Joan B. Beasley, Ph.D.
START, an acronym for Systemic, Therapeutic, Assessment, Respite and Treatment, has been providing clinical, emergency and respite services since 1989 (Beasley et al., 1992). The Massachusetts Department of Mental Retardation funds the START program in order to provide community based crisis intervention and prevention services to individuals with developmental disabilities and behavioral (mental) health care needs. The underlying philosophy of START is that services will be most effective when everyone involved in care and treatment is allowed to participate actively in treatment planning and service decisions. In order for this to occur, collaboration between service providers and with service users is needed.
The initial START program was funded as a four-bed respite center with a small crisis and consultation team. At that time there were no linkages to outpatient mental health services, inpatient mental health services, day treatment, day services, other respite resources or generic community emergency mental health services. Community education and access to services along with the development of affiliations and linkages with existing services was our primary mission in filling the gaps in the service delivery system. As a result, the development of service linkages and improved systems of communication between service providers was the focus of START. The services are provided region-wide, and over 1200 individuals have used Sovner Center and START services since they began in 1989.
In order to access appropriate mental health services and to facilitate a coordinated service approach and foster service linkages, START provides a number of opportunities for consultation, education, and individualized treatment planning. The services include collaborative contacts, after hour contacts, emergency team meetings, planned respite and emergency respite services.
Collaborative contacts: Collaborative contacts are made up of crisis prevention planning meetings, consultation visits, treatment planning meetings, and follow-up meetings. START clinicians are required to facilitate an individual crisis prevention planning meeting at least once a year. Whenever possible, the START clinician, the service user, members of the mental health service team (i.e., the outpatient therapist, a representative from the mental health crisis team, the psychiatrist), members of the developmental disabilities service team (i.e., the service coordinator, residential and day program providers), and the individual's informal or social supports (family members, friends, and other interested parties) meet to develop a plan to assist the individual and his or her caregivers during times of difficulty. START clinicians are also required to maintain on-going contact with family members and other caregivers. Follow-up meetings are scheduled to evaluate the effects of treatment strategies, update crisis prevention plans, and to foster active communication amongst providers and with direct caregivers.
After hour's contacts: START provides 24-hour mobile crisis services to assist in times of crisis. START clinicians rotate on-call responsibilities and are available to provide assistance to families, DMR, psychiatric pre-screening teams, and residential providers 24 hours a day, 7 days a week
Emergency meetings: Emergency meetings are team meetings facilitated by START clinicians on a psychiatric inpatient unit or at the emergency respite facility following an admission. The purpose of the meeting is to allow the START clinician and other members of the team to provide information to the inpatient unit in order to assist with treatment and disposition planning. Family members and residential providers are strongly encouraged to participate in the meeting. In addition, the START clinician attempts to facilitate phone contact between the individual's outpatient and inpatient psychiatrists, and encourages on-going contact between the family and residential provider throughout the admission. Whenever possible, a discharge-planning meeting is also scheduled to ensure a smooth transition back home.
START Respite: START respite is a place where people can live for short periods of time when they are in distress or in need of support and assistance. The START respite facility is staffed with a full-time Director, a weekend coordinator, direct care specialists, and awake overnight staff. One to one staffing is provided as needed. All "guests" at the respite center have private bedrooms, and one bedroom has a private bath. The center is divided into two wings so those individuals who have more severe difficulties do not disturb or become disturbed by other guests. Additional facility based emergency respite is provided by independent affiliates of START. They work closely with START personnel.
Two of the beds in the four-bed respite home are designated as "planned respite beds". Planned respite beds at START are intended to serve individuals who have not been able to use respite in more traditional settings due to their on-going mental health and/or behavioral issues. Families participating in the program must be approved by DMR as eligible for these services, but once approved, they schedule visits as needed (when available).
Planned respite visits are provided to any START service recipient and are not restricted to people living with their family. An individual can visit respite for dinner, a recreational activity, or to just "check in" for a few hours.
Emergency respite services are provided at the START respite facility. Two beds in the four-bed respite facility operated by START are designated for emergency respite purposes. All START service recipients can access emergency respite as needed pending the approval of DMR. Emergency respite is designed to provide out of home housing and services to individuals who for a short period of time (suggested thirty days or less) cannot be managed at home or their residential program. Additional emergency respite services are purchased on an as needed basis from START affiliates.
Psychiatric inpatient services: Community mental health hospitals and general community hospitals provide psychiatric inpatient mental health services. Inpatient psychiatric services are expected to be very short term (7 days or less). Inpatient psychiatric services are primarily provided by three hospitals in the region that have affiliation agreements to coordinate services with START and DMR representatives. In order to access needed services, START relies upon the use of affiliation agreements and linkages with the developmental disabilities service system, the mental health service system and the individual's natural support system.
Difficulties Associated with the Service Linkage Approach to Coordinated Care
As the START system evolved over time, the service linkage approach was weak in providing services to some individuals and it became clear that additional service development was needed. This was not an unusual finding. Three difficulties associated with the use of a coordinated service approach that primarily employs service linkage described below are resource difficulties, communication limitations and organizational barriers.
Resource difficulties: A service linkage approach assumes that most services are present and in suitable supply. Considering the multiple service needs of people with developmental disabilities and behavioral health care needs however, problems with the availability and distribution of trained professionals were found to be just as serious as fragmentation of the service system.
Communication limitations: A service linkage approach to coordinated service delivery requires a sophisticated tracking system to stay on top of an individual's multiple service needs. Resource availability needs to be monitored to assist in the referral and placement process. On-going data collection is also needed to ensure the accountability of members of the service system. Due to the multiple services and systems involved in some cases, this can be a complex and cumbersome process. While many individuals referred to START were successfully treated with the limited resources made available by the START team, some individuals with more complex clinical presentations were not able to benefit from generic outpatient and inpatient mental health services. Generic service providers were unable to meet the on-going communication needs for some individuals. This resulted in ineffective services and frustration for service providers and service recipients. Some individuals placed too many communication demands on a generic system unaccustomed to meeting such demands. As a result, in some cases education and consultation were not enough to maintain constructive linkages.
Organizational barriers: Bridging the gaps in a service delivery system, which is made up of different organizational structures, reporting requirements, funding sources and priorities is a complex undertaking in practice. Total cooperation between service systems is at best an uncertainty. Differing interests may create organizational conflicts that interfere with cross system coordination and collaboration. The interests of the individual service user may be overshadowed by conflicting goals in a service system where an essential element is not designed to meet the needs of individuals with developmental disabilities in spite of linkages.
In some cases, service linkages alone did not meet the needs of all individuals with developmental disabilities and behavioral health care needs. As a result, both START and the community mental health system developed some specialized services.
The Development of Specialized Services
Over the years the START model and service philosophy evolved from an emphasis on access to services through a service linkage approach to the provision of some "specialized" services. While many individuals could successfully access generic services with support, training and education, other individuals with more severe and persistent needs required a level of experience and expertise only available through the development of specialized services. Named after the founding Medical Director the late Dr. Robert Sovner, the Robert D. Sovner Behavioral Resource Center expanded in 1997 to provide a comprehensive array of outpatient mental health services in addition to those provided in the original START model. The primary difference is that in addition to accessing generic community mental health services, service users can also access specialized outpatient and inpatient mental health services designed specifically for people dual diagnosed with developmental disabilities and mental illness.
In addition to the outpatient clinic services provided at the Sovner Center, there are currently four community psychiatric inpatient providers in Massachusetts designed to provide services specifically to individuals with developmental disabilities. Although these services receive some state funds, all of the new services are primarily paid through individual insurance and do not reflect an expanded financial commitment on the part of the DMR alone. Therefore, the use of these services largely depends on the needs and resources of the individual service user with some support by the State.
Beasley, J. B., Kroll, J., & Sovner, R. (1992). Community-based crisis mental health services for persons with developmental disabilities: The START Model. The Habilitative Mental Health Care Newsletter, 11, 55-57.
For more information regarding Cross Systems Service Linkage Models please contact: Joan B. Beasley, Ph.D. 184 Bonad Road, Chestnut Hill, MA 02467; (617) 469-7391; JBBeasley@rcn.com