The HomeRebuilders project was a major effort to change the foster care system in New York City. Based on the premise that paying for each day a child is in foster care (per diem payment) is a disincentive to return children home, the demonstration tested an alternative method of agency reimbursement. Instead of paying for each day in care, agencies were paid a flat amount of money or capitation payments. A 3-year projection of care day utilization was calculated based on each agency's historic care day usage. A strategy was agreed upon to pay agencies a percentage of the 3-year capitation each year. Funding was front loaded in the first year to encourage early discharge.
It was hypothesized that the change in the payment system would achieve earlier permanency for children through intensified discharge planning and aftercare services. Funds could be used for foster care costs and any services the agencies believed would achieve earlier permanency. Although the same fiscal methodology was designed for all six agencies, a particular program model was not mandated. Instead, the demonstration emphasized common themes, and it was incumbent upon the agencies to establish programs to achieve permanency in a more timely manner.
In this chapter we presented the service delivery changes implemented by the agencies. All agencies reported that they made a number of changes in their programs to accomplish the demonstration's objective. As a group, the agencies identified core features they believed were necessary to achieve earlier permanency for children. These include:
- Triaging procedures to prioritize cases that had been languishing in the system with problems that could be resolved quickly;
- Monitoring procedures to track the budget and progress of cases;
- Reducing caseload size to facilitate increased contacts and family problem solving;
- Implementing ongoing training of caseworkers, supervisors, and administrators;
- Developing partnerships between foster and birth parents to expedite permanency;
- Using flexible funding to develop resources necessary to expedite permanency (e.g., housing options and drug treatment); and
- Developing intensive discharge and aftercare services.
These core features comprise changes in decision-making and services provided. Changing the focus and approach to case planning decisions and service provision was accomplished in varying degrees across the agencies. Little Flower and St. ChristopherJennie Clarkson exhibited the most comprehensive changes in both decision-making and service provision. Triaging procedures, extensive case review, and intensive aftercare services were among the changes they systematically made. New York Foundling did not make extensive service provision modifications, but they made changes which had a direct effect on decision-making. They reported a new approach to handling adoption cases and extensive case review procedures that placed a new focus on permanency. By contrast, Harlem Dowling, Miracle Makers, and St. ChristopherOttilie said they focused on enhancing strategies and procedures that were already in place.
Triaging. While four agencies reported a method of prioritizing cases, only Little Flower and St. ChristopherJennie Clarkson implemented systematic procedures to prioritize cases and monitor their progress throughout the demonstration. Little Flower identified cases that could be returned home quickly and expended funds up front to achieve additional discharges during the first year. They then used aftercare services to maintain the savings accrued from the "early" discharge of these children. Little Flower maintained strong case planning throughout the project. St ChristopherJennie Clarkson began its planning by surveying workers about the three main problems preventing children from returning home in each case. Based on the results, specialists were hired and a family services unit was developed. The unit played an integral role in assessing family needs and working with caseworkers to make decisions about the services needed to achieve permanency. A focus on decision-making was a key aspect to both agencies' procedures.
The other agencies identified procedures for prioritizing cases. However, it was unclear whether these procedures were systematically implemented. Although New York Foundling did not identify procedures for triaging or prioritizing cases, there was an intensive case review process implemented for the experimental group. Each case was individually assessed with a strong focus on achieving permanency.
Monitoring. Two levels of monitoring were implemented, fiscal monitoring and individual case progress. Overall fiscal monitoring included matching the expected number of discharges to the actual numbers and the amount of money expended. The state helped the agencies monitor progress towards meeting their targets of reduced care days by providing reports on their care days. A joint monitoring venture between agency budget and program divisions was necessary to coordinate case decisions with financial reality. Again, agencies used these reports and implemented joint monitoring in varying degrees, and Little Flower implemented the most comprehensive monitoring. For example, they built an actuarial file of the children's length of stay from their own database. They monitored the expense and compared the number of actual discharges to the expected number and reviewed them case by case with program staff monthly. Although Miracle Makers hired a budget person to monitor the HomeRebuilders project, the extent of coordination between budget and program was not as apparent as at Little Flower. All agencies reported procedures to monitor individual case progress, but these procedures were not necessarily newly implemented for the demonstration.
Staffing Plans. Four out of six agencies recruited casework staff specifically for the experimental group. Only New York Foundling and St. ChristopherJennie Clarkson did not hire new casework staff. In the four agencies, hiring criteria were set at a higher level for the experimental group; at Harlem Dowling and Little Flower the experimental caseworkers were paid at a higher rate. All agencies hired a number of specialists to help address the problems preventing permanency for children. Little Flower and St ChristopherJennie Clarkson made the greatest investment in new staff. Both helped promote the relationship between foster parents and birth parents and visitation of birth parents by using case aides (Little Flower) and parent aides (St. ChristopherJennie Clarkson). In addition, all agencies except New York Foundling reduced caseload size for the experimental group.
Training. Training was similar across agencies. It was most prevalent the first year with the majority of caseworker training focused on casework issues rather than administrative tasks.
Flexible Funding. The agencies' ability to use funds for other than foster care costs was cited as critical to changing the focus of service delivery. The funding allowed flexibility in planning at the administrative level (staffing, investment in new resources) and also provided caseworkers flexibility in purchasing services for the family. They were able to purchase daily necessities such as groceries and clothing. In addition, money was available to use for housing security deposits and purchasing drug treatment services. There was no evident difference across agencies in the way front line staff used flexible funds. All staff expressed great enthusiasm about having the ability to purchase needed services. Staff at Harlem Dowling reported that resources developed through flexible funding have continued to be available to clients. There was a difference in the use of flexible funding across agencies at the administrative level. Little Flower's strategy was to spend money up front to achieve additional discharges during the first year. At Little Flower, there was a deficit during the first year in relation to the planned 43 percent of total budget. The other five agencies were more conservative in their approaches and underspent during the first year.
Aftercare Services. A hypothesis of HomeRebuilders was that stronger aftercare would allow earlier discharge of children from foster care. Agency staff reported that just knowing that aftercare was available allowed them to take more risks in deciding to return children home. Harlem Dowling, New York Foundling, and St. ChristopherJennie Clarkson used separate workers to provide aftercare. The other agencies used the same worker that provided in care services. Although all workers spoke about aftercare, it was evident that there was not a clear definition of what constitutes aftercare services. Frequency of service varied by agency and was usually determined by the family. Some staff confused the ability to provide aftercare services with the existing New York policy of a 3-month trial discharge.
Conclusion. Capitation payments were intended as a catalyst to change the way foster care services were provided. The intent was to accelerate decision-making to achieve earlier permanency for children. To help decision-making, a number of service delivery options were encouraged. While all of the agencies incorporated various options, Little Flower and St. ChristopherJennie Clarkson implemented change with a distinct purpose, and took advantage of the experiment to implement new decision-making procedures. They put systematic triaging strategies in place to identify cases for earlier permanency. They also made use of the demonstration to develop new resources that ensured more visitation and better relationships between foster parents and birth parents. Although New York Foundling did not incorporate major changes, it implemented two decision-making components to create early permanency. First, it changed the service delivery approach for adoption cases by beginning adoption procedures earlier and encouraging kin to adopt. Second, there was an emphasis on strong case planning in the experimental group, with management very involved in case review. The other agencies consciously decided to add resources to enhance their existing delivery systems. They did not systematically implement new decision-making processes in the experimental group. Instead, the initiatives focused on enhancing service options and reemphasizing permanency strategies. In Chapter 3 we explore whether capitated rates and agency distinctions affect the number of care days, rate of discharge, recidivism, and child and family functioning.
Agencies suggest that their success should be measured by how well they met their target goal of 10 percent reduction in care days from a baseline computed on the basis of historical experience in each agency. Based on an analysis done by the state, all sites had average care days that were lower than the baseline. However, this was true for both the experimental and comparison groups. Because both the experimental and comparison groups had declines in average care days, it is difficult to conclude that the experiment was the reason the care days declined (see Chapter 3 for further explanation).
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