Care coordination as a preventive intervention: effects on child welfare outcomes

Background: There is a paucity of information about the physical health needs of children receiving in-home child welfare services, how these needs may affect maltreatment risk, and whether interventions addressing medical needs may reduce abuse, neglect, and removal to substitute care. This dissertation examines care coordination, an intervention addressing the health needs of children receiving in-home child welfare services in ten New Jersey counties. Research Aims: The research aims correspond to the three manuscripts that comprise this dissertation. Research Aim 1 (Manuscript 1) was to explore who was assigned to care coordination to better understand what, if any, risk factors accompany children’s health-related needs in families receiving in-home child welfare services and which of these risk factors made caseworkers more likely to refer children to the program. Research Aim 2 (Manuscript 2) was to catalog the need for services addressing the health needs of children receiving in-home child welfare services as perceived and articulated by child welfare staff. Research Aim 3 (Manuscript 3) was to identify the effect of care coordination services on three core child welfare outcomes: case durations, removals to foster care, and new case openings after initial case closures. Design and Analyses: For Research Aims 1 and 3, nurses’ records and administrative child welfare data were used. Descriptive statistics, t-tests, chi-square tests, and logistic regressions were run to understand differences between children who received care coordination and those that did not (Research Aim 1). In pursuit of Research Aim 2, qualitative data was collected from 30 child welfare staff, including nurses who delivered care coordination and caseworkers and supervisors who referred clients to the service. An inductive, phenomenological approach was taken to capture and describe participants’ experiences and how they understand them. For Research Aim 3, children who received care coordination in the ten intervention counties were compared with a propensity score matched sample of children in the state’s remaining 11 counties to determine the program’s effect on case durations, removals to substitute care, and new case openings following initial case closures. Results: Analyses for Research Aim 1 revealed that domestic violence exposure was associated with significantly lower odds of assignment to care coordination (OR = 0.74, p < .001), while having a caregiver with mental health problems increased children’s odds of assignment (OR = 1.50, p < .001). Increases in both indexed individual (OR = 1.75, p < .001) and household (OR = 1.08, p < .001) risk were significantly associated with receipt of services. All participants interviewed for Research Aim 2 described an acute need for services addressing the physical health needs of children receiving in-home child welfare services, whose families face multiple, overlapping challenges. Interviewees indicated that such services could improve children’s health outcomes, correct an imbalance in child welfare services that prioritizes children in out-of-home care, and support frontline staff in their daily work. Analyses for Research Aim 3 revealed that recipients of care coordination were significantly less likely to have their cases close within a year of case opening (mean difference = .1507, p < .001). No significant effects of care coordination on removals or new case opening after initial case closure were discerned. Conclusions: Findings from this dissertation indicate that services embedded in the child welfare system that target children’s health needs in the context of cumulative family challenges may have the potential to mitigate risk for future maltreatment or removal to foster care. Such services may also be a critical support for child welfare staff, who are not trained in identifying or addressing children’s specific medical needs. As an intervention targeting the health needs of children receiving in-home child welfare services, however, care coordination had a limited impact on the short-term child welfare outcomes examined in this dissertation. More evidence is needed to determine if care coordination or a program like it can prevent maltreatment or negative child welfare outcomes or improve other markers of child health and well-being.Ph.D.Includes bibliographical reference