Variation and the IV-E Waiver: Know before you plan
As we’ve discussed in the last few posts, variation in outcomes is one indication that there is room for improvement somewhere in our system. When we know why an outcome varies, we can use that knowledge to deploy targeted interventions where they have the most potential to create the change we want to see.
No scenario highlights the importance of targeted interventions more than the Title IV-E waiver. The waiver is an opportunity for child welfare agencies to use flexible funds to improve outcomes for children and families. Because those funds are capped, operating under a waiver makes investing wisely—i.e., targeting CQI efforts—more important than ever.
For this reason, an understanding of how outcomes of interest vary throughout your system is an essential first step in crafting a IV-E waiver proposal. Often, a jurisdiction will decide on the programs it wants to institute with its waiver funds before generating knowledge about which outcomes need to be improved and for whom. As a result, agencies can wind up applying programs to subpopulations that are unlikely to benefit from them, and in the process, allocate precious waiver funds to initiatives that promise a less than optimal return on investment. Observing and interpreting variation before you propose a waiver program puts your agency in better stead to select programs and design implementation plans that maximize impact.
Pushing forward the group care example that we’ve worked with throughout this series, imagine our fictitious state is considering using part of its IV-E waiver to reduce its reliance on congregate care placements for children in foster care. We might start by looking at our own statewide performance and seeing how it stacks up against a handful of other states that are similar to ours:
Among these states, first placement in group care ranges from 52% in State A, to 7% in State M, with a “national” average of 25%. (Note: These data are also fictitious; the “states” represented above are not intended to reflect actual nationwide performance.) This look at state-to-state variation indicates that our state uses group care as a first placement type more often than almost every other state. The finding adds support to our hypothesis that congregate care in our state can probably be reduced.
The next step might be to look at county-to-county variation within our state. Do all counties in our state use group care as a first placement type for 50% of children entering care? Our analysis from the previous posts answers that question; first placement in group care ranges from 77% of children in Mott County to 0% in Spring, Varick, and Water Counties:
At this point in my analysis I might stop to take stock of what I know. I know that my statewide rate of first placement in group care is 50% compared to 25% in a set of comparable states. I also know that five counties in my state place children directly in group care at a rate higher than 50%, and that an additional seven counties do so at a rate higher than 25%. If I have limited waiver resources to dedicate to my group care reduction efforts, it might make sense to focus them on these 12 counties; the other 14 counties, comparatively speaking, appear to already be performing at a rate better than average.
The above is a very basic exploration of how an appreciation for variation can help you start thinking about which subpopulations within your child welfare system might make good candidates for waiver-supported initiatives. Certainly, an investigation into group care use would require a more nuanced look at which children are making use of which kinds of group care and when. And of course, selecting the best intervention will require determining the reasons why the observed variation exists.
What we can see from this simple example is how observing and interpreting variation can help a state hone in on which populations have the potential to benefit from flexibly-funded efforts. Doing this work early on in the waiver proposal process puts states in a better position to build defensible proposals for the use of waiver funds.