Residential Treatment System for Youth in Ohio: Challenges and Solutions

Residential Treatment System for Youth in Ohio Challenges and SolutionsResidential Treatment Facility (RTF) services are aimed at providing treatment and support to youth whose behavior and conditions may not be safely addressed in a community environment, such as youths with sexually troublesome behavior or those who start fires.

Every adolescent requiring RTF services has unique needs, and their treatment options should be determined according to those needs. Monitoring and measurement of outcomes should be performed carefully to ensure that the RTF services are meeting the needs of the youth and helping them achieve positive results.

At present, Ohio has issued licenses for 11 Certified Group Homes and 23 Children’s Residential Centers, which provide RTF services for juveniles. Studies in the past have estimated that about eight percent of juveniles with mental health needs make use of these RTF services. RTFs provide supervision and care 24 hours a day for two or more weeks consecutively.

Different RTFs offer different types of services, which may include group therapy, individual therapy, recreation therapy, substance abuse treatment, medication management, and various other services and support.

The stay in an RTF is intended to be for the short term and usually involves intense treatment with an aim to transition juveniles safely back to his or her home and community at the earliest possibility.

The RTF where a juvenile resides may be regulated by the Ohio Department of Mental Health and Addiction Services (OhioMHAS) or the Ohio Department of Job and Family Services (ODJFS), or both. Some of the juveniles at the facility may be placed through the juvenile court system. Some might also receive services from a county board of developmental disability.

Limited access to the required treatment services for mental health and trauma for juveniles results in an increase in placements in the RTFs.

Ohio has taken a number of steps to improve access to community and home based services, including investments in various programs, such as the SFSC or Strong Families Safe Communities program.

The Family and Children First Councils in Ohio are doing good work to provide coordination and other support and services for children and families that are at a risk of outside home placements. But these councils receive limited funding, and their service levels can significantly vary across counties.

Challenges Faced by the RTFs

Residential Treatment Facilities are institutional settings, which face a number of inherent issues and challenges that require serious consideration. The youth in these RTFs are impacted by the physical environment within the facility, service provision requirements, as well as sources of funding.

Ohio must focus on closing the gaps in the current systems, which increase the risk to juveniles in these facilities. One of the key concerns is that many families must give up their child’s custody in order to receive access to these intensive mental health services. Acute hospital care and outpatient treatment may be covered by private medical insurance plans, but not residential treatment services and community based services.

If a family is unable to afford such services they will either relinquish the child’s custody to the state in order to gain eligibility for Medicaid and get the required treatment or simply forgo the needed care. Relinquishing the child’s custody creates complications in the system of care as it will involve multiple agencies, and at the same time, it compromises the outcomes of a treatment because the family is no longer as involved in the treatment process for the child.

The result of this situation is that almost one-third of the children enter into agency custody because of the family’s custody relinquishment (as per the estimates provided by the Public Children Services Association of Ohio).

Along with the treatment in residential facilities for the juvenile, there is also a provision for education services for them, including special education service for eligible juveniles. Education services at the RTFs are organized in different ways, including providing on-site education in association with a local school, sending the juvenile to a local school, charter school, or educational service center.

Problems in this education system occur because of the competion for treatment and education. Juveniles frequently report that they receive fewer hours of education than what is required under Ohio state law for general students or what is required under the Individualized Education Program of a student. This lessens the chances of the juvenile to be able to keep up to the educational standards dictated by school boards.

For the juvenile growing out of the child serving system, very little is being done to plan for their post-secondary education or to create employment opportunities for them despite Ohio doing pretty well on the job front. Although many juveniles have the eligibility to receive services from Opportunities for Ohioans with Disabilities (OOD) in order to support their higher education or to get employment, the Residential Treatment Facilities are often unable to connect juveniles or young adults that well to these programs.

RTF placement, although widely used across Ohio, is restrictive and has proved to be potentially harmful or ineffective for some of the juveniles. Neglect and abuse risks for juveniles exist in the RTFs, and there have been cases of restraint related death and sexual abuse, which are well-documented. Furthermore, research shows that juveniles could develop anti-social or otherwise inappropriate behavior because of exposure to the behavior of other juveniles at a facility.

Although juveniles could achieve benefits between the period of admission and discharge, they may not be able to maintain civilized and responsible behavior once they go back to the community. This creates a re-admission cycle to the RTF or even a juvenile justice facility.

RTFs that are licensed by OhioMHAS will have resident rights officers, but juveniles are often unaware of the presence of these officers or how to reach them. These officers may have additional roles to perform at the facility, and the often lack in support, training, authority, and resources to address various youth related issues.

Ohio is making a dedicated effort to address the needs of juveniles for mental health care, but admissions to Residential Treatment Facilities, including children below the age of 12, are on the rise. Placement of children in various RTF programs continue, even when these programs have not shown to be as effective as community and home based services. Children’s placement continues to place some juveniles at risk as the evidence-based community and home services they need are just not available in their community.

Solutions to Improve the Residential System

Make Effective Use of Information and Data

Extensive information and data is available about children placed in RTFs and the kind of services they generally receive. Ohio must utilize this wealth of data to evaluate the services being given to the juvenile and take the necessary measures to improve those coveted success rates. Resources must be invested in services that have a better chance of creating positive outcomes for juveniles.

All the data, information, and analysis should be made accessible to the public in order to enable the youth, families, service providers, legislators, and all other stakeholders to make sagacious decisions about how the residential care system can be improved. The long-term care industry has accomplished similar efforts. The Ohio Department of Developmental Disabilities has created online tools to allow for a review of information pertaining to the regulatory compliance of the facilities.

Prioritize Community Based Services

Although it is widely accepted that the needs of juveniles can be best served in their own community and home, but many Ohio adolescents end up in residential facilities due to the lack of reliable community based services. This situation can change if Ohio commits to removing needless institutionalization and focuses on the development of high quality community based services.

If juveniles are diverted from unnecessary placement in RTFs, it would allow the state to make RTF services more effective for juveniles who truly require them for short term outside-home stabilization. The juveniles who are in need of mental health services must be able to receive them in community and home based settings instead of RTFs.

Needless institutionalization in various other settings has already been effectively addressed in Ohio, and the same strategies can be applied for juveniles who require mental health services. Ohio can create well-funded incentive programs to develop robust community based services that would minimize unnecessary placements in RTFs.

Ohio should carry out a needs assessment study across the state and create a professional level of care tool for RTF admissions. The state should also set adequately high rates for quality community based services so that service providers feel incentivized to offer these services across the state. Procedures must be put in place to monitor the fidelity and quality of the services.

Unify Standards for RTF Services Statewide

Residential treatment services must be provided in a way that is in alignment with best practices, protects juveniles from neglect and abuse, and is results driven. Although the current regulations specify the minimum standards for safety and health, they fail to ensure that the facility follows the most poignant practices that will help create sustainable and predictable outcomes.

A key hurdle to improving the quality of RTF services is that there is no single stage agency that can oversee the functioning of these facilities. Some of the RTFs are licensed by ODJFS alone, some others are licensed by OhioMHAS alone, and some others are licensed by both. This can create difficulties for providers because the rules of different agencies may not be consistent with each other, or may be subject to different interpretations from state surveyors.

To overcome this hurdle and provide stellar leadership to enhance the quality of RTF services, Ohio should create a single cross-agency team that licenses and oversees these departments. The Ohio Department of Education should be a part of this cross-agency team to oversee the delivery of educational services to juveniles in RTFs. One of the first steps should be unify the regulation of OhioMHAS and ODJFS.

Develop Evidence-Based Practices

Ohio should implement a comprehensive RTF quality improvement system that extends beyond basic licensing requirements. Such systems have already been modeled in the state in other areas, such as care programs and incentivized payments for nursing homes, and programs for early childhood education.

Standardized information about the programming offered by each RTF can be developed. This information may include what best practice or evidence-based programming is offered by an RTF, which strategies for behavior management are implemented, and what kind of training the staff at the RTF have received.

To promote quality improvement systems, Ohio can incentivize the adoption of best practices. The state can reimburse out of pocket expenses for service providers who adopt these best practices. However, caution should be exercised against creating a system where providers are reluctant to serve juveniles with complicated needs out of a worry that they may fail to meet the performance benchmarks.

Implement Trauma-Informed Care

Residential treatment will achieve cascading beneficial effects if trauma-informed care is implemented at RTFs. Youth at these RTFs often have a history of trauma, and many of them have been through multiple forms of trauma in their past.

Trauma exposure rates for juveniles in RTFs may range between 50 to 70 percent, according to researchers. Traumatized juveniles at these facilities have experienced multiple forms of trauma in more than 90 percent of the cases. They need care that correlates with the type of trauma they have experienced. Although significant progress has been made by OhioMHAS to create trauma-informed care systems, hurdles to thorough implementation at the treatment level still exist.

Oversight and monitoring to ensure appropriate training for the staff at RTFs and correct implementation of care practices is missing. As a consequence, RTFs continue to have physical environments as well as policies that fail to provide a sense of calm and comfort, or access to outdoor areas and safety.

Encourage Youth and Family Engagement

The chances of short term and long term success increase when juveniles at RTFs are involved in their treatment process, and care is family driven. However, the prevailing facility practices and funding structures are such that they have the opposite impact by alienating juveniles from their families.

Elimination of custody relinquishment should be Ohio’s first priority in this regard. If a family is left with no option but to relinquish custody in order to pay for RTF services, it prevents them from getting fully involved in the care of their child.

Residential facilities should also develop practices that promote the involvement of families and youth in their services. RTFs often work during regular business hours, when it is hard for members of the family to visit or get involved with the treatment process. Treatment programs are often scheduled to suit the convenience of the staff, and not the family.

Proper Discharge Planning and Transition

Discharge planning at RTFs should begin right at the time of admission itself, and should involve juveniles and their family. The goal must be to make the stays at residential facilities as brief as possible and help children transition back safely to their home and communities. The duration of stay at the facility should be no longer than what is therapeutically required for the youth. The treatment plan should include a focus on developing skills for the juvenile’s success in society.

The plans should incorporate the family’s needs as well so that both the child and the family are ready to function successfully following the juvenile’s return to the home. Facility practices and treatment plans should also foster connections between the community and the services the juvenile receives before, during, and after their residential treatment.

RTFs should ensure that the juvenile is suitably connected to educational services, employment services, as well as other community based services to help them transition successfully into their community and into adulthood.

Protect the Rights of the Juvenile

In order to provide protection to juveniles at residential facilities against abuse and neglect, it is crucial to ensure that the juvenile understands their rights. Every incident of neglect and abused should be reported. Under the current rules, the RTFs are required to notify juveniles about their rights. However, in many instances, such notifications are not adapted to suit the learning ability or age of the youth.

Notifications about their rights should be developmentally appropriate and should be written in a language they can comprehend. Regular reminders should be given to juveniles about how they can report abuse. Incident reports from the RTFs should provide more detailed information in order to ensure better compliance with policies and rules related to restraint and seclusion.

Conclusion

Ohio has a clear opportunity to examine and improve its system of mental health services, and particularly its residential treatment facility system, in order to create a significant positive impact on juveniles and their families that require these services. The state can maximize results by replicating the existing proven models in the state, and support the juvenile who needs residential services and prepare them for their transition into a healthy and productive adulthood.

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