Illinois Residential Transition and Discharge Protocol: Shifting Toward a Longitudinal
Perspective in Residential Care
Abstract
The Residential Transition and Discharge Protocol is a system approach for maximizing
treatment gains and increasing the stability of the youth following discharge from Illinois
residential programs. The paper focuses on the key components of the protocol designed
to support residential providers and address system challenges and Illinois’ statewide
implementation strategy.
Deann Muehlbauer, MPH, University of Illinois at Chicago
Catherine Francis, MPP, University of Illinois at Chicago
Alan Morris, PsyD, University of Illinois at Chicago
Deann Muehlbauer, MPH may be written at the University of Illinois at Chicago, Institute for
Juvenile Research, 1747 W. Roosevelt Road, M/C 747, Chicago, IL 60608
As is increasingly the case across the county, Illinois child welfare policy makers have raised
questions regarding the efficacy of residential treatment with a focus on the commonly observed
phenomenon that youth who appear to make significant progress over the course of treatment are
often unable to sustain that progress in subsequent less restrictive and open settings. In an effort
to reverse this trend, the Illinois Department of Children and Family Services (IDCFS), the
statewide child welfare authority, and the University of Illinois at Chicago (UIC) developed a
protocol aimed at enhancing transitions from residential treatment to community based settings
as well as integrating residential treatment programs into a broader continuum of care.
Initially, this effort was relatively modest. It was limited to development of a protocol that would
require one face-to-face meeting between the sending residential provider and the step down
placement provider, an event that, at the time, rarely occurred largely due to systems constraints
within child welfare. The intent of this required meeting was to facilitate consultation between
caregivers, thus providing the receiving provider with a better understanding of the youth so they
would be better prepared to effectively provide treatment and targeted interventions. This initial
requirement of a single face-to-face meeting has evolved over a four year period into a far more
comprehensive protocol that is currently IDCFS policy, contractually mandated for all providers
in FY09.
Background
Over the past thirteen years, and in response to a federal class action lawsuit against the IDCFS,
Illinois has seen a sharp decline in the number of IDCFS youth in residential treatment, from
4142 in 1995 to a current census of 1323. This dramatic decrease was largely due to the
development of a centralized level of care review and intake process. Additionally, Illinois no
longer utilizes out of state placements for its most challenging youth. As a result of these two
initiatives, the population of residential youth in Illinois can be characterized as smaller, but with
a much higher concentration of extraordinarily challenging youth.
As in many states, Illinois has historically viewed residential as a placement of last resort where
youth typically “failed up” before being assessed as appropriate for residential treatment. Given
the mandates for placing youth in the least restrictive settings, along with the significant costs
associated with residential treatment, and the referring agencies focus on clinical deficits, it is not
surprising that residential programs have emphasized short-term outcomes typically limited to
stabilization during a residential stay. Residential providers have rarely focused on treatment
planning that incorporates a longitudinal perspective or involves greater integration into a larger
system of care.
Consistent with this perspective has been the tendency of treatment programs to avoid risk taking
in an attempt to maintain youths’ treatment stability, often paying insufficient attention to the
development of those skills necessary for youth to successfully negotiate challenges encountered
in the communities where they will reside post discharge. Finally, in part due to a child welfare
system that was characterized by abrupt placement changes and a lack of collaborative planning,
thoughtful transition planning for youth experiencing discharge and transition from residential
treatment was the exception in Illinois.
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The highly context dependent youth in residential treatment today, impacted by the effects of
trauma on neurodevelopment, are especially vulnerable to abrupt transitions across settings
where there is a significant gap between the level of structures and supports available to them. It
is not surprising that most of these youth do not sustain progress post discharge. A IDCFS
review of 3,448 residential discharges in Illinois for three fiscal years (FY ’04 – FY ’06)
revealed that only 25%, or 854 youth, remained in the same less restrictive setting six months
post discharge.
Residential Performance Based Contracting
Partly as a result of these outcomes, IDCFS initiated a performance based contracting initiative
for their residential system. Through a federal HHS Children’s Bureau Performance Contracting
(PBC) grant and using existing collaborative private/public committees, IDCFS selected two
indicators for performance. One of the selections was designed to directly target the problem of
maintaining gains post-discharge - the sustained favorable discharge rate (SFDR).
In order to evaluate a residential provider’s success regarding SFDR, all discharges are
categorized as unfavorable or favorable. Essentially, unfavorable discharges are youth
discharged to the same level or a more restrictive level placement, to detention or due to
runaway. Favorable discharges are defined as a step down to a lower, less restrictive level of
care. Illinois uses a classification system (Reference: AACRC CD, Partnering for Progress ’05)
to determine levels within residential care. To be considered a sustained positive discharge, a
youth favorably discharged must not disrupt from the step-down placement for 180 days or six
months post discharge. For each agency, a rate is calculated, thus including LOS into the metric
in order to incentive treatment efficiency as well as outcome. SFDR benchmarks for each agency
account for case mix differences through a process called risk adjustment. (Reference: AACRC
CD, Measuring to Scale ‘08). For those residential providers who exceed benchmarks (i.e., a preidentified SFDR), large financial bonuses are provided.
The Residential Transition and Discharge Protocol and the Performance Based Contracting
SFDR incentives are powerful complimentary initiatives, providing the needed synergy to inspire
the paradigm shift to a longitudinal focus. By providing the expectations, systems supports and
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needed accountability mechanisms to support the efforts of residential providers, the protocol is a
roadmap for achieving SFDR and subsequently obtaining large financial bonuses. Early on, some
Illinois providers have recognized the opportunities available to those who embrace the protocol
and have invested in staff and other resources to help ensure success. In this environment of tight
state budgets, these "early adopters" have recognized that post-discharge placement stability is an
important step towards helping ensure their program’s long run viability.
Residential Transition and Discharge Protocol Implementation
IDCFS has a long history of partnering with private residential providers to help plan and stage
changes to the system. While many residential facilities closed during the period of declining
numbers, those who survived collectively forged a strong collaboration with IDCFS on policy
issues. It is through this system wide collaboration (including IDCFS, private providers and
university partners) that the Transition and Discharge Protocol has evolved into its current form.
In 2007 IDCFS and UIC conducted a year long Residential Transition and Discharge Protocol
Pilot Study, which informed ongoing development of the protocol. The pilot included
approximately 100 children and youth placed at eight geographically and programmatically
diverse residential programs. Following the pilot, “lessons learned” for achieving positive and
sustained transitions were articulated in an unpublished document completed by UIC. The
protocol was revised to address four key transition challenges reflected in the lessons learned.
1. Facilitating Adequate Coordination and Communication
Successful transitions are dependent upon facilitating broad stakeholder participation in the
treatment and transition process in order to ensure the involvement of all key individuals
involved in the youth’s life. These stakeholders typically include child welfare case workers,
supervisors, and monitors; family members and other community based supportive
individuals; court appointed representatives; staff from agencies identified as “step down”
resources as well as the residential program treatment team. This effort is often complicated
with challenges associated with communication and coordination of efforts across this often
highly diverse group. From the simple task of finding a mutually acceptable time that
everyone can meet to the complex dynamics of managing relationships within child welfare,
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coordination and communication problems abound. Thus, it is essential that strong teams are
developed. Frequent communication is critical, especially as discharge becomes more
imminent, and skills associated with group facilitation and leadership are required to
maintain the focus and arrive at consensus.
2. Encouraging Involvement of Family Members and Other Caring Adults
The histories of youth in the child welfare system are characterized by disruption of
placements and relationships; consequently, these youth struggle to find somewhere to
belong. To mitigate the impact of these disruptions, youth urgently require the benefit of a
support network that follows them across placements. Yet, by the time a youth enters
residential care, it is often considered impossible to find family and other supportive adults
interested in remaining involved in the youngster’s life. And even when someone is
identified, frequently, many cultural and logistical barriers can hamper engagement in the
treatment and transition process. There is evidence that with concerted efforts these support
networks can be established and nourished. Finding ways to engage family members and
other caring adults through family friendly and culturally competent programming is critical
to transition success.
3. Providing Transition-oriented Programming
Residential providers are frequently risk averse with respect to providing opportunities for
youth to learn and develop skills that will be required of them in their post discharge settings.
Concerns regarding liability, potentially destabilizing influences, and accessing resources
necessary to implement individual plans in this regard partly account for this reluctance.
However, it has been repeatedly observed that these inhibitions, in fact, merely shift the risk
to the subsequent community provider or caregiver, and limit the opportunities for youth to
practice independence and essential skills in a setting that offers maximum support. While
the protocol does provide mechanisms for residential programs to share the risk across
stakeholders as well as providing some additional funding to assist in these efforts, the
provision of effective and sufficient transition-oriented programming continues to be a
challenge.
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4. Ensuring Clinically Appropriate and Timely Transitions
The child welfare system in Illinois often mitigates against appropriately planed and
calibrated transitions by pressuring residential providers to discharge youth abruptly due to a
lack of coordination between caseworkers and treatment staff, and the need to quickly fill
openings in community based settings. Conversely, sometimes youth who are ready for
discharge wait for long periods for placement availability due to lack of appropriate
resources. The protocol provides mechanisms to address these systems issues, however,
challenges will continue until the overall IDCFS system is right-sized.
Transition and Discharge Protocol Structure
The Transition and Discharge protocol may be conceptualized as providing a structure for
implementation of best practices that characterize successful transitions. At its core, it has
become clear that it requires most residential providers to make a significant paradigm shift in
thinking about the youth in their care. The protocol requires residential providers to broaden their
evaluation of their effectiveness to include the youth’s post discharge stability. Consistent with
that notion, the protocol encourages an ecological approach and incorporates system of care
values and principles. While the protocol is not prescriptive in terms of specific modalities or
evidence-based practices, it does incorporate many of the best practice themes that support the
lessons learned noted above. These include: incorporating a strength based approach that
promotes the youth’s resiliency; team decision making characterized by efficient and inclusive
planning; clear identification and articulation of responsibilities across the broad treatment team;
development and implementation of transition-oriented services specifically informed by the
characteristics of the post discharge setting; youth engagement to promote ownership in the
treatment and transition planning process; and development and engagement with family and
community supports across levels of care.
The Transition and Discharge Protocol is broken down into three phases as illustrated in Figure
1. The first phase begins at admission to the residential program and incorporates assessment,
active treatment and preliminary discharge-planning. The second phase begins three to four
months prior to discharge and is an active transition-planning phase. The third phase begins at
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discharge and consists of post-discharge follow-up activities. Underlying all the phases is a
collaborative and inclusive staffing process that focuses on building a strong treatment team.
Figure 1
Introduction: Protocol Framework
Collaborative Staffing Process
& Ongoing Communication
Transition
Phase I
Transition
Phase II
Post-Discharge
Phase III
Begins
at
Admission
Begins
3 - 4 Months
Prior to
Discharge
Begins
at
Discharge
Transition Phase I
Phase I begins at admission and is typically the longest phase for Illinois providers, usually
lasting 12-18 months. The core work of Phase I includes stabilization and addressing risk
behaviors while simultaneously creating and supporting connections to family and other
significant adults that may have a role in the youth’s life across placements, developing youth
skills, talents and interests, and engaging the youth and other stakeholders in the treatment and
transition process. Preliminary transition planning also includes decentralized decision-making
by the treatment team regarding where (in terms of level of care and geographical location) and
when the youth is likely to transition following completion of the residential treatment program.
Building strong teams is a key to the success of Phase I. The first step is to establish a team that
includes broad stakeholder participation with the identification of family and other significant
adults as participants. Engagement of the team requires residential providers to have family
friendly programming that welcomes family and other adults into the planning process. This
often means tapping into the existing Child and Family Team to determine the needs of the
family and identifying essential informal supports that the family can contribute. Effective
staffing facilitation is another key to building strong teams. Given differing life perspectives,
values, and cultural factors, it is not uncommon for reasonable people to disagree about the
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youth’s treatment or transition decisions. Therefore, it is essential that residential providers have
skilled facilitators that can create a safe forum essential for building true consensus within teams.
Identifying and productively managing conflict appears to be an enduring challenge faced by
treatment teams.
The protocol includes several areas that address team accountability. First, the quarterly clinical
staffing policy incorporated into the protocol requires residential providers to schedule quarterly
staffings six months in advance on an Outlook calendar located on the IDCFS intranet in order to
facilitate total team participation. Second, a clinical staffing report is completed at each quarterly
staffing. This report documents whether the team is meeting the protocol requirements for Phase
I or II. Third, an “action plan” must be completed at the quarterly staffing to document the
assignment of tasks to responsible individuals and due dates. This plan is reviewed at each
subsequent staffing. Each of these components provides feedback necessary to assess fidelity to
the protocol and inform on-going modifications to the protocol as well as assist IDCFS in
managing the residential system.
It is commonly expressed that discharge planning begins at admission. The Transition and
Discharge Protocol specifically delineates components of that process. At each quarterly staffing
the team reviews the expectations regarding the timing of discharge as well as specific planning
efforts regarding the transition process itself. Teams must establish a clinical readiness date to
indicate the timeframe in which the youth should be clinically ready for discharge given their
recent progress. Initially, this date is an educated guess based upon the team’s knowledge of the
treatment program and the assessment of the youth, but over time this date should become
increasingly firm. The team must also identify a level of care (and possibility an alternative as
well) to which the youth will be transitioned once treatment is complete. This allows the
treatment to be tailored to include the skill building that will be necessary in the next level of
care. Preliminary transition planning also includes identifying and engaging family or other
significant adults to whom the youth may ultimately return or with a capacity to participate in a
support network for the youth and family. Finally, the team must develop a developmentally
appropriate plan for engaging the youth in their own in the treatment and transition process to
create ownership and investment. It is important to note that the purpose of preliminary transition
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planning required by the protocol during Phase I is to build a solid foundation for the actual
transition process completed in Phase II and establish consensus among the treatment team by
the time Phase II is initiated.
Transition Phase II
Phase II begins three to four months prior to the anticipated date of discharge and continues until
the youth is discharged. This phase is more intensive with respect to transition related efforts,
and requires more frequent staffings and an expansion of the treatment team. A key element to
successful transition in Phase II is the development of appropriate individual transition services.
These are services that allow the youth to experience elements of the next setting while still
within the supportive safety net of the residential placement. Individual transition services should
involve a gradual decrease in structure so that the team can assess the youth’s response.
Individual transition services must take into consideration “the context effect” or the degree to
which a youth’s overall level of functioning is impacted by the nature of the environments in
which they live work or go to school. Highly context dependent youth will often have a difficult
time with individual transition services and may require a longer more gradual transition period
in Phase II.
Often residential providers have difficulty with individual transition services. Even carefully
calibrated interventions designed to “test the waters” by relaxing the structure and increasing
opportunities for independent functioning may cause youth to experience set backs and failure.
While recognizing that progress of youth in residential care is seldom linear, many residential
providers are hesitant to take such risks. The problem with avoiding risk during Phase II is that in
doing so, the provider is, in essence, transferring the risk to the next placement that is less well
equipped clinically to deal with the set back. To allow youth to meaningfully generalize
treatment gains, it is extremely important for the treatment team to implement individual
transition services that gradually allow the youth to experience elements of the next setting
within the supportive web of the residential placement.
Phase II also challenging because of the introduction of the receiving placement and/or
community provider(s). Once a step down placement is identified, the strong team that has
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developed over the course of Phase I must expand to include the staff from the targeted receiving
placement and other community resources. Often these individuals bring unique expectations and
assumptions with respect to assessment and planning for the youth, and they may be unfamiliar
with residential treatment. It is critical that the residential treatment team takes a clinical lead in
treatment planning during Phase II with the objective of transferring its substantial knowledge
about what works with the youth and anticipated challenges while also appreciating and seeking
to understand the strengths and limitations the youth is likely to encounter in the next setting.
The protocol allows for specific reimbursement to be made available for receiving placements to
assist them in participating in transition team meetings, hosting visits for youth and “sending”
residential staff, and other Phase II activities. The transition support reimbursement includes
$600 for case management services and $300 for direct services for a 30-day period.
Reimbursement is available for an additional 30-day period but all payments are contingent upon
the youth’s admission to the program and assignment of a case manager upon case acceptance.
Transition Phase III
Transition phase III is the post-discharge stabilization period, which lasts up to 90 days postdischarge. The transition protocol requires the sending residential placement to provide at least
30-days of post-discharge stabilization services to the youth and/or the receiving placement. The
transition team determines the nature and intensity of these services, which are documented on a
transition plan agreed upon by the team.
There are two levels of post-discharge stabilization services. Moderate stabilization services
include telephone contact and active participation on the transition team by representatives of the
sending residential provider. Intensive stabilization services are direct in-person services
provided at least weekly along with telephone contact and participation on the transition team.
Reimbursement to the sending residential provider is $750 for a moderate level of services and
$1500 for intensive level for each 30-day period of involvement.
Phase III also incorporates an element of team accountability to ensure that all parties are
following through with the transition plan. Within 30 days post-discharge from the residential
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placement, the transition team participates in a stabilization staffing convened by an objective
and clinical staffing team, regionally located. The primary focus of the staffing is to evaluate the
youth’s placement stability. The staffing facilitator confirms full implementation of the transition
plan, works with the team to assess the youth’s progress and approves continued post-discharge
services for up to an additional 60 days. The staffing generates an action plan that assigns tasks
to transition team members going forward. If members are not providing services agreed to in the
transition plan or if there are other serious concerns regarding service access, the staffing
facilitator is required to initiate “supportive intervention.” Supportive intervention is a process
that alerts the appropriate chain of command within IDCFS, the residential agency, and/or the
sending program’s agency of issues identified during the stabilization staffing and necessary
follow-up tasks to be immediately completed.
Statewide Protocol Implementation
Statewide implementation of the Residential Transition and Discharge Protocol began July 1,
2008. The original pilot indicated that the learning curve for the entire system would be steep
and indeed, this has been Illinois’ experience thus far. Additionally, logistical issues have created
unforeseen problems. For instance, protocol training information did not consistently reach
individuals within the key targeted groups or staff at the direct service level, despite an ambitious
training initiative. Creating additional confusion were numerous modifications made to the
protocol immediately prior to implementation as a result of the system-wide training conducted
in March though June 2008. Furthermore, IDCFS rolled out several centralized administrative
processes during the early months of implementation and many providers are still requiring
ongoing clarification about the details of these processes. As a result of all these issues, many
providers are currently preoccupied with developing internal technical processes that comply
with the centralized expectations. In doing so, they are unable to implement the spirit of the
protocol from a practice perspective.
IDCFS has been patient with providers slow to comply but it is gradually increasing its
expectations for compliance in key areas. IDCFS has also recognized that only limited
systematic data feedback systems in place, and it would be a mistake to respond to anecdotal
observations. Instead, its focus has been on implementing these feedback systems on multiple
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levels. Once the feedback systems are effectively functioning, it will be in a position to identify
problems and respond systematically.
Despite the start-up issues, virtually all stakeholders find the protocol consistent with best
practices and support the philosophy of thinking longitudinally with respect to these youth. There
is also an increasing recognition that a longitudinal perspective will ultimately support the long
term viability of residential treatment. It is encouraging that new discussions regarding
accountability and system barriers are openly occurring more frequently. Although these
discussions can be difficult, they reflect a system that is truly grappling with change and indicate
that the protocol is doing its job on a conceptual level.
Additionally, several “early adopters” have begun to utilize the protocol creatively and success
stories regarding individual youth are beginning to emerge. These “early adopters” seem to have
in common an organizational capacity to assess their operations and strategically align their
programming with the principles of the protocol along a variety of dimensions. In the immediate
future, UIC will more fully focus its attention on understanding the emerging and promising
practices of the early adopters so that they can be replicated system-wide and perhaps eventually
developed into evidence-based interventions. To support this goal, UIC is planning a conference
in April 2009 to inspire and challenge the system to move beyond stabilization. In this context,
providers will have opportunities to share their experiences and program innovations associated
with the sustained positive discharge of youth to community-based settings.
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