On Tuesday, July 24, the House Ways and Means Subcommittee on Human Resources held an oversight hearing on the implementation of the Family First Prevention Services Act (FFA).

Based on the testimony and answers by Associate Commissioner Jerry Milner, Children’s Bureau-HHS, and the comments of Subcommittee members there are a lot of questions on the minds of state policymakers and a lot of blanks that HHS needs to fill regarding the implementation of the FFA.

Committee Chairman Adrian Smith (R-NE) said that the Subcommittee had solicited and received 200 questions to ask during the hearing and Commissioner Milner indicated that HHS has received 189 different sets of comments in response to the ACF request for input on services and programs to be approved under the FFA. (CWLA submitted its recommendations and comments the weekend before the hearing).

In his opening comments Chairman Smith took time to commend his state of Nebraska for being what he labeled as “on the leading edge of implementation and setting a strong example for others under the leadership of Dr. Courtney Phillips, CEO of the Nebraska Department of Health and Human Services, and Director Matthew Wallen of the Division of Children and Family Services (DCFS).”

Rankling Member and Congressman Danny Davis (D-IL) focused his comments and many of his questions on kinship care and the provisions of the law that will influence those services and supports.

In his initial testimony Mr. Milner said they were approaching implementation with as much flexibility as possible, saying that ACF does not intend to regulate definitions of key concepts beyond what is in the statute and said they will not define “candidate,” “imminent risk of foster care entry,” and “risk of sex trafficking.”

He also said that ACF is working on contracting to create a clearinghouse that will be responsible for identifying interventions and establishing criteria for reimbursement under the title IV-E prevention services program. He did not set a specific timeline but said it would be soon. He also said they were starting to evaluate the comments they had received and that they expect to release the criteria and a list of initial services within the first quarter of FY 2019 which stretches from October 1 through December 31, 2018.

In his testimony and comments, he highlighted some of the challenges:

Availability of an adequate array of placement options for children in foster care:
While congregate care placements have declined nationally from 14.6 percent of the foster care
population in 2012 to 12.2 percent in 2016, some youth currently in congregate care may be
unable to succeed in a foster family home because they may have needs that cannot be addressed
in a family setting.

Twelve-month availability of prevention services is too short for many families’ needs:
States are rarely able to enroll families in programs and services immediately due to limited
availability of services, wait lists, and other barriers. As a result, availability of federal
reimbursement under the title IV-E Prevention Services Program is likely to be less than the
12 months from the time the state identifies the child as being in need of programs and services
as allotted in the statute. States are also seeing a significant increase in the misuse of opioids and
other substances resulting in more families involved with the child welfare system. States will need to ensure they can promptly place families in these services to ensure they are taking full advantage of the twelve-month period of availability provided by the statute.

Review of all studies on prevention programs and services as part of the clearinghouse:
Although FFA criteria and evidence requirements closely align with existing evidence-based clearinghouses, significant differences exist that will likely make reviews time consuming and resource-intensive. Many studies of relevant programs and services have not been reviewed in accordance with the statutory requirements. For example, FFA broadens the type of research that may meet criteria to include rigorous quasi-experimental research designs in addition to randomized control trials for designating well-supported and supported practices.

Limited current availability of well-supported prevention programs and services:
FFA requires states to spend at least 50 percent of their IV-E prevention funding on well
supported programs. Few programs have been documented as well-supported.

Difficulty determining which kinship navigator programs would meet statutory criteria:
FFA opens reimbursement for kinship navigator programs that meet one of the
three levels of evidence (well-supported, supported, and promising) in prevention. It is unclear whether any kinship navigator programs meet the criteria because they have not been included in existing evidence reviews. Commissioner Milner did say that they are closely examining one program. He was also uncertain on whether navigator programs would have to meet the minimum 50 percent to be spent on the well-supported programs.

Limited number of qualified residential treatment programs meeting the statutory criteria:
There are currently a limited number of QRTPs that meet the statutory criteria. FFA requires
programs to be accredited, to be trauma-informed, and to provide aftercare services for six months following discharge. There are additional review and court review requirements. Mr. Milner did respond to a question on the 30 day and 60-day reviews mandated and indicated there was no flexibility on the time frames based on the statute.

Limited availability of qualified individuals to assess placements in QRTPs:
A state must ensure that a child’s placement is assessed by a “qualified individual” within 30 days of the start of the placement. States already struggle to meet existing needs and requirements given the low supply of qualified clinicians and this may become more difficult.

During the hearing it was clarified that states have until September 29, 2019 to decide if they will delay the QRTP provisions by up to two years. There had been some confusion with conflicting dates between the guidance and the request for delay form the Bureau published earlier this month.

Other issues addressed during the question and answer period: There will be a Federal Register notice very soon on the licensing standards for foster and kinship care. They will be soliciting what standards they should be looking at and will solicit other feedback. The notice is late in the internal review process, so it should be out in the next several weeks. Mr. Milner said he was uncertain on what happens once a person reaches the 12-month limit on services if an addition period could be used. Congressional comments have indicated that there is the potential for additional periods of 12 months of services. Miller also said that there was very little money to conduct additional research. He was also asked about the issue of “state wideness” that is the issue of whether the same services must be provided across the state. He indicated there could be some differences in services. In a state that has a strong county-run structure (Ohio was an example raised) it would be up to the state to opt into services and then within the state there would have to be decision about how that plays out at the local level.