Perf Based Contracting Mary Armstrong Sept09 by C48y311X


									Lessons Learned from
Other System Reforms

Mary I. Armstrong
  Associate Director, Division of State and Local Support
  University of South Florida
Key Topics

• Florida’s Child Welfare Reform – Community-
  Based Care
  – Key elements
  – Lessons learned
• The science of implementation
Evolution of Community-Based Care

• 1996 – Florida State Legislature mandates the
  privatization of child welfare
• 1997 – Initiation of pilots in 4 counties
• 1999 – Legislature amends earlier legislation to
  reflect the goals of ASFA; mandates statewide
• 1997-2005 – Staggered implementation by
  geographic areas
• 2005 – Statewide implementation of Community-
  Based Care

Community-Based Care               VS.    Privatization
• Building a better organized, more       • Focus on contracts for specific
  effective system of care                  services
• Resource base extends beyond            • Resources are limited by
  traditional government appropriations     appropriation
• Community driven process:               • Top down management
  planning, continuous improvement
                                          • Advocacy base not organized or
• Advocacy base better organized and        empowered
Comparison (cont.)

Community-Based Care              VS.   Privatization
• Total system reform                   • Outsourcing for specific services
• Enhance community ownership           • Contractor retains authority and
  through local boards of directors       power
• New shared risk management            • Risk avoidance
• Performance-based contracting
Responsibilities of the State Agency

• Quality assurance / regulatory compliance
• Maintain Child Abuse Hotline
• Maintain Statewide Information System
• Ensure that child protective investigations
  occur as required
• Lead agency contract management
• Manage limited financial risk pool
Responsibilities of the Lead Agencies

• Coordinate, integrate, and manage all child
  protective services in the community while
  cooperating with Child Protective Investigations
• Ensure continuity of care from entry to exit for all
  children referred
• Provide all child welfare services directly or
  through contracts with a network of providers
• Accept accountability for achieving the federal
  and state outcome and performance standards
  for child protective services
Lead Agency Responsibilities (cont.)

• Maintain and report required client and
  performance data
• Ensure that staff providing child welfare
  services receive the training required by the
  Department of Children and Families
• Assume and manage financial risk based on
  a capped budget
Lead Agency Responsibilities (cont.)

•   Adoptive home placement &            •   Foster care licensing, certification,
    adoption services                        recruiting & training
•   Foster care and therapeutic foster   •   Family preservation
    care support & placement             •   Family Builders
•   Kinship foster care                  •   Secondary prevention
•   Independent living support           •   Primary prevention
•   Shelter care placement               •   Case management
Child Protection Investigations

• As of 2009, there are 7 counties (including cities
  of Tampa, Fort Lauderdale, St. Petersburg)
  where the Sheriff’s Office is responsible for
• The Department conducts investigations in the
  remaining 60 counties
• Santa Rosa County is set to transition to the
  Sheriff’s Office in the near future
Conceptual Model
Contextual Issues – 2002
• CBC implementation complicated by other system
  changes and reforms, both within child welfare and
  in mental health (managed care), substance abuse,
  and domestic violence
• The early CBC sites were in reality demonstration
  programs with few models of privatization in the
  country to look to
• While important to DCF, the early CBC sites
  represented only a small portion of the Department’s
  overall operations and did not always receive the
  attention needed
Disposition of the Implementers
• Leadership – There needs to be a shared
  commitment on the part of leadership at all levels
  including a shared belief that they had done as
  much as possible to facilitate the process within their
  operational constraints
• A perception that some of the other systems such as
  mental health and substance abuse were not as
  committed to CBC concept and not willing to
  collaborate to the degree necessary
Complexities of Joint Action

• A growing realization that participation in CBC
  required a new way of doing business. All parties
  must be willing to make fundamental shifts.
• Some concern that lower level DCF staff not as
  responsive to CBC concerns because of
  commitments to ongoing operations
• Need to examine governance structure – clear
  delineation of lines of authority, roles and
  responsibilities, communication patterns among
  central office, regions, and CBCs
Early Implementation Issues

• Major issues that need to be resolved during early
   – The nature of the relationship between DCF and the lead
     agency and its provider network
      » Are the lead agencies simply extensions of DCF or are they equal
        business partners?
   – The role of the Department regional offices
      » Clarification around their authority to negotiate contracts and
        agreements and make decisions was seen as especially important.
Early Implementation

• Use technical assistance teams to support communities
  and Regional Offices in their development of supervising
   – Use the teams to assess the readiness of both the Department
     and the supervising agency applicant. A lack of readiness on
     either side will be problematic over time.
• Use of WA’s child welfare information system
   – Supervising agencies need direct access and the system needs
     the capacity to produce timely and useful reports on supervising
     agency performance
Early Implementation

• Rilya Wilson (Missing Child)
  Expect a crisis to occur. When it does, consider
   whether it is appropriate or beneficial to apply
   uniform mandates statewide. Lead agencies
   should be allowed to provide evidence that they
   have practiced due diligence and be able to
   negotiate any additional actions that have been
   mandated in response to the crisis. If new tasks
   are required of lead agencies, additional
   resources should be allocated.
Early Implementation

• Encourage and support flexibility in how community
  stakeholders structure their supervising agencies at the
  two pilot sites.
   – The fit between the design of the supervisory agency, local
     resources and context (rural vs. urban, existing provider
     network, socio-demographic characteristics) is a crucial
     factor in their success.
• Encourage CBC organizational arrangements with a
  distribution and balance of control and accountability for
  budget management, review of performance indicators,
  and continuous quality improvement processes.
Contracting Issues

• Ability to carry over unused dollars into subsequent
  contract years
   – Thus encouraging efficiency rather than rewarding the capacity
     to spend all monies annually allocated to lead agencies
• Alignment of outcomes
   – Federal, state, contractual
• Careful selection of outcome indicators so that they
  relate to positive outcomes and quality
   – e.g. - placement stability, number of placements per child,
     caseload size, turnover rates
• Inclusion of a clause regarding fiscal incentives and
  penalties related to CBC performance
Fiscal Design Issues

• Appropriate levels of funding
   – Determine an equitable allocation methodology
• Historical inequities in distribution of funding resources
   – Decide whether a redistribution of resources is necessary
• Risk sharing arrangements
   – Risk needs to be managed and shared between the Department
     and the supervising agency
• Administrative costs of supervising agencies and their
  provider networks
   – Reach agreement on an appropriate level/range of
     administrative costs
Program Design Issues

• Pay attention to the boundaries
   – In Florida, it was the relationship between lead agencies and
     Child Protective Investigations. Here, it is the relationship
     between the supervising agency and the case manager
• Evidence that lead agencies need additional support and
  technical assistance during the mid-implementation
  phase (7-17 months)
   – Tendency to lose start-up moment and community support as
     they are solidifying organizational infrastructure
• Composition of CBC Board of Directors
   – Need to decide the appropriate mix of providers and community
Program Design Issues (cont.)

• The program monitoring and auditing process
   – Avoid numerous and duplicative The number of audits and
     program monitoring functions.
• Clarify the quality assurance function
   – Including who does what, the role of accreditation in the quality
     assurance and the audit process need to be clarified.
• The management information system, data collection
  and reporting processes
   – How can the lead agency and state MIS systems, federal
     reporting requirements be integrated to minimize duplication and
     enhance useful information to each of the major stakeholders?
Practice Level Issues

• Organizational culture and the behavior of line staff
• Importance of the supervisory role
• Staff recruitment and retention
• Support for the introduction of evidence-based practices
• Need for a quality assurance process that examines
  practice on a regular basis
• Prioritize skill development and competency training at
  the supervisory and case manager levels in evidence-
  based practices (e.g. family group conferencing,
  individualized care, and strengths based approaches)
Implementation Science & Systems
• Multi-dimensional, fully integrated
  – Implementation drivers
  – Implementation stages
  – Implementation teams: Core group of individuals
    who are representative of the stakeholders and
    systems and who are changed with guiding the
    implementation from exploration to full
  – Improvement cycles

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