D.C. Child and Family Services Agency:

Performance Has Improved, but Exploring Health Care Options and Providing Specialized Training May Further Enhance Performance

GAO-06-1093: Published: Sep 28, 2006. Publicly Released: Oct 30, 2006.

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Kay E. Brown
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The District of Columbia's Child and Family Services Agency (CFSA) has a history of serious performance problems. A court case in 1989 set in motion sweeping efforts to improve the District's child welfare system. Since then, CFSA has worked to meet performance requirements ordered by the U.S. District Court. However, recent reports by the court monitor show that CFSA is not meeting performance requirements on many measures. To update Congress, we assessed (1) whether CFSA is likely to meet requirements by December 2006; (2) what factors, if any, hinder the agency from meeting requirements; (3) how CFSA is monitoring its progress; and (4) the extent to which CFSA has implemented initiatives to achieve unmet requirements. To conduct this work, we reviewed reports by CFSA and the court monitor and interviewed stakeholders, including the court monitor and CFSA managers, supervisors, and caseworkers.

CFSA has made progress, but the agency is not likely to meet all of the court-ordered requirements by December 2006, based on the recent court monitor's report and our work. From December 2005 to April 2006, CFSA improved its performance and met some benchmarks. However, CFSA's performance on other requirements remains well below benchmarks, raising questions about the agency's ability to meet all of the court-ordered requirements by December and sustain the improvements it has made. For example, only 29 percent of children in foster care received medical evaluations within 30 days of placement in April 2006, despite a benchmark of at least 90 percent. Several factors--complex caseloads and shortages of health care providers and qualified foster and adoptive homes--hinder CFSA's ability to meet court-ordered requirements. CFSA's cases are complex, in part because of the high proportion of hard-to-place teenagers and children with medical or mental health needs in the District's child welfare system. Caseworkers reported that they do not have enough specialized training to help them develop the skills they need to address these caseload complexities. CFSA's effort to meet court-ordered time frames is complicated in a small number of cases--those involving severe physical or sexual abuse--by the difficulty of coordinating with the District's Metropolitan Police Department. At the same time, CFSA officials told us there is a shortage of health care providers to serve these children, and the limited number of qualified foster and adoptive homes hinders CFSA's ability to give children the most appropriate and timely placements. CFSA uses routine reports and qualitative studies to determine whether it is meeting requirements, but current data may not provide an accurate picture of the agency's progress. Implementing the agency's new Web-based case management system has been challenging and caseworkers reported that because of these implementation difficulties, they have not always entered complete and accurate data on their cases into the system. However, CFSA has recently taken a number of steps to resolve these issues, including, for example, issuing frequent system upgrades to address identified problems and developing enhanced system training for caseworkers. Within the past few years, CFSA has implemented several initiatives to address the challenges it faces and achieve remaining requirements, but it may be too soon to know if they will yield long-term results. CFSA has hired new staff and reorganized existing staff to focus on key areas. In addition, CFSA has implemented new practices, such as a tool to prioritize investigations based on risk. CFSA is also beginning to hold its management staff and private contractors accountable for helping the agency meet specific performance requirements. Many of these initiatives seem reasonable, but it is too soon to tell whether these efforts will help CFSA meet the remaining court-ordered requirements.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In 2009, CFSA redesigned their training curriculum for caseworkers new to the agency, as well as the ongoing training provided to their more experienced caseworkers. To develop these training courses, CFSA worked with child welfare experts, both internal to the agency as well as outside the agency. Some of the new courses that were developed include training on responding to trauma, mental health in child welfare, and best practices on dealing with fathers.

    Recommendation: To improve CFSA's ability to serve the District's children and to help meet court-ordered requirements, the Mayor of the District of Columbia should direct CFSA to provide caseworkers with specialized training to help them develop the skills needed to address the complexities of their caseloads.

    Agency Affected: District of Columbia: Executive Office of the Mayor

  2. Status: Closed - Implemented

    Comments: To address the mental health needs of children in CFSA's custody, in 2008 CFSA established contracts with seven mental health providers to address the needs of children in foster care. These providers offer specific services identified through the 2007 Mental Health Needs Assessment including evidence-based and non-traditional therapies. To help address the medical needs of children in CFSA's custody, CFSA opened the Healthy Horizons Assessment Center (an on-site Agency clinic) in December 2009. According to agency officials, the clinic is designed to address the medical pre-placement and replacement screening needs of all children/youth in the custody of CFSA, and provides comprehensive physicals for children entering care. This in-house screening process has the potential for providing more timely identification and initiation of medical and mental health services for the children CFSA serves. The Healthy Horizons Assessment Center staffing consists of five Certified Medical Assistants and five Advance Practice Registered Nurses (Nurse Practitioners). Nurse Practitioners practice independently and are authorized to write prescriptions. In July 2010, CFSA is launching a Nurse Care Management (NCM) Program, which is a mechanism for integrating health and social services planning. Registered nurses staff the NCM Program to ensure that children in foster care receive necessary health care services to address their comprehensive health needs. In this new role the Nurse Care Manager will provide administrative health expertise and will serve as the designated Agency (CFSA) skilled professional medical representative. The major functions of the NCM will include collecting and updating health information, accessing and coordinating health services, health education, discharge planning and facilitating communication between families and health care professionals. Experts believe that an increase in case managers and in-house nurse practitioners could help decrease the demand on area providers, but the number of staff dedicated to these programs may not be sufficient to address the needs of all CFSA foster children.

    Recommendation: To improve CFSA's ability to serve the District's children and to help meet court-ordered requirements, the Mayor of the District of Columbia should direct CFSA to explore options for increasing the pool of providers for mental health, medical, and dental services.

    Agency Affected: District of Columbia: Executive Office of the Mayor


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