Building Accountability In Rural Child Welfare Systems: Service Providers' Perspectives on Possible Solutions for High-Needs Youth In Foster Care

Background and Purpose: Children with mental health concerns in foster care face significant barriers to mental health services, particularly in rural areas. Mental health provider shortages, long waitlists to access services, and limited foster care placement options leave children cycling through multiple foster homes. In some cases, when local resources are exhausted, children are placed out-of-county or state for psychiatric residential treatment (PRTF), losing critical bonds with their community and family. While existing literature broadly documents these barriers, little attention has been given to possible solutions that frontline child welfare service providers in rural areas believe are needed. This qualitative study explores service providers' perspectives on improving care for high-needs children in rural foster care settings.

Methods: Using a qualitative design, data were drawn from semi-structured interviews and focus groups (N=21) in a rural county in western North Carolina. Participants included child welfare workers (n=8), mental health providers (n=4), GALs (n=4), foster care youth (n=2), and foster care parents (n=3). Data were analyzed using reflexive thematic analysis.

Findings: Three themes were developed: (1) Mental health provider accountability — PRTFs conduct pre-admission interviews for foster care children, and those who are rejected risk being retraumatized and left with nowhere to go. In addition, PRTFs are supposed to be a last resort for children with severe mental health or behavioral problems, yet when they reject or discharge children, it can leave children with nowhere to go. Participants called for the need for standardized admission criteria and clear performance standards for providers; (2) Dedicated care coordination — participants emphasized the need for mental health case managers to ensure consistent service navigation across systems, as child welfare providers are burdened with high caseloads and do not have adequate time to provide needed attention to children and family; and (3) Rural-specific investment — participants stressed the need for state-level funding structures that go beyond caseload numbers, alongside provider incentive programs to recruit and retain mental health professionals in rural communities.

Conclusions and Implications: Findings underscore the urgent need for systemic policy reforms that center the rural realities of child welfare systems. Implications include establishing mental health provider (i.e., PRTF) accountability structures, funding dedicated mental health case managers in rural counties, and increasing state-level investment in rural child welfare infrastructure to better serve high-needs foster youth.