Family First Implementation of Congregate Care Reforms: Where are We One Year Later?

Signed into federal law in February 2018, the Family First Prevention Services Act (Family First) contains a major child welfare policy allowing states to use federal Title IV-E funds to support the judicious, time-limited, and clinically appropriate use of congregate care, including Qualified Residential Treatment Programs (QRTPs). October 2021 marked the deadline for redesigned federal fiscal support for states to implement these Family First congregate care reforms. The American Academy of Pediatrics (AAP) partnered with Chapin Hall to examine where states stand nearly 1 year after the implementation deadline, to describe what was and was not working to date, and to identify early lessons learned to inform future implementation decisions and child welfare policy deliberations. 

What We Did 

In this mixed-methods study, we first surveyed child welfare agency directors in 50 states, as well as Washington, DC and Puerto Rico. We asked how states are changing or reducing the use of congregate care under Family First, implementing and financing QRTPs and other congregate care settings, and navigating barriers, successes, and recommendations for future reforms. Then we conducted three targeted focus groups with young people with lived QRTP experiences, QRTP providers, and child welfare agency administrators implementing QRTPs to gather their perspectives on Family First congregate care reforms. 

What We Found 

By integrating findings from the national survey (92% response rate) with key themes from the three focus groups, we learned: 

  • State visions and goals for ongoing state congregate care reforms appeared to align with Family First.  
  • States have reduced the use of congregate care and have increased the use of kinship foster care. 
  • QRTPs are now a primary component of congregate care placement arrays in many states.  
  • States have undertaken substantial efforts and pursued different strategies to establish and implement QRTPs to meet federal requirements.  
  • Top implementation barriers concern resources and capacity in: (1) workforce and staff, (2) therapeutic foster care models, (3) funding, and (4) foster families.  
  • QRTPs lack tailored treatment, quality staff, and coordinated aftercare to meet young people’s needs.
  • Perceived lack of change in QRTPs from status quo is inconsistent with the intent of Family First.  
  • Despite initial evidence that some aspects of QRTPs are implemented, young people have not reported meaningful changes in their experiences or treatment. 
  • Child welfare systems need evidence at scale to examine QRTP outcomes. 

What It Means 

 We made several key policy recommendations to advance the implementation of Family First congregate care reforms:  

  • Provide states with additional state and federal resources such as technical assistance and funding.  
  • Facilitate cross-system collaboration to successfully implement Family First. 
  • Provide clear funding guidance to implement QRTPs. 
  • Require oversight for the full array of congregate care placements, including supervised independent living and settings for survivors of sex trafficking, and the use of out-of-state QRTP placements. 
  • Professionalize and invest in QRTP staff to ensure high-quality, individualized treatment.  
  • Establish standards and youth advisory boards for youth- and family-driven QRTP treatment. 
  • Integrate QRTPs into a continuum of prevention and aftercare. 
  • Establish performance- and outcome-based monitoring of QRTPs. 

Read the brief

Recommended Citation
American Academy of Pediatrics & Chapin Hall at the University of Chicago. (2023). Family First implementation: A one-year review of state progress in reforming congregate care. American Academy of Pediatrics & Chapin Hall at the University of Chicago.