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Chapter VI: Program Partnerships

To meet the comprehensive service needs of families as specified in the Head Start Program Performance Standards, Early Head Start programs are encouraged to collaborate with other service providers in their communities. Early Head Start programs typically establish formal (written) or informal partnerships with a variety of community agencies, such as child care providers, health and mental health providers, and social services agencies. The purpose of these partnerships is to promote efficient linkages between Early Head Start families and partner-provided services. In essence, partnerships allow families who enroll in Early Head Start to be linked to social services without the need to seek out each separate service on their own.

Partnership agreements establish a reciprocal relationship between Early Head Start programs and partner agencies. Early Head Start programs can refer enrollees for services (or for evaluation of services needed) and, ideally, will work with the partner agency to coordinate the services and collaboratively monitor families’ progress. In some cases, particularly when a child receives early intervention services from a partner agency, interagency cooperation may help to maintain continuity in the services received in both partner and Early Head Start settings. In addition to accessing needed services for Early Head Start families, partnership agreements enable Early Head Start programs to have a wider influence in the community. For instance, partnerships with community child care centers that include provision of training, information, and, possibly, access to materials and additional staff, can help to improve the quality of child care for children not in Early Head Start.

In this chapter, we describe Early Head Start programs’ partnerships with a variety of community agencies, most notably child care providers, those offering specialized services for children with disabilities, and providers of basic health and mental health services. We draw primarily on survey data; illustrative examples from site visits are described in text boxes.

EARLY HEAD START COMMUNITY PARTNERSHIPS

Early Head Start programs’ success in establishing partnerships with a variety of community agencies is one marker of the place programs hold in their communities. Overall, Early Head Start programs seem to have important roles in their communities. Ninety-five percent of programs participate in a local collaborative group of service providers; among programs participating in such a group, about three-quarters report they hold a leadership position. Further, many programs have established formal partnerships with key service providers in their communities, specifically child care, health, and mental health providers. The number of actual partnerships varies considerably and is related to community and program features, therefore we report on the number of different types of providers with which programs have formal partnerships. Nearly all programs have at least one formal partnership with a community provider (92 percent).1 One-third of programs have partnerships with three types (child care, health, and mental health) of providers asked about in the survey. The variety of partnerships may indicate the extent to which programs are integrated in their communities and may facilitate collaboration between and among various providers serving the same families.

PARTNERSHIPS WITH COMMUNITY CHILD CARE PROVIDERS

Early Head Start programs may pursue partnership with child care providers in the community to provide center-based services (Early Head Start slots) to enrolled children. Some center-based programs provide all services directly, others rely on partners to provide some or all of their center-based services. One notable finding from the survey is that formal partnership agreements with child care providers are relatively common. However, as we compare these findings with the ways that programs report serving children (see Chapter IV, Table IV.2), it is apparent that some programs are not using those partnerships for Early Head Start center-based slots at a given time. More than 40 percent of programs report having formal partnership agreements in place with child care providers, but fewer than 30 percent of programs report serving children through a child care partner. Possible reasons that some programs do not provide Early Head Start services through existing partners are that (1) the partnerships are with resource and referral agencies, (2) some programs may have what we consider to be “potential partnerships” that, although currently unused, may have been used in the past and will become active again as slots are needed, as funds become available, or if families choose to use the center, or (3) programs may have lapsed partnerships, with an agreement still in place with an inactive partner. Reasons for this may include a center’s location not being convenient for current families, or a partnership no longer used due to quality issues and the partner’s unwillingness or inability to meet performance standards. Box VI.1 describes features of child care partnerships in greater detail.

Among programs with formal child care partnerships (N = 268), more than 90 percent have agreements to coordinate services, exchange referrals, and share staff training. Nearly as many of the partnership agreements include provisions for technical assistance. Most agreements stipulate quality-of-care issues, such as requiring the partner to adhere to the performance standards, evaluate quality, allow the program to monitor quality, and conduct improvement planning (82 to 89 percent). About 81 percent of agreements include provisions for payments to the partner for child care slots (Figure VI.1).

BOX VI.1 CHARACTERISTICS OF CHILD CARE PARTNERSHIPS Early Head Start performance measures call for partnerships with child care providers to help expand the services programs can offer to Early Head Start families and to enhance the quality of child care available in Early Head Start communities. Site visits to Early Head Start programs offered an opportunity to explore the reasons some programs establish child care partnerships, especially for center-based placements; the structure of those partnerships; and the factors that can make partnerships difficult to establish or sustain. We specifically selected some programs that offered services through child care partners and other programs that had inactive partnerships for site visits. Here we present more information gathered in site visits. Programs’ motivations for establishing child care partnerships, according to staff interviews, include making center-based care available to families in home-based programs, increasing the capacity of center-based programs, and helping other child care providers improve the quality of their services. Staff at some home-based programs (where formal child care partnerships are most prevalent) note that establishing partnerships is important for helping parents access child care when they are working or in school. Several center-based programs partner with other child care providers to provide additional center capacity or to extend the hours that care is available, bridging the time between the end of the Early Head Start day and the end of parents’ work days. Finally, staff at a few programs specifically mentioned an interest in helping other providers achieve a higher standard of care. The director of one program notes quality improvement as a primary motivation for establishing a partnership with a private center operating under the same agency auspice. Staff members describe child care partnerships structured around such activities as financial support, joint staffing, and training or technical assistance. Some programs pay for slots in a partner center or make payments to the partner to enhance the salaries or benefits of teachers working with Early Head Start children. In one program we visited, the Early Head Start agency directly hires and supervises staff working in partner centers. Under some partnerships, Early Head Start specialists provide services to children and families in the partner centers, sometimes only to Early Head Start children and less commonly to non-Early Head Start children as well. Many partnership agreements also include provisions for specialists and managers to provide training and technical assistance on a variety of topics to partner agencies and their staffs. Another common aspect of partnerships is quality monitoring of partner centers, with programs typically using procedures similar to those used for their own in-house monitoring. Depending on the partnership arrangement, monitoring may focus on the partner’s entire facility or on just those classrooms where Early Head Start children are present. Staff members note the challenges of establishing or maintaining partnerships, ranging from partner agencies’ difficulty meeting standards to financial and logistical coordination. During site visits, staff at several programs shared examples of collaborations that broke down because partners—both centers and family child care providers—were unable to meet the quality standards required of Early Head Start providers. Programs also encounter problems with the reliability of funding for placements. For example, a partnership based on the assumption that parents will be eligible for child care subsidies (to help pay for care at a partner center) is vulnerable to the possibility that parents will lose their eligibility for subsidies or may move in and out of eligibility. One program we visited had opted to reduce slots with partners and open its own center because of this problem. Staff mentioned other financial issues, such as managing differences in the compensation levels of Early Head Start and non-Early Head Start teachers in the same center or classroom, and logistical challenges, such as coordinating training schedules for Early Head Start and partner staff. Finally, staff in at least one program note that the amount of effort required to establish and support a partnership can seem high relative to the number of children they can actually serve through it. The level of coordination and technical assistance required to operate a successful partnership may be the same whether the partner serves only a few individuals or several classrooms of Early Head Start children.

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Beyond serving individual children and families, Early Head Start also strives to improve the availability of services for infants and toddlers in the wider community, in part through improving the quality of child care. Frequently, programs open training to all staff at partner centers, even those not directly serving Early Head Start children. The performance measures specify that Early Head Start programs assist families in obtaining high-quality child care, and programs do so in a variety of ways. Box VI.2 describes the ways that programs interpret their responsibility to help families find non-Early Head Start child care and how they ensure this care is of sufficiently high quality.

PARTNERSHIPS WITH PART C PROVIDERS

Part C of the Individuals with Disabilities Education Act is a federal grant program that helps states operate a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through 2 years, and their families. Partnerships between Early Head Start programs and Part C agencies are particularly salient, not only because performance measures recommend linkages and coordination between them, but also because Early Head Start begins as children are at ages when early intervention may be most effective. As we note elsewhere, the performance standards require Early Head Start programs to make 10 percent of slots available for children with disabilities. Coordination with Part C agencies is one way to reach children with special needs. Using survey data primarily, we describe the prevalence and use of these partnerships.

BOX VI.2 WORKING WITH PARTNERS TO ENSURE QUALITY CHILD CARE IN EARLY HEAD START Early Head Start is charged with enhancing the quality of child care in communities through two performance measures: “Enhance the quality of local child care services through the sharing of resources, training, and knowledge” and “Help parents secure high-quality child care in order to work, attend school, or gain employment training.” The survey provided information on the prevalence of formal child care partnerships and use of them to provide Early Head Start center-based services, a topic discussed in greater detail in this chapter. We learned that more than 40 percent of programs have formal partnerships with child care providers, although not all programs use them for Early Head Start slots. We use site visit data to elaborate on these findings and to better understand how programs ensure quality child care in partner centers. The rest of the text box presents site visit data. Programs that offer center-based care monitor quality closely, whether the care is offered directly by the program or by a partner. Programs use a variety of methods of quality assurance in child care centers, generally including regular classroom observation, provider training, and use of standardized assessments. A few programs we visited feel that Early Head Start has improved the quality of care available, even outside of the program, through its monitoring and technical assistance activities. Chapter V discusses child care quality assessments in greater detail based on survey findings. Few programs make direct referrals to child care providers who are not formal community partners. Several programs have partnerships with local child care resource and referral agencies (CCR&Rs) and refer families there to access child care. Few of the visited programs track the use of child care not provided by Early Head Start or their community child care partners, although one program has begun to do so because the question appeared on the PIR last year. To determine whether a provider is meeting sufficient quality standards, this program requires regular staff training (that the program provides), holds annual health and safety screening, conducts classroom observations using the ITERS, and drops in for unannounced visits to observe informally. Staff members in many programs know about other child care arrangements that families use, even if the program does not formally track their use.

Nearly all Early Head Start programs have a formal partnership with at least one Part C provider, reflecting the program’s strong emphasis on early identification and treatment of developmental problems. Partnership agreements with Part C providers include three basic elements: referrals to and from each program, sharing assessment results, and holding staff meetings (89 to 99 percent for each). Although a third of programs report other features, these vary widely. Three percent of programs include service coordination in their partnerships, and two percent are SpecialQuest participants (Figure VI.2). SpecialQuest is a program developed by the Hilton Foundation as part of the Hilton/Early Head Start Training Program. These trainings are specifically designed to increase Early Head Start and Migrant and Seasonal Head Start capacity to provide excellent services to infants/toddlers with disabilities and their families.

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Identifying and Referring Children with Disabilities

The process of identifying children with disabilities occurs in stages, with several steps required for children to receive services from early intervention partners. The steps involved are (1) suspect a disability and share this concern with the family, (2) refer for further assessment, (3) conduct the assessment, and (4) provide services to those eligible (Figure VI.3). We rely on survey data to describe these stages and report these data based upon average proportions of children within programs at each stage.2

The first step occurs when staff suspect, or an initial screening indicates, a problem. Programs are mandated to conduct an initial developmental screening within 45 days of enrollment. The average proportion of children about whom staff have a concern warranting further evaluation and referral is 21 percent. (Not all children referred may have a problem serious enough to warrant special services or meet the eligibility requirements for Part C.)

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Among all enrolled children, about four percent have not yet been referred for further evaluation, although programs had concerns about them. When a problem is suspected, programs may choose to wait and reassess the child before referring the child to Part C, in case the child was having an “off day.” We note that the average may be misleading, as nearly half (45 percent) of the programs report there are no children they suspect have a problem but have not yet referred. Among programs that report at least one child awaiting referral, the range is between 1 and 43 children, although most report no more than 5.

When a suspected problem reaches a given threshold of severity (this may differ across programs), the child will be referred to a partner for further evaluation. On average, across programs, 17 percent of children who have been referred for evaluation are still awaiting it (Figure VI.4). We are particularly interested in this group, because the percentage indicates that children who may need services are not receiving them (Box VI.3).

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BOX VI.3 POSSIBLE IMPEDIMENTS TO EVALUATING REFERRED CHILDREN During site visits, we explored some possible reasons that children may be “stuck” after being referred for evaluation, but not yet having been evaluated. The two primary explanations are (1) parent reluctance to follow through with the evaluations and (2) lack of resources. Most commonly, reluctance is based on concerns about labeling the child as having special needs or denial that the child has any problems. These attitudes may be reinforced at times by physicians who are willing to wait and see whether children outgrow the problem. Cultural barriers may also be behind parental reluctance to seek treatment for their children. Resource issues include lack of adequate transportation for parents to take children to appointments, long delays before Part C staff conduct evaluations (providers have 45 days to complete their assessment), and low availability of specialized services (such as speech/language) or the home-based therapies that parents prefer.

Children who are ineligible do not have disabilities severe enough to receive Part C services. On average, few children (7 percent) who are evaluated are found to be ineligible for Part C services, indicating that program staff rarely make inappropriate referrals. Eligibility requirements vary by state, so a child may meet the threshold for services in one state and not in another.

Two-thirds of the children evaluated by Part C and found eligible receive the services they need from Part C partners. However, a few (16 percent, on average), although eligible, are not receiving services. This gap may be a result of limited access to certain services or delays in accessing services.

Children referred for emotional/behavioral or communication concerns were least likely to be receiving services. We asked programs to report the stage of evaluation for each child by his or her primary concern (emotional/behavioral, communication, developmental delay, sensory impairment, physical/orthopedic impairment, or other impairments). On average across programs, about 75 percent of children referred for concerns other than emotional/behavioral or communication had been evaluated, were found eligible, and were receiving services. In comparison, only 47 percent of children referred for emotional/ behavioral and 62 percent referred for communication disorders were receiving Part C services. Children referred for emotional/behavioral disorders were most likely to be awaiting evaluation—on average, 30 percent referred for evaluation had not yet been evaluated, more than twice as high as the proportions of children referred for other disorders (ranging from 10 to 14 percent of referred children across programs). Fear of social stigma may be a factor in keeping these children from formal evaluation and/or Part C programs may have fewer assessments or less expertise in diagnosing problems in these areas at such young ages. Children referred for communication disorders were slightly more likely to be awaiting evaluation (19 percent, on average).

PARTNERSHIPS WITH HEALTH PROVIDERS

An important aspect of the comprehensive services mandated by the performance standards, as well as the performance measures, is to ensure appropriate linkages between families and community health services. In the health care field, this is generally referred to as ensuring that children have a “medical home.” To prevent families from having treatment only for acute care or emergencies, Early Head Start strives to link them with health care providers for well-baby checkups, immunizations, and routine care. Programs also try to help families see the value of seeking routine preventive care even when their child is well.

Just over three-quarters of programs have partnerships with health care providers; the provisions of these agreements do not vary greatly across programs. Most include consultation and services for pregnant women; services are more likely to be provided off-site than at the Early Head Start program. Two-thirds include provisions to pay providers for health care services (Figure VI.5).

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PARTNERSHIPS WITH MENTAL HEALTH CARE PROVIDERS

Because of the high rate of mental health and substance use issues in populations served by Early Head Start (ACYF 2002; Knitzer and Yoshikawa 1997), identifying mental health needs and accessing treatment for children or their families is another area in which partnerships are key. Apart from parents and adult family members who may struggle with chronic mental health issues, infant mental health is also an important component of Early Head Start services. Infants and toddlers experience the gamut of emotions, and healthy development requires them to gradually take on more of the responsibility to regulate their interactions, attention, and behavior. To support positive emotional and social development, adults must understand their role in facilitating children’s capacity to regulate their emotions, explore their environments, and communicate with adults (Zero To Three 2001).

Among programs with formal mental health partnerships, nearly all agreements include consultation (98 percent, Figure VI.6). Other common features of these partnerships are providing training for Early Head Start staff and providing services at Early Head Start programs or elsewhere (all 90 percent).

More than 80 percent of programs have formal partnerships with mental health providers. Nearly all (92 percent; Figure VI.7) programs screen for mental health problems, and 98 percent provide referrals. Services may be provided at the program site, either through partners or their own staff members, or elsewhere, such as at the provider’s office. Programs reported the proportion of enrolled families that receive mental health services at the program, referrals, or both places. The overlap among programs is high, but 70 percent of programs report that at least some families received services only at the Early Head Start program. Eighty-one percent report that at least some families receive services only through referrals, and 79 percent of programs report at least some families receive service both at the program and through referrals (not shown).

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OTHER SCREENING AND REFERRAL SERVICES

Early Head Start programs play a key role in identifying health and mental health needs of families and getting them needed services. Programs can conduct screenings themselves or use consultants or community partners. Almost all programs (99 percent) report conducting developmental screenings—as expected due to performance standards requirements for ongoing assessment (see Chapter V). Most programs offer mental health, hearing, and vision screenings (all more than 90 percent), while dental screenings are offered by 85 percent of programs. Physical examinations and immunizations are offered by 70 percent of programs. Although not specifically asked, programs wrote in about other screenings they offer. About 15 percent of programs report providing lead, 9 percent nutrition, and 2 percent speech screenings (Figure VI.6).

When looking to fulfill the needs of families, programs can provide services themselves within the program using Early Head Start staff, by forging connections with community partners to provide services either on- or off-site, or by referring children and families to other community agencies with whom they do not have formal partnership agreements. We asked about the types of services for which programs provide referrals and found that most programs provide referrals for myriad services. Most infrequent service referrals are for English language learners (81 percent), transportation assistance (84 percent) and child care (87 percent; Table V.1). About 90 percent or more of programs report referring families for other services such as emergency assistance, disability services, or employment assistance. Although we cannot tell which specific services are provided by programs or through their partners, partnerships are most common for health, mental health, and disability providers, for each, more than 80 percent of programs have formal partnerships with some or all such providers. Least common are partnerships with legal, financial counseling or transportation providers (Table VI.1).

Table VI.1. Early Head Start Service Referrals

Type of Referral	Percentage of Programs	Partnerships with Some or All Providers a
Child Care	87.3	54.5
Health Care	99.0	78.2
Prenatal Care	95.6	66.2
Mental Health Care	98.1	83.7
Transportation Assistance	84.3	38.8
Disability Services	98.8	93.6
Employment Assistance	96.8	55.2
Emergency Assistance	98.3	46.2
Education or Job Training	97.5	58.5
Drug or Alcohol Abuse	93.9	46.1
Legal Assistance	90.4	29.2
Housing Assistance	98.2	46.2
Financial Counseling	88.5	37.3
Family Literacy	94.4	62.0
English Language Learner	80.6	52.1
Other	16.9	--
Sample Size (Programs)	562-598	440-576

Source: Survey of Early Head Start Programs. a Among programs that make such referrals.

KEY POINTS

• Ninety-five percent of programs participate in a local collaborative of service providers; of those, 75 percent hold leadership positions.

• Ninety-two percent of programs have at least one formal partnership with a community provider, and about one-third have a partnership with a child care, health, and mental health provider.

• More than 40 percent of programs report having formal child care partnership agreements in place, and 30 percent of programs report serving children through them.

• Among programs with child care partnerships, more than 90 percent have agreements to coordinate services, exchange referrals, and share staff training. Nearly as many of the partnership agreements include provisions for technical assistance.

• Nearly all programs have a formal partnership with a Part C provider, an important avenue for early intervention. Only 4 percent of all Early Head Start children have a suspected disability but have not yet been referred for further evaluation.

• About 60 percent of children evaluated for services are receiving them. Only 6 percent of those referred are found ineligible for Part C services. Seventeen percent of children who have been referred for evaluation were still awaiting evaluation at the time of the survey. Among referred children 16 percent had been evaluated and found eligible for Part C services, but were not receiving them at the time of the survey. Children referred for emotional/behavioral or communication disorders were least likely to be receiving services and more likely to be awaiting evaluation.

• About three-quarters of programs have partnerships with health care providers and more than 80 percent have partnerships with mental health providers. Many programs provide services at their facility and through referrals.

• Relatively few programs offer screenings for speech, blood work, nutrition, or lead. About 70 percent of programs offer physical examinations or immunization screenings. Eighty-five percent offer dental examinations.

• Nearly all programs offer developmental, mental health, hearing and vision screenings.

• Ninety percent or more of programs refer for myriad services such as emergency assistance, disability services, or employment assistance. Fewer, but still substantial proportions, refer for transportation assistance and child care.

• Among programs providing referrals the proportion reporting formal partnerships with some or all providers is much more variable. Most common are health, mental health and disability partnerships; least common are legal, financial, or transportation provider partnerships.

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