ISSUE

Children for whom the Department is legally responsible have a myriad of mental health service needs associated with their histories of severe abuse and/or neglect. In addition to the mental health issues that precede removal from their families of origin, the children also struggle with separation and loss issues, as well as adjustment to a substitute care placements. In many cases the children present behavioral symptoms ranging from mild intensity to very severe high-risk behaviors (e.g., danger to self and/or others). The challenge to the Department can be summed up in the following questions:

• How can the Department best evaluate the broad range of needs presented by children in the child welfare system?

• How can the Department best meet the needs of the children who present mild symptoms, but who over time are at risk for moderate to severe maladaptive behavior?

• How can the Department respond rapidly to children who present acute psychiatric symptoms that threaten the stability of their foster care placement?

• How can the Department assure that children with serious emotional disturbance (SED) receive the correct intensity of services for the appropriate duration, and in the most appropriate, safe, and home-like setting?

The Department’s vision is to create an organized system of care that is capable of meeting the mental health needs of children in the child welfare system. In general, these children have suffered serious and repetitive abuse and/or neglect, and as a result have been placed in substitute care living arrangements. For some, ambivalence about families of origin and conflicted feelings about placement are manifested by behavior problems that range from mild to severe intensity. Many of these children have diagnosable mental illness or emotional disturbance. Consequently, children with SED and serious maladaptive behavior are frequently recipients of acute psychiatric hospitalization, placement disruptions, and migration toward restrictive out-of-community residential care and treatment.

Progress has been made in some crucial individual areas of services for children with mental health problems. The Department is focusing on methods to better assess the need for and coordinate the transition from one level of service to the other.

DCFS children have historically been heavy users of acute psychiatric hospital services and placement in that setting beyond medical necessity has been a long-standing problem. In 1992, the Department implemented the Screening Assessment and Support Services (SASS) program to provide pre-admission screening services for all DCFS children thought to be in need of hospitalization. Since SASS has been implemented, we have seen dramatic reductions in the total number of hospitalizations, even during times of caseload growth. The department has also taken steps to review the profiles of children remaining in a hospital setting longer than necessary, and is developing methods to deal with these cases.

Children with mental and emotional problems at times need to be cared in residential facilities, either institutions or group homes. These facilities provide a less intense level of care than a psychiatric hospital, but provide a level of care not available in a community setting.

Since 1995 there have been dramatic reductions in the numbers of children placed in residential treatment facilities both within Illinois and out-of-state. The total residential care utilization has been reduced by 35%, and the out-of-state residential care utilization has been reduced by 80%. A study of the residential treatment system revealed that a significant number of children in care did not have a history of emotional disturbance or risk symptoms consistent with placement in high-end restrictive care. Based on this study, the Department established utilization management mechanisms to screen and approve all children prior to placement. In addition, a system of residential facility gatekeepers has been implemented to assure that children are more appropriately matched to their placement and to monitor progress in care.

With the return of children placed out-of-state and the pressure to avoid future placements outside of Illinois, it is necessary to improve the quality of service provided by residential facilities, as well as the planning and coordination with community based care structures. Beginning in 1993, the Department partnered with residential care providers to improve and enhance clinical capacity and capabilities through the use of the Medicaid Rehabilitative Option. Under this program, providers have become certified and contracts have been converted to the MRO format. This process has resulted in a transition from facilities which had a child welfare orientation to facilities with a mental health treatment orientation. The resulting system improvements laid the groundwork for managing the return of children from out-of-state placement. During this process there have also been dramatic reductions in the numbers of children placed in residential treatment facilities with a corresponding increase in the severity of symptoms of children taken into care.

There has been serious discussion about the need for secure care options for DCFS wards for the past ten years. The absence of this option has been cited as one of the primary reasons for out-of-state placement. The General Assembly passed legislation and the Department has been working on rules to bring secured care to Illinois for wards needing a more secure treatment environment.

The proposed Part 411 was crafted with the input, guidance and approval of the Secure Child Care Advisory Committee, with the intent that these programs would address the treatment needs of the defined population.

The Secure Care Advisory Committee convened 10 meetings over a six month period between July 1998, and January 1999, and developed proposed Rule 411, Licensing Standards for Secure Child Care Facilities. Proposed Rule 411 reflects a state-of-the-art secure residential treatment program for mentally and emotionally disturbed children and youth.

In order to allow more children to live in a community-based setting, the Department has expended significant effort to build and support the development of the Child and Adolescent Local Area Networks (C&A LAN). Training for the development of Child and Family Teams (CFT) and Wraparound individual plans of care has been sponsored in all regions of Illinois. Wraparound contracts have been used to provide mental health treatment and supportive services for children stepping down from high-end care and for children who are at risk of being extruded from their home communities. While LANs have improved the Department’s ability to treat children outside of an institution, improvements still need to be made in the ability of the LANs to quickly respond when a child is returning to the community or whose placement is at risk of disrupting.

A number of Department funded programs and initiatives predate the Child and Family Team Wraparound services and contracting process and are only minimally coordinated with the C&A LAN process. These contract categories include Screening Assessment and Support Services (SASS), Intensive Therapeutic Services (ITS), Counseling Contracts (i.e., Medicaid and non-Medicaid), Placement Stabilization Services for Wards (PSSW), and counseling services funded through the POS regular foster care rate methodology. It is a challenge to the Department to integrate these services with the Wraparound services to provide a coordinated approach for providing services for children in the community setting.

Children with special physical, mental or emotional needs may be placed in a home at a higher payment rate because the foster parents need special skills or need to access services to appropriately care for the child. Between 1990 and 1995, the specialized foster care program in Illinois grew from 2,380 children to 7,018 children, an average annual increase of approximately 24%. Much of this growth was associated with children originating in regular foster care and who are moved into specialized care. In many instances, the child might have been able to remain in a regular foster care placement had the family been supported by outpatient mental health and support services. It is a challenge of the Department to work with LANs to provide that support and to monitor the cases moving into specialized care.

Approximately 20% of the SED children placed out-of-state function in the mild to moderate range of mental retardation. These children also present serious and persistent symptoms (e.g., sexually aggressive behavior, aggression, self-hurtful behavior) that require programs that are tailored to their intellectual functioning level. In addition, it is likely that the number of children who fit this profile may actually be higher due to under-reporting of children with disabilities.

Although there have been some residential programs established to treat children with SED and mild mental retardation, the availability of outpatient services at the community level are very scarce. The lack of services contributes to problems with permanency goal attainment and stability in foster care placement.

It is the Department’s goal to have an organized system of care that is fully integrated at the community level with services delivered in response to the child’s treatment needs rather than by the availability of "programs." In order to accomplish this goal, the following implementation steps have been initiated or are being planned.

• Improvement of coordination between the ITS program and the CFT Wraparound planning process. A work group will be established to determine the best possible "fit" for these two programs. One possible option is to take advantage of the ITS program’s ability to rapidly mobilize services by using ITS as the front-end of the Wraparound process for children who are at extreme risk of stepping up to high-end care.

• Design single point access mechanisms in all C&A LANs to assure that services are coordinated and easily accessible.

• Utilize the C&A LAN to improve network design in their area. This would include planning and implementing a comprehensive array of behavioral health services by realigning existing services/programs to eliminate overlap and address service gaps. This would include improvements concerning "low intensity" mental health services for children in traditional foster care placement; comprehensive, periodic assessment of children’s loss and trauma experiences; and treatment for the impact of loss and trauma.

• Plan and implement quality management processes based on performance and outcome indicators. The focus of the outcome analysis should be the numbers of placement disruptions and ratio of children placed in high-end care.

In addition to the current steps being made to develop an integrated service model for mental health care, from Specialized Foster Care to high-end services such as Secured Care and Psychiatric Hospitals, the Department is also working to improve each individual service type.

To address this issue requires a combination of skillful planning, care management, and program development. The following are some of the recently implemented and planned actions that are intended to assure appropriate utilization of psychiatric hospital facilities.

• Revision and implementation of the Department’s policy guide on psychiatric hospitalization. This document clearly delineates and explains the duties and responsibilities of caseworkers, supervisors, hospitals, SASS, residential providers, and foster care providers. This step will improve the planning process for transition and after care.

• Organization of the Residential Provider Network for children with SED. The Department will identify residential treatment providers capable of serving children who present the most challenging emotional and/or behavioral symptoms. A direct assignment system will be designed to facilitate timely discharge for children in psychiatric hospitals who have placement issues as a result of their behavioral health needs.

• Utilization of the University of Illinois-Chicago (UIC) hospital program for the children who present the most serious risk and whose histories include multiple psychiatric hospitalizations and placement disruptions. This program consists of two components: the inpatient hospital is the Comprehensive Assessment and Treatment Unit (CATU); the transition, discharge, and follow-up consultation team is the Response Training System (RTS). The program will provide a comprehensive assessment capable of yielding practical and detailed recommendations custom tailored to the post-hospital placement.

• SASS will be refocused to manage compliance with Policy Guide 96.5 (see above). This will include facilitating the participation of either foster parents or staff from residential facilities in the treatment and discharge planning process during the hospitalization.

• The Intensive Therapeutic Services (ITS) program will operate a pilot program in the Cook North Region that will focus on children who enter the hospital from a foster care placement. ITS will be involved at the front end (within 72 hours) and will provide the intensive support necessary to return the child to the same foster home on discharge.

In order to build on recent improvements, the Department has begun the process of planning structures designed to shorten LOS and improve the proximity of placement. The following are some of the recently implemented and planned actions intended to assure that children remain in residential care no longer than necessary.

• Replication of the original residential care utilization study. The Northwestern University study (John Lyons, Ph.D.) will be completed to profile the psychopathology and risk issues associated with children who are currently placed in residential care. The findings of this study will provide the necessary data to set benchmarks for utilization levels in the next five years. It will also serve as an index to the efficacy of current utilization management processes.

• Improvement of the Placement Review Team (PRT) process for approval of children for residential care. The PRT protocol will be standardized for all regions of the state and will be linked to the constructs of the utilization study (the Children’s Severity of Psychiatric Illness). Placement decisions will be increasingly limited to within the child’s region of origin or the closest possible appropriate resource.

• Improvement of the facility Gatekeeper monitoring process. There will be increased focus on review of the child’s progress as it relates to LOS. Gatekeepers will be the glue that assures linkages between the residential facility and the Child and Family Team (CFT) assigned by the Local Area Network (LAN) or origin. LOS will be closely monitored.

• A placement protocol for the child’s CFT will define responsibilities and expectations during the course of placement in residential care. The focus of the protocol will be to plan for transition from the residential facility back to the community of origin.

• Improvements in monitoring and tracking children in residential care. The database for residential care will be expanded to include key performance information including participation of the CFT, progress toward accomplishment of treatment goals, identification of the target community based placement, and completion of the transition and discharge plan.

• Placement reauthorization mechanisms shall be put in place for children who exceed LOS benchmarks. Children who require continued residential care will be carefully reviewed to determine if continued stay is clinically justified.

• Increased foster care options for adolescents who are ready for discharge from residential treatment facilities. Improved utilization management of residential care requires the development and availability of creative foster care options for youth who are ready for discharge. This need is most pressing for middle and older adolescents. The lack of an appropriate foster care resource is the single biggest cause of discharge delays.

• Fund additional quality assurance staff positions in residential treatment facilities with responsibilities and expectations clearly defined. These positions will build on the current utilization review and program evaluation processes required under Part 132. System wide outcome and performance indicators will be the common denominator for evaluating quality improvements for all residential facilities.

• Profiles of all residential providers will be developed and will be based on defined performance specifications. Outcome measurements and criteria for residential facility profiling will include LOS information, unplanned discharges, negative outcomes, psychiatric hospitalizations, successful step-downs, and improvement in role functioning.

• Based on profiling data, the Department will organize the Residential Provider Network for Children with SED. The Department will identify residential treatment providers capable of serving children who present the most challenging emotional and/or behavioral symptoms. A direct assignment system will be designed to facilitate timely placement.

• The Medicaid Rehabilitative Services program will be refocused to provide more emphasis on quality indicators embedded in the requirements of the Rule. This will include improvement in the areas of assessment process, treatment planning, and the linkage of all services to the treatment plan.

• Linkages between the residential treatment providers and the child’s community of origin will be improved through the creation of protocols which define responsibilities and expectations for planning and coordination. The "disconnect" between residential providers and communities will be eliminated and this will increase successful outcomes.

• The Independent Utilization Review (University of Illinois–Chicago) process will be improved and will focus on defined quality indicators included in a protocol. There will be coordination will residential QA staff to assure that all recommendations have been followed.

• All high-end residential providers will be converted to the MRO format to assure consistency throughout the system. This step will assure that all programs are subject to the same requirements for staffing qualifications, client record keeping, and the delivery of mental health services.

• Implement a standardized client assessment protocol for all youth with SED who may be at risk of admission into residential treatment. The assessment protocol would specify mandatory and optional diagnostic instruments to facilitate appropriate treatment planning. The results of the assessments would be maintained in a database which fosters appropriate matching of the youth with the appropriate provider and allows accumulation of planning data on the performance of the service system.

Development of proposed Rule 411 is only the first step in the process of implementing secure childcare in Illinois. Many other tasks, such as the development of forms, protocols, and training programs, remain to be performed.

• Develop and conduct training for all licensing and gatekeeping staff. The curriculums will primarily focus on the requirements of proposed Rule 411.

• Develop the forms necessary for licensing secure childcare facilities, including the licensing application, an application checklist, site visit review forms and checklists, and other associated documents.

• Develop an application process and selection criteria for "independent examiners" as defined in proposed Rule 411. Finalize the "clinical evaluation" protocol for use by the independent examiners to determine appropriate admission of children to secure child care facilities.

• Develop the standardized admission packet for used by licensed secure childcare facilities, to assure compliance with due process requirements on admission of a child. The admission packet will explain the child’s rights related to their admission along with a detailed description of the secure care program. The packet will also contain the individual treatment goals for the child and a clear description of what it will take to "step-down" to a non-secure treatment setting.

• Develop a detailed, standardized, contract "program plan" for secure childcare facilities. The standardized program plan will assure that all secure child care facilities operate with a minimum of variation, and that all facilities fully comply with the intent of Public Act 90-608 and proposed Rule 411. The Advisory Committee stressed the importance of holding these programs to the highest possible quality standards.

• Develop a process for conducting frequent "degree of need" studies to determine the approximate numbers of children requiring placement in secure care. This study should also target the likely geographic origin of children requiring secure care to assure that secure childcare facilities are located in close proximity to the areas of need.

• Develop a process for profiling residential providers to identify programs that produce successful outcomes for children with "high-end" clinical needs. All secure child care facilities shall be profiled as capable of managing and treating the most seriously emotionally disturbed children and youth in the DCFS population.

• Develop protocols for monitoring the program operation of secure child care facilities, including protocols for site visits, structured checklists to assure full compliance with proposed Rule 411, and a standardized review process for all unusual incident reports. In addition, all secure child care facilities shall be subject to annual Independent Utilization Review as defined in Department policy and procedures.

• Integrate monitoring and compliance processes required by 59 Ill. Admin. Code 132, Medicaid Community Mental Health Services Program, with the monitoring protocol for proposed Rule 411.

For the Department to accomplish its goals related to the utilization of high-end services and permanency of children with SED, it is necessary for there to be a fully integrated system of care in all C&A LANs. The following is a summary of items in process or being planned to improve the community services system.

• Standardization of the Wraparound contracting process.

• Development of CFT protocols for children in high-end care. This will define CFT roles and responsibility for all children who are in out-of-community residential treatment facilities. In addition, Targeted Case Management (TCM) staff have been assigned to function as CFT facilitators. These TCM staff have been specially trained to process the development of Wraparound plans for children with SED.

• Implementation of the Wraparound Administrative Services Agents (WASA) in all C&A LANs to improve the Wraparound contracting and payment processes.

• Implementation of Information Management Systems necessary to monitor individual child plans of care.

• Development of access protocols that are designed to assure rapid development of services and organization of CFTs for all at-risk DCFS children.

• Network design and organization to assure a comprehensive array of behavioral health services. This process would include realignment of existing services/programs to eliminate gaps and overlap. This process should also look at how low intensity services are delivered to children in foster care.

• Quality management processes to assure that key performance and outcome indicators are being tracked (e.g., all children at-risk or in out-of-community placement have an active CFT).

The Department needs to support the development of specialized services and programs designed to treat SED children with mild mental retardation. The return of children from out-of-state placement and the stability of children currently placed in community foster care placements is closely linked to resource development for this population. The following items are either currently underway or in the planning process.

• Residential treatment providers capable of working with this population will be identified and program models will be developed based on examination of successful out-of-state models.

• The C&A LAN will plan to include local resources that are trained to work with this population as part of the SED service array. Child and Family Teams (CFT) will have access to the community providers with the skills to work with this population, and shall develop Wraparound plans incorporating their expertise.

• All children in residential treatment facilities who fit this profile shall be linked to a CFT and will follow the protocol to assure appropriate transition, after care planning, and timely discharge.

• A work group will be established to design a standard contract program plan for this population. Licensing standards will also be developed to better address the needs of these children.

The Department is implementing processes designed to improve traditional and kinship care, and at the same time, is taking steps to reconfigure specialized care. The following is a summary of items in progress or being planned to improve the operation of the specialized foster care program.

• Fully implement the use of Level of Care (LOC) processes as a utilization management mechanism to determine appropriateness for placement in specialized care. Consideration will be given to augmenting the Placement review Team (PRT) process to include LOC.

• Improvements to the regular foster care program are being implemented and include additional payments to providers for outpatient mental health counseling services. Also, the Child and Family Team (CFT) Wraparound contracting process has been streamlined to be more responsive to children at risk of stepping up to specialized care.

• Specialized foster care program plans are being developed to assure system wide consistency.

• The downsizing of the entire specialized foster care system creates special challenges to the provider community. The Department is working with the provider community to develop strategies for reducing program census while at the same time maintaining the required service mix.

The Department will work to put in place the organizational structures necessary to facilitate the implementation of fully integrated systems of care at the local community level. The following items are the primary implementation goals and objectives for the local systems of care:

• Development of WASA organized integrated systems of care that are consistent with the clinical needs of children for whom the Department has legal responsibility.

• Development of provider capability and capacity within the local system of care.

• Development of a full spectrum of mental health case management services including:

Prevention and early intervention

Crisis Management

Assessment and referral

Treatment planning and utilization management (UM)

Quality review and management

Outcomes monitoring and follow up

• Development of linkages with all other services impacting on the Department’s children including physical health care (i.e., primary care physicians), education, and juvenile justice.

• Management of service delivery in the local system of care consistent with wraparound care management requirements.

Desired outcomes associated with system of care development include improved psychosocial functioning, increased stability in community placements, appropriate utilization of high-end services, reduction in length of stay in high end care, rapid attainment of permanency goals, and overall quality improvement in the provision of mental health and wraparound services.