It wasn’t long ago that the only options available for intensive treatment of children and youth with severe emotional and behavioral problems were inpatient hospitals or residential care. Before the creation and expansion of community-based mental health services, some children spent many months or years of their lives in a hospital or a “home for children,” separated from their families, schools, and communities.
The availability of community-based services for those with social, emotional, and behavioral problems was not present until President Kennedy signed into law the Community Mental Health Act in 1963. This led to the creation of Community Mental Health Centers and made it possible for children as well as adults to receive treatment in the community rather than in a hospital. As these services took hold over the years, there was a collective realization that, not only are these community-based services more affordable, they also provide good clinical outcomes and quality of life for youth and their families. But there just weren’t quite enough of these services to meet all the needs, so institutions continued to fill the gap.
Over the years, the NYS Office of Mental Health has worked toward filling that gap with an array of community-based services for children and adults. For children, we have a range of services including outpatient clinics, family support, day treatment, and community residences. We were also one of the first states to offer Home and Community Based Services (HCBS) through a Medicaid Waiver. The HCBS Waiver provides children and youth at risk of institutionalization with care coordination and support services designed specifically to keep them at home, in the community. Over the past ten years, we have seized various opportunities to invest new money, and reinvest money from the closure of hospital beds, to grow the HCBS Waiver program, providing even more opportunity for youth to get the supports they need without going to a hospital or into residential services. In addition, our HCBS services form the foundation on which we are building a redesigned children’s behavioral health system in preparation for the transition to Medicaid managed care.
In the 1980’s, Residential Treatment Facilities (RTF) were added to the service array as an option for offering residential services to children and youth with severe mental health problems. In some instances, RTF can be an alternative to hospitalization, but more often it is used as a step-down for children and youth recently discharged from inpatient psychiatric treatment.
The NYS Office of Mental Health defines Residential Treatment Facility as an inpatient psychiatric facility that provides comprehensive mental health treatment for children and adolescents between the ages of 5-21. RTFs are certified by OMH to provide comprehensive mental and primary health care services including but not limited to: case coordination services, verbal therapies, medication therapy, therapeutic recreation services, task and skill building vocational training, creative arts therapy, and on-campus school program. The objective of the program is to help a child improve his or her daily functioning, develop coping skills, support the family, and to develop or strengthen community linkages and supports.
While for many years, the RTFs have provided very good care and have helped many children and families, the current research indicates highly effective outcomes can be associated with real access to community supports, meaningful integration into the community, and family involvement in treatment. The current RTF model, including programmatic, regulatory, and reimbursement aspects, can and should be modified to facilitate providers’ continued success in meeting the needs of children and families.
Despite the evidence that keeping children in the community whenever possible is desirable, the reality is that, today, children and youth and their families don’t always get the help they need in order to stay in the home and be safe. There is a tremendous need for crisis intervention, skill building, and respite that the current system can at best only partially meet. And, while we know that there will always be some children and youth who have a need for residential services at some point in time, what should that service look like? Where should the beds be? In what format? Under what reimbursement structure?
We are able to ask these questions, and have dialogue about the answers, because of a unique set of circumstances at this moment in time in New York State. The convergence of Medicaid Redesign and the Affordable Care Act is providing us with a golden opportunity to make significant reforms to the children’s behavioral health service delivery system. Over the past four years, there have been a number of Medicaid Redesign Teams working to make New York State’s Medicaid service delivery system more effective for those who rely upon it for their healthcare. There is a Children’s Medicaid Redesign Team which is currently working to create and implement a Medicaid Managed Care Behavioral Health benefit package for children and their families. The Children’s Medicaid Redesign is ambitious and comprehensive, and consists of three parts: care coordination via Health Homes, an expansion of Medicaid State Plan Services, and an expanded availability and alignment of existing and new Home and Community Based Services.
We believe the successful implementation of this expanded service array will make a redesigned and more effective RTF more possible. A new vision of residential treatment is one in which children and youth have ready access to short-term, effective treatment and stabilization services in a residential setting when this level of care is necessary. Inherent in this vision is the availability of the above-referenced continuum of home and community-based services and intensive care coordination which work both to prevent and limit the need for residential services in the first place, and to effectively receive the child back into the community after a brief residential stay.
The Delivery System Reform Incentive Payment Program (DSRIP) is the primary mechanism by which NYS is operationalizing Medicaid Redesign. The primary goal is to reduce unnecessary hospitalization. New York State was required to submit to the federal government a multi-year plan for payment reform in order to ensure the long-term sustainability of DSRIP investments; so the State created a Value Based Payment (VBP) Roadmap. VBP can create some interesting opportunities for innovative service delivery, and we are currently working together with providers and the Department of Health toward understanding how VBP options may further the evolution of residential treatment for children and youth in New York State. This creates the potential for RTF to be redesigned and to be thought of more as simply another good option in a continuous array of services.
OMH envisions this redesigned RTF as a program which could help fill critical gaps in the children’s mental health service system, divert children and youth in crisis from emergency departments and hospitals, and provide a transitional step-down program following psychiatric hospitalization. No matter what shape these RTFs ultimately take, critical to their success is the meaningful involvement of families, the engagement of youth, individualized service planning, and culturally and linguistically competent care.
The new model would include crisis and skill building services led by experienced staff able to assist families in their ability to build on their own strengths and to avoid crisis situations in the future. Family and youth peers with lived experience will be essential to provide needed support services to individuals and families in a non-threatening, culturally competent manner.
As a step-down program, residential providers would work with hospitals and the youth’s treatment team to offer support in transitioning back to the community from the inpatient program. As a respite program, providers could offer support to individuals and families by offering a short break from the current living situation, so as to improve everyone’s ability to cope with various stressors. Coordination and collaboration with current behavioral healthcare providers must be included in all the above program elements.
One expected outcome of this initiative is to demonstrate that by addressing crisis and hospital diversion needs, and by offering step-down services to the children and youth with the highest needs, quality of care will improve, costly admissions and readmissions will be reduced, and immediate Medicaid savings will be achieved. Another goal is to achieve improved and more sustainable outcomes for children, youth, and families. In order to demonstrate these expected outcomes, data collection and reporting will be a must.
Recently, RTF providers have formally joined with State leaders to formulate plans on how to redesign the model. Next steps will include obtaining feedback from youth and families and other stakeholders, such as counties. In order to realize this vision, the State, counties, providers, advocates, youth and families need to work in concert to overcome systemic and structural barriers which have historically made change and the evolution of residential services challenging. Reimbursement methodologies, regulations, and even statute will need to be changed in order to achieve something real.
We must build relationships and improve communication and coordination between residential providers and community-based services providers, including family and youth peer specialists. Those connections, in conjunction with Medicaid Redesign, will help us to achieve clinical results we have only dreamed of to date.