The Hard Work of Decreasing Residential Lengths of Stay

Parents and other agency referral sources often ask me how long their child will need residential services.  My standard answer is, “it depends.” The problem with my answer is that many people disagree on what the factors are that make up my answer “it depends.”  I have completed many literature reviews on factors related to lengths of stay in residential treatment.  This research can be confusing and often contradicts previous reviews.  Many factors have been examined including ethnicity, age, parental involvement, parental substance abuse, access to aftercare (hours/transportation), social economic status, and child diagnosis to name a few.  Truthfully, the research is contradictory at best.  For example, I have read research citing age and ethnicity as primary factors in determining length of stay, only to read another article that discounts age and ethnicity.  The same can be said for most of the other factors mentioned above. The bottom line is achieving truly time-limited residential treatment depends primarily on one thing: hard work.

The first focus must always be on family engagement. Parental involvement, from intake to discharge, is critical to returning a youth to his or her home community.  Parents must be engaged in family therapy sessions and function as true leaders of the transdisciplinary team meetings on a regular basis. We as service providers have to help make this happen, but as an industry we often don’t.  We need to offer family therapy and transdisciplinary meetings at times convenient to the family.  We need to look realistically at the overwhelming problem of transportation to and from these important meetings.  We need to streamline access to care and help parents wade through the minefield of securing funding for services.  But most importantly, our teams need to see parents  as true partners, not a “problem to be solved.”We will not partner with them as “patients,” only as people, people seeking ways to creatively solve problems.

Community resources, supports, and opportunities for Grafton youth post-discharge are also positive,crucial parts of the hard work we must undertake.  When the home community is able to offer professional and naturalistic supports,a young person is more likely to return to his or her community more quickly.  Examples of these supports include church activities, afterschool activities, in-home supports, and outpatient therapy.  My answer to the agency’s question of “how long” should actually be “how hard are you willing to work” as the agency representative (CSA/DSS/Probation).It’s all about the aftercare plan.  As a provider, we must work with the agency representative and family to minimize barriers to community supports (professional and naturalistic).

Finally, organizational factors are incredibly important.  Is every member of the team committed to evidenced-based treatment and measuring progress and trouble-shooting impediments in coordination with the team?  The quicker we help clients achieve functional autonomy,the quicker we can help them return to their home community.  At Grafton, our clinical teams are committed to providing evidenced- based treatment, and we employ our goal mastery method to ensure our clients are progressing in treatment.But, as with every organization in every industry, sometimes we achieve our goal, and sometimes we fall short. The transdisciplinary team, in which the referral source and parent are essential members, is our best barometer of how our teams are doing.

What generally happens with teams, especially in this era of tightened funding, is conflict. One part of the group chucks the other part of the group under the bus for perceived failures. The only solution we can muster is this: true TRANSdisciplinary treatment. Here’s a graphic representation of the three usual models of care:

private vs MDT vs TDT

In essence, the boundaries must blur. We must all accept total accountability FOR THE CONSUMER, not for our own processes. We don’t have the luxury of owning just one slice of what’s happening. In essence we are all in it together, for them. And we’re working hard…

Please comment if I’ve missed something! I want to invite the dialogue, because if we can get this right, we can give a lot of people their lives back.
Some reading on length of stay in residential care: