U.S. Flag

An official website of the United States government

Alternatives to Psychiatric Residential Treatment Facilities Demonstration

The Community Alternatives to Psychiatric Residential Treatment Facilities (PRTF) Demonstration Grant Program was authorized by Section 6063 of the Deficit Reduction Act of 2005 to provide up to $218 million to up to 10 states to develop 5-year Demonstration programs that provide home and community-based services to children as alternatives to PRTF's.

Nine states implemented Demonstration grants that ended on September 30, 2012. These projects were designed to test: 1) the cost-effectiveness of providing services in a child’s home or community rather than in a PRTF; and, 2) whether the services improve or maintain the child’s functioning.

The nine state grantees provided services to over 5300 children over the 5 years of the Demonstration. The chart below has information on the number of children served in each state including those enrolled in the bridge program at the end of the Demonstration and discharge from the beginning of the Demonstration:

State Date of Most Recent Enrollment Numbers Cumulative Enrolled Cumulative Discharged
AK September 2012 99 21
GA September 2012 722 238
IN September 2012 1644 898
KS September 2012 700 668
MD September 2012 272 156
MS September 2012 1484 1044
MT September 2012 169 117
SC September 2012 138 60
VA September 2012 86 61
Total 5314 3263

Demonstration, Evaluation and Findings

As part of the Demonstration, Section 6063 of the DRA required an evaluation provision of home and community-based services for children and youth as an alternative to institutional services provided in PRTF. The Demonstration was designed to answer two specific questions:

 The evaluation addressed these two questions, as well as additional questions introduced by CMS to help identify successful strategies and the subpopulations for which those strategies are most effective. The evaluation was designed to develop reliable cost and utilization data to evaluate the effectiveness of community-based service-delivery models.

Question One: Did the Demonstration services result in the maintenance of, or improvement in, a child’s or youth’s functional status?

The finding from the evaluation showed the Demonstration successfully enabled children and youth to either maintain or improve their functional status. The common theme across all states is that children and youth with the highest level of need at baseline benefited the most from participating in the Demonstration. These participants showed the most improvement over time in the following areas: decreased juvenile justice involvement, increased school functioning, decreased alcohol and other drug use and increased social support. The findings also indicate that children and youth that were transitioned out of PRTFs had better outcomes on average than children who were diverted from PRTFs.

Question Two: Was it cost-effective to provide coverage of home and community-based services as an alternative to psychiatric residential treatment for children and youth enrolled in the Demonstration?

For all nine states over the first three Demonstration years for which cost data was available to be collected, there was an average savings of 68 percent. In other words, the waiver services cost only 32 percent of comparable services provided in PRTFs.

The Demonstration proved cost effective and consistently maintained or improved functional status on average for all enrolled children and youth. As discovered through satisfaction surveys, it is encouraging that enrollees and their families liked the outcomes of the Demonstration and their involvement in the treatment, as well as other aspects of the Demonstration. 

For more detailed information, see the Report to the President and Congress (PDF, 121.27 KB)

Service Array and Lessons Learned

PRTF Demonstration programs offered an array of services to meet the multiple and changing needs of children and youth with behavioral health challenges and the needs of their families. While the core benefit package for children and youth with significant mental health conditions offered by these states included traditional services, such as individual therapy, family therapy, and medication management, the experience of the PRTF Demonstration showed that including a number of other home and community-based services significantly enhanced the positive outcomes for children and youth. These services include but are not limited to intensive care coordination (often called wraparound service planning/facilitation), family and youth peer support services, intensive in-home services, respite care, mobile crisis response and stabilization, and flex funds.  More information about these services can be found in the joint CMS and SAMHSA Informational Bulletin, Coverage of Behavioral Health Services for Children, Youth, and Young Adults with Significant Mental Health Conditions, issued May 7, 2013, at the following link (PDF, 271.63 KB) .

To hear more on the success of the programs and lessons learned from the states and participants in the program, follow this link to the award winning video on the Demonstration.

Sustainability and Capacity Building in the Nine States Post-Demonstration

States have reacted positively to the improved outcomes seen for children and youth participating in the Demonstration and seven states have received approval for “bridge” 1915(c) waivers. These bridge waivers permit states to continue services to the children and youth who started receiving services under the Demonstration but not to additional children or youth because of the statutory barrier to providing 1915(c) waiver services to children and youth meeting a PRTF level of care. The seven states operating bridge waivers have indicated that they would be interested in applying for a 1915(c) waiver to include children and youth not part of the Demonstration if the statute permitted a waiver for this purpose. Three states are using or considering the use of the 1915(i) state plan authority which allows children and youth to receive services in the community without the institutional level of care as long as the participants are at or below 150 percent of the Federal Poverty Level. Under this authority, however, the only way to increase the income limits would be for the children or youth to meet the same institutional level of care required for 1915(c) waivers. Income level restrictions, statewide requirements and the inability under the authority to regulate the number of participants in the program make this alternative less attractive to states.

The findings highlight the positive benefits of the project and the desire of states to sustain the waiver beyond the Demonstration period. The improved outcomes and positive reactions to the Demonstration may have increased the involvement of the participating children, youth and families, which is likely to have made the project even more successful in program adherence and behavior modification. In order for the positive outcomes of the Demonstration to continue, the statutory barrier to providing HCBS to children and youth who meet a PRTF institutional level of care criteria would have to be eliminated by identifying PRTFs as a designated institution under section 1915(c) of the Social Security Act so states could receive federal Medicaid matching funds for waiver services.

See the PRTF Implementation Status Reports from 2008, 2010 and the Interim and Final Reports from 2011 and 2012 at the links below.