START has undergone rigorous evaluation described in at least a dozen peer-reviewed publications. Outcomes from this collective body of evidence show that when implemented with fidelity:

• Children whose families were served through START entered out-of-home placement at half the rate of children from a matched comparison group (21% vs. 42%).⁵
• At case closure, more than 75% of children whose families were served through START remained with or reunified with their parent(s).⁶
• Mothers in START had higher rates of sobriety and early recovery than a matched comparison group (66% vs. 37%).⁷
• At 12 months post-intervention, more children whose families were served in START remained free from both out-of-home placement and recurrence of maltreatment as compared to children whose parents received usual child welfare services (68.5% vs. 56%).⁸
• At 12 months post-intervention, more Black children whose families were served in START remained free of out-of-home placement and child abuse and neglect than Black children whose parents were served in treatment as usual (80.6% vs. 56%).⁹
• Parents in START who received medication for opioid use disorders (MOUD) retained child custody at a higher rate than those with opioid use who did not receive MOUD (75% vs. 52%) and had improved family functioning. Every additional month of medication increased the likelihood of children remaining with their parents at the end of the case by 10%.^10,11
• For every dollar spent on START, jurisdictions saved an estimated $2.22 on costs associated with out-of-home placement.¹²

Jurisdictions also benefit from structural and practice improvements throughout the course of START implementation, such as:

• Quick access to substance use disorder treatment services.
• More parents entering and staying in treatment.
• Improved collaboration with community treatment providers.
• Fewer children entering out-of-home care.
• Workforce skilled in engaging and supporting families affected by substance use disorders.
• Applying the spirit of START — engaging families with compassion, understanding, and hope — to all families served through the system.

START has been replicated and scaled for effective implementation in rural and urban, public and privatized, and state- and county-administered child welfare systems (This link shows current operational sites, the number and location of state and local affiliates, and certified affiliates.) While Kentucky currently is the only affiliate with published impact studies, other affiliates are beginning to see preliminary outcomes, such as fewer children entering out-of-home care, improved collaboration with treatment providers, more rapid access to services, better reunification rates, and increased workforce skill in engaging families.¹³ As START is a complex, collaborative model, implementation requires a commitment to a dedicated multi-year, cross-system effort. This effort begins with readiness and feasibility planning, followed by standardized training and individualized technical assistance necessary for START implementation and certification.

Affiliates of the National START Model are state and local jurisdictions that are certified or are engaging in technical assistance with a commitment to reach fidelity to the model. Affiliates have access to START proprietary materials, such as the START name, logo, manual, training, and guidance documents. Certified affiliates have reached full fidelity and met all requirements of a three-step certification review. Some states with multiple local jurisdictions also request training and technical assistance to develop their own infrastructure — once all requirements are met, they may become Certified State Infrastructure START Affiliates. Affiliates in Kansas, Kentucky, North Carolina, and Ohio offer examples of effective implementation of START, along with unique considerations. All four states have added START to their Title IV-E Prevention Services 5-year plans, and three are currently drawing down federal funding for START.

Kansas

Since 2019, START has been implemented in four regions – Kansas City, Wichita, Topeka, and Pittsburg – totaling 22 counties. A private nonprofit, DCCCA, that provides both family preservation and substance use disorder treatment services contracts with the state to provide START to eligible families that state caseworkers refer for in-home child welfare services. The initial contract required quickly launching services – subsequent training and technical assistance has focused on shifting to fidelity in practice. Kansas operates a state-administered, privatized child welfare system, which can result in complex barriers to fidelity. For example, DCCCA has multiple types of state contracts, and in one, START families are transferred to another agency for services if a child removal occurs. Discussion is ongoing to resolve this barrier. Although it is too early for an impact evaluation, DCCCA is participating in a federally-funded cross-site evaluation of START called Replication of Recovery Reunification Interventions for Families (R3) and has reported that START has successfully diverted many participating families from out-of-home care.¹⁴

Kentucky

START currently is available in seven counties in Kentucky, which is a state-administered child welfare system. State-employed supervisors and child welfare caseworkers team with family mentors employed by the University of Kentucky, with contracted START directors reporting to state child welfare leadership and overseeing local model implementation. As Kentucky is the original site of replication, adaptation, standardization, and rigorous outcome evaluation, the state selected counties with populations large enough for up to four dyads per team, funding them through Temporary Assistance for Needy Families (TANF), state general funds, and Title IV-E Prevention Services dollars. While the counties involved in the original launch reached full fidelity, staffing shortages have slowed efforts to reach fidelity in expansion counties.