Psychiatric Residential Treatment Facilities Research Articles

Psychiatric Residential Treatment Facilities for Child Behavioral Health Services in North Carolina Medicaid

Background Psychiatric residential treatment facilities (PRTFs) are non-hospital inpatient treatment settings for children with severe be­havioral health disorders. PRTFs are a restrictive and costly form of care that can potentially be avoided with community-based behavioral health services. Methods Statewide Medicaid enrollment and claims data for 2015–2022 were used to describe PRTF utilization in North Carolina. We examined annual episodes of care in PRTFs and compared trends before and during the COVID-19 public health emergency. Results From 2015 to 2022, 10,038 children insured by NC Medicaid entered a PRTF across 10,966 episodes of care. In the past five years (2018–2022), care in PRTFs resulted in Medicaid expenditures of over $550 million total, or over $100 million per year. In 2022, 42% of children who entered PRTFs were in foster care and 44% of children were placed in PRTFs outside of North Carolina. Limitations The analysis was limited to data collected for administrative purposes. Conclusions Current trends indicate an ongoing overrepresentation of children in foster care placed in PRTFs and increased out-of-state PRTF placements. Coordinated efforts in future research, policy, and practice are needed to determine the cause of these trends and iden­tify solutions.

Using a Learning Collaborative Model to Improve Youth Psychiatric Residential Treatment

ABSTRACT As part of a transformation initiative, a behavioral health managed care organization partnered with 14 youth psychiatric residential treatment facilities (PRTFs) through a Learning Collaborative to support clinical training, family engagement, community integration, and medication monitoring. Self-reported progress toward sustainable implementation, monitored monthly, improved significantly over time (F = 15.05, p < .0001). Clinical and direct care PRTF staff (N = 1,580) received either in-person or virtual clinical training. Scores on a pre- and post-training knowledge test increased significantly for both in-person and virtual training (p < .001 for both), and training satisfaction was high. Percentage of youth with therapeutic family sessions per month did not change over the Learning Collaborative; this percentage began and remained high (Range: 90.71% to 93.37%). Strategies to engage youth and families in organizational governance increased significantly (e.g. including youth/family partners on staff and in program development). The number of partnerships between PRTFs and community-based behavioral health providers did not change over time. Instead, number of partnerships began and remained high (Range: 38.36 to 48.08). PRTFs also tracked medications monthly to develop internal systems to monitor prescribing practices. This study highlights the value of partnerships and the Learning Collaborative approach to support a continuous quality improvement process.

Predicting successful placements for youth in child welfare with machine learning

Out-of-home placement decisions have extremely high stakes for the present and future well-being of children in care because some placement types, and multiple placements, are associated with poor outcomes. We propose that a clinical decision support system (CDSS) using existing data about children and their previous placement success could inform future placement decision-making for their peers. The objective of this study was to test the feasibility of developing machine learning models to predict the best level of care placement (i.e., the placement with the highest likelihood of doing well in treatment) based on each youth’s behavioral health needs and characteristics. We developed machine learning models to predict the probability of each youth’s treatment success in psychiatric residential care (i.e., Psychiatric Residential Treatment Facility [PRTF]) versus any other placement (AUROCs > 0.70) using data collected in standard care at a behavioral health organization. Placement recommendations based on these machine learning models distinguished between youth who did well in residential care versus non-residential care (e.g., 80% of those who received care in the recommended setting with the highest predicted likelihood of success had above average risk-adjusted outcomes). Then we developed and validated machine learning models to predict the probability of each youth’s treatment success across specific placement types in a state-wide system, achieving an average AUROC score of >0.75. Machine learning models based on risk-adjusted behavioral health and functional data show promise in predicting positive placement outcomes and informing future placement decisions for youth in care. Related ethical considerations are discussed.

The Collaboration between Occupational Therapy and Psychology in Treating Adolescents in a Psychiatric Residential Treatment Facility. Multisensory Immersion Room as a Treatment Intervention

This article highlights the collaboration between the fields of occupational therapy (OT) and psychology in the development of a Multisensory Immersion Room (MSIR) within a Psychiatric Residential Treatment Facility (PRTF). An MSIR was designed to expand clinical treatment programming at the Albert J. Solnit Children’s Center-North Campus, within the Connecticut Department of Children and Families. The collaborative assessment between psychology and OT delivers a superior understanding of a youth, which is advantageous to planning treatment in an MSIR space. A case study is utilized to showcase this collaboration, while simultaneously paving the way for future providers.

3.70 Foster Care and Vitamin D in Females Admitted to a Psychiatric Residential Treatment Facility

3.70 Foster Care and Vitamin D in Females Admitted to a Psychiatric Residential Treatment Facility

Traumatic stress symptoms predict restraint incidents in children and adolescents in psychiatric residential treatment.

The early identification of youth at risk for restraint incidents is an important next step to reducing the likelihood of such incidents. Yet, the extant research has not comprehensively investigated the idiographic factors that contribute to the restraint of youth in psychiatric residential treatment facilities (PRTFs). The current study investigated client-level predictors of restraint incidents, with specific emphasis on youth client trauma history and traumatic stress symptoms as assessed at admission. Participants were children and adolescents (N=150; 55.3% female, 66.7% White, 33.3% Black or biracial) aged 6-17 (M=11.8 years) admitted to a PRTF in the northeastern United States. A negative binomial regression with maximum likelihood estimation was conducted to examine the relative contributions of age, gender, length of stay, number of psychiatric diagnoses, body mass index (BMI), and traumatic stress symptoms at intake to the frequency of restraint incidents. The model was significant, χ2 (6, N=150)=30.326, p<.001, and both length of stay, β=.005, p<.001, IRR=1.005, and traumatic stress symptoms at intake, β=.072, p=.007, IRR=1.074, were identified as significant predictors within the model. Although length of stay is an obvious predictor of restraint incidents, the current study is the first of which we are aware to identify traumatic stress symptoms at intake as a potential indicator of restraint frequency following admission. Clinical implications of these results are discussed.

Antipsychotic medications and admission to psychiatric residential treatment facilities among youth in foster care diagnosed with disruptive behavior disorders.

Many youth in foster care are diagnosed with disruptive behavior disorder (DBD), a diagnosis indicative of aggression and behavior problems. These youth, who are at high risk for being placed in psychiatric residential treatment facilities (PRTF), are commonly prescribed antipsychotic (AP) medications off-label. However, treating children in the community is an important goal, and although AP medications can have severe side effects, these prescriptions may help to achieve this goal. In this study, we used Medicaid data to determine whether AP medications reduce the risk of admission to PRTF among two groups of children with DBD: those with DBD only and those who were diagnosed with DBD in addition to at least one of two conditions indicated for AP prescribing (psychosis and bipolar disorder.) Event history models show that AP medications are associated with a high rate of admission, which are likely due to the higher mental and behavioral health needs of youth who are prescribed. However, youth diagnosed with both DBD and indications who are prescribed an AP medication have one-tenth the rate of admission of similar youth who are not prescribed. For youth with DBD only, the findings are inconclusive. Given these mixed results, practitioners should follow clinical guidelines; ensuring youth are treated with psychosocial interventions and other psychotropic medications prior to AP prescribing. Agencies should attempt to address systemic factors such as shortages of foster homes, increased availability of therapeutic foster care, and implementation of in-home prevention services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Designing and Testing a Developmentally Appropriate Intervention for Children in a Psychiatric Residential Treatment Facility.

Preadolescent children in residential care have treatment needs that are different from adolescents. An intervention was created using developmental theory to inform decisions about the timing, objectives, strategies, and context best suited to preadolescents in an intensive residential treatment center. Aggressive behavior, seclusions, and restraints data for preadolescents during a 32-month period was used in the analysis. There was a significant decrease in aggressive behavior, seclusions, and restraints for preadolescents during the periods when the developmentally appropriate intervention was used versus the times when they received same intervention as the adolescents.

Inter-class Concomitant Pharmacotherapy in Medicaid-Insured Youth Receiving Psychiatric Residential Treatment.

Background: Concomitant pharmacotherapy has become increasingly common in the treatment of youth, including in psychiatric residential treatment facilities (PRTF) despite limited efficacy and safety data. Research is reported on the prevalence of any class and interclass concomitant pharmacotherapy, specific class combinations of psychotropics, and changes in number of medications from admission to discharge for Medicaid insured youth treated in PRTFs in one mid—Atlantic state.Methods: Medicaid administrative claims data were examined for youth under age 18 years who were discharged from one of 21 PRTFs during calendar year 2019. Descriptive statistics were calculated to examine patterns of service utilization 90 days prior to admission. The rates of concomitant psychotropic use at admission were compared to the rates at discharge. Logistic regression models were used to examine covariates associated with discharging on 4 or more medications.Results: Fifty-four % of youth were admitted on either two or three psychotropics, while 25% were admitted on four or more psychotropics. The proportion of youth admitting and discharging on 2 or 3 medications was stable. There was a 27% increase in number of youth discharging on 4 medications with a 24% decrease in those on a 5- drug regimen. Only the number of medications prescribed at admission was found to be significant (p < 0.001), with more medications at admission contributing to probability of discharging on 4 or more medications.Conclusions: Concomitant pharmacotherapy is common in PRTFs. These findings support the practice of deprescribing and underscore the need for further research.

Institutions For Mental Diseases Medicaid Waivers: Impact On Payments For Substance Use Treatment Facilities.

The Institutions for Mental Diseases (IMD) exclusion prohibits use of federal Medicaid funds to treat enrollees ages 21-64 in psychiatric residential treatment facilities that have more than sixteen beds. In 2015 the federal government created a streamlined application pathway for state waivers of this rule to allow Medicaid coverage for substance use disorder (SUD) treatment in residential facilities. Nine states received IMD waivers during the period 2015-18. Using data from the 2010-18 National Survey of Substance Abuse Treatment Services, we examined changes in residential and outpatient SUD treatment facilities' acceptance of Medicaid and other types of health coverage, as well as self-pay arrangements and provision of charity care, after states' adoption of IMD waivers. Acceptance of Medicaid increased 34percent at residential treatment facilities and 9percent at intensive outpatient facilities two years after waiver implementation. Delivery of medications for opioid use disorder did not increase in residential facilities post waiver but did increase to some extent in outpatient facilities. Our findings suggest that IMD waivers may be an important tool for advancing access to a full continuum of SUD treatment for Medicaid enrollees.

Effectiveness of Intensive Alternative Family Treatment on Reducing Re-Admissions to Psychiatric Residential Treatment Facilities

Children and youth with high behavioral health needs can receive care in a psychiatric residential treatment facility (PRTF). Overutilization of PRTFs is concerning because they are highly restrictive and costly residential care settings. Intensive Alternative Family Treatment (IAFT®) is an intensive therapeutic foster care program combined with service implementation strategies that is designed to reduce risk for entry to PRTF among youth with high behavioral health needs. This article presents findings from a quasi-experimental study examining the effectiveness of IAFT services in such a population of youth. In this study, we balanced treatment and comparison groups by first sampling youth with intensive care needs as indicated by having a prior PRTF spell. We then used propensity score weighting and covariate adjustment to estimate the effectiveness of IAFT in preventing PRTF re-entry. We found that receipt of IAFT was associated with a 24% lower risk of PRTF re-entry compared with youth who exited from a PRTF in the same state but did not receive IAFT. Sensitivity tests yielded mixed results regarding the effect of IAFT. Overall, results suggest that IAFT is an effective treatment approach for reducing risk for PRTF entry among youth with high behavioral health needs.

Psychiatric emergency care during Coronavirus 2019 (COVID 19) pandemic lockdown: results from a Department of Mental Health and Addiction of northern Italy

BackgroundThe current COVID-19 pandemic and the consequent containment measures are leading to increasing mental health issues both in psychiatric patients and general population. ObjectiveWe aimed to compare the number and characteristics of emergency psychiatric consultations during the phase 1 of lockdown with respect to the same period in 2019 in a Department of Mental Health and Addiction (DMHA) located in Lombardy region. MethodsWe conducted a cross-sectional study including subjects consecutively admitted to two psychiatric emergency rooms of DMHA in Monza, Lombardy, Italy. Sociodemographic data, clinical characteristics, referred symptoms, diagnosis and information on patients’ illness course following the emergency consultations were collected. No subjects were excluded for the purposes of the study. ResultsBetween February 21st and May 3rd 2020, there was a marked reduction in the number of psychiatric emergency consultations, if compared to the same period of 2019. Subjects who were living in psychiatric residential treatment facilities, had cannabis addiction and a diagnosis of obsessive-compulsive disorder were significantly more likely to present to emergency psychiatric consultations during lockdown. ConclusionsCOVID-19 epidemic may have a negative impact on more vulnerable individuals. Strategies to enhance relapse prevention and the use of alternative approaches as e-health technologies should be promoted.

A systematic review of the effectiveness of children’s behavioral health interventions in psychiatric residential treatment facilities

ObjectiveThe purpose of this systematic review was to synthesize quantitative or mixed-method studies that evaluate the efficacy of interventions with youth in the context of psychiatric residential treatment facilities (PRTFs) in the United States. MethodsSystematic review procedures were conducted to identify relevant studies, both published and from the gray literature in the United States. Search terms were informed via consultation with a university social science reference librarian, and four electronic databases were searched. Using a priori inclusion and exclusion criteria, team-based search procedures yielded a final sample of 47 relevant studies. ResultsStudies varied with respect to publication status; sample size; research design; youth gender identity; youth racial/ethnic identity; youth behavioral, psychological, and developmental or intellectual concerns at intake; outcomes measures; and interventions evaluated. Evaluated interventions could be clustered into one of five categories: (a) modifications to system of treatment, (b) therapeutic modalities, (c) educational/alternative programs, (d) practice behaviors, and (e) post-discharge engagement. The majority of studies noted youth outcome improvements; however, some studies also yielded mixed, inconclusive, or null results. ConclusionsWe would characterize the breadth and depth of research in this area to be insufficient in providing PRTF stakeholders a clear and firm understanding of “what works” for youth. Thus, one major implication of our review is the need for more research and efforts to incentivize the evaluation of ongoing practices in youth PRTFs. Still, this systematic review can serve as a convenient reference that can inform tentatively PRTF stakeholders’ decisions about the selection of interventions or practice behaviors.

Spotlight on the Safety Net: North Carolina Families United Supports Mental and Behavioral Health for Children and Families.

Gail Cormier remembers a phone call from a Forsyth County woman worried for her life and the life of her child. The child was living in a psychiatric residential treatment facility, but their needs were not being met. The mother was hungry, in need of clean clothing, and unsuccessfully looking for

A Systematic Review of the Effectiveness of Children’s Behavioral Health Interventions in Psychiatric Residential Treatment Facilities

A Systematic Review of the Effectiveness of Children’s Behavioral Health Interventions in Psychiatric Residential Treatment Facilities

Emotion management, institutional change, and the spatial arrangement of care at a psychiatric residential treatment facility

At Psychiatric Residential Treatment Facilities (PRTF), the neoliberal reorganization of health and social care provision has come with increasing demands for financial efficiency, cost-containment, and evidence-based practices that affect workers’ performance of emotion management and their spatial relationship to the PRTF as a place of identity and connection. In this article, data collected via semi-structured interviews and autoethnographic methods are used to examine how long-term workers at a PRTF were affected by and responded to a merger that generated conflicts between the workers’ and new management’s values, norms of emotional conduct, and spatial understandings of the institution. The standard theories and analyses of emotional burnout in the human services argue that value conflicts between workers and organizations cause the former to withdraw from their clients. In contrast, drawing on Bolton's multidimensional theory of emotion management in the workplace, this paper finds that in the face of value conflicts and increased coerciveness in the workplace, certain dimensions of emotion management—namely workers’ engagement with one another and with the children and adolescents in their care—can become more apparently pleasurable and serve as sites of resistance and compensatory solace. Building on work on the geographies of care that troubles the boundaries between public and private space, this paper finds that long-term workers constructed the pre-merger institution as an “anthropological place” and coped with the new regime’s efforts to commodify it by reaffirming their relationships and memories.

A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities.

The child welfare system is an access point for children’s mental health services. Psychiatric residential treatment facilities (PRTFs) are the most restrictive, and most expensive setting for children to receive long-term care. Given the high rates of behavioral health concerns among maltreated children in out-of-home care, research is needed to examine the factors that predict entry in PRTFs among children investigated for maltreatment. This exploratory study used cross-sector administrative records linked across multiple systems, including child welfare records and Medicaid claims, from a single state over a five-year period (n = 105,982). Cox proportional hazards modeling was used to predict entry into a PRTF. After controlling for many factors, PRTF entry was predicted by diagnosis code indicating a trauma-related condition, antipsychotic medication prescriptions, and entry into lower levels of out-of-home care, supporting the view that youth are admitted to PRTFs largely due to clinical need. However, PRTF admission is also associated with characteristics of their experiences with the social service system, primarily foster care placement stability and permanency. Implications for practice and research are discussed.

A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities

A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities

Admission to Psychiatric Residential Treatment Facilities among Youth from Families Investigated for Maltreatment

This study uses large, longitudinal, multisector administrative datasets of families investigated by child welfare services for maltreatment to explore which children are more likely to later enter psychiatric residential treatment facilities. This question is grounded in a pressing interest to understand these costly, highly restrictive mental health treatment settings. We use statewide data from one Southeastern state linked from multiple systems (child welfare services, income maintenance, and Medicaid). We use Cox regression analyses to develop models predicting psychiatric residential treatment facilities entry among children 5–17 years, whose families were investigated for maltreatment between 2003 and 2012 (n = 182,676). Findings show children from these families who enter foster care have a heightened risk for psychiatric residential treatment facilities entry (hazard ratio = 11.63), after controlling for other factors. Study findings build on a body of research underscoring the importance of the overlap of child welfare and mental health systems to child well-being.

A Statewide Child Telepsychiatry Consult System Yields Desired Health System Changes and Savings.

Telepsychiatry has clinical efficacy with children, but questions remain about cost-effectiveness. State agencies and health systems need to know if a child telepsychiatry consult system can address system concerns and improve care quality while lowering costs. To assist care in a rural state with few child and adolescent psychiatrists, an academic center coordinated a consult system of (1) televideo consults for high-needs children with Medicaid and state Multidisciplinary Team (MDT)/foster care involvement, (2) remote medication reviews for beyond guidelines prescribing, and (3) elective community provider telephone-based consults. Consult service data were collected and analyzed with Wyoming's Medicaid and Foster Care Divisions between the program start in January 2011 until March 2013. There were 229 televideo MDT/foster care consults, 125 mandatory medication reviews, and 277 elective phone consultations supporting community providers during this period. Following implementation, the number of Medicaid children ≤5 years of age using psychotropic medications decreased by 42% (p<0.001), and the number of children using psychotropic doses >150% of the Food and Drug Administration maximum decreased by 52% (p<0.001). Televideo consults redirected 60% of children slated by caseworkers for a psychiatric residential treatment facility admission into alternative community treatment and placements. A financial return on investment was 1.82 to 1 for combined services. This coordinated child telepsychiatry consult system for a state Medicaid division reduced outlier pediatric psychiatric medication prescribing, supported local community-delivered treatments, and reduced unnecessary hospitalizations in a financially advantageous manner that was well received by the practice community.