Examining the Impact of Differences in Residential Care Providers on Children's Outcomes

Background and Purpose:

Despite long-standing efforts to reduce utilization, residential care still holds a place along the continuum of placement options in the US, especially for children who exhibit more severe behavioral problems. Questions about the use of residential care stem from concerns over how well residential care meets the needs of the young people referred to those services. Clinically, it is unclear whether young people benefit.

Although these concerns are well founded, the criticism paints residential care with a single, broad brush: residential care is not good for children. Missing from the literature are assessments of whether some residential care providers do the job better than others. It is an important question. So long as residential care is an option, it makes sense to work with providers that offer effective services.

In our study, we set out to understand whether providers differ with respect to their basic performance. To do this we studied children placed with 20 residential care providers in a large metropolitan area. We focused on basic outcomes such as permanency rates, unplanned absences (running away), and transfers to other levels of care.

Methods:

We analyzed the placement histories of 3,249 young people entering residential care between 2014 and 2018. In addition, we sent surveys to staff working in residential care and conducted focus groups with staff from a select group of providers. We then linked the survey and focus group data to the placement records of the children served by those providers. The linkage of qualitative data with the administrative records provided a way to relate staff attitudes to the performance of their agencies. We did this using multi-level models. The outcomes of interest were unplanned absences (running away), transfers to other levels of care, and permanency. With the multi-level model, we were able to make judgments about average, above average, and below average agency performance while controlling for the mix of children served and workforce attitudes.

Results:

The findings can be organized into two categories. First, staff attitudes matter. We found that children placed with providers whose staff self-reported adequate staffing levels were more likely to step down to a less restrictive residential care setting and less likely to run away. We also found significant between provider differences even after controlling for the mix of children served and the attributes of the agency.

Conclusions and Implications:

Although we tend to paint residential care with a single broad brush, our study shows that this may be misguided. Not all providers are the same. Moreover, so long as residential care persists, it is important to recognize and support providers that do a better job. Our study highlights the importance of adequate staffing. Having said that, we were not able to assess well-being. A thorough assessment of residential care and the impact of providers requires a careful look at whether young people are doing better when they leave residential care than when they started. Our study shows how that work might be carried out.