Tuesday, January 30, 2007

The Levels of Care Conundrum

Read through the post Levels of Care: An Unsolvable Conundrum and help provide insight to a way that this issue can be addressed so that children are not penalized, representation of children is more accurate, and recruitment is not as difficult.



Blogger Think Tank Moderator said...

debra hage writes;

Once a level of difficulty of care is established and the fee has been set that fee needs to stay the same regardless of the child’s “improvement”. It is stability that is required in the child’s life! The foster family took the child knowing how difficult the child would be. Even at the height of when they are getting the largest fee the agency pays it is inadequate to actually cover the expenses, time and energy the family invests in the child. Once the child begins to heal the family should not be penalized for doing their job well by having their pay cut. Foster parenting is the only job in the world where you get a pay decrease for being successful!!!

In order to maintain the same level of income they either have to lie or disrupt and take placement of another more difficult child. What a terrible position to put the child and the family in. The child gets well and then has to move?!?!?!?!? I have had children in care who continued to act out knowing that if they get well they will have to leave the home where they are loved, nurtured and cared for! There is no reason for the child to get well as they will be punished for it.

The system puts foster parents in the position of having to lie about the child’s issues and level of care in order to keep the child in their home where he/she is successful. As is seen bad behavior is emphasized and the child’s good behavior and progress in the home is down played in order for the placement and the placement fee to be preserved.

Once the child begins to heal then the child becomes ready to accept the stimulation and activities of a “normal” child. That is when the child needs to be taking music lessons, dance, attend athletic camps, go to the movies with friends, have nice clothes, etc. All of these take money. The foster family still needs the money to help the child become a normal child with a normal level of activities….it is just that now the child uses the money differently.

Not decreasing the payment as the child healds would allow for an accurate reflection in reports of the level of care the child needs and the progress the child has made without the money being paid to the family being called into question. Level of care required and child placement fee need to be completely total and separate issues and not inter dependent once the original fee has been set. They should only be connected during the initial placement decision and contract. After that they must become separate in order to avoid the numerous problems and issues that arise when they are tied together.

I am strongly opposed to ever lowering a foster payment when the child heals!

4:52 PM  
Blogger Think Tank Moderator said...

Linda posted this comment:

I can only speak for our family's experience: The child reported to have the lowest level of care (out of sib group of 4) has aboslutely the biggest issues and needs the highest level of care. Otherwise I would have suspected the same as you are suggesting: improvements would not be reported to keep the money coming.

5:55 AM  
Blogger Think Tank Moderator said...

PKP comments:

The other complication is that levels of care are subjective. There are not set criteria to determine levels. I'd love to see our state employ a medical professional and a behavior specialist to review and help set levels of care. For example, a child who requires occasional or even daily nebulizer medications shouldn't qualify for the highest level of care, but a child who has life-threatening asthma should. Our state uses a check list but its not very comprehensive.

It would be even more helpful if there was some consistency from state to state. One state sets a maximum rate regardless of level of care---unless the child is HIV positive. Not a very useful level of care determination.

I'd love to see some concrete suggestions on enhancing the level of care system to truly reflect a child's care needs. I think it would help families and workers determine best placement options.

AND why shouldn't kids who are SSI Disability eligible be able to stay in the SSI-D program regardless of parents income/resources? I think it would help bio and adoptive families to better provide for care needs and obtain services.....

6:01 AM  
Blogger Sbadeau said...

Personally, I have long felt that the "Level of Care" concept should be turned on its head and made into a "Level of Competency" rate instead. Foster parents would demonstrate levels of competency based on receiving certifications as a result of training and other experiences and then as they achieved these levels of competency, their rates - regardless of the child placed in their home - would increase accordingly.

IMHO this would go a long way toward further professionalizing the field, inicrease the quality and competence of all foster parents, provide motivation for foster parents to continue to learn more and develop more skills, etc.

It also removes the subjective factor of identifying a certain child as a certain "level of care" as PKP pointed out. It also removes the instability and ethical dilemnas that Debra Hage wrote of, and finally, it acknowledges that sometimes children labeled "difficult" are not so difficult for certain parents while other children not so labeled are actually much harder to parent for the same parents as Linda noted.

It takes the stigma away from children as being too difficult to care for, thus making them "unadoptable" and puts the onus on the system to ensure that every child has access to highly competent and qualified parents.

8:10 AM  
Blogger Think Tank Moderator said...

Thanks to Michael Yates for his thoughtful response:

A Complicated Conundrum

The January 30, 2007 post, “Levels of Care: An Unsolvable Conundrum?”,
suggested the traditional fee schedule for levels of care presents a formula that
encourages greater reporting, even misrepresentation, of significant incidents
and thereby hinders the adoption process for many children. To be sure, this is
a very real “puzzle” for child welfare advocates to solve. State agencies and
private providers have consistently wrestled with the dilemma of board rates
being associated with a child’s behavior (specifically misbehavior) than with
permanency and positive outcomes. I, for one, am not ready to resign myself
to the puzzle being unsolvable, but I do readily confess that it is tremendously

Having spent a considerable amount of time with staff and families wrestling
over this very issue, I certainly empathize with the yearning for a formula that
makes sense to caregivers and promotes positive outcomes for children. Though
we did not strike the perfect solution, we did identify a number of ways in which
we could modify traditional administration of board payments. Agencies should
consider the relevance of the suggestions identified below based upon their own
unique needs, which may include, but not be limited to, the following: core belief
of program, agency culture, fiscal stability, incremental versus significant
changes, etc.

1. Fiscal Disparity – reduce the gulf that exists between the foster parent
payment for level 1 and therapeutic. By reducing the disparity parents
are less likely to focus on “receiving less money for a job well done.”

2. Fiscal Responsibility – During both initial and ongoing parent training
opportunities we openly discuss the impact foster payments can and will
have on a family’s budget. It is critical that foster families not adjust their
standard of living based upon foster payments. Though this is a natural
economic occurrence for most American families, it is far more important
that foster families heed this advice due to the unpredictability of
placements and the changes in levels of care for children based upon their
progress. Hence, greater fiscal management at home is less likely to
skew the reporting of incidents.

3. Training – agencies should consider providing the training and support to
families so that they are “licensed” therapeutic as opposed to the child
experiencing yet another painful loss by having to move to another home
for the sake of being “therapeutic.”

4. Incentive-based fee schedule – payments increase over time so as to
promote stability of placement. A significant bonus for promoting
permanency for children. This system would require some capitation, but
would likely reduce placement movement. It would promote stability over
time, and it would emphasize permanency.

5. Performance-based fee schedule – as more and more agencies and
programs move toward performance based contracting, a trend will
emerge where similar contracting practices will occur with resource
families, that is to say, families will be compensated for partnering toward
positive outcomes, e.g. shorter stays in care, exiting into permanency, not
disrupting children, partnering effectively with permanency family,
heightened stability for children, etc.

The more programs and agencies synergistically wrestle with this very real
conundrum of foster care payments and levels of care, I’m confident they will
begin to think in new, exciting ways to practice foster care – ways that will make
more sense to the caregivers and ways that will result in better outcomes for
children and families. Unsolvable? I think not. Complicated? Absolutely!

8:09 AM  

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