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Placement Crisis: Children are younger, problems more acute while beds, workers are harder to find



Esther Hawkins remembers a first-thing-in-the-morning office conversation she used to have with Judy Wood.

Wood, then the executive director of the Mental Health & Recovery Board of Wayne and Holmes Counties, would ask Hawkins, “How’s it going?” accompanied by a knowing look.


“The kids are safe,” would come the reply from Hawkins, the executive director of the Wayne County Family and Children First Council.

But keeping those kids safe comes at a cost – and a growing one.


The number of children in out-of-home placements has actually gone down in Wayne and Holmes counties over the past decade. Those numbers, Hawkins said, are deceiving. The Wayne FCFC has been tracking Wayne County numbers the first Friday of every month and that data shows the highest reported number – 215 – was in January of 2013. Most recently, in December of 2023, that number was 111. In Holmes County, the Department of Job & Family Services reports a high of 67 children in placement in 2019 dropped to 48 last year.


But many of these children are getting younger when they enter care and have greater needs than ever.

The average cost per day for a youth in residential treatment is $320 and 14 Wayne County youths receive this type of care. The FCFC reports seven of those receive federal money that covers about 60 percent of the cost. All 14 have mental health disorders, four have co-occurring developmental disabilities, one has significant medical concerns and three are court involved.


The average age? Just over 12 years.


Another six are placed in homes with providers from the developmental disabilities system. All have mental health disorders, five have developmental disabilities and one has a medical disability. One is court involved.

Both counties have Family and Children First Councils, designed to provide service coordination. Depending on their level of need children can be placed in kinship foster care, traditional foster care, treatment foster care, residential care, juvenile detention, Department of Youth Services, providers licensed by Board of Developmental Disabilities or hospitals.


Regardless, Hawkins said, “For any kid in out-of-home placement, the ultimate goal is to return kids to community.”

The placement crisis, Hawkins said, is unfortunately paired with a mental health crisis coupled with a pandemic. Data from the Centers for Disease Control show the number of residential treatment facilities nationwide declined by 30 percent in the last decade, while in 2020 – the first year of the pandemic – emergency room visits for children ages 5 to 11 increased by 24 percent and by 31 percent for children ages 12 to 17.


The Family First Prevention Services Act included historic reforms designed to keep children in their homes, while also focusing on reducing out-of-home placement, the most restrictive of which would be a Psychiatric Residential Treatment Facility (PRTF), for which Medicaid may pay.


But, Hawkins noted, PRTF beds also require the highest level of staffing, which is difficult in a behavioral health care system already taxed for personnel. Even traditional foster care homes have been on decline; again, affected by the pandemic when families had their own children at home 24 hours a day, seven days a week.

It is a perfect storm for a crisis.


Last spring, a Wayne County teen spent a month in Cleveland’s University Hospitals Rainbow Babies & Children’s Hospital. The youth was ready to be discharged, but the mother, working with child welfare officials, was not able to find a treatment facility and refused to pick up the youth until she could secure a safe option.


Eventually, due to the hospital filing abandonment charges, the Wayne County Juvenile Court placed the teen in the custody of Wayne County Children Services, and hospital officials brought the youth to the agency office. With no identified placement, the teen stayed two nights at the agency before custody was returned to the mother. The mother then had to take the child home due to lack of a therapeutic placement.


 Two days later, police were called and the youth was arrested for domestic violence and stealing the mother’s car. The teen, still waiting for treatment, was taken to juvenile detention.


The problems in Wayne County are mirrored in Holmes County, according to Holmes County Commissioner Dave Hall. 


When a child enters the placement world, the costs are first billed to insurers, if any, but the remaining costs are borne by the county of their residence. And to add to the paperwork, any children needing PRTF placement must be assessed by the Ohio Resilience through Integrated Systems and Excellence (Ohio RISE) a state-approved managed care provider. There are 254 QRTP FACILITIES– 251 in Ohio and another three out of state  -- available for placements. There are only 12 PRTF beds in Ohio.


Costs billed back to the counties range anywhere from $100 per day to $1,350 depending on the level of care. Wayne and Holmes counties each have partners – like the Mental Health and Recovery Board – that pool funds to pay for out-of-home placements. In addition, Wayne County has a Children Services levy. Holmes County has no such levy, so when the money runs low, Holmes JFS goes to the county commissioners for money from the county’s General Fund. Last year, Holmes JFS placement cost totaled nearly $1.7 million. In Wayne County, that number was $5.3 million.


Two years ago, Wayne County opened Asha House in Wooster for respite, step down or emergency placements. The four-bedroom house is maintained by the Wayne Metropolitan Housing Authority, staffed by a provider licensed by the Department of Developmental Disabilities and controlled by FCFC and its partners. Children typically stay there three days for emergency placements or respite and up to three months when stepping down from residential to the community.


But it isn’t set up to handle the most aggressive children. Those go to hospitals, treatment stabilization facilities, home -- wherever a placement can be found. “We hate moving kids,” from one placement to another, Hawkins said, but “You do what you do to keep kids safe.






Statistics show nine out of 10 people in treatment for substance abuse started using in middle or high school, a time when the brain should be engaging in major developmental tasks.


Anazao Community Partners is doing work inside local schools to stem that statistic, while at the same time seeing students who may be struggling with either substance abuse, mental health issues – or both.


ACP’s J. Greg Morrison is an Ohio Certified Prevention Specialist and recipient of the Mental Health & Recovery Board of Wayne and Holmes Counties’ Shining Light Award for his work in the local schools, specifically West Holmes Local. There, he said, he sees both middle- and high-school students.

 “I’m coming alongside kids,” there, he said, “with parents in mind.” More recently, his role has morphed into more of a trainer, according to agency executive director Mark Woods, teaching school staff the very programs that he has made popular.


It all starts in grades six, seven and eight with two sessions of programming specific to middle-school students. “We’re helping young people understand their developmental capacity,” Morrison said. “They’re learning to value their behavioral health and trying to take care of it.”

So, these concepts are not completely foreign to students when they arrive at the high school as freshmen, when they will again see Morrison in the 10-session, semester-long, self-titled “Youth Development with Mr. Morrison,” class. Using the evidence-based  and nationally acclaimed Botvin’s Life Skills program, the class is not only instructional; it also partially fulfills the state-required SAVE Students Act need for violence prevention and social inclusion programs.


The thread running through the program, Morrison said, is “See Yourself Better” which is turn is bolstered by three pillars: focus, effort and heart. Students choose a way to better themselves – getting better sleep, exercising, managing emotions, etc. – and work on those throughout the course.

Each session also includes what Morrison called a “brain break” – to not only help the students get relaxed but also to help them learn to manage their emotions.


While Morrison loves teaching the class, he said he has gone from teaching the students to more so teaching the teachers. There are several  prevention strategies that Anazao can provide in local districts, Woods said, but the question has been “how do we build that same culture across not only West Holmes but across our whole service array.”


At West Holmes, Anazao staff have been keynote speakers during teacher in-service days. “Each time” they presented, said guidance counselor Dawne O’Donnell, “it was both personal and impactful.”


Just as impactful, O’Donnell said, has been having Anazao providers in the school to see individual students for private appointments. In addition to providing case management and treatment in all four West Holmes buildings, Woods said the agency serves 21 different buildings across the Wayne-Holmes area in a given day.


At West Holmes, “(I)t takes away the barrier that was having a negative impact on how accessible counseling and case management was to our students. In the past, we would recommend counseling but students many times were unable to physically get there due to work schedules, gas money, distance or no transportation at all,” said O’Donnell. “By having the services in the school, students are seen either during their study hall or their lunch period. This makes it so much easier and less of a burden to families.”


Billing for those services comes from the student’s private insurance or Medicaid, United Way, federal funding  or the Mental Health & Recovery Board. No one, Woods said, is turned away due to an inability to pay.


There are a few wrinkles in the system. During the summer months, some students will be seen in a school building – if that building is open – or at a local Anazao office. “Behavioral health needs don’t stop in May,” Woods said, though he added some of the school-year stressors are lighter during the summer months. Providers also have had to adapt to 50-minute or shorter sessions.


But, Woods said, “the proof’s in the pudding – the fact that we cannot keep up with demand. I could probably hire 10 people today and it wouldn’t be enough,” to cover districts across the two counties.


Whether it be for prevention services or treatment, O’Donnell said West Holmes welcomes Anazao. Morrison is appreciated and has become a part of the West Holmes family. “We cannot say enough how much we appreciate and love working with our Anazao partners,” she said. “They are a light in our building and their relationships are vital to our school climate.”

This story provided by the Mental Health & Recovery Board of Wayne and Holmes Counties


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MHRB-funded health officers, WPD collaborate to tackle mental health crisis calls


Law enforcement and behavioral health agencies often find themselves working together when it comes to helping a person experiencing a mental health crisis – and that’s a good thing. 

In Wooster, the majority of police officers are Crisis Intervention Team certified, according to assistant Chief Scott Rotolo. And now, their efforts are further enhanced by the addition of four health officers housed at The Counseling Center of Wayne & Holmes Counties, with crisis funding supplemented by the Mental Health & Recovery Board of Wayne and Holmes Counties.


A health officer, TCC Executive Director Tiffanie Kestner said, is authorized via the Ohio Administrative Code “to assess if someone is mentally ill and subject to hospitalization.” These cases involve a mental illness goes well beyond anxiety or depression and may require hospitalization, even if the person involved cannot or will not agree to voluntary hospital admission.


“Of equal importance,” Rotolo said, “is following due process, as is (the mentally ill person’s) right.”

While law enforcement officers can have someone involuntarily hospitalized – often known as “pink slipping” – that process could be done collaboratively with a health officer. There also are cases where law enforcement is not involved, but rather where a crisis worker is called to the scene.  And while that worker can assess the situation, said TCC Chief Clinical Officer Jeff Bradford, unless he or she meets the educational and licensing requirements of a health officer, that person would need a designated health officer to sign off on the commitment paperwork.


Not all the agency’s crisis workers qualify to serve as health officers, he said. The accepted agreement between the MHRB and TCC is that Health Officers will have a master’s degree, an independent license to diagnose and treatment mental health issues, plus additional training in a variety of areas, from the state’s commitment process to knowledge of the local emergency services to CPR.


Joining long-time health officer, TCC’s Gail Garrod -- who would handle involuntary commitments raised by any of the agency’s crisis workers – are four other TCC staff, Bradford said, with more going through training now.


Kestner said she is aware “law enforcement was having to make more mental health decisions” and while she appreciates the collaboration, it wasn’t always as effective as having a health officer with mental health assessment and specialized training involved. And, she added, when there was just one health officer “people were getting frustrated by the lag time” should that person have multiple calls in two different counties. 


In acute situations, Rotolo, police will take a mentally ill person directly to a local hospital and establish their safety. After that, he said, a health officer could oversee the process of getting them moved to a psychiatric facility. 


Both the TCC and WPD are doing what they can to best serve the public. At the TCC, that also means having crisis administrative staff to deal with paperwork and phone calls and preparing to launch a dedicated crisis line. 


Having additional health officers onboard goes beyond collaboration; it also allows for “the right person for the right job” on each call, Rotolo said.