Department of Health and Human Servces 

OFFICE OF 

INSPECTOR GENERAL 

RESPITE CARE SERVICES 

FOR FOSTER PARENTS 

.., SERVICe" "Y' 0. 

"'''d3a 

JUN GIBBS BROWN 

Inspector General 

AUGUST 1994 

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. 

OFFICE OF INTIGATIONS 

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. 

OFFICE OF EVALUATION AN 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. 

500 (In Thousands) 

450 

400€

300€

200€

259€

140 125 

100€

1983 1992 

FOSTER CHILDREN E2FOSTER HOMES. 
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-ofhome 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. 

Tho Recognized TYpe of Res pile Care Are Formal and Informl 

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 adhoc 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 " GAOHRD-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€

RESPIT CA 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. Ninetyfive 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. 

TIE MAOR SOURCE OF RESPIT CA 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 

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 months. 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€

FOSTER PARNT USE OF AVAILALE RESPIT CA 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.€

Ski Of ResiJe Prvirs€

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.€

Transportatin To Respite Provirs€

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€

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 problems. € , 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.