Characterizing the use of home-based behavioral health services among children in foster care

Background: Children in foster care (FC) experience disproportionately high rates of mental health (MH) needs and frequently use behavioral health services. They are overrepresented in restrictive MH settings and are more likely to be prescribed psychotropic medications. Home-based behavioral health services (HBHS) offer a less restrictive alternative for addressing the complex needs of children in FC, but their use and effectiveness remain understudied. Methods: Using Medicaid data from 28 states, we examined MH service utilization among children aged 3–18 with primary MH diagnoses across three eligibility groups: FC (n = 128,180), disability (n = 214,959), and low-income (n = 1,054,426). We summarized utilization patterns, estimated multivariable models of HBHS take-up, and assessed associations between HBHS and other MH-related care. Results: About 60% of children in FC had a MH diagnosis, compared with 65% of children with disabilities and 19% of children with income-based eligibility. HBHS use was highest among children in FC (29%), exceeding use among children with disabilities (15%) and low-income children (10%). Among children in FC, HBHS use was associated with greater MH diagnostic complexity, Black and Hispanic race/ethnicity, and certain MH diagnoses. HBHS use (vs. no use) was associated with lower odds of hospitalization (aOR = 0.82), ED visits (aOR = 0.75), and new psychotropic prescriptions (antipsychotics aOR = 0.76; SSRIs aOR = 0.80; ADHD medications aOR = 0.77), and higher odds of school-based MH service use (aOR = 1.47). Conclusions: HBHS are widely used within FC and serve clinically complex populations. Their use was linked to reduced reliance on restrictive and pharmaceutical care, suggesting that expanding access may enhance MH services for children.