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Nicole Nesmith shows a picture of her child, Phoenix, from when the two went to see the musical “Rent” in Omaha, Nebraska. Earlier that school year, the Nesmiths had been denied psychiatric residential treatment for Phoenix. MADELINE FOX / KANSAS NEWS SERVICE Nesmith was working on a social work degree, so she was familiar with self-harming — she just hadn’t expected to deal with it so close to home. Phoenix’s confession started a cycle familiar to families who have kids with severe mental illness — therapy, crisis hospitalizations, medication, more therapy, new meds when the old ones stopped working well, more hospitalizations. But in the fall of Phoenix’s freshman year of high school, even that exhausting pattern wasn’t enough. “There was a two-week period when I really didn’t leave the house at all,” said Phoenix. When kids are chronically in distress — suicidal, self-harming, harming others, running away repeatedly — there had been a place for them: psychiatric residential treatment facilities.

That’s where the community mental health center treating Phoenix sent the Nesmiths when the care it could offer no longer kept Phoenix stable. Residential treatment centers take children for long periods of time — weeks, sometimes months — to do more than talk kids down from crisis. They work to get at the root causes of their distress and help patients develop coping mechanisms to better manage the stressful things that set off a crisis. Cost-cutting measures In 2011, the state decided Kansas was sending too many kids to residential facilities for too long. At $500 a day or more, it cost too much.

The state pushed to divert kids from residential care and bring down the length of their stays. That loss of business prompted many treatment facilities to close some or all of their beds, resulting in a sharp drop from nearly 800 spots for care to the current 282. More changes swept through with Kansas’ privatization of Medicaid in 2013.

Under KanCare, community mental health centers no longer decided whether kids needed residential treatment, as they had for Phoenix. Instead, that decision passed to the private companies managing Medicaid under KanCare. In 2015, the Nesmiths sought a third residential stay for Phoenix. After years of struggling with depression, anxiety, and thoughts of suicide, the looming milestone of a 17th birthday, college and a future prompted the Nesmiths to seek another round of longer-term intensive care.

“I was trying to figure out a future I never thought I’d have,” Phoenix said. “And that was just another source of stress.” But the Nesmiths say Phoenix’s insurance company denied residential treatment. Instead, it pointed Phoenix to group therapy.

But the family had already tried that and was no longer eligible. Two of the state’s Medicaid providers, Sunflower Health Plan and United HealthCare, declined to comment on how they authorize residential stays, deferring comment to the state. Even as it got harder to access, the need for residential treatment didn’t go away. In fact, with shorter lengths of stay, kids might get stable but didn’t have the time to develop good coping mechanisms and trauma management to stave off future crises. They’d often end up referred back to a treatment facility when suicidal, aggressive or self-harming tendencies returned.

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But now, there weren’t enough beds available. In 2019, that means 150 kids in urgent need of treatment languish on a waitlist. That means foster kids who land at facilities with less intensive care, youth residential centers, show up with behavior more extreme than those residential centers are equipped to handle.

Headline-grabbing problems, but little change The overflow of kids needing beds in residential treatment facilities has served as an underlying cause of what’s driven headlines over the past year. Many of the children were either waiting for a psychiatric bed or had just left one. Kids who are suicidal — an epidemic so troubling that the state has to deal with it — land in a mental health system stretched beyond capacity. And substance abuse by parents or kids can push children into needing intensive inpatient care. Recommendations this year from a child welfare tax force to fix the overload of the residential treatment system echoed similar results from previous years.

Whether their focus is mental health, children’s care or foster care, panels have found time and again that psychiatric residential treatment facilities don’t have enough space and aren’t given enough time to treat kids properly. Kids are discharged, but problems persist The people who run residential treatment facilities say that shortening kids’ length of stay pushes the facilities more into a stabilization role, which they say is supposed to fall to hospitals and crisis centers. Residential facilities often don’t see kids until they’ve had multiple hospital stays, when it becomes clear crisis behavior is becoming a chronic pattern. “We are a part of changing that child’s trajectory in their life,” said Cheryl Rathbun, who oversees a residential treatment facility run by St. Francis Community Services. “It needs to be more about treatment, and not just about simple stabilization.” But providers say they’re sometimes pushed to release kids who haven’t yet made progress on the deeper issues driving harmful behavior.