Evaluation of the New York City Home Rebuilders Demonstration. 2.2 The Planning Phase

09/14/1998

In September 1991 the state and city met with the directors of six selected agencies to propose the radically new funding mechanism that became HomeRebuilders. Subsequent talks were held and one of the agencies dropped out of further involvement. This agency was primarily involved in providing congregate care and determined that the proposed reimbursement structure would not be beneficial. Representatives from the remaining five agencies along with staff from the city and state became known as the Interagency Steering Committee. The committee met at least once a month during the planning stage, during which time the city and state officials involved (notably Claude Meyers and George Gabel from the city and Don Smith and Fred Wulczyn from the state) became convinced of the commitment of the agencies to the project. A sixth agency was added to the group after the planning process had begun. The six agencies were Harlem Dowling, Little Flower, Miracle Makers, New York Foundling Hospital, St Christopher-Ottilie, and St. Christopher-Jennie Clarkson. These agencies included both Catholic and Protestant affiliated organizations.

Executives or senior program managers represented the six agencies. The committee addressed policy and organizational issues. Major topics discussed included clarification of legal and programmatic aspects of aftercare, program evaluation, cash flow and fiscal risk, community-based service delivery, identification of target populations, and triaging of services to families. Initially, the HomeRebuilders program was conceptualized as a reunification program. In some of the agencies, there were not enough cases with a reunification goal and the program was expanded to include adoption cases. The inclusion of adoption cases broadened the scope of HomeRebuilders beyond reunification to permanency more broadly.

Planning meeting discussions frequently focused on service triaging. In the medical profession triaging refers to servicing cases based on the severity of the problem. Treatment is directed where it will do the most good. For the HomeRebuilders demonstration, triaging also meant sorting cases by severity of the problem, and the concept was used to identify those cases that would most likely be reunified or adopted if services were provided. Agencies were encouraged to develop a framework to (1) establish criteria for identifying children who were most likely to be reunified or adopted, (2) communicate the criteria to staff, and (3) support staff through developing new resource options. Historically, service provision was based on availability of service and eligibility of the child and his family. Coupled with the new options provided through flexible spending, triaging was introduced as a new way to prioritize and deliver services. Service decisions were not to be based on "categorical need," but on whether the service helped reunification occur faster and more securely.

The steering committee discussed the barriers related to reunification and struggled with identifying criteria that separated children who were "short stayers" from "long stayers." This concept was critical to identifying families that might benefit from quick intensive intervention versus those for whom intervention would unlikely produce reunification.

The committee discussed triage as the key component of budget planning within a capitation setting. Agencies were challenged to develop strategies to meet their overall goals of reduced care days. For example, agencies might triage by identifying a small number of families they felt could be discharged earlier if appropriate services were provided. Investment could be made to reunify families quickly and then work hard to avoid recidivism. Although agencies might expend extra money upfront, savings were to be accrued by having these families reunified throughout the 3-year project. Another option might be to put in place services that focused on reunifying more families by gradually trying to improve the timeliness of each discharge throughout the three years. This might entail targeting specific problems (e.g. housing) which create barriers to reunification rather than classifying families as short or long stayers. Each agency then designed implementation procedures around their decisions about how to prioritize cases. As discussed later, some agencies made broad changes while others changed only slightly.

Some program staff were concerned that triaging could be interpreted as denying services to families who were not selected for specialized service. Also, agency staff questioned whether the differentiation of services for the experimental and comparison group could be considered negligence and lead to lawsuits. In fact, legal staff were drawn into the discussion and the conclusion was that HomeRebuilders was a demonstration and until evaluated, no one could be sure that the program was delivering better services.

Steering committee discussions also addressed issues of organizational culture. How do you help caseworkers and city case managers go from an environment of categorical funding to triage? Areas of training and need for supervision were emphasized. Most participants agreed that all the debates and discussions were vital training for executives planning to participate in a demonstration of any managed care principles.

Once the demonstration began, the steering committee continued to meet, although less frequently. In addition to the steering committee, a program directors committee was established. This committee also included direct service representation from each of the six agencies, the state, and the city. This group focused on operational issues of implementation. Special attention was given to training and interagency coordination. Several program directors described this committee as a unique experience that struggled with solving problems. In particular, the tension around meeting target goals pressed members to bring issues to the table and share recommendations for quick resolution. This committee continued to meet regularly during the entire project.

The steering committee established criteria for the characteristics of children to be included in the demonstration. For the most part, the agencies were allowed to choose which of their sub-populations would be sampled for the demonstration. Agencies made their population selections based on adequate population size and programmatic interest. The state required that each agency choose criteria to ensure that the population size was adequate to select a sample of 400 children.

During the planning stage, the state led discussions to help each agency understand the city's and each individual agency's historical pattern for discharges and readmissions. The impact on length of stay on age of children, whether the children were in relative care, and whether the children had a permanency planning goal of adoption were considered.

Table 2-1 depicts the final agreed upon criteria for each agency with respect to age, permanency goal, type of placement, time in care, and the number of children assigned to the control and experimental groups. Case characteristics of study populations varied by agency. Children's ages ranged from younger than 12 to 17 years old. Two agencies included only children in foster boarding homes, with a permanency goal of return to home, while the remaining agencies included children with the goal of adoption. These same four agencies included children in both foster boarding homes and approved relative placements. Four of the agencies included children who were in care for more than 90 days, while the remaining two agencies included all children.

Table 2-1.  Assignment of Children

  Number of Children Criteria        
Agency Experimental Group Control Group Age Permanency Goal Type of Placement Time in Care
Harlem Dowling 197 182 Under 12 RTH
ADP
FBH
ARH
Over 90 days
Little Flower 302 290 Under 17 RTH FBH Over 90 days
Miracle Makers 217 188 Under 12 RTH
ADP
FBH
ARH
Over 90 days
New York Foundling 380 403 Under 17 RTH

ADP

FBH
ARH
Any child
St. Christopher­Ottilie 200 200 Under 13 RTH FBH Over 90 days
St. Christopher­Jennie Clarkson 250* N/A Under 18 RTH
ADP
IND. LV.
FBH
ARH
Any child

* After 1 month of participation, the agency placed the remaining children in the experimental group.  This increased its total to 484.

Key:  RTH = Return to Home; ADP = Adoption; FBH = Foster Boarding Home; ARH = Approved Relative Home; IND. LV. = Independent Living.

The demonstration was originally designed with procedures for random assignment of children to either a comparison group that received the regular services offered at the agency or an experimental group that used the HomeRebuilders model. Every attempt was made to assign all siblings from one family to the same group. Three agencies, Miracle Makers, Little Flower, and Harlem Dowling, used random assignment procedures. Two agencies, St. Christopher-Ottilie and New York Foundling, divided the comparison and experimental groups based on agency sites. One agency, St. Christopher-Jennie Clarkson, placed all of its children in the experimental group.

From the beginning, HomeRebuilders was viewed by all state officials interviewed as a unique and creative example of managed care that provided new ways to think about planning, rate-setting, and practice. The model broadened people's thinking about program design and rate setting and the relationship between the two. HomeRebuilders was seen as an important initiative for the field of child welfare. Respondents clearly recognized the importance and potential cost saving of programs that addressed the back end of the system (i.e., rates of foster care discharges and reentry into the system) and length of stay.

City officials did not accept the concept with the same enthusiasm; their reaction was mixed. Some of the administrators liked and wanted to test HomeRebuilders as a financing strategy, and they noted that HomeRebuilders forced fiscal and program directors in the agencies to manage care together by looking at data on outcomes. Case management staff liked the new roles and responsibilities that were being created for case managers. This constituted a fundamental change in the role of case managers who previously monitored paperwork and did not go into the field. On the other hand, some city officials saw HomeRebuilders as a state initiative, one that was too expensive and did not save money.

Private agency administrators understood that the state's overall goal was a reduction in the number of children in foster care. They believed that the goals set by the state were appropriate and within reach. The state's goal for HomeRebuilders was seen as a positive step toward families and communities. Most of the agency administrators believed that the city's goals were never as clear as the state's. HomeRebuilders was seen as the state's idea. Initially, the administrators believed that the city showed much resistance to the program. Some administrators believed that the city accepted the state's goals while others believed the city did not.

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