At Calif. Locked Facility, High Demand for Intensive Services

Most group homes in California are poised to embrace mandated changes to the way they administer services under a new law if they want to continue providing care to children and youth in foster care.

But for one residential facility in Los Angeles County, business will continue as usual—with locked doors and restraints to keep the state’s most traumatized foster youth from harming themselves, their peers and staff.

As California has moved toward deinstitutionalization in the last generation, the state still relies on a special class of facilities designed to meet the needs of severely emotionally disturbed children. Under Assembly Bill (AB) 403, recently signed into law by Gov. Jerry Brown, lawmakers and advocates have lauded the opportunity to transform the scope of residential facilities for foster youth, supported by an increasing body of research that has tracked the negative impact of long-term stays in group homes. But as the heralded law changes incentives and standards for residential care, the highest-needs children in foster care continue to face waiting lists and uncertain futures under so-called congregate-care reform.

Located in Torrance, a mid-size town south of Los Angeles, Star View Adolescent Center is one of only two secure residential facilities in California, also known as community treatment facilities (CTFs). Originally designed as an alternative to out-of-state placements and the state’s psychiatric hospitals, CTFs provide mental health treatment to children ages 12 to 18 who are deemed seriously emotionally disturbed.

Nearly all of these children are involved with the child-welfare and juvenile-justice systems in California and have a history of severe abuse and trauma. The most common diagnoses include bipolar disorders, serious depression and post-traumatic stress disorder, along with substance abuse issues.

Youth in residential care at Star View also attend South Bay High School on campus, a learning institution that’s only open to the 40 youth in the program as well as the 16 youth who reside at the psychiatric health facility that’s part of the campus. The population is predominately female and is drawn from across the state, though most come from Los Angeles County through contracts with that county’s Department of Children and Family Services. About 30 percent of the youth have endured commercial sexual exploitation.

But Star View is unlike other group homes in California designed to handle foster youth with the greatest mental health needs. All foster youth at Star View are confined behind locked doors, and the staff is authorized to use restraints and seclusion, though state law mandates that such measures must be overseen by a psychiatrist and a registered nurse.

CTFs initially faced an uncertain future under AB 403, though a late amendment of the bill preserved the place of CTFs in congregate-care reform. But the all-important question of whether the state will allocate adequate money to support the rising costs of meeting the intensive needs of this extremely needy population remain.

Like group homes in the state, the Community Care Licensing Department of the California Department of Social Services (CDSS) oversees CTFs. All group homes are categorized into a series of 14 levels based on the type of care and services provided. The highest level is 14, reserved for children with severe emotional and developmental issues.

But the CTFs are off the scale, according to administrators at Star View.

“The children who come to us usually have had services at all different levels, typically multiple treatment failures and placement changes,” said Kent Dunlap, senior vice president of operations for Stars Behavioral Health Group, the organization that oversees Star View. “This is the last and highest level of care available.”

Dunlap says that the psychiatric facility offers a unique opportunity to help many of the youth in the CTF. Instead of the disruptions caused by being moved from a residential treatment program into a psychiatric hospital, youth are able to preserve their treatment team and continue classes at the South Bay High School.

But even as Star View has provided some stability for many disturbed children, its future is far from certain in the face of a continuing philosophical shift in the way California thinks about children’s mental health.

A Wave of Deinstitutionalization

Fifty miles north of Los Angeles lies a stark reminder of the last time California attempted a broad-based change to the way it administered mental-health services to children in a residential setting.

For more than 60 years, the massive Camarillo State Hospital housed the largest children’s mental health unit in the state, an imposing monument to old-fashioned institutional care. Since closing in 1997, the state shifted the population to smaller psychiatric hospitals and boosted wraparound services in an effort to bring more children back into the community. Wraparound services are individualized intensive services designed to support children in the community, often after school or at home during evenings and weekends.

By 2008, the last children in residential psychiatric care in California departed from the state-operated Metropolitan Hospital in Norwalk, Calif.

For some like Carroll Schroeder, director of the executive director of the California Alliance of Child and Family Services, the CTFs offer a potential look at the how the residential care options could be structured in the wake of the state’s congregate-care reform.

Under AB 403, existing high-level group homes will be forced to transition into short-term residential treatment centers (STRTCs), programs with new licensing standards that would provide temporary services rather than long-term residential placements for children who can’t be kept safely with families. Keeping children and youth in the community as much as possible is the underlying goal of changes suggested by AB 403.

“CTFs have always been a prototype for STRTCs,” said Schroeder. Though the use of restraints and locked doors are reminiscent of the old-school practices at state hospitals, CTFs have been promoted as a result of wraparound services designed to move children back into either a lower-level group home or, if possible, with relatives.

Success outlined in the congregate-care reforms of AB 403 place an emphasis on avoiding extended placements in residential treatment facilities, not necessarily the quality of care provided.

“It’s all based on there being a home-based option available to them, going back to parents, or family members or foster parents,” Schroeder said.

At the CTFs, most children stay for about nine months, though it depends on the individual case. Over time, Dunlap of Star View says children are staying for shorter periods, something he attributes to the state’s emphasis on providing intensive services to youth at home.

“Now we have a larger number of children going to a community setting,” Dunlap said. “ I would attribute that to having better services in the community with wraparound [services]. We’ve also done a better job of finding family supports—finding relatives and connecting with them to find a way to support a child to be with a family in the community.”

An Increase in Higher-Needs Youth

But even as more children are returning to a community-based setting than 10 years ago, Star View has also seen a shift in the population it serves.

Star View Administrator Natalie Spiteri has been at the agency for 10 years. Before that, she spent eight years at a similar facility. She says that she has seen a marked change in the composition of youth at the group home.

“Over my career at Star View, seeing about 56 kids at any given time, we used to have maybe one or two kids who are really challenging,” she said. “Now its more like 10. It’s become a much more acute setting. The kids are much more challenging.”

Spiteri recalled one of these children, a youth who constantly ripped out her eyebrows and toenails and would swallow batteries as a result of severe trauma caused by abuse. Though 16 years old, the teen acted more like a toddler and required nearly constant monitoring. Cases like these are very hard to place in the community, and speak to the potential difficulties in achieving the sweeping goals of recently passed AB 403.

Part of the issue lies with the high cost of intensive services provided by facilities like Star View and the fact that group homes serve a need that is becoming increasingly difficult for many counties across California to provide.

“Nobody likes the idea of a kid raised in a group home,” Spiteri said. “But there are still some children who are not equipped to do that without intensive services. The need is there. We’re at full capacity with a waiting list, so there’s still a need for these services.”

“Their counties are saying, we don’t have the facilities, we don’t have the resources, we don’t have the programs, you do. Can you please help us?”

Contributing to the problem is the fact that, in recent years, several CTFs have closed, leaving Star View as the only facility in the state for foster youth dealing with severe emotional disturbances. The facility has contracts with more than 20 counties across the state to take children when there is space. Typically 15 of the 56 slots at Star View are claimed by kids from counties across the state; the rest originate from Los Angeles County.

In 2011, a CTF in Contra Costa County operated by Seneca Family of Agencies (formerly Seneca Center) closed, followed by another one run by Seneca in San Francisco. Stars Behavioral Health Group also shuttered a CTF located in Santa Clara County in 2008.

“They’re complicated, they’re a regulatory nightmare, it’s hard to find good staff, and they’re expensive,” said administrator Spiteri of CTFs.

Dunlap sees the closure of the Santa Clara facility as an overlooked success story of California’s push toward bringing children back into the community. But with a continued demand for services plus the high cost of providing intensive services, the future of CTFs is being squeezed by the state’s funding system.

CTFs qualify for the level 14 rate, which amounts to nearly $9,700 a month per child, plus a $2,500 monthly supplement available to CTFs. But while the level 14 rate sees cost-of-living increases every year thanks to a 2009 federal lawsuit, the CTF supplement has remained frozen for nearly 15 years.

Dunlap says the discussion over finances is a critical element that has been left out of discussions around congregate-care reform.

“There’s an expectation of minimizing the use of group homes but there hasn’t been the funding to make that happen,” he said.

Working out the cost of rates for CTFs and their ability to stay in business are one of many issues left to figure out in the coming year. Legislators and state agencies are beginning the laborious process of providing details of the sweeping changes laid out in AB 403. Gov. Brown’s budget allocates $9.6 million to support and recruit resource families, but funding for other parts of congregate-care reform still remains unknown.

The Future of Services Aimed at High-Needs Foster Youth

As congregate-car reform moves forward, the pressures and successes of CTFs are a potential cause for concern about the way that foster youth with the greatest mental health needs may be moving through the new system.

Many counties place children with serious mental-health needs at a lower-level group home and bounce them around until a better placement is available at a higher levels, a practice that Schroeder says will have to change under the new congregate-care reform.

“There is an increased need for those higher-level programs simply because you’re not going to have the safety valve of just letting kids just languish or go through a revolving door at the lower-level programs,” Schroeder said.

A critical part of the discussion is what will happen with attempts to move children from the highest-level of services at CTFs and at higher-level group homes (levels 12 to 14). AB 403 specifies that temporary stays in the new type of facilities (STRTCs) for high-needs youth will be followed by placements with resource families—residential arrangements that will be able to safely meet the needs of youth in the community.

However, California has experienced continued difficulty in recruiting these type of families. As the state makes a reliance on resource families the linchpin of its new congregate-care strategy, this could increase the pressure to find solutions for high-needs children, according to Schroeder.

“That’s going to be a big question: if the lower level [group home] kids suck up all the home-based family care options, where are the other [high-level] kids going to go?” he said. “Then you can’t figure out what to do with the kids on the higher end to bring them down.”

Dunlap of Star View says that the new reforms are built on the premise that shorter stays in congregate care and more time spent in the community will lead to cost savings that can be re-invested in additional resources to support community-based care.

But many questions remain as the state imagines the future of congregate care without an exact idea of how it’s going to get there. Dunlap welcomes a discussion about the better options and alternatives for highly traumatized foster youth, though he remains circumspect about the path forward for the state’s most vulnerable children. 

“Our organization is mission-driven and if there are other ways to serve these high-needs youth with alternatives that are either cheaper or easier to provide, we’re obviously all for it,” he said. “We don’t know what those are and for right now, CTFs are the best option.”

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