Using Flexible Funds to Improve Child Welfare Evaluation of Ohio’s Title IV-E Waiver Demonstration Project September 2002

PROTECTOHIO: Title IV-E Waiver 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 Flexible funds Capitated payments Managed care strategies

LOGIC MODEL Waiver Systems Reform Interventions Improved Outcomes for children & families Any service Any clients $ up front Keep savings Internal organization Services available Financing patterns MC strategies What’s done for what families and children How they go through the system Services received Use of relatives  placement days  permanency  functioning  well being

Green = demonstration PCSA Yellow = comparison PCSA Ohio’s Evaluation Counties

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.

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

Ohio’s 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

Changes in Service Array

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

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

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

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

Use of Managed Care Strategies

“Preferred” Areas of MC Activity: “Preferred” Areas of MC Activity: Utilization Review Quality Assurance Service array Targeting Contrast between Demonstration and Comparison sites: Contrast between Demonstration and Comparison sites: Demonstration sites scored higher than comparison sites in 7 of 8 areas Most differentiation in financing and targeting Least differentiation in case management, utilization review, and QA

Interagency Collaboration  Overall:  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

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.

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.

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

Abuse/Neglect Incidents Fell During Waiver Period for Both Groups

During Waiver Period, Number of Children in Caseloads Increased in Demonstration Counties

Number of Children Entering First Placements Increased in Large Demonstration Counties

[1][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][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. Changes in Case Mix of Children Entering First Placement

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

Destinations of Children Leaving First Placements is Shifting

Differences By Type of Exit Table 3.16: Different Exit Types: Length of Stay Findings Significant Findings on Children Who Have Left Out-of- Home Care During the Waiver Overall Effect in Demonstration Counties Compared to Comparison Counties Children exiting first placement in out-of-home care for any reason None Children reunited with parents or guardians at the end of first placement in out-of-home care Longer time in care Children whose custody was transferred to a relative at the end of first placement in out-of-home care Shorter time in care Children adopted at the end of first placement in out-of- home care None Children who run away from first placement in out-of-home care Shorter time in care

Findings from the Fiscal Outcomes Study Foster Care Expenditure Patterns Additional Revenue Additional Revenue Purchases

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.

Change in Total Foster Care Expenditures

Change in Placement Day Utilization

Change in Foster Care Unit Cost Figures

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.

Additional Revenue Received

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.

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.

Changes in Per Diem Costs of Foster Care Case Management

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.

Lorain County and ProtectOhio Sandra Hamilton Lorain County Children Services

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. Demographics

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

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.

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

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

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 County’s population.

Service Enhancements continued Collaboration with the County’s 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 master’s degrees in Social Work.

Strengthening the Children’s 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.

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

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

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