Nicole Nesmith’s voice shakes a little when she recalls the night her child, Phoenix, revealed a painful secret.
“Phoenix got really quiet and was like, ‘I have something to tell you and I’m really sorry I didn’t tell you sooner, but I’ve been cutting for about a month now.’”
Nesmith was working on a social work degree, so she was familiar with self-harming — she just hadn’t expected to deal with it so close to home.
Phoenix’s confession started a cycle familiar to families who have kids with severe mental illness — therapy, crisis hospitalizations, medication, more therapy, new meds when the old ones stopped working well, more hospitalizations.
But in the fall of Phoenix’s freshman year of high school, even that exhausting pattern wasn’t enough.
“There was a two-week period when I really didn’t leave the house at all,” said Phoenix.
When kids are chronically in distress — suicidal, self-harming, harming others, running away repeatedly — there had been a place for them: psychiatric residential treatment facilities.
That’s where the community mental health center treating Phoenix sent the Nesmiths when the care it could offer no longer kept Phoenix stable.
Residential treatment centers take children for long periods of time — weeks, sometimes months — to do more than talk kids down from crisis. They work to get at the root causes of their distress and help patients develop coping mechanisms to better manage the stressful things that set off a crisis.
In 2011, the state decided Kansas was sending too many kids to residential facilities for too long. At $500 a day or more, it cost too much. The state pushed to divert kids from residential care and bring down the length of their stays.
That loss of business prompted many treatment facilities to close some or all of their beds, resulting in a sharp drop from nearly 800 spots for care to the current 282.
More changes swept through with Kansas’ privatization of Medicaid in 2013. Under KanCare, community mental health centers no longer decided whether kids needed residential treatment, as they had for Phoenix. Instead, that decision passed to the private companies managing Medicaid under KanCare.
In 2015, the Nesmiths sought a third residential stay for Phoenix. After years of struggling with depression, anxiety, and thoughts of suicide, the looming milestone of a 17th birthday, college and a future prompted the Nesmiths to seek another round of longer-term intensive care.
“I was trying to figure out a future I never thought I’d have,” Phoenix said. “And that was just another source of stress.”
But the Nesmiths say Phoenix’s insurance company denied residential treatment. Instead, it pointed Phoenix to group therapy. But the family had already tried that and was no longer eligible.
Two of the state’s Medicaid providers, Sunflower Health Plan and United HealthCare, declined to comment on how they authorize residential stays, deferring comment to the state.
Even as it got harder to access, the need for residential treatment didn’t go away.
In fact, with shorter lengths of stay, kids might get stable but didn’t have the time to develop good coping mechanisms and trauma management to stave off future crises. They’d often end up referred back to a treatment facility when suicidal, aggressive or self-harming tendencies returned. But now, there weren’t enough beds available.
In 2019, that means 150 kids in urgent need of treatment languish on a waitlist. That means foster kids who land at facilities with less intensive care, youth residential centers, show up with behavior more extreme than those residential centers are equipped to handle.
Headline-grabbing problems, but little change
The overflow of kids needing beds in residential treatment facilities has served as an underlying cause of what’s driven headlines over the past year.
Many of the children sleeping in foster care contractors’ offices were either waiting for a psychiatric bed or had just left one.
Kids who are suicidal — an epidemic so troubling that the state has convened a task force to deal with it — land in a mental health system stretched beyond capacity. And substance abuse by parents or kids can push children into needing intensive inpatient care.
Recommendations this year from a child welfare tax force to fix the overload of the residential treatment system echoed similar results from previous years.
Whether their focus is mental health, children’s care or foster care, panels have found time and again that psychiatric residential treatment facilities don’t have enough space and aren’t given enough time to treat kids properly.
Kids are discharged, but problems persist
The people who run residential treatment facilities say that shortening kids’ length of stay pushes the facilities more into a stabilization role, which they say is supposed to fall to hospitals and crisis centers. Residential facilities often don’t see kids until they’ve had multiple hospital stays, when it becomes clear crisis behavior is becoming a chronic pattern.
“We are a part of changing that child’s trajectory in their life,” said Cheryl Rathbun, who oversees a residential treatment facility run by St. Francis Community Services. “It needs to be more about treatment, and not just about simple stabilization.”
But providers say they’re sometimes pushed to release kids who haven’t yet made progress on the deeper issues driving harmful behavior. That happens, providers say, because insurance companies haven’t seen enough improvement to justify paying for additional treatment.
Dana Schoffelman, who runs a residential facility in Topeka, said she sometimes hears from the insurance providers that kids are at their “baseline” and need to be moved out of her facility because residential care isn’t able to move them past what’s become the kids’ new normal.
“The youth is actually here because that’s their baseline,’’ she said. “You can’t use the definition of what got you into services as the reason to stop services.”
The Kansas Department for Aging and Disability Services doesn't track how frequently kids cycle back through residential care, but providers and mental health advocates say it’s gotten more common since the lengths of stay got shorter.
A struggling mental health ecosystem
The direct hits to residential treatment facilities — shorter and fewer stays — came amid other changes to mental health services and treatment that weakened the continuum of mental health care.
Cuts to Medicaid reimbursements in 2016, though they were restored the next year, made it even harder for residential facilities to stay open.
And some have pointed to juvenile justice reforms passed in 2016 that divert kids out of the justice system as a driver of more high-needs kids into foster care, and particularly into residential treatment.
Some residential facilities were already taking kids in the juvenile justice system. But Schoffelman, who runs Florence Crittenton in Topeka, said the shortage of beds has made it harder for kids who are particularly aggressive or high-needs to get treatment.
With beds mostly full, the people caring for them are stretched to the limit. That makes it hard for those residential centers to take on kids who need even more supervision while making progress with less severe cases.
Providers also talk repeatedly about the continuum of care. They say residential treatment needs to be part of a system that includes therapeutic care in the community, options for short-term hospitalization, and other mental health services.
When Kansas took the decision-making about who needs residential care out of the hands of community mental health centers, officials at those facilities say, it made it harder for kids to stay on that continuum.
Now that community mental health centers aren’t calling the shots, the first time the centers hear a kid was in residential care might be when they’re expected to put therapy services in place immediately after the child’s discharge.
Then, it’s a scramble to get the right services in place to keep that child from needing to go right back in, said Jessie Kaye, president of Prairie View Inc. mental health center.
Providers’ wish list
The people who run community mental health centers and residential facilities want to see a return to the pre-2011 model: stays approved by the community centers, not insurance providers; and more days in care.
That means more money for residential providers. Cheryl Rathbun told lawmakers in 2017 that it can cost $500 to $700 per night for children to stay in St. Francis’ facility. But providers say that funds the kind of therapy, round-the-clock staffing, and time to work with the kids’ families that means long-term improvement for kids.
Tara Wallace, a social worker and therapist for foster kids who used to work in a residential treatment facility, said short stays put impossible pressure on therapists and social workers who are trying to get as much done as possible to help the kids in their care before their time is up.
And Kyle Kessler, who heads Kansas’ association of community mental health centers, said adding more beds isn’t the only solution. It needs to be balanced with more front-end services, as well, so kids who can be served closer to home, are.
“I don’t think it’s an ‘either-or,’ ” he said. “I think it’s an ‘and.’”
Some have been encouraged by Gov. Laura Kelly’s interest in residential treatment. Kelly was an outspoken critic of long waitlists and shorter stays while she was a state senator. As governor-elect, she sent members of her transition team to meet with the heads of residential facilities to talk solutions.
But Kaye said changes can also be disruptive.
“Established relationships now have been severed,” she said. “It’ll be another year lost because we’ll have to start over with so many things.”
Madeline Fox is a reporter for the Kansas News Service, a collaboration of KCUR, Kansas Public Radio, KMUW and High Plains Public Radio covering health, education and politics. Follow her on Twitter @maddycfox.
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