In This Issue:
- Work First: How to Implement an Employment-Focused Approach to Welfare Reform
- Suicide Intervention and Prevention: Evaluation of Community-Based Programs in Three American Indian Communities
- Improving Health in the Community: A Role for Performance Monitoring
- Privacy and Health Research: A Report to the U.S. Secretary of Health and Human Services
- National Survey of Current Former Foster Parents
- Assessing the Viability of All-Payer Systems for Inpatient Hospital Services
- Responsible Fathering: An Overview and Conceptual Framework
- Measuring Expenditures for Essential Public Health Services
WORK FIRST: HOW TO IMPLEMENT AN EMPLOYMENT-FOCUSED APPROACH TO WELFARE REFORM
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 replaced the entitlement to Aid to Families with Dependent Children (AFDC) with a block grant that covers both cash assistance and work activities. Temporary Assistance for Needy Families (TANF) block grants give states new flexibility to design innovative welfare-to-work programs, but many of the Act's provisions (including capped funding, time limits on program eligibility, and demanding work requirements) place pressure on states and localities to operate large-scale programs that effectively help welfare recipients find and keep jobs.
This guide, Work First: How to Implement an Employment-Focused Approach to Welfare Reform, seeks to assist states and localities in designing and implementing the popular "work-first" strategy already in use in some states. These programs attempt to move participants into unsubsidized employment as quickly as possible through job search and short-term education, training, or work experience activities. The philosophy behind these programs is that the best way to succeed in the labor market is to work in a real job so that the necessary work habits and skills may be acquired on the job rather than in a classroom. Individuals who are unable to gain employment after an initial job search participate in additional activities to increase employability. These activities, including education, training, and work experience, are usually short-term and closely monitored, and are either combined with or closely followed by additional job search.
The Guide summarizes the knowledge about work first programs and does not prescribe any single program model. Instead, the Guide presents the central elements of a successful Work First program and provides information on how to choose among the many options. The Guide is organized into several sections that offer advice on how to implement and manage a work first program: planning, administration, activities, and case management. Another section discusses financial incentives and time limits.
The first section addresses how to plan the transformation of a program to a work first model. It discusses certain key features of work first programs, such as enforcing mandatory participation, shifting to a quick employment focus, emphasizing the idea that everyone is capable of finding work and allowing the labor market itself decide who is employable and who needs extra help, and focusing on outcomes rather than on processes. This section also discusses common work first activities as participants move through the program. These activities include: (1) the applicant job search; (2) orientation; (3) initial assessment; (4) job club activities; (5) in-depth assessment; and (6) additional job search, education, vocational training, and work experience or subsidized work. At any of these levels, participants are encouraged to become employed, and to leave the welfare rolls. In this first section, the Guide also discusses the necessary support services that will enable participants to acquire and keep jobs. These services include child care, transportation, and other support services (such as the provision of work clothes, tools or other equipment, and books). The section also addresses the question of which participants should be required to participate, exemptions and deferrals, hours of participation, mandates and sanctions, and the like. Finally, the section discusses how to analyze and understand the labor market and the caseload, how to build support for the program, and how to evaluate the program's performance.
The next section of the Guide gives specific advice on how to administer a work first program. Specific suggestions are given on such subjects as hiring and training staff, setting caseload sizes and allowing caseload specialization, the role of the eligibility office, co-location of services, how to promote a focus on employment, management information systems, interagency linkages, program costs, and strategies to reduce these costs. The Guide continues with a discussion of how work first programs can structure activities such as applicant job search, orientation, assessment, job club, job development, the role of education and training, and work experience. The Guide also discusses how to maximize the effect of case management for participants. Finally, the Guide offers an account of the effect that other kinds of policies may have on work-first programs. These other policies include transitional benefits, financial incentives, the Earned Income Credit, and time limits.
The Guide concludes that the most successful work programs share a mixed strategy. Successful programs maintain a consistent emphasis on employment throughout the range of activities they offer, in terms of job search activities, education and training activities, as well as other services. The Guide also notes that programs must employ adequate resources so that mandatory participation levels are met and participation requirements may be enforced.
The Guide was sponsored by the Administration for Children and Families and the Office of the Assistant Secretary for Planning and Evaluation and was prepared by Manpower Demonstration Research Corporation. The Guide's project officer was Audrey Mirsky-Ashby. Copies of the Guide may be requested from Ethel Norris at 202-690-6809. The full text of the Guide is available on the Internet at: http://aspe.hhs.gov/hsp/isp/work1st/frontm.htm.
SUICIDE INTERVENTION AND PREVENTION: EVALUATION OF COMMUNITY-BASED PROGRAMS IN THREE AMERICAN INDIAN COMMUNITIES
Suicide is the second leading cause of death for Native Americans between the ages of 15 and 24. American Indian/Alaska Native (AI/AN) young people are more likely to attempt suicide; they are also more likely to choose highly lethal means in their attempts (e.g., firearms or hanging), and they are more likely to be successful at committing suicide. Furthermore, although the correlation varies from tribe to tribe, suicidal behaviors and alcohol or substance abuse are usually very closely linked. Complex forces are thought to be at the root of the higher incidence of suicide among this population, including: (1) rapid, forced social and cultural changes and the subsequent breakdown of traditional communities and kinship roles; (2) the presentation of suicide, and violence in general, as a "way out" of problems, both within Native American communities and in the culture as a whole; (3) racism and oppression which isolate Native American communities; (4) social problems such as alcohol and substance abuse, family violence and child abuse, lack of economic and educational opportunities, and the lack of non-violent coping strategies within Native American communities; and (5) depression and anxiety.
This report, Suicide Intervention and Prevention: Evaluation of Community-Based Programs in Three American Indian Communities, evaluates a cooperative agreement entered into by the Centers for Disease Control and Prevention (CDC), the Mental Health/Social Services Branch of the Indian Health Service (IHS), and the governments of three geographically diverse American Indian tribes. The cooperative agreement evaluated local community-based suicide intervention and prevention programs and documents the outcomes from the inception of the programs. In two of the tribes, suicide intervention efforts had been in place since 1989 and 1990, respectively; while, in the third, a suicide crisis in late 1992 spurred the implementation of the effort. The report evaluates which types of suicide intervention and prevention strategies offer the most promising practices to prevent suicide in AI/AN adolescents. The three interventions examined were in place in the Jicarilla Apache tribe of New Mexico, the Western Athapaskan tribe of Arizona, and the Northern Woodlands tribe of the Midwest. All three tribes have young populations and a majority of residents living in unemployment and poverty.
The Jicarilla Apache Tribe launched its National Adolescent Suicide Prevention Project in 1990 in response to a suicide rate that was at least 22 times the national average in the late 1980s. The project is comprehensive and multi-faceted program that provides services at the primary, secondary, and tertiary levels. It uses a community-based, family-centered approach to suicide prevention, and emphasizes cultural values and traditions. In particular, the project focuses on specific risk factors for suicide, particularly alcohol and substance abuse and physical, sexual, and emotional abuse and neglect of young children. The project comprehensively addresses community problems through education on various subjects, including domestic violence, child abuse, economics, teen pregnancy and sexuality, substance abuse, and parenting. It also trains teachers and school personnel, peer counselors, emergency medical transportation staff, and law enforcement officers in suicide risk assessment. The Community Resource Action Group (CRAG), of which the project is a part, consists of community leaders and service providers and helps to mobilize political and legal changes that will have an impact on social problems on the reservation.
The National Adolescent Suicide Prevention Project tracks data on high-risk youth and families that has been gathered through various mechanisms. This suicide register database includes archival information (1980-1989) from health clinic records, emergency medical services records, and the nearest IHS hospital; data prior to 1985 are incomplete. Since 1980, several community agencies have submitted data for each suicide attempt to the suicide register. The data are analyzed mid-year by the resident psychologist, who submits an annual report on suicide trends and program activities to the Tribal Council and the IHS. However, despite the simplicity, flexibility, and widespread acceptance of the suicide register data, it is important to note that increases in suicide activity are generally identified informally rather than through formal analysis of the suicide register data. The suicide register database contains data on 205 cases of suicide attempts and gestures, as well as completed suicides, for 1988 through 1995. Of these, 10 (5 percent) were completed suicides. The most frequent methods used in suicide attempts were drug overdoses (66 percent), hanging (11 percent), and firearms (6 percent). Males tended to use more lethal means of attempting suicide, while females were more likely to choose drug overdoses. Over half of the records in the database have a history of previous attempts; most attempts involve alcohol; and most attempts and completions occurred in the home.
The report finds that, prior to the implementation of the suicide prevention program, the average number of suicide attempts and gestures was 34.5 per year. After implementation, this number had dropped to 20, a 42 percent decrease. Finally, after a high rate of suicide attempts in 1988- 1989, the number of suicidal gestures, attempts, and completions dropped by a third in 1990, and remained stable until 1995, when they dropped to half their initial frequency.
The Western Athapaskan Tribe's Suicide Intervention Program shows more mixed results. From December 1992 through February 1994, 15 people committed suicide on the reservation and over 100 made serious attempts. Alcohol was involved in the overwhelming majority of incidents, and 91 percent of all completed suicides were 25 years of age or younger. The Chief of Police instituted the suicide intervention program in response to a "suicide epidemic" which reached its peak in n December 1993 when a suicide pact among at least 23 middle and high school students was discovered. Administration and supervision of the program is shared by the police department and the Behavioral Health Program. The intervention team consists of five tribal members who are constantly available for suicide crisis response and intervention, training, and education. The team members respond to suicidal persons and situations anywhere on the reservation and work directly with mental health personnel. From March 1993 to February 1994, the team had over 250 calls and provided follow-up on over 200 people who had attempted suicide in the previous two years. Collected suicide register data show that, between 1990 and 1994, there were 352 suicide attempts, gestures, or completions. Of these, 18 (5.1 percent) were completed. The median age of those in the register was 23-24, with cases ranging in age from 13 to 54. The most frequent method of attempted suicide was an overdose of prescription medications (33 percent), followed by an overdose of alcohol or non-prescription drugs (22 percent), and hangings (21 percent).
The report finds that, prior to full implementation of the program in 1994, the average annual number of suicidal gestures was 28.3; these dropped by 71 percent in 1994-1995 to an average of eight per year. However, suicide attempts increased during the same period by nearly 50 percent, from 26.5 per year in 1990-1993 to 40 per year in 1994-1995. Suicide completions decreased from 3.5 per year prior to program implementation to 2.0 per year after the program was operating. The report notes that the cyclical and sporadic nature of attempts highlights the unpredictability of suicidal behavior among Western Athapaskan tribes in general; it also concludes that suicide prevention efforts among American Indians have their biggest impact on very young, impressionable individuals in adolescence or pre-adolescence.
In 1990, the Northern Woodlands tribe experienced a very large increase in its number of suicides and suicide attempts. In 1990, there were four suicide completions compared to an average of less than one completed suicide per year for the previous five years; there were also 53 suicide attempts, up from a previous decade high of 26 for a single year. In response, a grass roots community effort was established, leading to the formation of a suicide intervention team of volunteers. The volunteer team established a variety of new approaches to suicide intervention. These included: (1) 24-hour availability of volunteers; (2) team-provided support for emergency room personnel and the attempters' family; (3) encouraging 72-hour voluntary placement for attempter protection whenever possible; (4) the provision of an informal, non-judgmental person to listen to the attempters' concerns; (5) case management of attempter progress and referral to psychiatric services; (6) intense intervention during the suicide crisis itself to establish a rapport with attempters and to forge a no-suicide contract; (7) continuing education for intervention volunteers; and (8) clarifying the roles of and responsibilities of all personnel in regard to suicidal individuals.
The Northern Woodlands suicide intervention was successful in preventing completed and re- attempted suicides. In 1991, the suicide rate dropped 75 percent from the previous year, while the suicide attempt rate fell by 30 percent. In 1990, 14 percent (26 percent of all attempters) tried to commit suicide again within the year. In 1990, there were only 2 re-attempters (5 percent of the total attempt population). The intervention was most successful in reducing the numbers of people who re-attempt suicide, but little has been done to intervene with those who might attempt suicide for a first time.
The report draws several general conclusions about the effectiveness of suicide interventions in these communities. First, it notes that all the communities had a difficult time performing the evaluation of their program activities, suggesting that an outside agency or person conduct further evaluations. It also notes that the two programs that used a staff model were more consistently successful on a year-to-year basis. Furthermore, the more centralized program model in use on the Jicarilla Apache reservation seemed to work best. Finally, the report notes that the smaller, more centralized, and mor cohesive reservation communities had greater success with their suicide prevention efforts than more the diffuse communities.
This study was sponsored by the Centers for Disease Control and Prevention and was prepared by the Family Violence Prevention Team of the Indian Health Service. The study's project officer is Lloyd Potter, Ph.D. He may be reached at 770-488-1557. Copies of a summary of the report (PIC ID No. 5504) are available from the Policy Information Center.
IMPROVING HEALTH IN THE COMMUNITY: A ROLE FOR PERFORMANCE MONITORING
A community's health is affected by many complex factors. Health is now seen as the result of a complex interplay of influences; ideally, health is well-being, not simply the absence of illness. The community plays a large role in fostering or hindering this positive notion of health. Stakeholders such as health care providers, public health entities, other government agencies, community organizations, private industry, schools, employers, social services and housing agencies, and faith communities all play a part in affecting public health. Public expectations have made accountability for a community's health a vital issue. Thus, tools are needed to assess the impact of many activities and to improve a community's collaboration and accountability. Performance monitoring offers such a tool.
The report, Improving Health in the Community: A Role for Performance Monitoring, examines the role of performance monitoring. It describes an approach known as a community health improvement process (CHIP) as an effective way to develop a shared vision and to support a planned, integrated approach to community health improvement.
While each CHIP will be unique to the community implementing it, the report suggests a basic framework for the process. Two interacting cycles comprise the CHIP: a problem identification and prioritization cycle and an analysis and implementation cycle. The process differs from other approaches primarily in that it emphasizes performance measurement and accountability on a community-wide basis. The report notes that the CHIP process is iterative and evolving, rather than linear. Communities can enter the cycles at any point, depending upon the resources they have available.
The problem identification and prioritization cycle has three main phases: (1) forming a community health coalition; (2) collecting and analyzing data for a community health profile; and (3) identifying critical health issues. During this stage, performance measurement centers around the community health profile. This profile provides basic information to a community about its demographic and socioeconomic characteristics and its health status and risks. The report lists 25 indicators that can be used to measure performance. These indicators cover such topics as: (1) the race/ethnicity of the community; (2) educational attainment in the community; (3) infant mortality; (4) teenage pregnancy and parenting; (5) child abuse and neglect; (6) childhood vaccination levels; (7) per capita health care spending under Medicare; and (8) satisfaction with health care and quality of life in the community, and the like.
Once a health issue has been targeted by the community, the analysis and implementation cycle begins. As in the problem identification and prioritization cycle, a community can begin with any of the activities. However, the activities interact and are likely to be repeated a number of times as a community tries to effect change in a particular health area. The activities included in this cycle allow the community to analyze the problem, develop a strategy to deal with it, implement the strategy, and monitor the outcome of efforts by accountable entities. For example, the community must analyze the health issue to determine the factors that contribute to it. Either the community's health coalition or an agent such as the health department should carry out this analysis. Behavioral risks, clinical indications, and the social/physical environment must be considered. Another activity is the inventory of health resources. Once the problem has been identified and analyzed, the community must determine the resources available to it to deal with the problem. Resources include those that can be applied to required tasks (organizations, influence, expertise, funding, etc.); protective factors within the community that might mitigate the impact of the health problem; and public- and private-sector support available to the community, such as technical assistance. The community must also develop a strategy to improve community health. This strategy should apply available resources as effectively as possible, giving priority to activities proven to be productive and cost-effective. Accountability is key to measuring the performance of any health initiative. Specific entities must be willing to be held accountable to the community for activities expected to effect the desired health outcomes. Part of the accountability process is the development of a set of performance indicators. These quantitative measures must apply to specific community entities that have accepted responsibility for some aspect of the health initiative. Of course, for performance measurement to work, a community must implement the improvement strategy. This requires action and cooperation from many community entities, including public- and private-sector stakeholders. Once the health initiative has been implemented, the community will monitor the process and outcomes. Information provided by the selected performance indicators should be reviewed regularly and used to fine-tune the initiative.
The report provides specific recommendations on making the CHIP concept work. These include: (1) communities should use a broad definition of health and a comprehensive conceptual model of how health is produced or hindered in the community; (2) a CHIP should develop its own set of specific, quantitative performance measures and should hold specific community entities accountable for their attainment; (3) a CHIP should balance long-term health improvement with goals that are reachable in the short term; (4) community coalitions should be inclusive of diverse groups in the community; and (5) a CHIP should be centered in a community health coalition or similar entity.
Federal, state, and local governments can do a great deal to make the CHIP concept work in communities. For example, state and local public health agencies should encourage the formation of CHIPs in all communities; they should participate in all CHIPS, and may provide leadership in some communities. State health agencies should also make sure that community-level health data is available so that community health profiles can be developed. The report also recommends that states and the federal government work to implement standardized data reporting by all public and private health insurance providers.
Finally, the report urges that the Public Health Service (PHS) encourage and monitor the CHIP process in a number of communities around the country. It should also work with local and state health agencies, professional organizations, and foundations to develop appropriate technical assistance tools for communities seeking to implement a community health improvement process.
This report was sponsored by the Office of the Assistant Secretary for Planning and Evaluation and was prepared by the National Academy of Sciences, Institute of Medicine. The report's project officer, Jim Scanlon, may be reached at 202-690-7100. Copies of the executive summary, PIC ID No. 6583, are available from the Policy Information Center.
PRIVACY AND HEALTH RESEARCH: A REPORT TO THE U.S. SECRETARY OF HEALTH AND HUMAN SERVICES
The rise of managed care, with its previously unknown command of people's health care, and its centralization of health decision-making and payment, has sparked an important policy debate on the balance that must be reached between the individual's right and desire for the privacy of their health information and the greater societal need for health data for research purposes. The issue is given particular urgency by the existence of new computerized systems that make aggregation of data from private sources easier and more common. Genetic research, which offers unprecedented opportunities to understand the mechanisms of disease and cure, requires information on individuals' genetic make-up -- information that, if not kept confidential, might affect a person's ability to gain employment, credit, or health and life insurance. Finally, the security of computerized health records and electronically-transmitted health data is not assured.
The report, Privacy and Health Research: A Report to the U.S. Secretary of Health and Human Services, examines this contentious issue. It addresses several areas, including: (1) the kinds of health data that are available; (2) the entities that have access to personally identifiable health data; (3) the uses of personally identifiable health data for research; (4) informed consent and data subject protection; and other issues. The report also proposes principles that should guide the use of personally identifiable health data.
Personally identifiable health data is located in a number of sources. These sources include: (1) primary medical and hospital records; (2) pharmacy and laboratory data; (3) vital records; (4) administrative and financial data; (5) data from surveys, clinical trials, adverse-drug-event reports, and outcomes and health economics studies, and (6) registries organized by diseases, by treatment regimens, by demographics, or by other categories, and many other compilations. This data may be personally identified, key-coded (pseudonymized), or fully anonymized. Fully anonymized data is the most private, while personally identified data is the least private kind of data. However, large amounts of data lie between these two poles. Much of this data is key-coded or pseudonymized. Key-coding data removes identifiers from the data and replaces them with code. These identifiers are traceable through the code to a matching file. Computers' ability to powerful, extensive, and rapid searches, and the pressures for access mean that simply giving data pseudomyms or key-coding it without adequately protecting the identifying data are inadequate. Thus, new measures are needed to mask the data's identifiability near the source, to separate and secure the identifiers, to protect the linking code, and to carefully manage linking back to the data subject when necessary.
The potential for misuse of personally identified health data might lead one to question whether such data is needed at all. The report examines the reasons that health data should be personally identifiable, and asserts that such data is of significant benefit to the research community and to research subjects. Benefits to research include: allowing technical validation of reports in order to prevent scientific error or fraud, ensuring that two records are truly unique from one another and are not just the same case recorded in two files, facilitating scientific data quality control, allowing case follow-up if more evidence or information is needed, and ensuring that data-subjects gave informed consent or facilitating Institutional Review Board (IRB) oversight of a case. Patients might also benefit from the existence of personally identifiable data. For example, the consequences of a research intervention can be tracked over the long term and patients or physicians may be notified of changes or problems if necessary. Finally, long term tracking of these consequences is made possible by personally identifiable data; the subject's descendants may even be recruited for research.
Given the benefits of personally identifiable data, it is necessary to ensure that the privacy and confidentiality of data subjects is protected. There are two primary mechanisms used to afford this protection: (1) the use of informed consent; and (2) Institutional Review Board (IRB) oversight. In the ideal form of consent, the data subject is notified prior to participating in a research effort that his or her personal information will be on record and that it will be protected and used in specific ways. The data-subject then gives informed consent, aware of the extent to which confidentiality of records identifying him or her will be maintained. In clinical trials and much other research, informed consent is routinely sought and IRBs supervise the protocols. In many other kinds of research, however, notice is not routinely given nor consent sought. For example, retrospective studies, such as epidemiological reviews begun years after the initial medical events are especially difficult circumstances in which to obtain informed consent. Institutional Review Boards (IRBs) provide external oversight of research studies. These bodies, which are required for all federally-sponsored research, provide varying degrees of protection for data-subjects' privacy. In addition, some private-sector institutions, such as managed-care organizations, have established IRBs. It is important that IRBs establish clear standards for their oversight of data privacy issues.
After presenting a list of principles by which those who collect personally identifiable data should be governed, the report goes on to discuss several important ancillary issues. These include: (1) secondary uses of data and data linking; (2) research on private-sector health data; (3) cybersecurity; and (4) genetic privacy. Secondary uses of data occur when data is used for a purpose other than the one it was collected to serve. For example, the databases of health care finance systems and managed-care systems are in great demand. The public will benefit greatly from examining these databases as systems, as well as from the research that uses this data in a secondary way. The report proposes a scheme of "consent scenarios in secondary research". It also discusses the concerns that center around data linking, especially the fear that linking information from several databases might lead to identification of data subjects by induction.
Managed care organizations, pharmaceutical and medical device companies, and other private sector institutions hold large amounts of personally identified and lightly masked health data on individuals, in addition to key-coded and truly anonymized data. Some state legal controls apply to the use of this data, as do the federal Privacy Act and other laws where there is federal involvement. However, there are many cases where private sector data is not legally protected or where the few existing protections are not enforced. The report proposes that a uniform federal measure might be needed to govern the use and release of this privately-held data. The entire world is looking at how to protect the confidentiality and security of health data, especially for data that are stored, processed, and transferred electronically. An especially pertinent issue is how the various consents and differential access conditions are to be transmitted along with data as they are electronically moved, combined with or linked to other data, split apart and reassembled, and processed by different users for different purposes. Finally, the report looks at the privacy of genetic data. It stresses that genetic information in personally identifiable data must not be used to determine employment eligibility, financial credit, or health/life insurance eligibility.
This report was sponsored by the Office of the Assistant Secretary for Planning and Evaluation and was written by Bill Lowrance, Ph.D. The report's project officer, John Fanning, may be contacted at 202-690-5896. Copies of the executive summary, PIC ID No. 6605, are available from the Policy Information Center.
NATIONAL SURVEY OF CURRENT FORMER FOSTER PARENTS
The National Foster Parent Association estimated that there were about 125,000 foster parents in 1989, a decline of 9,000 since 1984. At the same time, the need for foster families was growing: there were 259,000 foster children in 1983 and 407,000 in 1990. This disparity between the need for and the availability of foster homes produced several negative results, including: placement of children in the more restrictive setting, overcrowding in licensed foster homes, inappropriate relaxation of licensing or certification standards, mismatching children and families, and placing children in makeshift shelters until appropriate placements can be found. These negative impacts highlight the need to recruit and retain foster parents.
The report, National Survey of Current and Former Foster Parents, is intended to provide information on a nationally representative sample of current and former foster parents in order to provide policy direction. Specifically, the report: (1) identifies the characteristics of foster parents and any changes in these characteristics between the group of parents who recently entered the system from those who began as foster parents before 1980; (2) identifies the differences between current and former foster parents; (3) identifies the experiences of foster parents with the children placed in their care and with the foster care system; (4) identifies agency practices regarding foster parent recruitment, licensing, training, and placement, as well as monitoring of children placed in foster family homes; and (5) explores the implications of this information for recruitment and retention of foster parents.
A mail and telephone survey of 1,572 current and 362 former foster parents in 16 counties (or clusters of rural counties) in nine states was undertaken for the report. An overall response rate of 71 percent was achieved. Data obtained through the survey were supplemented with discussions with child welfare administrators and foster parent association directors in the relevant counties.
Utilization Patterns of Foster Family Homes
There are about 131,000 licensed family foster homes, excluding those that are licensed to care for relatives only. Each foster family home was licensed to care for, on average, 3.1 children, resulting in a total availability of foster care places of 406,400. However, there is an imbalance between the type and location of foster family homes and the needs of foster children. For example, 35 percent of foster families surveyed did not have any foster children in their homes at the time of the survey, and 63 percent had fewer children than they were licensed to house; 11 percent were operating above their licensing capacity. Rural foster homes were more likely not to have foster children than suburban or urban homes. Black foster families are less likely to have no foster children than either Hispanic or white foster families. Furthermore, black foster families are 13 percent more likely than white families to have three or more foster children. In short, the report finds that there is a shortage of foster parents in urban areas, particularly minority foster parents and those who will accept teenagers (44 percent of foster parents surveyed said that they would not accept teenagers). Another problem is that more recently licensed foster homes have less capacity than those licensed in previous years. As older foster families leave the system, the shortage of available foster home places will worsen.
Foster Family Recruitment Issues
Twenty-six percent of foster mothers had worked formally or as a volunteer with mentally retarded, handicapped, or emotionally disturbed children. Thus, recruitment efforts might focus on health care facilities, schools, professional associations, volunteer organizations, and parent support groups. Despite the fact that 37 percent of current foster parents reported that they learned of the need for foster parents from other parents in the foster care system, agencies do not seem to fully use current foster parents as recruitment resources. The survey found that foster families were similar demographically, no matter in what time period they were licensed (prior to 1980, between 1980 and 1985, and after 1985). The only significant difference between these cohorts was the number of foster mothers who participated in the work force: 60 percent of foster mothers licensed after 1985 worked part-time or full-time, in comparison to only 42 percent of those licensed before 1980. This suggests that day care will be increasingly necessary in recruiting foster parents. Furthermore, placing pre-school children in foster homes may become more difficult as both parents and caseworkers question the suitability of working parents to be foster parents. Finally, it may become more difficult to place children with special needs. These children require more time and attention than other children, and working parents may be unable to provide these unless respite care and day care for special needs children are available.
Another difficult recruitment issue is foster parents' apparent unwillingness to provide homes for certain categories of children. In varying degrees, foster parents were unwilling to accept teenagers, children with emotional problems, drug-exposed infants, children with physical handicaps or serious illnesses, and infants who are HIV-positive. Foster families are also needed for sibling groups: only 25 percent of children recently placed in foster care with the parents surveyed had a sibling living with them in the same foster home, but 42 percent had siblings living in other foster homes.
Agencies should also be aware that no evidence has been found to support the commonly-held belief that foster families who are allowed to adopt their foster children will no longer be interested in fostering children. Nearly one-third of the foster parents in the study were also adoptive parents.
Foster Family Retention
Most parents who have left the foster care system (37 percent) cited various foster care agency policies and practices as the reason that they left the system. The second most common reason for leaving the system was problems with the behavior of foster children. It is important to note, however, that both current and former foster parents experience problems with behavior at an equal rate: former foster parents were also more likely to have had problems with the foster care agency, which may have affected their ability to deal with a child's problem behavior. Similarly, foster parents who had left the system were more likely to have had misunderstandings with the foster child's caseworker. They were more likely to report that the caseworker did not understand their problems or that the caseworker implied that any problems were their fault. They also believed that the caseworker did not properly understand the child's needs. A related problem concerns the lack of foster parent participation in the administrative processes concerning their foster child. Former foster parents were also less likely to have received support from other foster parents and were three times more likely to cite child or family counseling as their primary service need. Current foster parents indicate that their service needs include: respite care, day care, reimbursement for health care costs not paid by Medicaid, and transportation services. Additional foster parent training was also needed.
The report concludes that the shortage of foster parents will increase during and after the 1990s unless better recruitment efforts and improved policies and practices are instituted by foster care agencies. The report recommends that:
· Foster care agencies should recruit new foster families through foster parent associations and child disability workers.
· Families which reflect the racial and ethnic distribution of the foster children, and those who will care for sibling groups, teenagers, and disabled children, are particularly needed.
· Agencies must include foster families more actively in the planning and conduct of case plans, and must provide more services such as respite care, day care, reimbursement for health care costs, transportation, and training.
This report was sponsored by the Children's Bureau, Administration on Children, Youth, and Families within the Administration for Children and Families. It was prepared by James Bell Associates, Inc., and Westat, Inc. The report's project officer, Penelope Maza, may be reached at 202-205-8172. Copies of the executive summary of this report, PIC ID No. 6470, are available from the Policy Information Center. Free copies of the complete final report are available from the National Clearinghouse on Child Abuse and Neglect Information (1-800-FYI-3366).
ASSESSING THE VIABILITY OF ALL-PAYER SYSTEMS FOR INPATIENT HOSPITAL SERVICES
The project which this report describes had its genesis in the atmosphere of health care reform that accompanied 1993 health care reform effort. Although an all-payer system was not envisaged as an end result of health care reform, the Health Care Financing Administration (HCFA) believed it might be used during a transitional period. The project was designed to test the practicality of adapting or extending Medicare's Prospective Payment System (PPS) to either other payers or to all payers. In the absence of health care reform, all-payer systems could be useful to Medicaid programs and private insurers as a basis for paying or, in the case of managed care plans, in negotiating financial arrangements with hospitals and physicians.
The report, Assessing the Viability of All-Payer Systems for Inpatient Hospital Services, is the final report in a series of studies to explore alternative approaches to the development of an all- payer prospective payment system for reimbursing hospitals for inpatient care. The all-payer system could encompass both Medicare and non-Medicare patients, or could be composed of separate prospective payment systems that use the same or a similar methodology, distinguishing patients by insurer type for payment purposes.
The report describes the various steps involved in developing this kind of system, which is composed of several different payment components, including payment weights, rates, and adjustors. Derivation of each component requires separate analytic steps and several types of data. For example, admission record must be sorted according to a specific patient classification scheme so that payment weights can be created and hospital-specific casemix indices can be derived. Hospital-specific costs data by payer category are used to determine costs per case, which will in turn be used to set payment rates. Hospital area characteristic data are needed to determine the need for and level of payment adjustors. The report describes methodologies used to determine these data in detail, as well as the steps involved in creating a data file to represent all short-term general hospitals.
The data developed by the report is then used in two analyses. The first determines whether diagnosis-related group (DRG)-based payment rates for Medicare and non-Medicare patients should be adjusted based on hospital characteristics. The specific adjustments considered are those that have been incorporated into Medicare PPS payments in recent years. They include, for example, adjustments for differences among hospitals in local labor costs, casemix, urban/rural development, involvement in the training of interns and residents, and the percentage of hospital's caseload that comprises low-income patients. This analysis showed that, in contrast to Medicare costs, non-Medicare costs did not have a proportional relationship between costs per case and casemix. This implies that payment rates for non-Medicare patients based on average cost per case would systematically pay hospitals with complex cases substantially more than the costs they incur, and would pay hospitals with less complex cases less than their costs. Under such a system, more than 30 percent of hospitals would experience payment errors of more than 10 percent relative to their costs.
The second analysis was undertaken in the light of this finding. It concentrates on potentially useful refinements to the existing Medicare payment system. Specifically, it examines an alternative approach to defining the standardized Medicare prospective payment rate. In the current formula used to determine this rate, the payment level (the standard amount) is based on the average historical costs of care for all Medicare patients. The new analysis suggests that the payment level should be based only on Medicare admissions to hospitals that provide care efficiently. The report presents a methodology for determining whether or not a hospital's provision of care is efficient, in addition to simulations of several variations on the proposed policy in order to determines its effects on payments to individual hospitals and on aggregate spending.
The report concludes that, since a hospital's costs and its efficiency are not well correlated, the new model it proposes has several advantages over the current method which uses cost as a proxy for efficiency. These advantages are: (1) the new model does not rely upon an arbitrary model specification, and does not require proxies for omitted or unobservable factors that should have been included in the model, nor does it include fixed inputs or an unconventional measure of input; (2) it accounts for the fact that hospitals produce multiple outputs and experience joint production costs that are difficult to allocate across different types of patients; and (3) it takes into account economies and diseconomies of scale which may be present over various parts of the size distribution of hospitals and recognizes the costs of inputs other than labor. The report also notes that the use of this kind of model can result in substantial savings, ranging from $1 billion to almost $9 billion, depending upon the threshold level assigned to the inefficiency measure. These savings represent a reduction in payments ranging from 1 to 13 percent. Another major advantage of this approach is that it does not affect any one kind of hospital more than another. This kind of approach has considerable potential to achieve Medicare program savings by recognizing only the costs of efficient hospitals.
The report was sponsored by the Health Care Financing Administration and was prepared by the Urban Institute. The project officer, Jesse Levy, may be reached at 410-786-6600. Copies of a summary of the report (PIC ID No. 6594) may be obtained from the Policy Information Center.
RESPONSIBLE FATHERING: AN OVERVIEW AND CONCEPTUAL FRAMEWORK
Social and economic forces in the late twentieth century have affected the roles of parents enormously. More than half of mothers are now in the work force, half of new marriages end in divorce, and almost one-third of births are to unmarried women. These factors have, in turn, affected the role of fathers in families. There has been an upsurge of interest in fathers' roles. Research has suggested that fathering is fundamentally a social construction. It cannot be examined in isolation from mothers' roles and expectations and the large social context. Indeed, fathering may be more sensitive than mothering to contextual forces, which may create more obstacles than bridges for fathers. Responsible fathering is a term which has recently come into use to describe a desired norm for fathers' role. This term reflects a shift from a value-free social science analysis to an analysis which explicitly embraces a moral stance. A responsible father is understood to: (1) wait until he is emotionally and financially prepared to father a child; (2) establish his legal paternity when he does father a child; and (3) actively share with the child's mother in the continuing emotional and physical care and financial support of the child, from pregnancy onwards.
The report, Responsible Fathering: An Overview and Conceptual Framework, examines the concept of responsible fathering, summarizes findings from the major areas of research on responsible fathering, offers a conceptual framework to guide future research and program development, and describes implications for programs to promote responsible fathering.
Only about one-third of nonmarital births in the United States are followed by paternity adjudication, despite the fact that an established paternity holds tangible benefits for the child and some degree of protection for the father's rights. Benefits include health care benefits if the father is employed, social security benefits, mandated child support benefits, Armed Forces benefits if the father is in the military, and the benefit of knowing one's biological heritage and having a clearer sense of social identity. Although there is little research on the reasons for these low rates of paternity establishment, they may include a lack of information about the benefits of legal paternity, the dynamics of the couple relationship, opposition from mothers, cultural issues, social policy barriers, and low priority actions on the part of social institutions.
A number of studies have documented how mothers and grandmothers act as "gatekeepers" for the father's presence in the child's life, and how institutional practices create barriers, especially for young fathers. A nationally representative sample shows that about three-fourths of young fathers who did not reside with their children at birth never lived in the same household with them. About 50 percent of these fathers did visit their child once a week, but about 20 percent never visited or visited only once a year. Furthermore, fathers in the sample tended to have less contact with their children as time passes. There are racial differences in these findings: African American fathers are more likely to live close to their children and to see them more frequently than Hispanic or white fathers. The consequences of divorce on father-child relationships are equally damaging: the children of divorced fathers report increased alienation from their fathers, especially if one of the parents remarried. If the divorced parents get along well, high levels of fathers' involvement with their children have positive behavioral outcomes. However, if the parents are in more serious conflict, this involvement can lead to worse behavioral outcomes.
A major problem associated with irresponsible fathering is the nonpayment of child support by nonresidential fathers, whether they are divorced from or had never married the mother. Only 48 percent of mothers who are awarded child support by the courts receive the full amount due. The other half of mothers are more or less equally divided between those who receive less than the full amount and those who receive no support at all. Other research has shown that, even if the full amount awarded is paid, the amount received by the mother is not adequate to support a child. The situation is even more dire for children of never-married mothers. For example, in 1993, 38 percent of children living with divorced mothers were living below the poverty line while 66 percent of children living with never-married mothers were below the poverty line. Only 27 percent of these children have a child support award, and many have not had legal paternity established. Studies of fathers show that joint custody or visitation rights result in more compliance with child support orders. Recent studies of child support paid by non-custodial mothers reveals that these parents are even more likely than non-custodial fathers to neglect their child support obligations. Therefore, researchers suggest that it is the structure of nonresidential parenting that inhibits economic support for children outside of marriage, rather than the culture of fatherhood itself. The fact that non-custodial parents must send money to an ex-partner or an ex- spouse, that they must provide economic support in the absence of daily contact with their children, and that they have no influence over how child support funds are spent are the factors inherent in nonresidential parenting that inhibit economic support for children.
Other research examines the role of the residential father, and suggests that fathers' perceptions of their own success as breadwinners has a very strong effect on the way in which they parent. Feeling like a failure as a breadwinner, even more than his actual financial situation, is associated with demoralization for fathers, damaging their relationships with their children. The report also examines research on the effects of fathers' accessibility to and engagement with their children. However, the report also cautions that much of the research on these issues assumes that the mother is the "standard" parent to which fathers' behavior must be compared. This leads to fathers being ignored or studied for how they differ from mothers or for how they neglect or abandon their children.
In response to this need for a systemic, ecological approach to parenting in which the behaviors and beliefs of children, fathers, and mothers are viewed as part of an organic web of personal, relational, and community influences, the report proposes a conceptual model of the influences on fathering. The model is intended to include fathering inside or outside of marriage, and regardless of the father's co-residence with the child. The model suggests that father-child relations are more strongly influenced than mother-child relations by the coparental relationship, by factors in the mother, and by larger contextual factors. Studies have shown that fathers appear to withdraw from their children when they are not getting along with the mother, while mothers do not show similar levels of withdrawal. Furthermore, men have a less clear idea of what fathering entails than women do in regard to mothering. The conceptual model suggests that the family environment most supportive of fathering is a caring, committed, and collaborative marriage. Furthermore, the report shows that, even within good marriages, a father's involvement with his child is often contingent on the mother's attitudes towards, expectation of, and support for the father, as well as by the extent of her involvement in the labor force. Among contextual factors that influence fathers' involvement in their children's lives, the most strong are changes in economic forces in the work force and marketplace. On the positive side, cultural factors encourage responsible fathering in almost every culture. The report stresses that this model should be seen as representing a dynamic process, rather than a set of linear, deterministic influences. Individual fathers choose how and to what extent external factors affect their relationships with their children.
The report offers several recommendations for fathering programs, based upon the conceptual model. These suggest that fathering programs should: (1) concentrate on all aspects of responsible fathering that need support: paternity, presence, economic support, and involvement; (2) involve mothers when feasible; (3) promote the well-being of mothers and the mother-father partnership; (4) take into account the influence of the mother's and father's own families; (5) emphasize critical transition points for fathers and children; (6) foster employment for fathers; (7) deal with the father's relationships with his community; (8) train all staff who work with children and families to promote responsible fathering; (9) involve fathers working with other fathers; and (10) promote the viability of caring, committed, and collaborative marriage.
This report was jointly sponsored by the Administration on Children and Families and the Office of the Assistant Secretary for Planning and Evaluation. Mark Fucello of ACF and Linda Mellgren of ASPE were project officers; the former can be reached at 202-401-4538, and the latter can be reached at 202-690-6806. Copies of the executive summary for this report, PIC ID No. 5981, are available from the Policy Information Center.
MEASURING EXPENDITURES FOR ESSENTIAL PUBLIC HEALTH SERVICES
Essential public health services were defined by a subcommittee of the Public Health Functions Steering Committee, under the aegis of the Public Health Service (PHS), representing the broad consensus of the public health community on what public health does and how it carries out its mission. These essential public health services include: (1) monitoring health status to identify community health problems; (2) diagnosing and investigating health problems and health hazards in the community; (3) enforcing laws and regulations that protect health and ensure safety; (4) informing, educating, and empowering people about health issues; (5) mobilizing community partnerships to identify and solve health problems; (6) linking people to needed personal health services and assuring the provision of health care when otherwise unavailable; (7) evaluating effectiveness, accessibility, and quality of personal and population-based health services; (8) assuring a competent public health and personal health care workforce; (9) developing policies and plans that support individual and community health efforts; and (10) researching for new insights and innovative solutions to health problems. (Source: Essential Public Health Services Workgroup of the Public Health Functions Steering Committee).
In 1993, a PHS pilot project attempted to quantify expenditures for "core" or essential public health services. Officials from Connecticut, Iowa, Missouri, Oregon, and Rhode Island participated in the development of a set of guidelines for documenting these expenditures. In 1994, the states of Illinois, New York, and Texas joined the pilot project. This attempt constituted the first phase of the pilot project. The first phase found that the eight states reported spending about $2.8 billion on core public health functions in Fiscal Year 1993, representing a combined per capita expenditure of $44. The first phase also found that core public health functions accounted for 27 percent of total expenditures of public health, mental health, substance abuse, and environmental agencies in these states. However, the first phase of the pilot study suffered from three major limitations: (1) the guidelines were not adapted to the activities and services of mental health, substance abuse, and environmental agencies; (2) estimates for local health department spending were difficult to establish at the state level; and (3) the comparability of expenditures data was difficult to establish.
The second phase of this pilot project was undertaken by PHS in 1995, in part to correct some of the limitations of the first phase. The report, Measuring Expenditures for Essential Public Health Services, presents the findings of this second phase. All of the Phase I states agreed to participate in Phase II, except Connecticut and Missouri. Three additional states (Arizona, Louisiana, and Washington) also participated.
The report first tests the feasibility of the methodology used by the pilot project. It finds that the methodology consistently defines, measures, and monitors public health expenditures from year to year. The study then goes on to produce state-level estimates of essential public health services spending; these estimates show that expenditures for personal health services take up more than two of every three dollars spent by the nine pilot-study states. In contrast, population-based health services spending ($36 per capita) was only 1 percent of total health care expenditures in the participating states ($3,342 per capita). Of this, the largest amount (26 percent) was spent on enforcing laws and regulations that protect the health and ensure the public safety, while training (4 percent) and research (2 percent) received the smallest investments.
The study also indicates that, while the federal government has a large role to play in some essential public health services (namely research), states are the largest funders of population- based health services, providing fully 50 percent of funding for these services. Federal funding accounts for 32 percent of funding for population-based health services, while local and other sources accounted for the remaining 18 percent. These proportions are reversed in the case of research. Of the $7.1 billion reported spent by PHS on essential public health services, $2.4 billion (34 percent) supported prevention-related research. Two billion dollars were spent on personal health services, accounting for 29 percent of PHS spending on essential public health services. Most of these personal health services expenditures went for Indian Health Service (IHS), the Health Resources and Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) programs.
The report makes several recommendations designed to improve the methodology for future data collection. For example, the report recommends that the usefulness of data collection be promoted at the state and local levels and that the essential public health services terminology be linked to other public health data collection efforts. Furthermore, the report strongly recommends that data collection instructions and reporting formats be further standardized to ensure comparability of data across states. Finally, the report suggests that the methodology be incorporated into on-going financial processes and that it be integrated into data collection efforts of national-level associations.
This report was sponsored by the Office of Public Health and Science and was prepared by the Public Health Foundation. The report's project officer, Deborah Maiese, may be reached at 202- 205-8583. Copies of the executive summary, PIC ID No. 6194, are available from the Policy Information Center.
Recently Acquired Reports
- Development of a Performance Management System for Ryan White Titles I, II, and SPNS (PIC ID No. 5954.1)
- National Cancer Institute: Characterization of User Population and User Satisfaction of the PDQ Database -- Documentation for Tracking System (PIC ID No. 6092)
- Efforts by Child Welfare Agencies to Address Domestic Violence: The Experiences of Five Communities (PIC ID No. 6155)
- Evaluation of Nine Comprehensive Community-based Child Abuse and Neglect Prevention Programs: Cross-Site Evaluation Report (PIC ID No. 5851)
- Child Maltreatment 1995: Reports from the States to the National Child Abuse and Neglect Data System (PIC ID No. 5387.4)
SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research; and policy-oriented projects conducted by HHS as well as other federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to to PIC Central Mailbox, or to (202) 690-6445