ACUTE RESIDENTIAL TREATMENT:
ADAPTING OUR EXPERTISE FOR MANAGED CARE

ABSTRACT

As the application of managed care principles has spread through our country's health delivery system, hospitals have struggled to survive. Now the same managed care principles are stARTing to be introduced into the child welfare world, precipitating much anxiety.

Providers of residential treatment certainly have reason to be concerned. With a focus on reducing costs, "managed care poses risks especially for children with the most intensive service needs, who require comprehensive, long-term and often expensive treatment" - the very children served by residential treatment centers (Emenhiser et al, 1995).
To meet the needs of these children and their families, as well as to ensure their own financial viability, residential treatment centers need to adapt their programs and practices to respond to the new demands of a managed care environment.
To exemplify one way we can do this, this paper examines Germaine Lawrence's acute residential treatment program - a short-term crisis intervention program - which blends the core skills of residential treatment with the demands of managed care organizations to provide an effective service for children and families.

I. INTRODUCTION

As the application of managed care principles has spread through our country's health delivery system, hospitals have struggled to survive. Now the same managed care principles are stARTing to be introduced into the child welfare world, precipitating much anxiety.

Providers of residential treatment certainly have reason to be concerned. With a focus on reducing costs, "managed care poses risks especially for children with the most intensive service needs, who require comprehensive, long-term and often expensive treatment" - the very children served by residential treatment centers (Emenhiser et al, 1995).
To meet the needs of these children and their families, as well as to ensure their own financial viability, residential treatment centers need to adapt their programs and practices to respond to the new demands of a managed care environment.
The need to adapt traditional practices to new environmental conditions is not unique to residential treatment centers. Interestingly, the New York Times Magazine recently published an ARTicle that described how one church adapted many traditional practices to better meet the needs of families it wanted to serve.
A few years ago the Harvard Business School gave its blessing to the Willow Creek Community Church. In a distinctly flattering case study, the school sought to explain why this pARTicular interdenominational evangelical church was booming.

"In less than 15 years Willow Creek had grown from a hole in an Illinois wheat field into the largest church in America....
Before he built Willow Creek, the Rev. Bill Hybels went door-to-door in the Chicago suburbs and asked those who said they didn't attend church why they stayed away. They offered him a lot of specific suggestions: ditch the organ, pad the seats, drop the cross and all other aggressive or threatening images.
Hybels took these suggestions and built (Willow Creek)... "

All in all, concluded the Harvard study, Willow Creek was a tribute to "knowing your customers and meeting their needs..." The important point to the people at Willow Creek is that they have enjoyed their astonishing success without altering in any way core Christian beliefs. (The New York Times Magazine, July 21, 1996.)

Our agencies can survive and perhaps thrive in a managed care environment if, like Willow Creek, we adapt in a way that meets the needs of our customers. Also like Willow Creek, it is critical that as we adapt our traditional practices, we do so without altering our core beliefs and values.
To exemplify one way we can do this, this paper examines Germaine Lawrence's acute residential treatment program (ART) - a short-term crisis intervention program - which blends the core skills of residential treatment with the demands of managed care organizations (MCOs) to provide an effective service for children and families.

First, the paper contrasts the new demands and expectations of the managed care environment with many traditional practices at Germaine Lawrence.
Next, I describe the acute residential treatment program in detail, with an emphasis on how Germaine Lawrence adapted its traditional practices to achieve the goal of satisfying the demands of MCOs while providing a valuable service to children and families.
Then the paper presents an analysis of outcome studies that examines the effectiveness of the program.

II. ADAPTING TO A MANAGED CARE ENVIRONMENT
Faced with the threat of reduced demand for long-term residential treatment, Germaine Lawrence looked for new applications for the agency's expertise that would attract business in a managed care environment and be a valuable resource in a "system of care" (Stroul and Friedman, 1986; Friedman 1983) based on family preservation principles.
We spoke to some MCOs and learned that they were much more demanding, with significantly higher expectations, than the state agencies we were used to doing business with.
Four specific themes emerged as requirements if we were to be successful working in the managed care environment.

A. Timeliness
MCOs demanded radically shorter time lines and quicker responses that we were used to. Intakes would have to be immediate, 24 hours per day, 365 days per year, compared to our practice of having pre-intake interviews and a week of planning. Initial psychiatric assessments would have to be completed in 24 hours compared to 30 days. Comprehensive assessments with final recommendations would have to be produced in writing in seven days compared to 45 days. Clients would be discharged in a maximum of fourteen days with an expected average length of stay of about ten days. Our treatment program had an average length of stay of 14 months.

B. Intensive Case Management and Communication
MCOs expect almost constant communication with our agency's case manager who has total case responsibility from intake to after care. Our case manager, the client's therapist, is expected to communicate the initial discharge plan to the managed care company's Utilization Reviewer within 48 hours of placement and then ARTiculate the progress made towards achieving the goals of that plan, and a rationale for continued treatment, at least every three days. In contrast, public agencies that used our treatment programs expected the first communication in 45 days, and were delighted if our case manager communicated with them monthly. MCO case reviewers expected our case manager to handle all case coordination, such as planning for assessments and arranging post-discharge services, while public agencies expect their case workers to provide much of that coordination.

C. Brief, Problem-Focused, Clinical Services
With lengths of stay of about fourteen days, clinical services need to focus on the problems that precipitated the crisis and need to be resolved before the child can return home. Other issues are identified so that community-based therapists can continue the work. To accomplish this objective, our therapists are expected to meet with each client individually at least four times weekly, and have at least two family contacts weekly. Our traditional practice was to do the trauma work in individual and group therapy over many months until significant healing had been achieved. Individual therapy had been held once per week and family therapy twice a month.

D. Accountability
Another striking difference between working with managed care companies compared to public agencies is the quantity and quality of accountability. State agencies give providers little if any feedback concerning performance unless program functioning fails to comply with minimum licensing requirements. The only documentation regularly reviewed is quARTerly reports that update the treatment plan. Some MCOs, on the other hand, develop measurable expectations for service provision and service outcomes. Then they collect data to evaluate and compare program functioning. Programs that compare poorly may lose contracts.

So it was critical to document aspects of service delivery and client outcomes more rigorously than we had before if we wanted to satisfy managed care demands.
We were willing to adapt many of our traditional practices to meet these expectations - we believed the viability of our agency was at stake. However, we wanted to adapt in a way that applied our core skills and reflected our core beliefs.
We saw such an opportunity in providing residential crisis intervention services. Assuming that the introduction of managed care and family preservation principles would decrease the use of traditional group care, we believed that families would need more crisis intervention services and that some of those crises would require the removal of a child from the home to ensure the safety of family members.
We also believed that many family crises could be resolved quickly and would not require extended out-of-home placements if adequate community-based support services were in place before the child returned home.
Furthermore, we believed that the large majority of these family crises could be resolved effectively at an ART and did not require psychiatric hospitalization of the child. It seemed to us that hospitalization had become an overused intervention in the '80s, and ARTs would prove to be an effective alternative.
Finally, we believed that we already had developed the core skills needed to run an effective ART.
In our residential treatment centers, and especially at our 90 day assessment center, we had developed the following skills that would be critical in a successful ART: - behavioral stabilization through highly structured milieu therapy; - problem-focused individual therapy - assessment-based, goal-oriented treatment planning, and - intensive discharge planning including family work and developing community supports. Given these beliefs, we perceived the development of an ART as consistent with our organization's core beliefs as well as being a new application of our core skills.
Most importantly, we believed the ART program model would fill an important gap in the emerging service delivery system and would provide valuable services to children and families.

III. ACUTE RESIDENTIAL TREATMENT: PROGRAM DESCRIPTION

A. Clients
The clients of Germaine Lawrence's ART are adolescent and pre-adolescent girls from 10 to 18 years old. They are referred by managed care case managers, psychiatric emergency teams who screen youth in crisis, and Department of Social Services social workers. All referred clients are admitted to the program as long as they are medically screened.

In 1994 and 1995, the years of the outcome study, every client that was referred was admitted unless all beds were filled.
Clients are referred for a variety of difficult-to-manage behaviors that often result in psychiatric hospitalization.
The most common presenting problem (see Table 1) is suicidal ideation and gestures, followed by physical aggression and then running away.
It seems that a significant majority of the ART clients would have been hospitalized if the ART was not available.
Interviews with psychiatric emergency team staff found that those staff believe at least 75% of the youth referred to ARTs would be hospitalized in the absence of ARTs, and that in many other cases ARTs are being used as a step down from a hospital, reducing the length of stay. These staff believe that ARTs have "tremendously reduced" the number of hospitalizations and hospital days.
In addition, the ART psychiatrist, who has been on staff at McLean Hospital serving adolescents since 1984, believes that the ART is serving youth who, a few years ago, would have been served in a hospital.
Before the development of ARTs, she said, mental health professionals believed that youth who were scratching or mutilating themselves, or running away, needed a locked setting and they would be hospitalized. Now, she said, they are served in ARTs.

B. Goals
The goals of ART are significantly different and much diminished compared to the goals of traditional residential treatment. Rather than expecting the kind of working through of abuse and learning of new behaviors that is expected from residential treatment, ARTs aim to only start the treatment process before transitioning the more long term treatment process to out-patient providers.
As a crisis intervention, ARTs do not attempt to attain the same goals as residential treatment. The first goal of ART is to stabilize the child's behavior. To be considered effective, ARTs must be able to contain difficult behaviors until they are diminished and the child can be considered behaviorally stable.
Moreover, if ARTs are to serve as alternatives to psychiatric hospitals, ARTs must be able to maintain the safety, and stabilize the behavior, of the great majority of its clients.

The second goal is to prepare the child and family for successful discharge and reunification.
First, the precipitating crisis needs to be resolved. Then on-going community supports need to be established.
Since an ART is a crisis intervention and not a "cure", ART staff must link the child and family to community-based services that will provide any extended treatment that is required to support a successful reunification. In fact, research on residential treatment shows that the most important factor in determining post-discharge success is the network of community supports available to the child and family (Whittaker and Maluccio, 1989).
That is, those children and families that have more supports in the community - therapists, friends, ministers, coaches - reunify more successfully.
Hence it seems critical for ARTs to focus their efforts on developing community based supports for the families they serve.

C. Program Components

As discussed above, our ART was developed to achieve two key goals: to stabilize the behavior of the youth in crisis and to prepare the youth and family for a successful reunification.

The paper uses these twin goals to describe the program's components.
The first section describes what the ART does to promote behavioral stabilization. The second section examines the clinical services that prepare the child and family for rapid reunification.
Lastly, I discuss how we document service provision and client outcomes to meet managed care requirements.

1. Behavioral Stabilization
Behavioral stabilization, the first goal of an ART, is challenging for several reasons.

First, clients usually enter the program immediately after a crisis - so angry or depressed that they are at high risk for running away, being assaultive, or hurting themselves.
Second, because of the short length of stays, the group is always changing and there is a high risk of a negative peer group developing that undermines treatment and destabilizes behavior.
Third, the stabilizing relationships between staff and children that take time to develop are missing.
Fourth, children cannot develop new, internal controls in a matter of days.
Compared to traditional residential treatment, then, ARTs lack some of the critical elements that stabilize difficult behaviors. Our ART's approach to highly structured, staff secure milieu therapy was designed to meet these challenges.

There are three main elements that lead to rapid behavioral stabilization for most individuals as well as a peer group supportive of treatment.

First, staff make it hard for girls to run way or hurt themselves or others, creating a sense of psychological containment and safety.
Second, staff keep clients focused on their goals and meet their psychological needs, undermining the girls' motivation for acting out dangerously.
Third, the peer group is managed so it supports each individual's stable behavior and goal attainment.

These elements are described briefly below.

a. Psychological Containment
To create an environment where treatment can progress, the clients have to believe that the staff can keep them safe and contained. Although the facility is not locked, clients feel contained by a number of the program's practices that provide external, psychological controls.
First, constant eyesight monitoring, that can be reduced to arms length, helps create a perception of containment.
Second, staff quickly label or sanction any behavior that is dangerous or threatening. Such behaviors include not only self-mutilation and assault, but swearing, verbal abuse, and yelling. This helps the girls feel they will be kept safe from impulses of themselves and others.
Importantly, staff intervene early with behaviors that often precede dangerous behaviors. For example staff intervene when they see whispering, note passing, or any negative expressions. The intervention is usually labeling the behavior and asking the girl what is happening. Such frequent intervention short circuits many upsets as well as help the clients feel contained and safe.
Third, when they enter the program, clients are given slippers to wear and their shoes are kept by staff. Although they can still run away with slippers, clients feel more psychologically contained.
Finally, Germaine Lawrence staff use physical restraint whenever a client is dangerous to herself or others. If a client tries to runaway, staff will intervene physically to keep her in the facility. If she escapes from the building, staff will follow her and talk to her in an attempt to help her to choose to return voluntarily. Clients are not terminated from the program either for requiring physical restraint or for running away.

b. Focus on Treatment Goals and Issues
Right from intake when a discharge goal is developed, staff keep clients focused on what she wants and what she can do that will get her to that goal. Staff also help each girl focus on identifying and owning the problem behaviors that resulted in her placement at the ART.
When problem behaviors are exhibited, staff help the girl "process" what has happened, linking her feelings and thoughts to the problem behavior, and considering alternative, positive behaviors for dealing with those feelings and thoughts.
Group therapy is a critical activity in maintaining the client's focus on their goals and issues. Some groups focus solely on girls sharing their treatment goals and issues, and receiving support from their peers.

Other groups are aimed to deal with more specific issues such as substance abuse, Children of Alcoholics, violence prevention, and social skills.
Our behavior management system intervenes in escalating behaviors and emphasizes the client's choices. We teach clients about their recurrent cycle of behaviors, thoughts and feelings that lead to crises, and the different choices they have, especially early in the cycle, to short circuit the crisis. Then staff work with each client to identify key maladaptive behaviors that need to change and new prosocial behaviors that would help her be more successful.
They develop a contingency contract that provides rewards the absence of the problematic behaviors and for using new behaviors. These contracts provide additional focus for clients and staff.
In addition, staff work hard to meet clients' psychological needs quickly by giving them "check-ins", listening and responding to their complaints, and resolving conflicts that create fear or anger.
By responding quickly, staff keep the milieu as clean of psychological static as possible and help to maintain a strong focus on the treatment issues that the clients are there to work on.

c. Group Management
To keep a rapidly changing group supportive of treatment it is important to observe the group as a whole carefully and intervene quickly when the group becomes negative.
Daily group therapy is one basic tool for managing a group. Conflicts and other problems can be raised and resolved so they do not become a competing focus to the youths' treatment goals.
Each client can speak about their goals and the help she needs from the group to realize it. Girls who are close to discharge can speak about their experience in the program and how others can get the most out of it. Keeping the clients engaged all day in prosocial activities that prepare them for a successful discharge also helps to maintain a positive group.
A psychoeducational day program provides them with a success-oriented academic program in the mornings and a social skill building program in the afternoons. Clients have recreational activities in the late afternoon and the evening.
Apart from a one-hour quiet time after dinner that can be used for homework, phone calls and hobbies, the rest of the day is spent actively engaged with staff and peers. When problems develop in the group, staff take action.
Special plans are implemented when the group develops a negative (counter-therapeutic) culture or acting out behaviors increase.
For example, a positive peer plan rewards the group for prosocial, constructive behavior. Girls who are especially oppositional or hostile may be removed from the main group while staff meet with them individually to refocus them on their goal in treatment.
In addition, staff intervene early in peer conflicts, helping the clients involved to resolve the problem and using community groups to smooth out the conflict.
Because of all these elements of our approach to milieu therapy, most clients are contained in the program and they stop presenting their problem behaviors soon after intake. This stabilization allows the family work and discharge planning to be the focus of their treatment.

2. Clinical Services

The clinical component was designed to prepare the child and family for rapid reunification with support services in place. Since so much had to be accomplished in a short amount of time, this component had to be substantially changed from our traditional practices.
Everything from intake to discharge had to be adapted to fit the crisis intervention and managed care models. The way we adapted the various elements of our clinical services is discussed below.

a. Intake
Our past practice of planned intakes with pre-intake interviews had to be changed radically. We developed an intake process that permitted immediate intake at any hour, with transportation arranged if necessary.
A new telephone line was dedicated to intake calls and staffed 24 hours a day. Administrators rotated on-call to manage intake calls.
All staff were trained in collecting information required for intake. We even contracted with an ambulance company to assure access to emergency transportation for all youths.

b. Psychiatry
Previously clients only saw our consulting psychiatrist, who was on site twice weekly, on an as-needed basis.
To ensure psychiatric assessments for all clients within 24 hours and at least one psychiatric review weekly, we contracted with McLean Hospital for a daily consultation as well as weekend assessments as needed.
McLean also provided psychopharmacological and neurological assessments on an as- needed basis.
The psychiatric component ensures that all but medically at risk youth can be served in ARTs safely.
The staff psychiatrist is available to see residents two hours each weekday. The psychiatrist initially interviews the resident to determine appropriateness of the placement and the need for psychopharmacological assessment.
Referrals for neurological or other assessments are made immediately and are completed at McLean Hospital before discharge.
The psychiatrist continues to meet with the resident at least weekly until discharge and is an active participant on the inter-disciplinary treatment planning team. The psychiatrist also sees each girl on the day of discharge to ensure her safety and the appropriateness of the discharge plan.

c. Other Assessments
We were used to clients coming with complete assessments. Now we were responsible for providing psychological and educational assessments within one week.
We contracted with two sources for psychological assessments to ensure that written reports could be completed within seven days. When one provider could not meet deadlines, we found another provider.
In addition, our staff were closely monitored to ensure that their psychosocial, educational, and behavioral assessment reports were completed on time, within seven days. Missed deadlines resulted in corrective action.

d. Clinician Responsibilities and Case Load
Our staff clinician's job expectations changed significantly. Rather than once a week individual therapy, twice a month family therapy, and quarterly reports, clinicians now were expected to see each client four times per week and make two family contacts weekly including one meeting.
Initial discharge goals had to be developed within 48 hours of placement, the initial treatment plan within 72 hours, and comprehensive assessments were due in a week.
This requires extensive communication with collaterals such as school systems and previous therapists and/or placements. A minimum of two detailed communications a week with Utilization Reviewers was required.
Given these responsibilities and the unforgiving nature of the managed care companies, case loads were set at four per clinician rather than eight.

e. Discharge Planning
An initial discharge goal is developed within 48 hours after the case manager has met with the client and her family to determine where she will go when she leaves and what problems have to solved before she is able to go there.
This formulation is the foundation of acute residential treatment, providing the sharp focus required for effective time-limited treatment.

f. Individual and Family Therapy
Once established, the discharge goal becomes the organizing framework for individual and family therapies. Staff social workers meet with the child daily and have two contacts weekly with the family, including at least one face-to-face therapy session, to prepare for discharge in ten to fourteen days.
The emphasis of the work is conflict resolution and problem solving needed to stabilize the family crisis. The therapist helps the family determine what has to change in the family to avoid future crises, and what services the family needs to effect those changes. We acknowledge that the short length of stay at an ART is insufficient to make the progress needed to avoid future problems.
So it is critical to develop a plan for post-discharge services that will continue the work started at the ART.

g. Linking to Community Based Support Services
The final task for clinicians is to link the child and family with a network of community support services to meet their long term needs.
Clinicians locate providers of the services the child and family needs and sets the first appointment (see Chart 2 for a list of community services established for a sample of clients).
In this manner the ART ensures that it serves as part of a continuum of care, achieving important but circumscribed goals in a short amount of time and then linking the child and family to providers who provide extended treatment.

h. Documentation
Documentation of the provision of clinical services had to change significantly in form and content.
Every contact with the child and family had to be documented in a manner that made a file review easy. Ultimately we redesigned client records with checklists at the front and a contact sheet for each type of service (psychiatry, individual therapy, etc.) on which the professional entered every contact with a brief summary of the content. This allowed reviewers to easily locate the documentation of service provision.

3. Preparing for Accountability

Some MCOs rigorously review client outcomes and compliance with their service standards.
Length of stay and recidivism form one type of outcome measure. Appropriate, accessible documentation in our files is another basis for their evaluation of our performance.
In Massachusetts the company that managed mental health benefits for Medicaid clients, MHMA, implemented a comprehensive data collection plan to quantitatively identify programs that were not meeting their standards.
Data was collected through their billing system on what MHMA considered quality indicators such as:

• readmission rate to hospitals and ARTs
• % of clients stepped up to hospitals
• length of stay
• use of out-patient services after discharge.

• MD contact within 24 hours and then weekly
• two family contacts weekly including one face-to-face meeting
• completed discharge information at discharge
• aftercare appointments set before discharge

Using this data, MHMA developed reports that compared provider effectiveness. Providers that performed significantly poorly were given improvement goals; some providers were said to lose referrals.
Germaine Lawrence's outcomes compared favorably to other agencies, however in the first year of monitoring, Germaine Lawrence scored poorly in a number of service provision categories.
We learned that organizing client files in a manner that made file review simple was also important in being evaluated positively.
We needed to adapt our record keeping and documentation methods to meet managed care standards. After making those changes, our documentation improved so significantly that we were asked to give a "best practice" presentation at MHMA's annual conference.

Developing systems to document our work was actually quite simple.
We created new forms and organized client records for ease of data entry and file review. Getting the documentation consistently, however, did require the discipline to follow the systems. We had to hold our staff accountable and intensify our internal monitoring.
With the Program Director committed to timely and compete documentation, monitoring it monthly, and providing staff who were out of compliance with critical feedback, the program received positive recognition for its excellent documentation.

4. Acute Residential Treatment: OUTCOMES

a. Hypotheses
Based on the goals of the program, we chose to test two hypotheses:

1. ARTs can stabilize and contain adolescents who would otherwise be placed in psychiatric hospitals.

2. Short term treatment programs, such as ARTs, can provide effective treatment that prepares adolescents for successful post-placement discharges.

b. Data Collection
To test the first hypothesis we reviewed every intake from the 1994 and 1995 calendar year using the program's "Placement Register" in which every intake and discharge is recorded.
We categorized each intake as either "Stabilized", meaning that the youth was discharged to a community setting (e.g. home) after dangerous behaviors ceased, or "Not Stabilized", meaning that the youth either was hospitalized because dangerous behaviors could not be stabilized safely or because she ran away.
The Placement Register also records the referral source, either the Department of Social Services or a managed care company. So data comparing outcomes for DSS and managed care clients was analyzed also.

To test the second hypothesis we reviewed a number of variables.
First, we used the Placement Register to determine where each resident was discharge to.
Second, from a random sample of 20 client records, we determined the types of community support services to which we linked clients before they were discharged.
Third, we mailed Satisfaction Surveys to all parents and funding sources to learn:

• if the youth's behavior improved
• if the family gets along better
• if the program developed a useful discharge plan
• if they were satisfied with the services they received.

• their need for another placement
• their use of the support services arranged by the ART
• whether they were doing better or worse.

Our final source of data was collected by MHMA, our largest managed care customer.
Pertinent findings for this study focus on length of stay, readmission rates, and continuing care rates.

c. Findings
Table 2 summarizes the "Stabilization Rates" for every resident during 1994 and 1995.
Of the 157 managed care residents, 148, or 94%, were stabilized in the program, and returned to a community setting without need for a more restrictive setting.
Eight were hospitalized due to continued dangerous behaviors and one ran away.
Six per cent of these residents, then, were not behaviorally stabilized by the program.
93 of the 102 DSS residents, or 91%, were stabilized in the program, with seven requiring hospitalization and two running away for a total of nine per cent not stabilized in the program.

The community support services to which the ART linked residents and families are listed on Table 3.
In a random sample of 20 cases, all of the residents were linked to an individual therapist in the community and the majority also had first meetings established with a family therapist and psychiatrist.
On average, each ART resident had three different types of community supports arranged for them by ART social workers.

The discharge placements of the residents is shown in Table 4.
76% of the managed care residents returned to their placement of origin.
For 58% of these clients, that means they went home.
The other 18%, returned to their previous placement in a group home or treatment center.
The remaining 29% of the managed care clients that were discharged to a community setting went to new, publicly funded placements
. During their treatment at the ART, it was determined that they needed out-of-home placements and ART staff linked the resident to DSS which made the placement.

The discharge placements of the DSS clients are quite different.
Only 23% returned to their previous placement.
More than two thirds, 70%, were placed in new, out-of-home settings after their assessments.

Responses to the Satisfaction Surveys show a high level of satisfaction from both parents and funding sources. Table 5 shows that 93% of the parents responding felt their family gets along better and that their daughter behaves better.
All of the parents were satisfied with the services.
All of the funding sources that responded believed that the client's behavior improved, that the discharge plan was useful, and they were also satisfied with the services.

The follow-up telephone interviews, summarized in Table 6, show that managed care clients continue to do much better after the resolution of the crisis at the ART.
90% have not required another placement and 78% report doing better since discharge.
DSS clients have also done well with 80% not requiring another placement and 67% reporting they are doing better. MHMA collected data on the 56 adolescents it placed at our ART during 1994.
They found that the average length of stay was 13.6 days and throughout the state the average was 12.2 days.
Readmission rates, the percentage of discharges readmitted to a 24 hour mental health facility within 30 days, was 10.7% for our ART and the state average was 15.1%.
The percentage of discharges attending at least one outpatient appointment per month for four months was 40% and the state average was 31%.

d. Discussion
Although this study lacks the rigor of a scientific study, our findings lend support to both hypotheses.

First, the ART successfully contained and stabilized over 90% of the youth it served.
Second, the ART achieved its goal of resolving the precipitating crisis and preparing the family for successful post-placement discharges. Residents were linked with a variety of community based services which most continued to use for several months, few required another placement in the next six to twelve months, the significant majority of post-discharge adjustments were positive, and both parents and funding services were satisfied with the services.
These findings provide tentative support to the premise that ARTs are viable alternatives to psychiatric hospitals for the great majority of adolescents requiring out-of-home crisis intervention.
Based on limited, qualitative data, ARTs seem to work with a population similar to a population previously hospitalized, and have been able to safely contain and stabilize the great majority of clients.
It also seems that ARTs provide effective treatment and achieve meaningful outcomes for the great majority of youth and families. The time-limited treatment model not only stabilized behavior effectively, but linked the youth and family to on-going services.
In the great majority of cases this brief intervention was enough to support successful post-discharge adjustments.
It is also interesting that all parents and funding sources were satisfied with the services they received. Since the ART is an alternative to hospitalization, one might expect parents to resent the use of a less expensive option for their child and then to be critical of the services.
However, parents experienced positive outcomes and were satisfied with the intervention.
Reflecting on these findings, it makes sense that crisis intervention might be done better by child welfare agencies than hospitals. The in-home family work, community outreach and problem solving techniques that help families resolve crises are not medical in nature and do not require more expensive medical care.
Working with families in crisis, and linking families and children to resources in the community, is a core skill of child welfare programs. It should be no surprise that residential treatment centers can provide this needed service successfully and cost effectively. This suggests that a new and meaningful niche is available for our treatment centers in a managed care environment.

5. CONCLUSION

Our experience suggests that child welfare professionals do not have to compromise their values and beliefs to survive with managed care.
Based on our experience, it is possible to adapt one's core skills while remaining true to one's values. The key is focusing on meeting our clients' needs.
As long as we are providing helpful services that effectively meet our clients' needs, we can continue to be proud of our work.
However, managed care may well change residential treatment's role in the continuum of care. We may not provide treatment the way we have in recent years, and we will probably feel the pain of that loss.
But children and families will continue to need the skills and resources our programs have developed. So if we can adapt our programs to meet the demands of managed care, then our treatment centers can maintain their viability, both programmatically and financially, without compromising our mission and values.

References

Emenhiser, D., Barker, R. & DeWoody, M. (1995).Managed Care: An Agency Guide to Surviving and Thriving Washington, DC: Child Welfare League of America.

Friedman, R. M. (1983).Planning and Developing Community-Based Mental Health Services for Children and Adolescents Tampa, Florida; Research and Training Center for Children's Mental Health. University of South Florida.

Goldman, S.K. (1988). Volume II: Crisis Services . Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

Stroul, B. A., & Friedman, R. M. (1986). A system of care for severely emotionally disturbed children and youth. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

Whittaker, J. K., & Maluccio, A. N. (1989). Changing paradigms in residential services for disturbed/disturbing children: Retrospect and prospect. In R. P. Hawkins & J. Breiling (Eds.)Therapeutic foster care: Critical Issues. Washington, DC: Child Welfare League of America.

BIOGRAPHICAL NOTES

David Hirshberg is the Executive Director of Germaine Lawrence Incorporated in Arlington, Massachusetts, a provider of residential treatment for girls.

Ann Horgan is the Program Director of Germaine Lawrence Assessment, a short-term, acute residential treatment center in Framingham, Massachusetts.

Deborah Douglass is the Director of Administration and Quality at Germaine Lawrence and was formerly the Program Director of the Germaine Lawrence Diagnostic Center in Arlington, Massachusetts.