"No Eject, No Reject" Policies

Increasingly we are hearing states, communities, and programs discuss ‘no eject, no reject’ policies. Can you please share your experiences with the policy (does your state enforce it? Have you adopted it? What are the pros and cons of the policy?)

The idea of no reject/no eject is not new but I wasn’t sure myself of how ingrained it’s become in systems around the country. As you’ll see from the responses below, there are mixed feelings. Certainly the overriding goal should be to meet the specific needs of the individual child/family. You’ll see both sides of the coin below.

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I think adopting this type of policy creates arenas of jeopardy for youth and families- the youth being accepted and those already in the program. In so doing it creates risk for the agency. Basically it assumes one size of residential intervention fits all.

We had experience with this type of policy. It led to regular patterns of dysregulation in our milieu related to the mix of youth, along with an accompanying sense of disenfranchisement from staff, turnover, and other issues in the culture. Our risk went up considerably, but more importantly our ability to help all of the youth in our program diminished. I believe this was an early precursor to the cultural issues that eventually manifested in the problems we experienced. Here are follow up thoughts about what a system can put in place to respond to those youth who present such severe problems that programs don’t accept them for admission: What is critical is that the system redevelops or redevelops capacity to be able to respond to individual needs and strengths of the youth. Much easier to say than to do of course. Nonetheless levels of response can be established based on presenting behavior combined with our best individual assessment, such that youth don’t just get sent to residential for behavior, and when the level of dysregulation indicates a residential intervention there is sufficient capacity to make the necessary discernments as to what best might meet the youth’s and family’s needs. Assuming an organization is able to do that- establish that it will respond to highly dysgregulated youth but still exercise admission discretion based on the clear clinical indicators (and be able to justify that in writing if necessary)- then that organization incurs an ethical responsibility to not simply and summarily discharge in response to behavior. Its obligation at any point at which it appeared the intervention was not effective, and could in fact be iatrogenic, would be to convene the care team- parents, relevant partners, community wrap team- to discuss the circumstances and come up with a plan for effective transition to another situation, with follow up plans in place. Such provisions can be created in rule to establish a framework for a better system. In the meantime states can initiate processes, with all stakeholders involved, to design short and long term mechanisms for better responding to the immediate issues. This of course will likely include necessary funding in order to achieve successful outcomes.

Here are some quick policy provisions that could be recommended:

  • · Develop or redevelop capacity to respond to higher degrees of dysregulation- community mobile crisis, short term crisis respite stabilization (2-3 days), residential stabilization (2-8 weeks), longer term residential intervention (2-6 month average LOS ideal), even longer residential home/community living capacity; ensure adequate, cost based payment rates; establish clear differentiations between levels of responsiveness and a process for addressing unmet needs across the population; focus on community developed strategies
  • · Incentivize this system development and responsiveness to community needs
  • · Incentivize trauma informed practices and program models consonant with the latest research (especially the neuroscience) and evidence; establish state standards of practice based on this; support training;
  • · Incentivize community and residential integration/collaboration
  • · Incentivize youth and family voice at all levels
  • · Incentivize and evaluate performance
  • · Use inclusive processes for establishing incentives, standards, rules, etc and for ongoing quality review and monitoring

Key is that there is a clear vision, commitment of leadership at all levels of the system, all ideas at the planning table, and resources. 

Only our secure programs are governed by these policies. I believe the state’s short-term crisis shelters operate under those policies but we are not operating any so I can’t evaluate the impact of the policy on operations. DYS (Massachusetts’ juvenile justice agency) determines where a youth will go for secure treatment after adjudication and commitment to the Department for a serious delinquency finding, based on a pre-established grid for matching serious adjudications with a range of treatment locations and time-assignments. If the youth is assigned to our program, they will be transferring from a secure detention center and we receive a background profile ahead of time and have time to review any immediate concerns including medications, urgent medical and psychiatric issues, recent acute behaviors, etc. We also operate 3 secure treatment units for the state’s Department of Mental Health. Youth are screened while at an acute psychiatric hospital setting and if they’re considered in need of our program, we receive the referral and have 7 days to go meet the youth in person and explain our program. In Massachusetts, these DMH secure settings require the youth and/or a legally authorized guardian to voluntarily assent to admission. No one is sent to us against their will. SO while we can’t reject the youth, they can reject us. It happens rarely. Usually both sides are agreeable. On very rare occasions, we’ve notified DMH that the youth is still too unstable to transfer to our program (actively suicidal, homicidal, serious self-injuries or multiple restraints currently occurring) and the agency has been willing to delay the admission to allow the youth time to stabilize. Both systems work pretty well. The referrals are usually reasonable and we get time to review the background materials, though sometimes we’re rushed to do that, check on any follow up questions, meet the youth and most often family as well, and schedule an admission within 7 days. Our DYS and DMH programs are small (up to 17 youth) but they cover the whole state so getting out to see the kid can take a whole day. On the other end, we are able to receive support from state agencies if despite our best efforts, a youth is considered too dangerous or acutely mentally ill to be safely and therapeutically treated in our programs. These are infrequent events. Usually they follow an emergency psychiatric hospitalization and the program leaders and state agency contacts will negotiate a plan for either returning the youth with additional supports such as a one-to-one staffing supplement to the budget; a follow-up plan for more assessments and re-visiting the treatment plan; or in rare cases, a determination that our program is no longer the best location. Then the youth will go to a more secure setting (DYS) or a more intensive inpatient unit (DMH) with 24-hour psychiatry and medical support.
  

Here is Illinois we have been under no reject policy for about 10 years. Talk to different providers and you get different feelings about it. The kids we get here in Illinois are majority child welfare and when they are assed for residential they are classified as either severe or moderate. We have a contract with the state and I really do not have many problems with it. We do have some exclusion criteria i.e. IQ below 70, sexually aggressive / problematic behaviors, autistic but for the most past if we have a bed we take them because that is who we serve. It’s the moderate providers (lower daily rate, lower staff to kid ratios) who often are fighting over if the kid being referred to their program is moderate or severe. What is interesting here in Illinois is with this push to get kids back into their communities and homes, is that our system is beginning to say if a kid needs residential that kid better be severe, which I agree with, for the most part. We are currently around 900 kids in Rx in Illinois the lowest it’s been in years, so maybe that it true.
 

We are still dealing with it in Iowa, especially in the DHS system. They now put that stipulation into almost all of their RFP requests. It is an expectation for child welfare contracts.
 

New Jersey has had a "no reject, no eject" policy in all of their contracts for many years now. NJ providers were initially very concerned but it has not caused any problems . The State folks, NJ has a state run referral system, are very understanding. It certainly helped that Bonnie Brae tried to never say no and would not give up on a young person after they had been admitted. It really comes down to how reasonable are the folks enforcing the policy.
 

For our Residentially Based Services (RBS) program we have it and it is enforced and we are ok with it. Yes, we pride ourselves on taking the most difficult youth. Cons: you can have too many of the youth dealing with the same challenges which can overwhelm the staff. For an example, if I have 4 of my boys struggling with an addiction and they are progressing in their ability to fight the addiction, supporting each other, etc. and I have a youth come in that is not as far along in his treatment, he can influence the other youth backwards. The same is true for other behaviors such as runaway. Pros: is our staff get used to dealing with big behaviors and their skill sets get good. i.e. they learn how to engage some of the most challenging youth to invest in the program.
 

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