Children’s Intensive Mental Health Services Study

Children's Intensive Mental Health Services Study

Final Report to the Minnesota Legislature

Author: Melanie Ferris Contributing authors: Glenace Edwall, Chris Bray Collaborators: AspireMN, MACMH, NAMI Minnesota, Glenn Andis

MARCH 2019

Contents

Study overview ................................................................................................................... 1 Common terms................................................................................................................ 2 Acronyms ........................................................................................................................ 3 About the project team.................................................................................................... 3 Methods........................................................................................................................... 4 Limitations ...................................................................................................................... 7

Background ......................................................................................................................... 9 Current status: Children's residential treatment ........................................................... 10

Youth with intensive mental health needs ........................................................................ 16 Estimates of youth receiving residential treatment ....................................................... 17 Descriptive information ................................................................................................ 19

Treatment effectiveness: The evolution of residential mental health services ................. 30 Milieu as treatment ....................................................................................................... 30 From traditional milieu to trauma-informed care ......................................................... 33 Changes in family involvement .................................................................................... 34 Residential treatment as part of a continuum of care.................................................... 35

Treatment effectiveness: Current residential treatment approaches ................................. 38 Factors contributing to positive outcomes during residential treatment ....................... 38 Factors that support positive outcomes post-discharge ................................................ 47 Use of best practices among current residential providers...................................... 47 Synthesis: Current use of best practices in residential treatment.................................. 52

Best practices: Residential treatment as part of a community-based continuum of care.. 54 Synthesis of stakeholder input ...................................................................................... 55 Minnesota's current continuum of care: Capacity, gaps, and opportunities for enhancements .......................................................................................................... 62

Potential service models and funding mechanisms .......................................................... 79 PRTF design and implementation................................................................................. 79 Bridging models and other intensive services .............................................................. 87 Large scale reform efforts ............................................................................................. 94 Potential financial mechanisms..................................................................................... 97

Looking forward: Recommendations to support a robust continuum of care ................ 101 References....................................................................................................................... 110 Appendix......................................................................................................................... 119

Children's Intensive Mental Health Services Study

Wilder Research, March 2019

Figures

1. Pathways to children's mental health residential treatment for youth in insured through public plans .................................................................................................. 11

2. Minnesota's children's residential treatment centers and IMD designation ............. 12 3. Alignment between residential treatment approaches and best practices ................. 53 4. Minnesota's continuum of children's mental health services ................................... 63 5. Pediatric (0-17) mental health inpatient hospitalization and emergency

department use........................................................................................................... 64 6. Location and capacity of children's mental health residential settings..................... 66 7. Location of Children's Therapeutic Services and Supports (CTSS) and

school-linked mental health services......................................................................... 70 8. Assessment of children's mental health service availability, 2013-14 ..................... 73 9. Minnesota Department of Human Services: planning regions.................................. 73 10. Mental health services, Medicaid and commercial private insurance

plan comparison ........................................................................................................ 75 11. Potential enhancements to Minnesota's continuum of care ...................................... 76 12. DHS guidance on medical necessity definitions and populations served

at residential facilities (2018) .................................................................................... 79 13. Financial mechanisms used to support integration of residential and

community-based care............................................................................................... 99

Children's Intensive Mental Health Services Study

Wilder Research, March 2019

Study overview

The Children's Intensive Mental Health Services Study was commissioned by the Minnesota Department of Human Services (DHS) at the request of the 2017 Minnesota Legislature. The purpose of the study was to conduct an analysis of Minnesota's current continuum of intensive mental health services and identify the service models and funding mechanisms needed to address gaps in the state's system of care; ensure that youth and families have access to appropriate and effective residential and community-based treatment options; and ultimately improve youth well-being and success in home, school, and community settings.

The specific goals of the study are to:

Assess the purpose, need, and appropriate role for children's mental health residential treatment in Minnesota's publically financed continuum of care

Describe the effectiveness of Minnesota's current residential treatment services and other intensive mental health service models

Establish criteria or characteristics of effective treatment models and identify effective treatment models that could be adopted in Minnesota

Analyze changes in service delivery capacity, financial implications, and potential impacts on youth and families resulting from federal Institution of Mental Diseases (IMD) designation

Recommend one or more children's mental health treatment models with potential funding options

This report describes the current context for the study, including implications of the IMD designation and a description of youth currently receiving residential treatment services, drawing on data currently available. The report includes a review of the literature to describe effective residential intervention strategies and compares those best practices to current practices in Minnesota's children's residential facilities and experiences shared by caregivers and local stakeholders.

The report then describes the role of residential treatment as a component of a more enhanced continuum of children's mental health services and provides an assessment of Minnesota's current capacity to offer these services across the state. Examples illustrating ways that provider agencies and state administers have adopted these best practices into the design and implementation of new services, as well as examples of efforts to reform residential services are offered to both highlight promising approaches and to identify potential challenges.

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Common terms

Throughout the report, there are key terms that are used to describe broader concepts or to simplify terminology. These are briefly described below:

Continuum of care. In this report, this term is used to refer to the array of mental health services that should be in place to ensure youth with mental illnesses receive the right level of care at the right time. Although a full continuum of care includes prevention and early identification services as well as traditional clinical services (e.g., outpatient therapy, psychiatry), this study focuses largely on the more intensive services available in community-based and residential settings.

Intensive mental health needs or treatment. Throughout this report, when referencing intensive mental health needs, we are referring to symptoms and behaviors that necessitate supervision and mental health treatment multiple times a week. When used broadly, we consider these to include needs that can be treated in community-based settings or, when appropriate, in residential settings.

Residential treatment. The phrase "residential treatment" is used to reinforce that changes in outcomes are a result of the mental health services provided in a residential setting, rather than a result of the placement itself.

Residential treatment centers (RTCs). We are using this term to describe the residential settings where youth are receiving mental health treatment. Unless specified otherwise, these are all licensed in the state as Children's Residential Facilities (CRFs).

Youth with mental illnesses. Many state statutes and regulations use the categories of emotional disturbance (ED) or severe emotional disturbance (SED) when describing eligibility for services. ED is a category that includes a number of mental health diagnoses and indicates the child's mental health symptoms are impacting daily functioning at home, at school, or in the community. The SED category adds that the mental health symptoms or behaviors are more intensive (e.g., self-harm), have lasted more than a year, and may require intensive mental health treatment in a residential setting. Throughout this report, the reference to "youth with mental illnesses" is referring to youth who are included in this SED category.

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