July 27, 2007
HOSPITALIZING CHILDREN WITH MENTAL RETARDATION AND BEHAVIORAL HEALTH PROBLEMS
By: Saul Spigel, Chief Analyst
You asked about the state's policy concerning hospitalization of children who have both mental retardation and behavioral health problems. You specifically wanted to know whether any policy uses a child's IQ score as a factor in hospital admission.
We found no state policy or guideline that calls for using a child's IQ score as a factor in a psychiatric admission to a hospital. The criteria the state uses to decide if it will pay for a child's hospitalization states only that mental retardation or developmental disability cannot be the sole cause of the functional impairment leading to hospitalization. But hospitals set their own admission criteria to psychiatric units, and state officials note that children with developmental disabilities stay in emergency departments awaiting inpatient admission three times longer, on average, than those without developmental disabilities.
According to one private psychiatric hospital staff member, a hospital unit that admits children with mental retardation needs more, specially trained staff and must use more intensive behavior management techniques than one that does not admit such children.
STATE PSYCHIATRIC HOSPITAL ADMISSION POLICIES
The Connecticut Behavioral Health Partnership (BHP) is responsible for adopting and implementing policies concerning hospitalization and other treatment for children with behavioral health problems who are insured through state programs. The BHP is a collaboration between the Social Services (DSS) and Children and Families (DCF) departments to provide behavioral health planning and services for children covered under HUSKY A and B and DCF's voluntary services program. It develops the standards and guidelines that Value Options, the organization with which the BHP contracts for administrative services, applies when a health care provider seeks to find treatment or placement for a covered child.
BHP hospital admission authorization guidelines do not differentiate between clients based on IQ or other developmental factors. The guidelines are based on the client's overall psychiatric presentation and level of acuity. They require a child to present with:
1. a diagnosable psychiatric disorder;
2. symptoms and impairment that result from the disorder;
3. functional impairment that is not solely the result of mental retardation or pervasive developmental disabilities (PDD);
4. at least one of the following symptoms, (a) imminent risk of suicide or self-injury, (b) imminent risk of homicide or other danger to others, (c) acute and serious deterioration from baseline mental status or functional level, (d) acute medical risk, or (e) the need for a hospital setting to adjust medication after meeting any of the above symptoms within the past 12 months; and
5. the need for 24-hour medical management of his or her symptoms.
ADMISSION DELAYS AND CONTRIBUTING FACTORS
“Boarding,” that is staying in a hospital emergency department (ED) after stabilizing because an inpatient hospital bed is not available, is a significant nationwide problem for people, particularly children, with mental illness. In Connecticut, the problem appears to be even more acute for children with both mental illness and developmental disabilities.
BHP staff report that children with developmental disabilities whose discharge from the ED is delayed stay in the ED, on average, three times longer than those without such disabilities. This information is based on an analysis of 164 BHP children in “delayed status” who were seen in EDs for psychiatric reasons between April and June, 2007. (Delayed status refers to children who are awaiting placement after ED staff have evaluated their psychiatric and medical condition and determined they need hospitalization.) Of these children, 136 (83%) had IQs above 70 (the threshold for defining mental retardation). Their average ED stay was 1.3 days. The average length of stay in the ED for the remaining 28 children diagnosed with mental retardation or PDD (17%) was 3.5 days—almost three times the length of stay for the non-MR cohort.
BHP staff note that neither they nor ED staff control admission to hospital inpatient units. Once ED staff determine a child meets the admission criteria for inpatient care (see above guidelines), they start calling all inpatient units in the state to find a bed. But no state law or policy requires a hospital to (1) admit a patient even if a bed is available or (2) accept a patient who has been “boarding” in the ED over another patient who has only just arrived there.
Many factors contribute to a hospital's decision to admit a particular child or adolescent. These include:
1. whether or not the patient requires a single room (for safety purposes),
2. the patient's gender (hospitals often have separate male and female units),
3. the distance between the hospital and the patient's home (for coordinating contact with family members and facilitating local discharge planning),
4. foreseeable disposition issues (for example, no home to return to),
5. current patient mix on the inpatient unit (to maximize unit stability and staff resources), and
6. the cost of serving challenging clients (e.g., one-to-one staffing).
The latter is probably a significant factor when it comes to admitting a child with mental retardation. A Natchaug Hospital admission staff member said that a hospital unit that admitted children with moderate or severe mental retardation would need more staff than a unit that did not accept this population. It would need to use more structured behavior management interventions, such as token economies (awarding tokens for appropriate behavior, which can be accumulated and used for tangible rewards), and its staff would need to be trained in using these interventions. They would also need training in dealing with behaviors that some children with more severe mental retardation exhibit, which differ somewhat from other children with mental illness. Finally, he noted that people with mental retardation respond differently to medication than other people and often take more types of medications. This, too, would require special staff training. For these reasons, he said, Natchaug generally does not accept patients, children or adults, with IQs under 60.
BHP staff report that no hospital has specifically informed them that it denied a client admission to an inpatient unit due to mental retardation or other developmental disability. BHP has approved sending some patients with developmental disabilities to an out-of-state hospital to receive specialized inpatient care. These include Hampstead Hospital in New Hampshire, KidsPeace in Pennsylvania, and the University of Massachusetts Developmental Disabilities Unit.