Develop a Prevention Approach to Child Welfare in Texas

The Legislature should develop a prevention approach to child welfare in Texas by implementing two new prevention programs, using the Healthy Start and Homebuilders models.


Background
Most states, including Texas, have responded to the problem of child abuse and neglect by developing a system of child protective services and foster care. This type of system is a no-win system because it only intervenes in cases of suspected abuse or neg lect after the damage is done.

Although the system offers some in-home services, its primary remedy is foster care separation of the child from the family which can also harm children. It does little to help parents control abusive behavior. The costs are high for the children, the parents and the taxpayer. Social workers feel frustrated by the system, often leaving them burned out after only a short time on the job.

In Texas, as in the nation as a whole, the number of child abuse and neglect reports investigated has grown significantly, by 10 percent in only one year (from 82,308 in 1990 to 90,601 in 1991). 1 An additional 430,588 children in Texas are estimated to be at risk of abuse and neglect. 2 In 1990, almost half of all reported Texas child abuse victims were age six and younger, and 4,509 were babies under 12 months old. 3 In 1991, 97 children died from child abuse and neglect. 4

In response to these trends, foster care placements rose 69 percent from 1987 to 1991. The average stay in foster care in Texas is 12.5 months to 15.1 months with 40 percent of children remaining in care for more than two years. 5 Many of these children will experience multiple placements before return to their homes, adoption or placement in permanent foster care.

Child protective services will cost taxpayers an estimated $83.6 million in state funds and $91.5 million in federal and other sources in fiscal 1993. Foster care will cost taxpayers an estimated $101.1 million in state funds and $38.7 million in federal a nd other funds. Another $70.7 million is budgeted for foster care administration. Other protective service-related programs include alternative treatment for youth, truant and runaway servic es and family violence services at a cost of $9.9 million in state funds and $4.3 million in federal funds in fiscal 1993.

Two states have taken important steps to develop cost-effective alternatives that benefit the children, parents, social workers and taxpayers.

These two programs, enacted and thoroughly evaluated in other states, could make prevention a reality in Texas, and at less cost than relying on the current system. Hawaii has enacted a statewide system of risk assessment at birth and voluntar y parenting education for high-risk parents, called Healthy Start. Evaluation indicates exceptional success at preventing child abuse and neglect. Another program, developed in the state of Washington, called Homebuilders , has also been highly effective.

Hawaii s Healthy Start Program
Hawaii s Healthy Start Program starts at birth. Recognized nationally, this program has become the model for prevention programs across the country. 6 Begun in 1985 as a pilot, it was implemented statewide in 1989. While othe r states have been showing increases in instances of child abuse and neglect, Hawaii s incidence declined each year from 1986 through 1990.

The program involves a risk assessment for 60 percent of children born in the state, with plans to increase to 90 percent by 1995. The risk assessment is conducted using medical records or interviews at the hospital if records are unavailable. About 20 per cent of families fit a risk profile and are offered the opportunity to participate in voluntary parenting education and other services. In Hawaii, 85 percent of those offered the services accept them.

Services include community-based home visiting, intervention services, linkage to primary health care services and coordination with and referral to community resources, such as the Women, Infants and Children (WIC) program and child care. Families can ele ct to continue services until the child is five years of age.

San Antonio and hospitals in several Texas cities have begun similar programs; however, these often rely on volunteers, target only teen parents or offer only pieces of the program. The Children s Trust Fund of Texas has funded a Healthy Start pilot in San Angelo for $118,473. 7

Washington s Homebuilders Program
Also in response to the increase in child abuse and foster care, public and private mental health practitioners have developed a new early intervention treatment approach known as family preservation. Most parents involved in abuse and neglect situations do not want their children removed from thei r home and are willing to participate in intensive short-term treatment to maintain their families. Such treatment keeps families together and avoids the trauma of foster care placement. It is also a much more cost-effective response to the problem of chil d abuse.

The Homebuilders model, developed in Tacoma, Washington, is the most extensive and evaluated example of the family preservation approach. Twenty-three states have established Homebuilders programs in both rural and urban settings. The program has extensive documentation demonstrating its effectiveness and cost savings for the 17 years of its existence.

Homebuilders targets families with children at imminent risk of being placed in foster care or in juvenile or psychiatric institutions for a four-to-six-week program of intensive counseling and support. It uses a behavioral-oriented treatment approach in which a socia l worker spends up to 20 hours per week with a family in their home, helping reduce stress on the family by very practical interventions, such as locating needed resources and providing therapeutic counseling on new ways to parent.

In the past, Texas has implemented several programs using the family preservation approach on a small scale. In 1984, the Department of Human Services (DHS) established a Child Protective Service (CPS) unit in Houston using a family preservation model. In 1986, San Antonio started a similar program, and there are five such programs in the Dallas-Fort Worth area. In 1990, the Texas Department of Mental Health and Mental Retardation (TxMHMR) allocated $2 million in general revenue for a family preservation program in conjunction with DHS and the Texas Juvenile Probation Commission (TJPC). Services are provided at five community mental health centers serving chi ld welfare, mental health and juvenile justice clients. This program was expanded to 16 centers in 1992 under the Children s Mental Health Plan.

Given the extent and critical nature of the child abuse problem, Texas should implement these programs on a statewide basis.


Recommendations
A. The Legislature should mandate a statewide phase-in of the Healthy Start program in Texas over a five-year period. The Legislature could substitute the savings indicated in the fiscal impact table for general revenue, thereby achieving real savings, or could use the savings to expand this initiative or for other child protec tive services needs.

The program should include a voluntary initial screening process in hospitals to detect high-risk families, child assessment , family visitation and health, education and other service referrals. The program should be administered by the Texas Department of Health in cooperation with the Department of Protective and Regulatory Services and hospitals.

B. The Legislature should mandate a statewide phase-in of Homebuilders family preservation services in Texas over a five-year period. The Legislature could substitute the savings indicated in the fiscal impact table for general revenue, thereby achieving real savings, or could use the savings to expand this initiative or for other child protective services needs.

Because Homebuilders is the only program that has been so extensively evaluated and so widely used, the enabling legislation should specify Homebuilders as Texas model program.

Target populations should include children being considered for placement in any state system. Homebuilders should be administered by the Department of Protective and Regulatory Services in cooperation with other health and human service agencie s that refer children to foster care.

C. The Legislature should direct the Health and Human Services Commission to establish a task force to oversee the phase-in of Healthy Start and Homebuilders family preservation services in Texas.

The task force should use criteria that include improved family functioning, avoidance of placement, cost-effectiveness of administration and ease of implementation in both rural and urban settings.


Implications
The primary advantage of phasing in Healthy Start and Homebuilders programs statewide would be to preserve the family unit and to provide children a better alternative to foster care. These programs would reduce the costs of caring for abused children and hospitalization costs. They would also reduce the costs of later t reatment or incarceration of abused children. Many abused children end up abusing their own children or committing other crimes.

These programs would reduce some of the social stigma for dysfunctional families and incidents of severe abuse by earl y intervention and would provide services to more families than the current system allows. Since the Healthy Start program would provide screening on a voluntary basis, and would emphasize parenting education, it would provide a positive prevention alterna tive to the negatives of child abuse.

Phasing in the program would allow time for the system to adapt to the change and to train workers. They would reduce the strain on the foster care system, which is having difficulty recruiting enough foster parents.

On the other hand, since these programs are aimed at early intervention, they would probably lead to an increased demand for services. Initial costs of implementing the programs would require additional training of child welfare workers.

Several recent studies have questioned whether some family preservation services prevent out-of-home placement. 8 To alleviate this concern, programs need to target services to families truly at risk. For these families, research on Homebuilders family preservation services indicates success in preventing foster care placement for one out of two families. 9 In addition, a 1990 evaluation of the Iowa family preservation program reported lower foster care intakes in counties with the service than in counties without it. 10

Initial fear by child protective service workers and the general public that a child would be abused as a result of remaining in a home where abuse had occurred would need to be overcome.


Fiscal Impact
Healthy Start could be funded partially from Medicaid through the Early Periodic Screening, Diagnosis and Treatment program (EPSDT), which screens children for medical and related problems. Children eligible for Medicaid can receive EPSDT screens and problems identified through the screen funded with Medicaid . Being at risk of abuse or neglect would be an eligibility factor for Medicaid follow-up. Medicaid is funded at a federal matching rate of approximately 64 percent.

The Health Start program would be partially funded with Medicaid through EPSDT since many of the at risk mothers are Medicaid eligible. The cost savings estimate assumes the program is funded primarily with General Revenue funds with a 64 percent reimbursement for Medicaid-eligible client costs.

Once implemented, Homebuilders or other family preservation models would offer large savings over alternatives such as foster care and hospitalization. It costs approximately $20,532 a year on average to maintain a child in foster care and $219 per day ($79,935 per year) to treat a chi ld in a state hospital in Texas. Homebuilders would cost between $2,000 and $3,000 per family annually.

Various states have used Title IV-B, Title IV-E, Medicaid and other sources for federal funds to finance Homebuilders family preservation programs. 11 However, this methodology assumes full funding from general revenue. Even assuming full funding from general revenue, the Homebuilders program would still net the state estimated cost savings of $6.2 million in fiscal 1994 and $19 million for the biennium.


Table 1 - Healthy Start Program

General Revenue General Revenue Net Savings to the
Fiscal Percent Cost of Cost of General Revenue Change in
Year Screened Foster Care/CPS Healthy Start Fund 001 FTEs

1994 10% $ 3,840,000 $ 3,799,000 $ 41,000 0
1995 30 11,544,000 11,396,000 148,000 0
1996 50 19,248,000 18,994,000 254,000 0
1997 70 26,934,000 26,591,000 342,000 0
1998 90 34,617,000 34,189,000 428,000 0


Table 2 - Homebuilders Program

General Revenue General Revenue Net Savings to the
Fiscal Percent Number Cost of Cost of General Revenue Change in
Year Served Served Foster Care Homebuilders Fund 001 FTEs

1994 10% 1,019 $ 13,852,000 $ 7,613,000 $ 6,239,000 0
1995 30 3,057 39,457,000 26,016,000 13,441,000 0
1996 50 5,095 65,784,000 43,385,000 22,399,000 0
1997 70 7,133 92,088,000 60,711,000 31,377,000 0
1998 80 8,152 105,241,000 69,400,000 35,841,000 0


Table 3 - Summary Table

General Revenue General Revenue Net Savings to the
Fiscal Cost of Cost of General Revenue Change in
Year Foster Care/CPS Prevention Programs Fund 001 FTEs

1994 $ 17,692,000 $ 11,412,000 $ 6,280,000 0
1995 51,001,000 37,412,000 13,589,000 0
1996 85,032,000 62,378,000 22,654,000 0
1997 119,021,000 87,302,000 31,719,000 0
1998 139,858,000 103,589,000 36,269,000 0

Endnotes
1 Texas Department of Human Services, 1991 Annual Report (Austin, Texas: Texas Department of Human Services, 1991), p. 65.
2 Ibid., p. 67.
3 Texas Department of Human Services, 1990 Status Report (Austin, Texas: Texas Department of Human Services, 1990), p. 9.
4 Deborah Daro and Karen McCurdy, Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1991 Annual Fifty State Survey (Chicago, Illinois: National Committee for Prevention of Child Abuse, April 1992), p. 14.
5 Texas Department of Human Services, 1991 Annual Report, p. 68.
6 Family Support for High-Risk Infants: Prevention of Child Abuse (March 1991), p. 25.
7 The Children s Trust Fund, a source of funding for child abuse prevention programs in Texas, has an appropriation of about $1.5 million, which comes from a portion of the marriage license fee.
8 Ying-Ying Yuan, Evaluation of AB1 562 Demonstration Programs (Sacramento, California: Walter McDonald and Associates, May 1990).
9 Center for the Study of Social Policy, A Re-evaluation of Family Preservation Services Evaluations, (Washington, D.C.: Center for the Study of Social Policy, March 1991).
10 Alice Thielman and Karen Linman, Iowa Family Preservation Three Year Pilot Project: Final Evaluation Report (Ames, Iowa: Child Welfare Research and Training Project, Iowa State University, November 1990).
11 National Conference of State Legislatures, Family Preservation Services State Legislative Initiatives (Washington, D.C., June 1991), p. 31.