Two studies are useful for understanding the development and implementation of the HomeTies Program: a study by the Tennessee Department of Finance and Administration, Division of Budget, of children in state care in Tennessee in 1989; and the evaluation of the HomeTies program by the University of Tennessee Social Work Office of Research and Public Service (SWORPS).
In 1989, during the pilot phase of the HomeTies program, the State of Tennessee conducted the Assessment of Children and Youth Committed to State Care. This report was compiled with the hope of locating inefficiencies in the current placement, tracking, and management process in child welfare. It explored the kinds of children committed to state care and the types of placements and services provided and needed by those children. Teams of professionals reviewed a random sample of 247 children (out of a total of 3,018 children) who were in various types of substitute care through the Department of Human Services as of May 1, 1989. Based on reviewers' judgments, the researchers found that 59 percent of children committed to the state's care were appropriately placed, 31 percent needed less intensive placement (including the option of not being in substitute care), and 10 percent needed more intensive placement. The study also found that too many children were placed in foster care. These and other findings from the study were used extensively in discussions with legislators to support the need to expand the HomeTies program; resulting ultimately in the dramatic increases in the program in the early 1990s.
One important limitation of this study was that only those cases in which children were already in substitute care were examined. This sample of cases skews the findings in the direction of concluding that more children need less intensive placements by: a) not examining non-placement cases, some proportion of which would likely to have been rated as needing more intensive services, including placement; and b) selecting cases only at the high end of the continuum of case severity, setting a ceiling for many of the cases on the possibility of recommending more intensive placements.
The University of Tennessee's statewide evaluation of the HomeTies program "was designed in response to both a legislative mandate and an interest in generating management information for ongoing program planning" (Homer, Cunningham, Bass, Collette, and Evans, 5/15/96). This research provides helpful descriptive information about referral sources, characteristics and problems of the population served, presenting problems in the family, prior placements, length of service termination status, and trends over time in these areas between FY 1993 and FY 1995. Some key information and findings are described below.
Demographic Characteristics of Children. Table 5-7 shows the age, race, and gender of children targeted as being at risk of placement for the state. For children at risk in FY 1995, 27 percent were under 10 years of age while 60 percent were teenagers (aged 13-18). There was no substantial change in the age of children at risk between FY 1993 and FY 1995. A large majority of the children served in the HomeTies program were white (67%), with African American children comprising 31 percent in FY 1995. This represented a slight increase in African American children, from 27 percent in FY 1993. The percentage of males grew from 52 percent in FY 1993 to 55 percent in FY 1995.
The relatively small proportion of cases referred for child maltreatment shows that, although CPS cases became eligible in 1991, the HomeTies program continued to serve a large majority of families with older children and families that were not referred because of child abuse or neglect.
Presenting Problems of Parents and Children. The most common presenting problems of families entering the placement prevention program in FY 1995 were parenting issues (91% of parents), child behavior problems (85% of children at risk), family conflict (78% of parents and of children at risk), and school problems (64% of the children at risk). Running away (29%) and juvenile delinquency (23%) were other frequent problems associated with children. These items are also indicative of the types of problems of families with older children and adolescents.
Home management needs (27% of parents), concrete service needs (21%), child and parental violence (19% and 17%), parental and child alcohol/drug abuse (17% for each), and severe financial hardship (16%) were also common problems of families. Mental illness of parents was listed as a presenting problem in 13 percent of families. The three types of maltreatment--physical abuse, neglect, and sexual abuse--were each listed as presenting problems in less than twelve percent of children at risk and in a separate listing of the problems of parents. There were few changes in presenting problems or demographic characteristics over time, although severe financial hardship declined by 6 percent from FY 1993 to FY 1995--paralleling a 7 percent decline (from 20% to 13%) in families with gross family incomes of less than $5,000 and a 4 percent decline in families with concrete service needs.
Prior Out-of-Home Placements.For children at risk at the time of referral to the placement prevention program, 28 percent had experienced at least one prior out-of-home placement. The mean number of prior placements was 1.6 for this population. Emergency/runaway shelters (43% of all prior placements) and juvenile court (37%) placements were the most common types of prior placements--no other placement types constituted over 10 percent. It is not clear how many children were in placement at the time of referral. Given the types of prior placements experienced by children, it is possible that many children were in short-term placements immediately prior to referral.
|Percent of All Families or Children (FY1995 Prevention Cases)
N = 2,777 families
N= 3,591 children
|Age of child a|
|Race of child|
|Gender of child|
|Child behavioral difficulties|
|Child behavior problems||85|
|School problems of child||64|
|Physical child abuse||11|
|Physical child abuse||11|
|Poverty-related parental needs|
|Concrete service needs||21|
|Home management needs||27|
|Severe financial hardship||16|
|Prior out of home placement of children at risk at the time of referral||28|
|Age of mother figures (percentage of the 93.5% of families in which mother figures were reported as present and data on age were provided)|
|19 or younger||1|
|Marital status (percent of families in which mother or father were present and data were provided) a|
|mothers who are single||15|
|fathers who are single||3|
|mothers who are married||43|
|fathers who are married||73|
|Family composition (percent of families in which mother or father were present and data were provided)|
|Birth or adoptive mother only||32|
|Birth or adoptive parents||16|
|Birth mother/stepfather or adoptive father||13|
|Birth mother and other adults||15|
|Birth father and stepmother or adoptive mother||4|
|Birth or adoptive father only||4|
|Employment status (percent of non-missing data where mother or father figures were present)a|
|mother employed full time||44|
|father employed full time||72|
|mother employed part time||9|
|father employed part time||5|
|father student/not working||<1|
|Gross Family Income (percent of non-missing data)|
|Less than $5,000||14|
|$35,000 and over||8|
|a Percentages that should add up to 100 but do not because of rounding errors.
(Note: missing data make up no more than 4.3 percent of the total of children or families for the characteristics listed here).
Demographic Information About Parents and Families.Consistent with the paucity of infants served, only 13 percent of mother figures whose age was known were younger than thirty. Fifteen percent of the mothers being served by HomeTies were single, 30 percent were separated or divorced, and 43 percent were married. Only 3 percent of fathers being served were single, 11 percent were separated or divorced, and 73 percent were married. With regard to family composition, single-parent families headed by birth or adoptive mothers (with no other adults) were the most common type of family--32 percent of all families; followed by birth or adoptive parents (16%), birth mother and other adults (15%), and birth mother with stepfather or adoptive father (13%).
Forty-four percent of mothers served were employed full time, compared with 72 percent of fathers. Twenty-six percent of mothers were unemployed, compared with 11 percent of fathers. Seventy-three percent of families had gross incomes of less than $20,000 in FY 1995, with 37 percent of families earning less than $10,000, and 14 percent earning less than $5,000.
Findings: Out-of-Home Placement.The Homer, et al., report examined placement status of children at termination of HomeTies and six and twelve months later. "Placement data were obtained from the Client Operation and Review System database (CORS) by matching the information about children to HomeTies information". (59) Two limitations of the data should be noted: only first placements were counted and data on the type of placement are available only for placements at termination of services. Data on identifying information (3.0%) or placement (.6%) were missing on 3.6 percent of cases. For children who received placement prevention services in FY 1995:
- 85.0 percent had no out-of-home placements for one year, conversely 15 percent (n = 523) of the children were placed;
- 5.3 percent were placed at termination of services; of these 186 children, most were placed in psychiatric hospitals (28.5% of the 186 children), foster homes (23.1%), or correctional institutions (14.0%);
- In addition to the 5.3 percent of children placed at termination, another 5.2 percent were living with friends or relatives and .9 percent were classified as runaways;
- 8.1 percent were placed between termination and six months after termination; and
- 1.6 percent were placed between six and 12 months after termination.
The figure of 15 percent of children placed within one year in FY 1995 is substantially lower than FY 1994 (20.4% of children placed within a year) and FY 1993 (24.7% of children placed within a year). Thus, there was a 40 percent decrease in the one-year placement rate from FY 1993 to FY 1995. It is not clear whether differences are due to larger numbers of records missing in previous years (704 in FY 1993, and 216 in FY 1994), a trend toward less risky referrals, or improved program targeting and outcomes.
Cost analysis. The University of Tennessee report initially recognized the limitations of studying outcomes without a comparison group. Despite this, a detailed analysis of costs concluded that over $74 million was saved by the HomeTies placement prevention program as a result of preventing various types of placements. Like other optimistic estimates of cost savings, this estimate incorrectly assumes that all children at risk would have been placed in the absence of the program.
Other Services Available to Referring Workers in Shelby County.
In addition to HomeTies, Shelby County has a large number of both in-home and office-based programs that provide counseling and some that provide concrete services. Most of these services are free to families, and few have waiting lists. They are either DCS funded programs or community based programs funded through other agencies, such as the schools. Some require TennCare (Tennessee Medicaid) eligibility, some require private insurance. The programs that frontline CPS workers are using in place of, or in addition to HomeTies are:
Life Coach, also provided by Frayser Family Counseling, is an in-home, case management program with case staffing comprised of one therapist and one supervisor. Service intensity varies depending on family needs. At minimum, there are three face-to-face visits a week. Therapists provide counseling, teaching, and concrete services including transportation. Services are funded through TennCare, the Community Mental Health Agency, (formerly ACCT), and DCS, and self pay on a fee-for-service basis. (While Life Coach is viewed as one of the most viable options for some control group cases, workers note that making a referral to Life Coach also requires considerable paperwork and involves uncertainty about whether cases will be accepted into the program.)
Homeworks, also provided by Frayser Family Counseling, is an in-home, case management program staffed by one therapist and one supervisor. Less intensive, Homeworks therapists provide counseling and teaching services on average once a week. Services are funded through TennCare, the Community Mental Health Agency (formerly ACCT), DCS, and self pay on a fee-for service basis.
Frayser Family Counseling Outpatient Therapy is weekly individual, couple, or family therapy. Services are funded through TennCare, Social Service Block Grant, and private insurance.
The Exchange Club provides office-based counseling in parenting and anger management. It is funded by DCS or TennCare.
Intercept, like HomeTies, provides intensive, home-based services (24 hour availability, four to six cases a worker, service duration of three to six months, minimum of three visits a week) and is offered by Youth Village. The program requires an eight-page application form. Intercept is "very expensive" and requires ACCT approval and funding but the program also accepts TennCare and some private insurance. For nearly half of the workers we interviewed, Intercept has replaced HomeTies as the intensive model of choice since the study began. This is partly because in the words of both front line staff and supervisors, Intercept has been coming to DCS to "drum up business."
Memphis City School Mental Health offers services for children who have been sexually abused, including child-on-child sexual abuse. While the services are free to families, there is generally a waiting list. Services funded by DCS Social Services Block Grant.
Child Advocacy Center offers counseling to children and their parents. Services are funded by DCS, private funds, federal grants, and the city and county government.
The Center for Children in Crises provides comprehensive evaluation (social, medical, psychological, and psychiatric) of all family members in abuse/neglect cases and makes placement recommendations. Services are funded by DCS and TennCare.
Homemaking Services in-home services provided by the Memphis City Schools. Services are funded by DCS.
Lakeside Hospitals, in-home service using Behavioral Sciences Institute-trained staff.
Monitor Prime, in-home services, largely case management, that are sometimes tried before HomeTies.
According to the DCS front line staff interviewed, approximately 50 to 60 percent of substantiated CPS cases are encouraged to accept some services. Jean Taylor, the CPS Program Supervisor, estimated that for control cases, over 50 percent currently go to Community Service Agencies to access services not otherwise funded by DCS. For families in treatment, most of the requests for flexible funds are to support concrete needs like home repair or specialized psychiatric services not otherwise covered by TennCare.
48. Formerly the Department of Human Services.
49. As discussed later, implementation of managed care for non-custodial services has changed this structure.
50. Sources of data for this report include Tennessee's Family Preservation/Family Support Five Year Plan (1994); Family Preservation in Tennessee, The Home Ties Interventions: Selected Findings from the Program's Operation from 1989 to 1995 (Homer, K.S. Cunningham, M.L., Bass, A.S., Collette, S., and Evans, M.S., 1996); the State of Tennessee's Assessment of Children and Youth Committed to State Care (1989); Tennessee Home Ties History, and interviews with public and private agency staff.
51. Wraparound services are not available to families receiving services in the HomeTies program, but they are available for use following intensive family preservation services as aftercare services.
52. Until 1996, the Department of Youth Development provided all youth correctional services in Tennessee. In 1996, these three agencies, along with others were combined to form the Department of Children's Services.
53. At the same time that DCS is preparing to shift to a managed care model for noncustodial cases, the state is experiencing a significant budget shortfall which threatens to eliminate large amounts of DCS prevention services. If the state is unable to raise additional funds through tax increases, the shift to managed care will probably not occur.
54. The Director of State DCS Finance reported that because networks will not bill for individual services, state finance will no longer track the exact service families receive.
55. The state's 98/99 APSR reported that funding is also coming from savings generated by the continuum of residential care.
56. It is important to note that both DCS and HomeTies staff had been concerned that many DCS workers didn't refer to HomeTies. One person estimated that 50 percent of DCS workers did not make any referrals to HomeTies prior to the study, suggesting a large degree of indifference to or ignorance of the program among some workers. Based on our interviews, antipathy toward the program appears to be an unlikely explanation for non-referral for most workers.
57. One worker was no longer using HomeTies because of these issues, while other staff appeared to be merely pointing out the program's shortcomings and will continue to use the program.
58. The Shelby County director explained that while rates for HomeTies had not increased since 1992, the costs of providing services have increased substantially. Consequently, he was only able to support 18 workers. Because of lower than average caseloads, he has been forced to keep the number of staff below 18.
59. Homer, et al., 1995, p. 79.