In This Issue:
- Project Network Evaluation
- Overcoming Barriers to Immunization
- Child Maltreatment 1992: Reports from States to the National Center on Child Abuse and Neglect
- Child Support for Children in Foster Care
PROJECT NETWORK EVALUATION: RESEARCH DESIGN
Project NetWork is a Social Security Administration (SSA) demonstration project which tests alternative approaches to assisting people with disabilities in finding and maintaining employment. The demonstration, which began in June 1992 and will end in March 1995, operates in eight sites throughout the nation.
The report, Project NetWork Evaluation: Research Design, examines the issues involved in evaluating the demonstration's effectiveness, and includes analyses of demonstration participation; service delivery and receipt; case/referral management impacts; waiver impacts; and benefits-costs.
Several subsequent study reports are planned, with the final evaluation report to be issued in 1997.
The study is the nation's first rigorous large-scale evaluation of vocational rehabilitation assistance to persons with severe disabilities. The evaluation utilizes a randomized field experiment design to measure the net impact of the demonstration on participant employment, earnings, receipt of transfer benefits, social and psychological well-being and other variables of interest to policymakers. Data will be analyzed on approximately 8,000 project volunteers randomly assigned to treatment and control status, as well as an additional 200,000 project eligibles living in the demonstration areas who did not decide to volunteer for this return-to-work experiment.
All title II Social Security Disability Insurance (SSDI) beneficiaries and all blind or disabled applicants for and recipients of Supplemental Security Income (SSI) who live in the demonstration areas are eligible to volunteer for the demonstration. All volunteers will receive waivers so that their eligibility for benefits is not affected by their participation. However, one half of volunteers will receive case or referral management services, while the other half will receive waivers only. The demonstration tests four methods of delivering case/referral management strategies and waiver provisions. These methods include using SSA staff as case managers; using contractors to deliver and manage services; outstationing vocational rehabilitation counselors in SSA field offices; and using SSA staff as referral managers.
The first task of the evaluation is to describe the demonstration's operations. The report outlines how the evaluation should go about this task. It describes how site level attributes (such as the number of providers for particular services or the number of job vacancies in a site), treatment models, process attributes, and participant characteristics can be assessed at each site. This assessment should use a review of background information available in secondary documents; in-person, structured interviews with site, coordinating agency, and community agency staff; and ongoing, unstructured telephone interviews with site staff. It should also utilize the automated management information system (MIS) in each site to obtain information on the number of outside services provided to NetWork participants. This MIS was developed by SSA, and is called the Case Management Control System (CMCS).
The report also discusses how to assess the demonstration's case management activities and service delivery. The assessment should focus on individual interactions between case managers and clients. The report describes the case management process used by the demonstration. In order to understand a site's activities and service delivery, client outcomes must be examined. These outcomes will be assessed by looking at CMCS for information on services purchased for clients, by examining case folders and interviewing case managers, by conducting bi-annual site visits, and by analyzing individual employment plans (IEPs).
The next stage of the evaluation addressed in the report is the analysis of client participation in the demonstration. This component of the research design is not focused on the services delivered to clients, nor upon their outcomes. Instead, it seeks to understand why clients choose to participate in the demonstration. There are three measures of participation which might be used in the analysis: continuation rates (how many individuals proceed from one step to the next of the intake process); population comparisons (focusing on the differences in continuation rates between subgroups); and how provider and client behaviors influence participation.
The measurement of the impacts of case and referral management and waivers upon clients is crucial to the evaluation. Employment and earnings, transfer incomes, health and functional status, and other non-economic outcomes will be assessed. Equally important to client effects is the measurement of the benefits and costs of the demonstration to society. This component of the evaluation will include a benefit-cost analysis, a cost-effectiveness analysis, and a budgetary analysis. Fixed project start-up costs; ongoing administrative and supervision costs; client outreach, recruitment, and assessment costs; and the costs for each type of service provided will be measured. Costs will be examined at the site level, at the SSA Central Office level, and at the SSA local office level.
The final stage of the evaluation will consider whether the demonstration is replicable in other sites. It will involve two steps: (1) comparing Project NetWork demonstration sites to the rest of the United States to determine the degree to which the results generalize to the rest of the nation; and (2) examining the influence of local conditions on Project NetWork outcomes to determine whether location changes might undermine the replicability of the results.
The demonstration evaluation design and early results have been summarized in an article by Kalman Rupp, Stephen Bell and Leo McManus published in the Summer 1994 issue of the Social Security Bulletin, "The Design of the Project NetWork Return-to-Work Experiment for Persons with Disabilities," (Vol. 57, No.2, pp. 3-20).
This report was performed by Abt Associates, Inc. and was jointly sponsored by SSA and the Office of the Assistant Secretary for Planning and Evaluation (ASPE). The SSA project officer, Leo McManus, may be reached at (410) 965-0111; while its ASPE project officer, Kalman Rupp, may be reached at (202) 690-5489. Copies of the Executive Summary, #4946.1, are available from the Policy Information Center.
OVERCOMING BARRIERS TO IMMUNIZATION
More than ninety-five percent of children entering school are properly immunized. However, a much lower percentage of two-year olds have received the full complement of immunizations appropriate to their age. In 1993, the President's Childhood Immunization Initiative re-emphasized the importance of improving immunization rates among preschool children. It set 1996 as the target date for ninety percent of two year olds to complete the basic immunization series against the major preventable childhood illnesses.
The report, Overcoming Barriers to Immunization: A Workshop Summary, assesses important non-financial barriers to immunization of preschool age children, and discusses how to overcome them. In particular, it highlights the importance of (1) accountability for delivery of immunization services; (2) improving and protecting public health resources available for immunization; and (3) effective collaboration between public and private providers of immunization services. This report is the product of a workshop held in December, 1993. It makes no formal recommendations, but identifies opportunities for action in general policy areas.
The report reflects assumptions that all children should receive age-appropriate immunizations; the environment for vaccine delivery is rapidly changing; immunization should be part of comprehensive primary and preventive care; and underimmunization needs to be addressed regardless of the status of health care reform efforts.
The report reviews factors that contribute to underimmunization of preschool children. It highlights factors related to: (1) the health care system; (2) the provider setting; and (3) personal and cultural characteristics of families.
The health care system generally lacks adequate information about immunization needs and resources available to meet them. In some localities, such as inner cities and rural areas, there are shortages of health care providers. Families can also have difficulty using available services because of problems such as limited hours of operation, long waits for appointments, or transportation difficulties. In addition, low Medicaid reimbursement rates, which in some cases do not cover the cost of the vaccine or the cost of administering it, can limit the availability of immunization services from private providers.
Providers also contribute to low immunization rates, particularly through missed opportunities for vaccination. Providers may not have full information on a child's immunization status, or may not review or correctly assess that status. Sometimes providers do not administer all medically indicated vaccines during a single visit or hesitate to immunize a child with a mild illness, even when that illness does not constitute a valid contraindication to immunization.
Families, too, play a role in children's underimmunization. Some families may not understand the risks and severity of vaccine- preventable diseases, and may not understand the importance of completing recommended immunizations by the time their child is two years old. Other families have concerns about the safety and efficacy of specific vaccines or objections
to the concept of immunization itself. Language barriers and differing cultural norms may also prevent children from receiving full immunization.
The report suggests focusing on efforts in five areas to overcome these barriers to immunization: providing leadership for immunization efforts; establishing accountability and responsibility for providing immunizations; promoting improved provider practices; improving communication with families and communities; and developing better information and more effective information tools to support other efforts.
Stronger leadership is needed at the federal, state, and local levels and in the public and private sectors to ensure that any gaps in children's primary care do not hinder appropriate immunization. States have a unique responsibility and the constitutional authority to protect the public health by assuring the delivery of necessary health services such as immunization. In some cases, meeting that responsibility requires state or local health departments to provide these services; but in other cases, collaboration with communities and health care providers can promote delivery of the services in the private sector. The report suggests that states can benefit from strong federal support (in the form of funding and policy development) from agencies such as the Centers for Disease Control and Prevention (CDC) and the National Vaccine Program Office (NVPO).
The report points to the contribution that Immunization Action Plans (IAPs) can make to state efforts to improve immunization rates. Working with CDC, states and some major urban areas receive funding that can help them take steps to reduce barriers to immunization, enhance the system for vaccine delivery, and support immunization and education activities. The report emphasizes the need for such efforts to promote collaboration with other agencies and programs in the public sector as well as with providers and organizations in the private sector.
Changing provider practices to make services more available and to reduce the number of missed immunization opportunities during health care visits is another approach to improving immunization levels among preschool children discussed in the report. It suggests the that the Standards for Pediatric Immunization Practices, published by CDC in 1993, offers a useful guide to providers. CDC, professional organizations, and academic health centers all can contribute to efforts to inform providers about new vaccines, changes in the immunization schedule, and appropriate immunization practices.
The report also notes that more and better efforts are needed to inform families and communities about the importance of immunization and to encourage them to have their children immunized by 2 years of age rather than waiting until they start school. Families can receive valuable information from many sources: individual providers, office and clinic staff, community groups, and public health organizations at the local, state, and national levels. The report points to the need to sustain public information programs and to develop strong community support and culturally appropriate messages and materials. It also suggests that immunization efforts would benefit from greater efforts to inform the public about successes, such as the recent dramatic reduction in meningitis after the introduction of Haemophilus influenzae type b (Hib) vaccines.
Finally, the report addresses the need that federal, state, and local public health authorities, as well as providers in the private sector have for information technology and tools. These tools can help them define specific immunization problems and can improve the delivery of immunization services to children who need them. The report notes that the CDC
quarterly telephone surveys of IAP areas will gather state and community level information on immunization rates. It also points to the development of computer-based registries and tracking systems that can help health departments, individual health care providers, health maintenance organizations (HMOs) ensure that preschool children are properly immunized.
This report was prepared by the National Academy of Sciences, Institute of Medicine, and was sponsored by the Centers for Disease Control and Prevention within the Public Health Service and the Carnegie Corporation of New York. The agency contact for this report is Roger Bernier, Ph.D. He may be reached at (404) 639-8204. Copies of the Executive Summary, #5314, are available from the Policy Information Center. Copies of the report may be obtained from the Institute of Medicine. Please call (202) 334-1513.
CHILD MALTREATMENT 1992: REPORTS FROM THE STATES TO THE NATIONAL CENTER ON CHILD ABUSE AND NEGLECT
The National Child Abuse and Neglect Data System (NCANDS) is a voluntary reporting program to which states and territories, and all branches of the Armed Services report data on child maltreatment.
This report, Child Maltreatment 1992: Reports from the States to the National Center on Child Abuse and Neglect, presents data collected from reports of child maltreatment investigated during 1992.
NCANDS has two components. The Summary Data Component (SDC) compiles key aggregate indicators of state child abuse and neglect statistics, while the Detailed Case Data Component (DCDC) compiles case-level data which allows more detailed analyses.
The child protective agency in each state or territory submitted its 1992 data on Summary Data Component Forms, which consist of 15 elements. These elements request data on the number, kind, and source of reports; the disposition of investigations and the numbers of children affected by the dispositions; the types of maltreatment to which children are subjected; and the characteristics of victims and perpetrators.
The report includes two warnings about interpretation of the data provided by states. First, children who are victims of multiple incidents of abuse or neglect are counted individually in most state data; therefore, represent incidents rather than unduplicated counts of children. Second, outcomes for victims and their families are difficult to determine because there is little coordination between the various information systems maintained by courts, police, child protective services, and foster care systems.
Keeping those caveats in mind, the report presents the results of the SDC. These results show that, in 1992, there were nearly 1.9 million reports received and referred for investigation on approximately 2.9 million children who were the alleged subjects of child abuse and neglect. Professionals, such as educators, law enforcement and justice agency personnel, and social services staff accounted for nearly 52 percent of all reports. Friends, parents, and other relatives accounted for 27 percent, while victims, self-identified perpetrators, and anonymous and other reporters accounted for 21 percent.
SDC data also contain information on the disposition of the investigations. The data show that 54 percent of allegations were unsubstantiated, while 41 percent were either indicated or substantiated, and 5 percent had unknown or other dispositions. Forty-nine percent of the victims suffered from neglect; 23 percent suffered from physical abuse; 14 percent experienced sexual abuse; 5 percent were victims of emotional abuse; 3 percent suffered medical neglect; and 12 percent suffered from other kinds of abuse or neglect.
The median age of victims was 6 years: 52 percent of victims were between the ages of 4 and 7 years, while 27 percent were age 3 and under. The data show that the percentage of victims decreases as age increases. Fifty-three percent of victims were female, while 46 percent were male. The majority of victims were white (55 percent), while 26 percent were black, 10 percent were Hispanic, and almost 4 percent were of other racial or ethnic backgrounds. Seventy-nine percent of abusers were parents; 12 percent were other relatives; 5 percent were noncaretakers; and 2 percent were foster parents, facility staff, and child care staff.
Based on data from 37 states, approximately eighteen percent of substantiated or indicated victims were removed from their homes. It is estimated that 17 percent had court actions undertaken on their behalf, based on data provided by 28 states. Over 273,000 families of substantiated or indicated child victims in 28 states received additional social services during 1992, while 365,000 children (including siblings of the abused child) received these services. These numbers are underreported due to poor intra- and interagency information linkages.
Forty-four states reported that 1,068 children in total died from abuse or neglect during 1992. Of the 42 states for which 1991-1992 comparisons can be made, 19 reported increases in child abuse or neglect deaths; 20 reported decreases; and 3 reported no change.
The National Center on Child Abuse and Neglect is currently phasing in the second component of NCANDS, the Detailed Case Data Component (DCDC), which will collect case-level information from the states. The DCDC addresses three main categories: (1) characteristics of the report; (2) data on the specific child who is the subject of a report; and (3) data on the perpetrator(s) of substantiated or indicated maltreatment.
The report concludes with a consideration of future directions in reporting child abuse and neglect. It maintains that the process of building a comprehensive and accurate database is slow, and depends upon the cooperation of the reporting jurisdictions. It also discusses two other federal efforts which, in conjunction with NCANDS, will contribute greatly to the provision of services to maltreated children. These efforts are: (1) the Adoption and Foster Care Analysis and Reporting System (AFCARS), which will provide data on children removed from their homes and placed in temporary or permanent substitute care; and (2) the Statewide Automated Child Welfare Information Systems (SACWIS), which is an Administration for Children and Families (ACF) initiative to improve the delivery and management of services to children.
This report was performed by Walter R. McDonald and Associates, Inc., and its subcontractors, Bowers and Associates and the American Humane Association, and was sponsored by ACF's National Center on Child Abuse and Neglect. The agency contact for this report is Gail Collins. She may be reached at (202) 205-8087. Copies of the report are available from the National Clearinghouse on Child Abuse and Neglect Information, P.O. Box 1182, Washington, D.C. 20013, telephone number (800) FYI-3366.
CHILD SUPPORT FOR CHILDREN IN STATE FOSTER CARE
The 1984 Child Support Amendments require that parents of foster children from families who are eligible for Aid to Families with Dependent Children (AFDC) (Title IV-E foster children) must pay child support to the foster care agency. However, estimates show that more than 260,000 foster children nationwide are not from these low-income families (non-IV-E foster children), and that, in fact, they may have been removed from homes with substantially higher incomes than AFDC homes. No requirement to collect child support from these families exists.
This report, Child Support for Children in State Foster Care, describes the potential for collecting child support for foster children who are not eligible for the Title IV-E foster care program. It examines the child support measures undertaken on behalf of a random sample of 70 non-IV-E foster children from each of nine states. It also examines whether the parents of these children were in a position to contribute financially for their foster care.
The report finds that child support payments were collected on behalf of seven percent of the non-IV-E foster children sampled, which extrapolates to nine percent nationally. 52 of the 1186 biological parents of the sampled children (4 percent) paid child support.
The reasons for this low collection rate are varied. For example, foster care agencies do not routinely collect all the information needed to pursue child support orders. The difficulties caused by this lack of adequate information are compounded by the fact that only 35 percent of parents of these non-IV-E foster children are referred to child support enforcement agencies for collection. Of these, 28 percent were incorrectly classified, in that the foster care agency was not named as the custodian of the child and could not receive collections made on the child's behalf.
The parents of about 44 percent of the sampled children were well able to pay child support, earning a total of $2.4 million in 1991. Based on 17 percent of this income (the standard child support order), the parents of these children should have paid a total of $403,000 per year in child support. However, they actually paid only $19,521, which represents about 45 percent of the total child support collected during 1991 for the sampled children.
The report finds that states have the potential to increase their child support collections for children in non-IV-E foster care. They can increase collections by pursuing child support payments from both parents. Historically, most states pursue only fathers, but, for children in foster care, there is no reasons that mothers should not also provide support for their children. States can also increase child support collections through better management of the process. Failure to collect basic information on the parents of children in foster care, as well as failure to refer parents for collections and to establish child support orders reduces collections. If states improve their performance in these areas, then the national potential for child support collections is high: if child support payments had been collected in 1991 for only half of the 260,000 children in non-IV-E foster care nationally, then $193,8 million dollars would have been collected by the states.
The report recommends that the Administration for Children and Families (ACF) and other organizations interested in foster care and child support encourage states to extend child support enforcement services to all children in foster care, regardless of their Title-IV-E status.
This report was performed by the Office of Inspector General, Office of Evaluation and Inspections. A copy of the Executive Summary, # 5322 is available from the Policy Information Center.
ERRATUM
The telephone number for the National Center for Service Integration was incorrectly listed in the last issue of PIC Highlights (Volume 4, No. 3). The proper telephone number is (703) 824-7447. We apologize for an inconvenience this error may have caused.
Recently Acquired Reports
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