Crisis Services and Quick Reaction Team (QRT)

A Quick Reaction Team (QRT) is a group of individuals across multiple divisions from the Department of Health and Welfare and their behavioral health managed care organization, Magellan Health, who have knowledge of Idaho’s youth-serving systems. A QRT provides support to your youth’s care coordinator and treatment team. Your team may need additional support when they are encountering complex challenges implementing a plan to resolve your youth and family’s safety and treatment needs. The QRT is here to connect you with whatever resources may be available to assist you during a time of urgent need.

The goal of a QRT is to provide an additional higher level of staffing support for your youth’s care coordinator when additional planning is needed to resolve complex barriers and/or brainstorm solutions. So, what does this mean for you as a parent/guardian? When a care coordinator accesses a QRT, they are planning and brainstorming with QRT representatives who bring expertise from their unique division's perspectives. 

You can submit a QRT referral at any point; however, the following criteria will prompt the team to assemble and begin staffing your family's concern. Therefore, the earlier the referral is submitted, the more time it allows for additional planning:

• Your child is in an out-of-home placement, AND 
• You are concerned about bringing them home due to safety needs stemming from their mental or behavioral health needs, AND
• The treatment team has not been able to mitigate these concerns. 

You can submit a referral through this link: https://app.keysurvey.com/f/41758922/34a2/. A referral can also be submitted on your behalf. For example, a treatment team member, such as a care coordinator or hospital social worker, will complete and submit the QRT referral at your request. In those cases, you will be sent a release of information (ROI) to sign. The ROI allows for the sharing of information and records to occur, enabling the QRT to know and address the needs you and your team have identified. 

The QRT coordinator receives and reviews the referral. The QRT coordinator will then reach out to the parent/guardian and/or referent to gain a better understanding of family concerns and treatment goals, prompting the referral for the QRT and determining how soon the QRT needs to be scheduled. If the youth already has care coordination, the QRT coordinator sends the referral, and any additional information is provided to the youth’s care coordinator to begin addressing the concerns identified. If the youth does not currently have care coordination, care coordination is initiated as part of the QRT process. Click here to see later steps in the QRT process. 

The treatment team can advocate with the facility to delay discharge to allow additional time for planning.  However, the facility must follow its guidelines for discharge, which include the least restrictive and medically necessary admissions. Therefore, it may still move forward with the set discharge date. The QRT works with available resources to develop strategies to address safety concerns and increase comfort with discharge if the process cannot be delayed as part of the QRT.

Parents/guardians do not attend QRTs, as all clinical recommendations have already been heard and collected from the treatment team. During the QRT, no additional clinical decisions are made. The QRT is where the Department’s internal teams troubleshoot barriers your care coordinator has had trying to implement the treatment recommendations made by your treatment team. The goal of the QRT is to assist with available resources when regular efforts have not been enough and to support the care coordinator and family in moving forward with fewer barriers.

Your child’s care coordinator will follow up with you after the QRT. The care coordinator will review the QRT notes and discuss the suggested next steps. These may include scheduling a child and family team meeting (CFT) to discuss the options to support your family moving forward. To learn more about CFTs, click here. If tasks were assigned to any additional member of the QRT team (Child Youth and Family Services (CYFS) has a prevention team, developmental disabilities has a crisis team, etc.) your care coordinator will let you know if another team member will be contacting you for coordination and support purposes. 

A CFT is a group of individuals the youth and family select to help support them in addressing the youth and family needs while building on their strengths. This includes the youth, family and local treatment providers, and other community members (such as a coach, friend, or church leader) chosen by the family. CFT meetings are where strategies are developed to address the goals of the youth and family and where clinical decisions are heard. To learn more about CFTs, click here.

Your youth’s QRT referral will not close until the immediate safety concerns, warranting the QRT, are mitigated. You are encouraged to work closely with your youth’s care coordinator to continue to plan for any ongoing concerns. If necessary, this can be elevated to the QRT again if barriers to the implementation of this plan continue to occur. If you feel the plan developed doesn’t address your safety needs adequately, you can request your care coordinator bring these concerns to the QRT. You can also request this yourself by emailing the QRT at DHWQuickReactionTeam@dhw.idaho.gov.

The QRT came about due to an amendment to the Children’s Mental Health Act that created a carve-out in the Child Protection Act. Youth experiencing SED can display out-of-control behaviors that put themselves and others at risk of harm. Families are in a challenging position, trying to keep all their children safe when treatment options for their child with SED are not readily available. The goal of the Child Protection Amendment is to provide a structure in which parents can explore all treatment options with the support of a multisystemic team without fear of being substantiated in a child protection action. While the structure (QRT) does explore all possible treatment avenues, there are times when all options have been exhausted despite the team’s collective efforts. When the system is out of options, the parent has done all they can AND a child remains unsafe to self and others due to the extent of his/her mental health concerns, a child protection report is made. The child protection report is a last resort effort to ensure all resources have been explored and exhausted.

In a QRT case, CYFS is informed that the referral made through the central intake is due to a youth impacted by SED with concerns about safety if the youth were to return home from the current out-of-home placement. Although a safety assessment is required as part of the CYFS process, the department will not make a substantiated disposition that a youth has been abused, neglected, or abandoned by a parent or guardian under the Child Protection Act because of a request for inpatient hospital treatment or an out-of-home placement for the child if:

• The child’s recent mental health condition demonstrates that the child is
  likely to cause harm to himself or to suffer substantial mental or physical
  deterioration, and/or   
• It is likely to cause harm to others, and
• If the risk cannot be eliminated before returning to the child’s family, and     
• the parent or guardian continues to actively engage in the planning process and
  recommended treatment plan.

Based on the Idaho Administrative Rule, a social worker will substantiate an incident when one or more of the following apply:

• The social worker witnessed the abuse or neglect.
• The Child Protective Court determines the child falls under the Child Protective Act due to abuse, neglect, or abandonment.
• The individual admits or confesses to the abuse, neglect, or abandonment.
• Physical or medical evidence establishes abuse, neglect, or abandonment has occurred.
• The facts of the assessment establish more likely than not, the abuse, neglect, or abandonment happened.

If none of the above apply, then the incident is unsubstantiated.

CYFS is a partner in the QRT. CYFS wants to be a resource to the family and be involved as soon as possible to provide access to resources intended to help stabilize your child’s SED and prevent your youth from being removed from your custody. Their goal is to collaborate with and support your family and your child’s team, to ensure your child and family’s needs are met. You, as the parent/guardian, are expected to participate and engage in all efforts for your youth with the expectation that once stable or your youth is no longer in active crisis, a plan will be in place to have your youth in the community and your care.

If, despite efforts made, there will still be a gap between discharge and initiating treatment needed and safety planning efforts do not sufficiently mitigate safety concerns for you and your family to safely take your child home, you have a choice to make. You can take your child home or have them remain in the out-of-home setting after discharge. Often, the facility will engage local law enforcement and child welfare for the next steps. Child welfare will always explore all options to support you and your youth’s identified safety needs so they can remain in your care. 

We would recommend providing the following information. 

• Your family is working with the Department of Health and Welfare’s QRT and your child’s treatment team to develop solutions to resolve immediate safety concerns, including a case worker from child welfare. Name this case worker(s) if you are aware of them.
• Ask if they are informing you the hospital is no longer willing to work with that team.
• If, despite your efforts to provide information on treatment team involvement, the officer’s stance does not change, you will have to make the decision on how to proceed.
• Should you experience this scenario, submit a YES complaint at 208-364-1910/1- 800-352-6044 or send an email to YES@dhw.idaho.gov. If you would like to be anonymous, please visit https://app.keysurvey.com/f/1391131/5d8d/ so the Department can follow up and continue to educate and improve the crisis response to build collaboration and prevent this from happening to other families. Across our divisions, we have been working diligently to educate child welfare case workers, law enforcement, and other system partners. However, when you have that rare experience of encountering someone who is not informed, we would like to be made aware. 

There are several options to address crisis needs, depending on the needs of your youth. Click here  to find crisis resources for your youth.

If you have a question or concern about QRT, please feel free to call the YES complaint/inquiry number at 208-364-1910/1- 800-352-6044 or send an email to YES@dhw.idaho.gov. If you would like to be anonymous, please visit https://app.keysurvey.com/f/1391131/5d8d/.

The origin of the QRT started with legislation (HB 233; I.C. 16-2426A) that amended the Children’s Mental Health Act. Part of the goal was to ensure that youth with mental or behavioral health concerns who are transitioning from an out-of-home placement have their needs met. This legislation created a carve-out in the Child Protection Act to prevent a parent from being substantiated for abuse, neglect, or abandonment when they are requesting inpatient hospital treatment or out-of-home placement for their child with serious emotional disturbance (SED) when their child is likely to cause harm to himself or others and/or suffer substantial mental or physical deterioration if discharged home and the risks cannot be mitigated before returning to their family. QRT was the state’s response to this legislation.

The purpose of the QRT is to find immediate and effective solutions for the appropriate levels of care placements when a youth with mental or behavioral health challenges is being discharged from an out-of-home placement, and the parent/guardian(s) express concern for safety if their child returns home. The goal is to develop these solutions through collaboration between parents/guardians, providers, natural supports, and system partners to ensure the needs of the youth transitioning from an out-of-home placement are met at the appropriate level of care with available resources and to address the immediate safety concerns of the family. 

QRT representatives are a group of individuals across multiple divisions from the Idaho Department of Health and Welfare and their behavioral health managed care organization Magellan Health who have knowledge of Idaho’s youth-serving systems. The teams they represent bring unique perspectives and knowledge to assist in finding solutions to barriers your team is encountering. The teams represented and the knowledge they bring are noted below.

QRT Representatives:

• System Design and Implementation (SDI) Children’s Mental Health (CMH): Coordinate QRT meetings. Focus on bringing services into our state to address gaps in our current system of care for youth. Team members bring clinical experience from prior direct services provided to youth and families.
• Magellan: Provide direct care coordination support to families. Assist families in connecting the youth to appropriate services available in their local community or residential placement when they meet medical necessity. 
• Medicaid- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT): Helps answer questions/provide context regarding Medicaid, psychiatric residential treatment facility (PRTF), or alternative placements. They can also provide information on options that Medicaid could potentially fund.
• Idaho Behavioral Health Plan (IBHP): Oversees the Magellan contract, brings knowledge about services included, and assists in troubleshooting barriers to accessing the quality of care needed.
• Crisis Prevention and Court Services (CPCS): provides consultation, training, and support from a multidisciplinary perspective to individuals with intellectual and developmental disabilities (IDD) to support them living in their community. CPCS also conducts court-ordered evaluations as the designated evaluation committee.
• Youth, Safety & Permanency (YSP), Continuum of Care (COC), Congregate Care Unit (CCU): Due to their work with youth with complex needs, these teams within Child Welfare have extensive knowledge about supports available to youth and families in accessing care, both in the community and in residential settings. The CCU teams have expertise in matching youth with residential placements to meet their unique needs when a youth needs that level of care. 

Case-specific QRT attendees:Participants may attend if they are working directly with your youth or if needs are identified (such as a youth with suspected/diagnosed developmental disability)

• Safety assessor: Will be a direct support working with your family. Will assist in exploring options to address immediate safety needs your family has identified that cannot be mitigated. 
• Medicaid-Developmental Disability Services: Have knowledge about developmental disability services available in your community, to support the treatment needs you and your child’s team have identified.
• Clinical Services Bureau (CSB): They provide clinical expertise and knowledge about services and treatment strategies that could be helpful in the youth’s community.

Clinical decisions are made with you and your youth’s treatment team, which should include providers with clinical expertise. Requests for residential placement are reviewed by Magellan Health or your other insurance provider to determine if they meet medical necessity criteria. The QRT does not make clinical recommendations. Their role is to troubleshoot barriers your family and treatment team are encountering while implementing treatment and safety plans developed and offer solutions with available resources. This team does have clinical experience, so we can make additional recommendations to support treatment planning. 

It is important to advocate for your family’s voice and choice during team meetings. Family voice and choice are very important. IDAPA 16.07.37 also requires treatment teams to ensure treatment is in the least restrictive setting possible. At times, that means exploring treatment options that differ from what you may prefer. The plan can change if your child’s needs change. You also have the right to put in a request for residential care with your care coordinator, if that is what you are seeking, even if treatment providers do not agree this is needed. This request will be approved by Magellan Health if it meets medical necessity criteria. If you get a denial, you have the right to the appeal process.

Serious Emotional Disturbance (SED) is a clinical term for a youth with a DSM-diagnosed mental health, emotional or behavioral disorder, or neuropsychiatric condition that impairs their ability to function in school, family, or the community as identified by an overall level of care need of 1 or
higher as noted by the CANS. You can request a QRT even if your child has not yet received an SED diagnosis.

Your youth is being assessed while in the hospital setting and will receive a diagnosis. The next steps include submitting a request for residential placement with your care coordinator to determine if they meet medical necessity criteria.