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Family First: Risks and Opportunities

(Originally published June 2019)

The Family First Prevention Services Act (FFPSA) became law on February 9, 2018 after more than a decade of persistent efforts by several influential foundations and advocacy groups in order to reach consensus regarding child welfare finance reform. State governments were adamantly opposed to block grants of child welfare funds intended to undo entitlements such as federal IV-E funding of foster care. Policymakers at the federal level during and following the Great Recession (of 2008-09) were equally resistant to expanding entitlements to a much larger percentage of children and parents with open child welfare cases for a wider range of services, including placement prevention services, without a way of controlling costs. However, all parties to these discussions (which seemed unresolvable) agreed that child welfare funding mechanisms which made it easier for state child welfare agencies to fund foster care than in-home services were perverse public policy and needed to be changed.

The impasse between and among child advocates and policymakers at the federal level was broken after the Annie E. Casey Foundation began to advocate strongly for policies and funding formulas that would reduce the use of residential care, the most expensive (by far) type of foster care. The Casey Foundation’s rationale for reducing use of residential care was not based on budget considerations, but rather on children’s need for family, along with a substantial body of research which found meagre benefits, if any, for youth (mostly adolescents) placed in residential care, (AKA group care, congregate care). Research studies gradually (but steadily) undermined the belief of advocates, practitioners and stakeholders in the effectiveness of residential care to the point in recent years that studies which found positive outcomes for some residential care programs and models (e.g., Boys Town’s model) have been largely ignored. In addition, many states, including Washington, have had major high-profile cases in which children and youth were seriously physically abused and/or sexually abused in residential care facilities for many years. Mistreatment of youth placed in the OK Boys Ranch during the 1980’s and 90’s led to dozens of tort actions and many millions of dollars in tort settlements in this state. Other states, e.g., Illinois, have experienced widespread systemic abuse in their residential care facilities during the past decade.

The loss of confidence in residential care among policymakers, practitioners, advocates and scholars presented a way to break the impasse regarding child welfare finance reform:

Reduce the cost of foster care by reducing federal support for expensive residential care placements while
Expanding the IV-E entitlement to another group of children, “candidates for foster care,” and their parents by
Funding 50% of evidence based mental health and substance abuse treatment programs and parenting programs for this group of children and their parents under the banner of placement prevention.

When advocates’ aspirations for bettering the lives of foster children were brought in line with a means of cutting IV-E expenditures for foster care, while incentivizing utilization of evidence-based practices endorsed by the Administration for Children, Youth and Families (ACYF), child welfare finance reform suddenly became possible. The Family First Prevention Services Act of 2018 lit up the night sky of child welfare reform by doing what stars do, i.e., balancing conflicting forces (expanded entitlements vs. cost controls). Whether these conflicting imperatives can be brought into a stable alignment that nourishes innovation rather than (mainly) creating chaos and desperation remains to be seen. Family First is a high stakes gamble on placement prevention during a period of acute and chronic foster care shortages, especially a lack of foster homes for teenagers, the population of children/youth who will likely be most affected by FFPSA.

Key Elements of Family First Related to Residential Care

Beginning October 1, 2019, children and youth placed in congregate care/ group care will not be IV-E eligible after two weeks in care unless the child is placed in a Qualified Residential Treatment Program (QRTP); or in a facility that provides prenatal, postpartum or parenting supports for youth; or in a supervised setting for youth, 18 and older, or in a licensed residential care facility for family-based substance abuse treatment.
QRTP’s must be trauma informed and capable of providing therapeutic care to children and youth with serious emotional and behavioral problems, and the program must be accredited by an organization approved by HHS, (the umbrella agency to which ACYF belongs).
Within 30 days of placement in a QRTP, the child/youth must be assessed by a “qualified individual” not employed by the state or by a treatment facility using an assessment tool that meets requirements outlined by HHS.
The assessment must find that the child’s needs cannot be met by family members or in a foster family home. The lack of foster homes is not an adequate reason for a QRTP placement.
The assessment must be completed in conjunction with the child’s family and permanency team which may include parents, extended family members and professionals from various disciplines.
A court must approve the QRTP placement within 60 days of placement.
For children in a QRTP placement for 12 consecutive or 18 non-consecutive months, the child welfare agency must submit to HHS justification for continuing the placement with a signed approval by the state director.
States can postpone implementation of the congregate care provisions of FFPSA for 2 years; but must give up the capacity to use IV-E funds for preventive services during the delay in implementation.
States are required to collect and report to HHS extensive data regarding children placed in settings other than foster family homes, including child specific information regarding children’s placement histories, and services provided to each child placed in a non-family setting.

These are (to put it mildly) administratively onerous requirements intended both to virtually eliminate the long term use of residential care facilities which lack a well- developed therapeutic program, and to create incentives for state child welfare systems to develop alternatives to group care/congregate care for behaviorally troubled youth. These requirements will almost certainly increase the economic and political costs of QRTP’s by requiring accreditation of programs and an independent assessment of the need for residential care, and by linking QRTP placements to court structure, thereby eliminating voluntary placements that extend past 14 days. In addition, involving agency directors in the approval of residential placements that extend for longer than a year is likely to be a disincentive to make these requests, as ACYF understands. What person or organization in its right mind would enter the residential care field given this regulatory framework! Directors of existing QRTP programs are likely to ponder the future of an industry the federal government clearly intends to marginalize.

Key Elements of Family First Prevention Services

Children and youth who are “candidates” for foster care, i.e., at imminent risk of entering foster care, are eligible for IV-E funded substance abuse and mental health services, and for parenting education services deemed “promising, supported or well supported” by an authoritative clearinghouse to be created with federal funding, or for services shown by research studies in states and communities to meet evidenced based standards. IV-E funds can be expended on these services for a maximum of 12 months.
The federal government will reimburse states 50% of the costs of these services until October 2026, at which time states will be reimbursed at their Federal Medical Assistance Percentage (FMAP).
To receive 50% reimbursement of costs, states must have a plan to conduct “well designed and rigorous” evaluations of prevention services reimbursed by IV-E, or in lieu of such evaluations, use programs approved by HHS.
States cannot spend less than they did on foster care prevention in FY 2014, i.e., state child welfare agencies cannot shift existing costs to the new IV-E funding stream without funding additional prevention services.
IV-E funds can be used to support Kinship Navigator programs.
Children can receive IV-E funded services for 15 months from the date of reunification.
State child welfare agencies can use IV-B funds for community-based services designed to support and retain foster families.
Under IV-B, $8 million dollars in competitive grants will be awarded to states to support foster family recruitment and retention, and to facilitate the licensing of foster homes.
State child welfare agencies will be required to collect and report extensive data regarding specific prevention services, and to provide child specific data regarding entry into foster care at 12 and 24 months for children who have received prevention services.
In 2021, HHS will establish “national prevention services measures,” i.e., the percentage of candidates for foster care who have not entered foster care by 12 and 24 months following the date when prevention services began.

These bullets are only highlights of a lengthy and complex law that creates significant implementation challenges for state child welfare agencies, challenges that will surely require a cadre of program managers, i.e., more bureaucracy, to develop guidelines, track and report data and meet a myriad of highly prescriptive requirements contained in the law. This is the type of legislation that gives the federal government a bad reputation with state agencies. The developers of FFPSA clearly did not trust state child welfare agencies to implement the law as written; and intend to track the actions of states to meet FFPSA requirements like “white on rice.” Advocates tend to be focused on the goals and values of new laws. Policymakers are concerned (as they must be) with the hidden costs of federal legislation. However, state agencies must first figure out the implementation challenges of new laws before worrying about outcomes. Coming to terms with FFPSA will likely absorb the energy (already stretched to the limit) of public child welfare agencies for the next few years.

Why is Family First a huge gamble?

A recent article from The Pew Charitable Trusts asserts that “Only 58% of foster teens live with a family, compared with 95% of kids 12 and under, according to a recent report by the Annie E. Casey Foundation.” States vary greatly in their rates of residential care. “In Colorado, which has the lowest rate of foster kids living with families, 31% of foster children reside in 120 congregate care facilities. Neighboring Nebraska, with a population one-third the size of Colorado’s, has only 24 group homes, and only 7% of the foster children in that state reside live in them.” Furthermore, “Forty-one percent of foster youth 13-17 are placed in a group home as soon as they are removed from their parents, according to a 2015 report by the Center for State Child Welfare Data at the University of Chicago.” (Pew Family Trusts).

Some states (e.g., Connecticut and Rhode Island) have been able to greatly reduce the percentage of children placed in residential care during the past decade, but other states (such as Washington) have created embarrassing and costly ‘train wrecks’ in their foster care systems by making draconian cuts to residential care without investing in alternatives, e.g., professional foster care or a cadre of well-trained and adequately supported therapeutic foster parents. Washington State can serve as an example of what not to do in reshaping foster care systems, i.e., don’t undermine residential care programs without having created viable alternatives for children and youth with serious behavior problems and other disabilities. The consequence of disastrous public policy decisions in Washington has been 50-100 youth placed in out of state residential care facilities on any one day, frequent use of costly hotel placements in some regions (especially King County) and 24-hour placements in which a child is moved daily from home to home and babysat in offices during the day. Out-of-county placements for children of all ages have become business as usual in Washington’s child welfare system. Washington State’s legislature recently restored $37 million dollars in funding for residential care programs after news stories of abuse of a disabled child placed by the child welfare agency in an out-of-state facility.

Washington State is an egregious example of the damage excessive budget cuts to residential care, combined with wishful thinking about the potential of kinship care to meet the needs of behaviorally troubled foster children, can do to a foster care system. Several other states currently depend on residential care programs to a far greater extent than Washington did prior to budget cuts in residential care. Furthermore, child welfare systems around the country have acute and chronic shortages of foster homes for all ages of children, shortages that in a normal political climate might well lead to larger investments in shelters and group care programs. Family First offers a paltry $8 million dollars in competitive grants to improve foster parent recruitment and retention, along with unspecified amounts of IV-B funding to better support foster parents. Investments in therapeutic foster care independent of QRTP’s, or professional foster care, is not a part of Family First.

In truth, influential foundations and advocacy groups who developed and advocated for of FFPSA have limited interest in (or actively oppose) strengthening non-kin foster care systems. Rather, Family First is an “all in” public policy gamble on reducing the need for foster care for all ages of children. It’s possible that this gamble will succeed in some states and fail in others; and there are several other possibilities which will require 5-10 years to begin to fairly evaluate.

Next month’s Sounding Board will discuss both the design flaws of FFPSA, and the opportunities presented by the boldest and riskiest child welfare legislation of recent decades.

References

The Family First Prevention Services Act: Historic Reforms to the Child Welfare System Will Improve Outcomes for Vulnerable Children. Children’s Defense Fund, February 2018.

Family First Prevention Services Act: Section by Section. First Focus Campaign for Children, March 2018.

Wiltz, T., Finding Foster Families for Teens Is a Challenge in Many States, Pew Charitable Trusts, June 20, 2019.

Quinn, M., The Federal Government is Overhauling Foster Care. States Aren’t Ready. Governing the States and Localities, March 2019.

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