Review of the Utilization of Congregate Care

Transcription

1 Review of the Utilization of Congregate Care Completed By Connecticut Department of Children and Families With consultation and assistance from the Technical Advisory Committee February, 2010

2 Table of Contents Section I - Introduction and Scope of Report 4 Page Section II - Data on Youth in Congregate Care Settings 4 Residential Treatment Centers (RTCs) State Operated Facilities o Connecticut Children's Place o High Meadows Safe Homes/Permanency Diagnostic Centers Short Term Assessment and Respite (STAR) Homes Group Homes o Therapeutic Group Homes (TGHs) o Preparing Adolescents for Self-Sufficiency (PASS) Group Homes o Maternity Group Homes o Supportive Work, Education, and Transition Program (SWETP) Section III - Utilization of Congregate Care 29 Section IV - Relevant Literature 38 Section V - Learning from Focus Groups and Peers 63 Section VI - Relevant Background and Current Procedures for Determining 70 Level of Care and Treatment Needs Section VII - Vignettes of Three Youth Referred to the CT BHP for 74 Congregate Care Section VIII - Congregate Care Discharge Planning Procedures 76 Section IX - Authorization Process for Continued Stays 77 Section X - Procedures for Pursuing Out-of-State Residential Treatment 78 2

3 Section XI - Strategies in Place to Improve the Approach to Congregate Care 79 Implementation of the CT BHP and a corresponding emphasis on utilization management The expansion of a community based service system Enhancing the competencies of providers in community based settings The implementation of Structured Decision Making Increased efforts to improve access to appropriate levels of service Clinical reviews and conferences Recent initiatives to preserve and support families Efforts in foster care Prevention and early intervention efforts Section XII - Summary of What We Have Learned 98 Section XIII - Reasonable next steps for systematic improvement 100 Section XIV- Implementation Process 103 Section XV- Appendix 106 3

4 Introduction and Scope of Report A Department of Children and Families (DCF) workgroup, with generous participation and assistance from the Technical Advisory Committee (TAC), collaboratively reviewed and assessed the models and utilization of congregate care in Connecticut. The purpose of this assessment was to evaluate DCF's current use of residential treatment and other forms of congregate care, and to evaluate the agency's ability to provide treatment in the least restrictive and most family-like setting that appropriately meets children's clinical and permanency needs. Members of the DCF workgroup included representatives from the Bureaus of Child Welfare, Continuous Quality Improvement, and Behavioral Health and Medicine. We began our review with an extensive and intensive review of the literature. Then, with consultation from the TAC, the DCF workgroup conferenced with four states (Tennessee, Colorado, New York, and Maine) to explore different approaches to the use congregate care. The workgroup also conducted three different focus groups with DCF involved youth, with Department of Mental Health and Addiction Services clients who had prior experience with the DCF system, and with family members of children who had been served in congregate care. The results are presented in this paper. Data on Youth in Congregate Care Settings Residential Treatment Centers (RTCs): Under the terms of Juan F. v Rell, Outcome Measure 19 specifies that no more than 11% of Class members in out-of-home care be placed in residential settings. As a result of multiple initiatives and activities, the Department has continued to meet this Juan F. Exit Outcome Measure. In the fourth quarter of 2004, the percentage of children in care who were in residential treatment was 13.9%. In contrast, in the fourth quarter of 2008, 10.1% of children in care were being served in residential treatment centers. In the first quarter of 2009, RTC admissions were 12% lower than in the first quarter of As depicted in Chart 1 below, Between January of 2000 and December of 2008, the number of children in a DCF placement declined from 7002 to This reflects a 26% reduction in the use of out of home care overall. When projected forward this trend indicates a further 12% reduction in the expected demand and utilization of out of home care including residential treatment. In short, the very population most likely to require residential treatment resources has been declining and is expected to continue to decline over the next several years. 4

5 Chart 1. Number of Juan F. children* in DCF Care on First Day of Each Month January 2000-Dcember Number of Juan F. Children* in DCF Care On First Day of Each Month January December 2008 DCF Office for Research and Evaluation Data as of February 24, % From 1/00 to 12/ Jan, 00 Jul, 00 Jan, 01 Jul, 01 Jan, 02 Jul, 02 Jan, 03 Jul, 03 Jan, 04 *Includes all Juan F. children in open DCF placements on the first day of each month; Excludes Committed On June 9, 2009, there were 329 DCF children served in state RTCs and 350 served in out-of-state RTCs. The number of out-of state admissions in the first quarter of 2009 increased 17% over the same time in the first quarter of By way of historical context, in December, 1994, there were 779 children served at in-state residential treatment centers and 186 served in out of state residential treatment centers. As of May 1, 2009, there were 530 Juan F. children placed in residential facilities 1. This is a decrease of four children in comparison to the 534 reported in the Juan F. v Rell Exit Plan Quarterly Report for the fourth quarter of Also as of May 1, 2009, the number of Juan F. children receiving treatment in out-of-state residential facilities increased by six to 289 in comparison with the 283 reported in the fourth quarter of Jul, 04 * Includes all Juan F. children in open DCF placements on the first day of each month; Excludes Committed Delinquent, Age >18, Voluntary, Probate and Interstate Delinquent, Age >18, Voluntary, Compac. Probate and Interstate Compact Page _ of Jan, 05 Jul, 05 Jan, 06 Jul, 06 Jan, 07 Jul, 07 Jan, 08 Jul, 08 1 Juan F. v. Rell Exit plan Quarterly Report (January 1, 2009-March 31, 2009). Civil Action No: 2:89 CV 859 (CFD). Retrieved August 17, 2009 online from 5

6 The out-of-state admissions increase in the first quarter of 2009 was influenced by at least two factors. First, the increase was impacted by the closing of 60 beds of a private residential facility and a loss of beds at two other private residential treatment centers. As a result of less bed availability referrals to out-of-state providers increased. Second, as more youth are served in home based community programs and diverted from RTCs, youth needing an RTC level of care present with more severe behavioral challenges and psychiatric diagnoses. In some cases specific youth may require a type of specialized treatment (e.g., for autism) that is not available in-state. In such instances DCF is committed to providing the most appropriate treatment in the setting which best meets the needs of the child and family. Treatment of a child in an RTC is reserved for children/adolescents whose psychiatric and behavioral status warrants the structure and supervision afforded by a selfcontained setting that can offer all services including education. Residential treatment is intended to be used as a treatment intervention, not as a placement alternative. Through the combined impact of rigorous "gatekeeping," improved bed management, and increased availability of community based alternatives, DCF utilization and demand for RTC beds has been declining since The capacity and array of community based alternatives to residential care has also expanded in the same timeframe. Chart 2 demonstrates RTC placement from SFY 2003 through SFY In 2003, 700 youth were in in-state RTCs and 387 were served out of state. This decline in RTC utilization for children served by DCF is evident in Chart 2 below. Chart 2. DCF RTC Utilization RTC Out-Of-State RTC In-State RTC-Total Years A more detailed table of utilization and the time in residential treatment centers for youth in the Juan F. class is outlined below in Table 1. 6

7 Table 1. Residential Placement Placement Feb May 2008 Aug Oct Nov Feb May 2009 Total number of children in Residential Treatment Centers (RTCs) Number of youth in RTCs, >12 mos. in RTC placement Number in RTCs, > 60 mos. in RTC placement During the same period capacity for community based intensive services, particularly intensive home-based services increased. The increase in in-home services between 2006 and 2008 is listed in Chart 3 below. Two complementary sets of data support that access to and utilization of community based services has expanded over the last several years. Data collected by the Connecticut Department of Social Services showing claims for Home-Based services (see Chart 3) demonstrates a steady increase in utilization of home-based services between January of 2006 and March of Data indicate (see Chart 4) that between January of 2007 and the 2 nd quarter of Calendar Year 2009 there have been significant increases in utilization for the class of home based services. These data further supports the growth in community based behavioral health services and the availability of these services as alternatives to residential care. 7

8 Chart 3. Number of Children Using Home Based Services 1/1/06-3/31/08 1,500 1,400 1,300 1,200 1,100 1, Q1'CY06 Q2'CY06 Q3'CY06 Q4'CY06 Q1'CY07 Q2'CY07 Q3'CY07 Q4'CY07 Q1'CY Quarter Chart 4. Home-Based Service Utilization Days/1000 # of Days/ DCF Non-DCF 0 Q1 '07 Q2 '07 Q3 '07 Q4 '07 Q1 '08 Q2 '08 Q3 '08 Q4 '08 Q1 '09 Q2 '09 8

9 Similar trends in utilization have been observed in the network of outpatient psychiatric clinics for children. Chart 5 below shows a nearly 9% increase in admissions to outpatient care between Calendar years 2007 and 2008 (titled outpatient number of admissions for children 0-18). Data on utilization in the first six months of 2009 suggest a projected 23% increase in outpatient admissions between 2008 and Chart 5. Outpatient (OTP/TST) Number of Admissions for Children (0-18 years) # of Admits Q1 '07 Q2 '07 Q3 '07 Q4 '07CY '07Q1 '08Q2 '08Q3 '08Q4 '08CY '08 Q1 '09 Q2 '09 YTD '09 Demographic data on residential treatment centers collected from LINK reports is presented in Table 2 below. Table 2. Residential Treatment Centers Demographic Data* Year Race/Ethnicity** Gender Age C= 338 B/AA= 177 H= 140 M=44 C= 396 B/AA= 253 H= 175 M= 32 C= 422 B/AA= 251 H= 200 M= 390 F= 243 M=479 F= 285 M= 523 F= 285 Number of youth 6-11 years = 19 Number of youth years = 595 Number of youth 6-11 years =35 Number of youth years = 718 Number of youth 6-11 years = 42 Number of youth years = 742 9

10 M= C= 452 B/AA= 297 H= 187 M= 42 M= 576 F= 311 Number of youth 6-11 years = 52 Number of youth years = 808 *This is point in time data from LINK reports. The data reflect demographic information recorded at the end of the month of July in 2009, 2008, 2007, and 2006) **C=Caucasian; B/AA=Black/African American; H=Hispanic; M=Multi-racial In late 2008, a finer analysis of RTC utilization and capacity was completed. The purpose of the analysis was to improve out of home service delivery and to help determine the optimal number of out of home programs to match the needs of Connecticut youth. As of 7/1/09, the current in-state utilization capacity for Residential Treatment Centers was 363 beds. Of note, this is a dramatic decrease since 2004 when there were 935 residential treatment center beds in Connecticut. The current capacity represents a 15% decrease in bed capacity from December, 2008, and a 40% decrease in beds since December, The overall distribution of in-state private provider RTC beds is detailed in Table 3 below. It is important to note that the number of beds actually utilized by DCF differs from the number of beds licensed by DCF since some providers have a licensed bed capacity in excess of that which is utilized by DCF. The additional capacity may be used by the provider to serve youth from other states and/or serve youth who are referred from school districts or DDS, or who are not eligible for services from the public sector. Table 3. In-State Provider Residential Treatment Center Beds Clinical population served Bed Capacity used by DCF youth Psychiatric 201 Developmental Disabilities/Mental Retardation 26 Conduct Disorder/Juvenile Justice 89 Substance Abuse 47 Firesetting/Sexually Reactive 0 Maximum Capacity

11 A review of current RTC utilization indicates that the majority of residential treatment is provided to youth between the ages of years of age. The average length of stay at RTCs decreased 12% in the first quarter of 2009 when compared to the third and fourth quarter of 2008 combined data. Data from the analysis indicated that there is a declining need for RTC beds serving the following: Adolescents with moderate psychiatric and behavioral disturbance; Youth with mild to moderate conduct disorder and juvenile justice involvement; Children under the age of 12; and, Adolescents with primary substance abuse disorders and co-occurring psychiatric disturbance, primarily males; There has been, and likely will continue to be, an upward trend in the number of inhome service cases in Connecticut's Child Welfare System (children and youth that are served in the community and are not in out-of-home care including residential placement). As shown on Chart 6 below, the average daily caseload of in-home cases (or those served in the community without the need for out of home placement) has risen from 2,917 in January of 2003 to 4,090 in December of 08 representing a 40% increase in inhome cases. This is evidence of some of the practice changes within the department and other measures that have resulted in fewer children entering out of home care (including residential treatment). The consistency of this trend over a five year period and the continued goal of reducing out of home care suggest that the trend will continue, further reducing demand for residential treatment and other forms of out of home care. 11

12 Chart 6. Number of Juan F. Children* in DCF Care On First Day of Each Month & Average Daily Caseload for CPS In-Home Cases January December 2008 Data as of February 24, ,993 6,340 5, , % Children In Placement 5,200 Children In Open DCF Placement* From 1/03 to 12/ Cases - CPS In-Home +40.2% ,905 4,090 Average Cases Open: CPS In-Home Services** , ,917 3, Jan, 03 Jul, 03 Jan, 04 Jul, 04 Jan, 05 Jul, 05 Jan, 06 Jul, 06 Jan, 07 Jul, 07 Jan, 08 Jul, 08 Dec, 08 * Includes all Juan F. children in open DCF placements on the first day of each month; Excludes Committed Delinquent, Age >18, Voluntary, Probate and Interstate Compact **This is the average number of Cases with open CPS In-Home assignments within each month Chart 7 below shows the Juan F. Exit Plan Report percentage of children in DCF care in residential placement by quarter from 2004 through the 1 st quarter of The chart shows a 33% decline in the percentage rate of DCF cases in residential care. DCF has met and/or been below the 11% goal/threshold since the 2 nd quarter of 2006 reaching its lowest value since the statistic has been recorded of 10% during the 1 st quarter of Calendar year

13 Chart 7. Percentage of DCF Cases in RTC Percentage in RTC Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q Period Recent data compiled by the CTBHP for the period of Q3 of 2007 through Q2 of 2009 and depicted in Chart 8 below, indicates a decline in the number of admissions to residential care during the period from 203 to 154. In addition the number of admissions in Q2 of 09 represents a 24% decline from the same period of the previous year. This finding indicates that not only is there a decline in the percentage of DCF children in residential care, but there has also been a decline in the number of admissions to residential treatment. Chart 8. RTC Admits vs Discharges - 24 months Q3 '07 Q4 '07 Q1 '08 Q2 '08 Q3 '08 Q4 '08 Q1 '09 Q2 '09 Total Discharges Total Admits 13

14 As indicated in Table 4 below, the average cost per child served in residential treatment has increased considerably. Indeed, in the five year period depicted below the average cost per child served in residential care has increased by almost 46%. This increase in average cost per child has been increased as a result of a focused effort to improve and enhance the treatment capacity of the program. Table 4. Year Total Dollars Children Average Cost Served Per Child Served 2003 $73,232, , $89,401, , $87,986, , $80,769, , $80,514, , $78,575, ,219 Currently, the Department has no discrete plans to change the approach to this level of care. However, the Department has begun to track post-discharge outcomes for youth treated at residential treatment centers and these data will be used to inform future discussions with respect to level of care. Specific steps to improve the quality of service delivery are included in this report's action steps. Recent Trends in Out-of-State Residential Placement As of January 1, 2009, 342 children and youth with a nexus to DCF were being treated in out of state residential treatment facilities. As of May 1, 2009, there were 289 Juan F. identified children served in out of state residential treatment centers. By way of context, this number represents a significant decrease from the number of youth placed out of state in 2001 when 479 youth were being served out of state and from March, 2004, when 510 children were being served out of state. However, the number also represents an increase from the number of children and youth being treated out of state in October 2006 when only 282 individuals fell in this category. Of the 342 children and youth who were receiving residential treatment outside of Connecticut in January, 2009, 277 had only a Child Protective Service status, 57 had only a Juvenile Services status, and 8 had a dual commitment status. This is important because, especially for those youth with a Juvenile Services status, the courts may have required an out of state placement for purposes of public safety or for other reasons entirely at the Judge's discretion. Approximately 75% of children being served out of state are being served in 14

15 neighboring New England states (i.e., 179 in Massachusetts, 34 in Vermont, and 23 in Rhode Island). In Calendar year 2008, 159 children were admitted to out of state placements. Of those 159 youth, 91 were female and 68 were male. The admissions were in the specialty cohorts listed in Table 5 below: Table 5. Cohort Type Number of children* Mental Retardation/Pervasive Developmental Disorder 32 Substance Abuse 4 Problem Sexual Behavior 49 Psychiatric 61 Juvenile Justice 3 Other 10 *This excludes the number of children placed through parole services or CSSD As discussed earlier in this report, multiple factors may necessitate the need for out of state placement. State Operated Facilities: In addition to licensing in-state residential treatment center beds operated by private providers, DCF manages and operates two residential treatment centers: Connecticut Children's Place (CCP) and High Meadows. CCP and High Meadows serve unique and specialized roles in the overall DCF continuum of care. They are a primary step-down discharge option from the state hospital for children who cannot immediately and safely return home and who are not accepted by private residential treatment centers by virtue of either their acuity or instability. They also serve other children and youth who cannot be served by private residential treatment centers either because of their acuity, risk, or their specialized clinical and/or medical needs. Third, they serve the judicial system by providing the only residential treatment centers to which children may be court-ordered, and finally, they serve the DCF system as a whole by providing a safe, intensively staffed emergency placement setting for youth with complex clinical needs who present in crisis and who are in need of immediate placement. Connecticut Children's Place (CCP): CCP is a 48 bed residential diagnostic center for male and female youth ages 10 through 18, who are in need of protection due to abuse, neglect, abandonment, unmanageable behavior or sudden disruption in their current placement or residence. An emergency component responds to those in need of immediate removal from their current setting and for whom there is no interim placement resources. Diagnostic and evaluation services are available for children and youth requiring a therapeutic plan for future placement. CCP also provides treatment until a more permanent setting can be provided for the child. In Calendar year 2007, 120 children were served at CCP with an 15

16 average length of stay of 232 days. In 2008, there were 109 children served at CCP. The average length of stay at CCP was 122 days. Table 6 depicts the average daily and monthly vacancy rate at CCP. However, it is important to note that 9 beds were reserved for utilization by Parole Services and of these 9 beds, 2 were intentionally held vacant to the maximum feasible extent for purposes of emergency placement of youth taken into custody. Once one inserts into the calculation those beds to which a youth is matched (even if he or she is not yet currently in the bed) the available capacity is essentially zero. Table 6. Connecticut Children's Place Average Daily Vacancy Report Month Average Daily Vacancy Girls Boys Parole Vacancies July August September October November December January February March April May June July August September October November December Average Daily Vacancy Per Calendar Year (2008) = 2.83 The Department has plans to connect the Connecticut Children's Place with the Connecticut Behavioral Health Partnership for emphasis on improving utilization management. Demographic information from CCP is presented in Table 7 below. 16

17 Table 7. Connecticut Children's Place Demographic Data* Year Race/Ethnicity** Gender Age C= B/AA= 14 H=10 M= 5 C= B/AA= 14 H= 7 M= 0 C= B/AA= 16 H=6 M= C= 20 B/AA= 14 H=15 M=0 M=15 F=24 M=16 F= 21 M= 17 F= 20 M= 18 F= 22 Number of youth 6-11 years = 1 Number of youth years = 38 Number of youth 6-11 years = 0 Number of youth years = 37 Number of youth 6-11 years = 0 Number of youth years = 37 Number of youth 6-11 years = 1 Number of youth years = 38 *This is point in time data from LINK reports. The data reflect demographic information recorded at the end of the month of July in 2009, 2008, 2007, and 2006) **C=Caucasian; B/AA=Black/African American; H=Hispanic; M=Multi-racial High Meadows: High Meadows is a residential treatment facility for male adolescents (12-20 years of age) who require intensive and comprehensive services. High Meadows residential treatment program is for those whose behavioral and emotional disturbances are such that treatment can only be effected in a setting which protects the youth and/or community in a structured program 24-hours a day. High Meadows currently operates with a capacity of 36 beds. In calendar year 2007, there were 98 children served at High Meadows with an average length of stay of 211 days. In calendar year 2008, there were 95 youth served at High Meadows. The average length of stay at High Meadows was 193 days. The facility is scheduled to close in January, As of January 25, 2010, there were 4 males residing at High Meadows. Table 8 depicts the average daily vacancy rate and the average monthly vacancy rate at High Meadows. The average daily bed vacancy per Calendar year 2007 was

18 Month Table 8. High Meadows Average Daily Vacancy Report Average Daily Vacancy Beds for Mental Retardation/ Developmentally Disabled General psychiatric bed July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec Safe Homes/Permanency Diagnostic Centers (PDCs): Safe Homes and PDCs are intended for children requiring stabilization and assessment after removal from home. These programs are intended for children in need of short term out of home care due to abuse or neglect. Currently, there are 17 Safe Homes (run by 13 providers) that have a bed capacity of 178. The contracted length of stay is 45 days. In April, 1999, a Safe Home initiative was implemented in Connecticut and the first Safe Homes were opened. The initiative was developed to address the specialized needs of children ages 3-12 years old experiencing first time out of home placements. The goal of the initiative was to successfully plan for permanent and secure homes for children. The Safe Home program goals were to keep siblings together, maintain children in their communities including their schools of nexus, return more children to their families, and when foster care was necessary, make it part of the child's permanency plan. Services in the Safe Homes were to include clinical and case management services, access to medical services, treatment planning, supervised visits with families, on-site activities, 18

19 continuity of educational programming, facilitation of pre-placement visits and contacts, and aftercare services. The Safe Home initiative was unique in its model implementation in that there were allocated dedicated liaisons in each regional office and a statewide Safe Home coordination in Central Office. In June 2003, Yale University Department of Psychiatry completed an evaluation of the Safe Home model and produced a report to DCF. A follow up report with results, conclusions, and recommendations was distributed to DCF in These reports were later published. 2 Authors of the initial Safe Home evaluation concluded that since the inception of the Safe Home initiative, there had been improvement in the number of children who experienced fewer than three subsequent placements within the first year of out of home placement. There was also a positive change in the number of siblings placed together and in placement outcomes. The study concluded, however, that this outcome represented a paradigmatic shift in social work practice in the state and could not be attributed to the Safe Home initiative. Results from the 2004 follow up evaluation indicated that the majority of children who enter out-of-home care, even for the first time, have an extensive history with DCF prior to their first removal. Seventy percent of the children in the study came into contact with DCF three or more years prior to their index removal, about fifty percent had three or more contacts prior to their removal, and about fifty percent had three or more prior substantiated reports of maltreatment. The trauma histories of the children were found to be severe overall and most children had experienced multiple types of trauma. The follow up study found that by a two year follow up, approximately half of the children who had entered care through the Safe Home programs were living in non-permanent settings. The report concluded that the most effective programs involve expert, comprehensive assessment, concurrent case planning, multi-faceted individualized treatments, and longer-term interventions. Recommendations included expansion of clinical support to address the trauma, attachment, and separation anxiety issues identified among many of the children in Safe Home care, more focus on family work, adequate transitioning, and extended aftercare services. PDCs opened in 2003 and were designed to stabilize and assess children. They have more intensive clinical supports than Safe Homes, and they serve children with more acute behavioral and mental health issues. There are 2 PDCs with a capacity of 22. The contracted PDC length of stay is days. In May, 2009, the number of children utilizing Safe Home placements increased to 125 in comparison to data reported in February, This number is far below the total capacity of 178 beds. The difference between utilization and available capacity may be related to DCF's focus on placing children in foster homes when possible and the 2 DeSena, A.D., Murphy, R.A., Douglas-Palumberi, H., Blau, G., Kelly, B., Horwitz, S., & Kaufman, J. (2005). Safe Homes: Is it worth the cost? An evaluation of the Connecticut model of intervention for children who enter out-of-home care. Child Abuse and Neglect, 29(6),

20 implementation of efforts to reduce overstays in this setting children in this setting were in over-stay status as of May, 2009 compared with 44 children in February, As of September 25th, 2009, Safe Homes served 123 children and PDCs served 18 children. The gender breakdown and length of stay for Safe Homes and PDCs as of September 25th, 2009 is listed in Table 9 below: Table 9. Male Female Average LOS in days Safe Home * PDC *There are currently two significant outliers placed at Safe Homes. When these outliers are removed, the average LOS is days. The Office of Foster Care Services (OFCS) assumed oversight of the Safe Homes in March, Immediate efforts began to reduce the length of stay and to assess the appropriateness of the model. Protocols were established and implemented both within the DCF Area Offices and with the providers. These efforts were increased in July, 2008 when the Department entered into the Juan F. Stipulated Agreement which mandated that all children in temporary facilities be discharged within 60 days of admission. These efforts included, establishing and implementing refined referral, assessment, and discharge protocols. Area Office liaisons became more actively involved in tracking children in the Safe Homes and PDCs. They met on a bi-weekly basis to review progress toward achieving the discharge plan and maintained logs that are updated and disseminated to key parties on a weekly basis. Communications among foster care, child protective services, and area resource group staff have been improved and contribute to enhanced, coordinated efforts to achieve successful discharge. Directives were issued to the Safe Home providers to ensure that assessments and discharge recommendations were being completed within the first 30- days of placement. The Safe Home and PDC providers are active partners in the effort to reduce lengths of stay in these temporary settings. The most significant impact of the targeted recruitment and retention efforts on the length of stays in congregate care settings is that more aggressive efforts are undertaken to identify relative homes and DCF foster homes to avoid placement in a congregate care setting. Better assessments are being conducted prior to placement to ensure the appropriateness of the child entering into the setting. Homes in the process of being licensed are often identified for a specific child in a Safe Home or PDC. 3 Juan F. v. Rell Exit Plan Quarterly Report (January 1, 2009-March 31, 2009). Civil Action No: 2:89 CV 859 (CFD). Retrieved August 17, 2009 online from 20

21 Two major obstacles identified in effectuating discharge within the 60 day time frame are: 1) While an appropriate placement may be identified, a child may require an extended transition into a home based setting that brings him/her over the 60 days and 2) At times, there are no suitable treatment matches identified within the designated timeframes. Another element of the Juan F. stipulated agreement required increased efforts to recruit and license foster and adoptive homes. The impact of increased recruitment would be more available foster homes for children resulting in less need for Safe Home and PDC placements. Shortly after the implementation of the Juan F. stipulated agreement, the utilization rate dropped significantly, in large part due to increased efforts by the Area Office Foster and Adoption Services Units (FASU) to identify foster families for children instead of making Safe Home/PDC placements. Historically the utilization rate of the Safe Homes has been approximately 85%-90%. Following the implementation of the stipulated agreement mandates, the utilization rate dropped steadily to a low of 53%. A downward trend in Safe Home/PDC utilization was noted through June, 2008 until March, 2009 when a large number of removals caused the utilization rate to increase. The utilization rate for Safe Homes as of September 25 th, 2009 was 69%. The utilization rate of PDCs was 82%. The trend of utilization of Safe Homes and PDCs is demonstrated in Chart 9 below: Chart 9. Safe Home and PDC Utilization 120% 100% 80% 60% 40% 20% 0% 87% May_08 June_08 85% 96% Jul_08 Aug_08 94% Sep_08 80% 72% 67% 62% 65% Oct_08 Nov_08 Dec_08 Jan_09 Feb_09 Mar_09 Apr_09 53% 71% 78% Percentage 21

22 Prior to the Stipulated Agreement, approximately 54% of all children in the Safe Homes and PDCs had been in placement there for over 60 days. As of September 25 th 2009, 46% of youth at Safe Homes and 68% of youth at PDCs were on overstay status. Table 10 below demonstrates demographic information on youth in Safe Homes. Table 10. Safe Home Demographic Data* Year Race/Ethnicity** Gender Age C= B/AA= 44 H=22 M= 6 C= B/AA= 65 H= 39 M= 5 C= B/AA= 37 H=34 M= C= 88 B/AA= 48 H= 37 M=12 M=74 F=47 M=100 F= 49 M= 88 F= 65 M= 98 F= 68 Number of youth 0-5 years= 51 Number of youth 6-11 years = 57 Number of youth years = 13 Number of youth 0-5 years= 61 Number of youth 6-11 years = 83 Number of youth years = 32 Number of youth 0-5 years= 45 Number of youth 6-11 years = 72 Number of youth years = 36 Number of youth 0-5 years=59 Number of youth 6-11 years = 73 Number of youth years = 34 *This is point in time data from LINK reports. The data reflect demographic information recorded at the end of the month of July in 2009, 2008, 2007, and 2006) **C=Caucasian; B/AA=Black/African American; H=Hispanic; M=Multi-racial The Department has developed plans to revise this level of care. The Office of Foster Care Services continues to engage in efforts to enhance the Safe Home and PDC models. Safe Homes and PDCs were targeted for reprocurement in state fiscal year 2010, and efforts are well already underway to carry out this process. Specifically, collaborative meetings have been held with the providers and among agency stakeholders and a draft Safe Home and Permanency Diagnostic Center redesign is being circulated to Area office Management and DCF Administration. Discussions with providers regarding the new model and next steps to move forward have continued to this date. The primary elements being addressed in the re-design are: model admission parameters, staff structure, service expectations, transition and discharge requirements, data reporting, and quality assurance. As noted earlier, there have been multiple efforts 22

23 to assess the viability of the model since the inception of the Safe Home model in The current effort incorporates present best thinking with recommendations generated previously in the context of available resources and the needs of the target population. Short Term Assessment and Respite Home (STAR): For many years, DCF operated shelters to provide temporary placements for youth involved in the DCF system. These programs provided basic housing and staff supervision for youth but did not provide behavioral health evaluation, treatment, or support. In 2006, DCF defunded existing shelters. The model for temporary placements was dramatically reconfigured. Through its redesign of services, the Department provided an opportunity to implement a program model better aligned with the characteristics of the adolescents who were utilizing the service. The STAR model was developed. This model of short term care was designed according to the following principles and components of care: Children and adolescents will be served in small, family-like settings; These settings will be geographically close to where the children live and/or the DCF office that supports them; Program staffing will provide improved supervision especially during key times of day (i.e., after school, weekends, holidays, etc.); Services will be informed by an overarching clinically based philosophy of care that is trauma informed; An array of on-site clinical services will be provided; and, Aftercare services and supports will assist with the transition to community based settings. The STAR programs offered many advantages over the emergency shelter system. These advantages included: more home-like settings to reduce the likelihood of institutionalized behaviors and smaller program size that support improved supervision and the development of nurturing relationships. These programs were also designed to incorporate best practice approaches to screening, assessment, and trauma informed care. Between the Department closed shelters. At the present time, five providers run 14 STAR programs across the state that serve children ages years. The core components of the model are as follows: a. Small, Family-like Settings: The six bed STAR bed homes provide a small, intimate atmosphere that supports nurturing and supportive interactions and positive interpersonal relationships. b. Gender Specific Services: There is a well-defined clinical approach that is gender specific to the population served. c. Program Supervision: The program model requires 1-staff to 3-youth ratio at all 23

24 times, while providing for enhanced direct-care staffing when necessary. d. Screening, Assessment, and Multi-disciplinary Evaluation (MDE): For those children/youth for whom placement in the STAR is a first time removal, the program is responsible for arranging for the completion of a MDE within 30 days of such children s admission to the program. e. Clinical Philosophy/Supports: All aspects of the program, including the physical design of the living and common areas, daily schedule, policies, procedures and practices, clinical interventions, access to adjunct services, etc., are informed by the clinical needs of the children and their families, where appropriate. These on site services include, at a minimum, individual and family therapy, case management, group therapy, crisis intervention, milieu treatment, psychiatric assessment, medication management by a psychiatrist or APRN, nursing services, and aftercare supports. All staff receive training in the model of care utilized by the program and the knowledge and skills necessary to perform their identified function(s). f. Trauma Informed Services: The treatment philosophy incorporates knowledge of the impact of trauma including how trauma is likely to affect development, cognitive processes, mood, affective regulation, psychiatric symptomology, interpersonal relationships and other aspects of functioning. Training in the treatment of trauma is provided to all staff commensurate with their position and role within the program. g. Respite Services: Respite is provided for children and families involved with DCF Protective Services to have a respite from each other during times of extreme conflict, stress, or periods of crisis. Respite is also made available to those children and youth who have been discharged from the STAR and require subsequent brief periods of respite to support permanency goals. h. Aftercare Services: Aftercare services following discharge is provided to promote the success and longevity of placements. An aftercare plan would include, but not be limited to the following elements: an outline of the aftercare services provided, the number and frequency of in-home child and family contacts, and plans for respite services. 24

25 i. Each STAR program is required to have the following staffing components: a. Clinician: A clinician provides on-site clinical services including individual, family and group therapy, crisis intervention, case management, and aftercare followup. This clinician also performs emergency assessments of youth as well as assessments needed for Area Office discharge planning. The clinician is responsible for the ongoing development and implementation of a therapeutic milieu to include an organized approach to behavioral management and conflict resolution, a complement of individualized and group oriented therapeutic services and supports, as well as a consistent, varied, and appealing recreational program. Clinicians have flexible schedules and work shifts that make them optimally available to serve youth and families. b. Psychiatrist: A psychiatrist (i.e., minimum of 2 hours per week) consults with the clinician regarding evaluations and prescribes and monitors psychiatric medications when necessary. The position also includes after hours coverage for emergencies and assisting the clinician in the facilitation of outpatient community therapy. c. Program Director: A Program Director oversees the STAR and provides management and supervision of the clinical staff as well as all other administrative functions. This individual also performs emergency assessments of youth as well as assessments needed for Area Office discharge planning. d. Direct Care: Each program maintains a minimum of one to three (1:3) staff to youth ratios during all program shifts. On second shift, the program maintains a one to two (1:2) ratio in order to accommodate the need to transport some clients to appointments, supervise visits, or otherwise meet the increased supervisory demands during the hours after school and through bed time. Direct care staff are responsible to provide improved care for youth during crisis and instability periods, more individualized support and management throughout their placement, and more effective service delivery in terms of making therapeutic, medical, and educational interventions and appointments. Direct Care staff report to the clinician and function in a therapeutic coaching role while providing support to the children and youth. As of February 20 th, 2009 there were 80 children in STAR Homes (44 females, 36 males). The average length of stay across all children in STAR programs in February, 2009 was 62 days (i.e., the range of average length of stay varied from 23 days to 94 days). The number of children in overstay status (i.e., over 60 days) in STAR placements decreased from 36 children in February, 2009 to 33 children in May,

26 Demographic data from LINK is outlined in Table 11 below: Table 11. STAR Homes Demographic Data* Year Race/Ethnicity** Gender Age C= B/AA= 34 H= 18 M= 4 C= B/AA= 23 H= 26 M= 3 C= B/AA= 33 H= 25 M= C= 42 B/AA= 27 H=23 M=50 F=49 M=46 F= 42 M= 49 F= 42 M= 35 F= 50 Number of youth 6-11 years = 8 Number of youth years = 84 Number of youth 6-11 years = 8 Number of youth years = 81 Number of youth 6-11 years = 10 Number of youth years = 84 Number of youth 6-11 years = 12 Number of youth years = 72 M=4 *This is point in time data from LINK reports. The data reflect demographic information recorded at the end of the month of July in 2009, 2008, 2007, and 2006) **C=Caucasian; B/AA=Black/African American; H=Hispanic; M=Multi-racial The Department has no plans to revise this level of care. The STAR programs were developed in 2006 and are currently managed by the Bureau of Child Welfare. Group Homes: Therapeutic Group Homes (TGHs): A Therapeutic Group Home (TGH) is a community based small, four to six bed program located in a neighborhood setting with intensive staffing and clinical services offered 24 hours, seven days a week. It is a structured highly intensive treatment program that creates a physically, emotionally, and psychologically safe environment for children and adolescents with complex behavioral health needs who need additional support and clinical intervention to succeed in either a family environment or in an independent living situation. A TGH is designed to serve as a step-down from inpatient care, or as a stepdown from or an alternative to residential level of care. Education is provided off site 26

27 through the local education authority. Community based activities (recreational, vocational, social development) serve as a focus for clinical and rehabilitative intervention. As of August, 2009, there were 288 clinical slots in therapeutic group homes. The 56 therapeutic group homes provided services to 262 residents. Of the 262 residents, 107 were female, and 155 were male. The age cohorts are broken down into: Pre-latency (5 years-9 years), Latency (10 years-13 years) and Adolescent (14 years-21 years). Age break down of therapeutic group home residents is listed in Table 12 below: Table 12. Age Groupings of Youth in Therapeutic Group Homes Age Grouping Male Female Adolescent Latency 33 9 Pre-Latency 8 2 As of August 1, 2009, the average length of stay for adolescents in TGHs is as follows: Male Adolescents=14.5 months; Female Adolescents=17 months. The average length of stay for latency residents is 11.3 months and for pre-latency residents the average length of stay is 14.3 months. Many therapeutic group homes serve specialty populations. For example, there were 35 children served in homes with developmental disabilities population, 36 served in homes specializing in problem sexual behavior, 10 children in homes serving pervasive developmental disorders, and four children in homes serving a juvenile justice population. The Department does not have plans to change its approach to this level of care. However, there will be efforts to help improve transition planning for the youth who are currently in these homes. Demographic data on all levels of group homes is presented in Table 13 below. Table 13. Group Homes* Demographic Data** Year Race/Ethnicity*** Gender Age C= 249 B/AA= 163 H=119 M= 17 C= 228 B/AA= 135 H= 99 M=285 F=191 M=258 F= 164 Number of youth 6-11 years = 32 Number of youth years = 368 Number of youth 6-11 years = 39 Number of youth years =

28 M= 23 C= B/AA= 154 H= 110 M= C= 201 B/AA= 118 H=85 M=8 M= 234 F= 177 M= 194 F= 157 Number of youth 6-11 years = 38 Number of youth years = 325 Number of youth 6-11 years = 30 Number of youth years = 293 * This is data for all group home levels **This is point in time data from LINK reports. The data reflect demographic information recorded at the end of the month of July in 2009, 2008, 2007, and 2006) ***C=Caucasian; B/AA=Black/African American; H=Hispanic; M=Multi-racial Preparing Adolescents for Self-Sufficiency (PASS) Group Homes: A PASS group home (Level 1.5 home) is a moderately sized home, with six to ten beds. In contrast to therapeutic group homes, PASS homes are not intended to be utilized as clinical programs. The homes are housed in neighborhood settings and are staffed with non-clinical paraprofessionals who provided services 24 hours a day, seven days a week. The homes are designed to serve adolescents ages years old with mild to moderate behavioral health needs who are either too young or lack the necessary skills to move into an independent living situation. These homes stress education, preemployment skill development and independent living skill. Youth attend school and obtain clinical services in the community. There are four PASS group homes for adolescent girls in Connecticut. The total bed capacity for adolescent girls is 34. In March, 2009, 33 of these 34 beds were filled. There are seven PASS group homes for adolescent males. The total bed capacity for this population is 60. In March, 2009, 57 of these beds were filled. The majority of youth served at PASS homes have permanency plans of APPLA (Another Planned Permanency Living Arrangement). As of May 12, 2009, the average length of stay across all PASS homes is 461 days. The Department has no plans to revise the PASS group home level of care. Maternity Group Homes: The DCF funded maternity homes are group home settings with six to 12 beds. They are similar to PASS Group Homes in terms of their staffing and available services. Staff members support the youth's life skills development utilizing tools such as the Ansell- Casey Life Skills Curriculum. There are currently two maternity group homes and these serve 23 pregnant females. The majority of youth served at maternity group homes have permanency plans of APPLA (Another Planned Permanency Living Arrangement). 28

29 As of May, 2009, the average length of stay at maternity homes group homes is 262 days. The Department has no plans to revise the maternity group home level of care. Supportive Work, Education, and Transition Program (SWETPs): SWETPs are small group homes serving male and female adolescents ages years. As with PASS homes, these are not designed as therapeutic clinical settings. SWETPs focus on development of independent living skills, including but not limited to, community awareness, education, and pre-employment skill development. There are three SWETP programs in Connecticut. The SWETPs have a capacity of 24 beds (i.e., eight beds for males, 16 beds for females with four of those beds for females who have children). In March, 2009, 18 of the SWETP beds were filled. The majority of youth served at SWETPs have permanency plans of APPLA (Another Planned Permanency Living Arrangement). The average length of stay is approximately 12 months. The Department has no plans to revise this level of care. Utilization of Congregate Care Recent utilization The Juan F. v Rell Exit Plan Quarterly report for the first quarter of 2009 included the following information on utilization of STAR homes by members of the Juan F. class based on point-in-time data: Table 14. STAR placements Placement Feb May 2008 Aug Oct Nov Feb May 2009 Total number of children in STARs Number in STARs >60 days Number in STAR >6 mos Point-in-Time data reported in the Juan F. v Rell Exit Plan Quarterly Report for the first quarter of 2009 indicates the following trends in Safe Home and PDC utilization by class members outlined in Table

30 Placement Feb Table 15. Safe Home and PDC placements May 2008 Aug Oct Nov Feb May 2009 Total number of children in Safe Homes Number in Safe Homes >60 days Number in Safe Homes >6 mos Total number of children in PDCs Number in PDCs >60 days Number in PDCs >6 mos Point-in-Time data reported in the Juan F. v Rell Exit Plan Quarterly Report for the first quarter of 2009 indicates the following trends in congregate care utilization for children 12 years and under outlined in Table 16. Table 16. Congregate Care settings for children 12 and under May 2008 Aug Oct Nov Feb May 2009 Placement Total number of children 12 years old and under, in congregate care In DCF facilities* In Group Homes In Residentials In Safe Homes

31 In Permanency Diagnostic Centers In STARs **This data includes all DCF facilities, including Riverview Hospital, the Connecticut Children's Place, the Connecticut Juvenile Training School, and High Meadows, a state facility scheduled to close by 12/09. Children who are committed delinquent to the Department are not included in this data. The Connecticut Behavioral Health Partnership tracks utilization data for services that use Medicaid funds. The data for utilization of residential treatment centers, therapeutic group homes, PASS group homes, and maternity homes in 2009 is presented below. Utilization data for residential treatment centers, therapeutic group homes, and PASS Homes for 2008 and 2007 are presented in the tables below: Table utilization data for DCF involved children* Residential Treatment Centers Age range Residential Admits/Discharges QTR 1, 2009 Residential Admits/Discharges QTR 2, 2009 Residential Admits/Discharges QTR 3, 2009 Year to Date** Admits/Discharges YTD 0-10 years 4/2 2/6 1/2 7/ years 10/17 6/10 0/7 16/ years 112/ /158 33/63 256/ years 19/18 22/33 7/8 48/59 *This data includes all children involved with DCF, including youth with juvenile justice commitments. **As of 8/3/09. 31

32 Table utilization data for DCF involved children* Therapeutic Group Homes Age range Therapeutic Group Home Admits/Discharges QTR 1, 2009 Therapeutic Group Home Admits/Discharges QTR 2, 2009 Therapeutic Group Home Admits/Discharges QTR 3, 2009 Therapeutic Group Home Admits/Discharges Year to Date** 0-10 years 3/8 4/10 3/2 10/ years 5/1 6/5 4/2 15/ years 19/19 24/19 6/13 49/ years 11/6 10/12 5/8 26/26 *This data includes all children involved with DCF, including youth with juvenile justice commitments. **As of 8/3/09. Table utilization data for DCF involved children* PASS Homes Age range Group Home Admits/Discharges QTR 1, 2009 Group Home Admits/Discharges QTR 2, 2009 Group Home Admits/Discharges QTR 3, 2009 Group Home Admits/Discharges Year to Date** years 16/10 11/11 4/6 31/ years 7/9 7/6 2/3 16/18 *This data includes all children involved with DCF, including youth with juvenile justice commitments. **As of 8/3/09. 32

33 Table utilization data for DCF involved children* Maternity Group Homes Age range Group Home Admits/Discharges QTR 1, 2009 Group Home Admits/Discharges QTR 2, 2009 Group Home Admits/Discharges QTR 3, 2009 Group Home Admits/Discharges Year to Date** years 3/4 6/3 0/3 9/ years 2/3 2/4 1/0 5/7 *This data includes all children involved with DCF, including youth with juvenile justice commitments. **As of 8/3/09. Data for 2008 is presented below: Table utilization data for DCF involved children Residential Treatment Centers Age range Residential Admits/Discharges QTR 1, 2008 Residential Admits/Discharges QTR 2, 2008 Residential Admits/Discharges QTR 3, 2008 Residential Admits/Discharges QTR 4, YTD 0-10 years 3/2 7/8 4/4 1/5 15/ years 15/13 12/12 12/22 7/11 46/ years 129/ / / / / years 16/14 23/22 13/20 19/11 71/67 *This data includes all children involved with DCF, including youth with juvenile justice commitments. 33

34 Table utilization data for DCF involved children Therapeutic Group Homes Age range Group Home Admits/Discharges QTR 1, 2008 Group Home Admits/Discharges QTR 2, 2008 Group Home Admits/Discharges QTR 3, 2008 Group Home Admits/Discharges QTR 4, YTD 0-10 years 8/5 8/10 10/12 7/7 33/ years 1/2 5/3 5/4 4/1 15/ years 17/10 19/18 32/18 26/22 94/ years 8/5 8/10 10/12 7/7 33/34 *This data includes all children involved with DCF, including youth with juvenile justice commitments. Table utilization data for DCF involved children* PASS Homes Age range Group Home Admits/Discharges QTR 1, 2008 Group Home Admits/Discharges QTR 2, 2008 Group Home Admits/Discharges QTR 3, 2008 Group Home Admits/Discharges QTR 4, YTD years 21/4 13/10 15/10 15/11 64/ years 2/0 5/1 10/7 13/7 30/15 *This data includes all children involved with DCF, including youth with juvenile justice commitments. 34

35 Utilization for 2007 is presented below: Table utilization data for DCF involved children* Residential Treatment Centers Age range Residential Admits/Discharges QTR 1, 2007 Residential Admits/Discharges QTR 2, 2007 Residential Admits/Discharges QTR 3, 2007 Residential Admits/Discharges QTR 4, YTD 0-10 years 2/3 4/7 2/8 2/3 10/ years 10/1 11/16 8/19 7/12 36/ years 113/ / / / / years 16/10 17/18 22/20 16/19 71/67 *This data includes all children involved with DCF, including youth with juvenile justice commitments. Table utilization data for DCF involved children* Therapeutic Group Homes Age range Group Home Admits/Discharges QTR 1, 2007 Group Home Admits/Discharges QTR 2, 2007 Group Home Admits/Discharges QTR 3, 2007 Group Home Admits/Discharges QTR 4, YTD 0-10 years 4/2 6/6 2/6 7/4 19/ years 2/4 6/0 4/3 6/1 18/ years 13/9 12/9 22/17 22/15 69/ years 4/3 9/4 9/6 8/4 31/17 *This data includes all children involved with DCF, including youth with juvenile justice commitments. 35

36 Table utilization data for DCF involved children* PASS Homes Age range Group Home Admits/Discharges QTR 1, 2007 Group Home Admits/Discharges QTR 2, 2007 Group Home Admits/Discharges QTR 3, 2007 Group Home Admits/Discharges QTR 4, YTD years 13/9 12/9 22/17 22/15 69/ years 1/1 1/0 2/2 7/0 11/3 *This data includes all children involved with DCF, including youth with juvenile justice commitments. Trends in Average Monthly Census Over Time: Data from LINK were used to create the tables below: Table 27. Residential Treatment Centers* Year Average Monthly Census** 2009*** *These are data collected from LINK Reports. **Average monthly census based on the number of youth at in-state and out of state residential treatment centers on the last day of a calendar month. ***Jan.-July

37 Table 28. State of Connecticut Facility: Connecticut Children's Place* Year Average Monthly Census** 2009*** *These are data is collected from LINK Reports. ** Average monthly census based on the number of youth at CCP on the last day of a calendar month. ***Jan.-July, 2009 Table 29. Safe Homes* Year Average Monthly Census** 2009*** *These are data is collected from LINK Reports. ** Average monthly census based on the number of youth at Safe Homes on the last day of a calendar month. ***Jan.-July,

38 Table 30. STAR Homes* Year Average Monthly Census** 2009*** *These are data is collected from LINK Reports. ** Average monthly census based on the number of youth at STAR Homes on the last day of a calendar month. ***Jan.-July, 2009 Table 31. Group Homes* Year Average Monthly Census*** 2009*** *This includes all group home levels. These are data is collected from LINK Reports. ** Average monthly census based on the number of youth at group homes on the last day of a calendar month. ***Jan., 2009-July, 2009 Relevant Literature As indicated above, we began our work with an extensive and intensive review of the relevant literature on the use of congregate care. Congregate care for children represents one level of clinical care in a continuum of treatment approaches. These approaches range from in-home supports to residential care to inpatient treatment, which of course is the most structured treatment environment. A residential treatment 38

39 center has been defined as a 24-hour facility designed for the treatment of mental health disorders that is not licensed or designated as a hospital. 4 The critical point, of course, is that residential treatment is a clinical intervention which needs to be conceptualized and evaluated as such. The majority of youth in residential treatment facilities are adolescent males. 5 The characteristics of the youth are certainly varied but frequently include multiple issues and challenges in school functioning, interpersonal relationships, and behaviors. They show higher level of internalizing and externalizing problems and have fewer adaptive behaviors than youth treated outside of residential environments and are frequently diagnosed with attention deficit and hyperactivity disorder, anxiety disorders, and conduct disorders. Many of their families experience multiple stressors such as domestic violence, psychiatric illness, involvement with the juvenile justice system, and substance abuse. 6 7 In 2008, Abt Associates of Cambridge, Massachusetts, prepared a white paper on the characteristics of residential treatment* for children and youth with serious emotional disturbances. The authors concluded that residential treatment is a critical component of a system of care for a percentage of young people whose needs are so complex or disabling that they require intensive 24 hour out-of-home residential treatment. 8 Results from the author's survey of members of the National Association for Children's Behavioral Health (NACBH) and the National Association of Psychiatric Health Systems (NAPHS) indicated that the children and youth served by residential treatment programs are clinically complex and functionally impaired, with multiple psychiatric diagnoses, and co-occurring substance use, neurological, developmental, learning, medical, and other behavioral disorders. Key informants in the white paper concurred that limiting access to care, including residential treatment when needed can lead to: eventual underemployment or unemployment, homelessness, incarceration, and, family burden and lost productivity. 9 4 Connor, D.F., Miller, K.P., Cunningham, J.A., & Melloni, R.H. (2002). What does getting better mean? Child improvement and measure of outcome in residential treatment. American Journal of Orthopsychiatry, 72 (1) Baker, A.J.L., Archer, M., & Curtis, P.A. (2005). Age and gender differences in emotional and behavioural problems during the transition to residential treatment:. The Odyssey Project. International Journal of Social Welfare, 14 (4), **In Connecticut, 62.8% of DCF youth in residential treatment centers were male (as of June 9, 2009). 6 Frensch, K.M., & Cameron, G. (2002). Treatment of choice or a last resort? A review of residential mental health placements for children and youth, Child and Youth Care Forum, 31 (5), Foltz, R., (2002). The efficacy of residential treatment: An overview of the evidence, residential treatment for children and youth, 22 (2), * For the white paper, residential treatment was defined as a specific level of care distinguished by services and setting: 24 hour therapeutically planned behavioral health intervention; highly supervised and structured group living and active learning environment where distinct and individualized therapies and related services are provided; multidisciplinary team of clinically licensed professionals; diagnostic processes which address psychiatric, social, and educational needs; individualized assessment, treatment planning, and aftercare, involving the child and family. 8 Abt Associates, Inc. (Summer, 2008). Characteristics of Residential Treatment for Children and Youth with Serious Emotional Disturbances. 9 Ibid. 39

40 There has been considerable debate regarding whether or not residential care is an effective intervention. In fact, literature reviews on the outcome efficacy for residential treatment have shown that group home placement alone may not result in lower rehospitalization rates and improved stability of living situation unless treatment is associated with a well conceived discharge plan. 10 To lead to better outcomes, it has been recommended that residential treatment programs offer individual and group counseling, life skills training, educational and employment assistance, and postplacement planning and support. 11 Maintaining improvements after discharge appears to rest on the degree of family involvement during treatment, and aftercare (i.e., the stability and support in the post-treatment environment to which a child is discharged). Therefore, family centered approaches and efforts that link residential treatment closely with community based services to ensure aftercare are gaining empirical support. 12 Measurement on the effectiveness of residential treatment as an intervention is challenging given that there is little agreement on the defining characteristics of residential treatment and there is considerable variability among programs. 13 Evidence for the effectiveness of residential treatment is mixed at best. While most children and youth make gains in residential treatment, it is estimated that 20-40% show no improvements or deteriorate. 14 Existing studies on residential treatment provide support for the importance of family involvement and regular contacts with families to ensure positive outcomes. According to a summary report on Best Practices in Children's Mental Health 15 other factors predicting positive outcomes include shorter lengths of stay (i.e., nine months or less), improvements in educational achievement, and successful engagement, involvement, and functioning of the child's family. Authors of a special issue of the American Journal of Orthopsychiatry 16 concluded that there is limited evidence for the overall effectiveness of residential treatment while an earlier review concluded that the research on residential treatment has not been able to demonstrate the effectiveness of any particular model of residential care. 17 A major review of evidence-based treatments concluded that residential treatment for children and adolescents is a widely used but empirically unjustified service and that any gains 10 Pumariega, A.J., (2007). Residential treatment for children and youth: Time for reconsideration and reform. American Journal of Orthopsychiatry, 77 (3), Mendes, P., & Moslehuddin, B. (2006). From dependence to interdependence: Towards better outcomes for young people leaving state care. Child Abuse Review. Vol. 15: DOI:1002/car Walter, U. (2007). Best practices in children's mental health; Report #20: Residential Treatment, A review of the national literature: August University of Kansas, School of Social Welfare. Retrieved from: 13 Leitchman, M., (2006). Residential treatment of children and adolescents: Past, present, and future. American Journal of Orthopsychiatry, 76: (3), Walter, U. (2007). Best practices in children's mental health; Report #20: Residential Treatment, A review of the national literature: August University of Kansas, School of Social Welfare. Retrieved from: 15 Ibid 16 Pumariega, A.J. (2006). Residential treatment for youth: Introduction and a cautionary tale. American Journal of Orthopsychiatry, 76 (3), Curry, J. (1991). Outcome research on residential treatment: Implications and suggested directions. American Journal of Orthopsychiatry, 61,

41 made during treatment are seldom maintained once the adolescent returns to the community. 18 In April, 2009, The Bazelon Center for Mental Health Law released a fact sheet 19 outlining why residential treatment centers are inappropriate for students with mental health and special education needs. The fact sheet was developed in response to a case in front of the U.S. Supreme Court (i.e., Forest Grove v. T.A., No ). The issue before the court in the particular case is whether parents may require a school system to reimburse them for their child's private boarding school tuition under the Individuals with Disabilities Education Act (IDEA) 20 when the school system had not previously recognized the child's need for special education. The Center's fact sheet asserts that public dollars should not be spent on residential placements. Authors of the fact sheet also argue that public funds should instead be invested in services that support children in their own homes, schools and communities. The fact sheet concludes that the consensus of mental health experts is that residential treatment centers are ineffective, primarily due to detrimental effects of group placements, failures to address problems in the child's home and community environment, little or inappropriate mental health services, and substandard educational programs. 21 In stark contrast, the Child Welfare League of America has maintained that residential treatment is an important component in the continuum of care and cites several studies of the effectiveness while acknowledging the limitation of much of the research in the field. 22 Recent research supports that family involvement appears strongly associated with obtaining better outcomes for youth. 23 Some authors have noted that diagnostic presentation is important in considering congregate care's usefulness. For example, in one study of responses to residential treatment, researchers concluded that children who demonstrated oppositional, defiant, or generally conduct-type symptoms seemed to do the most poorly in a residential treatment setting. 24 In general, the program factors associated with better outcomes include: smaller size of the program, 25 staff training, 18 Hoagwood, K., Burns, Kiser, L., Ringeisen, H., & Schoenwald, S. (2001). Evidence-based practice in child adolescent mental health services. Psychiatric Services, September, 2001, Vol., 52 (No. 9), Bazelon Center for Mental Health Law, U.S. Supreme Court to Decide Forest Grove v. T.A.: Parents Should Win, But Bazelon Center Opposes Therapeutic Boarding Schools. Available at 20 Individuals with Disabilities Education Act, 20 U.S.C 1400 et seq. 21 See Bazelon Center for Mental Health Law, U.S. Supreme Court to Decide Forest Grove v. T.A.: Parents Should Win, But Bazelon Center Opposes Therapeutic Boarding Schools and articles cited within, available at 22 Child Welfare League of America (CWLA). (2005). Position statement on residential services. Washington, D.C., Retrieved February 5, Available on-line format 23 Barth, R.P. (2002) Institutions vs. foster homes: The empirical base for the second century of debate. Chapel Hill, N.C.: UNC, School of Social Work, Jordan Institute for Families. 24 Joshi, P.K., & Rosenberg, L.A. (1997). Children's behavioral response to residential treatment. Journal of Clinical Psychology, 53(6), Ryan, J.P., et al., (2008). Juvenile delinquency in child welfare: Investigating group home effects. Children and Youth Services Review doi: /j.childyouth

42 family involvement, systemic interventions, and trauma-informed systems and interventions. 26 Current trends and challenges in residential treatment are summarized in at least two articles. 27,28 The overall trends noted include: Children are older at intake and stay for shorter lengths of time; A growth in the numbers of residential facilities with smaller sized living units; New partnerships on local, regional, and state levels; Increased standardization towards individualized, observable plans to return youth to the community as quickly as possible; An increased focus on mental health issues; Growth in information technology that streamlines work (e.g., electronic files); Increased demand due to more children entering the child welfare system; Children in residential setting demonstrating higher needs; and, Growing emphasis on specification of standardized child and family outcomes as well as on specifying treatment and care protocols. These authors outline issues and challenges in residential treatment, including the following: High costs of care; High turnover for childcare workers; Lack of consensus on critical intervention components; Limited development in residential treatment theory; Concerns that within some service systems children are placed in residential care without first attempting community and family based interventions; 26 Pumariega, A.J. (2007). Residential treatment for children and youth: Time for reconsideration and reform. American Journal of Orthopsychiatry, 77(3), Lieberman, R.E. (2004). Future directions in residential treatment. Child and Adolescent Psychiatric Clinics of North America, 13 (2), Whittaker, J.K. (2000). Reinventing residential childcare: An agenda for research and practice. Residential Treatment for Children and Youth, 17 (3),

43 Fears of abuse and neglect within residential settings; and, Concerns about disruptions in attachment through residential treatment. Specific suggestions 29, 30 to make residential treatment more family centered and linked with community based services include: 1. Establishing partnerships in the community and locating residential treatment in a community-service network; 2. Co-locating services such as family support and residential care; 3. Focusing on child well-being and family functioning as outcome measures; 4. Involving residential staff in community based services; and, 5. Developing models that serve the whole family. Review of the Literature on Length of Stay in Residential Treatment In order to further analyze and assess the agency's use of residential treatment it is important to assess not only the availability of this level of care but also the length of time for which utilization of this level of care is generally considered optimal. This literature review was thus conducted to better understand the issues which impact the length of stay of youth with mental health and/or substance abuse diagnoses who are treated in residential facilities. To begin, it may be helpful briefly to review some overall statistics on residential treatment nationally. In recent years there has been a concerted effort among State agencies to increasingly fund community based services and decrease reliance on longer-term and more costly out of home residential placements. To lend a perspective on the costs associated with residential care, one-fourth of the national outlay on child mental health was spent on care in residential settings, although only 8% of children with mental health problems were in residential treatment. 31, 32 In the most recent Child Welfare Survey from the Urban Institute, 33 45% of States out-of-home placement spending was on residential care (foster family care, correctional, shelter care and other were the remaining 55%). In comparison, the survey also noted 62% of Connecticut s spending on out-of-home placements in 1999 was for residential care. Nationally, the number of residential treatment centers for emotionally disturbed children has risen from 29 Leitchman, M., & Leichtman, M.L. (2002). Facilitating the transition from residential treatment into the community: IV. Making use of community resources. Residential Treatment for Children & Youth, 20 (2), Leiberman, R.E. (2004). Future directions in residential treatment. Child and Adolescent Psychiatric Clinics of North America, 13 (20), Teich, J. & Ireys, H. (2007). National survey of state licensing, regulating, and monitoring of residential facilities for children with mental illness. Psychiatric Services 58: , American Psychiatric Association. 32 Surgeon General (1999). Mental Health: A report of the surgeon general. Retrieved from: 33 Boots, S.W., Green, R., Tumlin, K., & Leos-Urbel, J. (1999). State child welfare spending at a glance: A supplemental report to the cost of protecting vulnerable children, Urban Institute, April. 43

44 13,489 in 1969 to 35,709 in The expense of residential treatment has spurred a movement in the past fifteen years to begin to shorten residential lengths of stay and ensure that residential care follows best practices and results in better outcomes. As part of the larger initiative in Connecticut to right-size the residential system, the Department of Children and Families, the Department of Social Services and Value Options, acting as the administrative service organization within the Connecticut Behavioral Health Partnership (CT BHP) have partnered to reduce the average length of stay (ALOS) in in-state residential programs. There was a slight downward trend in the average length of stay for Connecticut s residential programs from 2007 to There was a 10% decrease in ALOS from Quarter 3 and Quarter 4 of 2007 (i.e., 350 days) to 2008 calendar year average of 315 days. There was a 12% additional decrease in ALOS from calendar year 2008 in comparison to July, 2009 (279 days). A reduced average length of stay would conceivably increase timely access for residential treatment for more youth at the front end of the residential system. A second goal for Connecticut is to significantly decrease the use of out of state residential facilities. More beds freed up in in-state facilities due to a reduction in length of stay could help meet this goal. Decreasing length of stay in residential has inherent challenges. Therefore, several questions have become important: Is there an industry standard for average length of stay for residential facilities in the United States? What is the average length of stay for most residential facilities? What are the primary influencing factors related to short lengths of stay, long lengths of stay, reducing length of stay? Specifically, is length of stay more impacted by the youth s predisposing clinical and demographic factors or by the facility itself? Most of the literature found made similar statements that surprisingly little is published on residential care and length of stay. The length of stay data that was found showed a wide variance in the average length of stay among facilities and pointed to a multitude of variables that affect length of stay. A broad field survey was conducted by the Center for Mental Health Services between November 2003 and March 2004 regarding state regulatory practices among residential facilities in the United States for children with mental illness. 35 Thirty eight States responded, including CT. Among other survey questions, average length of stay information was gathered and reported in aggregate. Of the 3,628 residential facilities 34 Center for Mental Health Services. (2004). Mental Health, United States, 2004 Index. United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Table 19.5 Number, percent distribution, and rate of 24 hour hospital and residential treatment, by type of mental health organization: United States, selected years, Retrieved from: 35 Ireys, H.T., Achman, L., & Takyi, A. (2006). State regulation of residential facilities for children with mental illness. DHHS Pub. No. (SMA) Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. 44

45 included in the national survey, ALOS data was unavailable on 39.1% of the facilities, which represented almost half of all the beds in the survey. 37.6% of the facilities had seven months to twelve months ALOS; 12.9% had thirteen months or more ALOS; and, 10.4% had one to six months ALOS Longer lengths of stay were more common for facility types that averaged 3 to 16 residents as compared with facilities averaging 17 or more residents. For this survey, CT included 21 Residential Treatment Centers, each with an average of 47 children. For purposes of trying to understand the industry standard for average length of stay, this report is helpful but provides only a high level view of ALOS, and does not take into consideration variables such as clinical design and program philosophy, gender served, and admission criteria. Another national review containing length of stay information was found in an August 2007 report. 36 The authors concluded that across programs researched, overall the mean LOS varied from two months to more than two years, with only about half the placements ending in planned discharges. Additional research also suggested that there are increased positive outcomes when discharging youth sooner back to the community from residential. 37, 38 In a review of 14 outcome studies, 39 researchers looked at the characteristics of youth and family outcomes. The larger residential treatment centers showed that shorter LOS was a factor in predicting positive outcomes, along with clinical work with a child s family and improved academic performance while in the program. At the same time, another study was found that focused on the effectiveness of long lengths of stay versus shorter lengths of stay in residential. 40 Patients admitted during a six month period in 1985 were followed up six months after discharge. These results were then compared with a similar study conducted in 1973 where patients were also followed up six months after discharge. The results showed that the longer lengths of stay in 1973 (LOS was one year) was almost twice as effective in regards to positive outcomes than the shorter length of stay in 1985 (LOS was three months). Some information was found on length of stay related to individual programs. According to Colorado s February 2009 Monthly Population Report by the Division of Youth 36 Walter, U. (2007). Best practices in children's mental health; Report #20: Residential Treatment, A review of the national literature: August University of Kansas, School of Social Welfare. Retrieved from: 37 Hoagwood, K., & Cunningham, M. (1992). Outcomes of children with emotional disturbance in residential treatment for educational purposes. Journal of Child and Family Studies, 1, Pfeiffer, S.I., & Strzelecki, S. (1990). Inpatient psychiatric treatment of children and adolescents: A review of outcome studies. Journal of American Academy of Child and Adolescent Psychiatry, 29, Frensch, K.M. & Cameron, G. (2002). Treatment of choice or a last resort? A review of residential mental health placements for children and youth, Child and Youth Care Forum, 31, (5), Charuvastra, V.C., Dalali, I.D., Cassuci, M., & Ling, W. (1992). Outcome study: Comparison of shortterm vs. long-term treatment in a residential community. International Journal of Addiction. January, 27 (1),

46 Corrections Research and Evaluation Unit, 41 of the total 2009 YTD committed youth, 62% were committed to private secure/staff supervised or community residential programs. Of those discharged, the ALOS was 18.7 months. It is not known what percentage of these youth had psychiatric and/or substance abuse diagnoses, however it is probably safe to estimate that over half of these youth in residential had such diagnoses. Also it is not known whether the youth s length of stay was prescribed by the type of program they were admitted to. For example, a youth may have been committed to a program that requires a twelve month minimum stay. One such community residential program in Colorado is The Third Way Center. This well known program has five residential treatment programs with approximately 80 beds for co-ed youth ages These programs provide intensive mental health/behavioral health treatment, community based programming, family therapy, and teaching independent living skills. Although the program information that was available did not focus on length of stay, it was noted their ALOS (all facilities combined) is six to nine months. Additional program specific average length of stay information was found in the United States Government Accountability Office (GAO) January 1994 report on residential care. 42 Seventeen residential programs were included in the scope of this project, and among the data listed for each program was length of stay. This was the most recent data of this type by the GAO. Perhaps the most striking data on residential length of stay comes from Milwaukee, WI. 43 The well known Wraparound Milwaukee adolescent mental health treatment system began to form in Wraparound Milwaukee targets their services only to emotionally disturbed youth in residential treatment or at risk of referral to residential treatment. This program pooled $28 million/year from county agencies and Medicaid reimbursements to fund an array of intensive community based service strategies in addition to their residential programs. Payment to providers under Wraparound Milwaukee is via a capitated rate basis which helps minimize unnecessary residential stays, in addition to the aggressive use of tailored wraparound services. By 2000, Wraparound Milwaukee reduced the daily population in residential programs from 360 youth/day to 135 youth/day. Average length of stay in residential was reduced from 14 months to 3.5 months. Also, upon admission to residential, there is an understanding that the initial term of treatment will be 90 days followed by a discharge to wraparound services at the earliest possible date. Primary predictors of length of stay: In a large investigation of gender differences in adolescents in residential treatment 44 participants were 2,067 youth (mean age Colorado Department of Human Services, Division of Youth Corrections. February, 2009, Monthly population report, p. 3. Division of Youth Corrections Research and Evaluation Unit. 42 United States Government Accountability Office, January, Residential care: Some high-risk youth benefit, but more study needed. Appendix I., Retrieved from: publications and testimonies. 43 Bilchik, S. (year unknown). Challenge #5: Provide comprehensive supports and assistance to youth (and children) with behavioral disturbances. U.S. Department of Justice. Retrieved from: 44 Handwerk, M., Copton, K., Huefner, J., Smith, G., Hoff, K., & Lucas, C. (2006). Gender differences in adolescents in residential treatment. American Journal of Orthopsychiatry, Vol., 76, No.3,

47 years old) admitted to a large residential facility in the Midwest between January 1994 to September 1997 and May 1999 to September The mean length of stay for boys and girls combined was 17.6 months. Boys had a lower LOS, with a mean of 16.9 months and girls had the higher LOS, with a mean of 18.8 months. This program uses the behaviorally oriented teaching-family model where married couples who are highly trained supervise the treatment of six to eight same-sex youths living in a residential home. In addition to the girls having a longer length of stay, girls also exhibited more behavioral and emotional problems than the boys, had higher scores on standardized behavior checklists at admission, had more psychiatric diagnosis and more problems behaviors during their residential stay. This study used the DISC, 45 a highly structured interview with criteria. Using the DISC, the rates of internalizing disorders were significantly higher for girls at admission and at one year. Girls also exhibited equally high rates as boys of externalizing behavior. Among the several limitations of this study, the most significant one is that it used only one residential facility. One study conducted a five year study to identify predictors that might forecast lengths of stay in residential treatment. 46,47 No studies prior to this one (per author) looked at predicting length of stay in preadolescent residential care. The study included 126 youth ages 5-13 admitted to a psychiatric residential program in Ohio. The median length of stay was 374 days. However, the average length of stay was not reported. The majority of youth in this study population was from abusive environments (73%), from families with significant alcohol/drug (44.4%), had histories of psychopharmocological treatment (89.7%), had an average Full Scale IQ of 82.7, and at least 42.1% had at least one primary caregiver with mental illness. Unplanned discharges and elopement were rare occurrences. Five predictors were used in this study: Child s behavior problem scores based on The Devereux Scales of Mental Disorders (DSMD) 48 that was administered during the first days following admission, Demographics: age at entry, race, gender, IQ, Clinical characteristics and placement history: number of out of home placements And eight indicators of parental characteristics The primary statistical method used was Cox regression model. Significant findings of the study included the following: 45 Shaffer, D., Fisher, P., Lucas, C., Dulcan, M., & Schwab-Stone, M. (200). NIMH Diagnostic Interview Schedule for Children Version IV: Description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39, Hussey, D.L., & Guo, S. (2002). Profile characteristics and behavioral change trajectories of young residential children. Journal of Child and Family Studies, 11, Hussey, D.L., & Guo, S. (2005). Forecasting length of stay in child residential treatment. Child Psychiatry and Human Development, Fall, 36 (10): Naglieri, J.A., LeBuffe, P.A., & Pfeiffer, S.I. (1994). The Devereux Scales of Mental Disorders. Psychological Corporation. Hartcourt Brace & Co. Toronto, Ontario, Canada. 47

48 Using the DSMD, each one-unit increase in the score of critical pathology decreased the rate of discharge from residential by 4% (or 40% longer stay). Of the total DSMD score, children with the highest measure/score were discharged at the slowest rate. Of those with the highest score, 83% remained in care by the end of the 18 month period compared to 10% remaining in care with the lowest measure/score. This is a similar finding as the gender differences study cited earlier, which found a correlation with longer length of stay and those with more psychiatric symptoms and a higher score on a behavioral checklist at admission. Race was identified as a factor. African American youth were discharged at a rate 44% slower than for other children (56% remained in residential at end of 18 months vs. 35% other). Younger age at entry proved a significant factor for longer lengths of stay. For every year of increase in age at admission to residential, the rate of discharge increased by 30%. Children entering residential at age five had the slowest rate of discharge, with 80% remaining in care vs. 18% of thirteen year olds at the end of the study period. Parental Alcohol Abuse. Interestingly, youth whose parents had a history of alcohol abuse were discharged from residential care at a rate that was 183% quicker than the rate for the children with non-alcohol abusing parent(s). This was thought to be because discharges to foster and permanent adoptive placements occur more easily than attempting to discharge to the dysfunctional family. Psychopharmocological treatment. Youth on medication were discharged at a rate that was 61% slower than non-medicated youth. This is consistent with the finding that the symptoms and behavioral severity of psychiatric illness are linked to longer lengths of stay. Residential length of stay proved to be linked strongly in this study to presenting levels of psychiatric symptomatology. A standard deviation increase of ten-points in the DSMD score led to a 40% increase in length of stay. In total, the predictors of longer lengths of stay included the child s race, parental alcohol abuse, medication use, younger age, and high critical pathology scores on the DSMD. Limitations in this study included the use of a conservative chart review for some of the data and the study used only one residential facility and no control group. Similar findings were reported in another research study. 49 This study looked at variables affecting length of stay in one child welfare residential program. Researchers used an event-history analysis on 416 boys from admission to discharge. They looked at the rates of discharge over time and the covariates of LOS. On average the LOS was 1.7 years but varied greatly with type of discharge/exit. Results showed that longer lengths of stay were associated with youth that had mental health issues and returned 49 Baker, A.J., & Wulczyn, D., May-June (2005). Covariates of length of stay in residential treatment, Child Welfare. 84 (3): Center for Child Welfare Research, USA. 48

49 to the community (45% parents/relatives) or were transferred (41% transferred to other settings years). Children who aged out, ran away and had a substance abuse history were discharged at a faster rate, i.e. 14% of those who ran away did so within six months of admission. This study also found that psychiatric symptomatology and crises within the program added seven months onto length of stay for both reunified and transferred children. Covariates of quicker discharge for the transferred youth were prior placements and prior psychiatric hospitalizations or suicidal behavior. Discharge due to run away status was linked to substance abuse, parental incarceration, juvenile delinquency and being older. Data in this study was for only one facility. The several studies mentioned above on predictors linked to residential length of stay are similar to the same variables linked to length of stay in inpatient facilities. In a five year large scale study of admissions at Illinois State Hospital 50 it was found that longer lengths of stay was associated with: younger ages, race, diagnosis of attention deficit disorders, psychotic disorders, and conduct disorders, and higher number of previous psychiatric hospitalizations. In this study, however, males were associated with higher lengths of stay. In a 2005 dissertation on Factors Affecting Length of Stay in Residential Treatment the author examined the effects of various clinical and non-clinical factors on LOS for children with serious emotional disturbance. 51 In this study of one northeastern residential program, a cohort of 165 children admitted between September 1995 and December 2003 was used. Results showed the following factors predicted length of stay: number of previous psychiatric hospitalizations (probability of discharge was significantly lower for children with a high number of previous hospitalizations), DSMD externalizing and internalizing scores (only slightly longer lengths of stay were noted for children scoring high internalizing scores), and rate of physical restraint while in the program (high rates of restraint early in treatment were associated with quicker discharges and restraints occurring later in the stay led to a longer length stay). The author notes that when using a discrete-time hazard model and adding these variables together, only physical restraint retained significance. The following findings were also notable: The youth s age at intake into residential was not found to be a significant predictor. This is an opposite finding from Hussey, D. and Guo, S.l., (2005) study referenced earlier. Involvement of family members during the youth s residential stay did not result in a statistically significant longer length of stay. This is an opposite finding from Frensch, K.M. and Cameron, G. (2002) as noted earlier. 50 Meyer, E., Gray, C., Russell, R., & Johnson A. (2001). The utilization of inpatient hospitalization psychiatric services by children and adolescents in Broome County January: , p.7. The Broome County Mental Health Department, Binghamton, N.Y. 51 English, K.A. (2005). Factors affecting length of stay in residential treatment for children with serious emotional disturbance. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, May, 2005, Boston College, Graduate School of Social Work. 49

50 Reduced funding burden in the form of a cost-sharing agreement resulted in only a slightly lower LOS than for children placed/funded by only DSS or local education authorities. English posits that it is the variables specific to the current treatment that actually influence length of stay (i.e. physical restraint) and that predisposing factors (psychopathology, family involvement, gender, age, etc.) may effect the probability of a child being admitted to residential but may have little effect on length of stay once admitted. This author noted that it is extremely difficult to identify factors that are related to length of stay. The limitations of this study include that only one facility was used, data was based on an existing database, the reason for discharge was not taken into account, and the scale level of predictors was not always sensitive enough. For example, the family influence was measured only by the existing data that indicated a family member was available at time of admission. So if a family was involved during treatment but not indicated to be available at the time of intake, this would not be included. A facility s design and clinical programming is an important factor to consider as far as its impact on influencing length of stay. As is known, program lengths of stay are sometimes built into the youth s overall treatment plan, whether written or unwritten. English's dissertation concludes that it is not predisposing factors that determine length of stay, but rather factors related to the child s treatment while in the residential program. In researching for information on the effects of a facility on length of stay, there was only one study that could be found, however only the abstract was available from the Academy Health Meeting. 52 This study examined patient-level factors vs. facility-level factors impacting residential length of stay of youth with mental health, substance use, and co-occurring disorders. This study also included a methodology for identifying facilities whose patients on average had a marked short or long length of stay. Using a cross-classified structure/model (patients receiving care at multiple facilities during the study time period), the authors estimated LOS with the following covariants: Patient characteristics- age, gender, race, insurance, and diagnosis upon admission. Facility characteristics were facility type and primary specialty. Their findings suggest only 8% of the variation in length of stay was explained by variables at the patient-level versus 47% being explained at the facility level. They further suggest the importance of monitoring facility processes and outcomes. Summary: Length of Stay in Residential Treatment Centers The current literature that exists on residential length of stay is scarce. What we do know is that there is considerable variability in the lengths of stay among facilities and little agreement upon the factors that may predict length of stay. In general, not a lot of research has been done on residential programs as a discrete level of care. This, 52 Gifford, E., Foster, M.E., & Olchowski, A. (2004). Understanding provider influences on residential length of stay among youth with mental health, substance abuse, and co-occurring disorders: A multilevel approach. Abstract from the Academy of Health Meeting. 21: Abstract No Penn State University, Health Policy and Administration, 116 N. Henderson State College, PA

51 despite the system reform efforts over the years to treat children in the least restrictive environment. Residential treatment is used by mental health, child welfare, and juvenile justice and still there is no agreed upon standards for success of residential treatment and no real system for data collection. 53 Although most children make gains during residential treatment, 20-40% either had no improvement or deteriorated. 54 Based on the literature reviewed, the following items may be fruitful areas for further inquiry as Connecticut (i.e., DCF, the Department of Social Services, and CT BHP) works to decrease residential length of stay and right-size the congregate care system over the next several years: Conduct a comparative length of stay analysis of comparable Connecticut residential treatment centers and identify those with the highest/lowest LOS. Examine diagnosis or clinical indicators at admission for a discrete time period to evaluate if a correlation with diagnosis exists. Examine length of stay based on gender, age groupings, and race. Quantify family involvement and incorporate this as an outcome measure. Examine outliers: Conduct a case study of children who had relatively short lengths of stay and relatively long lengths of stay and qualify type of discharge; identify factors that may play a role in length of stay. Explore readiness for discharge to determine the critical factors indicating that a child is ready for discharge to a lower level of care. Flag children who have indicators for high-risk of long length of stay (i.e. young at admission, have previous psychiatric hospitalizations, and have significant psychiatric symptoms) for more aggressive discharge planning and to avert from residential care when possible. Contact two of more facilities in other States that have successfully decreased their residential length of stay and identify the program models used, strategies used to change the culture so a prescribed short length of stay upon admission is innate for a facility, levels of staff training (crisis and de-escalation), and, Identify one or two residential treatment centers willing to pilot a new clinical design and monitor for decreased lengths of stay In general, there is a dearth of quality research on group homes and on other congregate care programs other than residential treatment centers. One reason that 53 Walter, U. (2007). Best practices in children's mental health; Report #20: Residential Treatment, A review of the national literature: August University of Kansas, School of Social Welfare. Retrieved from: 54 Ibid 51

52 much of the research on congregate care focuses on residential treatment centers is that residential centers typically serve a larger number of children, which is often helpful in a research design. However, studies on other types of congregate care settings clearly exist. For example, in a comprehensive qualitative research study on adolescents living in group home settings in New York City, authors concluded that care for those youth was variable and that teens placed in these homes were at risk for a high level of violence. 55,56 The study was conducted by three advocacy groups and with cooperation from New York City's Administration for Children's Services (ACS). Authors noted that stealing was a pervasive problem in the group homes, and that permanency planning was inadequate. Recommendations from the study included: 1) New York City should reduce its reliance on congregate care and develop family based placements; 2) Congregate care in New York City should be redesigned so that the programs are service-based, family-like, and safe; 3) Private agencies that provide congregate care and ACS must be held fully accountable for the outcomes that are and are not achieved and that provider agencies should have contracts with outcome measures that are specific to the needs of the youth in congregate care. In a report on the Stanford Wraparound Program in Sacramento County, California, researchers used an experimental design to analyze program outcome data for children who received wraparound services in a Stanford group home in comparison to those who received traditional residential services in that home. 57 The wraparound program is a family-centered, strengths-based program that is designed to facilitate access to community options and activities for children. Data was collected between One finding was that children who received the wraparound services showed significantly more improvements in their behavioral functioning that did children who were in the traditional residential services group. In addition, youth in the wraparound group were more likely to be discharged to a more desirable family-based and community setting than the traditional residential services group. Research on congregate care placement for very young children (i.e., infants and toddlers) consistently demonstrates that group care placement for this population can be detrimental. The author of a research study comparing the development of a group of children raised in a congregate care setting with a comparison group of children placed in foster care homes concluded that the foster care group fared better than their group-reared counterparts on a variety of variables, including adaptive behavior and cognitive development. 58 In a similar vein, authors of a summary article on the effects of orphanage placement on infants and toddlers concluded that early institutional placement puts very young children at increased risk of serious infectious illness and 55 (2003) First qualitative research study of New York City teens living in foster care finds services extreme. Retrieved August 3, 2009 online from 56 Kaufman, L. (2003, November 6). Survey backs reputation of danger in group homes. The New York Times, Section B., p Richardson, G., & Fraguela, M. (2005). Additional findings from the Title IV-E child welfare project: Waiver demonstration project: A comparison of wraparound and residential treatment services using an experimental design. Retrieved August 17 th, 2009 online from 58 Harden, B.J. (2002). Congregate care for infants and toddlers: Shedding new light on an old question. Infant Mental Health Journal, 23(5),

53 delayed language development. 59 The authors concluded that, in the long term, institutionalization in early childhood increases the likelihood that children will have psychiatric impairments and economic challenges later in life. This is consistent with research on children raised in international orphanages. This research concludes that very young children raised in institutions demonstrate poorer physical growth and deficits in cognitive development and competence in comparison to peers who have never been institutionalized. 60 Viewing congregate care treatment as a necessary level of care in a continuum of service Several factors have converged over the years that have caused policymakers and researchers to question the effectiveness of congregate care treatment and its place in the treatment continuum. Beginning with deinstitutionalization in the 1980 s, a shift in the service delivery paradigm from a traditional two-tiered model has paved the way for continuum-based community treatment. Similar to the closing of state hospitals, over time residential treatment has come to be viewed by some as an archaic treatment that is detrimental to children and reminiscent of the old state hospital on the hill. Since the 1990 s, providing services to youth and families in the least restrictive and most appropriate level of care within a continuum based system of care model has been widely adopted in the child welfare and behavioral health field. The more structured settings, such as residential treatment, are usually seen as a last resort treatment option, even if residential treatment may in fact be the best fit. 61 The emphasis on least restrictive at times tends to drive practice patterns and program model development more than most appropriate. In efforts to develop these systems of care, federal and state dollars have been reduced over recent years for residential care and redirected towards funding less restrictive home-based care and community services. Another factor that causes policymakers to reconsider the effectiveness and need for residential treatment programs is the high cost of providing residential treatment, second only to inpatient care. In Connecticut the average cost per child for residential treatment has risen by almost 46% from , this despite the number of children served declining. Nearly 25% of the Nation s budget for child mental health was spent on residential care according to the Surgeon General s report in 1999, and this expenditure has increased in the past ten years. 62 During the twenty year period , the number of children utilizing residential treatment has increased significantly. In 1980 there were 125,000 children being treated in residential treatment and by 2000 the number of children treated in residential 59 Frank, D.A., Klass, P.E., Earls, F., & Eisenberg, L. (1996). Infants and young children in orphanages: One view from pediatrics and child psychiatry. Pediatrics, 97(4), Smyke, A.T., Koga, S., Johnson, D.E., Fox, N.A., Marshall, P.J., Nelson, C.A., Zeanah, C.H., & the BEIP Core Group. (2007). The Journal of Child Psychology and Psychiatry, 48(2), Bilchik, S. (2005). Residential treatment: Finding the appropriate level of care. Residential Group Care Quarterly, 6 & Temple University Remarks at Child Welfare League of America, 62 Surgeon General (1999). Mental Health: A report of the Surgeon General. Retrieved from: 53

54 treatment had risen to a quarter million. 63 Now that almost ten years of systems of care have been in place in many States, utilization and funding of residential care has begun to decrease gradually. Is residential treatment effective and does it have a place in the continuum of care? The answer is a qualified yes, when provided to the right child at the right time, for the right period of time. Despite its decrease in popularity over the years, residential treatment is an important tool within the continuum of care to be utilized by child welfare, juvenile justice and mental health as a necessary treatment option for youth and families. The often quoted Child Welfare League of America position statement on residential services 64 "strongly endorses a system of care that includes residential services as an integral component of the continuum of services. Just as the plan to increase outpatient clinics to stop the use of hospitalization was unrealistic, residential treatment cannot be replaced by community supports. As essential as community supports are, not all community supports can replace all other treatment interventions. Residential treatment should be considered an appropriate clinical intervention within the available continuum of care. How effective residential treatment is can be answered better by the questions: What youth are better served by residential treatment and what does a residential program need to look like in order to produce positive outcomes for youth and families? As we know, research on residential treatment is sparse and unfocused compared to research conducted for other levels of care. Outcome research results are mixed, and whether with positive or negative outcome results, results need to be interpreted with caution due to the many challenges in conducting research with residential treatment programs. 65 Some of the major challenges recognized throughout the literature repeatedly with respect to measuring the effectiveness of residential treatment are: A high degree of heterogeneity and variability exists within and between facilities. Treatment centers vary greatly in the populations served, therapy and educational modalities and expected/requisite length of stay. Accordingly, it is difficult to compare and generalize study results; "Residential treatment" is often used as an umbrella term which may obfuscate research finding with a broad-brush to all of residential treatment"; Residential treatment centers are not controlled settings that can be duplicated; Rigorous data collection is rare with most studies; No comparison groups and small sample sizes are characteristic of most studies; 63 Magellan Health Services (2008). Perspectives on residential and community-based treatment for youth families Bilchik, S. (2005). Residential treatment: finding the appropriate level of care. Residential Group Care Quarterly, 6 & Temple University Remarks at Child Welfare League of America, 65 Walter, U. (2007). Best practices in children's mental health; Report #20: Residential Treatment, A review of the national literature: August University of Kansas, School of Social Welfare. Retrieved from: 54

55 Studies fail to control for acuity or complexity of behavior dyscontrol; Less funding is available to study effectiveness of residential treatment Given the many challenges and limitations to conducting outcome research with residential treatment programs, it has been recommended that further research in the field be qualitative in nature (i.e. family involvement), not quantitative, to better capture the complexities of a residential treatment program. 66 This is an important point. Qualitative research is holistic and contextual and used alone, or if paired with quantitative research, may lead to more robust findings as to the effectiveness of residential treatment. How the youth and family experience their time in residential treatment and whether or not they thought the treatment was effective is, after all, what is truly important. And the benefits from residential treatment as determined by the youth and family upon interview may not even be known for years after discharge, and there are very few longitudinal studies that exist on residential care. Other invaluable qualities difficult to analyze and objectify are consistency, structure, caring, nurturing, self-reflection on mental health issues and limit setting. 67 Hence, Not everything that counts can be counted, and not everything that can be counted counts (Einstein, 1933). Without question, the power of a treatment milieu is difficult to measure and quantify. Whittaker (2004) has commented that the government ideology that shifts funding from service-centered planning to child and family centered planning threatens the focus of residential treatment as a total intervention. 68 He maintains that to understand the therapeutic milieu both types of planning are necessary. Although difficult to measure, the milieu should be studied for what it offers- a predictable and stable environment, educated staff and professionals, opportunities for therapeutic work and psychological support, a sense of community and culture, and the effects of a positive mentor or role model. It is the insufficient and weak efficacy research to-date on residential treatment that has led, in part, to funding cuts for the provision of residential treatment. 69 This has been influenced by reports by both the General Accounting Office (1994) and The Surgeon General s Mental Health Report. 70,71 Both have reported there is not enough research completed to-date, and the research is weak regarding the effectiveness of residential 66 Hair, H.J. (2005). Outcomes for children and adolescent after residential treatment: A review of research from Journal of Child and Family Studies, 14 (4), ; Data Trends, February, 2006, No Butler, L., & McPherson, P. (2006). Is residential treatment misunderstood? Journal of Child and Family Studies, at Springer Science and Business Media, LLC Whittaker, J.D. (2004). The re-invention of residential treatment: An agenda for research and practice. Child and Adolescent Psychiatric Clinics of North America, 13, Butler, L. & McPherson, P. (2006). Is residential treatment misunderstood? Journal of Child and Family Studies, at Springer Science and Business Media, LLC United States General Accounting Office, January, Residential care: Some high-risk youth benefit, but more study needed. Appendix I., Retrieved from: publications and testimonies. 71 Surgeon General (1999). Mental Health: A report of the surgeon general. Retrieved from 55

56 treatment. This lack of well-defined effectiveness research has posed a barrier to identifying best practices and has also been affected by federal agency and private foundation fiscal inattention to new residential treatment models as compared to other types of out-of-home placement. 72 In taking all of the above in to consideration, it is safe to say we are faced with 1) outcome research that is sparse, weak, and often challenging to interpret and to apply to the field, and 2) a somewhat discouraged residential care system providing level of care within the most difficult economic times. However, for almost every study found when conducting this literature review that showed negative outcomes for youth receiving residential treatment, there is at least an equal number of studies that was found showing positive outcome data. Among many programs reporting positive outcomes, some of the programs cited as having reported positive results from research are: Girls and Boys Town 73 The WAY (Work Appreciation for Youth) Program at Children s Village in Dobbs Ferry, NY 74 The IARCCA- An Association of Children and Family Service (Outcome Measures Project in Indianapolis, Indiana) 75 Lutheran Children and Family Services 76 Silver Springs Martin Luther School 77 Below is a compilation with brief summaries of some of the research studies reviewed, followed by a summary of the key characteristics common to residential programs that have been linked to positive outcomes: A study was conducted in 1992 by Hoagwood and Cunningham of 114 children and adolescents with serious emotional disturbance (SED) who were referred by school districts to residential treatment for educational purposes. 78 Results showed nearly 63% of the youth had made either no progress or little progress, had ran away from the program, or had been discharged with a negative outcome. 25% of the cases resulted in positive outcomes defined by the youth s placement in a vocational training school or return to school or placement, and positive outcomes were also associated with shorter lengths of stay. The availability of community based services was found to be the single-most likely reason for successful discharge with a positive outcome. 72 Whittaker, J.D., & Maluccio, A.N. (2002). Re-thinking "child-placement": A reflective essay. Social Service Review, 76, See 74 See 75 See 76 See 77 See 78 Hoagwood, K., & Cunningham, M. (1992). Outcomes of children with emotional disturbance in residential treatment for educational purposes. Journal of Child and Family Studies, 1,

57 A research study on the effectiveness of residential treatment was conducted by Zhang and Feller (2007). 79 This comprehensive computer search was conducted using eight scholarly/academic databases and twenty full articles were selected from 128 abstracts. Authors of this review found that, overall, positive outcomes were more commonly found in the literature review than negative outcomes. Some of their research cited included: Goodrich (1985) as finding a significant number of difficult adolescents showed improvement and were living relatively normal lives following longterm residential treatment. 80 In 2000 a study conducted by Hooper, Murphy, Devaney, and Hultman on 111 adolescents in an educational residential facility found that 60% had a successful outcome at 6, 12, 18 and 24 months post-discharge. 81 In Ireland, a study by Moore and O Connor (1991) was conducted using a retrospective chart review. It was found that most of the children with poor relationships with authority figures and peers upon admission improved to adequate or better skill level at discharge. 82 Hair (2005) conducted a research review for past empirical studies on positive outcomes of residential treatment at discharge and after discharge. 83 The author selected eighteen research studies conducted between with the following in common: each RTC treated youth with SED, provided on-site schooling, had trained staff, and had a discharge goal for the youth to return to the community. The research showed that frequent family visits while in residential treatment and participation in family therapy were associated with positive outcomes at the time of discharge. A shorter length of stay was also suggested to allow for more treatment gains as at-risk behaviors were typically reduced within the first six months of residential treatment. One such study showed significant improvements for young people who had just three to four months of residential treatment. 84 Success following RCT discharge was associated with three factors: extent of family involvement in treatment, stability of the youth s post-discharge placement, and available aftercare support. Hair s (2005) research conclusion was that "..children with severe emotional or 79 Zhang, S., & Feller, K. (2007). A brief review on outcomes of residential treatment for children and youth. Technical Assistance Center for Children's Services, Social Research Institute, University of Utah; p Goodrich, W. (1985). Symbiosis and individuation: The integrative process for residential treatment for educational purposes. Journal of Child and Family Studies, 1, Hooper, S.R., Murphy, J., Devaney, A., & Hultman, T. (2002). Ecological outcomes of adolescents in a psycho-educational residential treatment facility. American Journal of Orthopsychiatry, 70(4), Moore, L.M., & O'Connor, T.W. (1991). A psychiatric residential center for children and adolescents: A pilot study of its patients' characteristics and improvement while resident. Child Care, Health, and Development, 17, Hair, H.J. (2005). Outcomes for children and adolescents after residential treatment: A review of research from Journal of Child and Family Studies, 14(4), ; Data Trends, February, 2006, No Leichtman, M., Leichtman, M.L., Cornsweet Barber, C., & Neese, D.T. (2001). Effectiveness of intensive short-term residential treatment: A statewide evaluation. Journal of Child and Family Studies, 10:

58 behavioral problems and their families can benefit from residential treatment that is multi-modal, holistic, and ecological in its approach. The author also believed that residential treatment appears to be a valuable treatment option within the system of care for youth with severe emotional and behavior problems. Despite shortcomings in the research, residential services were found to improve functioning for some, but not all, youth. Gains were difficult to maintain following discharge. 85 The authors state that the level of family involvement during treatment and the availability of aftercare services are key to successful posttreatment adjustment. They recommend continued long-term follow up studies of youth discharged from residential settings. In a longitudinal study that was conducted of thirty young men who had previously been in residential treatment between 1986 and 1993, 83% of the young men were now living independently in the community or with significant others. 86 Achievement of treatment goals while in residential treatment and good social functioning were linked with positive outcomes. Most of the young men in the study benefited from residential treatment, especially their experience of academic achievement. Residential care that is family-centered has resulted in shorter lengths of stay, an increased rate of returning home at discharge, and improved stability after discharge compared to youth who were in traditional residential. 87 This study demonstrated that significant improvements for youngsters who had just three to four months of residential treatment. Success following discharge was associated with three factors: extent of family involvement in treatment, stability of the youth's post-discharge placement, and available aftercare support. The IARCCA Outcomes Measures Project of Indiana tracked 19 of its member agencies over a five-year period. 88 Authors found the following: 86.9% had positive educational outcomes at discharge and 86.8% had sustained them a year later Youth in residential care had made more gains in key areas than those in home-based foster care or shelter care As the number of prior placements increased, positive outcomes decreased 85 Frensch, K., & Cameron, G. (2002). Treatment of choice or a last resort? A review of residential mental placement for children and youth. Child and youth Care Forum, Volume 31, Number 5, pp Kaminsky, I. (1998). An assessment of young men previously in residential treatment: Is the past prologue? Residential Treatment for Children and Youth, 16 (2), Landsome, M.L. Groza, V., Tyler, M., & Malone, K. (2001). Outcomes of family-centered residential treatment, Children Welfare, 80 (3), IARCCA-An Association of Children and Family Services (2006). Indianapolis. findings. 58

59 A 1991 Canadian study found that for children who were severely impaired at admission, upon discharge they were moderately impaired and normal at one and three years after discharge. 89 The number of concerns expressed by caregivers decreased from admission to discharge, and six months, one year and two years after discharge, in a study for a group of children in residential care with conduct disorder. 90 A 23 year longitudinal Israeli study of 268 children placed in residential care found that these children following discharge functioned adequately or as well as young adults. 91 The authors concluded that neither pre-school nor long term residential care was harmful in terms of normative living, and that a majority of those functioning well during their teenage years significantly improved since then. The National Association of Therapeutic Schools and Programs (NATSAP) reviewed the findings of a large-scale multiphase study that was presented to the American Psychological Association in August The cohort consisted of 992 male and female adolescents ages years old admitted to a private residential treatment between The parents and adolescents were surveyed at the time of admission to residential treatment and at discharge. Aggressiveness, withdrawal and rule breaking had decreased to normal levels and the changes were both statistically significant and clinically meaningful to the family. Both the adolescents and their families rated the level of clinical impairment of emotional and behavioral functioning as normal after treatment. According to this study, most teens who had not responded to other treatments improved during treatment at a private residential treatment program. The recommendation for families was to seek programs with proven records of safety, licensed and accredited facilities and staffed with licensed and qualified therapists, teachers and administrators. The following characteristics have been associated with long-term positive outcomes: active family involvement and participation, caring adults to provide supervision and support, a skills focused curriculum, individualized treatment plans, positive peer influences, coordination of aftercare services, enforcement of 89 Blackman, M., Eustace, J., & Chowdhury, A. (1991). Adolescent residential treatment: A one to three year follow up. Canadian Journal of Psychiatry, 36, Day, D.M., Pal, A., & Goldberg, K. (1994). Assessing the post-residential functioning of latency-aged conduct disordered children. Residential Treatment for Children and Youth, 11, Weiner, A., & Kupermintz, H. (2001). Facing adulthood alone: The long-term impact of family break-up and infant institutions: A longitudinal study, British Journal of Social Work, 31, Behrens, E. (2006). Canyon Research and Consulting, Salt Lake City, Utah. 59

60 discipline, educational support, building self-esteem, and a family-like 93, 94 atmosphere. Magellan Health Services-Children s Services Task Force (2008) published their perspective on residential and community based treatment after reviewing the research. While focusing on community based and wraparound services as optimal when they can be used, they concluded that residential treatment remains an important component of the system of care and that when residential treatment is required, a short length of stay (three to six months), a focus on family involvement in treatment, and early discharge planning and community reintegration should be considered. In their review of the literature, they found that residential treatment may be more effective with PTSD and emotional disorders rather than ADHD and behavioral disorders. 95 Also, those who cannot be safely treated in a community setting are usually better treated in a residential setting. 96 They also cited research with negative outcomes. A large longitudinal six-state study of adolescents discharged from residential treatment found at a seven year follow-up that 75% had either been readmitted or incarcerated. 97 Some viewed residential treatment as associated with continuing placement and dependency. 98 Research studies completed to-date point to both predictor indicators and program qualities that appear to lead to positive outcomes. They are in the diagram summarized below: 93 Curtis, P.A., Alexander G., & Lunghofer, L.A. (2001). A literature review comparing outcomes of residential group care and therapeutic foster care. Child and Adolescent Social Work Journal, 18, Pecora, P.J., Whittaker, J.K., Maluccio, A.N., & Barth, R.P. (2000). Child Welfare Challenge. (2 nd edition). New York: Aldine DeGryter. 95 Lyons, J.S., Terry, P.I., Martinovich, Z., Peterson, J.I., & Bouska, B. (2001). Outcome trajectories for adolescents in residential treatment: A statewide evaluation. Journal of Child and Family Studies, 10: Mercer Government Human Services Consulting. (2008). White Paper Community Alternatives to Psychiatric Residential Treatment Facility Services Commonwealth of Pennsylvania, Office of Mental Health and Substance Abuse Services. 97 Burns, B.J., Hoagwood, K., & Mrazek, P.I. (1999). Effective treatment for mental disorders in children and adolescents. Clinical Child and Family Psychology Review, 2, Asarnow, J.R., Aki, W., & Elson, S. (1996). Children in residential treatment: A follow-up study. Journal of Clinical Child Psychology, 25 (2),

61 Diagram 1. To avoid an overreliance on congregate care, DeMuro (2008) 99 suggests the following concrete steps: 1. Develop flexible and supportive family and community supports that are available 24/7 so that children and teens can be diverted at the front door of the placement continuum; 2. Develop crisis resolution programs that are designed to reduce family and foster care disruptions; 3. Work to embed the belief in all staff and in agency policy and practice that adoption is a practical option for all children for whom the agency has permanent custody, including older children and teens; 4. Develop, maintain, and support an expanded network of neighborhood based foster homes, particularly foster homes that are "teen-friendly". Assist private agencies to develop new, intensive models of community and family focused interventions; 5. Work to ensure that all teens' need for permanence is kept at the center of their case plans, especially for all youth placed in shelter or residential care; 6. Implement strong gate-keeping processes that are in place before a residential placement for a youth is approved. Children and youth and their families should be given voice and choice during the gate-keeping process by involving them in the decision making process in their own cases; 7. Ensure that case reviews are held on a regular basis for all children and youth in residential placement. These reviews should include the children and youth and 99 DeMuro, P. (2008). Why child welfare agencies should limit the role of residential care. Journal for Juvenile Justice Services, 22 (1),

62 their families and should focus on the children and youths' need for permanence and not just focus on "clinical" issues; 8. Monitor the quality of all residential programs and monitor the length of stay for all children in placement--given that there is no documented association between longer lengths of stay in residential care and improved outcomes; 9. Ensure that child welfare workers visit children and youth in residential placement regularly and that they encourage family members to visit their family in placement; and, 10. Develop a placement continuum that emphasizes effective community based, family focused interventions that ensure that youth in placement remain geographically close to their families and communities. The National Building Bridges Initiative is an example of a trend towards linking congregate care and community based service delivery providers. Representatives from DCF have participated in Building Bridges activities and teleconferences. The first national Building Bridges summit occurred in 2006 and included professionals, family members, and youth. The purpose of the summit was to: 1) Establish defined areas of consensus, related to values, philosophies, services and outcomes; 2) Develop a joint statement about the importance of creating a comprehensive service array for children, youth, and families, inclusive of residential and out-ofhome treatment settings as part of the entire range of services; 3) Identify emerging best practices in linking and integrating residential and home and community-based services; 4) Set the stage for strengthening relationships and promoting consensus building; and, 5) Create action steps for the future. As a result of this summit a Joint Resolution of common purpose, shared principles, values, and practices was developed. 100 To continue the work initiated at this summit, a workgroup was formed to begin the process of identifying promising approaches and barriers to implementing the principles of Building Bridges. This workgroup held six two hour conference calls with over 100 participants from various states and agencies during 2007 to explore innovative practices in each of the following areas: Family driven and youth guided Cultural and linguistic competence Clinical excellence and quality standards Accessibility and community involvement Transition planning and effective workforce development Assessment, Evaluation, and Continuous Quality Improvement. 100 Building Bridges between residential and community based service delivery providers, families, and youth: Joint resolution to advance a statement of shared core principles. Available at 62

63 Workgroups towards implementation of the goals of Building Bridges was established in October, The Initiative is an effort to stimulate the development of practices that integrate all levels of care within local community systems. The Initiative was developed in response to a perceived disconnect between community services and/or systems of care and residential treatment. Learning from Focus Groups and Peers After completing a review of relevant literature, the workgroup undertook to meet with children, youth, and families who had direct or indirect experience with congregate care facilities in Connecticut. Thus, the DCF work group held three focus groups in order to better understand first-hand experiences. Below are the summaries of these groups: Focus Group with the DCF Youth Advisory Board. 15 participants from the DCF Youth Advisory Board attended a focus group on congregate care. Approximately 75% of the participants had personal experiences in congregate care and 100% of the group had relatives or acquaintances that had been in congregate care. Of the 15 participants, 100% reported that they believe that congregate care is necessary for some children. The group's concerns about congregate care included: Lack of adequate training for staff members to work with a specific population (e.g., older adolescents, young children, etc.); Lack of training in psychology, confidentiality, and child development Rules in congregate care setting change too often; Privileges in congregate care setting seem to be tied to impossibly high expectations. Group suggestions to improve congregate care included: Keeping the settings "small" (e.g., less than 10 children); Offering children after school programs such as art, martial arts, dance; Reducing the amount of "talk therapy" in congregate care settings and replacing the therapy time with hands-on and creative activities that "burn energy;" Emphasizing planful transitions from congregate care placements to less restrictive environments; Improving the matching system by allowing children to visit programs at least three times and have at least one overnight visit; Keep the child's actual length of stay consistent the original design of the program (e.g., 60 days, 90 days, etc.); Focus treatment on basic coping skills; Reduce reliance on "psychiatric medication" in congregate care treatment. The majority of the group had personal experiences in foster care. When asked if expanding foster care would be an appropriate alternative to congregate care, one 63

64 member responded "Yes, but only if DCF gets better foster families" for recruitment. Members of the group reported that their concerns about foster care included: Foster families lack training to handle multiple needs in foster children and that the "standards for being a foster parent are very low;" Foster parents should become "certified" and not just attend short classes for training. The group suggested that foster parents should attend the same training as congregate care providers; Several group members reported that they weren't always comfortable in foster care placements, that the families didn't generally care about them, or they had conflicts with the foster family's relatives; Some participants noted that foster families were too strict, and didn't have consistent core values with them; Others reported that, at times, congregate care settings were preferred to foster care placements because the intimacy in a family setting was not "bearable." Focus Group with the Department of Mental Health and Addiction Services-Young Adult Services (YAS): Nine former DCF clients served by YAS participated in this focus group. All of the participants had been in some form of DCF funded congregate care during their childhood and eight participants had been in foster care at least once during their childhood. Participants agreed that at times congregate care settings are necessary for children. Suggestions for DCF included: Giving parents be given "more time" and "support to get on their feet" before placing children outside of their home; Canvassing extended family members before using congregate care; Only place children in congregate care settings if they have "unstable homes," show "clear signs of abuse" and have failed in family placements and in foster care; Offering families help in finding community support services, programs to help single parents, and programs to support parents who have mental health/substance abuse problems; DCF should assess children's academic functioning before placing them in a congregate care setting with school on-site (e.g., in a residential treatment center); Suggestions on improving treatment/programming in congregate care settings included adding more 'hands on" activities such as art, music, and sports; Congregate care settings should slowly transition children into less structured settings since "children need to learn to crawl before they walk" and "children need to be ready for prime time." Concerns about DCF's use of congregate care included: 64

65 Children get into "trouble too easily" and lose privileges in congregate care placement; Staff do not seem to have adequate training in psychiatric disorders and in trauma; One group member noted that multiple placements interfere with academic progress and that multiple placements can prevent children from going to college; Point systems and level systems "are meaningless" used in congregate care programs don't help children return to the community; DCF places children in "too many places" and that children are moved too easily from one placement to another; Programs "give up too easily" and request a removal. When asked about foster care experiences, group members reported that the best foster placements were with families that treated them "like regular family and like their own children." The group also noted that they did have some strong attachments to various foster families. One suggestion for foster care was to "match" children and families more closely based on core principles and values. Focus Group with Family Members of Children/Youth: Representatives from 12 different families participated in a focus group on congregate care in Connecticut. Every member of the group had either children or grandchildren who had been served in a congregate care setting. The group unanimously agreed that congregate care treatment was necessary for children in Connecticut. Concerns about congregate care settings were that "direct care staff aren't trained well" and that "children can move from place to place without learning valuable skills." Participants identified "other people who have similar challenges at home" as the most important sources of support for them. Group suggestions to improve congregate care included: Requiring detailed assessments of children referred to congregate care treatment; Improving training for direct care staff in congregate care settings; Developing flexible treatment plans to "help treat children as individuals;" Working with families to replicate "what worked" in congregate care settings in children's homes; Family members also offered suggestions on how DCF can help support keeping children in home. These suggestions included Providing family members with advice on how to secure alternative wrap around services; 65

66 Providing guidance on the special education process (i.e., understanding special needs, educational plans, etc); Providing guidance on how to navigate insurance payment issues; Providing guidance to family members on how to find support groups; Over the same period of time that these focus groups were occurring, the workgroup also engaged in a series of consultative discussions with leaders from others states which had been identified by experts as having made notable gains in terms of how they used congregate care. The DCF workgroup contacted Tennessee, Denver, Colorado, New York, and Maine. These areas shared various strategies which they used to move toward a reduction in the use of congregate care and ways they endeavored to improve the congregate care system. All representatives found their strategies successful in reducing an overreliance on congregate care. Representatives from every state agreed that congregate care should be a part of a continuum of care. They also all agreed that the most essential challenge was how to provide the best combination of services to the children who need that particular level of care. Tennessee: A conference call was held between work group members and representatives from the State of Tennessee. Tennessee was chosen as a peer learning state because only 10% of children entering care in Tennessee are placed in congregate care settings in the state. This is half the rate of such placements in The percentage of children placed in emergency shelters of other temporary placements decreased from 9% to 2% over the same period. 101 Tennessee places only from within their Child Protective Service System and in the Juvenile Justice System. Unlike Connecticut, Tennessee does not have a consolidated children's agency. In Tennessee, financial incentives were built into provider contracts so that providers are financially incentivized to keep children at a lower level of care. Specifically, the same rate of payment is applied across the entire continuum of services offered by a provider network (i.e., residential placement, therapeutic group homes, foster care, and in-home services). Furthermore, incentives for the providers were tied to achieving timely permanency goals for the children in their care. Tennessee representatives emphasized the need to have providers or provider networks which have a continuum of services as well as performance based contracting. Tennessee representatives indicated that gathering political support was key in moving their system forward. Denver, Colorado: The DCF workgroup participated in a teleconference with representatives from Denver, Colorado. Denver participates in Colorado's county administered system. Counties in Colorado are responsible for placing children and controlling funds for children in their care. If counties exceed the capped number of 101 Source: Longitudinal analytic files developed by Chapin Hall from TN Kids data through April

67 children in congregate care, they have to fund the resultant deficit out of the County's general fund. Representatives from Denver indicated that a shift in their thinking and approach to congregate care started in At that time, the length of stay in residential programs was approximately two years. The Denver system administrators set a goal to reduce placements by 30% and a goal to reduce the length of stay significantly. They reported being successful in this goal, with most success in avoiding placement for children under age 12 (i.e., through increasing foster care placements). Largely through leverage from the courts (i.e., judges, Guardian Ad litems, attorneys, etc.) Denver demonstrated a shift in philosophy and demonstrated a reduction in use of congregate care settings. One representative reported that getting probation officers involved in the planning was also essential. Today, Denver has approximately 250 children in congregate care each day with a goal of bringing that number down to 160 and then 100 in the future. The average length of stay in residential care is approximately six months. Denver operates its own residential center (i.e., Family Crisis Center) and the average length of stay is three months. It should be emphasized that financial rather than clinical criteria drive the length of stay in Denver more than is currently the case in Connecticut. Denver representatives reported a particularly large reduction in shelter use since This occurred after their administrators examined after-hour placements for a six month period, and then built in contract language with foster care providers to accept placements 24-hours a day, seven days a week. In addition to the changes in foster care contracts, Denver set up a system that required family meetings take place before a child was placed in a shelter. The purpose of this meeting would be to explore wrap around possibilities, extended family member placement, and other options for kinship care. They indicated that bringing different systems (including probation, mental health, public schools, etc.) to case management meetings on children helped to develop wraparound plans for these youth. In Denver, both private and state funded foster care agencies have access to wraparound services to support and preserve foster care placements. For example, there are seven "Family to Family" sites across the County and each site offers a support group for foster families. Foster parents are also notified of relevant court dates. When foster families attend these meetings they may voice concerns about a placement. In addition, foster parents are also invited to attend their foster child's Team Decision Making (T.D.M) meetings. To increase engagement of families in residential treatment, Denver financially incentivizes family work occurring in residential treatment centers. The County does not pay for treatment in a residential program unless family work is an important part of that treatment. The County also developed a "preferred provider" network of providers. These providers consistently had good outcome data and worked under performance based contracts. Denver's Department of Human Services has developed formal MOU with these preferred providers and attempts to place children into that network first, before turning to a non-network provider. 67

68 Denver developed a number of strategic interventions with respect to residential treatment, including establishing expectations for residential providers to engage aggressively in family work and creating incentives for positive outcomes. Denver's team also developed an admission tool for day treatment and for residential care to standardize their assessment of needs. The County gathered data on "high system users" (i.e., children who spent extensive time in congregate care settings) and staffed these cases with providers and treatment teams to develop alternative plans for them. New York City: The DCF work group held a teleconference with representatives from New York City's (NYC) Administration for Children's Services (ACS). Representatives from NYC reported that they started reviewing their use of congregate care in At that point, the agency began several initiatives to improve placement of youth into family settings and community environments. ACS closed its agency run group homes across the city and shifted its focus towards retaining and supporting foster care placements. ACS targeted group homes for closure because the agency viewed the homes as non-clinically informed settings. By way of comparison, Connecticut's Therapeutic Group Homes were specifically developed and funded as highly clinical settings. Also in 2002, ACS began collaborating with residential treatment providers to reduce lengths of stay in congregate care. Residential providers were encouraged to aggressively pursue permanency planning for children served in their settings. Providers were financially incentivized to reduce the average length of stay. ACS administrators reported that this increased attention to permanency planning and significantly reduced the length of stay in their residential programs. To improve the stability of foster care placements, ACS strengthened in-home clinical supports that were available to families. The agency also hired trainers to work directly with foster care families on specialty issues (e.g., trauma) and increased the accessibility of foster care crisis services. Higher payment rates were established for foster families who took older adolescents, sibling groups, and those with special needs. In an effort to improve the matching process between older adolescents and potential foster families, ACS developed "Meet and Greets". These meetings allow the youth to interview the potential family and to help decide if the family is an appropriate match. The agency also started using videotapes of older adolescents to improve the matching process. ACS also relaxed its rules regarding kinship placement, allowing a godparent, coach, or family friend to take in a child. Representatives from ACS reported that the Bridges to Health (B2H) Home and Community-Based Waiver program 102 has been very important in maintaining children outside of congregate care settings. The B2H program provides opportunities for improving the health and well-being of children in foster care or community services. According to the ACS team, the purpose of the program is to avoid, delay, or prevent institutional care and to provide enhanced services to children with disabilities. With 102 See 68

69 approval from the federal government, B2H offers services not otherwise available in the community to children with complex conditions. These services are offered in the context of their family and caregiver network. By supporting children in foster care or in the least restrictive home or community setting, the B2H program provides opportunities for improving the well-being of the children served, and supporting permanency planning. To be eligible to participate in B2H, children must be in the custody of ACS/the Commissioner of the Local Department of Social Services (LDSS), or the Office of Children and Family Services (OFCS), be Medicaid eligible, have a qualifying diagnosis, and be able to benefit from the service. The following 14 services are offered through the B2H program: 1. Health care integration 2. Family/caregiver supports and services 3. Skill building 4. Day habilitation 5. Special needs community advocacy and support 6. Prevocational services 7. Supported employment 8. Planned respite 9. Crisis avoidance, management, and training 10. Immediate crisis response services 11. Intensive in-home supports 12. Crisis respite 13. Adaptive and assistive equipment 14. Accessibility modifications As a result of various efforts and initiatives, NYC reduced the number of children in congregate care by approximately 50% between 2002 and Maine: The DCF workgroup held a teleconference with representatives from the state of Maine on May 26, Representatives from Maine indicated that they began their initiative to change their approach to congregate care in In the past five years, they have reduced the percentage of children in care in residential treatment from approximately 28% to 10%. The number of children placed from the child welfare system was reduced more than 50%. However, a much smaller reduction (i.e. approximately 16%) of these youth were in placement as a result of behavioral health treatment needs. Maine representatives reported that their administration delivered a consistent and simple message that every child deserves a family. Administrators were able to gain support form their state's governor's office in delivering this message to providers, judges, legislators, and guardian ad litems. They enlisted the support of their Youth Advisory Board to communicate directly with the courts about the need to place children in families instead of in residential settings. 69

70 Maine collected and tracked utilization data on residential placement across their area offices, and followed up closely with offices that had very high utilization. Maine representatives credited passionate and organized leadership, management accountability, and data tracking on residential utilization as key strategies in revising their approach to congregate care. Maine's administrators indicated that they did not focus on expanding or improving foster care, but instead placed emphasis on placing children with relatives from their immediate or extended families. Maine representatives worked with residential providers to increase family engagement in treatment. All residential programs in Maine were reviewed by the state's child welfare administrators to assure that family involvement was a key component of every child's stay. Maine representatives also worked with providers to shift the focus of residential treatment from outcome goals driven by a child's behaviors to outcome goals that focused on family readiness. This shift in the core of residential work was instrumental in reducing length of stay to approximately 6-9 months in residential care. Maine also invested efforts in training child welfare staff to conduct family meetings with all of their clients. Additional strategies used by Maine appear quite similar to Connecticut's initiatives. For example, Maine introduced a prior authorization process for all residential referrals, and a continued stay review process. Of note, the prior authorization process involves a set of established guidelines and has resulted in approvals for residential care in only 60% of referred cases. Connecticut has an authorization process and a continued stay review through the CT BHP. Maine, similar to Connecticut, also expanded in-home services and community services. In both Connecticut and Maine, the selection of a residential program was moved away from individual case workers. In Connecticut, matches are made at clinical matching rounds and in Maine, match is made by a team that will assure a child is placed near his/her family. Maine's system also expanded its approach to emphasize transition planning and the availability of wraparound services for children moving out of residential care. When a child is ready to move from a residential setting to a less restrictive environment, a transition plan must be developed and approved by the senior manager in the child welfare area office. More expansive wraparound supports are now made available to children with complex behavioral health needs. There are rarely after-hours placements in Maine, and when they do occur, a prior authorization team meeting is held the next day so that all involved parties can plan the next step. Relevant Background and Current Procedures for Determining Level of Care and Treatment Needs In recent years, DCF has made a number of reforms to its out-of-home placement practices for the children and youth it serves. The overall aim of these reforms has been to assure that a child is receiving an appropriate treatment for the optimal length of time in the most appropriate setting. These reform efforts have been a critical component of DCF's work, and the monitoring activities under the Juan F. Exit Plan. 70

71 DCF's procedures for determining the specific level of care required have been refined over time. Two of the most significant changes in DCF placement processes occurred in 2006 with the development of the Connecticut Behavioral Health partnership (CT BHP) and in 2007 with the development of DCF's Residential Care Action Plan. The CT BHP is the result of the collaboration between DCF, the Connecticut Department of Social Services, and the agencies' Administrative Services Organization (ASO), Value Options. The purpose of the CT BHP is to plan and implement an integrated public behavioral health service system for children and families in the state. The primary goal of the CT BHP is to provide enhanced access to and coordination of an effective system of community-based behavioral health services and supports. Secondary goals include efficient management of state resources and increased federal financial participation in the funding of behavioral health services. The CT BHP is designed to eliminate the major gaps and barriers that exist in the current children s behavioral health delivery system. Both DCF and the Department of Social Services are committed to developing a full continuum of behavioral health services for children that include evidenced based programs, non-traditional support services and community based alternatives to restrictive institutional levels of care. The CT BHP is integral in the process of determining the Level of Care (LOC) which children require to treat their behavioral health disorders and in utilization management. In the winter of 2007, DCF developed its' Residential Care Action Plan. The purpose of the plan was to improve the stability, relevance, quality, and performance of our in-state residential care services. The Department focused on: 1. Assuring a more focused treatment intervention in residential settings that is designed to prepare the child for success in a less restrictive LOC consistent with the permanency goals for the child; 2. Assuring that the treatment provided in residential settings is consistent with the presenting needs of the child; 3. Reducing the average length of stay and the number of children and adolescents who remain in residential care beyond the point at which their treatment needs have been met, and; 4. Developing a new guide to discharge planning across the entire continuum of care so that there is prompt access to the levels of care needed. The Department's action steps in this plan included: 1) Developing and utilizing program logic models for residential treatment centers; 2) Developing quality improvement activities; 3) Developing internal utilization management activities (i.e., to assure a more clinically driven process of referral, admission and discharge to home, foster care, residential care and other Levels of Care); 4) Revising the procurement, contracting, and rate-setting processes; 5) Enhancing the communications platform with congregate care providers; and, 71

72 6) Building residential treatment competencies. In this process, DCF also intended to create clearer program expectations and values, better articulate a vision of the role and scope of residential care, and state and support how we want children, adolescents, and their families, to access and benefit from this level of care. Several efforts were taken within the Department and within the provider community to bring about important changes in how this level of care is delivered and experienced. Procedures at the Area Office level: When a child's social worker believes that a child's needs are complex enough to warrant out of home care, a consult with the office's Area Resource Group (ARG) is conducted. After that review, in-home service options and wraparound services are reviewed and explored with private providers at a local Managed Service Systems (MSS) meeting. The youth may also be presented for Therapeutic Foster Care at this MSS meeting as well. If in-home services or wraparound options are not clinically appropriate to meet the needs of the child, and if foster care is not a clinically appropriate alternative, the Area Office may pursue a congregate care treatment setting. A case conference must be held with the Director of Behavioral Health and Medicine or with the DCF Medical Director for all cases in which congregate care is pursued for children age 12 and under. Procedures at the Central Office level: In the winter of 2008, the CT BHP revised its placement process further. The revised process was designed to improve the process of matching children with congregate care settings best able to meet their clinical needs and to ensure that for every child referred to a congregate care setting the LOC was determined by Value Options and not DCF. This point is critical: The certification of clinical necessity for residential care is made by Value Options utilizing LOC criteria developed under the purview of the Legislatively mandated CT BHP Oversight Council. Youth are not referred to residential treatment centers as a "default" because community based care is not available, but rather because they demonstrate a clear pattern of symptoms and behaviors for which residential care is clinically indicated as the appropriate treatment intervention. A uniform process is utilized for all referrals to congregate care settings. In the process, DCF submits a completed CANS (Child Assessment of Needs and Strengths) 103 to Value Options with supporting clinical documentation and a registration form. Value Options staff review the packet and make a Level of Care (LOC) determination based on the promulgated guidelines. Subsequent to this determination, formal notification of the LOC determination is made to the referral source within 48 hours of receipt of a completed CANS. A review of the CANS can yield one of three outcomes: 103 Lyons, J.S. (1999). Child and Adolescent Needs and Strengths. Buddin Praed Foundation. Winnetka, IL. 72

73 1. Value Options is unable to determine the LOC from the CANS alone and additional clinical information must be reviewed in order to make a determination; or 2. Value Options is unable to determine the LOC due to omissions of specific information that is required. The CANS is returned to the referring source. Required information must be provided to Value Options within 5 business days or the CANS will be closed; or 3. Value Options determines the LOC; the registration will then be signed by a licensed Value Options Residential Care Team clinician and the placement packet will be forwarded to the DCF Matching Team for matching at Clinical Rounds. The Matching Team consists of representatives from Value Options, from the Bureau of Behavioral Health, the Bureau of Adolescent Services, Juvenile Services, and Court Support Services Division. The CANS and relevant historical and clinical information is presented at Clinical Matching Rounds held twice a week and chaired by the Director of Behavioral Health and Medicine. The youth continues to be presented at rounds until the youth is matched to an appropriate anticipated or current vacancy at the identified LOC. Matches are made at Clinical Matching Rounds based on the Team's understanding of the case, and the availability of a treatment program appropriate to meet the child's needs. If a youth is presented for referral to a congregate care treatment setting and the Director of Behavioral Health and Medicine does not believe that there is sufficient information or a compelling necessity for residential treatment, the placement will be deferred until a case conference is convened to explore possible alternatives. If a viable match cannot be achieved within 30 calendar days following a LOC determination, the LOC will be re-evaluated considering available resources. If the Area Office Social Worker, Parole Officer, or Probation Officer does not agree with a match, a request for a re-determination may be submitted. All requests for match redetermination must be made in writing to the Director of Behavioral Medicine and copied to Manager supervising the Residential Care Team, the Bureau Chief of Child Welfare or to the Bureau Chief of Juvenile Services (i.e., depending on a child's nexus to the Department). The reason for the request and the proposed alternative disposition must be articulated. If there is no disagreement over a match, the provider is notified and referral materials are faxed on the same day to the program to which the youth is matched. A preadmission interview is scheduled with the provider by the Matching Team to occur within 7 business days of match notification. The provider then notifies the Residential Care Team within three business days of the match of any need for additional information, or acceptance or denial of match. All pre-admission interviews are expected to conclude within four business days of match acceptance. 73

74 Vignettes of Three Youth Referred to the CT BHP for Congregate Care Below are three summaries of actual youth referred for residential treatment. These vignettes are intended to provide heuristic profiles of youth referred to and approved for congregate care. Sandy: Sandy is a 17 year-old female who is currently hospitalized. She has been involved with DCF since her removal from biological mother's care at age three due to abuse and neglect. Between the ages of three and five, Sandy and her biological twin brother lived with an aunt. Both children, along with a third sibling, were returned to their mother's care when Sandy was five but were removed again a second time when Sandy was eight due to physical abuse by mother. There are reports from family members that biological mother prostituted Sandy in exchange for drugs. Parental rights for both of Sandy's biological parents were terminated when she was ten. Her twin sister was adopted and moved to Alabama to live with adoptive family. Sandy has older siblings who live in Connecticut and in Alabama. Her sisters have maintained sporadic contact with Sandy through the years. Sandy also has extended family members in North Carolina. Her mother is incarcerated and has not returned calls from DCF or expressed any interest in seeing Sandy. Despite her struggles, Sandy has several strengths. She writes poetry, is very artistic, and loves to cook, swim, and decorate. Her DCF worker describes her as a loving and giving child. Sandy started to receive outpatient treatment at age seven for severe self-injurious behavior (i.e., cutting, strangulation, and ingestion of foreign materials). Family foster care was attempted on more than one occasion and was repeatedly unsuccessful. Therapeutic foster care was also attempted with three families. In 2008, DCF developed an individualized foster care program for Sandy and an identified foster care resource. This plan included a professional foster parent with a special foster care stipend, a part time back up caretaker, six hours a week of in-home consultation with a behaviorist, 15 hours a week of respite care, 10 hours a week of therapeutic mentoring, and home based clinical services (i.e., therapy, family therapy, medication management). However, the identified foster family decided not to pursue the plan due to the unremitting persistence of Sandy's challenging presentation. Sandy's psychiatric diagnoses include Reactive Attachment Disorder, Post-Traumatic Stress Disorder, and Mild Mental Retardation. Dean: Dean is a 15 year-old male who is currently in an out-of-state residential placement for fire setting treatment. A review of DCF case records reflects over 20 referrals involving his family from 1994 to the present. The earliest DCF involvement was due to the domestic violence and substance abuse in his home. From , there were multiple substantiations by DCF involving repeated incidents of physical abuse, physical neglect, and emotional neglect involving both parents. Investigations also indicated that the parents were not consistent in following through with Dean's psychiatric medication and recommended treatment. Both parents have issues with 74

75 substance abuse. Dean's father was dependent on crack cocaine when Dean was a young child and his mother believed that this contributed to chaos and domestic violence at home. Dean's mother has been hospitalized for depression, substance abuse, anxiety, and suicidality. His paternal aunt suicided when Dean was very young. After Dean's parent's separated, his mother relocated to Las Vegas and Dean was moved several times between his mother and his father. Dean's behavior problems began in elementary school. When in his mother's care, his difficulties most frequently involved aggression and homicidal ideation toward his mother followed by suicidal and self-injurious thoughts. Psychiatric hospitalizations, changes to the custody arrangements and, later, stays in detention resulted from his most severe episodes. His father is incarcerated and has no contact with Dean. His mother is his guardian and has remained in Las Vegas. Dean decompensates rapidly under stress and his triggers include perceived rejection and abandonment. He has a history of aggressive and explosive behavior-particularly towards his caretakers. On one occasion he chased his mother through their home with an ax. Mother called the police when she was barricaded herself in the bathroom to keep herself safe from her son. Dean has also wrapped his younger brother in a blanket and set him on fire three times. Dean has extended family members who have been visiting resources for him. However, his family members are not interested in being family foster care placements for him. Dean's mother has asked that Dean be placed in a program near her home until he can return to her care. Clinical evaluators have suggested a supervised and structured setting with limited access to younger children. Dean's psychiatric diagnoses include Bipolar Disorder, Anxiety Disorder, Expressive-Receptive Language Disorder, and Oppositional Defiant Disorder. Tim: Tim is a 17 year-old male who is committed delinquent to DCF. He has been involved with the DCF since early childhood, with four reports of abuse and neglect related to his mother (unsubstantiated) and one substantiated report of sexual abuse by a neighbor. Tim was exposed to domestic violence in his early childhood and to paternal substance abuse. His father also sold drugs from the family home and was incarcerated through most of Tim's early life. In kindergarten, Tim was physically aggressive with classmates and teachers and had difficulty following directions. His aggression continued in school and in the second grade, he was suspended from school fourteen times for threatening teachers and disruptive behaviors. His mother reported to court evaluators that when Tim was young, she used to not want him to come home when he stayed out past curfew so that he would be picked up by probation and sent to juvenile detention. She noted that his behavior was very difficult to manage and she felt that having him in detention would be better for her and the rest of the family. At age 12, Tim assaulted a stranger in the community and left the victim partially blind and with permanent brain injury. He was deemed a Serious Juvenile Offender by Juvenile Court and was remanded to DCF's Juvenile Training School. This year, Tim assaulted Juvenile Training School staff and a judge ordered that he be remanded to 75

76 Manson Youth Institution (i.e., a correctional facility) until a residential placement can be found. His diagnoses include Attention Deficit and Hyperactivity Disorder, Mood Disorder, Not Otherwise Specified, Conduct Disorder, and Mild Mental Retardation. These cases illustrate several issues. First, youth are, at times, referred to residential treatment because they require intensive care for the purposes of individual or community safety. Second, youth are referred to residential treatment only after all other family and community based options have been utilized without success. And finally, youth are referred for highly specialized treatment. Congregate Care Discharge Planning Procedures In 2008, DCF provided detailed guidelines and timeframes for discharge planning for youth in congregate care. On the first day of placement in a congregate care setting, the child's social worker provides relevant contact information and schedules a 60 day meeting with program staff. By Day 30, a minimum of one social worker visit must have occurred and an internal DCF meeting at the Area Office is held. This meeting is designed to anticipate discharge options and includes a review of the monthly progress note, the social worker's assessment of the child's progress to date, family participation in the child's treatment to date, identification of adult resources, ancillary service needs such as therapeutic staff support or one to one mentoring, and verification that medical/dental follow up has taken place as needed. The DCF Office of Foster Care's participation in the program's 60 day meeting is arranged if it appears likely that a youth will be able to be discharged into a foster family setting following placement. At Day 60 of congregate care placement, a Treatment Planning Meeting (TPM) is held at the congregate care treatment program. The purpose of the meeting is to review the plan for the child to assure it contains provisions appropriate to meet the child/youth's behavioral health, medical, dental, and educational needs. The meeting is also designed to assure that the residential treatment plan is congruent with the comprehensive DCF treatment plan and permanency plan and to identify criteria for the child's discharge. In addition, the meeting is to identify steps, roles, and responsibilities of each party in order to affect discharge by day 270. This might include family recruitment activity and submission of a request for therapeutic foster care. Family members of potential relative caretakers are invited to attend the TPM if reunification or transfer of guardianship is under consideration of if it is already the permanency goal (or if it is a Voluntary Services case). By Day 120 of congregate care placement, the Area Office holds an internal meeting to review the progress to date in terms of identifying foster family resources if that is the anticipated discharge placement. The Office of Foster Care regional manager attends the meeting, and presents recruitment status if placement in foster care is anticipated. The purpose of this meeting is to assure that the roles and responsibilities of each person stemming from the 60 day meeting are being attended to. 76

77 By Day 180, a TPM occurs again at the placement. At this point, the child's Social Worker will have had a minimum of six visits and received a minimum of five monthly progress reports from the placement. The purpose of this meeting is to determine if a child is on target for the projected discharge date, to identify barriers to that date, and to identify changed circumstances that may necessitate amending the projected discharge date. If the discharge plan has changed, Value Options must articulate their acceptance of the Area Office's rationale and inform their respective administrators to establish new re-authorization criteria and service provision oversight. By Day 270 and beyond, if a child's discharge date was amended, no less than bi-monthly meetings between DCF and the provider occur until discharge takes place. At any point in placement, the child's Social Worker can request to have a case conference with staff from the Bureau of Behavioral Health and Medicine staff. These conferences are held by the Director of Behavioral Health and Medicine and/or his designee, the DCF Medical Director, Regional Psychiatrists, or assigned clinical program leads. These staff may offer case specific consultation or program related consultation in order to inform and guide treatment decisions. Two different bureaus in the Department provide managerial oversight to the various congregate care programs. The Bureau of Behavioral Health manages the clinical treatment settings: Therapeutic Group Homes, Residential Treatment Centers, and the Connecticut Children's Place. The Bureau of Child Welfare manages temporary placements (i.e., STARs, Safe Homes/PDCs), Maternity Homes, PASS group homes and SWETPs. These programs provide some focused behavioral health services such as assessments but are not designed to provide longer term clinical services. Authorization Process for Continued Stays Value Options conducts independent authorizations of DCF's placements in residential treatment centers and group homes. Beginning in August, 2008, authorization for both initial placement and ongoing treatment have been tied to payment. In other words when a child no longer meets criteria for placement or continuing care, payment to the provider is withheld. After an initial placement is authorized, continued stays are reviewed by Value Options at 30 day intervals. As a child approaches discharge, this interval becomes shorter, so that plans to move a child to a lower LOC or home will stay on course. For Connecticut's different levels of group home care (i.e., Level 2 homes, or Therapeutic Group Homes and Level 1.0 or maternity group homes, and Level 1.5 homes or PASS homes) reviews are conducted on different schedules. Reviews of continued stays at Therapeutic Group Homes are conducted between 60 and 90 days. If a child is doing well, these occur at 90 days--if a child is moving toward discharge or is struggling in this placement and has multiple incidents then the reviews occur at 60 day intervals. At PASS group homes and maternity homes, Value Options reviews the authorization for continuing care at 180 days maximum. The child's specific schedule for the review depends on the child's status and on his discharge plan and permanency. Through the implementation of the CT BHP, Connecticut aligned authorization procedures and processes with the goals of increasing outpatient and community based 77

78 utilization, supporting family based interventions, and reducing residential and inpatient utilization. Since the CT BHP became fully operational, initial authorizations for outpatient care have been significantly relaxed and allow for up to 20 visits prior to reauthorization. On the opposite end of the spectrum, authorization and review processes for inpatient and residential care have been more rigorously designed and applied to achieve better management of these services. Procedures for Pursuing Out-of-State Residential Treatment DCF is committed to providing the most appropriate treatment to children and their families, striving to utilize local, community-based resources whenever possible. Once a child or youth is determined by Value Options to require residential care, the child's behavioral health needs may be such that residential treatment is appropriate. In such cases, the most local residential treatment center that is appropriate and available to meet the child's behavioral health needs is sought. While treatment as close to home as possible is preferred, the unique nature of a particular child's needs may make this difficult to achieve. Not all youth who are referred for congregate care treatment are able to be treated in Connecticut. If no appropriate in-state residential treatment option exists within Connecticut, a search is conducted for the most appropriate, closest and available residential facilities out of state. Prior to pursuing a youth out-of-state congregate care placement, a number of specific issues must be considered by the Area Office and Central Office staff. For example: The youth requires a specialized type of treatment which is not available in Connecticut: Some youth require specialized treatment for which there are insufficient or no appropriate community based or residential treatment programs in Connecticut (e.g., high-risk firesetting, psychosexual behavior problems, Autism). Specialized services are available in Connecticut but are not accessible in an appropriate timely manner: When in-state capacity for residential treatment is being fully utilized, and when there are no other in-state providers who are capable of and willing to admit referred youth, out-ofstate placement might be pursued. In some instances (depending on the youth's current placement and the stability thereof) it may be appropriate to wait for a bed to become vacant. In other instances, however, the need for treatment may be of sufficient immediacy that an out-of-state placement becomes the clinically appropriate alternative. An out-of-state placement is closer to a child's family: This is often the case for individuals living in both North Central and Eastern Connecticut. In such situations, where appropriate, every effort is made to treat the child as close to the family as is reasonable and clinically appropriate. If a child is to be treated out-of-state, the Department assesses the ability of the out-of-state provider to do what ever family treatment is necessary and 78

79 appropriate. Many out-of-state providers have made provisions for this by providing transportation and building in an expectation of frequent and ongoing family therapy. The out-of-state program offers a clinical service which is significantly superior to that which we can offer in Connecticut: A variety of out-ofstate residential treatment programs offer specialized services of high quality which are inadequately available in Connecticut. While the Department may have some capacity in-state for quality treatment of a specific type, the capacity may be limited. Accordingly, DCF must confront the dilemma of whether to send the child out-of-state in order better to meet his or her treatment needs or to place the child in a less adequate in-state program simply because it is closer, even if it is not of equal quality. A judge ordered a residential placement for which there are no in-state beds available now or in the foreseeable future: In such instances, out-ofstate placements must be considered. However, all of the considerations identified above (e.g., proximity to family, appropriateness of quality treatment, etc.) must also be weighed. The child is currently in detention awaiting discharge to a residential LOC for which no in-state opening is available: As with a judicial order for residential placement, in such instances out-of-state options might be appropriate to consider. The child has been rejected for admission by all appropriate in-state providers: Providers are not required to accept children who are outside of their eligibility criteria. When a youth has been rejected by all appropriate in-state providers, out-of-state providers must be considered. It should be noted that in order to assure that these questions have been asked and satisfactorily answered, any out-of-state referral to residential treatment must be approved by the Director of Behavioral Health and Medicine or, for youth who are committed Juvenile Delinquent, by the Bureau Chief of Juvenile Services. Strategies in Place to Improve the Approach to Congregate Care Since 2004, there has been a significant decrease in the use of residential treatment and other forms of congregate care. A variety of factors have contributed to this decrease. The most salient factors include: (1) The implementation of the CT BHP and a corresponding emphasis on utilization management; (2) The expansion of a community based service system; (3) Enhancing the competencies of providers in community based settings; 79

80 (4) The implementation of Structured Decision Making (SDM) 104 with a valid and a reliable Safety Assessment instrument; (5) Increased efforts to improve access to appropriate levels of service; (5) Clinical reviews and conferences; (6) Recent initiatives to preserve and support families; (7) Efforts in foster care; and, (8) Prevention and early intervention efforts. The implementation of the CT BHP and the emphasis on utilization management: The CT BHP was developed in 2006 with the focus of tracking behavioral health services utilization and using data to make improvements in the service system. A goal of the Department and the CT BHP is to increase community-based behavioral health services and reduce the need for residential-level care. Data provided to DCF by the CT BHP suggests improvements to the service system in recent years have begun to have this desired effect, with an overall trend in the reduction of use of highest level of congregate care, and an increase in the use of home-based services. The CT BHP analyzes issues of service accessibility and customer satisfaction as a method of continuous quality improvement to strengthen the statewide system of care. The state has increased its capacity to track behavioral health services utilization data and to use data to make improvements in the service system. Additionally, through the work of the CT BHP, more timely access to services has been addressed through the creation of enhanced care clinics that must meet specific timeliness standards in order to receive enhanced rates. The expansion of a community based service system: The expansion in community services since 2000 has been dramatic. Specific examples of the expansion in available community services are discussed below. Between 2000 and 2008 the capacity of the community service system has expanded significantly to better serve the children and youth of Connecticut. Through a combination of funding, the availability of evidence based and intensive outpatient services in Connecticut has expanded resulting in an array of comprehensive services. In 2008, there was a major re-design and/or expansion of several community-based services and programs. DCF expenditures for community based behavioral health services increased from approximately $14 million in 2001 to over $101 million in This increased funding enabled DCF to continue its focus on strengthening and expanding the diverse array of community based behavioral health services and programs across the state. A continuum of services ranging from least to most restrictive is available. Treatment, support, and care are locally coordinated through a nationally endorsed system of care model with 25 community collaboratives in 104 Structured Decision Making Policy and Procedures Manual, Children's Research Center, Madison, WI, September,

81 Connecticut. Each collaborative represents a consortium of service providers, family members and advocates. Through the services of care coordinators who employ a wraparound service delivery model, an individualized plan of care is developed for each child or adolescent and his family. A team of professionals work in partnership with parents, other caregivers, and natural support networks to implement the plan. Specific examples of community based service expansion have included: 1) Care Coordination: Care coordination is a community based service where paraprofessional staff members provide care management services and access to flexible funding to families of children with serious emotional disturbance. The current care coordination program has the capacity to serve approximately 1400 families per year. 2) Multi-Systemic Therapy (MST): MST an evidence based and well researched program that provides intensive services in the home and community to youth and their families. Between 1999 and 2008, DCF funding of MST has grown from $400,000 to 4,556,403. DCF funded MST has the capacity to serve over a thousand families each year. In 2008 there were 27 MST teams funded by DCF and the Court Support Services Division. 3) Multi-Dimensional Family Therapy (MDFT): MDFT is an intensive family and evidence-based treatment for children and youth based on the principles of strategic and structural family therapy. The target population includes children year olds with serious behavioral problems and substance abuse and their families. Recent program improvements include the integration of the Global Assessment of Individual Needs (GAIN) nationally recognized standardized assessment process into MDFT practice, and training in and delivery of a group curriculum for adolescents focusing on preventing sexually transmitted disease and HIV. Similar to the implementation of MST, Connecticut has been successful in implementing MDFT with fidelity to the evidencebased model and is achieving comparable outcomes to those documented through randomized controlled trials and that are superior to residential care and/or "treatment as usual." Funding for MDFT has grown from $440,000 in 2004 to $2,177,621 in The 14 teams serve 350 families annually. 4) Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS): IICAPS Is a program originally developed at the Yale Child Study Center. It is designed to address the behavioral health needs of children/adolescents and their families, experiencing emotional, behavioral, and/or psychiatric difficulties at risk of requiring outof-home clinical care, or returning home from out-of-home care. This intensive in-home service has resulted in significant improvement in both parent and child reports of problem severity and child functioning based on the results of data on cases discharged during DCF funded an expansion of IICAPS throughout Connecticut beginning in The number of cases served in SFY 2006 was 598. In SFY 2007, 702 families were 81

82 served. In SFY 2008, the number served was There are 14 provider agencies delivering IICAPS services, with some agencies operating more than one IICAPS site. In the fiscal year, there were 45.2% fewer psychiatric inpatient admissions, 22.6% fewer Emergency Department visits, and 44% fewer residential treatment admissions during the IICAPS intervention than for the six months prior to IICAPS. Service utilization data is outlined in Chart 10 below: Chart Service Utilization Data: Total Number of Treatment Events Fiscal Year 2007/ Number Prior to IICAPS During IICAPS Psychiatric Inpatient Admissions ED Visits Treatment Events Residential Treatment Admissions 5) Functional Family Therapy (FFT): FFT is an evidenced based model of clinical service developed at the University of Utah and the University of Indiana. The target population is children and adolescents who are at risk of entering higher levels of care or transitioning to their community settings following inpatient levels of care. It was first introduced in Connecticut in 2002, and has grown considerably. Between 2002 and 2008, funding for FFT increased from $210,000 to 1,875,785. Currently there are five provider agencies for this service. In SFY 2006, 108 families were served with FFT. In SFY 2007, 280 families were served. In SFY 2008, 427 families were served. FFT is also considered a model program for the treatment of youth at risk for juvenile justice system involvement or involved with the juvenile justice system. In 2007, FFT was made more available to children and youth involved with juvenile services. Additional funding was provided to each FFT program to develop service capacity reserved specifically for youth on parole. 6) Family-Based Recovery (FBR): FBR is a model of service for children and families introduced in The target population is prenatally drug exposed infants who are DCF involved and at risk of placement, and their families. FBR combines a 82

83 supported promising practice (The Yale Coordinated Intervention for Women and Infants) with an evidenced based treatment for adult substance abuse (Reinforcement Based Therapy). The goal is to maintain the intact family and avoid placement. Staff address parent/child attachment issues and parenting issues while simultaneously providing in-home substance abuse treatment for the parents/caregivers. The program promotes language development, appropriate medical care, and parent-child attachment through the provision of intensive in-home services to the mother and child. This focus on early childhood development is augmented by a simultaneous focus on supporting parent's recovery from substance abuse. The program has six teams statewide with a capacity to serve 120 families annually. The current funding is at $2,075, ) Family Support Teams (FST): FSTs were developed by DCF in 2004 to address the needs of children/adolescents, and their families, experiencing emotional, behavioral, and/or psychiatric difficulties at risk of requiring out-of-home clinical care or returning home from out-of-home care. FST programs are funded by state grants of $7,548,560. A year of treatment in FST costs approximately $16,500. There are nine provider agencies delivering FST services. In fiscal year 2008, there were 464 cases served by FST. 8) Emergency Mobile Psychiatric Services (EMPS): During SFY 2008 a plan to re-design EMPS including the service areas was developed. An additional $1,187,500 was appropriated, with a portion of these funds utilized for expanding teams in the highest volume areas to alleviate emergency department overstays. Nine additional staff were added to teams and funds were used to support a centralized statewide call center and allow for expansion of the hours of operation. The goals are: 1) to increase mobile response to community crises by expanding hours of mobility and service capacity during peak periods; 2) to reduce psychiatric visits to the local hospital emergency departments; 3) to increase the rate of emergency department diversion from inpatient admission to community care; and, 4) to expand/enhance EMPS utilization by key groups such as foster parents and school staff. 9) Child and Adolescent Rapid Emergency Services (C.A.R.E.S): To eliminate overuse and extended stays at the local hospital emergency departments in Hartford, an innovative six bed program was opened in C.A.R.E.S is a short-term (3-day maximum stay) stabilization inpatient service supporting the Connecticut Children's Medical Center Emergency Department. The unit is designed to serve those children for whom additional evaluation is required in order to determine a disposition or who are expected to be able to avoid a lengthy hospitalization and return to the community following a brief stabilization within C.A.R.E.S. Multidisciplinary staff provides evaluation and treatment services with the goals of stabilizing behavioral symptoms and connecting or returning children and youth to community supports within 72 hours. 10) Enhanced Care Clinics (ECC): The Enhanced Care Clinic (ECC) program developed under the CT BHP provides financial rate incentives to outpatient behavioral health clinics that meet a series of performance standards including improved access to care. The CT BHP provides these clinics with enhanced rates that are approximately 83

84 25% higher than average CT BHP rates. The ECCs must meet special requirements such as timeliness standards for access based on level of acuity and formal agreements with local primary care providers for care coordination. Clinics are responsible for developing Memorandum of Understanding's with at least two primary care providers in their service area and to develop relationships and activities that promote improved coordination of care. The ECC primary care component provides psychiatric consultation to primary care providers to assist in their provision of psychiatric medication management to children and youth in their care. This helps to expand access to medication management and to promote coordination between medical and psychiatric care. The overall goal is to improve timeliness to access to behavioral health care and improve quality of care. Currently 39 clinics have attained Enhanced Care Clinic Status throughout the state. Access requirements under the ECC include emergency visits within two hours, urgent visits within two days, and routine visits within two weeks. Provider performance related to access requirements is in the process of being evaluated by a combination of data analysis and secret shopper methodologies. Where implemented these programs reduce waiting time for treatment. 11) Community-Based Treatment Services for Detention Involved Children: There has been a successful completion of the Emily J. Settlement that established more than $6 million in community based treatment services for detention involved children who are at risk for residential treatment. The Emily J. settlement, stemmed from legal action taken in 1993 on behalf of children placed in detention centers, established increased funding to serve this population. As a result, 72% of children reviewed by joint DCF/Court Support Services Division (CSSD) teams were diverted from unnecessary residential placements, and two thirds of the children remained in the community successfully for at least six months. 105 To continue the collaboration and community-based services beyond the terms of the original settlement DCF and CSSD have signed a Memorandum of Agreement to convene teams to identify and divert children from unnecessary residential placements by providing community-based services. These services include: in-home substance abuse treatment, counseling, mentoring, educational support, therapeutic group homes, and therapeutic foster care. 12) The Connecticut Family and Consumer Partnership Wraparound Pilot Project to Divert At Risk Youth from the Juvenile Justice System: A competitive procurement process for this project was launched and completed in Two communities were selected to participate in this program which is developed and funded under the Connecticut Mental Health Transformation State Incentive Grant (MHT-SIG). The three-year collaboration effort by DCF and the Judicial Branch-Court Support Services Division supports a multi-system implementation of the communitybased wraparound model in these communities (i.e., Bristol/Farmington and Bridgeport). The goals are to decrease functional impairments, improve behaviors, improve school attendance, and reduce delinquency. The Child Health and 105 Connecticut Department of Children and Families (2008). Community Mental Health Services Implementation Report FY

85 Development Institute in Farmington serves as the coordinating center to oversee the initiative, train staff, conduct in-vivo coaching, analyze fidelity assessments, assure clinical quality and monitor quality assurance activities. Enhancing the competencies of providers in community based settings: In order to strengthen competencies available in community based settings, DCF invested resources in the following areas: Trauma-Focused Cognitive Behavior Therapy Learning Collaborative: During SFY 2008 six outpatient psychiatric clinics for children were awarded DCF contracts through a competitive procurement process to participate in the year-long Trauma-Focused Cognitive Behavior Therapy 106 Learning Collaborative. Each agency was awarded $31, 600 to offset training costs. The overall goal is to improve access to evidence-based treatment for children and adolescents suffering from PTSD and other traumatic stress symptoms. The core TF-CBT teams included 25 clinicians, 13 supervisors, 8 senior leaders, and six family partners. A total of 218 children and adolescents were identified as appropriate for TF-CBT. In addition, several sites have trained and added new clinicians to their teams. Multiple outcomes have resulted from this initiative. These include: universal screening for trauma exposure within participating agencies, increasing TF-CBT capacity within agencies, clinical competency of TF-CBT among clinicians, trained supervisors, adequate treatment fidelity, routine use of data to monitor progress and inform treatment decisions, and improved agency capacity to adopt and sustain the practice through attention by senior leaders. Four new sites were selected to participate in a second Learning Collaborative during SFY Enhancing Local Systems of Care: In 2008, to strengthen the local systems of care and enhance the competencies of the providers, DCF re-instituted pre-service, in-service, and follow-up coaching for care coordinators, family advocates, and other key stakeholders. Six pre-service and in-service modules were developed. The Connecticut KidCare Training Curriculum was updated and modified. A total of 59 care coordinators were consolidated into four coaching groups and received monthly consultation and support. Crisis intervention training was also provided. Participation in the Engaging Families Learning Collaborative: DCF has also worked to promote a family based model of care. In April 2008, DCF launched a nine month learning collaborative to integrate evidence based family engagement interventions across the 22 extended day treatment programs in the state. The purposes were to: a) increase and sustain child and family involvement throughout the course of treatment, and, b) support families to better meet the mental health needs of children. The 106 Treatment developers of TF-CBT: J. Cohen & A. Mannarino, Allegheny General Hospital Center for Child Abuse &Traumatic Loss, Drexel University College of Medicine, Pittsburgh, PA & E. Deblinger, New Jersey CARES Institute, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, Stratford, NJ. 85

86 learning collaborative consisted of 10 face-to-face didactic and experiential learning sessions focused on family engagement protocols and multi-family group work, monthly telephone consultations with expert faculty, ongoing activities with each provider's quality improvement team that includes parents, foster parents and other caregivers, and data collection/analysis. Each of the program sites has developed a Quality Improvement Team that includes family partners to explore and engage in small tests of change. Child/Family and System Outcomes: One of the areas of focused work for DCF includes measuring child/family and system outcomes. Currently many of the community-based service providers are utilizing the Ohio Youth Problems, Functioning, and Satisfaction Scales 107 (Ohio Scales). Two full-day "train the trainer" seminars were sponsored by DCF in 2008 for community-based providers and DCF behavioral health managers and data researchers. The purposes were to assist clinicians and supervisors in engaging clients, planning treatment, and measuring progress, promote quality improvement at the agency and state levels using aggregate outcome scores and to demonstrate the accountability of the public mental health system through information management, research, and reporting. The use of Structured Decision Making : Since 2006, Connecticut has embraced the Structured Decision Making system, developed by the National Council on Crime and Delinquency (NCCD) and the Children's Research Center (CRC). SDM 's goals are to reduce subsequent maltreatment to children and families and to expedite permanency for children. 108 SDM provides "workers with simple, objective, and reliable tools with which to make the best possible decisions for individual cases, and to provide managers with information for improved planning, evaluation, and resource allocation." 109 The principle behind the SDM system is that child welfare decisions can be improved by: Clearly defined and consistently applied decision-making criteria. Readily measureable practice standards, with expectations of staff clearly identified and reinforced. Assessment results directly affecting case and agency decision-making. The SDM system can be used in the Area Office to assess risk and safety and to make decisions on the direction of the case, including pursuing out of home placement. DCF and the broader stakeholder community engaged in targeted efforts in the past year to address the issue of service gridlock. The inability to access the appropriate level of service in a timely manner to meet the level of acuity of the children and youth is a critical issue. To achieve more timely discharges from higher levels of care such as psychiatric hospitals, residential treatment facilities and local hospital emergency 107 Ogles, B.M., Melendez, G., Davis, D.C., & Lunnen, K.M. (2001). The Ohio Scales: Practical Outcome Assessment. Journal of Child and Family Studies Vol. 10(2), Structured Decision Making Policy and Procedures Manual, Children's Research Center, Madison, WI, September,

87 departments and to decrease the unnecessary, extended stays in residential treatment facilities, multiple complementary strategies were implemented and a new facility was opened. Efforts to improve access to appropriate levels of service: Staff at the CT BHP implemented multiple strategies to minimize discharge delays from inpatient settings and worked aggressively to improve the timeliness of access to the most appropriate level of care. An intensive care manager was assigned to each DCF area office to assist with clinical treatment planning for complex cases. Among other activities, the intensive care managers track and monitor the status of children seen throughout the state's emergency departments and assist in identifying appropriate resources when diversion is indicated. They attend discharge planning meetings on inpatient units and work with DCF area office staff and family members to effectuate timely discharges. At the front end of the system, senior clinical staff were assigned to review all requests for higher levels of inpatient care to assure clinically appropriate referrals. Targeted reports such as inpatient census reports, delayed discharge status reports, and children under age 10 reports were routinely reviewed by clinical staff. Focused communication between DCF and the Department of Developmental Services was initiated to develop discharge plans for children with developmental disabilities who seemed "stuck" in emergency departments. Clinical staff were assigned to work directly with local hospital emergency departments to find alternative community-based treatment resources and to decrease the rate of youth being referred to inpatient settings. Also, staff worked to facilitate timely access to community-based services for those awaiting this level of care. A literature search was conducted by Value Options and five Discharge Planning Focus Groups occurred in 2007 to identify best practice protocols for clients receiving inpatient behavioral health treatment. Ensuing actions included developing a discharge planning process that begins at the time of admission and developing/maintaining a consistent communication pathway with involved parties. Two toolkits were developed, one for families to assist and support them through the discharge planning process and one for providers that included sample forms for planning purposes. Clinical reviews and conferences: It is generally agreed that the clinical framework utilized at bi-weekly clinical matching rounds has resulted in better matches to treatment programs for children. Clinical case conferencing has also contributed to in a clear decline in RTC placements for children ages 12 and under. Clinical Case Conferences: Clinical case conferences at DCF bring knowledge and resources to care planning for children/families involved with the child welfare, juvenile services, and voluntary services systems. Conferences are chaired by the Director of Behavioral Health and/or his designee, and/or the agency Medical Director. These conferences typically include the child, youth, and/or family where appropriate, the DCF worker/supervisor, behavioral health program director, area resource group 87

88 staff, community behavioral health providers, behavioral health program leads, and other resources to assist in case planning. Clinical case conferences bring a sophisticated clinical analysis to care planning and may also serve a gate-keeping function in relation to access to higher levels of care. These conferences also serve to educate staff regarding Behavioral Health issues. A case conference may be convened for any child at the request of the Area Office. Such conferences are mandatory for children who are 12 years old and under who are referred to a group home or to a residential treatment center. It is important to note that clinical case conferences for children ages 12 and under have resulted in a reduction in placements in these settings for that population. The dramatic decline in the numbers of children age 12 and under placed in residential treatment centers and group homes from 2004 through 2009 is demonstrated in Chart 11 below: Chart 11. Number of Children age 12 years and under in RTCs/group homes RESIDENTIAL GROUP HOME Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr It is important to note, however, that despite the marked decline in residential placement for children 12 and under, the number of children 12 and under in congregate care in 88

89 general increased between 222 in February 2009 to 238 in May, Most of the increase is due to utilization of the Safe Home services. 110 Recent initiatives to preserve and support families: DCF has operationalized several additional new initiatives to reunify children with their families. Three examples are the RSVP program, the Reconnecting Families program, and the Intensive Safety Planning program. In addition, strong support has been provided through FAVOR to expand and enhance the voice of families throughout the statewide system of care. RSVP Substance Abuse Treatment: Parents whose substance abuse led to the removal of their children are able to immediately access treatment as a result of a collaborative effort among DCF, the CT Judicial Branch, and the CT Department of Mental Health and Addiction Services (DMHAS). The Recovery Specialist Voluntary Program (RSVP), which is funded by a transfer of $144,000 from existing administrative services, began in the New Britain Juvenile Court in March, 2009 and in the Bridgeport Juvenile Court in May, The program will expand to include the Willimantic Juvenile Court before June 30, With the RSVP program, parents whose children are being removed in Juvenile Court because of their parent's substance abuse can volunteer for the program in order to increase the likelihood that their children will be returned to them. Parents will be assigned a "recovery specialist" who is responsible for administering drug tests and monitoring the parent's attendance in both substance abuse treatment and support groups. Program participation lasts nine to twelve months and is expected to increase permanency for children and streamline the court process so that less time and fewer resources are expended in the course of determining permanency planning. The program represents a unique opportunity to combine recovery supports and treatment services to help preserve families. The program will be evaluated to assess its effectiveness in the parent's recovery and to determine if it results in shorter stays in foster care for children, lowers repeat maltreatment rates, and improves permanency for children. These positive outcomes would increase the prospects of future funding. On an annual basis, it estimated that the program will serve between 100 and 125 families in the New Britain, Bridgeport, and Willimantic juvenile courts. Reconnecting Families: The Reconnecting Families initiative began statewide in April 2008 and serves 460 families annually with primarily home-based services to enable children to be safely returned to their parents. Using a team and strengthsbased approach, the program offers assistance beginning while the child is in out of home care and lasting three months after the child returns home. Service components include parenting education and skill building, parent-child relationship development, safety planning, and therapeutic visitation. The program responds to issues that arise 110 Juan F. v. Rell Exit Plan Quarterly Report (January 1, 2009-March 31, 2009). Civil Action No: 2:89 CV 859 (CFD). Retrieved August 17, 2009 online from 89

90 after the children's return and ensures that the family is linked to appropriate community services to ending its involvement. This service is designed to engage, support and intervene with family members through a short-term, intensive, in-home service model following the removal of a child due to abuse or neglect in order to promote and effect successful reunification and reduce the risk for further abuse and neglect. The ultimate goals of the program are to decrease repeat maltreatment and rates of re-entry, decrease length of stay for children in out of home care and increase the numbers of children reunified with birth family and kin. Intensive Safety Planning: The Intensive Safety Planning (ISP) program works to return children removed from home in the first few weeks after a removal by addressing the underlying reasons leading to the removal. This is a short term, intensive, in home service designed to intervene in order to address immediate safety factors in situations where abuse and/or neglect has been substantiated, a court order issued, and a child or children have been removed from the home. Services focus on active engagement and support, improving family functioning, parent education, crisis management, connection to needed services and assistance with obtaining essential concrete needs. The ISP worker and parents spend 14 hours per week together to develop and implement an action plan to reduce the safety factors that led to the child s removal. Each ISP case with a family is 24 calendar days. Family Advocacy: The Department funds FAVOR, Inc., and four subcontracted family advocacy agencies for the development of a statewide family advocacy network to support meaningful family involvement in the children s behavioral health system. During FFY 2008, FAVOR and its consortium agencies engaged in a variety of advocacy, technical assistance and infrastructure development activities. These included local grassroots family advocacy, direct advocacy to parents caring for children with serious emotional disturbance, and training and supporting parents to enhance participation in system planning, development and evaluation. During 2008 FAVOR served 5390 families through direct family advocacy services. In 2008, FAVOR identified five strategic directions as outlined below: 1. Build FAVOR s infrastructure to strengthen the family advocacy movement; 2. Enhance and expand programs and services; 3. Improve and integrate information technology systems and information management to better evaluate the outcomes of the plan and programs/services; 4. Ensure the sustainability of resources, operations and programs/services; and, 5. Assume a leadership role in shaping the statewide family advocacy movement in children s and young adults behavioral health. The following was subsequently accomplished in 2008 as part of the infrastructure development: 90

91 1. Statewide leadership was enhanced through improved communication and outreach. Senior FAVOR staff were represented across several committees and workgroups including the Behavioral Health Oversight Committee, young adult/transitional services work, Block Grant meetings and both local and statewide Systems of Care. The board minutes and monthly executive director s reports were disseminated broadly to insure awareness and support of FAVOR s mission and goals. Staff worked to expand membership and broaden the organizational culture in support of reducing linguistic and cultural barriers to access needed behavioral health services, including support for prevention and recovery services for dually diagnosed children and youth. Also, FAVOR developed and implemented a University of Connecticut MSW internship placement program and this past year placed one person in family advocacy services and one within the policy program. 2. There was an enhancement to programs and services due to expanding coordination and leadership work by convening and providing staff and website support to the following program service initiatives: a. FAVOR staff broadened outreach by initiating and hosting monthly meetings with and for all of the statewide autism groups/organizations. This new group is known as the CT Autism Action Coalition. They are actively pursuing federal funding for direct services for children and young adults on the spectrum. b. Using DCF-provided federal dollars, FAVOR developed the first statewide family advocacy organization for children, youth and families dealing with substance abuse. Policy statements, a large and successful legislative breakfast, two statewide conferences to share best practices, two presentations at a national conference and the creation of multiple family support groups are a sample of work in this area. c. FAVOR staff have become consultants to the Court Support Services Division (CSSD) and developed contracted training and family advocacy services to children, youth and families and staff in the Juvenile Justice system/ FAVOR staff are also partnering with the CT Center for Effective Practice in the recently awarded Transformation Grants model program offering a wrap around approach to the juvenile justice system. FAVOR's Director of Program Services has been working with interns to research best practices and services in Family Advocacy while working with relevant national and other statewide organizations. To upgrade and improve the information technology systems, data management and outcome evaluation, FAVOR has established a data development workgroup made up of FAVOR and member agency staff and colleagues at DCF and within the Foundation world. They are near completion of short-and long term outcome measures which will assist in learning about the degree of help they are providing to families. FAVOR has 91

92 made slow, steady progress with the asset mapping project, having shared it with statewide DCF SAMSHA grantees. Staff have delivered information technology training to membership agency staff and made great progress in developing a Family Resource Bank while working in a proposal to develop and implement a statewide Family Leadership Training Academy working with multiple partners skilled in Parent Training from a variety of perspectives. They have periodically documented success stories for use in public presentations and have begun to retain and store these anecdotes for multiple purposes. They are reviewing the System of Care and Family Advocacy Practice Standards to write in the necessary steps and data elements in order to complete a broad-based behavioral health needs assessment and begin implementing short term measures designed to answer the question are we making a difference in our advocacy work with families. To further enhance their leadership role in shaping the family movement in behavioral health, FAVOR, Inc. management has participated in several activities including the following: 1. Improved coordination with and supported family advocacy and family support groups across the behavioral health continuum of needs; 2. Re-instated the FAVOR Advisory group representing diverse family organizations across the state; 3. Played an active leadership role as part of the Family Support Council; 4. Co-chaired a system of care work group; 5. Co-chaired CT BHP oversight committees; 6. Made annual visits and presentations to the local systems of care; 7. Served as active member of CT Community Providers Association and CT Association of Non-Profits working towards strengthening relationships between families, private providers and the collaboratives; 8. Served as member of CT Health Foundation's mental health advisory committee; 9. Managed two statewide Citizen Review Panels reporting on child welfare staff performance to the DCF Commissioner; 10. Provided leadership and coordination to a statewide policy effort in concert with numerous coalition partners; 11. Delivered multiple advocacy and policy trainings to local collaboratives and family support groups; and, 12. Developed and ensured full integration of family advocates and community input into the public policy process. Efforts in Foster Care: A growing body of evidence suggests that specialized foster care settings like treatment foster care 111,112 are more effective and cost-efficient than group care. 113 There can be 111 Chamberlain, P., & Reid, J.B., (1991). Using a specialized foster care community treatment model for children and adolescents leaving the state mental hospital. Journal of Community Psychology 66(4), Fisher, P.A., & Chamberlain, P., (2000). Multidimensional treatment foster care: A program for intensive parenting, family support, and skill building. Journal of Emotional & Behavioral Disorders, 8(3):

93 no question that the provision of and availability of high quality foster care is a lynch pin in any child welfare system. Additional foster care and adoptive resources, are, without question, essential components to address the needs of children in the Department's system. DCF developed a foster care action plan for This plan is guided by DCF's values and principles, and is informed by data and trends. This plan seeks to accomplish the following results: 1. Achieve a net gain of 350 newly licensed foster homes on a statewide basis by June 30, Accounting for the anticipated home closures over this period, the department is targeting 600 new homes (i.e., 500 DCF homes and 100 private homes). 2. Assure that children and youths placed in foster care are in foster homes operating within their licensed capacity (i.e., at least 96% of all children placed in foster homes shall be in foster homes operating within their licensed capacity, except when necessary to accommodate sibling groups). 3. Assure the appropriateness of a child or youth's placement and reduce delay discharges and overstays in temporary and congregate settings. 4. Increase foster parent satisfaction. In addition, five statewide initiatives are outlined in a comprehensive work plan. The initiatives are: 1. Enhance retention efforts/pre-licensing experiences for all potential foster parents. 2. Provide foster families greater access to responsive services, training, and supports. 3. Better target and inform recruitment/public awareness resources and messaging. 4. Increase timely discharges from congregate settings. 5. Enhance organizational and workforce development. There is a comprehensive and detailed recruitment and retention plan for each Area Office. These Area Office plans set quarterly benchmarks for the recruitment of new family foster homes and describe in detail the goals, steps, persons responsible for each task. These local plans also identify primary and community partners. Taken as a whole, the action plan is designed to better link committed families with a system of support and services and an infrastructure of training that is both sufficient and relevant. If executed properly, this plan will yield positive results and will be done in partnership with providers and advocates throughout the state. Moving forward, DCF will build on the progress made in by updating action plans and benchmarks. 113 Chamberlain, P. & Reid, J.B., (1998). Comparison of two community based alternatives to incarceration of chronic juvenile offenders. Journal of Consulting and Clinical Psychology66(4),

94 According to the Juan F. v Rell Exit Plan Quarterly Report (June, 2009), in May, 2009, there were 2,366 licensed DCF foster homes. 114 This is an increase over the total reported in February 2009 of 2,340 licensed available foster homes. The number of available private foster care homes decreased from 1,037 homes to 1,018 homes. The Juan F. v Rell Exit Plan Quarterly report (June, 2009) indicates that as of June, 2009, the Department did not make any gain with respect to the Family Foster Care Action Plan goal to increase the net number of homes by 350. While the Department licensed many homes in 2009, it closed a similar number of homes. Approximately 50% of the homes closed after positive outcomes for individual children (i.e., adoption, transfer of guardianship, etc). The Court Monitor's Office began a review of DCF's progress in implementing the Family Foster Care Action Plan in July, Also within the past year, Foster and Adoptive Parent Support Teams (FAST) have been expanded. While FAST programs have been available for the past decade, enhancements to the program were necessary to meet the needs of today's children and foster/adoptive families. Within the past year, a new model was developed and the programs were competitively re-bid. The new program model includes more in-home behavioral work and its primary goals are to prepare parent caregiver(s) and the child for difficult situations and address those situations should they occur. In 2008, a pilot program was established that partners two DCF Area offices and the CT BHP. This program is designed to give foster families in Norwich and Waterbury extra attention and support. It targets children ages 3-18 years who are experiencing their first removal from home, HUSKY eligible, and have already been identified as having behavioral health issues, the program's goal is to support foster children by preventing disruptions from foster care homes. The CT BHP collected data on the characteristics of children in foster care between June 2007 and June They also looked at authorizations for behavioral health services for these children. One of the findings was that a large number of children who had disrupted from their placements had previously been involved with behavioral health services. Disruptions tended to occur within the first 45 days of placement. In December 2008, the CT BHP began collaborating with DCF to reduce foster care disruptions. As part of a small pilot project, both the children and their foster families would receive outreach calls from the CT BHP Peer Specialists. If interested, the foster parents could utilize the Peer Specialists to better understand, predict, and plan as the child's caretaker around some of the challenges associated with caring for a child with special behavioral health needs. Six families participated in this pilot program. The CT BHP received largely positive responses to these outreaches and in some cases foster parents had up to seven interactive calls with their assigned Peer Specialist in the course of a two month period of time. Intensive Case Managers from the CT BHP also became involved with every case, ensuring that children were connected and authorized for services in a seamless manner. Children who entered into this project 114 Juan F. v. Rell Exit Plan Quarterly Report (January 1, 2009-March 31, 2009). Civil Action No: 2:89 CV 859 (CFD). Retrieved August 17, 2009 online from 94

95 were reviewed after being in care for 45 days and of all of the children who entered into the project, none had disrupted from care. Re-design of Therapeutic Foster Care: Through a Request for Information (RFI) process during the spring of 2008, the Department solicited broad feedback from key stakeholders regarding a redesign of therapeutic foster care (TFC). This RFI set forth DCF's new vision with respect to re-conceptualizing and enhancing the provision of TFC services. Specific questions and items for input were also identified within the RFI to aid in the receipt of responses. The Department received twenty-four (24) responses to the RFI. The majority of the respondents were from current Connecticut Child placing Agencies or organizations that provided TFC in other communities. One response was received from a private individual. DCF also contracted with the University of Connecticut's (UConn) Pappanikou Center for the purpose of supporting input from foster families and providers regarding the redesign of the state's therapeutic level foster care system. UConn was engaged to facilitate a number of foster parent forums, a youth forum, and a provider forum as a means to allow those stakeholders to share their thoughts and ideas regarding how Connecticut's TFC services could be improved. Finally, a workgroup consisting of staff from DCF's Area Offices and Central Office was convened to review all of the RFI submissions and identify key recommendations, issues, enhancements, and services innovations that should be considered in reconstructing Connecticut's TFC service system. A foster parent workgroup was also convened and tasked with the same charge. They reviewed all the RFI responses and provided OFCS with written and oral feedback regarding those submissions. This information from both workgroups was used to guide the development of the TFC model articulated in a Request for Qualifications (RFQ) released in January, In the redesigned therapeutic foster care system, DCF sought to ensure effective, child specific, strengths based, family centered and culturally competent care. This RFQ represents an initial redesign phase of the TFC service. Additional procurements, within available resources, to allow for an independent evaluation of the TFC service, comprehensive clinical training for TFC families, and other foster parent support services are expected to occur over the next several months. Prior to this redesign, DCF contracted with a variety of therapeutic, behavioral health levels of foster care, including Therapeutic Foster Care, Specialized Therapeutic Foster Care, Treatment Foster Care, and Professional Parent Foster Care. The new TFC system was designed to help support DCF's goal, as clinically appropriate, to more expeditiously step children down into family settings from more restrictive levels of care. The service was also designed to serve children who need to exit from short term and assessment type settings. TFC providers awarded through the procurement will be expected to recruit, train, support, and retain qualified foster parents who are very able to meet the intensive supervision, service, and care demands of the children referred to the service, particularly those who are latent and adolescent age. In the RFQ, DCF sought to contract with up to nine agencies for the provision of TFC. This procurement was suspended, allowing existing TFC providers to submit a 95

96 comprehensive plan articulating how they would ensure that the core element s of a redesigned TFC service would be provided. In the redesign, the Department will be moving forward with new contracts with the existing therapeutic foster care providers for two levels of services: TFC and TFC-Enhanced. The target population of the TFC redesign were children ages 6-17 years old, with serious emotional disturbance and complex behavioral health care needs who require placement outside of their home and who are at risk of placement in a more restrictive placement setting. They will be expected to have a DSM-IV Axis I diagnosis and/or be identified by a licensed mental health practitioner as having serious and persistent emotional and/or behavioral problems that require treatment and care within a TFC structure. The target population will include children who present with challenging issues and behaviors. Youth over the age of 17 may, if determined appropriate and necessary by the Department, remain in TFC through the age of 23 if still in school or in a work program. Children eligible for TFC-Enhanced, in addition to the above target age and identified clinical issues, will be those who have an extensive history of psychiatric hospitalizations, residential care, and/or other high end interventions. This current design will be a component of the TCC level, providing statewide, rather than Area Office specific, programming for children discharging from select congregate care facilities who are ready for care in a family setting. Each TFC program also had a designated Safe Home/PDC assigned to it. As of August 31, 2009, there were 2,511 DCF children in foster care. In terms of age breakdown, 848 were 0-5 years old, 456 were 5-9 years old, 656 were years old, 471 were years old, and 80 were over 18. Prevention and Early Intervention Efforts: DCF has also increased its focus on prevention and early intervention activities. The overarching goal of these efforts is to promote a range of services that enable children and families to thrive independently in their communities and to apply best practice prevention approaches at points in the DCF continuum of care to ensure a smooth, timely and sustained transition for children, youth and families from DCF involvement to a state of independence or to prevent DCF involvement altogether. There can be little question that prevention and early intervention is preferable to and in some cases may mitigate the need for later out of home care. There is ample evidence that many prevention and early intervention programs work and that early intervention is more effective and efficient than intervening later after problems are entrenched. However, it can take many years before the benefits of a preventive or early intervention program are realized and such programs are often overlooked in a tight budget environment. DCF has engaged in the following activities to support prevention and early intervention activities. DCF/Head Start Statewide Collaboration: The collaboration promotes the strengthening of child and family relationships by developing a protocol for enhancing communication between each agency. As a result of the protocol, DCF and Head Start staff know more about one another's programs and services, thus they can use each others resources more effectively, and each agency can make and receive appropriate referrals to/from 96

97 their partner agency. Head Start and DCF staff work collaboratively to identify mutual families served and participate in all aspects of service provision to children and families including: DCF referral, investigation, and treatment planning and Head Start referral, enrollment and case management. Through partnering, both agencies build capacity in communities in the area of cross training and resource development. ECCP (The Early Childhood Consultation Project): The ECCP has just entered the first Quarter of its 6th year. ECCP stands out as one of the first statewide Early Childhood Mental Health Consultation Programs in the country. It is the only such program today to have had a large scale research evaluation conducted using a random assignment experimental design. The results of this evaluation support that ECCP has a significant and meaningful impact upon the children served. It further supports our strategies in effectively preparing ECCP Consultants to deliver high quality Mental Health Consultation services. ECCP Consultants are involved with capacity building at a systems level. Program staff is involved in various local and statewide early childhood collaboratives, and consultants facilitate community based monthly Mental Health Consultation groups. 97% of children at risk of suspension/expulsion, who completed ECCP childspecific services were not suspended or expelled at the one month, follow up. Served 8,816 children since ECCP s Information System is designed to collect data on services and produce reports that are used to guide families and centers, to assist with program reporting to our funding agency, and to inform early childhood stakeholders and policy makers. ECCP conducts an orientation and training system that builds the capacity of new and existing ECCP Consultants in the area of early childhood mental health consultation. Early Childhood Behavioral Consultation (ECBC) - This pilot project is co-funded with the State Department of Education to provide long term (year long) intensive consultation and support to change center-wide policies in large urban centers. The goal is to support mental health and wellness of children in large urban preschools. Behavioral Health Teams are assembled and trained by ECBC to: promote children mental health and safety educate teachers regarding social-emotional development of children assist teachers to develop strategies for positive behavioral supports prevents expulsion/suspension work intensively with families of children with challenging behaviors The number of children served during first year of pilot (7/1/08-9/30/08) was 1,

98 Building Blocks for Brighter Futures: This program provides mental health services to young children (birth to under six) with diagnosed mental health conditions. Building Blocks is located in New London, Groton and Norwich counties. Services are provided in the family's home. Comprehensive plans are developed which include: Diagnostic evaluation Therapy, play therapy Art therapy Therapeutic play groups Community resourcing Individualized family support plan Family support funds Family social activities Sibling groups Youth Suicide Prevention and Mental Health Promotion: The Department provides funds that are utilized by the Prevention Unit to contract for services and training related to youth suicide prevention and mental health promotion. DCF continues to train college students, faculty and staff, DCF social workers, foster parents, school nurses, and community providers. In 2007 through 2008 training was expanded to include two evidence-based curricula: Applied Suicide Intervention Skills Training (Asist) and Assessing and Managing Suicide. A private agency delivered additional training on Assessing and Managing Suicide Risk (AMSR): Core Competencies for Mental Health Professionals Clinical Training. In 2008, a total of 716 individuals received suicide prevention and crisis response training through this initiative. CTParenting.com: This website was launched in 2008 by DCF's Bureau of Prevention and External Affairs. The website provides families one-stop access to comprehensive information on a range of issues that affect the lives of children and families. This is an important education and prevention tool aimed at improving lives and promoting safety and well-being of children. The site contains information relevant for families with children of all ages and developmental states. There are special sections targeted to young children, teenagers, fathers, single and divorced parents, prospective parents, and grandparents caring for children, as well as specialized behavioral health topics such as adolescent rebellion, grief/trauma and stress and maladaptive behaviors. There are links to the American Academy of Pediatrics, universities such as Yale and the University of Connecticut, and federal government agencies. Summary of What We Have Learned DCF has a rich service array of community based and congregate care treatment options and continues to make steady progress in improving the services available for children, adolescents, and their families. Through collaboration with the CT BHP, the Department has established a Level of Care (LOC) process that has successfully moved children towards treatment options that meet their individual needs. When residential treatment is necessary, it is not considered a long term option, but is viewed as a clinical intervention with a defined purpose. 98

99 Without question, community based and wrap around services are less disruptive than residential treatment and should be used whenever possible and clinically appropriate. Identifying services within the system that best fit the child s and family s strengths, needs and permanency plan is paramount. During any phase of the child s treatment the most appropriate treatment may be residential care and it should not be used as a last resort option. Although it is clear that there is a need for continued outcome research, our focus on the positive outcomes to-date, what works, and a commitment to continuing to monitor outcome studies and adopt best practices is how we can build upon and improve the residential care system specifically and the treatment system holistically. It is important that the child and family believe they can benefit from residential treatment and not see the need for residential treatment as sign of failure, but rather as a holistic and temporary treatment option whose goal is to return the child back into his/her community as soon as possible. The multi-faceted rightsizing plan of the residential system now underway in Connecticut is working to develop a new paradigm for residential treatment in the continuum of services. Based on what we have learned from the outcome research to date on residential care and from public policy recommendations (e.g., CWLA, 2005), Connecticut is actively engaging in the following activities: Use of a child-specific clinical outcome tool (i.e., the T.O.P) 115 at residential treatment centers and therapeutic group homes is underway. Implementation began in December, A quality improvement project is underway in which DCF and Value Options jointly study outcomes for children discharged from residential care by use of post-discharge event data. Measuring gains during course of treatment and maintenance of gains following treatment will be considered. This is an opportunity to use these findings to improve our local continuum of care. A summary data analysis of utilization and demographic trends over eighteenmonths for youth in residential treatment is underway. A review of funding alternatives that would allow for fluid boundaries between residential and community based services is in progress. In addition, funding alternatives for residential treatment programs are under discussion. Such alternatives may allow for different programming and the implementation of new treatment models. A target has been established for shorter lengths of stay in residential programs with a decrease of 10% in The ultimate target for length of stay in residential programs is six months. 115 Kraus D.R., Seligman D., & Jordan J.R. (2005). Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: The Treatment Outcome Package. Journal of Clinical Psychology, 61(3),

100 Focal treatment planning training occurred at RTCs throughout Focal treatment planning requires the clinician to abstract pivotal problems from the formulation, select appropriate therapies, designate a target date, develop specific objectives, implement the plan, monitor progress regularly, revise the plan and to terminate treatment when goals and objectives are achieved. Focal treatment planning specifies contributing factors, interventions, and outcomes. Reasonable next steps for systematic improvement 1. Further refine wraparound and community based services to reduce congregate care utilization Given the importance of seamless connection between community based interventions and congregate care treatment, DCF will engage in coordinated efforts to improve collaboration between congregate care providers and community based wraparound providers. The goal will be to improve the collaboration between wraparound support and congregate care providers so that youth can be more quickly moved from congregate care settings to community based settings using an intensive array of supports. The Department will improve the connections between coordinated wraparound programs and the various congregate care settings. One potential model to explore would be the Stanford Home model in Sacramento County, California. The Department will use utilization data from the CT BHP to develop cohortspecific in-state wraparound services for children who are returning from out of state residential programs. 2. Increase use and support of in-home services to reduce congregate care utilization DCF will explore utilizing federal funding for in-home services and foster care support services (e.g., to parallel New York's Bridges to Health model). DCF will also continue to strengthen the community-based system of care including inhome services. 3. Continue to expand the use of foster homes and kinship placements DCF will continue to make aggressive efforts in recruiting, supporting, and retaining foster homes for children and youth. This, in combination with improving our practice of searching for and securing relative care, may diminish the need for congregate settings and permit more timely discharges for those who can appropriately be served by this level of care. In March of 2010, DCF will enter into new contracts with foster care providers to deliver improved therapeutic foster care services. The new service is principled in positive outcomes for children and families. It embraces a holistic, community 100

101 based systems of care approach and reframes therapeutic foster care as a clinical service. Level of Care (LOC) criteria guidelines are being expanded to apply to therapeutic foster care. The LOC criteria for therapeutic foster care will be used in conjunction with the LOC system for congregate care settings. The application of these guidelines will help keep youth in family based settings. DCF has obtained Technical Assistance from Casey Family Services on steps to maximize foster family resources. The Department utilized a logic model framework to come up with a new model to replace Safe Homes and Permanency Diagnostic Centers. The Department will issue a Request for Qualifications in February and will have the new model with new contracts effective July The capacity of the new model reflects a decrease of 50 beds statewide. The model is to serve children ages 6-13 experiencing one or more disruptions from other levels of care and who have significant behavioral issues. The Department will utilize their new case plan and newly enhanced administrative case review process to identify children who are in the new model for more than 60 days. The notification will be sent to the chain of command in the area office up to the Office Director and will prompt a collaborative team meeting to assist in discharge. 4. Engage the CT BHP in efforts to reduce congregate care utilization The CT BHP has been very successful in improving access to, and managing utilization of, behavioral health services. Given this success, DCF will continue to follow the current system for accessing congregate care treatment. Ongoing work with the CT BHP will result in improved data collection and analysis, and improved cohesiveness and functioning of program and service interventions. The Department will continue to collaborate with the CT BHP and with providers to identify service gaps in our treatment continuum and develop in-state resources to meet the needs of the children we serve. A redesign of in-state resources requires attention to in-state congregate care treatment modification, resource allocation, and the development of different intensity treatment services including at the community level. 5. Expand practices for reviews on youths referred to congregate care There has been a dramatic decline in congregate care placement for children ages 12 and under. This can be contributed, at least in part, to the clinical perspectives offered through case conferences. DCF will explore a process for reviews of children referred to congregate care who are 13 years old and under. 101

102 6. Use data on placements, length of stay, and outcomes to reduce congregate care length of stay and utilization Through coordinated efforts with Value Options, DCF now has the ability to track length of stay and outcomes in residential treatment settings. This is a change from the Department's capacity prior to DCF will continue to track these outcomes and such outcomes will continue to drive plans for improvement. The current residential performance project will provide the data needed to develop similar outcomes normed for Connecticut that will be used in setting future targets for treatment length of stay. DCF will continue to use an outcome measurement instrument across its congregate care settings. A focus on outcomes may be useful in guiding and planning the treatment process. One example of such an instrument is the Treatment Outcome Package (T.O.P), 116 an instrument which is now used in DCF's state facilities, residential programs, and in therapeutic group home settings. 7. Promote a consistent practice approach in congregate care settings that reduces length of stay and engages families and community providers in treatment DCF will work with congregate care providers to shift the core of the residential treatment work from a focus on a child's identified symptoms to family readiness and capacity to have the child return home. With these efforts, the focus of congregate care treatment could move from the identified child to the family or permanency resource. This approach has been highly successful in Maine. 8. Respond to the focus groups' suggestions on improving congregate care In two different focus groups, both DCF involved youth and DMHAS involved young adults stressed the importance of solid transition planning from congregate care settings. DCF will collaborate with congregate care providers to help make transitions to the community more planful. Transitions will also become particularly focused on successful movement into school settings. DCF will also consider the Youth Advisory Board's suggestion to supplement traditional "talk therapy" in congregate care settings with experiential and creative activities which could be helpful in engaging youth in treatment. 9. Revise business operations and contracting for congregate care 116 Kraus, D.R., Seligman, D., & Jordan, J.R. (2005). Validation of a Behavioral Health Treatment Outcome and Assessment Tool Designed for Naturalistic Settings. Journal of Clinical Psychology, 61 (3),

103 The Department will continue to review various strategies and revisions to purchasing congregate care services. This includes collaborating with private providers throughout the process. DCF will continue to contract with congregate care providers who offer the services that research support such as family involvement during treatment, aftercare planning, skills training, individual and group counseling, and educational and employment assistance. Congregate care providers will be encouraged to incorporate systematic interventions and trauma-informed interventions. The Department will pursue options related to converting residential programs to sub-acute treatment settings (i.e., PRTFs). PRTF settings offer 24-hour nursing coverage and are funded by Medicaid services. Youth in these settings need to meet strict criteria for medical necessity to be in that treatment environment. Residential services reforms that focus on staff training and program development to better meet the needs of cohorts of unserved or underserved youth being referred to out-of-state residential programs are required in order to permit more children and youth to receive those services in Connecticut. DCF will consider involvement in the national Building Bridges Initiative. The Initiative is an effort to advance a set of values and principles for comprehensive community approaches to address the needs of children with significant emotional and behavioral disorders and their families when the child's condition necessitates residential treatment. Implementation Process The scope of the "next steps" stemming from the Congregate Care Report that will affect the provision of congregate care services in Connecticut fall within three distinct implementation categories. While all phases of implementation will be managed by the Commissioner through the vehicle of the Executive Team, each has a corresponding structure leading to review and approval by the Commissioner. Among the next steps are a set of initiatives that represent existing implementation commitments by the Department. The modifications to the Therapeutic Foster Care contracts including changes to the financing, the delivery of support services and the establishment of a standard level of care are underway and scheduled for implementation in March, The re-design of Safe Homes is similarly underway and include a reduction in capacity, a change in the target population, increased clinical support and restriction to the placement of children under six. The changes to the Safe Home model are planned for implementation by July, Both changes are significant but neither requires an implementation strategy beyond what is already in place. 103

104 The second implementation category extends predominately to practice change within the Department and among its providers with the associated support of the CT Behavioral Health Partnership (CT BHP). Many of these changes including the continued reduction in length of stay in congregate care and the ongoing measurement of objective outcomes associated with congregate care placement have already been articulated and the data development necessary for managing to the outcomes has an April 2010 implementation schedule. The management of the remaining components of this category will be done through the Department's Operations Workgroup that includes its Chief Fiscal Officer and all Bureau Chiefs. The detailed work related to each associated next step has participation that varies according to specific step. For example, the CT BHP and the Bureau of Behavioral Health will establish a workgroup in the latter part of the current fiscal year to explore the conversion from Residential Treatment Centers to Psychiatric Residential Treatment Facilities, to consider changes to the finance model for residential treatment to add incentives for meeting target performance goals, and to better integrate community services with congregate placement to promote more timely and seamless transitions on the service continuum for children with complex behavioral health needs. The results of those efforts will be monitored and reviewed by the Operations Workgroup who will make recommendations to the Commissioner for resource allocations and the engagement of other State agencies as warranted. It is expected that the full scope of work in this category will extend months. The final implementation category fully recognizes that the re-allocation of resources and changes in practice and service models will only be successful in reducing the utilization of congregate care to the extent that viable placement options exist as an alternative to congregate care placement. In addition to the Foster Care Recruitment and Retention Plan already approved as a component of the Juan F. Stipulation Regarding Outcome Measures 3 and 15, additional opportunities may exist to further develop the foster family level of care as alternatives to congregate care. To that end, the Technical Advisory Committee (TAC) facilitated an engagement activity between the Department and the Annie E. Casey Foundation Child Welfare Strategy Group. The Department is currently in the assessment phase, but a working draft of the potential breadth and timeline of the engagement process is depicted in Appendix A. In the course of the development of the Congregate Care Report consideration was given to the establishment of a steering committee to oversee "next step" implementation. However, changes to the pattern of utilization of congregate care, while an important commitment, is but one of many changes occurring concurrently in the Department including the implementation of the federally required Program Improvement Plan, the corresponding implementation of the practice model, very recent changes to the case plan and case review process, and continued management of performance related to the Juan F. Exit Outcomes and the Juan F. Stipulation Regarding Outcome Measures 3 and 15. The Department has existing management structures in place that maintain the requisite perspective on agency functions to assure that the respective implementation steps are integrated in a way that promote positive, 104

105 enduring goal accomplishment rather than the peripatetic chasing of recurrent new initiatives based on the latest promising practice. 105

106 APPENDIX 106

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