As discussed previously in this journal (McElroy, 2012), Improving Outcomes for Children (IOC) is a comprehensive, citywide initiative aimed at improving the outcomes for children, youth and families receiving child protective services in Philadelphia. This Department of Health and Human Services (DHS) initiative builds on the belief that a community-neighborhood approach with clearly defined roles between county and provider staff best impacts safety, permanency and well-being outcomes. IOC aims to decentralize the provision of direct case management services through a network of Community Umbrella Agencies (CUAs) that demonstrate the capacity to engage families while providing community-based child protective services. Each CUA is required to have a community advisory board, which comprises a diverse group of community representatives who ensure that services are culturally appropriate and responsive. CUAs are charged with making local solutions and resources readily accessible to families, including formal and informal neighborhood networks as well as foster and adoptive homes. A critical component of this charge includes a requirement for the CUAs to develop culturally appropriate foster parent recruitment and retention strategies that lead to more children and youth being safely maintained in permanent homes within their communities of origin. Once IOC is fully implemented, Philadelphia will have ten CUAs, each geographically assigned based on police districts.
Performance-based contracts with the CUAs are designed to promote greater adherence to compliance standards as well as incentivize positive outcomes consistent with the Federal Child and Family Service Review (CFSR) emphasis on safety, permanency and well-being. The following goals have been created with measurable outcomes to assess the efficacy of this initiative:
- more children and youth maintained safely in their own homes and communities;
- increased timely reunification or other permanence;
- reduced usage of congregate care;
- improved child, youth, and family functioning.
With the support of Casey Family Programs and encouragement from DHS’s Community Oversight Board, planning for IOC began in 2008 with a series of visits to New York and Florida, jurisdictions already involved in the same type of initiative. DHS convened a steering committee comprising a wide array of city stakeholders to guide the initiative in designing and implementing a streamlined service delivery system.
The Issue: From Theory to Practice
During the extensive planning period, DHS engaged in the difficult task of facilitating change within the culture of the agency itself and among the supporting provider agencies. Large-scale innovations such as IOC require agencies to let go of old practices and engage in new ones, a process that has well-acknowledged challenges. A meta-analysis (Damanpour, 1991) of the relationships between organizational innovation and potential determinants yielded statistically significant associations for managerial attitude toward change, administrative intensity and external and internal communication. Rycroft-Malone et al. (2002), citing a Ward and McCormack (2000) study, maintain that existing organizational culture significantly impacts the ability to innovate. And Nanda (1996) asserts that organizational change can be induced only by “actively managing the change process, as by shuffling parts of the work force and nominating change agents from among the workers.”
These findings were taken to heart by DHS as they began to meet regularly with internal and external staff to enlist their help and keep them apprised of the process. Streamlining service delivery required a reorganization of staff positions and responsibilities, which in turn required collaboration with human resources, relevant unions and city solicitors. DHS committed to “no layoffs” of current staff, so realignment became crucial. Rethinking resource allocation required teamwork internally with its finance division and externally with financial consultants from Philadelphia’s PFM Group. Finally, DHS relied on the Annie E. Casey Foundation’s well-articulated theory of change, as well as the Casey Family Programs analysis of similar initiatives in Kansas and Florida. Findings emphasized the need to:
- use a phased-in transition with a clear and articulate plan;
- develop a strong public-private partnership;
- engage all stakeholders;
- commit to the change wholeheartedly.
Two issues remain particularly challenging as IOC unfolds: 1) running a dual system as cases gradually transfer to the CUAs and 2) identifying resource families, particularly for teens.
The Solution: Clarity, Transparency and Community Engagement
Within IOC, a clear delineation of case management services provided by the CUAs is aligned with DHS staff who facilitate family team conferences (FTC) to support family engagement and participation in case planning. Philadelphia’s FTC process is an enhanced version of the Annie E. Casey Foundation’s Team Decision Making (TDM) model, which Philadelphia innovatively expanded to include in-home cases in addition to placement cases. As Wildfire et al. (2010) note, TDM has been implemented in 60 sites across 17 states. TDM requires that meetings be held for all decisions involving child removal, change of placement and reunification or other permanency plans.
Philadelphia’s TDM/FTC meetings include youth, their immediate and extended family or other support persons, foster parents (as appropriate), service providers, community representatives and child welfare professionals. The meeting and resultant plan are designed to be family driven, and all participants are treated with dignity and respect. The goal is to foster open communication and sharing of information so that a plan is developed in a way that protects children and preserves families.
All families assigned to a CUA participate in the FTC process, and four types of teaming conferences have been designed for specific purposes and at key intervals:
- A child safety conference occurs at the onset of each case to ensure that identified safety threats are mitigated in a way that best maintains family and community connections for children and youth.
- Family support conferences (for in-home cases) and permanency conferences (for 2 placement cases) occur within 20 days of the child safety conference and every three months thereafter.
- Placement stability conferences occur when a child or youth experiences or anticipates a change in placement.
Data from April through September (Table 1) indicate that a total of 336 conferences have been completed, the majority of which were Family support conferences. This total includes cases that were transferred to the first two CUAs as well as cases that are still being case-managed by DHS. Of these cases, 167 have had only one conference and 75 have had more than one conference.
Built into the FTC model are DHS teaming coordinators, whose roles are to expand the presence of families’ informal supports and kinship resources through extensive search activities. To accomplish this task, they turn to the Family Findings Program, a recognized promising practice (Children’s Defense Fund, 2010) for reaching family members and other adults who are willing to care for youth in foster care who lack permanency. The goal of family finding is to locate long-term, caring, permanent connections and relationships for these youth. The teaming coordinators also serve as the people responsible for scheduling the family team conferences at times and places in the community that are most convenient for all stakeholders, especially the families. DHS practice specialists facilitate the meeting to ensure that all participants are provided with an active role and voice in the process, with the group striving for consensus. The specialists are a supervisory level position, which empowers them as authoritative figures at the meetings.
The development and use of a single case plan (SCP) is also a primary component of IOC and serves as one unifying plan for families receiving services through DHS. The SCP is developed as part of the FTC process and as such is family driven in collaboration with all stakeholders, with an emphasis on concurrent planning. In terms of quality control, the IOC implementation team—chaired by Brian Clapier, chief implementation officer and deputy commissioner of performance management and accountability—meets with the CUAs weekly to identify adjustments that need to be made to the practice model and policy guidelines are revised quarterly. DHS Director of Policy and Planning Paul Bottalla expects to issue the final policy and procedures manual for IOC by 2015.
Commissioner Anne Marie Ambrose and her executive staff worked tirelessly during the planning and design phases of IOC to ensure that the DHS community, the provider community and the neighborhood communities were actively engaged in IOC through focus groups, town hall meetings, public presentations and various information dissemination outlets. They continue to work toward that end by holding regular all-staff meetings to keep everyone apprised of progress with IOC implementation.
Externally, DHS community liaisons work to engage all community members in the IOC effort using the Strengthening Families program (SFP), a nationally recognized family skills program found to significantly decrease problem behaviors in both parents and children. The program is included in the National Registry of Evidence-Based Programs and Practices (SAMSHA) and is designed to enhance five protective factors:
- Resilience: parental resilience
- Relationships: social connections
- Knowledge: parenting and child development
- Support: concrete support in times of need
- Communication: social and emotional competence of children
CUAs have been empowered to hire community liaisons and Strengthening Families liaisons to be “bellringers” for the use of the framework in their daily case management activities. These liaisons, as well as CUA caseworkers and supervisors, receive training on the use of the program through DHS University (DHSU), the on-the-job training unit of DHS’ Administration and Management Division. DHS’s Achieving Reunification/Achieving Independence Center also provides dedicated training on maintaining program fidelity, using a train-the-trainer model.
One of the chief mechanisms used to implement SFP is the Parent Café, a vehicle for parents to have their own conversations about keeping their families strong. These structured small-group conversations are intimate enough to “create a level of candor that might not be achieved in a standard focus group” and parents trained as café hosts gain a new level of expertise that can be used in other leadership roles (Center for the Study of Social Policy). Meetings are held at different locations within each CUA area and are one of the most popular initiatives to come out of IOC. As Yvette Yates, IOC supervisor says, “innovation begets innovation,” and Parent Café peer-to-peer interactions are on the cutting edge of community empowerment.
The Innovation: The Difference Is in the Details
Chris Behan from Annie E. Casey notes that the difference between Philadelphia and other jurisdictions that have implemented a similar change is the community-based focus of IOC. Whereas Kansas and Florida have state initiatives that work with only a few large agencies to deliver case management and other services, Philadelphia remains focused on service delivery in the neighborhood. At the heart of the change is the geographic assignment of cases to each CUA based on police district, and each of Philadelphia’s 22 police districts has been assigned to one of the ten CUAs. Within the IOC model, DHS retains the responsibility for investigating all CPS reports, and DHS’s investigation sections are also assigned to the CUA geographic regions. This process aims to strengthen DHS’s relationships with families and community supports in specific areas of the city as well as develop relationships with identified CUAs.
CUAs are contracted through a rigorous and transparent RFP process. To date, five CUAs have been selected and five more will be selected by the end of the year (Table 2).
Asociación Puertorriqueños en Marcha (APM) is a nonprofit agency formed in 1970 for the purpose of promoting the welfare of Puerto Rican/Latino residents in Philadelphia. APM works directly with the community to convene and directly consult with community residents and provider networks, stakeholders, business owners and investors to create a long-term strategy for neighborhood change and improvement.
Northeast Treatment Center (NET), founded in 1970, provides a comprehensive recovery and resilience-oriented system of behavioral health and social services utilizing a quality-driven, cost-effective provider network. They are committed to keeping children and youth in community settings, preferably their own community, and have only pursued program development opportunities consistent with this vision.
Of particular note is the award to the fifth agency, Turning Points for Children (TPFC), because they represent an innovative response to the demands of IOC. TPFC has long supported Philadelphia families but recognized that to meet the service needs in a geographic CUA area, additional infrastructure support was essential. In February of this year, TPFC became an affiliate of Public Health Management Corporation, combining rich programming in child welfare with the fiscal control and management capabilities of a rigorous corporate structure. Clapier sees “partnerships like this as a way for smaller agencies to remain viable and stay community based” while also bringing economies of scale to the enterprise.
Over the last 20 years, Catholic Social Services (CSS) has created numerous programs, including: Del La Salle Aftercare (now known as Reintegration Services), the Mitchell Hall Program (farm-based residential program), Brother Rousseau Academy (day treatment for preadolescents) and DelStar (outpatient sex offense specific treatment program). Quality service provision is ensured via CSS’s continuous quality improvement process, which monitors both quantitative and qualitative measures throughout the case life cycle.
Wordsworth’s mission is to provide education, behavioral health and child welfare services to children and youth who are experiencing emotional, behavioral and academic challenges. The agency has prioritized the development and expansion of community-based programs that engage children, youth and families in their own homes and is committed to the belief that services are most effective, in both the short and long term, when they actively engage and collaborate with all systems that impact the child and family.
By November of this year, approximately 400 cases covering the spectrum of child welfare services from in-home through congregate care will have been turned over to APM and NET. Case transfers will begin for Turning Points and Catholic Social Services in January 2014 and for Wordsworth in July 2014.
As mentioned previously, challenges remain in terms of managing a dual system for the next year and recruiting resource families for teens. Vanessa Garrett Harley, DHS Deputy Commissioner of the Children and Youth Division, and Kimberly Ali, Operations Director, have taken steps to mitigate the pressure of the dual system by hiring internally when necessary and transitioning to appropriate roles within the new IOC structure. DHS Communications Director Alicia Taylor has done an exemplary job of keeping staff informed through a series of “Did You Know?” posters that update staff and alert them to upcoming job transition opportunities. In fact, a call for poster ideas led to a staff-designed IOC poster that succinctly illustrates IOC in a nutshell.
To meet the IOC goal of congregate care reduction, it is essential that youth currently in care achieve timely permanence and that appropriate resource families be identified before children reach adolescence. Our Congregate Care Initiative is designed to do just that through ongoing case file review and expedited decision making by Commissioner Ambrose. DHS also hired a congregate care integrity officer with a legal background to facilitate the reduction effort. In addition, CUA staff are currently being assisted in their foster family recruitment efforts by the Annie E. Casey Foundation’s Child Welfare Strategy Group. According to Jessica Shapiro, the Commissioner’s chief of staff, it truly does “take a village” to prevent youth from aging out of the system without permanent supports.
DHS continues to find avenues to increase its impact on the community through the use of strategic engagement strategies and programs based on the best available evidence. In September 2012, Pennsylvania was among ten states selected to participate in the five-year waiver demonstration project, which will occur from July 2013 to June 2018, and Philadelphia is one of the five counties involved in the project. The waiver grants states the flexible allocation of federal funding in order to promote evidence-informed and evidence-based innovative child welfare practices. The CUAs are charged with indicating the evidence-based programs they intend to implement by February of next year, which will allow these agencies to become mini-innovation centers with the capacity to make a significant social impact on their communities.
The United Nations Award
Due to our work on such innovative initiatives as IOC, Philadelphia’s DHS recently received the 2013 United Nations Public Service Award, second place, for improving the delivery of public services in the European and North American region. Philadelphia is the only United States city and the only place in North America to win a United Nations Public Service Award in any of the categories this year. The UN Public Service Award rewards the creative achievements and contributions of public service institutions that lead to a more effective and responsive public administration in countries worldwide. Through an annual competition, the awards program promotes the role, professionalism and visibility of public service and public service solutions. On June 24 of this year, Commissioner Ambrose accepted the award on behalf of DHS. She credits the award to the “dedication, diligence and determination” of her staff. We hope that funds from this grant will allow us to further improve the safety, permanence and well-being of our families and children.