Other Program Instruction Requirements

There are many collaborative groups well established while others are formed as needed to discuss and explore a particular subject. When these groups form at the local level, they often complete their work in a short amount of time and therefore do not remained established. This model of group formation fits hand-in-hand with our CQI philosophy and has provided staff at all levels a voice is resolving issues. Additionally, our intent is for this model to encourage forming a diverse group of individuals which may or may not include management.

For more information regarding individual partnership and collaborations, see Annual Partnership section

The Guiding Principles incorporate the continuum of publicly funded child and family services continuum for child abuse neglect prevention, intervention-treatment services for foster care, family preservation services, family support services, and services to support reunification, adoption, kinship care, independent living and services for other permanent living arrangements. Some of services mentioned above are received through a contractual agreement. However, all the aforementioned services are described in the Annual Progress Section of this plan.

Missouri has contracts to provide services for all programs under the Children’s Division’s umbrella including day care and residential treatment. In order to purchase a service from an agency or individual, they must be a vendor in our financial system. The vendor system is relatively a simple process, however, being a vendor does not guarantee the Children’s Division will purchase their service. Depending on the service the vendor intends to provide, there may be a need for a contractual agreement. If this is the case, there can be a RFP process that may accompany a particular type of service.

The number of contractors and the amount spent for the services is not an indication of service gaps for Missouri. Recently, we have asked all 45 circuits to self evaluate their services and identify the barriers families and children face when accessing services. These reports have not been completely synthesized into a single document for study. The plan is to not only look at the service gaps internally but also to collaborate with external partnerships to expand service areas. The data may show a need to form new groups in some geographical areas to look at catchment areas instead of circuits for service delivery.

Missouri failed the systemic factor of Service Array from the first round of the CFSR and is focusing on this issue in our next Program Improvement Plan. The National Resource Center for Organizational Improvement discussed ideas to remedy service array issues with Missouri; however, strategies have not yet been formalized pending the availability of Readiness Assessment data.

Below are three contracts major contracts utilized by the Children’s Division.

Case Management Contracts

CD administers an extensive array of purchased services. These are purchased from local public and private providers. Contracted providers play a major role in extending services to client families throughout the state.

The case management contracts were awarded on 6/1/05 to seven provider consortiums to serve the St. Louis, Kansas City, and Springfield regions. The St. Louis region consists of St. Louis City, St. Louis County, Jefferson County, and St. Charles County. The Kansas City region consists of Jackson, Clay, Andrew, and Buchanan Counties. The Springfield region consists of Greene, Christian, Taney, Lawrence, Barry, and Stone Counties.

The current contracts were awarded to the initial seven consortiums effective 8/11/08. Three additional contracts were awarded 9/1/08 to serve 12 counties in the central and southwestern part of the state. These regions consist of Randolph, Howard, Boone, Callaway, Camden, Laclede, Pulaski, Phelps, Texas, Jasper, Newton and McDonald Counties.

As of 2/28/09 the active caseload for private contractors consisted of 3,207 children. This compares to 9,546 children served statewide. Approximately 33.6% of the foster care population is served through contracted case management providers.

For more information see Foster Care Case Management in the Annual Permanency Section.

Specialized Care Management

See Specialized Care Management Contract in the Annual Permanency Section.

Residential Treatment Services for Children

See Residential Treatment Services in the Annual Permanency Section

When new contracts or renewal of existing contracts offered out for bid, the information is posted on the Office of Administration website and notification letters are sent to contractors providing similar services. The Office of Administration notifies the Children’s Division and the regional executive staff submits other names of agencies in their areas who may be interested in providing services. Notification letters are sent to existing contractors providing similar services and those identified by the Executive Staff.

Below are links to the DPMM enabling authority - Chapter 34 of the Revised Statutes and the Chapter 40 of the Code of State Regulations.

https://revisor.mo.gov/main/OneChapter.aspx?chapter=34

http://www.sos.mo.gov/adrules/csr/current/1csr/1c40-1.pdf

Missouri does not have any recognized tribes; however, in three sections of this plan, coordination with the Native American community has occurred through initiatives and program changes. They sections are found in the Annual Partnership, Annual Permanency and the Chafee sections.

See Healthy Care Services Plan for Children and Youth in the Annual Practice Section.

The Children’s Division is an active participant with the State Emergency Management Agency and crafted individualized emergency plans for specific purpose. All these plans are attached.

Attachment D,    The Children’s Division Emergency Plan

Attachment E,     Emergency Plan for CA/N investigations during a disaster

Attachment F,     Emergency Plan for addressing the needs and services of Foster Care children during a disaster

Statewide Plan to Improve Caseworker Visits with Children:

Goal 1: Improve frequency of worker visits with children in foster care.

Strategies:

1. Clarify policy related to frequency of worker visits with children in foster care.
   • Issue Practice Point covering frequency
   • Send clarification to contractors
2. Train on Frequency of worker visits with children in foster care
   • Contractor Training
   • Post Practice Point online - self training
3. Monitor Frequency of worker visits with children in foster care
   • Develop state worker visits with child report
   • Refresh report on 10th and last day of month
   • Develop state report reference sheet
   • Develop Federal Worker Visit Report
   • Report Monthly frequency by region at Executive Team Meetings
   • QA public and private staff to monitor ongoing basis
   • Use the quarterly CQI In Focus newsletter to highlight progress with worker visits.
4. Regional plans to improve frequency of worker visits with children in foster care developed, implemented and monitored
   • Regional Plans developed
   • Post regional plans on individual sites on intranet
   • QA Monitor Regional plans

Goal 2: Increase the number of visits occurring in the child’s placement.

Strategies:

1. Clarify policy expectations of what needs to happen during a worker/child visit in placement.
   • Develop practice point to include information on why it is important to meet with children in their placements.
2. Clarify documentation and data entry of worker visits with child in placement.
   • Develop Power Point training on data entry of worker visits in placement and post online - connect to practice point.
3. Train expectations on worker visits with children in placement.
   • Train Contractors
   • Post Practice Point
4. Regional Directors develop plan regarding visit expectations in placement.
   • Regional Directors develop plan
   • QA Monitor Regional plans

Goal 3: Increase the quality of worker visits with children.

Strategies:

1. Clarify policy expectations related to quality of visits
   • Develop intranet site from front page with all information about worker visits in one spot.
   • Post tip sheet or "best ideas" on intranet
   • Address quality in practice point
   • Develop laminated prompt cards
   • Continually tying the importance of worker visits to permanency.

Goal 4: Improve data entry of worker visits with children.

Strategies:

1. Modify FACES as needed to better capture actual contact and the quality of contact.
   • Team meeting held to develop screens
   • System Change Requests submitted
2. Increase Mobility for Field Staff
   • Develop project plan
   • Pre-post surveys
   • Monitor Outcomes

Regional Plans:

Jackson County:

• Casemanagers will schedule visits early in month to leave opportunity to make up cancelled visits prior to month end.
• Casemanager calendars will be reviewed during supervisor case conferences.
• Supervisors will assure worker calendars allow time for data entry of visits.
• Casemanagers, Supervisors, Upper Management and QA staff will utilize the FACES visit form to monitor visit performance.
• Local QA unit (Jackson County) will do random sample case reviews, including FCCM cases.
• Worker visit performance will be discussed during monthly Team Management meetings.
• Worker visit performance will be discussed at supervisor meetings at least semi-annually.
• Guidelines for data entry of worker visits will be distributed to all staff.
• A "Cheat Sheet" for data entry of worker visits will be developed.
• Supervisors and Office Program Managers in Jackson County will submit monthly management reports to the Regional Director.
• Any Casemanager having less than 90% completion rate will have an informal plan enacted.
• FCCM Oversight Specialists will monitor FACES to ensure visits for children assigned to contracted agencies are being completed.
• Resource Parents will be informed regarding the importance of caseworker visits in their homes via the Joining Hands Newsletter in Jackson County.
• A county wide meeting in Jackson County will be held with all staff to review results of the time-study and to discuss priority setting for worker time management.

Northern Region:

• The topic of visits is on every meeting agenda at all levels including unit meetings, "all staff" meetings, sub-Region management meetings, management meetings with Field Support Managers and Regional Director and CQI. Best practices are shared through these venues.
• Field Support Managers and Regional Director are reviewing the managed report on visits each month. Field Support Managers review this report with Circuit Managers each month.
• In weekly conferences, Supervisors review worker case management reports and discuss progress on visits including the content of visits. Individualized plans are developed to assure visits occur and are documented.
• Each Circuit Manager and supervisor was given a tool in early 2008 to use to track visits. The tool was not mandated but the instruction was to use the tool provided or to use one that captured the required elements. Each circuit has a tool and the Field Support Mangers review the progress at their monthly conferences with the Circuit Manager.
• Each Circuit has developed a local plan to address and maintain performance in meeting the worker visit with child standard of excellence
• March of 2008, all specialists in the Region were provided with a power point presentation on worker visits and this presentation has been made available to all circuits.
• Supervisors have developed processes that assist the worker in assuring that visits are scheduled per policy. Some examples of these processes are:
  1. An expectation that visits occur the 1st and 3rd week of each month
  2. Supervisors review worker’s calendar at each weekly conference
  3. A chart listing each child is posted in the supervisor’s office and workers mark when the visit has occurred
  4. Case managers email service workers at the beginning of each month to ask when visits are scheduled
• Instruction has been given to Circuit Managers on protocol if the visits required by service workers are not occurring per policy (supervisor to supervisor contact, Circuit Manager to Circuit Manager, Regional Director to Regional Director)
• COA maintenance "reads" focus on worker visits and the quality of the visits
• Many Circuit Managers are randomly selecting at least five cases each month to review the entry of worker visit information as well as to review the quality of the contact

Southern Region:

• Discuss information regarding worker child visits with all staff at every quarterly Circuit/Program Manager Meeting in the Southern Region
• Discussion will include the importance of the quality of worker/child visits, the importance of relationships with children (even with very young children) and the ability to help plan with FST members based on these relationships
• Supervisors will review CD Visitation forms and check FACES entries for compliance during weekly supervisory consultations (Worker Compliance Tracking, Attachment H)
• Circuit/Program Managers will monitor reports founds on FACES, PRR, SCRT’s to assess for compliance
• Implementation of Supervisory Consultation Visit Log (Attachment G)
• Additional FACES training for staff where available
• At "all staff" Circuit Meetings, at Supervisory Unit Meetings and Circuit/Program Manager’s Meetings, at Regional Staff Meetings, during individual conferences with staff at all levels, emphasize with the staff the relationship between visits and successful outcomes for children
• Children’s Services Specialists to provide ongoing training to Supervisors and CSWs
• Provide Examples to new staff of what to discuss with children during worker/child visit (contact listing for each county to assign service worker)
• Develop a system for the Southern Region to assure transfer requests between Circuits are handled in a timely manner
• Utilize the results from the Southern Region Worker Time Study completed in November 2008 to create a "Reduction of Administrative Activities and Paperwork" workgroup
• Education of Resource Parents on importance of worker/child visits and how to be supportive of these visits occurring
• Encourage Southern Region staff to continue to make progress through E-mailing, speaking at unit meetings and one-on-one conferencing

St. Louis City

• St. Louis City All Sups and Specialists meetings are being used as a Leadership and Practice Improvement Academy. At each meeting the staff chose a practice issue to focus upon for the next four to six weeks. During the month of February and the month of March, improving the percentage of visitation with foster youth has been the identified practice improvement strategy for the FCOOHC program area.
• All supervisors and program managers are expected to use the managed reporting for monitoring visitation. Each supervisor was expected to establish a baseline for their group and with each worker in order to evaluate progress.
• A local tracking tool was being used prior to the managed reporting coming on line. Managers are no longer expected to use the local tracking tool but are welcome to use it if it is helpful for the supervisors and the program managers.
• Program Managers are expected to monitor visitation outcomes for each of their supervisory groups. A reporting out at the Management meeting (the second one of the month) will be an expectation. Individual conferences will also focus upon the improvement/lack of the visitation outcomes.
• All case managers are expected to use a calendar to frontload their visits with foster youth each month. Supervisors are expected to use the calendars to monitor and assure that visits are occurring. Frontloading the visitations during the first two weeks of the month should allow for all visits to occur before the end of each month.
• Visitation outcomes will be a topic of discussion at each of the All Sups/Specialists meetings-held once a month.
• A number of supervisors have imposed the first two hours of each morning as "quiet" time where staff should be inputting information in the FACES system. Other supervisors are requiring staff to input a visitation in FACES the work day following the visit. Both strategies are to insure the timely input of information into FACES regarding the visitation.
• Strategies that are working are shared with the whole at the Sups/Specialists meeting.
• There is a peer supervisory meeting held each month. Visitation continues to be a topic for that groups' meeting with the idea of promoting "peer to peer" TA on what strategies are working.
• PBC contractors will be invited to the City All Sups/Specialists meeting for a portion of the CSFR content. Previously, the oversight specialists were sharing the practice goals from that meeting.

St. Louis County

• Inform staff of expectation to enter visit contacts within 5 business days of contact & to enter complete contact info (No "See CD-82" entries).
• Document contact entry date into FACES on CD-82; Submit form to supervisors within 5 business days of contact
• Verify entry date & completeness in FACES
• Submission of visit tracking form to program manager
• Monitor service workers' visit contact entries in FACES
• Provide worker child visit entry instructions to staff
• A cheat sheet w/tips for staff given to all case managers
• Check workers' case lists on visit report against local worker visits tracking form to ensure they match
• Submit tracking form to program manager
• Monitor Circuit Manager’s visitation schedules to ensure regular visits are happening
• Inform supervisor when visit policy expectations can't be met
• Monitor frequency of visits using Tracking tool & FACES Worker Visit Report to ensure visits are held 2 x month (after 10th business day of month)
• Provide strategy ideas to staff on how to improve visit frequency

In FY 08, Missouri did not receive adoption incentive payments to assist CD in covering the costs of adoption recruitment and related activities. However in FY 08, funding was set aside for faith based activities which also include recruitment of resource families and funding for One Church One Child.

New Objective for SFY 2010-2014

In addition to maintaining the current training structure and professional development for front line staff and supervisors, a Learning Lab Training structure will be implemented to provide ongoing professional development for supervisors beyond their first year of initial pre-service and in-service training.

Learning Labs will be provided for all front line supervisors in all 7 regions. Supervisors will be trained in how to create an organizational culture in the child welfare agency in which support, learning, clinical supervision, teamwork, professional best interest and consultation are the norm. The quarterly learning labs will be flexible enough to allow for crisis topics driven by the need identified in each region. Group facilitators will meet with the supervisors in each region to outline the learning lab model and identify regional needs .Subsequent learning labs will be held quarterly with topics driven by the region-specific needs. Structured topics may include Leadership and Management, Clinical Practice and Skill Building and Networking.

For more detailed training information see the Annual Professional Development and Training

Technical Assistance for Missouri occurs in two manners, internal and external. From the Central Office level, our field staff receive support and technical assistance from program development specialists, management analysis specialists, unit managers, etc. on specific program issues. If there are issues for policy interpretation, a process is in place for policy clarifications. The clarifications are sent to all staff and posted on the intranet for continual assistance. But, individual circuits may request technical assistance for a number of specific reasons. This technical assistance process is explain in the CFSP progress section 2005-2009 under the Practice Enhancement Teams / Technical Assistance.

Missouri has received technical assistance from the National Resource Centers on several occasions since 2005. In no particular order, Missouri has requested assistance with the following:

• Strengthening the Culture of Care (Residential Treatment Centers)
• Child welfare supervision
• Placement stability
• Improving outcomes for youth training
• Diligent recruitment
• Cross Jurisdictional Placements
• Recruitment and retention of resource families
• Indian Child Welfare Act
• Interstate Compact
• Worker visits

The following sections are brief descriptions for the technical assistance requested.

Strengthening the Culture of Care Training, Spring 2006

In early 2003, the Missouri Children’s Division (CD), Residential Program Unit, RPU, requested assistance from the National Resource Center for Youth Services (NRCYS) to help increase child safety and nurturance in licensed residential child care agencies. NRCYS and RPU enlisted the help of the residential child care agency community which resulted in NRCYS developing the Strengthening the Culture of Care curriculum. Train the trainer sessions were initially held in the summer of 2004.

Due to staff turnover and the request for a refresher, another round of train the trainer sessions was held in the spring of 2006. In addition, NRCYS is in the process of conducting a field study with a representative sample of agencies that received the training.

RPU found the efforts of NRCYS to be very helpful. NRCYS was well received by the training participants and there have been requests to have yet another refresher of the training with a curriculum revision helping supervisors support front line staff who use the training. RPU has had preliminary discussions with NRCYS regarding the possibility of more training in the future.

Child Welfare Supervision

On November 6, 2007 National Child Welfare Resource Center for Organizational Improvement (NRCOI) and the National Resource Center for Child Welfare Data and Technology (NRCCWDT) completed a two year effort to assist Missouri with designing its child welfare supervision. This effort arose out of a meeting held in 2005 to help Missouri determine what was needed for Program Improvement Plan implementation.

Many child welfare issues are typically addressed in child welfare supervision. Moreover, the field of public child welfare increasingly is focusing on supervision as a strategy for improving practice and outcomes. Across the United States, it is clear that supervisors are the most stable element of the child welfare system, and they are the keepers of the agency’s culture, and that to introduce and achieve systemic change, their involvement and support is crucial.

For these reasons, it was decided that one of the first priorities in using T/TA from the NRCs would be to convene a Child Welfare Supervision Work Group in Missouri, and to use that group to study how to better support supervisors and improve supervision and, ultimately, prepare and implement a Child Welfare Supervision Strategic Plan. This Work Group was to be supported through technical assistance provided by staff and consultants of the NRCOI.

This Work Group was formed with the assistance of the Regional Directors and Central Office staff. Since its inception the workgroup has met quarterly to discuss the culture of supervision in Missouri and what can be done to improve it.

Also on November 6 - 7, NRCOI and NRCCWDT met with division leadership to begin the planning of TTA needed to help prepare for the 2010 CFSR.

Missouri’s second CFSR is scheduled for June 2010. The leadership of Missouri’s Children’s Division requested the assistance of the NRCOI and the NRCCWDT to develop a plan for CFSR preparation. Region VII approved two days and the planning meeting was held on February 26-27, 2008 in Jefferson City. Participants included Children’s Division leadership, Region VII staff, NRCOI staff and staff from NRCCWDT. The second day was also attended by staff from the Office of Research and Evaluation and staff from the division’s SACWIS/FACES system section.

On the first day, the CFSR Outcomes and Systemic Factors were reviewed and the group determined where Missouri’s child welfare system was at developmentally. Also identified were community stakeholders who were critical for each outcome and systemic factors. The group identified potential training and technical assistance needs for each. Also discussed was the process to assess the service array and how Missouri’s jurisdictions might use the assessment to improve the well-being outcomes. An initial matrix was completed summarizing the work completed by the group.

Placement Stability

Placement Stability was an area identified in our last Program Improvement Plan (PIP) needing improvement. To help Missouri address this, the NRC for Family Centered Practice and Permanency appointed Lorrie Lutz to provide technical assistance with this task. The State of Missouri implemented a Placement Stability Committee to analyze this issue. The committee was comprised of all levels of staff across the state, resource providers and foster care youth.

With Lorrie Lutz’s assistance the committee was able to strategize new ideas to improve Missouri’s practice to better meet the needs of children and resource providers. Existing inconsistencies/barriers were identified, as well as current best practice. The committee developed recommendations designed to improve placement stability, and several were implemented in test areas or statewide. (See Attachment I-Recruitment, Retention and Placement Stability)

Improving Outcomes for Older Youth Training

Chaffee program services and issues such as permanency options, permanent connections with an adult, sibling connections, and permanency pacts were themes discussed at the regional older youth trainings in November, 2007. Sally Gaines, Program Development Specialist for Children’s Division, provided information on Chaffee. A foster youth panel was utilized to inform the audience about their personal experience in foster care. Andrea Khoury, National Child Welfare Resource Center on Legal and Judicial Issues, and Clayton Finck, National Resource Center for Youth Services, served as faculty at two of the five regional training sessions. Mr. Finck provided an overview of Improving Outcomes for Older Youth: What judges and attorneys need to know. CIP funds were utilized to purchase a copy of this manual for every training participant. In addition, training funds allowed for the purchase of Achieving Permanency for Adolescents: A Guide for Legal Professionals for all individuals who attended the training. Ms. Khoury served as one of the project directors and authors for this publication. In her presentation she stressed the importance of involving older youth with their permanency and transition planning and court hearings. A video entitled, "No Sweet Home: Aging Out of Foster Care" was provided to each circuit. Copies were also provided to CASA and the Children’s Division contracted case management agencies. The following individuals observed the first two training sessions and served as faculty for the other three: The Honorable Thomas Frawley, 22nd Judicial Circuit; Jeanne Gordon, attorney for the Juvenile Office in the 19th Judicial Circuit; and Phil McIntosh, full-time GAL for the 2nd Judicial Circuit.

There were 194 participants who attended this training. Attendees included judges, juvenile court staff, attorneys, court appointed special advocates, Children’s Division staff, and contracted case management staff.

The Assessment Resource Center (University of Missouri-Columbia) was contracted to evaluate the older youth training conducted in November, 2007. The evaluation was received in May, 2008 (see attached). This evaluation included a follow-up survey which was delivered six months following the training to determine if there has been an impact on practice. While there were some suggestions to improve the training, overall it received very positive feedback. Respondents reported that the training contributed to their knowledge, influenced their practice, and encouraged them to share the information from the training with their colleagues.

Diligent recruitment

AdoptUSKids MEPA Diligent Recruitment

Lori Lutz from the NRC provided Training and Technical Assistance focused on improved recruitment and retention of resource families. A plan was developed for implementation into programs and policy. This plan included utilization of a web front database to track the activities associated with families approaching the agency to become foster/adoptive resources throughout the process to determine what improvements could be made to our customer service of these families. The contract for this service has been in place for one year and we are tracking improvements in the follow through of staff with interested potential resource families as well as those who enter the application and training process.

Additionally, a resource family profile and child profile is being utilized to inform families and children about the potential placements.

Cross Jurisdictional Placements

Technical Assistance was provided at the Region VII Permanency Meeting in Kansas City in an informational session presented by Linda Foster from Oklahoma Department of Human Services. Ms. Foster provided an overview of the Oklahoma military family adoption recruitment and support program. Linda provided details of how Oklahoma has found Military families to be a great resource for harder to place children, mainly large sibling groups. Oklahoma has a special recruitment committee to recruit from the military bases in Oklahoma. Additionally Oklahoma has placed children for adoption with military families stationed overseas, becoming known across Europe for being open to placing children in other countries.

Resource materials were revised and reprinted by this group and have been being utilized for over one year with a new tagline for foster/adopt recruitment of "You Won't Believe What You've been missing, consider foster care or adoption."

Customer Service Assessment

Shari Black from the NRC for Recruitment and Retention of Foster/Adoptive parents came to Missouri to help us assess our customer service system as part of a review of the Region VII states. This assessment included the a review of the process for applicants, an explanation and review of our 800 number and recruitment and response team process as well as our web front database detailing the timeframes in which families are to be contacted. A review of our recruitment materials was conducted as well as the process involved in making application to the Children’s Division. Positive feedback was provided regarding our Missouri process of recruitment and customer service. A Region VII meeting to provide overall feedback has not yet been scheduled.

Indian Child Welfare Act

NRC for Family Centered Practice and Permanency Planning

Judge Thorne, a consultant with the Indian Child and Family Resource Center was brought to Missouri through the NRC to provide training to staff on the requirements of the Indian Child Welfare Act and Missouri’s compliance with the Act. Training was provided to upper level administrators and then to field staff in person and via teleconferencing. Judge Thorne also provided consultation on Missouri’s new ICWA tools and revised policy which will go into effect in May 2009.

Interstate Compact

Technical assistance was requested from the National Resource Center on Legal and Judicial Issues to provide ICPC training to Missouri’s judicial officers. The Honorable Stephen Rideout will serve as faculty, along with Children’s Division ICPC staff, and a panel of Missouri’s judges. The Supreme Court Chief Justice mandated all judicial officers who hear child abuse/neglect cases to attend this training. This training will occur in May, 2009.

Technical assistance was requested from the National Resource Center on Legal and Judicial Issues to provide training on educational laws to Missouri’s judicial officers. Kathleen McNaught will serve as faculty. Missouri’s Supreme Court Chief Justice mandated all judicial officers who hear child abuse/neglect cases to attend this training. This training will occur in May, 2009.

Worker Visits

Rose Wentz from the National Resource Center for Permanency Planning came to Missouri on November 5, 2008 to assist in a worker visit evaluation. Rose facilitated the review and led discussions on current policy and administration expectations. Following Rose’s visit, several internal meetings continued which led to a strategic plan to increase the worker visits with children.

The Children’s Division regularly participates in research initiatives evaluating child welfare issues either through direct collaboration, participation or by providing data or case level information.

Current and Pending Research Initiatives:

1. Missouri Institute of Mental Health: Youth in Transitions: Saint Louis System of Care

   Youth in Transitions: Saint Louis System of Care is a longitudinal federally funded initiative, to ensure that children and youth with severe emotional disturbance (SED) who are served within the St. Louis child welfare system receive needed mental health support through critical transitions into and out of the child welfare system thereby growing into successfully functioning adults. The study will explore the relationship between service use and outcomes by linking the services and costs data with outcome data collected through national evaluation on youth who are enrolled in Youth In Transitions: St. Louis System of Care. As part of the project’s requirements, data is collected from the Children’s Division on all youth participants. A Memorandum of Agreement was enacted between the Children’s Division and the Missouri Institute of Mental Health to complete this study.

2. University of Kentucky, Kent School of Social Work: Evaluation of Missouri Supervisor Professional Development Project

   The University of Louisville, Kent School of Social Work has been awarded a contract to provide consultation, training, and technical assistance to the Missouri Department of Social Services, Children’s Division regarding child welfare supervision.

   This study will evaluate the impact of a multifaceted professional development initiative designed to improve casework supervision in the Missouri child welfare agency.

   A series of focus groups and interviews will be conducted to identify the effectiveness of the intervention (360 evaluations and debriefings); the strengths and weaknesses of the process; the implementation of the project; and the impact of the process over time including examples of changes initiated as a result of the intervention. Supervisors, circuit managers, program manager, regional directors, and executive team members will be invited to complete the Missouri Supervisory Development Survey.

3. Research Triangle Institute: National Survey of Child and Adolescent Well-Being (NASCAW) II

   The National Survey of Child and Adolescent Well-Being (NSCAW) is a national longitudinal study of children and families in contact with child welfare, and will relate child and family well-being to family characteristics, experience with the child welfare system, community environment, and other factors. The study examines the interplay among the history and characteristics of children and families, their experiences with the child welfare system, other concurrent life experiences, and outcomes. It brings to bear perspectives from child welfare, child development, and other fields to focus on children’s well-being, including their health and physical well-being, social functioning, academic achievement, mental health, and behavioral adjustment. It relates these to developmental stage, prior experience, caregiver behavior, social services, and community environment. By drawing on these different perspectives, the study will provide new understandings of how family, child, community, and service factors affect children’s well-being and will provide the foundation for new improvements to policies, programs, and practices.

   NSCAW I was the first study to make available nationally representative longitudinal data drawn from first-hand reports from children, parents, and other caregivers, as well as reports from caseworkers and teachers and data from administrative records. It also was the first national study to examine child and family well-being outcomes in detail and to relate those outcomes to family characteristics, experiences with the child welfare system, community environment, and other factors. The study data describe the child welfare system and the experiences of children and families who come into contact with the system.

   This additional study will address crucial program, practice, and policy issues regarding the dynamics of the child welfare system and outcomes for children and families, and compare the findings between NSCAWs I and II. Data collection at baseline will include in-person interviews with children, their current caregiver, and their investigative caseworker, and a mail and web survey of teachers of school-age children. This baseline data collection will be complete in September 2009 and an 18-month follow-up (Wave 2) of the cohort in October 2009 will be launched.

   By participating in NSCAW, states and agencies, including the Missouri Children’s Division, have contributed to this major national effort to strengthen child welfare policies, programs, and services to children and families. Through direct interaction with those on the frontlines-caseworkers, family members, and children-the study team described the realities of the child welfare system; this will provide a basis for improving policy, program, and service planning and implementation at the Federal, State, and local levels.

4. Dave Thomas Foundation for Adoption, Child Trends: Evaluation of Wendy’s Wonderful Kids adoption program

   This impact and process evaluation utilizes child-focused recruitment strategies exclusively for a designated caseload of children awaiting adoption. The evaluation will document if, how, and when the Wendy’s Wonderful Kids model can improve the permanency of children in foster care (in particular, adoption versus aging out or long-term foster care), and to provide information to help guide ongoing program planning; specifically: to track progress and outcomes, to identify barriers and promising practices, and to assess program impacts.

   This program may lead to the permanent placement of children and youth in adoptive families. Benefits of the program include increased likelihood of adoption, decreased wait time until adoption, increased stability of adoptive and other placements, and improved child well-being, greater worker satisfaction, and more positive views of adoption in the child welfare agency and the public. Youth may also feel an increased sense of satisfaction and empowerment through the role they plan in their own behalf. This program may help reconnect children and youth with family and kin, which could be the basis for life-long, supportive relationships.

5. Washington University in St. Louis, Brown School of Social Work: Triple P with Parents referred to Child Protective Services

   This pilot project will provide important background data for a planned larger randomized controlled trial (RCT), which will advance the field by (1) testing the effectiveness of Pathways Triple P with maltreating parents referred to Child Protective Services, (2) determining for which maltreating parents Pathways Triple P is effective, and (3) identifying the specific processes through which Pathways Triple P impacts parenting capacities, child behaviors and child safety.

   Parents may benefit directly from participation in this study by learning (a) new parenting skills, (b) new ways to manage their child’s behavior, and (c) how to better cope with anger. Additionally, a potential benefit is the knowledge that their participation may assist other in need of parent training by information the implementation of an empirically supported parent training program within a child welfare system.

6. Washington University in St. Louis, Brown School of Social Work: Chronicity Initiative

   This study is an outgrowth of the current work with the children’s Division regarding Chronic Neglect, the Breakthrough Series funded by Casey, and request for assistance with decreasing chronic neglect re-reports. This project will assist with improving current assessment practices to better identify families that are at high risk for re-reports. Focus groups of experienced child welfare workers will be used to help identify a core group of themes that may be useful in improving the screening and assessment process for the Children’s Division. This information will be used in conjunction with other longitudinal studies with administrative data to help inform the assessment process. The study will serve to enhance the Children’s Division’s ability to meet the objective of preventing recurrence of maltreatment - particularly chronic neglect, and enhance future workplace practices, including both improving assessment tools and also training programs for new workers.

7. Missouri Institute of Mental Health: Circle of Hope, Keeping Children Safe and Families Together

   This project will increase the well-being of and improve permanency outcomes for children affected by methamphetamine or other substance abuse within Missouri’s Southwestern Region. Specifically, Kids Hope United - Circle of Hope (COH), the federal recipient, will augment the current regional interagency service delivery infrastructure by utilizing the Strengthening Families Approval to provide seamless, integrated, family centered services. The intended results are: a) to create an improved framework of support at the state and regional level, b) develop a service delivery grievance system beyond inpatient/outpatient (CSTAR) services for this target population who are at risk of losing their children, and c) increase client well-being through long-term stabilization and positive behavioral changes.

8. Washington University in St. Louis: Early Childhood Connections (ECC)

   Early Childhood Connections (ECC) is a novel service delivery model responsive to the "Innovative Services Research" objective. Using a randomized design, this developmental study tests ECC’s ability to prevent recurrent maltreatment, prevent or ameliorate maternal depression and stress in families with young children served by child welfare, in addition to preventing child development delay and later mental health disorders. To meet the needs of child welfare families, ECC is modifying existing services through coordination, collaboration and co-location by conducting a joint home visit with the family by ECC and Children’s Division workers. The target population is families with children under the age of three years with newly opened in-home family-centered service cases. This study will assess implementation of ECC. The benefits of this study include elimination of barriers to accessing in-home parenting services by ECC Parents as Teachers, which will improve child well-being outcomes.

9. Washington University in St. Louis, Brown School of Social Work: Treatment Foster Care for Older Youth with Psychiatric Needs (TFC-OY)

   This study is to develop and refine an evidence-based intervention that is effective in helping older youth from the foster care system with mental health problems who are in transition to adulthood and adult service systems. The specific goals of this study are 1) to determine feasibility and preliminary effect size estimates through a small pilot, comparing TFC-OY for older youth to a matched sample of young people receiving usual child welfare services and 2) to explore the experiences of older youth consumers, providers, and foster parents to TFC-OY. This study will provide a blueprint for effective treatment, giving the Children’s Division the tools to implement an evidence-based intervention into routine practice.

10. Jackson County Community Quality Assurance Committee (QCAC); Education Survey

    This longitudinal study is an evaluation of the education progress of children in alternative care between the ages of 5 and 18. Files will be selected on a random basis, based on a sample size of 10% from each office and reviewed by the Children’s Division Quality Assurance Administrator of Jackson County. This will help identify barriers to educational success, identify what works, identify special needs and assess if needs are being met.

Disproportionality and Disparity

A workgroup was developed to address disproportionality of African-American children in the child welfare system. The workgroup has reviewed data that verifies that disproportionality is occurring in Missouri, and is looking for ways to reduce it. Steps include looking at our agency’s :

• Mission Statement
• Organizational Structure
• Clients that we serve
• Personnel
• Programs/Policy

The group reviews each area to ensure that institutionalized racism is not affecting outcomes with children of color and that all families have equal access to services.

In partnership with Casey Family Programs, the Children’s Division designed an action plan designed to support the development of a strategic approach to address the issues of disproportionality and disparities. The workgroup will utilize this action plan in an effort to reduce disproportionality and disparities of African-American children in our state.

This chart shows disparity within service areas. For example, African American clients comprise a larger ratio of consumers of Foster Care (LS1 Point in Time) than other races where 30% are in foster care, but African American children only comprise 16% of the total Child Population in Missouri (based on 2007 census information).

Children’s Division staff participated in the "Undoing Racism" Workshop in April 2009, presented by the People’s Institute for Survival and Beyond. Staff were taught how to evaluate the system to ensure that imbedded bias and institutionalized racism are eliminated, allowing all families equal access to services.

This chart shows the disproportionate number of African American foster children compared to the census ratio, broken down by Missouri Judicial Circuits.

The Division will next be assessing and addressing other possible areas of disparity, such as age or gender differences.

In accordance with the total quality management (TQM) philosophy, the division maintains a strong partnering of Quality Assurance (QA) and Quality Improvement (QI). As previously mentioned, the QA program was restructured with the formation of the QA unit in March, 2005 and soon thereafter, the QI Unit was formed. Many QA and QI structured activities are in place to assure practice effectiveness and the achievement of desired outcomes. All of these activities have contributed to increased performance on a number of measures including the six national standards; recurrence of maltreatment, CA/N in foster care, length of time to reunification, placement stability, timely adoption and re-entry into foster care.

Quality Assurance

The Quality Assurance Unit consists of the Management Analysis Specialist responsible for CFSR Coordination, seven regionally based QA Specialists, and two Program Development Specialists. The QA Unit assists in oversight of the various QA activities, analyzing the information produced by the data system, targeting specific areas needing improvement and working with regional and frontline staff and QI Specialists to develop local action plans. The QA Unit receives direction from the State QA Unit Manager and the Regional Field Administrators to meet both regional and statewide quality assurance needs. All of the QA activities in which the division engages feed into a continuous quality improvement process. The QA data, CFSR outcomes, and accreditation best practice standards are used to inform and drive decision making in Central Office and in the field as illustrated below. Decision making based on these components results in CQI, a process to achieve positive outcomes for children and families.

Quality Improvement (QI)

In July 2006, CD leadership requested the QA Unit become involved in circuit readiness for Council on Accreditation (COA) site reviews. The QA Unit worked with the COA coordinator to assess circuit readiness in critical areas such as case record fidelity, CQI, staff educational levels, staff and foster parent training, personnel records, facility readiness and caseload size. Although QA staff worked with Circuit Managers to assess readiness in all these areas, their main focus was on the fidelity of case records and ensuring a strong CQI process. Recognizing the need to expand QI activities, the QI Unit was formed in June 2007, and QI Specialists were hired to assume the QI activities.

Like the QA Unit, the QI Unit is comprised of seven strategically-based QI Specialists who are co-supervised by the QI Unit Manager in Central Office and their respective Regional Director or designee. QI is involved in systematic and continuous activities to improve all processes and systems within the division.

Statewide QA/QI Collaboration

At least quarterly, QA and QI staff meet together with their respective units in central office and within their Regions. QA staff discuss statewide and local initiatives and receive skill building training on data systems, Excel, Word, PowerPoint and any other relevant topics. This training assists the QA staff in providing appropriate support and consultation to regional and circuit managers, supervisors and frontline staff on how to document and analyze data. Due to the skills these staff have developed, front line staff have a greater understanding of outcomes and how their work with families impacts these measures. QI staff meet to review COA and QI progress and initiatives. The two units recently began to combine meetings for a portion of the time to reinforce strong collaboration between the units. Private Agency staff will join the QA Unit meetings for a portion of the time to foster collaboration and streamline public and private QA processes.

Private Contracted Case Management Agencies have designated QA staff within their agencies per a contracted requirement. The private agency QA staff also serve the QI functions for their agencies. Private Agency staff include Children’s Division QA and QI staff in their regional CQI meetings in an additional effort to achieve practice consistency.

Continuous Quality Improvement

The Children’s Division has continued its formal Continuous Quality Improvement (CQI)

process during the past five years. The CQI structure involves all levels of staff and encompasses multiple strategies. CQI examines practice performance and how it can be systematically improved. CQI meetings are conducted at tiered levels beginning in every local office county with all types and levels of staff, to assure 100% staff participation and input into continuous quality improvement. Various structured case reviews occur statewide, including peer record reviews, supervisory case reviews, practice development reviews, local case reads for quality practice assurance, and COA case record reviews. Consumer surveys are conducted and constituent issues are monitored. Staff surveys are administered annually. Despite staffing and fiscal setbacks, the division has continued to recognize the importance of preserving these CQI processes, and staff have continued to participate and see achievements, both at a local and statewide level, through the CQI process. The CQI processes mentioned herein are described in more detail below.

The CQI newsletter was used as a mechanism to focus the CQI meetings on identified specific elements, thus focusing all staff at one time on salient issues related to CFSR outcomes, worker visits with children, and other critical areas of practice. The CQI newsletter was disseminated to staff one week prior to the beginning of the first level CQI meetings. Ongoing elements of the newsletter included:

• Message from the director
• Statewide trend chart on data element with discussion of best practice associated with this element and how it affects consumers
• Links to trend charts for data element for each circuit
• CQI calendar for the quarter
• CQI success section and recognition of positive practices from a specific circuit
• Statewide CQI meeting minutes link and summary of decisions made at state level from last quarter
• Power of Prevention-quarterly article about success due to accessing early childhood services
• PDR calendar
• Mission statement
• PIP/CFSR update
• Update on COA Accreditation efforts until a separate accreditation newsletter was implemented in 2007
• An update regarding the Supervision Advisory Committee activities

Use and Sharing of Data

During the past five years, the QA Unit continued to strengthen existing QA processes, clean up data entered into our information systems and provide technical assistance to all levels of staff.

All throughout 2005-2009, as an effort to communicate data outcomes and relate the data to areas of practice, the newsletter, entitled In Focus, was developed quarterly and distributed to all staff. Each In Focus' edition spotlights an identified issue, such as timely permanency and worker visits with child, providing data evidence and offering some practical solutions or insight into the issue. In addition, the newsletter provides updates on progress and successes from the Continuous Quality Improvement Process. Links within the newsletter have included circuit specific user friendly charts for each data element so staff can determine performance in each of these areas. Staff then discuss their performance in their quarterly local CQI meetings and develop local level strategies for improvement where needed. The In Focus quarterly newsletter is meant to provide guidance for the CQI Teams during each quarter. While teams are encouraged to use the In Focus Newsletter in their meetings, teams are not limited to discussing newsletter items only. Any service delivery issue is appropriate for discussion during CQI meetings. The newsletter has focused on older youth, timely reunification, re-entry, worker visits with children and families, timely initial contact, Permanency Planning Reviews, fatherhood initiatives, service planning, visitation plans, data accuracy including the significance of AFCARS, NCANDS and Worker Visit data. Positive feedback is routinely received from the field indicating the newsletter assists staff in understanding how their everyday work impacts safety, permanency and well being outcomes.

The unit conducted data accuracy training as well. During 2006, the QA Unit worked to increase the integrity of data entered into our Legacy information systems. This was done through the delivery of over 113 initial Data Accuracy trainings across the state. The training addressed data entry issues in the CA/N, Family-Centered Services, Alternative Care programs, as well as the vendor Legacy systems. In most regions the training was presented by QA staff to supervisors who then in turn co-trained along with the QA staff. Using the supervisor as a co-trainer, reinforced to their staff how proper data entry related to the outcomes reported from our systems. Following conversion to the SACWIS system (FACES), staff received training on entering data into FACES as well as on-going data accuracy updates. The adjustment to the new FACES system has posed to be a challenge for staff and creative training strategies are in the works to continue to support staff with data entry efforts. With guidance from the QA Unit, field staff and managers are regularly using data and reports to drive their decision making with families.

AFCARS, NCANDS and Worker Visits Data:

Missouri underwent an AFCARS Assessment in March 2009. As a result, the Children’s Division is working on a comprehensive AFCARS Improvement Plan to improve the quality and integrity of permanency and adoption data. Technical staff, training staff, policy staff and QA Specialists will be using strategies, including practice points, electronic and in-person trainings, policy memorandums and system modifications to improve data collection and reporting of AFCARS and NCANDS data. The QA Unit will be teaming with the state AFCARS and NCANDS liaison staff to use AFCARS and NCANDS validation reports to facilitate improved monitoring of data accuracy and outcomes.

QA Staff are aggressively involved in efforts to improve worker visits, including local improvement plans and monitoring data. See section on discussion in worker visits with children plan for additional specific information on worker visits activities.

Data accuracy training efforts during the next five years will focus on permanency, safety and well-being data, and the data integrity of AFCARS, NCANDS, MoHealthnet, IV-E and worker visits in particular. QA unit staff will conduct data accuracy training in person as well as develop electronic training which will be available through the intranet or otherwise sent out to private agency staff.

Survey of Organizational Excellence:

Each year, the QA Unit has administered the Survey of Organizational Excellence (SOE) to all staff. The SOE assessment is designed to link scores on the survey to issues affecting our organization. It examines five key Workplace Dimensions (Work Group, Accommodations, General Organizational Features, Information, and Personal Demands) which capture various aspects of the total work environment. In May 2008, 1,464 staff participated in the survey for a statewide response rate of 62%. Although this has declined from a peak in 2005 where the response rate was 69%, response rates over 50% are generally considered to be high.

Employee perception of areas of overall strength for the organization included; benefits, employee development, strategic orientation, external communication and availability of information. Employee perception of areas most needing improvement included; fair pay, job satisfaction, time and stress, internal communication and team effectiveness. These have consistently remained the highest areas of strength and weakness since 2006. The Division is exploring causes through timestudy analysis and exit interviews with staff leaving the agency to aid in determining strategies which may positively impact these factors.

The QA Unit has produced Regional Power Point presentations on the SOE results and these were provided to regional staff. A statewide summary of results were sent out to all staff and survey results were posted on the division’s intranet site. In 2008, results were featured on the CQI In focus newsletter.

Consumer Surveys

Consumer Surveys have been sent and received from resource parents, alternative care children, adoptive families, biological families receiving CA/N investigations, family assessments, family-centered services, or Intensive In-Home Services. With a brief cessation during SACWIS conversion of case management information, the surveys have otherwise been sent consistently during FFY05-FFY09. Surveys responses have been logged so trends can be tracked. Since the surveys are anonymous, individual surveys are returned to the Regional Directors so they are made aware and can address local issues.

Constituent Log

The Children’s Division maintains a log of all communications and responses to and from constituents. Information from the log is available for use by management to monitor field performance and improvements in customer service.

Case Reviews

Sequentially to the addition of the QA Specialists in 2005, the Peer Review Process and the Practice Development Review Process were enhanced. Soon after, the supervisory case review process began. All the aforementioned reviews are held on a statewide basis, however QA Specialists may perform "special studies" when requested. To address case record fidelity, the QA Unit developed the Case Record and Documentation training. This training information is also available on the CD Intranet for staff self-instruction or reinforcement as needed.

Peer Record Reviews

The QA Unit continues to administer and monitor the PRR process. Completed on a quarterly basis, 10 percent of in-home and foster care cases statewide were randomly selected for review in the last year. The review included a sample of Child Abuse/Neglect cases, Family-Centered Service cases, and Out-of-Home Care cases that were open or had been closed within three months immediately proceeding the quarter in which the review was being conducted, and adoptions records. As with any QA process, the PRR is continuously being refined. As PRR results are used to measure a number of items related to the CFSR, the QA Unit has continued to engage in activities which ensure these reviews are done as correctly as possible. Such activities include: utilizing the QA Unit PDS to centrally monitor and coordinate administration of the PRR; QA Specialists providing on-site regionally specific PRR training prior to reviews; discussion of PRR process in the In Focus newsletter; and development of statewide PRR training in December 2006. As a result of these activities, staff have a heightened awareness of how to properly complete the PRR tool hence making the PRR results more reflective of actual practice in the field.

All frontline staff have the opportunity to participate in the PRR process. To prevent a conflict of interest and increase objectivity, reviewers were instructed not to review any case in which they are or have ever been involved and even not to review a case from their own county if possible. The reviewers name was also removed from the protocol form. In addition to this procedural change, the PRR tool and process underwent several revisions including:

• Revising the tool to reflect current policy and to clarify questions which were confusing to staff. Also ensured the tool, instructions and database all matched.
• A memo was issued to all CD staff, discussing changes to the PRR process and made the following specific recommendations to increase the integrity of the PRR data:
• The Peer Record Review process is intended for front-line staff (Children’s Services Workers) to participate in reviewing cases, not supervisors or specialists.
• There should be a balance between new and experienced staff reviewing cases during the PRR process with all staff having an opportunity to participate in reviews during the course of the year.
• New workers should be trained on the PRR protocol/instructions prior to reviewing cases.
• The PRR Site Coordinator should be available to answer questions about the PRR protocol/instructions during the review process.
• The entry database was enhanced so demographic information was automatically populated.
• The entry database was enhanced so PRRs could be cross checked to ensure non-sample cases were not substituted for the sample cases. The enhancement also allowed for easier tracking of completions by central office.
• In May 2005, the QA Specialists received in depth training on the PRR database enhancement and began taking over the task of monitoring PRRs for completion in their regions.
• In June 2006 the PRR tool, instructions and database were revised to reflect new changes in policy.
• By December 2006, the QA Unit will develop a PRR training for use by field staff.
• Logic is being developed to incorporate the PRR into FACES. The timeframe for implementation depends on the SACWIS schedule of priorities.

These enhancement activities have caused a deflation in the PRR data in many areas making the information more reflective of actual practice in the field.

Child Abuse and Neglect Hotline Unit (CANHU) PRRs

The Child Abuse and Neglect Hotline Unit (CANHU) in conjunction with the QA Unit developed a peer review system at the hotline unit. Ten percent of all calls are automatically sampled for peer review and automatically forwarded to a hotline worker for review. In October 2005 a PRR tool was added for CANHU. In January 2006, CD began collecting and analyzing results for improved outcomes. The analysis revealed that the tool seems to achieve the goal of being a quick and complete instrument for reviewing calls. Dual reviews (each case being reviewed by two staff) will continue until there is more conformity in the review results. It is hoped that the reviewer agreement rate can be increased to at least 90 percent for each question before the review data can be used to properly inform the agency on strengths or needs in practice at the hotline. In the future, if a case does not pass peer review it will automatically be forwarded to a CANHU supervisor for review.

Peer Record Results are maintained on the Children’s Division Intranet and distributed to all staff each quarter.

Practice Development Reviews (PDR)

PDR is modeled after the Quality Service Review model developed by Dr. Ivor Groves and Dr. Ray Foster. A PDR provides a combination of quantitative and qualitative data which reveal the current status for children and their caregivers and the impact of the service system on their status. Recommendations from a PDR are case and circuit specific.

PDRs use a performance appraisal process to determine how children and families are benefiting from services. Key indicators are used to examine outcomes for individual children and families and for the service system as a whole. Through this process, strengths and areas needing improvement are identified to achieve improved system performance, strengthened front-line practice, and better results for children and families. The PDR provides a combination of quantitative and qualitative data that reveal in detail the current status for children and their caregivers and the impact of the service system on their status.

During a PDR, each case is rated on the child status and as well as how the child welfare system performed for the targeted child. Information gained through the PDRs is used to enhance the quality of services provided to families and children through providing direct feedback to front-line staff, supervisors, and administration. The QA Specialist in each region also provides presentation of the PDR results for the community.

2005 marked the first year the PDRs were decentralized. In April 2005, approximately 30 CD staff were provided with PDR reviewer train-the-trainer. Staff trained included all QA Specialists, PDS Quality Improvement Unit staff, Circuit Managers, Sup IIIs, and a variety of other staff. In addition, 23 of these staff received an additional day of training on how to provide TA to circuit managers during a PDR. QA staff were required to attend at least one more reviewer training and participate in at least two PDRs before being asked to provide reviewer training.

A reviewer training packet and PowerPoint was developed, the PDR protocol blue book was updated, an excel template for aggregating data was developed, and a template for community presentations was developed. All of the above materials and processes were based on the Jackson County model for PDRs.

Beginning May 2005, nine "decentralized" PDRs occurred across the state. Since then, each Region plans and administers their PDR’s with support and assistance from the QA Unit. During FFY05-09, the division conducted a total of 36 Practice Development Reviews (PDR) across the state as follows: St. Louis City: 2; St. Louis County: 2; Jackson County: 9; Northern Region: 9; Southern Region: 14.

Supervisory Case Reviews

The SCRT underwent several revisions in 2005 and early 2006. Policy citations were also included in the tool. In July 2006, the QA Unit implemented the new Supervisory Case Review (SCR) process statewide. This case review process was put in place to support the front-line supervisor in providing staff with enhanced clinical supervision. The SCR encourages and supports supervisors in teaching staff to recognize how current policy requirements and day-to-day decisions impact the safety, permanence and well-being of Missouri’s children.

Review lists are provided on a monthly basis. It is the responsibility of the Circuit Manager to provide this information to the supervisors and to ensure that the cases are reviewed at some point during the month.

The SCRT addresses child safety and well-being, as outlined in the Child and Family Services Review. Supervisors who oversee investigators and assessors review two completed hotlines from each worker each month. Supervisors who oversee FCS and out-of-home care cases review one child/case for each worker each month. Once a child/case has been reviewed, it is not selected again for at least 12 months.

As the case reviews are completed, the results are collected in two ways. First, the data from all reviews are sent to a database located in Central Office. The information from the statewide reviews are compiled and posted on the intranet quarterly. Second, the information is sent to a local spreadsheet housed on each supervisor’s computer allowing the supervisor continual access to the reviews they have completed. Supervisors are able to ascertain strengths and areas of need for the workers in their units. Supervisors are encouraged to use this information during case consultations to assist workers to improve child welfare practice with the children and families served.

The SCRT and process are intended to support the front-line supervisor in providing staff with enhanced clinical supervision. The tool is structured in such a way that the supervisor will not only be able to determine if policy was followed, but also to examine the quality of the work being completed with children and families. In turn, the supervisor will be able to utilize this information during supervisory conferences with their workers. The process encourages and supports supervisors in teaching staff to recognize how current policy requirements and day-to-day decisions impact the safety, permanence, and well-being of Missouri’s children.

Statewide SCR completion rates have fluctuated. In 2008, the completion rate averaged 78%, which is an improvement from the first full year of implementation where the completion rate was 75% in 2007. Results are posted on the CD Intranet and used by field managers, supervisors and QA Specialists to identify areas to focus improvement efforts on. Repeat maltreatment has consistently remained the highest score from 2006 -2008, with an average of 99% in 2008. In this measure, the supervisor determines whether the child has had multiple substantiated reports of abuse/neglect arising from the same general conditions or perpetrators. However, during 2008, educational needs of children resulted in a low score, with an average of 69%. In 2006, the lowest score was 60% for worker visits with children. The Division has made great strides in this area, as evidenced by the average SCRT score of 75% in 2008 for worker visits with children.

In 2008, the QA Unit conducted a formal classroom SCR training with 100% of field supervisors to assist them in understanding how the process and tool can assist them in their day-to-day supervision. Supervisors receive training credits for attending this training. Responses from the trainings were positive and a plan for sustaining statewide training for newly hired supervisors is in effect.

Additional Regional QA/QI Activities:

Fostering Courts Improvement

QA Specialists in four regions are actively involved with the Fostering Courts Improvement (FCI) Initiative. Eleven circuits are involved with this initiative. QA Specialists help FCI teams to establish and maintain strategic plans for change by regularly attending meetings and providing data on progress on permanency outcomes at the Circuit Level. For example, during 2009, the Circuit 13 Fostering Court Improvement Project Team suggested a case review to capture several data elements to determine which children were and were not reaching timely permanency. The QA Specialist created a draft review tool and presented to the team for input. After receiving approval, the QA Specialist recruited reviewers, sets up the logistics for the review, captures the data, analyzes the data and reports out the findings. See Fostering Courts Improvement Section for additional information.

Worker Time Study Analysis

The Southern Region conducted a full-scale region-wide time analysis study with frontline caseworkers. The response for the Southern Region was high. Other Regions also conducted a time study analysis with targeted circuits or staff. The time study has assisted in identifying which areas of practice need more time and those which can be reduced. The Southern Region conducted workgroups to discuss the results and to suggest improvements. The Southern Region QA/QI team is currently developing a plan with strategies for increasing staff time with clients, including increased time for caseworker visits with children.

Jackson County Community Quality Assurance Committee

Jackson County continues to support a Community Quality Assurance Committee (CQAC). The Committee meets half a day once per quarter. The membership of the CQAC consists of professionals from child welfare, or related disciplines, and child advocates to encompass a broad spectrum of professions so as to create a multi-disciplinary perspective within Jackson County.

Subcommittees within the CQAC have continued to meet and work on projects identified by the team members. Examples from the past year include:

• Education Subcommittee — This group meets to discuss education issues regarding children in foster care. The group is working to bring an educational collaboration program to the Jackson County area that will involve cross-training staff from the CD, resource providers, Guardian Ad-Litem’s , and local educators on the needs of foster and adoptive children while in the school setting.
• Needs Assessment — The Children’s Division is working with its Foster Care Case Management (FCCM) partners, and a CQAC representative, in looking at the data regarding children who enter care and our recruitment efforts. The purpose of this sub-committee is to ensure that there is correlation between our recruitment efforts and the children needing placements.
• Retention of Resource Parents — This work group is partnering with the CD staff retention unit to combine efforts as there is a connection to the retention or turnover rate of staff with that of providers.

For the upcoming year, a committee has been established to review the current policy and practice of providing medical consent for extraordinary medical care for children in CD custody. Additional CD partnerships with members of the CQAC include participating with the following local initiatives:

• CQI
• PIRT (Permanent Investigative Review Team) which is a team to staff resource homes who have had a finding of abuse, neglect or inappropriate discipline
• ACCOC (Alternative Care Children Oversight Committee) which problem solves and provides assistance in obtaining resources to provide medical, dental and mental health services to children

CQAC members also participate on state-wide committees regarding educational and psychological needs of children in care.

QA/QI Involvement with CFSR Process

Program Improvement Plan (CFSR - Round One)

During FFY05-08, the Children’s Division addressed areas needing improvement which were identified during the first round CFSR through implementation of a Program Improvement Plan (PIP). With the assistance of the QA Unit, each circuit assessed PIP identified data measures, monitored them on an ongoing basis, and developed strategies to address areas needing improvement. The QA Specialists were responsible for reporting to the Central Office PIP/CFSR coordinator all PIP action step completed by the circuits. Through joint and targeted efforts, strides were made to implement policy, practice and systems change strategies which resulted in measurable improvements in the safety, permanency, and well-being of children and families. The Children’s Division successfully completed all action steps and met all of the improvement goals in our PIP by early 2008.

Using the PIP as a compass, it drove statewide focus on certain data elements to be examined in CQI by the whole state. The Children’s Division plans to continue to use this model based on past success for on-going and future CFSR/PIP efforts. This chart illustrates how the PIP was used to focus the CQI process on salient PIP/CFSR items and outcomes.

QA Plan for Next Five Years (FFY 2010-1014)

Continuous Quality Improvement

The CQI process is currently working well and no changes to the process are expected. The QA Unit plans to provide reinforcement of the process by updating the CQI handbook, increasing communication through posting regional CQI information to the CQI Intranet, and conducting reinforcement sessions with field staff and managers for continued enthusiasm for the process. Annual reports or memorandums will be distributed highlighting CQI successes and activities.

Use and Sharing of Data

The CQI In Focus newsletter will continue to be produced and disseminated to all Children’s Division and contracted case management staff every quarter. Again, the newsletter reviews data for staff and emphasizes areas of practice needing attention. The newsletter exclusively focuses on outcomes related to child permanency, safety, and well-being. Following successful attainment of accreditation (COA) anticipated being in late 2009, the newsletter will once again highlight COA activities and updates, in addition to the other areas mentioned previously.

The QA Unit will continue aggressive efforts to increase staff competencies in using data to drive decision making based on performance in critical areas of practice, such as timely achievement of permanency, involvement of fathers in case planning, placement stability and worker visits with children. This will occur through direct support, data accuracy training using multiple strategies, and memorandums.

The QA Unit plans to develop and produce additional electronic reports like the worker visit with child report, as possible based on other SACWIS priorities to aid staff in monitoring other strategic areas of practice.

Survey of Organizational Excellence (SOE)

Other divisions within the Department of Social Services have begun to use the Survey of Organizational Excellence. Beginning in FFY09, the Children’s Division will change the time for distribution to align with the other divisions. Otherwise, no changes are planned for the SOE. Results will continue to be shared and used for continued efforts to increase staff retention and morale, to improve supervision, and other areas identified as a result of the survey.

Consumer Surveys

Beginning in January, 2009, the number increased so that 100% of alternative care children age 12 or older and 100% of resource providers will be surveyed once per year. The rate for the other consumers will remain the same. Surveys responses will continue to be logged to identify and address concerning trends. Individual surveys will continue to be returned to the Regional Directors to assist in oversight of local issues.

Constituent Log

The QA Unit plans to increase the use of aggregate information from the constituent log for field staff training and increase awareness on quality customer service.

Case Reviews

Peer Record Reviews (PRR)

Revisions to the PRR tool are currently underway; the questions are being revised to address quality of practice efforts, instead of a compliance focus. The QA Unit is also currently working with technical staff to electronically produce and distribute the PRR forms. Once the electronic process is completed, the distribution of the forms will vary from the current process, as staff from all areas of the state, including private agency casemanager, will receive notification of assignment to a PRR from anywhere in the state. It is believed this will improve consistency in practice between regions and public/private agencies, and will facilitate the process for the individual conducting the review. The review will be based solely on information contained in FACES. The reviews will continue to be selected based on a random sampling. PRR results will continue to get posted to the CD Intranet quarterly with notification of posting sent to all staff.

Practice Development Reviews

The Practice Development Reviews will continue to be Regionally driven and directed. No changes are planned for the PDR process at this time.

Supervisory Case Reviews

Supervisory Case Reviews will continue to be conducted in the current method. Except for additional "qualitative" type questions being added to the review tools. No changes are planned at this time. Results will continue to get posted monthly to the CD Intranet and notification of posting sent to all staff.

Accreditation (COA) Case Reviews

Objective #15 of the five year plan for 2010-2014, case reads for the re-accreditation process has been included in our five year plan. Progress of this process will be monitored and results reported in each APSR.

Mock Site Reviews

Case review replicating the process and using the same tool as the CFSR will be occurring in June, July and August of 2009. The information gathered from the reviews will assist us in the writing of our statewide assessment. We will be reviewing 48 cases in four circuits.

Additional Regional QA Activities

The QA Unit will continue to conduct local situational activities as areas of need are identified. This will include data accuracy training and support, worker/ supervisor/ administrator support, activities to emphasize practice areas needing improvement, regularly providing data and collaboration with QI Unit and Private Agency QA staff, and other activities as requested by the Regional Directors or QA Unit Manager.

QA/QI Collaboration

The QA and QI units are integral in attaining and maintaining best practice standards established by the COA, sustaining improvements made from the first round of the CFSR and PIP processes and preparing for the second round of the CFSR. When CFSR, PIP or practice concerns are identified, QA staff will review and analyze data performance to identify possible causes. QA will work collaboratively with QI to determine best strategies to employ to improve outcomes. QI Specialists will implement the change strategies and monitor their effectiveness. QI Specialists will also provide ongoing technical assistance and support to regional and local staff to assist with COA activities in preparation for their COA site visits and to ensure staff in COA-approved circuits are maintaining accreditation standards. They will assess the content and quality of case records, resource home files and personnel records; evaluate the effectiveness of practice and internal processes; and assist in developing and implementing improvement plans.

Strategic Planning

The Children’s Division believes the CFSR, Continuous Quality

Improvement (CQI), and efforts made toward achieving state accreditation through the Council on Accreditation, (COA) are intricately tied to one another. During the next five years, the division will continue to remain cognizant of developing solutions which meet best practice standards and are in alignment with our mission and principles.

A draft of the Title IVB Plan was placed on the internet for public comment on June 5, 2009. Emails with the web link and feedback instructions were sent to the CFSR Advisory Committee, Foster Care Case Management Contractors, Child and Neglect Review Boards, Task Force on Children’s Justice, Fostering Court Improvement Committee and Regional Directors. The CFSR Advisory Committee received training of Title IVB requirements per the Program Instructions on May 20, 2009. No feedback was received.