When Paris Hilton testified before Congress earlier this year about her traumatic experiences in a residential facility, she launched a national dialogue about whether such facilities should be federally regulated. We are pleased to see that U.S. Rep Ro Khanna (D-Calif.) is now leading efforts to ensure this issue is receiving legislative attention.
Rep. Khanna’s Accountability for Congregate Care Act (ACCA) of 2021, which will likely be introduced next year, would call for a congregate care youth bill of rights and an accountability for congregate care joint commission to advise on the closure of facilities that do not meet standards.
There is no question that ensuring quality congregate care settings is a shared priority for young people, families, providers, advocates and funders. But we need to develop an approach for federal oversight that actually ensures quality care, and does not become an exercise in additional administrative burden that does little to improve quality and safety.
These are important areas of focus as there are an estimated 120,000 youth who are currently placed in residential facilities in the United States. Many are there because they have complex clinical needs that cannot be addressed in the home or are perceived to require 24-7 intervention to ensure their safety.
Many of us in the field view residential as an intervention rather than a destination. It has a place in a well-developed, community-based service array that is driven by community needs and created through an inclusive and intentional youth, family and field-informed approach where quality and safety are primary objectives. Sadly, these comprehensive arrays do not exist nationwide, resulting in a misuse of and at times over-reliance on residential care.
While focusing on evolving the community-based system, it seems important to also establish what effective regulatory oversight of congregate care facilities should look like. How can we, as a field, ensure that the highest quality of care is offered that also places the emphasis on the right things for providers — delivering care versus responding to unnecessary administrative burden?
A federal regulatory approach could start by establishing a core set of quality indicators that address the needs of all funders (local, state, federal, private) across systems. A widely agreed to and adopted set of indicators would foster the ability of providers to invest time and resources into what is most important — young people, families and the interventions being delivered.
As a start, quality indicators should include:
- Clear rationale and justification of the need for residential intervention.
- A focus on family engagement, youth voice and choice.
- Standards for time at home and in the community (versus in a facility).
- Length of stay with an emphasis on short-term stays for stabilization.
- Individualized plans of care that are based on the strengths and needs of the family and youth.
- Skill development for families and young people that equip them to be successful at home and in community.
- A means of measuring outcomes that quantify the results that were the intent of the residential intervention.
- A plan to support the young person and family post-residential that focuses on sustained positive outcomes in the community.
- Resources for transitioning youth out of residential with appropriate community-based services and supports.
Many of these things are aligned with what has been proposed in Rep. Khanna’s youth bill of rights. What is important is that this must not be simply a piece of paper saying what should be, but rather an agreed upon set of standards that are implemented across residential settings and monitored accordingly.
Done properly, providers would likely welcome universal, realistic and relevant regulatory oversight. This requires engagement of the right voices to define and drive the approach — young people, families and providers must be involved in creating any federal oversight processes and these processes must not be yet another layer of requirement and burden for providers.
Among the proposals anticipated in the upcoming Accountability for Congregate Care Act is the concept of a joint commission that would drive the development of national standards and oversee residential settings. While we support the development of a national framework, we believe that it is unlikely that effective monitoring can be done federally. The need for oversight approaches to be culturally responsive and contextually relevant means that adherence to standards should be overseen at the state and local levels. For example, determining adequacy of transition resources for young people leaving residential is best assessed by those who have understanding of the local community and available resources.
By using local systems to enforce a consensus-based set of federal standards we enable young people, families and providers to have a common understanding and set of expectations for quality services regardless of jurisdiction. These federal rules could flow into state and local licensing requirements across jurisdictions and funding streams (including privately funded facilities) that would ensure standardization in what is being tracked, reported on and monitored.
Most importantly, there must also be a tremendous emphasis on ensuring the availability of a full array of flexible, community-based services and supports to address the needs of families and young people, including those with a focus on the social determinants. There is a growing chorus of voices in the sector that support the shift to a larger multidisciplinary child and family well-being system that is resourced at the front end to offer more upstream supports, including prevention and intervention as needs arise. This shift involves many actors and systems engaged in the broader child-serving ecosystem and changing them will be an evolutionary process.
This more holistic child and family well-being system must be universal and sufficiently funded. Reforming and investing in federal prevention programs like Title IV-B and the Child Abuse Prevention and Treatment Act and ensuring insurance coverage and the maximization of Medicaid are some of the necessary steps toward supporting and building out this array of supports. Federal agencies must also work to break down their own siloes that are replicated at the state and local levels and result in disjointed and uncoordinated systems that do not facilitate ease of access to desperately needed supports by families.
Research tells us that children do better in family and community settings. Residential programs must be used wisely and judiciously as an intervention. Just as the emergency room functions as a necessary but temporary treatment facility for people facing a health crisis, residential facilities will likely always be needed, but should be used as a temporary, short-term intervention for youth who need 24-7 intervention, with a goal of addressing their needs and transitioning them home to a family with sustainable supports.
This is not a simple fix, but it is an achievable one. By establishing consistent quality standards across child-serving systems that facilitate the delivery of impactful, evidence-informed and safe residential interventions, and by ensuring the availability of an array of community-based services and supports, we can ensure residential facilities serve the role they are meant for — as one possible intervention for those that require stabilization and 24-7 support.