The Challenge:

Caregiver substance misuse is suspected as a factor contributing to abuse or neglect in more than half of the child welfare investigations conducted by the Florida Department of Children and Families (DCF). Children in these families experience poor outcomes, including longer average stays in out-of-home care. In the SunCoast Region along the western coast of Florida – the state’s second largest child protection region with a population of over four million – many of these caregivers were referred by child protection workers to Family Intervention Specialists (FIS), a service designed to connect caregivers with suspected substance misuse to assessment and treatment programs. The FIS program was delivered by local provider organizations through contracts with the Central Florida Behavioral Health Network (CFBHN), a regional intermediary funded by DCF to lead and manage a network of publicly-funded behavioral health services in the community.

The department had observed what national research showed: that early access to substance use services often makes the difference in enabling children and families to stay together. Yet, DCF discovered that only 7% percent of caregivers with suspected substance misuse received treatment within 30 days of their initial referral to FIS.

DCF found that child protection units, the behavioral health regional intermediary, and local behavioral health providers were often working with the same families without communicating or coordinating about their care. Child protection workers sent families for behavioral health assessments with limited follow-up to see if families had enrolled in or completed services. Providers inconsistently prioritized these individuals and did not always follow up with the referral source when clients decided not to engage in services. Without a shared focus on coordinating care, it was easy for families to fall through the cracks.

Additionally, there were significant barriers for identifying and following up with clients who failed to show up for services after a referral. The department, the behavioral health intermediary, and the FIS providers maintained separate data systems for child welfare and behavioral health services, and DCF’s lacked a consistent space for collecting information on which families were referred. Providers did not report information on key milestones in the service delivery process, such as whether child welfare-involved clients started or persisted in treatment. With limited data about client progress or results, DCF and CFBHN interactions with providers primarily focused on compliance with contract requirements rather than whether families received treatment or how to improve services.

These management limitations made it difficult to troubleshoot barriers that clients faced in navigating the many steps necessary to reach treatment. For example, at some providers, intake screening and assessment processes required multiple visits by clients and were only available during business hours, creating burdens on caregivers to find child care and take time off work. Poor communication between child protection workers and providers resulted in some clients who were not necessarily informed that a referral had been formally made. High demand for outpatient services and ad-hoc scheduling practices created periodic backlogs, which led to caregivers waiting for weeks before treatment was available or between appointments.

The Project:

To improve outcomes for families affected by caregiver substance misuse and test solutions that could be scaled statewide, DCF selected the SunCoast Region to pilot a set of innovations to strengthen coordination and service delivery across the child welfare and behavioral health systems. Reforms in this region would have the potential to impact thousands of families by improving child safety and reducing lengths of stay in the child welfare system.

With GPL’s assistance, DCF, the regional behavioral health network intermediary CFBHN, and local providers of substance use treatment services:

1. Revamped collaboration and care coordination mechanisms with providers
DCF recognized that solving these challenges would require elevating performance expectations on its behavioral health intermediary and the local treatment providers while simultaneously helping to remove barriers that impaired clients’ care and stymied system- level reforms. It began convening a monthly active contract management meeting with CFBHN and the six local FIS providers focused on reviewing client progress against the new service delivery metrics (see below), swiftly responding when concerns emerged, and conceiving systemwide solutions that could be tested for future integration into all provider programs and contracts. These peer meetings with the department and CFBHN positioned providers to brainstorm on common problems, learn from each other’s best practices, and access data analysis and change management resources. CFBHN simultaneously increased the frequency with which it met individually with providers, enabling the intermediary to provide more intensive implementation support and accountability as providers experimented with new ways of working with clients.

To foster the development of new approaches for client engagement, DCF and CFBHN also removed existing reporting obligations for providers in the FIS program contract for the upcoming year. This would free providers from time-consuming compliance activities and enable providers to try new ideas and practices without fear of punitive repercussions.

2. Uncovered which clients were engaging and persisting in behavioral health services by tracking new measures that crossed system siloes
In order to improve outcomes for families with substance use challenges, DCF and the regional network intermediary needed to know which caregivers were being referred to treatment, and, once referred, who engaged in services and who did not. Historically, program data had been reported by providers in aggregate only, making it impossible for DCF or CFBHN to troubleshoot individual clients or share back with providers information about long-term client results.

The partners began to collect and track client-level data for a prioritized set of six key performance metrics linked to key milestones in the service model: referral from child protection, initial contact by the providers, completion of intake, assessment of needs, treatment recommendation, and treatment attendance. These behavioral health data were then matched by DCF to client-specific child welfare information so partners could track long-term child safety and family wellbeing outcomes and learn from the experiences of clients with the most successful results.

The newly collected data revealed that far fewer caregivers were successfully engaging in treatment than the agency had realized. Among all caregivers referred to FIS in June 2018, the first month of the new tracking system, only 45% of referred caregivers had completed intake screening, only 36% had completed an assessment, and only 7% began the recommended treatment within one month of being referred. The partners also discovered long wait times between initial contact by the provider, assessment for treatment, and the first treatment session with a clinician. For the first time, DCF, CFBHN, and providers had comprehensive information on the entire referral system that could be used to identify and overhaul the most significant barriers to caregiver engagement.

3. Implementing changes to increase caregiver engagement in treatment
Over the course of the subsequent year, DCF, CFBHN, and providers designed and tested solutions aimed at improving client engagement at each stage of service delivery.

Referral and handoff from child welfare
As the partners began to regularly review the status of individual cases, they encountered substantial variation in the information collected from child protection workers, as well as the mechanisms through which referrals were made. Client contact information shared with providers was often incomplete and, because DCF staff recorded referrals in the narrative section of case notes instead of a discrete field, it was difficult for DCF to generate for providers a list of all the clients that had been referred. Some workers emailed providers when they referred a family member for assessment and treatment; others would call or text message provider staff they knew, and occasionally providers had received no notification at all.

To overcome these barriers, DCF collaborated with CFBHN and providers to develop a new, standardized referral form for FIS clients that would be used for all cases across the region. The new form increased the consistency of information shared with providers, making it easier for them to quickly reach out to clients across multiple modes of communication. By regularly comparing the newly available list of referred clients with those that the providers had contacted, the partners were now able to quickly identify clients for whom additional follow-up was needed.

Initial engagement with behavioral health provider
Among all referred individuals that failed to make it to treatment within 30 days, the largest share – 38% of individuals experiencing incomplete handoffs – dropped out after being contacted by providers but before an initial intake appointment could be completed. An exercise mapping out the reasons that clients failed to show for intake or assessment pointed to several barriers faced by clients: lack of transportation to provider sites, challenges accessing child care during appointments, simply forgetting about appointments, and apprehension around engaging in treatment services.

Upon identifying these barriers, one provider launched a telehealth system with flexible hours so that caregivers would be able to complete assessments from their homes. Another provider began more systematically sending clients appointment reminders via text message. Several other providers decided to experiment with co-locating their FIS staff in child welfare field offices so that workers could more easily access information about treatment programs, including how to help clients access transportation and onsite child care resources often offered by providers.

Beginning treatment
Data also revealed that after completing an assessment, clients could often wait two or more weeks for the first available treatment appointment. Providers needed new solutions for addressing these wait times.

To provide child welfare-involved caregivers with timely access to services, several providers coordinated with their outpatient teams to reserve priority treatment slots for FIS referrals. Leaders at one provider shadowed clients to their first treatment appointments, where they encountered a significant backlog at the front desk discovering that clients often spent the duration of their scheduled treatment session waiting in line to be checked in. As a result, the provider reorganized front desk staffing and registration workflows. Another provider redesigned its treatment schedule so that clients could start outpatient treatment as soon as one day following assessment.

The Innovation:

Results in SunCoast were highly encouraging, including improvements in the share of caregivers quickly engaging in behavioral health treatment and the integration of reforms into permanent program structures:

1. Improving service delivery: Increasing parent engagement and treatment attendance, reducing wait times
As project partners implemented these innovations in service delivery, more caretakers with substance use rapidly engaged in behavioral health services (see chart below). In less than a year, the share of clients referred to FIS who completed a timely intake screening and needs assessment increased by 23% and 28%, respectively. The average time between referral and assessment dropped by five days, meaning that parents were connected to the services they needed more quickly. By April 2019, the share of referred caretakers beginning substance use treatment within 30 days of referral had more than doubled. If sustained, this rate would reflect approximately 300 additional parents per year in SunCoast who would begin treatment within 30 days of referral.

2. Integrating operational reforms into permanent program structures
DCF and CFBHN have incorporated lessons learned in this pilot into a broader strategy for integrating child welfare and behavioral health services. CFBHN has added new performance metrics to provider contracts and several of the operational changes tested by individual providers have been embedded as the new standards in every FIS contract. CFBHN also worked with the GPL to design a new data platform for monitoring and supporting provider performance in real time. The system will automate the matching process and provide real-time information for providers and DCF on caregiver engagement in services.

3. Demonstrating ways DCF can collaborate with its community-based providers to improve client outcomes
New information on referrals to FIS and subsequent treatment progress empowered DCF and CFBHN to identify opportunities for performance improvement and support providers in implementing and scaling effective strategies. With the problem-solving infrastructure developed through active contract management, DCF and CFBHN can monitor program performance in real time and quickly address any challenges that may emerge. The agency is also considering how a similar active contract management approach could be used to manage the intermediaries and providers responsible for child welfare case management services.

Former DCF SunCoast Regional Managing Director Lisa Mayrose described how the department’s approach to managing providers has been changed, reflecting: “One of the frustrations we’ve had for years in this program is the lack of data, leaving us to manage only by anecdote. Active contract management has moved the discussion away from anecdotal evidence and proven that the outcomes we’re asking for aren’t impossible. Active contract management has...unlocked momentum for finding new ways to improve program results that will continue long after [the FIS pilot].”