October 17, 2008

1. October 17, 2008 Office of Mental Health and Substance Abuse ServicesChildren’s Advisory Committee Residential treatment facility research and data overview Andy Keller, Boulder Peter Selby, Seattle

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

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

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

5. Use under 60 days/over 365 days 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Statewide HealthChoices Expansion Allegheny Philadelphia CISC under 60 days Non-CISC under 60 days CISC over 365 days Non-CISC over 365 days Example one: Residential treatment facility service use patterns vary at the county level • 2005 – 2006 patterns of RTF service by Child in Substitute Care (CISC) / non-CISC are stable at multi-county level • But there are major differences at the county-level

6. Example two: Diagnoses of residential treatment facility users also vary by county • Same pattern of CISC/non-CISC diagnoses is seen at each level of analysis • But there are major differences in proportion at county-level Primary diagnosis – CISC versus non-CISC 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Statewide HealthChoices Expansion Allegheny Philadelphia Conduct disorder (CISC) Conduct disorder (Non-CISC) Mood disorder (CISC) Mood disorder (Non-CISC) ADHD (CISC) ADHD (Non-CISC) Adjustment disorder (CISC) Adjustment disorder (Non-CISC)

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

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

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

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

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

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

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

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

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