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Parent, Staff, and StakeholderExperiences of Group Care Reform: FirstFindingsPeter J. Pecora a b , Hildegarde Ayer c , Victor A. Gombos d , GeriWilson e , Kelly Cross f , Liz Crudo g , Lyscha Marcynyszyn h & TylerW. Corwin ia Casey Family Programs , Seattle , WA , USAb University of Washington , Seattle , WA , USAc Formerly Casey Family Programs , Boise , ID , USAd Department of Children and Family Services , Norwalk , CA , USAe Sacramento County Residentially-Based Services Reform ,Sacramento , CA , USAf Human Services–Legislation & Research Unit , San Bernardino , CA ,USAg San Francisco City and County Child Welfare Services , SanFrancisco , CA , USAh Formerly Casey Family Programs , Seattle , WA , USAi Seattle Jobs Initiative , Seattle , WA , USA

To cite this article: Peter J. Pecora , Hildegarde Ayer , Victor A. Gombos , Geri Wilson , KellyCross , Liz Crudo , Lyscha Marcynyszyn & Tyler W. Corwin (2013) Parent, Staff, and StakeholderExperiences of Group Care Reform: First Findings, Journal of Public Child Welfare, 7:4, 447-470, DOI:10.1080/15548732.2013.806277

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Journal of Public Child Welfare, Vol. 7:447–470, 2013

Copyright © Taylor & Francis Group, LLC

ISSN: 1554-8732 print/1554-8740 online

DOI: 10.1080/15548732.2013.806277

Parent, Staff, and Stakeholder Experiences ofGroup Care Reform: First Findings

PETER J. PECORACasey Family Programs, Seattle, WA, USA

University of Washington, Seattle, WA, USA

HILDEGARDE AYERFormerly Casey Family Programs, Boise, ID, USA

VICTOR A. GOMBOSDepartment of Children and Family Services, Norwalk, CA, USA

GERI WILSONSacramento County Residentially-Based Services Reform, Sacramento, CA, USA

KELLY CROSSHuman Services–Legislation & Research Unit, San Bernardino, CA, USA

LIZ CRUDOSan Francisco City and County Child Welfare Services, San Francisco, CA, USA

LYSCHA MARCYNYSZYNFormerly Casey Family Programs, Seattle, WA, USA

TYLER W. CORWINSeattle Jobs Initiative, Seattle, WA, USA

Received: 05/30/12; revised: 05/11/13; accepted: 05/14/13We thank Fred Molitor for his help with refining the questions and human subjects

application, Rori Bonnell for helping to design the logistics for the data collection process,and the Walter R. McDonald & Associates staff who helped edit the technical report. TheResidentially-Based Services (RBS) Coalition gratefully acknowledges the RBS stakeholdersparticipating in the planning process, especially the members of the RBS EvaluationSubcommittee. The consultation on qualitative data analysis from Erin Maher and the otherteam members of the Travis County, Texas, Child Protective Services Reintegration projectis appreciated. Finally, the focus groups were made possible by the skill and hard workof the child welfare and group home staff in each county. For more information aboutthe RBS reform initiative, please see www.RBSReform.org or contact Karen Gunderson([email protected]) or Carroll Schroeder ([email protected]). For moreinformation about the RBS evaluation, please contact RBS evaluation co-leaders, Dr. DaveMcDowell ([email protected]) or Dr. Peter J. Pecora ([email protected]).

Address correspondence to Peter J. Pecora, Managing Director of Research Services,Casey Family Programs, 2001 Eighth Avenue, Suite 2700, Seattle, WA 98121, USA. E-mail:[email protected]

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448 P. J. Pecora et al.

Group care has been criticized for excessive lengths of stay and

inability to help children improve their emotional and behav-

ior functioning. The Residentially-Based Services (RBS) Reform

Project, with demonstration sites in four large counties in Cali-

fornia, is intended to transform the current system of group care

through (a) early engagement of families; (b) focus on therapeu-

tic enhancement of child well-being in tandem with immediate

permanency planning and aggressive family-finding; (c) concur-

rent planning in case the intended adult cannot be the child’s

permanent caregiver; (d) family services to help parents improve

their parenting; and (e) post-permanency supports. Focus groups

and interviews with 74 key stakeholders provided information on

implementation process challenges, successes, promising strategies,

and early outcomes.

KEYWORDS group care, group homes, consumer feedback, resi-

dential treatment, congregate care

GROUP CARE IN THE UNITED STATES

Group homes and residential treatment centers have continued to be acentral part of the child welfare continuum of services. Youth placed in-group care (group homes and residential treatment centers) comprised ap-proximately 15% of those in out-of-home care in the United States, as ofSeptember 30, 2011. Specifically, a total of 400,540 youth were in out-of-home care, with 23,624 (6%) placed in group homes and 34,656 (9%) placedin institutions of some kind (U.S. Department of Health and Human Services,Administration for Children and Families, Children’s Bureau [US DHHS],2012).

Recently, group homes and residential treatment centers have been chal-lenged to better define their intervention models and identify the youth thatthey are best suited to serve. The group care field responded by improvingmany aspects of intervention design, implementation, staff development, andevaluation (American Association of Children’s Residential Care Agencies,2011; Courtney & Iwaniec, 2009; Noonan & Menashi, 2010; Whittaker, 2012;Whittaker et al., 2006). In particular, the group care field has made effortsto shorten the length of stay for youth in care, to involve family membersmore extensively in treatment, to help youth learn skills that can be used inthe community (e.g., how to manage their emotions and behaviors), and toconduct more extensive evaluation studies (Barth, 2005; Jenson & Whittaker,1987; Kerman, Maluccio, & Freundlich, 2009; Pecora et al., 2009). However,partially because of a lack of government and philanthropic investment,some challenges remain in terms of specifying group care intervention mod-

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Parent, Staff, and Stakeholder Experiences 449

els and then measuring their fidelity and outcomes (James, 2011; Ringleet al., 2012). The extreme elasticity of ‘‘congregrate care’’ continues to be aproblem. In some reports, this could be anything from a highly structured,small, and focused Teaching Family application at Boys Town to an unli-censed, overcrowded facility for warehousing youth. The field needs a muchmore refined taxonomy to guide practice and research (personal communi-cation, James K. Whittaker, September 18, 2012). This article summarizesearly qualitative data about how one group care reform effort, Residentially-Based Services (RBS), is being implemented in four major counties from theperspective of key stakeholders such as parents of children served, otherfamily members, group care line staff, family therapists, referring public childwelfare agencies, and allied agencies such as mental health and juvenileprobation. The article showcases RBS strengths and limitations at an earlystage of development so program refinements can be made and the resultsshared with the many other counties in the United States who are also tryingto refine group care.

Group Care in California and Residentially-Based Services

In 2006, 11.7% of California’s youth in out–of-home care were in groupcare (US DHHS, 2011) and there was insufficient clarity about the criteriaused to select youth for group care placement, what services were provided,and the degree to which these services were effective in helping childrenachieve legal permanency. Referring agencies expressed concerns about thehigh cost of group home placements, the paucity of openings for youth,the lack of discharge planning, and the poor outcomes for many youthoverall.

Group care providers faced their own challenges: payment rates did notcover the full cost of care, there was pressure to maintain full occupancy toremain financially viable, and the ‘‘wrong’’ children were sometimes referred.It also appeared that a large amount of money was being expended on high-needs and high-risk youth with less than satisfactory outcomes to promotepositive change. A pragmatic agreement was needed among the Departmentof Social Services, county child welfare agencies, group care providers, andadvocacy groups.

Consequently, the RBS Reform Project was established by state lawin response to the growing frustration surrounding the shortcomings ofthe existing foster care group home system. This law authorized a multi-year pilot demonstration project aimed at eventually transforming the state’scurrent system of long-term, congregate, group home care into a system ofresidentially-based services programs. Employing alternative program andfunding models, four pilot demonstration sites comprised of select countiesand their non-profit providers sought to reduce the length of time in groupcare and improve permanency outcomes for youth by combining short-term,

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intensive, residential treatment interventions with community-based servicesaimed at reconnecting children in care to their families and communities.RBS aimed to accomplish this without increasing costs to the child welfareprogram.

The four pilot demonstration sites include ten private group care pro-viders and the public child welfare agencies in Los Angeles, Sacramento, SanBernardino, and San Francisco (as well as mental health, juvenile probation,and other partners, depending on the county). Each site is implementingunique RBS program designs and funding models. Over 24 months, thefour sites will serve approximately 300 children who would otherwise haveremained in Rate Classification Level (RCL) 12–14 group homes (the systemsused to classify the level of treatment intensity in group care in this state).Depending on the specific pilot program design, short-term intensive resi-dential services are provided for an average of 5, 9, or 12 months, followed bylower-cost placement in the community and/or placement into a permanenthome, with follow-up services available for both options.

The RBS implementation within the four participating counties beganin June 2010 and is currently ongoing. The timelines and processes for ad-ministering and collecting evaluation measures were staggered at the projectstart-up, thus the availability of data was limited. The overall purpose ofthe RBS evaluation is to describe the services provided and the outcomesachieved in a way that can be shared externally with other jurisdictions thatmight benefit from knowing more about the approaches taken, successesrealized, challenges faced, and lessons learned.

Practice Framework for Residentially-Based Services

The RBS framework was created by a group of stakeholders initially con-vened in 2004 to reassess the role of group care for children in the state’spublic systems of care. This diverse group included family members, eman-cipated youth from foster care, child and family advocates, county and statepublic agency officials, state legislators, and childcare providers. Briefly,the RBS framework consists of short-term behavioral and therapeutic in-terventions delivered in residential group care settings where children livewith and are supervised by professional staff. As mentioned previously,these interventions seek to facilitate the connection or reconnection with thehome, school, and community settings by addressing critical unmet needsand helping youth find ways to understand, reduce, and replace problembehaviors associated with those needs with positive and productive alterna-tives. RBS sites are implementing elements of group care treatment that someresearch studies, experienced practitioners, and participants (youth, families,and staff ) agreed should be available to all children in care or in need ofcare, including:

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� Early and intense engagement of families (Burford & Hudson, 2000; Jenson& Whittaker, 1987);

� A focus on therapeutic interventions that contribute to child well-beingin tandem with immediate permanency planning and aggressive family-finding (in three of four counties), and concurrent planning in case theintended adult cannot be the child’s permanent caregiver (Katz, 1999; NewYork State Citizen’s Coalition for Children, 2006; Rogg, Davis, & O’Brien,2011);

� Family services to help parents and other caregivers improve their par-enting knowledge and skills (Barth & Haskins, 2009; Maher et al., 2011);and

� Post-permanency supports that provide ongoing aftercare services to youthand families (Freundlich & Wright, 2003).

To achieve the mandated core goals, RBS is, and must be, service-intensive. The key RBS team players, which vary slightly by county, typi-cally include the following: educational liaison, life coach, family therapist,individual child therapist, family partner, birth parents and relative care-givers, RBS youth, county agency staff (such as the state social servicesdepartment, juvenile probation, and mental health), and a wraparound team(e.g., representatives from the range of RBS agencies that provide connectedservices to the child or family, such as a medical doctor, a foster parent, orcourt-appointed special advocate [CASA]). As required by state law, the RBSagencies ensured that services included the following components:

� Structures and protections to ensure that children will be safe;� Comprehensive up-front assessments that identify the strengths of the

children and their families;� Engagement of children and families at the point of introduction to the

program’s service environment in a way that facilitates understandingabout how the time spent in RBS will be used to accomplish the goalsthat were the basis for the placement;

� A complete range of therapeutic, educational, behavioral, and social inter-ventions to address identified needs;

� Involvement of children and families in treatment and placement decision-making;

� Development of a permanency plan to ensure that the placement processincludes activities to help the children reinforce, re-establish, or establishpositive connections with the family or a caring adult in a familial envi-ronment; and

� Assistance in the children’s transition from placement back to the familyor to another family setting, in cooperation with formal and informalcommunity supports.

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RBS also includes the following two unique and critical categories ofservices that group homes outside of those implementing RBS are not au-thorized or funded to provide: (1) family support services while the childrenare in the program in order to prepare families to be able to successfullycare for these children upon discharge, and (2) post-discharge follow-alongservices to assure that children are able to remain and thrive with theirfamilies after they leave the group living arrangement.

Target Population

Children in RBS are between the ages of 6 and 18 years with severe emotionalor behavioral problems. They are referred to group care agencies by childwelfare staff, school personnel, and their parents, and reside in a residentialtreatment or group home program with an RCL of 12–14. [See the RBS YearOne Evaluation Report for the specific criteria that each participating countyidentified for RBS services and variations in key program components acrossthe four counties (Molitor & Pecora, 2011).]

METHOD

Evaluation Design

The qualitative evaluation for the first year of the RBS Reform Project wasintended to address the following research questions:

1. What have been the successes of RBS implementation regarding youthreferrals, youth screening, services provision, and youth and family out-comes?

2. What have been the challenges of RBS implementation?3. What strategies seem promising to overcome those RBS challenges?

The study entailed focus groups with birth parents, stepparents, rela-tives, foster parent caregivers, line staff, and other staff during Fall 2011 (N D

74). A total of 74 people participated in the focus groups that ranged between5 to 14 participants in size but averaged 6 to 8 people in each group. Thesame two members of the research team conducted each group. Both focusgroup leaders have MSWs and more than 20 years of child welfare practiceand management experience, with one specializing currently in research. Thefocus group leaders used the same questions, in the exact same order, andrecorded notes by computer and by hand. (No audiotaping was employed.)Up to three separate focus groups were held in each county, composed ofthe following clusters of participants:

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� Birth parents. (Note: For two counties, there were too few parents tohold a focus group. About three birth parents were interviewed by phoneinstead.)

� Relatives of the youth (including fictive kin, who are viewed by parentsand children as relatives but who are not related by blood or marriage, andtribal members as appropriate), foster parents who were actively caringfor the child or recently had done so, and community supports such ascoaches, mentors (e.g., Big Brothers, Big Sisters), and others who wereexpected to remain active in the youth’s life.

� Line staff and supervisor representatives from child welfare, group care,day treatment agencies, mental health, and juvenile probation, as wellas youth/family advocates and parent partners who have had the mostexperience with the RBS program.

Because a small number of youth had been served in each county(15 to 45), county site administrators selected the focus group participantsfor the birth parent focus group and the relative/foster parent/fictive kinfocus groups. The providers tried to select a cross section of parents andrelatives who: (a) were in various program components of RBS so therewas representation from family members in various stages of permanencyprogress, and (b) who the providers believed would be willing to participatein a focus group. If the person declined, another person was contacted andoffered the opportunity.

Selection of participants for the third focus group type used three dif-ferent ‘‘strata’’: comprised of staff, supervisors, and representatives fromother systems (e.g., juvenile probation). Two sites sent a research teammember an exhaustive list of staff from each participating agency and alist of representatives from juvenile probation, behavioral health, and child/family services. From these lists, we selected 14 participants using a stratifiedrandom sampling method (staff, supervisors, and representatives from othersystems). After these 14 participants were contacted, replacement participantswere randomly selected (within strata) for those participants who declinedor were unable to participate. For one particular site, a full list of all 51RBS-associated social service staff members was obtained from the agencyliaison. While five staff members were randomly selected, three participatedin this focus group.

As described previously, the RBS focus groups were designed to helpcollect information about the early lessons learned from this reform initiative.The topic areas discussed in the focus groups were developed by the RBSevaluation team and RBS Research Advisory Committee, which is comprisedof representatives from RBS service providers, county child welfare staff, stateRBS managers, and the RBS evaluation principal investigators. The questions

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were designed to surface areas of strength and areas needing improvement,primarily included, but were not limited to the following areas:

1. What have been the successes of RBS implementation regarding youthreferrals, youth screening, services provision, and youth discharge?

2. What have been the challenges of RBS implementation regarding youthreferrals, youth screening, services provision, and youth discharge?

3. What strategies seem promising to overcome those RBS challenges?4. What kinds of early youth and family outcomes have you seen?5. What kinds of benefits from RBS, if any, have you noticed?6. What drawbacks from RBS, if any, have you noticed?7. Have there been any anticipated or unanticipated negative effects of RBS?

Negative side effects?8. Have there been any anticipated or unanticipated positive effects of RBS?

Questions used during the interviews were the same as the focus group topicareas listed previously.

Human Subjects Review and Incentives for Participation

Approval from the Walter R. McDonald & Associates Institutional ReviewBoard was granted on September 1, 2011. Gift certificates for $25 to Targetor Walmart were provided to focus group participants.

Evaluation Strengths

First, staff and other focus group participants were selected by the focusgroup coordinator in each county (randomly, if the county had a sufficientnumber of potential participants from which to select). Second, the burden ofthe evaluation procedures to parents, other caregivers, county case workers,and group care provider staff was limited as they were not asked to partici-pate in any additional activities, such as the completion of surveys. Third, thefocus groups were conducted by an independent evaluation contractor andone of the RBS evaluation principal investigators, offering greater participantconfidentiality.

Evaluation Limitations

While 74 people participated in the focus groups (including phone interviewswith 2 parents who could not attend the focus groups), not all of them wereselected randomly from those eligible; in addition, participants representeda modest proportion of the total number of parents involved with theseyouth (more than 100) and referral agency staff. Further, the RBS intervention

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model is evolving and may not be similar in certain sites after this initialimplementation phase.

Data Collection

Focus groups were 75 to 90 minutes in duration and were held in each ofthe four RBS counties in Fall 2011. Focus group participant names were notwritten down in relation to particular comments.

Data Analysis

A systematic qualitative method of coding was used to facilitate descriptiveand thematic analysis of the focus groups and interviews (Sommer & Som-mer, 2002). Using this method, two evaluators read the notes from eachfocus group and interview in their entirety. Potential themes and ideas wererecorded on a theme recording template, as well as quotes. In a separatepart of the notes, the focus group recorder’s additional comments for eachquestion were recorded to obtain an overall sense of the data without relyingon a priori concepts or expectations.

The qualitative evaluation team (the two focus group leaders and tworesearch analysts) then developed a set of themes for each data collectionmethod and participant category type to indicate common responses. Thethemes were used to group and summarize the results. The data were an-alyzed for general themes as well as for individual variations in themesacross the focus groups and interviews. Next, the team reconciled differencesbetween themes to increase the reliability of the analysis. A consensus-based approach was used to reconcile the 6–10 areas where there wassome difference in theme assignment. The themes and results summarieswere shared with the participants by mail, after which two conference calldiscussions were scheduled so that the participants from all of the countiescould participate in a call to review and discuss the summaries, in additionto inviting feedback via mail or e-mail. Only four participants took part inthe conference call discussions but written feedback was uniformly positiveabout the draft themes.

Participants

The 74 focus group and interview participants included 16 birth parents;17 relatives, foster parents, and advocates; and 41 line staff from the publicagencies and RBS provider programs. The family members represented morethan 25 different youth served by RBS. The relative focus group includedaunts, uncles, grandparents, CASA volunteers, and foster parents. The linestaff focus groups included social workers, probation officers, mental health

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representatives, RBS therapists, supervisors, caretakers, and family partners.No demographic data was collected about the focus group participants.

RESULTS

Overview

The themes for the demonstration sites are provided in this section. Quo-tations from participants are bulleted and italicized and were chosen torepresent the most common themes.

Certain RBS Practice Components Were Recognized

STAKEHOLDERS IN THE FOCUS GROUPS FROM ALL RBS SITES EXPRESSED A

STRIKING DEGREE OF APPROVAL, UNDERSTANDING, PRAISE, APPRECIATION,

RECOGNITION, AND COMMITMENT TO THE VALUE OF THE RBS APPROACH

There was a strong cross-site outpouring of enthusiasm for RBS that demon-strated understanding, acceptance, engagement, and hope from the families,youth, public and provider staff, advocates, and stakeholders who partici-pated. Comments demonstrated an awareness of the unique RBS programservices to families and youth provided by its staff.

RBS STAFF MEMBERS WORK CLOSELY TOGETHER WITH FAMILIES

For example, one family experienced two ‘‘youth blow-outs’’ during trialvisits; the RBS staff went out to the home promptly to help the family addressthe situation.

We can work more closely with families. (RBS staff)

I had not talked to the social worker in six months, but I talk to the RBStherapist all the time. My relationship with my son has improved. (Birthparent)

RBS has a great staff . . . They really support the social worker and thefamily. (Birth parent)

THE TEAM APPROACH SUPPORTS MORE INDIVIDUALIZED PLANNING AND

ATTENTION FOR EACH CHILD

The use of a team approach means that if the person cannot be at a childconference or on a crisis call, the child and parents know the other staff mem-bers who will participate in the staff member’s absence. For example, staffmembers interact with the children as a team, involving life coaches, familypartners, and therapists. All work together to connect the youth’s interests

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to activities in the community, to build or rebuild permanent relationships,and to establish practical and portable life skills.

Kids can voice opinions about what they need to succeed—there aremore people willing to listen to them and to get them the things theywant—activities, jobs, training. (RBS staff)

The community-based group home is like [a] real house and real home—with pumpkin carving, holiday decorating—even the 17-year-olds gotinvolved. (CASA volunteer)

They always let me know—if I need them, they’ll be there. (Fostermother)

MAJOR CHANGES IN CHILD BEHAVIOR OFTEN OCCUR

Staff and families also note that while a child’s behavior can improve duringthe group placement, it may then regress somewhat upon family reunifica-tion; the journey may be akin to three steps forward, one step backward.

I have seen results, now my daughter calls me from [the group home]when she is upset, and I can try to calm her down by asking what iswrong. (Birth mother)

Elimination of the seclusion room . . . Really minimizing restraints. Thisis a huge change as some youth were in seclusion every day. It is a huge‘Ah ha’ for the youth—I can de-escalate myself. (RBS staff)

There is work to do like helping youth establish relationships with auntsand uncles they have not seen in four to eight years. Some reunificationstake time (9 to 10 months) to set up. If you try to move too fast, thechildren refuse to move with you on the path because they feel over-whelmed. (RBS staff)

BIRTH PARENTS AND FAMILY MEMBERS FEEL INVOLVED, AWARE,

AND COMMITTED

Focus group and interview responses indicated that caregivers felt mean-ingfully connected to the program and their children. Communication andsupport from the staff help parents develop different perspectives of thetreatment, increasing their hope that their child can come home to livesuccessfully. The RBS staff members work with families and children col-laboratively and positively, and in ways that promote engagement throughactivities, conflict resolution, and improved parenting skills. Staff feel andare perceived as very engaged, committed, responsive, and supportive. Theintense, collaborative planning and attention leads to improvement in thechild’s well being.

We are learning that often birth parents and birth families need a lot ofsupport to address basic needs so they can better address the original

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[Child Protection Services (CPS)] concerns and have the child returned tothem. (RBS staff)

Parents are coming on the grounds and interacting with staff and others.There are some incredible benefits here. Parents see other parents inter-acting with and, in a sense, protecting their children. They, in turn, getthe chance to interact with other children. They see who else is strugglingwith or succeeding with an aspect of parenting. They learn they are notalone in this struggle—and that the staff have hope for them and theirchildren. This is a very powerful set of messages. (RBS staff)

One birth father said it was like he was in therapy in a ‘‘good way’’every time he talked with an RBS staff member on the phone to brainstorm asituation or when he stopped by for a meeting. The RBS staff worked throughissues with him and he felt like he was learning through this process.

There is nothing hard about RBS. I have to do a lot of meetings but thatis what I signed up for. (Birth parent)

I did wraparound services for five years and we weren’t well-preparedfor my child to return home . . . RBS prepares and provides aftercare.(Birth parent)

A neighborhood-based group home setting works out very well . . . [we]had a great party, kick-ball game, and barbecue to involve the families,including the siblings . . . [there were] lots of activities. You get to knowother families and parents and vice versa. (RBS staff)

They help us bond with the youth, . . . [the] family dinners on Thursdays. . . [A] mother and daughter [fixed] dinner together with staff support asher daughter tested her . . . Family barbecues, [taking] family pictures,and sending the pictures back to the families [helped bonding]. (Birthparent)

We do not have to cut off the trust and relationships built in the grouphome when the child leaves as many of the supportive services followthem into the community. (RBS staff)

As they see their siblings’ behavior improve, the family situation is lessstressed and tensions decrease; caregivers’ anxiety for the other children inthe family abates and their sense of hope increases.

It is really important to my daughter that her brother is back on the righttrack. (Birth parent)

Service Challenges and Areas for Refinement

While participants across the sites and focus groups made few complaintsabout RBS, they did voice ideas and recommendations to improve the RBS

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program services, which were consistently expressed within the context ofcommitment and support. For example, three focus group participants ex-pressed negative opinions about certain aspects of RBS, or lack of knowledgeabout RBS. One birth parent felt negatively about almost everything, statingshe felt ‘‘disparaged, looked down upon, and that county/provider groupstaff were on vacation all the time.’’ One CASA volunteer described RBSas no different than any other program she had ever seen; a second CASAvolunteer seemed unfamiliar with the program entirely.

PUBLIC SECTOR STAFF MEMBERS NEED TO BE ADEQUATELY PREPARED FOR

RBS INVOLVEMENT

Some participants voiced concerns that public agency social workers lackedknowledge about their cases. For example, one grandmother described acall from a new public agency worker who wanted the names of the youth’sfamily members. This worker did not know that this caregiver was the youth’sgrandmother and had been the primary caregiver for years.

IMPROVE COMMUNICATION BETWEEN THE RBS STAFF AND CAREGIVERS

One birth parent said that sometimes she was not notified when her child wasAWOL, and that some case team meetings were not communicated. Now,notification is much better, except for a few doctor visits and one diabeticclass that she needed to attend with her daughter, which was inconvenientlyscheduled at the last minute. Similarly, another parent said that when shefirst participated on the treatment team, she was either not notified abouta meeting or was notified at the last minute. She indicated that the timingof notification has changed since she became more involved at the agency.Another participant, a CASA volunteer, noted that the young woman shewas working with was taking three powerful drugs (e.g., anti-convulsive,anti-depressant). She wanted a drug review and that had not happened yet.

There are opportunities to build relationships that didn’t exist before . . .Once a month we all get together at my house . . . includes my fosterson . . . all working together. The main team has 6 to 7 people weekly.The monthly meeting is 15 people. The RBS staff support was initiallyalmost overwhelming and not always sensitive to family schedules—[butnow the] scheduling is better, and families over time [have] become morecomfortable with the support and attention. (Therapeutic foster parent)

RBS REFERRAL AND INTAKE PROCESSES COULD BE REFINED

RBS staff generally expressed deep appreciation for public agency workerswho were familiar with their cases, provided relevant information in a timelyfashion, and participated in the meetings and decision making. However,they also indicated that some public agency workers were neither helpfulnor interested in making RBS a success.

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We are getting emergency referrals rather than planned [referrals]. (RBSstaff)

Not all [Department of Children and Family Services (DCFS)] workers areinvested in the program . . . Sometimes it is difficult to get them invested. . . They are not interested in family or reunification. (RBS staff)

If CPS can brief the family before the Team Decision Making meeting,the family will be more prepared. Relatives will have thought throughwhether they can really handle the child . . . We will have less of a deer-in-the-headlights effect. (RBS staff)

Moreover, across counties, RBS agencies seemed to need a better-definedreferral process that lends itself to a steady flow of referrals.

The family therapist caseload was four to five and now it is seven toeight. One parent partner has 14 families, and another has 20 families ascompared to 12 at other places. This is too many to sustain. (RBS staff)

Caseloads can be heavy at times—too heavy with the many calls madefrom family members, youth, schools, therapists, others—plus the paper-work. (RBS staff)

CROSS AGENCY TEAMWORK AMONG ALL AGENCIES INVOLVED IN RBS IS

ESSENTIAL FOR THE PROGRAM TO BE EFFECTIVE

RBS requires staff from all involved agencies (public and provider) to worktogether and to communicate closely; this is happening in varying degreesacross the sites. All youth, families, cross-agency staff, and advocates nowattend to issues that may have previously been ignored or have arisen as aresult of the close collaboration.

Having a life coach is great. I know this client is connected with alife coach, a therapist, and a house supervisor. [This client] has threeresponsible adults—a lot in any given day. (Therapeutic foster parent)

Prior to RBS, DCFS dropped the kids at the group home and prayedthey would be there for a long time, . . . more for the convenience ofthe social worker than the kids . . . I used to see it in my workers . . .[There is] much more interaction now between the public workers andthe facility staff . . . [which] shows an attitude change. (Public agencysupervisor)

REUNIFICATION CAN BE VERY COMPLEX

Some public agency staff worry that the unreliability of family members orterminated parental rights sets a child up for disappointment. RBS focuses ona full range of permanency options with the recognition that people change

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over time and that youth may need to prepare for disappointment. RBS staffmembers work with youth to recognize the current realities and strengthsthat exist within their families. From another perspective, reunification cancreate frustration:

The county agency wanted this relative to adopt the two children forwhom she cares; they are, however, not promising any of the key sup-ports the children need, so timely permanency may not be achieved.(RBS staff)

Recommendations

Each of the following nine recommendations directly represents or buildsupon comments made during the focus groups or interviews. These areincluded because they could have implications for group care reform effortsin other states.

REFINE THE RBS BUSINESS MODEL, INCLUDING INCREASING INFORMATION

SHARING, PLANNING, AND TRAINING WITHIN AND ACROSS ALL SITES

Any group care reform effort needs to be based on a logic and businessmodel of what needs to occur for effective services. This has several compo-nents including achieving a steady rate of placement referrals to addressthe overall RBS agency cost of care; planning for the number of youthmoving into aftercare; staff overtime; caseload management; and resourceallocation. RBS is a significant change from the past; staff transitions, caseloadpressures, travel, court requirements, agency and facility protocols, and themultiple service demands of RBS work have not been fully factored intocase and workload management. In other reform efforts such as in NewYork City, Maine, and Virginia, attention was paid to financial incentives andhow to help group care organizations succeed (Annie E. Casey Foundation,2010).

Staff turnover is higher than what we would like and it is hard on parentsand children. (RBS staff)

Sometimes we have a one-hour, one-way drive to get to an emergency.So the RBS business model needs to be fine-tuned for certain serviceareas and agencies because travel eats up staff time and needs to beplanned for. Currently, travel is not budgeted adequately for staff timeand mileage reimbursement. (RBS staff)

Both group care and public child welfare agency staff need ongoingtraining and a means of exchanging information and ideas. Ongoing stafftraining and cross-site discussions could be implemented to assure a com-plete understanding of RBS philosophy and services. Protocols addressing

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common issues in behavior management and crisis situations could be de-signed and made broadly available. The RBS program description, expecta-tions, and service philosophy can be more clearly summarized by staff andshared with families. Foundation and other private sector funding might bea resource for technical assistance and training programs. Training can beavailable for a single site, as well as across sites using videoconferencing,webinars, or conference calls.

Every site has unique proactive ideas and observations that could beshared across sites; line staff would then benefit from sharing their clinicalexperiences with one another within an agency and across the RBS agencies.An RBS newsletter for all participants—youth, families, staff, and stakehold-ers—might function as an exchange of information, ideas, stories, activities,and tips that build on the RBS philosophy and concepts.

The development of ongoing clinical training and communicationprocedures could maximize agency collaboration, and needs to be fullyexplored. For example, what activities are consistently associated withpositive outcomes? Do these warrant implementation across all sites? IfFamily Night engages the families and promotes family reunification, shouldall RBS sites actively engage families in these types of events? This alsoincludes re-considering the number and function of the various meetings, thenecessity of participation, and the most effective means of representation,participation, and communication. The family or foster home needs toremain and function as a home. It is important to respect the time androutine of the youth and family. Staff should focus on certain days forscheduling home visits and other RBS work so the family and youth haveother days set aside for typical home routines. One focus group participantdescribed the importance of being intentional about establishing thesearrangements:

This means Tuesdays and Fridays are visiting, meeting, and work days. . . The life coach picks up the child directly at school so the child doesnot go home, and then is interrupted to do something with a worker. Iwant my foster son to have a home with a normal routine. (Therapeuticfoster parent)

Finally, it appears necessary to constantly assess the RBS program time-frame to determine its broader applicability. For some children, the RBSgroup placement timeframe is too brief to adequately prepare the youth forplacement in a foster home or with a relative. By the time a youth needsresidential group care, he or she has often developed severe attachmentproblems. It may take many months to connect with and build or rebuild arelationship with a family member particularly if the youth has not seenthat individual in several years. Some youth need more time upfront tobe successful later. Likewise, some reunification situations require a longerperiod of aftercare services.

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EXAMINE THE SERVICE VARIATIONS ACROSS THE RBS SITES TO UNCOVER

AREAS THAT MIGHT REQUIRE MORE CONSISTENCY ACROSS SITES

Sites may differ across the following dimensions: staff turnover, businessmodel considerations, caseloads, training, cross-site collaboration, referralpreparation, understanding of public and court sector requirements andtimelines, and information exchange. As any group care reform effort movesforward, these variations should be examined to determine the extent towhich they indicate some limitations in the staffing, training, supervision,quality assurance, or other aspects that need to be measured, discussed, andaddressed promptly. For example, public agency workers may vary acrossthe sites in awareness, knowledge of, and investment in RBS. RBS needssocial workers who are invested and interested, and who want to be a partof this program. Ongoing training that involves public child welfare agencycaseworkers who have lower caseloads (and who may not feel overloaded)are possible options to consider as well.

As in the Louisiana reform, if RBS is to succeed, agency leadershipneeds to make informed and engaged stakeholder participation a strong andtransparent goal (Annie E. Casey Foundation, 2010). RBS participants fromall of the involved agencies need to be invested in the process and thegoals. If not, court proceedings can be replete with the differing views andtestimony from representatives of the multiple agencies and professionals(RBS programs, public agencies, CASAs, social workers, attorneys, fosterfamilies, and family members). A well-planned referral process is critical toappropriate identification of youth and families for RBS as well as preparationof families and relatives.

IMPROVE FAMILY FINDING IN SOME SITES

In many child welfare systems across America, this key service is not availablein all communities in the same way or as adequately as it needs to be. (TheSeneca Center program is one example of a national family-finding servicehttp://www.senecacenter.org/familyfinding/support). Technology improve-ments may help (e.g., three-way calling on phones or Skype accounts toconnect family members); however, modern technology still has its limits.For example, one family could not communicate well from Hawaii becauseits Internet signal was weak. Focus group findings indicated that sometimesin-person visits with relatives were arranged with travel paid for by the RBSprogram.

INCREASE RECRUITMENT OF TREATMENT FOSTER HOMES

There is a need to aggressively recruit more ‘‘bridge’’ treatment foster homes.Such bridge treatment foster homes provide specialized family-based carebetween residential services and permanent families. Currently, only oneRBS demonstration site has therapeutic foster care, and more may be needed.

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For example, RBS staff indicated that it is difficult to locate family homes foradolescent males based on caretaker fears of aggressive and unmanageablebehavior. To help, the Foster Family Treatment Association has been identi-fying recruitment, training, coaching, and retention strategies for adolescentsfor more than 10 years (see http://www.ffta.org/fpcannouncement.pdf).

TEACH YOUTH SKILLS WITH PORTABILITY

This concept was initially popularized for group care by Professor TedTeather and James K. Whittaker of the University of Washington, Schoolof Social Work (Whittaker, 1997). Modern group homes and residentialtreatment centers are extending these concepts to help youth develop lifeskills, learn how to follow rules common to both group care and living athome, and provide opportunities to apply those skills in real-life settings.

EXAMINE MEDICATION AND HEALTHCARE PRACTICES, INCLUDING

TREATMENT OF DIABETES

Concerns surfaced in every focus group about psychotropic medications.For example, the number of medications prescribed at the same time, theneed for a thorough up-front assessment, regular reviews by a qualifiedmedical practitioner, and providing families, RBS staff, and guardians withinformation about the child’s various medical conditions were all mentioned.Diabetes seems to be an emerging concern among RBS youth—an issuethat has nutritional and mental health implications. Youth need an explicitmedication review by a psychiatrist upon entering the RBS program. Ascurrently discussed across child welfare, RBS agencies need to provide moreinformation to staff, increase awareness about overmedication, and trainfamilies and staff to be careful observers who understand what supportsand interventions are available if needed (see, for example, Naylor et al.,2007; U.S. Government Accountability Office, 2011).

PLAN FOR THE REALITY THAT SOME YOUTH WILL NEED TO RETURN TO

GROUP CARE

Nationally, on average, 13% of children re-enter foster care within 12 monthsof reunification (U.S. DHHS, 2010, p. 39). While some of those childrenwill return to group care, the right kinds of community supports may helpprevent this. For continuity, individuals and entities could be involved whilethe youth is in RBS group care and after RBS agency services end. RBSagency leaders have pointed out that the youth should be supported by localcommunity resources, and that some of those resources might be providedby an out-stationed adolescent or family therapist from the RBS agency. Butmore likely, services would be provided by a local provider—ideally, onewho has been trained in the RBS treatment philosophy.

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MORE COMPLETE FUNDING MAY BE NEEDED FOR CERTAIN RBSCOMPONENTS

Some of the main funding sources may not be well synchronized with RBSprogram needs, concepts, strategies, and components. For example, manybirth families need specific supports and activities to successfully surmountissues that led to the placement of their children. Supplemental fundingsources vary across the demonstration sites. Staff consistently commentedon the difficulty of accessing funding for such interventions as childcare,assistance with housing, storage, and community programs that promotefamily functioning. While some suggestions indicated that funding couldbe used more effectively and flexibly, we had insufficient information tomake a clear statement about the allocation of available funds. The rangeof funding sources and varying interpretations of flexibility lead to differentconstellations of services across the demonstration sites (Note: Some levelof diversity seems appropriate considering that services are often tailored tofit a site’s target population, which varies across communities.) Interagencypartnerships across Medicaid, state mental health, and child welfare in stateslike New Jersey, as well as other finance strategies in Maine and Michigan,are addressing funding and availability of high quality mental health servicesin creative ways (for example, Center for Health Care Strategies, 2012; Stroul& Friedman, 2011).

THE RBS PROGRAM COULD BE EXPANDED TO SERVE OTHER YOUTH

ACROSS THE STATE

Almost without exception, participants across the demonstration sites ex-pressed enthusiastic support for expanding RBS and serving more children.

This [program] should be available to all children. (RBS staff)

Issues are manageable. RBS can work, but the issues are funding related.(RBS staff)

RBS philosophy is amazing and it works, but it takes time and a man-ageable schedule. (RBS staff)

DISCUSSION

As mentioned in the beginning of this article, a large number of statesare trying to target those children who will benefit most from group care,and to reduce the average length of stay through better assessment, useof more evidence-based treatments, more aggressive permanency planning,increased family engagement, and other innovations. Successful group carereform efforts are occurring in many jurisdictions, including New York City,

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Maine, Louisiana, Texas, and Virginia (Child Welfare Information Gateway,2012; Annie E. Casey Foundation, 2010). For example, the Travis CountyChild Protective Services Reintegration Project evaluation in Austin, Texas,found that by providing the right intensity and duration of wraparoundservices and other supports, including dedicated staffing, reunification canbe achieved for youth with complex mental and behavioral needs, therebysaving costs to the child welfare agency over time (Madden et al., 2012).Like RBS, many of these reform strategies used clear performance targets,financial incentives, and monitoring to improve group care.

RBS services incorporate some essential child welfare best practicesthat are also used in Maine, Minnesota, Los Angeles Juvenile Probation,and other jurisdictions, such as solution-focused therapy, functional familytherapy, anger replacement therapy, family group conferencing, and familyteam meetings. Focus group attendees (birth parents, relatives, and staff )were clearly engaged in and committed to the RBS philosophy and programinnovations. Concerns, issues, and recommendations were presented in apositive context of wanting RBS to continue to improve, expand, and becomemore broadly available. The focus group findings suggest an enthusiasm andunderstanding of the commitments and work involved. Parents commentedthat RBS staff approach families and youth with a strengths-based perspectivethat is infused with realistic optimism. The RBS staff and the services theyprovide teach families how to live, work, play, and disagree together, aswell as how to problem-solve and fight in healthy ways. Labeling of familiesis avoided; instead, RBS staff members emphasize gaining trust, managingdisappointment, building relationships, and not giving up.

As the reforms in Virginia and other states demonstrated, one key drivingforce is targeted funding (Annie E. Casey Foundation, 2010). If RBS is tocontinue and grow across the state, stable funding to support the robustarray of services must be available. A small panel of federal, state, county,and private sector funding experts should be reconvened to explore allthe possibilities relevant to RBS. It would be useful to include a federalregional representative in such a meeting, which might address the followingquestions: Have the funding sources been fully maximized? Have all thepotential funding sources been addressed? What changes in federal, state,and county funding policies could be made that would strengthen RBS?How can the state’s approach to using Medicaid be refined to support thiskind of practice reform? How could recent developments such as the various

lawsuit settlements and the new permanency practice model in California,help support RBS in the future? What RBS program components might beattractive to foundations or other private sector funding sources?

The ways in which RBS dollars are spent should be analyzed in thecontext of emerging results and compared to other child welfare programsand strategies. In addition, it is important to assess the savings generated byRBS and its association with more healthy young adults and the avoidance

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of certain social problems, such as teen pregnancy and delinquency. Manyof the RBS youth served are older adolescents nearing adulthood. If RBSis not available, living situation instability and high-risk behaviors amongyouth may continue, which in turn could contribute to added societal costsvis a vis unemployment, incarceration, a lack of achievement, and othersocial problems (Cohen, Piquero, & Jennings, 2010).

CONCLUSION

Early stakeholder experiences of service quality and initial reports of youthoutcomes (Molitor & Pecora, 2011; Molitor et al., 2013) are promising, whichindicates that the RBS program has potential to improve outcomes for a muchlarger group of children and families if these early data are consistent withthe Year 3 RBS outcome report findings. Future RBS qualitative evaluationtimelines need to incorporate a determined effort to obtain information aboutRBS outcomes and implementation challenges from critical stakeholders suchas judges, school personnel, and other representatives who interact with theyouth and family in the community.

RBS may lay the groundwork for the residential group care services ofthe future and complement group care reform efforts in other states. Webelieve this would require the following:

� A business model reflecting the realities of public funding, and carefulanalysis of the costs of delivering RBS services, including ongoing training;

� More fully staffed aftercare services that are funded adequately to betteraddress the full range of child and parent issues that emerge as a childreturns home or is placed with a legal guardian;

� Public awareness that the community has a critical stake in the lives andwell-being of these at-risk youth and families as well as a commitment toadequate and sustainable funding;

� Creative, innovative, and practical partnerships with community sectors,where these youth and families live; and,

� Greater specification of the intervention strategies that are most stronglylinked with RBS and post-RBS success and for whom.

Group care agencies have the potential to be part of the vanguard ofagencies that can help keep families together with periodic ‘‘tune-ups’’ andcrisis services for a specified period of time after permanency is achieved. Formany parents and families, this is the first set of counselors, parent advocates,and youth advocates who have significantly connected with them and whomthey trust. For these reasons, group care staff can be a bridge for the familyto connect with local human services providers. This can only be achievedwith the committed support of the private and public sectors, including child

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welfare, mental health, education, and juvenile justice. While the need forcross-system integration is not new, the early group care reform findingsprovide a roadmap to support integration in order to meet the needs ofsome of our most vulnerable youth and families.

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CONTRIBUTORS

Peter J. Pecora, PhD, is the Managing Director of Research Services at Casey FamilyPrograms and is a Professor at the University of Washington in Seattle, WA.

Hildegarde Ayer, MSW, was formerly a Research Consultant with Research Servicesat Casey Family Programs in Boise, ID.

Victor A. Gombos, PhD, is a Research Analyst (III) in the Research and EvaluationSection, Business Information Systems Division at the Department of Children andFamily Services, County of Los Angeles in Norwalk, CA.

Geri Wilson, MS, is a Project Coordinator for the Sacramento County Residentially-Based Services Reform in Sacramento, CA.

Kelly Cross, MS, is a Statistical Analyst for the Human Services–Legislation & Re-search Unit, County of San Bernardino in San Bernardino, CA.

Liz Crudo, MSW, is a Project Manager at San Francisco City and County ChildWelfare Services in San Francisco, CA.

Lyscha Marcynyszyn, PhD, was formerly a Research Analyst with Research Servicesat Casey Family Programs in Seattle, WA.

Tyler W. Corwin, MA, was formerly a Research Analyst with Research Services atCasey Family Programs. He is currently a Senior Policy Analyst with Seattle JobsInitiative in Seattle, WA.

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