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This review focuses on 23 initiatives in 22 states. Each of the initiatives involves the implementation of financial arrangements to influence the behavior of private agencies. The fiscal strategies used by the states include capitated and case rates, risk sharing, performance contracting, performance incentives, privatization, and pooled or flexible funding. Although strictly speaking not all are managed care initiatives, most have incorporated managed care strategies (such as prospective payments, utilization management, and service coordination) at least to some extent.
This section provides an overview of the initiatives that were reviewed. Table 2-1 provides a descriptive summary of the initiatives. The information is “point-in-time” as of fall 2001, and much may have changed since it was collected, especially since most of the initiatives had been implemented relatively recently (see the table) and were still evolving. The information does illustrate the range of approaches states are using to better serve children and families. The report does not attempt to describe or draw any conclusions about the effectiveness of the initiatives; a few of the initiatives are being evaluated and will have that information (or do already) but evidence is still preliminary or lacking for most.
The “scope” of an initiative refers to the proportion of children and families in a state that are covered by the initiative and is defined by both the geographic area and the populations served. An initiative may be implemented in a small, defined area or the entire state. It may serve a subgroup of the child welfare population, such as children in traditional foster care only, or the entire child welfare population.
The initiatives investigated represented a variety of approaches, from small, contained projects that either stayed small (such as Kentucky’s initiative) or eventually expanded (Illinois, Tennessee), to projects covering, nearly from the onset, most (Massachusetts) or all (Kansas) of the statewide child welfare caseload. Several of the initiatives covered most or all of the state geographically but included a smaller proportion of the child welfare caseload (Arizona, Georgia, Oklahoma).(6) In Florida, a statewide fiscal reform is being implemented district by district, so it currently covers only part of the state but will target the entire child welfare caseload when fully implemented. In Missouri, the initiative is limited both to a narrower segment of the child welfare caseload and to a smaller area of the state. County-administered states such as California, Colorado, Minnesota, and Pennsylvania had county-designed and county-implemented projects that varied considerably in terms of populations and services covered. Some initiatives were designed for urban areas with large proportions of the states’ child welfare caseloads and specific system characteristics or needs (Baltimore, Detroit, Milwaukee, New York City). Title IV-E waiver demonstrations were implemented in limited areas of the states and/or targeted narrower segments of the child welfare population due to their waiver designs and the experimental nature of the demonstrations (California, Connecticut, Maryland, Michigan, Ohio, and Washington).
| Initiative | Geographic Coverage | Objectives | Year Implemented | Structural Model | Target Population | Caseload |
|---|---|---|---|---|---|---|
| Arizona Family Builders |
Most of the state | Provide voluntary services for families previously unserved | 1998 | Lead agency | Low-risk and potential-risk families with reports | 6000 referrals/year, 1900 family assessments, 1600 families receive services |
| California Project Destiny (W) |
Alameda County | Reduce length of stay in care, divert SED placement in residential facilities, serve children in the least restrictive environment | 1997 | Lead agency | SED children; those most at risk of placement in high level group homes | 90 children enrolled at time of interview; budgeted capacity of 256 over entire waiver period |
| Colorado Boulder County Managed Care Pilot Project |
Boulder County | Gain flexibility to enhance interagency partnerships and provide services in the community | 1997 | Public agency | Adolescents 12-18 in need of or at-risk of needing residential services | 500 youth |
| Connecticut Continuum of Care (W) |
North Central and South Central regions of the state | Reduce length of time in care, develop a localized network of services, improve outcomes by establishing flexible incentive-oriented environment | 1999 | Lead agency | Children ages 7-15 with severe behavioral, mental health, or educational problems | Maximum of 70 children |
| Florida Coalition for Children and Familiesa/ |
District 8 (Sarasota) | Provide services efficiently and effectively through community partnerships | 1997 | Lead agency | All children with founded neglect or abuse reports, regardless of whether in-home or out-of-home | 1650 children |
| Georgia Metropolitan Atlanta Alliance for Children (MAAC) |
Atlanta area | Place children in the best long-term and least-restrictive settings in a system that moves children out of high levels of care quickly and efficiently | 1998 | Managed care organization | Children needing residential care who are not eligible for Project Match | 40 children |
| Illinois Performance Contracting |
Statewide | Ensure more efficient use of limited resources, improve outcomes, control costs, increase permanency | 1998 (across state) | Public agency | All children in relative, traditional, and specialized foster care | 35,000 children and their families |
| Kansas Public Private Partnerships |
Statewide | Improve client outcomes, increase permanency, better protect children at risk | 1997 (total population) | Lead agency | All children in state custody and at risk of entering custody | 3000 families |
| Kentucky Quality Care |
Jefferson County | Decrease length of stay in care, improve outcomes, improve quality of services, provide individualized care | 2000 | Lead agency | Adolescent girls in residential placement, children transitioning home, children entering care and in need of intensive services | 30 children |
| Maryland Baltimore Child Welfare Managed Care Project (W) |
Baltimore City | Reduce congregate care and enhance permanency for children ages 0-5; decrease length of stay and recidivism for children in care | 2000 | Lead agency | Children ages 0-5 in out-of-home care and siblings; newly dispositioned children of any age and siblings; kinship conversions and siblings in care | 500 children |
| Massachusetts Family-Based Services |
Statewide | Implement a collaborative, community-based approach utilizing state resources and maximizing the use of other resources | 2000 | Managed care organization/ lead agency |
Primarily, children at risk of placement and their families; some children in care | 3300 families |
| Michigan Michigan Families (W) |
St. Clair, Monroe, Livingston, Van Buren, Jackson, and Newaygo Counties | Find innovative ways to serve and improve outcomes for children without necessarily putting them in foster care | 1999 | Lead agency | Children in out-of-home care or at risk of being placed | 190 children |
| Michigan Permanency Focused Reimbursement System |
Wayne County | Keep children out of residential facilities, provide as many services as possible in the community, allow flexibility in treatment approaches | 1997 | Lead agency | Children in care | 4000 children |
| Minnesota PACT 4 Families Collaborative |
Four rural counties in western MN (Kandiyohi, Meeker, Renville, Yellow Medicine) | Ensure that children receive needed services, including mental health, and provide early intervention | 1995 | Lead agency | Children ages 0-21 and their families | NA |
| Missouri Interdepartmental Initiative for Children with Severe Needs. |
Urban eastern region and rural central region | Provide better coordination of services to reduce barriers, enhance effectiveness and efficiency, and prevent children from falling through the cracks | 1999 | Managed care organization/ administrative services organization |
Children ages 4-18 in or at risk of long-term residential placement and with serious behavioral health needs as measured by a standardized instrument | 250 children |
| New York Safe and Timely Adoptions and Reunifications (STAR) |
New York City | Enhance permanency outcomes by providing flexible dollars based on agencies’ improvement in outcomes | 2000 | Public agency | All children already in care | 40 out of 44 providers participate |
| Ohio ProtectOhio (W) |
Franklin County | Use performance bonuses and managed care to reduce length of stay in care and increase flexibility of services | 1999 | Public agency/lead agency | All children and families with reports | Performance bonuses (public agency): 5100 children; managed care (contractors): 1200 children |
| Oklahoma Oklahoma Children’s Services |
Statewide | Keep families together, bring about reunification quickly, prevent disruption of placement | 1992 (across state) | Lead agency | Children at home and at risk of placement; children in care working toward reunification | 2000 families |
| Pennsylvania Berkserve (C) |
Berks County | Develop an efficient public-private partnership model using a network of local agencies to provide services | 1997 (ceased in 2000) | Lead agency | Any family with at least one child in the child welfare system | 24 families |
| Tennessee Continuum of Care |
Statewide | Provide services in the least restrictive and lower cost settings, as well as reduce length of stay and recidivism | 1995 | Lead agency | Children in state custody who require a level of care higher than regular foster care | 4400 children |
| Texas Permanency Achieved Through Coordinated Efforts (PACE) (W)b/ (C) |
10-county area around Fort Worth | Improve outcomes, ensure efficient use of limited resources, decrease lengths of stay, provide coordinated services | 1999 (ceased in 2001) | Lead agency | Children needing a level of care higher than regular foster care | 600 children at its peak |
| Washington IV-E Waiver Demonstration (W) (C) |
Spokane County | Ensure placement in the least restrictive setting, decrease length of stay, improve permanency outcomes | 2000 (operated 6 months) | Lead agency | Children ages 8-17 likely to enter high-cost care with a DSM diagnosis and with mental health or special education needs | 30 children at its peak (50 overall) |
| Wisconsin Bureau of Milwaukee Child Welfare |
Milwaukee County | Reform the child welfare system in Milwaukee County (the State took over the county's system) | 1998 | Managed care organization | All children in the county who are identified as at-risk of abuse or neglect, and all children in out-of-home care | Ongoing Case Management (children in out-of-home care): 6000 children; Safety Services: 200 children; Wrap-around: 1000 children |
| a/ Florida was granted a title IV-E waiver for its
privatization initiative, but the waiver was never implemented. b/ PACE began under a title IV-E waiver, then it was withdrawn from the waiver in 2000. |
||||||
Missouri Changes Mindsets About Children in In the belief that many youth stay in residential treatment too long and could safely go or stay home with appropriate services, Missouri implemented a comprehensive care management initiative for children with behavioral needs and their families. The initiative integrates funding from state social services, mental health, health, and education agencies. It provides coordination of services and funding to keep children and youth from falling through the cracks. One challenge has been changing the mindset of how to serve children with severe needs. As one program administrator said, “Some just don’t believe you can move these kids out. But how much of these kids’ behavior in residential treatment is just in response to being in residential treatment?” The state hopes to change this viewpoint and use residential placement only for brief periods when a child needs to be stabilized. |
Federal court orders or state legislation requiring changes in child welfare systems often prompted initiatives targeting a large proportion of the child welfare population. A court order or legislative mandate ensured that funds were appropriated to implement the changes. The earliest of these was in Oklahoma, where an initiative was designed in response to a consent decree involving adolescents in state custody. Kansas’s initiative was implemented as a result of a lawsuit regarding timely service provision as well as pressure from the governor and legislature to privatize services. In Florida, legislation requiring districts to contract with lead agencies for child welfare services was passed in a general climate of reducing government and providing more services at the local level. The initiative in Wisconsin was the result of a court order and a legislative change in which the state, previously entirely county administered, took over child welfare in Milwaukee County. In Berks County, Pennsylvania, the growing complexity of regulations and standards, as well as anticipation of state imposition of managed care requirements, prompted child welfare service providers to develop a local managed care pilot.
In several states (Arizona, Illinois, Kansas, Maryland, and Oklahoma), the initiatives started out as limited pilot projects. All but one have become permanent and expanded beyond the original geographic area to the entire state (although not the entire child welfare caseload, except for Kansas). The exception is the managed care initiative in Baltimore (a title IV-E waiver demonstration). The state plans to carefully examine indicators of service quality to assess its success before deciding about making the project permanent.
The initiatives were motivated by a large range of factors. Some were the result of court and state mandates to change practice, improve outcomes, and/or spend less money. Others addressed large and growing permanency backlogs that persisted despite intensive efforts and in the face of ASFA requirements. Concerns about families in crisis and children who languished in foster care or overly restrictive placements for extended periods underlaid many initiatives. In response to these concerns, the initiatives were implemented to achieve two types of objectives: (1) better outcomes for children and families and (2) system goals such as service flexibility and spending the dollars more effectively—both of which often involved obtaining more or enhanced services for the same amount of money.
Improving outcomes for children and families usually entailed redirecting resources from maintaining children in care to achieving permanency outcomes--preventing placement, reunifying children with their families more quickly, shortening length of stay in placement, reducing recidivism. The initiatives in Illinois and New York City have this type of objective, and both focus on their entire foster care caseloads (excluding children in residential treatment centers and specialized foster care). These initiatives provide fiscal incentives or rewards to agencies that meet standards or show improvements in permanency outcomes for children in care. Arizona uses a different means to improve outcomes by preventing placement; its fiscal reform initiative provides services to potential- and low-risk families only. The objective of Kansas’s initiative, which involves its entire child welfare caseload, is to use performance-based contracts to enhance child safety and well-being.
Massachusetts Emphasizes Networking and Informal Supports Lead agencies in Massachusetts’ Family-Based Services Initiative develop local networks to provide a broad range of formal and informal social services for families at risk of having children placed in out-of-home care. They also coordinate with educational, housing, and cultural resources that serve families. A key factor is a flexible service budget that is able to respond to changing client needs without burdensome administrative contract amendments. The initiative also emphasizes informal family and neighborhood supports as a primary component of each family’s service plan. Their rule-of-thumb is that 75 percent of treatment should come from family, faith, and friends, and 25 percent should come from funded services. |
One type of system goal involved gaining the flexibility to implement interagency or public/private partnerships and provide a broad array of services. These initiatives emphasized collaborations and community-based approaches as well as maximizing the use of other resources and enhancing federal reimbursements. For example, the initiative in Boulder County, Colorado, is an interagency collaboration established to provide the flexibility to “serve kids as Boulder County kids, not as DSS kids or juvenile corrections kids.” The initiative in Massachusetts provides a flexible collaborative response to family needs by customizing services based on community needs and resources. Minnesota’s PACT-4 collaborative pools funds from county agencies, school districts, and private partners in four counties to provide integrated, community-based services. Missouri’s initiative integrates funding from various state child-serving agencies to support comprehensive, coordinated services for children likely to be served by multiple state agencies. Often, the objective was cost neutrality, spending the dollars more effectively and providing flexibility to enhance outcomes for children and families.
Achieving system goals such as spending dollars more effectively usually involved implementing programs to prevent high-cost placements and ensure placement in the least intensive and least restrictive setting possible and appropriate. Developing local provider networks and enhancing community services were usually components of these initiatives, which generally targeted children requiring a level of care higher than regular foster care. For example, Tennessee’s initiative focuses on children who need a level of service higher than regular foster care; it provides fiscal incentives to agencies to provide services in the least restrictive settings and thus achieve savings for the state by avoiding high-cost therapeutic placements. Alameda County, California’s Project Destiny focuses on severely emotionally disturbed (SED) children. It provides wraparound services to shorten length of stay in expensive residential treatment. Money saved by preventing or shortening high-cost placements generally was not used to reduce child welfare spending; instead, it was used to enhance services, serve more children, or improve the system's capacity in another way.
The structural models of the various initiatives varied substantially regarding how many functions were retained by the public agency versus contracted out. In all the initiatives reviewed, the initial intake and child protective services (CPS) investigations were retained by the public child welfare agency. Beyond those initial functions, however, management and service delivery structures could be categorized into lead agency models, managed care organization models, public agency models, and administrative service organization models (see McCullough and Schmitt, 1999; and U.S. General Accounting Office, 2000). Most (15) of the initiatives followed the lead agency model, with three (Colorado, Illinois, and New York) following a public agency model and two (Georgia and Wisconsin) using a managed care organization model. Massachusetts utilized a mixed (managed care organization and lead agency) model, as did Missouri (managed care organization and administrative services organization) and Ohio (lead agency and public agency).
Flexibility for Kentucky’s Lead Agency The Quality Care Initiative (QCI) in Kentucky has endeavored to give the lead agency greater flexibility in serving children. QCI covers one county and serves three populations: adolescent girls in need of out-of-home care, children transitioning from out-of-home placement back into their homes, and children just entering the child welfare system. What is distinctive about QCI is that the lead agency has more responsibility for serving these children and more flexibility in how it serves them. But the state has not dropped out of the process altogether; it remains a partner in thinking through major difficulties. These discussions have the tone of constructive problem-solving rather than the state issuing directives. If this pilot can demonstrate that it results in improved outcomes for these populations of troubled children while keeping costs down, it is expected to gradually expand over the next few years. |
Lead Agency Model
In the lead agency model, the public child welfare agency contracts with a private nonprofit or for-profit agency to serve as a lead agency for a county, service area, or region. The lead agency then coordinates and provides all necessary services (either directly or by subcontracting with providers) and sometimes conducts utilization management and quality assurance. The goals in having a lead agency are to enable or encourage provider networks and provide accountability at the local level. In some cases, the lead agency assumed considerable financial risk (discussed later).
Every service district in Florida, for example, is required to contract with a lead agency (or, in the Miami area, more than one lead agency) that will take over all child welfare responsibilities beyond initial intake and investigative functions. In Kansas, the state child welfare agency maintained responsibility for administrative services (such as utilization management, monitoring services, and tracking performance and outcomes) and contracted with nonprofit lead agencies to coordinate and provide all child and family services. Maryland’s managed care initiative in Baltimore involves a vendor (a partnership of a nonprofit and a for-profit agency) that is responsible for all administrative functions, case management, and service delivery for children referred into the project.
Public Agency Model
Illinois and New York City followed a public agency model, which maintains the traditional management and service-delivery structure while incorporating managed care practices in its own practices or contracts with service providers. Both initiatives involve public agencies that maintain their previous management and service-delivery structure while incorporating financial incentives into their contracts with foster care agencies. In both cases, the public agencies closely monitor the agencies' performance and outcomes, and financial incentives are based on analysis of data on permanency outcomes. In Colorado’s Boulder County initiative (as well as in other managed care counties in Colorado), the public agency has joined with other public child-serving agencies to use managed care principles in case management and service delivery. Oklahoma also follows a public agency model in its capitated contracts with providers.
Managed Care Organization Model
The managed care organization model involves the public agency’s contracting with a private organization that incorporates managed care principles into its subcontracts with service providers. Generally the private organization does not itself provide direct services. For example, every service area in Massachusetts is covered by a community-based child welfare agency that receives a set amount of money each year to provide functions such as gatekeeping, utilization review, creating and maintaining provider networks, monitoring quality of services, and accessing third-party reimbursement. The lead agencies generally subcontract for services, although they are allowed to provide up to 20 percent of the services delivered. In Missouri’s model, a private for-profit organization, which was created for the purpose, manages a network of providers and monitors quality and utilization of services.
Mixed Model
At times more than one model was incorporated into the initiatives. For example, Missouri utilized both a managed care organization model and an administrative services organization model (in which a private contractor provides administrative services only). The state contracted with two agencies, one to manage the delivery of services and the other to provide operational support for its initiative, which targets children with severe behavioral health needs. Massachusetts also contracts with lead agencies to develop and operate provider networks (managed care organization model) and a separate vendor to develop and support a database for utilization management (administrative services organization model).
Prior research has found that most managed care initiatives targeted children in foster care, although there was a trend toward also including children at risk of placement (McCullough and Schmitt, 1999 and 2001). In the initiatives described in this report, the target populations range from a narrow population of children in care to the entire child welfare population. Many of the initiatives target children and families with high needs. The rationale for targeting a population with severe behavioral or mental health problems or special education needs is that often the outcomes are poor, which creates a need to find different ways to address the problems, and the costs are high, which creates a visible target and builds in incentives for reducing costs. These target populations include seriously emotionally disturbed children (California, Georgia); those with serious behavioral health needs as measured by a standardized instrument (Missouri, Texas, and Washington); those with placement needs higher than traditional foster care (Connecticut, Tennessee); and adolescents with high needs (Colorado, Kentucky). Generally these initiatives encourage service provision in the least restrictive and costly setting appropriate and often provide mechanisms for conducting enhanced assessments to better plan services.
Initiatives that target all or most of the foster care caseload hope to achieve widescale improvements in permanency outcomes. For example, the initiatives in Illinois and New York City were designed to encourage providers to achieve efficiencies and improve permanency outcomes for children in care, and both cover most of their foster care populations. Maryland’s managed care initiative in Baltimore was implemented to reduce placement length-of-stays for young children in care, and the target population is all children ages 0-5 in care and their siblings (and some other types of children). These initiatives attempt to address the economic incentives to keep children in care, discussed in Section 1, by offering economic incentives to shorten lengths of stay (with safeguards intended to ensure appropriate placements).
Some initiatives target children not in care but at risk of placement, both to avoid the costs of placement and to provide alternatives to removing children from their homes. The initiatives in Massachusetts and Oklahoma primarily serve children in their own homes who are at risk of placement, with some services provided to children in care (in Massachusetts, the initiative serves over 75 percent of all children in the child welfare system). Arizona’s initiative targets low-risk or potential-risk families in order to prevent escalation of maltreatment into a higher risk category that would require taking children into custody.
Other initiatives target the entire child welfare population, for all the reasons noted above. Florida’s and Kansas’s statewide privatization requirements include all children in the child welfare system. Ohio’s and Wisconsin’s initiatives also target all children in the child welfare system in their geographic areas (Franklin County, Ohio, and Milwaukee County, Wisconsin); Ohio has other managed care initiatives in several other counties (both as part of the title IV-E waiver and outside the waiver).
In most of the states, a caseworker or other child welfare worker refers children or families into the initiative by using guidelines or protocols (as in Arizona, Massachusetts, Oklahoma, Pennsylvania, Tennessee, and Wisconsin). The most complex guidelines were used by the managed care initiative in Berks County, Pennsylvania, which developed a detailed protocol for county intake workers to follow. After going through selection/admission criteria step by step, if the protocol indicated that a case was appropriate for the managed care initiative, the case was referred. Additional decision trees to be followed by service providers accompanied the case. The complexity of the protocol was one factor in the demise of the initiative, as both county workers and providers found the process daunting.
A few initiatives use other referral procedures. For example, initiatives incorporating title IV-E waivers (those in California, Connecticut, Maryland, Michigan, Ohio, and Washington) involve referral through random assignment after workers applied screening criteria, which is a component of the required evaluation design of these demonstrations. Other initiatives have automatic referrals if a report was founded (Florida) or if a case meets criteria (Missouri and Texas).
Sometimes cases are screened or even referred by an interagency team. Often the initiatives involve interagency teams developing treatment plans and, in effect, pre-authorizing services. Thus one of the major features of the fiscal reforms involves implementing a team approach to referring cases, identifying family need, and specifying services, taking that responsibility away from the individual caseworker. For example, the managed care initiative in Boulder County, Colorado, institutionalized the interagency approach by developing a new organizational entity comprising representatives of all local child- and youth-serving agencies (corrections, probation, mental health, social services, public health, substance abuse services, and other community agencies); each agency contributes funding that is pooled. The new entity handles case management and contracts with private providers for services. This approach takes a child or family out of a specific system, provides for collaborative decisionmaking, reduces cost-shifting, allows flexibility in services, helps to identify and address gaps in services, and eliminates duplication of services. A challenge is that cooperation and service integration require the development of trust and clear role definition. Although some caseworkers oppose the shifting of responsibility to a team, an advantage is that it gets more agencies invested in the care of the children and aware of the issues that need to be addressed.
Most of the initiatives have a "no reject, no eject" requirement whereby contractors cannot refuse any referral from the public agency or disenroll any child until all objectives are met. Kentucky’s initiative has a provision that allows contractors to protest a referral and a third party to decide whether the case is appropriate for the initiative. Michigan's experience with a title IV-E waiver initiative highlights the effect that risk aversion can have when contractors can choose whom they serve. In that initiative, community contractors are allowed to develop their own screening criteria, which has the effect of only relatively "easy" children being accepted for services. Since the capitated rate is based on historical averages of payments for all children (including children in specialized treatment foster care and residential placement), the contractors are able to minimize their risk and accumulate money in their "risk pool."
Tennessee’s Continuum of Care Prompts New Processes Youth Villages, Tennessee’s largest Continuum of Care provider, no longer uses a “cookie cutter” approach to treating troubled youth. In its second year as a Continuum provider, Youth Villages made a number of substantial changes in the way it serves children. The new referral and admission process allows children to receive services more quickly, and treatment plans change frequently to meet children’s individual needs. A transitional living program has been added to the provider’s array of services to prepare young men for independent living. For younger teenagers, services have been developed to help them successfully prepare for a transition from residential treatment to therapeutic foster care. Youth Villages’ school staff has designed a transition classroom to better prepare children to succeed in school. Treatment plans are now reviewed every 2 weeks instead of monthly to allow greater focus on individualized 2 goals in hopes that better collaboration on goals will ultimately help reunify children with their families. |
One of the promises of managed care is that it can promote efficiencies of time and money by providing more accurate assessments of client problems and the appropriate services for them through more rigorous assessment protocols. This assumes that there are a significant number of cases where the child is receiving services that are more intensive than necessary to reach desired outcomes and that it is possible to determine who these children are. These assumptions are supported by the extensive research on outcomes since the passage of the Adoption Assistance and Child Welfare Act (P.L. 96-272) in 1980, by the growing experience that social workers have in managing permanency outcomes, and by the ongoing refinement of assessment tools.
As with all aspects of managed care reforms, there is a wide variation in assessment protocols and their use in the initiatives. Numerous states require that contractors accept the state’s predetermined level of care for individual clients. Some states use independent third-party contractors to conduct a binding assessment. Most of the states allow a contractor to complete a postreferral assessment as the basis for determining a treatment plan. In some states where the target population is children with high-end needs, level-of-care assessments are often used as a screening mechanism to ensure the least restrictive setting for children. The rationale for this is that such children represent a small part of the total population but a significant part of expenditures.
Independent Assessments
Assessments can be performed by the state agency, the contractor, or an independent third party. Some of the most innovative approaches involve the use of independent third-party assessments. In Texas, the contractor performs a battery of assessments and then turns the material over to an independent third party who determines the level of care, which is absolutely binding on the contractor. Because these two agencies had extensive previous interactions, they are able to achieve agreement about the level of care for approximately 95 percent of the cases. There are real financial stakes for the contractor in correctly assessing the level of care because the flat-rate case payment is based on a historical average of the level of care needed for the target population. This average is about 3.6 on a scale of 1 to 6 where 1 is regular foster care and 6 is an intensive residential care facility. In the first year of the program, the average level of care was approximately 3.2. The second year, however, the average level of care was about 3.8-3.9, which exacerbated other financial strains facing the contractor.
In Kentucky, as well, an independent agency assesses level of care. The primary function of this agency is to adjudicate conflicts between the state and the contractor about the appropriateness of a referral. If the contractor disagrees about the appropriateness of the referral, it reviews the case with the state. If this review does not resolve the disagreement, the contractor can bring the case to the independent review agency, which examines the records and makes its own determination. As of the beginning of the second year of operation, this independent review had been used four times, with each party winning twice. Although the contractor is allowed to reject a limited number of cases over the course of a year, the contractor has continued to offer services to the children even when the level-of-care review supports their argument that the referral is inappropriate.
State Assessments
Some states perform assessments themselves. Upon referral in Connecticut, for example, a child is assessed for functionality, ability, behavior in the community, behavior in the family, and behavior in school and assigned a score which corresponds to a case rate. Children then are randomly assigned to either the experimental group (the initiative) or the control group (traditional public agency services). The state does not determine services; instead, the contractors develop treatment plans.
Contractor Assessments
Many states (such as Maryland and Tennessee) allow the contractors to conduct their own client assessments so that they can develop their own service plans. In Maryland, the contractor takes the service plan originally developed by Baltimore caseworkers and other case records, meets with the family, and then uses the Structured Decision Making assessment tool to see if the original service plan needs to be revised. In Tennessee, contractor caseworkers have 15 days to conduct a thorough assessment. They use a triage system to place the child initially while they perform the assessment. Their assessments include a social history; an Early and Periodic Screening, Diagnostic and Treatment screen; a community risk assessment to assess the risk the child poses to the community; and family strength and weakness screens. This assessment then feeds into the continuum of services the contractor offers. As a result of this system, Tennessee has been able to greatly reduce its use of emergency shelters.
There are degrees of integration of assessment and case planning. Some states (such as Connecticut) keep assessments separate from the development of a treatment plan. Connecticut initially assesses a child using a set of four-point scales that determine the child’s functioning. The assessment is then given to the contractor, which has the responsibility to develop a treatment plan for how it will broker the services. The reason for giving the contractor this responsibility is that the state does not want the assessment to limit the flexibility that the contractor has. However, many states seem to integrate assessment and case planning tightly. In Oklahoma, for example, all long-term cases requiring prevention, reunification, and placement maintenance services are referred to a contractor, which then conducts a battery of assessments and develops an intervention plan.
Traditional fee-for-service arrangements with contractors required that states purchase a specific bundle of services; any services not explicitly mentioned in the contract required the state’s permission before the contractor could provide them. Such arrangements reproduce traditional power arrangements between the state and agencies and have tended to restrict the flexibility of contractors in serving their clients. Many of the managed care initiatives undertaken over the past decade have sought to ease these limitations and to empower contractors to take more responsibility for their cases. Re-thinking pre-authorization procedures has been a feature of many?though not all?of the managed care initiatives.
Understanding this aspect of service provision sheds light on the autonomy of the contractor and how important decisions about a case are made. It is striking that none of the programs surveyed used the traditional model of having a formal process in which private caseworkers had to consult with state child welfare supervisors before initiating a new service for the client. Pre-authorization for some services remained necessary in at least three states (California, Connecticut, and Oklahoma). However, all of these services involve medical and mental health services that are paid by Medicaid. The pre-authorization is needed to meet federal Medicaid requirements, not because any of these states’ child welfare agencies mandated this process.
Based on the information collected from 22 states, there appears to be a continuum of collaboration. One pole of this continuum is represented by those states that only monitor outcomes, the other end by states that meet regularly with contractors to consult on case decisions and service provision. Table 2-2 below places each state along this continuum (referring to child welfare services only). No information is available on how child and family outcomes differ depending on the degree of collaboration.
| Only Monitor Outcomes | Some court or administrative involvement | Monthly or quarterly reviews | Frequent or continuous collaboration | |
|---|---|---|---|---|
| Florida Illinois Kansas Michigan Missouri |
New York Ohio Oklahoma Wisconsin |
Connecticut Georgia Kentucky Texas |
Arizona California Maryland Massachusetts |
Colorado Minnesota Pennsylvania Tennessee Washington |
The category “Only monitor outcomes” includes projects that privatized previously public services (Florida and Kansas) and implemented performance contracting (Illinois and Ohio). In most of these initiatives, no caseworkers from public agencies are assigned to a specific child; instead, contract monitors from the state or county evaluate overall contractor performance. In other initiatives, caseworkers from the state agency are assigned to monitor specific cases and are available for court appearances. For legal reasons, several states must provide caseworkers for court appearances even if their involvement in actually providing services is minimal (California, Michigan, Tennessee, and Texas). The category “monthly or quarterly reviews” refers not to administrative case reviews or other mandated procedures but to regular processes where various service providers (both public and private) meet to formulate case services. Finally, some states have devised projects in which there is constant collaboration between public and private agencies and often with the family as well. One example of this is Colorado’s Boulder County Managed Care Pilot Project. It has two interagency utilization review meetings a week, during which staff from state, county, and private agencies discuss cases and the appropriate services and outcomes for the clients.
It appears that in many cases the monitoring mechanisms of the state or county agencies have become embedded in the service provision process through these collaborative review processes. Minnesota’s collaboratives, for example, bring together various state and county agencies and private providers to pool funds and do assessment, coordination, planning, and purchasing of services. In Pennsylvania’s initiative, the extensive collaboration was a byproduct of the difficulty of the referral and assessment protocols, rather than an intentional feature of the pilot. The process never reached the point of cases making a smooth transition from county to contractor responsibility.
In keeping with the broader reorganization of the relationship between the state agencies and the contractors that is occurring in many of these initiatives, the process of monitoring contractor performance is being revised to accommodate greater flexibility.
Performance and Outcome Measures
Perhaps the most important change is in what gets monitored. In many traditional child welfare programs, monitoring mechanisms focused on process issues, i.e., were certain tasks performed (evaluations, number of visits and therapy sessions, etc.)? The new initiatives are part of a broader trend in child welfare that seeks to follow client outcomes instead of process. Performance contracting is the most direct example of this, but outcome measurement is integrated into almost every initiative. However, despite this shift in emphasis toward outcome measurement, no state has thus far completely abandoned process measures because of the continuing state responsibility to ensure quality services.
Information Flow Helps Accountability in Kansas In 1997, Kansas initiated its comprehensive privatization program that divided the state into four regions and established private agencies as the main provider of services for each region. These agencies had the freedom to provide services as they saw fit, and they received case rate payments. One agency used the flexibility to revamp its management information system and to devise extensive post-permanency services. The management information system compiles data on a daily, weekly, and monthly basis. Each division of the agency has clearly defined goals and there is a monthly meeting to see if each unit’s goal for the month is achieved. If not, there is a brainstorming session to determine what needs to be changed so that the goals are reached. With this increased flow of information, there is now more accountability within the agency. The emphasis on post-reunification services has kept the rate of disrupted adoptions at around 2 percent, much lower than average. There is a strong financial incentive for the agency to keep the disruption rates low because the agency is responsible for servicing the case without receiving further state funds if the child re-enters the child welfare system within 2 years. |
Specific outcome measures used by the states vary according to the target population served by the initiative. Initiatives that work with the general child welfare population have outcome measures such as the numbers of adoptions, children returned home without re-entering the system, and at-risk children safely maintained in their own homes. Programs that work with children with high-end needs have outcome measures that focus on placing the child in the least restrictive setting (including returning the child home).
Both state administrators and contractors indicated that this shift toward outcome measurement has been a positive step but that the process has been uneven. Some administrators noted that this has caused temporary difficulties for state personnel. As one administrator observed:
It’s been hard to get the monitoring staff around the state to look at things differently than how they’re used to. They’re used to just checking off on a list whether or not a provider did a service. Now they have to look at the providers’ work; did they do a good job? And they may need to interview kids, caseworkers, and parents. It’s a different mindset.
In addition to the changes in the mindset of workers, there has been a real revision in the responsibilities of state agency caseworkers. Another administrator noted that it is difficult for some caseworkers to relinquish the actual case decisionmaking authority in favor of a strictly monitoring relationship.
Monitoring Mechanisms
Many state administrators seem to expect that the reduced role in case decisionmaking will allow state agencies to focus more of their energies on ensuring child well-being through more rigorous monitoring processes. Many of the states retain traditional modes of accountability, including monthly reports to contract monitors or quarterly case review meetings. Some contractor supervisors have noted that the monitoring mechanisms impose another level of bureaucratic paperwork on their workers. In one state, a contractor complained that the state monitors focused on items like staffing patterns and turning case plans in on time instead of whether the child was safe.
In spite of these enduring processes and the complaints that go with them, new monitoring mechanisms have been devised by some of the states, although little is conclusively known about the effectiveness of the various monitoring systems. The two most prominent features of these systems are collaborative reviews and the integration of management information systems. As noted earlier in regard to the pre-authorization process, collaboration between state and contractor has become quite common in both case decisionmaking and performance monitoring. In Massachusetts, for example, there are several sets of meetings to discuss case issues. There is a weekly meeting between core team members to discuss current case issues. Then every 6 weeks, all of the relevant staff and the family review case plans and goals. The contractor is responsible for monitoring the specific aspects of the case such as level of involvement and the use of community resources.
Privatization in Baltimore Privatization of child welfare is viewed as a threat by many public child welfare workers, who fear their jobs will be abolished or at least extensively changed. In Baltimore, 500 cases were privatized through the Baltimore Child Welfare Managed Care Project, and no public agency layoffs were needed. Instead, vacant positions were eliminated, turnover was not replaced, and some staff were reassigned to areas more suited to their skills and areas of expertise. There actually may be more need for caseworkers under privatization, if caseworker/client ratios improve – for example, the caseworker/client ratio in Baltimore’s public agency is 1/20 while the contractor maintains a ratio of 1/16. However, this may not reassure caseworkers who are unwilling or unable to leave public employment for private. |
Another variation on collaborative monitoring was established in Maryland, which has two committees to review program progress. The Managed Care Committee looks at global program issues and includes staff from Baltimore City’s child welfare staff, state child welfare workers, lawyers from the state attorney general’s office and Baltimore City, as well as the evaluators. The Partners Committee meets regularly to review case plans and other details of service provision. This committee consists of city and state child welfare workers plus staff from the lead agency.
Some states have contract monitors that work with the contractors on an ongoing basis. For example, in Wisconsin there are two types of program evaluation monitors--one examines service provision, and the other looks at the fiscal component of the program. There is a formal quarterly review for each aspect of the program where they discuss program quality, patterns of expenditures, and permanency plans.
Another feature of some of these programs, as in Arizona, New York, and Ohio, is the greater importance given to management information systems for case decisionmaking and contractor monitoring and accountability. Our information is tentative, but some administrators indicated a frustration that current information systems did not put useful information in the hands of the workers. Sometimes the system is difficult to access, other times the data are not broken down in such a way as to guide decisionmaking in immediate case situations. New York’s initiative probably has the most highly developed data system; it incorporates a unique interactive system that allows the public agency to tie agency reimbursement to the outcomes for children.
All title IV-E waiver projects are required to have independent, third-party evaluations that examine both cost and quality concerns. Some of the programs did not have waivers and did not have such evaluations underway. Most of the programs had secured contracts, usually with local schools of social work, but had not yet produced reports. Several of the states were just beginning to implement their programs and had not made arrangements for evaluations. Four states where evaluation reports are available include Arizona (Arizona Office of the Auditor General, 2000), Colorado (Mercer, 2000), Florida (Paulson et al., 2002), and Kansas (James Bell Associates, 1999).
The next section describes in some detail the various financial arrangements that states adopted to achieve their objectives, including the specific managed care strategies used, administrators’ impressions of the effects on child welfare systems, and contractors’ reports of their resulting financial status.
(6) In states where less than the entire child welfare caseload is targeted by the fiscal reform, initiatives often target particular types of cases based on expected services or service intensity needed, such as intact at-risk families or seriously emotionally disturbed (SED) children in care. These differences in types of target populations are further discussed later in this report.
(7) This section describes the assessment process used by initiatives in initial referrals and placements. Ongoing assessment of children and families is a critical part of delivering services but is not described here because it was not a focus of the review.
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