Examining Quality of Care in Group Homes for Youth with Mental Health Problems

Background and Purpose: There has been substantial concern about quality of care/treatment in group homes that serve youth with mental health disorders and behavior problems. This concern has focused on potential iatrogenic effects of group treatment, issues related to unlicensed/unregulated facilities, and a lack of high-quality generalizable data on group home practices and outcomes to evaluate the veracity of such concerns. The current work focuses on an NIMH-funded study of group homes in a southeastern state. It builds from various conceptualizations of quality of care to examine variations in quality and relationships between these indicators of quality and youth outcomes.

Methods: Data come from a quasi-experimental study of group homes. The sampling frame included all homes in the focal state that implemented the Teaching Family Model (a promising model of care) as well as a randomly selected set of comparison homes that were located in the same geographic catchment areas as the Teaching Family Programs. The sample included 554 youth who were served across 50 group homes.  Data come from a variety of sources: interviews with program directors, review of enrolled youths’ records, in-person interviews with staff and youth, structured observations in each group home, and telephone interviews with youths’ caregivers from the pre-admission and post-discharge period. 

Results: The conceptual model for the analysis focused on extracting and identifying key components from several complementary approaches to assessing quality of care. Results suggested significant variation in quality across group homes – both between Teaching Family and non-Teaching Family homes and within each arm of the study. Overall, Teaching Family homes showed significantly higher levels of quality on most indicators (e.g., implementation of core components, staffing/training, organizational culture/climate). Youth respondents showed high levels of satisfaction and positive assessments of their experiences in the homes, across all homes, with slightly more positive views of Teaching Family homes. Analysis of youth across group homes showed that youth from vulnerable groups (e.g., racial/ethnic minorities, girls, with juvenile justice backgrounds, experienced childhood trauma/maltreatment) were actually more likely to experience high quality care. However, youth who had more severe psychiatric problems and histories were over-represented in lower quality homes.  Regression analyses to examine relationships between quality indicators and youth outcomes suggested that quality of care was relatively unrelated to positive youth-levels changes while the youth was in care. However, post-discharge maintenance and continuation of positive outcomes were significantly related to higher quality care.

Conclusions and Implications: This study provides an initial large-scale assessment of quality of care in residential care for youth with mental health problems. Findings suggest that, overall, group homes are effective for promoting relatively quick and significant changes in problem behavior. Higher quality of care appears to be more clearly linked to post-discharge sustainability of these positive gains. This suggests the need for further research to examine practices which maximize long-term gains of relatively expensive out-of-home treatment and to identify policies that support the most effective practices and sustainability.