What are some potential strategies for reducing reliance on congregate care?
We believe that children develop best within families and that every child deserves to grow up in a stable family that cares about how they will do in every aspect of their lives throughout their lives. When children are in the care of child welfare agencies, we believe they do best in the most nurturing and least restrictive home placement as possible. With those values in mind, group home care should be used only for treating complicated physical and behavioral health needs, never as a long-term placement. While some child welfare leaders are skeptical that youth who have lived in group placements for long periods can be moved back to family and community settings, we are seeing a select group of innovative leaders experience tremendous success reducing reliance on congregate care. This information packet was requested by an Office of Child Advocate in a mid-size Midwestern state, and we hope it will inform your strategies as well.
– David Sanders, PH.D., EVP of Systems Improvement, Casey Family Programs
Congregate care is costly on many levels: it is more expensive and produces poorer outcomes than family-based settings, and it poses roadblocks to the timely achievement of permanency.1 Over the past ten years, the child welfare field has seen a 37 percent reduction in the number of children living in congregate care nationwide. Data indicates that children and youth who live in congregate settings spend an average of eight months there.2 This document describes the key resources and strategies that may assist in reducing the reliance on congregate care.
The 2016 review of research, Using Evidence to Accelerate the Safe and Effective Reduction of Congregate Care for Youth Involved with Child Welfare, examines new federal and state policies, as well as clinical guidelines, and suggests that congregate care should be used only as a short-term treatment alternative to address complex, acute mental health problems.3
In a 2017 follow-up to this report, the Children’s Bureau identified practice and program strategies for safely reducing congregate care.4 The report includes links to evidence-based practices along with an organizational assessment designed to help child welfare agencies review their policies and practices to identify areas for improvement.
A literature review completed by the Southern Area Consortium of Human Services5 provides another comprehensive resource that highlights a range of strategies to support the safe reduction of congregate care. This review contains several alternatives for reducing congregate care, including: evidence-based behavioral health interventions; services and supports for home-based caregivers; foster family recruitment, support, and retention; treatment foster care; time-limited placements; and system reform strategies.
Safely reducing congregate care:
Taken together, the reports described above, as well as interviews conducted with jurisdictional leaders from Arkansas, New Jersey, Tennessee, and Virginia, highlight a range of practice, program, and three-branch strategies for review and consideration.
Jurisdictions that have implemented practice-level strategies recommend the expansion of services to prevent removal as well as support reunification. Examples of evidence-based treatment programs6 include Multi-Systemic Therapy (MST), Parent-Child Interaction Therapy (PCIT), Functional Family Therapy (FFT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), HOMEBUILDERS, and Positive Parenting Programs (Triple P).
Jurisdiction leaders recommend using early trauma screening and assessments that can provide tailored mental health services based on individual needs. The Child and Adolescent Needs and Strengths Assessment (CANS) is widely used in Texas, New Jersey, Tennessee, and Virginia, among other jurisdictions. Several jurisdictions identified increasing the availability of family-based placement options, including relative placements, as significantly affecting their ability to reduce congregate care. New Jersey is adopting this strategy as it moves away from large residential treatment centers to specialized five-bed family homes for short-term crisis stabilization and support.
Other states, such as Minnesota and Hawaii, have found permanency roundtables (PRTs) and individualized transition planning helpful in improving placement of older youth in family homes. Strategies also include targeted caregiver recruitment of therapeutic homes. Placement team meetings, sometimes called Family Team Meetings, involve a range of service providers along with the youth and family members who strategize together to resolve issues and ensure children and youth receive the correct level of care.
Program strategies identified by jurisdictions include working with congregate care providers to change their service array and practices. In Virginia, for example, financial rewards were put in place that incentivized congregate providers to change the way placement and services are provided to youth in foster care. In Tennessee’s continuum of care model, agencies are expected to provide for the whole continuum of placement options as part of their contract. In many jurisdictions, child welfare agencies have implemented performance-based contracting to incentivize placement of a child with a family and disincentivize placement in congregate care whenever possible and appropriate. Other program strategies include building trauma-informed workforce capacity; providing supports to families caring for children with challenging behaviors; engaging more relative care providers; reducing caseloads; and working with community programs that can be supportive.
All jurisdictions indicated that they were using data to inform practice and measure outcomes,7 along with monitoring facilities and programs to ensure quality services. Finally, many jurisdictions engage in a multi-disciplinary team of professionals, providers, and constituents to review individual placements and determine the appropriateness of that placement every six months or more, when needed.
Without strong three-branch strategies and support, agencies find implementing and sustaining congregate care reduction efforts significantly more challenging. Congress and state legislatures have considered and enacted policy changes to incentivize family-based placements, especially with relatives and kin, whenever possible and appropriate for a child who has been removed from his or her home. Proposals under consideration or that were enacted include:
- Increasing oversight of agencies to ensure they are considering kin and foster families first
- Providing subsidies to kinship caregivers to support children in their care
- Requiring regular assessment of a child to ensure that a placement is appropriate and meeting the needs of a child
- Increasing judicial oversight to ensure the child is in the appropriate placement to meet the needs identified in the assessment
- Increasing the supports for kinship caregivers
- Limiting the financial participation in the cost of congregate care settings if the placement is not appropriate for the child, based on an assessment
The Family First Prevention Services Act, passed by the U.S. House of Representatives unanimously by voice vote in 2016, did not pass the Senate. It was reintroduced in January 2017 and would ensure that congregate care placements are only used for children and youth when there is a current and documented need for such placement. Key provisions related to congregate care include changes to the types of out-of-home placements that would be eligible for federal Title IV-E reimbursement. In addition, Federal Financial Participation would only be provided for specific placements after a child’s second week in care.
State legislatures can play an additional role by updating statutes to match jurisdictional priorities for reducing congregate care (e.g., requiring a continuum of care). Strong leadership support and messaging from the governor’s office, as well as from executive-level administrators, is key in coordinating efforts across complex systems and reinforcing a consistent message about the safe reduction of congregate care. By focusing on the shared goal of improved outcomes for children, youth, and families, these leaders have found they can guide their staff and contracted agencies to identify alternatives to congregate care. A collaborative practice model focused on outcomes can positively support the safe reduction of congregate care usage and transition to a new continuum of care.
Strong judicial leadership is another key component to reducing residential treatment or congregate care placements. One jurisdiction identified training of their judiciary in trauma- and evidence-informed practices as a key factor in their success. The National Center for State Courts has also developed a web-based toolkit, Reducing Reliance on Non-family Placements: A Judicial Toolkit, to assist judges, attorneys, and advocates in reducing reliance on congregate care and supporting family-based placement decisions: http://www.ncsc.org/Microsites/EveryKid/Home.aspx. There is also a powerful video, available at https://vimeo.com/125083810,8 featuring a Virginia judge speaking about congregate care reform. Jurisdictions exploring congregate care reduction efforts should also include components of court supervision in their comprehensive plans.
1 Annie E. Casey Foundation. (2012). Reducing Congregate Care: Worth the Fight. Retrieved from http://www.aecf.org/blog/reducing-congregate-care-worth-the-fight
2 U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. (2015). A National Look at the Use of Congregate Care in Child Welfare. Retrieved from: https://www.acf.hhs.gov/sites/default/files/cb/cbcongregatecare_brief.pdf
3 Chapin Hall and the Chadwick Center. (2016). Using Evidence to Accelerate the Safe and Effective Reduction of Congregate Care for Youth Involved with Child Welfare. Retrieved from: https://comm.ncsl.org/productfiles/83453725/reduction_of_congregate_care.pdf
4 Child Welfare Capacity Building Collaborative. (2017). Working With Children and Youth with Complex Clinical Needs: Strategies in the Safe Reduction of Congregate Care. Retrieved from: https://capacity.childwelfare.gov/states/focus-areas/foster-care-permanency/congregate-care-guide
5 San Diego State University School of Social Work. (2016). Literature Review: Alternatives to Congregate Care. Retrieved from: https://theacademy.sdsu.edu/wp-content/uploads/2016/03/alternatives-congregate-care-feb-2016.pdf
6 The California Evidence-Based Clearinghouse. (n.d.). List of programs. http://www.cebc4cw.org/search/by-program-name
7 The Center for State Child Welfare Data at Chapin Hall. (2017). Managing the Use of Congregate Care: Using Your Administrative Data to Guide the Way. Retrieved from: https://fcda.chapinhall.org/congregate-care/webinar-recap-using-administrative-data-manage-use-congregate-care
8 Accessing the video requires the following password: CCvideo