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Children's Voice Article, January/February, 2004

Many Efforts, One Vision

CWLA's combined efforts to respond to the federal Child and Family Service Reviews with an eye toward the field-- and the future.

by Tegan Culler

As anyone who works in child welfare knows well, the tangible good the system accomplishes-- and its less tangible good intentions-- can be undercut by inefficiency, lack of funding, poor communication between service sectors, and inadequate staff training. At times, child welfare practice seems to be guided less by what is in the best interests of children and families than by serving the unremitting demands of the overburdened system itself.

For the last three years, however, the federal government has joined with the states to implement a research-based, outcomes-focused review system that evaluates states based on whether they are serving children and families in a way that is best for them in the short and long term.

A New Standard

Authorized by the 1994 Amendments to the Social Security Act, informed by the Adoption and Safe Families Act of 1997, and finalized in 2000, Child and Family Service Reviews (CFSRs) are an ongoing process that monitors how state child welfare systems measure up to national standards for child protection, family support, foster care, adoption, and other services funded by Titles IV-B and IV-E of the Social Security Act.

Conducted by the Children's Bureau of the U.S. Department of Health and Human Services' (HHS) Administration for Children and Families, each review consists of a statewide assessment and a weeklong onsite review based on 50 cases from three counties and stakeholder interviews.

The reviews evaluate states on seven outcomes in safety, permanency, and well-being, including recurrence of abuse and neglect at home or in care, reentry into foster care, the length and number of foster care placements before reunification or adoption, and the availability of appropriate health and educational services. Each state agency is also assessed on seven systemic factors, including its information system, the range and accessibility of services it offers, and how it trains its staff and foster families. (See "Benchmarks," page 22.) Ninety percent of a state's sample cases must achieve or surpass a given benchmark for the state to pass that benchmark.

By April 2004, all 50 states, the District of Columbia, and Puerto Rico will have completed the first phase of the process. To date, 45 jurisdictions have undergone the initial review-- 17 in FY 2001, 15 in FY 2002, and 13 in FY 2003. In every single state, the review has identified multiple areas that require improvement. No state has met the standards for more than three of the seven primary benchmarks. Among the 32 states with final CFSR reports, 10 did not conform with any of the seven outcomes, and 15 met the standards for only one of the outcomes. Only one state met the standards on three outcomes.

So far, states have fared better on measures related to child safety than to permanency and well-being; the strongest scores have been in limiting recurrence of child abuse or neglect, placing siblings together, and placing children in the care of relatives. The weakest scores are in length of time to completed adoptions, accessibility of services, and engaging families in case planning.

Although it's not good news, states' performances on CFSRs are not entirely surprising. From the beginning, HHS has emphasized the CFSR process is intended to be a tool for continuous quality improvement and system reform. The true test lies in states' abilities to remedy shortcomings over time. Any state that hasn't met each of the standards is required to submit a Program Improvement Plan (PIP) detailing how it will achieve the federal benchmarks. Once the Children's Bureau approves a PIP, the state has two years to implement its plan before the Children's Bureau reviews the state again. If, at that time, the state still does not meet the national standards, HHS could withhold a portion of the foster care and adoption assistance funding the state receives under Title IV-E of the Social Security Act.

A Holistic Approach

Although CFSRs measure safety, permanency, and well-being separately, in practice they're interconnected issues best examined together. In the League's capacity as a partner with the federal and state governments in aspects of the CFSR process, and as a membership, educational, consulting, and advocacy organization, its work on child safety, permanency, and well-being focuses not on complying with individual CFSR indicators but on improving overall services and outcomes for children and families.

>From its vision to its individual programs and projects, CWLA takes a "whole child" approach that complements the CFSRs and serves the public agencies that seek to improve their services.

CWLA's vision for the future of America's children, though broader in scope than the CFSRs, is consistent with the comprehensive reform of the child welfare system the CFSRs aspire to accomplish. In its 2003 monograph, Making Children a National Priority: A Framework for Community Action, CWLA sets forth a group of organizing principles designed to challenge communities to think and act in ways that ensure all children are safe, healthy, and thriving.

This Framework, which informs the entire body of CWLA's efforts, defines five universal needs of children:
  • the basics-- food, clothing, shelter, education, health care, and equality;
  • nurturing relationships;
  • opportunities for optimal development;
  • protection from harm; and
  • healing from physical or emotional harm.
Like the CFSRs, the Framework's objective is to ensure children's needs are met. Many other concepts in the Framework resonate with the CFSRs, including an emphasis on child well-being, prevention, and supporting families; a belief in strong communities and effective advocacy; a commitment to cross-systems collaboration; and support for measuring results and using evidence-based practice.

Although the Framework is a vision for all children, not just those involved with the child welfare system, "A good bit of overlap exists between the

CFSR outcomes and the Framework's five universal needs," says Linda Jewell Morgan, CWLA Director of Program Development. "The permanency outcomes relate to the need for nurturing relationships, and the safety outcomes parallel the need for protection," Morgan points out, although the Framework addresses protection from harm beyond abuse and neglect. Aspects of the other universal needs encompass the CFSR definition of child well-being-- the need for adequate physical and mental health services and appropriate education are both part of the Framework.

"Despite the differences in breadth," Morgan says, "both the CFSRs and the Framework aim for the same goal."

Crunching Numbers

To even begin a data-driven process such as the CFSRs, an agency must not only have accurate numbers on its performance, but it has to know what they mean.

"Most states have been collecting state child welfare data for a long time," says Don Perry, Project Director for the National Resource Center for Information Technology in Child Welfare (NRC-ITCW), "but they can't use it if they can't read it or if the numbers are no good."

A collaboration of the Children's Bureau, CWLA, the National Indian Child Welfare Association, and the technical consulting firm Xtria, NRC-ITCW offers each state public agency and federally recognized tribe 10 days per year of free, onsite technical assistance on CFSRs and other data and technology issues, as well as unlimited telephone and e-mail consultation. NRC-ITCW can help a state establish a child welfare information system or revamp an existing one, review and analyze its data, or establish internal, quantifiable benchmarks to measure its progress.

In April, NRC-ITCW will hold its annual data conference, Making IT Work, where CFSRs will be a primary focus. The preceding month, NRC-ITCW will host training for state agencies on reading, interpreting, and using data. "Data and data quality have a significant impact on policy and program work in the field," Perry says. "Each side needs to thoroughly understand what the other one does to be able to work together effectively."

Applying What Works

Improving the child welfare system is a worthy endeavor, but how do states know whether their work is genuinely in the best interests of children and families? The best approach is to use what is known about effective practice as a basis for planning and implementing child welfare programs, policies, and practices.

Evidence-based practice can help states craft realistic PIPs that will lead to better outcomes for children and families. "Applying knowledge of 'what works' to PIPs and other planning priorities has many benefits," says Sue Steib, Senior Consultant for CWLA's National Center for Research and Data (NCRD). "Practitioners gain greater satisfaction in their work, policymakers can demonstrate alignment between their intentions and long-term results, citizens see funds used more resourcefully, and, most importantly, children and families are served effectively and can therefore achieve brighter futures."

Supporting the states' improvement planning, CWLA's Research to Practice initiative (R2P) is identifying recurring themes and related practice areas in the published findings of each state's review and examining research associated with positive results in each practice area. Having explored such CFSR-related topics as individual and family assessment, parenting, family reunification, and positive youth development, R2P is making research and information about effective programs available to states that wish to base their PIPs on evidence-based practice.

R2P also offers onsite technical assistance to states and local jurisdictions. For example, Pennsylvania has sought R2P's input in implementing its own PIP as one facet of reforming its child welfare system. Combining R2P's knowledge of evidence-based practice with the expertise of CWLA's National Center for Field Consultation, the project weaves together data from Pennsylvania's CFSR-- such as the need to minimize a child's total number of pre-permanency placements-- with research that demonstrates why meeting this need is effective practice and descriptions of how the state's own practice standards dovetail with both the federal standard and the existing research.

Perfecting Practice

"If you look at what the CFSRs are showing us, it goes back to the basics of social work, to relationships," says CWLA Director of Foster Care Millicent Williams. "Kids who are visited more frequently by their workers do better; families who are involved in planning their cases do better."

For public agencies that are subject to CFSRs, improved practice will likely result in progress on the reviews. Private agencies, although they are not reviewed themselves, can ensure any state contracts they have are not compromised by subpar practice. One thing is clear: strengthening the essence of child welfare practice can only help children and families.

Several CWLA initiatives to improve child welfare practice generally will help agencies with the practice goals outlined in their PIPs. CWLA's most specifically practice-oriented publications, its Standards of Excellence and Best Practice Guidelines, are applicable to both general practice and the review process. "The states that appear to be the most successful on the CFSRs are in fact using best practices as described in our Standards and Guidelines," says CWLA Director of Standards Pamela Day.

For example, CWLA's Best Practice Guidelines for Child Maltreatment in Foster Care, developed in partnership with Casey Family Programs, is a practical tool for both public and private agencies, detailing comprehensive, quality practices for preventing, responding to, and investigating child maltreatment in out-of-home care. For states that are developing new investigation protocols or training their staffs as part of their PIPs, the Guidelines are also a resource on the recurrence of child maltreatment and on children's safety in foster care.

Another project, a collaboration between CWLA and the National Center for Missing and Exploited Children (NCMEC), will guide child welfare and law enforcement agencies in monitoring children in care and responding when a child goes missing. During the yearlong endeavor, CWLA and NCMEC will provide technical assistance and develop best practices for preventing and responding to such cases. CWLA will emphasize the importance of taking the most accurate, thorough, and timely assessments possible, as well as worker-client relationships.

Again, this is about core practice-- really knowing a child, knowing a family," Williams says, adding that improving these aspects will also improve states' outcomes in safety, recurrence of maltreatment, and permanency.

Bridging Gaps

The problems that face families in the child welfare system neither begin nor end with child abuse and neglect. Families may also be struggling with homelessness, addiction, domestic violence, or mental illness. Almost invariably, to heal and change, families need support from multiple service systems.

The states that improve most substantially may be the ones that adopt a holistic approach to meeting their challenges. "It's tempting, when you're presented with a problem, to regard it as an isolated issue and work to solve it from that perspective," explains NCRD Director Wendy Whiting Blome. "But when you look at the child welfare system as part of a continuum with other systems, it becomes apparent that the 'isolated' problem is not one-dimensional at all. It has an impact-- and is impacted-- at many different levels."

In the context of CFSRs, CWLA's strong history of and commitment to facilitating cross-system collaborations is more vital than ever.

Substance Abuse and Mental Health

Parental substance use is a factor in at least half of all child welfare cases. Children whose families don't receive appropriate treatment for substance abuse are more likely to remain in foster care longer and to reenter foster care once they return home-- outcomes specifically measured by CFSRs.

Yet, in their reviews, an overwhelming number of states cited a dearth of adequate, accessible substance abuse treatment services. As a consortium member of the National Center on Substance Abuse and Child Welfare (NCSACW), CWLA is helping to investigate and analyze the reasons for this and how to change it. NCSACW, jointly funded by the Children's Bureau and the Center for Substance Abuse Treatment, offers free technical assistance to national, state, and local agencies seeking to better coordinate substance abuse treatment and child welfare services. NCSACW also provides in-depth technical assistance to selected state and tribal agencies.

CWLA's behavioral health staff have presented in four states on linking the child welfare, mental health, and substance abuse systems, including the participation of family advocacy organizations. "The family voice is a critical component of this discussion that is often overlooked," says CWLA Behavioral Health Director Steve Hornberger, pointing out that family involvement in case planning is one of the benchmarks that CFSRs measure. "The CFSRs so far have demonstrated that creating opportunities for such family involvement improves outcomes for children and families."

Juvenile Justice

Children known to child welfare are more likely than their peers to be involved with the juvenile justice system, and vice versa, yet, despite this overlap, the two systems rarely share information or coordinate treatment or intervention.

CWLA is part of a new initiative in Pennsylvania to help county juvenile justice and child welfare systems coordinate their work. Besides training professionals from both systems about the crossover in their service populations, CWLA is supporting the Pennsylvania Department of Public Welfare Office on Children and Youth in its creation of a Center for Excellence in Child Welfare and Juvenile Justice, allowing public and private child welfare and juvenile justice agencies in Pennsylvania to request information or technical assistance from CWLA, the American Bar Association, national resource centers, and other organizations.

Apples to Apples

Although state feedback on the CFSRs has generally been positive, some stakeholders have questioned whether the reviews measure appropriate outcomes in the best way. The indicators themselves are continually reassessed to ensure they provide meaningful data. This is where CWLA's National Data Analysis System (NDAS)-- the premier web-based system of U.S. child welfare data-- can help.

Through its National Working Group to Improve Child Welfare Data (NWG)-- a partnership between CWLA and the state public child welfare agencies, with participation from the Children's Bureau and other stakeholders-- NDAS conducted a study in 2002 to determine whether states consider certain types of short-term placements when calculating a child's total number of placements. NWG found that states consistently report time children spend in shelter care, in family foster care, or with relatives, but vary widely in whether they report placements that should not be included in the final count, such as psychiatric hospitalization, incarceration, or trial home visits-- making it impossible to compare states.

A second NWG survey revealed that, because not all states identify kinship caregivers as foster parents, and because children who are not in a state's child welfare system may be reported as maltreated in institutional settings, data on child maltreatment in foster care may be misrepresented.

Based on these surveys and other data, NDAS and NWG have submitted recommendations to the Children's Bureau with the goal of refining the national standards and ensuring the next generation of outcome data is as precise and relevant as possible.

"True national indicators will remain elusive, or could be misunderstood by federal policymakers, unless the nuances of the data are revealed," says NDAS Director Carolyn Friedman. "For NDAS, the goal is to help put meaning to the numbers and create a context for understanding the data."

Funding, Workforce, and the State of Practice

As time goes on, the entire review process, not just the outcome measures, will likely evolve. In 2004, the states that were part of the first round of reviews will be evaluated on their progress. But there's no real sense of what to expect at that point.

"States are under enormous pressure to show quick and dramatic results," says NRC-ITCW Program Manager Tom Hay. "But we really don't have a broad base of research on what it takes to achieve a significant change in outcomes or how much is realistic in a two-year period."

In the current economic climate, such changes will be even more laborious for states. "The first PIPs were written based on resources that existed in FY 2002," says CWLA Vice President for Membership Services Skip Stuck. "But now some states are in their third straight year of deep budget cuts. At a certain point, there really is no way to do more with less."

Bart Baldwin, CWLA Director of Regional Public Policy, agrees: "In lots of states, prevention is gone, family support is gone. When there's no money for front-end, creative intervention, the only choice left is to put kids into out-of-home care. If that's what you're faced with, how do you write a program improvement plan for your state?"

This is complicated by the fact that states are not required to submit budget estimates with their PIPs, so it's not immediately apparent that achieving better practice-- and therefore better outcomes-- may require significant new resources.

The PIPs may provide advocates with vital leverage, because they are written by states in response to a federal mandate, and because they tend to reinforce issues CWLA and other advocates have struggled for years to bring to the attention of legislators: the need for improved substance abuse services, better support for children aging out of foster care, and better recruitment, training, and salaries for child welfare workers.

"The PIPs are the best materials [advocates] have had in a long time," says Liz Meitner, CWLA Vice President of Government Affairs.

One issue-- workforce-- has already captured the attention of Congress. At CWLA's behest, Representative Pete Stark (D-CA) commissioned a Government Accounting Office (GAO) study of the challenges facing the child welfare workforce. The study, released in March 2003, found "large caseloads and worker turn-over delay the timeliness of investigations and limit the frequency of worker visits with children."

Although CFSRs don't measure workforce data, the study reports that workforce issues have a significant negative effect on states' abilities to meet many CFSR standards. Among other recommendations, the report called for HHS to advocate for technical assistance and more funding to address training, accreditation, caseload caps, and recruitment bonuses.

The GAO report represents only the first of innumerable steps that will be required if states are to obtain the funding and practice improvements they will need to succeed on the CFSRs. Nevertheless, it is a victory. The study demonstrates that, regardless of whether they are specifically monitored by CFSRs, each of the various aspects of child welfare practice is interrelated and interdependent, and any aspect of child welfare can have widespread effects on outcomes for children, youth, and families.

As public agencies strive-- however incrementally-- toward meeting each standard, they must not lose sight of their ultimate goal. As Blome points out, "The most important thing to remember is that behind every number is a family and a child."

Tegan Culler is an editor for CWLA and a contributing editor to Children's Voice. Parts of this article are based on a presentation by Tom Hay, Project Manager, NRC-ITCW.

Benchmarks

The U.S. Children's Bureau is evaluating the 50 states, the District of Columbia, and Puerto Rico on seven broad outcome measures (with multiple subsections) and seven systemic factors.

Outcome Measures States
Meeting Standard*
Safety  
1. Children are, first and foremost, protected from abuse and neglect.
9
2. Children are safely maintained in their homes whenever possible and appropriate.
4
   
Permanency  
3. Children have permanency and stability in their living situations.
2
4. The continuity of family relationships and connections is preserved for children.
5
   
Well-Being  
5. Families have enhanced capacity to provide for their children's needs.
0
6. Children receive appropriate services to meet their educational needs.
9
7. Children receive adequate services to meet their physical and mental health needs.
1

Systemic Factors
  • Information system capacity
  • Case review system
  • Quality assurance
  • Service array
  • Staff and provider training
  • Agency responsiveness to the community
  • Foster and adoptive home licensing, approval, and recruitment
*Among the 32 states with final CFSR reports as of this writing.


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