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The Preferred Placement Initiative. The Preferred Placement Initiative, also known as the City Adoption Initiative, began in early 1995. Preferred placement was to provide incentives to agencies who finalized adoptions for children who were already freed. Those agencies that had high rates of finalized adoptions were given priority to receive new foster care placements. During HomeRebuilders, between July 1993 and December 1995, admissions were dropping and therefore agencies were vying for new cases. Consequently, many agencies invested in adoption staff and incentives to workers to increase their rates of finalizing cases. Freed children with the goal of adoption in the agencies with the HomeRebuilders model were targeted for both initiatives. One city official indicated that the Preferred Placement Initiative inappropriately provides a strong incentive for adoptions, with no consideration of reunifications. The official believed that the Administration of Children's Services (previously referred to as CWA), pressured agencies to use adoption and that HomeRebuilders agencies felt this pressure.
In the telephone follow-up interviews with agencies, a question was asked about the effect the Preferred Placement Initiative had on the agency or the HomeRebuilders model. Staff from five of the six agencies responded. Administrators from three of the five agencies said that the Preferred Placement Initiative had a positive effect on HomeRebuilders and the agency. One individual stated "adoptions were rewarded with future placements and therefore it was used as an incentive." Two other administrators concurred saying, "It was seen as a motivating factor at a time of shrinking resources and downsizing" and "it was the first time we were rewarded for efficiency." However, one administrator stated that the Initiative had little effect on her agency. She believed that the agency was "already outstanding at adoption." Finally, one administrator stated that the Initiative had a large effect on the agency but that it was completely separate from HomeRebuilders. Adoptions were given more weight than return to home. Therefore, she believed that the agency was affected but not HomeRebuilders. One comptroller believed that the Initiative put great budgetary pressure on the agency as a whole because of the high adoption completion target.
Other Initiatives. In the 1995 state legislative session, a block grant was created for child welfare and the amount of revenue available through the block grant reduced the money available for child welfare by more than one-third. In response, The New York City CWA developed a plan to institute capitated rates for all foster care cases. Unlike the HomeRebuilders demonstration, which was supposed to be cost neutral, the new capitated rates would significantly reduce payments to the agencies. In anticipation of the implementation of this plan, the City terminated the HomeRebuilders demonstration in December 1995. The comparison group cases would be covered by the new arrangements, so they would no longer provide a credible comparison for the HomeRebuilders group. The fiscal stringency and shift in funding arrangements caused considerable upheavel in CWA and the private agencies. As it turns out, the new capitation arrangement was not implemented.
Despite the early termination of the HomeRebuilders initiative, state and city officials and private agency staff were excited about it. The private agency administrators saw the program as a catalyst to think differently about case planning. Because these agencies volunteered for the program, the administrators believed that HomeRebuilders was a sound method for working with children and their families. One administrator stated that one of the biggest accomplishments of the program was that "it proved to be a successful tool in reuniting families." Another accomplishment mentioned was that in some cases the birth parents remained in contact with the foster families. Another administrator stated that good casework makes sense programmatically and fiscally. The children served needed the clinical services and the foster care. When the children are discharged, the state or city can save money if an investment is made up front. Some of the administrators spoke about the important role aftercare played in reducing the recidivism rate.
Finally, the administrators believed the HomeRebuilders model was a sound foundation for managed care. One administrator summed up by saying, "Any model of managed care must be established on primary fiscal principles which embrace issues related to working with multi-problem families in economically deprived communities." He believed that one lesson learned was the importance of working closely with the state, city, and other participating agencies. This collaborative arrangement can lead to creative management, shared resources, and training opportunities. HomeRebuilders also brought attention to the point that greater efforts must be made to engage other entities such as housing departments, courts, schools, and other social services and welfare departments to make managed care a success for families.
While administrators believed the demonstration tested some managed care principles, they cautioned against calling the project a managed care demonstration. They noted that agencies cannot be held fiscally responsible for outcomes over which they have little control. Whereas they are able to recommend a family be reunified, the city and court make the ultimate decision on placement.
Most state officials were also supportive of the demonstration. One state administrator noted that, in New York State, the child welfare system provided little in the way of aftercare services. This meant that workers had to hold off on discharges until all problems were solved. The aftercare component of HomeRebuilders made it possible for workers to stay with families and return the children to foster care if necessary. He believed that as agencies became more aware that discharge involves a risk, aftercare became more important. It helped clients maintain their gains.
Some officials indicated that one of the most important effects of HomeRebuilders was an unanticipated change in the role of the case managers from the city's Office of Case Management (OCM). Case managers played a more integral role in developing and monitoring service plans. They had lower caseloads, were allotted time to sit in on case reviews at the agencies, and were assigned to the cases served by one agency rather than cases that were served in different agencies. This involved a major realignment of cases for OCM, creating direct communication among public and private agency workers, so they were able to form good working relationships. In addition, HomeRebuilders created good checks and balances regarding early discharge, which was associated with reentry. The OCM staff had to approve discharges and HomeRebuilders held agencies accountable for reentry costs. Thus, unlike other programs, risks and benefits were carefully calibrated in HomeRebuilders.
This collaboration extended beyond the OCM office. In general, HomeRebuilders was viewed by both state and city people as a positive example of city-state collaboration. A high ranking city official said that this was one of the most collaborative ventures that the city and the state had ever had. This person said that this level of collaboration occurred because for the first time, state personnel approached the city as equal partners. Usually state officials approach city-state interactions solely in terms of the need to monitor the city's work. The private agencies also believed that for a time there was a close collaborative effort between the city and the state. It was positive for a while and there was a sense of "we are all in this together" for children and families.
All of the agency staff interviewed felt that the demonstration was cut midstream and that the city had not lived up to its commitment. The resulting low morale at several agencies was palpable. Some of the remaining caseworkers and administrators felt abandoned. Furthermore, some agencies expressed a lack of faith in promises made by the city and state. This, in part, may explain why some agencies have not kept components of the program, such as enhanced case planning, although the components were not dependent upon the fiscal aspects of the HomeRebuilders model. Although other training efforts continue at the agencies, little or no training continues on the HomeRebuilders model. Two administrators stated that the staff hired for the experimental group were greatly affected by the abrupt ending. The staff had been brought together for HomeRebuilders and then were reintegrated into the general structure of the agency. Workers in the experimental group felt disappointed and disillusioned. After making a commitment to learn and implement the HomeRebuilders philosophy, they were told the program was no longer being funded. This caused some staff to seriously question the philosophy, initial creation, and implementation of the project.
State officials unanimously stated that the program should not have been terminated early by the city. Some city officials shared this view. One city official who is no longer with ACS indicated that early termination occurred because another city official unrealistically thought that it would be possible to implement a managed care approach for the whole agency in 6 months.
Agency fiscal staff report several unresolved issues from HomeRebuilders. They include unpaid foster care reimbursement from the city and unpaid Medicaid per diem reimbursement from the DSS. Fiscal staff produced voluminous documentation required by the city to justify and reconcile payment for the three years of HomeRebuilders. All interviewed directors agreed that the payment issues continued to be burdensome for two years past the end of the program, with still some bills remaining in 1998. They all recommend that a new payment method is necessary if such a project is replicated.
The HomeRebuilders project was a major effort to change the foster care system in New York City. Based on the premise that paying for each day a child is in foster care (per diem payment) is a disincentive to return children home, the demonstration tested an alternative method of agency reimbursement. Instead of paying for each day in care, agencies were paid a flat amount of money or capitation payments. A 3-year projection of care day utilization was calculated based on each agency's historic care day usage. A strategy was agreed upon to pay agencies a percentage of the 3-year capitation each year. Funding was front loaded in the first year to encourage early discharge.
It was hypothesized that the change in the payment system would achieve earlier permanency for children through intensified discharge planning and aftercare services. Funds could be used for foster care costs and any services the agencies believed would achieve earlier permanency. Although the same fiscal methodology was designed for all six agencies, a particular program model was not mandated. Instead, the demonstration emphasized common themes, and it was incumbent upon the agencies to establish programs to achieve permanency in a more timely manner.
In this chapter we presented the service delivery changes implemented by the agencies. All agencies reported that they made a number of changes in their programs to accomplish the demonstration's objective. As a group, the agencies identified core features they believed were necessary to achieve earlier permanency for children. These include:
These core features comprise changes in decision-making and services provided. Changing the focus and approach to case planning decisions and service provision was accomplished in varying degrees across the agencies. Little Flower and St. ChristopherJennie Clarkson exhibited the most comprehensive changes in both decision-making and service provision. Triaging procedures, extensive case review, and intensive aftercare services were among the changes they systematically made. New York Foundling did not make extensive service provision modifications, but they made changes which had a direct effect on decision-making. They reported a new approach to handling adoption cases and extensive case review procedures that placed a new focus on permanency. By contrast, Harlem Dowling, Miracle Makers, and St. ChristopherOttilie said they focused on enhancing strategies and procedures that were already in place.
Triaging. While four agencies reported a method of prioritizing cases, only Little Flower and St. ChristopherJennie Clarkson implemented systematic procedures to prioritize cases and monitor their progress throughout the demonstration. Little Flower identified cases that could be returned home quickly and expended funds up front to achieve additional discharges during the first year. They then used aftercare services to maintain the savings accrued from the "early" discharge of these children. Little Flower maintained strong case planning throughout the project. St ChristopherJennie Clarkson began its planning by surveying workers about the three main problems preventing children from returning home in each case. Based on the results, specialists were hired and a family services unit was developed. The unit played an integral role in assessing family needs and working with caseworkers to make decisions about the services needed to achieve permanency. A focus on decision-making was a key aspect to both agencies' procedures.
The other agencies identified procedures for prioritizing cases. However, it was unclear whether these procedures were systematically implemented. Although New York Foundling did not identify procedures for triaging or prioritizing cases, there was an intensive case review process implemented for the experimental group. Each case was individually assessed with a strong focus on achieving permanency.
Monitoring. Two levels of monitoring were implemented, fiscal monitoring and individual case progress. Overall fiscal monitoring included matching the expected number of discharges to the actual numbers and the amount of money expended. The state helped the agencies monitor progress towards meeting their targets of reduced care days by providing reports on their care days. A joint monitoring venture between agency budget and program divisions was necessary to coordinate case decisions with financial reality. Again, agencies used these reports and implemented joint monitoring in varying degrees, and Little Flower implemented the most comprehensive monitoring. For example, they built an actuarial file of the children's length of stay from their own database. They monitored the expense and compared the number of actual discharges to the expected number and reviewed them case by case with program staff monthly. Although Miracle Makers hired a budget person to monitor the HomeRebuilders project, the extent of coordination between budget and program was not as apparent as at Little Flower. All agencies reported procedures to monitor individual case progress, but these procedures were not necessarily newly implemented for the demonstration.
Staffing Plans. Four out of six agencies recruited casework staff specifically for the experimental group. Only New York Foundling and St. ChristopherJennie Clarkson did not hire new casework staff. In the four agencies, hiring criteria were set at a higher level for the experimental group; at Harlem Dowling and Little Flower the experimental caseworkers were paid at a higher rate. All agencies hired a number of specialists to help address the problems preventing permanency for children. Little Flower and St ChristopherJennie Clarkson made the greatest investment in new staff. Both helped promote the relationship between foster parents and birth parents and visitation of birth parents by using case aides (Little Flower) and parent aides (St. ChristopherJennie Clarkson). In addition, all agencies except New York Foundling reduced caseload size for the experimental group.
Training. Training was similar across agencies. It was most prevalent the first year with the majority of caseworker training focused on casework issues rather than administrative tasks.
Flexible Funding. The agencies' ability to use funds for other than foster care costs was cited as critical to changing the focus of service delivery. The funding allowed flexibility in planning at the administrative level (staffing, investment in new resources) and also provided caseworkers flexibility in purchasing services for the family. They were able to purchase daily necessities such as groceries and clothing. In addition, money was available to use for housing security deposits and purchasing drug treatment services. There was no evident difference across agencies in the way front line staff used flexible funds. All staff expressed great enthusiasm about having the ability to purchase needed services. Staff at Harlem Dowling reported that resources developed through flexible funding have continued to be available to clients. There was a difference in the use of flexible funding across agencies at the administrative level. Little Flower's strategy was to spend money up front to achieve additional discharges during the first year. At Little Flower, there was a deficit during the first year in relation to the planned 43 percent of total budget. The other five agencies were more conservative in their approaches and underspent during the first year.
Aftercare Services. A hypothesis of HomeRebuilders was that stronger aftercare would allow earlier discharge of children from foster care. Agency staff reported that just knowing that aftercare was available allowed them to take more risks in deciding to return children home. Harlem Dowling, New York Foundling, and St. ChristopherJennie Clarkson used separate workers to provide aftercare. The other agencies used the same worker that provided in care services. Although all workers spoke about aftercare, it was evident that there was not a clear definition of what constitutes aftercare services. Frequency of service varied by agency and was usually determined by the family. Some staff confused the ability to provide aftercare services with the existing New York policy of a 3-month trial discharge.
Conclusion. Capitation payments were intended as a catalyst to change the way foster care services were provided. The intent was to accelerate decision-making to achieve earlier permanency for children. To help decision-making, a number of service delivery options were encouraged. While all of the agencies incorporated various options, Little Flower and St. ChristopherJennie Clarkson implemented change with a distinct purpose, and took advantage of the experiment to implement new decision-making procedures. They put systematic triaging strategies in place to identify cases for earlier permanency. They also made use of the demonstration to develop new resources that ensured more visitation and better relationships between foster parents and birth parents. Although New York Foundling did not incorporate major changes, it implemented two decision-making components to create early permanency. First, it changed the service delivery approach for adoption cases by beginning adoption procedures earlier and encouraging kin to adopt. Second, there was an emphasis on strong case planning in the experimental group, with management very involved in case review. The other agencies consciously decided to add resources to enhance their existing delivery systems. They did not systematically implement new decision-making processes in the experimental group. Instead, the initiatives focused on enhancing service options and reemphasizing permanency strategies. In Chapter 3 we explore whether capitated rates and agency distinctions affect the number of care days, rate of discharge, recidivism, and child and family functioning.
Agencies suggest that their success should be measured by how well they met their target goal of 10 percent reduction in care days from a baseline computed on the basis of historical experience in each agency. Based on an analysis done by the state, all sites had average care days that were lower than the baseline. However, this was true for both the experimental and comparison groups. Because both the experimental and comparison groups had declines in average care days, it is difficult to conclude that the experiment was the reason the care days declined (see Chapter 3 for further explanation).
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