Tennessee’s Continuum of Care Prompts New Processes
Youth Villages, Tennessee’s largest Continuum of Care provider, no longer uses a “cookie cutter” approach to treating troubled youth. In its second year as a Continuum provider, Youth Villages made a number of substantial changes in the way it serves children. The new referral and admission process allows children to receive services more quickly, and treatment plans change frequently to meet children’s individual needs. A transitional living program has been added to the provider’s array of services to prepare young men for independent living. For younger teenagers, services have been developed to help them successfully prepare for a transition from residential treatment to therapeutic foster care. Youth Villages’ school staff has designed a transition classroom to better prepare children to succeed in school. Treatment plans are now reviewed every 2 weeks instead of monthly to allow greater focus on individualized 2 goals in hopes that better collaboration on goals will ultimately help reunify children with their families.
One of the promises of managed care is that it can promote efficiencies of time and money by providing more accurate assessments of client problems and the appropriate services for them through more rigorous assessment protocols. This assumes that there are a significant number of cases where the child is receiving services that are more intensive than necessary to reach desired outcomes and that it is possible to determine who these children are. These assumptions are supported by the extensive research on outcomes since the passage of the Adoption Assistance and Child Welfare Act (P.L. 96-272) in 1980, by the growing experience that social workers have in managing permanency outcomes, and by the ongoing refinement of assessment tools.
As with all aspects of managed care reforms, there is a wide variation in assessment protocols and their use in the initiatives. Numerous states require that contractors accept the state’s predetermined level of care for individual clients. Some states use independent third-party contractors to conduct a binding assessment. Most of the states allow a contractor to complete a postreferral assessment as the basis for determining a treatment plan. In some states where the target population is children with high-end needs, level-of-care assessments are often used as a screening mechanism to ensure the least restrictive setting for children. The rationale for this is that such children represent a small part of the total population but a significant part of expenditures.
Assessments can be performed by the state agency, the contractor, or an independent third party. Some of the most innovative approaches involve the use of independent third-party assessments. In Texas, the contractor performs a battery of assessments and then turns the material over to an independent third party who determines the level of care, which is absolutely binding on the contractor. Because these two agencies had extensive previous interactions, they are able to achieve agreement about the level of care for approximately 95 percent of the cases. There are real financial stakes for the contractor in correctly assessing the level of care because the flat-rate case payment is based on a historical average of the level of care needed for the target population. This average is about 3.6 on a scale of 1 to 6 where 1 is regular foster care and 6 is an intensive residential care facility. In the first year of the program, the average level of care was approximately 3.2. The second year, however, the average level of care was about 3.8-3.9, which exacerbated other financial strains facing the contractor.
In Kentucky, as well, an independent agency assesses level of care. The primary function of this agency is to adjudicate conflicts between the state and the contractor about the appropriateness of a referral. If the contractor disagrees about the appropriateness of the referral, it reviews the case with the state. If this review does not resolve the disagreement, the contractor can bring the case to the independent review agency, which examines the records and makes its own determination. As of the beginning of the second year of operation, this independent review had been used four times, with each party winning twice. Although the contractor is allowed to reject a limited number of cases over the course of a year, the contractor has continued to offer services to the children even when the level-of-care review supports their argument that the referral is inappropriate.
Some states perform assessments themselves. Upon referral in Connecticut, for example, a child is assessed for functionality, ability, behavior in the community, behavior in the family, and behavior in school and assigned a score which corresponds to a case rate. Children then are randomly assigned to either the experimental group (the initiative) or the control group (traditional public agency services). The state does not determine services; instead, the contractors develop treatment plans.
Many states (such as Maryland and Tennessee) allow the contractors to conduct their own client assessments so that they can develop their own service plans. In Maryland, the contractor takes the service plan originally developed by Baltimore caseworkers and other case records, meets with the family, and then uses the Structured Decision Making assessment tool to see if the original service plan needs to be revised. In Tennessee, contractor caseworkers have 15 days to conduct a thorough assessment. They use a triage system to place the child initially while they perform the assessment. Their assessments include a social history; an Early and Periodic Screening, Diagnostic and Treatment screen; a community risk assessment to assess the risk the child poses to the community; and family strength and weakness screens. This assessment then feeds into the continuum of services the contractor offers. As a result of this system, Tennessee has been able to greatly reduce its use of emergency shelters.
There are degrees of integration of assessment and case planning. Some states (such as Connecticut) keep assessments separate from the development of a treatment plan. Connecticut initially assesses a child using a set of four-point scales that determine the child’s functioning. The assessment is then given to the contractor, which has the responsibility to develop a treatment plan for how it will broker the services. The reason for giving the contractor this responsibility is that the state does not want the assessment to limit the flexibility that the contractor has. However, many states seem to integrate assessment and case planning tightly. In Oklahoma, for example, all long-term cases requiring prevention, reunification, and placement maintenance services are referred to a contractor, which then conducts a battery of assessments and develops an intervention plan.