Using Flexible Funds to Improve Child Welfare

Evaluation of Ohio’s Title IV-E Waiver Demonstration

ProjectSeptember 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 fundsCapitated payments

Managed care strategies

LOGIC MODEL

WaiverSystemsReform

Interventions

ImprovedOutcomes

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 PCSAYellow = 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

Figure 2.2: Range of New Services

0

2

4

6

8

10

12

14

Placement MentalHealth

SubstanceAbuse

Other Non-placement

Other

Demonstration(n=14)

Comparison(n=14)

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

Figure 2.17: Overall Managed Care Ranking: Year 2 and Year 4

0

2

4

6

8

10

12

14

Demo Comp Demo CompYear 2 Year 4

High

Med

Low

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 Contrast between Demonstration and Comparison sites: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: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: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

Figure 3.1: Number of Child Abuse Incidents By Federal Fiscal Year

0

5000

10000

15000

20000

25000

30000

35000

1996 1997 1998 1999 2000 2001

Fiscal Year

Nu

mb

er o

f C

hild

Ab

use

In

cid

ents

DemonstrationCounties

ComparisonCounties

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

Number of Ongoing Cases at End of Federal Fiscal Year

0

5000

10000

15000

20000

25000

30000

1996 1997 1998 1999 2000 2001

Fiscal Year

Nu

mb

er

of

On

go

ing

Ca

se

s

DemonstrationCounties

ComparisonCounties

Number of Children Entering First Placements Increased in Large Demonstration Counties

Figure 3.4: First Placement by County Size and Fiscal Year, 1991-2001

0

500

1000

1500

2000

2500

3000

3500

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Fiscal Year

Nu

mb

er

of

Fir

st

Pla

cem

en

ts

Large DemonstrationCounties

Small DemonstrationCounties

Large ComparisonCounties

Small ComparisonCounties

Table 3.2: Percentage of Children in First Placement, Where First Placed, by Study Group and Time Period

Demonstration

Counties

Comparison

Counties

Difference Between Demonstration and

Comparison Counties

Child’s First Placement

Pre-Waiver

Waiver period Change

Pre-Waiver

Waiver period Change

Pre-Waiver

Waiver period Change

Residential Treatment Center

11.85

13.20

1.35

6.82

5.94

-0.88

5.04

7.26

2.22

Group Home 5.79 9.95 4.15 5.24 5.10 -0.14 0.56 4.85 4.29 Foster Home 43.41 42.36 -1.05 62.07 60.74 -1.33 -18.66 -18.39 0.28 Nonlicensed Nonrelative

4.03

3.95

-0.08

1.40

2.34

0.94

2.62

1.60

-1.02

Relative 30.82 25.93 -4.90 19.16 22.41 3.26 11.67 3.51 -8.16 Independent Living 0.05 0.04 -0.01 0.11 0.05 -0.05 -0.06 -0.01 0.04 Detention Facility or Hospital

4.00

4.53

0.53

5.19

3.39

-1.80

-1.19

1.14

2.33

Adoptive Home 0.04 0.05 0.01 0.02 0.02 0.00 0.03 0.03 0.01

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

Table 3.8: Destination of Children Exiting From First Placement Episode by Study Group and Time Period

Percent

Demonstration

Counties

Comparison

Counties

Difference Between Demonstration and

Comparison Counties

Exit Destination Pre-

Waiver Waiver period Change

Pre-

Waiver Waiver period Change

Pre-

Waiver Waiver period Change

n=29029 n=18498 n=16940 n=9476

Reunification 52.55 44.94 -7.61 45.27 48.86 3.60 7.29 -3.92 -11.21

Custody to Relatives

19.45 18.01 -1.45 24.58 22.42 -2.15 -5.12 -4.42 0.71

Adoption 8.28 9.30 1.02 9.14 10.31 1.17 -0.86 -1.01 -0.15

Runaway 1.55 1.04 -0.52 1.06 0.32 -0.74 0.49 0.72 0.23

Other 18.16 26.71 8.55 19.96 18.09 -1.87 -1.80 8.63 10.42

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

Evaluation Growth Group County Baseline - 2001Comparison Wood (55%)Comparison Butler (12%)Demonstration Clark ( 0%)Comparison Allen 8%Demonstration Portage 9%Comparison Mahoning 23%Comparison Trumbull 26%Demonstration Ashtabula 26%Demonstration Belmont 29%Demonstration Richland 35%Demonstration Muskingum 35%Demonstration Stark 40%Demonstration Greene 43%Comparison Scioto 54%Comparison Warren 60%Comparison Montgomery 67%Demonstration Franklin 77%Comparison Miami 88%Comparison Hocking 117%Comparison Columbiana 136%

Change in Placement Day Utilization

Evaluation Growth Group County Baseline - 2001Comparison Wood (55%)Demonstration Muskingum (37%)Comparison Butler (30%)Demonstration Belmont (29%)Comparison Mahoning (27%)Demonstration Clark (22%)Comparison Trumbull (21%)Demonstration Lorain (11%)Demonstration Portage ( 7%)Comparison Allen ( 7%)Demonstration Ashtabula ( 2%)Demonstration Stark 2%Demonstration Hamilton 3%Comparison Hocking 7%Comparison Clermont 9%Demonstration Richland 10%Demonstration Crawford 17%Demonstration Medina 17%Demonstration Greene 19%Comparison Montgomery 24%Comparison Scioto 25%Demonstration Fairfield 28%Comparison Summit 31%Comparison Columbiana 32%Comparison Miami 37%Demonstration Franklin 39%Comparison Warren 47%Comparison Hancock 115%

Change in Foster Care Unit Cost Figures

Evaluation Growth Group County Baseline - 2001Comparison Wood 2%Comparison Warren 9%Comparison Allen 16%Demonstration Portage 17%Demonstration Greene 20%Demonstration Richland 22%Comparison Scioto 23%Comparison Butler 25%Demonstration Hamilton 27%Demonstration Clark 27%Demonstration Franklin 28%Demonstration Ashtabula 28%Comparison Montgomery 35%Comparison Miami 37%Demonstration Stark 38%Comparison Trumbull 55%Comparison Mahoning 70%Comparison Columbiana 79%Demonstration Belmont 82%Comparison Hocking 101%Demonstration Muskingum 113%

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 ReceivedEstimated

ExpendituresEligible for Title Total ProtectOhio ProtectOhio

IV-E Foster Care Revenue Revenue as aBoard and Maint. ProtectOhio Available for Percent ofReimbursement Waiver Award Reinvestment Total

1998-2001 1998-2001 1998-2001 Expenditures

Ashtabula $ 1,958,000 $ 3,399,000 $ 1,441,000 7%Belmont $ 1,971,000 $ 2,463,000 $ 492,000 4%Clark $ 7,456,000 $ 9,772,000 $ 2,316,000 7%Fairfield $ 667,000 $ 697,000 $ 30,000 1%Franklin $62,216,000 $73,564,000 $11,348,000 2%Greene $ 3,932,000 $ 3,902,000 ($ 30,000) ( 0%)Hamilton $42,071,000 $59,259,000 $17,188,000 7%Lorain $ 5,013,000 $ 6,879,000 $ 1,866,000 4%Medina $ 1,163,000 $ 1,220,000 $ 57,000 1%Muskingum $ 4,366,000 $ 4,822,000 $ 456,000 2%Portage $ 4,540,000 $ 6,573,000 $ 2,033,000 9%Richland $ 5,087,000 $ 5,150,000 $ 63,000 0%Stark $18,620,000 $20,581,000 $ 1,961,000 3%

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

Evaluation Growth Group County 1997 - 2001Comparison Wood ( 9%)Comparison Miami ( 9%)Comparison Allen ( 9%)Comparison Hocking ( 8%)Comparison Trumbull ( 8%)Comparison Scioto ( 6%)Comparison Clermont ( 4%)Demonstration Franklin 8%Demonstration Greene 9%Demonstration Hamilton 25%Demonstration Portage 25%Comparison Warren 34%Comparison Mahoning 41%Demonstration Richland 51%Demonstration Ashtabula 52%Comparison Montgomery 55%Demonstration Clark 60%Comparison Butler 63%Demonstration Stark 86%Demonstration Muskingum 100%Demonstration Lorain 100%Demonstration Belmont 184%

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 HamiltonLorain 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:

38%

11%

51%

FederalStateLocal

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