Statewide Regional Summary Including And Non-Custodial Cases Brian A.,
Transcription
Statewide Regional Summary Including And Non-Custodial Cases Brian A.,
Tennessee Quality Services Review Review Year 2010-2011 Statewide Regional Summary Including Brian A., Delinquent, And Non-Custodial Cases Acknowledgments Quality Service Review (QSR) is a process requiring the coordinated efforts of regional staff, reviewers, partner agencies, and interviewees. Special thanks to regional QSR Point People and supportive staff for their organization and coordination of the regional reviews: Tyran Copeland and Amanda Schrock, Davidson; Jackie Stewart, East; Amanda Jones, Knox; Andrea Baker, Mid-Cumberland; Jamie Perkins, Northeast; Stephanie Coleman and Allison Downs, Northwest; Delsia Stokes, Shelby; Wendy Williamson, Smoky Mountain; Chris Griffy and Rebecca Whiteside, South Central; Amy Ford-Hulen, Tamara Bonds, Amelia Carlson, Mary Beth Duke, Kimberley Smith, and Shemeka Worles, Southwest; Elaine Hong and Mary Rivers, Tennessee Valley; and Carla Forsyth and Denice Whittaker, Upper Cumberland. Additional support for the organization and coordination of the regional reviews was provided from QSR liaisons to the regions: Sherry Haines and Doretha Johnson with the Tennessee Center for Child Welfare (TCCW) and Frank Mix and Bethany Womack with the Department. Quality Assurance-Technical Assistance during the review was provided by Steve Chester, Frances Lewis, and Pat Wade from the Tennessee Commission on Children and Youth (TCCY); Sherry Haines, Doretha Johnson, and Landra Orr with TCCW; and Stephanie Coleman, Chris Griffy, Rebecca Hendrich, Susan Mee, Frank Mix, and Bethany Womack with the Department. Workgroups and contributors for specific topics include: Dave Aguzzi, Diane Irwin, Beth Kasch, Lisa Lund, Kim Mallory, Barbara Maners, Jackie Moore, Connie Murphy, Tony Nease, Linda O’Neal, Pat Wade and Kelly Whitfield. Many thanks also to Carla Aaron, John Johnson, Andy Shookhoff and Sandra Wilson for supporting their participation. Thanks also to the reviewers – this year, 220 reviewers participated in reviewing 355 cases, completing a total of over 2700 interviews. The reviewer pool consists of regional and Central Office Department staff from a variety of program areas, Tennessee Commission on Children and Youth CPORT staff and Commission Members from different areas of the state, and Social Work Practice Specialists and University Consortium Trainers from the Tennessee Center for Child Welfare. This year, we were also joined by CASA and Juvenile Court Staff from Davidson County. A list of participating reviewers can be found in Appendix F. 1 Table of Contents Executive Summary 3 Strengths, Opportunities, System Issues and Next Steps 10 Discussion of Data and Charts 16 Non-custodial Cases 22 Permanence Permanency Goals Placement Type 25 27 32 Recruitment and Retention 40 Youth 41 Juvenile Justice 43 Court and Legal System 47 Appendix A – Review Process 50 Appendix B – Brian A. Charts 52 Appendix C – Severe Abuse Targeted Analysis 55 Appendix D – Regional QSR results 58 Appendix E – Critical Issues of the Custodial Population 70 Appendix F – List of Participating Reviewers 73 2 Tennessee Quality Service Review (QSR) Results 2010-2011 Executive Summary 3 Executive Summary Since 2005, the Tennessee QSR Team, comprised of staff from the Department of Children’s Services (DCS), Tennessee Commission on Children and Youth (TCCY) and the Tennessee Center for Child Welfare (TCCW) have worked collaboratively to conduct a comprehensive case-based quality services review (QSR) process. The process involves a comprehensive evaluation of service delivery outcomes by examining relevant aspects of the lives of children and families being served by DCS. The ultimate goal of QSR is to promote positive change by providing qualitative and quantitative information about the status of the child/family and service system function for the cases reviewed. QSR results can be used for continuous system improvement and implementation and reinforcement of best practices for children and their families. The reviews are conducted in each of the state’s 12 DCS regions on a stratified random sample of children in state custody sufficient to provide validity at the 99 percent level statewide and the 85 percent level regionally. In addition, two or three non-custody cases per region were selected for review from the DCS multiple response system (MRS) assessment track. A targeted review of children residing in Youth Development Centers was also completed, and information from this review is also included in this summary. For each case reviewed, the review team produced a narrative summary after the review was completed. The narrative summary provides a description of the findings, explaining the reviewer’s perspective about what seems to be working and what needs improvement. The narratives help explain the numerical results of the review by describing the circumstances of each case. The QSR process includes a review of records for the following items: • • • • • • • Psychological or other specialized evaluations; School records and Individual Education Plan(s), if applicable; Service Plan(s) or Individual Program Plan. Court order for custody; Family Functional Assessment; Petition that led to custody; Family Functional Assessment; The majority of information is collected through structured interviews with the following: Child, if age appropriate; Parent(s); Caregiver (resource parent or direct care staff in a facility); Family service work or case manager; Teacher or other school representative; Any other relevant service provider (Guardian ad Litem, therapist, etc.); Other significant/relevant person (relative, friend, coach, etc.). 4 Before writing the brief narrative case summary of the case, certified reviewers apply the pertinent information collected through the in-depth interview process to specific criterion measures or indicators regarding the status of child and family and the adequacy of the service system functioning Significant Achievements: • • • • • Practice across Brian A. cases continues to improve, as do Safety, Permanency, and Well-being measures. (See Appendix B) The percentage of ratings in the Poor or Adverse and Substantially Unacceptable range has steadily declined on both Child and Family Status and System Performance indicators, while the percentage of ratings in the Acceptable range is increasing (See charts on page 21). Practice with youth has improved significantly over the past year, with the percentage of cases rating acceptably for youth age 14 and older exceeding the statewide average on most indicators. This reverses a trend seen in previous review years. (See “Youth” beginning on page 41). The practice observed in Juvenile Justice cases is consistent with that seen in Brian A. cases. Family-centered practice is being effectively implemented in an everincreasing proportion of juvenile justice cases where youth are placed in community settings; however, family-centered practice with youth placed in hardware-secure Youth Development Centers is not as consistent.(See “Juvenile Justice” beginning on page 43) In non-custodial casework, early Engagement, teambuilding, and Assessment were linked to positive outcomes, as they are in custodial cases. In some cases, the referral that opened the case was “unfounded,” but the family and worker were able to identify areas that a team could support to enhance long-term safety and well-being. In others, the families and the Department could not clearly articulate how DCS involvement would enhance Safety and Well-being; when these cases were not promptly closed families reported DCS involvement felt intrusive rather than supportive. (See “Non-custodial” beginning on page 22). QSR Findings: Status of the Child and Family in Custodial Cases Reviewed • Child safety was maintained at a high level, with almost all children safe from harm (98%). • The physical well-being of the great majority of children was adequately addressed at the time of review (99%). • Caregivers were adequately meeting children’s needs (95%). • Most or many children were making progress in education or a vocation (83%), also the highest level achieved to date. • The emotional well-being of most children in custody was adequately addressed (81%), the highest percentage achieved to date. 5 • Permanency and Family Functioning are indicators that are linked heavily to System Performance. These continue to improve. • An indicator that could benefit from continued support is Family Connections (57%). QSR Findings: Service System Performance/Functions in Custodial Cases Reviewed • The system was engaging most children, if age appropriate, and their families in the planning and implementation of services (61%). • There was an adequate assessment of child and family needs in 50% of cases. • Conditions and attributes of practice that, as they improve, support best practice outcomes, include Resource Availability (71%), Informal Supports (62%), Placement Supports (93%) and Transitioning (49%). • In many cases the system adequately identified the long-term view for ensuring Safety, Permanency and Well-being beyond system involvement (42%), the highest level achieved on this indicator to date. • Despite improvements, Long-term View and Transitioning are areas that could benefit from more attention. System Recommendations • Develop a coordinated system of care network involving the Departments of Children’s Services, Education, Health, Human Services, Mental Health, and Developmental and Intellectual Disabilities at the state level, and with an array of public and private organizations, including courts, schools, child advocates and community organizations at the local/community level. These community partnerships are essential to prevent children from unnecessarily entering state custody, access needed mental health, substance abuse, and health services, link children and families to needed public assistance, access transition to adult service systems, and successfully implement Child and Family Team Meetings. • Continue to improve frontline supervision to support staff in implementing best practice. • Utilize the Quality Practice Teams to not just identify and address areas for improvement, but to also share experiences and successful strategies across regions and partner agencies to improve the implementation of best practice. • Continue to implement the Child and Family Team (CFTM) approach to serving children and families. Ensure all knowledgeable and relevant team participants are included in the Child and Family Team meetings to support optimal decision-making practices. Additionally, ensure team decisions are advocated in court. 6 • Continue implementing strategies that support ongoing functional assessment processes to identify strengths and needs of the child/family and make changes as necessary. Family Service Workers need access to Child Protective Services records and/or other previous intervention or prevention efforts for decision-making and planning strategic service delivery. Continue to develop caseworkers’ skills in practical casework and family system dynamics. Ensure family service workers (FSW) are fully trained and practice family-centered case planning that encourages, respects and incorporates input from the children and families it serves. • Improve coordination and communication between the Child and Family Team and DCS legal staff for improved outcomes for children and families. • Ensure children and their families receive timely evidence-based, best practice, culturally competent quality mental health services with attention to child/family resiliency, recovery and treatment. • Ensure adequate and appropriate independent living/transition services are provided to children aging out of foster care, including those adjudicated delinquent. • Partner with DCS Legal and local court staff to support the Child and Family Team decision-making process, even in cases where a Severe Abuse adjudication is being sought or criminal charges are being pursued and when no-contact orders are present. Barriers to communication and work with families during criminal investigations and delays in adjudication negatively impact outcomes for children. • Early engagement and teambuilding during the CPS and assessment work was associated with positive outcomes when that Child and Family Team is the primary decision-maker. Continuing strategies to support early work will likely help improve best practice outcomes in non-custodial cases and reduce the number of children entering custody. • Encourage frequent contact and partnership between Family Service Workers and the Case Managers in the Youth Development Centers to support implementation of best practice for youth in the facilities. • Improve advocacy for all children by ensuring that fundamental due process rights for children and families are met and that parties have adequate and effective representation. Opportunities exist with both Guardians ad litem and with attorneys representing parents. • Improve the overall internal communication between DCS Central Office program and DCS field staff to ensure overall goals of DCS are articulated clearly and provide support to regional efforts towards implementing best practice. • Continue to implement and support a qualitative case review process to provide a mechanism to identify opportunities to strengthen practice and overall system functioning. 7 Training Recommendations To enable staff to adequately serve children and families, provide detailed and specialized training for development of skills needed to implement job responsibilities. • Field staff express a desire to have more information regarding specialty areas related to transition services from the child-serving system to the adult-serving system, special education, mental health and substance abuse/addiction, and in some cases understand how to access Well-being units as a means to secure appropriate services. In addition, workers express a need for the practical knowledge in order to implement these processes, such as collecting necessary information and documentation. • Provide coaching and mentoring to Team Leaders and Team Coordinators around using principles of best practice at the supervisory level to enhance their teams’ ability to implement best practice principles. Continue to support training initiatives for supervisors to adequately develop leadership and skills necessary to support frontline staff in best practice principles. Recommendations for Additional Resources • Provide adequate placement resources for appropriate out-of-home placements in a timely manner as close to home as possible, preferably within the child’s home community. Distance to placement is a challenge to communication, maintaining family connections and can result in delays in achieving permanency. • Frequent contact between team members and visits between family members and Family Service Workers is associated with positive outcomes. Ensure resources are available to support frequent visits, such as transportation and financial support for travel. • Encourage continuum providers to adopt the practice of utilizing placements closer to the child’s home community. • Provide adequate placement resources for step-down for youth exiting residential treatment or YDC placements. • For expedited placements, once the PATH process is completed ensure board payments begin timely. • Improve the recruitment and retention of staff. Review the current administrative requirements that create barriers to frontline practice and lead to case worker turnover. The following information summarizes findings for the cases selected as part of the CPORT Statewide Sample, reporting on factors present in cases from a sample representative of the custodial population statewide. More Critical Issues impacting children in state custody may be found in Appendix E: 8 Demographic Information • For the 79% of families whose household income is known, 64% had incomes of less than $24,999, near or below poverty for a family of four ($22,350), and a notable number had incomes reported at less than $5000. • Twenty-six percent of children were from single-parent, mother head of household families; 23% from families with both birth parents; and 16% from relatives (not biological parents). Other family types include those with step-parents, adoptive parents, and single-parent, father head of household. • Children exhibiting behavior problems (26%) and neglect by caregiver (25%) were the main reasons for children to enter custody. • The largest age group of children in care was age 14 and older (44%). • The majority of children were Caucasian (63%). • The majority of children in custody were male (59%). • The average length of stay for all cases reviewed was 1.3 years. 9 Tennessee Quality Service Review (QSR) Results 2010-2011 In 2010-2011, the Department of Children’s Services, Tennessee Commission on Children and Youth and the Tennessee Center for Child Welfare worked collaboratively to conduct a comprehensive case-based quality services review (QSR) process. This process provides a way of knowing what is working/not working in practice and why for selected children and families receiving services. A stratified random sample of cases from each of the 12 DCS regions were reviewed to determine how well the system is performing to meet the needs of the children and families served. The purposes of QSR are to provide a tool that promotes overall quality improvement in providing services to children and families, to answer questions regarding current practice and to stimulate change and instill principles of good practice. Meeting the many needs of children and their families is challenging. The QSR results provide information that assists key stakeholders, policy makers and legislators to make informed decisions, and significantly influence the steps needed to maintain or enhance and improve services to children and their families in Tennessee. The following information summarizes the status of children and the performance of the service delivery system as it continues to evolve in Tennessee. 10 Strengths • • • • A number of regions had great success with supporting positive relationships between birth parents and resource parents. Shelby, Knox, Davidson and South Central regions had multiple cases where this positive teamwork was present. Resource parents were very active participants in the Child and Family Teams and understood their role as supporting the birth parents through the change process to allow for reunification. In Davidson County, this has been a trend over the past two years of review. In Davidson, resource parents seemed to identify their role as one of working with the whole family; in South Central, the resource parents were willing (and expecting) to be ongoing informal supports to the youth and family. In Knox and Davidson, cases were moving smoothly to adoption, supported by the trust built between birth and resource families. Family members, service providers, and FSWs in cases with successful Teamwork and Coordination nearly always cited “frequent communication” as a factor in casework moving forward. Strategies for accomplishing this included rapidly returning phone calls by FSWs and in a few cases, regularly scheduled meetings. The use of facilitators is generally prioritized for permanency planning meetings or in cases where there are differences in opinion among team members about case planning direction, and the presence of facilitators was generally seen as a positive attribute about these meetings. Some FSWs or agency workers would check in with parents a few days after a meeting, just to make sure decisions were understood or to follow up on any questions. The use of interpreters was very meaningful to families; in one case the parent spoke passable English but was more at ease in the teaming process when an interpreter for his native language was present. When family members were most satisfied with services and supports from the Department, they related this to the frequency and quality of the communication with their FSW. In a few cases, birth parents who were unlikely to achieve successful reunification nevertheless reported being satisfied with supports and services when they believed their FSW was sharing information with them honestly. Another element of Teamwork occurs outside of the individual family cases and encompasses the degree to which internal DCS staff team with each other. In Tennessee Valley’s review, the positive working relationship between FSWs and the YDC case managers was very apparent in the cases of youth placed in those facilities. In these cases, there were few barriers presented to face-to-face visitation between FSWs, parents, and youth – travel and transportation issues were able to be addressed by the team. Taft and New Visions YDCs were flexible about their internal meeting schedule to meet the needs of the families and home county workers, supporting Family Connections and Long-Term View from the beginning of cases. Internal teamwork between Education Specialists and Regional Psychologists was also a strength in several cases, with this contributing to positive outcomes in Ongoing Functional Assessment and Well-being indicators as well as Teamwork. Teambuilding early on in cases, including during any non-custodial casework prior to children entering custody, tended to have a lasting positive impact on family involvement and team functioning as cases progressed. Upper Cumberland achieved very strong ratings on Family Connections. Much of the success came from locating and utilizing paternal extended family in teaming, and diligent searches were conducted with a goal of identifying extended family and engaging them in the teaming process. When diligent searches were conducted early on in the life of a case, Shelby also had much success in identifying fathers and extended paternal relatives and supporting their involvement in the Child and Family Teams. In several of the non-custodial cases, teambuilding early in the assessment process 11 • • • • helped families overcome initial resistance to DCS involvement. Genuineness extending to trusted family supports seems to decrease the “intimidation factor” surrounding DCS involvement. It appears that transitioning is, for an increasing proportion of Child and Family Teams, a proactive rather than a reactive process. Many different types of transitions occur in cases. Children and youth experience age-appropriate transitions across school settings and in the types of activities they participate in, and each case also transitions into and out of service involvement. Some families and children experience service provider changes, FSW changes, and placement changes, and these can be planned or unplanned. When changes occurred, cases with strong teams with members who frequently communicate were able to mitigate any problems that might arise when team membership changes. Additionally, planning for transitions between placements and transitions home were managed well in a number of cases, with resource parent involvement in preparing children for moves also contributing to positive outcomes. East and South Central had a lot of success with Transitioning in cases where Informal Supports were utilized in Child and Family Teams. In South Central, a transitioning exercise used with staff seems to have produced very good results in this area. Supervisors and FSWs physically wrote out the “transition plan” for their families; this specific focus on transitioning out of custody/services helped them identify unanswered questions the team could consider as the cases moved forward. Strong family-centered practice was evident in cases of youth adjudicated delinquent, particularly in Southwest, South Central, Tennessee Valley, and Smoky Mountain. This has been a standout area of Southwest’s practice for the past 3 or 4 years, so it appears they have built some strategies within the region, with their providers, and with the Youth Development Center partners to sustain the family-centered approach in Juvenile Justice cases. Work with youth showed many positive results this year. For the first year since QSR began, practice outcomes achieved for youth were above the average of cases of children of all ages. Several strategies have been put into place to strengthen Independent Living programs. Another reason may relate to strategies such as FOCUS (an intensive and individualized recruitment process) and archaeological digs (a strategy to identify people with a previous relationship to a child) to help increase the likelihood of finding Permanency resources for teens and older youth. Burgeoning partnerships with private agency providers in the QSR process have the potential to support positive results by increasing partnership and communication around best practice expectations. Upper Cumberland and Mid-Cumberland had a lot of success in involving providers in their QSR process. Provider representation was present in the preparation workshop, in some of the feedback sessions with the FSW & TL, and at their Friday wrapup. Additionally, East and Knox regions have utilized private agency partners in their miniQSR processes. 12 Opportunities for Improvement • • • • While Teamwork is showing improvement in a statewide look at the population, there were some opportunities to strengthen Teamwork. Generally, the cases that seemed to have the most challenges in forming a cohesive team experiencing frequent communication tended to involve cases with children or youth placed in congregate care, including residential treatment centers and YDCs. In several cases, simply the distance to placement is a challenge to communication. Another common thread among these cases is that they tended to have the lowest percentage of cases with acceptable Informal Supports. This suggests a chicken-andegg pattern: while it may be that problems with forming and coordinating a team may mean informal supports are not identified, it could also be that a lack of informal supports input into a team may be limiting the teams’ effectiveness. In either case, the involvement of Informal Supports nearly always contributed to something positive in Teaming. Stability in these cases is also very challenged (46% acceptable compared with 73% acceptable among children and youth placed in family settings). Generally, youth in these placements have had several moves related to behavior problems – for Brian A. youth, placement in a congregate facility often occurs after disruptions in placements at lower levels of care. This results in turnover in team membership, which without a well-coordinated point of contact within the team can also contribute to challenges in effective Teamwork. Resource Availability and Use is increasing statewide. As we get better at implementing family-centered practice across a wide spectrum of case practice, resources available to parents to support stability and permanency are being identified more consistently. However, there are still examples of cases where teams have to creatively address challenges presented when services are located outside a practical travel area for families. Appropriateness of Placement was an issue for seven of the twenty cases of youth placed in congregate care who are members of the Brian A. class. For four of the youth, teams were looking for but had been unable to locate a suitable step down resource home for the youth at the time of the review. For two youth, the placements were meeting their level of care but were so far away from their home communities they had lost connections to remaining informal supports. Effective implementation of a family-centered practice model requires teams to have the ability to individualize services and planning based on the strengths and needs of the family. In some cases, we appear to be confounding our own efforts to individualize services by relying heavily on adherence to processes that are not relevant to, or achieving, desired outcomes for children and families. In a few cases, relatives who might not be eligible to be an expedited placement or be approved for Interstate Child Placement Compact (ICPC) were not utilized as supports even though their participation in planning would not pose safety risks. Some teams believed that adoption discussions could occur only after TPR, confounding efforts at concurrent planning. Challenges in court-involved cases were seen when the Child and Family Team and DCS legal were not well-coordinated. In some cases, teams were not clear about what information the DCS attorney needed from them to complete a petition, requiring some time spent revising petitions. Individual courts have different procedures for setting dockets and preferences about the presentation of petitions. In a number of cases, attorneys were participating on Child and Family Teams. While this is generally encouraged, in a few cases they were participating in such a manner that other team members were discouraged from sharing their thoughts. There has been much emphasis in the past few years on timely TPRs, for which legal staff are critical, but there are other opportunities to recognize the contribution DCS attorneys make in supporting best practice and advocating for other outcomes as well. 13 Systemic Issues In each case, there are opportunities to identify conditions of the child welfare system that influence practice. Specific cases are discussed in more detail throughout the summary. Key issues identified over the 2010-2011 school year include: • • • • • • There is limited availability for step-down placements for youth exiting residential treatment or YDC placements. For youth placed through continuums, in situations where step-downs are not available at the time of discharge, it appears that a certain period of time is allowed to elapse before teams consider seeking resources through another agency. The closure of the DCS Group Homes this year impacted a few cases; most notably those of youth adjudicated delinquent who were eighteen years of age. Because residential treatment programs that serve youth are not licensed to take adults (age 18 in that system), their only option for treatment placements is a Youth Development Center. TFACTS, the new SACWIS system, rolled out statewide in August of 2010. This system is designed to capture family-centered practice by organizing data by family rather than by person. Included in the roll-out strategy were discussions and trainings around using the new system. Report production is an area of ongoing development within TFACTS, for the field the new system produced some challenges as people adjusted to the new system. For a short time, one judge refused to sign Permanency Plans because of serious formatting issues with the new system’s production. Major issues have been and continue to be addressed through rebuilds. During this period covered by this statewide review, Department and Private Agency staff have been adjusting to using a new system while administrative and managerial staff are challenged by a wait to complete the production of reports that were available prior to the roll out. Regional feedback about the quality of casework done by stipend students was overwhelmingly positive. It was felt that the casework of participants in the program or recent graduates was strong and reflective of best practice outcomes, and that the educational program the students are receiving is highly consistent with best practice. A systemic issue that impacts every partner in the child welfare system related to financial resources. For the past few years the Department and other partners in the child welfare system have been trimming their budgets or responding to a reduction in resources. At the same time, it seems that more families are experiencing reductions in their own household resources. In some cases, the courts serve as primary decision-makers rather than the Child and Family Team. When this occurs, practice outcomes are poor – but then, child welfare practice is not driving the case. In some cases, this indicates a practice opportunity as courts step in as decision-makers when this function is not evident from the team; in others, cases become more about custody decisions between family members than in effecting change to improve functioning within a family. In others, cases get “stuck” in court when the team begins to see achieving TPR as the goal they are focusing on, rather than achieving TPR as a step in accomplishing a well-defined permanency plan. The Family Functional Assessment tool was designed to facilitate the ongoing recording of family assessment information, but it is generally regarded as unwieldy and no more conducive to quality assessment than other tools. A workgroup of Central Office and Regional staff are looking at this to identify ways this may be improved. 14 Next Steps and Recommendations • • • • • • • To help ensure that conditions conducive to positive outcomes are present, it may be worth looking at ways to shorten the expedited approval process and to consider the effectiveness of visits in overall practice when looking at budget and fiscal issues. Frequency of contact between FSWs, families, and children was cited in many cases as a major strength in Teamwork, and Family Connections was very important to reunification. Also, there were some examples of relative caregivers experiencing financial hardship and spending down their savings in order to bridge the gap between the date of their relatives being placed with them and receiving a board payment. Initial feedback about the Quality Practice Team (QPT) process has been positive. The organization of the teams makes it easier to identify the group that can most effectively address a particular issue. Continuing to use the QPT process and the field focus group both to identify areas for improvement, share experiences across regions, and identify working groups to develop potential solutions should assist Central Office program staff and regional staff in addressing barriers to best practice and supporting the strategies in place that are working. This year, the QSR process has seen an increase in the involvement of providers in sessions addressing QSR preparation and in the wrap-up sessions held on Fridays following the reviews. In the 2011-2012 review cycle, DCS is offering training credit for provider agency staff who participate in the reviews as shadows. The addition of focus groups to the QSR process will also help increase the opportunities for direct feedback about the child welfare system. No-contact orders are sometimes used in cases where a parent’s or sibling’s behavior might pose a safety risk or contact would be detrimental in some way to the children. If these are in place, the team should also be mindful that this is ineffective as a “status quo” measure. To avoid situations where no-contact orders become a barrier, teams would benefit from developing a means to assess the continued utility of these orders. In non-custodial cases, early engagement and teambuilding during the investigation or assessment phase helped support best practice during the ongoing work of the case, especially when informal supports are used in the assessment process and in identifying resources. Continuing strategies to support this early work will likely help improve best practice outcomes in non-custodial cases. There are opportunities to identify desired outcomes in non-custodial cases, as some of the cases were open longer than appeared necessary. Neither the families nor the Department could articulate a role for DCS in supporting Safety or Well-being. Including Central Intake in conversations about non-custodial casework will likely help identify opportunities to strengthen the Department’s gate-keeping processes. Across all types of cases, frequent contact between FSWs, families, and children is associated with positive outcomes. Distance and cost of travel is a consideration for all workers when travel to visits is required. However, regions seem to have different resources available to support family visitation. Likewise, it appears that in some regions FSWs face restrictions on travel that put a damper on the frequency of contact with children and families – and the development of a helping relationship. In the same way, encouraging frequent contact between FSWs and YDC case managers, youth, and family members should also support best practice. 15 Discussion of Data and Charts During the 2010-2011 review year 309 cases were reviewed during the statewide review cycle, with cases selected from the regional population, and 46 cases were reviewed during the summertime Youth Development Center targeted reviews, with a sample pulled from the YDC population. Over twenty-seven hundred interviews with key stakeholders including children, youth, and family members, resource parents, service providers, FSWs and agency staff, teachers, GALs and CASA volunteers, and other significant case members were conducted by two-person teams, with respondents providing information about their experience as providers of or recipients of services and supports from DCS and partner agencies, court systems, school systems, and healthcare systems. For each case reviewed, the reviewers assessed outcomes for each case through a series of 22 indicators - 11 child status indicators and 11 practice performance indicators. A six-point rating scale was used by reviewers to assess the status of outcomes for each indicator. The range of ratings is as follows: 1. 2. 3. 4. 5. 6. Adverse status/performance, completely unacceptable Poor status/performance, substantially unacceptable Marginal status/performance, minimally unacceptable Fair status/performance, minimally acceptable Good status/performance, substantially acceptable Optimal status/performance In each of the regional reviews, twenty-two cases were selected through a stratified random sampling process of custodial cases. Three non-custodial cases were selected for review with regions selecting three cases from a randomly-selected list provided by Central Office. In the YDC reviews held over the summer, six cases from New Visions and ten cases each from Mountain View, Taft, Wilder, and Woodland Hills were selected at random. As the following charts show, there has been very encouraging progress toward achieving desired outcomes. Over the past four years, every indicator has shown improvement, and many of the indicators have shown noticeable improvement between last year and this year. The indicators that directly capture how well we are implementing our Family-Centered Practice Model Principles (the “Practice Wheel”) have all shown improvement over the last four years, as have the Child and Family Status Indicators of Permanency and Family Functioning. Improvements in our work – that is, the System Performance indicators, are validated by the improvements we are seeing in our work product – that is, the Child and Family Status indicators. In the Child and Family Status domain, indicators speak to a “snapshot” of how a child and family are doing in the 30 days most recent to the review. Safety has been an area of strength within the custodial population, as has Appropriateness of Placement and Caregiver Functioning. Still, within the past four years there has been a general trend toward improvement in these areas as well. System Performance data, which speaks to a dominant pattern of practice over the last 90 days, may point to possible reasons why these areas remain strong. Some trends noted in the case stories that seem to play a role in these Status outcomes include caregiver participation in Child and Family Teaming, a family-centered focus on Assessment, positive Family Functioning and Family Connections, and Placement Supports – all of which can speak to the quality and 16 safety of visits as well as an increasing awareness among resource parents around their value as a Child and Family Team member. Well-being indicators, including Health and Physical Well-being, Emotional/Behavioral Wellbeing, and Learning and Development, have also shown an increase in the percentage of children and youth rating acceptably. Case stories speak to the involvement of Education Specialists, Independent Living Specialists and Regional Psychologists either acting as Child and Family Team participants or consultants to FSWs. Additionally, the Centers of Excellence are generally seen as a very helpful resource for teams working to support children and families with significant challenges. The Department identified an opportunity to strengthen practice by improving the use of these and other formal assessments in the planning process. Strategies to assist field staff were put into place, such as Assessment Integration Training and the utilization of the Social Work Practice Specialists and Regional Psychologists. Tools such as the Child and Adolescent Needs and Strengths and the Youth Level of Service (CANS and YLS) were implemented as well, with technical assistance resources in place to help ensure the information captured in the tools could be applied meaningfully. Improvements in QSR ratings on Assessment and Understanding and Child and Family Planning Process are based not just on use of the tools (which can be captured through other measurements), but on the quality of their application. An encouraging rate of improvement was noted this year in both of those measures; additionally, ratings on Ongoing Functional Assessment1 were strongly correlated with ratings on the Child and Family Planning Process – suggesting that teams are integrating assessment information into plans. The Child and Family Planning Process indicator has also shown a great deal of improvement in the last year. Cases that demonstrated an effective Planning Process typically demonstrated effective Teamwork as well. This was particularly supported by teambuilding early in cases, identifying family’s natural informal support network and utilizing their knowledge in assessment and resources in planning. For youth, the Planning Process greatly benefitted when the team could look beyond short-term needs and work with the youth toward long-term goals. During the 2010-2011 review year, the demonstration of best practice was noted in the majority of cases involving youth, and youth in turn make up the largest age group among the custodial population. This reverses a trend noted in previous years of review. The charts used in this summary reflect, except where noted, all custodial cases reviewed during the 2010-2011 review cycle. This includes Brian A. and Juvenile Justice cases. When data is broken out across different groups within the reviewed cases, striped columns are included for ease of comparison between subsets and the average across the review population. 1 The QSR uses similar language to describe the indicator capturing assessment as the Department uses to describe the primary tool used to capture ongoing historical and current assessment information. The tool used, the Family Functional Assessment, may inform the Ongoing Functional Assessment QSR indicator, but it is important to understand they are distinct from and not solely dependent upon each other. 17 2007-2008 n=243 2008-2009 n=243 2009-2010 n=253 2010-2011 n=256 41% 48% 52% 57% Le ar ar eg ni iv ng er Fu nc tio Fa ni m ng ily Fu nc Fa tio m ni ng ily C on ne ct io ns Sa tis fa ct io n C Be ha vi or al ea lth H ot io na l/ Em en cy Pe rm an en t Pl ac em St ab ilit y Ap pr op ria te Sa fe ty 17% 17% 26% 35% 28% 34% 41% 47% 72% 74% 79% 80% 89% 94% 93% 95% 71% 72% 78% 81% 68% 67% 52% 58% 74% 78% 78% 83% 98% 98% 98% 99% 86% 86% 91% 89% 94% 96% 98% 98% Child and Family Percent Acceptable Custodial Cases The chart above shows the percentage of cases rating acceptably (4, 5, or 6) by indicator. Cases shown here are custodial cases, including children and youth adjudicated Dependent/Neglected, Unruly, and Delinquent. Non-custodial cases were not reviewed in the 2007-2008 or 2008-2009 review years. Noncustodial cases are discussed on page 12. An additional 46 cases were reviewed in the summer of 2011 in a targeted review of youth placed in the five YDCs. Information about those cases begins on page 32. 18 82% 91% 35% 45% 49% 46% 50% 62% 64% 71% 59% 58% 54% 35% 37% 41% 52% 41% 30% 35% 36% 29% 35% 42% 33% 27% 29% 29% 36% 40% 50% 54% 59% 47% 43% 30% C As se ss m Te am wo rk an d En ga ge m en t oo en rd in t& at io Un n de rs ta nd Lo in ng g -T er m Pl Vi an ew ni ng Pl Pr an oc es Im s pl em Tr ac en ki ta ng tio & n Ad R ju es st m ou en rc t e Av ai la In bi fo lit rm y al Su Pl pp ac em or ts en tS up po rts Tr an si tio ni ng 45% 38% 46% 61% 2009-2010 n=253 2010-2011 n=256 89% 93% System Performance Percent Acceptable Custodial Cases 2008-2009 n=243 31% 31% 2007-2008 n=243 The chart above shows the percentage of cases rating acceptably (4, 5, or 6) by indicator. Cases shown here are custodial cases, including children and youth 19 adjudicated Dependent/Neglected, Unruly, and Delinquent. Non-custodial cases were not reviewed in the 2007-2008 or 2008-2009 review years. Non-custodial cases are discussed on page 12. An additional 46 cases were reviewed in the summer of 2011 in a targeted review of youth placed in the five YDCs. Information about those cases begins on page 32. Trending of Marginal Cases The following charts show the percentage of indicators in each domain for custodial children reviewed (Child & Family Status and System Performance) with findings in the acceptable (4,5,6), marginally unacceptable (3), and poor or adverse (1,2) range and compare this year’s data with data from earlier statewide review cycles2. One advantage of looking at the data this way is that it captures the percentage of ratings falling in the “marginal range,” that is, situations that are not currently acceptable although elements of practice may be present or, for Child and Family indicators, status may be mixed but risks of harm are minimal. Indicators rating a “3” are considered to be unacceptable in the short term, but refinement would bring it reasonably quickly into the acceptable range. Capturing cases in this range over time informs the system about what proportion of cases could become acceptable with minor adjustments to practice or system supports and minor improvements in status. If, over time, the percentage of cases rating a “3” decrease or remain fairly stable (as has occurred in the Child and Family Status domain) along with increases in the percentage of cases rating acceptably and decreases in the percentage of cases rating a “2” or “1,” this suggests the system is improving its ability to consistently support good outcomes in a variety of cases. If the percentage of cases rating a “3” increases in relation to cases rating acceptably or a “2” or a “1,” (as occurred on the System Performance domain between 2005-2006 and 2007-2008), that would suggest that practice is improving but not to the desired degree. That pattern would not be unexpected during early years of system reform, and since that time the percentage of cases rating acceptably on System Performance indicators has trended consistently upward, with a rather large increase between the last year’s review and this year’s. Concurrent with those improvements, acceptable ratings on Child and Family Status indicators have also consistently moved upward since the first year of review while “poor” or “adverse” ratings have declined to under 10%. While slightly over one quarter of our cases still fall into the “refinement” category on System Performance indicators, in 86% of the cases at least some elements of practice are noted with the majority of cases falling into the acceptable range. 2 Statewide reviews were completed during 2006-2007; however, quality assurance procedures were still developing at that time. In several regions, ratings tended to be quite high without a clear practice or system change-based reason. While information from the case stories and summaries is valuable within context, we do not feel the data quality from that year is useful for comparative purposes. 20 Statewide Child and Family Status - Custodial Cases 76.4% 73.4% 69.7% 67.4% 65.4% Percent of Scores Within Each Range 2005-2006 2007-2008 2008-2009 2009-2010 Acceptable (Score of 4,5,6) Marginally Unacceptable (Score of 3) 8.0% 10.3% 13.0% 14.5% 17.3% 15.6% 16.3% 17.3% 18.1% 17.3% 2010-2011 Poor or Adverse (Score of 1,2) Statewide System Performance - Custodial Cases 2005-2006 2007-2008 46.5% Acceptable (Score of 4,5,6) 2008-2009 Marginally Unacceptable (Score of 3) 14.0% 23.1% 22.2% 2010-2011 26.7% 31.6% 27.6% 30.4% 33.7% 34.0% 2009-2010 31.1% 44.1% 39.3% 37.3% 58.4% Percent of Scores Within Each Range Poor or Adverse (Score of 1,2) The above charts represent custodial children reviewed in the past 5 review cycles for which data could be obtained. 21 Non-Custodial Cases During the 2009-2010 review year, the Department piloted using the QSR tool to review noncustodial cases. In 2010-2011, non-custodial cases were reviewed with a semi-random sample. Sampling procedures were complicated by the lack of available reports distinguishing cases that met criteria for review from cases that did not. Consequently, regional feedback and selection among a group of cases was needed in order to identify three cases for review. Cases met criteria for review if they were consistent with one of the following: • • • • An investigation that has been classified and transferred to an FSW, with the FSW having had the case at least 30 days An assessment-track case transferred to an FSW, with the FSW having had the case at least 30 days An open case in the assessment track at least 60 days old An in-home case assigned to an FSW at least 30 days old that was generated due to court involvement. The QSR tool is designed to capture the outcomes present within cases, rather than relying solely on the activities occurring within a case. In order to effectively use the QSR tool, cases should be open a period of time long enough where one can identify what actions have been taken in the case and the results. Generally, non-custodial interventions are shorter in duration than in the custodial cases measured in QSR (the shortest-term custodial cases, such as those where children exit custody at the preliminary hearing, are excluded from review), hence the timeframes established for the non-custodial cases. The indicators in the QSR protocol were found to be relevant as written to the non-custodial cases, although some minor adjustments to language describing written plans, team meetings, and assessment tools were made in the 2011-2012 protocol to be more inclusive of non-custodial terminology. The charts used in this section show the percentage of non-custodial cases rating acceptably (4, 5, or 6) by indicator. Non-custodial cases were not reviewed in the 2007-2008 or 2008-2009 review years, and a non-random sample was piloted during the 09-10 review year. Therefore, comparative data for prior years is not available. The shaded bar representing custodial ratings achieved in the 2010-2011 review years are included as a comparative point of reference. 22 2010-2011 All custodial cases n=256 90% ac tio n isf ns Sa t ct io on ne ni ng ct io Fa m ily Fu n C ng ni ily Fa m ar e gi ve r Fu n ct io ar n in g l Le C av io ra na l/ Be h ea lth ot io Em Ap p ro pr ia te H Pl ac em en Pe t rm an en cy bi lit y St a Sa f et y 67% 80% 87% 100% 87% 85% 100% 2010-2011 n=30 83% 97% 100% Child and Family Percent Acceptable Non-Custodial Cases 2010-2011 All non-custodial cases n=30 In Child and Family Status, as might be predicted (and hoped for in a non-custodial population), Family Functioning, Stability, and Permanency were all noticeably higher than in the custodial population despite the shorter-term duration of most of the cases. This would be expected in non-custodial cases because it had been determined at case opening that risks in the home were not such that a custodial intervention was required to ensure Safety and Well-being. In 100% of the non-custodial cases, Appropriateness of Placement rated acceptably, meaning that in each of these cases the home or kin family setting was appropriate for receiving services. In only one of the non-custodial cases was it determined that the family was not receiving services at a level that risks were acceptably managed (NE-NC3). This case engendered much discussion among reviewers, QSR staff and the regional staff. In custodial cases, the immediate safety issues have been resolved by the removal of the child from the home, so the presence of a “minimally unacceptable” Safety status points to a crisis situation. Even though it is rated on a six-point scale like the other indicators, we became accustomed to thinking of Safety as an all-or-nothing indicator. In this case, the child remaining in the home was seen as appropriate and the interventions that had been planned for the family would likely resolve the risks after being consistently implemented. “Permanency” was already acceptable and “Safety” was the desired outcome of interventions that needed time to work; this is precisely the opposite of what we are used to seeing in custodial cases. This case illustrates the complexity of the assessment and decision-making that occurs in these non-custodial cases. 23 2010-2011 All custodial cases n=256 2010-2011 All non-custodial cases n=30 System Performance Percent Acceptable Non-Custodial Cases Te am w 69% 73% 50% 60% 60% 60% 50% 47% 57% or k En ga ge m an As en d se t Co ss or m di en na t& tio U n nd er st an Lo di ng ng -T er m Vi Pl ew an ni ng Pr Pl an oc es Im s pl em Tr ac en kin ta tio g n & Ad ju Re st so m en ur ce t Av ai la In bi fo lit rm y al Su Pl pp ac or em ts en tS up po rts Tr an si tio ni ng 63% 77% 2010-2011 n=30 As the case discussed above illustrates, Assessment is thought of as the critical Practice skill associated with non-custodial casework, indeed there is a case type called “Assessment” and those workers are called “Assessment” workers. At the beginning of the non-custodial QSR pilot, Field and Program staff identified Assessment as the area they expected to find the most challenges. One challenge thought to have an impact on this was the shorter-term nature of the casework. The other was in the quality of assessment tools and processes for non-custodial cases and workers’ skill in using them effectively. Comparatively, the Practice Wheel indicators rated acceptably at similar rates to custodial cases, with Assessment being only slightly lower than the custodial sample. Still, among the non-custodial cases it was the only Practice Wheel indicator to rate acceptably in less than half of the cases. In some cases, there is not a clear purpose around which to focus interventions. Sometimes this is the result of a case opening at the request of courts seeking more information about a family involved in a custody dispute, as in KX-NC1, KX-NC2, and SW-NC2. While these cases did show opportunity to engage and provide services to meet an identified need, it appears that an actual closure timeframe is tied to the resolution of the court case rather than a team’s determination that desired outcomes have been achieved. The most successful Practice Wheel outcomes among those cases was seen when both parents, despite their conflict, were engaged with a “team” around common outcomes. In another case, UC-NC3, the initial referral led to ongoing services to maintain a child in the home with his mother. Her mental health issues continued to escalate, and the child’s father was granted custody. Confusion then arose as to what the goal of DCS involvement should be. Court reviews were scheduled to review the 24 mother’s progress on the service plan, but at least for the near future the placement with the father appears more viable. While the team can identify services that support Family Functioning, they have not articulated when they think the Department will be able to exit the case. In other cases, concerns behind the initial referrals were truly “unfounded,” as in SH-NC2, NENC1, TV-NC1, and TV-NC3. In two of these cases, the Department’s presence is not contributing to improved safety and feels intrusive (SH-NC2 and TV-NC1). However, in the other two cases, (ET-NC1 and TV-NC3), the workers overcame initial resistance of the family’s and, although the presenting issue in the referral was not identified as a “founded” incident of maltreatment, was able to improve ongoing family functioning by addressing underlying needs identified through work with the families. In ET-NC1, communication between the mother and teenage youth contributed to circumstances that would have likely brought the youth to DCS attention as a probation case, if not through CPS-Assessment services. In TV-NC3, the worker’s “non-judgmental approach” helped form a team and resulted in improved communication between the family and the school. The worker also helped the family identify financial resources specific to home repair. Both of the families are highly satisfied with the Department’s intervention. While Assessment is clearly an important factor, the degree to which families are Engaged in that assessment and in determining the level of involvement is critical to Department involvement being supportive or feeling intrusive. Permanence Over the past four years, the percentage of custodial cases with an acceptable rating on Prospects for Permanence has doubled. In order for a case to be considered acceptable on this indicator, there must be evidence that the Child and Family Team is implementing “a realistic and achievable child and family plan” and the permanent home has been identified. The “work” of the child welfare system is captured in the System Performance Indicators, and the “work product” is the Child and Family Status Indicators. Permanence and Family Functioning especially are dependent on practice, as these represent the “end products” of DCS involvement. Improvements have been noted across the Practice Wheel indicators, and the improvements on Permanence and Family Functioning and Resourcefulness clearly validate that those practice improvements are helping achieve desired outcomes for children and families. Cases reviewed that had achieved positive outcomes on Permanence tended to also have defined, although to varying degrees, some form of a Long-Term View. Cases where positive results on Permanency were present or anticipated soon sometimes showed strength in effective Transition plans, informed by the Long-Term View. Ongoing Functional Assessment could also be linked to Long-Term View, especially in helping teams identify what information they needed to understand in order to make the most sensible plans for long-term success. Planning processes that could rapidly adjust to changing circumstances in the case also contributed to achieving positive results, as noted in cases from East, Knox, Mid-Cumberland, and Northwest. Other successful strategies seen in cases rating acceptably on Prospects for Permanence included: 25 • • • • Positive connections were maintained between children/youth and their families. In Juvenile Justice cases especially, there were excellent examples of family connections and visits occurring despite distance between the youth’s placement and the family’s home, particularly in cases from East, Knox, Tennessee Valley, and Upper Cumberland. Frequent, even daily contact with parents was noted in cases from South Central and Davidson; far from simply being a nice circumstance of the case, these frequent contacts were being used by the team to inform the Ongoing Functional Assessment and Child and Family Planning Process. Progressive visitation is a successful strategy, used pretty widely in Reunification cases. Cases from Davidson, East, South Central, and Upper Cumberland gave examples of this. Teams with good communication and good supports, many informal, that can assess how visits are going are very helpful in supporting these strategies. True concurrent planning, a cohesive team working more than one goal, worked well in cases where potential permanency resources were identified and concurrent goals were identified at the beginning of cases (typical when concurrent planning involved a relative) and where teams supported relationships between birth parents and resource parents. Early work to identify fathers and extended family not only yielded potential permanency resource, but also yielded results with identifying family supports. Diligent searches and work with families to identify these resources was particularly evident in Northwest, Shelby, and Tennessee Valley cases. In cases that were experiencing challenges to achieving Permanence, there were both practice and system support issues present. Just as a Long-Term View could assist teams, the lack of a Long-Term View presented challenges especially when other areas of team functioning were not adequate. When team members did not have a shared understanding of what the team was working toward, often case progress suffered. If team members did not support a familycentered approach, either because they did not understand team roles or because they simply disagreed with it, very little progress could be seen. When decisions were made based on rules (real or just understood), rather than individual circumstances, cases could stall completely. Examples of both excellent, creative family-centered work and cases where the family-centered approach was lacking were seen in nearly every region. Both Knox and Upper Cumberland showed very creative approaches to family-centered work in some cases, while allowing themselves to be limited by restrictive punitive approaches in other cases. Ongoing Functional Assessment issues were challenges in Shelby and Smoky Mountain in particular, where there were examples of cases where teams had worked a significant amount of a plan but still felt they could not return children home. Despite having examples of success reaching out to paternal and extended family, Shelby and Smoky Mountain also have examples where there were opportunities to strengthen the likelihood of achieving positive outcomes by working with both parents. Some other challenges are evident, many being “systemic issues,” that is, individual teams may not be able to solve the problem itself although they may be able to plan effectively with some support around these issues. Leadership at the Regional and Central Office levels, however, may be able to support work with families by addressing some of these issues: 26 • • • • Turnover in staff, including staff at residential placements and private agencies, creates challenges when it leads to gaps in information sharing or support to birth and resource parents. In adoption cases, challenges were noted in completing administrative processes (beyond achieving full guardianship). In some regions, clarity around roles and responsibilities for completing pre-placement summaries and other adoption work between DCS and the private agencies would likely have helped move cases forward more quickly. TFACTS implementation this year also presented a challenge as some time was spent getting accustomed to the new system; it is anticipated that this will be less of an issue next year as the implementation, not the system itself, was identified as the source of the challenges. A specific understanding of the documentation required to ensure ongoing TennCare coverage was also noted; Permanency Specialists are typically quite aware of this information but are not always available to teams when these questions arise. The Shelby region is absorbing a delinquent population previously served by the Youth Services Bureau. A comparably high proportion of cases from Shelby have determinate sentences. There is a great deal of variance in the speed with which cases move through the court system, and there does not appear to be much consistency or predictability to which cases will be tied up. However, a few themes were evident. Turnover in DCS legal staff and in court staff was cited as a factor in timeliness of petitions being heard. In cases involving other systems, such as cases where there are pending criminal charges against parents, cases could take quite a long time to be heard. Adjudications were sometimes not received for weeks or months, and this appears fairly common in some courts in Shelby and Upper Cumberland. Courts and families in a couple of cases were clearly out of sync as far as what was a reasonable period of time to finalize an adoption, with families and youth anxious to complete the process and clearly perceiving this to not be a priority for the court. And, perhaps most frustratingly, a lack of consistency between courts around requirements and preferences for petitions means DCS attorneys and DCS staff need to become experts on the customs of particular courts. Permanency Goal For each case, reviewers are asked to record the “working” goal(s) of the team. The “working” definition is used to ensure that the practice in cases is rated based on what the team is actually working toward, since there are times in every case when the written plan could be out of date – for example, when a goal changes and the new plan has not been ratified yet or data entry into the system has not yet occurred. Thus, the following charts show the percentage of cases rating acceptable by the goal identified by reviewers as the “working” goal. The most frequently occurring goals are represented here. Sole Goals Outcomes for children and youth with an Adoption goal and an Exit to kin goal were quite strong. Generally by the time Exit to kin is the sole goal identified on a plan the permanency resource is clearly identified and committed. Permanency rated acceptable in 62% of the Exit to kin cases, a notable improvement over the past few years with the implementation of Subsidized 27 Permanent Guardianship, the Relative Caregiver Program, and other initiatives within the system to help support enduring relative placements. Adoption cases did “next best” at 39%. Practice Wheel indicators were very strong in this group, pointing to process-related issues (including court, adoption assistance, and in a few cases an adoptive resource was yet to be identified). Process-related issues may also be dampening Permanency in Reunification cases; these cases are sometimes open only a few months at the time of review and one would not necessarily expect that Permanency would be achieved so quickly. Still, the rating on Family Functioning is much higher than that on Permanency, begging the question as to what remains to be done in order to reunify. Practice Wheel indicators are improving, but the ratings suggest that a key practice opportunity for our system continues to be work with birth families. 2010-2011 All custodial cases n=256 Child and Family Percent Acceptable Custodial Cases 2010-2011 Reunification n=110 2010-2011 Adoption n=59 79% 81% 81% tis fa ct io n 39% n=23 ct io ns ne Co n m ily Fa m ily Fa C ar e 74% 65% 75% 56% 16% n=19 tio Fu nc ct Fu n gi ve r l/ B na ni ng in g io n ar ni ng eh av io Le ra l th ea l H Em ot io Pe rm an en t cy 32% 39% pr o pr ia t e Pl ac em en ilit y St ab fe ty Sa Ap Sa 92% 85% 78% 73% 62% 65% 75% 65% 79% 93% 99% 98% 100% 89% 92% 88% 97% 100% 92% 98% 95% 90% Sole Goals 2010-2011 Exit to kin n=26 In cases with a sole goal of adoption, most are of children already in full guardianship. In that instance, Family Functioning is not rated and Family Connections is only rated based on siblings or other significant family relationships that would be appropriate to continue post-TPR. The number of cases for which these indicators were relevant is included above; one would not expect Family Functioning to rate at a high level of acceptability if Adoption is a sole goal. 28 2010-2011 All custodial cases n=256 67% 62% 78% 73% 63% 66% 65% 77% 42% 50% 53% 59% 68% 65% 51% ng sit io Tr an up po tS ni rts ts pp or Pl ac em en Su or m al ce ur es o R In f st m Av ai la bi lity en t n Ad ju & Tr ac ki ng Pl an Im pl em en Pr o ni ng ta tio ce ss w Vi e -T er m ng Pl an t& Lo Un d er st an d tio in a oo rd C d As se ss m en an k in n t em en ga g En am wo r Te g 31% 47% 52% 58% 59% 62% 68% 73% 73% 76% 62% 59% 88% 85% Sole Goals 2010-2011 Exit to kin n=26 61% 2010-2011 Adoption n=59 94% 95% 95% System Performance Percent Acceptable Custodial Cases 2010-2011 Reunification n=110 Concurrent Goals Only a small percentage of cases actually show a working concurrent goal of reunification/adoption. Most of the cases showing concurrent reunification/adoption goals began as sole reunification but adoption was added after the children either had been in custody a prescribed amount of time or reunification did not appear to be viable, which no doubt had some influence on the ratings reflecting several challenges in the cases. Because the ratings for concurrent reunification/adoption cases were so distinct from other cases, a workgroup that comprised Central Office Program staff in Safety, Permanency Planning, Recruitment and Retention, Continuous Quality Improvement, and the Brian A. monitor’s office was brought together to review the 19 case stories and discuss practice and systemic issues noted in the cases. Trends that emerged included: • • Staff appear to be adding adoption based on a belief that they have to when a child has been in custody a particular amount of time, even when the Child and Family Team may not believe adoption is in the best interest of the child and family. Across the state, among field staff there seems to be some inconsistency around what the role of team members are and to what degree legal team members participate in decisionmaking when it comes to adding adoption to the plan. Team members in one instance perceived the DCS attorney was in charge of driving the decision to adoption, although the rest of the team were still working with the mother and mentoring her on parenting. Confusion and mistrust between team members seemed to be a result of this dynamic. 29 • • Evidence that adoption was truly being worked as a concurrent goal would include more than just a verbal agreement from the resource parents that they are willing to adopt. Permanency Specialists are the Department experts on Adoption Assistance and explaining the process of adoption to the resource parents; however, it is generally accepted in the field that Permanency Specialists are not available to teams until adoption is a sole goal and children are in full guardianship. This effectively prevents concurrent planning from occurring in many cases. Clarification around this issue is expected as program staff and regional staff have conversations specifically addressing the steps can be taken toward adoption prior to full guardianship being attained. These sessions are scheduled to begin in the winter of 2011/2012. In several cases, workgroup members identified missed opportunities at the beginning of casework that were contributing to challenges later. In a few, diligent searches were not conducted (or conducted well) so that there was an extended period of time that cases were in concurrent limbo – that is, steps had to be completed in locating fathers before TPR could be pursued although the team had effectively abandoned reunification. In one case, this resulted in a viable relative appearing later on, changing the permanency conversation also. In other cases, the Ongoing Functional Assessment of the family’s strengths and needs did not yield a satisfactory plan that, once implemented, team members believed had achieved the conditions necessary for reunification. These cases are especially challenging, as there may be few obvious conditions for TPR when the parent has participated in the requested services. Adoption is really the only option to put on the plan for youth who are not approved for a goal of PPLA. The unit struggles with cases where poor outcomes related to poor practice in the early years of the case contribute to the desire not to adopt now. While some of these cases may reflect the legacy of prior practice, it may be useful to acknowledge as a system that the approval of PPLA now is not intended to validate earlier practice but to reflect the current best interest of the youth. We may see some negative impact from these legacy cases until they work their way out of our system; the key point is to make sure that our current implementation of practice is meeting the needs of youth and families. 30 or k em en t 13% 33% 45% 53% 55% 89% 84% Concurrent Goals on in g 16% 40% 30% 21% 16% 2010-2011 Reunification/Exit to kin n=20 45% 2010-2011 Reunification/Adoption n=19 16% 50% 2010-2011 All custodial cases n=256 40% 35% 32% 50% pr o pr ia t C Fa m ily Sa tis tio n tio ns fa c ne c ng ni ng ni Fu nc tio ct io g or al ea lth nc y Le ar ni n Co n Fa m ily H eh av i Fu n l/ B ar eg ive r ilit y Pl ac em en t St ab Pe rm an e e Em ot io na Ap fe ty 0% 11% 15% 44% 39% 16% 55% 84% 75% 89% 95% 74% 80% 95% 100% 84% 90% 75% 84% 68% 100% 95% 2010-2011 Reunification/Exit to kin n=20 11% 5% 21% Sa 2010-2011 Reunification/Adoption n=19 Tr an sit i Un de rs ta nd in g Lo ng -T er m Vi ew Pl an ni ng Pr oc es Pl s an Im pl em en ta Tr tio ac n kin g & Ad ju st m en Re t so ur ce Av ai la bi lity In fo rm al Su pp or Pl ts ac em en tS up po rts Co or di na tio n En ga g an d en t& w As se ss m Te am 2010-2011 All custodial cases n=256 Child and Family Percent Acceptable Custodial Cases Concurrent Goals System Performance Percent Acceptable Custodial Cases 31 Placement Type When cases were sorted based on placement type, a few trends emerged. Notable differences occurred between “temporary” placements, - that is, placements providing substitute care until the families could support reunification or an adoptive placement was identified. Placements where the child is expected to remain until maturity, for example in their family home or in an adoptive placement are referred to here as “permanent” placements. Cases were also grouped according to whether a placement was attached to a provider agency or DCS and family care or congregate care. “Temporary” Placements DCS and Agency resource homes are still “temporary” placements at the time of review for the children and youth placed in them, although some may become permanent placements in the future. These placements tend to capture children and youth at the beginning and middle of the custodial episode, whereas the adoptive and THV placements above generally reflected the end of the custodial episode. Placements captured under “kinship” are more likely to include cases from all through the spectrum, so in part some of the difference in Permanency ratings may be attributed to cases where the relative placements have been identified as a permanency resource if reunification turns out to not be a viable goal. Family Connections is a noticeable strength in kinship cases, as is Family Functioning. Among System Performance indicators, Informal Supports is also very high compared with other types of temporary family placements. Child and Family Percent Acceptable Custodial Cases 74% 37% 45% 55% 32% 50% n ac tio is f ne C on Sa t ct io ns 16% in g ily Fa m Fa m ily Fu Fu n nc t ct io io n ni ng in g ar n Le eg iv er ot Em C ar av io r al lth io na l/ Be h nc m an e H ea y 16% 16% P e ia t Pe r la ce m en t bi lit y St a ro pr Ap p y Sa fe t 75% 76% 74% 96% 96% 93% 77% 64% 78% 79% 80% 92% 87% 96% 100% 98% 100% Kinship, DCS, and Agency Resource Placements 96% 93% 92% 88% 100% 96% 98% 2010-2011 All custodial cases n=256 2010-2011 Kinship home n=24 2010-2011 DCS resource home n=45 2010-2011 Agency resource homes n=61 32 Among temporary family placements, Practice Wheel indicators and Transitioning were most strong in Kinship placements, with Long-Term View also being relatively strong compared to other indicators. This may be a reflection of the “Plan B” or concurrent work present in many kinship placements. There were four cases where Engagement was not acceptable but Teamwork and other Practice Wheel indicators were; these four cases reflect circumstances where relatives are available to take custody of the children if necessary, but birth parents are struggling to maintain involvement with the team due to ongoing issues or simply giving up on reunification (ET-16, KX-02, MC-17, and NW-19). It seems that in some cases family dynamics between birth parents and their relatives can play into whether or not a parent is able to effectively “ask” their family to care for their children or admit to them they are not able to. In each of these cases the children and youth are in stable placements with their relatives, and the forecast for the children was to improve or remain the same. Barriers that exist in making kinship placements involve processes that are determined, in some cases, outside DCS. The Interstate Compact (ICPC) process can be very time-consuming. Some relatives in metro areas that cross two states, like Chattanooga and Memphis, have offered to move to a part of the city in Tennessee, but are still required to reside at one address for six months before the home study in order for background checks to be considered valid. Minor criminal histories can also pose barriers to being an approved placement that comes with the supports available to expedited placements, even when team members “on the ground” with the families do not believe the criminal history indicates a present safety concern. Continuing to develop safe and sensible means of making relative placements would likely benefit outcomes. The major opportunity cited that, if addressed, would probably raise the percentage of Kinship cases rating acceptably on Placement Supports, was timelier board payments. DCS has been responding in some cases where financial need is present by paying utility bills, for example; still, there may be opportunities to speed up the process of securing board payments and avoid financial hardship. 33 93% 93% 67% 75% 74% 53% 51% 24% 35% 40% 41% 44% 62% 71% 88% 31% 23% 33% 39% 63% 67% 63% 67% 49% 49% 54% 44% 52% As se ss m Te am w or k an d Co or di na en tio t& n Un de rs ta nd in g Lo ng -T er m Vi ew Pl an ni ng Pr oc Pl es an s Im pl em en Tr ta ac tio k in n g & Ad ju st m Re en so t ur ce Av ai la bi lity In fo rm al Su pp Pl or ac ts em en tS up po rts Tr an sit io ni ng en t em En ga g 82% Kinship, DCS, and Agency Resource Placements 2010-2011 Agency resource homes n=61 33% 2010-2011 DCS resource home n=45 System Performance Percent Acceptable Custodial Cases 71% 2010-2011 Kinship home n=24 38% 44% 2010-2011 All custodial cases n=256 “Permanent” Placements Predictably, the indicator capturing Permanence rated the highest on cases where children were placed into Adoptive homes or were home on Trial Home Visits or placed in-home. These placements are generally made at the end of custodial services, and so provide some insight into Safety and Well-being at the time an exit from custody is anticipated. They also provide a picture of what System Performance outcomes look like around the time custodial service involvement is waning and involvement from ongoing services and the family’s informal support system should be increasing. The Well-being indicators were also very high in these cases, suggesting that children are not returning home “too soon” or that Safety and Well-being are compromised for a shorter length of stay. Additionally, the rating on Family Functioning and Resourcefulness suggests that positive changes occurred within the home and family. 34 2010-2011 All custodial cases n=256 Child and Family Percent Acceptable Custodial Cases 2010-2011 THV or in-home n=42 83% 84% 95% 100% 100% 100% 88% 96% 60% n tio tis fa c Sa Fa m ily Co n ne ct io Fu n ct io ns ni ng in g io n ct m ily ar eg ive C Fa rF un Le ar ni ng ra l l/ B eh av io ea lth na cy rm an en t Pe H Em ot io Ap pr o pr ia t e Pl ac em en ilit y St ab Sa fe ty 43% 67% 76% 68% 93% 91% 100% 96% 95% 100% THV, In-home, or Adoptive Placement 84% 95% 100% 2010-2011 Adoptive homes n=25 A note on the chart: Family Functioning was applicable in only 7 adoption cases; these are cases where full guardianship has not yet been achieved. Family Connections is also only applicable in 13 cases, 11 of these are of kids who are placed in-home or on THV but who still have siblings or other meaningful family members remaining outside the home. For the 2 Adoptive Home cases that did not rate acceptably the lack of connection reflects one birth father who reported he was asked not to contact the children and he is not contesting TPR (KX-20). Although extended family has been contacted for visits in TV-08, the local judge does not approve of children visiting with their parents while their parents are in jail. The TPR hearing had not occurred in that court yet at the time of review, although presumably TPR would occur at which time Family Connections could become Not Applicable in that case. Performance on Practice Wheel Indicators and Transitioning are also quite strong in these cases compared with the overall review sample. For cases with children and youth on Trial Home Visits, it appears a primary practice opportunity is to strengthen the development of a LongTerm View and Transition planning. This would likely help improve Stability, the primary challenge on the status side, as well. For adoption cases, System Performance is quite strong until Plan Implementation, suggesting some systemic barriers may be presenting challenges for even the most cohesive teams. Several case stories indicate opportunities to increase these indicators are primarily based in making sure all the “steps” involved in adoption planning, from specific court requirements for finalization and Adoption Assistance are well-understood. Several suggested the involvement of Permanency Specialists was an asset in this area of planning, and some recommended their involvement earlier so that resource parents have a 35 91% 64% 76% 67% 72% 74% 60% 71% 72% 80% 55% Te am w En ga ge or m k en an t As d C se o or ss di m na en tio t& n U nd er st an di ng Lo ng -T er m Vi ew Pl an ni ng Pr oc Pl es an s Im pl em en Tr ta ac t io ki ng n & Ad ju st R m es en ou t rc e Av ai la bi In lity fo rm al Su pp Pl or ac ts em en tS up po rts Tr an si tio ni ng 64% 84% THV, In-home, or Adoptive Placement 76% 84% 81% 88% 2010-2011 Adoptive homes n=25 86% 92% 2010-2011 THV or in-home n=42 92% System Performance Percent Acceptable Custodial Cases 2010-2011 All custodial cases n=256 100% 96% clearer picture of what the adoption process looks like and what they can expect from services after finalization. Congregate Care and Family Placements When cases are sorted based on congregate or family settings, there are some key differences in outcomes that are observed, many not surprising. Youth in congregate settings in this review were placed to address a serious mental health or behavioral issue.3 A meaningful trend identified here is that for youth in congregate care and children in family settings, Safety, Health, Caregiver Functioning, and Satisfaction with services was quite high for both groups. Some of the differences observed in the ratings between youth in congregate care and children placed in family settings are not surprising, given the largely different circumstances present in a case prior to placement. Placements in residential treatment, for instance, are often made after lower levels of care have been unsuccessful, contributing to lower percentages of acceptable ratings in Stability. For a similar reason, teams may be working toward supporting Emotional/Behavioral 3 Only one youth was placed in an Independent Living program at the time of the review (SC-22 JJ). He was placed there after completing residential treatment for sexual offenders. His commitment order was changed from a determinate to indeterminate sentence during his time in custody, but an agreement was reached between the youth’s attorney and the District Attorney that he would remain in custody until age 19. If he were to leave custody prior to his 19th birthday, he could face his remaining open charge for sexual battery as an adult. The youth will not be returning home but is able to attend college in his current IL placement. The child this youth committed crimes against continues to live in the same neighborhood as the youth’s parents, and both the victim’s family and the youth’s attorney were in support of this arrangement. 36 Well-being and Learning and Development but are starting from a different point with youth experiencing mental health problems. However, Appropriateness of Placement is a concern for those in congregate care. Generally, a key challenge was finding a suitable step-down placement rather than the placement having been unacceptable when the placement was made. An important distinction in these cases is the maintenance of Family Connections for youth in congregate care; the higher ratings for congregate care is due almost entirely to the Juvenile Justice facilities (YDCs and Group Homes); when Brian A. class members are compared, the difference between groups is negligible. Child and Family Percent Acceptable 2010-2011 Congregate Settings n=59 Custodial Cases 2010-2011 Family Settings n=197 67% 53% 53% 45% n tis fa ct io Co n Fa m ily Sa ct io ns ne ct io Fu n Fa m ily Fu n gi ve r C ar e na ni ng in g ct io n ar ni ng eh av io l/ B Le ra l th ea l cy rm an en t Pe H Em ot io Ap pr o pr ia t e Pl ac em en ilit y St ab Sa fe ty 22% 40% 46% On the Practice Wheel indicators, differences in the ratings between the groups are much smaller. Placement Supports was a strength for both types of placements, a very positive indication that the Department and Provider Agencies are able to effectively provide support to a variety of settings. In Engagement, Plan Implementation, and Tracking and Adjustment, the ratings were very similar. The ratings on Teamwork and Coordination and Long-term View suggest that among congregate placements, an opportunity may be to ensure that a familycentered approach and work toward a Long-Term View is present to the same degree as it is in family settings. Congregate settings are identified to meet specific needs of youth, and the challenge may be in achieving the balance between managing the urgent needs that elicit reactive practice within the framework of achieving a Long-term View for Safety, Stability, and Permanence. It may be counterintuitive that Resource Availability and Use is comparatively strong in the family settings, reflecting a lower level of care; however, the challenges present in 37 80% 78% 96% 86% 68% 73% 86% 95% 98% 99% 94% 73% 73% 98% 97% Congregate and Family Settings this indicator and in Informal Supports typically speak to a lack of involvement with the family. Distance between home communities and specialized settings can present a barrier to fully implementing family-centered practice. 45% 51% 67% io n sit up po tS Pl ac em en in rts g 46% ts Su pp or lity In f ce R es o ur & ng ki Tr ac or m al Av ai la bi st m Ad ju em en 58% 53% 54% en t n ta tio ce ss Im pl Pl an ni ng Pr o Vi e Pl an 53% 52% 49% 55% 34% 44% w g Lo ng er st Un d t& m en As se ss -T er m an d tio in a oo rd C d an k in n t em en ga g En am wo r Te 46% 52% 61% 49% 58% 61% 76% Congregate and Family Settings Tr an 2010-2011 Family Settings n=197 95% 92% System Performance Percent Acceptable Custodial Cases 2010-2011 Congregate Settings n=59 Provider Agency and DCS Placements When looking at placement by agency affiliation, there are few distinctions between cases on any indicators other than Stability. This is in part due to agency providers representing the higher levels of care among family settings and the residential treatment facilities. Nearly all of the kinship placements, the placement type with the highest percentage of acceptable Stability ratings, are DCS approved homes. Once again, Placement Supports was a strength in both groups. The majority of the Practice Wheel indicators are very similar between groups, which may indicate that, encouragingly, there is consistency in practice across teams with and without Agency Caseworkers. Resource Parents and staff in congregate facilities are critical Child and Family Team members, and these differences may indicate consistency in expectation for participation. Long-term View stands out as the Practice Wheel indicator with the largest discrepancy between groups, some of which like Stability is accounted for by the type of placement mentioned in the preceding section. However, there may be opportunities to ensure that FSWs maintain the focus on Long-term View for children and families, even when other professionals on the team are working heavily towards completion of a specific treatment or program. 38 As se s k & Ad ju st m en t ta tio n ce ss Av ai la bi lity In fo rm al Su pp Pl or ac ts em en tS up po rts Tr an sit io ni ng rc e ng Im pl em en es ou Tr ac ki Pl an Pr o Vi ew in g n t 74% 69% Agency and DCS Settings 93% 93% System Performance Percent Acceptable Custodial Cases 48% 50% 60% 64% 53% 55% 53% 51% 53% 55% 39% 45% 52% 49% 59% 59% 61% 60% 2010-2011 DCS Placements n=121 in g -T er m er st an d tio em en oo rd in a ga g pr o C Fa m ily Sa ra l th n ct io ns ni ng ng tis fa ct io ne ct io ni ar ni ng ct io Fu n Co n m ily Fu n Le io ea l cy t ilit y en eh av H rm an l/ B gi ve r Fa ar e St ab fe ty Pl ac em en Pe e na pr ia t Em ot io Ap Sa 58% 57% 49% 46% 33% 38% 59% 80% 79% 94% 97% 80% 86% 100% 98% 87% 92% 79% 84% 75% 99% 97% 2010-2011 DCS Placements n=121 R C Un d d Lo ng & an En 2010-2011 Agency Placement n=135 Pl an n sm en t Te am wo r 2010-2011 Agency Placement n=135 Child and Family Percent Acceptable Custodial Cases Agency and DCS Placements 39 Recruitment and Retention Placement Supports, an indicator capturing the support provided by DCS, private agencies, and other entities within the child welfare system to both resource parents and congregate care facilities, has been a consistently high rating indicator each year of review. Paid placements such as DCS and private agency resource homes and congregate care placements rate particularly high, with 95% of the congregate placements rating acceptably. Both DCS and private agency resource homes rated at 93%. Specific strengths reported throughout the year related to this indicator include: • • • • Resource Parents have their own strong support systems that are encouraged to become “informal supports” to the children in their care, seen in South Central and Northeast. Resource Parents reported good support from DCS FSWs and/or private agency case managers. This was noted in cases where there were frequent visits made to the resource home by these workers. Support from the DCS FSW was particularly important in cases where the resource parents hoped to adopt. There were examples of cases in Davidson, Mid-Cumberland, Northeast, Northwest, Smoky Mountain, South Central, and Tennessee Valley citing how important the DCS or agency worker contact and communication was to helping support the placement and their caregiving of the children. When regions supported the youth and families recruiting their own placement resources, these tended to work very well. Not only does this reflect family-centered practice, but it also contributed to positive outcomes as the trauma of removal was minimized when children moved to placements that the birth families supported. East, Knox, Shelby, Smoky Mountain, South Central, and Upper Cumberland all had cases where families and youth had recruited the placement resources themselves. Some regions especially had examples of cases where Resource Parent Support was encouraging positive relationships between birth parents and resource parents, and these resource parents also seemed to have an expectation that their work with children extended to the families. Many resource families were able to articulate ways, through some of this supportive work through the Child and Family Team, that they were supporting reunification efforts even while being willing to adopt. The trend toward positive relationships between birth and resource parents has been seen in Davidson for a couple of years now, this year there were also examples of cases like this in MidCumberland, Northeast, Tennessee Valley, and Upper Cumberland. While not speaking directly to Resource Placement or Congregate Care Supports, there were cases where Child and Family Teams used strategies that were successful at building supports among relatives even when those relatives could not be placement resources. Diligent searches conducted very early in the life of DCS involvement also built support for non-custodial cases also. Relatives that could not be placements could help make team decisions, as seen in cases from Mid-Cumberland, Northwest, and Upper Cumberland. Although well supported in a large majority of the cases, kinship placements as a group had the lowest percentage of cases rating acceptably on Placement Supports. The issue in these cases had to do with timely receipt of board payments. Some kinship caregiver providers were feeling financial hardship during the approval process, and in some instances DCS was providing funds 40 for utility bills to offset the cost to the families when they were not receiving a board payment. Still, a couple of families reported they were spending down their savings. These challenges were seen in several regions. Although not yet reflecting kinship caregivers in most cases, a related issue to kinship resource is the length of time the ICPC/ICJ process takes. Managing connections during this time is challenging, and waiting for approval creates uncertainty over several months. Child and Family Teams may be able to help normalize some of this experience for relatives and current resource parents, as well as helping them understand what to expect during this process. Kinship parents to a very large sibling group that was split between two expedited homes noted that even then, respite placements where the children can go without being separated further are not available. Other areas of opportunity for all placements with regard to Placement Supports mainly related to Teamwork-based issues around communication. Specific issues included: • • • Increasing the understanding of the Permanency Plan, or the planning process, would assist resource parents who are either unable to support the plan with their current knowledge or who feel unsure about how they can support the plan. Processes related to permanent guardianship or adoption can also be confusing to resource parents, but even in cases where there are concurrent goals in place Permanency Specialists are typically not available or not utilized by teams until adoption becomes a sole goal or after children are in full guardianship. In a few cases, resource parents perceived a lack of communication during children’s transitions from one placement to another. For resource parents, this resulted in the feeling like they were not as equipped to meet children’s needs as they would have liked. Turnover in private agency workers presented challenges in Resource Parent Supports during those transitions, especially if there was not coverage for a period of time or information was not effectively shared from one worker to another. Youth Youth age fourteen and older make up the largest age group of children reviewed, reflecting the proportion of age groups in our custodial population. Typically, the youth in custody have more challenges than do younger children in Well-being, as some struggle with mental health and/or substance abuse issues. Learning and Development can be an additional challenge for youth with these needs, especially when treatment needs require changes in school settings or when the team needs to prioritize mental health stabilization over academic progress for a period of time. The cumulative impact of behavioral or academic problems occurring over a longer school career can result in youth getting further and further behind their peers. Stability also is a challenge for more children in this age group than in others, but over the past three years Stability has shown some improvement concurrent with improvements in System Performance ratings. Over the past three years each of the System Performance indicators, Permanency, and Family Functioning have shown improving trends. The majority of cases of youth reviewed this year showed acceptable outcomes on Practice Wheel indicators, and the percentage of cases rating acceptably on these indicators exceeded that of the statewide average. This reverses a trend seen in previous years, where outcomes for youth tended to be below the statewide 41 average. A considerable amount of the improvement seen in the statewide ratings is reflective of the improvements in Practice seen among this age group. The following charts include youth in custody, age 14 or older, either adjudicated Dependent/Neglected, Unruly, or Delinquent. 2008-2009 age 14 and older n=122 2009-2010 age 14 and older n=124 Sa tis fa ct io n 56% 40% 46% Le ar ar ni ng eg iv er Fu nc tio ni Fa ng m il y Fu nc tio ni Fa ng m il y C on ne ct io ns Be ha vi or al 49% 54% 61% 69% 71% 77% 75% 77% 85% 91% 88% 94% 2010-2011 age 14 and older n=118 C Em ot io na l/ H ea lth 20% 28% 37% en cy Pe rm an en t Pl ac em St ab il it y Ap pr op ria te Sa fe ty 42% 56% 55% 63% 73% 75% 80% 81% 85% 94% 95% 97% 98% 98% 99% Child and Family Status Youth Youth with acceptable Family Connections tended to have a more positive six-month forecast – only two youth with a forecast of “decline” were rated as having acceptable Family Connections. Supporting positive relationships with family members, even when it is unlikely to result in Permanency, contributes to well-being for youth. Engagement and Teamwork with the youth themselves was particularly strong, and this seems to be the foundation for much of the practice improvement. Supports such as Education Specialists were helping teams navigate credit challenges in some cases of youth in high school. The involvement of Independent Living Specialists was helpful in most cases where youth were receiving specific assistance around deciding on Post-Custody options. The East region, for example, worked very well with the teens in their review, including youth struggling with serious mental health and behavioral issues. Tennessee Valley seemed to have fewer challenges placing children in their home communities than other regions. One issue that clearly informs their placement decisions for youth is the high school schedule – they were able in some cases to keep youth if not in the same school in a system that used the same block schedule so they wouldn’t 42 lose credits transferring between systems. A limited ability to ensure continuity of credits was noted in a few cases reviewed in Mid-Cumberland, although teams were certainly aware of the impact changing schedules had and were trying to avoid conflict. A challenge in that region is that many of their agency resource homes, who provide placements for many youth, are concentrated in one county in their region. There may be opportunities to develop strategies to help ensure youth’s progress in high school is not adversely impacted by placement changes, including regional assessment of the extent to which this impacts youth in their areas and resource development. While there remain opportunities to strengthen Long-Term View, a critical area for youth nearing a transition to adulthood, the work with the youth population is very encouraging in its improvement. 50% 64% tS Pl ac em en In fo rm al S up po rts up po rts 28% 34% 46% 38% 52% 60% 73% R es ou rc e Av ai la bi li t y en t 31% 38% 57% 58% Tr ac ki ng & Ad ju st m en ta tio n 32% 33% Pl an Im pl em Pr oc es s 26% 32% Pl an ni ng Vi ew 34% 42% 44% 55% Lo ng -T er m er st an di ng 32% 37% 43% 47% en t& As se ss m wo rk an d C Un d oo rd in at io n 45% 46% m en t En ga ge Te am 58% 65% 66% 2010-2011 age 14 and older n=118 88% 86% 94% System Performance Youth 2009-2010 age 14 and older n=124 Tr an si tio ni ng 2008-2009 age 14 and older n=122 Juvenile Justice Fifty-six cases reviewed during the 2010-2011 statewide review cycle were of youth adjudicated delinquent. An additional forty-six cases of delinquent youth were reviewed during the summer of 2011 in the targeted reviews that took place in the YDCs. The charts used in this section include those youth reviewed as part of the summer YDC reviews. To a great degree, practice outcomes for youth adjudicated delinquent who are placed in family or residential treatment/group home settings are fairly consistent with practice outcomes achieved for youth in the Brian A. class. Permanency rated acceptably in exactly the same percentage of cases for youth in the Brian A. class and youth adjudicated delinquent who were not placed in YDCs. Outcomes on Family Connections were considerably higher than the Brian A. average. In many 43 cases, depending on case circumstances, the team recommends that youth and their families receive some degree of family counseling prior to discharge. This likely supports Family Functioning and Family Connections, as well as Transitioning from the System domain. YDC placements were achieving positive outcomes for youth with regard to Safety, Health, and Emotional Well-being, and Learning and Development at a rate consistent with those of Brian A. youth. As with other JJ youth, Engagement showed the highest percentage of acceptable outcomes among the Practice Wheel indicators. Some youth exit to Trial Home Placements directly from YDC placements, but others do stepdown to lower levels of care before exiting custody. For purposes of classifying placements in the following charts, youth on a Trial Home Placement at the time of their review are categorized according to their prior placement. Twelve youth were on Trial Home Placements at the time of their reviews, four who were counted as being in a YDC placement and eight in other types of placements. Some of the difference in Permanency ratings across these groups can be explained by some of the youth in non-YDC placements being at a phase of their case that represents the latter part of their custodial stay, whereas for some youth the YDC represents an early or middle part of their custodial stay. However, the indicators for Long-term View and Transitioning on the YDC cases suggest that in most cases planning processes for youth in the YDCs are highly focused on the short-term treatment goals for the youth while they are in the facility but less so on a broad, family-centered plan to support long-term independence. 2010-2011 Brian A. youth n=62 Child and Family Percent Acceptable Youth Adjudicated Delinquent 2010-2011 JJ youth in non-YDC placements n=37 2010-2011 YDC placements n=62 53% 61% 52% 81% 84% 84% 94% 93% 86% 71% ar eg iv er Fu nc tio Fa ni m ng il y Fu nc tio Fa ni m ng ily C on ne ct io ns Sa t is fa ct io n Le ar ni ng C Be ha vi or al ea lth H ot io na l/ Em en cy en t Pe rm an Pl ac em St ab ilit y Ap pr op ria te Sa fe ty 11% 41% 59% 58% 76% 81% 84% 76% 97% 98% 100% 97% Placement Type 44 YDC cases did not rate as well on System indicators as the other cases, with the exception of Placement Support. A common theme among these cases, and one that likely underlies some of the other challenges to a great degree, is that planning in these cases centers around program completion and release from the facility rather than on successful achievement of a familycentered Long-term View. In short, the practice demonstrated in a number of cases is inconsistent with our practice model, remaining very child focused as opposed to family centered. Opportunities were identified for regional FSWs and YDC staff to team more effectively together throughout the duration of a case, not just to concentrate efforts at the youth’s entry into the facility and when a release is imminent. Commonly, the teaming process within the YDC was described as a “treatment team” approach. This clearly has helped yield good results in the Well-being indicators, and a strength identified in these cases is cohesion and communication among treatment staff within the YDCs. However, until this process more effectively integrates the Child and Family Team meeting approach, including family-centered Assessment and Planning Process, and guided by a Long-term View, these cases will likely continue to show lower percentages on desired practice outcomes. 2010-2011 JJ youth in non-YDC placements n=37 97% 97% System Performance Percent Acceptable Youth Adjudicated Delinquent 2010-2011 Brian A. youth n=62 Placement Type 26% 37% 45% 46% 59% 62% 60% 59% 62% 40% 41% g io n sit Tr an up po tS em en in rts ts pp or Su Pl ac ur es o or m al ce Av Ad ju R In f st m ai la bi lity en t n & ng ki Tr ac Im pl em en Pr o Pl an ni ng ta tio ce ss w Vi e Pl an -T er m ng Lo O ng oi ng Fu nc k t io an d na C lA oo rd ss es in a tio sm en n t em en ga g En am wo r Te t 21% 35% 44% 62% 54% 45% 55% 62% 70% 2010-2011 YDC placements n=62 A notable number of youth reviewed during the summer YDC reviews have experienced the loss of a parent or close family member, and in a few of the cases family members directly connected the youth’s behavior problems with this loss. Nineteen of the forty-six youth reviewed during the summer YDC reviews have lost either a parent or caregiving grandparent or sibling (this does 45 not include cases where one or both parents are “absent”). Two of these youth witnessed the shooting death of their family’s loved one. Of these youth, some lost fathers not to death, but to other unwanted separations. One is lost to TPR with no strategies in place to maintain family connections (in this case, the 17 year-old youth sought him out during a runaway episode within the year prior to the review); one began serving a 60-year prison sentence when the youth was in elementary school; two youth discovered that the men they thought were their fathers are not; and one father suffered a gunshot wound to the head resulting in a significant personality change. In a handful of these cases, the surviving parent reported that this loss impacted the youth’s behavior. While therapeutic services were generally regarded to be of fairly high quality once received, Resource Availability and Use and Plan Implementation outcomes were challenged by the waiting lists for specific services within the YDCs. Waiting lists for Alcohol and Drug treatment could be weeks to months long for certain youth depending on when a slot becomes available in a beginning cohort. At Mountain View, staff attempted to mitigate this wait by adapting A&D worksheets so that youth could work on them while awaiting a spot in the program, but even with these adaptations the team acknowledged that this was not an effective substitution and for the youth in MV-01, contributed to the Appropriateness of Placement rating being unacceptable. Waiting lists impact other services, too. The plans for youth generally reflect a variety of services identified for multiple issues, such as Aggression Replacement Training for behavior, Individual Counseling, and Alcohol and Drug treatment. However, the YDCs are unable to prioritize youth for services under the current system. One youth’s father, his only parent, died a month after he was sent to the YDC (WH-09). Upon his father’s death, he spent four months on a waiting list for grief and loss counseling before receiving it. Family therapy was an exception to the waiting list issue – these cases did not include any youth on waiting lists to receive family therapy, so it is likely this particular therapeutic intervention is generally available. However, an issue that relates to family therapy is that it is often offered at the end of the youth’s stay, as a transitioning strategy prior to going home. For a number of families, this results in missed opportunities along the way, and reinforces the thinking that the “child’s problems” resulted in custody. Cases where family involvement was encouraged throughout the duration of a case provided many more opportunities for the team to achieve family-centered practice outcomes. The YDC placements are the most restrictive placements available for youth adjudicated delinquent; given this, Appropriateness of Placement is a significant indicator for this group. Nearly a quarter of the cases reviewed over the summer noted that the YDC was not an appropriate placement for the youth at the time of the review. Some of these youth were struggling with mental health issues that the YDC program does not appear to be able to manage. These youth were spending so much time on Special Population for behavioral violations they were not able to complete the assigned treatment (NE-01 JJ, NE-10 JJ, WD-01 and MV-06). These youth were benefitting from the security of the placement, especially those with histories of runaway and whose behaviors are life-threatening while on run, but progress toward treatment goals is disappointing. Along with the youth in ET-12 JJ, it appears for this group of youth a different type of residential program would meet their needs more effectively than the YDC. For many of the remaining youth for which the YDC was considered not to be an appropriate placement, the YDC had been an appropriate placement when they arrived, and in fact they had succeeded to the point where a lower level of care would meet their needs. Problems with 46 completion of necessary paperwork for release was an issue in WD-09 and WH-03, and an incorrect release date entered into TFACTS makes it appear that the youth in WD-09 left custody after his eighteenth birthday, when in fact he was released at age seventeen – he was denied entry into an Independent Living program and “on paper” does not appear eligible for Chaffee funds. The group home closure played a role in the placement of at least three youth into the YDCs; two were eighteen at the time of the YDC placement so there were no alternatives for placement in other residential programs and one youth was experiencing behavior problems in a group home around the time they were closing (WH-06, TF-08, and NE-15 JJ). It was also identified for the youth in WH-07 and WH-10. Although serving determinate sentences until age 19, YDC staff indicated they were ready for step down but the limited availability of step-down placements presented a barrier. The youth in WH-07 declined two open step-down placements because they were far away from his family and they would be unable to visit. A challenge not unique to the YDCs, but a factor in most of them, is the distance between the YDCs and the families and FSWs. When staff at the YDC were able to be flexible with visitation hours and in scheduling Child and Family Team Meetings, this tended to support positive outcomes. When FSWs were available to visit frequently, this also supported positive outcomes. The Department has recently worked to clarify transportation rules about FSWs transporting family members in state vehicles for visits, and this may help increase the level of Family Connection and Engagement in the Child and Family Team. Face-to-face visits had not occurred between the youth and their family in over ten of these cases, with transportation and scheduling being the primarily identified barrier. An ongoing project is to support work between the YDCs and the regional field staff to devise ways the two entities can work more cohesively in implementing family-centered practice. Ensuring that teams continue to work toward a Longterm View that the youth, family, and others have identified will likely help support practice across several indicators. Court & Legal System This year, a few themes related to court issues emerged. Some challenges have been present within the system and require some adjustment on the part of DCS staff, for instance in regions where different courts follow different procedures and preferences regarding docket scheduling, processes for filing petitions and documents with the court, and other issues that require staff to become familiar with several court preferences. Other challenges were present in regions where there was turnover among attorneys. DCS attorneys had to “cover” for each other in several instances, and as it does with field staff this means additional time is spent on making sure information and understanding is up-to-date. Another opportunity within the Department is making sure that the way attorneys are supported in their work is consistent with the broader mission of implementing best practice to empower families and support community safety and partnerships. A major role for attorneys in achieving permanency is securing TPR when adoption becomes the goal and parents do not agree to surrender their rights. This may be a very visible role for attorneys, but it is required in a minority of our cases. Even if unintended, a focus on legal staff on ensuring a case for TPR can be made from the beginning of services can dampen engagement and reunification efforts. 47 Internal teaming between program staff and legal can help ensure the Department is handling cases with a coordinated approach. Delays in adjudication were seen in a number of cases, appearing as a trend in Shelby and Upper Cumberland courts, where a great deal of time has been invested by the region to address this issue. These resulted in returns of children to their families prior to the Department feeling confident that a return would be safe and stable, while also contributing to challenges in working toward timely reunification. In addition, some cases take so long to be adjudicated that even if the team has moved away from a reunification goal it becomes very difficult to effectively work toward anything else. The framework in which the Department must work is one in which the timeframes for law enforcement and some courts do not necessarily match up with our best practice timeline. This becomes particularly complicated in cases where an adjudication of Severe Abuse is being sought. A targeted review of cases from the QSR review that involve a severe abuse finding was completed to explore this further (see Appendix C). While 21 custodial cases and one non-custodial case involved severe abuse findings, in only one did it appear that Permanency (through adoption) would be achieved more timely (TV-17). There were few visible differences between these cases and the Brian A. statewide average in terms of Placement, Well-Being, and Conditions and Attributes of Practice indicators. However, Permanency was also more challenged than in cases that did not involve severe abuse. As the Practice Model endorses a team decision-making process, in cases where courts are the primary decision-maker typically the outcomes are not positive. A practice opportunity is to continue to work toward building family-centered teams even when a large part of the case hinges on a court decision. A practice opportunity exists around implementing quality practice and ensuring that team decisions are advocated for in court. It appears certain courts are taking full advantage of their decision-making authority in areas where court staff are not confident in the quality of the practice they see before them, frustrating efforts to implement team-based decisions in some cases. One region that appears to have the confidence of most of their courts is Northwest, where a number of cases saw extended Trial Home Visits and other visitation strategies agreed to by the court at the behest of a Child and Family Team. This region has much success with reunification, especially in cases involving drug use. It appears that the working culture here, including providers and courts, accept the premise that child welfare and family life in general carries inherent risk – so when minimally adequate parenting is achieved, the benefit of the doubt goes toward reunification with whatever level of in-home services or extended THVs are necessary to ensure safety and stability. This region also typically experiences low turnover, meaning that court staff and DCS staff have opportunities to develop a degree of professional trust over a period of time. In the 2011-2012 review cycle, the QSR protocol is adding an indicator to capture information about how the child welfare system and the court system are interfacing and working towards the shared desired outcomes of safety, permanency, and well-being. 48 Appendices 49 Appendix A Review Process From August 2010 – August 2011, the Tennessee Department of Children’s Services (DCS) partnered with the Tennessee Commission on Children and Youth (TCCY) and the Tennessee Center for Child Welfare (TCCW) to conduct the Quality Service Review of cases in the Department’s twelve administrative regions and five Youth Development Centers. Cases were reviewed over the course of two days by two-person teams made up of one lead reviewer and one shadow. DCS, TCCW and TCCY were joined by reviewers and shadows from our own and partner agencies. In the regionally-based reviews, the custodial cases were selected by TCCY based on a sampling matrix assuring that a representative group of cases was reviewed. Custodial cases were stratified based on regional demographics including age, adjudication, race, and gender. Three non-custodial cases were selected randomly by DCS central office. In the YDC-based reviews, cases were also selected by TCCY based on a random sample of the population of youth in each facility. Feedback was provided verbally when review teams met with Family Service Workers (FSWs) and supervisors at the end of each review to discuss individual cases, as well as at Grand Round sessions in which reviewers, field staff and QSR staff discussed the reviewed cases. Following the review, regional staff and reviewers met in a wrap-up session to discuss practice strengths and opportunities for improvement, to identify systemic trends and to initiate planning based on review findings. For each case reviewed4, the review team produced a narrative summary after the review was completed. The narrative summary provides a description of the findings, explaining the reviewer’s perspective about what seems to be working and what needs improvement. The narratives help explain the numerical results of the review by describing the circumstances of each case. The QSR process includes a review of records for the following items: • • • • • • • Psychological or other specialized evaluations; School records and Individual Education Plan(s), if applicable; Service Plan(s) or Individual Program Plan. Court order for custody; Family Functional Assessment; Petition that led to custody; Family Functional Assessment; The majority of information is collected through structured interviews with the following: Child, if age appropriate; Parent(s); Caregiver (resource parent or direct care staff in a facility); Family service work or case manager; Teacher or other school representative; 4 During the review year, twelve cases that were selected for review were unable to be finalized (two were non-custodial cases, three were custodial cases of youth adjudicated delinquent, and seven were members of the Brian A. class). In four of these cases, reviewers were unable to rate the case because key respondents did not participate in the interview process. In the remaining eight cases, the case was reviewed, feedback provided, and preliminary ratings produced, but a case narrative was not produced so the Quality Assurance process could not be completed on the cases. 50 Appendix A Any other relevant service provider (Guardian ad Litem, therapist, etc.); Other significant/relevant person (relative, friend, coach, etc.). Before writing the brief narrative case summary of the case, certified reviewers apply the pertinent information collected through the in-depth interview process to specific criterion measures or indicators regarding the status of child and family and the adequacy of the service system functioning listed below. Status of the Child/Family Service System Functioning 1. Safety 1. Engagement 2. Stability 2. Teamwork and Coordination 3. Appropriate Placement 3. Ongoing Functional Assessment 4. Health/Physical Well-being 4. Long-Term View 5. Emotional/Behavioral Well-being 5. Child and Family Planning Process 6. Learning and Development 6. Plan Implementation 7. Caregiver Functioning 7. Tracking and Adjustment 8. Permanence 8. Resource Availability and Use 9. Family Functioning and Resourcefulness 9. Informal Support and Community Involvement 10. Family Connections 10. Placement Supports 11. Satisfaction 11. Transitioning For Child and Family The overall goal of the review is to provide valid information on what is working/not working in practice and why. The QSR results assist key stakeholders including DCS Family Service Workers and leadership, providers, placements, schools and juvenile courts toward improving or maintaining an acceptable model of best practice that provides the most desirable and appropriate services to children and their families. Based on all the information collected in the QSR process, the results demonstrate the need for the following priority recommendations for enhancements in the child welfare system to improve both system functioning and outcomes for children and their families. 51 pr o C Fa m ily Sa ra l ng tio n ct io ns ni ng tis fa c ne ct io ni ar ni ng ct io Fu n Fu n Le eh av io Co n m ily gi ve r Fa ar e l/ B th cy ea l en t 23% 26% 16% 14% 23% 40% 44% 49% 52% 35% 42% 36% 73% 75% 81% 79% 77% 78% 81% 83% 92% 94% 95% 96% 97% 97% 99% 99% 87% 89% 93% 92% 73% 73% 81% 85% 58% 63% 70% 70% 2009-2010 n=191 H rm an Pl ac em en Pe e ilit y 94% 98% 98% 98% 2008-2009 n=189 na pr ia t St ab fe ty 2007-2008 n=196 Em ot io Ap Sa Appendix B Child and Family Percent Acceptable Brian A. Cases 2010-2011 Brian A. cases n=200 52 an ce & ni ng rts ts 30% 32% 34% 50% 64% 59% 60% 66% 53% 48% 52% 47% 36% 38% 41% 51% 53% 74% 82% 89% 89% 92% 2010-2011 Brian A. cases n=200 sit io up po pp or lity 43% 31% 35% 39% 28% 34% 34% 28% 28% 31% 51% 59% System Performance Percent Acceptable Brian A. Cases Tr an tS n en t ta tio st m Su w ce ss Av ai la bi Ad ju or m al ur In f es o ng em en Pl ac em en R Tr ac ki Im pl Pr o Vi e 30% 34% 40% 39% 45% 59% 2009-2010 n=191 ni ng -T er m g 31% 38% 45% 44% 2008-2009 n=189 Pl an ng t n in tio er st an d in a em en oo rd ga g 2007-2008 n=196 Pl an C En Un d d Lo t& k ss m en am wo r As se Te Appendix B 53 Appendix B 76.7% Acceptable (Score of 4,5,6) Marginally Unacceptable (Score of 3) 8.7% 9.3% 13.2% 13.8% 15.4% 14.7% 16.5% 16.9% 17.6% 2005-2006 2007-2008 2008-2009 2009-2010 2010-2011 16.3% 74.2% 69.9% 68.5% 68.3% Statewide Child and Family Status - Brian A Percent of Scores Within Each Range Poor or Adverse (Score of 1,2) Acceptable (Score of 4,5,6) 14.4% 22.7% 26.0% 30.3% 27.0% 31.2% 32.7% 34.2% 30.5% Marginally Unacceptable (Score of 3) 24.0% 2005-2006 2007-2008 2008-2009 2009-2010 2010-2011 58.6% 46.1% 43.4% 39.8% 39.2% Statewide System Performance - Brian A Percent of Scores Within Each Range Poor or Adverse (Score of 1,2) The charts reflect final statewide data of all the randomly sampled Brian A. class members. Cases reviewed as part of the “best practice” selection are not included. 54 Appendix C Severe Abuse Targeted Analysis As the review year progressed, it was evident in several of the regional reviews that cases involving a Severe Abuse finding against the parents and cases where a Severe Abuse Adjudication was being sought in the courts were often presented with multiple barriers to achieving desired outcomes. Central Office QSR staff conducted a targeted analysis of these cases and discussed key themes with Central Office Legal staff to identify system and practice based opportunities to strengthen practice in these cases. A summary of findings is provided below. 90% 86% Sa t is fa ct io n Le ar ar ni eg ng iv er Fu nc tio Fa ni ng m ily Fu nc tio Fa ni m ng ily C on ne ct io ns C Be ha vi or al ea lth ot io na l/ H Em en cy Pe rm an en t Pl ac em St ab ilit y Ap pr op ria te Sa fe ty 24% 35% 47% 62% 76% 95% Child and Family Percent Acceptable Cases Involving Severe Abuse 90% 100% 2010-2011 custodial cases involving Severe Abuse n=21 100% 2010-2011 all Brian A. cases n=200 A clear practice challenge is Engagement with families for whom the introduction of a severe abuse indication creates an antagonistic and mistrustful relationship with the system. In some cases, it appears that staff took the no contact order/no reasonable efforts finding to mean that we had no further responsibilities to communicate with families, creating barriers to positive outcomes that might have been avoided with more information-sharing about the court process, legal status and basic circumstances of the case (ET-18, KX-20, and SM-12). In other cases, families that had begun to work with a Child and Family Team toward developing a meaningful assessment and plan stopped when severe abuse or criminal charges became a possibility, sometimes on the advice of attorneys. An opportunity exists to strengthen our practice and communication with families in this difficult situation (UC-16, SM-03, SH-14, and UC-05). In two cases, DCS is pursuing a severe abuse finding but there is no indicated perpetrator for the abuse. In both cases, the parents are working the permanency plan and team members working directly with the families feel reunification is possible (MC-13 and SH-14). 55 Appendix C 2010-2011 all Brian A. cases n=200 62% 43% ng sit io Tr an up po tS em en ni rts ts pp or Su Pl ac ur es o or m al ce Av Ad ju R In f st m ai la bi lity en t n & ng Tr ac ki Pl an Im pl em en Pr o ni ng ta tio ce ss w Vi e ng Pl an t& se ss m en Lo Un d er st -T er m an d tio in a oo rd C d an As k in n t em en ga g En am wo r Te g 29% 38% 43% 48% 38% 48% 62% 71% 90% 2010-2011 custodial cases involving Severe Abuse n=21 System Performance Percent Acceptable Cases Involving Severe Abuse One case appears to describe the most textbook application and implementation of a severe abuse finding. In this case, severe abuse was indicated by CPS, no reasonable efforts ruling was made, and TPR hearing scheduled on the same day within 30 days of custody. Importantly, this was a physical abuse case with very clear evidence and a prior incident, not something we have in most cases. This is significantly consistent with the practice model, as the Child and Family Team developed and supported the decision-making in this case (TV-17). In seven of the cases, parents are working the permanency plans and some are successfully achieving reunification. In these instances, the involvement of a severe abuse finding did not contribute to the positive outcomes seen nor create large barriers to implementing team decisions, but was rather an additional process present in the case. The case stories do not address any additional protective factors present based on the Commissioner’s Review process that occurs prior to beginning unsupervised visits or reunifying in these cases, but some information about the team’s perspective on this process was captured. In one non-custodial case, UC-NC2, the team was satisfied with the timeliness of the Commissioner’s Review process but acknowledged that it did take some of the team’s ability to lead decisions away. Generally, field staff perspective about the Commissioner’s Review process is positive in that it goes relatively quickly as long as all the information is presented on the front end. Cases involving severe abuse with reunification occurring include SH-14, UC-18, MC-13, SM-03, KX-20, UC-16, and ET-18. Although the Commissioner’s Review process is not seen as a barrier to timeliness when these cases ultimately move toward reunification, there are some challenges in these cases related to the length of time these cases move through the court system when they are headed toward TPR and adoption. The 56 Appendix C process of adjudication of severe abuse is a court process that is (often) highly adversarial and can result in additional hearings and appeals in addition to the adjudicatory and permanency hearings that occur in every custodial case. In TV-11, the case is expected to be in court for several months. During the review, DCS respondents stated to reviewers that there was information they were intentionally not sharing among team members because they are seeking a severe abuse finding against the mother at court. While the CPS workers and the DCS attorney are confident that this information will result in a severe abuse finding against the mother, the resource parents, contract agency case manager, mother, and GAL all believe the child should be able to return safely to the mother – as do the FSW and TL, aside from knowing that the CPS worker and DCS attorney have this information that they are not sharing. It is anticipated that whichever side prevails in the initial round of court hearings, the other will appeal. In some of these cases, it might have been possible to secure a TPR based on other factors presented in the case without the severe abuse process occurring, as in SC-21, ET-18, SM-08, UC-16, SM-03, SW-07, and SH-14. In two cases involving youth, they desire contact with their parents. Because DCS is no longer working with the parents, opportunities to help these youth develop ways to preserve their sense of safety in these ongoing relationships were not taken up on. In one of these cases, the youth’s well-being status is declining as a result of separation from his family (SC-11 and SM-12). 57 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in Lo g ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m en so ur t ce Av ai la bi In lity fo rm al Su pp Pl ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 62% 62% 72% 71% Davidson 81% 83% 88% System Performance Percent Acceptable Custodial Cases 40% 35% 50% 48% 52% 48% 52% 48% 52% 67% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Em ot io na Pl a Pe rm an ria te St ab 17% 40% 36% 41% 29% 33% 61% 76% 69% 75% 67% 71% 76% 60% 53% 50% 78% 71% 69% 74% 56% 62% 94% 100% 100% 95% 95% 95% 100% 94% 100% 90% 83% Davidson 29% 22% 28% 33% 38% 48% 48% 52% Ap pr op fe ty 2008-2009 Davidson n=18 2009-2010 Davidson n=19 2010-2011 Davidson n=21 2010-2011 All custodial cases n=256 28% 33% 33% 28% 39% 50% 48% 52% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 58 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in Lo g ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m en so ur t ce Av ai la bi In lity fo rm al Su pp Pl ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 68% 68% 91% 100% East 88% 81% System Performance Percent Acceptable Custodial Cases 45% 45% 56% 57% 56% 57% 50% 57% 50% 52% 45% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 38% 59% 59% 53% 50% 57% 50% 47% 47% 39% 38% 50% 72% 81% 100% 95% 100% 90% 86% 78% 100% 100% 100% 100% 95% 91% 78% 81% 84% 71% 100% 100% 95% East 35% 33% 33% 33% 32% 43% 57% 62% 55% 57% 55% fe ty 2008-2009 East n=18 2009-2010 East n=21 2010-2011 East n=22 2010-2011 All custodial cases n=256 28% 27% 22% 28% 33% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 59 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta k in tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 68% 65% 84% 90% 82% Knox 100% System Performance Percent Acceptable Custodial Cases 50% 55% 50% 50% 59% 59% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 10% 10% 29% 28% 27% 56% 44% 50% 41% 56% 55% 70% 75% 73% 75% 75% 73% 100% 100% 100% 100% 100% 100% 95% 90% 85% 80% 75% 68% 90% 100% 100% 100% Knox 32% 37% 30% 35% 59% 55% 50% 40% 35% 45% 30% 30% 35% 40% 40% 59% 55% fe ty 2008-2009 Knox n=19 2009-2010 Knox n=20 2010-2011 Knox n=22 2010-2011 All custodial cases n=256 25% 25% 30% 30% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 60 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 59% 55% 56% 55% 64% 61% 55% 55% 50% 40% 44% 39% 86% 78% System Performance Percent Acceptable Custodial Cases Mid-Cumberland 95% 100% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 10% 29% 28% 32% 47% 41% 81% 100% 95% 70% 78% 86% 81% 100% 100% 100% 94% 86% 85% 75% 78% 86% 71% 56% 63% 59% 56% 72% 64% 55% 100% 95% 90% Mid-Cumberland 32% 35% 39% 30% 30% 56% 59% 61% 59% 78% fe ty 2008-2009 Mid-Cumberland n=20 2009-2010 Mid-Cumberland n=18 2010-2011 Mid-Cumberland n=22 2010-2011 All custodial cases n=256 35% 33% 41% 25% 40% 50% 55% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 61 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 24% 43% 48% 57% 47% 55% 62% 80% 84% 78% 95% System Performance Percent Acceptable Custodial Cases 44% 53% 65% Northeast 57% 52% 52% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Em ot io na Pl a Pe rm an ria te St ab 12% 100% 100% 95% 91% 100% 95% 90% 94% 91% 86% 76% 81% 79% 76% 70% 62% 55% 58% 50% 42% 35% 40% 39% 33% 82% 83% 76% 71% 71% 100% 91% 100% Northeast 43% 41% 52% 48% 41% 38% 35% 61% Ap pr op fe ty 2008-2009 Northeast n=17 2009-2010 Northeast n=21 2010-2011 Northeast n=21 2010-2011 All custodial cases n=256 43% 38% 35% 48% 41% 53% 52% 52% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 62 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 15% 20% 45% 48% 62% 71% 65% 57% 67% 57% 62% 67% 81% 81% System Performance Percent Acceptable Custodial Cases Northwest 100% 94% 89% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 19% 13% 10% 30% 40% 44% 43% 80% 86% 71% 95% 100% 94% 89% 90% 100% 100% 100% 90% 95% 90% 85% 81% 80% 76% 71% 71% 65% 61% 60% 95% 100% 95% Northwest 35% 33% 35% 35% 38% 52% 67% 67% 71% fe ty 2008-2009 Northwest n=20 2009-2010 Northwest n=21 2010-2011 Northwest n=21 2010-2011 All custodial cases n=256 30% 33% 50% 43% 40% 45% 38% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 63 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta k in tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 37% 33% 37% 38% 45% 42% 67% 62% 50% 58% System Performance Percent Acceptable Custodial Cases Shelby 94% 100% 100% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 24% 15% 36% 38% 65% 100% 95% 100% 79% 76% 81% 88% 88% 84% 90% 85% 79% 86% 70% 63% 71% 57% 60% 41% 47% 53% 37% 42% 100% 100% 95% 100% 100% Shelby 21% 26% 26% 30% 26% 29% 30% 26% 38% 25% 26% 32% 24% 48% fe ty 2008-2009 Shelby n=20 2009-2010 Shelby n=19 2010-2011 Shelby n=21 2010-2011 All custodial cases n=256 20% 30% 26% 29% 20% 25% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 64 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta k in tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 81% 87% 90% Smoky Mountain 50% 55% 58% 64% 65% System Performance Percent Acceptable Custodial Cases 27% 33% 41% 42% 45% 50% 45% 41% 35% 32% 29% 26% 21% 36% 45% 41% 50% 55% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op fe ty 9% 6% 31% 26% 27% 46% 40% 43% 43% 59% 65% 65% 58% 64% 100% 94% 93% 90% 91% 94% 100% 95% 89% 86% 76% 79% 78% 79% 77% 76% 100% 100% 100% 2008-2009 Smoky Mountain n=17 2009-2010 Smoky Mountain n=19 2010-2011 Smoky Mountain n=22 2010-2011 All custodial cases n=256 24% 21% 26% 21% 41% 41% 42% Sa Appendix D Child and Family Percent Acceptable Custodial Cases Smoky Mountain 65 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta k in tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 75% 100% 94% South Central 71% 70% 70% 80% System Performance Percent Acceptable Custodial Cases 35% 39% 47% 55% 75% 70% 65% 60% 75% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 15% 26% 38% 70% 68% 64% 62% 58% 95% 100% 100% 95% 89% 95% 85% 100% 100% 94% 90% 88% 95% 80% 74% 74% 68% 75% 62% 53% 45% 55% 95% 100% 100% South Central 42% 45% 42% 40% 42% 40% 37% 42% 65% 65% 80% fe ty 2008-2009 South Central n=20 2009-2010 South Central n=19 2010-2011 South Central n=20 2010-2011 All custodial cases n=256 30% 40% 32% 42% 55% 47% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 66 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta k in tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 35% 60% 70% 74% 75% Southwest 100% 93% 86% System Performance Percent Acceptable Custodial Cases 44% 47% 53% 47% 47% 70% 75% 75% 75% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op 6% 31% 26% 45% 45% 94% 95% 100% 89% 95% 88% 95% 90% 82% 86% 94% 100% 71% 79% 80% 72% 80% 76% 68% 62% 56% 50% 40% 44% 35% 94% 100% 95% Southwest 29% 24% 47% 42% 50% 35% 47% 40% 53% 53% 63% fe ty 2008-2009 Southwest n=17 2009-2010 Southwest n=19 2010-2011 Southwest n=20 2010-2011 All custodial cases n=256 24% 18% 35% 41% 53% Sa Appendix D Child and Family Percent Acceptable Custodial Cases 67 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 37% 97% 90% 100% 86% Tennessee Valley 67% 63% 58% 64% 63% 55% 55% 50% 59% 59% System Performance Percent Acceptable Custodial Cases 37% 31% 34% 37% 34% 50% 55% 68% 73% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op fe ty 18% 18% 34% 41% 60% 52% 55% 60% 50% 97% 82% 74% 86% 95% 86% 87% 84% 80% 75% 100% 97% 100% 89% 82% 95% 77% 71% 66% 66% 61% 97% 89% 100% 2008-2009 Hamilton and Southeast n=38 2009-2010 Hamilton and Southeast n=38 2010-2011 Tennessee Valley n=22 2010-2011 All custodial cases n=256 32% 26% 55% 55% 53% 45% 37% 39% 39% Sa Appendix D Child and Family Percent Acceptable Custodial Cases Tennessee Valley 68 w or k an d En ga g em en t Co or di en na t& tio n Un de rs ta nd in g Lo ng -T er m Vi Pl ew an ni ng Pr oc Pl es an s Im pl em Tr en ac ta kin tio n g & Ad ju st Re m so en ur t ce Av ai la bi In lity fo rm al Su Pl pp ac or em ts en tS up po rts Tr an sit io ni ng As se ss m Te am 11% 11% 27% 21% 78% 86% 87% Upper Cumberland 39% 50% 73% System Performance Percent Acceptable Custodial Cases 39% 59% 56% 58% 50% 50% 45% 41% 39% 33% 26% 33% 36% 33% 41% 39% 50% 50% 44% C ive r Fa m ily H th ne ct io ns ni ng ni ng Sa tis fa ct io n Co n Fu nc t io Fu nc tio Le ar ni ng ra l ea l en cy ce m en t ilit y l/ Be ha vi o Fa m ily ar eg Pl a St ab Pe rm an ria te Em ot io na Ap pr op fe ty 12% 31% 28% 16% 23% 45% 41% 54% 63% 67% 93% 89% 90% 82% 83% 78% 79% 77% 82% 81% 81% 100% 95% 95% 83% 84% 91% 72% 79% 73% 100% 100% 95% 2008-2009 Upper Cumberland n=18 2009-2010 Upper Cumberland n=19 2010-2011 Upper Cumberland n=22 2010-2011 All custodial cases n=256 16% 21% 16% 11% Sa Appendix D Child and Family Percent Acceptable Custodial Cases Upper Cumberland 69 Appendix E Critical Issues in the Statewide Custody Population – CPORT/QSR Evaluation Results Critical issues are defined as conditions children and families have experienced in their environment that contribute to the risk of children entering or remaining in custody. Data below are reflective of the population of children in custody of the Department of Children’s Services. At the beginning of 2010-2011, Tennessee had approximately 7200 children in custody. To evaluate critical issues for a representative sample of children served by the state, the sample size was predetermined in order that the results of the case review process would be statistically significant at the 85% level of confidence with +/- 15 % accuracy for each regional sample. The number of cases reviewed statewide is designed to be statistically significant at the 99% level of confidence with +/- 10 % accuracy for the state sample. These calculations indicate that a sample size of 264 children for the regional distribution of results and 163 for the statewide distribution of results would be sufficient in reflecting the target population. These data results below are reflective of the population of children (approximately 7,200) in the custody of DCS.In the following charts, percentages indicate the cases in which the identified issue was present. 70 Appendix E 71 Appendix E 72 Appendix F Participating Reviewers Tennessee Commission on Children and Youth Marietta Backus Cyndy Banks Sumita Bannerjee Beverly Bell Kimberly Bishop Peggy Carter Steve Chester Susan Cope Anne Marie Dudas Jennifer Hargis Peggy Haynes Martie Hendon Pam Kirkpatrick Frances Lewis Rosamond McLeod Lisa Rodriguez Cheryl Sahlin Deborah Stafford April Swoner Pat Wade Zanira Whitfield Tennessee Center for Child Welfare Jason Ball Liz Beach-Cutshaw Jill Black Sirena Bragg Tonja Brown Jennifer Buhl Twyla Correa Carolyn Crane Joye Duvall Stephanie Ellis Tameika Foreman Sherry Haines Kim Harris Linda Heckathorn Cindy Hensley Kellie Hilker Hope Hopkins Ramona Huggins Doretha Johnson Chris Keller Nancy King Carolyn Kiser Tamika Lott Freda Martin Laura Mathews Brandi McAninch Emily McCutcheon Michelle McGruder Kim Morris Landra Orr Kristi Paling Kerry Patterson Janel Seeley Shannon Starks Ed Stotts Cecilia Teal Jennifer Williams Lictoria Woods Davidson County Juvenile Court Mary Ann Bell Janet Neilson 73 Appendix F Court Appointed Special Advocates (CASA) Suzanne Harrison Vanderbilt Child and Adolescent Needs and Strengths (CANS) Consultants April Anderson Jennifer Conyer Chris Harris Sonya Miller Melissa Tanner Yolanda Woodard Department of Children’s Services Sherry Allen Sikitia Allen Andrea Baker Chris Baker Sharon Battle Loretta Beard Kathy Bell Daphne Billingsley LeeAnn Brabson Antonio Bratcher Tracy Brignac Carrie Brock Bret Brooks Charity Brown Pametria Brown Sally Brown Lia Buckner Sharon Burrus LaNae Cannon Tandra Carter Amy Cassell Laura Clabo Stephanie Coleman Michelle Collins Correnthia Copeland Linda Copeland Tyran Copeland Gwen Covington Regina Cox John Davis Tracy Davis Earla Denney Tammy Dixon Jason Dockery Allison Downs Andrew Duffel Mary Beth Duke Jana Elkins Tiffany Ellis Cynthia Ellison Becky Ervin Cheryl Fergerson James Field Amy Ford-Hulen Carla Forsyth Michelle Foshee John Gaeto Lakeisha Gatewood Candi Glasscock Tracey Golden Tiwanna Gorrell Tessa Gregg Vickie Green Chris Griffy Dave Hall Pam Harr Elane Hart Cha’Dawn Hayes Christina Headrick Rebecca Hendrich Pam Hickman-Winters Connor Hoke Sandra Holder Elaine Hong James Horine Quincy Hughes 74 Appendix F Marie Hurst Raymond Jenkins Amanda Jones Neil Jones Petrina Jones-Jesz Priscilla Juchemich Beth Kasch Pam Keene Kathy King Karen Kirkwood Mia Lester Donna Lorhorn Neil Lowe Suzanne Lowe Tiffany Lusby-Spivey Kay Luttrell Lea Mandle Barbara Maners Wanda Martin Brigette Massey Reba McBride Marsha McClure Shelby McClurkan Carrie McCrary Susan Mee Lisa Merritt Todd Mink Conni Mitchem Frank Mix Julia Mobiglia Chris Moser Connie Murphy Tony Nease Valeria Neumann Beverly Norment Reed O’Bear Amy O’Neill Deb Owens Crystal Parker Jamie Perkins Jemeca Pointer Sherry Porter Dwane Powers Cora Proctor Beverly Quinn Cheri Richards Jennifer Ricker Mary Rivers Kizzy Rogers Morgan Rogers Anne Ross Sevara Sawyers Amanda Schrock Jason Sharif Dava Silva Alisha Singley Rosie Skinner John Smith Terika Sneed Nikki Stamm Jennifer Stamper Calbirtha Stewart Jackie Stewart Delsia Stokes Misty Street Rachel Sullivan Cynthia Suttles Barbara Taylor Clifton Taylor Latricia Taylor Kristy Troutman Carla Tucker Cathleen Vaughn Jason Walker Potocha Walker Carol Waters Roger Webster Rebecca Whiteside Jim Wilkins Wendy Williamson Holly Wilson Cheryl Woodard Christina Wooden Kim Wright Jennifer Yarbrough Dierdre Young 75 76
Similar documents
Study MBBS in Georgia: Study Abroad Consultant
Find the international student placement consultant that delivers the right direction to study MBBS in Georgia at studyabroadconsultant.net. Call us at +1-9713044961 for any query! Get information to study in abroad! Visit Us: http://www.studyabroadconsultant.net/
More information