Children's Bureau Website - Colorado - Expedited Reunification Services

Colorado

Demonstration Type:	Managed Care Payment System¹
Approved:	September 14, 1999
Implemented:	October 26, 2001
Completion:	June 30, 2003²
Final Evaluation Report Expected:	August 25, 2003

Target Population

For this managed care project, eligible children were those ages ten and older who were assessed as being at high risk of, or were already experiencing, “placement drift” and/or were at significant risk of aging out of the system without a permanent relationship with a family. Children in high-cost residential care were also included.

Jurisdiction

The demonstration operated in Arapahoe County.³

Intervention

County child welfare agencies were to negotiate a payment rate with a private provider to deliver necessary services. The agreement included the identification of risk-sharing formulas, penalties, and performance-based incentives. The provider was to take responsibility for delivering intensive residential care, manage cases to move children to less restrictive levels of care, ensure that an array of prevention and intervention services were available, and otherwise arrange for all services for referred children and families.

Consistent with the original agreement, Arapahoe County negotiated a risk-based, performance-based contract with a consortium of service providers. Each month, the County paid the consortium established rates for case coordination and residential treatment for each client referred. Non-residential services were paid on a fee-for-service basis.

At the end of the contract period, the State calculated average costs for children in the experimental and control groups (excluding the most costly five percent of children in each group). If experimental group costs were lower than control group costs, the provider received full reimbursement for their costs, plus a share of the savings, up to a specified limit. If experimental group costs were higher than control group costs, the provider was responsible for a portion of the higher costs, up to a specified limit.

The demonstration focused on children from Arapahoe County who were determined to be in need of intensive residential services. These children were referred to Arapahoe County’s Pathways Team, a multi-agency team that approves all residential treatment center (RTC) level care.

Evaluation Design

The evaluation design consisted of process, outcome, and cost-effectiveness components. The County, in conjunction with the project evaluator, assigned eligible children randomly to experimental (managed care) and control (traditional fee-for-service) groups in October 2001.

In the experimental group, children approved for residential treatment care were served by a formal network of RTCs known as Colorado Care Management (CCM), delivering RTC-level and post-discharge care under a per-case, risk-sharing agreement. For the control group, children approved for RTC were placed at an RTC outside the CCM network.

The State planned to use the following outcome measures: rates of subsequent incidents of substantiated abuse and/or neglect, rates of family reunification, length of time in out-of-home placements, number of adoption disruptions, and measures of child and family functioning.

Premilinary Findings

Although the demonstration was expected to continue until 2006, it officially ended on June 30, 2003. Colorado attributes this to State budget problems and the fact that no additional counties participated. The following findings are based on the State's Final Report, which analyzed information through March 31, 2003.

Process Findings

Colorado reported that the following challenges caused delays in implementation:

Staff turnover: Personnel changes occurred in the State IV-E waiver liaison position, as well as in key county administrative staff positions.

Development of a fixed rate: The State faced challenges in determining payment rates based on the average case in out-of-home care, including difficulty gathering data and defining costs and funding sources.

Existing payment and claiming systems: The State operates with a fee-for-service reimbursement system. The State also needed to develop a method of allocating IV-E costs to experimental and control groups.

Due to the challenges in developing a fixed payment rate based on incomplete historical data, Arapahoe County developed an agreement with a provider network to define the case rate based on information gathered over time. The State and County identified financial variables and developed a tracking process for those variables. Financial tracking related to community-based services, however, continued to be difficult due to the fact that it required periodic manual entry.

There were 142 children participating in the demonstration as of March 31, 2003. Of these, 65 were in the experimental group and 58 were in the control group. Additionally, 19 children were included in the experimental group through a clinical override process. The State reports the following process findings:

At the time of placement, 74 percent of children in both groups had goals of reunification. For 60 percent of children, their prior living arrangement was in secure detention, while 13 percent were in foster family or group homes. Eleven percent had been in an inpatient psychiatric hospital or unit, while 9 percent were in the home of a parent or guardian. Remaining cases were referred from residential treatment or shelter care.

During the study, 39 percent of children experienced more than one RTC placement. There were no differences between the experimental and control groups on this variable.

The time necessary for those children who required sexual offender treatment to secure placement was slightly longer, although this difference was not statistically significant.

There was a notable difference between experimental and control groups in the number of children who were placed within one month. For the experimental group, only 44 percent of children were placed within one month, versus 71 percent for the control group. This was attributed to the fact that control group participants were generally added to waiting lists more quickly than children in the experimental group, given the structured admission process for CCM services.

Outcome Findings

Due to the early termination of the demonstration, sample sizes were insufficient to measure outcomes post-discharge. As of March 31, 2003, only 34 of the total participants in both experimental and control groups had completed treatment. The State concluded that this short time frame and small number of children having completed treatment were insufficient for reaching any statistically significant conclusions. However, the State noted that it was beginning to see a trend toward shorter lengths of stay and improved outcomes for the experimental group, which had received services through Colorado’s managed-care providers.

Arapahoe County and Colorado Care Management were pleased with the progress of the demonstration activities. They plan to continue the demonstration and evaluation without State involvement.

¹ Based on information submitted by the State as of August 2003. Back

²Colorado’s demonstration project was originally a five-year project; the State terminated the project early due to State budget constraints and a lack of interest among counties. Back

³Although the waiver specified that the State could implement the project in multiple counties, only one county participated. Back

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