Background: Signed into law in 2015, California’s Continuum of Care Reform (CCR) marked a critical inflection point in the state’s relationship with congregate care. Responding to longstanding concerns about congregate care’s high operational costs, limited use of therapeutic interventions, and mixed outcomes, the CCR aimed to reduce California’s reliance on congregate care by building a continuum of evidence-based mental health services that would allow youth in foster care to receive behavioral health services while placed in family-like foster care settings. Among other supports, the CCR resulted in a new, child-specific foster care rate structure, rate parity for kinship caregivers, and renewed investments in California’s intensive services foster care. Group homes were replaced with short-term residential treatment programs (STRTPs), residential facilities that provide trauma-informed behavioral health services to youth whose behavioral health needs could not be met within less restrictive, family-like placements. Theoretically, providing evidence-based practices on a condensed timeline would shorten the time spent away from family-like settings. While nearly a decade has passed since the CCR was signed into law, research has yet to examine congregate care utilization and placement outcomes following its implementation. Considering a similar model has since been implemented to reduce congregate care utilization nationally, there is a critical need for evidence that examines both the intended and unintended consequences of California’s efforts to build alternative care pathways for youth with heightened behavioral health needs.
Method: To address these gaps, this dissertation combines the analytic advantages of population-level administrative case records with rigorous quantitative methods to provide a preliminary examination of the CCR’s implementation. The following three papers answer three broad questions: (1) To what extent has congregate care utilization changed since California’s implementation of the CCR?; (2) Which placement types have become more and less common following the CCR?; and (3) What are the underlying placement patterns and characteristics of youth who have entered congregate care before and after the CCR? Using a sample of 23,878 adolescents who entered foster care before and after the CCR, the first paper uses Cox proportional hazard analysis and other regression techniques to examine changes in California’s utilization of congregate care. The second paper uses multinomial logistic regression and generalized linear models to examine changes in placement outcomes and stability within the same sample. Using a sample of 4,784 placed in child welfare-supervised congregate care, the final paper uses sequence analysis to empirically derive common pathways to and through congregate care before and after CCR implementation.
Results: Findings indicated that the overall hazard and number of congregate care placements decreased following the CCR. Simultaneously, the hazard of out-of-county congregate care placements has increased while the overall amount of time spent in congregate care settings has remained stagnant. Paper 2 showed that adolescents who entered foster care after CCR implementation had a higher risk of non-foster care placements. Among youth who did not have a congregate care placement during their first adolescent placement episode, predominant placements in non-relative family foster homes increased, while foster family agency (FFA) placements became less common. Although there were no changes in placement stability among the total sample, placement stability deteriorated among non-congregate care youth predominantly placed in non-relative foster family homes. Results from Paper 3 revealed four common pathways to and through congregate care, primarily characterized by youths’ age at first foster care entry and subsequent re-entries. Despite more than half experiencing at least one kinship placement, youth who initially entered out-of-home care during early and middle childhood (and ultimately experienced a congregate care placement) showed heightened rates of mental health concerns, re-entry rates, and experiences of physical abuse. In contrast, youth with later first entries to foster care spent a greater proportion of their total time in out-of-home care in restrictive placements and were less likely to step down to family-like placements before their final exit from care.
Implications: Findings from this dissertation provide preliminary evidence describing the intended and unintended consequences of the CCR. While progress toward reducing California’s reliance on congregate care has been made, results highlight opportunities for additional alignment between the child welfare and behavioral health systems. Further investments in behavioral health services available to youth in care, such as the pending Tiered Permanent Rate Structure due to be implemented in 2027, may provide a reprieve from the observed increases in non-foster care placements, placement instability, and out-of-county congregate care placements. Similarly, there may be opportunities to leverage prevention service funding from the Family First Prevention Services Act (FFPSA) to prevent frequently observed adolescent entries to foster care and instability following placements with kin. Finally, family-centric supports that ensure behavioral health services remain accessible after reunification may reduce the elevated re-entry rates observed among youth who experience congregate care. Altogether, the dissertation findings suggest efforts to specialize congregate care in California and nationwide partially hinge on developing a continuum of mental health services available to youth in family-like settings.
