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 Required within 2 weeks of PRTF Requested at regular admission admission and every 6 months if denied • • Records from past placements, All medical records from mental health services (inpatient, hospitalizations, or mental health placement, and outpatient) within the past 9-12 months. • services History and Physical • • School information Initial assessments • • Intake Packet 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 Monthly Reports – PRTF Admission • Multidisciplinary Treatment Plan • Multidisciplinary Treatment Plan • Prior Authorization • Prior Authorization (only if needed by • Extension Tool insurance provider) • Child Assessment of Needs • Psychiatric Evaluation • Total Staff involved in each report: 6 • Psychologist sign off • Therapist, Unit Supervisor, Medical staff, Teacher, Medical Records • Number of Staff involved in each report: 10 assistant, psychologist - 6 • 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
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