As children and families struggle to access care, new legislation aims to bolster funding for facilities. But money is only part of the solution.
St. Joseph’s Children’s Home in Wyoming looks like a typical school.
A manicured lawn leads to the orange brick building where children take K-12 courses in math, social studies and science. Inside, a library filled with books sits down the hall from a gym. On a Tuesday in November, a din rises from the lunchroom as elementary students eat.
But at the Newell Children’s Center next door, a security camera points toward the front door, and a tall chain-link fence secures the backyard.
Newell is home to children in crisis who are at risk of running away or harming themselves or others. Currently housing 12 girls, Newell is at capacity, as are three other residential units at St. Joseph’s — one of two psychiatric residential treatment facilities for youth in Wyoming. But there’s a fourth unit whose dozen beds sit empty not because of a lack of need, but because the facility cannot hire enough staff.
Over the last decade, a lack of state investment has left St. Joseph’s and the Wyoming Behavioral Institute in Casper underfunded amid rising staffing and operational costs. Children and their families have been forced to wait weeks or months to access the care they urgently need. New legislation aims to change that by bolstering funding for the state’s two PRTFs, allowing them to hire additional staff, expand their programs and better meet the needs of Wyoming’s families.
It marks a necessary step, providers, advocates and lawmakers say, but is not a panacea for the growing behavioral and mental health challenges among Wyoming’s youth.
“For so many years, the state of Wyoming has been in this cut, cut, cut, cut [mode]. I think we’ve probably cut too far,” said Ronda Meyer, executive director of St. Joseph’s. “We’ve lost services. We’ve lost providers. It’s all about squeezing the current dollars we have and not talking about: What does it truly cost to provide these services?”
Lagging funding and staff shortages
The Wyoming Department of Health receives more funding than any other agency in the state, totaling roughly $1.88 billion in the 2021-2022 biennium budget. But in 2016, the department’s budget was cut by $143 million. Then under the direction of Gov. Mark Gordon, the department slashed its budget by another $138 million in 2020.
Medicaid, the public health insurance program for those with low incomes and disabilities administered by WDH, has experienced a similar decline in funding. Wyoming’s spending on Medicaid dropped by $23.5 million from 2018 to 2020, declining to levels not seen since 2016. Only after the coronavirus pandemic led average monthly enrollment in the program to increase by nearly 20% did funding rebound.
Until July of this year, the daily rate Wyoming Medicaid paid St. Joseph’s for psychiatric residential treatment had not increased since 2012, Meyer said. Even with the approximately 12% bump for in-state providers approved by the Wyoming Legislature in 2022, rates have not kept pace with growing costs. “The increase was not based on current reality,” Meyer said. “It was based on cost reporting that is two years old.”
Wyoming Medicaid’s daily rate covers 68% of St. Joseph’s operational costs, leaving the nonprofit to subsidize the remainder through private donations, which bring in approximately $1.5 million per year and account for 10% of its budget.
St. Joseph’s funding challenges have compounded the difficulty the facility already faces attracting candidates to work with high-needs children in rural Wyoming, Meyer said. St. Joseph’s currently has a team of five licensed therapists, two short of the number needed to staff the dozen beds that sit empty.
“We have found that we have to be competitive now with the Walmarts, the McDonald’s, the Targets,” Meyer said. “What we are asking staff to do is to work with some of the most difficult youth with severe needs. We have to pay them appropriately.”
In the last two years, St. Joseph’s has increased wages almost 24% to keep pace with the private sector, Meyer said, adding to the 8% to 10% increase in operation costs it has also experienced over the same time. The facility has managed that despite the little change in Medicaid rates.
WBI, which operates a PRTF alongside the state’s only psychiatric hospital for children, has been better able to adapt to staffing challenges. Because WBI’s hospital and PRTF sit on the same campus, the facility can shift staff, said Emily Genoff, WBI’s director of business development.
Recruiting qualified caregivers has still proved difficult.
“In a state like this where there’s not many people relocating for the wages that we’re able to offer, it’s been a constant effort to stay staffed,” Genoff said.
Like St. Joseph’s, WBI’s staffing strain comes down to money. “We’ve seen a lot of economic pressure from a funding standpoint, especially working with the state and state funding,” said WBI CEO Mike Phillips. “As the revenues in the state go down, funding like Medicaid decreases. There’s less money to go around and costs continue to increase for facilities. That’s really the biggest challenge is a declining reimbursement model with a lot of inflationary pressures.”
It is Wyoming’s children and families who mostly keenly feel the impacts of limited funding and staff shortages at the state’s PRTFs. By many metrics, the situation for those children and families in need of crisis care is worsening.
Wyoming Medicaid has cut spending on psychiatric residential treatment by roughly one-fifth since 2020. Admissions have declined, dropping from 259 children in 2020 to 155 in 2022, according to WDH data.
Limited staffing has led to long wait times; St. Joseph’s referral list is eight pages long and families can wait weeks for a bed to open. WBI’s 30-bed PRTF serves only girls between the ages of 10 and 17, making St. Joseph’s the only PRTF in Wyoming that accepts boys and children between the ages of 6 and 10.
“We are unfortunately having to tell referrals that there’s right now a four-week waiting period for a bed,” Meyer of St. Joseph’s said. “It’s not referrals or a need that’s the issue. It is staffing that is a challenge.”
The average length of stay for patients has also decreased, from roughly 200 days in 2017 to 148 days in 2022. Readmissions for children who have been admitted to a PRTF within the last year, meantime, have more than doubled since 2017. Tim Jurkowski, the clinical director for St. Joseph’s, thinks the two are correlated.
“When I first started at St. Joe’s five or six years ago, the number of readmissions that I saw were pretty few and far between,” he said. “My understanding is that prior to when I came here, the length of stay was reasonable.”
As the lengths of stay diminished — a trend influenced by insurance allowances — readmissions climbed, he said.
“It was just constant justification for why this kid needs to stay, and a lot of times it just wouldn’t matter,” he said.
Though the pressure to limit stays has eased some, it has affected the way providers approach treatment, Jurkowski said. “We have shifted to: ‘OK, this is good enough.’”
For Wyoming families, the toll can be immense. Parents can lose employment responding to their children’s needs and trying to find and maintain adequate care, said Kat Campbell, a family support specialist with Uplift Wyoming, an advocacy group for families and children with emotional, behavioral and mental health needs. Trauma is often a constant for both children and parents.
“Day-to-day life is a crisis. Day-to-day life is exhausting,” Campbell said. “People aren’t sleeping. People are getting called out of work or they had to stop working. The poverty rate among families dealing with this is ridiculous.”
It took six weeks for Campbell’s son to be admitted to St. Joseph’s the first time, she said. The second time, it took two weeks largely because the risk of violence against her other children led to support from the hospital where he was staying. “That was the fastest I’ve seen it happen,” she said.
PRTFs are the second-highest level of care for children in crisis, following emergency rooms and WBI’s psychiatric hospital. To even get to the point of PRTF admission, families often undergo extreme situations, arduous admissions processes and years of intense advocacy for their children, Campbell said.
“Sometimes I’m having conversations with parents and … it’s talking them through how extreme it has to get before they can get help,” Campbell said. “It’s just heartbreaking to help families walk through this stuff.”
A path to more funding
In an April memo, the Joint Labor, Health and Social Services Interim Committee identified behavioral health as its second priority for the 2022 interim, following mental health. The committee outlined its plans to examine gaps in crisis care and assess a supplemental payment program for PRTFs.
For roughly two years, the Wyoming Hospital Association has been working to fund PRTFs beyond the $1.6 million the Wyoming Legislature designated for rate increases in the 2023-2024 biennium budget. Eric Boley, WHA’s president, worked with the state’s hospitals, PRTFs and the WDH to forge legislation that boosts funding without drawing from the state’s general fund.
The result is a bill that would expand on the hospital assessment system previously enacted by the Legislature in which Wyoming’s private hospitals pay an “assessment” to the WDH similar to a tax. The department pools the money to increase the matching funds it can collect from the federal government through Medicaid before redistributing the larger pot of money back to the hospitals.
“PRTFs are underfunded along with a lot of our mental and behavioral health services,” Boley said. “The state budget decides how much [of the] general fund goes towards these programs and it’s not enough, so we have come up with our own solution which is to assess ourselves.”
The proposed legislation would allow WDH to work with the federal Centers for Medicare and Medicaid Services to construct a supplemental payment program in which the state’s two PRTFs could tap into those hospital assessment funds and Medicaid dollars. The program could bring in $2 to $3 million annually that would be distributed to St. Joseph’s and WBI to support their services and staffing, Boley said.
As the joint labor committee considered the legislation, lawmakers questioned why the state’s private hospitals would be willing to pay to fund St. Joseph’s and WBI.
“The simple explanation is hospitals across the state have psychiatric patients that are sitting in their emergency room[s] because they can’t find a place for them,” said Rep. Sue Wilson (R-Cheyenne), who co-chairs the joint labor committee. “… The hospitals would be so happy to find more access to beds in the psychiatric facilities that they’re actually happy to assess themselves money on this issue. It shows you how bad the problem is.”
Staffing costs accounts for approximately 80% of St. Joseph’s budget, and the additional funding would allow the facility to retain and recruit qualified providers while strengthening programming for the children in its care, Meyer said. Phillips likewise said the funding would help WBI bolster staffing and expand programming. The program would have the added benefit of relieving some of the pressure on hospital emergency rooms by opening beds for psychiatric patients, said Stefan Johansson, director of the WDH.
At its October meeting, the labor and health committee passed the draft bill. It will now go before the Wyoming Legislature during the 2023 general session. Both Boley and Wilson expressed hope that lawmakers would see the value in expanding funding for PRTFs while leaving the state’s general fund untouched.
“I don’t know what else our PRTFs are going to do if we’re not able to get this additional funding,” Boley said. “Unless the Legislature wants to pony up quite a bit more money in the general fund to help shore them up.”
Even with expanded access to PRTFs there will still be gaps in care. The Wyoming Department of Family Services estimates 10-12 children per year have complex behavioral needs that challenge the state’s health care, education, child welfare and juvenile justice systems.
Neither St. Joseph’s nor WBI are currently equipped to help violent children. Both predominantly serve youth with mental health concerns such as depression or suicidal ideation. When boys who are a danger to themselves or others have nowhere else to go, juvenile detention facilities are the remaining option. “We don’t want to use that as an option, because we don’t think it’s appropriate, but a child has to be safe,” Korin Schimdt, the director of DFS, told WyoFile and Casper Star-Tribune. The publications’ recent investigation found the state-run juvenile detention facility — the Wyoming Boys’ School — has seen an uptick in violent altercations between staff and residents.
In 2021, the Wyoming Legislature passed House Bill 38, which required the state to redesign its behavioral health system in part to focus supportive services and funding on priority populations. Among the priority populations the state identified were high-risk families, including those with children recently discharged from psychiatric hospitals or PRTFs and families with children at risk of involvement in the judicial system.
The Wyoming Legislature continues to identify gaps in supportive services as it considers the role of the state in funding and developing supportive services, said Rep. Lloyd Larsen (R- Lander), chairman of the Select Committee on Mental Health and Substance Abuse. Identifying those gaps allows the state to begin correcting them, he said.
“Everything we do is reactionary,” Larsen said. “If the person has a meltdown, then we provide these services. The question — not just with adolescents, but with adults, with children, with everybody — is how can we get out in front and do the preventive component to reduce having to respond when their conditions become more acute.”
Efforts are underway to address the gap in early interventions. The Wyoming Department of Education received a five-year grant in August 2020 to expand mental health services in schools. But the acuity of children seeking care at St. Joseph’s has grown, and continues to grow, Meyer said, making support beyond funding only more critical.
“We’re seeing a higher need and a growing population needing services because providers have gone away, services have gone away,” Meyer said. “The state is talking about these 15 high-needs kids. A few years ago, that was only five. Now it’s 15. And while I think we absolutely have to address the needs and services for these 15, my concern is why are we not talking about how we got there and how do we intervene sooner, so that this population doesn’t continue to grow and grow.”