Evaluation of Family Preservation and Reunification Programs:

Chapter 5:
Tennessee

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Contents

• 5.1 Introduction
• 5.2 Characteristics of Tennessee’s Children and Families
• 5.3 History of Family Preservation in Tennessee
• 5.3.1 Background
• 5.3.2 Initial planning, program development, and training
• 5.3.3 Program expansion
• 5.3.4 Significant Events Affecting HomeTies
• 5.3.5 Description of Tennessee Family Preservation Model
• 5.3.6 Family Preservation Services in Shelby County
• 5.4 Implementing the Evaluation
• 5.4.1 Study Procedures
• 5.4.2 Other Evaluations
• EndNotes

5.1 Introduction

In Tennessee the Family Preservation Program (HomeTies) is a resource within the state’s Department of Children’s Services (DCS).⁽¹⁾ The 95 Tennessee counties are grouped into 12 regions for purposes of service delivery. During the study period, there was a family preservation coordinator who was responsible for overseeing the administration of the family preservation programs, including setting standards, contracting with private providers throughout the state, and providing training and technical assistance. Direct services were delivered by private providers under contract to the state.⁽²⁾

Shelby County (Memphis) participated in the evaluation. Study enrollment began in November 1996 and concluded in May 1998. Frayser Family Counseling provides the HomeTies Program in Shelby County.

The sources of material for this chapter are reports and documents produced by the state and interviews with personnel at the DCS and HomeTies program.⁽³⁾ This information is presented to help understand the context in which services were provided, and to identify any changes that occurred during the implementation of the evaluation. The observations only reflect the perceptions of the individuals we interviewed.

This chapter begins with an overview of the characteristics of Tennessee’s children and families. Details of the Tennessee family preservation program, service delivery in Shelby County, implementation of the evaluation, and other organizational initiatives are then provided.

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5.2 Characteristics of Tennessee's Children and Families

This section provides demographic statistics on Tennessee's children and families. Child welfare statistics are presented for Shelby County, which was the focus of the family preservation study in Tennessee.

There are approximately 1,300,000 children under age 18 in Tennessee, with the majority being white (76 percent), and two-thirds under twelve years old (Table 5-1).

Indicators of child health, education, and social and economic welfare in Tennessee as compared to the nation are presented in Table 5-2. Data have been abstracted from Kids Count Data Book, published by the Annie E. Casey Foundation. With respect to most indicators, Tennessee's families and children are similar to the national averages. The Casey Foundation developed a family risk index based on the following indicators: 1) number of children who are not living with two parents; 2) households in which the head of household did not have a high school degree; 3) family income below poverty level; 4) parents did not have steady employment; 5) the family was receiving welfare; and 6) no health insurance for the children. Using the Casey risk calculation, the percentage of children in Tennessee considered at risk is the same as in the nation as a whole, 14 percent.

Child Welfare Statistics for Shelby County. To provide background for the evaluation findings, an overview of the number of child abuse and neglect investigations and percent of indicated reports for fiscal years 1995–1998 is presented in Table 5-3. The number of children for whom there were abuse and neglect investigations shows a slight decrease in FY's 97 and 98. However, agency staff reported that lower abuse and neglect investigations may be due to administrative undercount rather than a decline in the number of children investigated. During those two years, administrative systems were being updated and the staff shortages in Shelby County resulted in data entry being a low priority. The percentage of cases substantiated remained fairly constant over the study years: FY 95, 36 percent; FY 96, 35 percent; FY 97, 41 percent; and FY98, 38 percent.

For all 4 years, children under one year of age had a slightly higher rate of substantiation than older children. Other than FY 96, males and females had similar rates of substantiation. Substantiation rates fluctuated by types of maltreatment within each year with failure to thrive, abandonment, educational neglect, physical abuse, substantial risk of physical injury, and substance affected infants being substantiated at higher rates.

Children in substitute care also remained fairly constant throughout the study period. In FY 95, the year prior to random assignment, 1,772 children were served. The number of children in care on the last day of each fiscal year rose slightly over the study years: 1,880 children in FY 96; 1,963 children in FY 97; and 1,943 children in FY 98.

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5.3 History of Family Preservation in Tennessee

5.3.1 Background

The family preservation program in Tennessee, HomeTies, began in October of 1989. State funding ($1.71 million in FY 90) for the program was provided through a joint legislative resolution signed by the Governor directing the Departments of Human Services, Mental Health, and Youth Corrections to proceed with an inter-departmental family preservation program. Eight teams, serving 24 counties, including Shelby County, were funded in 1989 (FY90) as pilot projects. The program initially served families with children diagnosed as seriously emotionally disturbed and adolescents charged with delinquent acts or status offenses who were at imminent risk of placement in substitute (i.e., out-of-home) care. Referrals were made by staff in the three state agencies who could place or cause the placement of children. HomeTies was, and is, based on the Homebuilders model of family preservation services--serving multi-problem families for 4-6 weeks using behavioral and cognitive therapeutic interventions and concrete services in order to prevent placement. Services are delivered through contracts with private and public agencies, most often community mental health agencies. This structure changed in 1998 when the state moved to a managed care model of purchasing and delivering services in one-half of the state.

The FPS and family reunification programs offered by HomeTies constitute one of the state's four programs designed to preserve families. Wraparound services (i.e., individualized services purchased to prevent placement, reunify families, or support community/family based placements) are also available statewide.⁽⁴⁾ Community intervention and intensive aftercare programs are also available in selected counties for families with youth in the correctional system.

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5.3.2 Initial Planning, Program Development, and Training

The impetus for HomeTies began at a conference in Nashville of southern state service providers and legislators in October 1987. Various models of intensive family preservation services were presented. Members of the Tennessee Select Committee on Children and Youth and others in Tennessee attended this conference and became strong advocates of FPS. There were initial differences of opinion about which FPS model or models should be chosen and, ultimately, the Homebuilders model was recommended to legislators in Tennessee. Family preservation advocates from the Behavioral Sciences Institute (BSI, the developers of the Homebuilders model of family preservation services in Washington State), the National Conference of State Legislators, the Center for the Study of Social Policy, and the Edna McConnell Clark Foundation made presentations to the state's Select Committee on Children and Youth about the value of and need for FPS in Tennessee. Legislators responded quite positively, and there was little controversy about starting the program. Significantly, there was a new Democratic governor in Tennessee at the time, and FPS fit well with his emphasis on shaking up the status quo and developing creative government programs that could make a difference.

The development and implementation of HomeTies involved collaboration among multiple state agencies, initially including the Departments of Human Services (DHS), Mental Health, Youth Development,⁽⁵⁾ and Finance and Administration. Representatives from these agencies met in 1988 to examine financing options, interdepartmental service coordination, and existing FPS models. This committee completed a policy-procedures manual, developed forms, and, with researchers from the University of Tennessee, designed the evaluation of HomeTies. The request for proposals was generated from this work, and required that agencies replicate the Homebuilders model.

The $1.71 million in initial funding for HomeTies in FY90 came from redirected foster care funds, block grants, and state dollars. No additional dollars were added to the state budget to fund FPS. The table below shows the source and types of funds used to provide initial program funding.

Start-up training included: (a) inter-departmental training for all referring staff on FPS policies and procedures; (b) a Homebuilders orientation by BSI for all referring staff; and (c) training by BSI on the Homebuilders model for all HomeTies workers in the contract agencies.

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5.3.3 Program Expansion

The HomeTies program was expanded several times between 1990 and 1994.

• In 1990, the program was expanded by three additional teams as a result of additional Title IV-E allocations. The Edna McConnell Clark Foundation also awarded the state $104,000 for coordination, training, and research, resulting in the hiring of a State Coordinator for HomeTies.
• The program expanded much more dramatically in 1991. The 1991 Tennessee Family Preservation Act mandated that the program serve all eligible families in the state. Seventeen new teams were funded. Expansion began in the fall of 1991 and was completed in May 1992.
• In 1992, child abuse and neglect cases were made eligible for the program. This policy change was preceded by extensive discussion and distribution of policies and guidelines for serving this new population.
• In 1993, program regulations added juvenile court judges and their staff to the list of professionals from whom the program could receive referrals.
• In 1994, HomeTies added another worker to each team and began accepting family reunification cases.
• Between FY90 and FY94, there was a 650 percent increase in the number of families served by placement prevention services, from 400 cases in FY90 to 2,976 in FY94. In FY95, there was a slight (4%) decrease in the total number of families served.
• Despite the slight decline in total families served in FY95, family reunification cases increased statewide by 18 percent from FY94 to FY95. (See the table below for the number of families served, percent change in the number of families served, and the number of FPS teams since the inception of the program through FY95.)

In its five-year plan for family preservation and family support services, Tennessee chose to put all new federal funds into family support rather than family preservation services. In FY95, the state planned to expand Healthy Start--an early intervention program for parents with newborns at risk of child maltreatment. In FY96, the state planned to add 31 Family Resource Centers -- networks of state and community based services designed to help families solve problems before crises occur.

HomeTies contracts for service providers were originally based on a $2000 per unit cost. In FY93, the state began reimbursing the agencies for cases served rather than a preset number of cases. This may, in part, explain the decreasing time frame of interventions and the increased numbers of families being served. Due to rising costs ($2028 per family in FY92 and $2624 in FY93), the state capped the contracts in FY95, resulting in lowered total expenditures ($7.8 million in FY96). HomeTies is a Medicaid reimbursable service and rates are set by the state's TennCare system. As of November, 1997, the Tennessee Director of Budget reported that 58 percent of HomeTies cases were eligible for full Medicaid reimbursement for services.

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5.3.4 Significant Events Affecting HomeTies

In 1991, the Department of Finance and Administration established the Children's Plan by creating a single funding pool to finance children's services. Looking for an independent agency that did not have a vested interest in maintaining the status quo, the Department of Health was selected to administer the Plan. Assessment, Care, and Coordination Teams (ACCT) were formed to provide comprehensive assessments of children entering care in order to make better initial placement decisions for children and youth. The ACCT would also monitor the child's progress through the placement system, manage the expenditures of flex funds, and function as a single portal of entry for children needing state services (pre-custodial, custodial, post-custodial). ACCT was housed in Community Health Agencies (CHAs) which were originally created in statute to advocate for community based medical care for the poor across the state. The CHAs were administered by the Department of Health and were located in 12 regional offices. The ACCT was suppose to review all referrals to HomeTies and to provide an assessment of whether children were at imminent risk of placement. The degree to which this actually occurred varied widely across the state and, in the fall of 1993, ACCT was dropped as the gatekeeper of HomeTies referrals. One example of the difficulty in implementing this referral strategy was that some juvenile court judges refused to send referrals through ACCT. In FY 95, ACCT staff continued to make referrals to HomeTies, accounting for slightly less than one-third of referrals.

In April, 1996, the Tennessee General Assembly passed legislation to remove child welfare services from the Department of Human Services and create the Tennessee Department of Children's Services. The new Department consolidates family and children services from several Departments and includes: child welfare, child development, day care licensing, pregnancy and parenting services, youth corrections, and the children's fiscal division. While the Department of Human Services continues to administer the Social Services Block Grant and Title IV-A funds, the Department of Children's Services (DCS) administers all Title IV-E and Title IV-B funds.

DCS has recently been operating under tight fiscal constraints. During site visits in 1997, DCS was altering the structure of service delivery in an effort to increase service provision without increasing personnel expenditures, strengthen follow-up services, and decrease duplication and problems associated with case transfers. The conversion process affected workers both in- and outside of DCS. The Assessment Care and Coordination Teams were dissolved and ACCT staff no longer reviewed any referrals to FPS. The community health agencies called Community Service Agencies (CSAs) became contract agencies that provided services directly to families (one person described this as quasi-privatization). CSA child welfare staff began to carry their own cases and be part of teams (along with high risk CPS staff, outreach, crisis intervention, youth development, and foster care staff). The Community Service Agencies were the fiscal monitors of flexible funds to prevent or reduce time spent in state custody.

The conversion process affected investigative staff. The emphasis changed from service provision to investigations which required strict adherence to the policy of completing investigation in 60 days or referring cases to ongoing service units. Staff were required to close or transfer cases within 60 days of case opening. Also if investigator caseloads were greater than 30 families at a time, they had to justify the number in writing. The conversion process had a strong negative effect on the morale of DCS workers due to a high level of uncertainty about how their job status would be affected.

Since 1997, Tennessee has been moving toward a managed care model of service delivery for noncustodial cases. Fifty percent of the state is currently using the new managed care system, but Shelby County, among others, is not expected to be converted until July 2000.⁽⁶⁾

The Department of Children's Services (DCS) reported that most non-custodial service contracts had been based on a fee-for-service basis without regard to level of service or quality of performance. Little evaluation had taken place and services were not distributed evenly across the state. As a consequence, the state asked all 12 Community Service Agencies to conduct local needs assessments for their regions defining service priorities and gaps in their current service continuum. The assessments were completed in late January 1998. The assessments focussed on three levels of service: prevention (community education and early prevention), intervention (treatment), and diversion (just prior to commitment services).

As a continued move towards managed care, the Department of Children's Services then issued a Request For Proposals for each region based on the local needs assessments. As part of the proposals, networks of agencies bid a case rate for families. Once in place, the network will decide the amount and kind of services families require and the length of service delivery to prevent placement.⁽⁷⁾ The state plans to have 12 networks across the state each with a lead agency which will subcontract with other agencies for services or with a coalition of service providers. The 12 networks will replace approximately 70 existing contracts for service. The networks are to be outcome focussed and will be financed by Social Service Block Grant (SSBG), some of the state's Family Preservation /Family Support funds, and all state HomeTies dollars.(8)

The state planned to have the networks in place by July 1, 1998. However, the state only approved proposals from six regions and rejected the remainder largely due to service cost estimates, particularly the capitaled rate amount for families receiving in-home services, with a specific annual cap of $1,550 per family. Following withdrawal of the RFP from the six regions not funded, Shelby's CSA submitted a plan which proposed a five year pilot program using “an integrated fee-for-service and risk- adjusted model” for children at risk of state custody

In essence, the plan is to have the CSA convene community members, including service providers, the courts and DCS, who will develop both a risk adjustment scale to classify children into moderate, high, and imminent risk of placement categories and a service delivery model to address each level of service need. Both the University of Tennessee and the University of Memphis will be part of this group to help review data and design the service model. Case rates will be established looking at historic expenditures of flexible funds, SSBG, and IV-E dollars. Once the model and fee structure are established, the group will prepare a program evaluation, funded by local resources and conducted by the two local universities. Finally, an RFP will be written, and after approval from the state, will be released into the community. Network provided services are expected to begin on July 1, 2000. The state's move toward managed care will also eliminate the state's Homebuilders family preservation program. While the new service networks will be required to offer some form of intensive family preservation, they will not be required to offer a Homebuilders model and the state will no longer provide uniform training and oversight.

At this time, there is no consensus about the role of Shelby County DCS in case oversight once the network is involved with the family. In other parts of the state, DCS acts only as a gatekeeper (accepting calls, conducting investigations, and making referrals) and the CSA monitors families' progress. It has also not been determined whether the Frayser HomeTies program will continue under the network; if it does not, a less intensive service model will be used.

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5.3.5 Description of Tennessee Family Preservation Model

HomeTies follows the Homebuilders model and utilizes a behavioral cognitive approach to work with multi-problem families. Workers try to engage the entire family and teach skills that will increase their ability to function more effectively. Workers carry two families for four to six weeks, and are available 24 hours a day, seven days a week. Through a wide range of services and the ability to access $250 per family in flexible funding, workers address crises, monitor family stability, assist families, create linkages, and obtain services in the community.

State guidelines rule out referring the following case types for HomeTies Services.

• Physical Abuse
• The physical abuse is considered life threatening, necessitating the children be immediately placed to ensure safety (for example, the parent threatens homicide of the child).
• Sexual Abuse
• The perpetrator of the sexual abuse resides in the same home as the victim.
• Substance Abuse
• The adults in the home are found incoherent all of the time due to substance abuse and all of their resources are used to support their addiction.
• Family members, including parents, fear being murdered by the drug community and move constantly to avoid harm.
• A parent wants the child(ren) to be placed and refuses to consider services that might enable the child(ren) to remain in the home.
• Neglect
• Neglect cases are not ruled out unless the family refuses services.

CPS intake workers complete a risk assessment form to identify high, intermediate, low, or no risk. High risk cases are identified as cases where “the child or children in the home are at imminent risk of serious harm if there is no intervention in the situation.”

A typical high risk case might involve such factors as: 1) a vulnerable child; 2) a history of previous maltreatment; 3) an active perpetrator who has continued access to the child, and; 4) no available support or family strengths to offset the stated risks.

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5.3.6 Family Preservation Services in Shelby County

Since Tennessee does not operate a central state hotline, all CAN calls for Shelby County come directly to two screeners within the county. The screeners determine risk levels and using a manual intake system, assign calls to the appropriate investigative unit.

During the study period, there were ten Child Protective Services units in Shelby County with approximately 65 staff. In addition to the Intake Unit, there were four Emergency Response Units (investigation within 48 hours), two Non-Emergency Units (investigation within seven days), and a single High Risk/CPS Ongoing Unit. There was also a High Risk, Multi-Victim/Multi-Perpetrator Unit, and a Court Unit which was primarily responsible for conducting home studies and visits for relative care and custody change cases.

Some investigative caseloads were as high as 150 cases/families per worker, causing great strain on and concern among staff at all levels. Caseloads within the Ongoing Unit averaged about 20. In May 1997, the service delivery plan for the new Department of Children's Services was implemented in Shelby County. Child Protective Services was divided into six work units, with a supervisor (team leader) and eight case managers, plus case manager positions responsible for CPS intake. The new service model called for CPS case managers to only do the investigative piece, referring any families who needed services beyond the investigation to child and family teams. Existing CPS policy requiring that investigations be completed in a 60 day time frame was strictly enforced. In Shelby County, the CSA provides all follow-up services and case management for these CPS cases. CPS case managers continue to refer to HomeTies because of the crisis nature of the service and its use to prevent placement.

In FY95, Shelby County served 12 percent of the state's accepted HomeTies cases (an increase from 8.3% in FY90), making it the second largest HomeTies program in Tennessee. The Shelby County HomeTies Program grew from 317 in FY93 to 391 in FY95, a 23.3 percent increase. This overall increase was due primarily to the inclusion of reunification cases (14 in FY94 and 58 in FY95). During the study years, the number of families served slightly decreased. (See Table 5-6.)

Shelby County DCS workers' views and use of HomeTies. Investigative and ongoing staff reported referring equal numbers of cases to HomeTies and cited several reasons that they use the program. Investigative workers reported that HomeTies was used as their first resort for families at imminent risk of removal because program staff could be in the home monitoring and assessing families around the clock. Ongoing workers reported that they used HomeTies as a last resort, after they had tried less intensive services because of the intensity of the intervention and the availability of concrete resources (flexible funding, transportation). Both investigative and ongoing workers said that HomeTies staff could be relied upon to provide thorough and frequent feedback about families, both during the course of treatment and at the end of treatment. Feedback was particularly useful because it included information on both family strengths and weaknesses.

Unlike many child welfare jurisdictions, Shelby County has a variety of in-home and office-based therapeutic programs to which workers can refer (these are described in Exhibit A, provided at the end of the chapter). However, supervisors and workers noted that, prior to the study, HomeTies generally had a waiting list and was a preferred option for many workers for a number of reasons.⁽⁹⁾ HomeTies could be relied upon to monitor and assess new cases in crisis and provide intensive support to ongoing cases which were perceived to be on the brink of placement. To a large extent, public agency workers had previously been able to make referrals directly to a specific HomeTies worker and they could contact this individual directly to set up and coordinate the intervention. Also, there was no paperwork or external review of referrals associated with referral to HomeTies. Some people stressed how important it was that HomeTies had been accessible to emergency staff around the clock and would engage the family within 24 hours of the referral--day, night, or weekend, which helped to stabilize families. This was especially important to investigative staff who have historically referred the cases, when they perceived families to be in crisis. Some workers thought that some of these advantages were reduced or eliminated by the initiation of the study (see discussion of the impact of the study on referrals below).

In general, most administrators and workers viewed HomeTies as successful in working with a wide range of families. DCS workers said that the best candidates for HomeTies were families who needed assistance with communication skills or anger management. Public agency supervisors said that HomeTies staff are often perceived by clients as allies whereas DCS staff are perceived as the enemy. The supervisors also said that HomeTies has been particularly successful with acting-out teenagers, and with families where parents do not want to work with DCS. HomeTies is willing to try a number of workers to create a “good fit” with a family.

DCS staff also had some negative comments and concerns about the program.(10) These included:

• Uneven staff - some staff are too “gullible” - they believe “stories” families tell;
• Some workers are intimidated by families or refuse to go to some homes (this appeared to be particularly frustrating to public agency staff because they do not have the option to refuse a home visit);
• Some staff are reluctant to work with drug using families (DCS staff believe this is because of personal risk issues of HomeTies staff and not a clinical decision);
• HomeTies recommends removal more frequently than agency staff.

HomeTies has very few “turnbacks,” DCS staff estimate 2-3 percent of all referrals are turned back to the agency, almost all within the first seven days. The majority of turnbacks are the result of a family's unwillingness to cooperate with the program. The other two reasons cited for turnbacks are: a) a family has too many problems (generally a violent adolescent) and the worker is at risk; or b) the children are not at imminent risk of state custody.

Once HomeTies has completed its four to six weeks of intervention, the worker reports to DCS staff about the continuing level of risk in the family and makes recommendations about the family's continuing service needs. DCS staff report that they almost always accept the program's recommendations about the family. According to Emergency Response workers interviewed (those that investigate within 48 hours), 90 percent of their cases are closed directly after HomeTies intervention. The remaining 10 percent are transferred to ongoing services for continued supervision. Ongoing/High Risk Workers estimated that 60 percent of their cases are closed directly after HomeTies intervention; the remaining 40 percent remain open.

Frayser Family Counseling's (FFC) HomeTies Program. In Shelby County, HomeTies is offered by Frayser Family Counseling, a private, non-profit community mental health center. The center has 95 employees including psychologists, psychiatrists, nurses, and other mental health personnel. The center provides voluntary outpatient services to individuals of all ages. Among its many services are individual and group therapy, in-home family preservation and support services, alcohol and drug therapy, victim assistance, and child and adolescent evaluations.

In May 1997, HomeTies had three supervisors and fifteen counselors,(11) with 5-6 workers per supervisor. In 1997 and 1998, HomeTies was funded for 21 counselor positions and three supervisors. Community mental health started losing dollars because of TennCare, and quickly learned that if they worked outside the model and saw more of the same numbers of families with fewer staff, they increased their revenue. The program director serves as one of the supervisors. Another HomeTies supervisor is responsible for the Life Coach program. Nine of the HomeTies workers also take Life Coach cases (see discussion below).

Two of the workers had over fifteen years of experience in the field, five workers had 5-10 years of experience in the field, and the other eight workers had 2-5 years experience. All staff are required to have two years of experience when they are hired. Twelve of the workers were female and twelve were African American. Sixty percent of the workers have master's degrees (the state requires at least 50%), six of which are in counseling, two have MSWs, and one has a masters degree in criminal justice. One of the staff previously worked at DCS.

Workers are supposed to serve 1.5 cases per month (21 case workers x 18 cases per year), for a total of 378 cases per year. The program director estimates that 60 percent of the cases are referred to HomeTies by DCS, 30 percent by Community Service Agencies, and 10 percent by the juvenile court, with less than 1 percent from mental health centers.

HomeTies cases can be extended for up to two weeks, but this occurs in less than 5 percent of cases. One possible reason for the rarity of extensions is the availability of other services in the agency (i.e., Life Coach, see below). The agency also provides a six-month check-in with families when the child is still in the home.

HomeTies and Life Coach. Because Life Coach serves some control group cases, it is important to describe the relationship of HomeTies to Life Coach. In addition to sharing staff, HomeTies and Life Coach (LC) are intermingled in several other ways. First, workers reported that approximately 35 percent of HomeTies cases go to Life Coach for follow-up services, usually with the same worker providing the services. These services ($60 per day, about 70 percent of the HomeTies rate) are usually provided for 30 days, but can last as long as needed. Second, control group cases were being referred to LC. The Life Coach supervisor said that there is no difference between LC and HomeTies. The program director basically agreed, but said that LC workers spent slightly less time with families (4-7 hours per week).

One difference between HomeTies and Life Coach is that referrals to LC must be reviewed by the prevention team (at the time, DCS and ACCT). Also, LC cases did not have access to flexible funds (i.e., $250 in cash). HomeTies workers often work overtime on LC cases. If a worker has two HomeTies cases, he or she can only have one LC case.

Other information about referrals. Many of the referrals involve parent-child conflicts in which the parent wants the worker to fix the child. According to therapists, approximately 65-70 percent of families have substance abuse problems and 95 percent include one person (usually the mother or the child) who takes psychotropic medication. Other prominent problems of children and families include school behavior and attendance, child behavior at home (e.g., not doing chores, not following rules), housing problems, parents' relationships, domestic violence (relatively few cases, some with past incidents), failure-to-thrive infants, and drug-exposed infants. Referrals of drug-exposed infants were more frequent earlier, and staff were unclear why these cases are not being referred.

Workers and supervisors were generally satisfied with the types of referrals they receive, though workers stressed that DCS should screen parents who are mentally ill for appropriateness. Turnbacks of referrals to DCS occur if there are seven days without contact with a child because of parents refusing services, parents wanting the child placed, the child running away, or failure to comply with safety plans.

When asked which cases were most appropriate or inappropriate, supervisors contested the idea of a typology of cases based on problems (such as drug abuse or mental illness) or even problem severity. They stressed instead that the issue of motivation was more important in determining the difficulty of a case, and they stressed techniques for building motivation (see below). This is consistent with some of the issues that have been raised previously in discussions of the difficulty of targeting families for referral to FPS--that one cannot know before referral the extent of family problems or the family's responses to intervention except within the context of the helping relationship.

Cases are assigned to specific workers based on openings, except for a small number of cases, for example, a sex abuse case might require a female therapist.

Training and supervision. All staff, called therapists, are trained by BSI in the Homebuilders model. While this basic training was viewed positively by supervisors, it was not considered sufficient preparation for actual work in the field, especially for younger, non-Masters level staff. Newer therapists receive individual supervision for 3-6 months, and they shadow other therapists for at least one full case, present cases at weekly staffings, and are shadowed by another therapist when they take on cases.

Supervisors provide general professional support to workers and personalized coaching on clinical skills. In addition, they described supervision as a process of helping workers learn to: a) focus their efforts with families by picking workable issues (i.e., ones that could be addressed in four weeks) and reducing DCS goals to core issues and goals; b) communicate to the family and DCS that the therapist is working with the family's agenda (knowing also that the family's goals can change as they become more aware of opportunities); and c) continually assess the family strengths, needs, and goals, and the situation, and to be flexible in their approaches to helping families based on assessments.

Practice approach. Supervisors and therapists identified important purposes and strategies of working with families (in addition to those mentioned above related to supervision), and some of the benefits of in-home services. The descriptions here are intended to be illustrative of how staff approach practice at FFC, not a comprehensive description of practice.

Staff noted the importance of identifying family strengths by looking at the situation and family members' motivation. Staff emphasized the importance of building motivation in the family to change and of building a sense of empowerment. These appeared to be interrelated goals that are particularly important for families who are referred to HomeTies --who wouldn't ordinarily seek help. These goals are accomplished through a variety of means, including:

• Spending time with families in their world and at times that are convenient for them;
• Assuring families that HomeTies staff are not from DCS and the families can ask them to leave;
• Listening to family members' perspectives in a non-blaming, respectful manner--this is often the first time families have experienced this;
• Determine what the family's goals are and examine how they can relate to the goals of the public agency;
• Showing them that they have power to change some things by identifying small steps that can be made to improve the situation--showing parents they can be different by breaking down big foggy clouds of problems into small parts; and
• Focusing on solutions.

Therapists note that the first things that they do is to assess and address safety issues and concrete needs. Safety issues include running away (e.g., you don't tell them what to do, but you talk with them about what they do to stay in the home), suicide assessment (e.g., ask about attempts, weapons, and pills; lock up pills), and physical abuse (agree to a no-hit policy while HomeTies is in the home).

Staff also noted that using flexible funds ($250 per family) generously and creatively (e.g., refrigerator, rent, car, utilities, moving, food, meals out) to meet a family's initial concrete needs is a very helpful strategy in HomeTies. Use of flexible funds must be approved by supervisors, and workers consider or try other means of addressing concrete needs first.

When working with parent/child conflict cases, therapists suggest that parents have generally lost their power, have their own issues with conflict, or inappropriately want the child to be their friend. Therapists often work with parents separately, and try to show parents that they can be powerful and help parents see the good in their children and respect the perspectives of the children. Therapists also noted that behavioral charts with agreed upon goals and reinforcers are very helpful in promoting specific changes in roles and behaviors.

Therapists refer to other social services in 50-60 percent of cases. They try to identify needs as early as possible so that referrals can be made. Sometimes families are able to start other services during HomeTies, other times they are placed on waiting lists. Services used include day care, homemaker services, and parenting groups, as well as other state and federally funded rape crisis services, HIV support groups, vocational rehabilitation for the mentally retarded, mentoring, respite, drug treatment, psychiatric treatment, housing advocacy, counseling, telephone hook-up, and free concrete services provided by churches.

While noting that in-home services are more difficult and stressful than traditional therapy and that they involve a shorter engagement period, the therapists believe that in-home services are better, “one month of in-home is worth 6-12 months of outpatient.” Therapists noted the following benefits of HomeTies:

• Better assessment: they know much more about families because they see conflict, caring, housekeeping, and parenting in the natural environment;
• Parents can see that they have power, that children have positives, and that children will change;
• Parents like the program;
• Families are empowered, and gain improved communication, relationship, and anger management skills;
• There are more teachable moments with in-home services; and
• Workers can be real with families.

Relationship with DCS. Supervisors expressed concerns about the low proportion of DCS workers who refer to HomeTies, the high turnover of DCS staff (many new DCS workers don't know about HomeTies), and the poor training and supervision provided to DCS workers. They viewed the DCS workers as pleasant, but noted that they frequently need to educate them about HomeTies. Sometimes, though this happens infrequently, DCS staff expect HomeTies staff to act as investigators rather than therapists. There was some concern among supervisors and therapists that DCS workers are hard to reach by phone, but therapists said that communication with DCS occurs during services and is generally good, and that DCS really tries to be available for meetings.

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5.4 Implementing the Evaluation

Having a well-established statewide program, Tennessee was one of the original sites considered for study participation. This site was selected as it met all study selection criteria – a well-defined, mature program using a relatively pure version of the Homebuilders model.

Site visits were conducted and state office administrators were very interested in participating in the study, with trepidation about a randomized experiment, the impending reorganization of state services for children, and whether or not the state would be in compliance with the “reasonable effort” requirement of Title IVB. Additional meetings were held with state and local personnel to address concerns and to explain the dimensions of the study.

Usual referral procedures in Tennessee included referring workers learning of an opening in family preservation or waiting to refer a case until an opening existed. If a worker learned a program was full, he or she might ask when an opening was expected, leading to cases being held until an opening occured. To address concerns about random assignment, it was suggested that since not all cases could be served and since it was largely a chance matter whether or not a case received services, random assignment might be just as ethical as the current procedure.

Random assignment was eventually agreed to, but not without major objections. One concern was whether or not the state was in compliance with “reasonable efforts” requirements to provide services necessary to prevent foster care placement. It was believed by agency staff that family preservation was the best way to prevent foster care placement. After conversations with the federal government, it was determined that random assignment did not prohibit efforts to keep children out of foster care and the state would not be out of compliance with “reasonable effort” requirements.

State and local personnel indicated that targeting was a concern, families currently being referred for family preservation were not necessarily those at imminent risk of placement and that there were many eligible families not being referred for services. To address these concerns, training was conducted to help tighten the screening and referral of families to family preservation. The state family preservation coordinator developed training materials to review appropriate cases for referrals to the HomeTies program. Prior to the study beginning a one day training was held with the entire CPS and HomeTies staff in Shelby County. Study procedures were presented at the same training. There were plans to have training “tune-ups” throughout the study but these did not occur.

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5.4.1 Study Procedures

Preparation and training for the experiment were conducted in the summer of 1996. Training sessions were held with both DCS screeners and family preservation program coordinators. During the training sessions study procedures were reviewed including use of study forms, the screening protocol, random assignment procedures, and the role of the study site coordinator. A meeting was also held with all HomeTies staff and DCS staff. The purpose of the meeting was to train staff on Shelby procedures and targeting appropriate cases for family preservation. In addition, periodic group meetings were conducted with caseworkers and supervisors to reinforce study procedures and solicit their feedback on the study. Workers were very resistant to random assignment and concerned that it would deny services to families, cause extra tasks, and delay referrals for their caseloads.

A site coordinator was hired locally to assist DCS and HomeTies staff in providing case information needed for random assignment and the conduct of interviews.

Referral to Family Preservation. Prior to implementing study procedures, workers identified families they felt were appropriate to receive family preservation services, got supervisor approval for the referral, and then made the referral directly to the HomeTies program. The HomeTies worker would determine whether or not the referral was appropriate and if there were any openings. The evaluation slightly altered these procedures. The major change was that workers no longer directly referred cases to HomeTies. Instead, if a worker saw the need for in-home services, he or she asked the family to sign a release form to participate in the study. If the worker selected HomeTies, the worker then completed a random assignment form and a DCS screener checked that the primary child was under 13, not a juvenile court case, and not already in foster care. Screeners assessed whether the child was at imminent risk; it was up to the worker's supervisor to assess level of need.

The screener's role was to call HomeTies to see if there was an opening and if there was, contact Westat to randomly assign the case to the experimental or control group.

Cases eligible for the evaluation were limited to those served by child welfare, even though HomeTies also served cases referred from juvenile justice and mental health. Also, referrals were limited to those cases that were in the course of an investigation of abuse or neglect or shortly thereafter, and had at least one child under the age of 13 years old. A 60/40 (60% treatment) random assignment ratio was used at the beginning. This was changed to 70/30 when the evaluation was under way.

Impact of the study on DCS workers. Both CPS workers and supervisors expressed frustration about the impact of the study. Supervisors reported that there was no change in the characteristics of families referred to HomeTies after the study began. The most commonly cited problems resulting from the study included:

• “Emergencies happen around the clock”; front line staff could no longer make referrals directly to HomeTies after 4:30PM weekdays or during the weekends due to the office hours of DCS screeners. (Frayser staff estimate this accounted for 5-10 percent of their referrals.)
• With caseloads higher than usual due to the hiring freeze, workers did not have time “to scramble” to identify other services when the screener told them their cases were in the control group.
• Additional time related to the random assignment process. For families without telephones, workers had to make one trip to investigate and get consent to participate in HomeTies and then a second trip to tell families about the services they were to receive. To compound this, workers were still required to complete all of the paper work associated with a control group case.
• A worker could no longer choose a particular HomeTies worker to help with a case. This was troubling to some CPS workers who had built relationships and felt particularly confident in the abilities of certain workers.
• The “transition” was already requiring workers to review all of their open cases and close as many as possible. Workers and supervisors reported that they already had a lot of paperwork to complete and that the evaluation contact sheets were a very low priority.
• Workers and supervisors also reported getting calls from Westat about cases two months after they had closed the cases. By this time, workers did not remember all of the specifics and did not have time to go back through their records. If a worker left or was transferred, the supervisor had to answer the questions and it was even more difficult for them to know the specifics of a case.

In response to these issues, many workers reported that they were referring their families to other services instead of HomeTies to avoid “the hassle” of possible control group selection. They identified nine such programs. Some workers even asked staff within the Juvenile Court system to make referrals directly to HomeTies to ensure that cases got HomeTies services. Screeners estimated that only 20 percent of front line staff made referrals to HomeTies during the evaluation, whereas in the past, closer to 50 percent made referrals.

In response to the staff's “rebellion” against the study, administrators and CPS supervisors actively encouraged front line staff to use HomeTies. Due to the strain of the uncertainty of random assignment, supervisors reported that front line staff perceived the evaluation to be more cumbersome than it really was. The screeners reported that the local Westat site coordinator/data collector was “very motivating” to staff. Using information from case records, the data collector filled in gaps in the initial referral forms and completed contact forms for workers. Workers also had the option of filling out the contact forms instead of completing the case narrative in the case record.

Reduced referrals and financial issues. At the end of April, 1997, HomeTies was down 56 cases in comparison to budget projections (at approximately $2,500 per case, this is over $125,000), the program's worst financial year to date. Referrals were low before random assignment, and were reduced further after random assignment. The HomeTies program director was working with DCS to increase referrals. There was considerable frustration and hostility among some of the staff regarding random assignment and the reduction in referrals. While acknowledging that random assignment was not the only problem, one supervisor believed that promises had not been kept, stating that Westat had said that referrals would increase and the state had said that they would not allow HomeTies to suffer financially--neither of these things was happening. This person noted that people's livelihoods were in jeopardy and this had a big impact on worker's attitudes and on data collection.

During study interviews with staff, the program director of HomeTies said that low referrals were having negative financial implications on the program. The state was considering reimbursing the Frayser Family Counseling at a higher rate for HomeTies referrals for the rest of the year to make up for the shortfall. (Because of the lower number of staff, it was not clear the extent to which Frayser Family Counseling was actually losing money.) The program director stressed that the agency was not accepting different cases just to meet the budget, that is, clinical decisions were not to be affected by the present shortfall.

With regard to the assumption made prior to the decision to use random assignment in Tennessee-that more families needed services than were actually referred, one of the supervisors noted that the number of families in need of HomeTies had little to do with referrals to HomeTies. He noted that relatively few DCS workers actually referred to HomeTies and that there never had been enough referrals--it was very rare that HomeTies was not able to see a family within seven days.

To allay some of staff concerns, the random assignment was changed to 70 percent treatment and 30 percent control.

Other issues related to the research and its effects on practitioners. HomeTies supervisors identified a number of other concerns related to the research:

• Supervisors had to do much more hand holding with staff in supervision because of the stress of fewer referrals/lowered caseloads and the increased paperwork related to the research cases.
• Workers said that Westat forms asked them to be judgmental and blaming toward families.
• The yes-no questions were often impossible to answer, and didn't fit complex situations.
• Westat interviewers were often not available.
• Therapists didn't like doing the contact form for each visit and thought a weekly form could be used.

Therapists noted that clients said that they liked the gift certificate from McDonalds that they get for participating in interviews and that the Westat interviewers were nice. Only one family had an issue with the consent form.

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5.4.2 Other Evaluations

Two studies are useful for understanding the development and implementation of the HomeTies Program: a study by the Tennessee Department of Finance and Administration, Division of Budget, of children in state care in Tennessee in 1989; and the evaluation of the HomeTies program by the University of Tennessee Social Work Office of Research and Public Service (SWORPS).

In 1989, during the pilot phase of the HomeTies program, the State of Tennessee conducted the Assessment of Children and Youth Committed to State Care. This report was compiled with the hope of locating inefficiencies in the current placement, tracking, and management process in child welfare. It explored the kinds of children committed to state care and the types of placements and services provided and needed by those children. Teams of professionals reviewed a random sample of 247 children (out of a total of 3,018 children) who were in various types of substitute care through the Department of Human Services as of May 1, 1989. Based on reviewers' judgments, the researchers found that 59 percent of children committed to the state's care were appropriately placed, 31 percent needed less intensive placement (including the option of not being in substitute care), and 10 percent needed more intensive placement. The study also found that too many children were placed in foster care. These and other findings from the study were used extensively in discussions with legislators to support the need to expand the HomeTies program; resulting ultimately in the dramatic increases in the program in the early 1990s.

One important limitation of this study was that only those cases in which children were already in substitute care were examined. This sample of cases skews the findings in the direction of concluding that more children need less intensive placements by: a) not examining non-placement cases, some proportion of which would likely to have been rated as needing more intensive services, including placement; and b) selecting cases only at the high end of the continuum of case severity, setting a ceiling for many of the cases on the possibility of recommending more intensive placements.

The University of Tennessee's statewide evaluation of the HomeTies program “was designed in response to both a legislative mandate and an interest in generating management information for ongoing program planning” (Homer, Cunningham, Bass, Collette, and Evans, 5/15/96). This research provides helpful descriptive information about referral sources, characteristics and problems of the population served, presenting problems in the family, prior placements, length of service termination status, and trends over time in these areas between FY93 and FY95. Some key information and findings are described below.

Demographic characteristics of children. Table 5-7 shows the age, race, and gender of children targeted as being at risk of placement for the state. For children at risk in FY95, 27 percent were under 10 years of age while 60 percent were teenagers (aged 13-18). There was no substantial change in the age of children at risk between FY93 and FY95. A large majority of the children served in The HomeTies program were white (67%), with African American children comprising 31 percent in FY95. This represented a slight increase in African American children, from 27 percent in FY93. The percentage of males grew from 52 percent in FY93 to 55 percent in FY95.

The relatively small proportion of cases referred for child maltreatment shows that, although CPS cases became eligible in 1991, the HomeTies program continued to serve a large majority of families with older children and families that were not referred because of child abuse or neglect.

Presenting problems of parents and children. The most common presenting problems of families entering the placement prevention program in FY95 were parenting issues (91% of parents), child behavior problems (85% of children at risk), family conflict (78% of parents and of children at risk), and school problems (64% of the children at risk). Running away (29%) and juvenile delinquency (23%) were other frequent problems associated with children. These items are also indicative of the types of problems of families with older children and adolescents.

Home management needs (27% of parents), concrete service needs (21%), child and parental violence (19% and 17%), parental and child alcohol/drug abuse (17% for each), and severe financial hardship (16%) were also common problems of families. Mental illness of parents was listed as a presenting problem in 13 percent of families. The three types of maltreatment — physical abuse, neglect, and sexual abuse — were each listed as presenting problems in less than twelve percent of children at risk and in a separate listing of the problems of parents. There were few changes in presenting problems or demographic characteristics over time, although severe financial hardship declined by 6 percent from FY93 to FY95 — paralleling a 7 percent decline (from 20% to 13%) in families with gross family incomes of less than $5,000 and a 4 percent decline in families with concrete service needs.

Prior out-of-home placements. For children at risk at the time of referral to the placement prevention program, 28 percent had experienced at least one prior out-of-home placement. The mean number of prior placements was 1.6 for this population. Emergency/runaway shelters (43% of all prior placements) and juvenile court (37%) placements were the most common types of prior placements — no other placement types constituted over 10 percent. It is not clear how many children were in placement at the time of referral. Given the types of prior placements experienced by children, it is possible that many children were in short-term placements immediately prior to referral.

Demographic information about parents and families. Consistent with the paucity of infants served, only 13 percent of mother figures whose age was known were younger than thirty. Fifteen percent of the mothers being served by HomeTies were single, 30 percent were separated or divorced, and 43 percent were married. Only 3 percent of fathers being served were single, 11 percent were separated or divorced, and 73 percent were married. With regard to family composition, single parent families headed by birth or adoptive mothers (with no other adults) were the most common type of family — 32 percent of all families; followed by birth or adoptive parents (16%), birth mother and other adults (15%), and birth mother with stepfather or adoptive father (13%).

Forty-four percent of mothers served were employed full time, compared with 72 percent of fathers. Twenty-six percent of mothers were unemployed, compared with 11 percent of fathers. Seventy-three percent of families had gross incomes of less than $20,000 in FY95, with 37 percent of families earning less than $10,000, and 14 percent earning less than $5,000.

Findings: Out-of-home placement. The Homer et al report examined placement status of children at termination of HomeTies and six and twelve months later. “Placement data were obtained from the Client Operation and Review System database (CORS) by matching the information about children to HomeTies information” (Homer et al., 1995, p. 79). Two limitations of the data should be noted: only first placements were counted and data on the type of placement are available only for placements at termination of services. Data on identifying information (3.0%) or placement (.6%) were missing on 3.6 percent of cases. For children who received placement prevention services in FY95:

• 85.0 percent had no out-of-home placements for one year, conversely 15 percent (n = 523) of the children were placed;
• 5.3 percent were placed at termination of services; of these 186 children, most were placed in psychiatric hospitals (28.5% of the 186 children), foster homes (23.1%), or correctional institutions (14.0%);
• In addition to the 5.3 percent of children placed at termination, another 5.2 percent were living with friends or relatives and .9 percent were classified as runaways;
• 8.1 percent were placed between termination and six months after termination; and
• 1.6 percent were placed between six and 12 months after termination.

The figure of 15 percent of children placed within one year in FY95 is substantially lower than FY94 (20.4% of children placed within a year) and FY93 (24.7% of children placed within a year). Thus, there was s 40 percent decrease in the one year placement rate from FY93 to FY95. It is not clear whether differences are due to larger numbers of records missing in previous years (704 in FY93, and 216 in FY94), a trend toward less risky referrals, or improved program targeting and outcomes.

Cost analysis. The University of Tennessee report initially recognized the limitations of studying outcomes without a comparison group. Despite this, a detailed analysis of costs concluded that over $74 million was saved by the HomeTies placement prevention program as a result of preventing various types of placements. Like other optimistic estimates of cost savings, this estimate incorrectly assumes that all children at risk would have been placed in the absence of the program.

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Exhibit A.
Other services available to referring workers in Shelby County

In addition to HomeTies, Shelby County has a large number of both in-home and office-based programs that provide counseling and some that provide concrete services. Most of these services are free to families, and few have waiting lists. They are either DCS funded programs or community based programs funded through other agencies, such as the schools. Some require TennCare (Tennessee Medicaid) eligibility, some require private insurance. The programs that front line CPS workers are using in place of, or in addition to HomeTies are:

• Life Coach, also provided by Frayser Family Counseling, is an in-home, case management program with case staffing comprised of one therapist and one supervisor. Service intensity varies depending on family needs. At minimum, there are three face-to-face visits a week. Therapists provide counseling, teaching, and concrete services including transportation. Services are funded through TennCare, the Community Mental Health Agency, (formerly ACCT), and DCS, and self pay on a fee-for-service basis. (While Life Coach is viewed as one of the most viable options for some control group cases, workers note that making a referral to Life Coach also requires considerable paperwork and involves uncertainty about whether cases will be accepted into the program.)
• Homeworks, also provided by Frayser Family Counseling, is an in-home, case management program staffed by one therapist and one supervisor. Less intensive, Homeworks therapists provide counseling and teaching services on average once a week. Services are funded through TennCare, the Community Mental Health Agency (formerly ACCT), DCS, and self pay on a fee-for service basis.
• Frayser Family Counseling Outpatient Therapy is weekly individual, couple, or family therapy. Services are funded through TennCare, Social Service Block Grant, and private insurance.
• The Exchange Club provides office based counseling in parenting and anger management. It is funded by DCS or TennCare.
• Intercept, like HomeTies, provides intensive, home-based services (24 hour availability, four to six cases a worker, service duration of three to six months, minimum of three visits a week) and is offered by Youth Village. The program requires an eight page application form. Intercept is “very expensive” and requires ACCT approval and funding but the program also accepts TennCare and some private insurance. For nearly half of the workers we interviewed, Intercept has replaced HomeTies as the intensive model of choice since the study began. This is partly because in the words of both front line staff and supervisors, Intercept has been coming to DCS to “drum up business.”
• Memphis City School Mental Health offers services for children who have been sexually abused, including child-on-child sexual abuse. While the services are free to families, there is generally a waiting list. Services funded by DCS Social Services Block Grant.
• Child Advocacy Center offers counseling to children and their parents. Services are funded by DCS, private funds, federal grants, and the city and county government.
• The Center for Children in Crises provides comprehensive evaluation (social, medical, psychological, and psychiatric) of all family members in abuse/neglect cases and makes placement recommendations. Services are funded by DCS and TennCare.
• Homemaking Services in-home services provided by the Memphis City Schools. Services are funded by DCS.
• Lakeside Hospitals, in-home service using BSI-trained staff.
• Monitor Prime, in-home services, largely case management, that are sometimes tried before HomeTies.

According to the DCS front line staff interviewed, approximately 50 to 60 percent of substantiated CPS cases are encouraged to accept some services. Jean Taylor, the CPS Program Supervisor, estimated that for control cases, over 50 percent currently go to Community Service Agencies to access services not otherwise funded by DCS. For families in treatment, most of the requests for flexible funds are to support concrete needs like home repair or specialized psychiatric services not otherwise covered by TennCare.

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Endnotes

(1) Formerly the Department of Human Services. [Back to Text]

(2) As discussed later, implementation of managed care for non-custodial services has changed this structure. [Back to Text]

(3) Sources of data for this report include Tennessee's Family Preservation/Family Support Five Year Plan (1994); Family Preservation in Tennessee, The Home Ties Interventions: Selected Findings from the Program's Operation from 1989 to 1995 (Homer, K.S. Cunningham, M.L., Bass, A.S., Collette, S., and Evans, M.S., 1996); the State of Tennessee's Assessment of Children and Youth Committed to State Care (1989); Tennessee Home Ties History, and interviews with public and private agency staff. [Back to Text]

(4) Wraparound services are not available to families receiving services in the Home Ties program, but they are available for use following intensive family preservation services as aftercare services. [Back to Text]

(5) Until 1996, the Department of Youth Development provided all youth correctional services in Tennessee. In 1996, these three agencies, along with others were combined to form the Department of Children's Services. [Back to Text]

(6) At the same time that DCS is preparing to shift to a managed care model for noncustodial cases, the state is experiencing a significant budget shortfall which threatens to eliminate large amounts of DCS prevention services. If the state is unable to raise additional funds through tax increases, the shift to managed care will probably not occur. [Back to Text]

(7) The Director of State DCS Finance reported that because networks will not bill for individual services, state finance will no longer track the exact service families receive. [Back to Text]

(8) The state's 98/99 APSR reported that funding is also coming from savings generated by the continuum of residential care. [Back to Text]

(9) It is important to note that both DCS and HomeTies staff had been concerned that many DCS workers didn't refer to HomeTies. One person estimated that 50% of DCS workers did not make any referrals to HomeTies prior to the study, suggesting a large degree of indifference to or ignorance of the program among some workers. Based on our interviews, antipathy toward the program appears to be an unlikely explanation for non-referral for most workers. [Back to Text]

(10) One worker was no longer using HomeTies because of these issues, while other staff appeared to be merely pointing out the program's shortcomings and will continue to use the program. [Back to Text]

(11) The Shelby County director explained that while rates for HomeTies had not increased since 1992, the costs of providing services have increased substantially. Consequently, he was only able to support 18 workers. Because of lower than average caseloads, he has been forced to keep the number of staff below 18. [Back to Text]

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