The Case for Investing in Enhanced Care Programs for Youth with Complex Challenges
The Case for Investing in Enhanced Care Programs for Youth with Complex Challenges
Blog Post by Sonali Bhargava, Catalyst Center
Caring for dependent children who have experienced adverse events can be financially burdensome on county and state systems, particularly when this care requires intensive, individualized supports, also called Enhanced Care Programs. However, while investing in Enhanced Care Programs for youth with complex challenges may contribute to high upfront costs for a period of months, over time these interventions can lead to significant cost savings for our systems of care and criminal justice systems. Sixty percent (60%) of states nationwide place youth in out of home care two or more times, which is likely to disrupt a youth’s well-being and sense of permanency. Children who experience multiple placements throughout their time in the system are between 36 and 63 percent more likely to develop behavioral challenges. Investing in the youth in our system is critical to helping them heal, and the long-term financial benefits of doing so are compelling. To learn more about the effects of placement disruption and instability on the life trajectory of youth with complex challenges, please visit this blog post HERE. Herein is an argument for investing in Enhanced Care Programs in order to emotionally benefit youth and financially benefit the systems responsible for providing care to them.
Youth who have complex needs often present with a variety of significant and impactful challenges - including but not limited to neuropsychological problems, developmental delays, and impaired social functioning, many of which are a result of exposure to various forms of abuse, neglect, and other adverse childhood experiences. Intensive and time limited behavioral health interventions within Enhanced Care Programs are not only the best option for youth with complex challenges and/or experiencing crises, but also have the best chance of preventing higher future costs that are often incurred for various systems of rehabilitation and support needed for adults who have histories of involvement with the foster care system.
One of the goals of Enhanced Care Programs is to return youth to lower levels of care, specifically to family-based settings. There are two service models, the Enhanced Short-Term Residential Therapeutic Program (E-STRTP) and Enhanced Intensive Services Foster Care (E-ISFC), designed to stabilize and treat youth with complex challenges. E-STRTPs are tailored individually with the programmatic flexibility designed to benefit each youth. Programs provide mental health services as often as indicated, with daily services occurring, in most cases. E-ISFC placements are in a family-based setting with a Specialized Resource Parent that lives in the home. Staff provide support and mental health services within the resource parent home (daily, in most cases). Both Enhanced Care models utilize a no-reject, no-eject model in order to best serve youth with complex challenges, and both staffing structures are tailored to meet the youth’s individualized needs. The goal is for youth to step down to a lower level of care in three to nine months.
There are long-term negative consequences that build upon one another when a young person fails to receive the proper support needed to stabilize and thrive. These outcomes, while largely emotional concerns, also build up over time to be financially burdensome on our systems of care. Enhanced Care Programs would disrupt such trajectories, and are in fact the most financially rational option. While Enhanced Care Programs can cost significantly more than traditional STRTPs or ISFCs, when compared with the prices of the pathways detailed below, the cost of Enhanced Care Programs is dramatically less over time.
When foster youth transition out of the system, a lack of support and prior appropriate treatment yields experiences of homelessness 25% of the time, creating both economic and social problems. Foster youth up to age 24 are 10% of California’s homeless, although they only benefit from 3% of federally funded aid for the homeless. Successful recovery requires permanent supportive housing along with other supportive services. Homeless individuals are more likely to enter the criminal justice system and require mental health services.
Current federal expenditures
On average, each homeless individual costs the federal government $35,578 annually. Over 4,000 foster youth become homeless upon exiting the system.
· $35,578 x 4,000 = $142,312,000 annually
As an example, in Los Angeles, the average cost of building one unit of housing for those experiencing homelessness is currently about $531,000. In the Bay Area, the cost is $450,000 per unit. Approximately 2 people can live in every unit. With Enhanced Care Programs in place, the number of homeless units needed can be reduced.
· $531,000/2 = $265,500 per homeless person in Los Angeles
Tyler’s* story illustrates the effects incarceration can have on financial and mental well-being. Tyler has a history of being sexually abused by a male sibling for years, beginning at the age of 6. When Tyler was 16, he was arrested for assaulting a peer at school – after his adjudication, he was removed from his home and placed in his first STRTP. Tyler had over 15 STRTP placements over the next year and a half. None of the congregate care settings could meet Tyler’s needs, as his trauma history was triggered by the presence of other males in the house and sharing a bedroom with a roommate. Although Tyler was eligible for extended foster care, his behavioral health symptoms kept him from succeeding in transitional housing, so he spent much of his time between the ages of 18 and 21 “couch surfing” and homeless, with some minor arrests. At the age of 21, Tyler was one of approximately 23,000 youth who must exit the foster care system annually in California. Upon being emancipated, he becomes involved with the criminal justice system on a charge of sexual assault. He is sentenced to 20 years of incarceration at the Todd Road detention center in Ventura County. The daily cost of housing Tyler as an inmate is $114.
365 days x $114 = $41,610 annually
$41,610 x 20 = cost of $832,200 to incarcerate Tyler for the length of his sentence
80% of all inmates in California have spent some time in foster care. Within two years of exiting the system, 25% of former foster youth are likely to be incarcerated. Incarcerated individuals are also more likely to need mental health care. The American Psychological Association details that incarcerated individuals report mental health concerns 64% of the time.
Current federal expenditures
· The 2020-21 California state budget includes a proposal to spend about $800 million on mental health care solely for state prisons.
· On average, each incarcerated individual costs the federal government $47,000 annually.
· 23,000 x .25 = 5,750 foster youth incarcerated annually
· 5,750 x $47,000 = $270,250,000 to fund incarceration of foster youth each year
Mental Health Services
When compared to the general public, foster youth exiting the system are 2-4 times more likely to have mental health disorders during their lifetime than other adults undergoing this transitional phase. Fifty percent (50%) of emancipated foster youth are suffering from moderate to severe mental illness. Amanda, a transgender emancipated foster youth, is battling Major Depressive Disorder (MDD). She was raised in a physically abusive household, where her father believed he should punish Amanda for being expressive about being transgender and her desire for sex-reassignment surgery. Amanda was ultimately removed from her parents due to the physical abuse she endured. She was placed into her first STRTP at the age of 12, and, at her request, received hormone replacement therapy throughout her time in the child welfare system. Amanda experienced significant suicidal ideation and attempts, which led providers to feel that they could not keep her safe. As a result, Amanda was frequently discharged from placements and she was never in any placement long enough to receive proper treatment for her trauma and depression. When she exited the system, she struggled to find stable, affordable housing due to her financial restrictions from only being able to obtain minimum-wage jobs, and frequently feeling too overwhelmed by her depression to attend work. Her challenging life experiences led her to a serious suicide attempt at 22, at which point she began treatment at a psychiatric hospital. For every 8 days of care in the hospital, the cost is approximately $6,990. Although her initial hospitalization is successful, Amanda has continued to suffer from relapses every 6-9 months, when her depression leads her to additional suicide attempts. The total cost for Amanda’s inpatient psychiatric treatment from the age of 22 until her current age of 28 amounts to approximately $1,822,392.
Alarmingly, the comorbidity rate between mental health disorders and substance abuse for individuals formerly in the system is 26%. Below is a summary of the costs of psychiatric hospitalization and substance use treatment. It is important to note that the cyclical nature of recovery and relapse equates to a recurring need for these payments over time.
Costs for Each Type of Inpatient Mental Health Treatment
Bipolar Depression: $7,593 for 9.4 days
Depression treatment: $6,990 for 8.4 days
Drug abuse treatment (California): $1,583 on average (over what time frame?)
Alcohol use treatment: $5,908 for 6.2 days
The average adult outpatient therapy session in California is $100-$200 and 12-16 sessions is recommended to make progress. 100 x 12 = minimum of $1200 per client
In California, by the age that dependent youth must exit the system (21), 37% of female foster youth will have given birth in Sacramento County. Nationally, about 48% of youth in foster care are female. With many current and emancipated foster youth unable to provide proper care to their children, more youth are put back into the system, contributing to patterns of intergenerational trauma and yielding to exponentially higher costs of homelessness and incarceration down the line. The lack of information and access to reproductive care and foster youth strivings for relational connection and permanency contributes to this reproductive health crisis among foster youth.
Current federal expenditures
Housing a Non-Minor Dependent (NMD) and their child increases the cost of the housing stipend that comes from the state budget
Exact dollar amounts are county-based
Foster youth receive a $900 infant stipend monthly
Current Reform Efforts
The Catalyst Center has partnered with Casey Family Programs in order to address the negative life outcomes detailed above through supporting counties and organizations providing Enhanced Care Programs for youth. This project, Youth First, intends to support the establishment of new enhanced care programs for youth with complex needs, with a focus on fostering permanency and stability. Currently, the Catalyst Center is providing technical assistance for participants to design programs, including aid on staffing models, clinical practices, budget development, licensing, and funding. For more information on the Youth First Project, visit HERE.
Our systems-involved youth need more support, and while that care requires a significant initial investment, the evidence is overwhelming that these interventions will result in an overall decreased expenditure on long-term systems of recovery. For example, Troy had sexually aggressive and violent behaviors towards other peers and staff in his residential homes1. No one wanted to take responsibility for his care, however with increased structure and behavioral plans in an Enhanced Care Program, as well as greater community involvement, Troy was eventually able to reduce his violent tendencies and step down to a lower level of care. Currently, due to the investments made by Troy’s county to fund his treatment, Troy is living with a relative and working part time in addition to working on his high school diploma. Enhanced Care Programs are often the best treatment option for youth with complex challenges to break the repeated cycles of placement changes and allow youth to heal from trauma. Not only do Enhanced Care Programs allow youth to begin to heal and step down to lower levels of care, but they can change their life trajectory – allowing them to become non-systems dependent, establish permanency and maintain positive relationships, and lead productive lives.
Investing in youth with complex challenges prior to their exiting the system has clear benefits. California made the decision to extend foster care from 18 to 21 years of age, with the adoption of AB12. Although a relatively recent legislative change, studies are already showing the long-term benefits of increased support. For example, leaving the system at 18 versus 21 often means reduced mental health services and an increase in unsafe sexual practices. Those who remain in foster care past age 19 report fewer cases of "arrest, conviction, and incarceration” (Courtney 160). The association between homelessness and a criminal record, along with mental health problems, clearly increases the federal financial burden in the long term. The returns on earlier investment in caring for foster youth are greater as these services can prevent or reduce later systems costs related to homelessness, incarceration, inpatient treatment, and the consequences of reproductive health crisis and intergenerational trauma.
Although this piece has focused on a financial cost/benefit analysis, the individual and social benefits of helping a young person heal and recover from trauma in order to lead a meaningful and fulfilling adult life are priceless. In fact, I would argue that for the wellbeing of our communities and future generations, we are obligated to meet the needs of all youth in foster care, regardless of the financial cost. By providing brief and intensive Enhanced Care Programs for youth with complex challenges, we are making an upfront investment that can prevent higher financial expenditures in the future.
*All names and identifying personal information have been changed for confidentiality.
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