OF MENTAL HEALTH CARE
FOR CHILDREN IN THE CHILD WELFARE SYSTEM
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:
can the Department best evaluate the broad range of needs presented
by children in the child welfare system?
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
can the Department respond rapidly to children who present acute
psychiatric symptoms that threaten the stability of their foster
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?
Departments 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.
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.
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
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.
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
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.
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.
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.
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.
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
Departments 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.
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.
Foster Care Services
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.
for Children with Mental Retardation
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.
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.
AND FUTURE STEPS
is the Departments goal to have an organized system of care
that is fully integrated at the community level with services delivered
in response to the childs treatment needs rather than by the
availability of "programs." In order to accomplish this
goal, the following implementation steps have been initiated or are
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 programs 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
single point access mechanisms in all C&A LANs to assure that
services are coordinated and easily accessible.
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 childrens loss and trauma experiences; and treatment
for the impact of loss and trauma.
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.
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
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.
and implementation of the Departments 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.
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.
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.
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.
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
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.
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.
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 Childrens Severity of Psychiatric
Illness). Placement decisions will be increasingly limited to within
the childs region of origin or the closest possible appropriate
of the facility Gatekeeper monitoring process. There will be increased
focus on review of the childs 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.
placement protocol for the childs 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.
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
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
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.
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.
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.
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
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.
between the residential treatment providers and the childs
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
Independent Utilization Review (University of IllinoisChicago)
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.
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
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
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.
and conduct training for all licensing and gatekeeping staff. The
curriculums will primarily focus on the requirements of proposed
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.
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
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 childs
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.
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.
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.
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.
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.
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.
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.
of the Wraparound contracting process.
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.
of the Wraparound Administrative Services Agents (WASA) in all C&A
LANs to improve the Wraparound contracting and payment processes.
of Information Management Systems necessary to monitor individual
child plans of care.
of access protocols that are designed to assure rapid development
of services and organization of CFTs for all at-risk DCFS children.
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.
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).
for Children with Mental Retardation
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.
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.
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.
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.
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.
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
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.
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.
foster care program plans are being developed to assure system wide
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
RANGE GOALS & OBJECTIVES
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:
of WASA organized integrated systems of care that are consistent
with the clinical needs of children for whom the Department has
of provider capability and capacity within the local system of care.
of a full spectrum of mental health case management services including:
and early intervention
planning and utilization management (UM)
review and management
monitoring and follow up
of linkages with all other services impacting on the Departments
children including physical health care (i.e., primary care physicians),
education, and juvenile justice.
of service delivery in the local system of care consistent with
wraparound care management requirements.
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