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![Page 1: Using Flexible Funds to Improve Child Welfare Evaluation of Ohio’s Title IV-E Waiver Demonstration Project September 2002.](https://reader035.fdocuments.net/reader035/viewer/2022062408/56649e4d5503460f94b4323f/html5/thumbnails/1.jpg)
Using Flexible Funds to Improve Child Welfare
Evaluation of Ohio’s Title IV-E Waiver Demonstration
ProjectSeptember 2002
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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
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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
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Green = demonstration PCSAYellow = comparison PCSA
Ohio’s Evaluation Counties
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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.
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Process Implementation Study Use of managed care strategies:
Service array Financing Case management Utilization review Managed Care index
Interagency collaboration
Systemic reform and leadership
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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
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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)
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Changes in Service Array (2) Most counties
experienced loss of services – 11 demonstration,9 comparison sites
Increased use of kinship placements
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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
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Case Management
Both demonstration and comparison counties experimenting with:
Staffing arrangements Team conferencing models Ways to involve families Screening criteria and procedures
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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
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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
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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
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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
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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.
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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.
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Findings from the Participant Outcomes Study
Changes in Caseloads
Changes in Case Mix
Waiver effects on length of stay in first placements
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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
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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
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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
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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
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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
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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
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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
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Findings from the Fiscal Outcomes Study
Foster Care Expenditure Patterns
Additional Revenue
Additional Revenue Purchases
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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.
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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%
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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%
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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%
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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.
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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%
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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.
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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.
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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%
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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.
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Lorain County and ProtectOhio
Sandra HamiltonLorain County Children
Services
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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
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Revenue Source The funding for Lorain County
consist of resources from the following 3 areas:
38%
11%
51%
FederalStateLocal
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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.
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Project Goals
Increase database capacity & accessibility to data
Enhance Quality Assurance activities
Staff Professionalism Special Service initiatives to front-
end services Reduce Placements
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Project Goals continued
Develop Managed Care contracts, internally & externally
Community involvement
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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.
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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.
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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.
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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
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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
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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