Ohio’s title IV-E waiver demonstration was implemented in October 1997, and Franklin county’s initiative (part of the waiver) was implemented in July 1999. This initiative combines performance contracting and managed care contracts. Its goal is to reduce length of stay and increase flexibility of services.
The target population is all children and families with reports. When a case comes in, it is randomly assigned (a requirement of the waiver) to the public agency or to one of two managed care companies. The public agency is using performance bonuses and incentives linked to success. The two managed care organizations include the Ohio Youth Advocate Program (a full-service provider) and the Permanent Family Solutions Network (a collaborative of three large services providers). Currently the managed care organizations are serving about 17.5 percent of cases (1200 children out of 6300).
The contractors have a "no reject/eject" requirement for all children randomly assigned to them. They are required to provide intake, assessment, and case management for all cases, plus whatever services indicated by the treatment plan. Services that the contractors must make available include crisis intervention, homemaker, home health, parenting skills education, home-based services, transportation, outpatient and inpatient mental health, partial hospitalization for children, treatment for children who commit sexual abuse, substance abuse assessment and treatment, programming for children with developmental disabilities, assistance in accessing services, access to medical services for children, emergency aid for household expenses, protective day care, crisis placements, foster care services at all levels, residential treatment for children, intermediate residential programs for children, reunification services, independent living arrangements for adolescents, and linkage to community services when families are reunified.
The public agency is using a staff "bonus" system as incentive to increase permanency in cases handled by public agency staff. They receive yearly raises based on success at achieving outcome goals including visits and recidivism. An interagency team (the Intersystem Program) is used to develop wraparound services for children in the care of the public agency.
The primary payment to the contractor is made on a Continuum of Services (COS) basis (i.e., case rate), which is $23,074. This covers all services provided to the child and family. Partial payments are made at three points: 50 percent is paid at referral, 40 percent is paid at three months from the referral, and 10 percent is paid at case closing. When the costs of a case exceed four times the COS payment amount, with prior written approval the County begins paying 50 percent of the direct service costs excluding the costs of case management.
The contractors utilize case management, outcomes monitoring, and service coordination. Contractors are responsible for all services needed for up to six months after the case is closed. After that, contractors can be paid in "fractional" payments after case closure. Risk corridors were established as follows: In the first year, the contractors are responsible for the first 5 percent of costs that exceed revenues and may retain the first 5 percent of "excess" revenue. In the second year, the risk corridor rises to 10 percent. In the third and subsequent years, the corridor is 15 percent. The next 10 percent of excess costs or revenues each year will be shared by the contractors and the County equally up to 5 percent each. The County is responsible for excess of costs beyond the corridors.
The County's quality assurance department monitors the contractors, and service provision is monitored against indicators of increased risk to children and expectations for client contact and service documentation. Outcomes are monitored, and each outcome indicator has a goal threshold. Client data are entered into the MIS daily. Franklin County is part of the IV-E waiver, which is being evaluated by independent evaluators.