Innovation at the Philadelphia Department of Human Services (DHS): Improving Outcomes for Children by Increasing Accountability and Strengthening Community Partnerships

The Issue: The State of Child Welfare in America

The federal government charges states and localities with ensuring the “safety, permanency, and well-being” of all children who may be at risk for child abuse or neglect (P.L. 105-89). To meet these mandates, child welfare agencies investigate reports of alleged child abuse and neglect, provide services to the family or, if the child’s safety is determined to be at risk, remove the child to a foster family home, the home of a screened relative of the child, or a group home. Roughly 1.3 million children are victims of substantiated child abuse and/or neglect each year (U.S. Department of Health and Human Services 2010). At any given time, almost 500,000 children are living in out-of-home care, with almost 800,000 children living in out-of-home care at some point each year (Children’s Bureau 2011).

Although some exceptional foster youth thrive despite the difficult circumstances of their childhoods, child welfare agencies nationwide struggle to meet their three goals of safety, permanency and well-being. Many children are forced to move between multiple placements. Also, over 30,000 foster youth age out of the system every year, meaning that they are forced to exit the foster care system, usually at age 18, with no permanent family to call their own (Children’s Bureau 2011). These youth overall experience markedly worse outcomes than their peers over the life course (Courtney et al. 2010).  Alleged system breakdowns often lead to tragedies such as child fatalities. Over 60 lawsuits have been brought against local and state child welfare agencies nationwide and 19 states are currently under pending settlement agreements (National Center for Youth Law 2010). 
In 1991, a commission established by Congress to study the child welfare system wrote: “If the nation had deliberately designed a system that would frustrate the professionals who staff it, anger the public who finance it, and abandon the children who depend on it, it could not have done a better job than the present child welfare system” (National Commission on Children 1991, 293). Most child welfare advocates believe the entire system should be transformed in a meaningful way. In the meantime, state and local child welfare workers must grapple with performing one of the most difficult jobs around. Despite the tireless efforts of committed administrators, managers and caseworkers, achieving safety, permanency and well-being for all children proves elusive.

Although the federal government sets the national standards for the services states must provide through their child welfare systems, states and local jurisdictions are charged with implementing these services in a manner that best meets the needs of their individual communities. Pennsylvania’s system is county-based, with all 67 county child welfare agencies in the state overseen by the Pennsylvania Department of Public Welfare (DPW). The Philadelphia Department of Human Services (DHS) is the largest child welfare agency in the state and among the largest in the country. Philadelphia handles both dependent and delinquent children, as well as families provided with in-home court-ordered or voluntary prevention services. However, unlike most other systems, Philadelphia also places children into the system for truancy, introducing a population of children into the system not normally seen by these agencies.

In FY11, on a budget of approximately $600 million,  DHS served a total of 11,330 children in dependent and delinquent placement settings, as well as 60,000 youth and 20,000 families through non-placement in-home services, both court-ordered and voluntary (PMA report, February 2012). Like so many other agencies, DHS has also suffered system breakdowns leading to tragedy. In early August 2006, an ambulance was called to the home of the family of a DHS client named Danieal Kelly to find the 14-year-old girl lifeless, weighing only 46 pounds, with weeks-old bedsores covering her body due to gross neglect. Most horrifying was that her family had been receiving services from DHS for years, and was supposed to be receiving biweekly visits from a caseworker through a private provider with whom DHS was contracting. Like other children before her, Danieal fell through the cracks of the system.

In the aftermath of the incident, then-Mayor John F. Street appointed a group of national and local child welfare experts to a Community Oversight Board (COB) to systematically investigate what led to Danieal’s death and make reform recommendations. In its first report, in 2007, the COB focused many of its recommendations on safety, which the panel identified as the primary and essential role of child welfare departments. To help ensure safety for children in care, the COB recommended that DHS implement an appropriate safety assessment tool to more accurately assess a child’s safety and risk in different placement settings, increase the number of face-to-face contacts required between caseworkers and children, and implement an intensive team decision-making process for all young children in care.

The COB also recommended that the agency improve its performance monitoring to track the outcomes of children served, measure the impact of policy changes, and identify areas needing improvement. This included enhanced oversight of the provider agencies under contract with DHS, including linking outcomes to financial incentives for the agencies. Responding to this recommendation, Commissioner Anne Marie Ambrose created the Division for Performance Management and Accountability (PMA). She further emphasized the importance of monitoring by recruiting a Deputy Commissioner to staff the new division and implement processes for rigorous quality assurance.  Although the federal government requires states to report basic statistics related to safety, permanency and well-being, for the first time DHS began to use them to describe its own performance.

In creating the new division, DHS made an important distinction in social sector management between outcomes and indicators. An “outcome,” as nonprofit consultant David Hunter argues, is “an enduring change in something about which the organization cares deeply.” For DHS, their primary outcomes are safety, permanency and well-being. “Indicators” are “concrete and measurable things that an organization will look at to assess whether it has succeeded in reaching a given outcome” (Hunter 2006). A decrease in the number of incidents of child abuse and neglect while receiving services, for example, is an indicator of safety; an increase in the number of children exiting foster care to a permanent placement (i.e., adoption or reunification with birth family) is an indicator for permanency; increased rates of school attendance is an indicator for child well-being.

This new focus on outcomes and accountability is also exemplified by the successful, though difficult, implementation of a Performance-Based Contracting (PBC) system, in which all provider agencies contracting with DHS are held to strict performance standards, including permanency indicators and placement stability (City of Philadelphia Department of Human Services 2011). Initially this system applied to general foster care agencies only, but has since been expanded to apply to treatment foster care and in-home protective services.  In 2009 DHS began publishing annual rankings of these providers, with an expectation that if the agencies do not perform well, DHS will no longer offer them the contract. This type of transparency was an enormous step towards increasing accountability within an agency that had operated for years without it. Concrete outcomes are now the norm by which provider agencies in Philadelphia live. Although it was a difficult reform process for both the agency and its provider partners, PBC has positively impacted the quality of care provided to DHS-involved families. By holding itself and provider agencies to continuously monitored outcomes and indicators, DHS has allowed thousands more children to experience permanency.

The challenge for all child welfare agencies is to ensure that no child falls through the cracks. As of June 2011, DHS had completed at least 19 of the 37 reforms the COB recommended (the others are in various stages of implementation), including a host of other reform initiatives not mentioned above, in furtherance of the three-part aim of safety, permanency and well-being. DHS is committed to seeing through the COB’s recommendations and its new policies and initiatives to keep Philadelphia’s children safe and protected.

The Problem: The Challenge of Keeping Children Safe

Despite the thousands of children that DHS does keep safe every year, and the enormous improvements that have been made since Danieal’s death, some children remain at risk. DHS, of course, wants to ensure that all children remain safe under their care, and both agency and city leaders continue to place that as a primary goal for the agency. Mayor Michael Nutter has made reforming DHS a priority during his tenure and, like Mayor Street, has relied heavily on the COB’s recommendations as a force for reforming the city’s child welfare department. Mayor Nutter also appointed Commissioner Anne Marie Ambrose, a child welfare and juvenile justice systems veteran with a record of reform, to take the reforms at DHS even further.

Under Commissioner Ambrose’s leadership, the agency has made impressive and measurable progress. She has devoted significantly more resources to the newly developed PMA Division of DHS, allowing for a more serious focus on data collection and tracking, and giving the division more muscle within the agency to create change. Since her appointment in June 2008, she has also decreased the number of children in foster care by 33%, decreased the number of out-of-state placements by 79% for dependent youth and 91% for delinquent youth, and increased the number of children leaving foster care to a permanent placement by 12% (PMA Division report, February 2012). The Philadelphia Inquirer editorial board, a harsh critic of DHS in the past, noted this progress in June 2011: “Important reforms have been made within DHS, with more to come. That means better protection for vulnerable children” (Philadelphia Inquirer Editorial Board 2011).

One of the most difficult of the COB recommendations left for DHS and Commissioner Ambrose to address spoke to the problem, caused by a “dual case management system,” of the lack of clarity regarding the responsibilities of DHS caseworkers versus provider agency caseworkers. To families and foster parents, the dual case management can feel like a rotating door: families don’t always know which caseworker will be visiting their home, which one to contact, and who will be with them in court. Importantly, and as illustrated by the Danieal Kelly tragedy, dual case management doesn’t allow for clear accountability. DHS is one of the largest child welfare systems in the nation that gives case management responsibilities to both DHS workers and provider agency caseworkers, and it has become clear that this duplication of roles could be eliminated with more clarity and structure between the agency and providers. With this in mind, DHS decided on a bold innovation¬¬, moving from the current dual case management system to a more streamlined model to improve the quality of services provided to families. On its face, this recommendation seems like better management through simplification, but within an agency as complex as DHS, it has proved daunting. The new initiative is appropriately named Improving Outcomes for Children (IOC) and the COB will oversee implementation.

The COB also recommended that DHS strengthen community partnerships to encourage community participation and input in DHS practices and improve continuity of care. This recommendation is based on a few model programs nationwide demonstrating that effectively engaging community partners can greatly improve outcomes for children and families (Center for the Study of Social Policy 2011). Although DHS has partnered with more formal organizations providing supports like legal aid, health care, and social services, they have yet to engage more informal supports such as faith-based organizations and community members in areas that touch the child welfare system the most. By not working alongside such partners, DHS is often viewed as an enemy by many communities, and fails to tap into networks that could help it stabilize families to keep vulnerable children safe.

To tackle these remaining challenges, DHS turned to Casey Family Programs (CFP), which has been supporting DHS’ reform efforts since 2006.  CFP is a highly regarded national foundation established by United Parcel Service founder Jim Casey in 1966.  Since its inception, the foundation has committed billions of dollars to improving child welfare systems at the local, state and federal levels. Casey has worked with countless child welfare agencies across the country to improve their practices according to the best knowledge in the field. Casey’s ability to leverage knowledge and talent, and bring new resources into a jurisdiction, makes them an ideal partner for DHS as it tries to implement change.  In addition, Casey Executive Vice President David Sanders serves as the chairman of the COB – further highlighting Casey’s commitment to child welfare reform in Philadelphia.

In his monograph, Good to Great and the Social Sectors, management expert Jim Collins identifies certain key features of what it takes to bring a social services agency from one that simply provides services to one that is truly impactful. Among these is assembling the right team of players before deciding on a path to move forward: “First who, then what” (Collins 2005). Philadelphia has followed this advice, consciously or not, by hiring the best of the best to be part of the reform initiative, beginning with the members of the COB, then the appointment of Commissioner Ambrose, followed by the expertise of Casey Family Programs.  To help coordinate this initiative, Casey Family Programs supported Philadelphia’s selection of Wanda Mial, an independent consultant and a lifelong Philadelphian with years of experience in the social sector.  Ms. Mial was instrumental in the development of the successful PBC initiative. She is a familiar and friendly face at the agency, and a true expert in child welfare. Commissioner Ambrose also created an IOC Executive Team to work internally at DHS; a Steering Committee consisting of both DHS staff and outside stakeholders; and six task-specific workgroups:  Practice; Policy and Legislation; Community and Systems Engagement; Data and Performance Management; Finance and Contracting; Staff Development and Capacity Building. With this team in place, DHS is in a position to create even more meaningful change for the children and families they serve.

The Solution: Improving Outcomes for Children

With the help of Casey Family Programs, DHS began exploration of the new IOC initiative in November 2008 by visiting New York City and looking at Commissioner Mattingly’s IOC Initiative and conducting a comprehensive review of initiatives around the country that have created a single case management system and effectively engaged community partners. After studying several individual reform models, DHS ultimately decided to design its own model based on similar initiatives in Florida and New York City, both of which, like Philadelphia, rely heavily on provider agencies for day-to-day case management. DHS believes that their new IOC model will be transformative for the agency, and do more to improve outcomes for all children and families in the system than any prior agency initiative. It is indeed the most ambitious of any of their reform efforts to date.

The research in child welfare is clear that children do best when they remain in families, preferably their own families, whenever possible (Doyle 2007). Emerging successful initiatives have shown that families, particularly families most at risk of coming to the attention of the child welfare system, need strong communities to support them, and that public child welfare agencies must partner with members of those communities to effectively ensure the safety and well-being of at-risk children. The theory holds that by engaging members of a community, making them aware of how the child welfare system impacts their community, and empowering them to intervene in a family who may be struggling, neighborhoods may recapture a sense of responsibility for the welfare of their children. This engagement helps protect vulnerable children by supporting families before child abuse and neglect occur in the first place, thus, in turn, preventing some families from coming to the attention of DHS in the first place.

The means to achieve this new community partnership approach will rely on a streamlined case management system and strengthening the level of performance monitoring and accountability at the agency to track in precise terms the outcomes of this initiative. The belief is:

If DHS partners with communities through a streamlined case management system and clearly defines and tracks relevant outcomes indicators, holding staff and providers accountable to these indicators, then Philadelphia children will remain safer, find permanent homes, and experience greater well-being.

DHS will measure the success of its programs, including IOC, based on a number of key child welfare indicators they believe can be substantially improved through the IOC initiative. Though DHS uses many more indicators to assess its overall performance, the IOC indicators do touch all aspects of the 3 essential goals of child welfare agencies:

Safety:

• Decreased rates of abuse
• Decreased initial placements
• Decreased rates of abuse and neglect occurring in care
• Decreased rates at which children return to care (re-entry)

Permanency:

• Increased discharges to reunification (biological or kinship family), adoption, or permanent legal custodianship
• Decreased length of stay in care
• Decreased number of movements between placements while in care

Well-Being:

• Decreased number of children in group home/institutional placements
• Increased sibling placements and connections over the life of a case
• Decreased racial disproportionality

Execution of this new strategic approach will span three phases: planning, design and implementation. The planning phase was completed in June 2011. DHS and its partners are currently in the design phase, during which the details of the model will be worked through. Throughout this four-year collaboration, the IOC team will rely heavily on the voices of children and families they serve, community residents, stakeholders, provider agencies, and DHS staff to inform the development of the model. The vision for IOC is “a service delivery system that will be provided by private agency workers, monitored and supported by DHS, and enriched by the contributions of neighborhood groups and programs” (DHS internal document). DHS believes that their formal system of care can be made better by involving informal systems of care, as well, including faith-based groups and other community members and stakeholders who may not have otherwise recognized the degree to which they can play a role in supporting the families in their neighborhoods.

Under this new case management system model, duplication will be eliminated and roles and responsibilities will be clearly delineated. Providers will become responsible and accountable for ongoing case management and day-to-day service delivery, while DHS’s role will focus on providing guidance and technical support to providers.

To begin the community engagement component of IOC, DHS is using Geographic Information Systems (GIS) to map the neighborhoods with the highest DHS involvement, and is meeting with stakeholders in those areas regarding how the entire community can work alongside DHS to support the families. DHS’s mapping technology is also able to show where children go when they are placed in foster care, information that community members would have had no way of knowing before now. Taking children out of their homes and neighborhoods entirely can be detrimental for communities. It also does not foster well-being for children in care: taking youth out of their communities can have the unintended effect of disconnecting a child from his/her neighborhood entirely, disrupting his/her schooling and friendships, and discouraging reunification with family. Keeping children within their own communities by encouraging community support networks to promote child safety is thus a desirable goal for the child, family, their community and the child welfare system as a whole.

The design phase of IOC is complete. The final implementation phase began in January 2012, with DHS focusing first on areas with the highest system involvement before moving to other areas of the city. 

The Innovation: Performance Accountability and Community Partnership

The innovation in the IOC initiative is two-fold. First, the data tracking component of IOC represents the latest, and boldest, step towards real and meaningful accountability within DHS ever. The initiative is results-oriented, making everyone single-mindedly focused on quality service delivery and improving clients’ outcomes. Accountability done well—using outcomes to assess the impact of programs and policies—leads to improved client outcomes. Although accountability is not a new concept in child welfare, and some agencies nationally have embraced it, most still have not. If Philadelphia can make its system more transparent and accountable, it could serve as an important model for similar jurisdictions around the country. 
The second true innovation in IOC is the community partnership component. The premise is fairly intuitive: Children belong in families, families operate in a sphere of communities, and most often the reason that families enter the child welfare system is that they are isolated from these communities and have nowhere to turn during times of need. If families are well-supported and have access to the resources they need during times of crisis, then children will do better too.

In some ways, enhancing community partnership can be best described as building a continuum of care for at-risk children and families. The model acknowledges that many of the children who touch the child welfare system come from broken communities, and are children of yesterday’s at-risk children from similarly broken communities, or even the child welfare system themselves. By working to establish a continuum of care that can catch families when they need support, and acknowledging that DHS cannot perform this task alone, DHS may be able to significantly reduce caseloads and improve outcomes for all children at risk of entering the child welfare system in Philadelphia.

These reforms are particularly innovative and meaningful given certain restrictions in federal child welfare financing. A gaping flaw in the federal funding structure is the inflexibility of Title IV-E (Title IV, Subpart E, of the Social Security Act) and its limitations for reimbursing certain services. Though it makes up the majority of the money spent on child welfare services, states may only be reimbursed for foster care services; funding from Title IV-E cannot be used for prevention services or other wraparound services to support families in other ways, which could prevent the need for children to enter foster care in the first place. The IOC approach is two-fold:  supporting a state request to the federal government for for a Title IV-E waiver and leveraging community resources to provide these up-front prevention and wraparound supports, in a community context. With no stigma of a DHS worker coming to the family home, DHS may be able to improve overall service delivery even within the confines of restrictive funding sources.

Barriers to Implementation

There are, of course, a number of potential barriers to implementation that DHS faces in the months to come. Chief among these is stakeholder buy-in. A unique feature of the child welfare system is that it involves multiple decision-makers. A typical child welfare case not only includes DHS but Family Court and the presiding judge, parent advocates, child advocates, family advocates, provider agency caseworkers, and the city itself through its policies. All of these constituencies are major stakeholders that must become a partner in the IOC initiative and this type of collaboration can be problematic. For IOC to be successful, DHS must bring them all stakeholders to a place where they can find something to agree on. To the extent that IOC is seen as a threat to key constituencies, the success of the initiative will be more difficult.
As is often the case in Philadelphia, unions are a huge stakeholder for DHS in IOC. Because changes in job descriptions and responsibilities will be required under the new single case management model, DHS must also work with both caseworker and supervisor unions in order to facilitate a smooth transition to the new system. To be sure, being a child welfare caseworker is one of the most taxing jobs in any child welfare agency, sometimes leading to high turnover rates and poor case management continuity for families. DHS has therefore made a concerted effort to bring caseworkers to the table, to reassure workers of their job security and that although their work may change it will not increase.  DHS workers will continue to provide a valuable service under IOC.
Another key stakeholder constituency is the provider community, whose perspective can get lost in discussions about increasing accountability. Under the new single case management system, provider agencies, in many ways the heart of the Philadelphia child welfare system, will be performing all of the day-to-day casework. Reforms of the magnitude of the IOC initiative will require significant changes to the provider agencies themselves, and must take into account the capacity of the agency to work through these changes. They are truly partners for DHS in this reform endeavor.
DHS leadership firmly believes that they can overcome these buy-in challenges. They are viewing all of these stakeholders as partners in the process with an important perspective to bring to the table. According to Mial, they are beginning slowly but surely beginning to get the buy-in they need. The collaboration of all stakeholders has been key to the planning for Philadelphia’s IOC.  They have been engaged as thinking partners throughout all phases of the work.

Financial Costs and Potential Savings

For the vast majority of children, simply entering the child welfare system puts them on an unstable path. A major goal of IOC is to reduce the number of children in residential and foster placements, and instead keep them within their own families and kinship supports whenever possible. It also turns out that the most restrictive settings, specifically residential and family foster care, are the most expensive. Table 1 shows the average monthly cost of different levels of placement. If DHS is successful in reducing the number of children in foster and residential care placements, and it can prevent the need for children entering out-of-home care in the first place, they will not only improve child welfare outcomes but reduce costs substantially for DHS. It is a true win-win.

Table 1. Average monthly cost of different forms of out-of home care (PMA, 2012 average).

• Approximate monthly cost of family foster care per child = $1800
• Approximate monthly cost of residential care per child = $3,900
• Approximate monthly cost of kinship care per child = $1,450

The challenge, now and in the future, is working within the funding structure in place to make these changes. Because the primary child welfare funding stream will reimburse child welfare dollars only for out-of-home care, DHS must learn to be creative with the money available as the agency could lose this needed reimbursement money for good if they are too successful at reducing the number of children in out-of-home care, money that neither the state nor the city governments will be able to compensate for in today’s budgetary conditions.
On the other hand, involving informal networks of support within communities that may be available to families can help DHS do a better job taking care of the families they serve without having to pay them to do it. To the extent that DHS is successful in its goals to connect families with community supports that already exist, they may be able to make up for the potential lack of resources.
Finally, streamlining case management means decreased duplication and more efficiency in their processes. Though DHS does not yet have an estimate for the financial savings that could result from this increased efficiency, and the Commissioner insists that DHS workers will not lose their jobs as a result of the initiative, eventually savings are likely to be substantial, and could free up resources to be invested in community prevention programs.

Policy and Practice Implications: DHS as a Model for Other Jurisdictions

In many ways, Philadelphia is acting as a pilot site to test the hypothesis that all components of the IOC initiative—community partnerships, single case management, rigorous data tracking and system accountability for articulated outcomes—will in fact lead to improved outcomes for children. Commissioner Ambrose envisions DHS becoming a leading child welfare agency in the nation. If she succeeds in this goal, as she has in many others, Philadelphia will become a model for child welfare system reform in other cities nationwide. This is particularly true given the oversight of the COB and involvement and strong support of Casey Family Programs in IOC. Regardless of the success of the initiative, lessons learned from this project will  inform other child welfare agencies as they consider potential reforms. Other jurisdictions will be watching with interest to see what happens.

Although the changes required to fully implement IOC will happen over several years, and progress may seem slow at times, DHS believes that through this process people will come to realize that they are sincere when they say will become a more transparent system. Their job in the meantime, and in the near future, is to help people see that there isn’t a hidden agenda in this initiative, nor is it just another reform initiative that everyone will forget about in a few years. They believe that IOC, like the PBC system, will stand the test of time and leadership change. As Mial put it, although the initiative is a big challenge, DHS would not be engaging in this enormous effort if they didn’t believe it could achieve concrete and meaningful outcomes for the children they serve.

Their attitude is reminiscent of another key feature of great social sector initiatives. According to Jim Collins, “In building greatness, there is no single defining action, no grand program, no one killer innovation, no solitary lucky break, no miracle moment. Rather, it resembles relentlessly pushing a giant, heavy flywheel in one direction, turn upon turn, building momentum until a point of breakthrough and beyond” (Collins 2005, 23). This is how DHS foresees its trajectory. In transforming their service delivery system, and holding all parties accountable to generating better outcomes for the children in care, DHS is building momentum to making itself a great public child welfare system.

Rebecca McElroy is a second-year graduate student at the University of Pennsylvania pursuing a dual-degree Master of Social Work and Master of Public Administration. Her first year MSW field placement was at Episcopal Community Services; her second-year field placement is at the Field Center for Children’s Policy, Practice & Research at Penn, where she works closely with Field Center Faculty Advisor Dr. Cindy Christian, who also serves as the DHS Medical Director.  Rebecca has also worked as a Public Policy Fellow at ChildFocus Partners, a national child welfare consulting firm.  Prior to graduate school, she spent 3 years as a Legislative Assistant for U.S. Congressman Jim Cooper (D-TN) handling social welfare issues, including child welfare.

References

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