From Mirage to Menu: What it Would Take to Scale EBPs
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From Mirage to Menu: What it Would Take to Scale EBPs
Moving beyond a few prevailing interventions in Family First
By Uma Ahluwalia, MSW, MHA
Enacted in 2018, the Family First Prevention Services Act (FFPSA) represents the most significant restructuring of federal child welfare financing in decades.
It left the underlying structural tension in child welfare financing untouched, but expanded the reach of open-ended financing in a way that suggests its eventual resolution.
The challenge is there’s a real rate limit on how FFPSA can unlock financing to deliver the full menu of evidence-based services to families at risk of foster care entry.
Eight years in, the menu remains a mirage; approved state prevention plans average only five or so programs, clustered around the same handful, despite nearly 100 with ratings that make them technically eligible for funding.
But there are structural and operational barriers to adoption and expansion. Here’s what they are and how leaders can push past them.
THE POLICY SIGNAL AND THE IMPLEMENTATION GAP
As of early 2026, 47 states, the District of Columbia, Puerto Rico, and 6 Tribal nations have approved Title IV-E prevention plans.
The number of jurisdictions claiming prevention services funding grew from 5 in FY2020 to 27 in FY2023.
Despite this growth, state plans remain narrow in their EBP selections. An ACF 2024 analysis of approved state prevention program plans found that programs requiring less intensive infrastructure—particularly Motivational Interviewing (MI) and home visiting models—dominate state menus.
Programs requiring more complex clinical delivery, higher fidelity infrastructure, or cross-system billing arrangements—such as Multisystemic Therapy (MST), Functional Family Therapy (FFT), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)—are present in far fewer plans.
This ASPE report confirmed that most state plans have only a handful of options, and the same ones dominate across them.
Juvenile justice and state Medicaid programs have built robust, billable EBP menus over decades. Child welfare’s is more underdeveloped and constrained by financing pressures.
A few key barriers are the limits leaders will have to surmount if they want a change in kind rather than degree.
Barrier #1: The Billing Pathway Exists on Paper, Not in Practice
Expanding entitlement funding to prevention services is a consequential policy shift. It only works if accompanied by the billing and claiming infrastructure needed to operationalize it.
As the universe of things child welfare can finance expands beyond out-of-home care placements and their contracted providers, it is encountering challenges Medicaid tackled years before.
Cost Allocation and Claiming Complexity
It’s not as simple as sending the state an invoice. Many of the strategies that make financing sustainable, like braiding funds with other payors and leveraging administrative claims, require cost allocation plan updates.
Cost allocation methodologies apportion program costs across eligible and non-eligible populations, document service delivery against approved program plans, and satisfy federal documentation requirements that most state child welfare information systems were not designed to support.
This takes creative collaboration between program and finance staff, federal approval of plans, and as a result, time and relationship building.
Private Agency Delivery
Most states are not hiring an army of prevention service delivery staff. They’re contracting with private agencies to execute it. That adds administrative complexity that policy often overlooks.
The state agency must pass through federal funds to private providers, ensure those providers are delivering certified EBPs with fidelity, collect appropriate documentation, and reconcile provider billing with Title IV-E claiming requirements.
They also still hold the risk when it comes to federal audits and accounting. For community-based providers operating on thin margins with limited administrative capacity, the documentation burden of Title IV-E claiming can be a decisive deterrent.
Providers that have historically gotten funding that flowed through Medicaid, TANF, or SSBG may not have the billing systems or staff expertise to support a new federal claiming stream.
What Are We Buying? Bundled Versus Unbundled Billing Structure
EBPs vary in whether their costs can be cleanly mapped to a billable unit of service.
“One” intervention of a program like MST or FFT might actually represent orchestration of a symphony of intervention strategies.
These programs are built around intensive, multi-component models with licensed therapist time, team supervision, and model developer consultation.
That makes it tricky to disaggregate into billable units under traditional fee-for-service structures.
What does work well through Medicaid is using case rates; bundling payments for the full episode of care. We don’t yet have the foundation for doing that consistently in Title IV-E, making it ad hoc.
Barrier #2: EBPs Are Expensive to Implement with Integrity
Clearinghouse approval gets you through the door. But it doesn’t come with payment based on what the interventions cost to run, which is a gap that states and providers must close on their own.
Research consistently shows that EBPs deliver their intended benefits only when implemented with fidelity to the model design. That requires training, monitoring, and oversight.
Title IV-E prevention administration can pay for much of that work, but doing so requires savvy coordination between a program and finance team within an agency.
Without those resources, efficacy and impact erode.
There's also a structural mismatch in who can bear those costs up front. The community-based service organizations most likely to be contracted to deliver services are usually least equipped to absorb those fidelity infrastructure costs.
Barrier #3: Workforce Is the Last-Mile Policy Delivery Problem
Even where billing pathways are cleared and fidelity infrastructure is built, delivery happens at the speed of the workforce.
The workforce pipeline required to deliver many EBPs as designed does not exist in most child welfare jurisdictions at the scale needed.
Child welfare is a high-turnover field that often has broad requirements for education, training, clinical supervision and licensing with specialized and required training and certification in that evidence-based intervention. Achieving fidelity requires training investment, but turnover continuously erodes the trained workforce base.
Research on EBP sustainability shows that roughly 37 percent of agencies discontinue evidence-based practices within six years of full implementation, with workforce issues and inadequate financial support as the primary drivers.
Title IV-E does provide enhanced federal reimbursement (75 percent) for certain staff training costs.
But training reimbursement covers discrete training events. The ongoing supervision, consultation, and coaching infrastructure that model-adherent EBP implementation requires don’t fit there.
Without the right workforce in place, delivery will fail to scale.
Infrastructure Is the Missing Layer, and the Limit
Closing the gap requires targeted investment in three areas of infrastructure: administrative capacity, program delivery, and the workforce.
In the face of so much uncertainty, waiting for federal clarity is understandable. But the most consequential early steps can and should come before federal action: key strategic decisions about priorities, governance, and resource allocation.
Acting now builds capacity before federal action and creates momentum. States can start by building claiming capacity incrementally, engaging model developers early, and braiding Medicaid with Title IV-E. Each step makes the next one easier.
FROM DIAGNOSIS TO DELIVERY: AN ACTIONABLE FRAMEWORK
States that have made progress in expanding their EBP menus have typically done so through structured planning processes that surface and surmount specific barriers with targeted solutions.
These diagnostic questions are organized around the three barrier domains and can guide conversations among leaders who want to shift strategy into high gear.
Administrative Capacity
Data systems
Is your CCWIS or legacy system configured to capture the service delivery data elements required for Title IV-E prevention claiming?
If not, what is the timeline and budget for that development, and what interim approaches can bridge the gap?
Cost allocation
Do you have a finalized cost allocation methodology for Title IV-E prevention services? What about associated administrative costs?
Has this been reviewed and approved by your ACF regional office? Where are the sticking points? If your plan is pending Children’s Bureau approval, what is the appetite for claiming against the pending cost allocation plan (CAP) recognizing that claims are retroactive to the CAP submission date?
Provider readiness
Have you assessed the billing and administrative capacity of your contracted prevention providers?
Which providers are currently equipped for Title IV-E claiming, and which need support to get there?
Payment Structure
For the EBPs you are considering adding to your plan, is a per-session or case-rate payment structure more appropriate?
Have you modeled what claiming would look like under each structure, and do you have state authority to implement it?
Medicaid coordination
For EBPs that overlap with Medicaid-covered services (mental health, SUD), have you mapped which services can be billed to Medicaid first and which are purely Title IV-E prevention costs?
Is Title IV-E functioning as the intended payer of last resort?
Program Delivery
Purveyor relationships
For the EBPs under consideration, have you engaged the model developers about implementation support requirements, cost, and timeline?
Are there state or regional intermediaries who can reduce the upfront investment in purveyor relationships?
Continuous Quality Improvement infrastructure
Do your contracted providers have CQI systems capable of tracking fidelity metrics?
If not, is there a state-level quality improvement infrastructure that can support this, or would the cost need to be built into provider contracts?
Startup costs
Have you identified a dedicated funding source for EBP launch costs that are not reimbursable under Title IV-E prevention claims, like training, materials, and initial consultation?
Could Title IV-E prevention admin, Title IV-B, TANF, or foundation funding fill this gap?
Portfolio balance
Given the 50 percent well-supported spending requirement, how does adding a new, more intensive EBP in any other category affect your overall portfolio balance?
Does it create risk of exceeding the well-supported cap before you’ve built claiming volume?
Workforce Capacity
Credential mapping
For each EBP you are considering, what are the licensure and training requirements for direct service staff and supervisors?
Do you have sufficient supply in your labor market, and where are the gaps?
Training pipeline
Is there a state training program, university partnership, or national training intermediary that can serve as an ongoing pipeline for EBP-trained staff?
What would it cost to sustain this pipeline given your turnover rates?
Supervision infrastructure
For clinically intensive EBPs like MST, FFT, or TF-CBT, do contracted providers have the supervisory infrastructure required by the model?
If not, is there a regional or statewide supervision network that could support multiple providers?
Workforce investment
Are you using the 75 percent federal match for Title IV-E training to support EBP-specific workforce development?
Have you mapped which training costs qualify for enhanced reimbursement versus which must be funded locally?
