On an early June day, five foster children were being housed by SSM Health at hospitals in the St. Louis area not because they were sick, but because there was no other place for them to live. They had each been in the hospital an average of 56 days.
There were 23 adult clients of the Department of Mental Health — people with a developmental disability or behavioral issue — being boarded by SSM. Each had been hospitalized an average of 193 days.
And there were 10 adults over age 65 or considered fragile, also mental health clients, boarded in SSM hospitals for no medical reason, who had been there an average of 403 days each.
SSM is not the only hospital system housing children and adults who have no other place to go after receiving treatment. All of Missouri’s hospital systems have served this function at one point or another in the last year, and the number of children in limbo has been growing.
Of the 13,183 foster children in the custody of the Missouri Children’s Division at the end of April, 52 were housed in medical facilities and 258 were housed in mental health facilities. At the end of April 2022, there were 72 foster children in medical facilities and 92 in mental health facilities.
The Department of Mental Health also has difficulty finding residential support providers. It has 704 clients who are developmentally disabled waiting for a residential placement, with the more than three dozen housed in hospitals considered among the most critical for placement.
“Unfortunately, right now, hospitals are a place where both residential facilities and in some cases, therapeutic foster families — or you know, or families in general — will bring their children because they don’t feel adept at caring for the child,” said Michelle Schafer, regional vice president for behavioral health at SSM. “There are usually significant behavioral components to the situation.”
‘It’s happening everywhere’
Foster children living in hospitals or other temporary locations for long periods isn’t just a Missouri problem. Many states are finding it difficult to recruit foster parents, especially in rural areas, KFF Health News reported this week.
But inappropriate placements are just one of the multiple issues for the struggling Children’s Division in the Department of Social Services. The first step to rollback years of cuts, remedy low pay leading to high turnover and reduce massive caseloads came this year when lawmakers funded a $13.7 million plan to rebuild the division.
For the Department of Mental Health, one of the biggest issues is community providers are struggling with staffing issues.
Many are working to regain staff lost during the COVID-19 pandemic or lured away by rising wages in less demanding jobs.
“We lost about 50% of our residential beds, because we had a workforce shortage, which then sort of turned this cycle into a situation where we had a lot of kids, and we had no place for them to go,” Schafer said.
During the legislative session that ended in May, lawmakers added a modest amount to the budget for community service providers supporting people with developmental disabilities. The extra money will allow those providers to boost pay by about $1 an hour, to just over $16 an hour.
They also passed legislation, sponsored by Sen. Elaine Gannon, directing the Mental Health and Social Services departments to study and report on the impact of hospitalizing foster children and Department of Mental Health clients “without medical justification because appropriate post discharge placement options are unavailable,” and how to end it.
The bill also includes a number of other provisions, such as changes to professional licensing and changes to where the mental health department must treat people facing criminal charges who are not competent to stand trial.
Gannon doesn’t remember who first convinced her to file a bill addressing foster children being housed in hospitals, she said.
But she remembers thinking it couldn’t be true.
“This doesn’t happen,” Gannon recalled thinking. “They don’t leave somebody in a hospital for six months, a year or even a month because they don’t have anywhere to send them. I can’t really believe that. Well, let me tell you, it’s the truth, and it is happening, and it’s happening everywhere.”
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‘All the top people’
If signed by Gov. Mike Parson, the legislation that passed this year would formalize work already being done in consultation with providers, clients, schools and the courts, thanks to a conversation Gannon had with Schafer after a hearing in 2022.
Schafer had followed Gannon back to her office.
“She comes in and sits down, and all of a sudden, I’m hearing all these issues in the mental health area, and the foster care system, and all the problems they’re having, this patient boarding, everything,” Gannon said. “And I’m just kind of sitting there overwhelmed.”
The problem, she recalls thinking, was too important to wait for the legislation.
“The biggest complaint was that there was a lack of communication,” Gannon said. “Nobody wanted anybody else telling them what to do. Or how to do their job. And nothing was getting done.”
That is when she decided to bring department and division directors together with hospital representatives, as well as advocates for children and people with developmental disabilities or behavior disorders. And although she has been a legislator since 2013, Gannon wasn’t sure exactly who to invite.
But she knew that Schafer did.
“I said ‘I want all the top people in this,” Gannon said. “‘I don’t want the person that’s three under the top person or even one under the top person. I want the top people. You know who they are. I do not know who they are.’ I said ‘You get a list.’”
And she made Schafer the chair.
The first meeting, in April 2022, brought together Robert Knodell, director of Social Services, Val Huhn, director of the Department of Mental Health, Darrell Missey, director of the Children’s Division, Brian Kinkade, vice president of children’s health and Medicaid advocacy at the Missouri Hospital Association, and about a dozen others.
(T)hat’s not a good setting either for the child or the young adult who’s in that situation. They need social supports, they need connections to communities, that a hospital just can’t provide.
– Brian Kinkade, Missouri Hospital Association
Given the name Children’s Behavioral Health Committee, also referred to as the Children’s Mental Health Collaborative, it now meets monthly and has at times 30 or more participants. Schafer said the emphasis has been on collaboration and keeping the focus on who is being served rather than finding blame.
“What we’ve decided to do instead is come together in what is truly a crisis and say, ‘You know, we’re all going to recognize that it is a failed system, that deinstitutionalization is failing right now. And we’re all going to lean in and be committed to doing our part to make it better,’” Schafer said.
What a hospital can’t provide
Kinkade, director of social services under Gov. Jay Nixon, said finding placements for foster children after treatment, especially for high-needs children, has always been difficult.
At the end of April 2017, about the time Kinkade left the department, there were 33 foster children in medical facilities and 53 in mental health facilities. The numbers were virtually the same in April 2019. The numbers started creeping up a year later, when the COVID-19 pandemic hit.
“The pandemic really kicked it into high gear in terms of being a major issue,” Kinkade said.
Hospitals are not designed or staffed to provide housing for foster children and adults with developmental disabilities or behavior issues that do not need treatment for acute conditions, Kinkade said.
“Equally important, and what we need to remain mindful of, is that that’s not a good setting either for the child or the young adult who’s in that situation,” Kinkade said. “They need social supports, they need connections to communities, that a hospital just can’t provide.”
The majority of children in foster care are removed from their homes because of neglect tied to behavioral health issues, explained Mary Chant, chief executive of Missouri Coalition for Children during a hearing this year on House legislation identical to Gannon’s bill.
She said in the hearing that the state has lost about half its residential placements for high needs foster children during the past three years.
“The reality of the situation is if we look at our entire continuum of care for children and youth, we’ve got issues and capacity at every point in time,” Chant said in an interview with The Independent.
Children in foster care and adults with behavioral and developmental issues living in hospitals is just a symptom of a bigger issue, Kinkade said, and the solutions have to be bigger as well.
“The way this problem presents itself, in the most stark and dramatic fashion, is in these boarding situations,” he said. “But in many ways, those boarding situations are reflecting kind of a general lack of capacity in the systems of care that treat these folks with developmental disabilities and with emotional or behavioral health problems.”
Missouri puts children into foster care at nearly twice the national average rate, according to the National Coalition for Child Protection Reform. And part of the process of rebuilding the division is focusing on preventing removal in the first place.
“If you put services on the front end to prevent those things from getting to a place where a child had to be removed, that’s a much better expenditure of money,” Children’s Division Director Darryl Missey said during a January budget hearing.
Each child in foster care costs the state around $25,000 per year. Traditional foster families receive a maintenance stipend of $450 to $630 a month, and the state pays up to $1800 a month for families fostering children with “elevated needs.”
Gannon’s legislation directs the committee to make three reports with the first due Dec. 1. The committee would continue working through 2024, with a second interim report in the summer and a final report due at the end of that year.
Whatever solution it offers is almost certain to cost money. And not a small amount.
Increasing the wages of direct care workers in residential programs serving people with developmental disabilities by $1 an hour cost $171 million. That is only a fraction of the $910 million in new funding called for by a market study on workforce needs.
Support for rebuilding the program and recognition that provider rates need to be increased are signs that lawmakers are taking the issues seriously, said Erica Signars, a special assistant professional in the Department of Social Services.
“We’re in a good place because we’ve got folks’ attention,” Signers said. “We’ve got good support by the legislature and others to kind of help us identify some solutions to solve the issues that we’re seeing today.”
The committee is considering statutory and administrative changes to make interagency communication and cooperation — identified as a major factor in some cases — easier. The point, Chant said, is to break down jurisdictional barriers where people disclaim authority, leaving people in limbo.
“Those things may be true, but none of those things help us figure anything out,” Chant said. “Our first question has to be: What is it that the child’s family needs? And what do we need to do to get them that?”
The committee is also looking at how services are funded, how they are delivered, and how to support better use of residential facilities, Schafer said. It is examining models for delivering residential support services to children with behavioral or developmental needs, and what can be adapted to the current problem, she said.
With everyone at the table agreeing Missouri’s systems are in crisis, the first step was to get past blame, Schafer said.
“Blame has no place in this,” she said. “It is literally all collaboration and partnership as we are committed to do this work, and up to it including having legislative support.”