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Key Considerations inKey Considerations in Enhancing Child Welfare System PerformanceSystem Performance

Presented b Monica E Oss Chief E ec ti e Officer OPEN MINDSPresented by Monica E. Oss, Chief Executive Officer, OPEN MINDSMarch 18, 2010

Agenda

I. Key Elements in Enhancing Child Welfare System Performance

II. Measuring Child Welfare System PerformanceIII. Aligning – And Realigning – of Stakeholder

IncentivesIV. Enhancing System Implementation &

Operation With Process ImprovementV. Supporting New System Construct With

Ch iChange Management Practices

OPEN MINDS © 2010. All Rights Reserved.2

I. Key Elements in Enhancing ChildEnhancing Child Welfare System

PerformancePerformance


Four Key Elements in Enhancing Child Welfare System PerformanceWelfare System Performance

1. Measurement of performance at all levels within the system

2. Continuous realignment of incentives for each system stakeholder to support system vision and objectives

3 O i i f i i h3. On-going improvement of system operations with process optimization

4 Utili ti f h t t h i t4. Utilization of change management techniques to support system evolution


Common Impediments to Innovation & Increased Effectiveness in Children’s SystemsIncreased Effectiveness in Children s Systems

Focus on accountability for prescriptiveFocus on accountability for prescriptive processes at the expense of accountability for “outcomes” or “performance”pLack of stakeholder coordination (including lack of alignment of incentives) in design and g ) goperation of service system model

The four elements for enhancing system performance address these two common impediments


II. Measuring Child Welfare SystemWelfare System

Performance


Measuring Performance (In Addition To Process) Keeps All Stakeholders Focused on Same ObjectivesKeeps All Stakeholders Focused on Same Objectives

Performance measurement: use of outcome and process measures to understand effectiveness in affecting positive g pchange – assessed at all levels:

Population/system levelService delivery levelService delivery levelClient level

Sets overarching objectives for stakeholdersAllows “mid course corrections” when implementing new systemsId tifi ‘ ithi t ’ b t tiIdentifies ‘within system’ best practicesTransparency in performance measures creates motivation for continuous improvement at all levels

OPEN MINDS © 2010. All Rights Reserved.

co t uous p ove e t at a eve s

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National Child Welfare Outcome Indicator M i O hi F kMatrix – Overarching Framework

Child Safety Family &

Community Support

yRecurrence of MaltreatmentSerious Injuries/DeathsChild Well-BeingSchool Performance

Permanence

Well Being

School PerformanceChild BehaviourPermanencePlacement Rate

Well-Being Moves in CareTime to Achieving PermanencyFamily and Community SupportFamily Moves

SafetyFamily MovesParenting Capacity SupportEthno-Cultural Placement Matching


Child & Family Service Review (CFSR) Outcomes Measurement – Overarching Framework

SafetyChildren are, first and foremost, protected from abuse and neglectChildren are safely maintained in their homes whenever possible and appropriate

PermanencyChildren have permanency and stability in their living situationsThe continuity of family relationships and connections is preserved for children

Child and Family Well-BeingFamilies have enhanced capacity to provide for their children's needsChildren receive appropriate services to meet their educational needsChildren receive appropriate services to meet their educational needsChildren receive adequate services to meet their physical and mental health needs


CFSR Systemic Factors Measured

Statewide information system

Case review systemParent licensing, recruitment, and

retention

Q litA Quality assurance system

Agency responsiveness

Staff and provider training

Service array and resource development


Use of CFSR System

U.S. states are assessed for conformity with certain Federal requirements for child protection, foster care,Federal requirements for child protection, foster care, adoption, family preservation and family support, and independent living servicesFocus is on States' capacity to create positive outcomes for children and familiesS i d d i d i lStates not meeting standards are required to implement Program Improvement Plans (PIPs)Significant financial penalties assessed for failure to makeSignificant financial penalties assessed for failure to make improvements



Kansas Child Welfare System Performance Measurement Example

Outcome Goal or Accountability Measure Federal Standard

Children are • 94.6% or more of children are safe from recurrent maltreatment• 99 68% or more of children are safe in foster caresafe • 99.68% or more of children are safe in foster care• 95% of families in Family Preservation Program will have children safely maintained at home

Children have timely and

• 69.9% of children released from custody of the Secretary and reunified are released from custody within 12 months of entering foster carey

permanent reunification

• Children discharged from custody and reunified have a median length of stay of 6.5 months or less

• 15% or less of children will not re enter custody within 12 months of release of custody

• 26.8% or more of children released from custody of the Secretary for reason of adoption are

Children have timely

adoption

y y padopted within 24 months of entering foster care

• Children discharged from custody for reason of adoption have a median length of stay of 32.4 months or less

• 20.2% or more of children will show progress toward adoption• 8.8% or more of children will become legally free for adoption in a timely manner

45 8% f hild l ll f f d i d d i l• 45.8% or more of children legally free for adoption are adopted timely

Children have timely

permanency

• 25.0% or more of children in foster care for two years will be released from custody before their 18th birthday

• 96.8% or more of children adopted are adopted before their 18th birthday• 47 8% or less of young adults released from custody are in foster care for 3 years or longer


• 47.8% or less of young adults released from custody are in foster care for 3 years or longer

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s 6 Discharge2 Rule 906 Rates

Illinois Residential Treatment Performance Indicators Report

• “Dashboard” of keyFe

atur

es 6. DischargeData Source: CYCIS Data Warehouse

2. Rule 906 RatesData Source: CYCIS Data Warehouse

14 Detention

15 Psychiatric Hospitalization

16 Elopement/Runaway

26 Stability at 90 Days

27 Next Placement Type (- + =)

28 Next Living Arrangement Type

Dashboard of key performance indicators

• 36 indicators• 8 domains• Developed collaboratively

7. ComplianceData Source: RTOS, CYCIS, Other

1. UIR RatesData Source: RTOS

1 Elopement/Runaway

2 Arrest

17 Quarterly Length of Stay18 Annual Length of Stay

g g yp

29 Provider Medicaid Tier/Level

3. Length of StayData Source: CYCIS Data Warehouse

4. Outcomes - FunctioningData Source: CANS Data Warehouse

3 Psychiatric Hospitalization

4 Restraint

5 Injury due to Restraint

6 Confinement

g y

19 Δ in CANS Dimension Scores

20 Δ i A ll C S

29 Provider Medicaid Tier/Level

30 CANS Completion Rate

31 Ansell Casey Completion Rate

32 Vineland Completion Rate6 Confinement

7 Suicide Attempt

8 Self Inflicted Injury

9 Sexual Aggression

10 S h l S i

20 Δ in Ansell Casey Score

21 Δ in Vineland Score

22 Δ in Grade Equivalency

33 Grade Equivalency Test Rate

34 UIR Fidelity Rate

5 Outcomes – Voc/Ed 8. Child SatisfactionData Source: Client Satisfaction Data

10 School Suspension

11 School Expulsion

12 Medical Psychiatric Emergency

13 Aggression

23 Educational Attendance

24 Educational Enrollment

25 Job Attendance

35 Child Satisfaction: Young/DD36 Child Satisfaction: Other

5. Outcomes – Voc/EdData Source: CYCIS Data Warehouse



Performance Measurement Approaches in the Context of Indigenous Communities

Performance measures when applied to Indigenous communities should carefully assess the appropriateness and

li bilit f thapplicability of the measuresResearch on evidence-based practices rarely includes Indigenous childrenIndigenous childrenMay fail to capture/reflect the multi-faceted social roles evidenced in Indigenous communities

Outcome measures need to take into account community history, culture, traditions, and norms (which vary both across and within communities)and within communities)Analytical approaches like practice-based evidence models can be used to assess variations in performance for specific


populations

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Using Performance Measurement To Engage Frontline Staffo t e Sta

Performance reporting should be designed to be appropriate for all stakeholders – and all staff levels including frontline staff Performance standards for frontline staff built into position descriptions (and incorporated into performance reviews)descriptions (and incorporated into performance reviews) Performance reports should be generated at least monthly and sent to managersManagers meet with teams to review results of team-specific performance measurement and share best practicespracticesUse feedback from frontline staff to facilitate process re-engineering


Considerations in System Performance Measurement InitiativesImpediments to system performance measurement

Gaining consensus on definition of ‘performance’ and performance standards – at every stakeholder levelNeed electronic information infrastructure to gather information affordably and accuratelyStakeholder fear of transparency in measurement and comparisonSupervisors and managers in service system not prepared for role in performance-based management

Keys to success in performance measurementFewer measures rather than moreFocus on ‘best practice’ and not ‘poor performance’Focus on best practice and not poor performanceOrganized process for metrics-based system management (use for continuous improvement)T f d t i ti l


Transparency of data is essential

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III. Aligning –& Realigning –& Realigning of Stakeholder

I tiIncentives


Desire for System Accountability Has Increased Use of Performance-Based Contractingof Performance-Based Contracting

Generally, increased regulation of process has not lt d i i ifi t i t i tresulted in significant improvement in outcomes

Created move to performance-based contracting --contracting system with formal structure for defining and g y gquantifying cost and qualityIncentives for superior performance often financial – but

l b fi i l i ti h i dcan also be non-financial incentives such as increased referrals, decreased oversight, or other measuresPay-for-performance (P4P) variant increasingly commonPay for performance (P4P) variant increasingly common -- contracting systems that offer financial incentives to agencies achieving specified performance benchmark


Performance-Based Contracting: The U.S. Experience

Currently 25 U.S. states use performance-based contracts for some of their child welfare services (11 other states moving in that direction)direction) Systems with performance-based contracting have generally reported improved performance in six areas: 1. Increase in number of children reunified with their families 2. Decrease in number of children reentering out-of-home care after

having been reunified with their families g3. Increase in the number of children in foster care who are adopted 4. Decrease in amount of time a child is in foster care before being

adoptedadopted 5. Increase in number of children placed with relatives and no longer

requiring foster care i i f ll f l d


6. Decrease in size of overall foster care caseload

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Performance-Based Contracting Example: Tennessee Child Welfare SystemTennessee Child Welfare System

Tennessee performance-based contracting (PBC) model l i id i i f ievaluates private provider organization performance in

their individual organizational improvement in three areas:Permanent exits – goal is 10% increase in number ofPermanent exits goal is 10% increase in number of children achieving a permanencyFewer care-days – goal is 10% decrease in number of care days used by getting children to permanence earlierLower re-entry rates – staying within a specified % for up to 12 months post dischargeto 12 months post discharge


Performance-Based Contracting Example: Tennessee Child Welfare System (cont)Tennessee Child Welfare System (cont)

Incentive Structure: P i i i id di b i b l lPrivate organizations are paid on a per diem basis by level of serviceOrganizations showing improved performance receive anOrganizations showing improved performance receive an enhanced per diem based on the estimated amount of funds “saved” (through faster time to permanency and reduced days in care)days in care)

At end of year, if savings estimates are not met, organizations repay some proportion of enhancement g p y p pper diem

Private organizations are not restricted in how they spend th i i t t i ti t


their reinvestment incentive payment

23

Performance-Based Contracting Example: Kansas Child Welfare SystemChild Welfare System

Kansas reimburses private provider organizations using a tiered payment system paid as a case ratetiered payment system paid as a case rateCase rate is paid as progress payment linked to 4 major milestones

Child referred to provider — 25% of case rate60-day report provided to state — 25% of case rate180 d id d 2 % f180-day report provided to state — 25% of case rateChild achieves permanent placement — 25% of case rate

Provider performance on system performance measuresProvider performance on system performance measures determines whether or not contracts are renewed


Considerations in Management of Performance-Based Contracting InitiativesImpediments

Difficulty in setting appropriate incentives (and planning for unintended consequences)q )Need for enhanced contract management infrastructure including monitoring and technical assistanceParticipating authority/agency data systems must be enhancedParticipating authority/agency data systems must be enhancedPrivate agency/public authority management teams need to move to metrics-based management model

Keys to successKeys to successPerformance standards (process and outcomes) are readily measurableClearly defined objectives and timeframes related to incentivesConsumer ‘choice’ and consumer ‘voice’ in designTransparency of all performance and incentive information Incremental approach to system implementation


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IV. Enhancing System Implementation &Implementation &

Operation With ProcessProcess

Improvement


Facilitating Improved System Operational Effectiveness Requires. . .Effectiveness Requires. . .

“Virtual” integration of services at the child and family level with three key integration axesfamily level with three key integration axes

Service system continuity/linkagesInformation flowFinancing model

Process optimization and improvementp pProcess mapping Decision support toolsInformation sharing toolsRemote management tools


Process Optimization Via Process MappingMapping

Process mapping identifies the sequence of events t b ild i d d tto build a service and produce an outcomeProcess map helps team members understand the entire process and the interdependenc of all theentire process and the interdependency of all the team members who are part of the process

Also helps team members identify potential fail pointsAlso helps team members identify potential fail points and redundancies in the process – in order to develop appropriate process improvement action plans

Process mapping also identifies the tools that will improve process “fail points”



California Process Map for Person-Centered Mental Health Service Delivery


Tools Supporting Process Improvement

Decision Support ToolsSoftware and automated models for decisionmaking in

l it ticomplex situationsFor implementing differential response, systematic structures and assessments for selecting a response track and allowing g p gchanges

Information Sharing ToolsEl t i dk i tElectronic recordkeeping systemsPersonal health records

Remote Management ToolsRemote Management ToolsLaptops and smart phonesTelehealth


U.S. Statewide Automated Child Welfare Information SystemInformation System

SACWIS (Statewide Automated Child Welfare Information System) is a comprehensive automated case management tool that supports p g ppsocial workers' foster care and adoptions assistance case management practice in the United States – both public and privateElective system but federal funding and training supports areElective system, but federal funding and training supports are available

32 states operationald d l9 states under development

9 non-SACWIS statesStates must agree that SACWIS will be the sole case management g gautomation tool used by all public and private social workers responsible for case management activities; SACWIS the state’s “official case record”


SACWIS Major Functional AreasSACWIS Major Functional Areas

1. Intake management2. Case management3. Court processing4. Administration5. Eligibility6. Resource management7. Financial managementg8. Interfaces with other health and human service

systems




Remote Support for Case Management At Fl id ’ O Kid f Mi i D d /MFlorida’s Our Kids of Miami Dade/Monroe

220 caseworkers carry a smart phone and220 caseworkers carry a smart phone and laptop to their monthly foster home visits“OK Connect” application allows them to document services and enter other data during home visitsHome visits have increased by 30%Home visits have increased by 30% since the technology was deployedIncreased compliance with state reporting deadlines


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37

Considerations in Process Optimization InitiativesImpedimentsImpediments

Starting with top-down process mapping approach (need bottom-up approach focused on frontline staff and consumer experience and information flow)Desire to use ‘tech tools’ that don’t solve basic process issuesLack of support (policy change operational procedures etc ) forLack of support (policy change, operational procedures, etc.) for system infrastructure

Keys to successLink process improvement initiatives to system performance measurement dataEngagement of consumers and frontline staff in process is key toEngagement of consumers and frontline staff in process is key to successSelection of tools that are appropriate to the process and to the improvement desired


improvement desired

38

V Supporting AV. Supporting A New System

Constr ct WithConstruct With Change

Management Practices


Eight Steps to Successful System Evolution

1. Establish a sense of urgency2 Create a “guiding coalition”2. Create a guiding coalition3. Develop a ‘change vision’ with

strategies and tactics4. Communicate the ‘change vision’5. Empower broad-based action6 G h “ i ”6. Generate short-term “wins”7. Consolidate gains to produce more

changechange8. Anchor new approaches in the

organizational culture


Planning Information Required to Facilitate System ChangeSystem Change

Analysis and strategic plan for system enhancementsenhancements

Current and future environmental situationIssues for coping with potential changes in environmentp g p gSystem change strategy and specific tactics Timeline for system development

Analysis of system change factorsImpediments to implementing specific change tacticsPlan to address those impedimentsPlan to address those impedimentsAdditional information needed to design change


5 Elements Required to Integrate Cultural Competence into System Change ProcessCompetence into System Change Process

1. Value diversity2 Have the capacity for cultural self assessment2. Have the capacity for cultural self-assessment

Organizations and individuals must establish and understand their own identity in order to develop and implement goals

3. Be conscious of the dynamics inherent when cultures interactHow and where services are provided are critical to service delivery

4 Institutionalize cultural knowledge4. Institutionalize cultural knowledgeAll levels of the organization must be culturally aware

5. Adapt service delivery based on understanding of cultural diversity

Programs and services must be delivered in a way that reflects the culture and traditions of the people served


p p

42

Considerations for Using Change Management Techniques to Support System EvolutionImpediments

No overarching “change vision”Inconsistent communication to stakeholdersLack of ‘buy in’ across system stakeholders “Hold out for failure” attitude among key stakeholder group(s)Operational impediments ‘defeat’ desire to change

Keys to success“Ch i i ” th t i b d t d id“Change vision” that is embraced across system – and can guide independent development of the system at all levelsOperational design and policy changes to support system design at all l llevelsAlignment of system incentives to support change in the short-term and reward ‘successful change’ among stakeholders


Factors Associated With Implementation Success in Child Welfare System EvolutionSuccess in Child Welfare System Evolution

1. The importance of collaboration and di ti t t k h ldcoordination among system stakeholders

2. The necessity of continuous, accurate data tracking and assessment of s stem performancetracking and assessment of system performance

3. Correction of barriers that impede system optimum performanceoptimum performance

4. Investment in a full care continuum supporting system goalssystem goals


B i i h MBringing the Managementof Behavioral Health& Social ServicesInto Focus

www.openminds.com163 York Street, Gettysburg, Pennsylvania USA 17325

i @ [email protected]

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