It is critical that Therapeutic Groups Homes be made available for Louisiana’s children who require more intensive treatment than can be provided in a Non-Medical Group Home. Everyone agrees this is true, but Louisiana’s CSoC has tied itself in knots with regulations that are too restrictive relative to a TGH’s location and with a reimbursement rate that is too low to entice current providers.

As it happened, all the pre-CSoC Group Home providers were given a choice between seeking licensure as a Therapeutic Group Home or continuing their operations as Non-medical Group Homes. It was a forced choice. What Louisiana left off the table to encourage the former Group Home providers to step up to TGH licensure were funds to cover the cost of the transition.

(The three Methodist children’s homes in Louisiana faced a similar scenario, but because we care for more than 16 children at each of our locations, our only option was licensure as psychiatric residential treatment facilities. We will not be reimbursed the cost of making the transitions from our former DCFS Class A Child Residential licenses to the DHH Psychiatric Residential Treatment Facility licenses. Baton Rouge warned that providers would be required to bring more to the table – it did not seem possible it would have been so much.)

Now, potential Therapeutic Group Home providers find themselves in the same spot. The difference is that many of them do not have the financial reserves to cover the cost of the transition from Non-Medical Group Home to Treatment Group Home.

As I wrote in “Two Missing Steps“, “Unfortunately, the per diem reimbursement rate is too low to allow a provider to ever recoup the start-up costs. Figuratively speaking, a new TGH provider will start out in a hole and never climb out.”

There are always solutions, but they will require movement on the part of state bodies such as the Department of Health and Hospitals, the Coordinated System of Care, and the Office of Behavioral Health.

Here are some ways DHH, CSoC and OBH might use to recruit current Non-Medical Group Home providers who wish to become Treatment Group Home providers:

1. Provide start up funds to cover the cost of the transition. This is important and here’s why. Before DHH will issue a license for a level of care, the potential licensee must be fully staffed and fully operational. There is no reimbursement for the cost of staff who must be added in order to acquire the license.
2. Create a Provisional Therapeutic Group Home license for providers who are diligently seeking Therapeutic Group Home licensure. Pay the Provisional TGH the TGH rate to help defray the costs of the transition.
3. Myers and Stauffer, the accounting firm contracted by DHH to establish the reimbursement rates for the various levels of care, chose different rate setting mechanisms for the residential levels of care. More than a year has passed since CSoC kicked off. Only one provider has stepped up to pursue TGH licensure. Perhaps the rate really is too low to entice significant interest. Reconsider the rate setting mechanism.
4. By contract, Louisiana’s Coordinated System of Care passed responsibility for recruiting TGH providers to the State Management Organization, Magellan of Louisiana. Magellan has recently posted Requests for Proposals for potential Therapeutic Group Home providers. Magellan’s RFP process is a good thing and should continue, but I believe, until the funding issues are addressed by DHH, Magellan’s repeated RFP releases will take much too long to generate the 34 Treatment Group Homes Louisiana requires for its children in out-of-home care.
5. After a year of CSoC operation without any Therapeutic Groups Homes for adolescents in Louisiana, perhaps it’s time for the state officials who planned CSoC to gather again with residential providers to learn what is not working and to explore solutions to the barriers that exist. There were several provider meetings before CSoC kicked off. It’s probably time for another meeting.
6. Begin transparently reporting the number of Louisiana’s children who are being placed out of state for residential care. If the number is 0, report it. If the number is 40, report it. Whatever the actual number is, Louisiana’s children have been placed in facilities out of state because the authorized CSoC services have not been available in Louisiana. This is important. The closer a child is to her or his family, the more family can participate in treatment. The more a family participates in treatment, the greater the chance of a successful outcome.

   By reporting all out-of-state placements, CSoC will create its own motivation to resolve the problem of the missing Therapeutic Group Homes.

Finally, you may wonder why Louisiana United Methodist Children and Family Services is advocating so persistently for the creation of Therapeutic Group Homes, a service we do not provide. It’s simple: Louisiana’s children need them.

The Louisiana United Methodist children’s homes provide the most intensive levels of residential care in Ruston, Sulphur and Mandeville. (We have the bootstrap, heel and toe of Louisiana’s boot covered.) Most of our children who are ready to leave our care cannot return home and the step from our psychiatric residential treatment facilities into a non-medical group home is much too far.

Many of our children who cannot return home require continued care in the next logical, less-restrictive level of care: Treatment Group Homes. Our children need Therapeutic Group Homes.

Rick Wheat, President and CEO of the Home, said, “Caring for children who are not your own is a high calling and a difficult duty. Our youth workers are the nurturing hands of our agency ministering directly to our residents. Their work requires heart, compassion, patience, wisdom, kindness, strength to turn the other cheek, and the grace to forgive.”

“Our youth workers build relationships with adolescents who have undeveloped relationship skills. They care for children who do not often have the ability to care in return. We have an excellent staff at the Home and I am grateful for the exceptional care they provide our children, for their commitment to our kids, and for their pursuit of our mission in Louisiana.”

According to the National Collaboration for Youth, a youth worker is any individual who works with or on behalf of youth to facilitate their personal, social and educational development and enable them to gain a voice, influence and place in society as they make the transition from dependence to independence. Brian Durand, Co-Organizer of the Thank a Youth Worker Day Steering Committee, says, “Everyone can point to a youth worker who had an impact in their life, formally as part of a youth-serving organization or informally as a coach, mentor, or friend. We need to thank those who mentor our youth and celebrate their contributions to our communities.”

Louisiana’s Children’s Code, the law that covers all things related to the care of children in our state, provides judges with the authority to place children into the care of an agency. This admission method bypasses the Coordinated System of Care, Magellan and all state agencies. This law exists to ensure that when a child needs care, the court does not have to wait on “the system” to decide how to care for the child. This law is a good thing.

Until a few weeks ago, we had never received a Judicial Commitment. In fact, the first one came out of the blue. It was such a new thing, several of us had to do our research to determine exactly what our responsibilities are related to our relationship to the court, custody matters, and how the other parts of Louisiana’s Coordinated System of Care operate when a Judicial Commitment occurs.

Generally, I believe these Judicial Commitments will be a good thing for children. Here’s why: A child in out-of-home care can have no more powerful advocate than a judge to ensure her or his unique needs are met appropriately. What a judge requires to make good decisions is solid information. We have a long history of evaluating the needs of children and providing good, solid treatment information.

My first experience with judges and their commitment to making decisions in the best interest of a child and his or her family occurred in the early 1990′s. Judge Robbie James held juvenile court in Ruston. I worked then as Director of the Reception Center and Admissions. Several others and I had the privilege of sharing information with Judge James about our children prior to their court sessions. I looked forward to those meetings. They were held before court because Judge James wanted the latest, most complete information available to help him make the best decision for each child.

I learned then that judges have absolute freedom to focus clearly on what a child or family really needs without being swayed by such things as utilization review or continued care criteria. I also learned that judges can make things happen for children when no other person or agency can. Judges have no financial incentive influencing their decisions about a child’s care. Judges are in the unique position of being able to consider a child’s needs cleanly without worrying about the system’s rules.

Because we have received three Judicial Commitments in the last few weeks, we expect more in the future. We will soon send helpful information to Louisiana’s juvenile judges and district attorneys.

In a nutshell, we will welcome them to our treatment teams and let them know that when they need to make Judicial Commitments we will partner with them and their courts as if they are a child’s care manager. We will keep judges informed of what their children’s needs are. We will also ask the courts to assist us in ensuring each child’s identified needs are met – even when the system isn’t working for the child. This may be pushing the expectations a bit, but we will ask for Certificates of Need and explain that PRTF services are not generally emergency placements. However, we also always want what is best for a child and we understand emergencies happen. Finally, we will ask judges to order responsible parties to pay for the care we provide.

Now, regarding our first Judicial Commitment – a child from Baton Rouge – the court reports hearing from third parties the child loves being in our care. That’s excellent and positive feedback about her experience in treatment.

The most significant action in the Spring meeting of our Board of Directors was the decision to create a permanent place to call home for Methodist Children’s Home of Greater New Orleans. The Board authorized the purchase of 80 acres in the greater New Orleans region, the design our first building for the property, the appointment of a capital campaign committee to raise funds, and the construction the first building.

Twice as large as our campuses in Ruston and Sulphur, a larger 80-acre property will allow us to designate 40 acres as a residential treatment center and allow us to create a 40 acre mini-Outdoor Wilderness Learning Center. This entire property will be the Methodist Children’s Home of Greater New Orleans. In addition to offering residential services and experiential therapies, it will also serve as our regional center for home and community-based services.

We are excited about creating our own Home in the region for our next 100 years of ministry to children and families in the greater New Orleans region. Join us as we make this happen!

A good pool has a place for every swimmer. In this analogy, Foster Care is the wading pool, Non-Medical Group Homes are the steps into the shallow end of the main pool, Treatment Group Homes are the shallow end, and Psychiatric Residential Treatment Facilities are the deep end. That makes for a perfect pool – a place for swimmers of every skill level.

Louisiana has an odd residential care swimming pool right now. We have the wading pool, the steps into the main pool, and a deep end. However, Louisiana’s pool has no shallow end. Until we have Treatment Groups Homes in Louisiana, the drop off from that last step into the water will be a real doozy right into the deep end.

Louisiana reports it needs 275 Treatment Group Home beds. A single Treatment Group Home can house no more than 8 children. Do the math and you see Louisiana needs at least 34 treatment group homes spread across the state.

It is vital that Treatment Group Homes be located across Louisiana because we know the closer a child in out-of-home care is to his or her family, the more likely the family can participate in care. The more a family participates in care, the more likely treatment will be effective.

So today, a year into Louisiana’s Coordinated System of Care, VOA’s Parker House in Baton Rouge is the only Treatment Group Home in Louisiana.

Louisiana has to find a way to build a proper pool!

1,980 years ago Jesus of Nazareth was killed by crucifixion on Friday. Acts 2:20 references a “moon of blood” which seems to reference a lunar eclipse which occurred on April 3, 33. If this is reference related to the eclipse, Jesus died on April 3, AD 33.

Had that been the end of the Jesus story, you never would have heard the phrase, “we are Easter people.”

During the Easter season, I’ve heard Christians of all denominations say, “we are Easter people!” I become curious when I hear diverse groups of people saying the same thing. Where did the words come from? Is it something someone started on Twitter? I had to find out.

The first use of, “we are Easter people”, seems to have happened about 1600 years ago. In the early days of Christianity, Augustine of Hippo proclaimed: “We are Easter people and alleluia is our song!”

As an aside, Augustine of Hippo (aka St. Augustine) was the church’s first solid theologian. He lived during the late 300′s AD and is responsible for formulating the Christian doctrine of Original Sin and for articulating the first doctrine of Just War.

Back to April 3, 33. Good Friday was a sad day for everyone who loved Jesus. Not only did they grieve his death, they grieved the loss of all He had represented to them about their hope for the future.

They also endured the emotional trauma of how he was killed. They saw it. Jesus, a gentle man, was physically beaten and tortured before he ever touched the cross. His family and friends watched him carry a cross beam, his own instrument of death, to the place were criminals were executed. They watched him bleed when soldiers nailed his hands and feet to the cross. They saw the man they loved racked with pain when his cross was tilted upward, its base slipped into a hole and then they heard it thud upright into place. They watched people make fun of him and taunt him as the weight of his body pulled against the nails.

Crucifixion caused a slow, painful death by trauma and asphyxiation. The victim became too weak over time to breathe. Jesus’ loved ones endured the long trauma of watching his crucifixion.

Now here’s something that fascinates me about his crucifixion: it was the standard way for the government to execute a criminal.

Today we use lethal injection. Then, crucifixion was the approved method. When I was child I felt sorry for Jesus, not so much because he died, but because he was crucified. Sunday school teachers made his crucifixion seem like something especially horrendous and reserved just for him. I remember when I first realized there was nothing unique about Jesus’ form of death. That simple awareness shifted my focus my sadness about the way Jesus died to what his death actually meant.

What made Jesus’ death unique was not that he was crucified. Again, that was pretty standard stuff in the Roman empire.

What made Jesus’ death unique was that he did not stay dead! He returned to life. That was the new thing! And the power of His resurrection is what makes us Easter people!

So now, we’re back to “Easter people”. The contrast between the death of Jesus on the first Good Friday and His return to life days later on the first Easter Sunday serves as a perfect metaphor for our ministry to children and families. (You knew I would get here.)

Our children have lived with trauma. For many of them, everyday was like a bad Good Friday. Even when safe at the Home, they live with fear. They protect themselves by staying out of close relationships. They fight quickly to protect themselves from small offenses. They run to get away from conflict, to feel free, to feel in control of their own destiny. Some have been raped, some have been prostituted, some have watched loved ones murdered. You know what our kids have experienced. I blogged about this trauma on the Home’s blog at: http://www.lmch.org/blog/traumatic-childhood-events/

Some of our kids are suicidal or consider suicide because the traumas they have experienced are so dark they feel like death. Wrongly, they believe a tomb is the only place of peace.

What does it mean to be an Easter person when you work with a child who feels the trauma of Good Friday? It means you know the rest of the story! You know the power of Life!

For every evil done to a child, for every pain felt by a child, for every trauma perpetrated against a child, for every fear a child carries, there is reason for hope. There is reason to continue life, pursue healing, look for peace, and join the living!

However dark life seems, Easter is the reason for hope. We do not fear the darkness of trauma or devastation. Ours is difficult work and we all have different roles in the process, but because we are Easter people we can join with children in the lonely darkness of their trauma and lead them out of those dark places into light! For many of our kids, that is the new thing!

I’ll summarize it like this: We now have federal regulations being interpreted by state regulations to create a coordinated system of behavioral health care from four state departments’ funding mixed with federal funds which are being managed by a state-based subsidiary of a public corporation traded on Wall Street. (I think that’s correct.)

Louisiana’s Coordinated System of Care (CSoC) is one year old this month. Created by an Executive Order issued by Governor Jindal on March 3, 2011, CSoC became operational when Magellan of Louisiana began acting as the State Management Organization on March 1, 2012.

CSoC (pronounced “sea sock”) is a managed behavioral health care system for Louisiana’s children who are in out-of-home placements or who are at risk of being placed out of their homes. Louisiana’s Coordinated System of Care (CSoC) is a cross-departmental project of the Office of Juvenile Justice, the Department of Children and Family Services, the Department of Health and Hospitals and the Department of Education to organize a coordinated network of broad, effective services for Louisiana’s at risk children and youth with significant behavioral health challenges or related disorder.

The cross-departmental nature of CSoC is chiefly related to funding. State General Fund dollars from each of the four state departments were pooled and used as a pot to pull down untapped Medicaid dollars at a ratio of 1:3. One state dollar brings down 3 additional Medicaid dollars.

Of course, anytime federal dollars are pulled into a state, those federal dollars have significant strings attached. When Louisiana converted to a federally-funded child welfare system, those federal strings required significant changes.

One imposed change was the creation of two new DHH-licensed levels of residential care: Treatment Group Homes (TGH) and Psychiatric Residential Treatment Facilities (PRTF). Mercer, a consulting firm which helped DHH design Louisiana’s CSoC, determined that Louisiana needs 340 PRTF beds and 250 PRTF beds.

Because each of our residential programs cares for more than 16 children, the Methodist Children’s Homes in Louisiana were required to become licensed as Psychiatric Residential Treatment Facilities. A PRTF license is not a hospital license. We continue operations as residential facilities with additional staff to provide for medical care and residential psychiatric care.

This is probably the best place to insert the chart I have created which demonstrates the levels of out-of-home care (Click the image for a larger view):

Notice the third step. That’s the PRTF step. Then notice that the second and fourth steps on either side are missing. There is no step for Longer Term Psychiatric Hospitalization. There is no step for Treatment Group Homes. This diagram describes the current status of the array of services available for children in Louisiana.

Let’s start with the Longer Term Psychiatric Hospitalization. To my knowledge, there are only a small number of these beds in Louisiana. 40 is the last official number I heard reported during a meeting in Baton Rouge in late 2010. I’ll assume the number of these beds today is still close enough to 40 to call it 40. I assume there are times when 40 beds are sufficient. There will also be times when 40 beds in the entire state are not enough for children who have longer term psychiatric hospitalization needs.

In terms of numbers, the most significant missing step is the absence of Treatment Group Homes. Louisiana reports it needs 275. There can be no more than 8 children in a single group home. Louisiana needs at least 34 treatment group homes spread across the state. Today, after a year of CSoC, there is only one Treatment Group Home. Parker House is the Volunteers of America’s TGH in Baton Rouge for boys under 13. (I commend the staff of VOA and Parker House for their work to license a Treatment Group Home. It was not an easy road.)

At Methodist we have reviewed the Treatment Group Home materials and we do not believe we can provide Treatment Group Home services. I’ll share some of the reasons we and others are unable to provide Treatment Group Home services.

1. Federal regulations dictate what a children’s home can do now that CSoC is at work. We have four houses on our Ruston campus that would make great Treatment Group Homes. However, because we have PRTF beds on the same property, all our beds on the property must be PRTF beds. Remember, because we have more than 16 children in care, we must be licensed as a Psychiatric Residential Treatment Facility.

2. The TGH minimum licensing standards require a Treatment Group Home be located in a neighborhood. Finding a suitable, existing house which meets the licensing requirements will be like finding a needle in a haystack. Homes built for families will not serve as great Treatment Group Homes. For example, few families require 8 bedrooms. If a provider builds their own house with 8 bedrooms it will be nearly impossible to sell in the future because, again, few families require 8 bedrooms.

3. I wrote earlier that it was initially reported that CSoC would bring $3 federal dollars into Louisiana for each $1 of State General Funds Louisiana tossed into the common pot. That’s a significant amount! I don’t believe it has worked out that way, though. Reimbursement rates for services are now lower than the cost of providing the service. The per diem payment for Non-Medical Group Homes is less than the rate providers received before CSoC was created. Several providers have crashed into their financial wall this past year because the current reimbursement rates do not support the costs of care. The Treatment Group Home reimbursement rate is low.

4. There are adolescent group home providers in Louisiana who have the experience and the heart to become Treatment Group Home providers. Unfortunately, CSoC does not pay for the start-up costs of making the transition from the former DCFS Child Residential license to the new DHH Treatment Group Home license. The cost of additional staff who must be hired prior to receiving the TGH license, the cost of licenses for evidence-based treatment practices, and the cost of accreditation are all financial burdens group home providers must shoulder to become Treatment Group Homes. Unfortunately, the per diem reimbursement rate is too low to allow a provider to ever recoup the startup costs. Figuratively speaking, a new TGH provider will start out in a hole and never climb out.

I’ll stop there because this is growing a bit long.

Scroll up and click on the chart again. Louisiana’s children need access to the two missing steps on the staircase of services. It’s a big step down from care in a psychiatric residential treatment facility to care in a non-medical group home. Some children require longer term psychiatric hospitalization because of significant mental illness.

CSoC still has important gaps to fill – the sooner the better.

The work of our Family Counseling Center in Ruston is a perfect example of how the continuing support of many and our solid partnerships with others make possible our ministry to children and families. Let me share some information about the impact of partnering.

The staff of the Family Counseling Center provided prevention, early intervention and treatment services to 7,323 individuals during 2012. Services were provided to individuals in 13 parishes and counties in Louisiana, Arkansas and Mississippi. The Family Counseling Center has become an important source of therapeutic services in the region.

We could not do it alone. United Way of Northeast Louisiana, Lincoln Health Foundation, Trinity United Methodist Church, Boys and Girls Club, Montessori School of Ruston, Northwest Law Enforcement Planning Agency, Union Christian Academy, Louisiana Tech University, University of Louisiana in Monroe, The Health Hut, and Lincoln Parish School Board are among those who have partnered with the Family Counseling Center to provide support or locations for our services.

When we consider the care we provide we know we are not an island. We are grateful to hold hands with strong partners who make our work possible, effective and accessible to children and families.

Visit LMCH.org and explore the Louisiana Methodist Children’s Home web site!

Howard Educational Center, the licensed alternative school on the grounds of Louisiana Methodist Children’s Home

In all of Louisiana, there is not another school like Howard Educational Center. Located on the grounds of Louisiana Methodist Children’s Home in Ruston, Louisiana, Howard School is a center of educational excellence which serves about 100 students. In addition to providing special educational services for the Home’s residents, Howard School also provides alternative educational services for about twenty students from the Lincoln Parish school system who cannot attend public schools because of their disruptive behaviors.

I am absolutely pleased to congratulate our remarkable group of teachers for their achievements. Individually, each of our teachers is exceptional and, together, they make up an awesome team of educators.

In addition to the recognition, this designation by the Louisiana Department of Education comes with a check from the state in the amount of $8,453.85. Howard School will invest these funds in further enhancing our educational environment.

Finally, as additional evidence of our school’s excellence, Howard School has had 4 students earn GED’s in the first semester of the year. Each of these students passed on their first attempt. Three of the four students scored well above the national average. The fourth student scored right at the national average.

Again, there is no school like Howard School!

Exposure to Childhood Traumas

The particular section is titled, “Exposure to Childhood Trauma”. The instructions state, “Place a check mark by any of the traumas the child has experienced. Provide information about the child’s experience of these traumatic events in the space below the checklist.”

Here’s the list (but I am leaving an item out because this blog is for the general public):

List of Traumatic Events the Child has Experienced

• Has been bullied
• Victim of physical assault resulting in injury
• Victim of physical assault with a weapon
• Has witnessed a shooting or knife attack
• Victim of a shooting or knife attack
• (This item removed)
• Robbed by a nonsibling
• Physically abused by a caregiver
• Has witnessed domestic violence
• Is a victim of domestic violence
• Has attempted suicide
• Has witnessed a suicide
• Was kidnapped by a stranger
• Was kidnapped by a family member
• Has witnessed the sexual assault of a family member or friend
• Is a victim of sexual assault by a family member or friend
• Has witnessed the sexual assault of a stranger
• Is a victim of sexual assault by a stranger
• Has been prostituted by a non-family member
• Has been prostituted by a family member
• Has witnessed the death of a loved one
• Has witnessed the murder of a stranger
• Has witnessed the murder of a friend/neighbor
• Has witnessed the murder of a parent
• Has witnessed the murder of a sibling
• Has witnessed the murder of any other family member

This is a heart-rending checklist. These are the children for whom we care. We ask for this information in a standardized way because the events are common enough childhood experiences. We expect to see check marks on the list and are surprised when there are none.

I believe our society’s immune system has become strong to the point of callousness to protect our sensitivities against what we know happens to children. We have become immune to what we see in the media because we see it so often and because it usually touches another family, not our own. When one reads about an assault or a murder in the newspaper or hears about it on the television news, it is easy to ignore it or move on quickly to the next story.

But that sexual assault, that murder, that rape, that fight mentioned in the news is often witnessed by children in the home or in their own neighborhood. Even a mature, psychologically stable adult cannot not walk away from those events untouched. Children are overwhelmed by them, become fearful, turn inward, become less verbal.

Simply stated, they are traumatized.

Then, and especially if no one has cared for their emotional needs, as they grow into adolescence they become incorrigible or even aggressive as they act out the pent up rage from unresolved trauma. (I believe Louisiana’s new Coordinated System of Care may be our state’s best shot at providing early intervention directly in the homes of children and families. The home and community-based services made available by CSoC must be developed in Louisiana.)

Of course, when the child is himself or herself assaulted the consequences are even deeper than when they are a witness to another’s victimization.

Notice some of the subtle differences in the checklist items which seek to find out if the traumatic event occurred to the child or was witnessed by the child. They also seek to clarify the child’s relationship with the person who committed the act, “loved one”, “stranger”, “friend/neighbor”, “parent”, “sibling”, “nonsibling”. These distinctions are important because the impact of childhood traumas will vary depending upon the child’s age, whether the child was a victim or witness and the child’s relationship to the person committing the traumatic act.

Who are our children? Who are the children we care for at Louisiana Methodist Children’s Home in Ruston, Methodist Children’s Home of Southwest Louisiana in Sulphur and Methodist Home for Children of Greater New Orleans in Mandeville? They are children who have experienced traumatic events like those in the list above and who need intensive treatment for the psychological and spiritual impact of their traumas. When you support us with your prayers, you now know how to pray for our children.