FOSTER CARE

HHS Could Do More 

to Support States’

Efforts to Keep 

Children in FamilyBased Care

Report to the Committee on Finance, 

U.S. Senate

October 2015

GAO-16-85

United States Government Accountability Office
Highlights of GAO-16-85, a report to the 

Committee on Finance, U.S. Senate. 

October 2015

FOSTER CARE

HHS Could Do More to Support States' Efforts to 

Keep Children in Family-Based Care

Why GAO Did This Study

About 14 percent of the more than 

400,000 children in foster care 

nationwide lived in congregate care at 

the end of fiscal year 2013, according 

to HHS data. Given the importance of 

family-based care to foster children’s 

well-being, GAO was asked to review 

state use of congregate care.

This report examines (1) how selected 

states have reduced their use of 

congregate care; and (2) some 

challenges with reducing congregate 

care placements, and efforts HHS has 

taken to help states reduce congregate 

care. GAO analyzed child welfare data 

from HHS; reviewed relevant federal 

laws, regulations, and documents; and 

interviewed state child welfare officials 

in eight states--Connecticut, Colorado, 

Kansas, Louisiana, Maryland,

Minnesota, New Jersey, and 

Washington. In four of these states, 

GAO also visited and spoke with local 

child welfare officials and congregate 

care providers. The selected states 

varied in their use of congregate care 

and geographic location, but cannot be 

generalized nationwide. GAO also 

spoke with child welfare experts.

What GAO Recommends

GAO recommends that HHS take 

steps to enhance its support of state 

actions to reduce use of congregate 

care as appropriate, by, for example, 

collecting additional information on state 

efforts and sharing best practices. HHS 

concurred with this recommendation.

What GAO Found

Eight states GAO reviewed had a variety of efforts under way to help ensure they 

placed foster children in family-based settings rather than in group homes or 

institutions, also known as congregate care. Federal law requires that foster 

children have a case plan designed to achieve placement in the least restrictive 

(most family like) and most appropriate setting available, consistent with their 

needs. States’ efforts to ensure appropriate placements included more oversight 

of decisions to place children in congregate care and the length of stay;

enhanced recruiting and training for specialized foster families to care for children 

with serious emotional, behavioral, or medical problems; and increased supports 

for families in crisis. Officials in the eight states generally credited these efforts 

with declines in their use of congregate care—on average a 47 percent decline 

from fiscal years 2004 through 2013, based on the most recent available data

from the Department of Health and Human Services (HHS). However, these 

states’ percentages of foster children in congregate care still ranged from 5 

percent to 34 percent, mirroring the variation nationwide in fiscal year 2013.

Percentage of Foster Children in Congregate Care by State (Sept. 30, 2013)

Selected stakeholders (state officials, service providers, and experts) cited 

challenges to more appropriate use of congregate care, such as providing 

specialized training to foster families, addressing shortages in mental health and 

other community services, and working with congregate care providers to focus 

more on providing services in family settings. In a May 2015 report, HHS said 

that states’ progress in reducing congregate care was inconsistent and

recognized that additional information was needed. HHS also proposed some 

relevant legislative changes. Stakeholders identified other HHS actions, such as 

additional data analysis and sharing of best practices that would help states 

facing challenges to transform their use of congregate care. HHS currently does 

not have plans to take further actions to support states.

View GAO-16-85. For more information, 

contact Kay E. Brown at (202) 512-7215 or 

brownke@gao.gov.

United States Government Accountability Office
Letter 1

Background 3

Eight Selected States Reduced the Use of Congregate Care 

Substantially Using Multiple Approaches, but the Rates of Use 

Varied Widely 10

Stakeholders Cited Challenges in Developing Alternatives to 

Congregate Care and HHS Has Begun Efforts to Help States 18

Conclusion 24

Recommendation for Executive Action 24

Agency Comments and Our Evaluation 25

Appendix I Types of Congregate Care Facilities Used by Four States We Visited 27

Appendix II Comments from the Department of Health & Human Services 28

Appendix III GAO Contact and Staff Acknowledgments 31

Table

Table 1: Examples of Efforts Reported by Eight States to Reduce 

Congregate Care for Children in Foster Care 13

Figures

Figure 1: Percentage of All Foster Children in Congregate Care by 

State, as of September 30, 2013 9

Figure 2: Changes in Congregate Care and All Foster Care in 

Eight States and the National Average (from September 

30, 2004 to September 30, 2013) 11

Contents

Page i GAO-16-85 Foster Care
Abbreviations

ACF Administration for Children and Families

AFCARS Adoption and Foster Care Analysis and Reporting System 

CFSR Child and Family Services Reviews 

HHS Health and Human Services 

PASS Preparing Adolescents for Self Sufficiency 

PRTF Psychiatric Residential Treatment Facilities 

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Page ii GAO-16-85 Foster Care
441 G St. N.W.

Washington, DC 20548

October 9, 2015

The Honorable Orrin G. Hatch

Chairman

The Honorable Ron Wyden

Ranking Member

Committee on Finance

United States Senate

About 14 percent of more than 400,000 children in foster care nationwide 

were living outside of a family setting in a group home or institution, 

commonly referred to as congregate care, at the end of fiscal year 2013. 

This is based on the most recent data available from the Department of 

Health and Human Services (HHS). State and local governments 

administer foster care programs, and HHS oversees their implementation 

of applicable federal requirements. Title IV-E of the Social Security Act, 

originally enacted by the Adoption Assistance and Child Welfare Act of

1980, requires that children in foster care have a case plan designed to 

achieve placement in a safe setting that is the least restrictive (most 

family like) and most appropriate setting available, consistent with their 

best interests and special needs.1 HHS data show that at the end of fiscal 

year 2013, states varied widely in the share of foster children living in 

congregate care settings, from a low of about 4 percent to a high of 34 

percent.2

Given the variation among states and the requirements of Title IV-E, you 

asked us to review state use of congregate care and efforts to reduce its 

use, as appropriate. This report addresses the following questions:

(1) How have selected states reduced their use of congregate care?

1 See 42 U.S.C. § 675(5)(A). States must comply with this and other requirements to be 

eligible to receive funding for foster care and adoption assistance programs under Title IVE.

2 National data in this report include data from the District of Columbia and Puerto Rico; 

we include these jurisdictions when we refer to all states in this report.

Letter

Page 1 GAO-16-85 Foster Care

 
(2) What are the challenges with reducing congregate care placements 

and what efforts has HHS taken to help states reduce congregate care?

To gain an understanding of the usage of congregate care and efforts 

taken or under way to reduce these placements, we interviewed 

stakeholders from state and local child welfare agencies, congregate care 

provider organizations, as well national research and advocacy 

organizations. We interviewed state child welfare officials in eight states—

Colorado, Connecticut, Kansas, Louisiana, Maryland, Minnesota, New 

Jersey, and Washington. For a more in-depth review, we conducted site 

visits in four of the eight states—Connecticut, Louisiana, Maryland, and 

Washington. In each state we visited, we interviewed state and local child 

welfare agency officials and congregate care providers. We interviewed a 

total of 14 providers and visited 7 localities representing a mix of rural and 

urban areas. We also toured several congregate care facilities in each of 

the four states for a better understanding of the types of congregate care 

facilities that are used in these states. We selected states to represent a 

mix of factors including: high and low share of foster children placed in 

congregate care, high and low rates of reduction in overall percentage of 

children placed in congregate care settings, and geographic dispersion. 

We did not assess the types, quality, or appropriateness of services 

provided by child welfare agencies or congregate care providers in each 

of the eight states. Information from the eight states cannot be 

generalized nationwide.

We also interviewed representatives from 12 national organizations who 

had expertise across multiple states based on their work researching 

child welfare issues, providing congregate care services, or advocating on 

behalf of children within the foster care system. We interviewed these 

experts to gain their perspective on the subject matter and considered 

recommendations from them especially to identify states that have had 

success in reducing the percentage of foster youth placed in congregate 

care settings. Experts and national associations were selected based on 

recommendations and previous published work on child welfare issues.

In the report, we refer to our interviews with “stakeholders” that represent 

the views of officials from the 8 state child welfare agencies, 7 local child 

welfare agencies, 14 congregate care providers that we visited in the four 

states, or 12 national organizations. In addition, in the report we use 

qualifiers, such as “several” and “many,” in some cases to quantify 

responses from stakeholders across our interviews with officials from 41 

entities in total. These qualifiers are defined as follows:

Page 2 GAO-16-85 Foster Care
• “All” stakeholders represents 41.

• “Most” stakeholders represents 21-40.

• “Many” stakeholders represents 10-20.

• “Several” stakeholders represents 4-9.

• “A few” stakeholders represents 2-3.

For the eight states included in our study, we analyzed state-reported 

Adoption and Foster Care Analysis and Reporting System (AFCARS) 

data for fiscal years 2004 and 2013 for information on the percentage of 

foster children and youth that are placed in congregate care settings and 

how these placements have changed over time, as well as how states 

vary in their usage of congregate care. We took a number of steps to 

assess the reliability of the AFCARS data, including discussions with HHS 

officials and statisticians and testing the reasonableness of selected data 

variables, and determined that the data were reliable for our purposes. 

We also interviewed HHS officials for an understanding of their efforts to 

assist states with reducing the usage of congregate care placements. In 

addition, we reviewed relevant federal laws, regulations and agency 

documents.

We conducted this study from January 2015 to October 2015 in 

accordance with generally accepted government auditing standards.

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

State and local governments are the primary administrators of child 

welfare programs designed to protect children from abuse or neglect.

Children enter state foster care when they have been removed from their 

parents or guardians and placed under the responsibility of a state child 

welfare agency. Removal from the home can occur because of reasons 

such as abuse or neglect, though in some cases a child’s behavior may 

also be a factor. When children are taken into foster care, the state’s child 

welfare agency becomes responsible for determining where the child 

should live and providing the child with needed support.

Title IV-E of the Social Security Act authorizes federal funding to states to 

help cover costs associated with states’ foster care and adoption 

programs. Title IV-E funds, which make up the large majority of federal 

Background

Federal Funding Sources 

for Child Welfare 

Programs

Page 3 GAO-16-85 Foster Care
funding dedicated to child welfare primarily provides financial support for 

the care of eligible children who have been removed from their homes 

due to abuse or neglect, as well as to families who adopt eligible children 

with special needs from the foster care system.3 For example, funds may 

be used to reimburse states for a portion of expenses to support eligible 

children in foster care (such as for food, clothing, and shelter), and for the 

costs of subsidies to parents who adopt eligible children with special 

needs (adoption assistance), as well as for related case management 

activities, training, data collection, and other program administrative 

costs.

While Title IV-E funds are used primarily for eligible children in foster 

care, Title IV-B funds may generally be used for services for children and 

their families regardless of whether those children are living in their own 

homes, have been removed from their homes and placed in foster care 

settings, or have left the foster care system. Title IV-B funds are provided 

primarily through two formula grant programs.4 Funds may be used for 

case planning and review services for children in foster care and other 

services to families such as parenting skills training or substance abuse 

treatment. Although Titles IV-B and IV-E are the primary sources of 

federal funding available to states for child welfare programs, states also 

use other federal funds, such as Temporary Assistance for Needy 

Families and Social Services Block Grant funds, as well as Medicaid.

HHS provides oversight and monitoring of states in a variety of ways to 

ensure their child welfare programs are in compliance with federal law, 

regulations, and relevant approved state plans. For example:

3 See 42 U.S.C. § 670 et seq. Title IV-E foster care support is limited to those children 

who are removed from homes with very low incomes (in most states the income standard 

is well below 100 percent of the federal poverty guidelines, according to HHS). Eligible 

children must meet certain additional federal criteria, such as age and certain 

requirements related to the child’s removal and placement. 42 U.S.C. § 672. The 

Fostering Connections to Success and Increasing Adoptions Act of 2008 changed the 

eligibility criteria for Title IV-E adoption assistance for children with special needs to 

eliminate the income requirements for the family from which the child is removed. This 

change is being phased in over time based on the child’s age at adoption. Beginning in 

2018, the revised criteria will apply to children of all ages. 42 U.S.C. § 673.

4 See 42 U.S.C. § 621 et seq.

Oversight and Monitoring 

of Child Welfare Programs

Page 4 GAO-16-85 Foster Care

 
• Twice a year, states are required to submit data on the characteristics 

of children in foster care. HHS compiles, validates, and reports data 

from state child welfare agencies on children in foster care and 

children who have been adopted from the child welfare system in 

AFCARS.

• HHS conducts statewide periodic assessments known as the Child 

and Family Services Reviews (CFSR) that involve case-file reviews 

and stakeholder interviews to ensure conformity with federal 

requirements for child welfare services. The reviews are structured to 

help states identify strengths and areas needing improvement within 

their agencies and programs.5

• HHS conducts periodic Title IV-E foster care eligibility reviews to 

monitor the state Title IV-E agency’s compliance with certain 

requirements of the Title IV-E foster care maintenance payments 

program. As part of the review, HHS examines a Title IV-E agency’s 

compliance with requirements related to placing a child in a licensed 

foster family home or child care institution, and ensuring that safety 

requirements are met by the child’s foster care provider.

• HHS also provides support and training through centers that provide 

states with training, technical assistance, research, and information 

through referral and consultation.

For the purposes of collecting data from states on their foster care 

systems, HHS uses the two terms below to refer to non-family settings, 

called congregate care in this report:6

• Group home: a licensed or approved home providing 24-hour care for 

children in a small group setting that generally has from 7 to 12

children.

5 In 2000, HHS issued regulations that specified that states must undergo a complete 

review of their child welfare programs every 5 years (every 2 years for states found not to 

be in substantial conformity). Title IV-E Foster Care Eligibility Reviews and Child and 

Family Services State Plan Reviews, 65 Fed. Reg. 4020, 4076-77 (Jan. 25, 2000) 

(codified in relevant part at 45 C.F.R. § 1355.32(b)). HHS has conducted two rounds of 

CFSRs to date. The third round, which should have started in 2012, was delayed because 

HHS was revising the instrument used to assess states to improve the CFSR process. 

HHS reports that the third round of reviews are expected to run from 2015-2018.

6 The term congregate care is also used in other fields—such as elder housing—but in the 

context of foster care, these settings only house children. However, the children housed in 

a congregate care setting are not necessarily all in foster care; such facilities might also 

house children placed by the juvenile justice system, the mental health system, or 

privately by individual families.

Page 5 GAO-16-85 Foster Care

 
• Institution: a child care facility operated by a public or private agency 

and providing 24-hour care and/or treatment for children who require 

separation from their own homes and group living experience. For 

example, these facilities may include: child care institutions, 

residential treatment facilities, or maternity homes, according to HHS.

Although states report data to HHS on the number of foster care children 

placed in two types of congregate care settings, states do not necessarily 

use the same terminology and may vary in the way they classify and or 

describe similar facilities. For detailed information on the types of 

congregate care facilities used by states we visited see appendix I. HHS 

has proposed revising its AFCARS regulations to collect more detailed 

information from states on the types of congregate care used, although 

the proposed changes have not yet been finalized.7

When children are removed from their homes, the child welfare agency 

may place the child in a foster home of a relative or non-relative, or in a 

congregate care setting, depending on the child’s needs. Children 

generally remain in foster care until a permanent suitable living 

arrangement can be made, either by addressing the issues that led to the 

child’s removal and returning the child to his or her family, or in cases 

where this is not possible in a timely manner, through adoption, 

guardianship, placement with a relative, or another planned permanent 

living arrangement. In some cases, the child reaches adulthood before 

leaving foster care, commonly referred to as “aging out of foster care”.

HHS’s Title IV-E regulations require that each child’s case plan include a 

discussion of how it is designed to achieve a safe placement for the child 

in the least restrictive (most family like) setting available and in close 

proximity to the home of the parent(s) when the case plan goal is 

reunification, and a discussion of how the placement is consistent with the 

best interests and special needs of the child.8 However, states have 

flexibility and discretion to make decisions for each child on a case-by7 HHS has proposed revising its AFCARS regulations to collect additional information from 

states on the types of congregate care used, although the proposed changes have not yet 

been finalized. Adoption and Foster Care Analysis Reporting System, 80 Fed. Reg. 7132 

(Feb. 9, 2015). Among other things, HHS proposed to expand the types of living 

arrangements reported in AFCARS to include a variety of placement settings, such as 

therapeutic foster family homes, group homes that may provide shelter care or be 

operated by staff or a family, supervised independent living, and juvenile justice facilities.

8 45 C.F.R. § 1356.21(g)(3). See also 42 U.S.C. § 675(5)(A).

Placement Decisions and 

Congregate Care

Page 6 GAO-16-85 Foster Care

 
case basis to ensure that the most appropriate placement is made and 

the individual needs of the child are met.

HHS issued a report on congregate care in May 2015 that stated that in 

addition to federal law, child development theory and best practices 

confirm that children should be placed in family-like settings that are 

developmentally appropriate and least restrictive.9 The report also stated 

that congregate care stays should be based on the specialized behavioral 

and mental health needs or clinical disabilities of children, and only for as 

long as needed to stabilize them so they can return to a family-like 

setting. Furthermore, the report noted that congregate care should not be 

used as a default placement setting due to a lack of appropriate familybased care, but as part of a continuum of foster care settings. Young 

children need family-like settings to form healthy attachments to adults, 

and older children need family-like settings to allow them to develop 

autonomy, according to research.10 This is also in keeping with changes 

in the field of congregate care, which is increasing its focus on stays in a 

residential center as treatment interventions to meet specific needs rather 

than a placement of last resort for foster children.11

However, a recent HHS study using AFCARS data on states’ use of 

congregate care found that for all children who entered foster care for the 

first time in 2008 (first-time entry cohort focusing on first episodes), an 

estimated 38,205 of these children experienced congregate care at some 

point during a 5-year follow-up period.

12

9 U.S. Department of Health and Human Services, Administration for Children and 

Families, Children’s Bureau, “A National Look at the Use of Congregate Care in Child 

Welfare” May 2015.

10 For example, see Mary Dozier et al., “Consensus Statement on Group Care for 

Children and Adolescents: A Statement of Policy of the American Orthopsychiatric 

Association,” Journal of Orthopsychiatry, 2014.

11See, for example, American Association of children’s Residential Centers (AARC), 

Redefining the Role of Residential Treatment, regarding efforts underway around the 

nation to redesign the role of residential treatment in local communities. Founded in 1956, 

AACRC is an association focused on the needs of children with serious mental and 

behavioral problems who are in residential or other milieu-based placements.

12 U.S. Department of Health and Human Services, Administration for Children and 

Families, Children’s Bureau, “A National Look at the Use of Congregate Care in Child 

Welfare” May 2015.

Page 7 GAO-16-85 Foster Care

 
• Of these children, 31 percent were aged 12 or younger when they 

experienced congregate care at some point during the 5-year followup. While one-fifth of these young children who experienced time in 

congregate care were in these settings for less than a week, 24.1 

percent were there for longer than a year.

• Of those aged 13 years or older who experienced some time in 

congregate care during that time period, about 40 percent were 

identified as entering foster care due to a child behavior problem and 

no other clinical or mental disability, highlighting the need for a 

thorough assessment to ensure children are placed in the least 

restrictive settings to meet their needs.

Additionally, of the children in care as of September 30, 2013, HHS found

that the overall total time in foster care was longer for children in

congregate care settings, with an average of 27 months in foster care

compared to 21 months for children placed in other types of out-of-home

settings. 

Over the past 10 years, the number of children and youth in the foster 

care system declined by 21 percent from 507,555 at the end of fiscal year 

2004 to 402,378 at the end of fiscal year 2013, according to data reported 

to HHS by the states. HHS reported that there were fewer entries into 

foster care, an increase in exits, and shorter lengths of stay during this 

time period; it did not attribute the decline to any particular factor. The 

number of children in congregate care also declined, and at a greater rate 

than children in foster care, 37 percent compared to 21 percent. 

According to the most recent data available, nationally, 14 percent of 

children in foster care were in congregate care placements at the end of 

fiscal year 2013, although the rates of congregate care use varied among 

the states (see fig. 1).

National Trends

Page 8 GAO-16-85 Foster Care
Figure 1: Percentage of All Foster Children in Congregate Care by State, as of September 30, 2013

Page 9 GAO-16-85 Foster Care
From September 30, 2004, to September 30, 2013, the share of all foster 

care children in congregate care in the eight states we reviewed declined 

47 percent on average, with reductions ranging from 7 to 78 percent, 

according to the most recent data available from HHS. This decline 

outpaced these states’ average decline of 26 percent in the number of 

foster children overall. However, the states’ percentages of congregate 

care placements ranged from approximately 5 percent in Washington to 

34 percent in Colorado (see fig. 2). Nationwide, congregate care 

placements are declining and this trend is reflected in the 8 selected 

states. 

Eight Selected States 

Reduced the Use of 

Congregate Care 

Substantially Using 

Multiple Approaches, 

but the Rates of Use 

Varied Widely

The Eight Selected States 

Averaged a 47 Percent 

Reduction in Congregate 

Care Use, Although the 

Current Rates of Use Still 

Varied among These 

States

Page 10 GAO-16-85 Foster Care
Figure 2: Changes in Congregate Care and All Foster Care in Eight States and the National Average (from September 30, 2004 

to September 30, 2013)

Note: HHS officials told us that a state’s congregate care numbers may include children and youth 

that are in the juvenile justice system as well as those in the child welfare system. For example, 

Colorado officials said that their data included youth placed in congregate care by the state division of 

youth corrections. According to the officials, the percentage of foster children in congregate care, 

excluding these youth corrections placements, was about 20.8 percent rather than 34.1 percent.

The eight selected states reported a variety of efforts they took to help 

reduce their use of congregate care for foster children. In some cases, 

reform efforts were intended to reduce the number of children removed 

from their homes or to improve the state’s overall child welfare system, 

while others focused specifically on reducing congregate care. Based on 

our analysis, we categorized these efforts into three areas: expanding 

services that may prevent entry into foster care, increasing availability of 

family-based placements in foster care, and revising how congregate care 

is used. These are discussed in more detail below.

Selected States’ Efforts to 

Reduce Congregate Care 

Included Expanding 

Services, Developing 

Alternative Placements, 

and Revising How They 

Used Congregate Care

Page 11 GAO-16-85 Foster Care
• Expanding services to avoid the need to remove the child in the first 

place and to support children in family-based settings. When sufficient 

resources are available and circumstances warrant it, caseworkers 

may decide to provide services for at-risk families in the home to help 

stabilize the family rather than remove the child from the home, as we 

found in our previous work.13 In addition, other resources can help 

ease the transition from congregate care to a family-based setting, 

whether in the foster care system or the home from which the child 

was removed.

• Increasing the availability of family-based placement options.

Increased efforts to find relatives who can care for children who are 

removed from their homes can help children remain in family settings, 

according to one child welfare official.14 In addition, caseworkers may 

also recruit or train foster families to serve as treatment or therapeutic 

foster families. These terms generally refer to a model of care that 

attempts to provide elements of traditional foster care with clinical 

treatment of a child’s serious emotional, behavioral, and medical 

problems in a specialized foster home. One state child welfare official 

told us that in the past, children and youth with significant behavioral 

or other problems were often placed in congregate care because 

foster families or relatives with the requisite skills to help the child 

were not always available, nor were adequate supports available in 

the community.

• Revising how congregate care is used for foster children. When 

congregate care is considered as a placement by a caseworker, 

specific policies can affect the level at which the final decision is 

made, what criteria are used, the duration of stay, and if a plan for 

transitioning out of the congregate care setting is established. One 

child welfare official told us her state agency’s efforts were often 

meant to ensure that all other placement options had been exhausted 

before congregate care could be considered, that the length of stay in 

congregate care was as short as possible, and that the child received 

appropriate treatment while in care. In addition, one congregate care 

provider noted that the provider had developed new service delivery 

13 GAO, Child Welfare: States Use Flexible Federal Funds, but Struggle to Meet Service 

Needs, GAO-13-170 (Washington, D.C.: Jan. 30, 2013). 

14 When a child is removed from the home, Title IV-E requires that the state exercise due 

diligence to identify adult relatives and notify them of the child’s removal and the relatives’

options to become a placement resource for the child. 42 U.S.C. § 671(a)(29).

Page 12 GAO-16-85 Foster Care

 
models, which in some cases included providing services when the

child returned to the home and community.

See table 1 for examples of selected state efforts and examples as 

described by state officials.

Table 1: Examples of Efforts Reported by Eight States to Reduce Congregate Care 

for Children in Foster Care

State efforts Specific examples

Expanding services to avoid the need to remove the child in the first place and 

support the child upon returning home 

Intensive in-home therapy Clinical services provided in the child’s home and 

community to prevent the child from entering into 

care.

Increased community wraparound servicesA team or group of individuals providing a range of 

services to youth with complex needs both in foster 

care and those still in the home. 

Utilization of crisis mobilization 

units

Crisis intervention specialists who are dispatched 

into the community 24/7 to stabilize a child or family 

in crisis.

Increasing the availability of family-based placement options

Intensive family searches Expanding search options to locate relatives to care 

for a child prior to entering into the foster care 

system or as a relative foster family.

Targeted recruitment for foster 

families

Specific recruitment for foster families to care for 

children with specific needs to avoid a congregate 

care placement. 

Family team decision meetings Involving family and others connected to the child 

when making decisions regarding a child’s safety 

and placement. 

Revising how congregate care is used 

Changes in removal and 

placement approval processes

Requiring multiple levels of approval before a child is 

approved for a congregate care setting. 

Time limits and monitoring of 

congregate care placements 

Requiring specified time limits (e.g., 6-18 months) for 

certain congregate care placements (e.g., shelter 

care placements and periodic review of need for 

congregate care).

Changing models of how 

congregate care is delivered

Finding new ways of working with congregate care 

providers, for example, by contracting with them to 

provide more diverse services, including for children 

in their own or foster homes and by ensuring 

providers plan for transitioning the child back to a 

family setting with appropriate support and services. 

Source: GAO analysis of interviews with state and local officials in selected states.| GAO-16-85

Page 13 GAO-16-85 Foster Care
The eight states used a combination of policies and practices noted 

above in their efforts to reduce or limit the use of congregate care. 

Because child welfare systems are complex with many interrelated 

features, states’ efforts often resulted in the need to transform several 

features of their systems at the same time, as described in the summaries 

below.

Washington had the smallest proportion of its foster care caseload 

placed in congregate care of the eight states we reviewed, as well as the 

smallest reduction from the end of fiscal years 2004 through 2013.

According to officials, intensive family searches to locate family members 

to care for youth has been a successful effort used by caseworkers in the 

state to help reduce congregate care. The state and local child welfare 

officials and service providers we spoke with placed emphasis on 

placements with available family members or foster homes, even for 

youth with a high need for treatment or other services. One official noted 

that the emphasis on family placements first has been a longstanding 

policy preference in the state. In addition, about 15 years ago, 

Washington changed its model of care for how services are delivered by 

congregate care providers. Officials said that the state changed its 

contract with providers from a structure with a set number of beds and 

service levels to a contract for an array of services which could be 

delivered in multiple settings, such as congregate care, treatment foster 

homes, regular foster homes, and family or relative homes.

Kansas had the second lowest percentage of foster children in 

congregate care of the eight states we reviewed with 5 percent as of 

September 30, 2013. Officials attributed a 31 percent decline in their 

congregate care population over the 9 year period to several factors. In 

1996, according to officials, the state began contracting with private nonprofit organizations to provide family preservation, foster care and 

adoption services. State officials told us that prior to establishing these 

contracts, up to 40 percent of their foster children were in congregate 

care settings. Officials also cited as contributing factors the method of 

payment to contractors and holding foster care providers accountable for 

meeting outcome goals established by the state to place children in a 

family-like setting when possible or face monetary penalties.

New Jersey began reforming its child welfare system about 10 years 

ago, and according to state officials, it has resulted in reductions in the 

state’s overall foster care population and congregate care. Officials 

explained that the state adopted a new family model of care that included 

extensive recruitment of foster, adoption, and kinship caregivers—

Page 14 GAO-16-85 Foster Care
referred to as resource families—that helped to reduce the overall foster 

care population and congregate care placements.15 In this model, these 

resource families are provided with extensive training and a resource 

worker is assigned to help provide services to the child in the home. One 

official told us that this is a new paradigm of care that is very intensive.

They work with the family and bring in as many community resources as 

possible to keep children in their homes, which has been effective in 

reducing the number of children entering foster care overall.

Louisiana officials told us that following Hurricane Katrina in 2005, state 

officials worked with the Annie E. Casey Foundation16 to improve 

performance in key areas in child welfare. Hurricane Katrina caused 

widespread destruction and displacement of youth. Many of the state’s 

foster children were temporarily displaced and child welfare officials did 

not have current emergency contact information, which made it difficult for 

them to find the foster families that had to evacuate. According to officials, 

over a 2-year period, they reduced the number of children in congregate 

care settings by approximately 200 youth through various efforts, 

including: (1) focused efforts on stepping down youth placed in residential 

levels of care into less restrictive placements; (2) recruited foster/adoptive 

homes that could accept placement of youth stepping down when relative 

resources were not available and recruited homes that could provide 

placement to children/youth entering care without relative resources; (3) 

increased availability of in-home services so that youth were stepped 

down, the services would be in place to assist in supporting the 

placement. To support the foster home recruitment piece, dedicated 

recruiters were hired and placed in all 9 regions of the state with the sole 

task of recruiting homes. Another effort officials described during this time 

was the revision of the licensing regulations for residential facilities and 

child placing agencies.

15 According to the New Jersey Resource Family Handbook (revised May 2015), kinship 

caregivers are related to a child in placement through blood, marriage, civil union, 

domestic partnership, or adoption. Kinship caregivers may also be connected to the child 

by an established positive psychological or emotional relationship. The guide notes that 

kinship caregivers may provide care before being licensed by the state, as may foster and 

adoption parents, if they are eligible for licensure and are in the process of being licensed. 

16 The Annie E. Casey Foundation states that it is a private charitable organization 

dedicated to helping build better futures for disadvantaged children in the United States.

The primary mission of the Foundation is to foster public policies, human systems reforms, 

and community supports that more effectively meet the needs of today’s vulnerable 

children and families.

Page 15 GAO-16-85 Foster Care

 
Maryland launched a statewide initiative in 2007 called “Place Matters”

that greatly affected the state’s child welfare system and improved 

outcomes for all children in the state, including those in congregate care, 

according to state officials. The goals of the “Place Matters” initiative 

include: (1) providing more in-home support to help maintain children with 

their families; (2) placing children in family settings (either with relatives or 

family-based care); and (3) reducing the length of stay in foster care and 

increasing the number of reunified families. By 2014, Maryland officials 

reported a reduction in the number of children in out-of-home care by 

over 50 percent and a reduction of children placed in congregate care of 

almost 60 percent. Maryland officials also described changes in the 

placement and review process that they said have helped reduce the 

number of children in congregate care. For example, a placement 

protocol was instituted to ensure that family settings were ruled out before 

children could be placed in congregate care settings. According to 

officials, several layers of review have also been added to ensure that 

more restrictive placements are warranted and necessary based on the 

child’s needs. Maryland also instituted a state-wide initiative that included 

an extensive search for relatives of a foster child, according to officials.

Minnesota continues to explore alternatives to group settings for children 

in foster care needing specialized services, such as behavioral and 

mental health needs that a foster family may not be capable of providing, 

according to state officials. The state is currently in the process of 

developing intensive treatment foster care services, as provided for under 

a Minnesota statute enacted in 2013, according to officials. These include 

intensive treatment services that will be provided within a foster family 

setting to help reduce the need for congregate care placements. In 

addition, in January 2015, the state implemented Northstar Care, a 

program intended to help children who cannot return home to find other 

permanent families. Officials expect that with the implementation of 

Northstar Care and other services, like treatment foster care services, the 

number of children in congregate care will continue to decline.

Connecticut officials told us that the primary impetus for their focus on 

reducing congregate care was a change in leadership that occurred in 

2011. At that time, the newly appointed head of the state child welfare 

agency set a goal of reducing the percentage of foster children in 

congregate care from 23 percent to 10 percent. Connecticut officials 

described going through the case files of all youth in foster care and 

working, in consultation with the youth, to identify possible options for a 

home for the youth that may include family members or close friends. 

Through this process, Connecticut officials told us they were able to place 

Page 16 GAO-16-85 Foster Care
some children into a home and out of a congregate care setting. 

According to officials, targeted family outreach and also engaging people 

not related by birth or marriage who have an emotionally significant 

relationship with a child has also resulted in a significant reduction in the 

number of children coming into foster care in general. Officials believe 

that this shift in attitude around connecting youth to their families and 

communities is leading to better outcomes for youth. Other efforts 

described by officials included increasing the availability of communitybased supports across the state to help prevent children from coming into 

care. Specifically, officials said the state modified its contracts with health 

care providers to increase access to emergency psychiatric services for 

anyone in the state, including those who are not currently in foster care.

Colorado had one of the higher percentages of youth in congregate care 

among our eight states, according to HHS data. The state is currently 

working with Casey Family Programs17 and the Annie E. Casey 

Foundation to improve placements for children in congregate care by 

finding creative ways of placing children into family homes. Colorado 

state officials described changes and new ways of working with the 

congregate care provider community to develop models of care that are 

more treatment-oriented to help children transition back into a community 

settings. For example, state officials held two forums with providers in 

their state to educate them on how to adjust their services and the service 

delivery expectations as the state is shifting towards using providers more 

for treatment than just a placement. State officials said they are also 

working with the judicial system to identify alternative options, such as inhome services, because according to these officials some judges are 

used to ordering that children be placed into a congregate care facility, 

often as a consequence of behavioral issues.

17 Casey Family Programs states that it is a foundation focused on safely reducing the 

need for foster care and that it works nationwide. State officials said they received 

additional resources from Casey Family Programs for the initiative.

Page 17 GAO-16-85 Foster Care

 
Stakeholders we interviewed described challenges involved as efforts 

were made to reduce reliance on congregate care where appropriate, or 

as one child welfare foundation says, to “right-size” states’ use of 

congregate care.18 From this information, we identified four areas that 

posed challenges in the selected states and that may inform other states’

efforts to reduce the role of congregate care in their child welfare 

systems.

Building capacity for family placements. While developing alternative 

family placements is a part of states’ efforts to reduce congregate care,

stakeholders we spoke with said that doing so posed challenges. Several 

stakeholders told us that too few foster families were available generally, 

and that traditional foster families can be overwhelmed by the needs of 

some foster children and youth, such as those with behavior problems.

Officials in one state also told us that building capacity in appropriate 

family placements to replace congregate care placements requires 

recruitment and training of specialized foster families and training to 

change caseworker’s existing practices. A few stakeholders also told us 

that this can require additional resources or a redirection of existing 

resources. In addition, because congregate care placements typically 

cost more than traditional foster families, less use of congregate care 

should free up state resources for developing more foster families with 

the training and skills to support children and youth with greater needs, 

according to an expert we spoke with.

18 See the Annie E. Casey Foundation. Rightsizing Congregate Care: A Powerful First 

Step in Transforming Child Welfare Systems. (Baltimore, Md.: 2010)

Stakeholders Cited 

Challenges in 

Developing 

Alternatives to 

Congregate Care and 

HHS Has Begun 

Efforts to Help States

Developing a Sufficient 

Supply of Appropriate 

Family Placements and 

Needed Services While 

Transitioning to a More 

Treatment–Based Model 

of Congregate Care Poses 

Challenges

Page 18 GAO-16-85 Foster Care

 
A few stakeholders we spoke with agreed that a shift away from 

congregate care must be planned and implemented carefully to ensure 

that children are placed with families adequately prepared to meet their 

needs and to avoid unintended consequences. For example, if a child 

with significant needs that require more attention is placed in a traditional 

foster family without adequate supports, the result may be multiple 

unsuccessful placements, inappropriate medications to manage a youth’s 

behavior, or entry into the juvenile justice system, according to some of 

the officials we spoke with. One expert said that, based on her 

observation, one state had rushed to reduce congregate care without first 

putting sufficient supports in place for foster families, which resulted in 

unintended consequences, such as unsuccessful placements.

Addressing shortages of needed services. In addition, several 

stakeholders noted the shortage of services that can help bolster 

supports for at-risk children and families before the child or youth is 

removed from home or during foster care to help avoid or reduce the 

length of a congregate care stay. This is consistent with the findings from 

our 2013 report in which we reported that local child welfare systems use 

existing community resources, which are sometimes in short supply, 

leading to gaps in areas such as substance abuse treatment, assistance 

with material needs, and mental health services.19 One stakeholder noted 

there is a lack of more holistic support systems in some communities, 

including access to behavioral and mental health services; crisis support 

24 hours a day, 7 days a week; housing; and education that would 

facilitate more use of family settings rather than congregate care.

However, Title IV-E funds are generally not available for services for 

children and families not in the foster care system.

Improving assessments. Having accurate information on a child or youth’s 

physical and mental health needs is a factor in identifying what, if any, 

treatments and services may be needed, and the eight states we 

reviewed told us they had assessment processes in place. While we did 

not review the types or quality of the assessment processes in these 

states, two experts we spoke with raised concerns about the variation in 

types and quality of assessments performed nationwide. This is due in 

part to insufficient caseworker training and large workloads in states and 

19GAO, Child Welfare: States Use Flexible Federal Funds, but Struggle to Meet Service 

Needs, GAO-13-170 (Washington, D.C.: Jan. 30, 2013). 

Page 19 GAO-16-85 Foster Care

 
localities generally, as we have also found in our previous work. 20 More 

specifically, one of these experts said that some child welfare 

assessments may result in an incorrect diagnosis due to lack of 

understanding of trauma-based conditions and treatments.21 In this 

expert’s opinion, children in congregate care were sometimes diagnosed 

with other conditions, such as bi-polar disorder, and were overmedicated 

to contain the issue rather than treat it. In our previous work, we have 

found that foster children may receive psychotropic drugs at higher rates 

than children not placed in foster care.22 We found in the five states 

analyzed that the higher rates do not necessarily indicate inappropriate 

prescribing practices, as they could be due to foster children’s greater 

exposure to traumatic experiences and the unique challenges of 

coordinating their medical care. However, experts that we consulted 

during that work explained that no evidence supports the concomitant use 

of five or more psychotropic drugs in adults or children, yet hundreds of 

both foster and non-foster children were prescribed such a medical 

regimen.

Retaining capacity for congregate care. State child welfare officials in all 

of the eight states told us that even though they have worked to reduce 

congregate care placements, they believed that they still require some 

amount of congregate care for children and youth with specific treatment 

needs and that retaining sufficient congregate care capacity may be 

difficult. In Washington, with its already relatively low use of congregate 

care, some officials were concerned about retaining enough congregate 

20 GAO, Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare Agencies 

Recruit and Retain Staff, GAO-03-357 (Washington, D.C.: Mar. 31, 2003).

21 A trauma-based child welfare system is one that recognizes and responds to the impact 

of traumatic stress on those who have contact with the system, including children, 

caregivers, and service providers. Such an approach may require changes from existing 

practices including shifting the goals of child welfare services from substantiating an 

occurrence of maltreatment and ensuring a child’s physical safety to broadening the focus 

to include healing the impact of trauma and improving a child’s social and emotional wellbeing. (Child Welfare Information Gateway. Developing a trauma-informed child welfare 

system, (Washington, D.C.: U.S. Department of Health and Human Services, Children’s 

Bureau, 2015.))

22 GAO, Foster Children: HHS Guidance Could Help States Improve Oversight of 

Psychotropic Prescriptions, GAO-12-201 (Washington, D.C.: Dec. 14, 2011). GAO, Foster 

Children: Additional Federal Guidance Could Help States Better Plan for Oversight of 

Psychotropic Medications Administered by Managed-Care Organizations, GAO-14.362 

(Washington, D.C.: Apr. 28, 2014).

Page 20 GAO-16-85 Foster Care

 
care capacity to meet the needs of children and youth they thought would 

require some time in a group setting. One stakeholder noted that 

adjusting to an appropriate level of congregate care can be challenging, 

as congregate care providers generally need to be assured of a sufficient 

level of “beds filled’ to continue their operations. He added that some 

providers have long-standing relationships with a state or county and 

have an interest in continuing their operations. This stakeholder said that 

in his view the number of “beds” or openings in a congregate care setting 

may have factored into the determination of where a child or youth is 

placed in some situations. In such cases, he noted, the supply of 

available beds may have driven the placement rather than the needs of 

the child.

However, according to a few stakeholders, congregate care providers are 

beginning to diversify their services, which could include providing care in 

a group setting as well as supports and services in a family setting. Two 

congregate care providers told us that their business model had changed 

in recent years, from predominantly caring for children residing in their 

facilities to providing services to children in their foster or original homes, 

and also planning for service provision when a child or youth left 

congregate care. A few stakeholders we spoke with confirmed that 

providers are re-evaluating their relationships with the states as states are 

moving toward offering a continuum of services to help youth stay out of 

or transition out of congregate care as quickly as possible.

HHS’s Administration for Children and Families (ACF) recently took steps 

to examine how states were using congregate care and as previously 

mentioned issued a report in May 2015 to help inform states and 

policymakers about the use of congregate care for foster children.23 HHS 

officials told us that the report was their initial effort to understand 

congregate care as a placement option for foster children because the 

agency had not taken a national look at congregate care previously. In 

the report, HHS raised concerns about some of its findings—which we 

discussed earlier—about the use of congregate care for children aged 12 

or younger and for placements for youth who do not appear to have high 

23 U.S. Department of Health and Human Services, Administration for Children and 

Families, Children’s Bureau, “A National Look at the Use of Congregate Care in Child 

Welfare” (May 2015). We have included some data from the HHS report in the 

background section of this report.

HHS Has Recently Taken 

Steps to Encourage States 

to Examine Their Use of 

Congregate Care, but 

Could Enhance Its 

Support to States

Page 21 GAO-16-85 Foster Care

 
clinical needs that might be better served in appropriate family settings. In 

addition, while the report cited that the decline in the percentage of 

children placed in congregate care nationwide suggested that child 

welfare practice is moving toward more limited use of congregate care, it 

also noted that the depth of improvement is not consistent across states.

In addition to its findings in the report, HHS included a legislative proposal 

in its fiscal year 2016 budget request to increase monitoring of 

congregate care use and support family-based care as an alternative to 

congregate care. More specifically, the proposal would, among other 

things, amend Title IV-E to require (1) documentation to justify the use of 

congregate care as the least restrictive setting to meet a child’s needs, 

and (2) judicial review every 6 months while a child is in that placement to 

confirm that the placement remains the best option. It also would provide 

support for a specialized case management approach for caseworkers 

with reduced caseloads and specialized training for caseworkers and 

foster parents to address the needs of children. HHS estimated that these 

changes would increase costs in the first few years of the proposal going 

into effect, and that overall it would result in a reduction in costs of Title 

IV-E foster care maintenance payments. More specifically, HHS 

estimated that this proposal would increase fiscal year 2016 funding by 

$78 million and reduce foster care maintenance costs by $69 million over 

10 years.24

Based on our discussions with stakeholders, we identified other areas in 

which state efforts could benefit from additional HHS support, 

independent of the legislative proposal. One stakeholder noted that the 

information HHS currently collects does not focus on congregate care, 

and there is a wide variation in state experiences, which our review of 

AFCARS data and HHS’s own May 2015 report confirm.25 However, 

24 In recent years, various groups and members of Congress have also put forth 

proposals to reform the child welfare system and related financing mechanisms, with a 

focus on increasing services and supports to keep families together or encouraging 

placements of children in family settings when they must be removed from their homes. 

Proposals have included features such as increasing Title IV-B funds for communitybased services, permitting use of Title IV-E funds for time-limited services for a family in 

crisis, limiting Title IV-E support for children placed in group care settings, or limiting the 

length of time a foster child may be in group care and receive Title IV-E assistance.

25 Fred Wulczyn et al. Within and Between State Variation in the Use of Congregate Care

(the Center for State Child Welfare Data, Chapin Hall, University of Chicago (Chicago: 

June 2015).

Page 22 GAO-16-85 Foster Care

 
without more information on states’ efforts to reduce their use of 

congregate care, HHS is unable to fully understand states’ activities in 

this area, including relevant changes in the states’ use of congregate care 

and their effect on state child welfare systems. Although HHS conducted 

some initial research in its May 2015 report, HHS has the opportunity to 

further enhance its understanding of state efforts, for example, by 

leveraging its CFSR process, its AFCARS database, and future research 

activities. Internal control standards for the federal government call for 

agencies to have the information needed to understand program 

performance.26

Similarly, stakeholders noted that given the relative recency of some of 

the state efforts and the potential for unintended consequences, HHS’s 

support in sharing best practices and providing technical assistance 

would be helpful to the states as they make changes to their systems. For 

example, consistent with the challenges we identified, states could benefit 

from HHS’s assistance in the areas of increasing capacity for specialized 

foster family placements and working with congregate care providers to 

diversify their services. As an HHS study has noted, system changes in 

the child welfare area can be difficult, and require leadership, stakeholder 

involvement, and capacity building, among other things, as well as time 

and sustained attention to succeed.27 In addition, our previous work has 

identified similar key practices that facilitate successful transformations, 

including leadership from the top, focus on and communication of key 

26 GAO, Standards for Internal Control in the Federal Government. AIMD-00-21.3 

(Washington, D.C.: November 1999). Internal control calls for the establishment and 

review of performance measures and indicators. Activities need to be established to 

monitor performance measures and indicators. These controls could call for comparisons 

and assessments relating different sets of data to one another so that analyses of the 

relationships can be made and appropriate actions taken. Controls should also be aimed 

at validating the propriety and integrity of both organizational and individual performance 

measures and indicators. 

27 Western and Pacific Child Welfare Implementation Center, A Framework for 

Implementing Systems Change in Child Welfare: A Practice Brief, U.S. Department of 

Health and Human Services, Children’s Bureau. 

Page 23 GAO-16-85 Foster Care

 
priorities, and monitoring progress, particularly because transformations 

may take a long time to complete.28

HHS officials told us they did not currently have plans to provide 

additional support for states related to congregate care, although with a 

new Associate Commissioner of Children, Youth, and Families in place as 

of August 2015, they may consider additional actions.

States’ foster care systems are responsible for some of the most 

vulnerable children in the nation. This includes responsibility for placing 

children removed from their homes in the most family-like settings that 

meet their needs. The eight states we reviewed reflect the downward 

trend in the use of congregate care nationwide, which could be seen as a 

sign of progress in states’ “right-sizing” of congregate care. At the same 

time, the wide variation in the percentage of foster children in congregate 

care among our eight—and all 50—states suggests that more progress 

could be made. HHS has taken an important first step by issuing its report 

on congregate care and recognizing that additional information is needed 

on how states use congregate care and what changes are appropriate. It 

is important that HHS continues to progress in its understanding of the 

national landscape of congregate care so that it can be better positioned 

to support states through their transitions. Significant changes in child 

welfare programs require thoughtful leadership, relevant information, and 

sustained attention. HHS’s continued leadership and support will be 

needed, particularly by states facing challenges in developing alternatives 

to congregate care, to make progress nationwide.

We recommend that HHS take steps to enhance its support of state 

actions to reduce the use of congregate care as appropriate. These steps 

could include:

• collecting additional information on states’ efforts to reduce their use 

of congregate care; and

28 GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers and 

Organizational Transformations, GAO-03-669 (Washington D.C.: July 23, 2003). GAO,

Highlights of a GAO Forum: Mergers and Transformation: Lessons Learned for 

Department of Homeland Security and Other Federal Agencies, GAO-03-293SP

(Washington D.C.: November 2002).

Conclusion

Recommendation for 

Executive Action

Page 24 GAO-16-85 Foster Care

 
• identifying and sharing best practices with the states and providing 

technical assistance that states could use to address challenges in 

the areas of building capacity for family placements, addressing 

shortages of needed services, improving assessments, and retaining 

sufficient numbers of congregate care providers, or other areas as 

needed.

We provided a draft of this report to the Secretary of Health and Human 

Services, for review and comment. HHS provided general comments that 

are reproduced in appendix II. HHS also provided technical comments 

which we incorporated as appropriate. 

HHS concurred with our recommendation stating that it was consistent 

with its current approach for supporting states. HHS stated that federal 

law and policy make it clear that children who come into care should be 

placed in the least restrictive setting possible. However, it noted that

states have the flexibility and discretion to make decisions for a child on a 

case by case basis to ensure that the best placement is made and the 

individual needs of the child are met. HHS also noted that to assist states

in reducing their use of congregate care, the fiscal year 2016 President’s 

budget request includes a proposal to amend title IV-E to provide support 

and funding to promote family based care for children with behavioral and 

mental health needs as well as provide oversight of congregate care 

placements, as we noted in the report. Additionally, HHS stated that it 

offers individualized technical assistance to help child welfare agencies 

build capacity and improve outcomes for children and families, and it has 

recently begun providing tailored services to two public child welfare 

agencies working to reduce their use of congregate care through a Title 

IV-E waiver demonstration program. HHS also stated it will continue to 

explore research opportunities as well as how to build state capacity for

family placements. We encourage HHS to identify and take additional 

steps to assist states with reducing their use of congregate care. 

As agreed with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days from its 

issue date. At that time, we will send copies of this report to the 

appropriate congressional committees, the Secretary of Health and 

Human Services, and other interested parties. In addition, the report is 

available at no charge on the GAO website at http://www.gao.gov.

Agency Comments 

and Our Evaluation

Page 25 GAO-16-85 Foster Care
If you or your staffs have any questions concerning this report, please 

contact me at (202) 512-7215 or brownke@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this report. GAO staff who made key contributions to 

this report are listed in appendix III.

Kay E. Brown

Director

Education, Workforce, and Income Security Issues

Page 26 GAO-16-85 Foster Care
Appendix I: Types of Congregate Care 

Facilities Used by Four States We Visited

Connecticut Louisiana Maryland Washington

Acute Inpatient Psychiatric Hospital:

Inpatient treatment at a general or psychiatric 

hospital; stabilization of psychiatric symptoms.

Psychiatric Residential Treatment Facilities 

(PRTF): Community-based inpatient facility for 

children with treatment needs that require a 

structured 24-hour setting. Less restrictive 

than a hospital, but more restrictive than a 

residential treatment center.

Residential Treatment Center: Integrated 

therapeutic services, education, and daily 

living with individually tailored treatment plans.

Therapeutic Group Home: A small, four to 

six bed program in a neighborhood setting with 

intensive staffing and services.

Preparing Adolescents for Self Sufficiency 

(PASS) Group Home: A 6-10 bed education 

program located in a neighborhood staffed 

with non-clinical paraprofessionals.

Level 1 Non-Clinical Group Home: A 6-12 

bed program in a neighborhood staffed with 

non-clinical paraprofessionals. These may 

have a special focus, such as transitional living 

apartment program or a maternity program.

Short Term and Respite Home: Homes 

provide temporary congregate care with a 

range of clinical and nursing services. Also 

used for respite.

Safe Home: Temporary service providing 24-

hour care for children. To engage, stabilize, 

and assess each child, generate level of care 

recommendation, and transition to an 

appropriate placement.

Psychiatric Residential 

Treatment Facilities 

(PRTF): Highest level of 

care for youth between the 

ages of 8-17 with severe 

behavioral and emotional 

issues.

Therapeutic Group 

Homes: Community based 

care in a home-like setting, 

generally for children and 

youth. Homes are less 

restrictive than PRTF, have 

no more than eight beds, 

and are run under the 

supervision of a psychiatrist 

or psychologist.

Non-Medical Group 

Homes: Generally serve 

older youth that are not able 

to be placed in a lower level 

of care and do not meet the 

eligibility requirements for 

the higher level care 

facilities. These homes have 

no more than 16 beds.

Alternative Living Unit:

Small homes (limited to 

three beds) that are 

specifically focused on 

children with 

developmental 

disabilities.

Diagnostic Evaluation 

and Treatment 

Program: For children 

with significant needs, 

but the needs do not 

meet the requirements 

for placement in a 

residential treatment 

facility.

Group Home (also 

known as Residential 

Child Care Facilities):

Traditional group homes 

for children with low-end 

needs.

Medically Fragile:

Similar to an alternative 

living unit.

Therapeutic Group 

Home/High Intensity:

Homes with a lower staffto-child ratio, on-call 

social workers, and onsite licensed mental 

health professionals.

Licensed Group 

Home: Typically standalone (6-8 bed) 

residential home 

programs in a 

community setting. 

There are a few settings 

where multiple 

programs and services 

are delivered on site.

Licensed Staff 

Residential Home:

Typically a smaller 

residential home of less 

than six beds. These 

homes are in 

community settings and 

have a rotating 24 hour 

staff.

Source: GAO analysis of information from state interviews and documents.| GAO16-85

Appendix I: Types of Congregate Care 

Facilities Used by Four States We Visited

Page 27 GAO-16-85 Foster Care
Appendix II: Comments from the Department Appendix II: Comments from the Department of Health & Human Services

of Health & Human Services

Page 28 GAO-16-85 Foster Care
Appendix II: Comments from the Department 

of Health & Human Services

Page 29 GAO-16-85 Foster Care
Appendix II: Comments from the Department 

of Health & Human Services

Page 30 GAO-16-85 Foster Care
Appendix III: GAO Contact and Staff 

Acknowledgments

Kay E. Brown, (202) 512-7215 or brownke@gao.gov

In addition to the contact named above, Gale Harris (Assistant Director), 

Anjali Tekchandani (Analyst-in-Charge), and Vernette G. Shaw made 

significant contributions to this report. Also contributing significantly to this 

report were Sarah Cornetto, Kirsten Lauber, Amber Sinclair, Greg 

Whitney, and Charlie Willson.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(131344) Page 31 GAO-16-85 Foster Care
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