In the past, Louisiana had a variety of residential providers. On one end, there were neighborhood group homes which served children who were able to attend public school and fully participate in a community. At the other end were facilities like Louisiana Methodist Children’s Home where we developed an on-campus alternative school to address the significant educational deficits and extreme behavioral needs of our children that public schools cannot meet. Most of our residents have been in multiple placements prior to their admission and each move has interrupted their educational process.

In the past, Louisiana Methodist Children’s Home provided many levels of care on a single campus with different staffing ratios and different levels of treatment. Those days are gone. We must eliminate four less intensive levels of care and can now provide only one level of care, psychiatric residential treatment.

Governor Jindal’s Executive Order BJ 2011-05, on March 3, 2011, granted Louisiana’s Department of Health and Hospitals’ (DHH) authority over Louisiana’s child welfare system by creating a Medicaid-funded managed care system for behavioral health. The Coordinated System of Care (CSOC) was created and is managed by DHH.

Louisiana’s Coordinated System of Care (CSOC) allows three distinct levels of care. Providers of residential care must choose one of the three levels: non-medical group home (the least intensive), treatment group home, or psychiatric residential treatment facility (PRTF – the most intensive). 16 is the magic number. DHH regulations prohibit children’s homes from caring for more than 16 children unless the children’s home gives up all other levels of care and provides only PRTF beds.

Today, Louisiana Methodist Children’s Home in Ruston is licensed by Louisiana’s Department of Children and Family Services (DCFS) to provide care for 106 children. For quite a while we have provided 5 levels of care: ESC, AC, WINGS, RGC, and CAB. To continue caring for more than 16 children, we must give up these levels of care. Regardless of a particular building’s original design, the beds must be PRTF-level beds. PRTF children really need single bedrooms. Because all beds must be PRTF-level beds, we will only license 84 beds.

The continuum of care we have provided at Louisiana Methodist Children’s Home will be eliminated once we receive our license from DHH. I anticipate losing this continuum of care will increase the number of moves children in out-of-home care must make. Here’s why. If a child is ready for a less-intensive residential program, she must move away from Louisiana Methodist Children’s Home to another group home with 16 or fewer beds. Because we can no longer provide a continuum of care, children must break relationships and move again, adding one more move to a string of out-of-home placements.

While CSoC plans for children to leave our care and return home to their families or to foster care, many of our children cannot return home because home is not safe. Our children are in the state’s custody because of abuse or neglect severe enough that a judge ordered their removal from their homes.

Of course, if a child’s home is not safe, an alternative to returning home would be placement in a less intensive level of care. If that less intensive level of care were permitted on a large residential campus, the child could continue in care without being required to move to a new group home, but as the regulations now require, a treatment group home or non-medical group home cannot be located on property with PRTF beds. The child must be uprooted and move.

Unfortunately, at least for the foreseeable future, those less intensive beds will be in short supply. DHH and Mercer, the consulting firm that put much of Louisiana’s CSoC together, have determined the number of beds needed for each of the three levels of care. I believe the last estimate I’ve seen is that Louisiana needs 250 psychiatric residential treatment beds, 340 treatment group home beds and 125 non-medical group home beds.

Next week I hope to announce we have the first 24 PRTF beds in Louisiana at Methodist Children’s Home of Southwest Louisiana. Our licensing site visit is scheduled for Wednesday, October 3. We intend to follow this with 84 PRTF beds in Ruston at Louisiana Methodist Children’s Home. What we will provide at Methodist Home for Children of Greater New Orleans is yet to be determined until we find a new place to land when DHH closes Southeast Louisiana Hospital.

I have talked to executives of private psychiatric hospitals who have called me to discuss whether PRTF beds would fit their plans, but to my knowledge no other provider is pursuing licensure to provide PRTF beds. Methodist will provide 108 of the 250 needed. If others do not step up to the plate, children who need PRTF care may be placed in out-of-state psychiatric residential treatment facilities – even further from home.

There is one treatment group home provider in Louisiana: VOA’s Parker House in Baton Rouge. (If you get a chance, congratulate Susan Butler and her staff for being Louisiana’s first licensed Treatment Group Home!) Still, we need another 320+ treatment group home beds in Louisiana.

Because most existing providers have chosen to become non-medical group homes (they had less than 16 beds and consider the TGH rate to be low for the level of care required), there are plenty of non-medical group home beds in Louisiana. However, it is a very large step in intensity to move a child from PRTF to NMGH.

Non-medical group homes are stand alone homes located in communities. Unlike a fully developed residential campus such as Louisiana Methodist Children’s Home, there are no extra support services available to staff and residents of a non-medical group home. Except for rare children, I believe the step in intensity from a psychiatric residential treatment facility to a non-medical group home is large enough that it would be risky for the child and the group home.

What is my point? It is this: now that Louisiana’s CSoC has enough regulation, structure and funding to be viable for managed care purposes, it’s time to start looking at the first round of significant improvements. The system is in place. Now let’s make it good for children.

I believe children will be better served if children’s homes with more than 16 beds are permitted to create continuums of care from the most intensive to the least intensive on the same property. This will reduce the number of moves children must make, reduce the number of times children’s relationships are broken and will reduce the number of new schools children must attend.

I will end this (and my future posts about tweaking CSoC) with this: CSoC has to be about children and families.