Child Welfare: Opportunities to Further Enhance Family Preservation and
Support Activities (Letter Report, 06/15/95, GAO/HEHS-95-112).
Pursuant to a congressional request, GAO reviewed federal and state
efforts to implement the family preservation and support (FPS)
provisions of the Omnibus Budget Reconciliation Act of 1993.
GAO found that: (1) although reliance on foster care decreased in the
early 1980s, the incidence of poverty, substance abuse, and child abuse
and neglect began to rise by the mid-1980s; (2) states focused on
services designed to prevent or remedy family crises that might result
in foster care placement, but their efforts were often constrained by
funding limitations and fragmented service delivery systems; (3) states
have appropriately focused on understanding the law and federal
guidelines, applying for funds, and initiating a comprehensive process
to implement FPS provisions; (4) the Department of Health and Human
Services has provided ongoing assistance to the states in implementing
FPS provisions; and (5) states anticipate difficulties in developing
various aspects of their implementation plans, such as goal setting and
funding decisions, and performing their own comprehensive program
evaluations.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-95-112
TITLE: Child Welfare: Opportunities to Further Enhance Family
Preservation and Support Activities
DATE: 06/15/95
SUBJECT: Foster children
Child abuse
Block grants
Child care programs
Families
State-administered programs
Child custody
Federal/state relations
Welfare services
IDENTIFIER: HHS Abandoned Infants Assistance Program
APWA Voluntary Cooperative Information System
Child Welfare Services Program
Social Services Block Grant
HHS Adoption Opportunities Program
Medicaid Program
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Cover
================================================================ COVER
Report to Congressional Requesters
June 1995
CHILD WELFARE - OPPORTUNITIES TO
FURTHER ENHANCE FAMILY
PRESERVATION AND SUPPORT
ACTIVITIES
GAO/HEHS-95-112
Family Preservation and Support
Abbreviations
=============================================================== ABBREV
ACF - Administration for Children and Families
ASPE - Assistant Secretary for Planning and Evaluation
FPS - Family preservation and support
HHS - U.S. Department of Health and Human Services
OBRA1993 - Omnibus Budget Reconciliation Act of 1993
Letter
=============================================================== LETTER
B-257596
June 15, 1995
The Honorable E. Clay Shaw, Jr.
Chairman
The Honorable Harold E. Ford
Ranking Minority Member
Subcommittee on Human Resources
Committee on Ways and Means
House of Representatives
The Honorable Rick Santorum
United States Senate
In the past 20 years, social, cultural, and economic changes--such as
increases in substance abuse, community violence, and poverty--have
increased the severity of families' problems and the number of
families coming to the attention of American child welfare agencies.
From 1976 to 1992, the rates of child abuse and neglect increased
fourfold. And from 1988 to 1993, the number of foster children
increased almost one-third, to nearly 450,000. States have struggled
to keep up with the increased demand for child welfare services, but
worsening state fiscal difficulties have further strained the child
welfare system's ability to serve vulnerable children and their
families.\1
To enable states to provide services designed to support families and
help keep them together, the Congress enacted legislation as part of
the Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) (P.L.
103-66) that authorized new funding for family preservation and
family support services. More recently, the Congress has considered
several proposals that would incorporate these funds, along with
various other child welfare programs, into a block grant program for
states.
This report responds to a request from the Subcommittee on Human
Resources of the House Committee on Ways and Means that we monitor
the implementation of the family preservation and support (FPS)
provisions of OBRA 1993. The report (1) describes the condition of
child welfare in America that precipitated OBRA 1993, (2) assesses
federal and state efforts to implement its provisions, and (3)
highlights areas in which these efforts could be enhanced.
To develop information about the state of child welfare before 1993,
we reviewed our past work and related congressional documents. To
assess federal and state implementation efforts and suggest areas
where improvements could be made, we conducted two nationwide
surveys, one of state child welfare agencies\2 and another of 509 FPS
program administrators; interviewed Department of Health and Human
Services (HHS) officials in its headquarters and 10 regional offices;
and interviewed representatives of organizations involved in
assisting states with implementing the new law, such as national
associations, child advocacy groups, national resource centers, and
foundations.
--------------------
\1 While many public, private, and nonprofit entities provide a range
of services to families in need, the primary governmental
responsibility for child and family services rests with the states.
Each state has its own legal and administrative structures and
programs that address the needs of children and families.
Traditionally, the child welfare system encompasses services
available to all children, including the disabled, homeless, abused
and neglected, and dependent.
\2 State child welfare agencies are responsible for administering
Title IV-B of the Social Security Act in each of the 50 states and
the District of Columbia. Examples of child welfare services include
child protection, care of the homeless and neglected, child social
and nutritional development, and out-of-home care.
RESULTS IN BRIEF
------------------------------------------------------------ Letter :1
Reliance on foster care decreased in the early years following
enactment of the Adoption Assistance and Child Welfare Act of 1980.
However, by the mid-1980s, the incidence of poverty, substance abuse,
and child abuse and neglect began to rise. Greater and greater
demands were being made on a service-delivery system ill-equipped to
handle the flow of troubled children and families coming to its
attention. Although states attempted to stem this tide by focusing
on services designed to prevent or remedy family crises that might
result in foster care placement, their efforts were often constrained
by funding limitations and fragmented service-delivery systems.
Early state implementation of the FPS provisions of OBRA 1993 has
appropriately focused on understanding the law and federal
guidelines, applying for funds, and initiating a comprehensive
process designed to culminate in a long-range plan. HHS' involvement
with the states has been one of partnership through ongoing
consultation and assistance.
While activities implementing the new law appear to be on target,
opportunities exist to further enhance state efforts to develop a
viable plan and monitor results. In particular, states anticipate
difficulties in (1) developing various aspects of their 5-year plans,
such as identifying useful and appropriate baseline information to
use in setting goals, making funding and service decisions, and
tracking results, and (2) performing their own comprehensive program
evaluations, which could help ensure that children and families'
needs continue to be met and determine if intended results are
achieved. Whether child welfare programs continue to exist under the
FPS program or as a block grant, states having the ability to set
outcome-based goals and to effectively measure progress towards
achieving these goals is important in ensuring adequate support for
our nation's vulnerable children and families.
BACKGROUND
------------------------------------------------------------ Letter :2
The FPS provisions of OBRA 1993 are administered by HHS'
Administration for Children and Families (ACF). OBRA 1993 authorized
$930 million in funding to states over a 5-year period to initiate or
expand family preservation services and community-based family
support services. The Congress appropriated $60 million for fiscal
year 1994, of which $2 million was reserved for federal evaluation,
research, training, and technical assistance, and $600,000 was
earmarked for grants to Indian tribes. The balance was available for
grants to states to fund family preservation and support services.
State grant amounts are to be based on each state's percentage of
children receiving Food Stamps, a food subsidy program for low-income
households. States may use up to $1 million of their grant amount
for planning purposes during the first year, with no required state
match. States must match the funds used for FPS services.\3
FPS funding under OBRA 1993 is limited compared with that of many
other federal programs. There is consensus among child welfare
experts and practitioners that these new dollars can best be used
strategically and creatively to stimulate the broader system reform
that is already underway in many states and communities. For
example, about one-half of the states had initiated a children's
agenda or comprehensive strategy to coordinate and integrate services
for children and families before OBRA 1993 was enacted. In addition
to funding new or expanded FPS services, the law enables each state
to use FPS funds during the first year to broadly review current
strategies for meeting the service needs of children and their
families. The planning period is viewed as especially critical
because the legislation provides a new focus on family-centered
services and community linkages that may require a change in the way
that child welfare services within each state are designed and
delivered.
--------------------
\3 Each state may receive federal matching grants for up to 75
percent of the costs to provide FPS services or an amount equal to
the state's grant amount, whichever is less. Other federal funds may
not be used for the state's match.
FAMILY PRESERVATION AND
SUPPORT SERVICES
---------------------------------------------------------- Letter :2.1
Family preservation and family support services emphasize safety; a
focus on the family; and a service-delivery approach that is
flexible, accessible, coordinated, and culturally relevant. The
distinction between these two types of services is sometimes unclear
because many service-delivery models or programs are available and
services may overlap. Family preservation services typically target
families in crisis whose members have experienced child abuse or
neglect. Family support services, while primarily available to the
general population, are often aimed at at-risk populations--those
identified as being in increased danger of becoming abusive, such as
families headed by single mothers or low-income families.
FAMILY PRESERVATION
SERVICES
-------------------------------------------------------- Letter :2.1.1
Family preservation services are typically designed to help families
alleviate crises that, left unaddressed, might lead to the
out-of-home placement of children. Although more commonly used to
prevent the need to remove children from their homes, family
preservation services may also be a means to reunite children in
foster care with their families. The goals of such services are to
maintain the safety of children in their own homes, when appropriate,
and to assist families in obtaining services and other support
necessary to address the families' needs. Examples of family
preservation services include crisis-related services to prevent the
need for out-of-home placement, respite care for parents and other
caregivers, services to improve parenting skills and support child
development, and follow-up services to support adoptive and reunited
families.
FAMILY SUPPORT SERVICES
-------------------------------------------------------- Letter :2.1.2
Family support services are primarily community-based activities
designed to promote the well-being of vulnerable children and their
families. The goals of family support services are to increase the
strength and stability of families, increase parents' confidence and
competence in their parenting abilities, afford children a stable and
supportive family environment, and otherwise enhance child
development. Examples of such services include respite care for
parents and caregivers; early developmental screening of children;
mentoring, tutoring, and health education for youth; and a range of
home-visiting programs and center-based activities, such as drop-in
centers and parent support groups.
During the 104th Congress, legislators have considered several block
grant proposals to replace various child welfare programs, including
the FPS program authorized under OBRA 1993. The largest of these
programs are Title IV-B (Child Welfare Services and FPS) and Title
IV-E (Foster Care and Adoption Assistance). Other categorical
programs that could be incorporated into a block grant include the
Abandoned Infants Assistance Act, Adoption Opportunities program,
Child Abuse Prevention and Treatment Act, Family Violence Prevention
and Treatment Act, and Temporary Child Care for Children with
Disabilities and Crisis Nurseries Act.
In general, block grants are a form of federal aid authorized for a
wider range of activities than categorical programs, which are
usually more specific in scope. Grantees are given greater
flexibility to use funds on the basis of their own priorities and to
design programs and allocate resources as they deem appropriate,
although funding levels are usually lower. Administrative, planning,
fiscal, and other types of reporting requirements are kept to the
minimum amount necessary to ensure that national goals are being
accomplished.
BEFORE OBRA 1993 CHILD WELFARE
WAS IN CRISIS
------------------------------------------------------------ Letter :3
In 1980, the Congress enacted the Adoption Assistance and Child
Welfare Act (P.L. 96-272) to combat the problems of increasing
numbers of children entering and remaining in foster care for long
periods of time. The primary goals of this act were to prevent the
unnecessary separation of children from their families, improve the
quality of care and services to vulnerable children and their
families, and ensure that children did not languish in foster care.
The 1980 law appeared to have achieved its intended effect as the
number of children in foster care decreased in the first few years
after its passage. By the mid-1980s, however, the foster care
population had begun to swell again. From 1988 to 1993, the number
of children in foster care rose 32 percent--from 340,000 to
449,000--according to the American Public Welfare Association's
Voluntary Cooperative Information System. This new growth in foster
care was fueled in part by an increasing number of child abuse and
neglect cases. According to the American Humane Association, reports
of child abuse and neglect quadrupled from 670,000 in 1976 to 2.9
million in 1992; an estimated 40 percent of these reports were
substantiated. Child welfare experts also attribute the rise in the
foster care population to such trends as the increasing use of
illegal drugs, especially among young mothers in inner-city areas;
rising numbers of homeless families; and growing numbers of children
and families living in poverty.
States faced substantial challenges in containing burgeoning foster
care costs while meeting the needs of the most troubled children and
families under these difficult conditions. Increasingly, these
families had multiple problems that required the intervention of two
or more service-delivery systems, such as child welfare, mental
health, employment, housing, child care, and drug treatment.
Families in these situations were expected to navigate among the
various service-delivery systems in order to arrange the "package of
services" that they needed. Ironically, negotiating these systems
required the greatest effort and sophistication from precisely those
families least capable of responding to this challenge. Furthermore,
services were often more focused on managing crises--such as
investigating allegations of abuse and neglect and removing children
from their families--and less focused on prevention and treatment.
Intent on improving services for children and their families as well
as reducing foster care placements and expenditures, states began to
reconsider their crisis-intervention approach to child welfare; that
is, they began to focus more on prevention and treatment and on
providing services that addressed the causes of family dysfunction
before removing children from their homes became necessary. These
services became known as family preservation and family support
services.
Originally, states funded these services themselves or with
nonfederal funds, but fiscal pressures led them to seek additional
funding from federal sources. Funds for FPS services were available
from two programs authorized by the Social Security Act--Title IV-B
Child Welfare Services and Title XX Social Services Block Grant--but
funding levels were capped and insufficient to keep pace with
increasing demand for services. So some states made greater use of
uncapped entitlement programs, including Titles IV-A Emergency
Assistance, XIX Medicaid, and IV-E administration.\4
Despite the new focus on prevention, child welfare agencies became
increasingly constrained by insufficient resources, high caseloads,
and overburdened workers. By the time we surveyed FPS programs in
1994, more than one-half said that they were unable to serve all the
eligible families that requested their services. The child welfare
system had become unable to fully realize the goals of the 1980 law.
--------------------
\4 Foster Care: Services to Prevent Out-of-Home Placements Are
Limited by Funding Barriers (GAO/HRD-93-76, June 29, 1993).
OBRA 1993 IMPLEMENTATION IS ON
TARGET
------------------------------------------------------------ Letter :4
During the first 18 months after OBRA 1993 was enacted, state
implementation activities proceeded according to schedule. All
states obtained funding for the first year and began extensive
planning efforts. Moreover, during that time, HHS worked
collaboratively with the states to help them implement the new law.
HHS' contributions to implementation of OBRA 1993 included working
closely with the states to educate and support them in their
implementation and planning efforts and arranging for evaluation of
state efforts.
STATES' IMPLEMENTATION
ACTIVITIES
---------------------------------------------------------- Letter :4.1
Within the first year after enactment of OBRA 1993's FPS provisions,
all states applied for and received first-year funding. They also
initiated planning processes that included conducting needs
assessments; including a diverse group of involved individuals and
groups\5 in plan development; and coordinating with other service
systems--such as public health and mental health. According to HHS
officials, states' planning efforts progressed at a pace that
generally reflected previous or existing state efforts to provide FPS
services, reform child welfare service delivery, or both. HHS said
that it expects all states to meet the June 30, 1995, due date for
their 5-year plans. (See app. II for summary baseline information
about previous state efforts at providing FPS services and reforming
child welfare service delivery.)
During fiscal year 1994, states planned to use $55.5 million in OBRA
1993 grant funds to develop their 5-year plans and provide FPS
services, as shown in table 1. In the 22 states that slated
first-year funds for services, 47 percent of the service dollars were
allocated for family preservation services and 53 percent for family
support services.\6
Table 1
Allocations for Fiscal Year 1994 Grant
Funds, by Purpose
Dollar amount Percent of total
Purpose (in millions) dollars
------------------ ------------------ ------------------
Services $26.1 47
Planning 23.2 42
Training and 4.0 7
technical
assistance
Administration 1.5 3
Other 0.7 1
==========================================================
Total $55.5 100
----------------------------------------------------------
Source: HHS analysis of state applications.
Furthermore, 25 states planned to contribute additional
resources--over and above their federal allotment and existing
funding levels--for planning and FPS service provision. Eleven of
these states planned to add resources for both planning activities
and providing FPS services; 12 states, only for FPS services; and 2
states, only for planning purposes.
--------------------
\5 People and groups involved in child and family service delivery
include representatives from public--federal, state, and local--and
nonprofit agencies and community-based organizations with experience
in administering programs of services for children and families,
including FPS services, special interest and minority groups,
parents, and other care providers.
\6 More details about states' use of funding are available in HHS'
Draft Preliminary Report: Analysis and Synthesis of First-Year Grant
Applications, Family Preservation and Family Support Services
Implementation Study (Washington, D.C.: 1995).
HHS' IMPLEMENTATION
CONTRIBUTIONS
---------------------------------------------------------- Letter :4.2
Overall, the federal approach to implementing the new law during its
first 18 months was one of open, active collaboration and
coordination with the concerned individuals and groups. To assist in
crafting guidelines and regulations, HHS consulted and held focus
groups with experts in FPS and related programs as well as with
public child welfare administrators, national advocacy and
professional organizations, parents, and foster parents. To
familiarize federal and state staff with OBRA 1993's FPS
requirements, HHS sponsored training and technical assistance
conferences and worked directly with state staff as they applied for
first-year funds and initiated the planning process. In addition,
HHS took steps toward improved coordination at the federal level by
exploring and acting on opportunities for collaboration among the
various federal programs that serve vulnerable children and their
families.
HHS also participated in ongoing discussions, consultations, and
negotiations with states to help them develop their 5-year plans.
This process enabled federal staff to monitor state implementation of
the FPS provisions of OBRA 1993 and to identify areas in which
additional training and technical assistance would be useful to the
states. For example, according to HHS officials, states did not
always involve all the concerned groups, particularly community-based
organizations, in the planning process. To ensure that the state
planning process was inclusive, HHS convened monthly conference calls
to discuss this issue with regional staff and continued discussions
with state staff.
Finally, HHS began efforts to fulfill the OBRA 1993 requirement of a
national evaluation of the effectiveness of FPS services. In
September 1994, HHS awarded three 5-year contracts to collectively
assess state implementation and the effectiveness of several FPS
programs. The state implementation study will annually analyze all
state applications and plans. It will also develop in-depth case
studies on the processes being used and the impact of the law's
implementation in 10 states and 20 communities. A second study will
synthesize the family preservation research literature and assess
program effectiveness at six family preservation sites. In addition,
a third study will synthesize the family support literature and
assess program effectiveness at up to 10 family support sites. The
family preservation evaluation, in particular, will use rigorous
methodologies, such as randomly assigned experimental and control
groups. At the time that we prepared this report, these three
evaluations were in the planning and design stage; interim reports
are expected by fall 1997.
OPPORTUNITIES EXIST TO FURTHER
ENHANCE IMPLEMENTATION EFFORTS
------------------------------------------------------------ Letter :5
While implementation of OBRA 1993 has progressed according to
schedule, we identified several areas in which efforts could be
enhanced by additional assistance from HHS. More than one-half of
the states reported that they were experiencing or expected to
experience difficulty in certain areas of implementation. Concerns
include developing information that will enable states to set
meaningful goals and measure results. In addition, states could
benefit from further technical assistance from HHS in evaluating
their programs. HHS is aware of states' concerns and has taken some
general steps to help them address these issues.
STATES UNDERSCORE AREAS IN
WHICH PLANNING IS DIFFICULT
---------------------------------------------------------- Letter :5.1
Twenty-nine states reported that developing baseline and trend
information--which should form the basis for developing their plans,
making sound service and funding decisions, and monitoring
results--will not be easy. States must analyze available information
on the well-being and needs of children and families and on the
adequacy of existing services and then identify trends in these areas
over time. HHS has suggested possible measures or indicators of
child and family well-being and the status of service delivery. But
the states are still responsible, although they are inexperienced at
using indicators, for selecting the most meaningful indicators for
their unique circumstances.
Receiving additional, individualized guidance in developing
appropriate baseline and trend information should help states
overcome several other areas that they cited as problematic. For
example, 27 states reported that making decisions on targeting their
funding will be difficult, given the limited funding provided under
OBRA 1993 and the strong competition among various state, local, and
community entities for service dollars. Once states identify the
vulnerable populations or target areas, they should be able to select
priorities for targeting funding and services.
In addition, states' inexperience or past difficulties in defining
measurable outcomes and indicators of change have fueled their
trepidation about setting outcome-based goals and measuring progress.
Thirty-four states reported that developing outcome-based goals--an
element of the required state plan--will be difficult. Goals must be
based on improved outcomes expected for children and families' safety
and well-being. Further, states' goals must be realistic, specific,
and measurable. Even once they have set goals, 26 states believe
that measuring progress in accomplishing their goals will be
difficult. Again, selecting appropriate indicators to measure
outcomes makes this task challenging.\7
--------------------
\7 See appendix II for additional information about previous state
monitoring efforts.
STATES COULD LEARN FROM
EVALUATING THEIR FPS
SERVICES AS THEY IMPLEMENT
OBRA 1993
---------------------------------------------------------- Letter :5.2
Another method by which states could measure progress and monitor
results would be to evaluate their FPS programs. While OBRA 1993
mandates a national evaluation of FPS services, it makes no such
requirement of the states. Nevertheless, conducting their own
evaluations of FPS services could help states manage their programs
better. For example, evaluations could provide information about the
economic efficiency of states' FPS programs and the impact on the
children and families served, the community, and the service-delivery
system itself. Yet 33 states reported that program evaluations would
be difficult for them to do, and 38 states indicated that HHS has not
provided enough assistance in this area.\8
Further, the methodologies of previous FPS evaluations limited the
ability of evaluators to draw meaningful conclusions about the
long-term effectiveness of FPS services in helping to keep families
together, improving the well-being of vulnerable children and their
families, and reducing foster care placements and costs. Evaluations
employing rigorous methodologies, such as randomly assigned
experimental and control groups, are needed to determine the
effectiveness of FPS services as compared with other service-delivery
strategies. Evaluations are also needed to provide insight into
which methods of intervention work best for which populations of
children and families.\9
The national evaluations of state implementation and the
effectiveness of FPS programs are designed to address these issues.
Although the national evaluations have begun and should continue to
provide useful information about the effectiveness of FPS services,
states may not have sufficient information about how well they have
implemented OBRA 1993 and how effective their programs are. States
could benefit from additional technical assistance to enable them to
conduct their own program evaluations, if they wish to do so.
--------------------
\8 Some states reported that they have evaluated their FPS programs
in the past; however, these results are not yet available. (See app.
II for more information about previous state evaluation efforts.)
\9 See Foster Care: Services to Prevent Out-of-Home Placements Are
Limited by Funding Barriers (GAO/HRD-93-76, June 29, 1993) and Karl
Ensign, "Prevention Services in Child Welfare: An Exploratory Paper
on the Evaluation of Family Preservation and Family Support
Programs," U.S. Department of Health and Human Services, Office of
the Assistant Secretary for Planning and Evaluation (Washington,
D.C.: 1991).
HHS HAS PROVIDED STATES
GENERAL ASSISTANCE IN THESE
AREAS
---------------------------------------------------------- Letter :5.3
According to HHS officials, HHS is aware of the difficulties that
states face and is interested in using our report results to enhance
its efforts to identify states' training and technical assistance
needs. Further, HHS is aware of the varying levels of expertise
among the states in areas related to developing the 5-year plan,
providing FPS services, and reforming child welfare service delivery.
To support the states in dealing with these challenges, HHS awarded a
contract in September 1994 to (1) coordinate efforts among a host of
resource organizations, including public agencies that administer
federal programs for children and families, national resource and
research centers, and national organizations and foundations involved
with FPS; (2) support regional conferences for federal and state
staff; and (3) provide direct assistance to individual states, as
needed. HHS has encouraged states to use these resources and is
committed to continuing to assist states through technical assistance
and joint planning.
While federal involvement would be minimized if child welfare
services were administered through block grant programs, the Congress
and federal agencies likely would maintain an interest in the use and
effectiveness of federal funds. Current federal efforts to assist
states in implementing the FPS provisions of OBRA 1993 would still be
worthwhile and have long-term ramifications. For example, by the
time a block grant went into effect, the states would have already
developed their comprehensive 5-year plans setting quantifiable goals
and methods for measuring outcomes. These plan elements would help
states focus on accountability for results; that is, ensure the
safety and improved well-being of vulnerable children and their
families. As we have previously reported, accountability is critical
to preserving state flexibility and, hence, reducing the likelihood
of increased federal intervention.\10 With continued HHS assistance
now, states could have in place the mechanisms to ensure such
accountability under a block grant environment.
--------------------
\10 Block Grants: Characteristics, Experience, and Lessons Learned
(GAO/HEHS-95-74, Feb. 9, 1995).
AGENCY COMMENTS AND OUR
EVALUATION
------------------------------------------------------------ Letter :6
In its May 15, 1995, comments on our draft report, HHS agreed that
early implementation of the FPS provisions of OBRA 1993 was on target
and attributed this initial success to the partnerships established
between federal and state staff. HHS reemphasized its commitment to
provide technical assistance to states as they develop their plans
and monitor progress; these efforts will also include technical
assistance to those states interested in conducting evaluations. At
HHS' suggestion, we added language in the report to more fully
describe the characteristics of family preservation services (see pp.
4 and 29). HHS also suggested minor technical revisions to the
draft, which we incorporated as appropriate.
HHS expressed concerns that under a block grant arrangement (1)
federal technical assistance efforts would be curtailed if funds were
not appropriated for this purpose and (2) states may not have
sufficient funds to serve the numbers of children and families who
could benefit from FPS services. A copy of HHS' comments is included
in appendix V.
---------------------------------------------------------- Letter :6.1
We are providing copies of this report to the Secretary of Health and
Human Services, state child welfare directors, and state FPS program
administrators. We will also make copies available to other
interested parties upon request. Should you or your staffs have any
questions or wish to discuss the information provided, please call me
at (202) 512-7230. Other GAO contacts and staff acknowledgments are
listed in appendix VI.
Jane L. Ross
Director, Income Security Issues
Page
SCOPE AND METHODOLOGY
=========================================================== Appendix I
To develop information about the condition of child welfare before
the enactment of OBRA 1993, we reviewed our past reports and related
congressional documents.
To obtain information about federal and state implementation efforts,
we interviewed officials from HHS' ACF, which is responsible for the
FPS provisions of OBRA 1993 at the federal level, in HHS'
headquarters and its 10 regional offices. We also reviewed federal
guidelines and proposed regulations\11 related to implementing the
FPS legislation, available literature on existing FPS programs, and
national and regional conference notes and literature related to
training and technical assistance provided to both HHS and state
staff. In addition, we interviewed representatives from several
national organizations involved with assisting states in their
efforts to implement OBRA 1993, including national associations,
child advocacy groups, national resource centers, and foundations.
To determine how states plan to use first-year funds, we reviewed HHS
documents that summarized state grant applications and surveyed the
state child welfare agency in each of the 50 states and the District
of Columbia. We did not verify the accuracy of these data; however,
we did review a sample of grant applications and verified some
amounts.
To obtain information about federal evaluation efforts, we
interviewed officials from HHS' Office of the Assistant Secretary for
Planning and Evaluation (ASPE) and ACF who are responsible for
overseeing the three national evaluation contracts that will
collectively assess state implementation and the effectiveness of FPS
programs. We also attended or reviewed the proceedings from meetings
of the national evaluation advisory panels\12 and reviewed drafts of
interim products that were prepared under the national evaluation
contracts as well as available research literature on the
effectiveness of FPS programs. Information was not readily available
on current state evaluation efforts.
--------------------
\11 Notice of proposed rulemaking pertaining to the implementation of
the FPS provisions of OBRA 1993 was issued in October 1994; final
regulations are expected in June 1995.
\12 Each of the three national evaluations has established an
advisory panel, which is comprised of outside experts on related
issues, to help guide the work of the project.
GAO SURVEY INSTRUMENTS
--------------------------------------------------------- Appendix I:1
We designed two questionnaires to obtain baseline information about
existing state efforts related to child welfare service delivery and
FPS services. We developed separate questionnaires to collect
information about state efforts from the following two perspectives:
(1) the state child welfare agency that is responsible for
implementing the FPS provisions of OBRA 1993 and (2) program
administrators who are responsible for operating or administering
state FPS programs. In some cases, the state child welfare agency
also administered one or more FPS programs and, thus, would have
received both questionnaires.
We discussed development of the two questionnaires with HHS
headquarters staff; several state child welfare agency officials;
staff from the Subcommittee on Human Resources of the House Committee
on Ways and Means; and representatives from such national
organizations as the American Public Welfare Association, Family
Resource Coalition, and National Resource Center for Family-Based
Services. In addition, some of these individuals reviewed drafts of
both questionnaires.
Before mailing the two questionnaires, we conducted two pretests--one
in Georgia and one in Oklahoma--involving the state Title IV-B agency
official responsible for implementing OBRA's FPS provisions (for the
state questionnaire) and the state program administrator from two
different FPS programs (for the program questionnaire). These
officials represented states and programs of different size,
geographic location, and FPS emphasis. Using the pretest results, we
revised the questionnaires to try to ensure that the questions (1)
would be easy for respondents to answer and (2) were relevant, clear,
and free from bias.
We did not verify the information obtained through the
questionnaires. However, we believe that our interviews with federal
and state staff and representatives from other national organizations
as well as our review of the literature reasonably ensure that the
information gathered through our questionnaires fairly represents the
described programs.
STATE QUESTIONNAIRE
REGARDING CHILD WELFARE
SERVICE DELIVERY
------------------------------------------------------- Appendix I:1.1
We surveyed the state child welfare agency in each of the 50 states
and the District of Columbia regarding the delivery of state child
welfare services, the role of FPS services, and monitoring efforts
before enactment of OBRA 1993. The questionnaire also asked about
state implementation of the new law and federal assistance provided.
In late August 1994, we mailed the questionnaire to the 51 child
welfare agencies and received responses from each one.
PROGRAM QUESTIONNAIRE
REGARDING FPS SERVICES
------------------------------------------------------- Appendix I:1.2
We designed a second questionnaire to obtain information about FPS
programs that were under the auspices of a state government; that is,
administered by, operated by, or otherwise affiliated with a state
child-serving agency--and which operated before enactment of OBRA
1993.\13 The questionnaire asked about these FPS programs' history
and administration, specifications, staffing, goals, funding, and
experiences with monitoring and evaluation.
Before mailing this questionnaire, we asked the child welfare
agencies to identify the universe of state-affiliated FPS programs in
their state. We mailed each state a listing of FPS programs that we
were aware of. The state child welfare agencies corrected our list
and added other programs, thus, identifying our universe of 552 state
FPS programs.\14
In late August 1994, we mailed the program questionnaire to the 552
FPS programs. To encourage participation and increase response
rates, we mailed a second copy of the questionnaire to all
nonrespondents in early October and a third copy in early November.
From the 552 questionnaires we mailed, we received 436 responses.
Based on returned questionnaires and telephone contacts from several
respondents, we adjusted our population size to 509 and the number of
valid responses to 393 to exclude 11 programs that did not meet our
selection criteria and 32 programs whose responses were incorporated
with responses from other programs (some agencies operated more than
one FPS program). The 393 valid responses resulted in an overall
response rate of 77 percent.
We conducted our audit work from January 1994 to March 1995 in
accordance with generally accepted government auditing standards.
--------------------
\13 Child-serving agencies outside of the child welfare system
include mental health, juvenile justice, education, and other public
health agencies.
\14 We recognized in March 1994 that states were just beginning the
grant application process and generally had not inventoried FPS
programs within the states. Until states had conducted this
inventory--a requirement for the state plan due in June 1995--the
true universe of state and nonstate FPS programs would be unknown.
BASELINE INFORMATION ON EXISTING
FPS EFFORTS
========================================================== Appendix II
The underlying principles of FPS services--services that are
family-focused, coordinated, flexible, accessible, and culturally
relevant--are not radically new to most states. Before enactment of
OBRA 1993, many state child welfare agencies had begun to change
child welfare service delivery in their respective states and provide
FPS services in ways similar to those promoted under the new law. In
addition, every state had one or more FPS programs operating,
although most FPS services were not available on a statewide basis.
Based on responses to two GAO questionnaires--one to each state child
welfare agency and the other to FPS program administrators--we
established baseline information about state child welfare service
delivery and FPS services before the new law. In the following
sections, we describe
previous efforts on the part of state child welfare agencies, who
are responsible for implementing the new law, to provide FPS
services, reform child welfare service delivery, and monitor
results; and
the characteristics of FPS programs that were affiliated with a
state child welfare agency, another state child-serving
agency--such as mental health or juvenile justice--or both.
Unless otherwise noted, the term state refers to the state child
welfare agency. FPS program refers to a program of FPS services
provided under the auspices of a state child-serving agency, both
within and outside the child welfare system.
STATE CHILD WELFARE AGENCIES
CAN BUILD ON PREVIOUS EFFORTS
-------------------------------------------------------- Appendix II:1
Many state child welfare agencies had taken steps to provide FPS
services and reform child welfare service delivery before enactment
of OBRA 1993. The extent of these efforts may not have been as
widespread or comprehensive as the new law and proposed federal
regulations require, but can still form a basis from which states can
move forward.
The FPS provisions of OBRA 1993 and draft regulations set out
requirements for states as they implement the new law. Before states
can use new federal funds to provide FPS services, they must
undertake a planning process that includes broad consultation and
involvement, an assessment of needs, and joint planning. States are
encouraged to develop a child and family service system that keeps
children and families safe; builds on the resources and strengths of
families; offers a continuum of services that is family-focused,
easily accessible, and culturally relevant; and links this service
continuum to other community services and service-delivery
systems--such as mental health and education--to ensure that families
have access to comprehensive services to meet their individual needs.
From our survey of state child welfare agencies, we provide
information about state efforts in these areas before enactment of
OBRA 1993. We did not assess the adequacy or completeness of the
survey information nor did we determine compliance with applicable
laws or how far along states might be in their planning process;
rather, this information provides some insight into states' previous
experiences that could form a basis for future planning, service
delivery, and monitoring activities. (See app. I for more details
on our survey methodology and app. III for a copy of the state child
welfare agency questionnaire.)
GUIDING PRINCIPLES PROVIDE A
FRAMEWORK
------------------------------------------------------ Appendix II:1.1
Both family preservation and family support services are based on a
common set of principles or characteristics that help ensure their
responsiveness and effectiveness for children and their families.
These principles should provide an organizing framework as states
plan for new FPS services, according to proposed federal rules.
Before enactment of OBRA 1993, 45 states had established guiding
principles for family preservation services, family support services,
or both. Such principles were formalized primarily in internal
agency documents, such as program instructions, policy manuals, and
plans. In addition, 27 states had embodied guiding principles in
state law. Most states shared similar principles as those outlined
in proposed federal regulations, with primary emphasis on maintaining
the welfare and safety of children, strengthening and preserving
families, focusing on the family as a whole, and delivering services
that were intensive enough to meet family needs.
In addition, 48 states had previously developed initiatives for child
welfare service delivery to meet objectives similar to those promoted
by the new law. Of these states, 44 had initiatives to either begin
or expand family preservation services and improve the well-being of
vulnerable children and their families, particularly those at risk of
or experiencing child abuse and neglect. In addition, 39 states had
initiatives to start or expand family support services and about 37
states had initiatives to develop a continuum of services that are
family-focused, comprehensive, and coordinated.
States' initiatives were most commonly the result of state
legislation, initiation or replication of a pilot or demonstration
project, or a formal planning process. However, 12 states had
undertaken these initiatives in response to a court order or consent
decree. In addition, 39 states indicated that their efforts were
part of broader state initiatives or reform efforts, such as
reinventing government or welfare reform. About one-half of the
states had initiatives underway to develop a comprehensive
service-delivery strategy for child and family services.
MOST STATES OFFERED FULL
ARRAY OF SERVICES
------------------------------------------------------ Appendix II:1.2
Every state offered most of the types of services that might
optimally comprise a full array of child welfare services. Among
elements that would ideally be part of a child welfare services
continuum, according to proposed federal rules, are FPS services;
child welfare services, including child abuse and neglect prevention,
intervention, and treatment services; foster care; and services to
support reunification, adoption, kinship care, independent living, or
other permanent living arrangements. States were least likely to
offer family support services as well as services after a child had
left foster care (although 38 states and 34 states, respectively,
offered these services). Most services were offered statewide;
services that were not, were generally moving in that direction.
Before OBRA 1993, 29 states reported that they emphasized family
preservation services more than family support services. A total of
48 states offered family preservation services compared with 38
states for family support services. While FPS services were included
in most states' array of available services, FPS services were least
likely to be available statewide. Family preservation services were
available statewide in 29 states and family support services in 22
states.
CHILD WELFARE SERVICES WERE
OFTEN LINKED TO OTHER
SERVICES
------------------------------------------------------ Appendix II:1.3
In addition to a continuum of services, according to proposed federal
rules, linkages to other services and service-delivery systems, such
as health, mental health, housing, employment, education, and child
care, complete the picture of a responsive service-delivery system.
Effective coordination of a broad spectrum of services provides a
holistic approach to serving children and families and increases the
likelihood of matching families' needs with appropriate services
rather than merely providing available services.
Many state child welfare agencies were connected to other
service-delivery systems by virtue of their organizational structure
and by establishing formal arrangements. The state child welfare
agencies had various types of formal arrangements or linkages with
other state programs that provide child and family services.
Regardless of the state program, the most common types of formal
arrangements were service coordination and collaboration, use of
other programs' services, and joint planning. State child welfare
agencies were least likely to have integrated services or pooled
funds with other state programs. Formal arrangements were most
common with juvenile justice and mental health programs--a situation
that may be facilitated by organizational structure because 43 state
child welfare agencies were part of an umbrella or consolidated
agency, most commonly with employment, juvenile justice, and mental
health programs. Few states had formal arrangements with state
housing programs.
In addition to connecting with other state service-delivery systems,
most states had established ties at the community level during the 5
years before enactment of OBRA 1993. In particular, 35 states had
initiatives that drew upon community-based programs for the design,
implementation, or both of the delivery of child welfare services.
Furthermore, about 35 states had established linkages with
community-based organizations related specifically to the delivery of
FPS services.
Of the 39 state child welfare agencies that offered both family
preservation services and family support services, the most common
linkages between the delivery of these two services were service
collaboration and coordination. Furthermore, most of these states
had ties between the two services within the state child welfare
agency as well as with other entities, such as other state programs
and community-level child welfare service providers. In 9 states,
the delivery of family preservation services was separate and
distinct from family support services.
STATES HAD PREVIOUSLY
CONDUCTED SOME PLANNING
ACTIVITIES
------------------------------------------------------ Appendix II:1.4
As states develop their 5-year plan, proposed federal rules require
them to establish baseline and trend information from which to base
funding and service decisions. Such information is needed to help
determine target populations, assess service needs and resources,
identify service gaps, and develop opportunities for bringing about
more effective and accessible services for children and families.
Most states had collected some of this information related to the
delivery of FPS services, as shown in table II.1, before enactment of
OBRA 1993. Furthermore, as the table illustrates, more states
undertook these activities for family preservation services than for
family support services. In addition, HHS recommends that FPS
services be targeted towards populations and in locations of greatest
need. Before the new law, most states that offered FPS services
targeted these services in various ways.
Table II.1
States That Undertook Planning
Activities and Targeted FPS Services
Before OBRA 1993
Family Family
preser suppor
vation t
servic servic
es es
-------------------------------------------- ------ ------
Activity
------------------------------------------------------------
Develop new and more effective approaches to 45 31
delivering services
Identify available resources 38 27
Establish linkages with community-based 35 32
organizations
Assess family and community needs 34 29
Identify child welfare service overlaps and 30 22
gaps
Targeting
------------------------------------------------------------
By client population 38 25
At county or local discretion 29 27
At selected locations 29 24
To support collaborative, community-based 21 23
service-delivery strategies
------------------------------------------------------------
MEASURING PROGRESS WAS
DIFFICULT
------------------------------------------------------ Appendix II:1.5
While 40 states monitored results for family preservation services
compared with 29 states for family support services, measuring
progress in accomplishing goals for either type of service was
difficult for most of these states in the 5 years before enactment of
OBRA 1993. States monitored progress towards accomplishing FPS
goals, primarily by internal program reviews and periodic progress
reports prepared by program staff. Fewer states relied heavily on
external program evaluations to monitor progress--20 states for
family preservation services and 7 states for family support
services. In addition to monitoring progress in accomplishing FPS
goals, most of these states used the monitoring results to assist in
program development. Furthermore, 34 states had evaluated or
reviewed family preservation services to determine program
effectiveness, compared with 18 states for family support services.
Information was not readily available on the scope, methodologies,
and results of state evaluations.
Although states undertook a variety of activities to measure the
progress of FPS services in accomplishing goals, most states found
these activities difficult to carry out. Regardless of whether the
progress of family preservation or family support services was
tracked, states had difficulties with or did not conduct the
following activities:
collecting useful and complete data,
selecting appropriate indicators,
measuring cost effectiveness,
identifying correlates of success or the program or client
characteristics that affect the likelihood of successful
outcomes, and
defining measurable outcomes.
In general, states had not used indicators to monitor results for FPS
services--less than one-half of the states for family preservation
services and less than one-fourth for family support services. Those
states that did used various indicators to measure the progress of
FPS services, as shown in table II.2. Most common were indicators
related to expenditures and child abuse and neglect reports. Beyond
that, for family preservation services, most states focused primarily
on indicators related to cost, systems, and service delivery, and
less so on family and child indicators. For family support services,
fewer states used indicators, but those that did focused more on
family indicators. States found these indicators to be of varying
usefulness, leaving little or no clear picture of what indicators
would be most useful for states to set goals, base funding and
service decisions, and track results.
Table II.2
Most Common Indicators That States Used
to Measure Progress in Accomplishing FPS
Goals Before OBRA 1993
Number Number
of of
Indicator Type states\a Usefulness\b states\a Usefulness\b
------------- ------------- -------- ------------- -------- ---------------
Expenditures Systems 33 Moderate/ 17 Somewhat
somewhat
Cost Cost 31 Spread\c 11 \d
effectiveness
Caseloads Systems 29 Moderate 16 Somewhat
Cases per Service 27 Spread\c 10 \d
worker delivery
Staffing Service 25 Moderate 15 Somewhat
delivery
Child abuse Community- 23 Moderate 17 Somewhat
and neglect wide
reports
Timeliness Service 23 Spread\c 11 \d
delivery
Family Family 22 Moderate 16 Moderate/
functioning somewhat
Child's well- Child 21 Very/ 16 Spread\c
being moderate
Parent-child Family 15 \d 15 Moderate/
relationships somewhat
--------------------------------------------------------------------------------
\a Represents number of states that indicated they used the indicator
to measure the progress of family preservation services (based on
n�42) and family support services (based on n�29) in accomplishing
goals.
\b Based on scaled response of "very/moderate/somewhat/not at all
useful," with "very" being the most useful and "not at all" being the
least; level of usefulness determined by majority of respondents.
\c State responses were spread among the "very/moderate/somewhat
useful" categories, without the majority of responses being in any
one or two categories.
\d Insufficient number of respondents (less than one-half of n).
STATE FPS PROGRAMS VARIED, BUT
SHARED SOME COMMONALITIES
-------------------------------------------------------- Appendix II:2
While family preservation programs encompass a variety of
service-delivery strategies, family support programs encompass an
even broader array of approaches. As a result, it is difficult to
define a typical program of family preservation or family support
services. From our survey of 393 FPS program administrators, we
provide some information about the characteristics of these programs
as they looked before enactment of OBRA 1993. We especially focus on
those aspects that are highlighted in the new law, such as
outcome-based goals and methods for monitoring progress towards
achieving these goals. We did not assess the adequacy or
completeness of the survey data. Furthermore, the information
described below pertains only to the population of FPS programs that
responded to our questionnaire and cannot be projected to the
universe of such programs. (See app. I for more details on our
survey methodology and app. IV for a copy of the state FPS program
questionnaire.)
About 66 percent of the programs we surveyed provided family
preservation services and 79 percent provided family support
services.\15 Regardless of whether a program provided family
preservation or family support services, about 35 percent of the
programs provided these services on a statewide basis. Over one-half
of those programs that were not available statewide were moving in
that direction.
--------------------
\15 The percentages reflect the number of respondents that answered
specific questions related to FPS services; hence, the ratios are not
always with respect to the total of 393 programs that responded to
our questionnaire. In addition, programs provided family
preservation, family support services, or both.
SOME FPS GOALS WERE
EMPHASIZED MORE THAN OTHERS
------------------------------------------------------ Appendix II:2.1
According to federal guidelines, which were based on focus group
discussions and the literature on professional practice, the goals
for FPS services should reflect the underlying principles of
family-focus, accessibility, flexibility, coordination, and cultural
relevance. Hence, FPS services should be directed towards assuring
the safety of all family members; enhancing parents' ability to
create an appropriate home environment that promotes healthy child
development; assisting children and families with resolving crises
and remaining safely together in their homes whenever possible; and
avoiding unnecessary out-of-home placement of children and helping
foster children reunite with their families or with placement in
another planned, permanent living arrangement, such as adoption or
legal guardianship.
Although goals varied among individual programs, most of the FPS
programs we surveyed had goals similar to those articulated in
federal guidelines. Programs that provided family preservation
services focused most often on improving parenting skills and
preventing the need for foster care placement, as shown in table
II.3. Family support services were also designed to improve
parenting skills as well as to connect or provide information to
families with other community supports and services, as shown in
table II.4. Regardless of whether family preservation or family
support services were provided, program goals were least likely to
include respite care of children to provide temporary relief to
parents and other caregivers, as shown in both tables.
Table II.3
Percent of Programs That Provided Family
Preservation Services With Goals Similar
to Those Under OBRA 1993
Percen
t of
progra
Goal ms\a
---------------------------------------------------- ------
Improve parenting skills 91
Help children at risk of foster care placement 86
remain with their families
Prevent foster care reentry after children have been 77
reunited with their families
Reunite children in foster care with their families 77
Place children for adoption, with a legal guardian, 27
or some other permanent living arrangement when
family reunification is not appropriate
Provide respite care of children for parents and 25
other caregivers
------------------------------------------------------------
\a Represents percent of programs that actually responded (n�171).
Table II.4
Percent of Programs That Provided Family
Support Services With Goals Similar to
Those Under OBRA 1993
Percen
t of
progra
Goal ms\a
---------------------------------------------------- ------
Strengthen parent-child relationships 92
Connect families with and encourage use of other 92
community supports and services
Improve parenting skills 91
Provide information and referral services 90
Improve family functioning 86
Prevent child abuse and neglect 79
Provide families with opportunities to interact with 73
other families and program staff
Promote family self-sufficiency 70
Assess children's early developmental needs 60
Prevent out-of-home placement 59
Provide respite care of children for parents and 36
other caregivers
------------------------------------------------------------
\a Represents percent of programs that actually responded (n�198).
MOST FPS PROGRAMS COULD NOT
FULLY MEET THE DEMAND FOR
SERVICES
------------------------------------------------------ Appendix II:2.2
Almost two-thirds of the FPS programs experienced difficulty in
meeting the demand for their services. Over one-half of the FPS
programs were not able to serve all eligible families who requested
services, primarily because of an insufficient level of funding and
number of staff to provide FPS services. These factors, according to
most program administrators, hindered the program's ability to
achieve its primary goals for FPS services. Nevertheless, almost 90
percent of the program administrators felt that, overall, their
program of family preservation services was very or moderately
effective in reducing the number of families at-risk or in-crisis
that might lead to foster care placement. By comparison, almost 80
percent of the questionnaire respondents felt that family support
services were similarly effective in reducing the number of families
at-risk of or experiencing child abuse and neglect.
PROGRESS MONITORED
INTERNALLY
------------------------------------------------------ Appendix II:2.3
Most programs monitored the progress of FPS services in accomplishing
program goals primarily by internal program reviews or evaluations
and periodic progress reports prepared by program staff. Less than
one-half of the programs used indicators to measure program outcomes.
In addition, less than one-half of the programs were reviewed or
evaluated by an organization outside of the program. Results from
these monitoring efforts were primarily used to determine program
effectiveness and assist in program development.
In the last 5 years, just over one-half of the programs were formally
evaluated. These evaluations focused primarily on the process of
program implementation, the impact of FPS services, and compliance
with applicable law or regulations. Furthermore, over 40 percent of
the family preservation programs were in the process of being
formally evaluated, compared with just over 50 percent for family
support programs. Information was not readily available on the
scope, methodologies, and results of these evaluations.
SERVICE-DELIVERY
CHARACTERISTICS OF FPS
PROGRAMS
------------------------------------------------------ Appendix II:2.4
How FPS programs were administered and operated appeared to be
related to the type of service offered. Family preservation services
were more likely provided within the context of the child welfare
system, while family support services were more likely provided under
the auspices of other state child-serving agencies, such as mental
health and education, as shown in table II.5. Moreover, family
preservation programs were more likely operated by other private
organizations under contract with a state or local public agency,
while family support programs were most commonly operated by a
community-based organization.
Table II.5
Comparison of FPS Programs Administered
Within and Outside the Child Welfare
System
Family Family
preser suppor
vation t
servic servic
es es
(n=179 (n=207
Type of state agency ) )
-------------------------------------------- ------ ------
Child Welfare 74 43
Nonchild Welfare
Mental Health 19 13
Juvenile Justice 11 4
Education 3 20
Maternal and Child Health 3 11
Other Public Health 1 4
Other 18 32
Total nonchild welfare\a 55 84
------------------------------------------------------------
\a More than one type of agency may be responsible for administering
family preservation services, family support services, or both.
Program approaches to the delivery of family preservation services
varied in many ways. However, the intensity, duration, and packaging
of services commonly differentiates such programs from the
traditional delivery of child welfare services. One way to
differentiate among family preservation programs is to describe them
by the type of intervention they employ. According to the
literature, such programs can be classified into three models--crisis
intervention, family systems, and therapeutic family treatment.\16
The crisis intervention model forms the basis for the Behavioral
Science Institute's Homebuilders service-delivery approach,
which began in 1974 in Tacoma, Washington. Intervention occurs
within 24 hours of a family's referral to the program. Services
are typically intensive in nature and are provided in the home
so that caseworkers can make accurate assessments and gain the
trust of the family.
The family systems model is typified by the FAMILIES program
originated in Iowa in 1974. Attention is focused on the family
as a whole, not specific family members, and seeks to correct
dysfunction by working on the family's interaction with the
community. Families actively participate in their assessment
and help establish the treatment goals of improved service
linkages, perception, and relationships within the family and
its environment.
Therapeutic family treatment relies less on the provision of
concrete, supportive services and more on family therapy. The
treatment is also less intensive. One of the first such
programs was the Intensive Family Services Program developed in
Oregon in 1980. Treatment, which is also based on family
systems theory, is comprised of three distinct
phases--assessment, treatment, and termination.
While these are three models of family preservation service delivery,
many variations of these models as well as other approaches exist.
Over one-half of the programs characterized their service-delivery
approach for providing family preservation services as one of the
three models described above. The remaining programs used either
other approaches or different service-delivery strategies depending
on the jurisdiction or program site. As shown in table II.6,
programs that used the three family preservation service-delivery
models had some commonalities as well as differences.
Table II.6
Characteristics of Three Family
Preservation Service-Delivery Models
Therapeutic
Characteristi Crisis Family family
c intervention systems treatment
------------- ------------- ------------- ---------------
Number of 50 27 9
programs\a (30%) (16%) (5%)
(percent)
Average 3 cases per 9 cases per 9 cases per
caseload per worker worker worker
worker
Percent of 44% 78% 56%
programs
using a
team approach
Average 1.5 months 5.7 months 5.9 months
duration of
services
Availability 24 hours a 24 hours a 24 hours a day,
of workers\b day, 7 days a day, 7 days a 7 days a week
week week
Types of Birth; Birth; Birth;
families extended; extended; extended;
receiving foster; foster; foster;
services\b adoptive adoptive adoptive
Location of In family's In family's In family's
service home home home
delivery\b
Minimum Bachelor's Bachelor's Master's degree
educational degree degree
requirement\b
------------------------------------------------------------
\a Of a total of 169 programs, we describe the characteristics of 86
family preservation programs in this table; the remaining 83 programs
used either other approaches or different service-delivery strategies
depending on the jurisdiction or program site.
\b As determined by the majority of respondents.
Unlike family preservation services, programs that provided family
support services were less likely to follow a particular
service-delivery model. Programs varied greatly in terms of targeted
populations and types of family support services offered. However,
according to the literature, family support programs can be
differentiated either by their service-delivery configuration or by
their service strategy. In terms of service-delivery configuration,
family support services are typically provided in the home or in a
center, such as program facilities or a school. With respect to
service strategy, programs can be differentiated by the areas in
which they focus, such as those that promote self-sufficiency or
emphasize child abuse and neglect prevention. In actuality, family
support programs are often not clearly delineated as services may be
multidisciplinary and strategies may overlap.\17
Over one-third of the family support programs provided services in
the home and just under one-third were center-based. Some
characteristics of these programs are arrayed in table II.7. The
remaining programs' populations were configured in other ways or
configurations varied depending on jurisdiction or program site.
Table II.7
Characteristics of Selected Family
Support Service-Delivery Approaches, by
Service Configuration
Characteristics Home-based Center-based
------------------ ------------------ --------------------
Number of 69 50
programs\a (39%) (29%)
(percent)
Average caseload 18 cases per 21 cases per worker
per worker worker
Percent of 56% 69%
programs using a
team approach
Targeted By geographic \c
services\b area; parents at
risk of child
abuse or neglect
Average duration 10 months 7 months
of services
Availability of \c \c
workers\b
Minimum \c \c
educational
requirement\b
------------------------------------------------------------
\a Total of 175 programs.
\b As determined by the majority of respondents.
\c Responses varied with no majority for any one response category.
Over one-half of the family support programs focused on one of three
service strategies--the prevention of child abuse and neglect; family
self-sufficiency; and early child development and school success.
These programs shared many common elements, as shown in table II.8.
Table II.8
Characteristics of Selected Family
Support Service-Delivery Approaches, by
Service Strategy
Child abuse Early child
Characteristi and neglect Family self- development and
c prevention sufficiency school success
------------- ------------- ------------- ---------------
Number of 139 109 109
programs\a (67%) (52%) (52%)
(percent)
Average 19 cases per 21 cases per 23 cases per
caseload per worker worker worker
worker\b
Percent of 65% 69% 64%
programs
using a team
approach
Targeted By geographic By geographic By geographic
services\c area; area; parents area; families
families with at risk of with children
children child abuse under age 5;
under age 5; or neglect parents at risk
parents at of child abuse
risk of child or neglect
abuse or
neglect;
pregnant
teens
Average 9 months 8 months 10 months
duration of
services
Availability \d \d \d
of workers\c
Location of \d \d \d
service
delivery\c
Minimum \d \d \d
educational
requirement\c
------------------------------------------------------------
\a Total of 208 programs; however, some programs focused on more than
one area.
\b One-half or more of the respondents indicated that workers did not
have cases.
\c As determined by the majority of respondents.
\d Responses varied with no majority for any one response category.
--------------------
\16 Karl Ensign, "Prevention Services in Child Welfare," citing K.E.
Nelson, M.J. Landsman, and W. Deutelbaumn, "Three Models of
Family-Centered Placement Prevention Services," Child Welfare, Vol.
LXIX, No. 1 (Jan.-Feb. 1990), pp. 3-21.
\17 Karl Ensign, "Prevention Services in Child Welfare," citing F.
Farrow, T. Grant, and J. Meltzer, "Challenges and Opportunities for
Public Policies on Family Support and Education," and G.C.
Christopher, "Community-Based Family Support and Education: Local
Program Examples," papers delivered at the Colloquium on Public
Policy and Family Support (1990).
GAO QUESTIONNAIRE TO STATE CHILD
WELFARE AGENCIES
========================================================= Appendix III
In this section, we present our questionnaire to state child welfare
agencies regarding child welfare service delivery before enactment of
OBRA 1993. Each question includes the summary statistics and the
actual number of respondents that answered each question. In each
case, we use the format that we believe best represents the data,
including frequencies, means, and ranges.
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
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GAO QUESTIONNAIRE TO FPS PROGRAM
ADMINISTRATORS
========================================================== Appendix IV
In this section, we present our questionnaire to state-affiliated FPS
program administrators regarding FPS services before enactment of
OBRA 1993. Each question includes the summary statistics and the
actual number of respondents that answered each question. In each
case, we use the format that we believe best represents the data,
including frequencies, means, and ranges.
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
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(See figure in printed edition.)
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(See figure in printed edition.)
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(See figure in printed edition.)Appendix V
COMMENTS FROM THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES
========================================================== Appendix IV
(See figure in printed edition.)
(See figure in printed edition.)
GAO CONTACTS AND ACKNOWLEDGMENTS
========================================================== Appendix VI
GAO CONTACTS
Karen E. Lyons, Evaluator-in-Charge, (916) 974-3341
Robert L. MacLafferty, Assistant Director, (415) 904-2000
ACKNOWLEDGMENTS
In addition to those named above, the following individuals made
important contributions to this report: Rodina S. Tungol led the
data analyses related to the FPS program questionnaire and coauthored
the report; Luann M. Moy assisted in developing, pretesting,
finalizing, and distributing the questionnaires; and Leonard J.
Hamilton and Wayne J. Turowski conducted the computerized analyses
of the questionnaire data.