Decree, along with drafting of regulations, have been awarded the slightly lower rate of $70.00 per hour, in recognition of the fact that these activities are, on the one hand, not as strenuous as litigation, but on the other hand are demanding tasks requiring a high degree of experience and professionalism. Other activities, including correspondence, telephone calls, general planning and negotiating sessions, general research and consultation activities and work in connection with preparation of the application for attorneys' fees have been compensated at the still lower hourly rate of $60.00 per hour,[4] recognizing that these activities are less strenuous and ancillary to the basic tasks of litigation and implementation of the Decree.
ROBERT D. FLEISCHNER
Robert D. Fleischner, co-counsel for the plaintiffs, is a 1973 graduate of Boston College Law School. As a practicing attorney at Western Massachusetts Legal Services for five years, Attorney Fleischner has had experience in representing clients in poverty law cases, and has specialized in juvenile and education law. As Assistant Director at the Mental Patients Advocacy Project he has, along with Attorney Schwartz, taken primary responsibility for the conduct of this litigation, for the years 1978-80. In addition, he has represented clients in civil commitment and guardianship hearings and participated as amicus curiae in related cases. Attorney Fleischner teaches mental health law at Smith College Graduate School for Social Work. As a mental disability law expert he has consulted nationally.
Attorney Fleischner's lodestar request is $80.00 per hour for 1978, $90.00 per hour for 1979, and $100.00 per hour for 1980.
For reasons described in the discussion regarding Attorney Schwartz, the Court will award a fee of $80.00 per hour for "core" litigation and fees of $60.00 to $70.00 per hour for other activities.
OTHER COUNSEL
Well over 90% of the hours expended by plaintiffs' counsel in this case were put in by Attorneys Schwartz and Fleischner. The hours claimed by six other counsel have not been broken down by task in the plaintiffs' 1077 submissions with the same specificity as the hours of Attorneys Schwartz and *1077 Fleischner.[5] It is clear from the submissions, however, that the bulk of the hours contributed by these attorneys came mainly in connection with core litigation activities, such as preparation of memoranda or strategy conferences. Recognizing the lack of specificity, however, the Court has set the rates of these attorneys towards the lower end of the allowable range.

JAN C. COSTELLO
As a 1976 graduate of the Yale Law School, Jan C. Costello worked for two years as staff attorney at the Mental Patients Advocacy Project, 1976-78. Prior to this experience, Attorney Costello worked as an intern/law clerk with the Mental Health Law Project in Washington D. C. Although a recent graduate, Attorney Costello had specialized training and experience in mental disability law.
The lodestar request for Jan C. Costello is $50.00 per hour for 1976, $55.00 per hour for 1977, and $60.00 per hour for 1978.
Because of her relative inexperience at the time, the Court has awarded a flat rate of $50.00 per hour for her work.
WILLIAM C. NEWMAN
Attorney Newman graduated in 1976 from Northeastern University School of Law and is a partner in the Northampton law firm of Lesser, Newman, Sibbison & Souweine. Attorney Newman has specialized in civil rights and mental health litigation. He has participated as a consultant in the preparation and litigation of this case.
The lodestar request for William C. Newman is $55.00 per hour for 1976, $60.00 per hour for 1977 and $65.00 per hour for 1978.
Because of his relative inexperience at the time, the Court has awarded a flat rate of $50.00 per hour for his work.
THOMAS B. LESSER
Attorney Thomas Lesser is a 1971 graduate of Harvard Law School and a partner of the Northampton law firm of Lesser, Newman, Sibbison & Souweine. Attorney Lesser has extensive trial experience in federal and state court and he has represented clients in commitment hearings at Northampton State Hospital. Attorney Lesser brought his expertise as a consultant in the early pre-trial and trial aspects of this case.
Thomas Lesser's lodestar request is $65.00 per hour for 1976, $70.00 per hour for 1977, $75.00 per hour for 1978.
The Court will award a flat rate of $60.00 per hour, given Attorney Lesser's background and taking into consideration that he acted mainly as a consultant without primary responsibility for the conduct of the litigation.
STEPHEN ARONS
Attorney Arons is an Associate Professor of Legal Studies at the University of Massachusetts and a 1969 cum laude graduate of Harvard Law School. Attorney Arons participated in the development of the Mental Patients Advocacy Project and acted initially as director. Attorney Arons has extensive knowledge and experience in constitutional law and federal court litigation. As an expert in the field of mental disability law, he has provided consultation to this lawsuit and other cases around the country.
The lodestar request for Stephen Arons is $100.00 per hour for 1976 through 1978. His awarded rate is discussed below.

IRA HOROWITZ
Ira Horowitz is a 1968 graduate from the University of Chicago Law School and was Director of Litigation and Training at Western Massachusetts Legal Services. Attorney Horowitz has had substantial experience in public interest litigation particularly in the federal courts. Attorney Horowitz acted as senior consulting attorney on this law suit providing expertise in developing legal theories and planning litigation. He has been a training consultant to the Office of Program Support of the Legal Services Corporation in Washington, D. C.
The lodestar request for Attorney Horowitz is $100.00 per hour for 1976 through 1978. His awarded rate is discussed below.
1078 *1078 E. OLIVER FOWLKES
Attorney Fowlkes is a 1968 law school graduate and an assistant professor of law at Hampshire College. Attorney Fowlkes is experienced in representing institutionalized persons and assisted in the development of the Mental Patients Advocacy Project. As an expert in disability law, Attorney Fowlkes has been involved in several class action suits representing institutionalized mental patients. He has published papers, and has acted as a consultant for the National Institute for Mental Health.
The lodestar request for E. Oliver Fowlkes is $100.00 per hour for 1976 through 1978.
Attorneys Arons, Fowlkes and Horowitz, as noted, are experienced attorneys in the area of mental health law, used mainly as consultants in the preparation of briefs and memoranda, or during meetings in the early stages of the litigation. Their experience, in more primary roles, might justify the award of higher hourly rates, but in view of their role as consultants only, the Court has awarded flat hourly rates of $70.00 per hour for each.
B. Hours Reasonably Expended
The plaintiffs have submitted schedules detailing the hours claimed to have been expended in connection with this litigation. The material was presented to the Court in two segments including a schedule of hours spent thru calendar year 1980 and a schedule of hours expended during the calendar year of 1981. For reasons to be explained, the Court will calculate the lodestars for the periods 1976 through 1980 and 1981 separately.
The attached appendix details the number of hours claimed by each of the eight attorneys involved in this case by year and, in the case of Attorneys Schwartz and Fleischner, by category of task.
1) 1976-1980
Attorney Schwartz has calculated the total hours spent by him in connection with this litigation for the five years in question as 4,143.75. Total hours claimed by Attorney Fleischner are 628.55.
The requested total hours for the other six counsel employed in this case are as follows:

Jan C. Costello William C. Newman Thomas Lesser Ira Horowitz Stephen Arons E. Oliver Fowlkes

Hours
140.0 63.0
127.5 84.8 50.2 21.5

Thus, the total number of attorney hours claimed by plaintiffs in the years 1976 through 1980 is 5,259.3.
Defendants have not suggested that any of the hours claimed in any way has been deliberately misrepresented. They do argue, however, that plaintiffs have made claims for unnecessary work, or for time not properly compensable. More vigorously, they criticize as unreliable the methods used by the plaintiffs in reconstructing time records which were not contemporaneously maintained. The Court will address each of the defendants' arguments.
First, the defendants argue that legal representation consisting of general monitoring and implementation of the Decree is not compensable. The only legal work for which plaintiffs' counsel are entitled to payment, say defendants, must grow out of post-Decree disputes in which plaintiffs can claim to be "prevailing parties."
This argument ignores the fact that the Decree itself clearly envisions a prominent role for plaintiffs' counsel in implementation. As described above, numerous paragraphs of the Decree mandate plaintiff involvement. Defendants signed the Decree knowing this fact and knowing, further, that an application for counsel fees by plaintiffs might be submitted. Deposition of S. Stephen Rosenfeld, at 40-41.
It would be entirely contrary to the concept of cooperation underlying a Consent Decree, and would compromise judicial economy, to require plaintiffs' counsel to inflate every implementation negotiation into a full scale dispute 1079 in which they would *1079 then "prevail," in order to justify attorneys' fees. As noted, the Court has found that the plaintiffs "prevailed" for purposes of § 1988 when the Consent Decree was entered; work necessarily related to insuring implementation of the Decree, or called for by the Decree itself, is compensable.[6] The Court finds that the sorts of tasks performed by plaintiffs' counsel fall into this category. See Northcross v. Board of Education, supra, at 637.
To the extent that plaintiffs' post-Decree activities may have been superfluous or excessive, the Court will consider this factor in determining a percentage reduction of the requested hours. To the extent that implementation activities are less demanding than actual trial work, the Court has already reduced plaintiffs' hourly rates.
Second, with regard to the period prior to entry of the Decree, defendants assert that no fees should be allowed for the period when plaintiffs were engaged in a "planning process" with defendants. They allege that the considerable number of hours spent by the plaintiffs in the biweekly planning meetings during this period "had little to do with the substance of the lawsuit." Defendants' Brief at p. 12.
This is not the case. The planning process was undertaken at the request of the Court explicitly as an effort designed to obviate the necessity for a trial and, if possible, deliver to the plaintiff class services that all parties seemed to recognize as crucial, without adversarial litigation. The last paragraph of the plaintiffs' written response to the defendants' letter of October 18, 1977 to the Court makes this clear.
We would hope that the above clarification will be promptly accepted by all parties in order that the planning process, and the eventual resolution of this litigation, can proceed without further delay.
Letter dated November 8, 1977 from plaintiffs' counsel Steven J. Schwartz and Boisfeuillet Jones, Jr. to Assistant Attorney General S. Stephen Rosenfeld, (emphasis supplied). Exhibit B to Affidavit of Catherine White, Defendants' Appendix at 12.
In addition, the biweekly planning meetings clearly generated the pitch of the subsequent Consent Decree. Properly understood, this process was essentially an extended settlement negotiation. It is hardly surprising, given the complexity of this form of public institutional litigation, that the negotiations were unusually protracted.
Finally, the defendants themselves have frequently conceded the plaintiffs' critical and appropriate role in the planning process that led to the Decree. In their letter to the Court of October 18, 1977, under the heading "Role of Plaintiffs," counsel for the defendants clearly recognized this.
The defendants envision counsel for the plaintiffs playing a substantial role in this process [i.e. the planning process] both in their formal capacity in this lawsuit and in their continuing capacity as

advocates for individual residents at Northampton. We see them making an especially valuable contribution in helping to develop procedures for transfer as well as assisting in the location and development of suitable community placements.
Exhibit A of Affidavit of Catherine White, Defendants' Appendix at 7.
It is hardly equitable for defendants to seek actively plaintiffs' assistance on the one hand, and bar fees for these very contributions on the other.
It is worth noting, moreover, that plaintiffs' activities during the "planning process" have generally been compensated at a lower hourly rate than other work. The Court finds that this reduced fee rate is appropriate.
1080 Defendants advance as their third argument for reducing the fee, that plaintiffs *1080 are not entitled to compensation for work devoted to discrete issues on which they clearly did not prevail. On this point, the Court agrees. This argument applies only to work done in 1981, however, and will be addressed below.
Fourth, defendants object to "over-lawyering" on the part of plaintiffs, as tending to inflate the fee claim. With this contention, the Court again agrees. Review of the plaintiffs' submissions demonstrates that as many as four separate counsel attended meetings at the early stages of the litigation. This factor has been considered by the Court in rendering a percentage reduction of the hours claimed.
Finally, and perhaps most importantly, defendants object to plaintiffs' manner of reconstructing time records. It is not disputed that for the years 1976-1979 plaintiffs did not maintain contemporaneous time records. To some extent this is understandable. The controlling statute did not take effect until 1976. Before Reynolds v. Coomey, 567 F.2d 1166, 1167 (1st Cir. 1977) some confusion existed as to whether legal services attorneys were always entitled to fees.
On the other hand, while a lack of contemporaneous time records would not justify elimination of attorneys' fees in toto, in this case the Court agrees that a significant reduction of the hours claimed is appropriate.
For the foregoing reasons, the Court will reduce all the compensable hours claimed by twenty percent. In making an across-the-board percentage reduction in requested compensable hours, rather than performing an item-byitem accounting, the Court is following accepted practice. Copeland v. Marshall, supra, 641 F.2d at 903.
The lodestar for the years 1976-1980 has been calculated in Section V. The totals are as follows:

Amount

Steven J. Schwartz Robert D. Fleischner Jan C. Costello Thomas Lesser William C. Newman Steven Horowitz Stephen Arons E. Oliver Fowlkes

$216,856.40 34,875.60 5,600.00 6,120.00 2,520.00 4,748.80 2,811.20 1,204.00

The plaintiffs have claimed up to $65.00 per hour for travel. Particularly in view of the necessity to commute from the western part of the state to Boston for frequent meetings, the Court finds that some fees for travel time are justified. Defendants concede this but object that the claimed rate is too high. The Court agrees that travel rates should be drastically reduced and will order $20.00 per hour for travel. Thus the total time claimed for travel for 1976-1980 is 303 which, at a rate of $20.00 per hour, leaves a total of $6,060.00. Adding $14,115.00 in costs results in a total lodestar for 1976-80 of $294,911.00.

2) 1981
Turning to the year 1981, the issues are both simpler and more complicated. On the one hand, claims are made only for the representation by Attorneys Fleischner and Schwartz, who claim 721.4 and 279.55 hours respectively. The details of their claims, by category, appear in Section V of this Memorandum. The issue of maintenance of contemporary time records is almost eliminated because by this period both attorneys were maintaining such records, in general. Similarly, the problem of duplication of representation is much reduced due to the absence of other attorneys involved in the case. In view of the complexity of the issues involved the Court is not inclined to penalize the plaintiffs for the attendance of two attorneys at some hearings or meetings. It is worth noting that the defendants in general had at least two, and sometimes more, attorneys at pertinent hearings or meetings.
On the other hand, the issues in calculation of fees during this year are more complicated, due to the failure of the plaintiffs to "prevail" on at least two issues.
On the issue of the fiscal year 1982 (FY '82) budget, two hearings were held before this Court and two arguments 1081 before *1081 the First Circuit Court of Appeals. Orders and memoranda were issued by this Court on September
15 and December 23, 1981, which were subsequently modified and affirmed in part and vacated in part by the Court of Appeals. Brewster v. Dukakis, 675 F.2d 1 (1st Cir. 1982). It is clear that at least as regards part of the FY '82 budget issue, the plaintiffs were not the prevailing party. At the same time, the fact that the plaintiffs were prevailing with regard to a portion of this issue makes it difficult to quantify arithmetically the precise number of hours that might be justified in connection with litigation of this issue.
In addition, the Court held hearings and rendered an opinion on the issues of legal advocacy and human resources for clients. Brewster v. Dukakis, 520 F.Supp. 882 (D.Mass.1981). While defendants did not appeal the Court's decision on human resources, the Court's Order on advocacy was appealed and has recently been vacated and remanded. Brewster v. Dukakis, No. 81-1687, (1st Cir. June 22, 1982). Again, because this Court's initial decision entwined two issues, a precise division of time is not possible. The fact that it is difficult to separate out time spent according to whether a litigant prevailed or did not prevail will not justify total disallowance of the claim. Nadeau v. Helgemoe, at 279.
Based on this, the Court will reduce the hours claimed by Attorneys Fleischner and Schwartz for litigation activities by one-third for 1981, and for all other activities by ten percent.[7] The computation is set forth in Section V; total hours for Attorney Schwartz are 619.52, and for Attorney Fleischner, 237.88. Multiplying these hours by the awarded rates results in a 1981 lodestar for Attorney Schwartz of $40,298.80, and for Attorney Fleischner of $15,966.70.
Calculating twenty-eight hours of 1981 travel at $20.00 per hour adds $560.00 to their total.
Thus, adding costs of $926.24, the total lodestar for 1981 is $57,751.74.
IV. Adjustment of Lodestar
The plaintiffs have requested that the Court increase the lodestar amount by 100%, pointing to the contingent nature of the case, the substantial delay in payment, the quality of the attorneys' work, and the significance of the results, all factors to be considered under the rubric of King v. Greenblatt, supra, in the framework of the LindyCopeland-Furtado decisions.
The Court finds that as to all of the factors suggested, a substantial increase in the lodestar amount would be warranted.
First, the case was highly contingent in nature. The judicial and constitutional underpinnings of the plaintiffs' claim, while not illusory, did lack definitive support at the time the suit was filed. Even today, the precise boundaries of the rights of the plaintiff class remain unclear. Courts have awarded an increase to the lodestar

amount in response to considerations of contingency such as were faced by the plaintiffs in this case. Stenson v. Blum, 512 F.Supp. 680 (S.D.N.Y.1981) aff'd, 617 F.2d 493 (2nd Cir. 1981), petition for cert. docketed, 50 U.S. L.W. 3744 (U.S. March 16, 1982) (50% increase), Halderman v. Pennhurst, 533 F.Supp. 661 (E.D.Pa.1982) (300% and 50% increases).
Second, the Court is sensitive to the excellent quality of work performed by the plaintiffs' attorneys and to their high degree of dedication, which has been far above the level that might ordinarily be expected from attorneys with their experience and background. Partly because of this level of competence and commitment, the Consent Decree was first negotiated and finally drafted, saving the Court and more importantly the disabled clients at 1082 issue here the strain and delay of a lengthy *1082 trial. Along with the staff of paralegals they have trained, they have represented clients in individual complaints both in the Hospital and in the scores of small programs now established in the community. They have not only assisted in drafting regulations, but have assisted all community programs under the Decree to give workshops to staff on the content of the regulations. In addition to legal skills, the issues in the Decree have necessitated a close familiarity with a body of relevant clinical knowledge, as well as knowledge of the state's fiscal and administrative processes. Since their efforts often broke new ground, they lacked the assistance of prior models to guide them in carrying out their broad responsibilities under the Decree.[8] The Court finds the quality of work justifies a percentage increase in the lodestar.
Third, the significance of the results obtained is unusually impressive. Only the faint outlines of the community mental health system could be perceived at the outset of this litigation; the Consent Decree has produced a functioning community mental health system able to respond flexibly in most cases to the needs of thousands of mentally disabled persons in the western part of the state of Massachusetts. Plaintiffs have had a substantial role in creating this system and deserve an increase to their fee based on this outstanding result.[9]
Absent countervailing considerations, the Court would be inclined to increase the lodestar amount by at least 50%. However, the Court agrees with defendants that countervailing considerations do exist in this case. First, the defendants themselves are to be complimented for their generally high degree of flexibility and dedication. Obviously the enormous amount achieved through the implementation of this Decree to date would not have been possible without a substantial degree of cooperation among plaintiffs and defendants. Second, the Court is sensitive to the fact that this legal fee will be paid out of the public treasury. See Keyes v. School District No. 1, 439 F.Supp. 393, 414-415 (D.Colo.1977). Third, the Court takes notice that the fee in any case is substantial, that a second application for attorneys' fees for the plaintiff-intervenor is still pending and, finally, that additional interim applications for attorneys' fees can be anticipated for at least this year and the coming year. For all the foregoing reasons, the Court has determined to increase the amount of the attorneys' fees by 10% in recognition of the contingent nature of the case, the high quality of work performed by the plaintiffs' counsel, and the significance of the result. This 10% adjustment will be added to the total actual attorneys' fees award.
V. Calculation of Attorneys' Fees
The detailed calculation of attorneys' fees is as follows:

ATTORNEY SCHWARTZ 1976-1980

Hours

Adjustment

General Correspondence:
Court Correspondence:
Telephone:

362.65
53.60 1023.30

290.12
42.88 818.64

Rate

Total

$60

$17,407.20

$60

2,572.80

$60

49,118.40

1083 *1083

Planning and Negotiating Meetings:
Litigation Meetings:
Monitoring and Implementation Meetings:
Attorney General Meetings:
Regulations: Court (briefs and
appearances): Research: Attorneys' Fees:
TOTALS

Hours
971.70
296.85
420.15
43.00 249.70
447.50 238.00
37.30 ________ 4143.75

Adjustment
777.36
237.48
336.12
34.40 199.76
358.00 190.40
29.84 _______ 3315.00

ATTORNEY SCHWARTZ 1981

Hours

Adjustment

General Correspondence:
Court Correspondence:
Telephone: Litigation
Meetings: Monitoring and
Implementation Meetings: Regulations: Court (In Court): Court (preparation): Briefs and Memoranda: Attorneys' Fees:

94.80
40.00 91.30
32.10
132.00 23.00 22.90
74.30
205.00 6.00
_______

85.32
36.00 82.17
21.51
118.80 20.70 15.34
49.78
136.66 5.40
________

TOTALS:

721.40

571.68

ATTORNEY FLEISCHNER 1976-1980

Hours

Adjustment

General Correspondence:
Court Correspondence:
Telephone: Planning and

61.45
0.00 39.80

49.16
0.00 31.84

Rate
$60 $80
$70 $80 $70 $80 $60 $60 ____

Total
46,641.60
18,998.40
23,528.40
2,752.00 13,983.20
28,640.00 11,424.00
1,790.40 ____________ $216,856.40

Rate
$60 $60 $60 $80
$70 $70 $80 $80 $80 $60

Total
$ 5,119.20
2,160.00 4,930.20
1,720.80
8,316.00 1,449.00 1,227.20
3,982.40
10,932.80 324.00
__________
$40,161.60

Rate $60 $60

Total
$ 2,949.60 0.00
1,910.40

Negotiating Meetings: Litigation Meetings: Monitoring and Implementation Meetings:

0.00 120.35
225.10

0.00 96.28
180.08

1084 *1084

Hours

Adjustment

Attorney General Meetings:
Regulations: Court (briefs and
appearances): Research: Attorneys' Fees:
TOTALS

0.00 111.35
5.50 63.00
2.00 _______ 628.55

0.00 89.08
4.40 50.40
1.60 _______ 502.84

ATTORNEY FLEISCHNER 1981

Hours

Adjustment

General Correspondence:
Court Correspondence:
Telephone: Litigation
Meetings: Monitoring and
Implementation Meetings: Regulations: Court (In Court): Court (preparation): Briefs and Memoranda: Attorneys' Fees:
TOTALS:

0.00
0.00 21.65
29.10
99.30 0.00
22.10
8.50
94.60 4.30
_______ 279.55

0.00
0.00 19.49
19.50
89.37 0.00
14.81
5.70
63.06 3.87
______ 215.80

COSTS: 1981

TRAVEL: 1981

(28 at $20.00)

OTHER COUNSEL 1976-1980

Hours

Adjustment

0.00

$80

7,702.40

$70

12,605.60

Rate

Total

$70
$80 $60 $60 _____

0.00 6,235.60
352.00 3,024.00
96.00 ___________ $34,875.60

Rate

Total

$ 0.00

0.00

$60

1,169.40

$80

1,560.00

$70
$80
$80
$80 $60 _____

6,255.90 0.00
1,184.80
456.00
5,044.80 232.20
__________ $15,903.10
$ 926.24
$ 560.00

Rate

Total

J. Costello W. Newman T. Lesser S. Arons I. Horowitz O. Fowlkes
TOTALS:
COSTS: 1976-1980
TRAVEL: 1976 - 1980

140.00 63.00
127.50 50.20 84.80 21.50
_______ 487.00

112.00 50.40
102.00 40.16 67.84 17.20
______ 389.60

(303.0 at $20.00)

$50 $50 $60 $70 $70 $70 _____

$ 5,600.00 2,520.00 6,120.00 2,811.20 4,748.80 1,204.00
_____________ $23,004.00
$14,115.00
$ 6,060.00

1085 *1085 GRAND TOTAL 1976-1981
Attorney Schwartz: Attorney Fleischner: Travel: Other Counsel:
SUBTOTAL: $337,420.70 × 10%:
COSTS:
TOTAL:
VI. Conclusion

$257,018.00 50,778.70 6,620.00 23,004.00
____________ $337,420.70 33,742.07 ____________ $371,162.77 15,041.24 ____________ $386,204.01

Because of its sensitivity to the fact that these fees are to be paid out of the public treasury and acknowledging that the fee award though much reduced is high, the Court will permit defendants to pay the fee in two equal installments, the first to be paid on or before September 1, 1982 and the second on or before September 1, 1983.

[1] This Memorandum pertains only to the application of attorneys attached to, or consulting with, the Mental Patients Advocacy Project, which represents the named plaintiffs and the plaintiff-intervenor Massachusetts Association for Mental Health. The application on behalf of plaintiff-intervenor Massachusetts Association for Retarded Citizens was received too late for consideration by the Court in this Memorandum and will be addressed at a later date.
[2] Defendants appear to concede that plaintiffs' actions were not "completely superfluous" in effecting programmatic change. Nadeau v. Helgemoe, supra, at 281. Defendants' Brief at 8, n. 4. Plaintiffs prevail if they succeed "on any significant issue which achieves some of the benefit the parties sought in bringing the suit." Id., at 279.
[3] The exception to this general conclusion is the work done during the year 1981, when plaintiffs did not prevail factually on two discrete issues. These issues will be addressed below.
[4] Defendants' brief suggests $57.50 as a reasonable hourly rate for preparation of the fees application. Defendants' brief at 27. Courts may use varying rates to compensate attorneys for more or less demanding tasks. Miles v. Sampson, supra at 9.

[5] A breakdown of hours by type of task is made only for "other" attorneys, so it is difficult to determine which of these attorneys was employed on which category of task.
[6] Despite the use of the term "monitoring" the activities of plaintiffs' counsel have not duplicated those of the court-appointed Monitor. The Monitor evaluates services under the Decree, resolves minor disputes, attempts to mediate major disputes, makes suggestions for implementation and submits reports to the Court. He does not have direct responsibility for insuring implementation of the Decree or advocating on behalf of plaintiff class members.
[7] In making the percentage reductions in claimed hours for all six years, the Court has taken into consideration that plaintiffs have made no claim for compensation for some 2,000 hours for work performed by paralegals and law students. It would not have been improper to claim paralegal hours as part of a fee request, Lamphere v. Brown University, 610 F.2d 46, 48 (1st Cir. 1979), and the Court's reduction might have been more severe had these hours been included in the application. See also Furtado v. Bishop, supra, at 920.
[8] Because of the uncertainty now surrounding the issue of the state's responsibility to fund advocacy services, and the expiration of the NIMH grant which has hitherto funded plaintiffs' counsel, an appropriate grant of attorneys' fees may be a significant source of funds for prospective legal services for the class.
[9] Plaintiffs have offered a fourth reason for increasing the lodestar amount 0907delay in payment 0907which the Court rejects. First, by waiting over two years to file their application, plaintiffs themselves contributed to the delay. Second, by assigning the same hourly rates for work over several years the effect of delay in payment is muted.
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 786 F.2d 16 (1986)
David BREWSTER, et al., Plaintiffs, Appellees, v.
Michael S. DUKAKIS, et al., Defendants, Appellants. David BREWSTER, et al., Plaintiffs, Appellants, v.
Michael S. DUKAKIS, et al., Defendants, Appellees.
Nos. 85-1775, 85-1776.
United States Court of Appeals, First Circuit.
Argued February 5, 1986. Decided March 14, 1986.
17 *17 Thomas A. Barnico, with whom William L. Pardee, Asst. Attys. Gen., Francis X. Bellotti, Atty. Gen., were on brief, for defendants, appellants.
Steven J. Schwartz, with whom Robert D. Fleischner, Center for Public Representation, were on brief, for plaintiffs, appellees.
Edward P. Leibensperger, Kurt A. Ogle, Nutter, McClennen and Fish, and Marjorie Heins, Massachusetts Civil Liberties Union Foundation, on brief for Civil Liberties Union of Massachusetts, Greater Boston Legal Services, Massachusetts Law Reform Institute and Massachusetts Correctional Legal Services, amicus curiae.
Before COFFIN and ALDRICH, Circuit Judges, and PETTINE, Senior District Judge[*].
COFFIN, Circuit Judge.
These are appeals from an attorney's fee award covering work performed by counsel for the plaintiff class, residents of the Northampton State Hospital, during two and one half years subsequent to entry of a complex consent decree. The decree bound the responsible Massachusetts officials to establish a system for the care and treatment of mentally disabled persons in community residential facilities and nonresidential programs.[1]
The litigation commenced in 1976; the decree was entered in 1978; and the district court made its first fee award in 1982, covering work performed from 1976 through 1981, in the amount of $386,204.[2] The decision, resulting in a two-thirds reduction of the amount claimed, included an extensive analysis in which the court discussed and distinguished four kinds of work done by plaintiffs' counsel in implementing and monitoring the decree. The court established different rates for court work, decree implementation and monitoring, general work, and travel. Id. at 1076. Although the decree called for a court-appointed Monitor, the decree also bestowed various responsibilities on the parties. Id. at 1072.
The present fee application covered the period from January 1, 1982 through June 30, 1984, and included 2537.93 hours of services performed by two lawyers and a paralegal. The 191-page application included some 3500 entries (at roughly eighteen items a page) accounting for time in tenths of an hour, and coded to identify six different kinds of work.[3] The entry described the kind of activity (e.g., "spoke w/", "met w/", "drafted letter", "reviewed letter", "deposition", "hearing", etc.), as well as the other person or group involved, and, usually, the subject matter (e.g., "on budget", "on crisis intervention program", "on deposition"). The amount claimed was $239,772.10.
The district court awarded $132,639.55, a reduction of forty-four percent. The court decided three issues in favor of the plaintiffs: (1) it rejected defendants' contention that, to recover post-judgment fees, plaintiffs must show that their efforts produced a better result than otherwise would have occurred, holding that "reasonable monitoring", under Garrity v. Sununu, 752 F.2d 727, 738 (1st Cir.1984) imposes a lesser burden; (2) it rejected defendants'

challenge to time spent on three motions to hold defendants in contempt, all settled before hearing, finding that 18 the efforts helped produce favorable results; and (3) it rejected defendants' claim that the fee *18 award should
be reduced to the extent that hours included in the fee application were also compensated by the Association of Service Providers for Persons with Handicaps ("Association"), accepting counsel's representation that all time claimed was for service benefiting the plaintiff class.
The court decided five issues in whole or in part against the plaintiffs: (1) it disallowed time spent in the unsuccessful defense on appeal of a legal services program ordered by the district court; (2) it disallowed time spent in a candidate search for the position of court Monitor; (3) it cut in half time claimed in connection with a Supplemental Agreement that never came to fruition; (4) it reduced, among other items, the claimed hourly rates from $125 and $115 for court activities to $95, from $115 and $105 for decree implementation to $85, and from $105 and $95 for general work to $75; and (5) it refused to grant plaintiffs' request for a fifteen percent upward adjustment of the lodestar, while also denying defendants' request for a downward adjustment.
Defendants appeal the court's refusal to adopt a rigorous "but for plaintiffs' efforts" standard for post-judgment monitoring fees and its refusal to reduce the award to reflect payments received from the Association. Plaintiffs cross appeal from the court's elimination of time spent in helping select a Monitor, from its reduction of time spent on the Supplemental Agreement, and from its reduction of hourly rates.
I. Post-Judgment Monitoring
Defendants' position is that in a post-judgment context where a defendant-funded court monitor is created by the decree, the only way to avoid creating a state-funded, open-ended "sinecure for counsel" is "to compensate counsel only where a substantial issue arises as to the defendants' obligations under the decree, and the work of plaintiffs' counsel yields a resolution more favorable to the class than the defendants were prepared to concede." They argue that such an extra burden is required to sift out progress or benefits flowing from the decree itself. They seek to distinguish Garrity v. Sununu, supra, on the ground that the instant case has in place a court Monitor, paid some $70,000 during the period at issue, whose presence presumably should have made unnecessary all time spent in routine monitoring. They argue alternatively that Garrity may need to be limited in light of Webb v. Board of Education of Dyer County, 471 U.S. 234, 105 S.Ct. 1923, 85 L.Ed.2d 233 (1985), which held that there should be no 42 U.S.C. § 1988 fee award for work in optional administrative proceedings unless it is "of a type ordinarily necessary" to advance the litigation. Id. 105 S.Ct. at 1929.
We appreciate the fact that devising workable ways, fair to performer and payor, to compensate legal services during the formative period (following issuance of a complex system-creating decree and before satisfactory implementation becomes largely routine) is a difficult and sensitive task. The services are of lower profile and often of a more routinized nature than services preceding judgments. Missing the refining fire of the basic litigation, plaintiffs' attorney may slip into a mode of spending too much time on too many matters, with the result that the decree institutionalizes the attorney, as well as the system.
Defendants' proferred standard, however, leaves us traumatized at the prospect of a multitude of trials 0907 not necessarily mini-trials 0907 on whether issue A, for which X hours are claimed, was really a "substantial" issue regarding a defendant's obligations, and, if so, did plaintiffs' work produce a more favorable resolution than defendants "were prepared to concede". Must the result be measurably more favorable? How may one prove what defendants were prepared to concede, but did not? Such a standard implies the availability of appellate review of each issue, an addition to our domain that we would welcome with something less than unbridled enthusiasm. Moreover, as Amicus points out, defendants' proposed standard would stimulate posturing and undercut the amicable cooperation that a consent decree is designed to foster; plaintiffs would opt for a combative, litigious route in preference to quiet negotiation. Whether we view the likely results in terms of delay, cost to the parties, inflated counsel fees, acrimony, or the additional burden on both the district court and the court of appeals, we see little to recommend the suggested innovation.
Perhaps the most salient approach is to see if the normal method of determining fees for monitoring has broken down. We cannot say that it has in this case, because, while it was begun, it was never completed. Plaintiffs 19 supplied their compendious fee *19 application, which, while often not facially self-explanatory, contained the

necessary keys to testing its reasonableness. Defendants generally knew the dates, subject matter, and people involved. They, at some expense to be sure, could have mounted challenges to specific claims 0907 if not on a comprehensive basis, at least on a random one. Had this happened, the district court would have had the benefit of the adversary process and could have developed a sense of the extent to which the claim for services was reasonable. We recognize that a specific challenge to every item in a 3500-item catalogue of time charges would be impracticable, but it is not too much to expect the Commonwealth, relying on its deep involvement in the litigation, to target significant and vulnerable areas for testing. We would have confidence that, given reasonable assistance by counsel, a court could arrive at a fair decision without a dismaying investment of time, particularly during the later, "tapering off" stages of implementing a decree.
This traditional approach not having been attempted, we are left with the general attack on the standard, together with the "Association issue", infra. Without specific indicia of unreliability, we are left with more general indicators, which do not support the Commonwealth. We note first the consistency of the district court's fee decision-making in this case with the approach taken in its earlier decision on the 1976-1981 applications. Second, we are mindful of the extensive forty-four percent reduction made in this case. Third, we do not think it excessive for attorney Schwartz to have spent about one-fourth of his time for two and one half years on this case (i.e., 1323 hours out of 5000), attorney Fleischner one eighth (i.e., 602 hours out of 5000), and paralegal Costanzo one eighth (i.e., 613 hours out of 5000). Fourth, we observe that the Commonwealth, when it perceives that matters have been sufficiently clarified and stabilized, may and indeed should petition the court to relieve it of the burden of paying for private party monitoring. Fifth, we note that plaintiffs will have waited from two to four years for their attorney's fees.
Finally, we are impressed by the fact that defendants have not been able to muster any authority for their proposition. Against the full array of authority for allowing fees for reasonable post-judgment monitoring,[4] the defendants can say only that these decisions are "a series of ad hoc assessments of factual circumstances quite unlike those presented here." As for their invocation of Webb v. Board of Education of Dyer County, 471 U.S. 234, 105 S.Ct. 1923, 85 L.Ed.2d 233 (1985), as Amicus points out, its requirement that services (in an optional administrative proceeding) be "useful" and "ordinarily necessary" is fully consonant with our insistence in Garrity that services be "necessary for reasonable monitoring of a consent decree". 752 F.2d at 738. And finally, defendants' effort to justify departure from the Garrity standard where a court-appointed monitor is in place seems to us to have been adequately answered by the district court in its first fee opinion.[5]
We therefore hold that the district court properly rejected defendants' plea to accept a different standard of proof for post-judgment monitoring.
II. The Association Issue
Plaintiffs' fee application was filed on August 16, 1984. Oral argument was had on October 19, 1984. Shortly thereafter, a routine audit revealed that the Association, a group of state funded contractors providing services to 20 plaintiffs under the consent *20 decree, had entered into a retainer agreement with a charitable corporation staffed by plaintiffs' counsel, the Center for Public Representation ("Center"). Under this agreement, the Center was obligated to provide fourteen hours of service a week to the Association, in return for which the Center received from each Association member one-third of one percent of its contract funding received from the Department of Mental Health. Between 1982 and 1984, the Association paid the Center $87,468.
Defendants moved to reopen the evidence and sought additional discovery on December 3, 1984 on the issues whether all of the time claimed was in reality for work done for plaintiffs and whether plaintiffs had already been compensated by the Association. Plaintiffs immediately moved to supplement their application and also opposed the motion to reopen, stating that the information as to compensation from the Association was irrelevant and that, in any event, they had now provided full information. Defendants countered with a proposal that the parties try to stipulate facts concerning the Center's representation of the Association, failing which they would seek discovery.

On December 13, 1984, the court allowed the defendants' motion to reopen for purposes of receiving written briefs 0907 within thirty days from defendants and sixty days from plaintiffs. It further stated that evidence on alleged conflicts of interest concerning payments of attorney's fees "shall be brought forward to the Court Monitor and he shall conduct hearings on same and make recommendations to the Court." On December 21, noting that the court had allowed the motion to reopen, defendants sought leave to file interrogatories requesting a list of all persons named in the fee application who were employees of a provider agency, and information concerning the make-up of the "Litigation Committee" mentioned in the retainer agreement, including whether it was the "Litigation Committee" referred to in various entries in the fee application. They also sought to telescope the time for responses so that they could incorporate them in their written brief. Plaintiffs opposed these requests, stating that the court had limited any reopening to written briefs. On January 4, 1985, the court denied leave to propound interrogatories, writing: "The Court did not intend that discovery should be reopened." We have traced this bit of procedural history in detail because it plays a large role in shaping our decision.
Defendants' position is that case authorities such as our Palmigiano v. Garrahy, 616 F.2d 598 (1st Cir.1980), holding that the presence of financial support for a public interest legal services organization is irrelevant to the calculation of a reasonable fee under 42 U.S.C. § 1988, do not apply to the instant case where the Association's retainer payments to the Center were for legal services rendered in the Association's behalf and where the Association's Litigation Committee has the power to determine the scope and type of work and legal positions to be taken by the Center. Defendants further point to specific portions of the record, which indicate to them that certain services were performed solely or dominantly for the Association (for example, meetings with the Litigation Committee and time recorded for conferring with employees of various providers). They also claim that their inability to probe further leaves an "irresolvable ambiguity" as to the object of counsels' work, which justifies a fee reduction of between fifteen and twenty-five percent (i.e., between $20,000 and $33,000).
Plaintiffs, on the other hand, claim that the principles of cases like Palmigiano govern, that the existence of additional sources of funding is irrelevant to the disposition of their fee application, that the overarching purpose of the Association, necessarily controlling its Litigation Committee, is the welfare of the plaintiff class, and that plaintiffs' attorneys have often taken positions contrary to the interests of individual providers and have always accorded the plaintiff class their "exclusive and unconditional loyalty". Most pertinently, they assert that their fee application includes no time spent for the Association on unrelated matters but only hours spent for the Association (50% of their total work for the Association) where the interests of the plaintiff class and the Association were identical.
The district court, noting that the key question was whether the time claimed in the fee application was expended for the benefit of the plaintiff class, proceeded to rely "on the demonstrated integrity of plaintiffs' counsel ... who 21 have shown themselves to be extremely conscientious and honest attorneys". The court stated *21 that "[w]hen they represent to the Court that 50% of their Association hours were also for the benefit of the plaintiff class, quite frankly, the Court believes them. Defendants' position that plaintiff's hours must be reduced for this reason is, therefore, rejected."
Such a credibility judgment and exercise of discretion would normally be unexceptionable, particularly in attorney's fee matters. But, as we earlier have signalled, the procedural history of this issue places the ruling in a different light. We have criticized defendants for not making discrete challenges to specific kinds of services performed or the time spent in performing them. But the issue of dual compensation and possibly divided loyalty did not arise until after the October 1984 hearing. Although plaintiffs' attorneys cannot be criticized for any concealment of the retainer arrangement, it clearly was not known by these defendants or their counsel.
The district court itself recognized the importance of the issue, but, when the issue arose, gave signals which were variously interpreted. Plaintiffs felt that only written briefs could address the issue; defendants felt that they were permitted to gather some facts. The court specifically allowed evidence on possible conflicts of interest to be submitted to the Court Monitor for his recommendations. Four months later, the Monitor did recommend, following the joint agreement of the parties, that the retainer arrangement be terminated. This of course avoids recurrence of any problem but did not dissipate any cloud hovering over the instant fee application.

We conclude that the district court should have allowed at least a limited discovery on this newly realized issue to test whether or not some of the time claimed was solely or principally in pursuit of Association purposes that were not coterminous with those of the plaintiff class. While our own impression of the time sheets is that plaintiffs' attorneys pursued a generally scrupulous approach to conscientious reporting, a cursory scrutiny reveals some twenty-five hours recorded as being spent in meetings with the Litigation Committee. Plaintiffs' attorney Schwartz, in an affidavit, stated: "As a practical matter, these communications [at meetings] were primarily for the purpose of my providing information to the Committee, and through them to the members, concerning the status of implementation of this Decree."
This indicates to us that the time spent in these meetings might well not have been spent for the principal benefit of the plaintiff class. Perhaps in the long run the class benefited, but, in view of the fact that defendants were precluded from any discovery or testing, the entries are sufficiently suspect to warrant exclusion. Rather than remand these already prolonged proceedings for reconsideration by the district court, we think it both fair and appropriate to deduct from the award a sum roughly equal to twice the amount of the entries that appear suspect to us 0907 $5,000.
III. The Cross-Appeal
Plaintiffs, regretfully, have engaged in three frivolous claims in their cross-appeal. Their fee application claimed hourly rates of $125 and $115 for court activities for their two attorneys and $115, $105, and $40 for decree implementation for their two attorneys and paralegal. The court, having allowed $80 an hour for court activities and $70 for decree implementation in 1982, increased the rates to $95 for court activities and $85 for implementation. Plaintiffs rely on their evidence of prevailing market rates in Springfield to urge that, as a matter of law, their evidence should carry the day. The legal work involved in this case was most intimately known by the district court; that the district court chose to increase fees by nineteen percent and no more was clearly within its discretion, especially in this advanced stage of implementation of the decree.
Plaintiffs' other two claims are that the court abused its discretion in excluding 64.7 hours of time spent (and consequently $12,629) in the search for a new court monitor and in excluding one-half of the 366 hours for what proved to be an unsuccessful attempt to negotiate a supplemental agreement. As to the former, the court acknowledged that the parties' attorneys were to consult and advise, but noted that the choosing was the court's responsibility. As to the latter, the court gently suggested that plaintiffs had "perhaps put in too much effort" on a supplemental agreement. Both judgment calls were clearly within the discretion of the court.
22 Accordingly, the judgment below is reduced from $132,639.55 to $127,639.55 *22 and, as reduced, is affirmed. The plaintiffs not having prevailed on part of the defendants' appeal and having lost on their cross-appeal, it is the judgment of the court that the parties bear their own costs and that no counsel fees be awarded for the appeals.
[*] Of the District of Rhode Island, sitting by designation.
[1] We have had two prior occasions to address this litigation: Brewster v. Dukakis, 675 F.2d 1 (1st Cir.1982); Brewster v. Dukakis, 687 F.2d 495 (1st Cir.1982).
[2] Brewster v. Dukakis, 544 F.Supp. 1069 (D.Mass.1982).
[3] The six kinds of work were as follows: court hearings, papers, and negotiations; work in connection with a Supplemental Agreement; decree implementation and monitoring 0907 meetings, communications, and drafting; general 0907 telephone calls, correspondence, and meetings not included in prior categories; work in connection with attorney fees; travel.
[4] See Garrity v. Sununu, 752 F.2d 727, 738 (1st Cir.1984); Burke v. Guiney, 700 F.2d 767, 771 (1st Cir.1983); Wuori v. Concannon, 551 F.Supp. 185, 190-191 (D.Me.1982) (court monitor in existence); New York Ass'n for Retarded Children v. Carey, 711 F.2d 1136, 1145 (2d Cir.1983); Delaware Valley Citizens' Council for Clean Air v. Commonwealth, 762 F.2d 272, 276 (3d Cir.1985); Willie M. v. Hunt, 732 F.2d 383, 387 (4th Cir.1984); Miller v.

Carson, 628 F.2d 346, 348 (5th Cir.1980); Northcross v. Board of Education, 611 F.2d 624, 637 (6th Cir.1979); Bond v. Stanton, 630 F.2d 1231, 1233 (7th Cir.1980); Rutherford v. Pitchess, 713 F.2d 1416, 1421 (9th Cir.1983); Williams v. City of Fairburn, 702 F.2d 973, 976-77 (11th Cir.1983).
[5] "Despite the use of the term `monitoring' the activities of plaintiffs' counsel have not duplicated those of the court-appointed Monitor. The Monitor evaluates services under the Decree, resolves minor disputes, attempts to mediate major disputes, makes suggestions for implementation and submits reports to the Court. He does not have direct responsibility for insuring implementation of the Decree or advocating on behalf of plaintiff class members." Brewster, supra, 544 F.Supp. at 1079 n. 6.
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 3 F.3d 488 (1993)
David BREWSTER, et al., Plaintiffs, Appellants, v.
Michael S. DUKAKIS, et al., Defendants, Appellees.
Nos. 92-2399, 93-1013.
United States Court of Appeals, First Circuit.
Heard June 8, 1993. Decided August 25, 1993.
489 *489 Stephen J. Schwartz, with whom Cathy Costanzo and Center for Public Representation were on brief, for plaintiffs, appellants.
Nonnie S. Burns and Hill & Barlow on brief for intervenor, Massachusetts Ass'n for Retarded Citizens.
Thomas A. Barnico, Asst. Atty. Gen., with whom Scott Harshbarger, Atty. Gen., Commonwealth of Massachusetts, and William L. Pardee, Asst. Atty. Gen., were on brief, for defendants, appellees.
Before TORRUELLA, SELYA and BOUDIN,[*] Circuit Judges.
SELYA, Circuit Judge.
These appeals mark the most recent chapter in institutional reform litigation that began almost two decades ago. [1] On this occasion, plaintiffs argue that the district court erred both in banning future fee awards and in calculating fees for services rendered by their counsel in connection with the latest round of litigation. We agree with certain of plaintiffs' contentions, disagree with others, and dispose of the appeals accordingly.
I
In December 1978, the district court entered a consent decree resolving a class action, started in 1976, that challenged the mental health regime maintained by the Commonwealth of Massachusetts at the Northampton State Hospital. The decree required the Commonwealth to develop a network of community residential facilities and nonresident support programs. On March 12, 1987, after approximately eight years of supervision, the district court entered a carrot-and-stick order in anticipation of bringing active judicial involvement to a close. The order set maintenance-of-effort provisions firmly in place, enunciated guiding principles, ranked priorities, and directed that certain further steps be taken. It also offered the Commonwealth a carrot, providing that, if all went well during the next three years, the district court would "end its jurisdiction" over the mental health system in Western Massachusetts. This meant, the court explained, that it would terminate the decree although continuing the maintenance-of-effort provisions in effect.
On October 25, 1990, the court issued a disengagement order that removed much of the case from judicial oversight but continued the court's control over a portion of the litigation until September 1, 1991. The 1990 order 490 reiterated the court's promise to terminate *490 supervision if sufficient progress transpired. On January 6, 1992, the court entered its final disengagement order. The court found that compliance had been achieved and, consequently, ordered:
... that the Consent Decree entered on December 7, 1978 is hereby vacated, the Court's active jurisdiction over the case and the mental health system in Western Massachusetts is hereby ended, and this action is hereby dismissed....
In the same document, however, the court also stipulated:

... that notwithstanding the foregoing order, the defendants are enjoined from violating Section III and Paragraph 43 of the Disengagement Order [continuing the maintenance-of-effort provisions] which shall remain in effect.
Then, avowedly "pursuant to" its January 6 order, the court entered what it styled a "judgment of dismissal." Neither side appealed.
In earlier proceedings, fees totalling approximately $675,000 had been awarded to plaintiffs' counsel for work done through October of 1990. After entry of the judgment of dismissal, the parties' attention returned to these verdant pastures. Plaintiffs filed a further fee application which, as later supplemented, sought close to $30,000 in fees for the period November 1, 1990, to June 1, 1992. The Commonwealth opposed the request in several particulars and also asked the court to rule out, or at least cabin, future legal fees.
On November 6, 1992, the district court granted the plaintiffs' fee application in part and denied it in part. Using reduced rates, the court awarded $12,766 for services rendered through January 6, 1992, but refused to allow fees for work performed after that date. The court also responded favorably to the Commonwealth's motion, stating that it would not award "any future attorneys' fees." Plaintiffs appealed.
II
Plaintiffs' first and most salient attack is upon the district court's issuance of a categorical ban prohibiting future fees. They argue that, although the January 6 order and separate judgment purport to disengage the court from oversight and dismiss the case, the order explicitly continues in effect an injunction embodying the maintenanceof-effort provisions. Because there is an ongoing injunction, plaintiffs say, the district court, consistent with 42 U.S.C. § 1988 (Supp.1991), cannot wholly preclude fee-shifting as it relates to future proceedings that may implicate the injunction.[2]
The Commonwealth adopts a posture of confession and avoidance. It does not argue that an absolute bar on future fees is legally supportable 0907 a stance we take as an implied concession of the plaintiffs' basic point 0907 but, rather, it suggests that the court below meant only to preclude compensation for self-initiated monitoring efforts that might be undertaken thereafter by plaintiffs' counsel. In support of this reading, the Commonwealth points to an earlier appeal wherein this court suggested that it might be appropriate at some stage to ask the district judge "to relieve [the Commonwealth] of the burden of paying for private party monitoring." Brewster v. Dukakis, 786 F.2d 16, 19 (1st Cir.1986). Thus, the Commonwealth asseverates, the November 6 order should be read not to prohibit all attorneys' fees, but simply to limit fees to future disputes, if any, in which the plaintiffs prove to be "prevailing part[ies]" within the meaning of section 1988.
It is true that the November 6 order is to some extent opaque and that the district court's intent in entering it is correspondingly tenebrous. It is also arguably true that the district court's judgment of dismissal, together with the court's references to complete disengagement, may be consistent with an unqualified end to the litigation. And if this case were complete, then the issue of future fees would be moot (although an order barring them would then 491 seem unnecessary). Yet the Commonwealth's interpretive legerdemain *491 overlooks a crucial fact: the January 6 order, quoted supra p. 3, states unequivocally that the maintenance-of-effort provisions continue "notwithstanding" the dismissal. Unless these provisions are purely hortatory 0907 and the Commonwealth itself does not make such a claim 0907 there is still a permanent injunction operating in this case.
We find that the injunction remains in effect. Our reasons are twofold. First, although the district court's dismissal in this case, taken alone, might betoken the end of the decree, the dismissal does not stand alone. By its terms, it was entered "pursuant to" an order of even date 0907 and the order itself is no less explicit that "notwithstanding" the proposed dismissal the defendants are "enjoined" from violating certain injunctive provisions which remain in force. A court's dispositive orders must be read as an integrated whole. Reading the instant record in that fashion, the various edicts clearly contemplate continuation of the injunction 0907 and so long as the injunction endures, the district court's enforcement authority can always be "reawakened." Consumer Advisory Bd. v. Glover, 989 F.2d

65, 67 (1st Cir.1993); see also In re Pearson, 990 F.2d 653, 657 (1st Cir.1993) (noting that when structural injunctions are left in place, they often require continuing judicial intervention).
The second reason why we interpret the January 6 order along these lines is prophylactic: when, as in this case, there are two possible interpretations of a decree, one of which would undermine the decree's validity and the other of which would be entirely unremarkable, the latter is plainly to be preferred. Were we to conclude that the Commonwealth's reading of the record was correct, a serious question would arise as to whether the judgment complied with the requirement that "a rather precise statement" be furnished before a district court can terminate an institutional reform decree. Board of Educ. v. Dowell, 498 U.S. 237, 246, 111 S.Ct. 630, 636, 112 L.Ed.2d 715 (1991). As we recently observed, courts entering such decrees often "pass through levels of disengagement as the decree moves toward achievement." Glover, 989 F.2d at 67. Termination of a decree has significant consequences for the parties, and Dowell requires that so important an event be plainly marked.
For these reasons, we construe the judgment of dismissal as closing the case administratively but leaving the injunction in effect. And, once this finding is juxtaposed with the text of the November 6 order 0907 which, as framed, can certainly be read to interpose a wholesale ban on future fees (indeed, that is the most natural reading of it) 0907 it follows inexorably that the latter order must be modified. Notwithstanding that 42 U.S.C. § 1988(b) provides that the district court "may" award reasonable fees to a prevailing party "in its discretion," the Supreme Court has ruled that attorneys' fees must be awarded thereunder to a successful plaintiff "unless special circumstances would render such an award unjust." Blanchard v. Bergeron, 489 U.S. 87, 89 n. 1, 109 S.Ct. 939, 942 n. 1, 103 L.Ed.2d 67 (1989); see also de Jesus v. Banco Popular, 918 F.2d 232, 234 (1st Cir.1990) (discussing operation of section 1988). Given this preeminent authority, an anticipatory negation of all future fees, in all circumstances, cannot easily be defended in an ongoing institutional reform case.
The matter before us adequately illustrates the point. Here, one can easily envision circumstances 0907 say, an egregious violation of the maintenance-of-effort provisions requiring litigation to set matters right 0907 in which 492 section 1988 could demand a further award of fees.[3]Cf. Pearson, 990 F.2d at 657 *492 (holding that when a structural injunction in an institutional reform case "has continuing effects, the issuing court retains authority to enforce it"). We could construct other examples, but no useful purpose would be served. Because it is perfectly plain that a total ban on future fees cannot be countenanced here, the district court's order needs adjustment.
Lest the baby be discarded with the bath water, we also uphold the district court's ban on future fees insofar as the ban represents a determination that it is no longer reasonable to remunerate counsel for routine monitoring of the decree (including the continuing injunction). Plaintiffs themselves do not object to this limitation on future compensable services and, given the lack of objection, we see no need to discuss the matter extensively. After all, when the court ruled that further monitoring would be superfluous, the litigation had been winding down for five years, the Commonwealth was in compliance, the decree had been truncated, and the case was being relegated to inactive status.
Without wishing unduly to prolong the discussion, we add one further observation: by tradition and almost by necessity, district judges have great discretion in deciding what claimed legal services should be compensated, see, e.g., Phetosomphone v. Allison Reed Group, Inc., 984 F.2d 4, 6 (1st Cir.1993); Lipsett v. Blanco, 975 F.2d 934, 939-40 (1st Cir.1992); Foley v. City of Lowell, 948 F.2d 10, 18-19 (1st Cir.1991), and there are times when an advance ruling by the trial court provides helpful guidance. So here, in regard to the gratuitous nature of future monitoring.
III
Another disagreement between the parties concerns the hourly rates that plaintiffs' counsel should earn for work done from November 1990 to June 1992. Each of plaintiffs' two attorneys submitted affidavits reciting their qualifications and attesting to fees charged and paid at $195 per hour (lead counsel) and $125 per hour (associate counsel), respectively. The district court did not succumb to these importunings, instead awarding lead counsel, Stephen Schwartz, $120/hr. for core legal work, and associate counsel, Cathy Costanzo, $80/hr. for such work. For non-core work, the court awarded lead counsel $80/hr. and associate counsel exactly half that

rate.[4] Plaintiffs assign error to the lower court's refusal to accept what plaintiffs term their lawyers' "established billing rates."
The standards governing hourly rates applicable to shifted legal fees are hardly models of precision. The Supreme Court has endorsed the use of market rates as a starting point, see Blum v. Stenson, 465 U.S. 886, 895, 104 S.Ct. 1541, 1547, 79 L.Ed.2d 891 (1984), but it also has approved consideration of adjusting factors. See Pennsylvania v. Delaware Valley Citizens' Council for Clean Air, 478 U.S. 546, 563-65, 106 S.Ct. 3088, 3097-98, 92 L.Ed.2d 439 (1986); Hensley v. Eckerhart, 461 U.S. 424, 434 n. 9, 103 S.Ct. 1933, 1940 n. 9, 76 L.Ed.2d 40 (1983). This court has followed the same course, see, e.g., Lipsett, 975 F.2d at 940-41; United States v. Metropolitan Dist. Comm'n, 847 F.2d 12, 19 (1st Cir.1988), and we have underscored the ample discretion of the district judge 0907 the judicial officer who is most familiar with the case, the attorneys, and the interactive nuances 0907 in constructing fee awards. See, e.g., Foley, 948 F.2d at 19.
We think the current dispute can best be addressed by putting it into historical perspective. In 1982, the district court allowed fees of $80/hr. for lead counsel's court activities and $70/hr. for his decree-implementation work. In 1985, these rates were increased to $95 and $85, respectively. In that time frame, we approved the rates as within the district court's discretion. See Brewster, 786 F.2d at 21. In 1991, the district court raised Mr. Schwartz's rates to $120/hr. for core work and $80/hr. for non-core work. At the same time, the court set associate counsel's 493 rates at $80/hr. for core work and $40/ hr. for non-core work. On each occasion, the *493 court rejected plaintiffs' requests for more munificent rates.
The several affidavits submitted to support plaintiffs' latest fee application aimed to fill gaps in proof and to show that counsel actually command the higher rates they seek here from other clients. In its fee order, issued on November 6, 1992, the district court reaffirmed the rates it had established in 1991, without discussing the latest set of affidavits. As a general rule, a fee-awarding court that makes a substantial reduction in either documented time or authenticated rates should offer reasonably explicit findings, for the court, in such circumstances, "has a burden to spell out the whys and wherefores." Metropolitan Dist. Comm'n, 847 F.2d at 18. But, there are occasions on which fee-setting judges "should be permitted to draw conclusions and make adjustments without full articulation." Jacobs v. Mancuso, 825 F.2d 559, 564 (1st Cir.1987).
This is such an occasion. The trial court made the necessary bottom-line findings. Although subsidiary findings would have been desirable, mitigating circumstances abound: the judge (who has done a stellar job over almost two full decades) knew the case inside out; the rates used by the trial court are the very figures adopted in 1991, the year in which much of this work was done; those rates were not appealed when first used; and the newly claimed hours are relatively few in number. Finally, this is the caboose of a litigation train that has chugged along for almost two decades. Given the singular nature of the situation and the age of the case, we are reluctant to press the district court for supplementary explanation. Believing, as we do, that the additional expense to be incurred in seeking perfection would be a poor investment, we decline to disturb the district court's reaffirmation of the rates it set in 1991.
IV
The last point of contention involves the district court's refusal to consider awarding fees for services rendered after January 6, 1992. The court took this position solely because it believed that no compensation should be paid for work performed after the date of its last disengagement order. In light of our holding that a categorical ban on future fees cannot stand, see supra Part II, the blanket disallowance of fees referable to services rendered subsequent to the bar date must likewise fall.
We must now decide what to do with the disallowed hours. Bearing in mind that the district court never addressed individual entries in the time records submitted for this period, we would ordinarily remand so that the court might reevaluate the situation. But, the circumstances here are out of the ordinary: the contentiousness surrounding the lawyers' compensation threatens to overshadow the main case 0907 a somewhat Kafkaesque development since the case furnishes the sole raison d'etre for the compensation. The Supreme Court has repeatedly cautioned that a fight over fees, within the broader framework of a litigated case, ought not take on a life of its own. See, e.g.,

Hensley, 461 U.S. at 436, 103 S.Ct. at 1941 ("A request for attorney's fees should not result in a second major litigation."). Put bluntly, fee disputes, unlike Jack's beanstalk or Pinocchio's nose, cannot be permitted to grow and grow and grow.
In kindred circumstances, we have refused to let the tail wag the dog. We have recognized, for example, that when a trial court has improvidently disallowed certain time, an appellate court, so long as the record is reasonably complete, may appropriately take the bull by the horns, forgo a remand, and recalculate the fee award without further ado. See, e.g., Pearson v. Fair, 980 F.2d 37, 45 (1st Cir.1992); see also Foster v. Mydas Assocs., Inc., 943 F.2d 139, 144 n. 8 (1st Cir.1991) (listing representative cases); cf. Navarro-Ayala v. Nunez, 968 F.2d 1421, 1428 (1st Cir.1992) (applying the same principle to a required recalculation of monetary sanctions). Because this case fits the model, we turn directly to the necessary computation.
The block of time in question aggregates 51.9 hours (31.6 hours attributable to Mr. Schwartz and the remainder 494 attributable *494 to Ms. Costanzo).[5]
Lead counsel's time entries deal exclusively with fee-related work. We have repeatedly held that time reasonably expended in connection with fee applications is itself compensable, see, e.g., Lund v. Affleck, 587 F.2d 75, 77 (1st Cir.1978), but, since time spent in this exercise often amounts to little more than "documenting what a lawyer did and why he or she did it," Gabriele v. Southworth, 712 F.2d 1505, 1507 (1st Cir.1983), it may fairly be compensated at a reduced rate. See id.; accord Jacobs, 825 F.2d at 563; Miles v. Sampson, 675 F.2d 5, 9 (1st Cir.1982). Thus, we accept lead counsel's fee-related time in toto, but direct that it be valued at the rate applicable to his non-core work. This portion of the incremental fee is, therefore, $2528, viz., 31.6 hrs. × $80/hr. = $2528.
We treat associate counsel's incremental time in two segments. We award plaintiffs the miscoded time, see supra note 5, in its entirety.[6] Using the dollar figure computed by plaintiffs under the district court's approved rates, see Appellants' Brief at 31 n. 19, and mindful that the Commonwealth has not criticized the computation, we value this time at $1150. We add to this figure $80, representing the remaining two hours of Ms. Costanzo's time. In doing so, we note that these hours were spent in fee-related endeavors and should, therefore, be remunerated at her non-core rate.
As a final check, we have paused to consider whether the fee award, as adjusted, appears reasonable in the circumstances and is in overall proportion to what remained at stake in the winding-down of the litigation. See Jacobs, 825 F.2d at 563 (suggesting such an overview). We conclude that the requirement of reasonableness is fully satisfied. The revised award is fair to plaintiffs and their counsel, although slightly less generous than they had thought due; it is, at the same time, fair to the Commonwealth, although slightly more extravagant than it had hoped. While we anticipate that all the parties will be displeased, the fact that a fee award leaves both payer and payee somewhat sullen is often a sign of fairness all around.
V
We need go no further. The order appealed from is affirmed in part and vacated in part. The case is remanded for the entry of a revised fee award for the period ended June 1, 1992, increasing the amount of attorneys' fees from $12,766 to $16,524. The court below shall also enter a new judgment eliminating the absolute bar on future fee requests (assuming such an absolute bar was intended), making explicit the bar on future fees for self-initiated monitoring, and clarifying that the limited injunction remains in effect until further order. Should plaintiffs believe they are entitled to fees or costs on appeal, they may file an application pursuant to 1st Cir.Loc.R. 39.2.
It is so ordered.
[*] Judge Boudin has recused himself in this matter. Therefore, the case is decided by the two remaining panelists. See 28 U.S.C. § 46(d)(1988).

[1] Prior phases of the litigation are chronicled in sundry opinions of this court. See, e.g., Brewster v. Dukakis, 786 F.2d 16 (1st Cir.1986); Brewster v. Dukakis, 687 F.2d 495 (1st Cir.1982); Brewster v. Dukakis, 675 F.2d 1 (1st Cir.1982). We refer persons who hunger for additional detail to those opinions.
[2] The statute pertinently provides that in any action to enforce specified civil rights laws, "the court, in its discretion, may allow the prevailing party, other than the United States, a reasonable attorney's fee as part of the costs." 42 U.S.C. § 1988(b).
[3] The Commonwealth agrees that, in theory, there could be future litigation in this case for which compensation might properly be sought, but urges that fees should be granted only if plaintiffs prove to be the prevailing parties in such future litigation. Plaintiffs, by contrast, claim that once a suitor is found to have prevailed on a significant aspect of a civil rights case and obtains some relief, the district court is not obliged to subdivide counsel's bill into successful and unsuccessful elements. In plaintiffs' view, even unsuccessful aspects can be compensated, although reasonableness remains a constraint and the degree of success is often relevant to the fee. We think it unwise to attempt to resolve this conundrum in the abstract; after all, the district court did not address the standard for future fee awards and the problem may never arise. Hence, we express no opinion on these competing contentions.
[4] In the district court's parlance, core work includes legal research, writing of legal documents, court appearances, negotiations with opposing counsel, monitoring, and implementation of court orders. Non-core work consists of less demanding tasks, including letter writing and telephone conversations. We upheld a similar taxonomy in Brewster, 786 F.2d at 21.
[5] The situation is complicated by a careless mistake contained in the plaintiffs' fee application. In that submission, plaintiffs identified a block of Ms. Costanzo's time, totalling 18.3 hours, as having been spent in 1992. So labelled, the time was disallowed. Plaintiffs now allege for the first time that these hours were misrecorded and actually represent time spent in 1991. Upon close perscrutation, the entries' text appears to bear out the allegation.
[6] In the circumstances at bar, we choose not to penalize plaintiffs for their labelling error. We do not mean to suggest, however, that a fee-setting court lacks discretion to discount fees because of sloppiness in the feeseeker's presentation. Cf., e.g., Grendel's Den v. Larkin, 749 F.2d 945, 956 (1st Cir.1984) (finding "no reason to apply the Fees Act in such a way as to give delinquent applicants a second chance to recover").
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 675 F.2d 1 (1982)
David BREWSTER, et al., Plaintiffs, Appellees, v.
Michael S. DUKAKIS, et al., Defendants, Appellants.
Nos. 81-1688, 81-1915.
United States Court of Appeals, First Circuit.
Submitted March 18, 1982. Decided March 24, 1982.
2 *2 Bruce E. Mohl, Asst. Atty. Gen., Boston, Mass., with whom Francis X. Bellotti, Atty. Gen., Thomas A. Barnico and Carl Valvo, Asst. Attys. Gen., Boston, Mass., were on brief, for defendants, appellants.
Steven J. Schwartz, Northampton, Mass., with whom Robert D. Fleischner, Springfield, Mass., Nonnie S. Burnes and Hill & Barlow, Boston, Mass., were on brief, for plaintiffs, appellees.
John D. Leubsdorf, Boston, Mass., Boston University School of Law, with whom Verne W. Vance, Jr., Scott C. Moriearty, Terry S. Kogan and Foley, Hoag & Eliot, Boston, Mass., were on brief, for Developmental Disabilities Law Center, et al., amici curiae.
Patricia E. Hennessey, New York City, on brief for Children's Defense Fund, et al., amici curiae.
Before COFFIN, Chief Judge, and CAMPBELL and BOWNES, Circuit Judges.
COFFIN, Chief Judge.
Defendants-appellants, various members of the executive branch of the Commonwealth of Massachusetts, appeal an order of the United States District Court for the District of Massachusetts enforcing a consent decree to which they are signatories. Although we avoid a detailed description of the circumstances giving rise to the order, the provisions of the order, and their modification by a second order, a brief review is necessary to set the stage for our discussion of this appeal.
The consent decree was the result of the negotiated settlement of a suit filed as a class action in the district court by nine residents of the Northampton State Hospital who claimed that the Commonwealth's programs to treat mentally disabled persons at the hospital violated their constitutional and statutory rights to less restrictive treatment through nonhospitalization programs. In the consent decree the Commonwealth 0907 represented by the Governor, the Attorney General and his assistants, the Secretary of Administration and Finance, the Secretary of Human Services and the Commissioner of the Department of Mental Health 0907 agreed to undertake specific programs that would provide a comprehensive system of community mental health and retardation services by offering less restrictive residential facilities and nonresidential treatment and support programs. Although many of the programmatic provisions are stated as absolute promises to provide the specified services, the consent decree also states that "defendants will use their best efforts to insure the full and timely financing of this Decree".
In July, 1981, two and one-half years into the life of the consent decree, the Massachusetts legislature appropriated approximately five million dollars less than appellants' budget request of 53 million dollars for the consent decree program. The Governor subsequently filed a supplemental budget request to try to obtain the money needed to comply fully with the decree. In early August plaintiffs-appellees, awaiting action on the supplemental request, filed a motion for a temporary restraining order and preliminary injunction to prevent appellants from curtailing the consent decree programs in light of the reduced appropriation, a process appellants had already initiated. Appellees claimed that any reductions in program violated the consent decree. On September 15, 1981, the district court issued an order directing appellants in effect to proceed with

implementation of the consent decree programs as though there were no shortfall in funding and to submit to the Court Monitor for the consent decree a report of all efforts taken to obtain full funding from the legislature.
3 Questioning whether the district court could order funding of programs contrary *3 to legislative desire, this court stayed the order pending appeal. On December 23 the district court modified its order and issued a new memorandum to make clear that it was not ordering the legislature to appropriate money but instead was requiring appellants to make their best efforts to obtain full funding. Because it found that appellants had not made their best efforts to date, it ordered them to continue to conduct programs at full funding levels until best efforts either produced results or were proven unsuccessful, in which event appellants were ordered to return to the court with a request for modification of their obligations under the terms of the consent decree. Pending our review of the September 15 and December 23 orders, this court on January 12 stayed the portion of the order requiring continued spending at full funding levels, and modified that section of the order which directed appellants to make their best efforts by increasing the specificity of appellants' obligation to make best efforts and to report to the court on those efforts.
We fully appreciate the delicate nature of this situation. By committing the Commonwealth to fulfilling certain responsibilities, appellants induced appellees to drop their suit. The district court, having approved the agreement, must ensure its continued execution, but is faced with the political reality that the legislature has refused to fund the consent decree to the extent requested by appellants.[1] Although the district court has recognized that the legislature is not subject to its injunctive power, it has sought to protect appellees' rights under the decree by prohibiting appellants from cutting consent decree programs until they have proven that their best efforts to obtain full funding are unavailing.
Proceeding to a review of the district court's orders, we first note that paragraph 6 of the consent decree provides that the district court retains jurisdiction "to enable any party to apply at any time for such further orders as may be necessary or appropriate for the interpretation, implementation, enforcement, or modification of the terms of this Decree". Appellees in this instance were not seeking modification of the decree, which would have resulted in a permanent, facial change in the decree. See, e.g., System Federation No. 91 v. Wright, 364 U.S. 642, 647, 81 S.Ct. 368, 371, 5 L.Ed.2d 349 (1961). See generally Delaware Valley Citizens' Council for Clean Air v. Pennsylvania, No. 81-2308 (3d Cir. Mar. 1, 1982). Nor were they applying for enforcement through contempt proceedings as is customary when a party believes that the provisions of a consent decree have been violated. See, e.g., Commodity Futures Trading Comm'n v. Premex, Inc., 655 F.2d 779, 782 (7th Cir. 1981); Interdynamics, Inc. v. Firma Wolf, 653 F.2d 93, 97 (3d Cir. 1981); New York State Ass'n for Retarded Children v. Carey, 631 F.2d 162, 163 (2d Cir. 1980).
Rather, appellees took an intermediate course by seeking clarification of duty and enforcement in an undifferentiated request for injunctive relief. Because an action for enforcement (i.e., contempt) would entail procedures and standards of proof not applied in this instance, we cannot view the resulting court order as an enforcement order. Instead, we deem the order to have been issued under the court's power to interpret the decree, a power clearly reserved to the court by the terms of the decree. On the periphery of the court's power to interpret is also a limited power to issue injunctive relief which may be used to protect rights and enforce duties once they have been clarified. Cf. Delaware Valley Citizens' Council for Clean Air v. Pennsylvania, supra, at 8 (after finding violation of consent decree, court issues injunction requiring specific implementing action not 4 contained in decree). Although we find *4 that the court partially abused its power in this instance, we recognize that the use of this limited injunctive power is appropriate when, as here, unusual and possibly unforeseen circumstances have required interpretation of the decree, some relief or enforcement may be in order, and yet the clarity of obligation necessary for enforcement through contempt has not yet been established.[2]
In the present situation, the district court was correct insofar as it interpreted the consent decree to require appellants to make good faith efforts to secure funding before making cuts in services. The terms of the consent decree clearly state that appellants' obligation is only to exert their best efforts to fully fund the consent decree programs by submitting budget requests, allocating funds appropriately among programs, and by efficiently managing the financial procedures involved in implementing the programs.[3] Although the programmatic provisions of the consent decree are often phrased as mandatory obligations of the state, we must interpret the provision requiring best efforts to fund these obligations as an overriding provision that modifies the apparently

mandatory nature of these obligations. The best efforts provision follows all of the substantive, programmatic provisions, and must be read as a modification of each because it relates to a common denominator essential to the implementation of each of those provisions 0907 funding.[4] Consequently, the court was not abusing its discretion when it interpreted the consent decree to require best efforts and ordered appellants to make best efforts to achieve full funding.
The court also found that appellants had not made best efforts as of the time of its ruling and imposed additional responsibilities on appellants as a result in order to implement the decree. We cannot say the district court lacked a sufficient basis to find that appellants had not made best efforts to obtain full funding as of December 23. There is enough evidence on the record to show that appellants might have persevered more than they did to obtain full funding. Nor did the court abuse its discretion by ordering appellants to undertake certain specific efforts to obtain funding and to report on their efforts to the Court Monitor. While attempting to implement the consent decree in the context of the peculiar circumstances that had evolved, the court was justified in reviewing appellants' efforts to date, and, finding them lacking, in imposing additional, consistent burdens on appellants to ensure implementation of the decree. Consequently, paragraphs 10 and 11 of the December 23 order, as modified by this court's order of January 12, stand in effect.
The district court imposed other obligations on appellants, however, that we feel exceeded the scope of the 5 court's power to interpret and implement the decree. Paragraphs 1 through 9 of the December 23 *5 order
generally require appellants not only not to cut down any FY '82 programs (¶ 1); but to develop, submit to bidding, contract, and fund all community programs originally planned for FY '82 (¶¶ 3, 6); promptly fill all authorized personnel positions and convert certain state positions into contract staff (¶¶ 4, 7); notify all providers of these requirements (¶ 2); do all this without reducing other programs (¶¶ 5, 8); and prepare all plans and documents necessary to accomplish the foregoing (¶ 9). Although the court can order appellants to do what they are required to do under the terms of the consent decree 0907 to make best efforts 0907 the court cannot require appellants to go beyond what their good faith professional best efforts can reasonably be expected to accomplish.[5] We therefore vacate paragraphs 1 through 9.
We also vacate paragraph 12 of the December 23 order which requires appellants to submit a motion for relief from the order in the event that their best efforts do not produce the funding necessary to fully implement the consent decree. Because the order, as modified by this ruling, no longer imposes a mandatory duty on appellants to continue conducting programs at full funding levels, it is no longer necessary to provide a mechanism for relief from that duty.
The implementation of the consent decree in this particular situation requires the parties continually to reassess their respective rights and obligations under the decree as the circumstances, such as the availability of funding, evolve. The court has the power both to interpret the consent decree in light of the changing circumstances and to enforce it through contempt proceedings. Given the fluidity of this situation, we stress that clarity of obligations must be a prerequisite to enforcement through contempt proceedings. In the future the separate objectives of interpretation and enforcement should be clearly kept in mind in framing pleadings and structuring court proceedings.
Paragraphs 1 through 9 and paragraph 12 of the district court's order of December 23 are vacated, and paragraphs 10 and 11, as modified by this court's order of January 12, are affirmed.
So ordered.
[1] The funding problem continues as of the writing of this opinion. The legislature has approved a three million dollar supplemental appropriation, but that amount is insufficient to meet the needs of the consent decree programs at issue here because it must be allocated among several other areas where the state has obligations under court orders. We are not aware that previously appropriated funds have been reallocated to allow full funding of the Brewster consent decree programs.
[2] We are wary of the fact that this protective injunctive power is, in ultimate effect, not too different from the court's power to enforce the consent decree, and that parties might seek enforcement through injunction, which

requires only a showing of a likelihood of success, rather than enforcement through contempt, which requires more rigorous proof of a breach. Accordingly, the proper use of injunctive relief must be restricted to a power exercised as an incident of the court's power to interpret the decree in the face of unusual circumstances.
[3] The provision of the consent decree states in part that:
"The defendants will use their best efforts to insure the full and timely financing of this Decree, including: submission of appropriate budget requests to the Massachusetts General Court; allocation of sufficient funds to insure that all existing and new programs meet the minimum standards therein; full allocation of funds appropriated for services during the fiscal year; allotments of appropriated funds as needed...."
[4] This interpretation is buttressed by paragraphs 9 and 11 of the consent decree that state that if appellants have any budgetary or programmatic reason to modify the community residential alternatives, nonresidential programs, and administrative management services, appellees are to have the opportunity to object to those modifications in advance. By inclusion of these terms, both parties would seem to have recognized that budgetary considerations may at times force deviation from the programs as outlined in the consent decree.
[5] We do not intend to foreclose the possibility that some extraordinary circumstances 0907 such as where time is of the essence, the party seeking relief has shown a substantial likelihood of success, and the opposing party has acted in bad faith 0907 might justify imposition of interim obligations significantly beyond the terms of the consent decree in order to preserve the rights of a party pending final interpretation of the decree or enforcement through contempt. Such extraordinary circumstances do not exist in this instance.
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