Health plan cuts kids’ hospital stays

For the child and family alike, they are devastating experiences. A suicide attempt, a drug overdose, an act of violence against parents or peers, a psychotic episode – followed by a 911 call, or a rush to the emergency room. And then, a psychiatric hospitalization.
Some children stay in secure wards for days, others for weeks, an experience that in itself can be jarring and disruptive. Still, they get expert care to stabilize them and try to prevent future crises, but when they are discharged, they may need a lot more than a daily pill and a weekly counseling session.
Now, as RIte Care faces another wave of expected cuts due to the state budget crisis, a study of how the program has worked to reduce children’s mental-health hospitalizations shows what many see as a promising sign.
From 2006 to 2007, the study found, Neighborhood Health Plan of Rhode Island, which covers the majority of RIte Care beneficiaries, cut the number of children’s mental-health hospital days by 25.4 percent to 9,302, and it did so by expanding, not reducing, services.
Working with state agencies, providers, advocacy groups and Beacon Health Strategies, its behavioral-health management partner, Neighborhood has developed a range of new options for children in their homes and in community settings, some as alternatives to hospitals.
And even with the cost of all these extra programs – not all of which are covered by other RIte Care payers – Neighborhood estimates it saved a net $5.24 million in 2007 alone, or 19.8 percent of the total cost of children’s mental-health hospitalizations in the previous year.
At a time when cutting costs is a priority for state leaders, said Neighborhood CEO Mark E. Reynolds, this is doubly good news: “This happens to be an area where there’s a positive outcome in terms of cost and in terms of care delivery for children,” he said.
Jim Spink, vice president of field operations and public policy at Beacon, said the study – which covers children in RIte Care as well as a smaller number of children in other state programs – could be a “catalyst” for the state and other payers to pursue innovation.
“We [have] to be more creative with the dollars we have,” he said, “so knowing that resources are extremely limited, we need to play within that budget and see what can we do.”
The work that yielded the 2007 savings wasn’t done in a single year, nor was it initiated by Neighborhood alone.
At the state level, the R.I. Department of Human Services, which runs RIte Care, and the R.I. Department of Children, Youth and Families (DCYF), which cares for children in state custody or under state supervision and runs the R.I. Training School for Youth, have encouraged the development of home- and community-based programs.
Policy experts such as Rhode Island Kids Count, clinicians at Butler Hospital and Bradley Hospital, and parents’ advocates – most notably the Parent Support Network of Rhode Island – have offered different perspectives on what is needed and helped shape the initiative.
Programs have been developed by providers such as Gateway Healthcare, St. Mary’s Home for Children, The Providence Center and community mental-health centers across the state, responding to prompts from Neighborhood and from state officials.
From 2004 to 2006, the initiative created six new options for children:
• The most intensive program, the Acute Residential Treatment Service (ARTS), offered by Gateway and St. Mary’s, is a lot like hospitalization, but without locked doors and in a community setting. It’s meant either as a step down from the hospital, or as an alternative – and it costs about one-third of the cost of a day in the hospital, Spink said.
• There are also two day programs – community-based “partial hospital” – which involves six to eight hours a day, five to seven days a week, in a structured, therapeutic setting, and going home at night, or “day treatment,” which focuses on enhancing functioning and skills.
• There are “intensive outpatient” services, three or more hours a day of therapy for children who need a lot of care, and “enhanced outpatient services,” which are provided by a team of therapists and case managers either in the child’s home, or in an office setting.
• And there is the Psychiatric Response Network, which delivers psychiatric evaluation and treatment services to children and adolescents in the custody of DCYF.
A seventh service, to stabilize children in crisis without hospitalizing them, is in the works.
Cathy Ciano, executive director of the Parent Support Network, said those new services could have made a big difference for her son, now 28, who has bipolar disorder. First hospitalized at age 12, he spent four years in institutional care, including the Training School.
When he finally came home, Ciano said, “he said he didn’t know how to be a part of a family anymore.” And lacking crucial support services, his parents couldn’t manage him at home.
“If we could’ve gotten respite services, that would’ve made a big difference,” she said. “We needed mentoring. We needed outreach and tracking. It wasn’t just clinical services.”
With these new services, Ciano said, “we’ve come a long way, but we still have a long way to go.” There are still not enough home- and community-based services, she said, and many families don’t know what’s available. “At Gateway, Katherine Powell, vice president of children’s services, said the new options are clearly making a difference. ARTS, for example, has served 243 youngsters since it opened in 2005, and “I have absolutely no doubt,” she said, “that there have been kids who have been diverted from hospitalization and are doing better because of ARTS.”
The program’s director, Charlene Leveillee, said children come from Bradley and Butler, from ERs, from DCYF and the courts, as well as through referrals from Beacon and outpatient service providers, and they stay for three weeks to a couple of months. There are only eight beds, plus four day slots, and there’s a waiting list.
Asked how the program changes young lives, Leveillee read from a letter from a girl who came to ARTS at age 16 and previously had been hospitalized.
When she arrived, the girl wrote, “I was a hopeless girl with suicidal thoughts. I had nothing to live for and felt that my life would never get better.” She saw no point in trying to change, yet over time, with the ARTS team’s help, she gave it a try.
“They believed in me even when I didn’t believe in myself,” she wrote. “They gave me a second chance and allowed me to grow. … I now have hope again, and I’m the happiest I’ve been in a long time.”
It’s been more than a year now, Leveillee said. The girl hasn’t needed ARTS again, or been hospitalized. “She actually is doing pretty well.” •