The Justice Department on Tuesday released findings from an investigation that show Nevada is institutionalizing children who could remain in their homes if provided with adequate community-based behavioral health services.
Such services include crisis response, care coordination, behavioral health care, respite care, peer support and therapeutic foster care.
A report on findings from the investigation details how the state’s failure to provide these services to children with behavioral health disabilities is a violation of Title II of the Americans with Disabilities Act.
Justice officials said that despite the State’s service system being designed to provide community-based services, it is not only not providing them but doesn’t have an adequate provider network to do so. Without these services, children aren’t being connected with services that could keep them in their homes or help shorten their stay in a residential facility and return home sooner.
In March 2021 the state reported 305 children in residential treatment facilities, with 130 of them in facilities outside the state. On average for the past three years, more than a third of children in residential care are treated outside of Nevada. The number of Nevada children in care both in and out of state has remained steady since 2016.
Gov. Steve Sisolak said a lack of state investment in public and behavioral health has led to these problems.
“For far too long, Nevada has not invested in the appropriate health resources for our children and our families – this new report shines a bright light on that fact,” Sisolak said.
The state has known about the inadequacies of the children’s behavioral health system since at least 2016 when a state-commissioned Children’s Mental Health Needs Assessment was completed. That report pointed out many of the same issues identified in the Justice Department investigation.
Nevada, for the last five years has placed 51st in the nation for children’s mental health care in a ranking by Mental Health America. Last year it earned a D+ in a similar review by Children’s Advocacy Alliance.
That is changing, however, Sisolak said. New federal funding is leading to what the governor said are “historic and unprecedented investments to shore up these systems and provide immediate resources and relief to our families and children who need community based behavioral health services.”
Those investments include $43 million for non-profit and community coalitions to support behavioral health at the community level; $15 million for wraparound care and case management; $5 million for in-home treatment options; $4.8 million for community-based assessments and treatment options with a focus on preserving the family unit; and millions more for oversight, emergency respite, peer support and crisis response.
Months-long investigation supported by state, families
“She is tired of her son not being home and tired of him not getting what he needs.”
Staff from the state’s Division of Public and Behavioral Health worked with the Department of Justice to facilitate the investigation that was launched following a complaint filed in December of 2020.
Investigators spoke with children who had been treated in institutional or residential care facilities, and their families. The report is riddled with their personal stories, which detail a 14-year-old girl with three years of care in 10 different treatment facilities; prison-style behavior “level systems” where losing points could result in a longer stay; tearful calls from children as young as 10 begging to come home and see mom; and children shipped to other states where their parents are unable to visit them.
“Children in settings far from home experience additional harms over and above those associated with segregated placements generally. Nonetheless, the State has financed residential treatment for Nevada children as far away as Missouri, Georgia, Michigan and South Carolina,” Justice officials said.
Not only did the Justice Department review of residential treatment records reveal a “vast majority” of children admitted were appropriate for community-based services, but that their families overwhelmingly want such services.
Many families said sending their children to such facilities was the only choice available to them. Some also said that residential treatment made the situation worse.
“One parent summarized the overall sentiment we heard from parents: She is tired of her son not being home and tired of him not getting what he needs,” officials reported.
Multiple barriers limit access to services
The community-based services referred to in the report include the state’s Mobile Crisis Response Team, a statewide crisis response program that helps families during behavioral or mental health crises. The state-funded program on its website notes “MCRT diverts roughly 85% of children from Emergency Room visits during crisis,” along with providing short term counseling and case management.
The Justice report, however, noted that “capacity issues have substantially increased the response time to crisis calls, leaving many children and families to seek care from hospitals.”
“For example, we learned of a six-year-old who spent ten days in an emergency room in a hospital in Reno seeking behavioral health services,” officials stated in the report.
Further down the page it documented a 15-year-old who had experienced 14 psychiatric hospitalizations and a 17-year-old admitted and discharged from the same hospital eight times.
The pandemic led to the call volume to MCRT tripling from 2020 to 2021. From March 2021 to March 2022 MCRT answered more than 4,500 crisis hotline calls and responded to more than 2,400 families statewide, according to DHHS officials.
Despite this, families say it’s not enough. In one instance where MCRT was unable to respond, the parent was told to call 911 if the problem continued, potentially leading to an unnecessary interaction with police.
Gov. Sisolak said the state is already addressing MCRT’s capacity issues, and is investing $3.4 million in the program to support Clark and Washoe school districts and the Department of Education for after-hours deployment when district teams aren’t available.
MCRT is just one example of worker shortages in the state. In a July presentation to the Legislature’s Interim Health and Human Services Committee, DHHS’ Stephanie Woodard, a senior advisor on behavioral health, said Nevada would need far more school-based behavioral health providers to meet recommended ratios.
That would mean bringing on nearly four times as many school psychologists, 35 times as many school social workers and twice as many school counselors.
The interim committee heard similar news in March, also during a DHHS presentation on MCRT.
Megan Freeman from the Children’s Mental Health Authority said Nevada’s existing shortage of mental health providers means expanding crisis services just moves providers from one setting to another, leaving shortages elsewhere in the system.
But investigators added that many children and families don’t get the State’s behavioral support services before or after placement in a hospital or residential facility.
There are cracks in the system, with many providers unaware of resources available, the report notes.
“Because the [children’s mental health] system has never had true oversight or regulation, there isn’t a database anywhere of what services exist,” said one state children’s health official.
Other providers don’t provide certain needed services because of administrative barriers, along with low reimbursement rates and limits on coverage from Medicaid. In rural areas telehealth is often the only option. Language barriers and a lack of culturally appropriate care are also cited as barriers for some families.
Focus on lasting change
Health officials say they know what needs to be done, but it will take funding and time.
The Nevada Children’s Behavioral Health Consortium in March outlined priorities for Clark and Washoe counties and the rural and frontier areas of the state to legislators on the interim health committee. The priorities included sustainable funding for crisis response programs, expansion of family support including peer mentoring and transitioning from care, and improving early access to behavioral health to help prevent children from needing residential care.
Gov. Sisolak said his administration is committed to creating lasting changes for children and families.
“Funds are already being built into my recommended budget, and we look forward to partnering with experts and our community to better serve all of our children in their homes and communities,” he said.
Justice Department officials also outlined recommendations for Nevada to improve its community-based services for youth behavioral health. If the state doesn’t improve, it could be hit with a federal civil rights lawsuit.
