Outcome-Based Social Welfare "Reform" in Rhode Island

Rhode Island Department of Children, Youth, and Families Performance Improvement THE CHALLENGE Rhode Island’s governor requested the GPL's assistance in turning around the state’s troubled child welfare agency (DCYF). DCYF ranked as the fourth worst child welfare system in the country in the share of youth in state care living in group settings rather than with families and second worst in the percentage of children re-entering DCYF care after family reunification. Icon THE PROJECT The GPL worked with DCYF on strategic planning to assess service needs and design an approach for improving services for children and families, executing a results-driven procurement for a new set of service contracts, strengthening their contract and provider performance management practices, and designing a strategic procurement management system to improve the results of contracted spending throughout the agency. Icon THE INNOVATION DCYF has reduced the number of children in group care by over 20 percent, reduced the number of children entering state custody due to the improved performance of preventative services, dramatically expanded its portfolio of family-based services and supports, and strengthened the department’s financial controls and contract management practices. See Full Project Description THE CHALLENGE: In January 2015, Rhode Island’s Department of Children, Youth, and Families (DCYF) faced a series of pressing challenges. Outcomes for children and families in DCYF care were among the worst in the country, with critical numbers of foster children living in group settings rather than with families, high rates of removals of abused and neglected children into protective custody, and an alarming frequency of repeat maltreatment. Since 2011, most family preservation and placement services for children and families had been contracted, delivered, and paid for through two networks of care, each managed by a lead agency that subcontracted with 8-14 direct care providers. Yet DCYF had little understanding of what interventions were being delivered for those dollars, the relative effectiveness of different services in preventing maltreatment and readying families for successful reunification, and where there were gaps in the service array that resulted in children and families being placed on waitlists or referred to second-choice programming. Siloes between case management, contract and fiscal compliance, and program evaluation units stymied agency performance improvement efforts, as no single unit was accountable for driving ongoing improvements in outcomes for children and families. Some program-specific outcome data was periodically reported on DCYF’s website, but time lags and aggregation among providers made it difficult to draw connections between specific practices and results. Performance implications of provider data was not regularly discussed with frontline staff nor was input regularly solicited about areas for improvement. Incidents of poor performance were often addressed in isolation, with cures specified through one-off, provider-specific corrective action plans without sharing lessons learned with peer providers. The result was an agency that spent approximately 40% of its budget on contracted services, yet did not know if the children and families it care for were receiving services that improved their chances of safely and permanently living together. THE PROJECT: The GPL provided DCYF with pro bono technical assistance to transform service delivery by 1) overhauling the mix of family preservation and placement-based services available to address the needs of families involved with the department, and 2) establishing a data-driven approach to overcome internal siloes and collaborate with providers to improve client results: 1. Restructuring the agency’s array of family preservation and placement-based contracts to expand services that keep children with families As a first step, the GPL helped DCYF to strategically assess its service needs and design an approach for improving services for children and families. More than 5,000 pieces of unique input were collected from DCYF frontline caseworkers, department supervisors, direct care providers, and other stakeholders on service needs, expansion priorities, programs with frequent waitlists, and opportunities for new interventions. These stakeholders highlighted services where inadequate capacity had resulted in waitlists and others where excess capacity had made it difficult for providers to cover the fixed costs of keeping a program open. Shifting needs of at-risk children and families – such as the growing frequency of human trafficking and sexual exploitation among young women – had not been matched by evolutions in services available to them. Many providers cited a need for new contract structures that helped them fund startup activities for new programs and gave that better information from the department about the long-term outcomes of their clients. Due to these and other operational challenges, DCYF determined that all network functions would be transitioned back to the department. With this change, the state had an opportunity to redesign the array of services under contract. Three strategic priorities had emerged as the organizing principles for the changes: shift spending to services that could safely support and maintain children in their homes and family-based foster care rather than group care, increase the volume of programming backed by research and evidence, and spur innovation with new high-quality, cost-effective services. In March 2016, the state released a request for proposals for Home- And Placement-Based Services to Improve Outcomes for DCYF Children, Youth and Families. DCYF’s solicitation reflected its redesigned service array, which was organized around 15 outcome-based service categories that were based on subpopulation needs and tied to specific performance objectives. Unlike conventional solicitations that request that vendors deliver a predetermined service model, the procurement asked providers to propose the programs, supports, and resources that would best enable children and families to achieve any of the prioritized outcomes. The flexible nature of the solicitation leveraged the expertise of local experts and community providers to offer programs not previously considered by DCYF. Once contracts were in place, this framework also enabled more consistent matching of families and children to services based on client needs rather than caseworker familiarity. 2. Strengthening performance management practices to drive continual improvements in results of contracted services delivered to clients As DCYF revamped its service array, it recognized the need to implement better practices for effectively managing those newly contracted resources. In early 2016, DCYF began piloting active contract management strategies with the state’s four regional providers of community-based voluntary prevention services for families at risk of maltreatment. Each month, agency leaders from programmatic and contract oversight units met with executives and program staff from all four providers to review performance data, discuss client outcomes, and share ways to improve results. Early in this process, the department and providers clarified a more explicit definition of success linked to serving more families and preventing families from subsequent involvement with child protection – previously, these measures were buried in the middle of a quarterly data report. Monthly meetings focused on developing strategies to more consistently engage all families referred for services rather than those most proactive about participating. Provider executives were expected to be prepared at each meeting with information on the enrollment status of every client referred to them and, for each unenrolled client, know what outreach efforts had been tried by provider staff. When referral volume unexpectedly spiked, the department and providers found that waitlists were shorter at the provider where its program administrator had temporarily assigned herself cases to manage; this solution was quickly established as the norm for all providers – an example of a best practice being identified and rapidly spread across providers. In addition, the department collaborated with providers to revamp expectations for the first 30-days of support with an increased focused on stabilizing immediate risk factors before beginning longer-term service planning as narrow adherence to the original wraparound-based practice model created barriers to meaningful engagement with families in crisis. DCYF also integrated into all of its new contracts for family-based and residential services a very small performance-based bonus payment for every client who was living in their permanent home 180 days after service delivery. In most cases, this payment was worth between 0.25% and 5% of the total contract value for a provider. By linking payment to performance, the department sought to make permanent its own production of client- specific outcomes data so that providers would continue to learn about the results of families they served long-after programming ended. Tracking a common metric across all providers would also help DCYF make more informed referral and contracting decisions in the future. THE INNOVATION: Results at DCYF for children and families were highly encouraging, including: 1. New contracts for 100+ services, including major expansions to family-based programs DCYF entered into 116 new contracts collectively representing approximately $90 million of services per year – about 40% of DCYF’s budget. Through this procurement, DCYF dramatically expanded its portfolio of family-based services, including alternatives to group care, and added new programs not previously available in the state. These improvements include a 50-percent expansion of foster care resources for the most challenging adolescents, doubling the capacity of high quality family visitation and reunification services, additions of new therapeutic services and mentoring programs to help victims of sexual exploitation and human trafficking, and start-up investments of $1.2 million in nonprofit community organizations to support new and expanded programming. In 2018, DCYF’s procurement was highlighted as the nation’s single leading example of contracting for outcomes by the organization Results for America in its 2018 Invest in What Works State Standard of Excellence. 2. Made permanent strategies to use data to improve performance Following DCYF’s successful pilot with prevention providers, the department expanded active contract management to its providers of group care and has plans to spread these strategies across all agency-contracted services. In January 2019, DCYF launched “active divisional management” as an internally-facing adaption of the performance improvement strategies used with providers, with an initial focus on revamping service planning in order to improve reunification and adoption outcomes for children and families cared for by the department’s family services unit. In the three months following the launch of these changes, service plan timeliness in Rhode Island has tripled: from 17% of case plans filed on time in February 2019 to 51% as of May 2019. To sustain and build upon these reform strategies, DCYF also established a new Division of Performance Improvement. This unit worked across all areas of the department to use data to identify challenges, partner with staff to identify solutions, develop work plans and implement projects. Together with the contracts unit, the division also periodically reviewed upcoming priorities and advised agency leadership on how to allocate planning resources to the most critical procurements. 3. Substantial gains in placement and prevention outcomes for children and families Since undertaking these reforms, DCYF has achieved and sustained meaningful improvements in outcomes for children and families as of January 2019, including: - Reducing the share of foster children living in group homes by 23 percent – including a 3.5x acceleration of improvements when the newly procured contracts came online. - Reducing the share of clients in community prevention programs that subsequently open to DCYF care from 8% (over the 12 months prior to active contract management) to ~3%.