Research and Evidence Based Practice for Community Alternatives to PRTF

Research and Evidence Based Practice for Community Alternatives to PRTFToni Shelow, Ed.S., Psy.D.Judith Collins, LPACreating a NewParadigmBetween SMC and ResidentialProvidersGeneral Findings on Residential Treatment50,000 children admitted annually 25% of national funding

8% of children with mental health needs require residential care

3.

The North Carolina Medicaid Annual Report

$532,992,752 inpatient hospitalization

$380,955,083 outpatient hospitalization

$40,476,581 child psychiatric hospitalization

(NCDHHS, 2008)

Increasing resources and appropriate community treatment would cut these costs.

Would allow for treatment and service specific to childs needs, close to home and with support of family and communityMost Common Conditions of Children (9-17) with Serious Emotional Disturbance (5% of the population)Disruptive Behavior Disorder70%Anxiety Disorder27%Depression20%Substance use16%ADHD13%

Likelihood of Mental Health Services for These Youth40%

Data from Great Smoky Mountains Study; Costello, 20066Research Indicates:

Gains made in PRTFs do not necessarily generate to youths natural environment

50% of children were readmitted to RTC and 75% were with re-institutionalized or arrested (Frisen et al., 2001)

7PRTF found to be associated with continued placement and dependency with risk of returning to placement:

32% after one year53% after two 59% and the end of the third year

(Asarnow, et al., 1996)The 1999 Surgeon Generals Report of Mental Health states:

Residential treatment centers are the second most restrictive form of care

In the past, admission to an RTC was justified on the basis of community protection, child protection and benefits for residential treatment.

None of these justifications have stood up to research scrutiny.

9Multiple sources have shown residential treatment overall to be ineffective or mixed in their outcomes for addressing the primary reasons for admission.

Research, cont. There is no evidence of a relationship between any outcomes achieved in residential treatment and subsequent functioning in the community (Friesen et al., 2001; Bickman, et al., 2000; Burns, et al., 1998)

11Research cont., PRTF milieu often problematic because children in PRTFs enter a situation where their peer group is other troubled children, a major risk factor for later behavior problems (Dishion, et al., 1999)

Few children thrive when confined to Residential facilities due to:

Removed from families

No Natural Support

Unable to benefit from strengths of their community

Community unable to contribute to their treatment

Wide range of treatment interventions

Contributing Factors to PRTF Utilization..Why?JJS kids and lack of access to appropriate intensive community based programsLack of knowledge by providers on alternative to PRTFTendency to equate restrictiveness of service to service intensityLimited inpatient beds for youth and perception that PRTF is only option for intermediate stabilizationLack of timely crisis intervention servicesLack of services for youth with Substance AbuseResidential Programs Best for those who cannot be safely treated in community (Barth, 2002)

High Risk Behavior (Suicidal Ideation)Self-MutilationAggression toward OthersFire SettingSexual OffendersRun AwayDestructive BehaviorWhen Residential is NecessaryWhat is Most Effective (Magellan, 2008)Focus on Family Involvement

Discharge Planning

Community Reintegration

Average 3-6 months durationAs an alternative to Residential Treatment Facilities, Community Based Services:

Preserve the familys integrity and prevent unnecessary out of home placements

Put adolescents and families in touch with community agencies and individuals

Create an outside support system

Strengthen the familys coping skills and capacity to function effectively in the community after crisis treatment is completed17Restrictive vs. IntensiveService Restrictiveness= extent to which youth has opportunity to participate in natural activities in community

Intensiveness=reflects the dose of the treatment and is unrelated to setting

If intensive treatment is needed, community based alternatives offer a more cost effective optionBuilding Bridges (SAMHSA, 2008) The best intervention for serious mental health issues that cannot be treated in the childs home environment is a facility that has a multidisciplinary treatment team providing safe, evidenced based care that is medically monitored.

19Building Bridges, contLed by mental health professional

Child Psychiatrist to inform and monitor the process

Treatment family driven with parent and family included in care

Building Bridges, cont.Maximize regular contact between child and family

Actively involve and support families with a child in residential treatment

Provide ongoing support and aftercare for child and family

Medical Necessity for ResidentialAs documented in a comprehensive psychiatric evaluation, medical necessity drives admission to RTC.

Primary treatment goal is to return the child or adolescent to the community in order to resume the family, social and educational functions that contribute to normal development.

Discharge planning should begin at time of admission and shape treatment

The RTC has the responsibility to collect data on treatment outcomes and report on that data to assess whether the facility is achieving positive outcomes

(AACAP, June 2010, Principles of Care for Treatment of Children and Adolescents with Mental Illnesses in Residential Treatment Centers)22What is Evidence-Based Practice?The term Evidence-based practice, used to describe a treatment or service, means that the treatment has been studied, usually in an academic or community setting and has been shown to be effective.

It is the integration of the best research evidence with clinical expertise and patient valuesSystem of Care Based on Evidenced Based PracticesParent-Child Interactive TherapyParent Management TrainingIncredible YearsSeeking SafetySecond StepsTF-CBTMSTFamily Centered TreatmentMulti-dimensional Foster Care

EBP, continuedAdolescent Community Reinforcement Approach (A-CRA)Prime SolutionsSexual Offenders TreatmentResponse Prevention CBTGood Lives ModelMST

What We Know About Residential ServicesResidential Levels of CareDescriptors:Child is medically stableFrequent and severely disruptive verbal aggression towards othersOccasional moderate physical aggression towards self and othersSchool FailureInappropriate sexual acting out with others with low risk for reoffendingFrequent conflict in current family/home settingLEVEL II ResidentialDescriptors:Child is medically stableInvolvement in high risk behaviors that are potentially life threateningSchool Failure that is due to behavioral issuesFrequent and severe property damageSevere aggression towards self or othersFrequent and severe conflict in current family/home setting

LEVEL III ResidentialMedical Necessity Criteria for PRTF Admission:Diagnosis that can be expected to respond to therapeutic interventionChild is not stable to be treated outside of a 24 hour, highly structured environmentChild demonstrates a capacity to respond favorably to therapeutic and rehabilitative interventionChild has history of multiple treatment episodes or recent inpatient stay with poor outcomeChild and family functioning do not allow for child to receive care in the home environment.32Continued Stay Criteria:Child continues to meet all admission criteria*No other level of care can meet this childs needsSpecific requirements about treatment planning(eg. Includes family involvement)Services designed to achieve optimum results efficientlyIf no progress evident, treatment plans have been adjusted to address thisCare is focused on behavioral and functional outcomesIndividualized discharge plan includes specific requirementsChild is actively participating in treatmentFamily/guardian is actively involvedPsychopharmalogical intervention has been evaluated/implementedDocumented active discharge planning from the outset of treatmentDocumented active attempt at coordination of care with outside agencies. Criteria Continued:Handouts

Medical Necessity Checklist

Appeal & Denial Guide

Helpful Documents to Support SAR

Appeal/Denial ProcessWhen a service has been denied, reduced or suspended:The following information applies:If the provider submitted the request at least ten calendar days prior to the end of the current authorization period and the request is DENIED or REDUCED, the effective date of the change in services shall be no sooner than 10 days after the date the notice is mailed. Requests for prior approval to authorize a service the recipient is currently receiving that are received LESS than 10 calendar days prior to the end of the authorization period, if DENIED or REDUCED, authorization at the prior level of service will be entered for ten days beginning on the date of the decision. (Letters re: denials, reductions/suspensions are mailed within one business day of the decision)Keep in Mind Two Things:

A. Providers must submit their SAR 10 calendar days prior to the end of the current auth

AND

B. Care Management has 14 days to review a SAR and make a decisionWhen denials occur due to lack of medical necessity, this can result in the following scenarios:Scenario #1:

Providers current auth expires on November 10th

Provider submits SAR on November 1st (on time)

SAR is reviewed and denied on November 12th Result: Care Manager enters an authorization for the same LOC for November 11th-21st. No interruption in authorizations.

Scenario #2:

Providers current auth expires on November 10th

Provider submits SAR on November 9th (late)

SAR is reviewed and denied on November 12thResult: Care Manager enters an authorization for the same LOC for November 12th-21st. Provider will not have an authorization for November 11th.

Key Points to Keep in Mind:

Prior to requesting residential services, expect to be asked, Has this consumer had a lower level of care?

By 12/15/12 Treatment Plans should be submitted outlining plan for discharge within 90 days for PRTF consumers

Clinical Reviews and discussion with providers for exceptions

Medical Necessity continues to drive decision making. It is not do they need services instead, its what dose and how often?