Foster Care: HHS Could Do More to Support States' Efforts to Keep Children in Family-Based Care
Published: 2015-10-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.
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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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. 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.
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?  (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. “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.
subsections: section_title: Background
paragraphs: 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.
subsections: section_title: Federal Funding Sources for Child Welfare Programs
paragraphs: 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  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. 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. 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.
section_title: Oversight and Monitoring of Child Welfare Programs
paragraphs: 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:
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.
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:
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.
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.
section_title: Placement Decisions and Congregate Care
paragraphs: 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. However, states have  flexibility and discretion to make decisions for each child on a case-by- 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. 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 family- based 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. 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.
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.
Of these children, 31 percent were aged 12 or younger when they  experienced congregate care at some point during the 5-year follow- up. 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.
section_title: National Trends
paragraphs: 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).
section_title: Eight Selected States Reduced the Use of Congregate Care Substantially Using Multiple Approaches, but the Rates of Use Varied Widely
subsections: section_title: The Eight Selected States Averaged a 47 Percent Reduction in Congregate Care Use, Although the Current Rates of Use Still Varied among These States
paragraphs: 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.
section_title: Selected States’ Efforts to Reduce Congregate Care Included Expanding Services, Developing Alternative Placements, and Revising How They Used Congregate Care
paragraphs: 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.
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. 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. 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  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.
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 non- profit 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— referred to as resource families—that helped to reduce the overall foster  care population and congregate care placements.  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 Foundation 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.
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  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 community- based 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 Programs 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 in- home 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.
section_title: Stakeholders Cited Challenges in Developing Alternatives to Congregate Care and HHS Has Begun Efforts to Help States
subsections: section_title: Developing a Sufficient Supply of Appropriate Family Placements and Needed Services While Transitioning to a More Treatment–Based Model of Congregate Care Poses Challenges
paragraphs: 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. 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.
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. 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  localities generally, as we have also found in our previous work.  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. 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. 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  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.
section_title: HHS Has Recently Taken Steps to Encourage States to Examine Their Use of Congregate Care, but Could Enhance Its Support to States
paragraphs: 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. 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  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.
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. However,  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.
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. 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  priorities, and monitoring progress, particularly because transformations  may take a long time to complete.
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.
section_title: Conclusion
paragraphs: 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.
section_title: Recommendation for Executive Action
paragraphs: 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  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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.
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.
section_title: Appendix I: Types of Congregate Care Facilities Used by Four States We Visited
paragraphs: Connecticut  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.
Louisiana  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.
Maryland  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 staff- to-child ratio, on-call  social workers, and on- site licensed mental  health professionals.
Washington  Licensed Group  Home: Typically stand- alone (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.
section_title: Appendix II: Comments from the Department of Health & Human Services
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: 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.