OUT-OF-STATE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY PLACEMENTS: CAUSES, CONSEQUENCES, AND SOLUTIONS

Psychiatric Residential Treatment Facilities (PRTFs) serve as the most restrictive level of care for youth with serious emotional disturbances. Despite policy goals to provide care in the least restrictive environment, North Carolina saw out-of-state (OOS) PRTF placements increase from 15% to 36% between 2015 and 2021. This dissertation examines the systemic causes, clinical consequences, and potential solutions to this trend through three distinct research aims.Aim 1 utilized Group Model Building workshops with stakeholders to identify the drivers of OOS placements. The findings suggest that workforce fragility and a punitive regulatory environment lead in-state facilities to avoid admitting youth with complex needs, effectively "cherry-picking" stable cases and pushing high-acuity youth to OOS facilities.Aim 2 analyzed North Carolina Medicaid data (2016–2022) using Cox regression survival analysis to evaluate the impact of placement location on readmission. The study found that youth placed out-of-state had a 26% higher hazard of readmission to a PRTF compared to those treated in-state. Additionally, foster care involvement was associated with an 81% higher hazard of readmission, highlighting significant disparities in outcomes for vulnerable populations.Aim 3 employed a discrete-event simulation (DES) model to test the efficacy of supply-side interventions. Results indicated that increasing the operational capacity of existing licensed beds to 85% or higher would reduce OOS placements by over 60%, whereas simply adding new licensed beds had a negligible impact if workforce and regulatory issues remained unaddressed.This research demonstrates that OOS placement is a systemic response to constrained in-state capacity rather than a clinical necessity. Policy interventions must prioritize workforce stabilization, regulatory reform, and the optimization of existing infrastructure to ensure youth receive high-quality care close to home and their support networks.