Community-based care: A growing trend



“Transition is the Achilles’ heel of residential treatment,” says Stuart Fisher, Ph.D., assistant executive director of the Devereux Center in Rutland, Massachusetts. (photo by Tom Croke)

By Phyllis Hanlon

Many mental health professionals agree that keeping children in a home environment rather than in an institutional setting is better for the individual. In recent years, the legislative mandate to provide care in the least restrictive environment as well as reductions in inpatient mental health benefits has prompted a trend toward community-based care. Still in the fledgling stage, this concept is experiencing some successes while also facing challenges.

Bob Wentworth, director of integrated services at the Mass. Department of Social Services (DSS), reports that a number of positive changes are taking place in Massachusetts. He points out that DSS is in the planning stages of evaluating community assets and trying to identify gaps between residential treatment centers and outpatient care. "We are asking the provider community for feedback," says Wentworth. With input on the challenges and expectations relating to community-based services, DSS will develop appropriate programs as well as guidelines for pricing those services.

Although care will shift to the community in the future, residential centers will continue to play a role in managing certain cases. According to Wentworth, schools and families need to know that resources are available to help support children. "This is where residential centers can help whenever necessary. They have the experience in behavioral management and can help kids develop a locus of control. They can also teach parents effective management skills and are available for emergency respite," says Wentworth.

The state government's financial picture is also evolving. "Previously, money was allocated for a specific purpose. Residential funding was always more than community-based funding," says Wentworth. "This is structured differently now. The legislature allows DSS to transfer funds to other accounts. We are choosing to focus on community-based services."

Stuart Fisher, Ph.D., assistant executive director of the Devereux Center in Rutland, Mass., says that although many residential facilities have done a good job of creating a homelike atmosphere, problems sometimes occur at the time of discharge. "Transition is the Achilles heel of residential treatment," he says.

Devereux is one of a handful of residential treatment centers that has developed a pilot program designed to transition children back into their homes or into therapeutic foster care. Fisher says that Devereux or one of its partners in the project will hold a bed for a child if he needs to return for any reason without enduring extensive red tape.

Also, Devereux has adopted existing principles and ideas and tailored them to specific circumstances. The facility coordinates with various agencies and providers to ensure a seamless re-entry into community life. "We negotiate each case on an individual basis, which is time consuming and tedious," Fisher says. "But once lead agencies get together, it will be easier."

One area that concerns Fisher is the educational component of the process. As DSS transitions children into the community, it will have to consider the academic aspect of treatment. "I'm not sure if the public schools are ready for [the children]. I fear the schools will be overwhelmed," says Fisher. He points out that specialized programming as well as more special education teachers will be needed to make the transition successful.

At the Walker Home and School in Needham, Mass., Executive Director Richard Small and his staff focus their planning on the integration of children into the community. "When you engage this issue, you have to look at it from the family's perspective," he says. "We all assume it's better for kids to be in the home, but what does it take?" Small believes that the community should be ready to support the child on all levels, relying on residential care as a backup for overnight respite.

Walker has partnered with community agencies as well as with 37 schools to provide an appropriate network within which all entities can work together. The facility's expert staff serves as a bridge between residential and community-based care. Walker sponsors support groups for parents with children in residence as well as those who live outside the facility that offer encouragement through shared experiences. Small believes that to be effective, a social network map must be implemented, one that talks about supports in a person's life, including church, family and friends. With that information, gaps can be identified and necessary services put into place, says Small.

Richard Lanza, M.A. Vermont master's level psychologist and director for severe and persistent mental illness at the community mental health center in Morrisville, Vermont, notes that the trend toward teaching system management skills prior to discharge contributes to successful transition into the community. Individuals who are taught to identify trigger situations and understand their illness and how to treat it usually fare better outside a residential facility. "There are three factors to success," he says. "With the right combination of knowledge, skills and supports, anyone will be successful." Admittedly, the severity and longevity of illness will impact the type of community treatment needed as well as the success rate.

The increasing popularity of the wraparound concept continues to drive mental health policy, according to David Prescott, Ph.D., director of psychology and clinical research at Acadia Hospital in Bangor, Maine. Although community living is the ideal, he cites some important challenges. "There tends to be a strong need for case management," he says. "In a hospital setting, we can coordinate easily. If someone needs a psychologist, I'm available. If I need to speak to a neurologist, he's down the hall. Now imagine a Mom or Dad having to manage all these appointments. It's easy to get fragmented."

In spite of these difficulties, Prescott says a successful transition is possible and offers some of Acadia's effective strategies. "Provider meetings when a child is discharged to community entry is one of the tried and true strategies," he says. The hospital also educates the consumer and sponsors parent group meetings that explain in detail how the system works. "These are effective self-help/self advocacy groups," he says.

Prescott adds that Maine has invested significant time and money into foster family training, another option for children discharged from residential care. Prescott admits that hospitals do not face the funding challenge that private residential treatment programs do. "We have a broader range of things we can get paid for," he says. "Maine puts proportionally more dollars into behavioral healthcare than other states. However, the sheer geographic spread of the state makes the situation difficult."

Community-based care: A growing trend (October 2005 Issue)

Community-based care: A growing trend
(October 2005 Issue)