Getting to Yes!

The MHCH has helped over 200 youth in behavioral health boarding situations get connected to mental health treatment providers and safe support in the community. Cases are submitted with de-identified information that matches to providers across the state who offer services that may help

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Lessons Learned

In August 2022, hospital systems and child and family service providers started a grassroots effort to share ideas and resources to get to yes and deliver appropriate community-based care for children boarding in hospitals.

Designed to capture data and track outcomes, this effort has yielded valuable data and become a venue to identify barriers to care. The Mental Health Collaboration Hub is focused on children who are boarding and do not meet criteria for a hospital level of care. The model replicated the centralized communication strategy used during the COVID-19 pandemic which was supported by the coordination and leadership Metro Health Care Coalition.

  • The collaboration launched with the consensus that it was better to attempt to coordinate resources to serve children who are boarding than to do nothing.
  • Children are boarding in Juvenile Detention and “hoteling” with counties in addition to boarding in hospitals, the Hub has invited these systems to also engage and have had limited success in fully expanding to meet these unique system needs.
  • Relationships are critical to Getting to Yes – within the MHCH and for designing solutions for children.
  • Creating shared understanding of systems and networking is foundational to individualizing services for children.
  • Clinical decisionmakers are essential to better understand the unique assets and challenges to provide individualized care.
  • Transparency and candor are key features – to the extent it can be achieved with client and systemic limitations.
  • Foster care is important and underrecognized as a critical factor to support children to access care in the community
  • All systems players are required to design “yes” solutions (community providers, safety net providers, counties, state, and client/family/natural supports).
  • Individualization is critical and challenging to achieve – due to barriers of information, timing, training and capacity to design individualized responses in an environment of scarcity.
  • Liability concerns for both the boarding setting, and possible treatment setting are added barriers.
  • The ability to support a child with unsafe behaviors is challenged by: staffing (ability to staff 1:1), training (equipping staff to best support the child), milieu safety concerns, insufficient information shared with the service providers.
  • Care needs often fall within numerous disconnected service silos, requiring bespoke coordination for optimal intervention.
  • Families are often not able to fully engage; they have been challenged with the lack of care and are reluctant to trust, often mired in their own life challenges, and other complexities can make full participation difficult or impossible.
  • We need greater flexibility in residential care – especially group home level of care where services can be individualized and where children are able to experience stability.
  • Counties authorizing payment for care in a timely manner is a common barrier.

Looking Forward

  • The Mental Health Collaboration Hub will continue to gather data and perspective that is otherwise not available in our system; including learning from care pathways that come from discussions and collaborative work.
  • Leverage growing dataset to create shared understanding between providers and policymakers.
  • Identifying resources to support creative service solutions and expedite care when there are delays for the payor is an opportunity to improve outcomes and pilot solutions that may have greater systemic application.
  • Collaborate with the newly stood-up Acute Care Transitions team within DHS to swiftly identify and execute the systemic flexibilities and enhanced funding required to get to yes for children boarding.

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A bed is not a bed

There is an alarming number of youths in psychiatric or behavioral health crisis stuck boarding in emergency departments, medical units, county buildings, jails, and even hospital parking garages. These situations are intense, and the needed interventions and services are scarce. The average time spent boarding is increasing, in some cases up to weeks or even months. This is a result of an underfunded and understaffed mental health care system, that is ever-changing.

Complex mental health needs:

Most youth in boarding situations require complex mental health treatment provided by specific programs that range from group homes, children’s residential facilities (CRF), therapeutic foster care psychiatric hospitals, or psychiatric residential treatment facilities (PRTF). The American Psychiatric Association has defined nearly 10 different types of inpatient psychiatric beds. While not necessarily standardized, they range from state operated and community-based to specialized geriatric and forensic. For individuals with a mental or behavioral disorder, it is critical to have a clear diagnosis to understand the best treatment or intervention. The Diagnostic and Statistical manual of Mental Diseases (DSM) details more than 300 distinct conditions. The most common disorders in boarding cases are neurodevelopmental and externalizing disorders characterized by aggression, opposition, and maladaptive behaviors. Nearly 75% of these cases have multiple diagnosis that often include autism, developmental delays, ADHD, conduct disorder, and substance abuse. This requires the boarding settings to manage risk factors such as self-harm, elopements, suicidality, and combativeness.

A shortage of facilities:

More than 80% of counties in Minnesota have a shortage of mental health professionals. We have seen a 30% reduction of children’s residential treatment beds since 2020, and there are fewer than 200 operational inpatient psychiatric beds for youth in the state today. This is a startling lack of options that is further exacerbated by staffing shortages that limit these capacities. Minnesota currently has 93 licensed children’s residential facilities with a total of 1,586 beds, each serving a unique population. Facility sizes range from a handful of beds to large campuses with upward of 100 beds. Each facility serves a distinct age range, specializes in treating certain conditions, and may have acceptance criteria regarding gender, IQ, and county of residence. Additionally, certain certifications are required to treat conditions such as substance use disorders. Some specialties include eating disorders, autism, sexual misconduct, and obsessive-compulsive disorder. It is not uncommon for organizations to change acceptance criteria as they evolve, particularly the age range that they treat. These various specialties can be highly effective for some individuals, but the imbalance of capacity within each of them and the constantly changing landscape creates frustration for providers making referrals. Creating a shared understanding of the nuances in the different types of beds will strengthen our ability to collaborate and help kids.


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