T.R. v. Dreyfus and the Road to Reform

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T.R. v. Dreyfus and the Road to Reform

Improved Mental Health Services for Young People in Washington State – Part 2

This blog post is the second of a three-part series highlighting mental health reform litigation that Young Minds’ has been working on with our co-counsel in Washington State.  Filed in 2009, T.R. v. Dreyfus is a federal class action lawsuit brought on behalf of Medicaid-eligible youth in Washington. The lawsuit seeks to improve children’s access to intensive home and community-based mental health services and supports.

                 Part 1: Intensive Home & Community Based Service – The Benefits of Individualized                                              Services (Posted on 8/15/13)
                 Part 2:  The Challenges and Opportunities for Reform in Washington
                 Part 3: T.R. v. Dreyfus – A Statewide Partnership for Reform

Stay tuned for the final part of this series—COMING SOON!


PART 2 – The Challenges and Opportunities for Reform in Washington 

In Part 1 of this series we defined Intensive Home and Community Based Services (IHCB) and described the benefits IHCB services can have for young people with unmet mental health needs. In Part 2 we discuss the historical inadequacies of the public mental health system in Washington State that led to the filing of T.R. v. Dreyfus in 2009. 

Historical Inadequacies of Washington State’s Public Mental Health System

Many public mental health systems fail to offer IHCB services despite strong evidence that they offer positive individual outcomes and systemic benefits. At the time that the T.R. complaint was filed, Washington State’s Medicaid program offered a very limited range of intensive treatments for youth with serious mental health needs. As stated in the complaint, “many children with significant mental health needs can only access a limited tool kit of weekly office-based therapy and medication management. If those limited services are insufficient, the only option generally available for these children is hospitalization in an acute care psychiatric hospital or placement in a long term institutional mental health facility.”

Washington’s Department of Social and Human Services (DSHS) itself documented the inadequacies of the children’s mental health system of care in numerous reports generated over the past decade. As recently as Fall 2009, DSHS’s Mental Health Division authored a summary report that identified several barriers to appropriate service delivery for children, including  “a limited array of intensive community and family-based services for children and youth…insufficient transitional programs to support successful returns to the community…

[and] insufficient targeted treatment and security options for special populations such as youth with co-occurring developmental disabilities and mental health needs, and highly aggressive youth.”

As a result of these inadequacies, many children in Washington with intensive mental health needs were denied access to the services they needed to correct or improve their condition. Without these services, youth often cycle in and out of avoidable psychiatric hospitalizations and unnecessary institutional placements. As stated in the T.R. complaint, “over-reliance on restrictive, institutional settings is often harmful to children with mental health problems, placing them in a setting that is antithetical to their successful treatment, in part because removing a child from her parents or a caring adult is, itself, harmful.”

High Costs for Less Effective Care

More costly levels of care aren’t necessarily the most effective. As observed by the National Alliance on Mental Illness (NAMI), “research shows that for many children, the most effective mental health services and supports are those delivered in their home and community. Also, outcomes improve for many children when therapeutic interventions focus on the child and family, which is harder to do when a child is receiving out-of-home services.”

Without a broader continuum of services to meet youth’s needs, Washington’s public mental health system was forced to divert its scarce resources towards high cost institutional care as those children with unmet mental health needs cycled through hospitalizations and other out-of-home placements. As observed in the complaint, “inadequate care leads to a worsening of symptoms, with costlier consequences requiring more expensive responses.”

This experience in Washington State is a prime example of the systemic inefficiencies that many youth and families face across the country. NAMI notes:  “The most restrictive services serve the fewest children and are typically the most costly. As a result, most child-serving systems spend a high percentage of their budget on a small percentage of children.” Illustrating this systemic inefficiency, at the time the T.R. lawsuit was filed, the daily cost for hospitalization was over ten times the cost of multi-systemic therapy—a type of intensive home-based service—under Washington’s State Medicaid plan. 

Opportunities for Reform in Washington State

Beginning in early 2011, Washington State’s administration engaged with Plaintiffs’ counsel in an effort to explore options for improving access to appropriate mental health services for Medicaid-eligible youth and their families. That effort culminated in an interim agreement in March 2012, which suspended litigation and committed the state to build the institutional framework necessary to delivery intensive services to thousands of Medicaid-eligible youth. The parties restarted negotiations in March of this year in order to reach a final settlement agreement this summer.

Washington has made substantial progress implementing the interim agreement’s commitments, including the development of a statewide screening and assessment capability using the Child and Adolescent Needs and Strengths (CANS) tool.

In addition, the government recently appropriated funding to support DSHS efforts to build a framework for intensive wraparound service delivery. On June 30, Governor Jay Inslee signed into law the 2013-2015 State Budget. The two-year budget included over $18 million in state and federal appropriations for DSHS Mental Health Program Support operating funds. As part of this allocation, Washington State’s budget provides: 

                         “Within the amounts appropriated [for DSHS Mental Health Program Support],
                         funding is provided for the department to continue to develop the child
                         adolescent needs and strengths [(CANS)] assessment tool and build workforce
                         capacity to provide evidence based wraparound services for children, consistent
                         with the anticipated settlement agreement in T.R. v. Dreyfus and Porter.

The administration’s willingness to work collaboratively with plaintiffs’ counsel is consistent with the state’s leadership on reforming its children’s mental health delivery system.  It also provides a promising example for other states that seek to reform their own systems.

What will a successful conclusion to these efforts mean for young people in Washington State? Stay tuned for our third and final part in this series to find out! 


By |2019-04-24T13:43:34-08:00August 22nd, 2013|Featured Posts, Litigation, T.R.|0 Comments

About the Author:

Annabelle Gardner
Annabelle Gardner is the director of communications at Young Minds and editor in chief of our blog, Hear Me Out. She believes storytelling is a powerful tool for social change.