Since Tennessee does not operate a central state hotline, all CAN calls for Shelby County come directly to two screeners within the county. The screeners determine risk levels and using a manual intake system, assign calls to the appropriate investigative unit.
During the study period, there were ten Child Protective Services units in Shelby County with approximately 65 staff. In addition to the Intake Unit, there were four Emergency Response Units (investigation within 48 hours), two Non-Emergency Units (investigation within seven days), and a single High Risk/CPS Ongoing Unit. There was also a High Risk, Multi-Victim/Multi-Perpetrator Unit, and a Court Unit which was primarily responsible for conducting home studies and visits for relative care and custody change cases.
Some investigative caseloads were as high as 150 cases/families per worker, causing great strain on and concern among staff at all levels. Caseloads within the Ongoing Unit averaged about 20. In May 1997, the service delivery plan for the new Department of Children's Services was implemented in Shelby County. Child Protective Services was divided into six work units, with a supervisor (team leader) and eight case managers, plus case manager positions responsible for CPS intake. The new service model called for CPS case managers to only do the investigative piece, referring any families who needed services beyond the investigation to child and family teams. Existing CPS policy requiring that investigations be completed in a 60 day time frame was strictly enforced. In Shelby County, the CSA provides all follow-up services and case management for these CPS cases. CPS case managers continue to refer to HomeTies because of the crisis nature of the service and its use to prevent placement.
In FY95, Shelby County served 12 percent of the state's accepted HomeTies cases (an increase from 8.3% in FY90), making it the second largest HomeTies program in Tennessee. The Shelby County HomeTies Program grew from 317 in FY93 to 391 in FY95, a 23.3 percent increase. This overall increase was due primarily to the inclusion of reunification cases (14 in FY94 and 58 in FY95). During the study years, the number of families served slightly decreased. (See Table 5-6.)
Shelby County DCS workers' views and use of HomeTies. Investigative and ongoing staff reported referring equal numbers of cases to HomeTies and cited several reasons that they use the program. Investigative workers reported that HomeTies was used as their first resort for families at imminent risk of removal because program staff could be in the home monitoring and assessing families around the clock. Ongoing workers reported that they used HomeTies as a last resort, after they had tried less intensive services because of the intensity of the intervention and the availability of concrete resources (flexible funding, transportation). Both investigative and ongoing workers said that HomeTies staff could be relied upon to provide thorough and frequent feedback about families, both during the course of treatment and at the end of treatment. Feedback was particularly useful because it included information on both family strengths and weaknesses.
Unlike many child welfare jurisdictions, Shelby County has a variety of in-home and office-based therapeutic programs to which workers can refer (these are described in Exhibit A, provided at the end of the chapter). However, supervisors and workers noted that, prior to the study, HomeTies generally had a waiting list and was a preferred option for many workers for a number of reasons.9 HomeTies could be relied upon to monitor and assess new cases in crisis and provide intensive support to ongoing cases which were perceived to be on the brink of placement. To a large extent, public agency workers had previously been able to make referrals directly to a specific HomeTies worker and they could contact this individual directly to set up and coordinate the intervention. Also, there was no paperwork or external review of referrals associated with referral to HomeTies. Some people stressed how important it was that HomeTies had been accessible to emergency staff around the clock and would engage the family within 24 hours of the referral--day, night, or weekend, which helped to stabilize families. This was especially important to investigative staff who have historically referred the cases, when they perceived families to be in crisis. Some workers thought that some of these advantages were reduced or eliminated by the initiation of the study (see discussion of the impact of the study on referrals below).
In general, most administrators and workers viewed HomeTies as successful in working with a wide range of families. DCS workers said that the best candidates for HomeTies were families who needed assistance with communication skills or anger management. Public agency supervisors said that HomeTies staff are often perceived by clients as allies whereas DCS staff are perceived as the enemy. The supervisors also said that HomeTies has been particularly successful with acting-out teenagers, and with families where parents do not want to work with DCS. HomeTies is willing to try a number of workers to create a “good fit” with a family.
DCS staff also had some negative comments and concerns about the program.10 These included:
- Uneven staff - some staff are too “gullible” - they believe “stories” families tell;
- Some workers are intimidated by families or refuse to go to some homes (this appeared to be particularly frustrating to public agency staff because they do not have the option to refuse a home visit);
- Some staff are reluctant to work with drug using families (DCS staff believe this is because of personal risk issues of HomeTies staff and not a clinical decision);
- HomeTies recommends removal more frequently than agency staff.
HomeTies has very few “turnbacks,” DCS staff estimate 2-3 percent of all referrals are turned back to the agency, almost all within the first seven days. The majority of turnbacks are the result of a family's unwillingness to cooperate with the program. The other two reasons cited for turnbacks are: a) a family has too many problems (generally a violent adolescent) and the worker is at risk; or b) the children are not at imminent risk of state custody.
Once HomeTies has completed its four to six weeks of intervention, the worker reports to DCS staff about the continuing level of risk in the family and makes recommendations about the family's continuing service needs. DCS staff report that they almost always accept the program's recommendations about the family. According to Emergency Response workers interviewed (those that investigate within 48 hours), 90 percent of their cases are closed directly after HomeTies intervention. The remaining 10 percent are transferred to ongoing services for continued supervision. Ongoing/High Risk Workers estimated that 60 percent of their cases are closed directly after HomeTies intervention; the remaining 40 percent remain open.
Frayser Family Counseling's (FFC) HomeTies Program. In Shelby County, HomeTies is offered by Frayser Family Counseling, a private, non-profit community mental health center. The center has 95 employees including psychologists, psychiatrists, nurses, and other mental health personnel. The center provides voluntary outpatient services to individuals of all ages. Among its many services are individual and group therapy, in-home family preservation and support services, alcohol and drug therapy, victim assistance, and child and adolescent evaluations.
In May 1997, HomeTies had three supervisors and fifteen counselors,11 with 5-6 workers per supervisor. In 1997 and 1998, HomeTies was funded for 21 counselor positions and three supervisors. Community mental health started losing dollars because of TennCare, and quickly learned that if they worked outside the model and saw more of the same numbers of families with fewer staff, they increased their revenue. The program director serves as one of the supervisors. Another HomeTies supervisor is responsible for the Life Coach program. Nine of the HomeTies workers also take Life Coach cases (see discussion below).
Two of the workers had over fifteen years of experience in the field, five workers had 5-10 years of experience in the field, and the other eight workers had 2-5 years experience. All staff are required to have two years of experience when they are hired. Twelve of the workers were female and twelve were African American. Sixty percent of the workers have master's degrees (the state requires at least 50%), six of which are in counseling, two have MSWs, and one has a masters degree in criminal justice. One of the staff previously worked at DCS.
Workers are supposed to serve 1.5 cases per month (21 case workers x 18 cases per year), for a total of 378 cases per year. The program director estimates that 60 percent of the cases are referred to HomeTies by DCS, 30 percent by Community Service Agencies, and 10 percent by the juvenile court, with less than 1 percent from mental health centers.
HomeTies cases can be extended for up to two weeks, but this occurs in less than 5 percent of cases. One possible reason for the rarity of extensions is the availability of other services in the agency (i.e., Life Coach, see below). The agency also provides a six-month check-in with families when the child is still in the home.
HomeTies and Life Coach. Because Life Coach serves some control group cases, it is important to describe the relationship of HomeTies to Life Coach. In addition to sharing staff, HomeTies and Life Coach (LC) are intermingled in several other ways. First, workers reported that approximately 35 percent of HomeTies cases go to Life Coach for follow-up services, usually with the same worker providing the services. These services ($60 per day, about 70 percent of the HomeTies rate) are usually provided for 30 days, but can last as long as needed. Second, control group cases were being referred to LC. The Life Coach supervisor said that there is no difference between LC and HomeTies. The program director basically agreed, but said that LC workers spent slightly less time with families (4-7 hours per week).
One difference between HomeTies and Life Coach is that referrals to LC must be reviewed by the prevention team (at the time, DCS and ACCT). Also, LC cases did not have access to flexible funds (i.e., $250 in cash). HomeTies workers often work overtime on LC cases. If a worker has two HomeTies cases, he or she can only have one LC case.
Other information about referrals. Many of the referrals involve parent-child conflicts in which the parent wants the worker to fix the child. According to therapists, approximately 65-70 percent of families have substance abuse problems and 95 percent include one person (usually the mother or the child) who takes psychotropic medication. Other prominent problems of children and families include school behavior and attendance, child behavior at home (e.g., not doing chores, not following rules), housing problems, parents' relationships, domestic violence (relatively few cases, some with past incidents), failure-to-thrive infants, and drug-exposed infants. Referrals of drug-exposed infants were more frequent earlier, and staff were unclear why these cases are not being referred.
Workers and supervisors were generally satisfied with the types of referrals they receive, though workers stressed that DCS should screen parents who are mentally ill for appropriateness. Turnbacks of referrals to DCS occur if there are seven days without contact with a child because of parents refusing services, parents wanting the child placed, the child running away, or failure to comply with safety plans.
When asked which cases were most appropriate or inappropriate, supervisors contested the idea of a typology of cases based on problems (such as drug abuse or mental illness) or even problem severity. They stressed instead that the issue of motivation was more important in determining the difficulty of a case, and they stressed techniques for building motivation (see below). This is consistent with some of the issues that have been raised previously in discussions of the difficulty of targeting families for referral to FPS--that one cannot know before referral the extent of family problems or the family's responses to intervention except within the context of the helping relationship.
Cases are assigned to specific workers based on openings, except for a small number of cases, for example, a sex abuse case might require a female therapist.
Training and supervision. All staff, called therapists, are trained by BSI in the Homebuilders model. While this basic training was viewed positively by supervisors, it was not considered sufficient preparation for actual work in the field, especially for younger, non-Masters level staff. Newer therapists receive individual supervision for 3-6 months, and they shadow other therapists for at least one full case, present cases at weekly staffings, and are shadowed by another therapist when they take on cases.
Supervisors provide general professional support to workers and personalized coaching on clinical skills. In addition, they described supervision as a process of helping workers learn to: a) focus their efforts with families by picking workable issues (i.e., ones that could be addressed in four weeks) and reducing DCS goals to core issues and goals; b) communicate to the family and DCS that the therapist is working with the family's agenda (knowing also that the family's goals can change as they become more aware of opportunities); and c) continually assess the family strengths, needs, and goals, and the situation, and to be flexible in their approaches to helping families based on assessments.
Practice approach. Supervisors and therapists identified important purposes and strategies of working with families (in addition to those mentioned above related to supervision), and some of the benefits of in-home services. The descriptions here are intended to be illustrative of how staff approach practice at FFC, not a comprehensive description of practice.
Staff noted the importance of identifying family strengths by looking at the situation and family members' motivation. Staff emphasized the importance of building motivation in the family to change and of building a sense of empowerment. These appeared to be interrelated goals that are particularly important for families who are referred to HomeTies --who wouldn't ordinarily seek help. These goals are accomplished through a variety of means, including:
- Spending time with families in their world and at times that are convenient for them;
- Assuring families that HomeTies staff are not from DCS and the families can ask them to leave;
- Listening to family members' perspectives in a non-blaming, respectful manner--this is often the first time families have experienced this;
- Determine what the family's goals are and examine how they can relate to the goals of the public agency;
- Showing them that they have power to change some things by identifying small steps that can be made to improve the situation--showing parents they can be different by breaking down big foggy clouds of problems into small parts; and
- Focusing on solutions.
Therapists note that the first things that they do is to assess and address safety issues and concrete needs. Safety issues include running away (e.g., you don't tell them what to do, but you talk with them about what they do to stay in the home), suicide assessment (e.g., ask about attempts, weapons, and pills; lock up pills), and physical abuse (agree to a no-hit policy while HomeTies is in the home).
Staff also noted that using flexible funds ($250 per family) generously and creatively (e.g., refrigerator, rent, car, utilities, moving, food, meals out) to meet a family's initial concrete needs is a very helpful strategy in HomeTies. Use of flexible funds must be approved by supervisors, and workers consider or try other means of addressing concrete needs first.
When working with parent/child conflict cases, therapists suggest that parents have generally lost their power, have their own issues with conflict, or inappropriately want the child to be their friend. Therapists often work with parents separately, and try to show parents that they can be powerful and help parents see the good in their children and respect the perspectives of the children. Therapists also noted that behavioral charts with agreed upon goals and reinforcers are very helpful in promoting specific changes in roles and behaviors.
Therapists refer to other social services in 50-60 percent of cases. They try to identify needs as early as possible so that referrals can be made. Sometimes families are able to start other services during HomeTies, other times they are placed on waiting lists. Services used include day care, homemaker services, and parenting groups, as well as other state and federally funded rape crisis services, HIV support groups, vocational rehabilitation for the mentally retarded, mentoring, respite, drug treatment, psychiatric treatment, housing advocacy, counseling, telephone hook-up, and free concrete services provided by churches.
While noting that in-home services are more difficult and stressful than traditional therapy and that they involve a shorter engagement period, the therapists believe that in-home services are better, “one month of in-home is worth 6-12 months of outpatient.” Therapists noted the following benefits of HomeTies:
- Better assessment: they know much more about families because they see conflict, caring, housekeeping, and parenting in the natural environment;
- Parents can see that they have power, that children have positives, and that children will change;
- Parents like the program;
- Families are empowered, and gain improved communication, relationship, and anger management skills;
- There are more teachable moments with in-home services; and
- Workers can be real with families.
Relationship with DCS. Supervisors expressed concerns about the low proportion of DCS workers who refer to HomeTies, the high turnover of DCS staff (many new DCS workers don't know about HomeTies), and the poor training and supervision provided to DCS workers. They viewed the DCS workers as pleasant, but noted that they frequently need to educate them about HomeTies. Sometimes, though this happens infrequently, DCS staff expect HomeTies staff to act as investigators rather than therapists. There was some concern among supervisors and therapists that DCS workers are hard to reach by phone, but therapists said that communication with DCS occurs during services and is generally good, and that DCS really tries to be available for meetings.
(9) 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% 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.
(10) 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.
(11) 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.