The current Local Business Plans reflect good first steps toward a comprehensive reform effort. For reform to be successful, however, these plans will need to be refined and improved over time through a partnership between the state, LMEs, and community stakeholders. Policy and operations will need to change at both the state and local level. Key elements that need additional attention:

• In the absence of financial data, clear financial objectives and lack of programmatic direction from the State, the Local Business Plans are difficult to evaluate and are in themselves not appropriately termed "business plans". Fully articulated business plans should be requested soon after LMEs are given the financial data and other direction with which to complete them.

• The structure of the Local Business Plan itself should be reviewed and refined. There is a need to reduce redundancy, particularly in the areas of Quality Management/Quality Improvement, and non-target populations and the development of community supports. Clarity of the information requested also needs to be refined. Throughout this review we identify a number of areas in the Local Business Plans that need improvement. Often what is needed is more clarity in expectations.

• To provide clarity, the Division of MH/DD/SAS will need to provide leadership to better define its expectations, particularly in areas that have cross program and statewide implications. Specifically, the Division needs to clearly articulate expectations for quality indicators, provider profile dimensions and provider technical assistance, outcome measures (system and individual), best practices, development of community supports, and client rights. We strongly believe that the development of these expectations needs to come from the state, not 20-30 different programs.

• The establishment of a statewide appeals and grievance process for all clients and the support and integration of client rights activities into quality management processes is essential. The state should immediately address this issue.

• At the present time there is no consensus around the critical areas of Qualified Provider Network Development and Quality Management and far too much variability around how these are defined and how they should be operationalized. The Division needs to facilitate the development of this consensus and should consider involving not only LME staff, but national consultants to develop state of the art protocols in these areas.

• At the state and local levels there must be an investment in meaningful technical assistance in all areas. We are concerned that the massive changes created by reform efforts are being undertaken without the resources and expertise to make the change positive and successful.

• The Local Business Plans themselves should be become a vehicle for system quality improvement. The written Local Business Plans should be updated and refined based on Division feedback and further clarification and development as noted above.