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Using Flexible Funds to Improve Child Welfare

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Title: Using Flexible Funds to Improve Child Welfare


1
Using Flexible Funds to Improve Child Welfare
  • Evaluation of Ohios Title IV-E Waiver
    Demonstration Project
  • September 2002

2
PROTECTOHIOTitle IV-E Waiver
Flexible fundsCapitated payments Managed care
strategies
  • Goal Redesign system for increased
    effectiveness and efficiency, through a managed
    care approach
  • Desired Outcomes reduced placements, increased
    permanency, improved family functioning,
    maintained safety
  • Scope 14 counties/PCSAs , each with own plan

3
LOGIC MODEL
ImprovedOutcomesfor children families
Waiver
SystemsReform
Interventions
  • Whats done for what families and children
  • How they go through the system
  • Services received
  • Use of relatives
  • Any service
  • Any clients
  • up front
  • Keep savings
  • Internal organization
  • Services available
  • Financing patterns
  • MC strategies

? placement days ? permanency ?functioning ? well
being
4
Green demonstration PCSAYellow comparison
PCSA
Ohios Evaluation Counties
5
Primary Evaluation Areas
  • Process/implementation study innovations in
    agency operations, service offerings, interagency
    relations, etc.
  • Fiscal outcomes study shifts in expenditures
    from placement to non-placement activities.
  • Participant outcomes study changes in caseload
    trends and in length of time children stay in
    out-of-home care.

6
Process Implementation Study
  • Use of managed care strategies
  • Service array
  • Financing
  • Case management
  • Utilization review
  • Managed Care index
  • Interagency collaboration
  • Systemic reform and leadership

7
Ohios Managed Care Strategies
  • Service array (care criteria) new services,
    shifting focus
  • Financing (capitation risk) capitated case
    rate contracts, use of IV-E
  • Targeting (eligibility) special initiatives,
    specialized units
  • Case management unit structure, transfers
  • Provider competition provider affiliations, rate
    changes
  • Utilization review placement reviews, service
    reviews
  • Information management automated MIS, mgrs use
    info
  • Quality assurance control enhancement, outcome
    focus

8
Changes in Service Array

9
Changes in Service Array (2)
  • Most counties experienced loss of services 11
    demonstration,9 comparison sites
  • Increased use of kinship placements

10
Innovative Financing Arrangements
  • 3 demonstration counties have managed care
    contracts
  • Why so few?
  • Caseload size, predictability
  • Historical cost information
  • What problems encountered?
  • Goal clarity
  • Model structure
  • Implementation issues

11
Case Management
  • Both demonstration and comparison counties
    experimenting with
  • Staffing arrangements
  • Team conferencing models
  • Ways to involve families
  • Screening criteria and procedures

12
Utilization Review
  • Placement review processes
  • Pre-placement 9D, 8C
  • During placement 8D, 5C
  • Oversight of non-placement resources
  • Pre-service review 4D, 4C
  • Subsequent review 2D, 3C

13
Use of Managed Care Strategies
14
Use of Managed Care Strategies
  • Preferred Areas of MC Activity
  • Utilization Review
  • Quality Assurance
  • Service array
  • Targeting
  • Contrast between Demonstration and Comparison
    sites
  • Demonstration sites scored higher thancomparison
    sites in 7 of 8 areas
  • Most differentiation in financing and targeting
  • Least differentiation in case management,
    utilization review, and QA

15
Interagency Collaboration
  • Overall While some variation exists between
    demo comp counties, differences do not appear
    to be significantly related to participation in
    Waiver
  • PCSA relationship with Juvenile Court
  • Majority of demo comp counties have strong
    relationship
  • Inappropriate referrals continue to be issue in
    a few demo and comp counties
  • PCSA relationship with Mental Health
  • Relationships remain strong in most counties, no
    significant change over course of Waiver
  • Lack of adequate mental health services for
    children and families, resulting in PCSAs (both
    demo and comp) developing and purchasing own
    mental health services

16
Overall Findings From Process Implementation Study
  • Little systematic difference between the
    demonstration and comparison county groups.
  • The Waiver has provided opportunities for all 14
    demonstration counties to modify their operations
    in ways that might not be possible without the
    Waiver.
  • Some counties have taken full advantage of these
    opportunities, while others have made less
    significant changes in many of the areas explored
    in the evaluation.
  • Further, some comparison counties have moved in
    directions similar to the active demonstration
    counties, without the benefit of the Waiver.

17
Overall Findings From Process Implementation
Study (cont.)
  • Overall, these insights suggest that the
    flexibility provided by the Waiver
  • may facilitate reform efforts where other factors
    are already conducive
  • but may not itself be robust enough to generate
    consistent changes across the varied set of
    demonstration sites.

18
Findings from the Participant Outcomes Study
  • Changes in Caseloads
  • Changes in Case Mix
  • Waiver effects on length of stay in first
    placements

19
Abuse/Neglect Incidents Fell During Waiver Period
for Both Groups
20
During Waiver Period, Number of Children in
Caseloads Increased in Demonstration Counties
21
Number of Children Entering First Placements
Increased in Large Demonstration Counties
22
Changes in Case Mix of Children Entering First
Placement


1 Nonlicensed nonrelative includes family
friends, godparents, etc. In Ohio, county staff
refer to this as kinship placement.
Nonlicensed nonrelative was chosen to
distinguish this category from nonlicensed
relative and the modern connotation of kinship.

1 Nonlicensed nonrelative includes family
friends, godparents, etc. In Ohio, county staff
refer to this as kinship placement.
Nonlicensed nonrelative was chosen to
distinguish this category from nonlicensed
relative and the modern connotation of kinship.

23
Exits from First Placements
  • Overall, when controlling for case mix, no change
    in both groups during Waiver Period
  • For the two large counties, especially for
    children first placed in residential centers,
    there has been decrease in length of stay

24
Destinations of Children Leaving First Placements
is Shifting
25
Differences By Type of Exit
26
Findings from the Fiscal Outcomes Study
  • Foster Care Expenditure Patterns
  • Additional Revenue
  • Additional Revenue Purchases

27
Foster Care Expenditures
  • No significant differences were found between
    demonstration and comparison counties in patterns
    of
  • total foster care expenditures,
  • placement day utilization,
  • unit cost figures, or
  • residential treatment usage.

28
Change in Total Foster Care Expenditures
29
Change in Placement Day Utilization
30
Change in Foster Care Unit Cost Figures
31
Additional Waiver Revenue
  • Most demonstration counties received more revenue
    through the Waiver than they would have received
    through normal Title IV-E reimbursement for
    foster care board and maintenance reimbursement.

32
Additional Revenue Received
33
Additional Revenue Purchased
  • All but two of the demonstration counties spent
    additional Waiver revenue on child welfare
    services other than board and maintenance
    payments.
  • As a result, spending on all other child welfare
    services increased significantly more among the
    group of demonstration counties than among the
    group of comparison counties.

34
All Other Child Welfare Expenditures
  • Increases in the per diem costs of foster care
    case management were significantly higher among
    demonstration counties than among comparison
    counties.
  • This suggests that demonstration counties chose
    to spend the bulk of additional revenue on
    internal foster care administration costs.

35
Changes in Per Diem Costs of Foster Care Case
Management
36
Individual County Profiles
  • Profiles enable study team to examine how system
    reform efforts have impacted outcomes in 2
    particular demonstration counties.
  • Lorain and Muskingum commitment to systemic
    change appears to have fostered a greater degree
    of success, in terms of fiscal and participant
    outcomes, than occurred on average for other
    counties in the evaluation.

37
Lorain County and ProtectOhio
  • Sandra Hamilton
  • Lorain County Children Services

38
Demographics
  • Lorain County is located in the North East
    Section of the State of Ohio. The population of
    our county is approximately 282, 149 and consists
    of a mixture of rural and small city communities.
  • The County has a child population of 30 and the
    percent of children living in poverty is
    approximately 22.5.
  • The Agency has approximately 433 children in
    custody each year and the number of child
    abuse/neglect reports investigated is 2,020.

39
Revenue Source
  • The funding for Lorain County consist of
    resources from the following 3 areas

40
Impact of IV-E Waiver on Revenue Sources
  • The local share represents monies received from a
    property tax levy that is in effect for a 5-year
    period. Having the flexibility of the IVE Waiver
    dollars allowed the agency to use the money for
    all children needing services, with out regard to
    income, and the agency could then allocate our
    levy dollars to enhance services.

41
Project Goals
  • Increase database capacity accessibility to
    data
  • Enhance Quality Assurance activities
  • Staff Professionalism
  • Special Service initiatives to front-end services
  • Reduce Placements

42
Project Goals continued
  • Develop Managed Care contracts, internally
    externally
  • Community involvement

43
Enhancing Safety, Permanence and Well-Being
  • Quality Assurance
  • Family Based Care Foster Care recruitment
  • Wrap Around Services-providing financial
    resources to prevent placement or to reunify
    families and children within a safe environment
  • Additional staff positions in the following
    areas
  • Intake
  • Behavioral Services, consisting of staff who
    address substance abuse and mental health issues
    for clients
  • Recruit and hire Spanish-speaking staff to help
    serve the Hispanic community, which is
    significant part of Countys population.

44
Service Enhancements continued
  • Collaboration with the Countys Mental Health
    Board, Mental Retardation Board, and Juvenile
    Court to address children needing high cost
    placements and intensive services.
  • Providing monies to custodial relatives for
    permanent placement for children.
  • Provide funding to social service staff to pursue
    masters degrees in Social Work.

45
Strengthening the Childrens Safety Net
  • Overall the IVE Waiver dollars hasve enhanced
    Lorain County Children Services ability to
    provide a safety net for children who come in
    contact with us.

46
Innovations in Two Demonstration PCSAs Lorain
  • Lorain
  • High scores on use of managed care--particularly
    service array competition
  • High scores on leadership index--systematic
    attention to organizational development
    collaborative management
  • Children whose first placement is in residential
    care return home more quickly than in comparison
    counties
  • Faster growth (63) in all other child welfare
    services than comparison and most demonstration
    counties
  • Significantly higher than average growth in
    children eligible for adoption subsidy

47
Innovations in Two Demonstrations Muskingum
  • Muskingum
  • Among highest on Leadership and interagency
    collaboration
  • Moderate use of managed care strategies
  • Dramatic decrease in paid placement days
    increased spending on non-foster care services
    however, foster care costs up 34 in last four
    yrs
  • 30 decrease in children in custody
  • Since the waiver began, children exiting
    out-of-home care (besides residential) spend less
    time in care than children in comparison counties

48
The Future
  • Likely a few more years of the demonstration
  • Evaluation focus
  • More in-depth analysis of length of stay in
    foster care
  • Further analysis of expenditure patterns
  • Targeted investigation of county by county
    changes
  • Cost effectiveness
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