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Effectiveness of Children's Home and Community-Based Waiver Program

Effectiveness of Children's Home and Community-Based Waiver Program

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Limited alternatives exist to residential treatment or hospitalization for children with the most serious emotional disturbances. Community-based interventions are intended to offer less restrictive and expensive options than traditional treatment. One such program is New York State’s Home and Community-Based Services (HCBS) Waiver Program.
Limited alternatives exist to residential treatment or hospitalization for children with the most serious emotional disturbances. Community-based interventions are intended to offer less restrictive and expensive options than traditional treatment. One such program is New York State’s Home and Community-Based Services (HCBS) Waiver Program.

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Published by: Child and Family Institute on Jan 18, 2012
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EffectivenessofaChildren’sHomeandCommunity-basedServices Waiver Program
Ramon Solhkhah, M.D.
Cathryn L. Passman, C.S.W.
Glenn Lavezzi, B.A.
Rachel J. Zoffness, M.A.
Raul R. Silva, M.D.
Published online: 12 June 2007
Springer Science+Business Media, LLC 2007
Limited alternatives exist to residential treatment or hospitalization for childrenwith the most serious emotional disturbances. Community-based interventions are intendedto offer less restrictive and expensive options than traditional treatment. One such program isNew York State’s Home and Community-Based Services (HCBS) Waiver Program.
From 1996 to 2002, 169 children were enrolled in the Manhattan HCBS. All spentat least one month on the wait list prior to admission to the waiver program. We used ourwait list as a control group (WLC), allowing for comparison of the HCBS intervention.
Sample consisted of 169 children between the ages of five and eighteen. The ethniccomposition was 46.8% Hispanic (
= 79), 47.9% African-American (
= 81), and 5.3%Caucasian (
= 9). Average stay was 12 months in the HCBS program and 3.5 months forthe WLC. Only 30% of children in the WLC were maintained in the community, while 81%of children in the HCBS were similarly maintained (
< 0.001). Also, the rate of hospital-ization for the HCBS group was significantly lower (3 versus 41%;
< 0.001). There wasalso a trend for the WLC group to have had substantially higher rates of removal by theAdministration for Children’s Services (New York City’s protective service agency) (8.3versus 1.8%) and to more frequently require residential treatment (13.0 versus 8.9%).
It would seem that the HCBS program appears to be a clinically and cost-effective method of maintaining children in their community.
Home-Base Community Service
Child services
Presented in part at the 50th annual meeting of the American Academy of Child and Adolescent Psychiatry,Miami, FL Oct. 14-19, 2003.R. Solhkhah, M.D. (
C. L. Passman, C.S.W.
G. Lavezzi, B.A.
R. J. Zoffness, M.A.
R. R. Silva, M.D.The Child and Family Institute at St. Luke’s and Roosevelt Hospitals, 411 West 114th Street, Suite 5C,New York, NY 10025, USAe-mail: rsolhkhah@chpnet.org
Psychiatr Q (2007) 78:211–218DOI 10.1007/s11126-007-9042-2
Epidemiological research suggests that as many as 7.5 million children in the United Stateshave a diagnosable mental disorder, yet many go undiagnosed and therefore receive littleor no treatment for their problems [1]. Others receive inappropriate services or are placedin restrictive settings, such as inpatient psychiatric hospitalization or residential treatmentfacilities [2]. Recent literature has documented poor outcomes for students with seriousemotional disturbance (SED), showing that more than 5% of children and adolescents withserious emotional disturbance are suspended or expelled from school annually [3]. How-ever, research over the past decade has indicated a variety of effective evidence-basedinterventions for children in the community, such that children who were once treated ininstitutions can now remain at home [4,5]. These evidence-based interventions call for innovative service delivery, which provides home-, and community-based services, familysupport, case management, respite care, crisis response, and individualized treatment planfor both child and family [4].In communities throughout the United States, there is a growing desire to coordinateactivities of the many individuals and agencies serving SED children and their families. Byway of definition, SED youth may be diagnosed with one or more Axis I psychiatricdisorders, including anxiety disorders, Attention-Deficit/Hyperactivity Disorder (ADHD),bipolar disorder, major depressive disorder, psychotic disorders, substance use disorders,and/or suicidal behavior [6]. Moreover, many subjects with serious psychiatric illness areunable to function either at home and/or at school without long-term help and have dif-ficulties in the realms of educational, vocational, health, child welfare, or juvenile justice[7]. The Medicaid Home and Community-Based Services (HCBS) Waiver Program is arelatively new option for this population, although it was established in 1981 and autho-rizes states to provide home- and community-based alternatives to institutional care [8].The HCBS waiver program is able to offer a wide range of medical and non-medicalservices related to personal assistance, including case management, respite care, and home-based services.The prioritization of at-risk youth and their families is a relatively recent goal. Somestates have developed individualized systems of care specifically for SED children andfamilies, including Alaska, Vermont, Idaho, and Washington [9,10]. Improving services for these children and their families requires knowledge of the target population, thecommunity in which they live, available resources, procedures for initiating cooperativecommunity efforts, effective communication, and definitive goals [11]. Stroul and Fried-man [10] outline a system of care for SED children and youth that proposes a community-based, collaborative service delivery system that provides an individualized planaddressing mental health, environmental, familial, and social service needs. However, inmany regions of the country there are limited alternatives to long-term residential treat-ment or hospitalization for children and adolescents with serious emotional disturbances.Theoretically, community-based interventions are intended to offer less restrictive andless expensive options than traditional treatment [5,12]. One such program is New York  State’s Home and Community-Based Services (HCBS) Waiver Program. This programprovides a menu of six different wraparound services that are offered in addition totraditional outpatient treatment. These services include: 1) Individualized Care Coordi-nation, 2) Respite Care, 3) Family Support Services, 4) Skills Building, 5) Intensive In-Home services, and 6) 24-hour Crisis Response.
212 Psychiatr Q (2007) 78:211218
New York County’s (Manhattan’s) HCBS program currently has the capacity to serve48 children, although at inception the program’s maximum census was 24 children. Whenthe program is at full capacity, prospective applicants are then placed on a wait list. Allapplicants must meet the criteria delineated below, and be approved by a local govern-mental unit prior to being assigned to the HCBS program or being placed on a wait list. Await list of no more than 24 patients is permitted at any given time. While children are onthe wait list they continue to receive traditional forms of outpatient treatment, such asoutpatient psychotherapy, medication management, or day hospital treatment.In order to be eligible for the St. Luke’s-Roosevelt HCBS waiver program, childrenmust meet the following criteria: they should be between 5 and 18 years old, and meetcriteria for a DSM-IV Axis 1 psychiatric diagnosis, as well as New York State criteria forserious emotional disturbance. SED is defined in the state of New York as having func-tional limitations due to emotional disturbance over the past 12 months, with a score of 50or less on the Children’s Global Assessment Scale. If not admitted to the HCBS program,they would otherwise require a level of care of inpatient psychiatric hospitalization orresidential treatment, be at imminent risk of admission to inpatient psychiatric hospital-ization or residential treatment, or have need for continued hospitalization. Perhaps mostimportantly, the child has to have a viable living environment in the community, withparents or guardians who are willing to participate in the HCBS program. Finally, the childwould be eligible for Medicaid under the HCBS waiver, and it is fiscally reasonable for thechild to be cared for in the community. To be eligible for Medicaid, the child must meet allof the criteria for HCBS and is then considered a ‘‘family of one.’’ New York Statebudgets an average of $47,500 per child enrolled in the waiver program per year.Once in the HCBS program, each child is assigned an Individualized Care Coordinator(ICC) who meets with the child and family in their home environment, taking into accountthe community in which the child lives. It is important to note that this study focuses onchildren from New York City, an important factor in their treatment given that researchshows that urban environments can affect a child’s development and increase their risk foradverse mental health problems [14]. The ICCs conduct assessments to determine therequirements of each individual, and subsequently implement services such as respite care,family support services, skills building, and intensive in-home as needed. Incorporation of the family in treating children and adolescents is widely evidenced to be effective; this istherefore an essential part of the HCBS program [15].While these types of programs have been described for many years [16,17], there is a dearth of information regarding the systematic evaluation of effectiveness and outcomes of community-based interventions. To this end, we analyzed the effectiveness of our programover a six-year period, utilizing a within-group design with a primary outcome measure of maintenance in the community.
PatientsDuring the period of 1996–2002 (since the inception of this HCBS program) 169 childrenand adolescents were enrolled in the HCBS. All of these children spent at least one monthon the wait list prior to admission to the waiver program. In addition, all of the subjectscome from the same referral sources (including physicians, schools, hospitals, outpatientclinics, and residential treatment facilities), differing only in time of referral. We were
Psychiatr Q (2007) 78:211218 213

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