Final Evaluation of the Title IV-E Waiver Child Welfare Demonstration in New Hampshire

1
Final Evaluation of the Title IV-E Waiver Child
Welfare Demonstration in New Hampshire

• Ninth Annual Child Welfare
• Demonstration Projects Meeting
• June 2005
• Glenda Kaufman Kantor, University of New
  Hampshire
• Bernie Bluhm, NH DCYF

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State of New Hampshire Study Sample Sites
3
Challenges of NH Environment
4
Baseline Status of Substance Abuse in NH
5
History Higher Incidence of Problem Drinking NH
Women Than National Average
6
Current Status of NH Substance Abuse (2002)

• 31 Past Month Illicit Drug Use
• (18-25 yrs) 2nd Highest in U.S.
• 50 Past Month Binge Alcohol Use
• (18-25 yrs)- 3rd Highest in U.S.
• 21 Past Month Binge Alcohol Use
• (26 yrsgt) (National Average)
• 300 children lt17 living under court order in
  secure facilities due to D/A charges, related
  crimes (2001)

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Since 1994, less than 15 of NH CPS assessments
completed each year have been substantiated
(Founded).
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Key Project Aims

• Identify Address Parental Substance Abuse
  Problems co-occurring with suspected child abuse
  or neglect.
• Better Decision-Making about Safety
• Reduce Substance Abuse Risk Behaviors of Parents
• Fewer Subsequent Founded Referrals
• Prevent or Shorten Placement of Children in
  Foster Care
• Improve Stability and Adjustment of Children
• Cost Neutrality/Savings of Project

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Project Design
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Target Population

• Credible report of suspected CA/N
• Substance Abuse Current Risk Factor Related to
  CA/N
• Reside in Hillsborough Co area covered by the
  Manchester/Nashua D.Os.
• No Open Case at Intake into Study
• Accessible to DCYF CPSW

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LADC Role

• Engage Client at Time of Assessment of Allegation
• Immediate Screening Assessment by LADC
• Immediate individual treatment for AODA
• Immediate and ongoing consultation for CPSW

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For people awaiting treatment

• Individual counseling
• On-going contact with counselor
• Treatment window extended 60 days from CPS
  assessment or case closure
• Treatment provider connections

13
For Families Receiving Services

• Consultant participates in case planning
• Keep focus on parent issues
• Include parenting in treatment goals
• Aftercare with focus on parenting
• Support to relative caregivers

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Benefits to CPS During Assessment

• Regular Consultation
• Preliminary Screening (SASSI) of Parental
  Substance Abuse
• Impact of Parental Substance Abuse on Safety and
  Risk of Harm to Children
• Recommendations for Services and Treatment

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Benefits for CPS Cases When Children Are In
Out-Of-Home Care

• Comprehensive assessment with DX
• Assistance with goal specific case planning
• Continued consultation
• Recommendations for parents and children

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Evaluation
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Evaluation Design

• Experimental Model with True Randomized Design to
  Standard/Enhanced Services at 2 District Offices
• Standard group received the usual services
  provided by NH DCYF
• Parallel Data Collection for Standard and
  Enhanced
• Process Outcomes
• SACWIS Data
• Interviews at Baseline Follow-up
• Cost Benefit

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Final Evaluation Status

• Conducted 11/15/99 through 10/15/04
• 437 families eligible
• 212 baseline interviews (49)
• 156 follow-up interviews (74)

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Study Sample Demographics Primary Caregiver

• Enhanced Group (n222)
• Mean Age 33 Years
• White 92
• Any Employment 59
• Relationship of Alleged Perp. to Child Bio.
  Mother 69
• Mean Family Size Total Adults 1.83
  Total Children 2.80

• Standard Group (n215)
• Mean Age 33 Years
• White 90
• Any Employment 63
• Relationship of Alleged Perp. to Child Bio.
  Mother 72
• Mean Family Size Total Adults 1.85
  Total Children 2.84

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Study Sample Demographics Child

• Enhanced Group (n222)
• Female 51
• Mean Age 8 yrs. Median 9
  yrs. Range 0-17 yrs.
• Ethnicity White 87
  Black 6 Latino/Hispanic
  5 Other 2

• Standard Group (n215)
• Female 51
• Mean Age 8 yrs. Median
  8 yrs. Range 0-17 yrs.
• Ethnicity White 89
  Black 6 Latino/Hispanic
  2 Other 3

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Maltreatment CPS Factors

• Enhanced Group (n222)
• CPS Factors Prior Referrals 44
• High Risk at Entry 11
• Type of Maltreatment Physical Abuse
  25
• Phys. Abuse Negl. 13 Neglect
  52 Sexual Abuse 3
  Psychological Abuse 1

• Standard Group (n215)
• CPS Factors Prior Referrals 51
• High Risk at Entry 14
• Type of Maltreatment Physical Abuse
  21
• Phys. Abuse Negl 9 Neglect
  56 Sexual Abuse 5
  Psychological Abuse 2

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Family Risk Factors

• Enhanced (n222)
• Domestic Violence 33
• Adult Mental Illness 18
• Adult Phys. Disability 4
• Homeless 17
• Incarceration (Case Level) 32

• Standard (n215)
• Domestic Violence 33
• Adult Mental Illness 20
• Adult Phys. Disability 7
• Homeless 14
• Incarceration (Case Level) 28

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Child Risk Factors

• Enhanced Group (n222)
• Mental Illness 6
• Phys. Disability 3
• Learning Disabled
  11
• Neonatal Addiction 2
• Severe Behavior Prob.
  5
• JPPO Involvement
• at Case Level 26

• Standard Group (n215)
• Mental Illness 7
• Phys. Disability 5
• Learning Disabled
  13
• Neonatal Addiction 1
• Severe Behavior Prob.
  9
• JPPO Involvement at
• Case Level 24

DHHS Division for Juvenile Justice Services
Juvenile Probation Parole Officers, involved
due to child status offenses or delinquency.
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Co-Morbidity in Interview Sample
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Victimization Trauma Hx. Of Adult
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Probability of Having a Substance Dependence
Disorder
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Co-Morbidity

• 45 of high-probability have prior diagnosis of
  mental illness.
• 45 of high probability have clinical levels
  of depression
• 18 prior hx of mental illness documented in
  initial record data.
• 45 Clinically Depressed using CESD measure.

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Domestic Violence in Initial CPS Study Referrals

• Over half (58) had a prior Order of Protection
  at some time
• Over 1/3 report DV in current year
• 19 got a protective order on current partner in
  the past

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PROCESS EVALUATION
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Implementation Challenges

• Engagement of Client Timing
• Randomization of LADC Services within Sites
• District Office Cultures
• Different Therapist Effects
• Attrition of LADC CPSWs
• Need to build consensus between co-located
  systems
• Information sharing/confidentiality
• Focus on Primary Client
• Treatment recommendations from different points
  of view
• ASFA 12 month clock vs recovery clock

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LADC Challenges of Engagement
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Challenges of Engagement
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Correct Assignment of Subsequent Referrals by
Group Site
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Percentage of Families Completed SASSI by Site
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Percent of Initial Referrals Founded by Group
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Final Founded Dispositions of Initial Referrals
by Group Site
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Client Satisfaction w/ LADC

• Manchester (n27)
• Overall Satisfaction Satisfied 52
• Overall Satisfaction by Substantiation
• No Case Ever Opened Satisfied 40
• Case Opened Satisfied 67

• Nashua (n19)
• Overall Satisfaction Satisfied 90
• Overall Satisfaction by Substantiation
• No Case Ever Opened Satisfied 92
• Case Opened Satisfied 86

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Mean Therapist Referrals for Clients After
Initial Eval. by Site
1
2
3
4
1,2,3,4 statistical significance found between
sites ANOVA p gt .05
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Treatment Utilization
40
Treatment Utilization by Group
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LADC Networking
42
LADC Networking
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Outcomes
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Outcomes Substance Abuse Assessment
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Preliminary Findings on System Status 1999
Substance Abuse Incidence Case Outcome

• Review of NH Cases for 1 month 640 Cases
• 546 cases completed assessments
• Substance Abuse documented as a factor in
  completed assessments 159/546 or 29
• Proportion of substance abuse referrals founded
  as cases35/159 (22)

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Project First StepSubstance Abuse as a Factor
in Completed Assessments

• 1999 Substance Abuse documented as a factor in
  completed assessments
• 159/546 or 29
• 2004 Substance Abuse documented as a factor in
  completed assessments
• 66 of Enhanced Group
• 47 of Standard Group

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Substantiation by High Probability of Having a
Substance Dependence Disorder
Cases opened for continued services and/or
placement directly supervised or paid by DCYF
Significant statistical difference found
between substantiation Chi Sq 9.51, 1df,p.002
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Percentage of Cases Open on Subsequent Referral
by Group Site
Significant statistical difference found between
groups within Manchester Chi Sq. 1-Sided p
(.036) gt .05
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Subsequent Referrals by Group
Enhanced (n 228) Standard (n 219)
CASES FOUNDED ON SUBSEQUENT REFERRALS MEAN SUBSEQUENT REFERRALS 46 1.04 49 1.20
Referral Report to NH DCYF based on a suspicion
of child abuse or neglect. All NH citizens are
mandated reporters.
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Characteristics of Child Placements
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In-Home Services for Families with Cases by Group
IN-HOME SERVICES Enhanced Standard
FAM. ANY IN-HOME SERVICE MEAN FAM W/ IN-HOME SERVICE OF FAM. RECEIVING IN-HOME SERVICES W/ A VOLUNTARY/B-CASE 12 0.14 2 16 0.16 0
In home services means services paid for
and/or supervised by DCYF in founded cases after
due process was provided or afforded. There are 8
families, in which one child received In-Home
Services and was not removed, but another child
within that same family was removed.
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Out of Home Placement (OHP) Types by Group
Enhanced Standard
KIN CARE FAM. ANY KIN CARE MEAN FAM. W/ Children in KIN CARE 22 0.41 16 0.24
FOSTER CARE FAM. ANY FOSTER CARE MEAN Child Placements for FAM W/ FOSTER CARE Placements 63 1.78 62 2.72
OTHER OHP FAM. ANY OHP MEAN FAM W/ Children in OHP 26 0.82 28 0.68
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Mean Number of Children in Placement per Family
by Group Site
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Mean length of placement (days) per child in
placement by group site
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Mean Number of Placements per Child in Placement
by Group Site
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Percentage of Families with TPR by Group
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Percentage of Families with TPR by Group Site
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Mean Length to TPR by Group
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ADULT OUTCOMES
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W1 W2 RX Utilization by Groups Interview
Sample, Self Reports
Enhanced Standard
Resp. attend AA W1 (ever) W2 (past yr.) 40 (45/112) 69 (19/28) 43 (43/100) 45 (10/22)
Resp. help for drinking W1 (ever) W2 (past yr.) 25 (28/112) 48 (11/23) 32 (32/100) 43 (6/14)
Resp. hospitalization for drinking W1 (ever) W2 (past yr.) 16 (18/112) 27 (4/15) 18 (18/100) 11 (1/9)
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W1 W2 RX Utilization by Groups Interview
Sample Reports on Partner
Enhanced Standard
Partner attend AA W1 (ever) W2 (past yr.) 31 (20/65) 62 (8/13) 44 (25/57) 46 (6/13)
Part. help for drinking W1 (ever) W2 (past yr.) 25 (16/64) 25 (2/8) 22 (12/65) 43 (6/10)
Part. hosp. for drinking W1 (ever) W2 (past yr.) 16 (9/64) 27 (4/15) 18 (8/54) 11 (1/9)
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W1 W2 Parent Outcomes Interview Sample, Self
Reports
Enhanced Standard
Clinically Depressed W1 W2 39 36 40 32
Heavy Drinking W1 W2 29 35 53 42
Hard Drug Hx W1 W2 43 44 47 48
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W1 W2 Parent Outcomes Interview Sample, Self
Reports
Enhanced Standard
Employed FT W1 W2 32 38 32 24
Enrolled Educ/Voc. Program W2 28 16
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Child Outcomes
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Child Outcomes for Index Children ages 4-17

• Children in Enhanced Groups had greater declines
  in 7 of 8 problem categories
• Anxiety Depression
• Withdrawn/Depressed
• Somatic Problems
• Attention Problems
• Aggressive Behavior

66
Child School Health Outcomes

• Enhanced Group
• Repeated Grade 10
• Academic/Other School Problems 39
• MD concerns re health 11

• Standard Group
• Repeated Grade 29
• Academic/Other School Problems 43
• MD concerns re health 14

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Cost Analysis
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Shortfall EXPER. GRP. EXPEND. IN EXC. OF CNL -
FFP TOTAL (B7d(e)) 280,000.00 (IV-E funds)
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IV Cost-Benefit Analysis       - Costs to date
1,569,065.00       - Major funding
streams Title IV-E     
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What Contributed to Higher Costs?

• Few differences between standard and enhanced
• Prior referrals significantly higher among
  enhanced high cost group
• JPPO referrals significantly greater among
  enhanced high cost group
• More child mental health problems identified at
  intake for enhanced group

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Cost Benefits Analysis by GroupIncluding LADC
Costs
Avg. Cost/Child1 Savings Child Not Removed2 Savings Kin Care3 Total Avg. Cost/Child4 Total Avg. Savings5
Enhanced 23,709 23,709 5,952 23,709 29,660
Standard 20,951 20,951 4,920 20,951 25,871
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Conclusions

• Key Outcomes
• Significant Effects of Assessment
• Strengths of Effects Diminished by Site
  Differences
• More Long-Term Substance Abuse Treatment of
  Adults
• Child Safety Outcomes fewer subsequent founded
  reports, more stability, decrease in time to TPR
• Improved Well Being for Adults Children

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LADC Closing
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Finale LADAC clip