Dear Parent or Caregiver:

You have probably heard and read a great deal of information relating to children in Level III & IV residential placements. Some of the information you have heard has been accurate, and some of it has been inaccurate, or it has changed. This letter intends to correct any false information that you may have received regarding the nature and function of your child's Child and Family Team (CFT) and your child's rights related to this process.

What is Least Restrictive Environment?
Least restrictive environment means a child should live in an environment that is as natural as possible. When the CFT meets, it is important to recognize that children should receive treatment in the least restrictive environment. If a child is able to live at home and get the psychiatric care that he or she needs, then that child should stay in his or her home. But if the CFT determines that a child needs a higher level of care like residential placement, then the CFT may consider Level III or IV Group Homes.

What if my child needs admission to a Level III or IV group home?
For those children who do require residential placement in a Level III or Level IV Group Home, there are some important steps that should be followed:

The current provider (the group home) and the Local Management Entity's (LME's) System of Care Coordinator (SOCC) must call a Child and Family Team (CFT) meeting. In this meeting, the Child and Family Team must review the most current comprehensive clinical assessment (the psychological report) that includes a discussion of all aspects of that child's life (emotional, social, safety, housing, medical and health, educational, vocational, and legal).

The Child and Family Team should discuss all the service options with you and your child. There are many different kinds of treatment options for children with mental health needs. You should be sure you understand what treatment options the team is proposing. If something isn’t explained to you, please ask for more information. The Child and Family Team must develop a discharge plan. The CFT should understand that the purpose of this plan is to keep everyone focused on effective treatment and eventual discharge. It is very important to remember that the actual date of discharge may have to be revised over the course of treatment. This is because a child's needs may change over the course of treatment and the team cannot predict your child's progress before treatment has begun. It might seem too early in the process to be talking about discharge, but this discharge plan has to be submitted in order for the team to get your child residential placement. Submission of the discharge plan is required in order for the request to be considered complete.

Can a child who is involved with the juvenile justice system still qualify for residential treatment?
If your child is entering the system by way of the juvenile justice system, he or she is entitled to have a range of services available to him or her. Children with mental health needs should not be lingering in detention centers, youth development centers or in jail. One option the team can consider is Level III or Level IV group homes.

What if my child is already in a Level III or IV placement?
If your child is currently residing in a Level III or Level IV residential placement, you should already be attending Child and Family Team meetings to discuss what services your child needs now and after discharge. It is very important that you understand what this process entails so that you can be sure that your child is receiving the right services in the least restrictive environment. The point of these meetings is to talk about your child's needs with your family as well as other necessary people (such as the clinical provider, department of juvenile justice, school and probation officer).

What do you need to know about discharge?
In your Child and Family Team meetings, you are probably hearing lots of discussion about discharge. This is because the team is required to be focused on effective treatment and to think of your child's placement in the group home as temporary.

Some children will be able to be discharged from their group homes as planned. If your child is expected to be discharged, then the Child and Family Team should begin talking about something called a step down plan. The CFT should meet to discuss a step down plan at least 30 days before discharge. A step down plan is the plan for what comes after group home placement. A child is “stepping down� if he or she is leaving a Level III or Level IV group in order to begin receiving a lower level of services. Step down services in the community can include intensive in-home, therapeutic foster care, in-home therapy, multi-systemic therapy, and day treatment services. The Qualified Professional (QP) should lead this discussion and should explain the different options to you. Finally, the QP should make sure the step down plans are included in the discharge plan.

Other children may require more treatment in this level of care past the date in the original discharge plan. In order for a child to remain in a Level III or Level IV placement past 120 days, the child will have to receive an additional, newly prepared comprehensive clinical assessment (a thorough psychological report) by a psychiatrist that does not work for the group home. This report has to include the reason the psychiatrist thinks your child needs to stay in the group home. If a psychiatrist agrees that your child should not be discharged, then the CFT will review goals and treatment progress and create a revised discharge plan. The team should also be sure your child's Person Centered Plan reflects how you and your family are involved in your child's treatment.

Your CFT should send the new psychiatric assessment, the Person Centered Plan and the revised discharge plan to be approved by a company called ValueOptions. ValueOptions is the company in charge of approving these placements for North Carolina's Department of Health and Human Services.

What if I hear that my child cannot stay in his Level III or IV facility, even though his doctor says he needs to?
If a psychiatrist (or a physician’s assistant working under a psychiatrist) who does not work with your child's group home determines that your child continues to require services in a Level III placement, then your child should continue to get these services. Under the federal Medicaid program, states are required to cover certain necessary services for children under the age of 21. Under Medicaid, North Carolina must provide the necessary treatment services to correct or improve a child's health. Sometimes, a child requires treatment just to be sure that the problems he or she has don't get any worse. Even if the service will not cure the child's condition, the services have to be covered if a doctor has determined that the services are medically necessary.

What if my CFT and a psychiatrist determine that my child continues to require Level III or IV placement, but Value Options denies the request?
If you have been denied services and disagree with this decision, you may ask for an appeal. Immediately contact the person who sent you the letter denying the services. Enclosed are fact sheets explaining both the Medicaid Appeal and the Non-Medicaid Appeal processes. (Click Here to Link to the Fact Sheets)

In Summary
When a Child and Family Team determines to place a child out of his or her family home, there are many procedures that must be followed. As a parent or caregiver, you have the right to understand what is happening. In short, you should expect:

1. Well trained case managers and System of Care Coordinators (SOCCs) who deliver accurate information to families.
2. Discharge decisions based on medical necessity; and
3. Treatment in the least restrictive environment.