Things to Know for States Interested in IV-E Waivers

YSI was on hand for this week’s town hall meeting on Title IV-E foster care waivers, hosted by Administration for Children and Families, a division of the Department of Health and Human Services.

The two-hour session was a bit light on the “town” aspect, as speakers swallowed up all but the final 20 minutes, which were left for a handful of questions from the 125 phone attendees and two dozen people who showed up. But the meeting did provide some helpful hints for child welfare systems interesting in becoming on of the ten new waiver states.

For the waiver-uninitiated, the chosen states will be provided a block of inflation-pegged money in lieu of the traditional Title IV-E foster care entitlement, and will be allowed to use that money for a wider array of ventures than the entitlement traditionally allows. These ten projects, which will roll out over the next three years, will bring the total number of IV-E waivers to 33 between 1994 and 2014.

The flexibility attached to the waiver is connected to a state’s proposal: it must propose to address some specific aspects of the child welfare system that would be more difficult under the IV-E entitlement, which directs most of the federal share of child welfare costs toward services for children removed from their families.

Of course, the language of the legislation itself has the most influence on what demonstration projects will look like, and in this waiver round, Congressional authors laid out specific reforms it wanted to see. States had to pick two reforms to include in waiver plans from the following menu:

-Establishing a foster care bill of rights

-Development and implementation of a plan for meeting the health and mental health needs of children in foster care

-Implementing a IV-E Guardianship Assistance Program or increasing the age limit for IV-E programs, both of which were made possible by the Fostering Connections to Success and Increasing Adoptions Act in 2008.

-Limiting the use of congregate care

-Keeping siblings together

-Recruiting and supporting quality foster parents

-Preparing foster teens for a transition to adulthood

-Helping foster teens reconnect with their biological family members

-Establishment of specific programs to prevent foster care entry

But it is ACF that published the memorandum with guidelines on applying for a waiver, and the agency will oversee the proposal review process and then manage the waivers.  So the agency’s own priorities will obviously carry some weight in determining which states get shown the money.

What did we learn at the meeting? A few tips for potential applicants based on the meeting:

Pitch the Long Game Over the Easy Win

ACF leadership isn’t likely to be enamored of proposals that sound really attainable and simple to implement. Samuels made a point of saying that HHS was looking for “transformative change…the kind of change that can lead the field in future directions.”

“Don’t think of the waiver as something to be implemented all in year one with the same plan for all five years,” he told attendees. “Lay it out in a phased approach, and make sure each component is in place by year five. We believe that’s a far more rational approach.”

ACF Is Interested in Well-Being As An Outcome

Commissioner of the Administration on Children, Youth and Families (ACYF) Bryan Samuels, who answers to ACF Commissioner George Sheldon, spoke first and longest at the meeting.

He made it clear that his remarks were not meant to spell out the only themes for winning waivers, but the interest in these two themes was unmistakable.

“States have made great progress on safety and permanency,” Samuels said. “The next logical step is to build on that success and add the third dimension of well-being.”

Samuels, who presented with the aid of a Power Point outline [National Child Welfare Town Hall – Well-Being Through Trauma Focus (5-21-12)], laid out ACF’s view on the hallmarks of well-being:

-The ability to manage emotions

-Ability to sustain relationships

-Feeling safe

-Possessing a positive self-image

-Social connectedness

-Self-efficacy

By addressing the characteristics of well-being, Samuels said, you lower the likelihood a child will re-enter or ever enter foster care.

For youth development strategy champions, such a statement from a federal agency with billions at its disposal is music to the ears. It’s an indication that instead of just making sure nothing horrendous is happening to a kid, HHS wants positive outcomes for kids to be the deliverables attached to federal dollars.

It is difficult, however, to effectively track and measure whether services lead to a child improving his self-image or connecting more to society in a meaningful manner; far more difficult than measuring the movement of a child in and out of foster care, or a re-abuse rate.

On top of which, child welfare cases generally arise not directly from the struggles of children but of the adults who care for them, so building up the assets of a child (while a great idea) can’t in and of itself prevent a biological or foster parent from failing a child.

Another Interest: The Influence of Trauma Assessments

“We know more from the literature that abuse and neglect has a fundamental and profound effect on a child’s ability,” Samuels said. Trauma assessments could inform and shape new programs, case planning and interaction with families, he argued.

Samuels suggested the idea of essentially categorizing the main driver of trauma – neglect – into four tiers based on the level of intervention that might be needed to address it.

The fourth tier, for example, would be family income or housing issues, trauma that clearly could be addressed by offering additional supports to the child’s family. The first tier would include neglect that caused serious functional problems for a child.

Such an approach might help systems develop ways to address more trauma induced by neglect without the removal of children, Samuels said. “Not everyone comfortable with idea that families found to have neglected children should be served in-home. It’s important for states to move in that direction, there are

increasing numbers of families that could be served” with in-home programs.

Tap Into Other Funding

Three sources in particular were mentioned:

Medicaid: The holy grail of extra funding. Drawing more federal Medicaid dollars into child welfare services is the simplest way to connect a system to a sustainable source for programs. This has reared its head in an ugly way of late: the ability to bill Medicaid for psychotropic medications certainly plays into the highly disproportionate number of foster youths who are prescribed those drugs.

Samuels’ suggestion of directly addressing trauma and well-being in children ties in here, as those services are easier to pay for with Medicaid than family-based services.

Connecting teens that are aging out of foster care to Medicaid-funded services could soon get easier. The Affordable Care Act, assuming it is still intact, would make former foster youths automatically eligible for Medicaid up to age 25.

Pay For Success/Social Impact Bonds: This wasn’t brought up by any of the town hall presenters, but the concept of using incentive-based schemes within waiver plans was mentioned in the waiver memo published on May 14. The idea is that private industry or philanthropy would assume the cost of developing new ventures with the carrot of repayment and additional profit pegged to the success of the venture.

So YSI asked Samuels how he saw such plans fitting into the waiver proposals? He said the most rational scenario was starting up programs with high up-front costs, but reliable outcomes, where private money could finance the start-up and reap financial reward if the programs had an impact.

“A small number of private foundations expressed an interest in pursuing social impact bonds,” Samuels said. ACF sees the waivers as a way for the feds to be “a matchmaker of sorts” between the foundations and state agencies.

So, what foundations are we talking about? Samuels cut that question off before we could even ask it.

“I can say that over that last 12 months, we have heard considerable interest in doing this work,” he said with a rye smile. “I’ll leave it to the foundations to make public who they are and what they want to do.”

If YSI had to guess, the list will include some of the foundations with the word “Casey” in it: Jim Casey, Annie E. Casey, Marguerite Casey, Casey Family Programs.

Other Funding from ACF: ACYF Deputy Commissioner Clare Anderson alerted attendees to Fiscal 2012 discretionary grants that might dovetail into waiver plans. Recent funding solicitations include grants to connect more foster youths to Head Start and Early Head Start; serve families affected by drug abuse or HIV/AIDS; improve access to health services; and demonstrate effectiveness of housing assistance programs for families in the child welfare system. YSI couldn’t find funding notices for the latter two, so perhaps those haven’t been made available yet.

Letters of intent from candidate states are due on June 4 (e-mail cwwaivers@acf.hhs.gov) and proposals are due on July 9 (to the same e-mail).  ACF expects to have the decisions made and waiver terms signed by September 28, just before Fiscal 2013 begins.

It will be a rolling review process, though, so if a state misses the July 9 deadline it does not have to wait a year to re-compete for a waiver; the proposal will just be considered for a later start date.

Youth Services Insider is produced by John Kelly with the help of other reporters at The Chronicle of Social Change. It is a business and policy analysis column on child welfare and juvenile justice services.

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John Kelly
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John Kelly is senior editor for The Chronicle of Social Change.