Office of Mental Health and Substance Abuse Services Children

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Office of Mental Health and Substance Abuse
ServicesChildrens Advisory Committee
Residential treatment facility research and
data overview

• October 17, 2008

Andy Keller, Boulder Peter Selby, Seattle
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Current residential capacity in Pennsylvania

• 3,038 in-state accredited residential treatment
  facility (RTF) beds as of September 1, 2008
  (versus 3,223 in October of 2007)
• 1,309 non-accredited RTF beds
• Non-Medicaid beds
• Youth development centers 4 facilities, 696 beds
• Secure care 9 facilities, 267 beds
• Secure residential 4 facilities, 98 beds
• Juvenile detention centers (JDCs) 22 facilities
  with 870 beds
• What does it mean that 1,700 youth per year from
  other states use Pennsylvania RTF facilities?

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What kind of transformation is needed?

• Goals related to RTF for transforming the
  behavioral health system for youth
• Reduce reliance on RTFs
• This will require enhancement of community
  capacity
• This will require a reduction in RTF capacity
• Intensify and improve the quality of the
  treatment in RTFs.
• This will require improved quality standards for
  RTF care across the board standards that are
  enforced
• This will require development of specialized RTF
  capacity for key groups trauma, young women,
  youth with aggressive behavior, co-occurring
  substance use and mental health needs
• Bring youth back to their communities from out of
  state, as well as from distant out of community
  placements
• Make family involvement a fundamental component
  of RTF services

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Can the strategy be statewide, regional or
county-level?

• It must be county-level because local systems of
  care vary widely in their needs, available
  services, and strategies
• It must be regional because smaller counties will
  need to share some specialized capacity
• It must be statewide because the funding and
  standards to drive the transformation require
  that scope
• Bottom line It must be an integrated strategy
  encompassing all three levels

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Example one Residential treatment facility
service use patterns vary at the county level

• 2005 2006 patterns of RTF service by Child in
  Substitute Care (CISC) / non-CISC are stable at
  multi-county level
• But there are major differences at the
  county-level

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Example two Diagnoses of residential treatment
facility users also vary by county

• Same pattern of CISC/non-CISC diagnoses is seen
  at each level of analysis
• But there are major differences in proportion at
  county-level

Primary diagnosis CISC versus non-CISC
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Statewide
HealthChoices
Expansion
Allegheny
Philadelphia
Conduct disorder (CISC)
Conduct disorder (Non-CISC)
Mood disorder (CISC)
Mood disorder (Non-CISC)
ADHD (CISC)
ADHD (Non-CISC)
Adjustment disorder (CISC)
Adjustment disorder (Non-CISC)
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Will require new rate structure

• Evolution of rate structure over time
• Historically, there had been cost-based methods
  to develop rates
• With the statewide implementation of managed
  care, there has been less focus on cost-based
  reimbursement with rates more subject to
  negotiation
• Current rates are low, creating pressure to limit
  quality of care and sell capacity to other states
  at higher prices
• There is now a need to develop cost-based
  methodologies for targeted new RTF modalities and
  partner with providers and behavioral health
  managed care organizations (BHMCOs) to implement
  them

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Infrastructure for new rate structure

• New RTF regulations include a review of the
  fee-for-service (FFS) rate setting
• New FFS rate structure can serve as a benchmark
  for BHMCO rate setting
• BHMCOs have historically used FFS rates as a
  reference point for their rates
• The new structure should include
• A base rate for all accredited RTF care
• Differential rates to be paid in addition to the
  base rate for each of the areas of specialization
  prioritized by OMHSAS
• Development of a process to engage RTF providers
  in transformation efforts, including inclusion of
  performance incentives

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Essential to define the need for residential
treatment facility capacity at the county and
regional levels

• Important to carry out needs assessment to
  determine appropriate capacity for basic and
  specialized RTF services
• Will require a collaborative process involving
  the Department of Public Welfare (DPW), Office of
  Children, Youth and Families (OCYF), OMHSAS,
  counties, BHMCOs, families, and key stakeholders
  in each county
• Determine each countys need for RTF capacity in
  each area of specialization identified by the
  service array subgroup
• Transformation will require reductions in current
  RTF capacity and more RTF specialization
• Without reductions, beds will continue to be
  filled even if community options are expanded
• Increased costs to deliver enhanced RTF care and
  expanded community services will require offsets

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Need to set standards to enhanced continuum of RTF

• Standards would be developed for the following
  areas of specialization
• Specialized residential programming
• Gender-responsive services
• Secure RTF
• Other specialized programs, including treatment
  for co-occurring mental health (MH)/developmental
  disability, autism spectrum, co-occurring
  MH/substance abuse
• Placement options that vary by intensity and
  focus
• Extended sub-acute stabilization and evaluation
• Family-based RTF (30 60 days, fewer beds)
• Longer-term intensive and restrictive RTF
• Small group homes in community (non-RTF)

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Examples of success from other states

• In many ways, Pennsylvania must be a leader on
  this initiative
• No other state that we know of has the amount of
  existing RTF capacity that OMHSAS has
• No other large state has fully implemented a
  similar statewide strategy
• That being said, we can learn from the
  experiences of other states and RTF providers

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Examples of success from other states

• Oregon cut its RTF use in half through policy
  changes and changes to the RTF referral process
• Without any new funding, the State, in
  partnership with stakeholders, significantly
  enhanced capacity to track resources and outcomes
• Oregon also targeted improved services at the
  local level, using evidence-based practices
• State administrative rules were rewritten to make
  sure all clinical procedural codes needed were in
  place and care coordinators were accessible in
  each community
• The State used policymaking and purchasing to
  leverage changes focused on increasing family
  voice across all levels
• Success was seen in changes in the role of family
  members, the location of services and type of
  services provided

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Examples of success from other states

• New York is in the early stages of a transition
  driven by their Office of Child and Family
  Services that will
• Establish criteria to access services that
  include standardized assessment tools (Child and
  Adolescent Needs Strengths), integrated use of
  evidence-based practice, and requirements to
  expand community-based services
• Commit 620,000 per year to the operation of a
  statewide evidence-based dissemination center
  that has already trained over 400 clinicians in
  trauma-focused cognitive behavioral therapy

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Examples of success from other states

• Individual RTF providers have successfully
  transitioned from large institutional models to
  family-based group home, therapeutic foster care,
  mobile crisis and stabilization services and
  wraparound-based community approaches
• Two programs in California
• Hathaway-Sycamores Child and Family Services
• EMQ Children and Family Services
• The Drenk Center in New Jersey

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