Last year, approximately 2,700 youth accessed residential treatment in Virginia, including roughly 1,900 Medicaid members.(*1) Psychiatric residential facilities provide structured, intensive treatment, at times as a step down from acute psychiatric hospitalization, focusing on family and individual therapies, crisis prevention, and the development of psychosocial supports to decrease repeat hospitalizations and future out-of-home placements. Placement in residential treatment facilities may be recommended for youth who have repeated acute psychiatric hospitalizations and have not been able to benefit from less restrictive levels of care. Best practice for use of residential treatment requires that the youth meet medical necessity criteria and that less restrictive, community-based options have been explored prior to placement.

The process for approval of and placement in residential treatment for youth in Virginia is fragmented, time-consuming, confusing, and inefficient. The Children’s Residential Workgroup (HB 728/SB 734) convened between September and November this year to review the current process for approval and placement; identify barriers to timely placement; and develop recommendations for improving and expediting the process.

The principal barriers to timely placement into residential treatment for children and adolescents included:

1. A lack of a collective understanding of the approval and placement process – including the Independent Assessment, Certification, and Coordination Team (IACCT) and the Family Assessment and Planning Team (FAPT) processes – and the roles of different stakeholders in the process;

2. The time-consuming nature of the authorization and admissions process, which consists of medical necessity determination as well as engagement of local FAPTs and a determination that all possible alternative services have been explored; and

3. Challenges identifying a willing and appropriate residential provider with availability once it has been determined that a youth’s symptoms and needs meet medical necessity criteria and FAPT has been engaged and approved the educational costs.

In order to improve and streamline the process for Virginia’s families, the workgroup developed seven, core recommendations:

1. Improve the alignment of the IACCT and FAPT processes to ensure efficient, timely, and better coordinated access to residential treatment.

2. Improve information sharing across the system of care to ensure timely, relevant, and necessary information about the individual and family seeking residential treatment is exchanged by involved stakeholders.

3. Standardize the training and education materials for individuals, families, and other stakeholders to provide comprehensive and uniform information about the referral and admissions process to children's residential placements.

4. Standardize the admissions referral material through a universal application process to decrease the administrative burden on individuals, families, referring agencies, and treatment providers who are seeking timely admission to children's residential treatment.

5. Continue to build out the comprehensive continuum of care for the behavioral health system to increase access to, and availability of, alternatives to residential and inpatient treatment.

6. Increase the availability of residential treatment facilities (including those that specialize in evidence-based treatment for specific disorders or complex needs) so that individuals and families have an informed choice of the right provider to meet their needs.

7. Increase the use of family support partners and peer navigators to provide support and improve timeliness in accessing services.

The workgroup stressed the importance of continued investment in developing a comprehensive continuum of trauma-informed, evidence-based behavioral health services for children and adolescents, which would include less restrictive community-based alternatives to residential treatment. Case management and care coordination also must be sufficiently resourced to support families in navigating the service delivery system and accessing appropriate interventions. The workgroup agreed that out-of-home placements should be avoided whenever possible. Nevertheless, when placement in a children’s residential facility is the treatment modality that best meets the individual’s needs, the current process needs reform to ease the burden on Virginia’s families, and the Commonwealth needs additional facilities to treat more challenging and specialized cases here in Virginia.
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(*1) Data from the Office of Children’s Services, FY2019 and from Magellan BHSA, CY2019. Numbers include group home and psychiatric residential treatment.