Foster Care: Additional Actions Could Help HHS Better Support States' Use of Private Providers to Recruit and Retain Foster Families

Foster care caseloads have increased in recent years due, in part, to the national opioid epidemic. States have struggled to find foster families for children who can no longer live with their parents, including those who need TFC services. States may use private providers, such as non-profit and for-profit organizations, to help recruit and retain foster families. States may also use federal funds provided by HHS for these efforts. GAO was asked to review states' efforts to recruit and retain foster families.

This report examines: (1) how state child welfare agencies recruit foster families, including those who provide TFC services, (2) any challenges in recruiting and retaining foster families, and (3) the extent to which HHS provides support to child welfare agencies in these efforts. GAO reviewed relevant federal laws, regulations, and guidance; interviewed HHS officials; surveyed child welfare agencies in all states and the District of Columbia; held discussion groups with private providers and foster parents who provide TFC services; and conducted interviews with officials in California, Georgia, and Indiana, which were selected for factors such as changes in foster care caseloads, opioid abuse rates, and geographic location.

States employ a range of strategies to recruit foster families and nearly all use private providers to recruit, particularly for therapeutic foster care (TFC) services, in which parents receive training and support to care for children who need a higher level of care. Recruitment strategies include searching for relatives, conducting outreach to the community, targeting certain populations, and obtaining referrals from current foster families. In response to GAO's national survey, 49 states reported using private providers to recruit foster families. In the three selected states where GAO conducted interviews, private providers were responsible for both recruiting and retaining foster families, such as helping families become licensed and providing them with support (see fig.).

States reported various challenges with recruiting and retaining foster families in response to GAO's survey. In recruiting families, over two-thirds of states reported challenges such as limited funding and staff, which can make prioritizing recruitment efforts difficult; extensive licensing processes; and difficulties finding families willing to care for certain children, such as those with high needs. In retaining families, 29 states reported concerns about inadequate support for foster families, which can include difficulties contacting child welfare agency caseworkers. In addition, 31 states reported limited access to services needed to care for children, such as child care.

The U.S. Department of Health and Human Services (HHS) provides a number of supports to help states recruit and retain foster families, including technical assistance with their recruitment programs, guidance and information, and funding. Most states GAO surveyed found HHS's supports moderately or very helpful. However, several private providers GAO interviewed in three selected states said they have not received guidance or information from child welfare agencies about recruiting and retaining foster families. In addition, 11 of the 14 providers said they were unaware of related HHS supports and all of them described concerns about communication with child welfare agencies. HHS officials said they encourage states to involve all relevant stakeholders in their efforts, though HHS has focused on supporting child welfare agencies. Consistent with internal control standards on communication, determining whether information on working with private providers would be useful to states could help HHS better support states' use of private providers in efforts to recruit and retain foster families.

GAO recommends HHS seek feedback from states on whether information on effective ways to work with private providers to recruit and retain foster families would be useful and if so, provide such information. HHS agreed with GAO's recommendation.

After steady declines for more than a decade, foster care caseloads  nationwide rose from about 400,000 children in fiscal year 2012 to nearly  440,000 in fiscal year 2016. According to a recent study by the U.S.  Department of Health and Human Services (HHS), the national opioid  epidemic has contributed to this increase because parents under the  influence of opioids are often unable to care for their children. Child  welfare officials in many states have noted challenges finding placements  for children who can no longer live with their parents, and media reports  have described instances in which children were placed in hotel rooms,  emergency shelters, and child welfare offices until appropriate  placements could be found.

States may place children in a variety of settings depending on a child’s  needs, including placements with unrelated foster parents, relatives, or in  congregate care settings such as group homes and residential treatment  centers. States may use several federal funding sources administered by  HHS to assist in these efforts. However, a 2015 HHS study found  agreement among multiple child welfare stakeholders that children are  best served in family settings, and many states have reduced the number  of children in congregate care in the last decade. The reduction in states’  use of congregate care has contributed to the need for foster families,  particularly for children who require a higher level of care, such as those  who have severe mental health conditions or who are medically fragile. A  potential alternative to congregate care is therapeutic foster care, a  family-based model in which children who need a higher level of care are  placed with foster parents who are trained, supervised, and supported by  qualified program staff to provide services such as crisis support,  behavior management, medication monitoring, counseling, and case  management. There is no national definition of therapeutic foster care  and these programs can vary widely among states.

You asked us to explore issues related to states’ efforts to recruit and  retain foster families. This report examines (1) how state child welfare  agencies recruit foster families, including those who provide therapeutic  foster care services; (2) what challenges, if any, there are in recruiting  and retaining foster families; and (3) the extent to which HHS provides  support to child welfare agencies in their efforts to recruit and retain foster  families.

To address all three of our objectives, we conducted a web-based survey  of state child welfare agencies in the 50 states and the District of  Columbia to obtain national information. The survey was administered in  September 2017 and we obtained a 100 percent response rate. We also  conducted interviews in three states—California, Georgia, and Indiana— to obtain more in-depth information from officials from state child welfare  agencies, representatives from 14 private foster care providers working  with these child welfare agencies, and foster parents working with 8 of  these providers. The three states were selected for in-person and phone  interviews based on factors such as recent changes in foster care  caseloads, opioid abuse rates, variation in child welfare administration  systems (i.e., state- versus county-administered), and geographic  location. In California, the only selected state with a county-administered  child welfare system, we selected three counties—Los Angeles,  Sacramento, and Sonoma—and interviewed officials from the respective  county-level child welfare agencies. These counties were selected based  on factors similar to those mentioned above, as well as variation in  population density (i.e., rural versus urban). The information gathered in  the three selected states is not generalizable to all states.

To obtain perspectives on providing therapeutic foster care services  specifically, we conducted two discussion groups with representatives  from 17 private providers and one discussion group with eight sets of  foster parents. Our discussion groups were held at a conference hosted  by the Family Focused Treatment Association, a non-profit organization  that aims to develop, promote, and support therapeutic foster care  services. The information gathered in our discussion groups is not  generalizable, though it provides valuable insights on the recruitment and  retention of families who can provide therapeutic foster care services. To  develop our methodologies, we reviewed related literature and  interviewed child welfare experts. In addition, to examine how HHS  supports child welfare agencies in their recruitment and retention efforts,  we interviewed HHS officials and reviewed relevant documents obtained  in these interviews. We also reviewed relevant federal laws, regulations,  and HHS policies, as well as federal internal control standards. See  appendix I for additional information on our objectives, scope, and  methodology.

We conducted this performance audit from January 2017 to May 2018 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Placements for Children Entering and Exiting Foster Care

Children enter foster care when they have been removed from their  parents or guardians and placed under the responsibility of a child welfare  agency. Reasons for a child’s removal can vary, though 61 percent of  nearly 275,000 removals during fiscal year 2016 involved neglect and 34  percent involved drug abuse by the parent(s), according to the most  recent available HHS data. Child welfare agencies most commonly place  children with unrelated foster parents, with relatives, or in congregate  care settings. Coordinating placement and support services for these  children, such as physical and mental health services, education, child  care, and transportation, is typically the responsibility of child welfare  agency caseworkers. Caseworkers may also coordinate placements for  children exiting foster care, which most commonly include reunifications  with the child’s parents or permanent placements through adoption, legal  guardianship, or other living arrangements with a relative. Children who  age out of the foster care system without a permanent placement with a  family may receive transitional supports, such as housing and job search  services.

Children placed in foster families—including unrelated foster parents,  relatives, and fictive kin (e.g., close family friends who are not relatives)— live in the family’s home and are typically incorporated into an existing  family structure. For example, these families may include biological  children and other children in foster care. Families may receive a  payment from the child welfare agency to help cover the costs of a child’s  care, as determined by each state. Families who are trained to provide  therapeutic foster care services are supervised and supported by  qualified program staff to care for children who need a higher level of  care. Therapeutic foster care families may have fewer or no other children  in the home, and parents in these families may be required to provide a  higher level of care and supervision for the child. In addition, the payment  provided to these families may be higher.

Responsibilities for Recruiting and Retaining Foster Families

States are primarily responsible for administering their child welfare  programs, consistent with applicable federal laws and regulations. Their  responsibilities include recruiting and retaining foster families and finding  other appropriate placements for children. In recruiting foster families,  states generally require that families undergo a licensing process that  includes a home study to assess the suitability of the prospective parents,  including their health, finances, and criminal history, and take pre-service  training on topics such as the effects of trauma on a child’s behavior. In  retaining foster families, states may provide support to families, such as  through ongoing training classes and regular visits from child welfare  agency caseworkers if a child is placed in their home.

State and county child welfare agencies may work with private foster care  providers, commonly through contracts, to help them administer child  welfare services. Private providers can include non-profit and for-profit  organizations that provide a range of public and private services in  addition to foster care, such as residential treatment, mental health, and  adoption services. For foster care, private providers may be responsible  for recruiting foster families, which may involve identifying prospective  foster parents, providing information on and helping with the licensing  process, and conducting home studies and training. If the child welfare  agency places a child with a foster family working with a private provider,  the private provider may also be responsible for activities that can help  retain foster families, such as conducting regular visits with the family (in  addition to visits from child welfare agency caseworkers) and helping  them access needed services. Child welfare agencies may pay these  providers based on the number of children placed. This payment may  include an administrative payment to the private provider, as well as a  payment that the private provider passes on to the foster family to help  cover the costs of a child’s care.

Child welfare agencies and private providers may also work with other  entities to recruit and retain foster families. For example, they may  collaborate with community partners, such as faith-based organizations  and schools, to share information about foster care and recruit families.  Child welfare agencies and private providers may also work with direct  service providers, such as hospitals and community-based mental health  clinics, to obtain services to support children in foster care and their foster  families, which can help retain these families.

Federal Supports Related to Recruiting and Retaining Foster Families

HHS’s Administration for Children and Families (ACF) administers several  federal funding sources that states can use to recruit and retain foster  families, in addition to state, local, and other funds. For example, funding  appropriated for title IV-E of the Social Security Act makes up the large  majority of federal funding provided for child welfare, comprising about 89  percent of federal child welfare appropriations in fiscal year 2017  (approximately $7 billion of nearly $7.9 billion), according to ACF. These  funds are available to states to help cover the costs of operating their  foster care, adoption, and guardianship assistance programs. For  example, in their foster care programs, states may use these funds for  payments to foster families to help cover the costs of care for eligible  children (e.g., food, clothing, and shelter) and for certain administrative  expenses, including recruiting and training prospective foster parents.  Title IV-E funds appropriated specifically for foster care programs totaled  about $4.3 billion in fiscal year 2017, comprising about 61 percent of title  IV-E funding, according to ACF.

In addition, title IV-B of the Social Security Act is the primary source of  federal child welfare funding available for child welfare services. States  may use these funds for family support and family preservation services  to help keep families together and reduce the need to recruit and retain  foster families. Such services can include crisis intervention, family  counseling, parent support groups, and mentoring. States may also use  title IV-B funds to support activities to recruit and retain foster families.  Federal appropriations for title IV-B comprised about 8 percent of federal  child welfare appropriations (approximately $650 million of nearly $7.9  billion) in fiscal year 2017, according to ACF.

ACF is responsible for monitoring states’ implementation of these  programs. For example, ACF monitors state compliance with title IV-B  plan requirements through its review of states’ 5-year Child and Family  Services Plans and Annual Progress and Services Reports. Child and  Family Services Plans set forth a state’s vision, goals, and objectives to  strengthen its child welfare system, and Annual Progress and Services  Reports provide annual updates on the progress made by states toward  those goals and objectives. Child and Family Services Plans are required  for a state to receive federal funding under title IV-B, and document the  state’s compliance with federal program requirements. One requirement  is that states must describe in their plans how they will “provide for the  diligent recruitment of potential foster and adoptive families that reflect the  ethnic and racial diversity of children in the State for whom foster and  adoptive homes are needed.” In addition, ACF conducts Child and  Family Services Reviews, generally every 5 years, to assess states’  conformity with requirements under these federal programs. These  reviews involve case file reviews and stakeholder interviews, and are  structured to help states identify strengths and areas needing  improvement within their agencies and programs. States found not to be  in substantial conformity with federal requirements must develop a  program improvement plan and undergo more frequent review.

States Employ a Range of Strategies to Recruit Foster Families and Nearly All Use Private Providers to Recruit, Particularly for Therapeutic Foster Care

States Recruit Foster Families by Searching for Relatives, Conducting Outreach, Targeting Certain Populations, and Obtaining Referrals

In addition to the diligent recruitment requirements under title IV-B of the  Social Security Act, states receiving federal foster care funds under title  IV-E are generally required to search for relatives when a child enters  foster care. In the three selected states—California, Georgia, and  Indiana—child welfare officials said their first priority is to recruit relatives  or fictive kin to care for children entering foster care, when appropriate.  Officials in California and Georgia discussed recent initiatives to expand  the search for relatives and fictive kin for children already in foster care.  For example, county child welfare officials in California said they  contracted with a private provider who they also use to recruit and retain  foster families to conduct these searches. This particular private provider  told us that they can access the child welfare agency’s case management  system to review information about each child to determine which  relatives or fictive kin have already been contacted. The private provider  said they may contact these relatives or fictive kin to see whether  circumstances have changed such that they would now be able to care  for the child. In addition, the private provider said they may use existing  contacts, social media, and an identity search program to locate  additional relatives or fictive kin for a child. This private provider reported  that from July to September 2017, their searches yielded 36 additional  relatives or fictive kin, on average, for each of the 23 children in one  county for whom the private provider conducted a search. In addition,  officials in Georgia said they initiated pilot projects in two regional offices  to train staff on how to search for relatives and fictive kin.

Community outreach to a broad population of prospective foster families  is a moderately or very useful recruitment strategy, according to 36 states  that responded to our survey. In addition, child welfare officials and 11  of the 14 private providers in the three selected states said they engage  in community outreach events to recruit prospective foster families. For  example, they said they attend local events (e.g., state fairs) or visit local  organizations (e.g., faith-based organizations or schools) to provide  information about becoming a foster parent. One private provider said  they attend local markets and summer festivals to talk with prospective  families and provide them with informational materials. Another private  provider said they hold meetings for prospective foster parents to answer  questions and provide additional information about foster care and the  role of the private provider.

In addition, 20 states reported in our survey that marketing campaigns,  such as mailings and media advertisements, are a moderately or very  useful recruitment strategy. In the three selected states, child welfare  officials and 12 of the 14 private providers said they use different forms of  media, such as newspapers, radio, television, billboards, social media, or  printed advertisements, to solicit foster families. Child welfare officials we  interviewed in Georgia and Indiana said they have implemented statewide  media campaigns that incorporate both traditional and digital media.  Officials in Georgia told us the campaigns have successfully increased  inquiries through the agency’s website and toll-free phone line. A private  provider in one county said they worked with a marketing firm to create  advertisements that were shown in movie theaters, which also resulted in  additional inquiries from prospective families. With regard to therapeutic  foster care services, private providers we spoke with in both of our  discussion groups said they use strategies such as yard signs, television  commercials, and social media to recruit therapeutic foster care  families.

In our survey, nearly all states reported having targeted recruitment  strategies as part of their recruitment plans or practices, such as  strategies that focus on certain populations of prospective foster parents  (e.g., those in faith-based communities or of a certain race), families for  certain populations of children in foster care (e.g., teenagers and sibling  groups), and families living in specific geographic locations. To help  inform their recruitment strategies, 39 states reported in our survey that  they collect and use information on children awaiting placement, such as  their backgrounds and service needs, and 31 states reported that they  collect and use information on available foster families, such as their  preferences for placements and where they are located. In the three  selected states, child welfare officials and 8 of the 14 private providers we  interviewed said they use targeted recruitment to identify prospective  foster families. In addition, child welfare officials and five private providers  said they collect or use demographic data on children needing placement  and available foster families to inform their efforts. For example, child  welfare officials in one county said they use data to target recruitment  efforts in the neighborhoods where children entered foster care. Similarly,  one private provider told us they use data on the demographics of  successful foster families to target recruitment efforts toward those types  of families, such as social workers and parents whose children have  grown up and left home (i.e., “empty nesters”).

Targeted recruitment can be a particularly useful strategy to identify  families who can provide therapeutic foster care services for children who  need a higher level of care, such as those who have severe mental health  conditions or who are medically fragile. In the three selected states, child  welfare officials and four private providers said they use targeted  recruitment strategies to search for families who can provide therapeutic  foster care services. For example, child welfare officials in one state said  they focus on recruiting individuals with specific skillsets, such as doctors  and nurses who have experience working with children who need more  care. Private providers in both of our discussion groups also said they use  targeted recruitment strategies for these purposes.

When asked in our survey about the usefulness of various recruitment  strategies, states most often cited referrals from current foster families as  a moderately or very useful recruitment strategy. In the three selected  states, child welfare officials and all 14 private providers said they use  referrals from current foster families to recruit new families, and the  majority of these officials and private providers said such referrals are the  most effective recruitment strategy. One private provider emphasized that  current foster families are better recruiters than private providers because  these families can speak from first-hand experience about the potential  benefits and difficulties of caring for a child in foster care. Another private  provider said that referrals occur through regular interactions in the  community or through information meetings and events facilitated by  private providers, such as movie nights. To encourage referrals, 6 of the  14 private providers in the three states said they offer financial incentives  to current foster families who help recruit new families. For example,  three of these private providers said they offer incentives ranging from  $100 to $500. In regard to therapeutic foster care services, private  providers in both of our discussion groups said referrals are the most  effective recruitment strategy. Private providers in one group said they  offer financial incentives ranging from $200 to $300, which generally are  paid after a new family becomes licensed to provide therapeutic foster  care services and a child has been placed in their home.

Eight of the 14 private providers in the three selected states said they try,  in general, to employ multiple types of recruitment strategies. Further,  many of these private providers explained that prospective foster parents  typically hear about foster care through multiple mediums before applying  to become a parent. For example, a prospective parent might hear a radio  advertisement, then see a billboard, and later talk to a private provider at  a state fair before deciding to apply. Foster parents we spoke with in the  three states, as well as in discussion groups on therapeutic foster care  services, discussed a number of reasons why they became foster  parents, including knowing others who had provided foster care, having  the desire to give back, and wanting to expand their family by fostering  with the intention to adopt a child (see text box).

Almost All States Reported Using Private Providers to Recruit Foster Families, Particularly for Therapeutic Foster Care

In our survey, 49 states reported using private providers to recruit foster  families, including 44 that use private providers to recruit families who can  provide therapeutic foster care services for children who need a higher  level of care. Specifically, 30 states reported that they use private  providers to recruit both traditional and therapeutic foster care families, 14  reported that they use private providers to recruit therapeutic foster care  families exclusively, and the remaining 5 reported that they use private  providers to recruit traditional foster families exclusively. In the three  selected states, child welfare officials said they initially developed  agreements with private providers to recruit families who can provide  therapeutic foster care services. However, as state caseloads have risen,  these officials said they have also referred children who do not need  therapeutic foster care services to private providers.

Child welfare officials and private providers in the three selected states  said that private providers in their states are responsible for both  recruiting and retaining foster families. They said responsibilities of  private providers can include helping families become licensed,  suggesting possible matches between children and available families,  and providing support to help families access services needed to care for  children in foster care (see fig. 1).

Child welfare officials and private providers in the three selected states  described ways they have collaborated to recruit foster families, and  discussed the benefits of using private providers to recruit and retain  these families. For example, child welfare officials in one county said they  collaborated with private providers to create common marketing materials  that included information about the child welfare agency and each private  provider, which helps prospective foster families decide which entity they  want to work with. Officials and private providers in this county said  collaborative recruitment efforts are an efficient use of resources and  reduce competition in recruiting from the same pool of prospective foster  families. Nearly all of the 14 private providers we interviewed in the three  selected states said they can help child welfare agencies support foster  families, particularly those who care for children who need more care than  others, because they can maintain lower caseloads and be more  accessible to families than child welfare agencies. These private  providers explained that they accept placements for children only when  they have available foster families and staff, whereas child welfare  agencies cannot choose how many children they have in their caseloads.

Specifically, four private providers noted that private providers typically  maintain small caseloads, such as 10 children per private provider  caseworker. In contrast, seven private providers said child welfare  agencies manage larger caseloads—as high as 40 children per  caseworker—which can strain their ability to support foster families. In  addition, eight private providers said families can contact them 24 hours a  day, which may not be the case with child welfare agency caseworkers.

All of the 49 states that reported using private providers in our survey also  reported having various oversight mechanisms to monitor them. These  mechanisms include periodic audits and site visits, regular calls for  information sharing, periodic check-ins with foster families working with  private providers, and requirements for providers to develop recruitment  plans. Child welfare officials in the three selected states provided detail  on a range of oversight activities. For example, child welfare officials in  Georgia said their agency conducts comprehensive audits of private  providers annually, which include an examination of the facility, case file  reviews, and staff interviews. In addition, county child welfare officials in  California said their agency requires private providers to attend monthly  meetings with agency staff and submit quarterly outcome reports.

States Reported Various Recruitment and Retention Challenges, Including Difficulties Prioritizing Recruitment Efforts and Supporting Foster Families

In Recruiting Foster Families, States Reported Challenges with Prioritizing Efforts, Extensive Licensing Processes, and Finding Families Who Can Meet the Needs of Children Difficulties Prioritizing Recruitment Efforts

In response to our survey, 34 states reported that limited resources to  focus on foster family recruitment made their recruitment efforts  moderately or very challenging. In the three selected states, child welfare  officials raised concerns about their ability to prioritize foster family  recruitment efforts, given large increases in their foster care caseloads  and other demands for resources. Nationwide, caseloads increased by  over 10 percent from fiscal years 2012 through 2016, according to HHS  data. In addition, 8 of the 14 private providers in the three states told us  that a lack of dedicated funding for recruitment from child welfare  agencies made recruitment efforts challenging. One private provider said  they have recently put recruitment efforts on hold to focus on serving  children in existing placements.

States also reported in our survey that eligibility requirements for federal  foster care funding have affected their ability to prioritize resources for  recruitment. Specifically, of the 34 states that provided a response on this  issue, almost half reported that requirements that tie eligibility for  receiving federal funds under title IV-E of the Social Security Act to  income eligibility standards under the discontinued Aid to Families with  Dependent Children program have affected their recruitment efforts to a  moderate or great extent. States may use title IV-E funds to assist with  the costs of operating their foster care programs, and are generally  entitled to receive these funds based on the number of eligible children  they have in their programs. To be eligible for title IV-E foster care funds,  a child must have been removed from a home that meets income  eligibility standards under the Aid to Families with Dependent Children  program as of July 1996, among other criteria. The Aid to Families with  Dependent Children program was replaced by the Temporary Assistance  for Needy Families program beginning in 1996, and the income eligibility  standards for title IV-E foster care funding have not been changed since  then. We reported in 2013 that a family of four had to have an annual  income below $15,911 to meet the income eligibility threshold in 1996. If  adjusted for inflation, the threshold would have been $23,550 in 2013.  Due, in part, to fewer families meeting these income eligibility standards,  we found that the number of children who currently meet title IV-E  eligibility requirements has declined. As a result, we reported that states  have received less federal funding under title IV-E and have paid an  increasingly larger share of funds for their foster care programs. The  percentage of children eligible for title IV-E foster care funds decreased  from about 54 percent in fiscal year 1996 to nearly 39 percent in fiscal  year 2015, according to data published by the Congressional Research  Service (see fig. 2). Given fiscal constraints, child welfare agencies, like  other state agencies, may need to make difficult choices about how to  allocate their limited resources.

The process for licensing foster families can help ensure that children are  placed in safe and stable environments that meet their needs. However,  35 states reported in our survey that lengthy licensing processes made it  moderately or very challenging to recruit new foster families. In the three  selected states, child welfare officials and 7 of the 14 private providers  discussed extensive state licensing processes that may discourage  prospective foster families, including delays in getting fingerprints,  completing background checks, or reviewing applications. Some private  providers said delays are likely caused by competing priorities at state  licensing agencies or limited staff in child welfare agencies. One private  provider told us that families may wait several months for approval after  completing an application. Another private provider told us that in the past  year, approval time frames for licenses have, in some cases, increased  from 1 to 2 weeks to 3 to 6 months. In regard to therapeutic foster care  services, private providers in both discussion groups raised similar  concerns (see text box).

Child welfare officials in California told us they are in the process of  restructuring their licensing process to improve efficiencies and reduce  burden for foster families. In addition, county child welfare officials in the  state told us they are offering families additional support to help them  through the licensing process, such as assigning staff to prospective  foster families as soon as they initiate the licensing process to help them  complete required paperwork and schedule pre-service training.

Finding Families Who Can Meet the Needs of Children and Other Challenges

In response to our survey, states reported difficulties finding families who  can meet the needs of children, particularly for therapeutic foster care  services. Specifically, 37 states reported that the needs of children  entering foster care have increased, and 35 reported that there are not  enough foster families willing to care for the types of children needing  placement. For example, nearly all states cited difficulties finding families  for children with aggressive behaviors and severe mental health needs,  as well as for teenagers and sibling groups. Consequently, 36 states  reported difficulties appropriately matching children with families, and 30  reported having moderately or significantly too few therapeutic foster care  families (see text box).

In the three selected states, child welfare officials and 7 of 14 private  providers discussed similar challenges finding appropriate families for  children needing placement. For example, officials in one state said the  increased demand for both traditional and therapeutic foster care families  has caused them to place children in the first available home rather than  match them with families based on the family’s preferences and ability to  provide care. One private provider told us that due to the increasing  number of referrals for placements, they are not able to be as selective  during the matching process as they have been in the past. Another  private provider said child welfare agencies may be so pressed to find  placements for children that they may call foster families working with the  private provider directly, which can put pressure on the family to agree to  the placement even when the family does not believe the child is a good  fit. One private provider told us that a foster family accepted a child who  had been sleeping in the child welfare agency caseworker’s office, but the  placement was not a good fit and was eventually disrupted, which was  traumatic for both the child and the foster family. Private providers in both  of our discussion groups said finding families willing to provide  therapeutic foster care services to children can be difficult. They noted  that parents may be required to take on more documentation and  supervision responsibilities for a child who requires a higher level of care  and complete more intensive training, which may be difficult for working  parents.

In addition to challenges finding appropriate families for children, 34  states reported in our survey that a negative perception of foster care  made it moderately or very challenging to recruit new families. Child  welfare officials in two states and 5 of the 14 private providers we  interviewed raised similar concerns. For example, child welfare officials in  one county told us that they recruit foster families in an environment  where media reports have highlighted challenges with overburdened  caseworkers and turnover of agency directors. These officials also said  foster parents may share negative experiences with family and friends,  leading to an unfavorable impression of child welfare agencies within the  community. In addition, child welfare officials in one state and four private  providers said some families who provide foster care services have faced  false allegations of child abuse and subsequent investigations. Some  private providers said these investigations can be emotionally draining or  disruptive to the family, and some said that fear of such allegations and  investigations may deter prospective families from becoming a foster  family. Other recruitment challenges cited by several child welfare  officials, private providers, and foster parents we interviewed included  concerns by prospective foster families about caring for children who  have high needs or who are certain ages, or that providing foster care will  disrupt their nuclear family. While many child welfare officials and private  providers we spoke with acknowledged these negative perceptions and  fears, parents in all eight foster parent groups we interviewed in the three  states also discussed how being a foster family can be a positive  experience. For example, several foster parents said providing foster care  to different types of children has enhanced their family. Private providers  and foster parents also said it is important to share personal experiences  to bring understanding about what it is like to be a foster family. For  example, one foster parent told us about a blog she writes to describe  normal family activities that include children in foster care, such as taking  family trips.

In Retaining Foster Families, States Reported Challenges with Inadequate Support for Families and Limited Access to Services for Children

In response to our survey, 29 states reported that inadequate support for  foster families from the child welfare agency made it moderately or very  challenging to retain these families. In the three selected states, all 14  private providers we interviewed and foster parents in all eight of the  foster parent groups we spoke with emphasized the importance of  supporting families in order to retain them. All 14 private providers  discussed concerns about communication with child welfare agencies,  which they said can affect the quality of services they provide to foster  families. For example, 10 of the private providers said they have difficulty  contacting or receiving a response from child welfare agency  caseworkers when they try to obtain information needed to comply with  child welfare agency requirements. One private provider explained that  they are required to develop a service plan for each child they place with  a family, and the plan must be signed by the child welfare agency  caseworker within 5 days of placement. However, this private provider  said they often cannot reach the caseworker to have plans reviewed and  approved within the required time frame. Seven private providers told us  that there often is confusion on the part of child welfare agency  caseworkers about the role of private providers. For example, these  private providers said child welfare agency caseworkers may not know  which tasks the private providers are responsible for or may be unfamiliar  with the paperwork they need to give to the private provider. Similarly,  foster parents in five groups expressed dissatisfaction with the level of  support they have received from child welfare agency caseworkers.  These foster parents described instances in which they were unable to  reach their caseworker during emergencies, such as when they needed  permission to administer medications to their foster child. One foster  parent told us she had waited approximately 8 weeks for her caseworker  to approve her child’s medication. This parent said she worked with her  private provider to email the child welfare agency caseworker on a daily  basis, but received no response. Foster parents in our discussion group  raised similar concerns (see text box).

Reasons why child welfare agency caseworkers may be limited in their  ability to support foster families can include high caseloads and  caseworker turnover. For example, 33 states reported in our survey that  having too few staff and inadequate funding made it moderately or very  challenging to retain foster families. In the three selected states, child  welfare officials, 9 of 14 private providers, and foster parents in five of the  eight foster parent groups noted that high caseloads contribute to a lack  of support for foster families. Child welfare officials in one state said  although their regulations stipulate a maximum caseload of 12 to 17,  many caseworkers have caseloads that exceed those levels. In addition,  a private provider in this state told us that child welfare agency  caseworkers typically carry about 35 cases. Other private providers  explained that the demands on child welfare caseworkers to meet basic  paperwork and case planning requirements and conduct visits for a large  caseload may prevent them from responding to requests or returning  phone calls in a timely manner. Child welfare officials in two states, 11  private providers, and foster parents in three foster parent groups also  explained that frequent caseworker turnover can affect the level of  support foster families receive, particularly when new caseworkers are  unfamiliar with a child’s history and needs. One foster parent told us that  she had worked with eight different child welfare agency caseworkers in a  19-month period. Another foster parent said she maintains all of her foster  children’s records, since in the past, documents have been lost in  transfers between child welfare agency caseworkers. Child welfare  officials in the three selected states acknowledged difficulties supporting  foster families due to high caseloads or caseworker turnover. Officials in  one state said they recently requested additional state funds to add 500  caseworker positions, and officials in another state said they have made  efforts to revisit staffing levels following reductions during the economic  recession in 2008.

In addition, many private providers and foster parents we interviewed  noted limitations with other supports for foster families. For example, 10  of 14 private providers and foster parents in three of the eight foster  parent groups in the three states discussed their concerns about low  payment rates for foster families, which some said may not adequately  cover the costs of caring for a child. A 2012 study on payment rates for  foster families found that basic payment rates (e.g., for traditional foster  care services) in the majority of states fell below estimated costs of caring  for a child, based on data from the U.S. Department of Agriculture. Five  private providers and foster parents in five foster parent groups also  discussed a lack of access to respite care services or a lack of “voice” for  foster parents in contributing to decisions regarding children in their care.  These private providers and foster parents said these circumstances can  be frustrating and cause parents to leave the system.

Limited Access to Services for Children and Other Challenges

In response to our survey, 31 states reported that inadequate access to  services, such as child care and transportation, made it moderately or  very challenging to retain foster families. In the three selected states,  child welfare officials, 9 of 14 private providers, and foster parents in six  of eight foster parent groups discussed similar difficulties. For example,  they discussed difficulties accessing child care services, which some said  are particularly needed because of the increasing number of opioid- affected infants coming into care. Some officials, private providers, and  foster parents said their state may offer child care subsidies, but waitlists  can be long, and foster families may have difficulties finding an approved  childcare center, particularly for children who need a higher level of care.  Further, child welfare officials, private providers, and foster parents  discussed challenges accessing transportation services. For example,  child welfare officials said children are sometimes moved to homes  outside their original community due to a lack of available homes, which  places a burden on foster families to transport children to physical and  mental health appointments, regular visits with their biological families,  and school. A private provider we interviewed said many parents who  provide transportation to these various appointments also must go  through a burdensome process to claim mileage reimbursement from the  child welfare agency, so many parents do not submit a claim. In addition,  child welfare officials, private providers, and foster parents discussed  challenges accessing mental health services. For example, one private  provider said they have been unable to find a qualified mental health  provider who accepts Medicaid to deliver needed services to an autistic  child. Further, child welfare officials we interviewed in one county  discussed difficulties connecting children with therapists who have an  understanding of childhood trauma.

In addition to these challenges, child welfare officials and private  providers we interviewed said many foster families leave the foster care  system due to family or life changes, including adoptions of children in  their care, retirements, health issues, and relocation to a different state.

HHS Supports States’ Recruitment and Retention Efforts with Technical Assistance, Guidance, and Funding, though Private Providers Were Unaware of Some Supports

HHS’s Administration for Children and Families (ACF) provides a number  of supports to help state child welfare agencies in their efforts to recruit  and retain foster families, according to ACF officials we interviewed and  agency documents we reviewed. These supports include technical  assistance, guidance and information, and funding.

Technical assistance. ACF provided technical assistance through its  National Resource Center for Diligent Recruitment (the Center), and  subsequently, the Child Welfare Capacity Building Collaborative.  The Center provided several types of technical assistance to achieve  its aim of helping states develop and implement diligent recruitment  programs to achieve outcomes such as improving permanency and  placement stability for children in foster care. The Center provided on-  and off-site coaching to states in a number of areas, such as  developing a mix of general and targeted recruitment strategies, using  existing data to target recruitment efforts, and developing a  recruitment plan. Staff who worked at the Center reported providing  direct technical assistance and training to 30 states. The Center also  provided toolkits that guide states through the process of developing a  comprehensive diligent recruitment plan to meet federal  requirements. For example, the toolkits include discussion questions  about the goals states have for their plans, suggestions on which  stakeholders to include, and worksheets to help states analyze  existing data. ACF officials told us that they also review states’ diligent  recruitment plans and may provide feedback to states.

In addition, ACF provides technical assistance to states through its  Child and Family Services Reviews. These reviews are generally  conducted every 5 years and examine a number of factors in states’  foster care programs to assess conformity with federal requirements,  including factors related to recruiting and retaining foster families. In  its reviews of 24 states in fiscal years 2015 and 2016, ACF reported  deficiencies for 18. ACF officials said these deficiencies included a  lack of adequate state recruitment plans and data used for recruitment  efforts. In addition, they said they will be working with states to  address identified deficiencies in subsequent program improvement  plans, which are to be developed in consultation with ACF.

Guidance and information. ACF provides a wide range of guidance  and information to states to support their recruitment and retention  efforts. For example, the Center distributed free monthly electronic  newsletters that provided information on new tools, resources, and  webinars related to foster family recruitment and retention. The Center  also developed or provided links to publications on topics such as  using data to inform recruitment efforts, taking a customer service  approach in working with current and prospective foster families, and  lessons learned from related projects funded by ACF. The Center  facilitated information sharing among states by holding webinars, such  as one on the benefits of implementing a comprehensive diligent  recruitment program, and peer-to-peer networking events on topics  such as recruiting, developing, and supporting therapeutic foster care  families. In addition, ACF’s Child Welfare Information Gateway is a  website that provides access to a broad array of electronic  publications, websites, databases, and online learning tools for  improving child welfare practice. For example, its resources related  to recruiting and retaining foster families include publications on  strategies and tools, as well as examples from state and local child  welfare agencies on promising practices.

Funding. HHS administers a number of federal funding sources that  states said they used for their foster family recruitment and retention  efforts. For example, in our survey, states most often cited using child  welfare funds under title IV-E and IV-B of the Social Security Act for  these purposes in fiscal year 2016 (see fig. 3).

ACF also provided a number of discretionary grants to support state  efforts to recruit and retain foster families through the Adoption  Opportunities program, which funds projects designed to eliminate  barriers to adoption and help find permanent families for children,  particularly older children, minority children, and those with special  needs. Specifically, ACF awarded cooperative agreements to 22  states, localities, and non-profit organizations in fiscal years 2008  through 2013 for 5-year projects that aim to enhance recruitment  efforts and improve permanency outcomes for children, among other  things. For example, ACF awarded a cooperative agreement in 2010  to the county child welfare agency in Los Angeles, California to launch  a project that targeted recruitment efforts to prospective foster families  in African American, Latino, LGBT, and deaf communities to increase  permanency outcomes for their foster care population. In addition, it  awarded a cooperative agreement in 2013 to Oregon’s state child  welfare agency to implement a project that focused on developing  customer service concepts in working with foster families, increasing  community partnerships, and using data to inform recruitment efforts  and outcome measures. In addition, ACF also awarded two  cooperative agreements to Spaulding for Children to develop training  for prospective and current foster and adoptive families. The first,  awarded in fiscal year 2016, was for a 3-year project to develop a  foster and adoptive parent training program to prepare families who  can care for children who have high needs, such as children needing  therapeutic foster care services. The second, awarded in fiscal year  2017, was for a 5-year project to develop a foster and adoptive parent  training program for all individuals interested in becoming a foster  family or adopting a child from foster care or internationally.

In response to our survey, many states reported that they found these  federal supports helpful to their recruitment and retention efforts. For  example, guidance and information, such as the electronic newsletters,  publications, and webinars provided by the Center, were cited most often  by states as being moderately or very helpful (31 states). Over half the  states reported that networking opportunities, such as peer-to-peer  networking events facilitated by the Center, and technical assistance  provided by the Center were moderately or very helpful to their efforts (28  and 27 states, respectively).

However, similar to concerns raised by all 14 private providers in the  three selected states about communication issues with child welfare  agencies, several private providers told us they have not received  guidance or information from these agencies about recruiting and  retaining foster families, and most were unaware of some of the supports  provided by ACF. Specifically, 11 of the 14 private providers said they  were unaware of the National Resource Center for Diligent Recruitment,  and 7 told us that the information offered by the Center would have been  useful to their recruitment efforts had they known about it. For example,  one private provider told us they have been trying to use data to more  effectively recruit foster families, and the Center’s resources on  recruitment strategies and tools would have been helpful in these efforts.

Another private provider said each private provider in their area conducts  recruitment activities based on its own ideas and experiences, and the  Center’s resources would have been helpful in ensuring that they use the  most effective strategies.

ACF officials said they encourage states to involve all relevant  stakeholders in their efforts to recruit and retain foster families. They  acknowledged that ACF has not provided specific guidance and  information to states on working with private providers, but noted that  some supports, such as online publications and webinars, are available to  private providers working in the public sector. ACF officials explained that  their efforts have focused on child welfare agencies because these are  the entities that receive federal funds. However, federal internal control  standards state that agencies should communicate necessary  information, both internally and externally, to achieve their objectives.  The mission statement for ACF’s Children’s Bureau is to partner with  federal, state, tribal, and local agencies to improve the overall health and  well-being of the nation’s children and families. According to its website,  the Children’s Bureau carries out a variety of projects to achieve its goals,  such as providing guidance on federal law, policy, and program  regulations, offering training and technical assistance to improve child  welfare service delivery, and sharing research to help child welfare  professionals improve their services. Given that almost all states use  private providers to help them recruit foster families, and that private  providers may be responsible for providing supports to help retain these  families, it is important for HHS to determine whether additional  information on working more effectively with private providers would be  useful to states. This could help HHS better achieve its goals in  supporting states’ efforts to recruit and retain foster families.

States face challenges recruiting and retaining foster care families and  almost all states rely on private providers to help them meet the demand  for appropriate foster families, particularly those who can provide  therapeutic foster care services. However, private providers used by child  welfare agencies in the three states where we conducted interviews  raised concerns about the level of communication they have with these  agencies. Such communication issues can affect the quality of services  provided to support foster families, as well as the level of guidance and  information private providers receive from child welfare agencies.  Although HHS has provided various supports that states have found  useful in their efforts to recruit and retain foster families, many of the  private providers we spoke with were unaware of some supports that they  said could have helped them. Given the important role private providers  play in recruiting and retaining foster families, state feedback to HHS on  whether child welfare agencies could benefit from information on how to  work more effectively with private providers could help HHS determine  whether it needs to take action to better support states’ use of private  providers.

GAO recommends that the Secretary of Health and Human Services seek  feedback from states on whether information on effective ways to work  with private providers to recruit and retain foster families would be useful  and if so, provide such information. For example, HHS can seek feedback  from states through technical assistance and peer-to-peer networking  activities. If states determine that information would be useful, examples  of HHS actions could include facilitating information sharing among states  on successful partnerships between states and private providers and  encouraging states to share existing federal guidance and information.  (Recommendation 1)

We provided a draft of this report to the Secretary of HHS for review and  comment. HHS agreed with our recommendation and said it will explore  with states whether additional materials specific to private providers  would be useful. While HHS noted that it has no authority over private  providers, it provided examples of ways the agency has supported states’  efforts to recruit and retain foster families and encouraged them to involve  private providers in these efforts. We believe that seeking feedback from  states on whether they would like information on effective ways to work  with private providers would be a useful first step. With that information,  HHS could then determine if additional supports are needed to help  states meet the demand for appropriate foster families. A letter conveying  HHS’s formal comments is reproduced in appendix II.

We are sending copies to the appropriate congressional committees, the  Secretary of the Department of Health and Human Services, and other  interested parties. The report will also be available at no charge on the  GAO website at www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix III.

Appendix I: Objectives, Scope, and Methodology

This report examines (1) how state child welfare agencies recruit foster  families, including those who provide therapeutic foster care services, (2)  challenges, if any, to recruiting and retaining families, and (3) the extent  to which the U.S. Department of Health and Human Services (HHS)  provides support to child welfare agencies in their efforts to recruit and  retain foster families. To address our objectives, we administered a web- based survey of state child welfare agencies in the 50 states and the  District of Columbia to obtain national information. To obtain more in- depth information, we interviewed child welfare officials, private providers,  and foster parents in three selected states (California, Georgia, and  Indiana). To obtain perspectives on providing therapeutic foster care  services specifically, we conducted three discussion groups with private  providers and foster parents at a national foster care conference. To  develop our methodologies, we conducted a literature search related to  foster care recruitment and retention, including for therapeutic foster care  services, and we interviewed experts with a range of related research,  policy, and direct service experience.

To examine how HHS supports child welfare agencies in their efforts to  recruit and retain foster families, we interviewed officials from HHS’s  Administration for Children and Families (ACF), Centers for Medicare &  Medicaid Services, Office of the Assistant Secretary for Planning and  Evaluation, and Substance Abuse and Mental Health Services  Administration. We reviewed relevant documents obtained in these  interviews and other information available on HHS’s website, such as  from the National Resource Center for Diligent Recruitment and the  Child Welfare Information Gateway. We focused on HHS efforts from  fiscal years 2012 through 2016. We also reviewed relevant federal laws,  regulations, and HHS policies, as well as federal internal control  standards.

To obtain nationwide information on our objectives, we surveyed officials  from state child welfare agencies in the 50 states and the District of  Columbia. The survey was administered in September 2017, and we  obtained a 100 percent response rate. The survey used a self- administered, Web-based questionnaire, and state respondents received  unique usernames and passwords.

To develop the survey, we performed a number of steps to ensure the  accuracy and completeness of the information collected, including an  internal peer review by an independent GAO survey expert, a review by  an external foster care expert, and pre-testing of the survey instrument.  Pre-tests were conducted over the phone with child welfare officials in  four states to check the clarity of the question and answer options, as well  as the flow and layout of the survey. The states that participated in pre- testing were selected based on recommendations from foster care  experts and variation in child welfare administration systems (i.e., state-  versus county-administered) and use of private providers. We revised the  survey based on the reviews and pre-tests. The survey was designed to  gather information from state child welfare agencies rather than county- level child welfare agencies or private providers. As such, we included  questions in the survey to ensure that respondents were knowledgeable  about foster family recruitment and retention efforts if the state child  welfare agency was not directly involved.

Our survey included a range of fixed-choice and open-ended questions  related to recruiting and retaining foster families, including those who  provide therapeutic foster care services. These questions were grouped  into six subsections that covered (1) the states’ administrative structure  for recruiting and retaining foster families, including the use of private  providers; (2) information on states’ recruitment and retention plans and  the usefulness of various strategies in recruiting and retaining foster  families; (3) challenges states face in their efforts; (4) perspectives on  various federal supports in this area and any additional supports needed;  (5) data collected and used in recruitment and retention efforts; and (6)  oversight of county child welfare agencies and private providers, if  applicable.

To obtain our 100 percent response rate, we made multiple follow-up  contacts by email and phone in September 2017 with child welfare  officials who had not yet completed the survey. While all surveyed  officials affirmatively checked “completed” at the end of the web-based  survey, not all state child welfare agencies responded to every question  or the sub-parts of every question. We conducted additional follow-up  with a small number of state child welfare agencies to verify key  responses.

Because this was not a sample survey, it has no sampling errors.  However, the practical difficulties of conducting any survey may introduce  errors, commonly referred to as non-sampling errors. For example,  unwanted variability can result from differences in how a particular  question is interpreted, the sources of information available to  respondents, or how data from respondents are processed and analyzed.  We tried to minimize these factors through our reviews, pre-tests, and  follow-up efforts. In addition, the web-based survey allowed state child  welfare agencies to enter their responses directly into an electronic  instrument, which created an automatic record for each state in a data  file. By using the electronic instrument, we eliminated the errors  associated with a manual data entry process. Lastly, data processing and  programming for the analysis of survey results was independently verified  to avoid any processing errors and to ensure the accuracy of this work.

To gather more in-depth information representing a variety of  perspectives on our objectives, we interviewed officials from three state  and three county child welfare agencies, representatives from 14 private  foster care providers working with these agencies, and foster parents  working with 8 of these private providers in the three selected states  (California, Georgia, and Indiana). The states were selected based on  factors such as recent changes in foster care and congregate care  caseloads, opioid abuse rates estimated by HHS in June 2016, variation  in child welfare administration systems (i.e., state- versus county- administered), and geographic location. Interviews were conducted during  in-person site visits in California and Indiana and via phone in Georgia.  We used semi-structured interview protocols for child welfare agencies,  private providers, and foster parents that included open-ended questions  on the strategies and challenges in recruiting and retaining foster families  and federal supports in this area, among other topics. We interviewed  officials from state-level child welfare agencies in each of these states. In  California, the only selected state with a county-administered child  welfare system, we selected three counties— Los Angeles, Sacramento,  and Sonoma—and conducted interviews with officials from the respective  county-level child welfare agency. These counties were selected based  on factors similar to those mentioned above as well as variation in  population density (i.e., rural versus urban).

In addition, we interviewed 14 private providers in the three selected  states, including 3 private providers in California (1 in each county we  visited), 4 in Georgia, and 7 in Indiana. Private providers were chosen for  interviews from a list of all private providers working with state child  welfare agencies to recruit foster families. This list was provided by child  welfare officials from each selected state. We considered factors such as  the number of foster families private providers worked with, their  involvement in recruiting families who provide therapeutic foster care  services, and geographic location.

We interviewed foster parents working with 8 of the private providers  mentioned above, including 2 groups of foster parents in California, 1  group in Georgia, and 5 groups in Indiana. Each of these groups included  between one and three sets of foster parents (e.g., one foster parent or a  couple). Due to the sensitivity of the topics discussed, we worked with  private providers to identify foster parents who were able and willing to  participate in interviews. We discussed several considerations for  selecting foster parents, such as gathering parents with a range of  experience providing foster care services to children in both traditional  and therapeutic foster care settings. Because foster parents we  interviewed self-selected to participate and were all working with private  providers we interviewed, their views do not represent the views of all  foster parents, such as those working directly with child welfare agencies.  We also reviewed relevant documents that corroborated the information  obtained in our interviews with child welfare agencies and private  providers, such as recruitment plans, marketing materials, and child  placement reports.

Because we conducted interviews with a non-generalizable sample of  child welfare officials, private providers, and foster parents, the  information gathered in the three selected states is not generalizable.  Although not generalizable, our selection methodologies provide  illustrative examples to support our findings.

To obtain information specifically about efforts to recruit and retain  families who provide therapeutic foster care services, we conducted three  discussion groups at a conference hosted by the Family Focused  Treatment Association, a non-profit organization that aims to develop,  promote, and support therapeutic foster care services. The conference  was held in July 2017 in Chicago, Illinois. We held two discussion groups  with representatives from 17 private providers and one discussion group  with eight sets of foster parents. To solicit participants, we used email to  invite all individuals who registered for the conference to participate in our  discussion groups. These emails explained our objectives and potential  discussion topics related to recruiting and retaining therapeutic foster care  families. Participants who volunteered were sorted into the three groups.  Discussion groups for private providers and foster parents were guided by  a GAO moderator using semi-structured interview protocols. These  protocols included open-ended questions that encouraged participants to  share their thoughts and experiences on recruiting and retaining  therapeutic foster care families, including strategies and challenges in  these efforts, as well as differences in providing therapeutic versus  traditional foster care services.

Discussion groups are not designed to (1) demonstrate the extent of a  problem or to generalize results to a larger population, (2) develop a  consensus to arrive at an agreed-upon plan or make decisions about  what actions to take, or (3) provide statistically representative samples or  reliable quantitative estimates. Instead, they are intended to generate in- depth information about the reasons for participants’ attitudes on specific  topics and to offer insights into their concerns about and support for an  issue. For these reasons, and because discussion group participants  were self-selected volunteers, the results of our discussion groups are not  generalizable.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contact and Staff Acknowledgments

In addition to the contact name above, the following staff members made  key contributions to this report: Elizabeth Morrison (Assistant Director);  Nhi Nguyen (Analyst-in-Charge); Luqman Abdullah; Laura Gibbons; and  Elizabeth Hartjes. Also contributing to this report were Sarah Cornetto;  Tiffany Johnson Lapuebla; Cheryl Jones; Kirsten Lauber; Serena Lo;  Hannah Locke; Mimi Nguyen; Samuel Portnow; Ronni Schwartz; Almeta  Spencer, and Kathleen van Gelder.