A new policy brief by Chapin Hall and the Chadwick Center, Using Evidence to Accelerate the Safe and Effective Reduction of Congregate Care for Youth Involved with Child Welfare was released in the past week.  The research could be important in light of the Senate Finance Committee’s still-in-development Families First Act which could potentially open up some Title IV-E foster care funding to limited in-home, substance use and mental health services while also placing restrictions on some forms of residential and group care.

In examining the use of residential and congregate care across the states the study observed:

  • Use of congregate care has decreased by 20% since 2009, but there is substantial variation among and in states (suggesting detailed analysis to understand local trends).
  • States that rely heavily on congregate care as a first placement suggests capacity building for foster homes is needed.
  • Youth placed in congregate care and therapeutic foster homes have significantly higher levels of internalizing/externalizing behaviors than those in traditional foster care meaning that increased access to services that effectively address these behaviors are essential to safely reducing congregate care.
  • Compared to youth whose clinical needs are met through therapeutic foster care, youth placed in congregate care are more likely have externalizing problems. Strategies for serving these youth in home-based settings should focus on preparing homes to respond by de-escalating difficult behaviors.
  • The California Evidence Based Clearinghouse for Child Welfare (CEBC) contains tested strategies for disruptive behavior problems but many of them have not been tested for use in the child welfare population. That suggests that support is needed to implement and evaluate interventions that may stabilize foster care placements.

The Families First Act has not yet been scheduled for a Senate Finance Committee vote after initial hopes had been for a November 2015 action. As currently proposed it would place limitations on federal foster care funds for placements that don’t fit into the definition of family foster care or a Qualified Residential Treatment Program (QRTP) and it would open up Title IV-E foster care funding to provide limited funding to prevent foster care placements conditioned on meeting certain research based parameters.

The Chapin Hall/Chadwick Center recommendations for making improvements include:

Customize strategies for reductions in the use of congregate care.

States differ in their use of congregate care and that means it will be important for policymakers-state agencies-treatment providers to work collaboratively toward customized solutions tailored to jurisdictions. Solutions should include stabilizing and fortifying community placement resources, strategies to shorten length of stay in congregate care settings through facilitation of step-downs and discharges to permanency.

Differentiate intensity of treatment from restrictiveness of placement.

The view of the placement continuum as a progression of restrictiveness on a single dimension has resulted in a system in which some youth “fail up” to higher levels of placement after experiencing instability at “lower” levels. Others who begin their spells in high levels of care are likely to remain or return. Placement continuum into one for intensity of services and another for restrictiveness of placement – will allow practitioners/policymakers to consider whether more intensive services may be provided in less restrictive settings, with foster parents equipped to manage behavior.

Incentivize increasing capacity for skilled and/or specialized home-based placement.

To avert congregate care it will be necessary to substantially increase the capacity in home-based placements, especially for youth entering child welfare at ages older than 11 years. Capacity must be pursued strategically to ensure foster parents are prepared to meet the needs of older youth and other specialized populations diverted or leaving congregate care including children and youth with sexual behavior and chronic medical needs.

Support access to evidence-based interventions designed to help stabilize placements and/or enhance clinical outcomes for youth in foster and kin placements.

Plans must be developed to ensure that support continues across placement changes, including after reunification, so that all caregivers have the necessary care is prevented.

Provide direct and indirect resources for the implementation of evidence-based approaches to deflect youth from congregate care settings.

Some states have pilot implementations to test community-based treatments, implemented with specialized foster homes, to deflect youth from higher-end costly congregate care placements. Pilots should be monitored to assess the potential.

Enhance access for child welfare systems to technical assistance for selecting and successfully implementing evidence-based practices.

The CEBC has worked with numerous child welfare agencies that have experienced failure on previous efforts to implement new practices. Failures have resulted from poor program selection and planning during the early implementation. The CEBC has developed technical assistance materials but more hands-on, data-driven support may be needed. 

Promote research on these interventions, especially in child welfare settings.

Few mental health treatments were designed for child welfare so research is needed to ensure the efficacy of these interventions. Limited federal research has resulted in fewer rigorous studies.

Develop funding streams to support flexibility in the delivery/intensity of outpatient services.

To step-down youth who have benefited from congregate care, especially residential treatment, to a community based home-like setting may require a combination of intensive evidence-based or supported treatments and support services before disruption. To support some of the high-need children in home-like settings, states may need to allow more clinical contacts; expanded use of follow-up in-home services combined with center-based therapy; day treatment, therapeutic day care; direct clinical care for caregivers; or clinical contacts for a longer than current reimbursement rules allow. This may require changes to existing Medicaid Plans or other funding reimbursement rules.