Improving Outcomes for Children and Families Through Collaboration and Integration of Services

1
Improving Outcomes for Children (and Families)
Through Collaboration and Integration of Services

• Diana J. English PhD
• Child Welfare League of America
• May 2, 2007
• Halifax, Nova Scotia

2
What Outcomes?

• Before we can improve outcomes for children we
  must be clear about what outcomes we want to
  improve
• System or Child/Family Outcomes does one equate
  to the other ?

3
System Outcomes (Examples)

• Recurrence (Safety)
• Placement Stability
• Permanency

4
Child/Family Outcomes

• Well-being (minimally acceptable levels of
  social, emotional, behavioral and adaptive
  functioning) of children.
• What about parents minimally acceptable levels
  of parenting/caregiver functioning to ensure
  adequate care for the child?

5
How are the Children Safety and Well-Being

• Aggregate data
• Cross sectional research indicates recurrence
  rates of 18 and re-referral rates around 35.
• No difference in outcomes for re-referral and
  recurrence compared to not referred.
• Child Specific Data - LONGSCAN

6
Number of CPS Reports Per ChildSeattle LONGSCAN
(By the Age 12 Interview)
N 254 Children 1,275 Reports 2,226 MMCS
Allegations
(Final Seattle LS Sample)
LONGSCAN Data Sources mltx0610.sav Received
from LS CSCC 10/2006
Note Includes all reports codable using
Modified Maltreatment Coding Scheme (MMCS)
7
How Are The Children Doing?

• Functioning
• Development
• Cognitive
• Adaptive
• Behavioral
• Social
• Emotional

8
Battelle Screener at Age 4Percentages of
Children with Total Battelle Scores By Ranges
N 238 Children
Score Interpretation Domain scores are added to
compute total raw score. Raw scores are converted
to standard scores 0 normal 1
borderline 1.5 developmental problem 2
serious developmental delay
Normal N96 (40)
Serious Delay N94 (40)
Problem N24 (10)
Borderline N24 (10)
Data Source BSTS received from NC 12/2000
Seattle, Longscan,
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Percentage of Children with Developmental Delays
at Age 4(Battelle Screener gt 1.5 S.D. Below
Norm)
N238
60
52
50
49
50
43
Cognitive
40
29
26
30
20
Social
Total
Motor
10
0
Adaptive Behavior
Communication
Data Source BSTS Measures Manual rev. 8/17/00
Seattle, Longscan,
10
Peabody Picture Vocabulary TestRevised (PPVT-R)
Age 4
Moderately High N1 (lt 1)
N 241 Children
Peabody Picture Vocabulary Test
Data Source PPVA received from NC 12/2000
Seattle LONGSCAN
11
Percent of Seattle-Site LS Children (Ages 4, 6,
8, 12)Scoring in Borderline or Clinical Ranges
on CBCL (T-Scores of 60 to 63 borderline gt
63 clinical)
LONGSCA Data Source cbcs0607 Received from LS
CSCC 07/2006
12
Percent of Seattle-Site LS Children (Ages 6, 8,
12)In Moderately Low or Very Low Ranges on
Vineland (Std. Scores of 70 to 84 Mod. Low lt
70 Very Low)
81
53
45
33
30
26
LONGSCAN Data Sources VNLS0607
VSBS0607 Received from LS CSCC 07/2006
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Child Outcomes

• Are these children doing well?
• Are they safe?
• Are their basic needs being met?

14
Do System Outcomes Equate to Child and/or Family
Outcomes?

• What about family outcomes often measure
  compliance, not reduction in risk or attainment
  of minimally acceptable parenting skills

15
Engagement and Resolution for Risk Factors
Influencing Placement

• Key Risk Issues
• Substance abuse
• Parenting skills
• Mental health/emotional functioning
• Lack of motivation
• Lack of recognition of problem
• Domestic violence

16
Engagement and Resolution

• 92-100 of families identified as needing
  services, and were offered services to address
  the risk issue.
• 96-100 of services were identified as available.

17
Engagement and Resolution

• About one-half of the parent (s) engaged in the
  service offered
• Of those who did engage, between one-quarter and
  one-half (27-51) were assessed as likely to
  resolve the risk issue within 12 months (required
  timeline for permanency)

18
Engagement and Resolution

• 42-68 of the risk issues that influenced
  placement of the child were present in prior
  investigations/cases for the same child/family.

19
Engagement and Resolution

• Are families unable to engage?
• Are child welfare workers not engaging families
• Are community providers not providing effective
  services? (match of service to need)

20
Improving Outcomes Through Collaboration and
Integration of Services

• Are these outcomes acceptable, and if not, how
  can we improve services to children and families
  to achieve more acceptable outcomes?

21
System Integration What is it?

• System from systema what stands together.
• Integrate combine into a whole

22
Systems Integration What is it? External or
Internal Agency Integration

• Many different things
• Collaborations that form to overcome differences
  in service goals and objectives with the goal of
  improving services to children and families
• Identify needs
• Goal service array that meets/matches needs of
  children and families
• Establish accountability
• Nurture consensus
• Reduce inefficiencies
• Monitor results

23
Who Should Be At The Table?

• Public agencies
• Private providers
• Business
• Government
• Families/Children

• Educators
• Health care
• Court, legal, law enforcement
• Other key providers (housing, transportation,
  food)
• Faith community
• Labor

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Systems Integration What Does It Take?

• Leadership - someone needs to form a commitment
  and forge relationships with others to achieve
  the goal of integrated, relevant services.
• Public Child Welfare
• Private Providers

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Systems Integration What Does It Take?

• Relationship building among partners
• Inclusiveness
• Identifying common goals and objectives
• Transparency
• Support

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Purpose

• Creating a community level discussion of need and
  service array
• Based on empirical (quantitative and qualitative
  data)

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Match Between Need and Services

• Requires assessment of needs of children and
  families
• Social, emotional, behavioral
• Well-being, safety, permanency
• Risk and protective factors

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Service Array Assessment

• Type
• Capacity
• Evidence-based (promising practices)
• Overlap
• Availability of critical services (continuum)
• Accessible
• Individualized

29
Service Array Assessment

• Community/Neighborhood Prevention/Early
  Intervention
• Investigative/Assessment
• Home-Based Interventions
• OOH Reunification/Permanency Services
• CW System Exits (IL)

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Resource Development Plan

• Once gaps are identified develop a plan for
  closing those gaps,
• Identify possible interim measures to address the
  need while longer term strategies are developed

31
Monitoring Effectiveness (QI)

• Were expected results achieved?
• What factors facilitated achievement of results?
• What factors were barriers?
• What can be done to increase results and reduce
  barriers?

32
Example of a Collaborative Effort Hale County
(Rural) Thinking Outside the Box

• Initiated by the local juvenile court judge
  frustrated because no early intervention services
  available for teenagers in the community
• Formed a group called HERO Hale County
  Revitalization Organization inclusive of
  public, private agencies and families.

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Hale County

• Sub-committee for children, youth and families
• Applied for a grant to fund effort but didnt get
  it continued with process anyway
• Established goal
• coordinate existing services
• _ forum for identifying community issues and
  solutions

34
Hale County

• Lessons learned from assessment
• Everyone received the same service whether they
  needed it or not
• Services were not accessible
• Service didnt match need
• Services that did exist were not coordinated

35
Hale County

• Operating principle
• identify needs and search out resources
• Vision empowering families will lead to
  education, family support and workforce
  development
• GED program
• Emergency home repairs (by architectural
  students)
• Rehab of community center day care, client
  interviews and visitation, early childhood
  education, teen pregnancy program

36
Hale County

• Resource Center in a central location landlord
  agreed to provide at 1/3 rent
• Local University students rehabilitated the
  building as part of their architecture class (DHS
  paid for the supplies) estimated cost 100K,
  actual cost 20K

37
Hale County

• Mobile services (out of service ambulance)
• Tutoring
• Alternative GED
• Adult GED and literacy classes

38
Hale County

• Workforce Training and Welfare to Work Programs
• On the job training (supported by labor)
• Mentoring
• Mobile classrooms

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Case Example

• Young mother neglecting four young children (lack
  of supervision, unsafe housing conditions)
  initial removal then reunification.
• Case plan
• Connected to job readiness
• Home repairs by Rural Studio (architecture
  students)
• Provision of child care supports to support work
  training

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Community Outcomes

• Infant mortality rate went from 67/67 to 3/67
  (from the worst, to nearly the best)
• Substantiated maltreatment rate reduced from
  36/1000 to 4/1000 (in 10 year period).
• Reduction in child poverty rate from 47 to 34.

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Barriers to Collaboration

• Turf issues
• Categorical funding streams

42
Principles of Integrated Services

• Comprehensive services coordinated across
  programmatic lines
• Community based geared toward strengthening
  community resources to serve children in their
  own homes
• Strengths focused

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Three approaches to collaboration

• Supporting local collaborations
• Redirecting funds performance based contracting
  incentives
• Pooling funds for multi-agency children

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Key to Success

• Engaging private sector
• Conscious effort to build relationship
• Focus on common need of children/families
• Redeploy current funds and create new resources
• Bi-partisan appeal (better services, eliminate
  waste) survive political change

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Key to Success

• Data
• To describe the need
• To describe match between need and services
• To identify gaps
• To measure outcomes

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Expectation of performance

• Within public agency
• With private providers

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Expectation of Performance

• Specify outcomes in contracts and increase
  monitoring of outcomes
• Redeploy funds from across systems a system of
  care approach
• Reimbursement level tied to achievement of
  outcomes in child welfare contracts
• Outcomes focused
• Incentives to achievement of established goals

48
Lessons learned from performance based approach

• Performance contracts work best when
• they are designed to serve as an engine for
  broader systems goals
• They fit the environment in which results are
  expected
• Outcomes and incentives are aligned

49
Performance Contracting

• Should reinforce a sense of partnership in
  getting results
• Does provider have necessary resources to achieve
  results
• Align outcomes with financial interest of
  providers
• Does contractor have adequate leverage to enforce
  consequences for failing to get results

50
Change Theory

• Pre-contemplators
• Contemplators
• Ready for action
• Actively Engaged in Change
• Relapse

51
Case Example

• A community that was ready to do something
  different

52
Case Example

• Goal from a systems integration perspective
• Community based
• Comprehensive across programmatic lines

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Approach Supporting Local Collaboration

• Caring Communities Initiative Family Investment
  Trust supports 14 community partnerships 84
  neighborhood Caring Communities sites

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Local Collaboratiion

• Funds State money, plus agencies redirected
  funds
• Goals
• Parents working
• Children safe in families and families safe
• Children ready to enter school and succeed
• Children and families healthy and youth prepared
  for productive adulthood.

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Case Example

• Laura single mother age 29
• Didnt finish high school, no work experience
• AFDC two children age 11 8
• Depression, alcoholism, domestic violence

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Case Example

• Boys arrive at school dirty and hungry
• 11 year old diagnosed with ADD, and severe
  hyperactivity shoplifts and is truant
  aggressive and violent in school
• 8 year old irregular school attendance, severe
  asthma

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Case Example

• Substantiated for neglect case opened
• limited in-home care provided
• Wait list for other in-home services and alcohol
  treatment
• Community MH 1 hour and 3 bus rides away (for
  mother and son)
• Truancy officer and probation have limited
  contact (but have open cases and listed as
  workload)

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New Collaborative Approach

• The CW caseworker is stationed at the school
• Laura is connected to a support group and
  parenting classes at the childrens school
• A clinical social worker at the school provides
  therapy for Laura and 11 year old
• 8 year old is treated at school health center

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Local Collaborative

• The family court truancy officer is based at the
  school and does home visits.
• Boys are referred to an after school program, a
  Summer Fun program, and conflict mediation
  program based at the school.

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Conclusion

• While the current system is successful with some
  families, an accumulation of evidence suggests a
  need to do something different.
• Since increased funding is unlikely, need to do
  something different with what we have?

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Conclusion

• Increasing evidence that thinking outside the
  box, and willingness to pool resources, giving
  up turf and developing a continuum can achieve
  better outcomes for children/families (and
  systems).

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Conclusion

• Helping providers succeed rather than penalizing
  them, however, also establishing benchmarks and
  accountability along with incentives.