Prior research has found that most managed care initiatives targeted children in foster care, although there was a trend toward also including children at risk of placement (McCullough and Schmitt, 1999 and 2001). In the initiatives described in this report, the target populations range from a narrow population of children in care to the entire child welfare population. Many of the initiatives target children and families with high needs. The rationale for targeting a population with severe behavioral or mental health problems or special education needs is that often the outcomes are poor, which creates a need to find different ways to address the problems, and the costs are high, which creates a visible target and builds in incentives for reducing costs. These target populations include seriously emotionally disturbed children (California, Georgia); those with serious behavioral health needs as measured by a standardized instrument (Missouri, Texas, and Washington); those with placement needs higher than traditional foster care (Connecticut, Tennessee); and adolescents with high needs (Colorado, Kentucky). Generally these initiatives encourage service provision in the least restrictive and costly setting appropriate and often provide mechanisms for conducting enhanced assessments to better plan services.
Initiatives that target all or most of the foster care caseload hope to achieve widescale improvements in permanency outcomes. For example, the initiatives in Illinois and New York City were designed to encourage providers to achieve efficiencies and improve permanency outcomes for children in care, and both cover most of their foster care populations. Maryland’s managed care initiative in Baltimore was implemented to reduce placement length-of-stays for young children in care, and the target population is all children ages 0-5 in care and their siblings (and some other types of children). These initiatives attempt to address the economic incentives to keep children in care, discussed in Section 1, by offering economic incentives to shorten lengths of stay (with safeguards intended to ensure appropriate placements).
Some initiatives target children not in care but at risk of placement, both to avoid the costs of placement and to provide alternatives to removing children from their homes. The initiatives in Massachusetts and Oklahoma primarily serve children in their own homes who are at risk of placement, with some services provided to children in care (in Massachusetts, the initiative serves over 75 percent of all children in the child welfare system). Arizona’s initiative targets low-risk or potential-risk families in order to prevent escalation of maltreatment into a higher risk category that would require taking children into custody.
Other initiatives target the entire child welfare population, for all the reasons noted above. Florida’s and Kansas’s statewide privatization requirements include all children in the child welfare system. Ohio’s and Wisconsin’s initiatives also target all children in the child welfare system in their geographic areas (Franklin County, Ohio, and Milwaukee County, Wisconsin); Ohio has other managed care initiatives in several other counties (both as part of the title IV-E waiver and outside the waiver).