Use of Therapeutic Residential Care in the U.S.: Shifting Away from Therapeutic Residential Services to Family-Based Services

Objectives: This paper will review current public policy initiatives at the Federal and State levels as the use of “Congregate Care” continues to be questioned as a placement resource for youth involved with the Child... [ view full abstract ]

Objectives: This paper will review current public policy initiatives at the Federal and State levels as the use of “Congregate Care” continues to be questioned as a placement resource for youth involved with the Child Welfare System in the United States.
Method: The model for funding congregate care in the US will be reviewed and concerns about overutilization of group homes presented. Insight into proposed funding reforms will be discussed.
Results: In fiscal year 2013, the US spent 22.9 Billion US dollars on child welfare administrative costs and direct services. The largest amount, 24% was spent on administrative services; 23% on family support and independent living services; 21% on adoption and guardianship services; 17% of that amount or $3.8 Billion was spent on Congregate Care and 15% on family foster/kinship care. Since 2004, the percentage of youth placed in Congregate care settings has declined from 18% to 14% with approximately 80,000 youth being placed in congregate care in 2013 and 324,000 placed in foster/kinship homes (Open Minds, 2016).
Foster care in the US is the responsibility of states. However, the funding for foster care is supported by the Federal government. States get money allocated based on the number of youth they have in foster care. This has raised concerns that there is a perverse incentive for states to remove more children from their biological families in order to maximize the federal contribution to foster care even though the federal contribution to states has been dwindling since the mid-1990s and now amounts to an average of about 35% of the costs incurred by states.
Congregate care is the term being used by policy makers to include any “non-family based placement” and range from group homes and shelters with minimal or no on-site clinical services to Therapeutic Residential Care. The greatest concern from those opposed to the use of congregate care is in the group home and shelter models where there is a perception that children are merely “housed and forgotten”. This shift away from using congregate care settings to foster/kinship homes is likely to increase despite the limited availability of foster/kinship homes in most states and the concern that youth with significant behavioral health needs will be poorly served in family-based settings.
The prevailing argument is that youth should be in families. This is clearly preferable but ignores the significant mental health needs of this population. Most studies report between 50-80% of youth entering care have a diagnosed behavioral health disorder. While some youth could be helped in traditional outpatient settings, a significant proportion will need higher levels of care. Group homes typically will facilitate a youth receiving any indicated mental health service in the community. By removing this “intermediate level of care” from the service continuum, we may end up with two options: family/kinship care and Therapeutic Residential Care which can cost in excess of $150-200,000 per year.
Current finance reform proposals would require a clinical assessment be used to determine whether and how long a child could be placed in a Therapeutic Residential Program. There would be a federal definition of a “Qualified Residential Treatment Program (QRTP)” written into law for the first time. Periodic reassessment would be required to determine when the youth was ready to be placed in a family resource setting. Judges would be involved in approving placements in a QRTP.
Conclusions: An increasing focus on using family-based care has been and continues to be public policy in the US. It will be critically important to monitor the outcomes of this policy change for youth who would have previously been cared for in therapeutic residential settings.