In 1991, the Department of Finance and Administration established the Children's Plan by creating a single funding pool to finance children's services. Looking for an independent agency that did not have a vested interest in maintaining the status quo, the Department of Health was selected to administer the Plan. Assessment, Care, and Coordination Teams (ACCT) were formed to provide comprehensive assessments of children entering care in order to make better initial placement decisions for children and youth. The ACCT would also monitor the child's progress through the placement system, manage the expenditures of flex funds, and function as a single portal of entry for children needing state services (pre-custodial, custodial, post-custodial). ACCT was housed in Community Health Agencies (CHAs) which were originally created in statute to advocate for community based medical care for the poor across the state. The CHAs were administered by the Department of Health and were located in 12 regional offices. The ACCT was suppose to review all referrals to HomeTies and to provide an assessment of whether children were at imminent risk of placement. The degree to which this actually occurred varied widely across the state and, in the fall of 1993, ACCT was dropped as the gatekeeper of HomeTies referrals. One example of the difficulty in implementing this referral strategy was that some juvenile court judges refused to send referrals through ACCT. In FY 1995, ACCT staff continued to make referrals to HomeTies, accounting for slightly less than one-third of referrals.
In April, 1996, the Tennessee General Assembly passed legislation to remove child welfare services from the Department of Human Services and create the Tennessee Department of Children's Services. The new Department consolidates family and children services from several Departments and includes: child welfare, child development, day care licensing, pregnancy and parenting services, youth corrections, and the children's fiscal division. While the Department of Human Services continues to administer the Social Services Block Grant and Title IV-A funds, the Department of Children's Services (DCS) administers all Title IV-E and Title IV-B funds.
DCS has recently been operating under tight fiscal constraints. During site visits in 1997, DCS was altering the structure of service delivery in an effort to increase service provision without increasing personnel expenditures, strengthen followup services, and decrease duplication and problems associated with case transfers. The conversion process affected workers both in- and outside of DCS. The Assessment Care and Coordination Teams were dissolved and ACCT staff no longer reviewed any referrals to FPS. The community health agencies called Community Service Agencies (CSAs) became contract agencies that provided services directly to families (one person described this as quasi-privatization). CSA child welfare staff began to carry their own cases and be part of teams (along with high risk CPS staff, outreach, crisis intervention, youth development, and foster care staff). The Community Service Agencies were the fiscal monitors of flexible funds to prevent or reduce time spent in state custody.
The conversion process affected investigative staff. The emphasis changed from service provision to investigations, which required strict adherence to the policy of completing investigation in 60 days or referring cases to ongoing service units. Staff were required to close or transfer cases within 60 days of case opening. Also if investigator caseloads were greater than 30 families at a time, they had to justify the number in writing. The conversion process had a strong negative effect on the morale of DCS workers due to a high level of uncertainty about how their job status would be affected.
Since 1997, Tennessee has been moving toward a managed care model of service delivery for noncustodial cases. Fifty percent of the state is currently using the new managed care system, but Shelby County, among others, is not expected to be converted until July 2000. (53)
The Department of Children's Services (DCS) reported that most non-custodial service contracts had been based on a fee-for-service basis without regard to level of service or quality of performance. Little evaluation had taken place and services were not distributed evenly across the state. As a consequence, the state asked all 12 Community Service Agencies to conduct local needs assessments for their regions defining service priorities and gaps in their current service continuum. The assessments were completed in late January 1998. The assessments focussed on three levels of service: prevention (community education and early prevention), intervention (treatment), and diversion (just prior to commitment services).
As a continued move towards managed care, the Department of Children's Services then issued a Request For Proposals for each region based on the local needs assessments. As part of the proposals, networks of agencies bid a case rate for families. Once in place, the network will decide the amount and kind of services families require and the length of service delivery to prevent placement. (54) The state plans to have 12 networks across the state each with a lead agency, which will subcontract, with other agencies for services or with a coalition of service providers. The 12 networks will replace approximately 70 existing contracts for service. The networks are to be outcome focussed and will be financed by Social Service Block Grant (SSBG), some of the state's Family Preservation /Family Support funds, and all state HomeTies dollars. (55)
The state planned to have the networks in place by July 1, 1998. However, the state only approved proposals from six regions and rejected the remainder largely due to service cost estimates, particularly the capitated rate amount for families receiving in-home services, with a specific annual cap of $1,550 per family. Following withdrawal of the RFP from the six regions not funded, Shelby's CSA submitted a plan which proposed a five-year pilot program using "an integrated fee-for-service and risk- adjusted model" for children at risk of state custody
In essence, the plan is to have the CSA convene community members, including service providers, the courts and DCS, who will develop both a risk adjustment scale to classify children into moderate, high, and imminent risk of placement categories and a service delivery model to address each level of service need. Both the University of Tennessee and the University of Memphis will be part of this group to help review data and design the service model. Case rates will be established looking at historic expenditures of flexible funds, SSBG, and IV-E dollars. Once the model and fee structure are established, the group will prepare a program evaluation, funded by local resources and conducted by the two local universities. Finally, an RFP will be written, and after approval from the state, will be released into the community. Network provided services are expected to begin on July 1, 2000. The state's move toward managed care will also eliminate the state's Homebuilders family preservation program. While the new service networks will be required to offer some form of intensive family preservation, they will not be required to offer a Homebuilders model and the state will no longer provide uniform training and oversight.
At this time, there is no consensus about the role of Shelby County DCS in case oversight once the network is involved with the family. In other parts of the state, DCS acts only as a gatekeeper (accepting calls, conducting investigations, and making referrals) and the CSA monitors families' progress. It has also not been determined whether the Frayser HomeTies program will continue under the network; if it does not, a less intensive service model will be used.