In This Issue:
- Migrant Head Start Grantees
- Minority Community Health Demonstration
- Evaluation Design for the Turning Points Program
- The AHCCCS Demonstration
- National Center for Service Integration Series
MIGRANT HEAD START GRANTEES: PERSPECTIVES AND CHALLENGES
Head Start is a federally funded child development program committed to preparing preschool children for success in school by addressing their families' educational, economic, social, physical, and emotional needs in a comprehensive manner. The Migrant Services Branch of the Administration for Children and Families' (ACF) Head Start Bureau oversees all migrant Head Start grantees. These 28 grantees serve approximately 28,000 migrant children nationwide.
The report, Migrant Head Start Grantees: Perspectives and Challenges, examines the particular problems faced by migrant Head Start grantees as they attempt to carry out the Administration's and Congress's commitment to expanding Head Start.
The clientele served by migrant Head Start grantees is unique. Migrants lead transitory lives, are inexperienced with the human services system, and are faced with language and cultural barriers. The grantees serve a broader age range of children, including infants and toddlers, than other grantees. These children require different facilities, equipment, and staff skills. Grantees must provide services for children whose parents work ten to fourteen hours daily, six or seven days per week. Finally, services must be provided in a shorter time frame, since migrant families may not remain in the program more than a few weeks before leaving a locality.
Thus, migrant Head Start grantees face very different challenges than other Head Start grantees. The report finds that some Head Start program requirements, such as parental involvement, home visits, medical and dental screens, and enrollment and education requirements, may not be appropriate for migrant grantees. Furthermore, some of the proposed infant and toddler program standards may be unrealistic, particularly the child-to-staff ratios and medical examination requirements. Funding delays, unreliable information about the demographic trends of migrants, and problems with the on-site review process, statistical reporting requirements, and the Migrant Services Branch also pose challenges particular to migrant Head Start grantees.
The report recommends that ACF include concerns specific to the migrant program in its review of Head Start management. In particular, the report concludes that ACF should determine whether separate performance standards should be established for the migrant program, and whether funding and expansion cycles should be tailored to migrant grantee needs.
This report was performed by the Office of Inspector General of the Department of Health and Human Services. Copies of the Executive Summary, #4977.2, are available from the Policy Information Center.
MINORITY COMMUNITY HEALTH DEMONSTRATION GRANT PROGRAM: MULTIPLE CASE STUDY
Between 1986 and 1989, the Office of Minority Health (OMH) awarded twenty-six two-year grants in support of community coalitions which actively promoted health risk reduction at the community level among minority populations. Compared to the general population, African Americans, Asians/Pacific Islanders, Hispanics, and Native Americans/Alaska Natives are at higher risk of health problems, such as accidental injuries, hypertension, cancer, diabetes, cardiovascular disease, low infant birth weight, AIDS, violence, and alcoholism.
The report, Minority Community Health Demonstration Grant Program: Multiple Case Study, determines how coalitions can effectively promote health risk reduction among minority populations. The report examines the process of coalition and intervention development, project outcomes, factors which lead to project success or failure, and OMH administration and operation of the program. It also recommends ways in which projects can enhance their health promotion efforts and OMH can maximize program effectiveness.
The study employs a multiple case study approach. Visits to 13 demonstration program sites; interviews with project staff, coalition members, and volunteers; and review of secondary data on all twenty-six programs allowed the generation of 35 hypotheses testing the relationship between positive outcomes and project characteristics. The positive outcomes examined are: the achievement of project objectives; the continuation of the coalition past the funding period; the continuation of the intervention program; community empowerment; and spread effects of the project beyond its original target population and health problem focus. Whether these positive outcomes are realized depends in large part on the level of community involvement in the project's design, implementation, decision making, and activities. Community leaders, volunteers, and the target group must all be recruited in support of the project. The project design and implementation must also be culturally appropriate, and the composition of the project staff must reflect the ethnicity of the target community. Finally, it is also important that early attention be paid to project evaluation, that OMH offer consistent technical assistance to project staff, that the project design and implementation be flexible, and that a community-based organization serve as the project grantee and the coalition's lead organization.
The report also finds that 73 percent of the coalitions did not exist before OMH funding, but that 81 percent continued after it had ended. Those intervention projects which continued obtained funding from other public and private sources in amounts ranging from $50,000 to $2.3 million.
The report recommends that OMH consider extending the grant period to five years, strengthen its application review process, strengthen evaluation guidelines, provide more timely and effective technical assistance, and improve coordination and information sharing within the Department of Health and Human Services and with other federal agencies that provide assistance and support to racial and ethnic minorities.
This report was performed by Tonya, Inc. and was sponsored by the Office of the Assistant Secretary for Health within the Public Health Service. The report's project officer, Joan Jacobs, may be reached at (301) 594-0769. Copies of the Executive Summary, # 5008, are available from the Policy Information Center.
EVALUATION DESIGN FOR THE TURNING POINTS PROGRAM: FINAL REPORT
The report, Evaluation Design for the Turning Points Program: Final Report, provides a detailed plan for a multi-year evaluation of the Turning Points Program. The report outlines a design for a process evaluation, an impact evaluation, and a cost evaluation. This report and the proposed evaluation design may be relevant for similar community programs.
The Turning Points (TP) program is a demonstration program that provides comprehensive, school-based prevention and early intervention services to youth in four District of Columbia (D.C.) public junior high schools. The four demonstration sites serve approximately 2,000 of D.C.'s most disadvantaged students. The TP Program has four major objectives: (1) to prevent family dysfunction and delinquency; (2) to foster development of healthy, productive lifestyles; (3) to orient adolescents to a lifetime of meaningful work; and (4) to encourage and support good citizenship. Each demonstration site must identify the health and social services needs of its clientele and provide a concentrated array of services targeted to participants and their families through case management. Core services provided by the program are: case management; tutoring/mentoring; health screening and referral; counseling; assemblies and workshops; parent support groups; pre-vocational activities; and other activities.
Prior to detailing the evaluation design, the report examines issues central to the evaluation effort. These include definitions of participants, interventions, and comparison groups; measurement issues; how to follow-up on participants and comparison groups; and the external validity and generalizability of evaluation findings.
A process evaluation would focus on (1) how the program was implemented; (2) what services and assistance it provides; and (3) the population that it serves; as well as some short-term participant outcomes. It would rely on primary data gathered from interviews with all groups affected by TP and on secondary data found in program documents and in an automated client information data system. The report discusses questions to be asked in the interviews, how they are to be conducted, and what each group should be able to tell the interviewer. It also addresses where to find secondary data in case files, statistical reports, and other program documents. Finally, the report examines how to standardize client information forms so that data from them can be entered into an automated client information data system.
The report next turns to the impact evaluation design. Here, two kinds of evaluation are discussed: an initial impact evaluation and a long-term follow-up evaluation. An initial impact evaluation would use readily available data on school attendance, in-school violence, arrests, drop-out rates, pregnancies, births, promotion to the next grade, grade-point-average, and standardized test scores to examine short-term educational and behavioral outcomes for all TP participants and all students in TP schools. The report recommends using either a cohort comparison approach, which examines aggregate statistics for cohorts of students before and after TP program inception, or a pre-post approach, which measures changes in relevant areas for students at TP schools from 6th grade through 9th grade. The follow-up impact evaluation would be the most costly of the evaluation components. It would compare numerous short-term, intermediate, and long-term outcomes for TP participants, non-participating students in TP schools, and students who never attended TP schools. A longitudinal survey is recommended to measure these outcomes, beginning with a baseline survey at the beginning of the 7th grade and including follow-up surveys one and three years later. The follow-up impact evaluation would measure educational attainment, health, violence, drug abuse, criminal behavior, self and cultural development, sexual activity, welfare receipt, and employment levels.
Finally, the report sets forth a cost evaluation that would identify direct and indirect costs of the program and would examine its cost-effectiveness compared to similar programs. It would measure resources used by the program, the cost-effectiveness of specific TP services, expenditures on non-TP social services, and long-term savings from changes in behavior. The most vital part of the cost evaluation would be the measurement of resources used by the program. These resources may be either on-budget items, or off-budget items, such as volunteer labor, space provided without cost, or donated equipment, goods, and services. The report recommends that each site complete annual expenditure forms which are uniform across sites. The cost evaluation design also addresses how cost-effectiveness should be measured, how types and units of service should be defined, and how the cost of non-program social services used by program participants should be measured.
The report concludes by prioritizing and giving a suggested timetable for completion of the different components of the evaluation and by recommending the types of reports which should be generated as a result of the evaluation.
This report was prepared by James Bell Associates, Inc. and was sponsored by the Office of the Assistant Secretary for Planning and Evaluation. The report's project officer, Emily Novick, may be reached at (202) 690-5937. Copies of the report, #5274, may be obtained from the Policy Information Center.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM DEMONSTRATION: SECOND OUTCOME REPORT
The Arizona Health Care Cost Containment System (AHCCCS) provides medical services to approximately 460,000 indigent persons in Arizona, which is the only state without a traditional Medicaid program. AHCCCS differs from other states' indigent health care programs in that it capitates acute care plans and long term care contractors to provide medical services to eligible beneficiaries. Each of the 14 acute care plans and 7 long term care contractors participating in the plan receives a monthly prospective payment for all eligible beneficiaries enrolled in the plan on the first of the month. Each plan also receives a monthly payment for retroactive adjustments. AHCCCS also makes fee-for-service payments for services delivered to eligible beneficiaries not yet enrolled in a prepaid plan. Plans are also protected against catastrophic costs incurred by any one beneficiary in a twelve-month period through reinsurance for claims exceeding a large deductible. Finally, deferred liability coverage compensates plans for automatic assignment of medically indigent (MI)and medically needy (MN) eligibles who were hospitalized on the date of enrollment. The total AHCCCS program budget is projected to be $1.6 billion in state fiscal year 1994, with the federal government financing 56 percent, the state financing 32 percent, and the counties paying for 12 percent.
The report. Evaluation of the Arizona Health Care Cost Containment System Demonstration: Second Outcome Report, examines program outcomes through September, 1991. These outcomes include: (1) the cost of the program compared to a traditional Medicaid program; (2) service utilization; and (3) the quality of care provided.
Costs of the program are generally lower than those of a traditional Medicaid program. Costs are computed separately for the acute care program (AHCCCS) and the long term care program (ALTCS). For the first five years of the program, administrative costs were not considered; however, overall, medical services under the AHCCCS acute-care program cost 6 percent less than they would in a traditional Medicaid program. In program years 6 and 7, savings were 2 percent and 9 percent, respectively; while in years 8 and 9, they were 6 percent and 13 percent, respectively. These estimates include administrative costs. The acute care program has also experienced slower cost increases over time than traditional programs. In program years 8 and 9, the increase was 26 percent as compared to 33 percent for a traditional program. Since fiscal year 1983, the increase has been 69 percent as compared to 113 percent for a traditional program. ALTCS costs are also lower than those of a traditional long-term care program. Although costs were approximately the same as for a traditional program in fiscal year 1989, they were 6 percent less in fiscal year 1990 and 13 percent less in fiscal year 1991. These savings are driven by the much smaller per capita costs experienced by mentally retarded/ developmentally disabled (MR/DD) beneficiaries.
Utilization data is difficult to measure because there are reporting problems with AHCCCS encounter data. However, several generalizations may be drawn. Utilization rates are comparable to what could be expected, except that beneficiaries experience shorter hospital stays and there is a larger hospital admission rate, which could be related to the large number of one-day stays recorded in the data. The AHCCCS program generally has rates of hospital days per beneficiary which are larger than those of the Aid to Families with Dependent Children (AFDC), health maintenance organization (HMO), and general population comparison groups, but tend to be smaller than those reported for the overall Medicaid population and Supplemental Security Income (SSI) eligibles. Physician service utilization is greater for AHCCCS beneficiaries than for almost all comparison groups, but laboratory and radiology services are used at rates either lower or equal to other Medicaid beneficiaries.
The quality of care delivered by the AHCCCS is determined by comparing nursing home records for beneficiaries enrolled in the ALTCS program and for 300 New Mexico beneficiaries who were enrolled in one nursing home for 12 months over the period from January 1, 1990 through December 31, 1991. The incidence of conditions thought to indicate a lower quality of care, such as decubitus ulcers, falls, fractures, fevers, use of indwelling urinary catheters, influenza vaccine administration, and use of psychotropic drugs, was recorded. Other information, such as cognitive status, demographic information, disposition at the end of the study period, and hospital use, was also collected. This examination revealed that ALTCS nursing home residents are more likely to experience a decubitus ulcer, a fever, and a catheter insertion than New Mexico nursing home residents, are less likely to receive an influenza vaccination, and are equally likely to experience falls, fractures, and administration of psychotropic drugs. These results suggest a somewhat lower quality of care in Arizona's program, but caution should be used in attributing this to the recently-initiated ALTCS program.
This report was prepared by Laguna Research Associates, and was sponsored by the Health Care Financing Administration. The study's project officer, Ron Lambert, may be reached at (410) 966-6624. Copies of the Executive Summary, #5284, are available from the Policy Information Center.
NATIONAL CENTER FOR SERVICE INTEGRATION SERIES
The National Center for Service Integration (NCSI) was established with grants from the Department of Health and Human Services (HHS) and private foundations in 1991. Its purpose is to stimulate and actively support service integration efforts as a means of improving services for children, families, and other persons. NCSI operates a clearinghouse of information about state and local activities and develops technical assistance resources. As part of its technical assistance effort, NCSI has published six resource briefs, a directory of resource centers and clearinghouses, an annotated bibliography, and the proceedings of an invitational conference on "going to scale" with comprehensive service strategies.
The resource briefs are intended to help states and communities initiate and sustain integrated human services programs. Some are general in nature, and indicate how states and communities might institute a framework within which integrated service efforts may be carried out. For example, Getting Started: Planning a Comprehensive Services Initiative, presents questions which must be considered in planning an integrated services initiative and describes documents which may be used for guidance during the planning process. So You Think You Need Some Help? Making Effective Use of Technical Assistance addresses the use which states and communities might make of outside technical assistance providers and describes a good technical assistance relationship. Charting a Course: Assessing a Community's Strengths and Needs presents practical advice on how to conduct community assessments and provides examples of assessments which have been successful in articulating community needs.
Other briefs are more specific, and delineate particular strategies which states and communities might use once they have instituted integrated service systems. Who Should Know What: Confidentiality and Information Sharing in Service Integration addresses issues of privacy and confidentiality, and describes ways in which agencies can use legal, regulatory, and administrative means to facilitate necessary information sharing. Getting to the Bottom Line: State and Community Strategies for Financing Comprehensive Community Service Systems considers specific financing strategies which states and communities might use and outlines the principles which should undergird creative financing strategies. Making It Simpler: Streamlining Intake and Eligibility Systems describes programs for streamlining eligibility and intake systems at state level, and suggests ways in which legislative, regulatory, administrative, and technological means may be used to enhance streamlining these systems.
The Directory of Federally Funded Resource Centers--1993 provides information on federally funded resource centers and clearinghouses that serve as repositories of information on child and family welfare, health, and education issues of interest to states and communities. The bibliography, Service Integration: An Annotated Bibliography, describes books, papers, and articles written about efforts to integrate and improve human services for those living in poverty. The proceedings of an invitational conference, Going to Scale with a Comprehensive Services Strategy, presents the reflections of a group of experts convened to consider how to translate the successes of many small-scale programs and projects into large-scale reform of entire systems.
Three more publications are in preparation. Their subjects include: "exemplary practices of frontline workers," "outcomes for children and their families," and "information technology to support comprehensive services."
This series was sponsored by the Office of the Assistant Secretary for Planning and Evaluation. The project officer for NCSI is Richard Silva; he may be reached at (202) 690-6805. Copies of the documents in the series, #5307-5307.8, may be obtained from the Policy Information Center or directly form the NCSI, which may be reached at (703) 824-7747.
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