Wraparound and Therapeutic Foster Care and Their Implications for Taxpayers

Wraparound

With wraparound services, many children with serious emotional or behavioral disorders who would otherwise be institutionalized have been able to live at home or in a homelike setting. By definition, wraparound is individualized to address a child’s specific needs and build on the child’s and family’s strengths, so the exact services vary. The services are provided through teams that link children, families and foster parents and their support networks with child welfare, health, mental health, educational and juvenile justice service providers to develop and implement comprehensive service and support plans.

Wraparound services consist of both natural and formal supports. Among formal services are diagnostic evaluations; behavioral support services; individual and family crisis planning and intervention services; parent coaching and education; medication monitoring; intensive in-home, individual, group and family therapy; interactive psychotherapy using play equipment, physical devices or other mechanisms of non-verbal communication; and rehabilitation services. Therapeutic behavioral aide services are a frequent part of wraparound, provided by experienced staff working one-on-one with a child in his or her home and community. The services offered by these aides are aimed at helping the child improve, maintain or restore skills. Examples include teaching the child appropriate problem-solving skills, anger management and other social skills or engaging the child in constructive activities in the community.

Wraparound services are reimbursable under various Medicaid categories. For example, counseling and therapy can be covered as either clinic or rehabilitation services. Services, such as those provided by behavioral aides, that are aimed at eliminating psychosocial barriers that impede the development or modification of the skills a child needs to function independently in the community are rehabilitation services. The Medicaid Rehabilitation Option specifically provides that services may be furnished in a variety of community locations, including the child’s home, school, daycare program or other natural setting.

Frequently cited as an example of wraparound is a program in Wisconsin, Wraparound Milwaukee. The public system’s use of expensive and restrictive residential treatment has decreased 60 percent since Wraparound Milwaukee began five years ago, and inpatient psychiatric hospitalization has dropped by 80 percent. The experience of Wraparound Milwaukee also illustrates the fiscal benefit of these services. Last year the monthly costs of all its services, including foster care, were approximately $3,900 per child, while children in residential treatment centers each cost taxpayers $8,000 to $10,00

Some California counties now provide wraparound to some children through a pilot program. According to an expert declaration cited in the lawsuit, the Sacramento County wraparound program reduced the percentage of “the most challenging” children in residential care from 45 to 11, with 74 percent going to family settings or independent living. Mendocino County also has a pilot program. The county spends an average $9,495 per month for a child in out-of-home placement, while per-child costs for wraparound averaged $6,065.

Therapeutic Foster Care

Therapeutic foster care (TFC), sometimes called multidimensional treatment foster care, is a service for children with serious emotional or behavioral needs who cannot be cared for in their own homes. Like wraparound, it is designed to be flexible. TFC programs recruit, train and support foster families, who generally take in only one child, although they may also have biological or adopted children of their own. The families are closely supervised and supported, and receive a monthly stipend.

TFC programs use a strengths-based team approach much like that used by wraparound, working with providers from many aspects of the child’s and family’s life. Intensive, individualized services are provided both to the child and to all members of the foster family. In addition, TFC programs prepare and support the child’s family to enable a successful transition when the child returns home.

TFC is less restrictive than other types of out-of-home placement, and studies of children in this type of foster care show behavioral improvements and more successful transitions to less restrictive environments. It is also less expensive. The director of an Oregon program serving children referred for delinquency cites a report finding that “overall, taxpayers gain approximately $21,836 in subsequent criminal justice cost savings for each program participant.”

Whether billed as separate services or bundled, TFC is Medicaid-reimbursable as a rehabilitation service. A number of states use Medicaid dollars to fund TFC programs. Some California counties have a version they call “intensive treatment foster care” serving a few hundred children. However, state officials have been unable to clarify what services are available through this program, and the state’s restrictive rules have combined with low reimbursement rates to suppress participation in it.