Room 450G, HHH Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
1650 Research Boulevard
Rockville, MD 20850
Chapin Hall Center for Children
University of Chicago
1313 East Sixtieth Street
Chicago, IL 60637
James Bell Associates
2111 Wilson Boulevard, Suite 1120
Arlington, VA 22201"
The Evaluation of Family Preservation and Reunification Programs, INTRODUCTION
The Evaluation of Family Preservation and Reunification Programs is a study of family preservation and family reunification programs. It is being conducted in response to the requirements of the 1993 Omnibus Budget Reconciliation Act (OBRA), which established a 5 year capped entitlement program totaling nearly $1 billion to encourage the development and expansion of family preservation and family support programs. Subsequently, the Adoption and Safe Families Act of 1997 reauthorized the family preservation and family support provisions of the 1993 OBRA for three additional years with slightly increased funding. The 1997 Act also places greater emphasis on reunification and adoption services.
The evaluation assesses whether the key goals of family preservation and reunification programs are being met. These goals are to avoid unnecessary foster care placements, with their related human and monetary costs; to ensure the safety of children; and to improve family functioning. The evaluation examines how family preservation and reunification programs work, for whom they are most effective, and the extent to which program variables, child welfare system variables, and other factors in the service delivery environment affect outcomes of programs. Family preservation programs in four states and one reunification program are being evaluated.
For the family preservation sites, an experimental design is being used in which families are randomly assigned either to an experimental group that receives family preservation services or to a control group. The control group does not receive family preservation services, but receives other services provided by the child welfare agency.
Sites in four states were selected for participation. These sites include: Louisville, Kentucky; seven counties in New Jersey; Philadelphia, Pennsylvania; and Memphis, Tennessee. At this time enrollment of cases in the experiment has been completed in Kentucky, New Jersey, and Tennessee with enrollment expected to be complete in Philadelphia by December 1998.
Information will be collected through interviews with caseworkers and caretakers to examine caretakers' parenting practices, interaction with children, discipline, social networks, economic functioning, housing, abuse and neglect, psychological functioning, child well being, and caseworker/caretaker interactions. These interviews are being conducted with:
- The investigating worker, caseworker, and caretaker of each family at the start of services;
- The caseworker and the caretaker at the conclusion of family preservation services, and at a comparable point in time for those families in the control group; and
- Caretakers one year after entry into the experiment.
After each in-person contact with families, experimental and control caseworkers complete a one page form describing the services provided during the contact. Also, cost data and case history information are collected through administrative data. Administrative data will provide information on children's placements, reentries, and subsequent abuse and neglect allegations up to 18 months after entry into the experiment. Staff attitudes and characteristics are collected through a one-time self-administered questionnaire. Throughout the project, discussions are being held with personnel of the public agency and service provider agency to gather information about agency services, policies, staffing, training, and the context of services.
While data collection efforts are the same across sites, the sites vary in their approach to identifying families for services, the populations served, and the type of services provided.
- Kentucky has a state-wide program that uses the HomeBuilders model. A state office coordinator is responsible for developing uniform selection criteria, training, contracting with family preservation providers, and oversight of the state program. The evaluation is being conducted in Louisville, where there is a single family preservation program provider and child abuse and neglect cases are being referred from intake or ongoing workers. There is no age limitation on the children included in the experiment.
- New Jersey also has a state-wide program using the Homebuilders model. As in Kentucky, there is a state office coordinator responsible for uniform selection criteria, training, contracting with providers, and oversight of the program. The study is being conducted in seven counties: Bergen, Burlington, Camden, Essex, Monmouth, Ocean, and Passaic. Each county has a separate family preservation provider. The study population includes Division of Youth and Family Service child abuse and neglect cases referred from intake or ongoing workers. The state has been trying to refocus delivery of family preservation services to families with younger children. Not all counties have modified their service delivery, so all children under 18 are included in the experiment.
- Tennessee has a state-wide program using the Homebuilders model. It also has a state office coordinator responsible for uniform selection criteria, training, contracting with providers, and oversight of the program. The evaluation is being conducted in Memphis and is focusing on children under 13 years old who are being referred from the Department of Children's Services. Cases are being referred only from intake workers.
- Pennsylvania's child welfare system is county based. The experiment focuses on the family preservation program in Philadelphia in three private agencies. Family preservation is a three-month program that requires workers to spend at least 5 to 10 hours per week with the family. The public agency has a specialized family preservation unit that develops selection criteria, approves families to receive family preservation services and works closely with the private providers. All other in-home services, known as SCOH (Services to Children in their Own Homes), are provided by private providers and monitored by the Department's caseworkers. For the experiment, private agencies, which provide both SCOH and family preservation services and treat a large number of families with substance abuse problems were chosen. Experimental cases receive family preservation services and control cases will receive SCOH services. Cases with children under 18 years old are included in the study. Ongoing cases are not included.
The reunification program being studied is New York City's HomeRebuilders Demonstration.
- New York's HomeRebuilders program began in 1993. The project was a major demonstration 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 payment. It was hypothesized that the change in the payment system would achieve earlier permanency for children through intensified discharge planning and aftercare services. Six agencies were involved in the program and random assignment was employed in three of the agencies.
This project supplemented the evaluation efforts of New York State by conducting follow-up interviews with a sample of workers and client families; analyzing administrative data; and conducting interviews with administrative, supervisory and front line staff about the implementation of the initiative.
This report presents the findings from the New York HomeRebuilders evaluation. Subsequent reports will provide analyses on each of the family preservation experiments. In addition a supplemental report on the current status of family preservation programs is in process. The report will address questions about the state of family preservation services. It provides a current picture of family preservation and the important issues affecting its use.
1. NEW YORK HOMREBUILDERS DEMONSTRATION INTRODUCTION
In 1993, the New York State Department of Social Services (DSS) and the New York City Child Welfare Administration (CWA) began testing a new approach to the financing of services to foster children and their birth families based on concepts from managed care. Before this initiative, private child welfare agencies providing foster care services were reimbursed by the state for each day a child was in foster care. Under the new approach, agencies were promised a flat amount for a 3-year period which was intended to cover the costs of providing services for an identified group of children. It was hypothesized that the change in the payment system would achieve earlier permanency for children through service continuity, intensified discharge planning, and aftercare services. The initiative involved six agencies. An experimental design was implemented involving comparison groups in five of the agencies, with random assignment in three. The new financing mechanism was to be used in the experimental groups while services to the comparison group would be paid for under the old system. Funds could be used for foster care costs and any other services the agencies believed would achieve earlier permanency.
The original intent in the initiative was to collect follow-up data from workers and perhaps families and to analyze administrative data on these families to compare the foster care experiences of children and costs in the experimental and comparison groups. However, resource limitations prevented the collection of follow-up data from workers and families and also limited the analyses of administrative data. The Evaluation of Family Preservation and Reunification Services has supplemented the evaluation efforts of New York.
The purpose of the evaluation was to document the implementation of the program and its effects on percentage of case closings, average days in foster care, family functioning, and child behavior. The evaluation included follow-up interviews with a sample of workers and client families, analysis of administrative data, and interviews with administrative, supervisory, and front line staff about the implementation of the demonstration. Administrative data on foster care careers of children were examined.
Six New York City child welfare agencies participated in the HomeRebuilders program: Harlem Dowling, Little Flower, Miracle Makers, New York Foundling, St. Christopher-Ottilie, and St. Christopher-Jennie Clarkson. The sample for the demonstration was initially selected by New York State from its records of foster care cases in the selected agencies. Criteria for selection were agency specific. The criteria were developed to fit the particular composition of each agency's foster care population.
The evaluation began about 2 years after the demonstration began and as it was facing a precipitous ending 6 months early. Involvement in the HomeRebuilders' experiment in midstream has resulted in some design limitations. While agency caseworkers had completed structured baseline assessments of the families at the beginning of the experiment, these were incomplete and were inconsistently available across agencies. For these reasons, it was decided not to use these assessments and rely solely on follow-up data. As a result it has been possible to assess differences between experimental and comparison group cases at Time 2, but change with respect to family functioning and child behavior between Time 1 and Time 2 could not be measured. Furthermore, entering the experiment at a time that a fair number of caseworkers had already left the agencies and the experiment faced termination inevitably resulted in gaps of information about the startup of the demonstration.
1.2 Sampling Strategy and Response Rates for the Follow-Up Evaluation
The experiment was originally designed with procedures for random assignment of children to either a comparison group that received the regular services offered at the agency or an experimental group that used the HomeRebuilders model. Three agencies, Harlem Dowling, Little Flower, and Miracle Makers, used random assignment procedures. Two agencies, New York Foundling and St. Christopher-Ottilie, compared children in two different offices. At New York Foundling the Bronx office was considered the experimental office and followed the HomeRebuilders approach while the Queens office continued with practice as usual. St. Christopher-Ottilie also divided its caseload geographically with the experimental group at the Queens office and the comparison group served by the Brooklyn office. At St. Christopher-Jennie Clarkson, the entire foster boarding home population was selected to participate in the HomeRebuilders project.
Based on the selection criteria, the state selected children for participation in both the experimental and comparison groups. There were about 3000 cases in the demonstration. Analysis of the administrative data used the entire sample. For the interviews, a sample of caretakers was drawn, with the goal of conducting 500 face-to-face interviews with caretakers and 500 telephone interviews with their caseworkers. To conserve resources, it was determined that interviews would only be conducted with the experimental and control cases in agencies that randomly assigned cases to these two groups. Therefore, no interviews were conducted with New York Foundling comparison cases. St. Christopher-Jennie Clarkson did not have a comparison group. Caretakers served by St. Christopher-Ottilie were interviewed because it was initially thought that the agency had applied random assignment procedures to selecting experimental and control cases. Caseworkers from St. Christopher-Ottilie were not interviewed.
A total of 433 caretaker interviews were completed and caseworkers of 407 cases were interviewed. This represents 73 percent of the caretaker and 70 percent of the caseworker cases that were released for interview.
This report documents the demonstration's implementation process and reports the evaluation findings. Chapter 2 describes the implementation of the demonstration. Chapter 3 presents findings from the analysis of administrative data and interviews with caretakers and caseworkers, conducted approximately 3 years after the demonstration began. Appendix A provides a detailed description of the design and implementation of the follow-up evaluation, Appendix B presents additional tables, and the study questionnaires are in Appendix C.
2. IMPLEMENTATION OF THE HOMEREBUILDERS DEMONSTRATION
The information presented in this chapter is based on interviews during four separate time intervals. The first set of interviews took place between January 1996 and June 1996. During this period, staff from Westat and James Bell Associates conducted site visits to each of the six agencies that participated in the project: Harlem Dowling, Little Flower, New York Foundling, Miracle Makers, St. Christopher-Jennie Clarkson, and St. Christopher-Ottilie. Both administrative staff and caseworkers were interviewed. The second set of interviews was held between December 1996 and February 1997. Chapin Hall conducted in-person and follow-up telephone interviews with public agency staff from New York City and New York State. The third set of interviews was held with one to three administrators at each agency via telephone from June through August 1997. Finally, in-person and telephone interviews were held with program and fiscal administrators in February 1998. These interviews were conducted to review and clarify study findings. This chapter documents the implementation of the HomeRebuilders Demonstration from the public and private agency participant perspective. Whenever possible, multiple sources were used to confirm information; however, it must be noted that this chapter represents the opinions voiced at each agency. In addition, the data were collected retrospectively. The study began approximately two and one-half years after the HomeRebuilders program was initiated, close to the time that funding for the program ceased. Therefore, all of the interviews were conducted after the program ended. The effect this had on the interviewees' comments is not known.
As in other areas of the country, New York experienced an unprecedented growth in its foster care population during the last half of the 1980s. Poverty, lack of education, AIDS, and the effects of crack-cocaine were some of the primary causes for new cases entering the system. Growth was also due to an increase in the length of time children remained in foster care. Between 1986 and 1990, the number of children in foster care in New York State rose from 27,000 to 65,000 (an increase of 140 percent), placing stress on the foster care system. This surge in the foster care population brought a renewed sense of urgency to the ongoing debates within child welfare regarding the role, availability, and effectiveness of program, and about funding for foster care and preventive services. There was concern that not enough service emphasis was being placed on the "back end of the system," those children remaining in foster care.
In response to these needs, the New York State DSS began the HomeRebuilders Demonstration Project, a 3-year collaborative effort among the state, the City of New York CWA, and six voluntary (private) child care agencies. The project was scheduled to run from July 1993 to June 1996. However, the project ended in December 1995, 6 months early.
The demonstration tested an alternative to the per diem method of agency reimbursement. This alternative was tested because some critics of the child welfare system argued that the per diem reimbursement mechanism slowed the discharge of children. Under the HomeRebuilders program, agencies were paid a flat amount of money, or capitation payment, instead of being paid for each day in care. The state calculated a 3-year projection of care day utilization based on each agency's historic care day usage. Agencies could spend the money on a combination of placement and social services, depending on the needs of the child and his or her family. The capitation-like payment was designed to give the agencies flexibility and still maintain accountability for quality service delivery. This funding scheme could also stimulate agency investments in services that could lead to early discharge from placement, resulting in fewer days spent in care. In particular, the funding strategy was designed to allow agencies to increase their aftercare services.
It was hypothesized that the change in the payment system would achieve earlier permanency for children through intensified discharge planning and aftercare services. If the program was successful, children in the HomeRebuilders program would spend less time in foster care than a comparable group of children not in the program. A goal of reducing time in care by 10 percent was set. Besides reducing care days it was also expected that participants would experience a reduced rate of reentry when compared with historical patterns and a suitable comparison group.
The funding for the HomeRebuilders program was based on a 3-year projection of care day utilization. Funds were frontloaded, that is, money that would have been spent in the second and third years of the project was moved to the first year so that discharge planning and aftercare services could be intensified in years 1 and 2. Funding also included a feature that permitted agencies to carry cash deficits or cash surpluses from one year to the next during the 3-year period.
The HomeRebuilders demonstration was intended to be cost-neutral for agencies, the city, and the state in regard to foster care payments for children. Funding for the comparison group used the traditional per diem mechanism, a payment for each day in care. Agencies were paid by the city, based on rates calculated by the state. A capitation rate was determined for the 3-year demonstration project based on a 3-year history of care day usage by the subpopulation in each agency. An allocation strategy was agreed upon to pay agencies up to 43 percent in the first year, 34 percent in the second year, and the balance in the third year.
Title IV-E of the Social Security Act provides for federal participation in the costs of foster care room and board and associated training and administrative costs. These funds may not be used for services to promote reunification or other outcomes. During the planning of HomeRebuilders, New York State officials worked with Congress to develop legislation that would authorize use of Title IV-E funds for the HomeRebuilders project. This legislation (included in the Urban Aid Bill) was passed by both houses but vetoed by President George Bush in November 1992. Despite this setback, the state determined to move forward, and the city and participating agencies were assured the project would proceed.
2.2 The Planning Phase
In September 1991 the state and city met with the directors of six selected agencies to propose the radically new funding mechanism that became HomeRebuilders. Subsequent talks were held and one of the agencies dropped out of further involvement. This agency was primarily involved in providing congregate care and determined that the proposed reimbursement structure would not be beneficial. Representatives from the remaining five agencies along with staff from the city and state became known as the Interagency Steering Committee. The committee met at least once a month during the planning stage, during which time the city and state officials involved (notably Claude Meyers and George Gabel from the city and Don Smith and Fred Wulczyn from the state) became convinced of the commitment of the agencies to the project. A sixth agency was added to the group after the planning process had begun. The six agencies were Harlem Dowling, Little Flower, Miracle Makers, New York Foundling Hospital, St Christopher-Ottilie, and St. Christopher-Jennie Clarkson. These agencies included both Catholic and Protestant affiliated organizations.
Executives or senior program managers represented the six agencies. The committee addressed policy and organizational issues. Major topics discussed included clarification of legal and programmatic aspects of aftercare, program evaluation, cash flow and fiscal risk, community-based service delivery, identification of target populations, and triaging of services to families. Initially, the HomeRebuilders program was conceptualized as a reunification program. In some of the agencies, there were not enough cases with a reunification goal and the program was expanded to include adoption cases. The inclusion of adoption cases broadened the scope of HomeRebuilders beyond reunification to permanency more broadly.
Planning meeting discussions frequently focused on service triaging. In the medical profession triaging refers to servicing cases based on the severity of the problem. Treatment is directed where it will do the most good. For the HomeRebuilders demonstration, triaging also meant sorting cases by severity of the problem, and the concept was used to identify those cases that would most likely be reunified or adopted if services were provided. Agencies were encouraged to develop a framework to (1) establish criteria for identifying children who were most likely to be reunified or adopted, (2) communicate the criteria to staff, and (3) support staff through developing new resource options. Historically, service provision was based on availability of service and eligibility of the child and his family. Coupled with the new options provided through flexible spending, triaging was introduced as a new way to prioritize and deliver services. Service decisions were not to be based on "categorical need," but on whether the service helped reunification occur faster and more securely.
The steering committee discussed the barriers related to reunification and struggled with identifying criteria that separated children who were "short stayers" from "long stayers." This concept was critical to identifying families that might benefit from quick intensive intervention versus those for whom intervention would unlikely produce reunification.
The committee discussed triage as the key component of budget planning within a capitation setting. Agencies were challenged to develop strategies to meet their overall goals of reduced care days. For example, agencies might triage by identifying a small number of families they felt could be discharged earlier if appropriate services were provided. Investment could be made to reunify families quickly and then work hard to avoid recidivism. Although agencies might expend extra money upfront, savings were to be accrued by having these families reunified throughout the 3-year project. Another option might be to put in place services that focused on reunifying more families by gradually trying to improve the timeliness of each discharge throughout the three years. This might entail targeting specific problems (e.g. housing) which create barriers to reunification rather than classifying families as short or long stayers. Each agency then designed implementation procedures around their decisions about how to prioritize cases. As discussed later, some agencies made broad changes while others changed only slightly.
Some program staff were concerned that triaging could be interpreted as denying services to families who were not selected for specialized service. Also, agency staff questioned whether the differentiation of services for the experimental and comparison group could be considered negligence and lead to lawsuits. In fact, legal staff were drawn into the discussion and the conclusion was that HomeRebuilders was a demonstration and until evaluated, no one could be sure that the program was delivering better services.
Steering committee discussions also addressed issues of organizational culture. How do you help caseworkers and city case managers go from an environment of categorical funding to triage? Areas of training and need for supervision were emphasized. Most participants agreed that all the debates and discussions were vital training for executives planning to participate in a demonstration of any managed care principles.
Once the demonstration began, the steering committee continued to meet, although less frequently. In addition to the steering committee, a program directors committee was established. This committee also included direct service representation from each of the six agencies, the state, and the city. This group focused on operational issues of implementation. Special attention was given to training and interagency coordination. Several program directors described this committee as a unique experience that struggled with solving problems. In particular, the tension around meeting target goals pressed members to bring issues to the table and share recommendations for quick resolution. This committee continued to meet regularly during the entire project.
The steering committee established criteria for the characteristics of children to be included in the demonstration. For the most part, the agencies were allowed to choose which of their sub-populations would be sampled for the demonstration. Agencies made their population selections based on adequate population size and programmatic interest. The state required that each agency choose criteria to ensure that the population size was adequate to select a sample of 400 children.
During the planning stage, the state led discussions to help each agency understand the city's and each individual agency's historical pattern for discharges and readmissions. The impact on length of stay on age of children, whether the children were in relative care, and whether the children had a permanency planning goal of adoption were considered.
Table 2-1 depicts the final agreed upon criteria for each agency with respect to age, permanency goal, type of placement, time in care, and the number of children assigned to the control and experimental groups. Case characteristics of study populations varied by agency. Children's ages ranged from younger than 12 to 17 years old. Two agencies included only children in foster boarding homes, with a permanency goal of return to home, while the remaining agencies included children with the goal of adoption. These same four agencies included children in both foster boarding homes and approved relative placements. Four of the agencies included children who were in care for more than 90 days, while the remaining two agencies included all children.
|Number of Children||Criteria|
|Agency||Experimental Group||Control Group||Age||Permanency Goal||Type of Placement||Time in Care|
|Harlem Dowling||197||182||Under 12|| RTH |
| FBH |
|Over 90 days|
|Little Flower||302||290||Under 17||RTH||FBH||Over 90 days|
|Miracle Makers||217||188||Under 12|| RTH |
| FBH |
|Over 90 days|
|New York Foundling||380||403||Under 17|| RTH |
| FBH |
|St. ChristopherOttilie||200||200||Under 13||RTH||FBH||Over 90 days|
|St. ChristopherJennie Clarkson||250*||N/A||Under 18|| RTH |
| FBH |
* After 1 month of participation, the agency placed the remaining children in the experimental group. This increased its total to 484.
Key: RTH = Return to Home; ADP = Adoption; FBH = Foster Boarding Home; ARH = Approved Relative Home; IND. LV. = Independent Living.
The demonstration was originally designed with procedures for random assignment of children to either a comparison group that received the regular services offered at the agency or an experimental group that used the HomeRebuilders model. Every attempt was made to assign all siblings from one family to the same group. Three agencies, Miracle Makers, Little Flower, and Harlem Dowling, used random assignment procedures. Two agencies, St. Christopher-Ottilie and New York Foundling, divided the comparison and experimental groups based on agency sites. One agency, St. Christopher-Jennie Clarkson, placed all of its children in the experimental group.
From the beginning, HomeRebuilders was viewed by all state officials interviewed as a unique and creative example of managed care that provided new ways to think about planning, rate-setting, and practice. The model broadened people's thinking about program design and rate setting and the relationship between the two. HomeRebuilders was seen as an important initiative for the field of child welfare. Respondents clearly recognized the importance and potential cost saving of programs that addressed the back end of the system (i.e., rates of foster care discharges and reentry into the system) and length of stay.
City officials did not accept the concept with the same enthusiasm; their reaction was mixed. Some of the administrators liked and wanted to test HomeRebuilders as a financing strategy, and they noted that HomeRebuilders forced fiscal and program directors in the agencies to manage care together by looking at data on outcomes. Case management staff liked the new roles and responsibilities that were being created for case managers. This constituted a fundamental change in the role of case managers who previously monitored paperwork and did not go into the field. On the other hand, some city officials saw HomeRebuilders as a state initiative, one that was too expensive and did not save money.
Private agency administrators understood that the state's overall goal was a reduction in the number of children in foster care. They believed that the goals set by the state were appropriate and within reach. The state's goal for HomeRebuilders was seen as a positive step toward families and communities. Most of the agency administrators believed that the city's goals were never as clear as the state's. HomeRebuilders was seen as the state's idea. Initially, the administrators believed that the city showed much resistance to the program. Some administrators believed that the city accepted the state's goals while others believed the city did not.
2.3 Overview of Each Agency
HomeRebuilders was implemented differently by each agency. To begin to understand how each agency embraced the intervention, we provide an overview of each agency's stated purpose for the demonstration; steps taken to implement the project; and a chart summarizing each agency's major initiatives, population, and general programming.
- Harlem Dowling
- Little Flower
- New York Foundling
- Miracle Makers
- St. Christopher-Jennie Clarkson
- St. Christopher-Ottilie
2.3.1 Harlem Dowling
At the beginning of the program, the executive director of Harlem Dowling, Melba Butler, saw HomeRebuilders as an opportunity for change. She felt that the city and state were moving in a family-oriented direction and that was the direction she wanted her agency to take. Therefore, she and her staff looked at the various models that were being used internally at the agency and pulled together a model they thought was workable. Ms. Butler believed that if the agency chose a model that incorporated strategies already known to work at the agency, there was a greater chance to continue the model after HomeRebuilders ended.
Ms. Butler believed HomeRebuilders "changed the urgency with which we could or should treat reunification. We found ways to cut the red tape, creative ways to provide services, and have workers trained in the concepts behind HomeRebuilders." Early in the project, agency meetings were held to inform staff about its implementation and requirements. Procedures were established to help ensure that caseworkers adhered to the programmatic recommendations to move cases forward. These procedures included meetings between caseworkers and their supervisors and oversight by management.
According to Ms. Butler, the success of the program was to be realized through the number of children reunified and adopted. The original target for Harlem Dowling's experimental group was for 40 percent of the children to be adopted, 10 percent by kin. Ms. Butler indicated that there was a shift during the program to change some children from the goal of reunification to either adoption or kinship placement. By the end of the program, the permanency planning goals of children had shifted to 80 percent adoption. The shift occurred mainly in the second year. Ms. Butler believed that the goals changed to adoption at a quicker rate in the HomeRebuilders group (as opposed to the control group) because the HomeRebuilders group examined the families more intensively during the first year and therefore knew sooner which goal they believed was best. HomeRebuilders put adoption proceedings on a different track, attempting to overcome obstacles, and the agency moved swiftly toward final adoption. The goal was changed to adoption when "we felt we couldn't reunite with parent or kin." Under HomeRebuilders, the agency was less likely to extend the time the children spent in foster care. The goal was a move toward permanency. Finally, Ms. Butler stated that the HomeRebuilders model didn't change the agency's philosophy toward independent living or toward kinship placements. The agency had always looked at families as caretakers. However, the program may have intensified the delivery of services a little.
The director of the Harlem Dowling HomeRebuilders program stated "the HomeRebuilders model distinguished the experimental group from the control group by focusing on case management rather than casework." She also noted that HomeRebuilders focused on the whole family and kinship support instead of being child centered. For example, money toward living expenses was provided to the family rather than being limited to financial assistance for the child's needs. Other distinguishing factors included offering housing assistance and hiring a staff person to focus on drug rehabilitation. This administrator believed that services offered through HomeRebuilders shortened the process of meeting goals by approximately 3 months.
Major Changes Initiated During HomeRebuilders for Experimental Group Only:
Agency-Wide Programs During HomeRebuilders:
2.3.2 Little Flower
To implement the HomeRebuilders demonstration, Little Flower undertook a 6-month strategic planning process carried out by a task force comprising of supervisors from departments throughout the agency. The task force concentrated its efforts on developing a paradigm, organizing a vision, developing guidelines for needed training, and soliciting staff input.
The agency's philosophy for the HomeRebuilders program was based on three principles. These principles follow the general philosophy of HomeRebuilders, and, in general, staff were chosen for the program based on these criteria.
- A belief that children should return home whenever possible. This involved taking a chance with families, returning children home on a trial basis, and monitoring closely through aftercare. Agency management reported that the few staff members drawn from the adoption unit had the most trouble adapting to this concept.
- An understanding of cultural differences. Staff members needed to be adaptable to build on family strengths associated with different cultures or circumstances. Using extended families to make contact with birth families or returning families to kin were cited as examples.
- Seniority and the ability to elicit respect from other staff were important. To be part of HomeRebuilders, staff were required to have been with the agency for at least 1 year.
John Courtney, the associate executive director during the program, but no longer with the agency, stated that HomeRebuilders did not change Little Flower's philosophy on permanency, it was always a major emphasis. Case goals were changed when the agency staff believed that placement with parents was no longer a viable option. With permanency the ultimate goal, the agency then moved toward adoption. He also stated, "There was no planned shift from the goal of reunification to either adoption or kinship placement, and it didn't happen to a large degree. The agency conducted a monthly comparison between the experimental and the control group, and found in the control group that more cases had changes in their goals than in the experimental group. At the end of the study, the experimental group caught up somewhat, in part because the caseworkers knew the project was coming to the end. A renewed emphasis was placed on closing cases and this pushed the experimental group to change some of their cases to the goal of adoption. Few children moved to kinship placement in either group." From the beginning, a concerted effort was made to include all levels of staff in planning, service delivery, and monitoring case progress.
Major Changes Initiated During HomeRebuilders for Experimental Group Only:
Agency-Wide Programs During HomeRebuilders:
* NOTE: There were clusters of offices at each location in Brooklyn, NY and Wading River, Long Island.
2.3.3 New York Foundling
New York Foundling summed up its philosophy by saying it was committed to permanency. Staff defined the difference between the experimental and control groups as the extent to which they sought to speed up permanency. According to the administrators, on average, the experimental group finalized goals earlier than the comparison group, in part because parents' rights in the experimental group on average were terminated earlier.
The program director, Luisa Doyle, discussed how the HomeRebuilders model changed the agency's philosophy on permanency. She believed that the intensified services offered during the first few months of placement were a critical component for reunification. The agency promoted the belief that no obstacle was too big to overcome, and it could help families overcome obstacles and care for their children. Also, intensive aftercare services were seen as a key factor. Aftercare could continue for 3 months to 2 years after reunification. In many cases, the goal of independent living was not affected by HomeRebuilders. However, in other cases, because of the change in philosophy, caseworkers reevaluated whether the goal of independent living was appropriate and instead began reexploring families as discharge resources.
The adoption process was given as much priority as reunification. Caseworkers began to complete the adoption process requirements (e.g., homestudy, subsidy, etc.) as soon as the case goal was changed to adoption. Prior to HomeRebuilders, the agency would begin this process after the child was freed for adoption. During HomeRebuilders, the agency did not allow long-term care for kinship families. If return to parent was not an appropriate goal, the agency promoted adoption. If the kinship family did not want to adopt, then the agency promoted discharge to the custody of kin. The agency also negotiated more conditional surrenders for adoption for these cases. Conditional surrenders allow parents to maintain certain rights such as continuing visitation. This change was conducive to the agency's philosophy in that it helped shorten the length of stay for children in foster care.
NEW YORK FOUNDLING
Major Changes Initiated During HomeRebuilders for Experimental Group Only:
Agency-Wide Programs During HomeRebuilders:
2.3.4 Miracle Makers
According to William Wren, Executive Director, Miracle Makers' philosophy did not radically change as a result of its involvement in the HomeRebuilders' project. However, the philosophy was greatly enhanced. Miracle Makers is a community-based organization that emphasizes working with families and considers family reunification its fundamental objective. The HomeRebuilders project provided a great impetus and focus to pursue this goal in a more collaborative approach among management, supervisors, caseworkers, birth parents, and foster parents.
As in other agencies, Miracle Makers was keenly aware of the fragmentation of services for families within the community. The agency staff strongly believed that if the program were to prove successful, other policy initiatives would be necessary. For example, housing and employment were critical resources, and without them family reunification was difficult to achieve. The shortage of other resources and the quality of other programs such as day care, aftercare, and preventive services were also critically important to the success of the program.
In the initial stage, some cases with goals of adoption were changed to reunification. These were cases where the parents were considered marginally involved in planning toward reunification. The heightened focus on family reunification and the diligence of the caseworkers based on the HomeRebuilders philosophy resulted in a significant degree of optimism toward reunification. In some cases, however, this created problems with foster parents who were anticipating adoption. There were also problems engaging foster parents to work in partnership with birth parents. Foster parents were informed of the program changes, and many embraced the principle. However, they found it difficult to put these ideas into practice when the shift in focus became reunification. This was especially true for cases where the child or children had been in care for a considerable amount of time and the foster parents' expectation was adoption.
There was no significant philosophical shift with regard to kinship families because the agency had always viewed and engaged the extended family network as an important resource to achieve permanency. HomeRebuilders did have an effect on independent living. The program led to the realization that there were limited resources available to young people leaving care. Post HomeRebuilders' efforts are being made to address this problem. Miracle Makers is in the process of establishing permanent and short-term housing and related resources and in-home training and support to redress this problem.
Major Changes Initiated During HomeRebuilders for Experimental Group Only:
Agency-Wide Programs During HomeRebuilders:
2.3.5 St. Christopher-Jennie Clarkson
Prior to the start of the demonstration project, Luis Medina became executive director of St. Christopher-Jennie Clarkson. His vision was to create a family-centered approach to rebuild families, and that biological parents are the pillars of the family. He strongly believes that the HomeRebuilders model was an appropriate vehicle for his vision. During an interview he stated, "Parents remain parents even while their child is in foster care." Parents were strongly encouraged to be responsible for maintaining regular contact with the agency, being active participants in identifying the issues that needed to be addressed, and demonstrating through their actions that reunification was their goal. For example, to promote this interaction, staff wore beepers so that parents had 24 hour a day access to staff. Also, much emphasis was placed on ensuring that staff treated families respectfully and that services were delivered as promptly as possible. Foster care parents were asked to serve as mentors and friends to the biological parents. This concept was stressed during a mandatory 6 week course that individuals took to become foster parents. Also, when feasible, the agency worked closely with the extended families. Finally, after children were discharged, families were encouraged to maintain regular contact with the agency. The caseworkers stated that they called families at least every other month to find out how they were doing. They would stop calling only when the parents made that request.
From the initiation of HomeRebuilders, caseworkers played an integral role in developing the project. In preparation for implementing HomeRebuilders, caseworkers were systematically surveyed to identify up to three reasons each of the children on their caseloads was placed in foster care. Substance abuse, lack of parenting skills, and housing problems were the three main reasons for placement. This became the basis for developing new service initiatives that included hiring new staff, developing a family services unit, and restructuring the traditional hierarchy of service delivery. The agency hired a number of staff, including a housing and substance abuse specialist. In addition, extending the hours of service provision expanded parent training and parental visitation opportunities.
Previously, service delivery was based on caseworkers identifying the needs of the children on their caseloads and then obtaining services for children outside of the agency. With the onset of HomeRebuilders, a family service unit was developed which consisted of workers who could provide services directly to families. This unit allowed the caseworker's role to change from the traditional one of identifying problems and finding outside services to becoming part of a team. Still responsible for conducting the initial assessment of the family's problems and service needs, the caseworker now had a team of people who could directly provide needed services. This arrangement provided the opportunity for workers to consider family needs rather than individual child needs.
Checks and balances were implemented to ensure that families ready for discharge were receiving the services necessary to expedite the process. The program director reviewed the progress of all cases monthly. In particular she asked supervisors to identify anticipated discharges. Barriers to discharge were identified, and it became incumbent upon the family services unit to contact the appropriate worker to offer services to help resolve problems that were impeding reunification or adoption. In addition, caseworkers completed tracking forms for each case. These forms played an integral role in case decision-making and were perceived as part of the planning process.
In a follow-up interview with Jeremy Kohomban, Assistant Program Director, the agency's philosophy toward permanency was discussed. He stated that the philosophy of permanency was started before HomeRebuilders; the administration at St. Christopher-Jennie Clarkson already believed that the length of stay was too high. Because staff felt so strongly about the concept of HomeRebuilders, all of the children in the agency were in the demonstration. At the start of the program, 50 percent of the children in foster care had a permanency plan of adoption, a percentage that the agency believed was too high. The philosophy of the agency was that not more than 25 percent of children should be placed through adoption. Although adoption may be the easier route, the philosophy at St Christopher-Jennie Clarkson was that it should be used only in extreme cases. For example, adoption was used in cases where the parents were dying from AIDS, the children were truly abandoned, or where multiple children in one family could stay together through adoption but not otherwise. To achieve this reduction in adoptive placements, more training on life skills, stress management, and other issues that kept families apart was given to the parents and extended families. Through HomeRebuilders, some of the children with the placement goal of adoption returned to their biological families.
The HomeRebuilders model also had an effect on young adults at this agency. Instead of allowing them to age-out of the program, they were placed into independent living. The rationale for this strategy was to enhance the agency's ability to monitor these teenagers. If the caseworker believed they were having a difficult time, they were put back into foster care. Before HomeRebuilders, the young adults were not monitored, and consequently, some teenagers became homeless or went to jail. The use of independent living situations created a buffer because the caseworkers were instructed to monitor this population group.
ST. CHRISTOPHER-JENNIE CLARKSON
Major Changes Initiated During HomeRebuilders:
Agency-Wide Programs During HomeRebuilders:
2.3.6 St. Christopher-Ottilie
St. Christopher-Ottilie has had a deep-rooted family focus that was established long before the HomeRebuilders model was developed. Its model is based on providing:
an integrated and full range of personal and social services to sustain children, families, and individuals in their own homes, to provide out of home placement to those who need it in the least restrictive setting, and to do so in an atmosphere of care, concern, acceptance and the dignity of the person through love, service, and respect.
This statement describes a philosophy rooted in empowerment of the birth parent, using the premise that a child remains the child of the birth parents, even while in foster care. This philosophy has long been held by the agency and is based on the agency's participation in a demonstration headed by Salvador Minuchin that took place 1986. Participation in that 2 year demonstration involved intense training of foster parents and agency staff on how to work together to empower the birth parents of children in care. Participation in that project seems to have had a lasting effect on the administrators and staff.
The agency has always maintained the philosophy that foster homes are temporary homes for children. Consequently, as part of their training, all foster parents are told that they are an important part of the reunification process and are expected to take an active role in assisting the agency in reuniting the families.
HomeRebuilders was viewed as a chance to demonstrate the type of model the agency desired, a neighborhood-based approach to services. St. Christopher-Ottilie believed in the concepts of intensified counseling and aftercare. Its philosophy toward permanency included reunification with parents or kin as well as adoption. The process of making good decisions about placement was also seen as a way to expedite permanency. The foster family was the first choice for adoption or permanent placement after establishing that placement with the biological parents was not a viable option. Robert J. McMahon, the Executive Director, emphasized the importance of HomeRebuilders as a service delivery philosophy rather than a mere fiscal mechanism. He believes, "The demonstration showed what directors already know, decision-making is the hard part of the field. The risk in HomeRebuilders was not the money, but how you support workers to make tough decisions." He believes that focusing on length of stay and discharges is a good starting point for a decision-making framework.
"Through a neighborhood-based approach, an integrated and full range of personal and social services to sustain children, families, and individuals in their own homes, to provide out of home placement to those who need it in the least restrictive setting, and to do so in an atmosphere of care, concern, acceptance and the dignity of the person... through love, service, and respect."
Major Changes Initiated During HomeRebuilders for Experimental Group Only:
Agency-Wide Programs During HomeRebuilders:
This section provided an overview of each agency's plan for implementing the HomeRebuilders demonstration. The six agencies shared common elements in their plans for changing service provision. They reported that HomeRebuilders permitted service delivery to be family-focused rather than child-focused and it reemphasized the importance of achieving permanency for children. A project wide perspective of families served, and the implementation of practices and procedures is presented in the following sections of this chapter.
2.4 Characteristics of the Families Served
In part, the outcomes of the project are dependent on the families served. As shown in the previous section, the agencies were located in diverse sections of New York City and Long Island. However, the agencies reported similarities in the characteristics of families served.
All of the agencies reported that most of the families served were either Black or Hispanic and that most of the "families" consisted of single mothers ages 20 to 40. Miracle Makers reported serving a significant number of teen mothers who caseworkers indicated were one of the most resistant groups to serve. New York Foundling reported serving teen mothers through a program outside of the HomeRebuilders demonstration. The majority of families had at least two children. Although the agencies were unable to quote an average age for the children in care, several of the agencies reported a decline in the number of newborns served. The agencies reporting a decrease attributed it to a change in New York City policy regarding babies born with positive toxicology reports. In 1992, a clarification of state policy regarding children reported by hospitals with positive toxicology for cocaine was issued. Up to this time, children in allegations with a confirmed positive toxicology report were routinely placed into foster care based solely on that evidence. The clarification emphasized that the medical report alone was not credible evidence of child abuse or neglect. The new state policy required that other credible evidence was necessary to substantiate an allegation of abuse or neglect and place the child into the care of the state.
All of the agencies reported that parental substance abuse played a role in the majority of cases. Crack cocaine, alcohol, and to a lesser extent heroin (one agency reported a rise in the use of heroin during the study) were used by many of the parents. AIDS was another factor reported. Several of the administrators stated that during the period of the study, the number of families with AIDS may have been at its peak, which therefore had an effect on the number of children orphaned. All of the agencies reported that some of their parents were mentally ill, depressed, or were abused by other family members or significant others. Some of the agencies emphasized that a percentage of the parents had only a grade-school education. Lack of adequate housing plagued families in all of the agencies.
Although the majority of the parents lived in the borough or county in which the agency was located, all of the agencies reported serving families living in all five boroughs. Two of the agencies, Harlem Dowling and St. Christopher-Jennie Clarkson, reported that they were serving families that had relocated either upstate or out-of-state. In some cases, the parent moved for better drug rehabilitation programs and decided to stay instead of returning to the drug-infested areas in which he or she lived. Other families moved to be closer to family members.
2.5 Implementation Practices and Procedures
2.5.1 Fiscal Issues
An inherent characteristic of the planning and implementation of HomeRebuilders was the coordination of program and fiscal staff in the agency. The flexibility of spending permitted agencies to individually determine a plan which balanced additional expenditures against savings from reduced care day usage. As one director describes it, this was a new "marriage" of budget and program staff. Virtually every program and budget administrator described the value of this new relationship. The following reflects how this relationship was operationalized.
Three Year Staffing Plan. The HomeRebuilders capitation funding required that agencies consider staffing, not in the context of static yearly caseloads, but in relationship to a fixed caseload of children moving in and out of care for the three year period. Under the traditional per diem rate, each agency budgets for a fixed level of children in care, expecting that children discharged each month will be replaced by new entrants. Minimal dollars are budgeted for aftercare for children who are in trial discharge. Under the capitation methodology, the agency was held responsible for its assigned fixed number of children for the three year period, for those in-care, and for preventing those out-of-care from returning.
Discussions with participants suggest that several upfront decisions had to be made in staffing the project to meet this new challenge. This included caseload sizes for in-care caseworkers, aftercare workers, hiring and designation of specialized staff such as substance abuse workers and housing specialists, and a plan for the adjustment of staffing ratios over the course of the demonstration period.
For example, Little Flower developed a staffing model for the three years based on expected discharge rates of children. The model included caseloads of eight families (15 children) per caseworker, one parent aide per two caseworkers, a supervisor per every four caseworkers, and increasing ratios of aftercare workers for up to 18 months after trial discharge. While they anticipated an immediate and gradual decline in the number of in-care caseworkers, there would be an increase in the need of aftercare workers. The total number of caseworkers would not begin to decline until the end of the first year.
In most agencies, the typical turnover and attrition rate was expected to make the necessary staff shrinkage palatable to staff during the last two years of the program. Little Flower replaced some staff during the first year and consolidated units as staff left during the last two years. At St. ChristopherOttilie, an adoption worker was assigned to the project during the third year because of the unexpected shift of children to the adoption track. The executive director also felt that a higher supervisor ratio was needed for HomeRebuilders, but was unable to implement it. Further discussion about each agency's staffing decisions is provided in section 2.5.2.
Monitoring of Expenses Against Expected Length of Stay. The fiscal director at each agency used the expected rate of increased discharge each year (10 percent), to monitor their success in the demonstration and to monitor budget expenditure. Each agency developed periodic reporting to match expected number of discharges to actual number. At Little Flower, there appeared to be more intensive monitoring. They did not use the provided state CCRS data, but 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. Unfortunately, they felt the monitoring process was hindered by the demands the city placed on the agencys' budget staff. Budget staff were required to provide detailed child-by-child expenditure data to reconcile the HomeRebuilders rates with the rates applied to the remainder of the agencies' children.
Three agencies spoke specifically about the need for better software and information tools to manage expectations about length of stay. Beyond the data provided by DSS, the information system must collect data on important characteristics of the children and their families that might affect length of stay. Suggested variables include substance abuse problems of the caregiver, death or incarceration of the caregiver, positive toxicology at birth for the child, and presence or severity of child abuse or neglect as reason for placement.
Flexible Spending. The demonstration allowed agencies to be more flexible in their expenditures for each case. They were not restricted to room and board, the primary categories of IV-E reimbursement, or the city's standards of payment. As stated by the fiscal director at Little Flower, "budget is usually the 'abominable no-man', but not in HomeRebuilders." For example, cars for visitation were made exclusively available to HomeRebuilders workers at this agency.
At New York Foundling, to expedite reunification, special funding was budgeted for trainers, housing, adoption attorney time, family social activities for visitation, and emergency household funds for such items as furniture, clothing, and food. Miracle Makers reported that new streamlined procedures for obtaining emergency funds were instituted. St. ChristopherJennie Clarkson used flexible funding to pay rent for families. Staff reported that the usual city housing subsidy often took an inordinate amount of time to access and HomeRebuilders allowed the agency to enter into individual contracts with landlords. Obtaining adequate housing for families was often cited as a barrier to reunification, and this flexibility allowed the agency to alleviate a problem that hindered children from returning home.
The flexible funding allowed agencies to be reimbursed for services to families, not specifically directed at the child in care. At Little Flower, the use of case aides and additional training for foster parents permitted the use of birth parent visitation at the home of the foster parent and not always at the agency office. St ChristopherOttilie also used flexible funds to train foster parents as aides/mentors to birth parents.
Although each agency implemented the concept of flexible spending somewhat differently, all caseworkers had more flexibility in service provision. Some were allowed to request cash to help a family buy groceries, clothing, prescriptions, other necessities, transportation to see their children, or activities during visitation. The total amount of money was limited at each agency. Realizing that funds were being used too rapidly, some agencies tightened access to these funds as the demonstration progressed. Prior to the end of the demonstration, some agencies did run out of flexible funds.
Agency Consideration of Financial Risk. Agency financial risk depended upon the extent to which agencies invested money upfront to develop resources and whether the dollars expended were recouped through fewer care days. If an agency believed they could cut care days by 10 percent and this translated into expected availability of one-half million dollars for new services, anything less than a 10 percent reduction could be a financial loss. A board of directors governs each of the participating agencies. The financial risks of the demonstration had to be presented and approved by each agency's board. At Little Flower, the board was initially concerned that the city and state would not follow through on their commitments. They requested monthly reports on the project. They were more supportive after the success of the first year. The Board of Directors at St. Christopher-Otillie required that an independent auditor verify the actuarial baseline for the capitation. Once completed, the board felt the risk was acceptable and proposed care day reduction achievable. No other agencies reported any board hesitancy for support of the program.
Several agencies stated that they had not anticipated the shift in the number of cases to adoption. Little Flower identified two problems in the planning. First, the 1988-1992 historical data used by the state did not reflect the policy shift toward adoption in the 1990s in New York City. Second, in their budget modeling, they used their internal electronic data and did not account for the added time and expense for adoption. In fact, the agency comptroller suggested that the early ending of the program might have protected them from the adoption costs that were accrued after the project ended early. At New York Foundling, the Fiscal Director senses that adoption goal decisions were made more expeditiously under HomeRebuilders. He was concerned about the legal costs, additional days in care during the adoption process, and the extra caseworker time required for adoption cases. Miracle Makers was not as affected by adoption shifts, since they served many kinship families which had slower rates of adoption.
Per Diem versus Capitation Payment for Service. The DSS sets a maximum state aid rate for each private agency's foster care program. The city then determines whether it will pay a percentage or the full amount of the maximum state aid rate. Agencies were concerned that the city would change the payment rate and upset the capitation rate set for HomeRebuilders. The city developed an understanding with each agency to hold the agency harmless from any system-wide reductions during the demonstration. Also, each agency would benefit from a system-wide increase during the period. In fact, the 1994-1995 city budget initiative reduced the foster care rate paid by the city. Reimbursement for children in the HomeRebuilders program was held harmless from the reduction. However, the children in the control group and the rest of each agency had their rates reduced. Agencies experienced revenue reduction and several agencies reported agency cash flow problems.
Medicaid per diem. Plans for the demonstration also called for a capitation rate for Medicaid payments for children in the project. The state agreed to fund applicable Medicaid payments at the current rate for actual care day usage and provide additional Medicaid funding at 65 percent of the current rate for each day saved, compared to historical usage pattern. For example, if during HomeRebuilders, an agency used 200 fewer care days than expected, the agency was to be paid 65 percent of their current Medicaid rate for the 200 days. In discussions with fiscal directors, it was not clear that most agencies made modifications in their budgets to use this extra funding. Little Flower budgeted for a medical HomeRebuilders Team that enhanced mental health staffing for children and families in the HomeRebuilders group.
Reconciliation of Per Diem/Cash Flow. The city reimbursed agencies on a quarterly basis. Agencies considered the methods for HomeRebuilders reimbursement cumbersome and burdensome. They were paid in two components following bill submissions: the regular agency per diem for each day a HomeRebuilders child spent in care, and a HomeRebuilders add-on to bring the year's total up to the agreed capitation amount. Agencies spoke of delays and requests for expansive justification of amounts each quarter. Two agencies reported hiring additional budget staff just for this function.
One agency, Miracle Makers, reported that it experienced cash flow problems during the second year as a result of the delays in payment. They decided to suspend some of the HomeRebuilders features including real estate security deposits for families and emergency cash funds for birth families. In addition, they chose to not fill vacant staff slots, including the budgeted, but never filled slot for a housing specialist. The agency's comptroller suggested that morale problems began at this time, with the rumor of layoffs from the program.
At the end of the year, each agency had to reconcile yearly expenditures with the city and state. At Little Flower, there was a deficit during the first year in relation to the planned 43 percent of total budget.As agreed, the state did a reconciliation and adjustment of the 3-year expenditure plan. The other five agencies were more conservative in their approaches and underspent during the first year. Unfortunately, this artificial surplus resulted in confusion in the city's fiscal office and delayed payments for the five agencies, according to one agency fiscal director.
2.5.2 Program Staffing
A HomeRebuilders project director was identified for each of the experimental programs. Within each program there were units with approximately four to five caseworkers to one supervisor. Each caseworker was the primary person responsible for a set of clients.
Experimental Group Caseworkers. Four of the six agencies, St. ChristopherOttilie, Little Flower, Harlem Dowling, and Miracle Makers, recruited caseworkers specifically for the experimental group. The criteria set for these caseworkers were at a higher level than for the comparison group. For example, some agencies stipulated that the caseworker have at least 1 year of experience and good writing and assessment skills. Some of the directors stated that they looked for "mature" staff. Little Flower and Harlem Dowling paid the experimental group staff higher salaries. In part, the higher salary was because the staff had either more credentials or were more experienced. Although the administrators at St. ChristopherJennie Clarkson did not specifically hire new staff at the beginning of the HomeRebuilders program, staff were expected to adhere to the set of beliefs that were promoted through the HomeRebuilders program. Staff who weren't able to or didn't agree with the philosophy of the program were let go. At New York Foundling, because the agency assigned cases by location, the existing staff at each location served as the experimental and comparison group staff.
Specialists. Each agency hired a number of specialists for the experimental group. Table 2-2 summarizes the area of expertise of the staff that were hired specifically for the HomeRebuilders program. As shown, a wide variety of specialists were hired to implement the program; the number of specialists ranged from 4 at Miracle Makers and St. ChristopherOttilie to approximately 22 at St. ChristopherJennie Clarkson, excluding caseworkers and aftercare workers. The agencies assessed the needs of their clients in relation to the services already in place at the agency. Almost all of the agencies found a need to hire additional housing and substance abuse specialists. In addition, the six agencies mentioned 16 other specialists that were hired to implement the HomeRebuilders model.
|Specialist||Harlem Dowling||Little Flower||New York Foundling||Miracle Makers||St. ChristopherOttilie||St. ChristopherJennie Clarkson|
|Child Special Needs||1|
|Case Aides||5||3 (1 yr.) 4 (2nd & 3rdyr.)|
|Parent Advocate||1||8D(average at one time)|
A. This person provided support to the experimental caseworkers for cases in which the goal changed from return to home to adoption.
B. This person served the experimental and the control group.
C. During the study, these two positions were combined.
D. 23 were trained over the course of the program.
The comparison group, except as noted for Miracle Makers, did not have access to these specialists. In addition to the specialists, some of the agencies had individuals or clinics that served both the comparison and the experimental groups. Some examples of these services included in-house or affiliated medical and preventive health clinics and staff, social support groups, mental health staff, dentists, attorneys to work on case processing, visiting nurses, Healthy Start programs, and housing programs.
In some agencies, the caseworkers in the experimental group had lower caseloads with the expectation that families would receive more attention from the caseworker. Two methods were used by the agencies to count caseloads in the experimental group. During the study, some of the agencies began to count the number of families for each caseworker, while the remaining agencies continued to count the number of children served by a caseworker. The agencies tried to place all siblings in either one home or in the same neighborhood. This allowed the caseworker to get to know each child's foster parent and environment a little better and to reduce the amount of time traveling from home to home.
Table 2-3 shows the number of children or families served per caseworker for the experimental and comparison groups. At Harlem Dowling, the control group was divided into two units: a foster care unit and an adoption unit. Although each caseworker had the same caseload of 29-35 children, both units are listed because the units were programmatically different. The comparison group at St. ChristopherOttilie also reported having a foster care and an adoption unit prior to July 1994, but assigned a different number of children per caseworker in each unit. Little Flower reported both the number of children and the number of families assigned per caseworker in the experimental group. Finally, New York Foundling reported assigning 18 children per caseworker and 15 children or 5 to 10 families per aftercare worker in the experimental group. In its comparison group, it reported assigning 18 children per caseworker during the study and increased that number to 22-24 children after the project ended.
|Agency||Experimental Group Caseloads||Comparison Group Caseloads|
|Harlem Dowling||20 children per caseworker|| 29-35 children per foster care worker |
29-35 children per adoption worker
|Little Flower|| 8-10 families per caseworker |
13-17 children per caseworker
|20 children per caseworker|
|New York Foundling|| 18 children per caseworker |
15 children per aftercare worker
5-10 families per aftercare worker
| 18 children per caseworker (during the demonstration) |
22-24 children per caseworker (after demonstration)
|Miracle Makers||12-15 families per caseworker||21-27 children per caseworker|
|St.ChristopherOttilie||14 children per caseworker||18 children per caseworker*|
|St. ChristopherJennie Clarkson||14-16 families per caseworker (not to exceed 21 children)||N/A|
* St. ChristopherOttilie: The staff ratio changed to 18 children to 1 caseworker 7/94; prior to that time the ratio was 18:1 for foster care and 21:1 for adoption.
In four of the agencies, the experimental group had lower caseloads than the comparison group. The caseloads for the caseworkers at New York Foundling appeared to be equal for the experimental and comparison groups during the demonstration. However, at all of the agencies, the experimental group had more support from other staff (e.g., housing specialists, aftercare workers, drug rehabilitation specialists, etc.).
Since 1994, there has been a significant drop in the number of children in foster care in the city, apparently due largely to a decrease in admissions to care. As a result, the non-HomeRebuilders caseloads of the agencies involved in HomeRebuilders declined. In addition, as agencies worked toward a shorter length of stay for clients, planned reductions in HomeRebuilders staff were supposed to occur as the cases were closed. In combination, these phenomena resulted in downsizing or displacement of workers. Downsizing did not occur smoothly at most of the agencies, and this was probably a major factor negatively affecting staff morale. For the most part, downsizing was accomplished by moving staff to other positions in the agency or not refilling positions that were vacated.
The director at Little Flower reported that one month the administration spoke to the staff about eliminating positions and moving people to different positions based on the number of reunifications that had occurred. That month the staff recommended no children for reunification. The administration attributed this lack of recommending reunification to the staff's fear of losing their jobs. At Miracle Makers, the administration anticipated this same problem. Therefore, the administration told the staff that the success of the demonstration would determine their future positions at the agency. Caseworkers were told that the least productive staff would be the first to be reassigned or eliminated from the agency. The administration believed that this was both an honest approach and that it provided an incentive for workers to achieve results with families.
The staff at St. ChristopherJennie Clarkson seemed to tolerate the downsizing fairly well. During the second year of the program, the agency's revenue was reduced by 22 percent. To adjust to this reduction, many of the clerical staff were eliminated, and the staff were given computers. The housing specialist position was eliminated, and one of the administrators took on those tasks as an addition to his workload. This was done deliberately to show the staff that the administration would change its workload to compensate for the loss of revenue.
The interviews that were conducted after the demonstration ended revealed that the staff morale in three of the agencies was very low. For example, at one agency, the caseworkers said that they had been promised that if they worked hard during the first 2 years of the program, they would not be given new cases during the third year of the program. They were counting on having this reduced caseload in order to concentrate on the remaining cases (which were the most difficult) and to have a chance to work at an easier pace. However, these caseworkers stated that as a result of downsizing, cases were redistributed and therefore their caseloads did not decrease. At another agency, the morale of the experimental group staff seemed high, but the morale of the comparison group was low. Further questioning revealed that the comparison group had lost more staff through attrition. Administrative staff and caseworkers at a third agency also reported low morale. They believed that the combination of downsizing and the unexpected budget cuts in the entire agency in 1995 severely hurt staff morale.
Training was most prevalent during the first year of the demonstration. To orient the staff to the HomeRebuilders program, in June 1993 a training conference was held at Fordham University to kickoff the project. Individuals from each of the six agencies attended. A general session was held to teach staff members how to complete the assessment tool that was to be completed for each family in the experimental and comparison group. Also, a variety of workshops were offered at the conference including:
- Quality Management
- Family Network Intervention
- Family Centered Empowerment
- Family Practice
- How to Identify and Locate Community Resources
- Involving Foster Parents in Building Partnerships To Reunify Families
- Visitation-A Central Theme in HomeRebuilders
- When is a Family Ready for Reunification?
- The Effective Use of Self To Empower Families
Approximately one year later, there was a second joint training session for all of the agencies. This training session was designed to boost morale and to emphasize important constructs of the HomeRebuilders model. In addition, each agency held training sessions for its staff and in conjunction with other agencies involved in the project. Some of the topics included cultural diversity and impact on multicultural families, conflict resolution and team building, working with disorganized families, separation and loss, and working with medically fragile children.
During the interviews, one agency administrator spoke about the importance of time management skills for his administrative staff.Another agency gave a detailed description of the types of training sessions that it held at the beginning of the program. The administrator stated that individuals from the Annie E. Casey Foundation led some of the training sessions and that information from the book Teaching Family Reunification: A Sourcebook (Child Welfare League of America) was used. Another agency received training from the Child Welfare Institute (CWI) in Georgia.
The following list contains the topics mentioned by all of the participants. It demonstrates the breadth of topics covered and reflects an emphasis on improving a wide variety of staff skills. The topics were taken from several different family service models (e.g., Oregon Model, CWI).
- The importance of visitation
- The belief that children could go home
- Defined family reunification
- Review of family therapy techniques
- How to provide good casework by utilizing local resources
- Techniques that promote trust between the family and caseworker
- Assessment and interviewing techniques
- How to conduct a family service plan review
- How to provide aftercare
- What permanency planning means to children
- Visitation as a training tool
- How to involve foster parents
- How to interview substance abusers
- Time management skills
- HomeRebuilders philosophy
- Team building
- Access to entitlements
- Case management
- Case planning
- Stress management
- Family consciousness training based on the Oregon Model
Table 2-4 describes the level and type of training that was held at each agency. As shown, two of the agencies held mainly joint training sessions for their administrators and caseworkers. Among the other agencies, the proportion of training time administrators spent on administrative issues was approximately one-third to three-fourths of the session time, while caseworkers spent the majority of their training session time on client issues (approximately 65 to 85 percent of their training time).
|Harlem Dowling||Mainly separate sessions for caseworkers and supervisors|| Majority of time for each group was spent on casework issues |
Remaining time on administrative issues
| Twice a month for at least the first two years |
Then approximately 1 time per month
|Little Flower||Mainly joint sessions for caseworkers and supervisors|| Majority of time was spent on casework issues |
Remaining time on policy and philosophy
| Every other week initially until all HomeRebuilders topics were covered (3-4 months) |
Then 1 time per month for remainder of first year
Then as needed mainly for new staff
|New York Foundling||Mainly separate sessions for caseworkers and supervisors|| Caseworkers spent approximately 25% of time on administrative issues and 75% time on casework issues |
Administrators spent approximately 33% on administrative issues and 66% on casework issues
| Caseworkers trained 1 day per month |
Administrators trained at least one day per month
|Miracle Makers||Mainly separate sessions for caseworkers and supervisors|| Caseworkers spent approximately 15% of time on administrative issues and 85% of time on casework issues |
Supervisors spent approximately 75% of time on administrative issues and 25% of time on casework issues
| During first year joint meetings with caseworkers and supervisors were held weekly or biweekly |
Training sessions were held October, November, and December 1993; April, May, June, August and November 1994.
|St. ChristopherOttilie||Mainly joint sessions for caseworkers and supervisors||Mostly conducting reviews, team building, and accessing services||Once per month at agency plus outside training|
|St. ChristopherJennie Clarkson||Blend of separate and co-sessions for caseworkers and supervisors during first year. After that, trained based on staff needs|| Caseworkers spent at least 70% of time on casework issues and less than 30% on administrative issues |
Supervisors spent at least 60% of time on administrative issues
| Caseworkers and administrators met weekly during first year |
Second and third year as needed
2.5.5 Case Processing
All of the agencies had similar case processing procedures, following those set forth by the city and state. All cases were placed into care by the New York City CWA and CWA had case management responsibility.
A CWA worker was assigned as the case manager to each case to provide authority for the case planning developed at each agency. Case planning included service assessment, provision, arrangement, coordination and evaluation. For the HomeRebuilders group, the caseworkers were required to work closely with CWA. The CWA workers generally visited the agency once or twice a month and participated in case review and planning. When there was a good relationship between the caseworker and CWA worker, the process went fairly smoothly. Usually a positive relationship was the result of the same individuals having an opportunity to work on a series of cases together. Sometimes one or two CWA workers would be assigned to a particular agency. This allowed agency staff and CWA workers to get to know each other and to get to know each others' philosophy on HomeRebuilders and views of when it was safe to return a child to the parent.
2.5.6 Assessment and Prioritizing Cases
At the beginning of the project in 1993, provider agency workers completed an assessment form on cases in the experimental and comparison groups. The assessment form contained information on family composition, the child's foster care placement, and court actions. It contained information on the child's physical and mental health, development, and education. Each agency was to administer the demonstration-wide assessment to every case in the experimental and comparison groups. The assessment revealed inadequate access to substance abuse counseling, housing and housing assistance programs, lengthy processing requirements associated with finalizing adoptions, and a lack of aftercare resources for children returned home. However, most of the agencies did not find the assessment particularly helpful; a common complaint was that it was too long. Some of the agencies reported that caseworkers in both the experimental group and comparison group were to be paid $25 for completing the assessment; however, in most agencies the comparison group money was not funded. Some of the agencies also developed their own assessment instruments or used other standardized assessments.
Another intended use for the assessments was as a tool to prioritize cases and, at the start of the study, at least half of the agencies developed prioritization procedures. As discussed earlier, all agencies were encouraged to develop triaging plans to prioritize service delivery (see Section 2.2). The rationale behind the priority system was to determine which cases had been languishing in the system with problems that could be solved relatively quickly. Little Flower divided its cases into two categories, fast movers and slow movers, and worked on the fast moving cases first. Harlem Dowling categorized families by the number of problems they had: red flag families had six problems, yellow flag families had four to six problems, and green flag families had two or three remaining problems. The plan was to first provide services to those with fewer problems. St. ChristopherJennie Clarkson determined which families needed housing and established a goal of finding a family a home within 4 weeks. Staff indicated that this helped to discharge many families during the first year of the study. Miracle Makers indicated that it attempted to look at cases with one pending situation (needed housing or completion of parenting program) and worked to rectify that problem to move toward reunification. However, interviews revealed that this prioritization was not implemented consistently. St. ChristopherOttilie and New York Foundling said they did not prioritize cases. Instead, New York Foundling implemented a rigorous case review process for each case, and St. ChristopherOttilie used the city's required service plan reviews augmented by administrative review.
2.5.7 Role of Foster Families and Kin
Foster parents and kin who assume responsibility for the children are an important permanency resource for children in New York City. Many foster parents enter the program with the intention of adoption or long-term placement. At the beginning of the demonstration, letters were sent to the foster parents (and to the biological parents) explaining that one of the main goals of the HomeRebuilders program was to reunite children with their biological parents, and this concept was expressed throughout the course of the study. However, when reunification was not possible and the goal was changed to adoption, in most cases, the foster family or the kin who had primary responsibility for the child became the adoptive parent. In some cases, the foster parent became the adoptive parent because of failed intervention with the families prior to HomeRebuilders. In these cases, it was not feasible to reverse the legal efforts already under way to free the child for adoption.
Many of the agencies indicated that some of the foster parents had difficulty accepting the goal of returning the child to his/her home. This concept was most difficult for foster parents who had already had the children in their care for a considerable period before the start of the study. For example, one administrator related a story of a father offering his child a piece of candy in the presence of the foster parent. The foster parent admonished the father in front of the child for giving the child candy. The administrator quickly stepped in and reminded the foster parent of her role in the situation. Another administrator stated that as a group, the foster parents in their Long Island locations were less willing to trust the biological parents than the foster parents in Brooklyn. This administrator believed that cultural values played a role in this mistrust. Other foster parents enjoyed a close working relationship with the birth parents and caseworkers and felt more valued working as part of a team. In fact, in some cases after the child returned to the birth parent, the foster family continued to support the family by babysitting and being a mentor. There are even cases where the birth parent asked the foster parent to serve as the child's godparent. At one agency in particular, there appeared to be a great difference between the experimental group and the comparison group in the relationship between the foster parents and birth parents. In the experimental group, interaction was actively promoted, with the opposite happening in the comparison group.
All of the agencies required foster parents in the experimental group to take a mandated 6 week training course. However, the agencies also offered additional training. Some agencies offered the foster parents and biological parents in the experimental group joint training sessions that focused primarily on birth parent issues. Other agencies invited both comparison and experimental groups to the sessions.
2.5.8 Discharge Planning
The HomeRebuilders program guidelines allowed a mix of services to achieve permanency, including counseling, day care, homemakers, or any other service needed to stabilize the family immediately before or after reunification. In short, agencies were given greater flexibility concerning how money that would otherwise be used to purchase space in the foster care system was spent on services to the family.
Each agency was allowed to design its own discharge planning and aftercare program. However, all of the programs were required to contain certain elements. For example, families were required to actively participate with the provider to plan discharge and coordinate post-discharge services. In general, the agencies followed the guidelines prescribed in city and state rules and regulations regarding case management. Family readiness was evaluated (see each agency's description below) and when the timing was appropriate, the family met with the caseworker, the CWA worker, and other staff members such as supervisors and other support staff to write a discharge plan. Families progressed from weekend visits to extended visits. The final discharge was usually preceded by a trial discharge period of up to 3 months. The case would close at this point, depending on whether other children were still in foster care or if contracted or court-ordered in-home services were still being provided to the family.
Miracle Makers stated it enhanced the HomeRebuilders program with guidelines from the HomeBuilders family preservation model. The agency followed the guidelines very closely and believed that this aided in the reunification of families. These guidelines included more "hands on" management with the parents. For example, workers would go into the homes of the parents and determine if there was a need for cleaning or budgeting skills. In the process, the caseworkers would wash dishes, help paint a room, show parents how to do laundry, assist parents with budgetary matters, and teach them how to shop more cost-effectively. The administrator stated that the process reduced the return to care rate in the experimental group to approximately 2 percent and believed that the rate was higher in the control group.
A St. ChristopherOttilie administrator stated that there was no difference in guidelines for discharge planning for the experimental and comparison groups. As reported in Chapter 3, this agency's comparison group actually had more case closings during the first two years, but by the end of the experiment, proportions of closings were similar. The administrator attributed the difference that was found in the first year to the fact that the comparison group families remained with the same caseworkers, while the experimental group was assigned new caseworkers specifically for the project.
A St. ChristopherJennie Clarkson administrator stated that family readiness for reunification was determined by the level and quality of involvement exhibited by the families. The agency held readiness classes and gave the following example to describe how it measured readiness. "If a family showed up to the Saturday family days that was step one. If they showed up on the Saturdays in between family days, we took it as a sign that they were more interested. If they showed up with food for their child it meant even more." Before a child was returned to the parent, a discharge plan was made. Part of the plan included an "ABC Plan" with A representing a plan for everything working out well; B, the parent relapses; and C, the parent relapses and returns to an abusive partner. Scenarios for all the plans were worked out ahead of time with the parent. The administrator acknowledged a degree of risk in this alternative planning but valued reunification as worth taking a certain amount of risk.
An administrator from Little Flower stated that during HomeRebuilders good case planning took place. As at all of the agencies, the staff considered the safety of the child first. During the case conference, they reviewed the reasons for initial placement and ensured that those issues were no longer barriers for reunification. Then outcome statements were written. Since HomeRebuilders ended, this level of case planning is no longer occurring.
A New York Foundling administrator reported that specific guidelines on case closing were not developed. Case reviews were initiated on an as-needed basis, and parenting skills and readiness to reunite were evaluated on an individual basis. Case reviews were conducted monthly and attended by the program director, supervisor, caseworker, and any specialist involved in the case.
Harlem Dowling also stated that families were assessed for their ability to provide a safe and nurturing environment. The guidelines were the same for the experimental and control group; however, they were followed more intensely for the experimental group. In general, bonds with the foster care workers were stronger, and there was more teaching and modeling for the families in the experimental group. While working with the families, administrators said that caseworkers were informally measuring progress. Also, the staff evaluated families' linkages to family and community supports, their progress in addressing problems such as substance and alcohol abuse, the interactions between the parent and child, and the child's progress in school. During the first 2 years of the program, children in aftercare were closely followed. However, during the third year almost no aftercare took place.
Continuing support to families after they had been reunited was another key component of the HomeRebuilders program. The goal of this component was to empower families so they were able to access resources available within their communities and thereby promote less dependence on the agency and more support from the community. A hypothesis of HomeRebuilders was that stronger aftercare would allow earlier discharge of children from foster care. The frequency of visits by a caseworker during aftercare varied from family to family (Table 2-5). Some agencies reported that some families had contact with the agency several times per week, while others only spoke with agency personnel occasionally. At all agencies except Miracle Makers, families determined the frequency unless the caseworker believed that the situation was dangerous (this is reflected in Table 5 as "as needed"). Also, many families went through periods of needing more attention. At Miracle Makers, for both the control and the experimental group, the caseworkers who provided services while the child was in foster care visited the family at home during the first 2 months of aftercare. If the family continued making satisfactory progress, during the third month the family was contacted by phone. Three agencies reported providing aftercare services to the comparison group for 3 months. However, it is unclear whether these were truly aftercare services or whether they were normal services provided during the 90 day trial discharge period.
In three of the agencies -- Harlem Dowling, New York Foundling, and St. ChristopherJennie Clarkson -- a separate caseworker provided aftercare services. At Miracle Makers, the philosophy was that the caseworkers were already invested in these families and had gained the trust of the parents. For the families, this eliminated the need to confide in yet another person. In other agencies, using a different caseworker during the aftercare period allowed each set of caseworkers to work on different issues to reduce caseworkers' loads and thereby allow them to concentrate more on their assigned cases. When the method worked well, caseworkers discussed the cases with each other and the transition went smoothly. However, at least one agency reported serious personal conflicts between the aftercare worker and the other caseworkers. This conflict led to a breakdown in services to families.
|Agency||Provided to Experimental Group||Provided to Comparison Group||Aftercare Provider for Experimental Group|
|Harlem Dowling||Yes, as needed for entire project||No||Separate aftercare worker|
|Little Flower||Yes, as needed for entire project||Yes, goal 3 months|| Same aftercare |
|New York Foundling||Yes, as needed for entire project||No||Separate aftercare worker|
|Miracle Makers||Yes, goal 3 months||Yes, Goal 3 months||Same caseworker|
|St. ChristopherOttilie||Yes, as needed for entire project||Yes, goal 3 months||Provided by HomeRebuilders caseworkers|
|St. ChristopherJennie Clarkson||Yes, as needed for entire project||N/A||Separate aftercare worker, during a crisis, by a clinical psychologist|
2.6 Other Initiatives During HomeRebuilders
2.7 Public and Private Agency Perspective on HomeRebuilders
Despite the early termination of the HomeRebuilders initiative, state and city officials and private agency staff were excited about it. The private agency administrators saw the program as a catalyst to think differently about case planning. Because these agencies volunteered for the program, the administrators believed that HomeRebuilders was a sound method for working with children and their families. One administrator stated that one of the biggest accomplishments of the program was that "it proved to be a successful tool in reuniting families." Another accomplishment mentioned was that in some cases the birth parents remained in contact with the foster families. Another administrator stated that good casework makes sense programmatically and fiscally. The children served needed the clinical services and the foster care. When the children are discharged, the state or city can save money if an investment is made up front. Some of the administrators spoke about the important role aftercare played in reducing the recidivism rate.
Finally, the administrators believed the HomeRebuilders model was a sound foundation for managed care. One administrator summed up by saying, "Any model of managed care must be established on primary fiscal principles which embrace issues related to working with multi-problem families in economically deprived communities." He believed that one lesson learned was the importance of working closely with the state, city, and other participating agencies. This collaborative arrangement can lead to creative management, shared resources, and training opportunities. HomeRebuilders also brought attention to the point that greater efforts must be made to engage other entities such as housing departments, courts, schools, and other social services and welfare departments to make managed care a success for families.
While administrators believed the demonstration tested some managed care principles, they cautioned against calling the project a managed care demonstration. They noted that agencies cannot be held fiscally responsible for outcomes over which they have little control. Whereas they are able to recommend a family be reunified, the city and court make the ultimate decision on placement.
Most state officials were also supportive of the demonstration. One state administrator noted that, in New York State, the child welfare system provided little in the way of aftercare services. This meant that workers had to hold off on discharges until all problems were solved. The aftercare component of HomeRebuilders made it possible for workers to stay with families and return the children to foster care if necessary. He believed that as agencies became more aware that discharge involves a risk, aftercare became more important. It helped clients maintain their gains.
Some officials indicated that one of the most important effects of HomeRebuilders was an unanticipated change in the role of the case managers from the city's Office of Case Management (OCM). Case managers played a more integral role in developing and monitoring service plans. They had lower caseloads, were allotted time to sit in on case reviews at the agencies, and were assigned to the cases served by one agency rather than cases that were served in different agencies. This involved a major realignment of cases for OCM, creating direct communication among public and private agency workers, so they were able to form good working relationships. In addition, HomeRebuilders created good checks and balances regarding early discharge, which was associated with reentry. The OCM staff had to approve discharges and HomeRebuilders held agencies accountable for reentry costs. Thus, unlike other programs, risks and benefits were carefully calibrated in HomeRebuilders.
This collaboration extended beyond the OCM office. In general, HomeRebuilders was viewed by both state and city people as a positive example of city-state collaboration. A high ranking city official said that this was one of the most collaborative ventures that the city and the state had ever had. This person said that this level of collaboration occurred because for the first time, state personnel approached the city as equal partners. Usually state officials approach city-state interactions solely in terms of the need to monitor the city's work. The private agencies also believed that for a time there was a close collaborative effort between the city and the state. It was positive for a while and there was a sense of "we are all in this together" for children and families.
All of the agency staff interviewed felt that the demonstration was cut midstream and that the city had not lived up to its commitment. The resulting low morale at several agencies was palpable. Some of the remaining caseworkers and administrators felt abandoned. Furthermore, some agencies expressed a lack of faith in promises made by the city and state. This, in part, may explain why some agencies have not kept components of the program, such as enhanced case planning, although the components were not dependent upon the fiscal aspects of the HomeRebuilders model. Although other training efforts continue at the agencies, little or no training continues on the HomeRebuilders model. Two administrators stated that the staff hired for the experimental group were greatly affected by the abrupt ending. The staff had been brought together for HomeRebuilders and then were reintegrated into the general structure of the agency. Workers in the experimental group felt disappointed and disillusioned. After making a commitment to learn and implement the HomeRebuilders philosophy, they were told the program was no longer being funded. This caused some staff to seriously question the philosophy, initial creation, and implementation of the project.
State officials unanimously stated that the program should not have been terminated early by the city. Some city officials shared this view. One city official who is no longer with ACS indicated that early termination occurred because another city official unrealistically thought that it would be possible to implement a managed care approach for the whole agency in 6 months.
Agency fiscal staff report several unresolved issues from HomeRebuilders. They include unpaid foster care reimbursement from the city and unpaid Medicaid per diem reimbursement from the DSS. Fiscal staff produced voluminous documentation required by the city to justify and reconcile payment for the three years of HomeRebuilders. All interviewed directors agreed that the payment issues continued to be burdensome for two years past the end of the program, with still some bills remaining in 1998. They all recommend that a new payment method is necessary if such a project is replicated.
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).
3. FINDINGS IN THE HOMEREBUILDERS DEMONSTRATION
Data from New York State on the foster care placement histories of 2987 children in the experiment were analyzed. This figure excludes 4 children who died during the experiment, 17 children who were born after the experiment began and who were subsequently placed, 5 children who were first placed after the experiment began, 14 children who were in placement both before and after the experiment began on July 1, 1993 but were not in placement on that date, and 9 children who were on trial discharge or otherwise absent from their placement homes on that day. The numbers of children by agency and experimental group are shown in Table 3-1. In the three "true experimental agencies" (HD, LF, and MM) there were 640 control cases and 696 experimental cases.
3.1 Administrative Data
3.1.1 Case Characteristics
Sex. Overall, 51 percent of the children were female. There were some differences in sex distributions among agency groups as indicated in Table 3-2.
Ethnicity. In 17 percent of the cases, the administrative data did not record the race of the child. Of the remainder, 74 percent were African American, 7 percent Puerto Rican, 14 percent other Hispanic, 2 percent white, and 2 percent other (Table 3-3). Again, there were small differences among agencies and experimental groups. As can be seen, the OTT comparison group and the NYF experimental group had somewhat more Puerto Rican and other Hispanic children (a combined total of 34% and 32% respectively) and somewhat fewer African American children (65% and 63%) than the other groups (it should be remembered that the groups in these agencies were not randomly assigned). In MM, there was also a bit of a difference, 11 percent of the experimental group and 21 percent of the control group were Puerto Rican or other Hispanic.
Note: Due to rounding, percents may not all equal 100%
Age. The median age of children at the time the experiment began on July 1, 1993 was 5. Seven percent were less than 1 year old, 19 percent were 1 or 2 years old, 28 percent were at least 3 but less than 6, 31 percent were between 6 and 11, and 14 percent were 11 or more (Table 3-4). Again, there were some differences across agencies. Children in OTT were generally younger than those in other agencies.
|Less than 1||6||6||9||8||4||8||9||18||5||6||5||7|
|11 or more||4||8||18||16||11||14||9||10||22||15||15||14|
Note: Due to rounding, percentages may not always equal 100%.
Placement Histories. The vast majority of children (88%) were in their first placements at the time the experiment began. There were no important differences among the agencies and experimental groups on this characteristic.
Length of Time in Placement. At the time the experiment began, the length of time children had been in placement varied widely from 1 day to 11.6 years. The median length was 2.6 years, the mean 2.9 years. The interquartile range was from 1.2 to 4.3 years. There was some variation among agencies and groups (Table 3-5). Children in LF, JC, and OTT had been in care a shorter period of time than those in the other agencies. The differences between experimental and comparison groups are significant in LF, NYF, and OTT at the .03 level. In LF, MM, and OTT, the experimental group had been in care a shorter period of time than the comparison group, on average, while in NYF the comparison group had been in care a shorter period of time. The averages in HD were very close. The differences between experimental and control groups in LF and MM appeared despite random assignment of cases in those agencies.
As will be seen, length of time in care at the beginning of the experiment was related to outcomes of the experiment.
|Mean years in placement at 6/30/93||3.099||3.132||2.166||1.843||3.083||2.888||2.274||1.843||1.916||3.274||3.611|
Type of Placement. On July 1, 1993, 72 percent of the children were in nonrelative foster boarding homes, 24 percent were in "approved relative care," and the remainder in various forms of group homes. There were substantial differences among agency groups in these percentages (Table 3-6). LF and OTT had far fewer relative placements than other agencies while JC had far more.
|Foster Boarding Homes||73||70||89||87||68||67||90||86||51||70||61||72|
Note: Due to rounding, percentages may not always equal 100%.
Permanency Goal. The permanency goal on July 1, 1993 was return home for 65 percent of the children and adoption for 32 percent. The remaining children had goals of independent living, "other primary resource," or "placement prevention." Again, there were differences among the agencies (Table 3-7). LF and OTT had far fewer cases with the goal of adoption than other agencies.
Note: Due to rounding, percentages may not always equal 100%
Summary. Children in the HomeRebuilders experiment were almost entirely African American or Hispanic. Over one-half were less than 6 years of age. Most were in their first placements in nonrelative foster homes and had been in placement a fairly long period of time, on average a little less than 3 years. The original intent of the experiment was to include only children for whom the goal was return to birth parents, but that requirement was relaxed and about one-third of the children had goals of adoption at the time they entered the project. On many of these characteristics, there was variation among agencies and between experimental and comparison groups within agencies. The differences among agencies in child characteristics suggest that the agencies were dealing with somewhat different populations of children. The differences between experimental and control groups in the true experimental agencies occurred in spite of random assignment.
3.1.2 Outcomes from the Administrative Data
The rapid achievement of permanency and reduction in days in care were central objectives of the HomeRebuilders program. Two measures were examined: the percentage of children whose cases were closed and the number of days in care subsequent to July 1, 1993. Obviously, these are highly associated measures. The first of these measures concerns the first time cases were closed following July 1, 1993. The primary reasons for case closing were return home and adoption, although a few cases were closed for other reasons, for example, when the child aged out of the system. The number of days in care takes into account all placements subsequent to July 1, 1993, but subtracts days in which the child was on trial discharge or otherwise absent from the foster care placement. The intent of this measure is to capture the number of days of paid foster care. It can be used as a rough indication of the costs of foster care for a child.
The status of cases may be examined at various points in time. In the following, we examine status at various points following the beginning of the experiment up to April 1997, the last date for which we have data. Outcomes were examined only within agencies. In most of the analyses, there is considerable variation among agencies so that combining across agencies would not be meaningful, since it would obscure the between agency variations. In OTT and NYF, cases were not randomly assigned, so comparisons between the experimental and comparison groups and the significance levels of those comparisons are less meaningful. In JC there was no comparison group.
Percentages of Cases Closed. Table 3-8 shows the status of children at two points in time, December 31, 1995, when the experiment was ended and April 1997. As can be seen, there is considerable variation among the agencies and comparison groups. By December 1995, in most of the groups fewer than 50 percent of the cases were closed. By April 1997, this figure had increased but varied considerably among the groups, from 44 percent in the HD experimental group to 78 percent in JC. As to comparisons between experimental and control groups, in LF the experimental group had closed significantly more cases than the control group by December 1995 (p < .001). By April 1997 the difference had narrowed somewhat (p = .06). In MM, the control group had closed more cases than the experimental group by December 1995 (p = .03); proportions of closed cases by April 1997 were very close. In HD, the difference between the experimental and control groups in December 1995 was not significant, but by April 1997 the control group had closed more cases (p = .02). As to the nonexperimental agencies, in OTT differences were not significant at either point in time while in NYF, the experimental group had closed significantly more cases at both points in time (both differences,
p < .001). In JC the proportion of closed cases was relatively high, but it is difficult to know what to make of this, given the lack of a comparison group in that agency.
|Still in Foster Care||59||63||66***||48***||55*||65*||59||54||43||61***||44***||55|
Note: Significant differences between experimental and control groups in percent closed are indicated by symbols attached to the compared percentages: # = p < .1; * = p < .05; *** = p < .001.
|Still in Foster Care||44*||56*||46#||39#||49||51||41||39||22||45***||25***||39|
Note: Significant differences between experimental and control groups in percent closed are indicated by symbols attached to the compared percentages: # = p < .1; * = p < .05; *** = p < .001.
Of interest is the relatively low proportion of children in the experimental group who were returned home. The group with the highest proportion of children returned home was the LF experimental group, 39 percent by December 1995 and 44 percent by April 1997. Agencies varied considerably in the extent to which they used return home, and conversely, adoption, as routes to case closing. Particularly interesting is a comparison of LF and NYF, two agencies in which the experimental group closed significantly more cases than the comparison group. LF returned more children home and used adoption much less than NYF. Reasons for closing as percentages of all cases closed can also be examined. (see Appendix Table B-6). Except in OTT, as a proportion of closed cases, the experimental groups had fewer adoptions and more returns home than the comparison groups.
Figure 3-1 provides more detail on percentages of cases closed over time. The graphs indicate the widening and then narrowing of the differences between the experimental and control groups in LF. In NYF the increasing difference between the groups is evident, with the experimental group closing ever more cases over time. Of interest is what happens to these graphs following the end of the program. In the LF experimental group the graph flattens after that point, so that the difference between experimental and control groups narrows. In HD, the experimental group graph also flattens while the control graph continues to rise, leading to greater differences between the groups. The flattening of the graphs for the experimental groups might reflect the withdrawal of the fiscal incentives of the program, but these dynamics are not seen in the other experimental groups.
Days in Care. Table 3-9 shows the average days in care for children in the experiment at the end of 1995 and by April 1997. The results are similar to those in the analysis of closed cases in that the experimental groups in LF and NYF have significantly lower levels of care days than the comparison groups at both points in time. At the end of the project in December 1995, the LF experimental group had 13 percent fewer days in care than the control group and the NYF experimental group had 7 percent fewer days in care. By April 1997, the LF experimental group had 15 percent fewer days in care than the control group and the NYF experimental group had 14 percent fewer days in care. In this analysis, in no agency does the comparison group have significantly lower days in care than the experimental group at either point. Also consistent with the case closing analysis, JC had relatively low levels of average care days.
|Mean Days in Care|
|To 12/31/95||To 4/30/97|
Figure 3-2 displays number of care days at several points in time. In HD, MM, and OTT, the curves for the experimental and comparison groups are remarkably similar, while the lower days in care in the experimental groups in LF and NYF is evident.
It is of interest to examine lengths of time in care for differing outcomes, in particular, for adoption versus other outcomes. Considering only those cases that closed by April 1997, as would be expected, time in care was considerably higher for children that were adopted.
For all cases that were closed, the total length of time in care was 60 percent higher for adopted children. The differences in LF between experimental and control groups in lengths of time in care may be due in part to the much lower number of adoptions in the LF experimental group. However, it must be noted that NYF, with a significant difference between experimental and comparison groups in days in care, had a large number of adoptions overall and little difference between experimental and comparison groups in proportions of closed cases that were adoptions (67% vs. 70%).
3.1.3 Refinements on the Above Analysis
The original conception of the HomeRebuilders experiment called for limiting the sample to cases that were not in relative care and that had a goal of return home. However, these restrictions were subsequently relaxed and a number of children were included in the experiment who were in relative care and a number who had adoption as a goal at the beginning. Analyses only of children in nonrelative foster care and in nonrelative foster care with a goal of return home are shown in Appendix Tables B-8 and B-9. The results are very similar to those for all children shown above.
Regression Analyses. A regression analysis was performed to "control for" characteristics of children at the time the experiment began. The dependent variable in the analysis was days in care through April 1997 while the independent variables were child characteristics available in the administrative data: ethnicity, sex, age, days in care at 7/1/93, goal at the beginning of the experiment, and experimental versus control group. Separate analyses were performed for each of the agencies. The results (shown in Appendix Table B-10) indicate that, controlling for the other factors in the equations, the HomeRebuilders groups in LF and NYF continued to have significantly fewer days in care than the comparison groups in those agencies. The effects in reduction in days in care were slightly larger than the uncontrolled effects shown above. The effects on days in care for the other agencies were not significant.
The results also indicate that in all agencies, Hispanic children tended to spend less time in care than African Americans, although the effects of ethnicity were significant only in HD. Sex was not significant, except in NYF, where males had longer times in care. More previous placements tended to result in more days in care while longer length of time in care at the beginning of the experiment tended to result in a lower number of subsequent days in care. A goal of return home had mixed effects in the various agencies. In LF, it led to a lower average number of days in care (p < .1) while in MM it led to more days in care (p < .05).
Goals for the case often changed in the course of work with the family. Table 3-10 shows goals at the time the experiment began by goals at the time the experiment ended in December 1995.
The most frequent goal change was from return home to adoption (39% of cases with an initial goal of return home were changed to adoption). When adoption was the initial goal, it was infrequently changed (90% of initial adoption goals remained adoption at December 31, 1995).
|Goal at July 1, 1993||Total (column %)|| Goal at December 31, 1995 |
(or last goal before that)
|Total N||2974|| 896 |
| 1635 |
| 443 |
|Return home|| 1919 |
| 838 |
| 744 |
| 337 |
|Adoption|| 937 |
| 44 |
| 841 |
| 52 |
|Other|| 118 |
| 14 |
| 50 |
| 54 |
Note: "Other" goals include independent living, "other primary resource," and "placement prevention."
Changes in goals by agency are shown in Appendix Table B-11. For cases with an initial goal of return home, the variation among agencies in percent of cases with changed goals was not large (from 48% in the LF control group to 66% in the HD control group and NYF experimental group). However, the proportion of changes from return home to adoption did vary considerably, from 19 percent in the LF experimental group to 53 percent in the HD experimental group. Most cases with an initial goal of adoption continued to have that goal in the agency subgroups. The exception is the LF experimental group, where changes occurred in 80 percent of the small number of cases (15) with an initial goal of adoption.
It has been suggested that "managed care" programs like HomeRebuilders should result in quicker decisions on courses of action to take. It was thought that in HomeRebuilders, changes of goals might occur more quickly than in the comparison group. Thus, dates of the last goal change were examined. Details are shown in Appendix Table B-12. Although there were few significant differences, the date of the last goal change was, on average, earlier in the experimental groups, consistent with expectations. The exception was decisions to move to adoption in LF, where such decisions took longer in the experimental group.
Of the three true experimental agencies, the LF experimental group had more case closings and fewer days in care than the control group. In the other two experimental agencies, there is little evidence of a positive effect of HomeRebuilders on case closings and days in care. Among the nonexperimental agencies, the NYF experimental group had significantly more case closings and fewer days in care than the comparison group. The results for LF and NYF were confirmed in a regression analysis controlling for certain characteristics of the children.
About two-thirds of the children began the experiment with a permanency goal of return home; nearly all of the remainder had a goal of adoption. Many of the original goals of return home were subsequently changed to adoption, so that by the end of the experiment, in December 1995, the proportions had substantially reversed, with 55 percent of the children having been adopted or having a goal of adoption.
3.2 Interviews with Caretakers
3.2.1 Caretaker Interview Sample Description
In a sample of the cases included in the administrative data analysis, caretakers and their caseworkers were interviewed. The interviews were designed to provide data on services delivered to the families and children and on child and family functioning following the experiment.
Services were examined in order to describe the activities undertaken on behalf of these families and to determine differences between experimental and comparison groups in those activities. At the outset of the project, it was intended that the experimental group would receive more intensive services directed at reunifying the children or bringing about other permanent arrangements. The analysis aimed at determining whether, in fact, the services provided to the two groups were different.
The effects of the experimental intervention on child and family functioning was also examined. It is not entirely clear how one should think about child and family functioning as an outcome of this effort. On the one hand, it would seem that any new program should strive to enhance the functioning of the clients it serves and should be judged at least in part on the extent to which improvement occurs. On the other hand, the primary intervention in HomeRebuilders was a fiscal one, directed at lowering the number of days in foster care. Hence, one might view the program as a success if care days were lowered while functioning was not negatively affected.
The sample of cases for caretaker and caseworker interviews was restricted to cases that had a goal at the beginning of the experiment of return home and at least one child under 13 years of age. Thus, the interview sample is not parallel to the entire group of cases analyzed in the previous section. Furthermore, strictly speaking, the experimental and control group interview samples cannot be considered to have been randomly assigned, in part because response rates were not perfect (see Appendix A) and may have led to some differences between experimental and control groups in the families actually interviewed. In addition, the process of determining the caretaker to be interviewed may have resulted in differences between groups in the characteristics of the interviewees. Interviews were held with caretakers in both the experimental and comparison groups in HD, LF, MM, and OTT. Caretakers in the comparison groups in NYF and JC were not interviewed (there was no comparison group in JC). Because of the complexity of some cases, the determination of the caretaker to be interviewed required detailed rules, which are given in Appendix A. A total of 433 caretakers were interviewed. Thirty percent were birth parents, 26 percent relatives, and 43 percent nonrelatives. There were 52 percent adoptive or preadoptive respondents and 11 percent foster parents. Relative adoptive or preadoptive caretakers accounted for 14 percent, nonrelative adoptive or preadoptive for 38 percent. Relatively few respondents were foster parents. The breakdown of respondent category by agency and experimental group is shown in Table 3-11.
|Birth parent-all children in home||14||12||20||34||26||20||26||26||26||24||23|
|Other birth parent||5||6||13||9||5||7||13||5||6||14||8|
|Adoptive or preadoptive relative||10||16||5||3||17||25||--||13||23||18||14|
|Adoptive or preadoptive nonrelative||52||47||43||31||33||39||42||37||30||28||38|
|Foster parent or other relative||19||18||20||23||19||8||19||18||15||16||17|
Within agencies, there were relatively few differences between experimental and comparison groups. In OTT, no comparison group cases were adoptive or preadoptive relatives, while 13 percent of the experimental group was in that category. In MM, 19 percent of the control group were foster parents or nonadoptive relatives, while 8 percent of the experimental group was in that category. In LF, there are two important differences between the experimental and control group -- more experimental group respondents were birth parents (with or without all of the children having been returned; 34% of the experimental group vs. 20% for the control group) and fewer were adoptive or preadoptive nonrelatives (31% vs. 43%).
There were some differences across agencies. HD had fewer birth parents and more adoptive or preadoptive nonrelatives than other agencies. NYF had fewer adoptive and preadoptive nonrelatives, while LF had fewer adoptive and preadoptive relatives.
Respondent Characteristics. The respondents were 95 percent women, 72 percent African American, 24 percent Hispanic, and 4 percent white (2 respondents were an "other" race-ethnicity). As shown in Table 3-12, race/ethnicity varied by agency.
JC and NYF had fewer African American and more Hispanic respondents than the other agencies. In HD, LF, and MM, the race/ethnicity distributions in the control and experimental groups were very similar. In OTT, there were more African American respondents in the experimental group (84%) than the comparison group (65%) and fewer Hispanic respondents (11% in experimental group, 32% in comparison group).
Note: Due to rounding percentages may not always equal 100%.
The average age of respondents was 46 (s.d.: 11.8). The average size of the respondents' households was 5.3, with an average of 3.5 children. Forty-nine percent of the children in the homes were female. The median age of the youngest child was 4 (mean of 4.9), the oldest, 12 (mean 11.5). Thirty-two percent of the respondents were married, 21 percent single, 23 percent never married, and divorced and widowed accounted for 12 percent each. Birth parents were more likely to be never married (45%) and less likely to be married (20%). In MM, 52 percent of the control group were married and 17 percent never married compared to 32 percent and 15 percent in the experimental group. Sixty percent of the respondents had less than a high school education, 15 percent had graduated from high school, and 24 percent had at least some college. There were no strong differences in education by type of respondent, although adoptive relatives and foster parents/other relatives more often had an 8th grade or less education (19% and 14% respectively, compared to 7% of birth parents and other adoptive parents). There were some differences in caretaker education among agencies and between experimental and control groups within agencies as shown in Table 3-13. Within the true experimental agencies, the control group in MM had a larger proportion of cases with eighth grade or less than the experimental group, although the numbers are quite small (7 versus 2). In LF, the experimental group had lower levels of education than the control group while in HD the opposite was true. These differences may have affected the comparison of the experimental and control groups on outcomes that are reported below.
|8th grade or less||15||8||5||15||17||3||7||5||7||24||11|
|Some high school||49||42||55||62||38||44||63||61||60||42||50|
|High school graduate or GED||20||10||8||12||19||20||23||13||9||14||15|
|Some college or vocational school||5||25||25||9||19||22||3||18||20||14||17|
A majority (52%) of respondents reported they were unemployed and not looking for work (45% of birth parents, 60% of adoptive relatives, 53% of other adoptive parents, and 56% of foster parents/other relatives), 34 percent were employed, and 14 percent were looking for work. Birth parents were a bit more evenly split among these three categories (45%, 27%, and 28%). There were some differences among agencies (Table 3-14). There were no strong differences between experimental and ccomparison groups within agencies, except in LF where 38 percent of the control group were employed and 40 percent not looking for work compared to 20 percent and 57 percent in the experimental group: (again, this difference may have affected comparisons in LF). Most (75%) of the respondents rented their residences, including 93 percent of birth parents, 76 percent of relatives, and 62 percent of nonrelatives.
|Unemployed and looking for work||10||23||12||8||20||14||14|
|Unemployed and not looking||59||48||45||51||52||62||52|
Summary. Consistent with the characteristics of the child sample, most respondents were African American or Hispanic. Nearly all were women and their average age was 46. Their households tended to be large, an average of over 5 members including 3.5 children. More than one-half of the respondents had less than a high school education. Only about one-third were employed and another one-seventh were looking for work.
3.2.2 Experience of Respondents with Maltreatment
It is often thought that child maltreatment is an intergenerational phenomenon, that parents who were abused as children are more likely to abuse their own children. Respondents were asked whether they were abused or neglected as children (Table 3-15). Fourteen percent said they had been abused, including 29 percent of birth parents, 10 percent of relatives, and 6 percent of nonrelatives. Eleven percent had been neglected, including 23 percent of birth parents, 10 percent of relatives, and 4 percent of nonrelatives. Six percent (26) had been in foster homes or institutions, including 18 birth parents, 3 relatives, and 5 nonrelatives. Evidently, birth parent respondents were more likely to have been maltreated.
|In foster home||14||3||4||6|
|Not in foster home or institution||86||97||96||94|
The interviews included a number of questions that measure outcomes. Some of these items had very little variation in response. The relationship between membership in experimental and comparison groups was examined for those items that had at least minimal variation. In addition, summations of various individual items formed scales. Differences between the experimental and comparison groups were analyzed within the four agencies in which we interviewed caretakers in both groups (HD, LF, MM, and OTT). Three of these agencies (HD, LF, and MM) were considered "true experimental" agencies. We did not analyze combinations of all experimental groups against all comparison groups, since such combinations would have little meaning, given the lack of control groups in JC and NYF and the nonrandom formation of groups in OTT.
Three categories of significant findings were identified, those at or below p = .1, .05, and .01. Probabilities reported are two-tail, based on Chi-square, Fisher exact, or t-tests, as appropriate. T-tests of differences in group means were used for scales and for a few items involving ordered categorical responses. A large number of statistical tests were performed and this invariably leads to the identification of spurious results, so caution must be used in interpreting isolated significant findings.
Parent and Family Functioning. Parent and family functioning was examined only for respondents who were birth parents. Although the functioning of other caretakers and their families is not unimportant, HomeRebuilders was originally conceived as a program that would enable birth parents to regain custody of their children. The focus of the intervention was to be on the functioning of those parents. Furthermore, when other goals were pursued (most notably, adoption) involving other caretakers, the extent of involvement of the agencies with those other caretakers varied considerably, making comparisons problematic. Unfortunately, the numbers of birth parents within experimental and comparison groups within agencies was very small, ranging in these analyses from 6 to 19, making it difficult to detect significant differences. Table 3-16 summarizes the results.
|Items and Scales||Number of Items||Number of E-C Comparisons for 4 Agencies||Results of Within Agency Comparisons of Experimental and Comparison Groups|
|Personal life events (Q41)||14 (7 analyzed)||28||No significant differences|
|Depression subscale||4||4||No significant differences|
|Caretaking behaviors (Q55)||15 (8 analyzed)||32||No significant differences|
|Punishment subscale||5||4||LF exp group higher levels of punishment, p < .05|
|Positive family life events scale (Q40)||6||4||No significant differences|
|Negative family life events scale (Q40)||8||4||No significant differences|
|Difficulties paying for things scale (Q52)||4||4||OTT exp group less difficulty, p < .1|
|Overall assessment of changes in family life (Q69)||1||4||No significant differences|
There were two series of yes-no questions. The first (Personal Life Events) asked whether any of 14 "things have happened to you in the last three months," and included both positive ("gotten together to have fun or relax," "felt happy") and negative ("felt blue or depressed," "felt nervous or tense," "felt you had few friends," "not enough money for essentials," "overwhelmed by work or family responsibilities") experiences (caretaker interview, question 41). Seven of these items had too little variation to analyze further. On none of the remaining seven items were there any significant (p < .1) differences between comparison groups in any agency. Sometimes the experimental group had better outcomes, other times the comparison group. Four of the items could be thought of as reflecting depression and were combined into a "life events depression" scale. None of the comparisons of the birth parents in the experimental and comparison groups were significant on this scale.
The second series of yes-no questions was 15 items tapping caretaking behaviors ("In the last three months, have you . . .") (caretaker interview, question 55). Seven of these items had too little variation to compare experimental and comparison groups. Of the remaining eight items, five were positive ("praised your child for doing well," "listened to music together," "gone to an amusement park, pool, etc.," "encouraged your child to read a book," and "had your child handle household chores on a regular basis") and three were negative ("lost your temper when your child got on your nerves," "things got out of control when punishing your child," and "blamed your child when things were not his or her fault"). Five of the fifteen items formed a "punishment" scale.
On the eight items with adequate variation, none of the 32 within agency comparisons of birth parent respondents proved significant. For the punishment scale derived from these items, there was one significant difference: the experimental group in LF had a higher mean score (higher level of punishment) than the control group (p < .05).
The interview included a family life events inventory of 15 items ("has anything like this happened to you or someone in your household in the past three months") (caretaker interview, question 40) from which were derived two scales, positive life events (6 items) and negative life events (8 items). None of the within agency experimental-comparison group comparisons for birth parents were significant on these scales. Four yes-no questions were asked about difficulties in paying for things, from which a scale was derived consisting of a count of yes responses (caretaker interview, question 52). Only in OTT was there a significant difference on this scale: the experimental group had fewer problems in paying for things than the comparison group (p < .1).
Respondents were asked for their overall assessment of changes in family life since the agency began work with them (caretaker interview, question 69). A five point scale, ranging from great improvement (1) to a great deal worse (5) was provided. Examining means on this item, there were no significant differences between experimental and comparison groups within agencies, for either all respondents or for birth parents only. Means were lower (better) for the experimental group in HD and LF and the comparison group in OTT. In MM the means were the same for all respondents and lower in the control group for birth parents. Responses to this question, collapsed into three categories, were also examined in crosstabulations, (the categories "same," "somewhat worse," and "a great deal worse," were collapsed, the latter two having very few responses). Analyzing all respondents in the true experimental agencies combined, experimental group respondents more often said "great improvement" (41% vs. 28% for the control group) and less often rated matters as same or worse (28% vs. 40%). The significance of this difference was .11. The result held in HD and LF (nonsignificant for HD, p = .095 for LF) while it was reversed for OTT (comparison group respondents more often rated things as greatly improved). In MM, the percentages in the three categories for the experimental and control groups were almost the same. Separate analysis of birth parent responses yields similar nonsignificant patterns.
Child Outcomes. A series of 35 yes-no child behavior questions were used to derive four scales (caretaker interview, question 57):
- Proportion of 25 negative child behaviors,
- Proportion of 10 positive child behaviors,
- Number of four child aggression items yes (these items were among the negative behaviors), and
- Proportion of five school problem items yes (also among the negative behaviors).
These scales were analyzed both for all respondents and for birth parents separately. In the all respondents analysis, no significant differences were found between experimental and comparison groups in any of the agencies. For birth parents, there was one significant difference: in OTT, average scores for child aggression were lower in the experimental group than in the comparison group (p < .05).
Even more than in the case of parental functioning, issues arise in the interpretation of child behavior as an outcome of these services. Most of the services of programs like HomeRebuilders are directed to parents. Therefore, the effects on child behavior are necessarily indirect and might be expected to be relatively small.
Summary. Given the large number of comparisons examined, little can be made of the few significant differences noted above. Nonsignificant differences often favored the comparison group. There is no conclusive evidence in the interviews of caretakers that the HomeRebuilders group had better child and family functioning than the comparison group.
Respondents were asked a number of questions about social program involvement, services received, and caseworker activities. A few indexes were constructed from these items and again the focus was on differences between experimental and comparison groups within agencies. These items were examined both for all respondents and for birth parents separately. The results are shown in Table 3-17.
Respondents were asked about involvement in the last 3 months in 11 programs, including income support programs (e.g., food stamps, WIC, and AFDC) and various treatment programs (alcoholism or drug addiction programs, marriage counseling, and community mental health programs) (caretaker interview, question 53). There was enough variation in involvement in six of these programs to make comparisons between experimental and comparison groups. In the analysis of all respondents, 3 of the 24 within agency comparisons were significant. A scale was constructed of the number of income support programs received. There were no significant differences in means of this variable within agencies. Also determined was whether respondents had been in any treatment program. For all respondents, in only one group did this percentage exceed 15 percent (in the JC treatment group it was 19%) and it was often less than 10 percent. For birth parents only, the percentages were higher (reaching 60% of 15 respondents in JC, but 33% or lower in the other groups). None of the comparisons between experimental and comparison groups were significant on this variable.
|Items and Scales||Number of Items||Number of E-C Comparisons for 4 Agencies||Results of Within Agency Comparisons of Experimental and Comparison Groups|
|Involvement in programs (Q53)||11 (6 analyzed)||24|| All respondents: |
MM: exp group less often received AFDC (26% vs. 50%, p < .1) and more often received social security disability (33% vs. 13%, p < .1) LF: exp group more often received social security disability (43% vs. 16%, p < .03)
Birth parent respondents:
|Income support programs scale (Q53)||5||4|| All respondents: |
No significant differences
Birth parent respondents:
|Any treatment program (Q53)||4||4|| All respondents: |
No significant differences
Birth parent respondents:
|Receipt of services (Q54)||13(9 analyzed)||36|| All respondents: |
HD: exp group more day care (53% vs. 11%, p < .01), exp group more medical or dental care (84% vs. 58%, p < .1)LF: exp group more day care (22% vs. 4%, p < .1), exp group less counseling (13% vs. 36%, p < .1)MM: exp group more medical or dental care (78% vs. 46%, p < .05)OTT: exp group more educational services (19% vs. 0%, p < .1), exp group more parent education (p < .05)
Birth parent respondents:
|Receipt of services scale (Q54)||13||4|| All respondents: |
No significant differences
Birth parent respondents:
In the analysis of birth parent respondents' involvement in programs, there were two (out of 24) significant differences within agencies, both in MM. In MM, experimental group birth parent respondents less often received food stamps and AFDC (both comparisons, p < .05).
Respondents were also asked about the receipt during the past 2 years of 13 services, including day care, help in finding a place to live, medical or dental care, and transportation (caretaker interview, question 54). Nine of these services had enough variation to proceed with between group analyses. In the analysis of all respondents, 7 of the 36 within agency comparisons were significant. In all but one of these comparisons, experimental group families more often received the service. In all three true experimental agencies, experimental group clients more often received help finding a place to live, although the differences were nonsignificant.
A scale consisting of a count of these 13 services received was constructed. In the all-respondents analysis, there were no significant differences within agencies, although in all of the four comparison group agencies the experimental group had a higher average number of services received. For birth parents alone, experimental group respondents in MM had a significantly higher level of service use (p < .05) and in LF, experimental group families had a nonsignificantly lower level of use. Otherwise, the results paralleled those for the all-respondents analysis.
Respondents were asked whether their caseworkers had engaged in any of 17 activities, including help with money, transportation, advice about job training programs and school, and help with handling feelings (caretaker interview, question 64). Twelve of these items had enough variation for analysis (see Table 3-18). In the all-respondents analysis, 4 of the 48 comparisons in the control group agencies were significant. In the birth parent analysis, there were five (of 48) significant differences, all in the "wrong" direction, that is, the control group more often experienced the activity. Four of these differences were in MM and one was in LF. On an overall index of caseworker activities, caseworkers for control group birth parents in MM engaged in more kinds of activities (p < .1); there were no significant differences in the other agencies.
|Items and Scales||Number of Items||Number of E-C Comparisons for 4 Agencies||Results of Within Agency Comparisons of Experimental and Comparison Groups|
|Caseworker activities (Q64)||17(12 analyzed)||48|| All respondents: |
LF: exp group more discussions on getting better place to live (23% vs. 8%, p < .1), exp group more advice on schooling (17% vs. 5%, p < .1)MM: exp group less advice on job training programs (5% vs. 17%, p < .1), exp group less advice on getting a paying job (2% vs. 12%, p < .1)
Birth parent respondents:
|Caseworker activity scale (Q64)||17||4|| All respondents: |
No significant differences
Birth parent respondents:
Nonadoptive and preadoptive respondents were asked whether their workers helped them see their good qualities and their problems (caretaker interview, question 68). None of the within agency comparisons were significant on these two items. For the true experimental group agencies, experimental group respondents more often reported the worker helped them see their problems, but the differences were not significant. For birth parents only, there were no significant differences, but the directions of associations were similar to those for all respondents.
Birth parents whose children had returned home were asked whether there was discussion with the caseworker, foster parent, and child about the child's return home. None of the comparisons within agencies were significant, although the numbers in the agency subgroups were quite small. These respondents were also asked whether the number and length of visits with children had increased in the month before the children returned home. There were no significant differences between the experimental and comparison groups. They were also asked whether they had received any help from the agency since the return of the children. Again, there were no significant differences between experimental and comparison groups. The percentage varied widely in subgroups (from 0% to 56%) and in LF, MM, and OTT such after return involvement was higher for the control group, although again, the numbers were very small.
Respondents were asked about the frequency of contact with the worker in the last 3 months. In nearly all of the comparisons of experimental and comparison groups, for both all respondents and birth parents alone, members of the comparison group had more contact with the worker. This may be due to the fact that experimental group cases were closed earlier than comparison group cases, so that more of the experimental group cases had no opportunity to meet with the worker during the three months prior to the interview.
Finally, respondents were asked whether the worker listened to their concerns and understood their situations. For the birth parents in HD and LF, experimental group respondents more often answered "most of the time" on these two questions, though the differences were not significant. There was little difference between groups in the all respondents analysis of these two questions.
Relationships with Foster Parents. Birth parents were asked about their relationships with the foster parents responsible for their children. The results are shown in Table 3-19. The small number of cases in the analysis hampers interpretation. In LF and MM the experimental group had more contact with foster parents than in the control group. The reverse was true in HD. As to the five activities that were asked about, there were no strong trends in any agency; within agencies, the foster parents in the experimental group engaged in some activities more than the comparison group and in other activities, less than the comparison group. In HD and LF, birth parents in the experimental group rated their overall relationships with foster parents higher than did control group parents; there was little difference between the groups in MM and OTT.
|Contact once a week or more (N)|| 70 |
| 20 |
| 43 |
| 55 |
| 53 |
| 68 |
| 56 |
| 60 |
| 76 |
| 56 |
|FP sometimes or often provide transportation|| 25 |
| 30 |
| 20 |
| 10 |
| 27 |
| 44 |
| 13 |
| 15 |
| 50 |
| 39 |
|FP sometimes or often join in play|| 50 |
| 20 |
| 10 |
| 60 |
| 80 |
| 56 |
| 47 |
| 38 |
| 44 |
| 48 |
|FP sometimes or often lend or give you money|| 13 |
| 10 |
| 0 |
| 0 |
| 13 |
| 22 |
| 13 |
| 8 |
| 38 |
| 22 |
|FP sometimes or often take you shopping|| 13 |
| 10 |
| 0 |
| 5 |
| 13 |
| 6 |
| 13 |
| 0 |
| 6 |
| 17 |
|FP sometimes or often teach about cooking|| 0 |
| 20 |
| 0 |
| 20 |
| 13 |
| 17 |
| 7 |
| 15 |
| 31 |
| 22 |
|Overall relationship (N) Excellent Good|| (10) |
| (10) |
| (14) |
| (22) |
| (15) |
| (19) |
| (16) |
| (15) |
| (17) |
| (25) |
Summary. One would expect to find that the experimental group received more services than the comparison group and that these services would be more intensive. A liberal reading of the above findings might conclude that the experimental group received slightly more and more intensive services. But the evidence in that direction is not strong, and there are a number of instances in which the comparison group received more service.
3.3 Interviews with Caseworkers
Caseworkers were interviewed in both experimental and control groups in HD, LF, and MM, and in the HomeRebuilders groups in JC and NYF. Attempts were made to interview caseworkers for the same sample of families as that used for the caretaker interviews, except that it was not possible to interview caseworkers in OTT. As indicated above, the sample was limited to cases in which the goal at the beginning of the experiment was return home and in which there was at least one child under 13 years old.
Caseworkers were interviewed on a total of 407 cases. Some caseworkers were interviewed about more than one case. These cases were distributed among the agencies and experimental groups as indicated in Table 3-20.
As in the caretaker interviews, caseworkers were asked a number of questions regarding child and caretaker functioning at the end of the experiment and about the services provided to the family. Again, we analyzed differences between experimental and comparison groups within agencies. Separate analyses were not conducted for birth parents, as in the caretaker interviews. Caseworker respondents varied considerably in their relationships to the families. Some were caseworkers who provided services during the experiment, some were successor workers, and others were supervisors. Sometimes respondents did not have personal knowledge of the family and were responding based on case records.
Family and Caretaker Functioning. Three scales were constructed based on items in the caseworker interview, as follows:
- Household condition, proportion yes on 13 yes-no items on problems (caseworker interview, question 22a);
- Caretaker problems, proportion yes on 21 items (caseworker interview, question 24); and
- Caretaker functioning, average of 9 items, scaled from 0-4, not adequate to very adequate (caseworker interview, question 23).
Two of the nine within-agency comparisons on these scales were significant at .1; in both, the control group was doing better (HD: caretaker problems, LF: caretaker functioning). As with caretakers, caseworkers were asked for their overall assessments of improvement in the families. There were no significant differences within agencies in the responses to this question.
It would be desirable to have records of subsequent allegations of abuse or neglect from the administrative data. Unfortunately, such records were not available. As an alternative, workers were asked whether there had been subsequent allegations and whether they had been substantiated. Table 3-21 shows the results. As can be seen, there were relatively few substantiated allegations. Differences between experimental and comparison groups were small and not significant, due in part to small numbers of families.
Child Functioning. Caseworkers were asked two series of questions about child functioning problems. The first asked about the children collectively, as part of a question on problems in the family (this question included the items on caretaker problems discussed above) (caseworker interview, question 24). There were 10 yes-no items in this question (e.g., physical or mental health problems, substance abuse, learning problems, behavior problems), and a scale consisting of the proportion "yes" was formed. There were no significant differences between experimental and control groups within agencies on this scale.
A second set of eight questions was asked about each child in the family (caseworker interview, question 25). These questions were:
- Is the child alert and interested in what is going on?
- Does the child appear to be small in size and light in weight for his/her age?
- Does child appear to be irritable and easily upset?
- Do you think the child's use of language and vocabulary is adequate for his/her age?
- Is the child aggressive toward the caretaker?
- Does the child have problems in school?
- In the last 3 months has the child been truant from school?
- In the last 3 months has the child run away from home?
Whether any child in the family had a problem in any of these eight areas was determined. A count of the number of problem areas for any child in the family was then formed. None of the mean differences between the experimental and control groups were significant on this scale.
Summary. As with the caretaker interviews, the caseworker interviews provided little evidence for differences between experimental and control groups in child and family functioning outcomes.
Two scales were constructed:
- Number of services provided out of a list of 26 services (caseworker interview, question 26); and
- Number of different kinds of caseworker activities, based on a list of 17 possible activities (caseworker interview, question 27, except r).
In LF, the experimental group had significantly higher means than the control group on these scales (for number of services, p < .01; for kinds of caseworker activities, p < .1). On kinds of caseworker activities, the other two true experimental agencies (HD and MM) had results in the same direction. On number of services, MM was in the same direction while in HD the control group had a higher number of mean services.
Clusters of similar services were also examined. Table 3-22 shows percentages of families provided services within each of these clusters. In LF, experimental group families received each of these clusters of services more often than control group families and the differences were significant for income support and health care or assessment. In HD, experimental group clients more often received drug or alcohol treatment (p < .1).
|Any income support service||5||11||9||33**||7||6||28||15|
|Drug or alcohol treatment provided||3||16#||23||37||38||35||42||15|
|Health care or assessment||50||53||51||71*||56||56||51||77|
|Inpatient or outpatient mental health services||25||29||46||51||31||34||40||49|
|Any housing service||15||24||28|| 45 |
# = p < .1; * = p < .05; ** = p < .01
It would have been useful to examine the "match" of services to problems. Unfortunately, matching is hampered by the fact that we do not have data on the problems of families at the outset of the experiment, only at the time of the interview with the caseworker. Workers were also asked how often they visited caretakers. In LF and HD experimental group workers reported more frequent visits (HD: p < .1; LF: p < .003).
The results indicate that in the perception of caseworkers, in LF, experimental group families received more service. There is little evidence for higher levels of service in the experimental groups of the other agencies.
3.4 The HomeRebuilders Findings
The HomeRebuilders project was an ambitious effort to test a major reform of the foster care system in New York City. Planning for the project extended over more than 2 years and involved many staff from the state, city, and the private agencies delivering services. The project entailed countless hours of effort, required negotiations of new relationships among the organizations involved, and took all participants into uncharted territory. It was the first large-scale experiment with managed care concepts in child welfare, and it may still be the largest.
The HomeRebuilders project was built on the notion that the current financing arrangements for foster care, primarily payments for each day in care, create all the wrong incentives for agencies providing the service. Criticisms of per diem payments are based on the view that they do not encourage agencies to work toward reunifying the child with birth parents or toward other resolutions, such as adoption. In fact, the incentive is to retain the child in care because a child in care assures a steady flow of dollars into the program. To correct these perceived distortions in incentives, HomeRebuilders offered agencies capitation payments, a central feature of managed care programs. Agencies were paid a flat amount to work with a group of children who were in foster care at the end of June 1993. Instead of payments for each day in care, the agencies received the predetermined funds, no matter how long the children were in care. Agencies thus assumed the financial risk that children might stay in care longer than projected. The funds were to be used for the costs of foster care, but could also be used for services designed to effect reunification or other permanency arrangements. Funds could also be used for aftercare services, intended to prevent reentry to foster care. The agencies believed that the new arrangements gave them an opportunity to develop new ways to work with families.
As in any major initiative, HomeRebuilders encountered some problems along the way. Agencies did not receive promised funding from Medicaid. During the experiment New York City adopted a new focus on adoption. The shift of a substantial number of cases in the HomeRebuilders group to adoption created financial pressures, since adoptions cost more than returns home (in part, because they take longer on average). There was also a significant decrease in numbers of children entering foster care. Although not directly affecting the HomeRebuilders program, the decrease caused financial stress in the agencies involved and required shifts in personnel and layoffs. Finally, and perhaps most important, the program was terminated after two and a half years, 6 months before its scheduled ending date, causing considerable disruption in the agencies.
It should be noted that the agencies insisted to us that HomeRebuilders was not a managed care program. In the pure form of managed care, agents given responsibility for cases also have the authority to make critical decisions. In HomeRebuilders, agencies had to have the approval of the New York City CWA and the court to return children home, close the case, change the goal to adoption, and to take other actions in the case. Thus, there were risks that were imposed on the agencies that were not under their control, in particular, the possibility that a child would remain in care longer than the agency thought was necessary. The agencies had to bear the financial effects of these longer stays.
As indicated above, the focus of analysis of outcomes was on differences between experimental and comparison groups within agencies. There is considerable variation in results between agencies, such that combining across agencies would not be meaningful. Furthermore, one must distinguish between "true experimental agencies" in which random assignment to experimental and control groups was employed and the other agencies in the project.
Discharge and Days in Care. The data indicate that the New York HomeRebuilders program had the effect of speeding up discharge and reducing days in care in one of the three agencies using random assignment of cases (LF). In that agency, the difference between experimental and comparison groups in days in foster care at the end of the program was on the order of 13 percent. A 13% improvement is not large, but it is larger than the program planners anticipated for the program as a whole (planners had hoped for about a 10% reduction). If this percentage had held generally, one could point to the substantial dollars that such an improvement would represent. Since it did not hold generally, claims of potential large cost savings cannot be supported. In the other two random assignment agencies discharge proportions and days in care did not significantly favor the experimental group. In one of the nonrandom assignment agencies (NYF), discharge rates were higher and days in care lower for the HomeRebuilders group compared with the comparison group. Because the groups were not randomly formed, the possibility that these differences are due to characteristics of the groups cannot be excluded. However, the observed effect survived a regression analysis using available administrative data on a number of control variables, thus providing some reason to believe that the differences in NYF reflect a real effect of the program. JC had high proportions of cases closed and low average days in care, but definitive conclusions cannot be drawn about those results because there was no comparison group in that agency.
Child and Family Functioning. The caretaker and caseworker interview data reveal few effects of the program on family and child functioning. There are always many possible explanations for findings of no difference: the intervention theory was faulty, the theory was inadequately implemented, the program had positive effects but they were not measured, the measures that were used lacked reliability or validity, experimental conditions were not maintained (e.g., the experimental group did not receive the intended intervention or the comparison group received some or all of the services intended for the experimental group), or the experiment lacked statistical power to detect effects (because numbers of cases were small, a particular problem when the expected effects are small). There may also have been major shifts in the environment of the program; shocks to the system that seriously affected the outcome.
It is possible that these and other factors played at least some part in the lack of detected effects on family and child functioning. One aspect of the data collection should be noted: interviews were held with caretakers and caseworkers 6 to 12 months after the end of the program. Furthermore, many cases had closed much earlier and in those cases the time between the last contact with the agency and the interviews was even longer. Thus, the interview data are subject to problems of recall. There were also problems of low sample size. Although the overall number of cases in the experiment was fairly large, subgroups within agency experimental and control groups in the interview data were quite small. In the realm of program implementation, there were a number of problems, noted above.
As suggested earlier, there can be argument about the interpretation of findings of no effect on child and family functioning. On the one hand, one would like to believe that programs such as this have positive effects on functioning. However, it can be argued that lowering care days without adversely affecting functioning is an accomplishment. It is often claimed that managed care programs, because of their focus on fiscal outcomes, fail to maintain quality of services, to the detriment of clients.
Can the data be used to throw light on this proposition? The issue can be explored in LF, where there was a lowering of care days and comparative data on functioning is available from interviews with caretakers and caseworkers in the experimental and control groups. Can it be shown that no harm was done to children and families in the HomeRebuilders groups in this agency? The problem faced here is classical in statistical analysis: it is quite difficult to "prove the null hypothesis." Finding no significant difference in functioning between the experimental and comparison groups is not the same as demonstrating that there was no difference. There are a number of other explanations for lack of significance, as indicated above. In particular, using no significant difference findings as evidence for no real difference requires high statistical power. Power in these comparisons suffers because of low numbers of interviewed caretakers and caseworkers. Furthermore, the nonsignificant differences in means and proportions of functioning variables often favor the comparison group.
A second way to explore the hypothesis of no harm to the experimental group would be to compare the variances of outcome measures in the experimental and comparison groups. It is possible that the new service benefited some families while causing deterioration in others, so that the average outcomes were about the same as in the comparison group. This would be evidenced by a larger variance in the outcome measures in the experimental group. Conversely, it is possible that the program resulted in less variation in outcomes, although the average outcome was unaffected, so that fewer people in the experimental group were at the "low end" (fewer people would be at the "high end" as well). The variances of the family and child functioning outcome variables were examined to test these possibilities. Unfortunately, the results were quite inconclusive. More often than not, the variances in the experimental group were higher than in the comparison group, but the differences were rarely significant. The findings are not conclusive evidence that harm was caused, nor do they show that it did not occur.
Still another refinement would be to examine the functioning of families and children in experimental group cases in which children were returned home. This is the group that would be most likely to experience the hypothesized detrimental effects of managed care since some of these cases might have been returned home too quickly because of the financial incentives of the program and might have suffered as a result. Efforts to explore this possibility also were inconclusive.
Reasons for Lower Care Days. What were the reasons for the higher discharge rate and lower days in care in the LF (and possibly the NYF) experimental groups? The causal factors cannot be specified with precision, but some hypotheses will be presented about what the critical elements might have been, hypotheses that need further testing.
The intervention in HomeRebuilders may be thought of as consisting of two main aspects: an altered financing mechanism and a different approach to practice. The approach to practice may be seen as being motivated by the shift in financing, although many agencies had previously contemplated changes in their approaches. It is clear that the financing mechanism was implemented more or less as intended, except that the project was terminated 6 months before the agreed ending date. The approach to practice called for more intensive work with HomeRebuilders clients, lowered caseloads, quicker decisions to confirm or change initial permanency goals, and involvement of specialists in such areas as housing and substance abuse.
Interviews with caseworkers provide some evidence that the HomeRebuilders group in LF received somewhat more extensive service than the comparison group; results were in the same direction for MM and HD, but were not statistically significant (because comparison group caseworkers were not interviewed in NYF, the group cannot be compared in that agency). Unfortunately, these results were not confirmed in the caretaker interviews. Caretakers in the experimental and comparison groups did not report receiving different levels of service in any agency. It is possible that the failure to find differences in the caretaker interview data is due to problems in recall or other difficulties in data collection mentioned above.
It is thought that one of the most important aspects of reunification work is aftercare services, that is, services to prevent reentry to foster care provided to families following the return of children (and possibly to adoptive families after the adoption). The agencies stressed that the availability of aftercare services enabled HomeRebuilders workers to take greater risks in returning children home. Neither the caseworker nor caretaker interviews uncovered differences between experimental and comparison groups in level of aftercare services. In any event, rates of reentry to foster care were very low in both groups. The contribution of services to that outcome is unknown. Beyond the interviews with clients and caseworkers, there are other data from interviews with program directors on the nature of programs in the agencies. In all of the agencies, it is clear that workers were dedicated to their tasks and invested in helping clients improve their lives. In the LF HomeRebuilders program a number of specialists in housing, nursing, budgeting, education, and psychology were hired. JC hired parent advocates. Specialists were also hired in the other agencies, but they sometimes worked on behalf of both the experimental and comparison cases. In the LF experimental program, there appears to have been extensive worker training, perhaps more than in the other agencies. Experimental group workers in LF and HD were paid a small salary premium for their work on the project. In all of the true experimental group agencies (LF, HD, and MM), experimental group workers had somewhat smaller caseloads than did control group workers.
Although all of these elements might help explain the observed effects on time in care, there is more to the story. Activities with clients may be thought of as composed of services provided and decisions made. In part, the altered financing mechanism was intended to change the ways that decisions were made about cases, in particular, to speed them up when possible. There is evidence that in the LF HomeRebuilders program there was a systematic effort to assess the caseload at the beginning of the project. An important aspect of this assessment was triaging, that is, determining the group of cases most likely to be able to return home quickly and directing initial efforts to that group. This contrasts with the approach often taken in social programs, in which the greatest efforts are expended on those cases that are most difficult -- those most in need. But those most in need are not necessarily those most likely to benefit from a program. These observations reflect a general sense that the LF HomeRebuilders program displayed considerable clarity of purpose.
Other agencies also engaged in efforts to set priorities among cases. JC determined which families needed housing and established a goal of finding homes within a short period of time. MM identified cases with one pending major need (e.g., housing) with the intent of focusing on those cases first; however, it is not clear whether these priorities were consistently implemented.
Some observers have suggested that another possible contributing factor to effectiveness is the availability and use of data systems. LF was reported to have quite a good system for tracking cases and utilized the system in sophisticated ways. The effective management of programs such as this obviously depends on ready accessibility of both individual and aggregate information on cases.
The differences among agencies in the use of adoption as a permanency outcome require some comment. Originally, HomeRebuilders was conceived as a program to reunify children with their birth parents, and the target group was specified as children in family (nonkin) foster care with a goal of return home. That conception was broadened to include adoption as a possible outcome, and some of the agencies accepted cases into the project with goals of adoption. In four of the five agencies with comparison groups, the experimental program used adoption less frequently than the comparison program. Fewer children were adopted in both groups in LF, but adoption was particularly rare in the LF experimental group (32% of cases closed in the control group were adoptions compared with 9% in the experimental group). NYF, on the other hand, had a far higher number of adoptions (70% in the comparison group, 67% in the experimental group). The differences appear to reflect differences in values. In LF, we heard strong opinions that work should be focused on returning children to their birth parents and that adoption was a much less desirable outcome. Evidently the approach in other agencies, particularly NYF, was different. Of course, this suggests that the outcomes that families are likely to experience depend very much on the agencies with which they are assigned to work.
3.4.2 Future Work
Additional analyses could be done on these data. Data obtained from caretakers on social support have not been analyzed. The data on services might be examined further, for example, determining the relationship between services generally and particular types of service and outcomes. The role of foster parents and of visitation might be more extensively examined.
But the data of this study are limited, particularly because the interviews were retrospective, conducted sometimes long after caretakers and caseworkers were involved in services. Prospective studies of managed care efforts, studies employing strong evaluation designs, preferably with randomized comparison groups, are needed. Data need to be collected from participants (perhaps including children) before, during, and after the intervention.
The results suggest further study of a number of issues. Prominent here is the question of the conditions under which changes in fiscal incentives and other features of managed care have the effects theoreticians ascribe to them. Since social programs are never implemented under ideal circumstances, there is a need to better understand the interaction between new programs and context. Beyond that, further study is needed of important components of reunification programs: how critical decisions get made, the importance of intensive services, the role of foster parents, and the place of aftercare services. Future experiments in this area should explore the use of clear protocols for decision-making about cases, the use of triaging strategies, and the availability of data systems for case and program management.
A primary goal of initiatives like HomeRebuilders is to reduce days in foster care. The principal mechanism by which this is to be achieved is a shift in the fiscal incentives provided to agencies. The findings of this evaluation suggest that the goal is likely to be achieved only under certain circumstances: in agencies with particular characteristics or with particular approaches to the work. Among necessary preconditions, the data suggest the importance of clear decision-making protocols, triaging strategies, and data systems that can be used for case and program management. Hence, changes in fiscal incentives do not appear to be sufficient causes of major reform in child welfare. Although the flexibility in funding provided the opportunity for agencies to develop creative approaches to service delivery, one might also ask whether such funding changes are necessary for reform, or whether other approaches might achieve the desired benefits. There are current in the field proposals for major change that do not place fiscal reform at the center of concern, most notably the shifting of responsibility for response to child maltreatment to communities. At the moment, there is no dominant approach to change in the child welfare system that has been empirically demonstrated to be superior. More experimentation is needed, with both managed care and other approaches.
Appendices are available as PDF files (see below).