A Gap In The System

This is skipping to the end of our story, but I was reminded of this by a discussion that I had this weekend and it’s what I want to write about now.

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Children’s Long-Term Inpatient Programs (CLIP) is the adminstration in charge of the Washington State programs for children who are too mentally-ill to function in society. They are often violent and suicidal and can be seriously involved in the juvenile justice system. Families are usually at the absolute end of their rope when their children are sent to one of these programs. For a child to be admitted to CLIP, they have to meet the Medicaid criteria for medical necessity.

CLIP was first mentioned to me in 2005, as something that we might want to look into if things continued as bad as they were. That person, a Children’s Crisis Outreach Response Services (CCORS) therapist, was the only person through out this whole mess to look towards the future with J. and it was determined that it was probably too early to look at that long term of a solution at that point. We were told that the waiting list was very long, so we would want to keep that in mind.

In theory, children are usually admitted to CLIP by two procedures (SOURCE):

Involuntary Commitment (ITA) 180-day Restrictive Orders for Inpatient Treatment

Under Washington State’s juvenile mental health services law (RCW 71.34), adolescents aged 13-17 may be committed for up to 180 days of involuntary inpatient psychiatric treatment. Under this 180-day restrictive court order, the adolescent becomes eligible for admission to a CLIP Program. The adolescent’s name is placed on the statewide waiting list as of the date of the 180-day Restrictive ITA order.The CLIP Administration’s Placement Team is legally authorized to assign committed adolescents to one of the four CLIP Programs. The assignment is based on preferences expressed by family members, and by professionals directly involved in the adolescent’s care. The location of the adolescent’s supports and the availability of beds within the CLIP Programs also influence the assignment. Once admitted to a CLIP Program, the adolescent may agree at any time to remain as a voluntary patient.

Voluntary Application and Certification

In accordance with the CLIP/RSN Agreements, the Regional Support Network (RSN) must review any voluntary CLIP application. Voluntary applicants or their guardian(s) must be residents of the state of Washington. In addition, voluntary applicants must have a severe psychiatric illness that warrants intensive services in an inpatient setting.The RSN refers children to the CLIP Administration only after consideration and approval of the application at the local level. Application requirements are comprehensive and include records that document the child’s inpatient and outpatient treatment, any out-of-home placements, school history and any other services the child may have received.The CLIP Administration compiles a written summary that is submitted to the CLIP Certification Team for review. Based on the materials provided, the CLIP Certification Team determines whether an individual applicant meets Medicaid medical necessity criteria. If the CLIP Certification Team approves the application, the child’s name is placed on the statewide waiting list until a bed becomes available at the most appropriate CLIP Program.

In practice, children are almost always admitted through Involuntary Treatment Act Orders. This process begins in Seattle with a child being taken to Harborview Medical Center’s emergency room, where they are evaluated and a County Designated Mental Health Professional called in, if the psychatric department determines it necessary. More information on Mental Health Crisis and Commitment Services in King County can be found here.Why are ITA orders the main source for admissions to CLIP? Because the system is so completely overloaded that getting in voluntarily via the Regional Support Networks (RSNs) is nigh near impossible. It can take 1-2 years to get a child admitted. That waiting period is after a child has been assessed by the RSN and all other possibilities have been exhausted by the RSN.From the website for CLIP:

There are 91 CLIP beds in the state of Washington. Forty seven beds are at Child Study & Treatment Center (CSTC) which is the state-operated psychiatric hospital for children.

The remaining 44 beds are available in the three contracted Residential Treatment Facilities (RTFs).

You read that right. There are 91 long-term beds for mentally ill children in the entire state system. In King County alone, 78 children were involuntarily committed on 72 hour ITA orders last year (SOURCE, .PDF). I have not been able to find out how many of those children went on to 14 and then 180 day orders, but it does give some perspective.

Regional Support Networks (SOURCE)

There are 13 RSNs in Washington State. Each RSN has a contract with the Mental Health Division to administer all public mental health services within their region (WAC 388-865-0200).

One of the responsibilities of the RSNs is to refer children to the CLIP Administration only after a comprehensive assessment of their needs and a concerted effort to provide alternative community-based services.

The King County RSN is handled by three Interagency Staffing Teams (ISTs).

I was handed an application for an IST by someone at the Inpatient Psychiatric Unit (IPU) at Children’s Hospital in the autumn of 2006. It was September, I think, but it may have been early October. I would have to go back through my records to find out exactly. She would not fill it out for me, as the form seemed to ask, but did give me a few pointers and fax it in for me. She also gave me the contact information for the person I would need to talk to and said that they were looking at opening new cases in November.

I called this contact a bit later to make certain that she had my application. She had received it and told me that there would be more cases being opened some time in November.

In November, I called her and she told me it was looking like December.

I never heard from her, the IST, or Seattle Mental Health ever again.

Seriously. (To be continued.)