Topical Paper #3
U.S. Department of Health and Human
Office of the Assistant Secretary for Planning and Evaluation
|This paper was prepared by Planning and Learning Technologies, Inc. in
partnership with The Urban Institute for the Office of the Assistant Secretary
for Planning and Evaluation, U.S. Department of Health and Human Services,
under contract HHSP233200600242U. The opinions expressed in this paper are
those of the authors and do not necessarily represent positions of the U.S.
Department of Health and Human Services.
This issue paper was written by Elizabeth Lee and Cynthia Samples of Planning and Learning Technologies, Inc. Paper review and comments were provided by Crystal Collins-Camargo of the University of Kentucky; Karl Ensign of Planning and Learning Technologies, Inc. and Nancy Pindus of The Urban Institute.
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This project builds on the resources available at the Quality Improvement Center on the Privatization of Child Welfare Services (QIC PCW), funded by the Childrens Bureau. We want to acknowledge all of the state and county child welfare administrators and private providers that shared their experiences with us and the QIC PCW. Additional information on child welfare privatization issues is available through the QIC PCW website: http://www.uky.edu/SocialWork/qicpcw/.
This is the third in a series of topical papers on the privatization of child welfare services. The project was funded in 2006 by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (DHHS, ASPE). The paper series is designed to provide information to state and local child welfare administrators who are considering or implementing privatization reforms. It is also intended to highlight some of the key issues about privatization efforts that have implications for Federal child welfare programs.
For the purpose of this paper series, privatization is defined as the contracting out of the case management function with the result that contractors make the day-to-day decisions regarding the child and familys case. Typically, such decisions are subject to public agency and court review and approval, either at periodic intervals or at key points during the case. For our purpose, it is not the geographic size of the initiative that defines privatization, but the degree to which this essential case management function is transferred. Two research efforts conducted in the last five years (Westat & Chapin Hall, 2002; Collins-Camargo, Ensign & Flaherty, 2007) have identified a limited number of state and local initiatives where, for certain contracts, primary case management authority has been shifted to private providers.
This paper series emphasizes the systemic nature of privatization efforts. Decisions to expand the use of contracted case management services or even to restructure existing contracts involve choices of program, payment and administrative models; decisions about roles and authority of public and private agency workers; and contract monitoring systems. Each decision must be aligned and continuously refined, to help ensure that system goals are met. Each paper in this series focuses on a different component of privatization, but each returns to the central message that: 1) transferring primary case management to private providers involves careful consideration of a number of decisions; and 2) these decisions have an impact on a range of stakeholders in and outside of the child welfare agency.
This paper builds on information contained in the prior two papers in this series. It focuses on transitioning case management functions from public to private agencies as well as on how roles and responsibilities are shared and divided once privatization occurs. The other five papers in this series (available online as they are completed at: http://aspe.hhs.gov/hsp/07/CWPI/) focus on:
This paper series builds on research conducted under the Quality Improvement Center on the Privatization of Child Welfare Services (QIC PCW), funded in 2005 by the Childrens Bureau, Administration for Children and Families, U.S. Department of Health and Human Services. It also draws from the research on privatization in other, closely related social services. Information used for this paper series comes from several sources, including:
It is important to note that information in this and the other papers in this series is largely anecdotal. In fact, there has been very little rigorous research to confirm that one privatization model, contracting method, or management model outperforms another (McCullough, 2005; Lee, Allen and Metz, 2006). The information contained in this series of papers should serve as a starting point for a sites own research and assessment about program and design considerations and fiscal models.
The remainder of this paper is divided into four sections. The first section describes the history and complexity of defining privatization in child welfare services with a focus on the evolving roles of public and private agency workers in case management decisions. The second section describes how some states have prepared their workforce for these new roles and responsibilities. The third section provides specific examples of how jurisdictions in seven states are dividing key case management activities for their out-of-home care population including initial case assessments, roles in dependency hearings, and ongoing case decision making. The final section describes the experience of a group of states that use private agencies to deliver foster care case management and have operational SACWIS systems. It presents some of the challenges faced by public and private agencies with their new information systems and offers examples of how states have facilitated the transition.
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While a working definition of privatization has been provided for this paper series, the term is not well defined in the child welfare field. As context, child welfare services actually originated in the private sector (Embry et al., 2000). States and local governments in some parts of the country have relied on child welfare services in the private, voluntary sector since at least the early 1800s. Until well into the 20th century, mutual aid and faith-based charities provided child protection, institutional placements and foster homes. Governments gave grants or subsidies, but these programs were privately operated. It was not until the 1930s, and continuing through the 1970s, that federal social security and public social service systems, including a child welfare component, emerged (Kahn & Kamerman, 1999).
The extent to which public child welfare agencies relied on privately delivered services has always varied across the country. Rural, western states have had less reliance on private sector agencies than other regions (Rosenthal, 2000). While nearly all jurisdictions have used the private sector to provide discrete services such as counseling, home visiting, or foster home recruitment, their case management authority was limited. This changed in the 1990s when public child welfare agencies and other social service programs began to expand their reliance on the private, primarily nonprofit, sector. As opposed to earlier increases in the private sector driven by overall service expansion, in the 1990s, the shift to privatize services was the result of efforts to downsize government, improve service quality and contain costs (Rosenthal, 2000). National surveys found that during the 1990s, between 50 to 80 percent of states had increased their reliance on contracted social services to cope with new constraints on public resources (GAO, 1997a).
Also in the 1990s, two states, Kansas and Florida, chose to privatize most of their child welfare programs and a broader number of states began to outsource the case management function and introduce fiscal risks and rewards with the use of contracts that linked payment to performance. In fact, a key feature of privatization efforts today is the matter of financial risk. Under traditional cost-reimbursement or fee-for-service contracts, private providers are reimbursed for allowable service expenditures. When public agencies began to contract for case management services and establish financial incentives and disincentives for performance, an opportunity was created to stimulate innovation and improve results by sharing potential risks and rewards with contract providers. Researchers have noted that these changes in approaches to purchasing services reflect recognition of the power of financial incentives to change practice (McCullough & Schmitt, 2003; Wulczyn, 1998).
In the fall of 2005, one of the first research activities conducted by the QIC PCW was to estimate the extent to which states have privatized core child welfare services such as foster care and adoption. To do this, QIC PCW staff asked state officials about the extent to which they had transferred the case management function to private agencies, subject to periodic review and approval by the courts and public agency. What was learned first was that, like privatization, the term case management is not well-defined. To some, this is day-to-day care management, limited to service decisions and/or the coordination of services. To others, this includes primary responsibility for case planning including decisions about placement levels and visitation, with periodic oversight by the courts and public child welfare agencies.
Across the country, there is great variability in how case management decisions are handled in contracted services. In some initiatives, private agencies have assumed some or all of the core case management functions from the time of referral until the achievement of permanency or until some other specified endpoint is reached. In other initiatives, the public and private agencies share some case management responsibilities, particularly related to establishing permanency goals and managing court-related duties, but the private agencies have near total control over other decisions such as determining appropriate services and placements. Several states have created dual case management systems with overlapping public-private responsibilities in virtually all decision making areas.
While dual approaches can be costly and duplicative, many states choose this approach, at least initially, because it is required under existing labor agreements or state laws (McCullough, 2005). For instance, Philadelphias foster care system operates under a dual case management system. Case managers in both the private and public agencies share responsibility for each child. Workers in both agencies have a set of responsibilities in preparing for court hearings, and Family Court judges expect these workers to present a united position on petitions that are filed (Hollingworth and Roth, 2006).
In a recent study of the Philadelphia foster care system, researchers noted that Philadelphias dual system still struggles to clearly define roles of both public agency workers and workers employed by private providers. Further, the study authors describe several risks of using two workers to make decisions and caution that this approach may cause an agency to fall short of its permanency target. The authors explain:
Planning meetings must be scheduled and fully attended. The two social workers may have different beliefs about the appropriate placement goal for a child because of differences in philosophy, differential access to information, or both. Two workers, not just one, may make an error or oversight that causes a judge to continue the case for another six months, which is both the statutory maximum and the customary interval between formal permanency hearings. And dual case management magnifies the adverse effects of staff turnover. In one sample of cases, the average child encountered an average of four [public agency] workers and six provider workers during her first two years in placement. In that situation, it is not surprising that vital decisions or actions are sometimes delayed when one or the other social worker wastes time by simply trying to contact the wrong person in the other agency. (Hollingworth & Roth, 2006, p. 8)
In their 2002 national study of child welfare privatization reforms, Westat and Chapin Hall offer an explanation of why decision making, and shared decision making in particular, is difficult in child welfare. The researchers argue that unlike the medical model of managed care, in child welfare there is rarely a clear method for determining the most effective treatment. In child welfare, practitioners struggle over definitions of problems and needs and there is still relatively little concrete research on best practice and the correctness of decisions. In fact, there is evidence that there is considerable disagreement among experts in the field as to the correct decision in any particular case (Westat & Chapin Hall, 2002).
Rules within titles IV-B and IV-E allow States to make their own decisions about how to assign certain responsibilities to private providers. Several states or jurisdictions have transferred, or are in the process of transferring, significant if not primary case management authority to private providers. Kansas, Florida, and Illinois, for example, maintain that the federal requirements for states to have overall responsibility for cases can be fulfilled through administrative oversight, quality assurance, and monitoring. Several direct service contracts in Washington DC and New York City have moved in this direction as well. In these states or jurisdictions, a public agency caseworker does not review day-to-day case management decisions for some contracts; instead, contract monitors from the state or county monitor large numbers of cases and/or evaluate overall contractor performance.
Even under a fully privatized system, the public agency retains ultimate case authority through oversight. All states interviewed for this paper described systems where the public agency set performance standards, and then monitored performance through contract monitoring and quality assurance systems. Other responsibilities retained by the public agency include contract procurement, program funding, research and policy agenda setting. This paper focuses on how public and private agencies share case management functions. The fifth paper in this series focuses on how public and private agencies share quality assurance and quality improvement efforts. Ultimately, both papers aim to answer the same question: What has the field learned about sharing service delivery responsibility for the children and families in care?
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Prior to discussing how case management functions are shared and divided between public and private agency workers, this section presents some lessons learned from the field about how public agencies can help prepare their staff for privatization. It also describes how some states have worked with private agencies to train case managers for their new or expanded case management responsibilities. For more information about preparing to privatize child welfare services, readers are encouraged to read the first paper in this series: Assessing Site Readiness: Considerations about Transitioning to a Privatized System. [Available at: http://aspe.hhs.gov/hsp/07/CWPI/]
Discussions about privatizing a service produce high levels of anxiety among public agency workers and can lead to poor morale. McCullough (2005) advised officials from one state considering large scale privatization to:
recognize the significant impact the contract reform will have on the public agency work environment and staff. In the early stages of privatization, it is essential to overcome resistance to change within the public agency ranks. Without a clear understanding of why services are being privatized and how the effort will benefit children and families, cultural inertia (or outright hostility) among public agency staff affected by the change may destabilize the workforce and jeopardize a projects success (McCullough, 2005).
Kansas, the first state to privatize most of its child welfare services, serves as a cautionary tale about the need for careful and inclusive planning of reforms. In Kansas, several interrelated issues during privatization planning and implementation ultimately impeded the ability of the private agencies to conduct their work.
In Kansas, statewide privatization of most child welfare services (family preservation, foster care and adoption) was conceived, planned and implemented in under two years. The state-funded implementation study of privatization found that frontline workers in the public agencies had only minimal involvement in the planning and implementation roll-out. Public agency workers were deeply frustrated about the new system. Workers reported to the study team that they believed the decision to privatize reflected on how leadership valued the quality of their work (James Bell Associates, 2001). Both before and during the transition to privatized services, public agency workers questioned why case management was being transferred to private agencies that were having difficulty hiring, training and retaining qualified staff. Part of this problem stemmed from the fact that public agency workers did not transition to private agencies as expected by leadership in initial reform planning. Private agency benefit packages were less favorable and jobs remained in the public agency to conduct investigations, monitor private agency decisions and comply with activities related to an out-of-court settlement reached with the American Civil Liberties Union just prior to privatization (James Bell Associates, 2001).
Due to the resentment of the public agency workers and the legitimate concerns about the skill levels and caseloads of the new private agency workers, in many regions, interaction between public and private agency line workers was based on mistrust. During the first several years of implementation, public agency staff closely monitored and questioned case management and service decisions reached by private agency staff on a case specific basis. In turn, private agency workers complained that their decisions were often micromanaged and required excessive justification and documentation. Private agency workers argued that this interfered with the timely and efficient achievement of permanency for children in their care. The tensions and mistrust between public and private agency workers had broader ramifications as well. A recent article on Kansass experience states:
[The state child welfare agency] quickly realized that a formalized process for reconciling areas of disagreement was needed and moved to establish one, but at times, differences spilled over into the courtroom and/or discussions with foster parents. Further complicating the situation was the fact that the judges responsible for overseeing dependency case hearings expressed concern that the child welfare system changed quickly without their input and that neither public nor private agency staff seemed fully accountable for service delivery. As a result, many courts adopted checklists, specifying the completion of parent and child assessments from community mental health and substance providers regardless of whether private or public agency staff felt these relatively high-end assessments were needed (James Bell Associates, 2001). Specifically, courts increased the routine ordering of parenting and psychological evaluations and assessments and drug testing, simply to get an independent assessment from community mental health and/or substance abuse providers (Ensign and Metzenthin, (2007).
Given that privatization may cause anxiety, a first step for public agencies is to create a communications plan for both internal and external stakeholders to minimize the amount of misinformation (McCullough, 2005). It is also widely suggested that public agencies and project planners reach out to agency workers and their unions early in the process in order to better understand and address their concerns. Front line workers and supervisors have important information and insights about how best to address and improve services to families. Planners and policy makers should explore what front line staff view as challenges and barriers to meeting family needs in the current system. This is important because transferring case management to private agencies will not by itself address the systemic needs of an often overburdened and under funded system. Front line workers can help to identify both challenges and solutions for system reforms.
To support public agency staff, several states have engaged in workforce transitions that bring public employees who might be displaced into the planning process and offer them training and other benefits. A 1997 Government Accountability Office report on the experience of six state and community governments that had privatized services found that all the selected sites had provided safety nets for displaced workers. Workers were offered early retirement, severance pay, buy-outs and, in some cases, the opportunity to compete with private providers for the contract work. In some cases, workers were offered career planning and training to encourage them to move into the private sector (GAO 1997b). Some sites required contractors to give public agency staff preferential consideration in hiring practices.
It is important to note that not all privatization initiatives result in public agency staff reductions. Missouri for instance, is working to become a fully accredited child welfare system and needed to reduce its caseloads to do this. In 2005, rather than asking the legislature for additional public agency staff, the state chose to expand its use of private providers for foster care case management in three regions of the state (St. Louis, Kansas City and Springfield), while also maintaining its public agency units. A state child welfare administrator explained that everybody, both public and private agency workers, believe that accreditation is a good thing. Accreditation required that the state support lower caseloads, enabling workers to spend more time with families and provide better casework. It was broadly accepted that these changes would result in better outcomes for children and families.
After two years of implementation, each of the three Missouri regions has been able to reduce caseloads within the public agencies without loss of public agency staff. While not all states operate both public and private agency divisions that provide case management services to families within the same jurisdictions, some do, including Illinois, New York and Ohio.
Preparing Private Agency Workers
In addition to preparing public agency workers, public agencies must make decisions about the qualifications and training needs of private agency workers. Preparing private agency staff to assume case management responsibility typically requires an additional investment in frontline training. This investment is complicated by Federal Title IV-E rules related to reimbursement for training costs. While states are reimbursed for 75 percent of title IV-E foster care and adoption training costs when the training is delivered to public agency workers; similar training delivered to private agency workers is reimbursed at a lower, 50 percent rate (GAO, 2004).
States have addressed training and qualification issues in a variety of ways. Some states, including Illinois, Missouri, Kansas and Florida, require contractors to meet national accreditation standards. Michigan and Wisconsin require that private agency caseworkers participate in the state funded training and complete all of the same casework training required of public agency workers. Wisconsins Department of Health and Family Services, Division of Children and Families has contracted with the University of Wisconsin-Milwaukee Helen Bader School of Social Welfare to provide training and professional development coursework for both public and private agency staff in Milwaukee. Training involves both pre-service and in-service training as well as opportunities to gain additional credentials through the schools professional development unit. The projects website: http://www4.uwm.edu/mcwppd/aboutmcwppd/index.cfm provides extensive information on trainings that are offered.
When jurisdictions and states choose to significantly expand their use of private providers in a short time frame, there is a particular need to develop training programs that offer flexible and ongoing schedules. This allows new workers to receive training as they join the agency. Ortega and Levy (2002) described how Kansas adjusted its training program to meet the states new needs. As discussed above, Kansas privatized most of its child welfare services very rapidly; private agencies as much as tripled in size during the four month shift to privatization. Many new workers were young and inexperienced because public agency workers did not transition over to the private sector at the expected rate. In addition, for the first two years of privatization, staff turnover approached 50 percent in some agencies (Ortega & Levy, 2002).
To address the needs of young and professionally inexperienced staff, the training curriculum for the newest workers focused on basic risk assessment skills, case planning and goal setting, and developing relationships with clients. Initial training also involved enabling workers to examine their own belief systems about parenting, ethnicity and social class. It was also aimed at familiarizing them with basic child welfare policies and state statutes. Furthermore, due to the near crisis-like environment produced by increased number of cases entering the system and worker caseloads, training modules that had been delivered in 1-2 full day sessions was broken out into 3-4 hour sessions delivered over time, to permit new workers to remain in the field as much as possible. More advanced training was generally delivered in shorter segments as well, and technical assistance sessions delivered by both state and national experts was provided as new issues arose (Ortega and Levy, 2002).
Missouri has also worked to offer its providers flexible training options. In 2005, when it chose to expand the role of private agency workers in three regions, the state offered providers a choice of training opportunities. Providers could send their front line staff to state sponsored training or, to receive train-the-trainer classes from the state enabling providers to deliver the training on their own schedule and deliver it on an ongoing basis.
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As discussed above, until only about a decade ago, public agencies retained nearly all responsibility for case management decisions (McCullough, 2003). As authority for some decision making is shifted, states and jurisdictions are working to establish clear roles and responsibilities for public and private agency workers. It is widely reported that this has been one of the more complex activities in implementing these new contracts (ORC Macro, 2003; Kansas Action for Kids, 2003; Figgs & Ashlock, 2001; US DHHS, 2003, OPPAGA Report No. 05-40). States have selected various models of case decision making and as with other elements of privatization, roles and responsibilities evolve over time.
Today, all states retain the child investigation and protection functions that officials believed to be critical to meeting their legal responsibility for the safety and well-being of children in the child welfare system. Otherwise, across the country, there is great variability in the use of private providers to deliver direct services to families.
The remainder of this section presents information gathered from seven jurisdictions that have transferred much, or most, of the case management function to private providers. The discussions were unstructured, so the examples provided below were volunteered. The seven jurisdictions are: the District of Columbia; Floridas Circuit 10; Sedgwick County, Kansas; Kent County, Michigan; St. Louis, Missouri; Franklin County, Ohio; and Milwaukee, Wisconsin. In four of the seven jurisdictions (the District of Columbia, Kent County, Michigan, St. Louis County, Missouri and Franklin County, Ohio), there are parallel state operated case management units that is, foster care cases can be served by either a public agency or private agency within the same area. In the remaining sites, all cases are served by private providers.
This section provides summary information about:
States were also asked about what they had learned about establishing these roles and responsibilities. What we found was that even within these jurisdictions which have gone well down the road of privatization, sites use a range of approaches to decision making, case planning and court reporting.
Under privatized foster care models, one of the first responsibilities assigned to the private agency is the case assessment. How this function is carried out will be influenced by how the case is transferred from the public intake and investigation unit and the extent of direction given by state staff at that time. In all but one of the seven jurisdictions we contacted, there is some form of face-to-face meeting between the investigative staff and the private agency assigned to the case, to discuss the familys strengths and needs and initial case planning. The one jurisdiction where face-to-face meetings for case transfers are not mandated, Franklin County, Ohio, reported that if either the public or private agency worker involved with the case believes that there is a need for a meeting, one is called. In all other jurisdictions, respondents discussed some form of case staffing at, or near, the time of case transfer.
In Missouri for example, there is a Family Support Team meeting held within 72 hours of the child coming into care. For the three regions that use private providers for case management services, these meetings include the investigative staff, the new private agency case manager and supervisor, the childs Guardian ad Litem (GAL), the family and any informal supports the family wants to include. The meetings are held to discuss the reason for removal and the initial case plan, including placement and the visitation schedule. Similar meetings are held at 30, 60 and 90 days after placement and every six months thereafter. Public agency oversight specialists attend each six month permanency meeting to review and sign off on the case plan.
A second related area is the formalized assessment of child and family needs. The first round of Child and Family Services Reviews found that states did not perform as well as expected on the quality and depth of child and family assessments and service planning (US DHHS, 2004). In discussions with county officials, we explored which workers, those in the public or private agency, conduct the case assessment beyond the original safety assessment completed during the investigation.
Several sites explained that this was a slightly blurred function between systems. The Kent County, Michigan official explained that the assessment begins with the public agency intake worker and investigative worker but that the ongoing services team within the managed care agency was responsible for completing the full child and family assessments.
Individuals from Circuit 10 in Florida described a multi-tiered approach to case assessment and transfer activities. As background, Florida has gone farther than any other state in transferring day-to-day case management authority to the private provider community. In Florida, the state child welfare agency retains responsibility for child protective investigations, program oversight, and child welfare legal services. The private community-based lead agency receives the case during the investigation when it becomes clear that ongoing services (either voluntary or court ordered) are needed. The lead agency retains the case until the case is closed. The responsibilities of the private agency include placement and service delivery functions in addition to case management.
In Floridas Circuit 10, public agency protective investigators conduct an initial safety assessment during the investigative process and must complete a home study and risk assessment prior to placement of a child in the home of a relative or non-relative. Protective Investigators also initiate the comprehensive behavioral health assessment which is completed on every child sheltered away from a parent. The referral for a comprehensive behavioral health assessment must be completed by the protective investigator within 7 days of the shelter and the assessment is completed within 24 days of the referral. The results of the comprehensive behavioral health assessment are shared with the private provider in an effort to better address the physical, educational, environmental and mental health needs of the child and family.
Cases and case management authority are transferred to the private, lead agency at the early intervention staffing. This staffing is designed to ensure that the appropriate services for the child and family are identified and steps to ensure early engagement of the family are outlined. The Protective Investigator presents the case to the private agency and a standing committee of treatment professionals. The group reviews and assesses the service intervention needs of the child and family and provides advice about appropriate interventions and permanency options. The private agency has a Staffing Master who facilitates the meeting and takes the lead during the staffing in developing an initial service plan. This plan is used by the case manager as a precursor to the initial case plan that will be developed with the family and submitted to the Court for approval. Decisions are made during the staffing regarding the familys risk level, intensity of services, identification of absent parents and frequency of contact needed to ensure continued safety.
Because the information on the comprehensive behavioral health assessment is not available at placement, a placement assessment which gathers information on mental health and the delinquency history of the child among other things, is conducted by the Placement Unit within the private agency prior to placement of a child in a licensed setting.
In studies of the privatization process in Kansas, researchers found that one area overlooked in the initial round of privatization reform was the specification of the contractors role in determining eligibility for federal funding namely title IV-E foster care maintenance and Medicaid case management funding. Following privatization, the state noted that the information needed for this function rested with private providers. Yet private providers focused on delivering child welfare services within negotiated reimbursement rates and schedules viewed this as an additional burden that fell outside their contracts as originally negotiated (Ensign and Metzenthin, 2007).
Under federal rules, only state agencies can make the final determination of a childs eligibility under title IV-E and submit claims to the Federal Administration for Children and Families for reimbursement. Five of the seven sites interviewed described systems where public agency staff continue to carry out most of the functions for determining eligibility for Federal IV-E funds and Medicaid. While private agencies may supply the state with support information and documentation, it is the public agency that determines eligibility and prepares the paperwork for Federal claims.
In the two remaining sites, private agencies played larger roles in this process. In Milwaukee, Wisconsin, there is a separate private contractor that completes eligibility determination based on information received from the private agency case manager and then State public agency staff are responsible for final approval of submissions. In Floridas Circuit 10, the private lead agency has an eligibility determination unit that focuses on title IV-E claims. In this circuit, the state co-located two public agency staff in the private agency offices that focus on determining Medicaid eligibility. These public agency staff also review and approve information collected by the private agency staff for title IV-E claims.
The literature on child welfare privatization suggests that of all case management decisions and functions, the most commonly transferred to private providers involves selecting and coordinating client services (Westat & Chapin Hall 2002; McCullough, 2003). This was supported in our seven sites. In six of the seven sites, site officials reported that the private agency makes decisions about the appropriateness of services to be provided or purchased for clients. In two instances, county officials volunteered that private providers needed to get authorization for services not typically funded through child welfare or Medicaid payments, including specialized therapies or for specialized events such as surgery.
Kent County, Michigan was the only site of the seven where a worker in the public agency continued to have primary decision making authority for client services. The county official explained that public agency workers make the initial determination about service needs and private agency case managers carry out the plan and may offer suggestions.
Officials in six of the seven sites reported that private providers had primary case management authority to determine level of placement for clients, subject to periodic review or review of certain placements by a public agency worker and the courts. For instance, in the District of Columbia, private providers make most placement decisions but must get permission to use a residential treatment facility prior to placing the child. (In this case, the public or private agency worker must first get authorization from the citys Department of Mental Health before placing children in these facilities.)
In Sedgwick County (Wichita), Kansas, while private agency workers were recently given primary authority for placement decisions, the county official explained that during intake and investigation, when out-of-home placement becomes likely, public agency workers look for relatives with whom to place the child(ren). If relatives are identified by the time of referral to the private agency, public agency workers encourage the private providers to pursue these leads.
Site officials described more public agency or court input into decisions about visitation schedules. For instance, the Kent County, Michigan official explained that provider contracts clearly stipulate the intensity of visitation schedules and the number of required casework contacts.
In the District of Columbia, the implementation decree associated with the court settlement the agency operates under specifies that if the plan is reunification, visitation between parents and children must occur weekly and visitation between siblings must occur twice per month. If the private provider cites extenuating circumstances such as the child not wanting to visit the parent or if the parent presents a clear threat to child, then the private provider must document these issues and seek a court order changing pre-established visitation schedules.
All sites concurred that the decision to return home is made by the courts. In most cases, the private agency develops a recommendation, and in some sites, there is a case staffing with the public agency worker prior to the hearing.
Similarly, all sites discussed the fact that it is ultimately the courts decision to terminate parental rights. Kent County, Michigan described a process where the private agency worker makes suggestions, but the public agency worker makes the determination. In Floridas Circuit 10 and Milwaukee, it is the private agency worker that puts forth this recommendation to the courts with limited public agency involvement.
Both Franklin County, Ohio, and Sedgwick County, Kansas use some form of a formalized case staffing to reach agreement about the appropriateness of the termination. In Ohio, the private agency managed care agency submits a recommendation for TPR to the public agency. This is followed by a meeting that includes the public agency attorney and public agency director as well as the managed care staff to review the case, the recommendations and the criteria for TPR. If the public agency approves the decision, the case is returned to the public agency and the public agency worker pursues TPR. If the public agency denies the recommendation for TPR, the reasons are put in writing and the managed care agency continues working with family to identify needs and services, and to seek alternative placements when necessary.
In Sedgwick County, Kansas, following the private providers recommendation for TPR, there is a permanency staffing involving the private agency case manager, two co-chairs who are independent of the case (one from the public and one from the private agency), therapists, the representing attorney (from either the public agency or Assistant District Attorney) and the Guardian ad Litem. The group reviews whether reasonable efforts to return the child home have been implemented and together, decide the appropriateness of TPR. Once this is decided, the group considers options for adoption.
In all seven sites, for hearings held after the detention or protective custody hearing, a private agency case worker presents the case plan in court, with some exceptions described below. In several cases, a public agency worker also attends the hearings. For instance, in Sedgwick County, Kansas while private providers present all case plans in court, a public agency worker is also present to discuss policy and procedural issues if they arise (e.g. the adoption assistance program and other funding matters). This public agency monitor, who carries a caseload of approximately 140 families, is familiar with the case plan if other issues arise. Also, in Franklin County, Ohio, if the decision is made to terminate parental rights, it is a public agency worker that presents the case in court. In Sedgwick County, Kansas, both the private and public agency workers present the case for termination to the judge.
In Kent County, Michigan, the private agency worker presents the case in all quarterly hearings held subsequent to the initial hearing. The site official interviewed explained that this process had evolved over time because judges once expected a public agency worker to attend all hearings (as they do in other parts of the state.) However, if the judge has questions or concerns about the case, they can request that a public agency worker be present. Like Kansas, these public agency case monitors carry large caseloads and are familiar with the case. It was noted that there are instances when the private agency requests that the public agency worker attends a hearing in anticipation of questions or concerns from the bench. In these instances, the public agency workers primary role is to reassure the judge that the agencies concur on the case plan decision.
States use various arrangements to provide legal representation for the states case. Attorneys playing this role ranged from District Attorneys (WI), to agency attorneys (FL), and Assistant Attorneys General (DC). In some instances, the attorney assigned changes at different points in the case, for instance, in Sedgwick County Kansas, the states case is first represented by the Countys Assistant District Attorney at the disposition hearing, and then by the public agency attorney for all remaining hearings.
All but two of the sites consulted (Floridas Circuit 10 and St. Louis) discussed instances when the private agency also brought its own attorney. In Milwaukee, private agencies bring attorneys when there are divergent interests between the public and private agency. In Kansas, it was reported that the only time a private agency brings its own attorney is when the worker is in contempt of court, which was described as a very rare event. At these times, the only role of the private agency attorney is to provide consultation on the private agencys actions, not to present information on the case plan.
Among the initiatives consulted, only Franklin County Ohio uses private agency attorneys for child welfare proceedings on a regular basis once the case is disposed. These attorneys are responsible for representing the caseworker and filing motions. However, if the decision is to terminate parental rights, the public agency attorney is solely responsible for representing the case in court. Public and private agency legal staff meet quarterly to discuss issues as they arise on both a case-level and policy basis.
All sites were asked what they had learned about establishing roles and responsibilities in the privatization process. Three lessons emerged across the sites:
Importance of clarifying roles and responsibilities: Floridas Circuit 10 discussed the importance of having roles and responsibilities clearly established early on to avoid confusion and to ensure that needed work gets done. St. Louis echoed this and added that it is equally important to clarify roles and responsibilities within the public and private agencies to ensure that workers understand their responsibilities, their reporting structure and who to contact when issues arise.
Need for ongoing communication between systems: Kansas discussed the importance of establishing ongoing, structured means of communicating both system and case management issues. While Kansas privatized its child welfare services a decade ago, in Sedgwick County, there continue to be monthly meetings with judges, and public and private agency officials; quarterly meetings with both the public and private agencies and the District Attorneys Office, Guardian ad Litem and agency legal staff; and quarterly meetings with the areas service providers (mental health, etc.).
These meetings can be short often no longer than an hour but serve as opportunities to resolve system needs and communicate new or revised system mandates. The District of Columbia echoed this, discussing the need to clearly communicate agency mandates to the private provider community. The District realized that its providers did not fully understand the court decree under which the child welfare system was operating, nor were providers clear about all Federal mandates. The public agency has had to clearly communicate the system needs that applied equally to the public and private agencies.
Appreciate that roles and responsibilities will evolve over time and consequently, so will the training and support needs of private agencies: Kansas explained that it had recently restructured its permanency case monitoring units. These public agency staff increased their caseloads from 25-35 cases per worker to approximately 140 per worker. In the words of the county contact, until recently, the case manager had a pretty heavy hand in case management decisions, participating in discussions about the case plan goals, service, visitation and permanency decisions. After extensive work with both public and private agency administrators where all dual case management functions were identified, the decision was made to streamline the system, and core activities were gradually transitioned to the private agencies. The central role of the case monitors today is to review plans and provide guidance about key decisions or assist the private providers when specific questions arise.
Because roles and responsibilities continue to evolve, the site official from Franklin County explained that the public agency must continually assess the needs of the private providers and support their work when issues emerge. She highlighted as an example the recent implementation of SACWIS in the state and the provider needs associated with using this system.
The public agency official in Milwaukee also described the evolving need for training and other supports for private providers. She explained that when the county was first privatized, the pressing need was to prepare clear procedures and policies that had to be followed to ensure that services were delivered and families were served. Once providers were able to comply with these standards, the agency began to spend more time helping providers understand why they were carrying out these tasks and the importance of this work. She explained that in order to improve the quality of services, workers need to move beyond checking off tasks to understanding the value and meaning of their work.
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One central responsibility for case managers is data entry into computerized case management systems for the purpose of tracking cases and monitoring results. This has presented as a challenge in many places where private and public agency information systems are incompatible, necessitating dual data entry. Between 1993 and 1997, the Federal Childrens Bureau made enhanced funding available to states to support the development of comprehensive automated case management tools that would support case management practice for child welfare workers, known as SACWIS or State Automated Child Welfare Information Systems.
This section summarizes anecdotal reports resulting from an August, 2007 inquiry from the Quality Improvement Center on the Privatization of Child Welfare Services (QIC PCW) to states and jurisdictions who participate on the projects listserv. The QIC wanted to hear about states experiences using SACWIS in jurisdictions where private providers deliver foster care services. Using these messages as a source, this section summarizes:
Some states and jurisdictions, including Illinois, New York, Florida, Franklin County, Ohio, Washington, DC, and the Bureau of Milwaukee Child Welfare, have allowed or have contractually obligated private agency staff to enter case management information directly into state SACWIS systems. In New York, 50 to 60 percent of the states SACWIS system users are private agency staff who are responsible for prevention, foster care and adoption cases. In Milwaukee, private agency personnel are also required to enter case documentation into Wisconsins SACWIS. Similarly, in the District of Columbia, private case management agencies have contract stipulations regarding the use of DC SACWIS as their comprehensive web-based case management system.
Jurisdictions reported challenges related to designing systems to serve both public and private agencies as well as addressing compatibility issues between states automated systems and private agencies proprietary systems.
Designing systems to meet public and private agency needs: Several jurisdictions cited challenges when SACWIS systems were not designed to accommodate needs of private providers. New York reported issues related to designing a SACWIS compliant system that meets the needs of government agencies and diverse private providers ranging from very small agencies in rural areas to large agencies in urban areas. In another example, Franklin County, Ohio has used private contractors since 1999, but because no other county had the same type of arrangement, the SACWIS system was not set up to easily accommodate the private providers. This required several adaptations to the SACWIS to make it possible for the private providers to use the system.
Proprietary systems: Both New York and Missouri described issues where the private provider had already invested heavily into their own propriety case management systems which were not compatible with SACWIS. Agencies are having to decide if caseworkers enter information in both systems or if the private agency must abandon its own system.
States have actively tried to facilitate access through collaborative implementation activities and infrastructure enhancements.
Inclusion of private agencies in the implementation: Private agency providers in the Milwaukee were included on workgroups to obtain feedback about the system, and to discuss proposed improvements and enhancements to the system. New York State involved private agencies from the beginning implementation of SACWIS. New York held forums, and teleconferences to explain the system to public and private agency users. It also published job aids to help users learn the new system. New York also engaged agencies in a systems improvement process and agencies have identified additional system needs including the ability to access SACWIS remotely.
Infrastructure: Wisconsin purchased wireless PC tablets for both Bureau of Milwaukee Child Welfare state and private agency staff. They also provided training, technical support for their use of the technology as well as hardware and maintenance for the SACWIS. New York originally provided computers for private providers. Since that time, access to SACWIS has been expanded through the states development of technology that permits private agencies to use the state SACWIS application on their own networks. Subsequently, private agencies have assumed the maintenance for the systems and New York State has made changes to the rate structure to permit agencies to hire IT staff and be reimbursed for these costs. Additionally, all county government and private agency staff received the same SACWIS training. In New York, new functionalities to the system are typically introduced to executive and administrative staff through the use of statewide regional forums or teleconferences. Supervisory and direct service workers are provided direct training and other training aids, such as Step by Step manuals.
Private providers report that the District of Columbia invested a great deal of effort into SACWIS training, and, although the training has been time consuming, they credit it as a key aspect of the success of the SACWIS implementation. For the training, the District of Columbia created nine distinct training manuals and classes to meet the needs of various SACWIS users.
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As states and counties shift additional case management authority to private providers, there is a greater need to partner effectively within a contracting relationship. As presented in this paper, states and jurisdictions have taken several approaches to preparing for and providing case management services to clients under privatized child welfare systems. Local implementation is influenced by local context as well as state and federal regulations and, in some cases, agency labor agreements. While there is no single road map to follow, the lessons learned by these jurisdictions echo the literature in this field (Figgs and Ashlock, 2001; McCullough, 2003; Freundlich & Gerstenzang, 2003; Freundlich, 2007). Sites discussed the importance of:
Perhaps as important as anything else is the understanding and anticipation of change. Oversight needed to make privatization work initially may not be necessary several years later as public and private agencies, the courts and other partners, become familiar, and comfortable, with the new system. These processes are fluid. What is most effective at one stage of implementation will likely change at the next stage.
The next paper in this series presents examples of what the field has learned about writing effective contracts for child welfare services. It will describe key topics to include in contracts based on information from the child welfare literature and that of related fields and from public and private agency officials with experience in this area.
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Collins-Camargo, C., Ensign, K., & Flaherty, C. (In Press). The National Quality Improvement Center on the Privatization of Child Welfare Services: A program description. Manuscript Invited For Publication By Research On Social Work Practice. Currently Available Via Onlinefirst at: Http://Rsw.Sagepub.Com/Cgi/Rapidpdf/1049731507303495v1
Embry, R.A., Buddenhagen, P., & Bolles, S. (2000). Managed care and child welfare challenges to implementation. Children and Youth Services Review, 22(2), 93-116.
Ensign, K., & Metzenthin, J. (2007). Achieving desired outcomes by privatizing child welfare service delivery: Lessons learned through the Kansas experience. Professional Development: The International Journal of Continuing Social Work Education, Vol. 10, No. 2. pp. 7-15.
Figgs, J. & Ashlock, S. (2001). Family preservation/foster care/adoption: Kansas public/private partnership initiative. 2001 Better Government Competition: Honorable Mention Paper. Retrieved February 2, 2006 from http://www.pioneerinstitute.org/pdf/bgc01_kansas.pdf
Freundlich, M. & Gerstenzang, S. (2003). An assessment of the privatization of child welfare services: Challenges and successes. Washington, DC: CWLA Press.
Freundlich, M. Dollars and Sense: A guide to achieving adoptions through public-private contracting. Retrieved October 10, 2007 from http://www.adoptuskids.org/images/resourceCenter/dollarsAndSense.pdf
Hollingworth. A. & Roth, J. Philadelphia Department of Human Services & Fels Institute Child Welfare Partnership: Implementing Performance Management and Enabling Partnership in Child Welfare, Fels Government Research Service, March 29, 2006.
James Bell Associates, Inc. (2001). External evaluation of the Kansas child welfare system: July 2000-June 2001. (FY 2001 Final Report). Arlington, VA: Author.
Kahn, A. J. & Kamerman, S. B. (1999). Contracting for child and family services: A mission-sensitive guide. Baltimore: Annie E. Casey Foundation. (ERIC Document Reproduction Service No. ED450179). Retrieved August 2, 2007 fromhttp://www.eric.ed.gov/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/16/d9/51.pdf
Kansas Action for Children. (2003). A Case for Contract Reform: The Development of a Single Regional Contract for Foster Care and Adoption Services in Kansas. Topeka: Author.
Lee, E., Allen T. & Metz A. (2006). Literature review on the privatization of child welfare services. University of Kentucky & Planning and Learning Technologies, Inc. Retrieved August 2, 2007 from University of Kentucky, Quality Improvement Center on the Privatization of Child Welfare Services Web site: http://www.uky.edu/SocialWork/qicpcw/documents/QICPCWLiteratureReview.pdf
McCullough, C. (2003). Better results for kids issue paper: Financing and contracting options and considerations. Retrieved March 7, 2006 from Iowa State Department of Human Services Web site: http://www.dhs.state.ia.us/dhs2005/dhs_homepage/index.html
McCullough, C. & Schmitt, B. (2003). 2000-2001 management, finance, and contracting survey final report. Washington, DC: CWLA Press.
McCullough and Associates (2005). Child welfare privatization. Retrieved on May 10. 2006 from http://www.azdes.gov/dcyf/cmdps/cps/pdf/Final%20Report.pdf
McHugh, D. W. (2000). The implementation of managed care in child welfare: The legal perspective. Retrieved June 5, 2007 from Hunter College School of Social Work, National Resource Center for Foster Care and Permanency Planning Web site: http://www.hunter.cuny.edu/socwork/nrcfcpp/downloads/managed_care_report-all.pdf
Office of Program Policy Analysis and Government Accountability, Florida Legislature. (2004). Special Report: Child welfare legal services should be provided by DCF or private law firms. (Report No. 04-05).
ORC Macro. (2003). Connecticut Title IV-E waiver demonstration program: Final report.
Ortega, D. M., & Levy, M. M. (2002). Facing the challenge of a changing system: Training child welfare workers in a privatized environment. Journal of Health and Social Policy, 15(3/4), 177-187.
Rosenthal, M. G. (2000). Public or Private Children's Services? Privatization in Retrospect. Social Service Review, 74(2), 281-305.
U.S. Government Accountability Office. (2004). Child welfare: Improved federal oversight could assist states in overcoming key challenges. (Publication No. GAO-04-418T). Washington, DC: Government Accountability Office. Retrieved August 2, 2007 from http://www.gao.gov/new.items/d04418t.pdf
U.S. Government Accountability Office. (1997a). Social service privatization: Expansion poses challenges in ensuring accountability for program results. (Publication No. HEHS-98-6). Retrieved March 1, 2006 from http://www.gao.gov/archive/1998/he98006.pdf
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U.S. Department of Health and Human Services, Administration for Children and Families. (2003) Michigan: Managed care payment system. Retrieved June 23, 2005, from http://www.acf.hhs.gov/programs/cb/programs_fund/cwwaiver/2005/michigan.htm
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Westat & Chapin Hall Center for Children. (2002). State innovations in child welfare financing. Retrieved February 16, 2006 from http://aspe.hhs.gov/hsp/CW-financing03/report.pdf
Wulczyn, F. & Orlebeke, B. (1998). Four state study of fiscal reform. Retrieved February 22, 2006 from Chapin Hall, Center for Children at the University of Chicago Web site: http://www.chapinhall.org/article_abstract.aspx?ar=1325&L2=61&L3=129
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 This information is excerpted from a more comprehensive literature review (Lee, Allen and Metz, 2006).
 For some states, the percent of a states overall budget that is allocated to contracted services may not dramatically increase with the launch of a privatization reform. For example, performance based contract reforms in Illinois and the District of Columbia did not significantly increase the proportion of services that were outsourced. However, contract expectations, roles and responsibilities of public and private agency workers, and contract payment arrangements, did change significantly in these sites.
 Open-ended discussions were held with: Roseana Bess, Director for LaShawn Accountability, DC Child and Family Services; Marcie Biddleman, Director, Heartland for Children, Circuit 10, Florida; Karen Wahlmeier, Child and Family Services Program Administrator, Sedgwick County, Kansas; Andrew Zylstra, Director, Department of Human Services, Kent County, Michigan; Marcia Dunnegan, Childrens Services Specialist, St. Louis Region, Missouri; Tina Rutherford, Director of Performance Improvement, Franklin County Childrens Services, Ohio; and Denise Revels Robinson, Director, Bureau of Milwaukee Child Welfare, Milwaukee, Wisconsin.
 In Florida, local law enforcement offices conduct the child protective investigations in some Districts.
 Between 1993 and 1997, the Childrens Bureau reimbursed states at a 75% rate. Since that time, states can continue to receive a 50% matching rate for ongoing development and operational costs.
 The Quality Improvement Center on the Privatization of Child Welfare Services (QIC PCW) operates an open listserv for public and private agencies to communicate about issues of interest. In this case, QIC PCW posted an inquiry to listserv members asking for their input and comments about using federally funded SACWIS systems.
 All 50 states and the District of Columbia received this inquiry and those that responded included several jurisdictions that have not privatized the case management function. However, we focused our analysis of the state responses on those that had previously identified themselves as using, at least partially privatized foster care system.
 NYS email Diane Ewashko 8/14/07
 Tina Rutherford, Franklin, OH, email 8/16/07
 NYS email Jim Purcell 8/14/07
 NYS email Diane Ewashko 8/14/07; NYS email Jim Purcell, 8/14/07
 NYS email Diane Ewashko 8/14/07
 DC consortium for child welfare
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Last updated: 09/30/2008