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The Senate Committee on Health and Human Services met on April 20, 2016 to discuss the current problems facing the foster care system such as higher acuity needs and adoption disruptions.
 

  • Study the increase in higher acuity children with trauma and mental illness in the state foster care system, and recommend ways to ensure children have timely access to appropriate treatment and placement options.
  • Examine the frequency, causes, and effects of disrupted foster care adoptions and make recommendations to improve the long-term success of adoptive placements. Study and make recommendations on ways to ensure a smooth transition for foster care children who are exiting the system.
  • Examine the current process that Child Protective Services uses to track recurrence of child abuse and neglect, and make recommendations to improve data tracking and the use of that data to assist in preventing recurrence. The study should examine the differences in recurrence among families who received services, families who received no services and had their cases closed, and families who had their children removed from the home.

 
 
Opening Remarks
 
Chairman Schwertner

  • Goal of committee should be to improve the services to foster children

Sen. Uresti

  • Do not need to reinvent the wheel but need to build upon the work from last session but also says more can be done: expanding nurse family partnerships/wrap around partnerships, expand outreach to connect to resources

Sen. Campbell

  • In light of recent tragedies, hope it spurs action

Sen. Perry

  • There is a lot of money in the system, wants to reallocate funds from Austin to the case workers in the local community

Sen. Rodriguez

  • Issues sounds like a personnel issue, wants to address issues in the future because they continue to find themselves in similar situation session after session

 
INCREASE IN HIGHER ACUITY
 
Judge John Specia, Commissioner of the Texas Department of Family and Protective Services
Handouts

  • Main issues with the system are the high caseloads and too many staff leaving in frustration.
  • CPS interventions must be precise and families must be better after our intervention.
  • High acuity needs of children have increased in population size. Children have needs like emotional disturbances, trauma, chronic medical issues, or disabilities.
    • 2,900 out of 5,900 have  higher acuity needs
  • High service level has grown with the foster population 5.5% to 7% of all children served.
  • By the end of 2016, costs for acuity services with be $81 million.
    • More foster children are placed with relatives and children so the highest needs children end up staying in the system. Children or guardians lack the understanding of services and when to seek them.
    • We need to know if these kids have high needs before they are hospitalized and as early on as possible to develop a preventative plan.
    • Other factors compound inability to find placement option through a lack of capacity in some areas. Children with high acuity needs should be close to specialists and there isn’t always capacity in an urban setting.
    • The goal is trying to keep children out of residential programs.
    • All players in the foster care system need to coordinate case management.
  • Rodriguez – I think you brought up a good point about how all these professionals are involved in case management, why isn’t this working?
    • All of those professions are silo-ed and we have to remove those boundaries. Some organizations are working on creating that model. We need the whole team together of medical professionals, therapists, the court, foster care, case workers, etc. to work on a single consolidation plan.
  • Rodriguez – what do we need to do to make that happen?
    • There needs to be a smoother transition of understanding what exactly the child needs. Our workers need to understand what services are available, especially the new workers who are still trying to understand their jobs.
  • Schwertner – I think you bring up a good point about a consolidation plan and sharing the responsibility of case management among all of the systems.
  • Campbell – you discussed about escalating needs and coordinating the system. How did we find this out?
    • We discovered it through the increase in psychiatric hospitalizations and then we asked ourselves why aren’t we intervening soon enough? Each foster child deteriorates with every move so we need to minimize their displacement as much as possible.
  • Campbell – when did we know that? And why we aren’t intervening sooner?
    • We noticed it earlier in the year and we asked Mr. Stevens to put some recommendations together from this study that was released in November.
  • Perry – how many kids are in the foster care system?
    • On any given day 28,000-30,000. Roughly 16,000 are in some form of paid care. The rest are in kinship placement.
  • Perry – how many kids leave the foster care system that age out?
    • About 9%
  • Perry – do they have issues?
    • Children who age out of foster care usually have very serious issues. Aging out is one of the worst outcomes for kids. They are the ones with severe mental illness, are in prison, or are homeless.
    • We do 5,000 adoptions in a year. Children with high needs are over represented in the 9%.
    • We do a good job working with the younger children because they are sent to live with family members or are adopted out, etc. But it’s the older kids that stay longer in the system that typically have more issues.
  • Campbell – what is the age of when they age out?
    • You can leave at 18 but you can choose to stay until 21. The older children usually want to leave the system to go to school. Additionally, there are transitional programs for them where they can live more independently.
  • The agency is currently experiencing a budget shortfall due to increase of higher acuity needs in foster care.
  • Finding placement after a child is released from a psychiatric hospital is difficult and DFPS enters in a Child Specific Contracts to pay off the services as a last resort.
    • Contracts can be with hospitals, medical providers, as well as psychiatric providers.
  • Uresti – is the sole reason why we are leaving these kids in psychiatric hospital is because there is no other option or is it financial reasons?
    • There is no other option, but when we enter these contracts it’s because we then have the capacity to do more for them.
  • Rodriguez – you mentioned the budget shortfall, what’s the amount?
    • Today it’s around $20 million but it’s predicted to be around $40 million.
  • Rodriguez – where are the biggest areas of the shortfall?
    • The money would go towards the case workers to keep the children to stay in day care.

 
John Stevens, Managing Director of The Stevens Group

  • The Stevens Group put together a report in November that has data regarding the higher acuity needs of foster children which is called the Steven Group Assessment.
  • Campbell – when did you do this report?
    • This study was done on the high acuity needs focus and the report was released in November 2015.
  • Schwertner – The Stevens Group has experience working with the legislator in a number of settings. A previous report by the Stevens Group has been put in place by the legislature through Sunset.
  • The Stevens Assessment looked at gaps in the foster care system and highlighted recommendations to the legislature.
  • The Group conducted interviews with all professionals in the system, consulted with national professionals, and actions of other states.
  • Defining what the high needs of children are isn’t easy to identify because data doesn’t tell you enough.
  • There needs to be a definition of how to respond to certain needs and a navigation system so future professionals can react uniformly.
  • Study showed:
    • 2.7 years is the average for foster child’s placements
    • Average number of placements is 5.7 for children with an emotional indicator
    • If you reduce the number of placements, you’ll make a significant impact on the system
    • Difficult to achieve permanency
    • 990 children in the state had 10 or more placements in the foster care system
    • If the systems continue to speak and interact, they can act quicker
    • Texas doesn’t have performance based contracting, but the other states that do says it works well
  • STAR Health is a model for the nation and should be utilized more. It has a health passport and managed care coordination.  If this services was utilized more you could be far ahead than other states because Texas already has the state authority to deliver services. You have a lot of good services, they just need to be coordinated.
  • Some other recommendations to improve the foster system includes:
    • Needed more skilled and well trained CPS workforce
    • Moving seamlessly and rapidly between placements
    • Identifying needs during the first evaluation
    • Providers should not reject serving a child, ever
      • This really needs to change
  • Strengths of the current Texas foster care system includes:
    • Training with CPA for providing good mental and behavioral health services
    • Starfish program (but it needs to start earlier)
    • Texas systems of care
    • National best practices
    •  Efforts to seek collaboration with STAR Health
    • CPS continues to build upon the capacity (suggests building in the faith based community)
  • Gaps in services include:
    •  Workers might not identify needs or know how to meet them
    • Services may be unavailable in the geographic location the child is in
    • Or sometimes when the services are available the benefits don’t cover the child because no one notified the provider
    • Some providers might be unwilling to serve
    • Case management coordination
  • Schwertner – who do you recommend should be in charge of case management?
    • CPAs because they have the capacity, resources, and the training needed to better handle case management.
  • Schwertner – and then include a provision that they can’t reject a child?
    • Exactly because the foster care needs redesign for high needs children.
  • Kolkhorst – I couldn’t agree more about there being an incentive to find permanent placement. It is unbelievable of the differences we paid for CPAs and CPS workers. There is plenty of money in the system but it’s not going towards effectively helping the children. Am I saying that right?
    • Couldn’t have said it myself. In Florida they are providing bonuses to case workers who provide good quality outcomes to the children. For example, if the child doesn’t return to the foster care system after 6 months of placement, the worker receives a bonus.
  • Kolkhorst – I think we do have all of the ingredients to fix the system, but I think it needs to be more integrated. You really believe CPA should be the answer to the system?  
    • Yes, the system in Florida works really well.
  • Perry – don’t you feel like you missed including the foster parent on your integration chart? Did you include their input in your study?
    • Yes we interviewed some
  • Perry – I’ve interview some too. I know that maybe wasn’t your scope but I don’t know how we can do this without their integration. Another thing is early detection. There are some metric systems set up already that can identify some issues. I would like to encourage you to just put things in place with what we already have. We often forget what the parent needs.
    • These aren’t issues that can’t be solved; we are just identifying some of the gaps in the system.
  • But ultimately, it all comes down to communication and coordination. Our number one recommendation is building a more responsible case management system, and testing it with a pilot program.
  • Schwertner – Commissioner, just to clarify, we have given the agency the power to do the pilot but we just haven’t put out an RFI for it?
    • Yes and Mr. Jessee will discuss that some more.
  • Additionally we recommend continuing capacity building and conduct in home therapeutic services for foster care parents.
  • Kolkhorst – define what you mean by therapeutic services? Are the parents trained in that? Do you train the parents?
    • Gary Jessee, HHSC – it can vary. We have trauma care, sometimes we match the foster child with a foster home who can relate or provide that care. There could just be strategies to adjust for daily living. The variety of training provided is on a case by case basis of what the foster parents and the child may need.
  • Kolkhorst – it might help us recruit more foster parents if they know they have more of a support system and resources available to them.
    • Gary Jessee, HHSC  – The strategy is minimalizing placement. There are some strategies just to help families not give up on the kid they already have. The training can provide a level of understanding to what the child is experiencing.
  • Uresti – we’ve known early intervention is the key and you have to have wrap-around services. We don’t need a study to tell us that. We have been talking about the same thing for years. At some point the legislature needs to step up and yes it will cost us some money but we need to be willing to do it.
  • Kolkhorst – I think you are correct. The Stevens group said we made great strides but we have all taken stabs at the system from urban vs. rural vs. Democrats vs. Republicans. I’m wondering could we get this system back in shape within a year or so?
    • Texas has been successful at improving some programs within a year. For example the mentorship competency based training changed within a year. You also put structured decision making in place within a year.
    • But you have to be patient and I think you are heading in the right direction.
  • Van Taylor – is there a surge in certain locations, like Dallas? To what extent is the system unbalanced because of demand?
    • Well each place has their unique problems. There’s really high turnover in Dallas
    • We designed a master’s program to specifically look at hotspot cases throughout the state.
  • Van Taylor – in terms of staff, do you have an inability to hire more staff or is it a surge in case load?
    • Judge John Specia, DFPS – We can hire people; the real issue is keeping them. Retention is critical especially in the investigation phase. We are trying to deal with a constant vacancy rate.
  • Van Taylor – so it’s not so much you needing more workers as you need to retain workers?
    • Judge John Specia, DFPS – Well, we need to keep more staff but there’s an issue with the case load level. Currently we are conducting work load studies to determine the amount of time it actually takes to work one case. That way we can coordinate the work load based on the time of each case.
  • Schwertner – points out last session put in funding to recruit case workers
    • Judge John Specia, DFPS – Need to define what workload and case load needs to be, demand keeps growing but case workers do not
  • Perry –I’m concerned if you are going to come in next session with more things you need later. Are you sure you didn’t use a different gauge to determine what is medically necessary and that’s what increased the high acuity needs population?
    • Judge John Specia, DFPS – No that’s specifically a capacity problem, it is consistent over time.
  • Perry – are Residential Treatment Centers (RTSs) a good or a bad thing?
    • Judge John Specia, DFPS  – There will always be a need but needs to be fewest possible
    • Judge John Specia, DFPS  – There should be enough RTCs spread out across the state and they should be short term. There should never be an instance where a child is in an RTC for more than a few years.
    • Judge John Specia, DFPS  – However we lack the capacity to move them out of the RTCs. Which is why we need wraparound services, etc to keep children in lower level placements.
  • Rodriguez – I had a question about the federal litigation case you were in. I was concerned by the comment of the federal court saying that Texas hasn’t taken action on the foster care system and kids are coming out more damaged than when they went in. How much of that can you weigh in on?
    • Judge John Specia, DFPS – We have shut down bad facilities and stopped doing business with bad facilities because our kids’ safety is our ultimate priority.
  • Rodriguez – We had a case of a kid in the foster care system with teachers saying they knew he had severe mental health issues but his electronic health record didn’t reflect that. Is that an issue with Superior or on the case workers?
    • Judge John Specia, DFPS – I’m not going to comment on that case because it’s confidential. I can send someone to you but I’m not sure the news is always right.
  • Campbell – do case workers go through specific trainings on the expectations? Are they getting adequate information to know the demands of the job?
    • Judge John Specia, DFPS – We have dramatically changed the training program to more of a field based program. No job is harder or more dangerous than the CPS workers and we fail them by not giving them enough resources to do their job.
  • Campbell – who has outcry authority that would make a CPS worker actually investigate? My concern is one professional wanting to report something but CPS can’t investigate it. There was a case where a doctor reported the sexual abuse of a child but CPS didn’t investigate it. Who is the case worker receptive to as an outcry authority?
    • Judge John Specia, DFPS – Doctors are often the outcry witness, so I would like to talk about that case with you because hearing a doctor report something like that is gold. Anyone who has guardianship or dealing with the child has outcry authority.
  • Uresti – I think we forget these case workers are family members too. What does it cost to train a case worker?
    • It costs us $54,000 and we pay them $32,000- $36,000 and the lowest turnover rate is 20%.
  • Uresti – we are wasting millions on training these workers. If we were able to give these case workers a higher salary, we will see turnover rates decrease and we will save money on training. I think increasing their salaries will help even if it’s a small percent.
  • Schwertner – I saw the top 3 reasons for turnover were work environment, culture, and compensation. As a result we added the training program. But can you speak to that Mr. Stevens?
    • The training program has helped. What we heard the most about why case workers left were because of the supervision and the stress of the job, not really compensation.
  • Van Taylor – I think Senator Uresti hit on a great point. I’m stunned we don’t know how much time it takes to finish a case. The first step is just figuring out how many people we need to do the task at hand. That way we can determine if they are quitting because they can’t complete their work. That’s the first thing we determine for every other job is how many hours it will take to complete.
    • Judge John Specia, DFPS – Studies for conservatorship and think investigation – these numbers are being worked on
  • Perry – How much of caseloads workers frustration is due to court system? Process to triage cases that requires much attention
    • Judge John Specia, DFPS – in operational review only 24% of time was spent with families so driving all over town, working on ineffective computer system, inefficient courts are all part of frustration. Court system is integral – some courts move more quickly.
    • Judge John Specia, DFPS – that is the pilot they are working on
  • Committee discussed starfish program – working well
  • Judge John Specia, DFPS – No eject/no reject are currently NOT in contract remedies

 
Gary Jessee, Texas State Medicaid Director at HHSC

  • STAR Health is for children in conservatorship and has been in place since 2008
    • 31,000 supported under this model
    • We still have significant improvements to make
  • STAR Health extends supports for individuals when they age out of foster care systems. Benefits are available to them until age 26
  • STAR Health State benefits includes/offers:
    •  Immediate eligibility (case worker will enter the information into their enrollment eligibility file)
    • Children have increased need for behavioral supports
    • Focused on better coordination for child placing facilities to provide additional wrap-around supports
    • Screening from MCOs to collect information about the child and their needs, as well as how quickly they need to move to develop a service plan
    • Health passport – which is a comprehensive electronic system that all medical and foster care professionals can access and update  information about the child
      • Trying to make improvements
    • Value-added services that are not covered to Medicaid benefits that the MCOs can offer as support. For example a sport physical, access to boys and girls clubs, etc.
    • Case-by-case services such as specialized therapies (equine therapy)
      • Psychiatric diversion program
    • A trauma and behavioral health model
      • A Psychotropic drug review in order to evaluate real need of medication
      • Review of psychotropic medication could determine if there is a risk for an individual to take that medication
  • Schwertner – who is responsible for coordinating care of the child? Who is making sure STAR Health services are being utilized?
    • All parts of the system have a responsibility for that. We can provide these services, but we can’t determine if and how they will be used. If the foster parents, children, or placing facilities don’t fully understand how to access or use the benefits then we have failed on improving these children. However you can’t say that one person will affect the outcome individually.
  • Schwertner – What’s the hold up on getting that coordinated services program pilot started?
    • We wanted to make sure we organized a model to get the outcomes we wanted before implementing the program
    • Currently we have 3 programs we are working on:
      •  (1) Coordinated services with MCOs and CPS workers – There was some discussion about the outcomes they want to achieve.
      • (2) RFI – Request for Information to develop a program based on the Stevens report to improve placements for high acuity children.
      • (3) Treatment options – We have been working with foster care families with children who have high needs to understand what services they need.
    • We’ve been working on all 3 and soon we will be able to share some information moving forward. The results from the pilot will be released once it gets started and we hope to have some information to share before the next session.
  • Uresti – are children in conservatorship receiving STAR Health?
    • Yes
  • Rodriguez – earlier you mentioned everyone should be involved in care coordination. Doesn’t that contradict the consolidation plan mentioned by Commissioner Specia?
    • We want to everyone to have some responsibility. The MCO is always going to have a responsibility for care. You will always have two parties, on the medical side and the court side. We aren’t trying to create something new. We just want them to each understand their roles so they can better coordinate care.
  • Perry – why would it be optional for CPAs to provide coordinated care? Shouldn’t we require in the licensure to provide coordinated care?
    • We wouldn’t be able to do that in the licensure but we are working with them to become coordinated care providers.
    • We are working with CPAs who have the ability to provide a benefit. In that case, they aren’t required to provide that benefit. We are talking about a unique benefit they aren’t required to do already.
  • Perry – I don’t want to silo the benefits if CPAs are the recommended people to provide benefits.
    • I agree. It will become a challenge to force them to provide a service.
  • Campbell – Who actually evaluates CPAs and how are they evaluated? Is it on performance based models?
    • Specia, DFPS – We have a pilot going on right now, not just buying a bed but evaluate them based on performance measures and the success of the child. There could be an incentive piece.
    • Every worker has a supervisor and they are directly responsible for the quality of the work they are providing.
  • There are two other supports of STAR Health:
    • The 1115 Waiver (YES Waiver) – which we are hoping to expand
    • We also have a number of children with intellectual disabilities so we are working with MCOs to collect enough information to determine intellectual disability with the local authorities to increase capacity.
  • Specia, DFPS – reviews last three slides on solutions, working to stop disruptions and displacements, high needs children need to be put with foster parent that has training
  • Schwertner – we don’t incentivize special services in foster homes? Can we pay extra rates on wrap around services? Foster Care redesign, where are we? And could we roll it out in other areas of the state?
    • Specia, DFPS – Have performance based contracts that could later be incentivized
    • Should be released Foster care redesign very soon, Yes should roll out but court cases may determine how it is rolled out

 
Dr. David Harmon, Chief Medical Director for Superior Health Plan

  • Superior Health Plan offers several services to foster care children:
    • Physical, pharmacy, dental, and vision services
    • Provide long term and support management services
    • Able to coordinate health care for children in foster care system
  • We have a service management model in which we take population health management approach for children in foster care and provide service management then service coordination.
    • Children can move in and out of these levels.
  • Schwertner – what percent require service coordination?
    • About 18%
  • Schwertner – we have all of these entities trying to help but we can’t seem to get it together. How can we move forward?
  • Kolkhorst – this is more important as a mother than as a Senator. It’s already complex as a parent for a normal child. We have to get better about this. Help me help you.
  • Rodriguez – question on resulting outcomes, is there an increase in preventable events? Emergency Department visits? Etc.
    • Comparing different measurement methodologies – but does see point
    • Jessee, HHSC – some of the benefits were not even in place yet, data does demonstrate readmissions are reduced, data being presented today is fairly new
  • Schwertner – crisis diversion program, who started?
    • Started in Fort Worth to prevent foster children from becoming hospitalized. We try to provide services in the home. The crisis is identified wherever the child is at the time. So it could be in the home, at the hospital, or at the school and it depends on whomever initiates the outcry.
      • The program is also called Turning Point (inpatient diversion program). We just got it started in Houston and we are trying to work on it in San Antonio.
  • We are working with providers to train to provide trauma informed services. We also offer the Psychotropic utilization review program.
  • Rodriguez –Superior has decided to reduce the acute care therapy service rates in the managed care arena. Can you tell us if that reduction in rates will impact the providers?
    • There is currently litigation surrounding this so I can’t discuss that in detail however, we are making sure no children goes without services.
  • Rodriguez – what concerns me is the providers for acute services have to shut down so there will be less reduced network adequacy and then reducing rates will also lead to more issues. Are you reducing rates based on the fee-for-services rates by HHSC?
    • That’s also part of the litigation I can’t speak to.
  • Perry – All of the testimony reaffirms to me that if we aren’t specific enough, we can’t write an effective policies. I want some people to step up in leadership to say what’s not working. Have a benefit available but not make it required Mr. Jessee? You as agencies have to take leadership in doing what’s right and if you mess up ask for forgiveness later.  It seems like every agency comes back to us saying the legislature didn’t give them enough direction.
  • Kolkhorst –I too am frustrated about the specifics needed and how long it takes. Are there special master’s involved? And what are we paying them?
    • There are 2 special masters, and the state pays them at $340 per hour.
  • Kolkhorst – concerned and asked who is in control?
    • Agrees there are silos that need to be managed
  • Rodriguez – I hear what Senator Kolkhorst is saying and I’m trying to tackle that with discussing the reduced rates for therapy. Reducing the rates will cost the state more money in the long run and we need to consider the long term impacts moving forward.

 
Nancy Holman, Texas Alliance of Child and Family Services

  • Presented slides to committee to provide background
  • Illustrated limitations impact the system
  • Recommendations are listed on slide 4
    • Stabilization funding and capture the cost of care (has not done so in past decade)
    • Wrapping around services are really needed
    • Support care coordination pilot but think in advance how it would be blended into foster care redesign  
    • Performance contracting – outcome has to link to authority, there are flaws in CPS data which takes time
    • Build capacity – there is a certain business side to building capacity and they do not receive good information on where it is needed
  • Discussion on eject/reject contracts – there are ways to incentivize it but there are risks for having this for every contract
  • In regards to belief on role for CPAs, each (CPS, CPA, STAR) has area of coordination, CPA will ensure the child get STAR health services and support CPA role
  • Commit to reform but cautious of redesign
  • Schwertner – regarding failed redesign, would it have worked if there was more support in Region 8
    • Challenge will be in rural areas
  • Best practice is that state should be working with child and family with continuity when the child goes home but that is not how the system is set up
  • Schwertner – Do think performance metrics would work for CPAs?
    • It needs to be carefully thought out – need more case management responsibility  
    • Need to make sure if outcomes are put in the contract, the contractor has the authority to deliver it/ability to perform
  • Rodriguez – Inquires about witness slide, what is recommendation with in regards to the rates?
    • Rates are potentially a factor
    • Cannot be certain when rates are so old and have not been reviewed recently

 
Wayne Carson, Chief Executive Officer of ACH Child and Family Services  

  • Presents slides regarding foster care redesign in region 3b
  • Redesign is a different way of doing business
  • Reviewed contract and tracking well on benchmarks
  • In first few month able to improve conditions of children in their care
  • Have started identifying children in institutional settings that may be able to be moved into a family setting with special training and additional support (have done so with just over 30 children)
  • Encourages fully funding of system
  • Schwertner – asked about pitfalls in redesign in their region to help inform
    • Comprehensive approach to recruitment
    • Biggest challenge out of the gate was data
  • 1492 in care last week, 180 in residential treatment centers
  • Schwertner – no eject, reject referrals as a model
    • Hardest thing to do but believes can do better for kids in this model
  • Schwertner – regarding Legacy system, any thoughts on what can be done with it, incentive based funding?
    • State is so big and diverse, agrees with idea of having responsible party 
    • State needs every bed they can get, needs to be done carefully
  • Kolkhorst – emphasized speed in which they moved or are capable of moving, this was put in place in 2011; how quickly could rest of state move?
    • Stage 2 is targeted to start this year
    • Stage 3 would be a year within start of Stage 2 
    • Rolling this out statewide – have learned a lot and state has learned much so next implementation should be easier
  • Kolkhorst – hearing no foster parents in some counties (just outside of Harris county) and how can that be addressed?
    • Palo Pinto County had 81 children and 3 foster parents and went to providers and they sent in plan on how to approach
    • Had relationship with Pastor and he was willing to go recruit foster families in the faith community
    • It is one viable approach
    • Another provider offered to rent an office to do training locally
  • Kolkhorst – how do you do on keeping children in the school district?
    • Does not have that data at this point
  • Schwertner – how many children in your region have been admitted to a psych hospital
    • Will get the committee that data
  • Perry – is there anything statutorily or by rules to give RTCs accountability to expand network, do they have barriers in the way?         
    • Holman – From RTCs have heard it would help if there was funding for transition
    • Carson – RTCs play a role but someone needs to be managing the case for that child, looking for opportunities to move into a residential setting 
    • Holman – funding for transition planning could be an add on
    • Perry – very little incentive for RTC to move children out of RTC 
  • In regards to high needs children – example of girl talking her way out of being arrested, was placed with a family and will graduate and take class to be a CNA

Dr. Anu Partap, Children’s Health Specialty Center Plano

  • There is a lack of understanding Abuse histories, transitions and multiple decision makers who do not have medical experience making decisions on behalf of kids
  • Stories of children moving because foster homes are not prepared to address health care needs
  • Need specific health care standards, separate foster kid standards
  • Safety and reporting standards
  • Improve health care child welfare collaborative – regional consult teams
  • Electronic health care records for kids – child welfare information
  • Caregiver support and education in medical hospitals
  • Uresti – asked about health passport
    • Because it is a Medicaid claims listing, not able to remove inaccurate diagnosis
    • Not up to date for vaccines
    • Actually have to call each provider
    • Not uploaded for two weeks
    • Passport is a great framework but needs to have open discussion on how to make it readily useable
    • Typical community based clinicians don’t have resources to use passport in the way it can be used and the way it is intended to be used
  • Campbell- further inquired about problems in health passport, what is remedy? 
    • It works the way it was designed
    • Great starting point but need medical team to update the information
    • 31k is a small manageable population, all children have medical homes so there is a partnership ready
  • Rodriguez – Who needs to update the passport? Multiple parties? Should you have access to abuse history?
    • Believes claims data goes into the passport when children get into the system
    • There is sequential data on a child
    • Need abuse and neglect history

Katy Bourgeois, Travis County Collaborative for Children

  • Reviewed history and model of collaborative – started in 2013
  • Established a structure that spanned silos and got communication going
  • Worked on building strong communications, trainings, gap analysis, etc
  • Recognize communities are diverse but think there are core elements: sense of urgency, early creative leaders, standard evidence based training
  • Funded by private funding including Michael and Susan Dell, etc
  • Working on getting numbers to committee – cost to provide training is $3,500 per person but then there are ongoing monthly supports, etc
  • Schwertner – asked about achieving goals
    • In the process of collecting data from all the partners
    • Don’t have numbers yet but have anecdotal information

Annette Rodriguez, The Children’s Shelter

  • Provided background on the shelter and reviewed slide handouts
  • Reduce length of stay from 24 months to 9 months and goal is further reduction
  • Have been able to reduce length of stay by using trust based relational intervention and other models
  • Perry – do you receive federal dollars?
    • Just pass through – through state
    • Bulk of money is contract through state
  • Uresti – if you could point to one or two things doing right?
    • Community, courts and providers
    • Support of CPS caseworkers
  • Kolkhorst – asked about number of RTCs increases believes some were looking at it as a business model (200 beds examples), do you see it as a business model?
    • RTC is not a business model, would be losing money
    • RTC must supplemented
    • More diverse, more tailored to children then more successful will be

 
RECURRENCE OF CHILD ABUSE AND NEGLECT
 
Judge John Specia, Commissioner of the Texas Department of Family and Protective Services

  • Many ways to utilize data and always looking at ways to use data better
  • Reviews slide presentation to committee
  • Uresti asked about risk factors reviewed
    • Look at age of child
  • Schwertner asked about the Dallas case, high priority cases are reviewed by…
    • Every fatality goes through safety specialists
    • Have child safety specialists review high priority cases
  • They are reviewing child safety specialists to be sure they are using them as effectively as possible
    • Child safety specialists is a secondary review
  • Campbell – how long does it take for everyone to review? Dallas example
    • Does not have specifics on case
    • Could have two levels of mistakes
  • Family based safety services – use this while working with the parents
  • Conservatorship – work to ensure the places are safe and appropriate
  • Kolkhorst – kinship care question, do not seem to pay kinship care very much and thinks this issue should be revisited
    • Pay them zero, just integration payment and maybe yearly help for clothes
    • Now that relying so heavily on kinship placement agrees this needs to be reviewed
  • Campbell – how does kinship become conservatorship
    • Once they identify children at risk in the home the first thing that is done is look for kin
    • High priority on looking at kin on both sides
    • Need some type of kinship process but not same process as foster
    • Hopes there is some sort of payment for kinship in LAR
  • PEI programs engage high risk families – 5% of budget when including nurse family partnership
    • Not available in every county
    • Strictly contractual program
  • Uresti – way to prevent child abuse
    • Yes it is a community wide issue and there are markers
  • Discussion on communication and sharing data in most effective way
  • Perry – would like specific details on data needed
  • Campbell – road block is HIPPA? But if we have conservatorship then we are talking to ourselves
    • There are some confidentiality laws but some agencies have the ability to talk to each other

Dyann Daley, The Center for Prevention of Child Maltreatment by Cook Children’s

  • How to find children at risk for maltreatment before coming into the  hospital
  • Adverse child experiences study is where they began and wondered if looking in medical setting is most impactful way
    • What if looked at where things occur and then overlapped in the community
  • Risk Terrain Modeling – prevent things like shootings, tells you how to change things to prevent the outcome – they used this
  • Found 98% of cases down to location
  • Recommendation: expand risk terrain modeling all over the state (already doing so for major cities) and same concept to look at objective data already being evaluated but look at it ahead of the process so people can spend more time with children
    • May need access to state crime data 
  • Campbell – who did study, who paid for it
    • Cooks Children’s and criminologist
    • Cooks Children’s foundation and what they do is freely available to everyone
  • Perry – what reviewed, state could get it? Resources need to go from top to boots on the ground
    • Looked at address where violence occurred
    • Dallas example – multiple calls to CPS, mother on parole for drugs and boyfriend in house had lots of drug arrests, etc
  • Kolkhorst – Thanks Cooks Children’s and Foundation for the research and TCU as well, gives glimpse of all resources available
  • Kolkhorst – lets look to see how to expand
    • Have secured funding for project from foundation so do not need to request funding from the state
    • Just need access to the data
  • Campbell – risk factor is known drug use by parents, how is it measured or known
    • Police data – arrests
    • Campbell – reminds committee of drug screening for parents who receive benefits will help members look at one risk factor  

Madeline McClure, TexProtects

  • Been working with UTD and getting ready to roll out their risk terrain modeling by zip code in their area
  • Slide presentation was reviewed
  • Presents details on number of children re-abused – measure of systems failure
  • 10,200 children who entered the system in 2010 were subsequently abused in 2015. Could have different abusers but same child – rate of recurrence increased by 70%
  • Caseworkers should be held accountable for things like outcomes, not processes and outputs
  • Discussion on SafeCare model – evidenced-based parent-training, cost effective programs
    • Maybe could be used during family reunification 
  • Number one risk factor is poverty but also could include drug abuse, etc

Dimple Patel, TexProtects  

  • Cases reviewed – looking at recurrence is extremely important
  • Need to do more than look at one year out – look at 5 year out
  • Evidence based services are needed
  • Need consistent dispositioning
  • Need to do risk readings on more cases to help with newer case workers entering

Joy Hughes Rauls, Children’s Advocacy Centers

  • Good investigation mean good information and can hopefully prevent recurrence
  • Hard part is operationalizing practices
  • Concerned with implementing best practices and protocols. Realized not all children who come to (Children’s Advocacy Centers) CAC came in through a facilitated approach.
  • Every intake is tracked in real time and information is used to call CPS and Law enforcement to check protocol.
  • There has been an uptick in referrals through new coordination program.
  • Information sharing occurs through face to face interaction but more is needed to break down technological barriers in information sharing.

 
STRENGTHENING ADOPTIONS

Judge John Specia, Commissioner Department of Family and Protective Services

  • Positive permanency discussed – still large number of children need adoption
  • While the number of adoptions has increase, the number of children available for adoption has stayed the same. This is a rolling number.
  • Texas compares well to other states in number of adoptions. Texas receives the more funding in awards than most states.
  • Law requires for a child to be placed in an adoptive home for 6 months before the adoption is official.
  • Challenges that can disrupt adoptions- changing circumstances, deaths in the family, behavioral health needs of child.  Only a small number of adoptions fail (2-3%) but no number is good.
  • When adoptions dissolve or fail CPS takes legal control of the child.
  • Schwertner – Is it true that when dissolutions occur it is because the parents do not receive full information on a child?
    • Parents are given complete access to a child’s file, something that did not happen 10 years ago.
  • Schwertner-  Is it a lack of understanding the information by the part of the family that leads to dissolution?
    • There is an issue with a lack of understanding. Families want to adopt and sometimes they do not read the file. We need to be more transparent about the child’s special needs. We try to give them all the information but there is an information gap sometimes.
  • Rodriguez – What can be done when families do not read the information on the child?
    • Workers spend a lot of time talking about children and issues
    • Giving them file is out of abundance of caution
    • We need to do a better job of dealing with the child’s trauma. We have post-adoptive services that are not as good as they need to be.
  • Rodriguez. – The funding for post-adoptive services is low isn’t it?
    • Yes. We need to increase funding.
  • Rodriguez. – Where are you going to place this in your LAR?
    • Kids that age out do the worst. We need to provide support services to help children get adopted.
  • Permanency Care Assistance- started in 2009. Not adoption but legal guardianship.
  • Have put together a best practices hand book so all employees have access.
  • Working with faith based partners and communities to recruit foster and adoptive parents.
  • Campbell- How do we balance adoption process requirements so they’re safe but do not turn people off from adoption?
    • It needs to be a thorough but simple process. We are auditing it right now.
  • Campbell- Do you have data on those who have applied for adoption and then decided not to adopt?
    • It may be in the audit.
  • Rodriguez- Is there a reason the disruption rate is growing?
    • The data does not reflect that claim.
  • Rodriguez- do you have data on children who return due to dissolution?
    • We take all children back after dissolution.
  • Rodriguez- Do you know how many children come back?
    • It is the same as the number of dissolution and disruption number.
  • Campbell- Do we have data on why kids are being disrupted? Is it just teenage years?
    • We don’t take children back just because they’re teens we have services in place. We are going to do everything we can to prevent dissolution.
  • Uresti- Can you give reasons why a couple that wants to adopt is disqualified?
    • It should be in the audit.
  • Uresti – do we allow out of state residents adopt?
    • Yes absolutely
  • Uresti – Is there a website, how do you promote site?
    • Site needs to be improved but it can be googled
  • Campbell – can people from other countries adopt? How do you measure a responsible, mature adult?
    • Not sure but will find out

Dyann Daley, The Center for Prevention of Child Maltreatment by Cook Children’s

  • Working with a consumer analytic company to help find people who are more likely to foster or adopt. The firm is working pro-bono. Using market segments to identify those that are likely to adopt. 
  • Discovered it is not a recruitment problem but a process problem
    • Example given of licensing being different – every single adoption agency has a different standard
    • Need to develop community structure to have an effective recruitment strategy
  • Right now the goal is permanency but we need safe, health homes that mold children into healthly adults.
  • Would like to develop a recruitment process that streamlines the application with an online process that uses effective parenting training. This program would also track children’s well-being measures. It is possible but it is a data sharing issue.
  • A program like this could further define characteristics for analytics to recruit even more parents.
  • Gladney, ACH and Qualtrics are willing to work together to develop this.

 
Renee Price, DePelchin Children’s Center

  • Families are assessed with a home visit to ensure that the family can be matched. Home study is reviewed by a committee.
  • Family is informed of child’s background and legal issues.
  • At any time the family can decide to move forward or not.
  • After adoption, there are ongoing post-placement support services.
  • There are different options for training. If a family wants to just adopt there are less barriers but they cannot take a child from foster care because of priorities given to foster care parents.
  • Training often reveals information on parents. Screenings are done throughout the whole process.
  • Campbell- How do you determine a parent is a mature adult?
    • There is no specific definition.
  • Campbell- do we know the number of parents that have been turned down?
    • We do not know but have worked on tracking.
  •  Schwertner- what is the state wide average for disruptions?
    • 2-3%
  • Schwertner- and Mrs. Price your agency has a similar number, correct?
    • Yes.
  • Schwertner- So what is the benefit of the added training?
    • It keeps the numbers down to 2%.
  • Schwertner- Trauma training is not a state requirement for adoption is it?
    • For foster homes, yes but may not be for adoption.
  • Schwertner- it looks like the CPA’s add on their own training but do we as a state need to add on to our guidelines?
    • Texas has the minimum guidelines allowing differences are important because of how faith based groups recruit.  

 
Ryan North, Director, Tapestry Adoption & Foster Care Ministry

  • Tapestry has created a holistic family training program.
  • The system needs to be adjusted to understand and care for children.
  • Six risk factors- pre-natal stress, difficult delivery, early medical trauma, abuse, trauma and stress.
  • Training is divided into two courses: pre-course and post-course and takes a Christian prospective.
  • Course is well received and could be mandated state wide for consistency and better equipped foster parents.
  • Issues facing the program: not everyone knows about post-adoptive services and there is a distrust of the state. There needs to be a separation between CPS and the state. There is also a funding issue.

 
Holly Ann Petrie, Self

  • Only provide services for adoption children – considered untouchables by many
  • Need to be more tools for parents to be able to respond
  • Need support and training for adoptive parents

Texas CASA Representative

  • Shared personal letters from people who have been in the system
  • Stories of children had good outcomes but much help from CASA Volunteers
  • Allow for longer transition into homes and allows for families and fosters to be involved in counseling for children when they are placed into the home

CASA Williamson County

  • Talked about process used in CASA which can be used in other situations
  • Seen many cases of misinformation or miscommunication 

Grandmother from Palo Pinto County

  • CPS is not working with her and not gotten any help
  • Told she has no rights as a grandmother but she believes her grandchildren are being harmed in the current foster situation they are in

Dimple Patel, TexProtects 

  • Personal story from CPS case worker – child entered into system at birth and now 3 still waiting for adoption
  • 2 years a child spends in care on average before they have a permeant home
  • Should capture data on age of children having disruptions and dissolutions
  • Campbell – why the gap?
    • Its case by case
    • Agree there needs to be a sense of urgency in matching kids up front

Sarah Crockett, Public Policy Coordinator for Texas CASA

  • Provided written comments from Volunteer in Bastrop
  • Conducted statewide survey – believe Texas Foster care system must become more trauma information, report on project provided with testimony 

Greg Hansch, NAMI Texas

  • Incidence of mental illness and trauma is well documented in foster system
  • Medications used more often than robust mental health care
  • Children need to be identified earlier in order to provide additional services
    • Can take significant time
    • Reality that requirements can delay or deny needed treatment options

Josette Saxton, Texans Care for Children

  • Parents need support and training
  • Look within for areas to support – Within DPSH children recovering trauma initiative, etc
  • Until address effects of trauma they will continue to have bad outcomes
  • Region 4 provides training – recommended model for discipline and looking to expand mental health services within the framework
  • Mental health providers should partner with schools – Crockett HS in Austin is doing great things on that

Will Francis, Gov Relations National Association Social Workers

  • Need to hire social workers at CPS
  • Social workers are more prepared for child welfare system
  • Texas is relaxing and looking at associates degrees for caseworkers
  • CPS should have a bachelor or masters degree in social work  
  • Turnover higher when
  • CPS cannot access data which he finds concerning
  • VanTaylor – degree vs outcomes, how are metrics
    • State with higher degrees have better outcomes
  • Campbell – is retention rate in other states greater?
    • Longer and greater retention for those with higher degree
  • If don’t look long term – will not get real outcomes that are desired

Doug Reeves, self

  • Granddaughter was murdered in the system
  • Every other month it seems a child or baby has been killed
  • Believes should look to caseworkers who left the system have the answers
    • Size of caseloads (15-20 cases at one time) 
  • Kolkhorst – inquired about a name of person and asked about her relation
    • They were involved in a custody battle

Emily Decker, TexProtects

  • Spoke on Multidimensional Treatment Foster Care (MTFC) – evidenced based treatment

James Castro, licensed counselor and therapist

  • Mandatory assessment be done within 45 days of entering foster care system – believes 45 days is too long (14-21 days)
  • Spoke in favor of Turning Point program

Janis Dvorkin, self

  • Evidence based results presented on music therapy 

Ana Alicia Lopez, self

  • Board certified music therapist
  • Need diagnosis to received services can address many issues with music therapy 

Annie Vandervoort, self

  • Music therapy services can benefit children in the system

Roberto Eschaszerta, self

  • Very difficult state for entry into market, billing practices on coding can only be provided by primary care physician or find someone specialized so he recommends look at billing practices and how those rates are set
  • Perry – asked for a copy of his data

Candice Ailer, consultant in family and trauma informed care

  • Working to help others becomes trauma informed care and it is more than a training but shift in focus/how care is provided

Lee Spiller, ED for Human Rights Texas

  • Higher acuity – should make sure looking at higher acuity
  • Have utilization review but given history with contactors would like to have unit in state government to make sure they are accurately monitoring

Linda Litzinger, self

  • Would like to encourage as much information to be disclosed as possible – gave personal story

Tyrone Labasoky, self

  • Veteran of the system and grateful but says young people are now in unprecedented danger
  • Acute psychological distress comes form begin in an environment that is conducive to mental illness
  • Environment needs to be created where they can survive

Judy Powell, Parent Guidance Center

  • Solutions brought to table repeatedly – safe housing, transportation, drug treatment

Dan Johnson, Behavioral Advocacy of Texas

  • Adopt consistent training practices and use only evidence based services (Turning Point Initiative)

Randall Stone, self

  • Dealt with CPS on false allegations and now working with parenting groups, not happy with system

Jusmenda Dashevanglesta, self

  • In foster care system out of state since birth and now aged out, concerned about having children because of damage in foster care 

Mike Foster, self

  • Gave written testimony – need to get out of treatment business and into the healing business

Samantha Crumermine, self

  • Gave written testimony – took pictures of children in the system to give them a face, found there are not enough case workers

Cecilia Wood, Texas Homeschool Coalition

  • Homeschooling children is legal and should not be investigated for it nor should it be grounds to remove children