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Research and Evidence Based Practice for Community Alternatives to PRTF. Toni Shelow, Ed.S., Psy.D. Judith Collins, LPA. Creating a New Paradigm Between SMC and Residential Providers. General Findings on Residential Treatment. 50,000 children admitted annually 25% of national funding

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Research and Evidence Based Practice for Community Alternatives to PRTF

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Research and Evidence Based Practice for Community Alternatives to PRTF

Toni Shelow, Ed.S., Psy.D.

Judith Collins, LPA

Creating a New


Between SMC and Residential


General Findings on Residential Treatment

  • 50,000 children admitted annually

  • 25% of national funding

  • 8% of children with mental health needs require residential care

  • .

  • 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 child’s needs, close to home and with support of family and community

Most 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 Youth


    Data from Great Smoky Mountains Study; Costello, 2006

  • Research Indicates:

  • Gains made in PRTFs do not necessarily generate to youth’s natural environment

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

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

  • 32% after one year

  • 53% 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.

  • Multiple 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)

Research 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 programs

  • Lack of knowledge by providers on alternative to PRTF

  • Tendency to equate restrictiveness of service to service intensity

  • Limited inpatient beds for youth and perception that PRTF is only option for intermediate stabilization

  • Lack of timely crisis intervention services

  • Lack of services for youth with Substance Abuse

  • Residential Programs Best for those who cannot be safely treated in community (Barth, 2002)

  • High Risk Behavior (Suicidal Ideation)

  • Self-Mutilation

  • Aggression toward Others

  • Fire Setting

  • Sexual Offenders

  • Run Away

  • Destructive Behavior

When Residential is NecessaryWhat is Most Effective (Magellan, 2008)

  • Focus on Family Involvement

  • Discharge Planning

  • Community Reintegration

  • Average 3-6 months duration

As an alternative to Residential Treatment Facilities, Community Based Services:

  • Preserve the family’s 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 family’s coping skills and capacity to function effectively in the community after crisis treatment is completed

Restrictive vs. Intensive

  • Service 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 option

Building Bridges (SAMHSA, 2008)

  • The best intervention for serious mental health issues that cannot be treated in the child’s home environment is a facility that has a multidisciplinary treatment team providing safe, evidenced based care that is medically monitored.

Building Bridges, cont

  • Led 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 Residential

  • As 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)

What 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 values”

System of Care Based on Evidenced Based Practices

  • Parent-Child Interactive Therapy

  • Parent Management Training

  • Incredible Years

  • Seeking Safety

  • Second Steps

  • TF-CBT

  • MST

  • Family Centered Treatment

  • Multi-dimensional Foster Care

EBP, continued

  • Adolescent Community Reinforcement Approach (A-CRA)

  • Prime Solutions

  • Sexual Offenders Treatment

    Response Prevention CBT

    Good Lives Model


What We Know About



Residential Levels of Care


  • Child is medically stable

  • Frequent and severely disruptive verbal aggression towards others

  • Occasional moderate physical aggression towards self and others

  • School Failure

  • Inappropriate sexual acting out with others with low risk for reoffending

  • Frequent conflict in current family/home setting

LEVEL II Residential


  • Child is medically stable

  • Involvement in high risk behaviors that are potentially life threatening

  • School Failure that is due to behavioral issues

  • Frequent and severe property damage

  • Severe aggression towards self or others

  • Frequent and severe conflict in current family/home setting

LEVEL III Residential

Medical Necessity Criteria for PRTF Admission:

  • Diagnosis that can be expected to respond to therapeutic intervention

  • Child is not stable to be treated outside of a 24 hour, highly structured environment

  • Child demonstrates a capacity to respond favorably to therapeutic and rehabilitative intervention

  • Child has history of multiple treatment episodes or recent inpatient stay with poor outcome

  • Child and family functioning do not allow for child to receive care in the home environment.

Continued Stay Criteria:

  • Child continues to meet all admission criteria*

  • No other level of care can meet this child’s needs

  • Specific requirements about treatment planning(eg. Includes family involvement)

  • Services designed to achieve optimum results efficiently

  • If no progress evident, treatment plans have been adjusted to address this

  • Care is focused on behavioral and functional outcomes

Criteria Continued:

  • Individualized discharge plan includes specific requirements

  • Child is actively participating in treatment

  • Family/guardian is actively involved

  • Psychopharmalogical intervention has been evaluated/implemented

  • Documented active discharge planning from the outset of treatment

  • Documented active attempt at coordination of care with outside agencies.

  • 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


B. Care Management has 14 days to review a SAR and make a decision

When denials occur due to lack of medical necessity, this can result in the following scenarios:

Scenario #1:

Provider’s 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:

Provider’s current auth expires on November 10th

Provider submits SAR on November 9th (late)

SAR is reviewed and denied on November 12th

Result: 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, “it’s ‘what dose’ and how often?”

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