In most of the states, a caseworker or other child welfare worker refers children or families into the initiative by using guidelines or protocols (as in Arizona, Massachusetts, Oklahoma, Pennsylvania, Tennessee, and Wisconsin). The most complex guidelines were used by the managed care initiative in Berks County, Pennsylvania, which developed a detailed protocol for county intake workers to follow. After going through selection/admission criteria step by step, if the protocol indicated that a case was appropriate for the managed care initiative, the case was referred. Additional decision trees to be followed by service providers accompanied the case. The complexity of the protocol was one factor in the demise of the initiative, as both county workers and providers found the process daunting.
A few initiatives use other referral procedures. For example, initiatives incorporating title IV-E waivers (those in California, Connecticut, Maryland, Michigan, Ohio, and Washington) involve referral through random assignment after workers applied screening criteria, which is a component of the required evaluation design of these demonstrations. Other initiatives have automatic referrals if a report was founded (Florida) or if a case meets criteria (Missouri and Texas).
Sometimes cases are screened or even referred by an interagency team. Often the initiatives involve interagency teams developing treatment plans and, in effect, pre-authorizing services. Thus one of the major features of the fiscal reforms involves implementing a team approach to referring cases, identifying family need, and specifying services, taking that responsibility away from the individual caseworker. For example, the managed care initiative in Boulder County, Colorado, institutionalized the interagency approach by developing a new organizational entity comprising representatives of all local child- and youth-serving agencies (corrections, probation, mental health, social services, public health, substance abuse services, and other community agencies); each agency contributes funding that is pooled. The new entity handles case management and contracts with private providers for services. This approach takes a child or family out of a specific system, provides for collaborative decisionmaking, reduces cost-shifting, allows flexibility in services, helps to identify and address gaps in services, and eliminates duplication of services. A challenge is that cooperation and service integration require the development of trust and clear role definition. Although some caseworkers oppose the shifting of responsibility to a team, an advantage is that it gets more agencies invested in the care of the children and aware of the issues that need to be addressed.
Most of the initiatives have a "no reject, no eject" requirement whereby contractors cannot refuse any referral from the public agency or disenroll any child until all objectives are met. Kentucky’s initiative has a provision that allows contractors to protest a referral and a third party to decide whether the case is appropriate for the initiative. Michigan's experience with a title IV-E waiver initiative highlights the effect that risk aversion can have when contractors can choose whom they serve. In that initiative, community contractors are allowed to develop their own screening criteria, which has the effect of only relatively "easy" children being accepted for services. Since the capitated rate is based on historical averages of payments for all children (including children in specialized treatment foster care and residential placement), the contractors are able to minimize their risk and accumulate money in their "risk pool."