Title: Using Flexible Funds to Improve Child Welfare
1Using Flexible Funds to Improve Child Welfare
- Evaluation of Ohios Title IV-E Waiver
Demonstration Project - September 2002
2PROTECTOHIOTitle 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
3LOGIC 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
4Green 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.
6Process Implementation Study
- Use of managed care strategies
- Service array
- Financing
- Case management
- Utilization review
- Managed Care index
- Interagency collaboration
- Systemic reform and leadership
7Ohios 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
8Changes in Service Array
9Changes in Service Array (2)
- Most counties experienced loss of services 11
demonstration,9 comparison sites - Increased use of kinship placements
10Innovative 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
11Case Management
- Both demonstration and comparison counties
experimenting with - Staffing arrangements
- Team conferencing models
- Ways to involve families
- Screening criteria and procedures
12Utilization 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
13Use of Managed Care Strategies
14Use 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
15Interagency 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
16Overall 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.
17Overall 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.
18Findings from the Participant Outcomes Study
- Changes in Caseloads
- Changes in Case Mix
- Waiver effects on length of stay in first
placements
19Abuse/Neglect Incidents Fell During Waiver Period
for Both Groups
20During Waiver Period, Number of Children in
Caseloads Increased in Demonstration Counties
21Number of Children Entering First Placements
Increased in Large Demonstration Counties
22Changes 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.
23Exits 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
24Destinations of Children Leaving First Placements
is Shifting
25Differences By Type of Exit
26Findings from the Fiscal Outcomes Study
- Foster Care Expenditure Patterns
- Additional Revenue
- Additional Revenue Purchases
27Foster 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.
28Change in Total Foster Care Expenditures
29 Change in Placement Day Utilization
30Change in Foster Care Unit Cost Figures
31Additional 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.
32Additional Revenue Received
33Additional 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.
34All 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.
35Changes in Per Diem Costs of Foster Care Case
Management
36Individual 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.
37Lorain County and ProtectOhio
- Sandra Hamilton
- Lorain County Children Services
38Demographics
- 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.
39Revenue Source
- The funding for Lorain County consist of
resources from the following 3 areas
40Impact 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.
41Project Goals
- Increase database capacity accessibility to
data - Enhance Quality Assurance activities
- Staff Professionalism
- Special Service initiatives to front-end services
- Reduce Placements
42Project Goals continued
- Develop Managed Care contracts, internally
externally - Community involvement
43Enhancing 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.
44Service 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.
45Strengthening 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.
46Innovations 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
47Innovations 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
48The 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