Colorado Residential Care
Outcome Study
A partnership of the Colorado
Health Foundation and the
Colorado Association of Family and
Children’s Agencies (CAFCA)
Participating Agencies
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Alternative Homes for Youth
Children’s ARK
Denver Children’s Home
Devereux Cleo Wallace Centers
Excelsior Youth Center
Griffith Centers for Children
Jefferson Hills
Mt. St. Vincent Home
Shiloh Home
Tennyson Center for Children
Third Way Center
The Study
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24 months (2009-2010)
Over 1200 admissions
Data analysis is being conducted by
PSI (David Price and Anita Cohen),
independent contractors reimbursed
by the Colorado Health Foundation
Data Collected
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Admission Data (CANS and admission
information)
Discharge Data (CANS and discharge
information)
Post-Discharge Follow-up Data (CANS and
follow-up information at 4 and 12 months)
Colorado TRAILS data is in the process of
being integrated with the data collected
Demographics of Participants
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Ages
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5-11
12-14
14-17
18+
13.2%
25.5%
52.7%
8.6%
Gender
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Male
Female
58.7%
41.3%
Setting Prior to Placement
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Home
Foster Care
Group Care
Psychiatric Hospital
Detention
DYC Commitment
15.4%
13.8%
15.8%
13.6%
32.8%
8.3%
The Study Found
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Residential Care was
found to be effective
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All of the seven CANS clinical domains
demonstrated statistically significant change
The data from post-discharge follow-up
shows a trend towards continued
improvement after discharge
This study found very similar levels of
reliable change to a multi-year study in
Indiana of residential treatment
Results and Discharge Status
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Discharged to a less restrictive
 Home
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65%
40%
Whereas only 14% of the children
referred by Child Welfare were living at
home at the time of referral
Foster/Kinship Care
Group/CPA
16%
9%
Significant Results Findings
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Medications
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70% of the youth admitted without a prescription
for medication were NOT prescribed a medication
A statistically significant decline in the number of
medications was found for youth treated in
residential care
High Risk Behaviors Declined with Treatment
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Decreases were found in suicide attempts,
homicidal treats, psychiatric hospitalizations and
run-away behavior
Comparison Kids on CANS
Percentage of Actionable Items
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Trauma
Trauma Symptoms
Beh/Emot Needs
Life Domain
Risk Behavior
Transition to Ad
Child Strengths
Caregiver Stren
Males
Females
82.0%
59.6%
92.8%
92.8%
88.1%
68.2%
90.2%
56.4%
70.9%
55.8%
80.1%
80.9%
75.1%
63.4%
79.9%
48.2%
What Surprised Us
We have known:
• The family environments these children
come from have contributed to their
problems
• Treatment for the whole family system is
an important part of addressing the needs
of the children
Parental Rights Terminations
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Parental Rights had already been Terminated or were
Pending Termination for 24% of all youth referred to
residential treatment
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This is associated with increased client acuity:
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More frequently special education
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More previous hospitalizations
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Greater history of runs from placement
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More frequently adopted
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A greater trauma history on the CANS
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Younger children were more likely to have parental
rights terminated
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Ages 5-11
44.1%
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Ages 12-14
24.1%
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Ages 15-17
19.1%
Comparison Kids on CANS
Scale Scores
Intact
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Trauma
Beh/Emot Needs
Life Domain
Child Strengths
Caregiver Strengths
7.7
11.3
10.0
14.5
6.9
PRT
10.6
11.8
10.0
16.1
6.4
Comparison Kids on CANS
Percentage of Actionable Items
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Trauma
Trauma Symptoms
Beh/Emot Needs
Life Domain
Risk Behavior
Transition to Ad
Child Strengths
Caregiver Stren
Intact
PRT
74.2%
53.2%
87.7%
87.5%
82.5%
65.6%
85.7%
54.5%
88.8%
74.6%
89.9%
92.2%
85.1%
69.0%
89.2%
46.2%
Recommendation 1
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Parental Rights Termination is a major stressor
that needs to be better addressed
 Any youth who is undergoing or had their
parental rights relinquished needs intensive
trauma focused treatment to deal with that
loss
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All of these youth should be monitored throughout their
childhood
Additional services should be provided when issues
resurface
If they are too young at the time of
relinquishment to benefit from treatment then
ongoing monitoring should be vigilant in
assessing when treatment services are likely to
be beneficial
Permanency and Adoptions
Percentage of Youth Adopted 17.1%
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5-11
16.3%
12-14%
19.0%
15-17
15.9%
>18
20.0%
Not all of these are the result of parental
rights terminations; they include private and
out-of-country adoptions
Recommendation 2
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Families who adopt children from the child
welfare system or who assume guardianship
of children from the system need to be better
supported
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They need accurate information at the time of placement
Need to be provided services that will make the placement
successful
They need to be able to come back later and ask for
help/treatment
We need to have a serious dialogue
regarding families who have privately
adopted being held accountable for not
walking away from their children
Permanency Continued
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Caregivers Not Wanting Youth to
Return Home
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Total
5-11 years
12-14 years
15-17 years
>18 years
23.8%
18.3%
8.7%
24.6%
65.9%
Recommendation 3
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As we address the permanency
discussions we need to address kids
with families that do not want them to
return home and the underlying issues
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Concerns about safety
Lack of services to manage children in
these homes
Parental issues such as mental health,
substance abuse and legal issues
Critical Finding
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Clients referred to Residential Care have
experienced extreme trauma histories
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98.7% had experienced some type of trauma event
in their life
80.3% had experienced four or more different
types of trauma (versus 16.4% of the general
population)
51.3% had experienced seven or more different
types of trauma
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53% Sexual Abuse
67.2% Physical Abuse
70% Neglect
76.4% Emotional Abuse
65% Family Violence
Recommendation 4
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All youth entering care should have a
trauma assessment and receive trauma
informed services based on that evaluation
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We applaud CDHS for making this a priority in the
Title IV-E Waiver
High Need Children (4 or more Adverse Childhood
Experiences – 80% of youth entering residential care
have experienced this level of trauma which correlates
with major life problems) need to be identified and
treated
CAFCA had a positive experience utilizing the CANS
and volunteers to work with the State regarding the
selection of a proper assessment tool
Severely traumatized youth need more than just a
loving home, they require treatment
Profound Mental Health Needs
The Youth in the Study had profound mental health
needs:
 45.6% had been in a psychiatric hospital and 29.6% had
been hospitalized more than once
 79.8% of youth referred had a GAF (Global Assessment of
Functioning) score of 50 or less and 44% had a score of
40 or less (the level that several years ago was proposed
as the criterion for Psychiatric Residential Treatment
Facilities/PRTFs)
 81% of youth referred had multiple diagnoses at the time
of admission
 55% were on psychotropic medication at the time of
admission
Understanding Congregate
Care usage in Colorado
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At this year’s JBC hearing on Mental Health it was
reported that Colorado ranks 48th on the percentage
of psychiatric hospital beds per capita
In the mid-90s Colorado closed over 700 psychiatric
hospitals for children and adolescents in Colorado.
Today we have fewer than 200 psychiatric hospital
beds for children and adolescents.
The study compared youth in child welfare, the
division of youth corrections, youth referred by
mental health and youth referred privately or who
came from other states and found few differences
between the populations
Study Highlights
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Inquires regarding psychiatric hospitalization have revealed
that only about 15-25% of the psychiatric hospital beds in
Colorado are occupied by youth with Medicaid
It’s not bad but Colorado has organized its continuum of
care differently; children who in other states would be in the
hospital or Psychiatric Residential Treatment Facilities are
served in Colorado’s Residential Child Care Facilities. The
study estimated that approximately 26% of youth served in
the RCCFs would qualify for an inpatient level of care using
the Indiana Decision Support Instrument for the
determination of the level of mental health service needed
while also suggesting that as many as 61% of the youth in
the study might have been treated at a lower level of care if
appropriate services were available.
Study Highlights
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Adjudicated
Substance Abuse
Danger to Others
Sexual Aggression
Runaway History
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Developmentally Delayed
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CW
41.7%
19.9%
32.4%
12.6%
25.3%
12.6%
DYC
100%
48.7%
16.4%
10.8%
32.0%
5.6%
Study Highlights
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Critical Treatment Issues
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Child Welfare referrals who were in
32.6%
Detention immediately prior to placement
History of Homicidal Threats
31.4%
Danger to Others
30.9%
Prior OOH Placement History
74.0%
Identified as Special Ed
58.9%
Runaway History From Home
37.1%
Runaway History From Placement
28.9%
History of Fire Setting
3.4%
Comparison Kids on CANS
Scale Scores
CW
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Trauma
9.2
Beh/Emot Needs
11.6
Life Domain
10.2
Risk Behavior
8.6
Child Strengths
14.9
Caregiver Strengths 7.8
DYC MH Private
8.1
11.0
9.8
8.4
14.2
6.7
7.8
12.4
9.0
8.2
13.4
4.6
6.0
10.5
10.0
8.6
16.7
4.7
Comparison Kids on CANS
Percentage of Actionable Items
CW
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Trauma
Trauma Symptoms
Beh/Emot Needs
Life Domain
Risk Behavior
Transition to Ad
Child Strengths
Caregiver Stren
83%
66%
91%
92%
86%
65%
90%
62%
DYC MH Private
78%
49%
86%
87%
81%
72%
81%
50%
78%
67%
92%
90%
87%
56%
90%
48%
59%
37%
75%
76%
72%
59%
75%
34%
Congregate Care in Colorado
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Concerns have been raised about the poor
outcomes for children in residential
treatment. These kids have poor outcomes
for the same reason that so many of them
stay in care for so long.
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THEY HAVE A VERY HIGH LEVEL OF NEED DUE
TO SEVERE EMOTIONAL/BEHAVIORAL
PROBLEMS
THEY HAVE EXPERIENCED VERY HIGH LEVELS
OF TRAUMA
Most Frequent Diagnoses
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The Outcome Study found the
following were most frequent
diagnoses given to youth in residential
treatment
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Mood Disorders
Conduct Disorders
PTSD
33.3%
22.8%
18.9%
Treatment of Severe Mental Illness
is Extremely Difficult
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Does this mean we are wasting resources
treating patients that suffer from major
psychiatric problems?
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Would we restrict physical health hospitalization
because not all clients are cured?
Would we eliminate involuntary commitment
procedures?
How about the treatment of substance abuse? It
has even higher recidivism rates………
Recommendation 5
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The Colorado System of Care serving youth
and families needs to be more effectively
organized into an integrated continuum of
services
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We need to breakdown the silos
Every piece of the system needs to be strong:
Children accessing services anywhere in the
system need to be more effectively served.
Transitions should be better managed:
Traumatized youth have greater difficulty with
transitions. Children transitioning between out-ofhome care and community based services need
effective transition plans to address recidivism
Recommendation 6
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The State/Counties need a universal, reliable and
standardized way to accurately assess treatment needs,
measure outcomes and do program evaluation of the
agencies serving them
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Too many fields in TRAILs are optional resulting in an
inability to clearly define the treatment population we are
dealing with.
Treatment needs should be determined with a reliable
assessment procedure that can be utilized across systems of
care
Client needs should be matched with the proper treatment
modalities
Whichever assessment tool is utilized it should have utility for
both the determiner of services and the agency providing
services, and should be able to be used to assess treatment
effectiveness (for the client and for the agency providing the
service)
Lesson Learned from the Study
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Residential Treatment is an effective treatment methodology
for the mental health problems of child welfare and juvenile
justice youth
While CAFCA supports the state’s current Permanency
Initiatives, we believe that these permanence connections
absolutely have to be supported with appropriate services to
ensure their success
We think that the new Waiver money and the reinvestment of
current saving should be targeted towards areas of greatest
need
The new AECF recommendation for differential
reimbursement to the counties for utilization of residential care
is likely to further inhibit the ability of youth to access
appropriate and necessary mental health services within the
child welfare system and should be opposed
For more information
The complete report can be reviewed at
www.tennysoncenter.org?documents.doc?id=138
Or contact Dr. Skip Barber at
 skipbarber@earthlink.net
 720-570-8402