Department of Health and Human Servces 
OFFICE OF 
INSPECTOR GENERAL 
RESPITE CARE SERVICES 
FOR FOSTER PARENTS 
"Y' 0. 
.., SERVICe"
JUN 
GIBBS BROWN 
Inspector General 
AUGUST 1994 
"'''d3a  OEI-0493-0070  OFFICE OF INSPECfOR GENERA 
The mission of the Offce of Inspector General (DIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services' (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs. This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three DIG operating components: the Offce of Audit Services, the 
Offce of Investigations, and the Offce of Evaluation and Inspections. The DIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT SERVICES 
The DIG's Offce of Audit Servces (OAS) provide:; all auditing servces for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilties and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and effciency throughout the Department. 
INTIGATIONS 
OFFICE OF 
The DIG's Offce of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
AN 
OFFICE OF EVALUATION  INSPECfONS 
The DIG's Offce of Evaluation and Inspections (DEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department 
the Congress, and the public. The findings and recommendations contained in these inspection 
reports generate rapid , accurate, and up-to-date information on the effciency, vulnerabilty, 
and effectiveness of departmental programs. 
DEI's Atlanta Regional Offce staff prepared this report under the direction of Jesse J. 
Flowers, Regional Inspector General, and Christopher Koehler, Deputy Regional Inspector 
General. Principal DEI staff included: 
Atlanta Region  Headquarters 
Paula Bowker, Project Leader  AJan Levine, Program Specialist 
Ron Kalil  Mark Krushat 
Ruth Reiser 
Barbara Tedesco 1 
Maureen Wilce  EXECUTIVE  SUMMAR Y

PUROSE 
To describe availability and use of respite care services for foster parentf.. 
BACKGROUN 
Between 1983 and 1992 the number of children entering foster care increased about 
74 percent, while the number of family foster homes decreased about 11 percent. 
major reason for the decline in family foster homes is stress. 
Respite care may help retain foster parents. It is intended to relieve stress and 
prevent disruptions of placements of foster children. Respite care may be formal or 
informal. Formal respite care is governed by agency policy while informal is not. 
Federal funds are available for respite care from a variety of sources. For example 
the Omnibus Budget Reconciliation Act of 1993 authorized funds for Family 
Preservation and Family Support Services. While respite care for foster parents is 
included in such funding authorities, it is not mandated. 
SCOPE 
We surveyed a random sample of 11 State foster care agencies, 66 local foster care 
agencies, and 5 State foster parent associations. Our inspection focused on availability 
and use of respite care. Based on prior studies and expert opinions, we assumed that 
respite care is an important servce for recruiting and retaining foster parents. We did 
not attempt to prove any beneficial effects of respite care. 
FIINGS 
Respite Cae Is Available Mostly Though Other Foster Parents 
Nearly all local foster care agencies (64 of 66) said either formal or informal respite 
care was available to foster parents. About 55 percent of local agencies said formal 
respite care is available. About 92 percent said informal respite care is available. . 
However, most foster care staffs who responded to our survey said more formal 
respite care servces are needed than are currently available. Most respite care 
whether formal or informal, is provided by other foster parents. Ninety-five percent of 
the local foster care agencies (38 of 40) we surveyed said other family foster homes 
provide formal respite care, and nearly ninety percent (53 of 59) said other family 
foster homes provide informal respite care.  The Major Source Of Respite Cae Is Declig 
During the first six months of 1993, the number of family foster homes declined by 
about 2 percent. Since foster parents themselves are the primary source of 
respite
care, potential respite providers are also decreasing. 
Foster Parent Use Of Available Respite Cae Servces Is Unknown 
We could not precisely determine the extent that available respite care servces were 
used by foster parents. Foster care agencies have inadequate or nonexistent tracking
systems for respite care. Only seven of the 66 local foster 
cl!re' agencies we surveyed
could furnish data about use. Those senn reported that about 9.
5 percent of foster
parents used respite care servces in the first six months of 
1993. This limited data
suggest that available respite care may be under-used. 
Potential Barers To Foster Parent 
Use Of Respite Care 
Staff at a few local foster care agencies identified barriers that might inhibit use of 
respite care servces by foster parents. The barriers frequently cited were foster 
parent concern about settings for respite care
, concern about respite provider skils
and lack of transportation to respite. 
OPPORTU 
FOR PROGRA ENHCEMENT 
The provision of respite care servces could help retain and recruit foster parents. 
Consequently retaining foster parents can help avoid trauma caused by multiple 
placements of foster care children, cost of institutional care for foster care children
and cost of foster parent recruitment. ACF can enhance the 
accomplishment of such
objectives by (1) encouraging States to take advantage of funds made available by the 
Omnibus Budget Reconcilation Act of 
1993 for Family Preservation and Family
Support Servces, as well as other sources, (2) continuing to provide training and
technical assistance for developing and improving respite programs through current 
mechanisms such as the ARCH in Chapel Hil
, North Carolina, and (3) providing
encouragement, leadership, guidance and information to States on developing 
systems
for tracking use of respite care
, program practices to increase use of respite care
servces by foster parents, and sources of formal respite care other than family foster 
homes.  . . . . ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  .. . . . . . 
TABLE OF CONTENTS
PAGE 
EXECU SUMY 
INODUCfON . 
. . . . . . . . . . .. 1
FIINGS. . 
. . . . . . . . . . . . . . . . . 6
Respite Care Available Mostly Through Other
Foster Parents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " . . . . . . 6
The Major Source Of Respite
Care Is Declining. . . . . . . . . . . . . . . . . . . ". . . . . . . . . . . . . . . . . . . . . . . . 7
Foster Parent Use Of Respite Care Is Unknown  . . . . . . . . . . . . . . . . . . . 8
Potential Barriers To Use Of Respite Care  . . . . . . . . . . . . . . . . . . . . . . . 9
OPPORTU 
FOR PROGRA ENHCEMENT. . 
. . . . . . . . . . . . . . .. 10 INTRODUCTION
PUROSE 
To describe availability and use of respite care servces for foster parents.
BACKGROUN 
Numer Of Fosler Chilen Increasg While Numer Of Fosler Home Decreasing 
The number of children entering foster care increased about 74 percent from 1983 to 
1992. During this ten year period, the number of foster homes declined by nearly 11 
percent. The figure below shows National Foster Parent Association (NFPA) and the 
Administration for Children and Familes (ACF), Department of Health and Human 
Servces (HHS), estimates of foster care children and foster homes. 
(In Thousands) 
500 
450 
400
300
259
200
140 
125 
100
1983  1992 
FOSTER CHILDREN  HOMES. 
E2FOSTER  Stres Is A Major Contrutor To Declin In Fosler Parents 
According to a 1992 ACF report written by James Bell Associates, children entering 
foster care today have more emotional and behavioral problems than ever before. 
Foster care children are tyically medically fragile, handicapped, or seriously il. They 
frequently suffer from serious physical and mental problems caused by fetal alcohol 
syndrome, and exposure to HIV, drugs, and sexual and physical abuse. Such children 
place a high level of social and economic stress on foster parents. Many foster 
parents are not able, or willng, to give the time and attention needed by medically 
fragile children. As a result, it has become increasingly more difficult to recruit and 
retain foster parents. 
Respite Care May Help Retain Foster Parents 
Foster care experts and advocates generally agree that respite care for foster parents 
is important for recruiting and retaining foster parents. It also helps prevent out-of-
home placement of children. The Director, Information and Services Office, National 
Foster Parent Association, stated that respite care is the most important factor for 
retaining foster parents--particularly those caring for special needs children. Further 
James Bell Associates reported survey results showing that in 1992 current and former 
foster parents identified respite servces as their fourth most important unmet need. 
The first three were counseling, day care, and health care that is not covered by 
Medicaid. 
Respite care for foster parents is generally defined as planned, temporary, periodic
relief from foster care responsibilities. Respite care is intended to relieve foster 
parents' stress and prevent disruption of placements of foster children. Respite care 
helps minimize "burn out" and loss of existing foster parents. As a result, the (1) 
trauma of multiple placements of a foster child may be avoided, (2) cost of recruiting 
and training new foster parents may be 10Her, and (3) higher cost of institutional care 
for some foster children is avoided. 
Recognized TYpe of Res pile Care Are Formal and Informl 
Tho 
Respite care may be provided both formally and informally. Formal respite care is 
provided according to set policies and procedures. For example, formal policies 
procedures, and rules exist for locating respite providers, assuring that they meet 
specific technical, moral, and social qualifications, and matching foster families with 
respite providers. The policies and procedures frequently provide for formal training 
and monitoring to assure that respite providers give appropriate care. In a formal
respite care program a foster care agency actively attempts to get foster parents to use
respite care.

The National Study of Current and Former Foster Parents - Draft Final Report " the 
Administration for Children and Familes, by James Bell Associates, December 1992.  Conversely, informal respite care is obtained by foster parents themselves on an ad-
hoc basis. Informal respite care is not guided by policies and procedures. Payment 
for informal respite care is the responsibilty of the foster parent receiving the services. 
However, a foster care agency might ultimately pay for respite servces renctered. For 
example, a foster parent may arrange for another foster parent to provide respite 
care, and then notify the appropriate foster care agency to transfer part of the child 
care payment to the respite provider. In such instances, a foster care agency does 
nothing more than perform a bookkeeping function. 
Availbil And Use Of Respite Care Are Unkown 
Little information exists on the availability of either formal or informal respite care 
and the extent that foster parents use it. In 1990, the U. S. General Accounting Office 
reported that information on respite care services was scarce and difficult to obtain. 
A 1992 ACF study conducted by James Bell Associates suggested that the availabilty 
of respite care may be greater than expected, but that it is not used because foster 
parents are unaware of its availability. 
Fedral Funing Is Availble For Respite Care 
Historically, the ACF, HHS has supported respite care through demonstration grant 
projects authorized by the Temporary Child Care for Children with Disabilities and 
Crisis Nursery Act. The ACF administers the grants and funds a center charged with 
providing training, technical assistance, evaluation and research to demonstration 
project grantees. The center, located in Chapel Hil, North Carolina, is called the 
Access to Respite Care and Help (ARCH). The ARCH also publishes and distributes 
a quarterly newsletter to approximately 600 organizations that have some involvement 
in foster care and respite care programs. Beginning in 1994, ARCH plans to serve as 
a referral system for foster parents seeking respite care. 
Also, Federal funds for respite care are available as part of Family Preservation and 
Family Support Servces authorized by the Omnibus Budget Reconciliation Act of 
1993 (OBRA 93). OBRA 93 authorized funds for States to plan and implement 
services intended to keep families together and to strengthen them. Each State child 
welfare agency desiring funds must develop and submit a five-year plan to the 
Department by June of 1995. . Respite care for foster parents is one tye of family 
preservation and one tye of family suppert service which a State may elect to include 
in their five-year plan. Respite care, however, is not mandated. 
Finally, the HHS funds several other programs that agencies servng foster children 
may use to obtain respite services for foster parents. They include Maternal and Child 
Health Servces Block Grants, Medicaid, Social Services Block Grants
, fIHS' 
Respite Care - An Overvew of Federal , Selected State and Private Programs " GAO-
HRD-90-125, September 199.  Abandoned Infants Assistance Program, and HHS' Child Welfare Research and
Demonstration Program. 
As shown above, Federal funds are typically made available as part of other family
and children programs. Therefore, we could not readily determine the extent of
Federal funding and support for foster parent respite care servces.
SCOPE
We surveyed a random sample of 11 State foster care agencies, 66 local foster care
agencies, and 5 State foster parent associations. Our inspection focused on availability
and use of respite care. Based on prior studies and opinions, expressed by experts, we
assumed that respite care is an important servce for recruiting and retaining foster
parents. We did not attempt to prove any 
beneficial effects of respite care.

METHODOLOGY
We used a two-stage cluster sampling proeess for selecting States and counties for our
survey. First, we randomly selected 12 States. Next, we randomly selected 72 counties
-- six counties from each selected State.
In selecting counties, we stratified the counties of selected States into two groups.
One group of counties represented heavily populated counties and the second group
represented sparsely populated counties. Except for one State, we selected 3 counties
from each of the 2 stratifcations within each State. In one State, we arbitrarily
selected one county that contained over half of the State s entire population. We then
randomly selected 5 counties from the sparsely populated group of counties in that
State.
We mailed survey questionnaires to (1) foster care agencies in each of the 12 selected
States, (2) 69 local foster care agencies that served our 72 selected counties, and (3)
11 State foster parent associations. One State did not have a foster parent association.
Eleven State and 66 local foster care agencies responded to our survey. Five of the
State foster parent associations responded.
To determine availabilty and use of respite care, we (1) aggregated responses by
selected local foster care agencies, and (2) used information obtained from State foster
care agencies and State foster parent associations to corroborate and clarify our
findings. In instances where all local foster care agencies did not respond to a
particular survey question, we based our analyses on the number that did respond
rather than the total number responding to the survey. To ilustrate, 39 of the 66 local
foster care agencies responded to our quef,tion on whether or not fost
rr parents were
aware of available respite care. In such instances, we based our analyses on 39 rather
than the 66 agencies that returned a SUrvf'y instrument. We conducted this inspection in accordance with the  Quality Standards for Inspections 
issued by the President s Council on Integrity and Efficiency. 
Concurrent with this inspection, we performed an inspection to describe effective 
programs for providing respite care to foster parents. That report is titled Respite 
Care Servces for Foster Parents: Six Case Studies (OEI-04-93-00071). It describes six 
sample programs that child welfare experts and public officials who operate child 
welfare programs said are effective at providing respite care.  FINDINGS
CA 
RESPIT  IS AVAILALE M()S1LY TIROUGH OIDER FOSTER PARNT
Nearly all local foster care agencies we surveyed (64 of 66) said that either formal or
informal respite care was available to foster parents. All eleven State foster care
agencies that responded to our survey said some form of respite care was currently 
available to foster parents. Four of the five State foster parent 
associations that 
responded to our survey said respite care was available for foster parents in their 
States. The fifth State association said respite care was not currently available to 
foster parents in their State. 
TYPE OF RESPITE CARE
AVAILABLE TO FOSTER PARENTS 
Formal Only
No Response
Both Types
50% Foster parents are the major source of both formal and informal respite care. Ninety-
five percent of local foster care agencies (38 of 40) said another family foster home is 
the setting for formal respite care, and nearly ninety percent.53 of 59) said another 
family foster home is the setting for informal respite care. 
About Half Of Loal Agencie Make Fonnl Respite Care Servces Availble 
About 55 percent (36 of 66) of the local foster care agencies we surveyed. offered 
formal respite care servces to foster parents. 
Infonnl Respite Is Availble In Nearly All Commilie 
About 92 percent (61 of 66) of the local foster care agency staff that responded to our 
survey said informal respite care servces are available to foster parents in their 
jurisdiction. 
More Fonnl Respite Care May Be Need 
Officials from local and State foster care agencies, and from State foster parent 
associations said more formal respite care is needed. To ilustrate, about 68 percl:nt 
(32) of the 47 local foster care agencies that responded to our question said more 
formal respite care servces are needed than are currently available. Likewise, about 
36 percent (4 of 11) of the State foster care agencies, and 60 percent (3 of 5) State 
foster parent associations we surveyed said more formal respite care servces are 
needed for their States. Most of the officials who commented on the need for respite 
care said more formal respite servces are needed in both rural and urban 'areas. 
About 15 percent of the 66 local foster care agencies we surveyed said a shortage of 
formal respite care providers already exists. 
CA 
TIE MAOR SOURCE OF RESPIT  IS DECLINING 
Foster parents themselves are the primary source of respite care. According to the 
local foster care agencies we surveyed, most respite care is provided outside of a foster 
parent s home by another foster parent. Typically, one foster parent wil keep foster 
children of another foster parent, thus allowing a respite from the stress and 
responsibilty of foster care. 
However, the number of family foster homes is declining. Therefore, the number of 
potential respite providers is declining. According to estimates provided by the 
National Foster Parent Association and the ACF, HHS, the number of family foster 
homes declined about 11 percent between 1983 and 1992. According to the local 
foster care agencies we surveyed, the number of licensed family foster :homes 
months. 
continued to decline rapidly during the first 6 months of 
1993 (See figure on the 
following page). The local foster care agencies provided estimates showing a decline 
from 44 098 family foster homes to 43 236. This represents a two percent decline in 6 DECLINE IN FAMILY FOSTER HOMES 
# of Respite Providers (Thousands)
44.098
43.236
JANUARY  JUNE
1993
CA 
FOSTER PARNT USE OF AVAILALE RESPIT  SERVICES IS
UNKOWN
We could not precisely determine the extent that available respite care servces 
(formal or informal) were used by foster parents. We asked Jocal fostrr care agencies 
to provide data showing the number of foster parents who had used formal respite 
care during the first 6 months of 1993. Only seven, or 11 percent, of the 66 local 
foster care agencies we surveyed could furnish such data. Such a low response rate by 
the local foster care agencies may not provide a reliable indicator of foster parent use of respite care. However, the data provided by the local foster care agencies showed 
that about 9.5 percent of the foster parents in those seven communities used formal 
respite care during the first 6 months of 1993. Staff at several of the remaining 59 
local foster care agencies said they do no  have adequate systems for tracking foster 
parent use of respite care. Further, local foster care agencies do not know the extent 
that informal respite care is used. 
POTENT BARERS TO FOSTER PARNT USE OF RESPIT 
Staff at some local foster care agencies we surveyed said foster parent use of formal 
respite care may be inhibited by certain barriers. Local foster care agency staffs 
frequently cited the following potential barriers. 
Foster parent concern about setting for respite care 
Foster parent concern about respite provider skils 
Foster parent lack of transportation for respite care 
Settg For Respite Care 
About 33 percent (13) of the 39 local foster care agencies that responded to our 
question on barriers to providing respite care said the setting is not acceptable to 
foster parents. 
Most respite care is provided in an out-of-home setting. Forty (98 percent) of 41 local 
foster care agencies who commented on formal respite care said it is provided in an 
out-of-home setting. Likewise, 59 (94 percent) of 63 local foster care agencies who 
commented on informal respite care said it is provided in an out-of-home setting. 
Most out-of-home settings for respite care are in the home of another foster parent. 
To ilustrate, 95 percent (38) of the 40 local foster care agencies who said formal 
respite care is provided out-of-home said the setting was the home of another foster 
parent. Similarly, about 90 percent (53) of the 59 local foster care agencies who said 
informal respite care is provided out-of-home said the setting was the home of another 
foster parent. 
The State foster care agencies and State foster parent associations supported the 
comments of local foster care agencies on the settings for respite care. 
Nine of the 11 
(82 percent) State agencies and one of the five State foster parent associations we 
surveyed said formal respite care is provided in the home of another foster parent. 
Also, 10 of the 11 State agencies and two of the associations said inforpal respite care 
is provided in the home of another foster parent.  During a companion inspection, we examined respite programs of six communities that
various foster care experts said were effective (OEI-04-93-00071). Our inspection
report showed that respite care can be provided effectively in various settings.
Prvirs
Ski Of ResiJe 
About 26 percent (10) of the 39 local foster care agencies that responded to our
question on barriers to providing respite care said foster parents are concerned about
respite provider skills. They said foster parents feel that respite providers lack
adequate skills to meet the needs of their foster children.
However, many foster care agency staffs said they match respite care providers to the
specific needs of foster children where possible. Agencies tyically separate foster
care into categories such as regular, specialized, or therapeutic. Categories other than
regular encompass foster children with special emotional or physical needs. For
example, therapeutic foster care is for children with severe emotional problems. Of
the 64 local foster care agencies where respite care is available, 48 (75 percent) said
they assist foster parents in finding appropriate respite providers. To assure quality
care, the six communities we inspected in our companion inspection (OEI-04-93-
00071) had all developed procedures for screening, training, and monitoring respite
care providers.
Some foster care agency staffs said respite care is required for foster parents of
certain children. For example, in Kansas, therapeutic foster parents are required to
use respite servces. Likewise, in South Dakota foster parents for 15 to 18 year old
boys in a special program are required to use respite care.
Provirs
Transportatin To Respite 
About 26 percent, (10) of the 39 local foster care agencies who commented on
barriers to respite care for foster parents said the distance to respite care was a
barrier. Generally, foster parents have transportation or can obtain it from friends
and family. In some instances, local foster care agencies and respite care providers
may assist with transportation needs to help foster parents obtain respite care.
OPPORTU 
FOR PROGRA ENHANCEMENT
Respite care is generally perceived as important for retaining foster parents. It gives
problems. 
foster parents an intermittent break from the constant demands of caring for their
foster children. While our survey showed no clear shortage in availability of respite
care, and no clear unmet demands for respite care, it did surface two potential
First, the source of respite providers is declining. Although respite care services are
available in most localities, it may not be available in sufficient quantity. The number of respite providers is declining, and many local foster care agency staffs stated that 
more formal respite care servces are needed. 
Second, foster parents may not be taking full advantage of available respite care. We 
could not obtain reliable estimates on foster parent use of respite care because foster 
care agencies do not track its use. Therefore, we could not determine that more 
respite servces are needed. Based on data furnished by seven local foster care 
agencies, available respite care could be under-used. Some foster parents may not use 
available respite care because of their personal concerns or lack of knowledge. 
While we did not assess the beneficial effects of respite care, based on prior studies 
and expert opinion, respite care servces are generally perceived as important for 
retaining and recruiting foster parents. Consequently retaining foster parents can help 
avoid trauma caused by multiple placements of foster care children, cost of 
institutional care for foster care children, and cost of foster parent recruitment. 
ACF can help accomplish such objectives by encouraging States to enhance and 
develop formal respite care programs. For example, ACF can 
encourage States to take advantage of funds made available by the Omnibus 
Budget Reconcilation Act of 1993 for Family Preservation and Family Support 
Servces, as well as other funding sources. 
continue to provide training and technical assistance through current 
mechanisms, such as the ARCH in Chapel Hil, North Carolina. 
provide encouragement, leadership, guidance and information to States to 
develop systems for tracking use of respite care, such as the Statewide 
Automated Child Welfare Information System (Federal funds are 
available for such systems at a matching rate of 75 percent for three 
years), 
initiate program activities to increase foster parent use of respite care 
services, and 
identify sources of formal respite care providers other than family foster 
homes. 
ACF can partly accomplish such objectives by providing information to States and 
local communities on what" respite program practices work most effectively. We have 
prepared a companion report (OEI-04-93-00071) on respite care whiqh may be useful 
for this purpose. That report identifies and describes six communities that various 
experts deemed to have successful respite programs. ACF could also identify other 
successful respite care programs for States and local communities to use as guides in 
improving their respective programs.