Authorized Seclusion, Restraint, and Safeguards in Home and Community Based Medicaid Programs for Children With...

1915(c) Home and Community-Based Services (HCBS) Medicaid waivers allow states to finance community-based alternatives to institutional psychiatric care for youth with Serious Emotional Disturbance (SED), including diversion from Psychiatric Residential Treatment Facilities (PRTFs). Although federal HCBS policy emphasizes freedom from coercion and restraint, states define which seclusion, restraint, and restrictive interventions (SR/RI) are permitted and what safeguards apply. Waiver applications therefore provide a systematic source for examining how states structure SR/RI authorization and safety oversight in community settings. This study's objective was to quantify state policies governing SR/RI in SED HCBS waivers, examine changes over time, and compare these policies with PRTF-linked HCBS demonstration programs, which operated from 2007 to 2017. Directed content analysis was applied to 138 waiver applications from 19 state SED programs (approved between 2006 and 2022). A Restrictiveness and Safety Index (RSI) was developed by subtracting authorized SR/RI types from the number of safeguards (e.g., monitoring, reporting, training), with higher scores indicating more safeguards relative to permitted interventions. PRTF demonstration waivers (9 states, 2007-2017) were analyzed separately. Mean RSI was 3.94 (SD = 3.73) for HCBS waivers and 2.62 (SD = 2.52) for PRTF demonstrations. RSI increased in 17 of 19 states, and declined in 2 states. The national HCBS mean rose from 2.18 (2009) to 5.02 for waiver periods approved through 2027, reflecting increased safeguards, reduced SR/RI authorization, or both; PRTF programs increased from 1.63 to 3.42 (2007-2017). HCBS waivers generally specified more safeguards per intervention category than PRTF demonstrations. HCBS waiver policies have shifted toward more safeguards relative to authorized SR/RI. These findings describe policy change only and do not establish reduced SR/RI use or improved outcomes. Further research linking policy to practice and patient outcomes is needed.