No one wishes to hold a hot potato. Imagine attending a crawfish boil with friends. One of you scoops a potato from the pot and tosses it to a friend. It’s hot! No one will hold it long enough to feel the heat. It gets passed around quickly. Eventually, though, one of you will have the determination to withstand the heat long enough to juggle it between your hands and then you’ll take care of it.

As Louisiana’s Department of Health and Hospitals managed the transition from the former child welfare system to the new Coordinated System of Care and Louisiana Behavioral Health Partnership, DHH reported in April of 2011 that Louisiana’s children who cannot live with their families or in foster care would require 275 beds in Therapeutic Group Homes. Because a Therapeutic Group Home can have no more than 8 beds, Louisiana’s foster children who cannot live with foster families require at least 35 Therapeutic Group Homes (275 divided by 8).

Today, after 18 months, there are only two licensed Therapeutic Group Homes in all of Louisiana. One is in Baton Rouge. One is in Baker. We’re still missing 33 Therapeutic Group Homes!

Of the 275 beds required for children who cannot live in less therapeutic settings, Louisiana has no more than 16. We have two Therapeutic Group Homes and we need at least 35 spread throughout Louisiana. These homes need to be spread throughout Louisiana because the closer a child is to her family while in out-of-home care, the easier it is for the family to participate in the treatment and reunification process.

This persistent shortage of Therapeutic Group Homes is not new news. All the people and all the agencies involved in Louisiana’s Medicaid-funded managed behavioral health care system know we have this gaping hole in our new system of care. The absence of Therapeutic Group Homes is discussed with frustration in nearly every meeting.

The absence of Therapeutic Group Homes for adolescents frequently arises when we at Louisiana Methodist Children’s Home begin work on discharge planning for a child who will be leaving one of our intensive residential treatment facilities.

We all know about the hole. DHH, Magellan, providers, and interested parties have held meetings about the missing Therapeutic Group Homes. Research has been conducted regarding how other states make this happen. Still, Louisiana’s children who require Therapeutic Group Homes wait.

“CSoC: Two Missing Steps on Both Sides of PRTF” was published in this blog on March 27, 2013. In that article, I mentioned 4 barriers I believe are preventing the development of sufficient Therapeutic Group Homes.

“Louisiana Needs Treatment Group Homes for Children” was published in this blog on May 7, 2013. The article contained six suggestions for facilitating the development of Therapeutic Group Homes.

As I re-read both of those articles, it strikes me that the issue comes down to the current imbalance between requirements and funding. A combination of over-regulation and under-funding is at the heart of the Therapeutic Group Home hole.

Control of regulations and minimum licensing standards sits exclusively with Louisiana’s Department of Health and Hospitals. The matter of reimbursement rates sits there, too.

With DHH sitting at the fulcrum of the see-saw (regulatory requirements on one side and reimbursement rates that make sense on the other) there is an important decision to be made. Is it better to reduce requirements so they can be met with the current daily rate? Or, is it better to increase the daily reimbursement rate to fund the current requirements?

I believe the current minimum licensing standards for Therapeutic Group Homes are sound. The 8 bed limit seems contrived, but I understand the desire to keep the number of children low and more home-like. Rather than tweak the regs, the reimbursement rate seems the logical place to effect change that will allow a Therapeutic Group Home to break even.

It appears money to fund the current minimum licensing standards is available. According to an analysis conducted earlier this year for the Louisiana Legislature by the Legislative Fiscal Office,

“In FY 13, there is $384,845,287 allocated in the
Medicaid Medical Vendor Payments (MVP) Buy-Ins
Program via a selective services 1915(b) Medicaid
waiver for the LBHP. However, according to the most
recent Medicaid forecast in December 2012, only
$333,303,830 in FY 13 total expenditures is anticipated.
As a result, there is an estimated $51,541,457 in excess
budget authority allocated to the LBHP for FY 13.
According to DHH, the reasons for the difference are 2
month’s delay in the start-up of the LBHP and slower
than anticipated enrollment of residential providers
including therapeutic group homes and psychiatric
residential treatment facilities. Additionally, the CSoC
has not been implemented in half of the planned
service regions.”

Focus on the Fisc, February 2013 Edition, page 11
http://lfo.louisiana.gov/files/publications/FY13_FocusOnTheFisc.pdf (The monthly Focus on the Fisc reports from 2013 have been aggregated into the single PDF file linked above. Page 11 of Feb 2013 is actually page 20 of the PDF file. Bold is not original but for emphasis.)

Do you see the reason funding is available? It’s right there: “slower than anticipated enrollment of residential providers including therapeutic group homes …” That’s the hot potato!

It is past time for Louisiana to consider how a portion of the $51 million excess budget authority might be used provide the Therapeutic Group Home care required by Louisiana’s children whose needs prevent them from living at home or with foster families. It’s time we take care of this hot potato!

Rick Wheat, President and Chief Executive Officer
Louisiana United Methodist Children and Family Services