Lessons Learned

Lessons Learned from States' Experiences with Assisted Guardianship

Although the States' substance abuse waiver demonstrations differed from one other along several important dimensions, they experienced some common problems regarding case identification, participation in assessment, referrals, and service coordination. The demonstration States have not been alone in facing these problems; other substance abuse programs have experienced similar problems in recent years (U.S. Department of Health and Human Services, 1999). Although the approaches taken by demonstration States may be promising, these challenges underscore the continuing need to refine the policies and procedures for providing substance abuse services to caregivers involved in the child welfare system.

In reviewing the issues and findings presented in this synthesis paper, several important lessons emerge that serve as useful guidelines to other States considering substance abuse waiver demonstrations:

To maximize referral rates, States must examine their assumptions regarding the identification of substance use disorders and carefully define the target populations for their demonstrations.

All of the demonstrations operated under the assumption that significant proportions of their child welfare caseloads had caregivers with substance use disorders. Some States further assumed that child welfare workers could easily identify these cases and would readily refer them for enhanced substance abuse services once such services were made available. It appears, however, that the States overestimated the number of caregivers who would actually be referred for services. This was especially true in Delaware, Maryland, and New Hampshire, States in which child welfare staff were expected to identify caregivers with a substance problem soon after they entered the child welfare system. The referral process in these three States was further complicated by their inclusion of both in-home and out-of-home cases. Illinois' demonstration, by contrast, only included caregivers with children placed in foster care and who had already been referred for substance abuse treatment by a licensed substance abuse specialist. Illinois' more focused definition of its target population made the referral process less problematic. Once initial case coordination problems had been resolved, referral rates in Illinois increased to levels similar to those anticipated at the start of its demonstration.

Child welfare staff need early and ongoing training regarding substance abuse waivers.

Although demonstration States routinely informed staff about the existence of new substance abuse waiver demonstrations, interviews and focus groups with frontline staff often revealed a lack of knowledge about the substance abuse services available through the waiver and the eligibility criteria for receipt of waiver services. In light of the significant problems with turnover in child welfare workers and substance abuse specialists noted in some States, it is also important to develop mechanisms to repeat training for new staff regarding waiver services and eligibility criteria.

Front-line child welfare staff need better training and tools to identify the presence, nature, and severity of substance use disorders.

Although child welfare workers may have a "hunch" about suspected alcohol or drug abuse, they may be reluctant to confront clients openly about a substance abuse problem and make a formal referral for treatment services. The challenge of identifying a probable substance use disorder consistently and accurately was most prevalent in Delaware and Maryland, States that relied on child welfare workers to make an initial determination of likely abuse or dependency and to refer caregivers to the waiver demonstration. This problem was less marked in Illinois, a State in which trained substance abuse specialists conduct formal assessments and make treatment recommendations for caregivers before they enroll in the demonstration.

Identifying the nature and severity of a substance use disorder often involves the administration of formal screening and assessment tools to assist in classifying and documenting drug and alcohol problems. Although New Hampshire and Illinois used licensed substance abuse specialists who followed formal protocols in identifying and assessing substance use disorders, Delaware and Maryland relied in part on child welfare workers with limited training and skill in conducting substance abuse screenings. Maryland in particular identified several instruments it planned to administer as part of a "global" assessment of caregiver and family needs, but it remains unclear to what extent waiver staff employed these tools or whether they received adequate training in their use and interpretation. This lack of training in the use of formal screening or assessment instruments may have exacerbated the problems experienced by staff in some States in identifying and documenting caregivers' substance use disorders. The administration of screening and assessment instruments by trained workers using standardized protocols would improve the systematic measurement of substance abuse and dependency among caregivers in the child welfare system and might increase workers' confidence in making appropriate service referrals.

Substance abuse treatment-child welfare collaborations are most successful when backed by strong managerial support.

Strong managerial support is needed to encourage workers to make referrals to substance abuse demonstrations and to adopt innovative practices in working with the families of substance-abusing caregivers. Delaware in particular noted the importance of supervisory support to facilitate referrals to its waiver program and to promote joint case planning by child welfare workers and substance abuse counselors.

Successful demonstrations require careful service coordination and consistent communication between child welfare staff and substance abuse professionals.

The experiences of all States highlight the need to coordinate service planning and case management activities between child welfare and substance abuse treatment personnel. The mere co-location of substance abuse professionals in CPS offices will not ensure that workers communicate about their cases. Successful service coordination requires the establishment of formal systems to share case information and to keep all staff informed about caregiver progress.

Successful substance abuse demonstrations have access to adequate and appropriate substance abuse treatment resources.

States based their substance abuse waivers in part on the assumption that adequate inpatient and outpatient treatment services would be available and accessible to clients. As Delaware's experience demonstrates, this assumption is not always valid. States need to coordinate with appropriate public and private treatment agencies to ensure access to adequate and suitable treatment services for caregivers with substance use disorders. Residential treatment facilities, particularly those that allow caregivers to reside with their children while they receive treatment, are of special importance.

States need reliable information tracking systems to promote the coordination of case management services and to improve the quality of evaluation data.

To support improved case management and service coordination, States must develop comprehensive and reliable tracking systems that give child welfare staff access to information on clients' treatment status, including treatment compliance and the results of drug tests. In addition, the establishment of effective information systems will strengthen the evaluation of substance abuse demonstrations by facilitating the collection of detailed process data associated with all stages of casework, from case referral through post-treatment follow-up. A broader range of information will increase States' understanding of what is required for the child welfare system to respond effectively to the needs of caregivers with substance use disorders.

To ensure cost neutrality in the context of a title IV-E waiver demonstration, States must carefully define the eligibility criteria of their target populations.

It is important to note that three of the four demonstration States (Delaware, Maryland and New Hampshire) made substance abuse treatment services available to all cases assessed as having a caregiver with a substance use disorder. These cases included those in which children remained at home while waiver services were provided. Due in part to the broad definition of their target populations, these States experienced greater difficulty in achieving cost neutrality; in other words, the costs of serving families in their experimental groups were not offset by decreases in foster care spending adequate to ensure cost neutrality. In contrast, Illinois targeted its demonstration on caregivers whose children were already placed in foster care and focused on the goals of early reunification and preventing placement re-entry. By limiting the eligible population to foster care cases, States are more likely to avoid spending more title IV-E funds than they would have spent in the absence of the substance abuse waiver. Although in-home cases may indeed benefit from the enhanced services offered through the substance abuse waiver demonstrations and such services may produce cost savings in other areas over time, States may find it easier to realize title IV-E savings by targeting caregivers with children already in foster care.

At present, States implementing substance abuse waiver demonstrations have reported mixed success in improving substance abuse treatment and child welfare outcomes. The Maryland demonstration ended early due to a lack of program referrals, while both Delaware and New Hampshire have experienced difficulties with maintaining cost neutrality. Preliminary findings from Illinois suggest that its program may enhance access to treatment services, shorten the duration of foster care placements, and reduce the risk of maltreatment recurrence while realizing cost savings for the child welfare system. However, no State has been successful to date in promoting significantly greater rates of reunification or other forms of permanency. Other States considering the development of new interventions for families with caregivers experiencing substance use disorders are encouraged to study the lessons learned from these early demonstrations.

Back to Table of Contents

Next Steps

Final evaluation reports from New Hampshire and Illinois are forthcoming in July 2005 and December 2005, respectively. Results from these and future substance abuse waiver demonstrations will produce additional insights into the issues discussed in this synthesis paper and will further enhance our knowledge regarding the characteristics of successful substance abuse programs and their potential benefits for children, their parents, and the child welfare system.

Back to Table of Contents

References

Government Accounting Office (1994). Foster care: Parental drug abuse has alarming impact on young children (Rep. No. HEHS-94-89). Washington, DC: Author.

_________ (1998). Foster care: Agencies face challenges securing stable homes for children of substance abusers. (Rep. No. HEHS-98-182). Washington, DC: Author.

Illinois Department of Children and Family Services (1995). Child protection and child welfare services fact book, FY 1995. Springfield, IL: Author.

Institute for Health and Recovery (1998). Project on addressing substance abuse. Springfield, MA: Massachusetts Department of Social Services.

National Center on Addiction and Substance Abuse at Columbia University (1999). No safe haven: Children of substance-abusing parents. New York, NY: Author.

U.S. Department of Health and Human Services (1999). Blending perspectives and building common ground: A report to Congress on substance abuse and child protection. Washington, DC: U.S. Government Printing Office.

Young, N., Gardner, S. L., and Dennis, K. (1998). Responding to alcohol and other drug problems in child welfare: Weaving together practice and policy. Washington, DC: Child Welfare League of America Press.

Back toTable of Contents