Never in Louisiana’s history has our state’s child welfare system been more highly regulated. Never has so much significant change occurred in such a compressed period of time than during the last 18 months.

I’ll summarize it like this: We now have federal regulations being interpreted by state regulations to create a coordinated system of behavioral health care from four state departments’ funding mixed with federal funds which are being managed by a state-based subsidiary of a public corporation traded on Wall Street. (I think that’s correct.)

Louisiana’s Coordinated System of Care (CSoC) is one year old this month. Created by an Executive Order issued by Governor Jindal on March 3, 2011, CSoC became operational when Magellan of Louisiana began acting as the State Management Organization on March 1, 2012.

CSoC (pronounced “sea sock”) is a managed behavioral health care system for Louisiana’s children who are in out-of-home placements or who are at risk of being placed out of their homes. Louisiana’s Coordinated System of Care (CSoC) is a cross-departmental project of the Office of Juvenile Justice, the Department of Children and Family Services, the Department of Health and Hospitals and the Department of Education to organize a coordinated network of broad, effective services for Louisiana’s at risk children and youth with significant behavioral health challenges or related disorder.

The cross-departmental nature of CSoC is chiefly related to funding. State General Fund dollars from each of the four state departments were pooled and used as a pot to pull down untapped Medicaid dollars at a ratio of 1:3. One state dollar brings down 3 additional Medicaid dollars.

Of course, anytime federal dollars are pulled into a state, those federal dollars have significant strings attached. When Louisiana converted to a federally-funded child welfare system, those federal strings required significant changes.

One imposed change was the creation of two new DHH-licensed levels of residential care: Treatment Group Homes (TGH) and Psychiatric Residential Treatment Facilities (PRTF). Mercer, a consulting firm which helped DHH design Louisiana’s CSoC, determined that Louisiana needs 340 TGH beds and 250 PRTF beds.

Because each of our residential programs cares for more than 16 children, the Methodist Children’s Homes in Louisiana were required by state regulation to become licensed as Psychiatric Residential Treatment Facilities. A PRTF license is not a hospital license. We continue operations as residential facilities with additional staff to provide for medical care and residential psychiatric care.

This is probably the best place to insert the chart I have created which demonstrates the levels of out-of-home care (Click the image for a larger view):

Notice the third step. That’s the PRTF step. Then notice that the second and fourth steps on either side are missing. There is no step for Longer Term Psychiatric Hospitalization. There is no step for Treatment Group Homes. This diagram describes the current status of the array of services available for children in Louisiana.

Let’s start with the Longer Term Psychiatric Hospitalization. To my knowledge, there are only a small number of these beds in Louisiana. 40 is the last official number I heard reported during a meeting in Baton Rouge in late 2010. I’ll assume the number of these beds today is still close enough to 40 to call it 40. I assume there are times when 40 beds are sufficient. There will also be times when 40 beds in the entire state are not enough for children who have longer term psychiatric hospitalization needs.

In terms of numbers, the most significant missing step is the absence of Treatment Group Homes. Louisiana reports it needs 275. There can be no more than 8 children in a single group home. Louisiana needs at least 34 treatment group homes spread across the state. Today, after a year of CSoC, there is only one Treatment Group Home. Parker House is the Volunteers of America’s TGH in Baton Rouge for boys under 13. (I commend the staff of VOA and Parker House for their work to license a Treatment Group Home. It was not an easy road.)

At Methodist we have reviewed the Treatment Group Home materials and we do not believe we can provide Treatment Group Home services. I’ll share some of the reasons we and others are unable to provide Treatment Group Home services.

1. Federal regulations dictate what a children’s home can do now that CSoC is at work. We have four houses on our Ruston campus that would make great Treatment Group Homes. However, because we have PRTF beds on the same property, all our beds on the property must be PRTF beds. Remember, because we have more than 16 children in care, we must be licensed as a Psychiatric Residential Treatment Facility.

2. The TGH minimum licensing standards require a Treatment Group Home be located in a neighborhood. Finding a suitable, existing house which meets the licensing requirements will be like finding a needle in a haystack. Homes built for families will not serve as great Treatment Group Homes. For example, few families require 8 bedrooms. If a provider builds their own house with 8 bedrooms it will be nearly impossible to sell in the future because, again, few families require 8 bedrooms.

3. I wrote earlier that it was initially reported that CSoC would bring $3 federal dollars into Louisiana for each $1 of State General Funds Louisiana tossed into the common pot. That’s a significant amount! I don’t believe it has worked out that way, though. Reimbursement rates for services are now lower than the cost of providing the service. The per diem payment for Non-Medical Group Homes is less than the rate providers received before CSoC was created. Several providers have crashed into their financial wall this past year because the current reimbursement rates do not support the costs of care. The Treatment Group Home reimbursement rate is low.

4. There are adolescent group home providers in Louisiana who have the experience and the heart to become Treatment Group Home providers. Unfortunately, CSoC does not pay for the start-up costs of making the transition from the former DCFS Child Residential license to the new DHH Treatment Group Home license. The cost of additional staff who must be hired prior to receiving the TGH license, the cost of licenses for evidence-based treatment practices, and the cost of accreditation are all financial burdens group home providers must shoulder to become Treatment Group Homes. Unfortunately, the per diem reimbursement rate is too low to allow a provider to ever recoup the startup costs. Figuratively speaking, a new TGH provider will start out in a hole and never climb out.

I’ll stop there because this is growing a bit long.

Scroll up and click on the chart again. Louisiana’s children need access to the two missing steps on the staircase of services. It’s a big step down from care in a psychiatric residential treatment facility to care in a non-medical group home. Some children require longer term psychiatric hospitalization because of significant mental illness.

Louisiana still has important service gaps to fill for children – the sooner the better.

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