We recently covered the Joint Commission’s release of new and revised standards for child welfare provider organizations (see The Joint Commission Updates Child Welfare Standards To Promote Family Preservation & Reunification). The new standards focus largely on using evidence-based practices (EBPs) and providing trauma-informed care across the service system—intake, assessment, reunification, trauma-informed care, and case closing. The standards go into effect quickly, on September 13, for the 200 accredited organizations and include 74 new and 12 revised elements of performance.
This is happening at time of great change in children’s services. Substance use by parents is leading to increased rates of child abuse and neglect, as well as high rates of foster care entry and poor foster care outcomes. Since 2016, we’ve seen a 10% upswing in the number of children placed in foster care. From 2009 to 2016, entries submitted to foster care, for which parental substance use was a contributing factor, rose from 26% to 34%. Parental substance use was also identified as a leading cause for home removals. State child welfare directors in various localities attributed a significant portion of the rise in foster placement rates to parental substance use, particularly the rise in opioid and methamphetamine use (see Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Cost).
A report from the Brookings Institution points out that the COVID-19 crisis has unveiled many holes in the child welfare system (see What COVID-19 Means For America’s Child Welfare System). “COVID-19 has created a perfect storm of factors that will almost certainly lead to a sharp increase in unreported cases of child abuse and neglect, as children are cut off from interactions with professionals and teachers, confined at home with caregivers and relatives, and families are feeling the stress of job loss and economic uncertainty,” say the report authors.
Social distancing during the pandemic has had devastating effects on the child welfare system, reported NPR (see Child Welfare Services And Caretakers Grapple With COVID-19 Effects). In some cases, social workers were virtually visiting homes, and parents with children in foster care had to connect with them via FaceTime only, exacerbating the separation and isolation issues.
And just last month, the Trump Administration issued an executive order to strengthen the child welfare system. The order directs the Secretary of Health and Human Services (HHS) to strengthen family reunification, reduce unnecessary removals, increase the number of foster families, and issue guidance to states on partnering with private provider organizations (see Presidential Executive Order On Child Welfare To Increase Partnerships Between Public, Private, Faith-Based & Community Organizations)
Add to this the push for more “whole person” approaches—managed care, value based reimbursement, integrated care, and the push toward children’s health homes (see Ready For Children’s Health Homes?).
In this very fluid market landscape, what are the management challenges presented by these new Joint Commission standards? My colleague and OPEN MINDS Senior Associate, Paul Neitman, points out that many of the standards related to family-centered, individualized case planning have been in place for twenty years or more. Even the expectations for the incorporation of evidence-based practices and trauma-informed interventions have been a part of the field for nearly a decade.
But he cautions, “These new standards represent an extensive and overwhelming challenge for child welfare system provider organizations that have not already integrated a ‘best practice approach’ into their service delivery models.” Why? Because the emphasis on evidence-based practices demand a fundamentally different way of thinking and operating—one that spans strategy, culture, attitudes and beliefs, customs and norms, training, and operating procedures. As Mr. Neitman said, “Creating and maintaining a trauma-informed, family-focused, evidence-based service delivery is not just a training issue. Provider organization managers need to critically rethink how these concepts affect current operations and understand that they will require administrative, clinical, and perhaps financial changes.”
Mr. Neitman pointed out three operational areas that executives need to focus on if they are to build a high-performing operation that can adopt and adapt to new performance standards as they come on the market.
Staffing—There is a two-fold talent management issue. First, it’s difficult to recruit direct care professionals, including master’s level social workers and licensed professional counselors, and they often don’t have the EBP and trauma-informed training necessary. The second issue is retaining these professionals after they have the training and experience that makes them effective in this new environment. Mr. Neitman explained, “The recruitment and retention issue includes residential treatment where failure to hire, train, and retain a professional child care staff can result in poor treatment and significant safety risks. The ability to recruit and retain highly qualified staff is also exacerbated by low pay and eroding employee benefits. These are issues that need to be addressed.”
Caseloads—A number of states are placing limits on caseloads. But these limits are often still too high to meet best practices and standards, especially with high-needs, high-risk children and youth (see 15% Of Virginia Foster Care Caseworkers Have High Caseloads, Nearly One-Third Of Children Affected, and Federal Appeals Court Rules Texas Child Welfare System Must Reduce Caseloads & Better Monitor Foster Care Provider Organizations). This creates a management challenge—how to demonstrate to payers the “value” of the higher caseloads and the new models for delivering services.
Data—Moving to a metrics-based model for assessing the specific needs of each child—including the mental, physical, and social determinants of health challenges that each faces—is the key for success in a competitive, value-based environment. This means organizations serving children need a robust internal data tracking system and the ability to blend data from multiple payers and referral sources. Good data with good insights will help to assess service integrity and effectiveness for quality and safety improvement. (For a great example of this, watch the case study presentation, Measurable Client Outcomes – A Provider’s Journey Continues, by Jeremy Ulderich, director of education consultation and development and Scott Zeiter, executive vice president and chief operation officer of development of Grafton Integrated Health Network at The 2020 OPEN MINDS Strategy & Innovation Institute.)
While the challenges faced by provider organizations serving children in the child welfare system are many, the “new” standards are not “that new”—but then neither is the failure to incorporate them into business operations. Mr. Neitman warned, “Simply setting new standards will not in and of itself lead to more effective, higher quality, and safer child welfare services for children and youth. It takes implementation and adequate resources—the lack of which will continue to plague the system.”
And to add to that, my experience over the years is that new standards rarely get implemented without transparency in the data that compares organizational performance and tying provider organization reimbursement to “success.” I expect we’ll see more of that in the years ahead.
For more on evidence-based practices and trauma-informed care, check out these resources from The OPEN MINDS Industry Library.
- Making EBP Adoption Happen
- Evidence-Based Telehealth Practice In The Time Of COVID-19
- Embracing Evidence-Based Practices & Analytics To Thrive With Value-Based Care Models
- Behavioral Health Evidence-Based Practices As Population Health Management Tools
- Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment?
- Best Practices For Ethical Evidence-Based Prevention Programs
- Making Trauma-Informed Care An Operational Reality
- Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
- The Trauma Quandary
- Evidenced-Based Practices in the Era of “Personalized Medicine”: Tools, Concepts and Challenges
For OPEN MINDS Circle Elite member organizations serving children in the child welfare system that would like more information on implementing the new Joint Commission standards, call 1-855-559-6827 or email firstname.lastname@example.org for a Quick Consult session with Paul Neitman.
And for even more on making innovation happen, join us on August 25 for The OPEN MINDS Care Innovation Summit: Solving The Problem Of Access For Consumers With Complex Care Needs. Registration is free for Elite members of the OPEN MINDS Circle.