Increasing the Stability of the Secure Care Units Shirley Ryan, MS, - - PowerPoint PPT Presentation

Increasing the Stability of the Secure Care Units

Shirley Ryan, MS, LMHC, LMFT Director of Clinical Services Crossroad Child and Family Services Fort Wayne, IN

Increasing the Stability of the Secure Care Units

Secure Intensive Program / Unit

• Olivet (Girls) and Grinnell (Boys) Unit
• 15 beds each
• Licensed for ages 6-21
• Entrances and Exits Require Keys
• Placed by:
• Department of Child Services (DCS)
• Department of Education (DOE)
• Probation
• Parent / Medicaid Placement (Psychiatric Residential Treatment Facility – PRTF)

Population

• Diagnoses: Post Traumatic Stress Disorder, Disruptive Mood Dysregulation

Disorder, Major Depression, Reactive Attachment Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder

• History: complex trauma, multiple hospitalizations and residential placements,

inconsistent family involvement

• Behaviors: destruction of property, verbal and physical aggression, self-harming,

running away, and suicidal ideation

PRTF Definitions

• Psychiatric Residential Treatment Facility (PRTF) has two definitions
• The first is as a secure care unit – require increased staffing, locked doors, and safety

precautions

• Can also refer to the type of funding, in this case – Medicaid funding. Individuals placed

in the PRTF program reside on a secure care unit, have Medicaid payment, and family involvement

Long Term Goals

• 1) To fill both units to maximum capacity
• Grinnell last filled to 15 in January 2019
• Olivet last filled to 15 in June 2018
• 2) Receive consistent reimbursement for beds
• Awareness that there may be some ‘lost days’ but should be very few and far between

Obstacles to Long Term Goals

• September 2018 – Department of Child Services mandated that all secure

care placements apply for PRTF (Psychiatric Residential Treatment Facility) – Medicaid placement

• Treatment teams had to submit applications for all the current secure care residents

before September 2018 to determine if any could be approved for PRTF funding

• Any new admission has to apply for PRTF at intake and then again every 6 months

following any denials as long as they remain in secure care

• April 2019 – Indiana State Department Health audit results indicate that

multidisciplinary treatment plans have to be completed monthly

• Previous audit allowed it to be completed every 3 months with a monthly progress

report completed by therapist

Comparison of Admission Process

Requested at regular admission

• Records from past placements,

hospitalizations, or mental health services

• School information
• Intake Packet

Required within 2 weeks of PRTF admission and every 6 months if denied

• All medical records from mental health services (inpatient,

placement, and outpatient) within the past 9-12 months.

• History and Physical
• Initial assessments
• Multidisciplinary treatment plan
• Prior Authorization
• Psychologist sign off sheet
• Psychiatrist sign off form
• Pre-admission screening
• Child Assessment of Needs
• Intake Packet

Comparison of Monthly Reporting

Monthly Reports – Regular Admission

• Multidisciplinary Treatment Plan
• Prior Authorization (only if needed by

insurance provider)

• Total Staff involved in each report: 6
• Therapist, Unit Supervisor, Medical

staff, Teacher, Medical Records assistant, psychologist - 6

Monthly Reports – PRTF

• Multidisciplinary Treatment Plan
• Prior Authorization
• Extension Tool
• Child Assessment of Needs
• Psychiatric Evaluation
• Psychologist sign off
• Number of Staff involved in each report: 10
• All from regular admission plus psychiatrist, Utilization

Review, Clinical Director, Residential Case Manager

Concerns

• Lost Bed Report
• Submitted to Compliance committee in September 2019 – last

month of Quarter 3

• Loss of 163 days ~ $50,000
• Received 27 suspensions of claims from Medicaid for additional

information before approving/denying payment

Streamlining PRTF process - Necessary

• For our survival as DCS provider
• DCS compliance
• To stabilize the secure care units
• Decrease wait time to fill beds
• Decrease time and stress of staff involved – higher case loads
• Increase consistent reimbursement
• And to meet Crossroad Vision: Creating promising futures for children—

whatever it takes.

Root Cause Analysis

Findings:

• Lack of written procedures
• Team members did not understand the flow
• Confusing Schedules
• Use of 2 calendars with 2 different dates
• Reports taking 6-7 days to complete – close to missing deadlines
• Lack of back up systems
• Reports taking much longer when members are sick or on vacation
• Poor Tracking system
• Stemming from poor communication

Objectives

• Creation of Written PRTF Procedures
• Addressing Schedules
• Creation of Back Up System
• Implementing tracking system

Creation of PRTF Procedure

• Procedures that breaks down steps required and responsible party
• Admission
• Monthly Reviews
• Six Month Recertification
• Updated Residential Checklist and training packet for Therapists
• All Staff were trained on procedural steps and their role

Addressing Schedules

• Schedule Confusion –
• Updated Prior Authorization Calendars and Reporting Schedules to use

same dates

• Provide more reminders to staff
• Provide current statuses through emails with primary staff of PRTF

process

Back up System

• Cross trained staff to cover steps when primary staff is on vacation or sick
• Nurses
• Unit Supervisors
• Residential Case Mangers
• Intake Specialist
• Director of Clinical Services
• Teachers
• Medical record assistant
• Psychologist

Tracking System

• Intake specialist sends notifications when phone certification is completed

and paper packet is submitted

• Utilization reviewer sends notifications with outcome of packet – approved,

suspended or denied

• Director of Clinical Services scans PRTF packets to Utilization Review and

Therapist after Psychologist signs

Procedural Outcomes

• Utilization Review, Medical Record Assistant, Intake Coordinator, and

Clinical Director know status of any PRTF Packet at all times

Stability of Unit Results

• Grinnell was filled in November 2019 – Christmas and again in January 2020
• Olivet has been stable since October 2019

Report Results - Days

Financial Results

Next Steps

• Empowering primary team members to:
• Follow procedures as outlined
• Identify and communicate any concerns quickly
• Decrease the intense involvement of middle and upper management
• Allows primary team members to utilize their skills and receive praise for their hard

work

Shirley Ryan, MS, LMHC, LMFT Crossroad Child and Family Services 1825 Beacon Street Fort Wayne IN 46805 (260) 484-4153, ext. 2058 SRyan@Crossroad-fwch.org