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Maryland’s Family Recovery Courts: Successfully Reuniting Families with the Help of Customized Substance Use Disorder Treatment
To reduce substance use as a key cause of children removed from their homes, Maryland implemented a Family Recovery Court program in 2004 that connects parents to intensive treatment for substance use disorder (SUD) and provides case management and incentives. Over a one-year period, program evaluations show the program produced a 25 percent higher reunification rate, reduced days that children spend in non-kinship foster care (252 vs. 346), and produced more than $1 million in savings for the state’s child protective system due to reduced foster care utilization.
Background
Substance use is a major contributing factor in child removals. The rate of removals associated with substance use rose nearly 20 percent between 2000 and 2016 and peaked at 36 percent in 2018 before falling slightly to 34 percent in 2019. To address substance use as a driver of children entering foster care, Maryland uses a Family Recovery Court (FRC) model that connects parents to intensive services, case management, and incentives – all emphasizing SUD treatment as an opportunity to support family reunification.
FRC is a civil court proceeding that works closely with the state’s child welfare/child protection system. Individuals are referred to the FRC when they interact with the judicial system because their abilities to parent have been impaired as a result of SUD. Parents participating in FRCs have an underlying child welfare case in civil family court, where they often face the threat of losing custody following allegations of neglect. Maryland’s FRCs recognize the chronic nature of SUD and that without support and treatment, parents with SUD may continue to struggle. Maryland’s successful model is centered around services and engagement that incentivize the safety, health, and stability of families.
Establishing Family Recovery Courts
Maryland’s Code and Court Rules established a formal process for creating “problem-solving courts” that include FRCs. An administrative order from the Chief Judge of the Court of Appeals details the court’s process.
- A county circuit court or district court judge is required to lead its development, which includes consulting with and receiving commitments from other government agencies that are willing to participate as partners in the problem-solving court.
- Planning must establish community need indicated by SUD rates, child abuse/neglect cases related to parental SUD, rates of SUD treatment retention. The leaders outline program goals, protocols, and an estimated budget.
Maryland established its first FRC in Harford County in 2004, followed by Baltimore City in 2005. Today, the state operates five such courts across the state. To standardize best practices and requirements across jurisdictions, the Maryland Office of Problem Solving Courts released Guidelines for Planning and Implementing Family/Dependency Drug Treatment Court Programs in 2017. These guidelines spell out the process of establishing a FRC, including programming details, target populations, the role of the judiciary, policy issues, and funding strategies.
Eligibility:Parents who participate in Maryland’s FRC programs do so voluntarily, understanding that family reunification is the goal of the program. Eligible participants include:
- Parents of infants with positive screens for substances;
- Parents with reported neglect;
- Parents who maintain custody, but neglect is indicated through a petition; and
- Parents who maintain custody following a court’s disposition.
Parents may be referred into the program by child protective services, public defenders, magistrates, and social workers.
Services: Parents participating in a Maryland FRC are provided with an immediate assessment followed by comprehensive SUD treatment services and intensive supports to stabilize the family unit. “The range of services available are so rich and so focused on getting at the source of the medical issue that is driving their use disorder,” noted one Maryland state official. “[The goal is] not to simply achieve a period of negative urine analysis screenings, but to get to the core causes that will bring them to that ‘I’m done’ day.” All parents undergo extensive intake by internal court case managers who develop personalized treatment plans. Plans are closely monitored by the court, which convenes weekly to review open cases and participant progress.
Through the FRC, parents can access:
- Psycho-social supports, including counseling, as well as medication for opioid use disorder (MOUD) when clinically indicated;
- Peer support;
- Assistance in applying for Medicaid;
- Linkages to housing and transportation;
- Life skills training; and
- Continued access to the staff and resources of the FRC to gain continued parenting and SUD support.
FRCs take an incentives-based approach that embraces the reality that SUD is a chronic relapsing disorder – it does not terminate parents from the program solely on the grounds of their return to substance use.
Funding/State Support: Maryland utilizes several funding sources to operate its FRCs. State grant funds from the Office of Problem-Solving Courts, within Maryland’s Administrative Office of the Court, are the primary source of financial support. These grants cover administrative, staffing, training, and drug testing costs, and some ancillary services. In recent years, the state legislature has reduced the judiciary’s budget, but exempted problem-solving courts from any reductions. In 2017, the state’s Heroin and Opioid Prevention Effort (HOPE) and Treatment Act included an ongoing, mandated an appropriation to fund drug courts, including FRCs. FRCs and the Office of Problem-Solving Courts also partner with the Department of Behavioral Health, Department of Social Services, and other agencies to fund and navigate services such as transportation and housing supports. Finally, health care services, such as in- and outpatient treatment, psycho-social therapy, and MOUD are covered by Maryland Medicaid for eligible participants.
Outcomes:While the core goal of this court model is to achieve residential permanency for children, Maryland’s FRCs seek to achieve the often more difficult goal of family reunification by emphasizing holistic rehabilitation. In addition to treatment adherence, parental skill development and engaged participation are critical to the program’s success, and meeting the requirements for graduation from the program can be challenging. As part of annual reporting, the Administrative Office of the Courts routinely reviews all problem-solving courts, including FRCs. The 2020 Annual Report to the legislature indicated that, after adjusting for participants who left for administrative reasons, an average of 19 percent of participants graduated across FRCs in the state; Baltimore County had the highest graduation rate at 34.5 percent.
An external evaluation covering one year in 2008 also showed:
- A reunification rate of 70 percent for families participating in FRCs, as opposed to a 45 percent reunification rate among families who did not participate;
- Fewer days spent in non-kinship foster care placement (252 days vs. 346 days)
- A net savings of over $1 million for the state’s child protection system due to decreased utilization of the foster care; and
- A treatment completion rate by participating parents of 64 percent, compared to 36 percent of non-FRP parents.
Further, one FRC in a small jurisdiction was closed as the result of positive outcomes that led to a lack of subsequent need in the community.
Key Takeaways
To establish an FRC in a state, Maryland officials recommend policymakers:
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- Seek judicial leadership. Maryland’s Problem-Solving Courts are championed, developed, and supported by leadership within the judiciary, included judges across the state and from various levels of the state’s court system. Critical administrative funding, guidance, and enabling regulation flows from and is overseen by the judicial system, contributing to the program’s overall sustainability and success.
- Frontload a diverse and intensive array of services, and then maintain connections. State officials credit the program’s wraparound approach as an integral part of its success. Maryland’s FRCs provide case management services, short- and long-term family housing and transportation assistance, and employment preparation and life skills development. State leaders view the FRC as a lifelong program. FRCs employ parent locators who seek out FRC alumni and either re-engage them in treatment or encourage their participation in the program as peer support specialists. Parents may continue to receive services in the community after program completion.
- Encourage cross-agency collaboration. Maryland’s FRCs and adult drug courts are administered by the Office of Problem-Solving Courts and share an oversight committee, which provides an opportunity for collaboration across criminal and civil dockets. This approach also requires coordination among systems and agencies – the courts work with social services, health and behavioral health/SUD providers, and housing and transportation services to align resources and policies to ensure that the necessary supports are in place to help parents and families remain unified, healthy, and safe.
The National Academy for State Health Policy is providing this fact sheet with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. The authors would also like to thank Richard Abbott, Director, Juvenile and Family Services, Gray Barton, Director, Problem Solving Courts, Lou Gieszl, Assistant State Court Administrator for Programs, and the Hon. Robert Kershaw, Associate Judge, Baltimore Circuit Court, for contributing their expertise and state experiences to this report.
Implementing the Family First Prevention Services Act: What to Watch in 2021
Enacted in 2018, the Family First Prevention Services Act (FFPSA) significantly reformed the child welfare system and allowed states to use Title IV-E funds to reduce out-of-home placements for children and youth. When those placements are necessary, the FFPSA authorized specific types of allowable congregate settings, including qualified residential treatment programs (QRTPs).
States now have until October 2021 to implement these allowable congregate settings or risk losing Title IV-E foster care maintenance payments, which fund room and board and other activities in these approved settings.
With this deadline looming, many states are accelerating implementation of these newly authorized congregate settings, which may have potential implications for their child welfare and Medicaid programs and the funds states are able to capture under Title IV-E. This is particularly relevant as states struggle with budget shortfalls stemming from the COVID-19 pandemic.
Background
The FFPSA has generated significant reforms to the child welfare system and several key provisions allow states to use Title IV-E funds, which is the largest federal funding source for child welfare activities for certain evidence-based prevention services to reduce unnecessary out-of-home placements for children and youth. When out-of-home placement is necessary, FFPSA prioritizes Title IV-E funds for placements in foster family homes over those in congregate care, in part, by authorizing specific types of allowable congregate settings. These include qualified residential treatment programs (QRTPs), among others. States that do not implement QRTPs or other allowable congregate settings will soon be limited in their ability to claim Title IV-E foster care maintenance payments.
These new restrictions went into effect Oct. 1, 2019, however states had the option of delaying implementation of this provision for up to two years, until Oct. 1, 2021. At least 11 states opted for early adoption of these changes to congregate settings, with others opting for a delay. States that opted to delay implementation of these specific types of allowable congregate settings were simultaneously unable to use Title IV-E funds for prevention services under FFPSA – one of the hallmarks of the new law.
Changes to Congregate Settings Under FFPSA
Prior to FFPSA’s passage, states were able to claim federal Title IV-E for children in congregate settings with few constraints. But, as the final implementation date nears, only the following settings will be eligible for Title IV-E foster care maintenance payments:
- QRTPs designed to address the clinical needs of children with serious emotional or behavioral disorders. Key requirements include:
- Utilization of a trauma-informed treatment model;
- Having a registered or licensed nursing staff or other licensed clinical staff available 24/7;
- Facilitating family participation in the treatment process;
- Offering at least six months of support after discharge; and
- Being licensed and national accredited.
- Specialized settings for youth ages 18 and older who are living independently;
- Settings providing high-quality residential care and supportive services to children and youth who have been found to be, or at risk of becoming, sex trafficking victims; and
- Children who are placed with a parent in a licensed residential family-based treatment facility for substance use disorder for up to 12 months.
While there are limited exceptions, states will be unable to claim Title IV-E foster care maintenance payments after two weeks of placement in “childcare institutions” (i.e., congregate settings) that do not meet the above criteria. While existing congregate care settings will not necessarily close, their reimbursement structures may change. While the priority is to prevent children from being placed in congregate care, it remains an important option for some children and youth.
Approximately 10 percent of children and youth in out-of-home care were placed in a congregate setting in during fiscal year 2019. As a result, a delay in uptake of these changes beyond the final implementation date could represent a significant shift in costs onto states’ already constrained budgets. Texas estimates it will lose $26 million annually in federal Title IV-E funds if the state is unable to implement these provisions by the October 2021 deadline.
State Efforts to Implement QRTPs under FFPSA
Since the provision went into effect in October 2019, states have been at various stages of implementing allowable congregate settings that are eligible to claim Title IV-E foster care maintenance payments under FFPSA. Nearly all states have either implemented or are working to implement QRTPs, with many states launching and/or refining their program models in the coming months of this year.
- Michigan added the definition of QRTP to its state statute and is scheduled to submit its Title IV-E state plan amendment for federal review in early 2021, with contracts with QRTPs executed by February 2021.
- North Dakota began implementing QRTPs in October 2019 and now has three in place. This effort included making policy updates and the writing of a comprehensive document outlining answers to common questions.
- Virginia is scheduled to implement QRTPs by Jan. 31, 2021. The state also developed a comprehensive document outlining answers to common questions to provide clarity around the state’s implementation of the new congregate changes under FFPSA.
- Washington Statereceived federal approval in October 2020 for its updated QRTP policy and related Title IV-E state plan amendments to implement QRTPs. The state also received federal approval of a corresponding waiver allowing “qualified individuals” to perform the required assessments under FFPSA. The majority of the state’s QRTP facilities are accredited.
To support the uptake of QRTPs, some states are exploring use of supplemental funding, such as rate increases and federal Family First Transition Act funds. Many of these efforts are designed to incentivize providers to scale up their service delivery models to become QRTPs, reimburse providers for accreditation costs, and pilot QRTPs during the initial transition period.
- Maine is investigating opportunities for incentives and/or rate increases for providers that become accredited QRTPs. Maine is also working to develop and implement an application for providers becoming accredited QRTPs to receive partial reimbursement using the state’s federal Family First Transition Act funding.
- Texas is using federal Family First Transition Act funds awarded to support the state’s implementation of FFPSA to develop a two-year QRTP pilot program.
- Virginia officials indicated the state may provide funds to temporarily cover the cost of Title IV-E ineligible placements during the transition period as QRTPs are phased in. The state is also conducting a rate analysis to determine if a Medicaid rate adjustment is needed as providers transition to become accredited QRTPs.
- Washington State is working to establish dedicated funding to support providers working through the QRTP accreditation process.
The National Academy for State Health Policy will continue to monitor implementation and financing of QRTPs and other allowable congregate settings under FFPSA at both the state and federal level during 2021 and in the future.
States’ Recent 1115 Waiver Applications Include Provisions to Support Children during the Pandemic
More than a dozen states have recently submitted 1115 waiver applications that have the potential to safeguard access to care and increase support for children during the COVID-19 pandemic.
If approved, these 1115 waivers would be retroactively to March 1, 2020, and expire “no later than 60 days after the end of the public health emergency.” The Centers for Medicare & Medicaid Services (CMS) created an 1115 waiver template for states to use when requesting authority to address the impact of COVID-19 on their Medicaid programs. The National Academy for State Health Policy (NASHP) April 6, 2020, blog, State Medicaid Strategies to Maintain Access to Care for Children with Special Health Care Needs during the Pandemic, outlines steps states are taking to support children with special health care needs using 1135 and 1915(c) Appendix K emergency waiver authorities.
Of the COVID-related 1115 waiver applications reviewed by NASHP, several contain provisions related to children. The 1115 waiver provisions listed below represent a selection of key strategies for serving children during the COVID-19 pandemic that other states may want to consider for their Medicaid programs, including payments to foster caregivers, reimbursement of family caregivers, and telephonic and virtual care coordination services.
Payments to foster caregivers: Children in foster care are more likely to experience physical and mental health challenges compared to children in the general population. During the COVID-19 pandemic, children in foster care may not be able to access their typical support services through schools and specialty physical and mental health providers. Arkansas, for example, is acknowledging the importance of providing stability and support to these vulnerable children by requesting authority through a 1115 waiver, to provide an additional monthly payment to all foster caregivers (“licensed foster parents, relative caregivers, and fictive kin”) for providing at-home care for children in their care. These monthly payments would be designed to “prevent negative impacts to physical and mental health during emergency period.”
Reimbursement for family caregivers: Both Georgia and New Hampshire have included provisions in their 1115 COVID-19 waiver requests asking for Medicaid reimbursement of family caregivers for caring for youth with special health care needs. Georgia’s 1115 waiver request would add a family caregiver service to its Georgia Pediatric Program in the event that licensed professional nurses (LPNs) are not available to provide the child’s needed services. New Hampshire’s 1115 waiver request asks to waive CFR 440.167 and allow family members to perform and be reimbursed for personal care services. Both of these approaches allow children who receive services in their homes to remain in a home setting and potentially reduce the need for hospital or nursing facility placement during a time when these facilities are being overwhelmed with COVID-19 patients.
Care coordination through telehealth for Medicaid managed care organizations (MCOs): Care coordination services are critical for children with special health care needs and are important services to improve health outcomes, reduce caregiver and patient burden, decrease health care costs, and strengthen systems of care for children with chronic and complex conditions. Currently, New Mexico’s Medicaid MCOs are required to conduct many care coordination activities (including initial screenings, needs assessments, and nursing facility level of care determinations) via home visits involving face-to-face interactions. As a result of COVID-19, New Mexico is requesting in its 1115 waiver application to allow its MCOs to continue to conduct their care coordination supports virtually – by telephone or, if possible, using video technology. This provision may help ensure that these valuable supports and services are continued and that children and youth with special health care needs (CYSHCN), in particular, are maintaining access to their care coordinators and care coordination services.
The National Academy for State Health Policy will continue to closely follow CMS responses to these waiver submissions and track any additional state 1115 waiver actions in response to the COVID-19 pandemic.
As states look for ways to ensure their systems are designed to support children during the pandemic, especially those with special health care needs, the National Standards for Systems of Care for CYSHCN can be a helpful resource. The standards address the core components of the structure and process of an effective system of care for CYSHCN such as access to care, eligibility and enrollment, and care coordination.
Many state waiver proposals during the pandemic are designed to improve aspects of the health care delivery system that are addressed by the National Standards, such as acknowledging the critical role families play in caring for children and children with special health care needs and allowing for flexibility in how care coordination is provided to best meet the needs of families and children. The standards can provide states with a framework to help ensure that key provisions and health care system components and protections are maintained during a time of disruption in the traditional health care delivery system.
States Use Policy Levers and Emerging Research to Address Antipsychotic Use in Children in Foster Care
State policymakers must often take action during an emerging crisis even when evidence identifying the best policy approach is not be available. This report, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, explores successful state responses to dramatic increases in antipsychotic prescription rates in Medicaid-enrolled children in foster care. It highlights several strategies, including payment reforms, delivery system innovations, and quality supports for clinical care.
The report results from a convening by the National Academy for State Health Policy of researchers and state officials with expertise in financing and operating Children’s Health Insurance Program and Medicaid programs, children’s health, and health policy and pharmacy research. The meeting preceded the release of a Patient-Centered Outcomes Research Institute-funded study, which examines the comparative effectiveness of state oversight systems in Ohio, Texas, Washington, and Wisconsin.
Read or download: Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System
Growing Pains, Seeing Gains: Improving Youth Transitions
Thursday, August 16th
10:00am – 11:30am
Transitioning from youth to adulthood requires increased responsibility for many areas of life, including managing one’s health. This can be particularly challenging for children with a range of social and health care needs, particularly children with special health care needs. Policymakers from several states, including Georgia and Wisconsin, discuss innovative approaches to support young adults’ transitions to adult health care services and programs through managed care, quality improvement, family engagement, care coordination, and interagency collaboration and cooperation.
This session is supported by the Lucile Packard Foundation for Children’s Health
Moderators
Lori Abramson, Director-Georgia Families 360, Georgia Department of Community Health
Lori Abramson, LCSW is Director of the Georgia Families 360° program at the Georgia Department of Community Health. She ensures that children in foster care, adoption assistance, and youth in the juvenile justice system receive medical, dental, and behadvioral health care without barriers. Lori has 38 years’ experience in clinical practice, advocacy, collaboration building, and the managed care environment. Lori’s professional focus is about leveraging that experience on behalf of Georgia’s children and families.
Donna Bradbury, Associate Commissioner, NYS Office of Mental Health
Donna Bradbury directs the Division of Integrated Community Services for Children and Families at the Office of Mental Health. She oversees all community-based children’s mental health programs in New York State. She is currently leading the effort to transition children’s behavioral health services into Medicaid managed care as part of the larger Medicaid Redesign project.
Prior to state service, Donna worked for twelve years for the Rensselaer County Department of Mental Health. She delivered clinical services to children and their families, served as a consultant to Family Court as well as county-operated human service departments and schools, ran a specialized treatment program which successfully prevented institutional placement for many youth, and assisted in the creation and implementation of several interagency initiatives that resulted in children and their families having easier access to better quality services.
Speakers
Becky Burns, Statewide Coordinator, Wisconsin Children and Youth with Special Health Care Needs Program
Becky’s career centers on supporting children and families whose lives have been affected by unanticipated journeys through the world of disability services. She treasures the opportunities to work with these families whose resilience and growth continues to astound her. With a Master’s of Science in Social Work, she has used her education along with her personal experience of being raised in a family with a child who has a disability to influence her work with families. She has worked in one capacity or another for the state of WI for over 18 years.
Gordon Lee, Health Program Administrator, KY Office for Children with Special Health Care Needs
Lee holds a Master of Public Administration (MPA) and a Bachelor of Health Science in Health Administration. He is employed by the Office for Children with Special Health Care Needs (OCSHCN) where he carries out the duties of the agency’s Transition Administrator. Lee works with children, adolescents, families, support groups, service providers and OCSHCN staff to help ensure that Kentucky’s children with disabilities are prepared to successfully transition from pediatric to adult health care, from school to work, and from home to independent living. Lee coordinates the activities of the OCSHCN’s Youth and Parent Advisory Councils.
Peggy McManus, President, The National Alliance to Advance Adolescent Health
Peggy McManus is President of The National Alliance to Advance Adolescent Health and Co-Director of Got Transition. With Dr. White, she led the revision of the Six Core Elements of Health Care Transition, developed new transition quality improvement and consumer feedback measurement tools, published systematic reviews on transition outcomes and measures, and published extensively on transition quality improvement, payment options, state Title V transition efforts, and the status of transition preparation in the US.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
