Therapeutic Group Homes: Needed Programs in Danger from Family First Act

It is a fact universally acknowledged that some children cannot thrive in foster care. This includes children whose behaviors are so challenging that most foster parents will be unable to cope. These children often go through many foster homes before they are finally placed in a more appropriate placement, usually a therapeutic group home or residential treatment program.

One of the goals of the Family First and Prevention Services Act (FFPSA), passed last year as part of the Bipartisan Budget Act of 2018), was to reduce the use of placements other than relative homes and traditional foster care. However, FFPSA recognized that some children and youth cannot thrive in foster care and allowed for placements to meet their needs. Unfortunately, the many restrictions imposed by the Act mean that many of these young people may not able to access these facilities or will be prematurely removed from them.

Many youth who are placed in foster care have serious emotional and behavioral issues. Many have endured years of trauma, including physical and sexual abuse, severe neglect, and living in dangerous and chaotic conditions. Some have cognitive or neurological issues caused by drug exposure in utero or severe neglect. Some have violent outbursts, many are verbally aggressive, and many have difficulty in making attachments. As a result of these problems, many of these hard-to-place young people have been placed in ten or more foster homes.

High-quality therapeutic group homes are more able than foster families to work with challenging youth for a number of reasons described in an excellent video from the Sonoma County Juvenile Justice Commission. Their staff are trained in working with behaviorally challenging youth and often operate from a trauma-informed perspective. These facilities often have therapists and psychiatrists and other mental health personnel on staff. Good therapeutic group homes create a homelike environment, with young people living in cottages with a total of six or eight youths. Staff are dedicated and passionate about what they do. Unlike foster parents, these staff usually work shifts and thereby avoid burnout. Residents also draw strength from peers with similar issues, especially older peers who have improved and can serve as role models.

Some hard-to-place youth could thrive in the right kind of foster homes, those with training, time, and willingness to work with young people whose behavior is challenging. But many foster parents refuse to take teens or any or children with behavioral or mental health problems. Some states are trying to increase the availability of therapeutic foster homes, but funding and supply constraints mean that such efforts will be far too small to replace therapeutic group homes.

Unfortunately, the restrictions imposed by FFPSA may make it difficult to for many needed therapeutic group homes to continue operating. FFPSA allows the federal government to share the costs of treatment-based congregate care only at facilities that qualify as Qualified Residential Treatment Programs (QRTP). These programs must meet several criteria, including accreditation, a trauma-informed model, medical staff on call, and an aftercare program, among others. Accreditation especially is a long and arduous process that generally takes 12 to 18 months and some homes may not be able to accomplish it by the time the Act takes effect on October 1, 2019 (unless the state chooses to delay implementation for two years). Accreditation is a difficult and costly requirement for a smaller facility. It is important to ensure that only high-quality group homes retain state contracts, but accreditation may not be the best way to ensure quality for smaller programs.

Even more concerning are the limits on which children can be placed at these facilities and for how long. A child’s initial placement in a QRTP will not be reimbursed unless a “qualified professional” determines within 30 days of placement that the child needs to be placed in such a setting rather than a relative or foster family home.  This assessment must use an approved tool and be conducted by “a trained professional or licensed clinician who is not an employee of the State agency and who is not connected to, or affiliated with, any placement setting in which children are placed by the State.” The decision must be approved by a court within 60 days and must be reviewed at subsequent status hearings. Moreover, a child cannot remain in a QRTP for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

There are several problems with these restrictions. It is not clear that agencies can find enough qualified professionals who are not employed by the agency or connected to any placement setting used by the state. More concerning are the time limits. Many therapeutic group home professionals believe that most children with emotional and behavioral problems cannot be in and out of therapeutic residential settings in six months. Many will need to stay a year or even longer.

Without needed therapeutic group homes, many children will experience a string of failed foster home placements, with each one leading to further damage to the child, who may end up on the streets or in jail. As a director of a facility that closed in North Dakota put it, new policies mean that “You are only going to refer kids to (residential child care facility) levels of care after you have exhausted all the other less restrictive options of care. That means putting them with their families, in foster care and repeating failed foster care placements several times before a referral to this level of care would be entertained.”

Group homes have already been closing around the country as states have adopted policies against congregate care (and also due to failure to provide adequate funding) and some states are already seen bad consequences from these closures. In Baltimore, the number of children sleeping in offices shot up from less than five per six month period in 2015 to 130 in the first half of 2018 due to a shortage of foster homes and a dramatic reduction in group home capacity. In Hillsborough County, Florida, hard-to-place foster youths have been spending the night in cars for lack of appropriate placements. In the state of Washington, group homes have been shutting down for years due the state’s failure to keep up with the increasing costs of care. This has contributed to a crisis in care for older, harder-to-serve youth, who are being put up in hotels, offices and $600-per night emergency foster homes and being sent out of state for care. In Illinois, hundreds of foster youths were being kept unnecessarily in psychiatric hospitals as of last August because of a decline in licensed residential facilities.

The attempt to close congregate care facilities without providing an alternative is eerily reminiscent of the closure of institutions for the mentally ill in the 1960s. These hospitals were supposed to be replaced with community health services that were never funded. We are still reaping the consequences with the abundance of mentally ill people sleeping on the streets of America’s cities.

As I mentioned in last week’s post, FFPSA’s group home restrictions were not based on ideology alone. The cost savings from reducing federal reimbursement for group homes were necessary to offset the increased cost of funding services to prevent children’s placement in foster care. But penny-wise is often pound-foolish and the future costs of eliminating therapeutic residential options for foster youth may be much greater than the present savings.

It is not too late for Congress to amend the Family First Act to reduce restrictions on therapeutic group care. Until we have an abundance of qualified therapeutic foster parents willing and able to take the hardest to place youth, cutting down on therapeutic group homes is irresponsible, short-sighted, and a recipe for possible disaster.

\