Indicator 1: Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner.

Illinois Department of Human Services
Division of Community Health & Prevention
Bureau of Early Intervention

Revised on 02/01/07
Second Revision on 02/01/08
Third Revision on 02/02/09
Fourth Revision on 02/01/10

Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner.


(The following items are to be completed for each monitoring priority/indicator.)

Monitoring Priority: Early Intervention Services In Natural Environments

Indicator 1: Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner.
(20 USC 1416(a)(3)(A) and 1442)

Measurement:
Percent = # of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner divided by the total # of infants and toddlers with IFSPs times 100.
Account for untimely receipt of services.

Overview of Issue/Description of System or Process:

The problem of timely service delivery has remained almost constant for the last three fiscal years at about 0.6% of children with IFSPs at any point in time. (Delay is defined as the inability to identify services that can be initiated for a child for more than 30 days, either initially or during an IFSP.) It is somewhat surprising that the delivery of timely services has not been a large and growing problem in this period. Since a short six-month period of caseload decline in the first half of SFY 02, the Illinois EI program experienced dramatic growth in the number of children receiving services through IFSPs. In the 42 months between December 2001 and June 2005, the caseload grew from 9,910 to 16,647. This represents growth of 68% for the period, including 13.2% in SFY 03 and 22.9% in SFY 04. This rapid increase in the number of eligible children means the number of providers needed to cover all authorized services also increased by approximately 68% as well.

Finding enough providers to assure that an appropriate service provider is available for every child for every needed service is challenging in the face of such growth. It is further complicated by other factors, including but not limited to:

  • Rapid growth in the Hispanic caseload, which has increased from approximately 16% to approximately 23% in this period, necessitating the need for more bilingual providers and translators.
  • No provider rate increases in this period, which has made it harder to recruit and retain therapists.
  • Slow but steady progress towards the delivery of services in natural settings, even in the face of resistance in some parts of the state.

The state's relative success in fulfilling such a large increase in the need for services is probably best explained by its use of a market-based service system. Any willing and qualified provider is eligible to provide services, either individually or as part of a group. As a result, while there has been much discussion and concern in Illinois about the decline of traditional center-based providers, organizations and individuals who have been willing to provide services in home and community settings have not only filled the void but also the growing demand. The EI program also has reached out to provider groups and to specific agencies serving growing populations, such as Hispanics, to help generate more providers. Individual Child and Family Connections (CFC) offices have undertaken various activities in their own areas to encourage providers to come into the system.

Service coordination agencies are required to submit the names of every child with any delay in identifying an appropriate service provider each month, including the nature of the delay. The program maintains records any time a provider could not be identified, even for just a day. The baseline data below tracks performance history based on delays that exceed 30 days as a reasonable time period to start services.

Baseline Data for FFY 2004 (2004-2005):

Illinois Early Intervention ProgramHistory of Service Delays - Count of Child MonthsUnable to Identify Provider >30 days
CFC FFY 02
SFY 03
FFY 03
SFY 04
FFY 04
SFY 05
FFY 02
SFY 03
FFY 03
SFY 04
FFY 04
SFY 05
CFC 1 9.6% 9.0% 6.5% 521 598 468
CFC 2 0.3% 0.2% 0.4% 25 17 41
CFC 3 0.8% 0.2% 0.4% 26 9 15
CFC 4 0.3% 0.1% 0.1% 19 9 8
CFC 5 0.1% 0.1% 0.5% 10 7 65
CFC 6 0.5% 0.4% 0.5% 41 46 70
CFC 7 0.1% 0.0% 0.0% 5 - -
CFC 8 0.0% 0.6% 2.2% 3 47 192
CFC 9 0.2% 0.0% 0.1% 12 - 15
CFC 10 0.1% 0.0% 0.1% 6 1 7
CFC 11 0.0% 0.0% 0.0% 1 - -
CFC 12 0.3% 0.1% 0.6% 26 9 74
CFC 13 0.6% 0.1% 0.6% 18 2 20
CFC 14 0.3% 0.0% 0.0% 12 1 -
CFC 15 0.2% 0.1% 0.0% 20 6 1
CFC 16 0.9% 0.8% 2.0% 46 45 122
CFC 17 0.1% 0.1% 0.0% 3 1 -
CFC 18 0.1% 0.1% 0.3% 3 5 13
CFC 19 0.0% 0.0% 0.1% - - 2
CFC 20 0.0% 1.2% 1.6% - 46 72
CFC 21 0.1% 0.0% 0.0% 4 1 1
CFC 22 0.2% 0.1% 0.0% 8 2 -
CFC 23 0.1% 0.0% 0.0% 2 - -
CFC 24 0.1% 0.0% 0.3% 2 - 4
CFC 25 0.9% 0.4% 0.4% 28 20 19
Total 0.6% 0.5% 0.6% 841 872 1,209

NOTES:

  • CFCs 8-11- Chicago (CFC 8 - Southwest Chicago)
  • CFCs 6, 7 & 12 - Suburban Cook County
  • CFCs 2, 4, 5, 25 & 15 - Collar Counties
  • All others downstate, including:
  • CFC 1 - Rockford in Far North Central Illinois
  • CFC 20 - Effingham in South Central Illinois
  • CFC 16 - Bloomington, Champaign & Danville in Central Illinois

Discussion of Baseline Data:

The baseline data displays the number of delays and the percent of total caseload delayed by region (Child and Family Connections Agency) and statewide by state fiscal year (ending June 30). This allows us to look at three full years of performance. However, the magnitude of the problem statewide has remained relatively steady over time at 0.5-0.6%, although the problem has risen and fallen in different areas. In most areas of the state it has been sporadic, small, and resolved within a few months. Ten CFCs have completed at least one of the last three years without a delay in finding an appropriate service provider for more than 30 days after initial IFSP. However, none went from SFY 2003-2005/FFY 2002-2004 without any delays.

For the baseline year, three regions of the state had the greatest difficulty. During SFY 05/FFY 04 CFCs 1(Rockford), 8 (Southwest Chicago) and 16 (Bloomington) accounted for 64.7% of the occurrences of service delays. However, as of the end of SFY 05/FFY 04 caseload at these three CFCs accounted for just 11.2% of IFSPs statewide.

The only area of the state where service delays have been substantial and chronic is Rockford. In fact, until SFY 05/FFY 04, CFC 1 accounted for over 60% of all delays statewide. The problem can further be isolated to a deficit in the availability of speech therapists. This is true statewide but is particularly acute in Rockford. Rockford is also the second lowest area in the state in terms of the delivery of services in natural environments. Provider resistance to the idea of natural settings and their hesitancy to move to deliver services in the home and community instead of clinics and centers has further complicated efforts to recruit enough providers for the area as both the state and local agencies have attempted to increase the delivery of services in natural environments, in accordance with law and policy.

Special efforts to reach out in the Rockford area, particularly to the speech therapy community, have been having positive affects. In SFY 04, delays were encountered for an average of 9.0% of children with IFSPs and they accounted for 68.6% of all delays. However, delays in Rockford fell noticeably in SFY 05. While the area still represents the largest problem in the deliver of services in a timely manner in SFY 05, the average level of delays fell to 6.5% and they constituted 38.7% of all delays. They also have been increasing the proportion of services delivered in natural settings. Unfortunately, the proportion of children experiencing delays in the Rockford area spiked again in recent months, so the improvement may prove to have been temporary. Additional targeted efforts in Rockford will be required.

The Bloomington/Champaign/Danville region (CFC 16) also has experienced long-term problems with service delays. This is partially due to the fact this is the only largely urban region of the state where the CFC does not serve an area with a single clear population or economic center. This means they must maintain relationships with a number of different communities where other CFCs can generally build from a single, interrelated network. It took most of SFY 05 for the new agency that had been selected to serve this area to overcome problems and improve performance. In recent months they have had among the lowest levels of delays seen in their area in a number of years.

The only CFC to experience a level of delay in excess of 1.0% for a year between SFY 03/FFY 02 and SFY 05/FFY 04 in the Greater Chicago area is CFC 8, which serves the southwest area of Chicago. This area is economically disadvantaged. Only 26.1% of families have health insurance, compared to 44.0% statewide. However, both CFC 9, to their north, and CFC 10, to their east, have caseloads with even lower levels of access to insurance and higher levels of Medicaid eligibility. There is no obvious reason for CFC 8 to be having greater problems than their Chicago neighbors. However, neighboring south suburban CFC 12 has also experienced a noticeable increase in delays, just not to the extent of CFC 8. It may be that the system is having a difficult time filling the need in south Cook County. Both areas have experienced particularly rapid caseload growth. If that is the case, availability should be able to grow to meet the demand as caseload growth is now slowing.

The only other area of the state that has experienced delays for a year in excess of 1% of service is CFC 20, which is housed in Effingham in south central Illinois. They serve a particularly large area geographically that is completely rural. Its 11 counties stretch from the Indiana border to the outer eastern suburbs of St. Louis. Within that area they have only two communities with populations over 10,000 and none reaches 13,000. The larger medical facilities for the area are outside of their service area in such cities as St. Louis and Springfield. Some area residents even travel to Indiana. Maintaining capacity to provide all the services children need in all of their rural and relatively isolated counties presents a challenge. We do not know what child will appear at any point in time, with what needs or where they will be located. The rural areas of Illinois overall have not had greater problems with providing timely services. However, when there are problems, they present greater challenges than in urban areas because the options available are more limited. A special set of approaches will be required to address delays experienced in rural areas.

In addition to problems that can be measured on a regional level, there is a clear seasonality in when the system experiences delays. They begin to grow in April at the same time the program experiences most of its caseload growth. They begin to diminish soon after the end of the school year as caseload growth slows. Strategies for recruiting new therapists should take into account the anticipated need for more services in the spring.

The following discussion was added as part of the submission of the 2005 Annual Performance Report:

During initial development of the State Performance Plan, a dialog started regarding the recording of service delays. Reporting showed low rates of service delay and there were no solid evidence of underreporting, although discussions with CFCs uncovered misunderstandings and uneven practices. The program explained that it was important to report all kinds of delays. These discussions probably have more to do with the increased reporting of service delays than changes in the field. Overall, the reported volume of delays represents slippage but it is just as likely that this represents improved reporting as a decline in system performance.

While engaging in the discussion with CFCs on the importance of openly and fully reporting service delays in a uniform manner, the program also decided its service delay reporting system did not provide everything needed to full measure service delay and needed to be upgraded. A new reporting system will replace the old one by the end of February 2007. It is currently being pilot tested. The new system will allow new functionality not previously available:

  • The old system was on paper and only included child names. The new system will include county and zip code and other case identifiers to assist in researching the nature of the problem. Since it will be an electronic system the program will be able to sort delays in various ways to help pinpoint problems and aid in recruitment.
  • The new system will ask service coordinators to estimate the monthly shortfall of service in hours. The only old system only indicated a problem. It indicated nothing about the actual amount of the shortage. One hour and 12 hours were treated the same.
  • The new system will include situations where some service is available but not as much as desired. This is not a violation of the federal requirements but it does represent a problem in completely meeting the needs of children. The program wants to include these situations to get the full measure of the problem.
  • The new system will include reporting where service is being provided in a non-natural setting only because no provider is available to deliver service in the home or community. Again, since service is being provided it does not technically represent a service delay but it does indicate the system is not able fully meet the needs of each child in accordance with state and federal rules. This will be added to the total shortfall for each area.
  • Although the current system includes the service that is delayed, it did not accommodate sorting. The new system will allow us to identify the full amount (children and hours of service) the program is short of statewide and on other geographic levels.
  • The new system will make it easier for the program to sort delay reasons, particularly family delays.

In summary, the program has decided it will defined service delay much more widely than required by federal rules, although it will still be able to report based on federal requirements. In addition to the new reporting, the program has reinforced the importance of reporting various kinds of service delay by pledging that it will not be used as an element that carries incentive funding in the performance contracting system. This also is the only 100% compliance measure we are not including in our calculation of program determinations. Our research has shown that service delay is more subject to interpretation than one might expect. It is important that the program not take action that might discourage service delay reporting.

FFY Measurable and Rigorous Target
2005
(2005-2006)
100% of infants and toddlers with IFSPs will receive the early intervention services on their IFSPs within 30 days.
2006
(2006-2007)
100% of infants and toddlers with IFSPs will receive the early intervention services on their IFSPs within 30 days.
2007
(2007-2008)
100% of infants and toddlers with IFSPs will receive the early intervention services on their IFSPs within 30 days.
2008
(2008-2009)
100% of infants and toddlers with IFSPs will receive the early intervention services on their IFSPs within 30 days.
2009
(2009-2010)
100% of infants and toddlers with IFSPs will receive the early intervention services on their IFSPs within 30 days.
2010
(2010-2011)
100% of infants and toddlers with IFSPs will receive the early intervention services on their IFSPs within 30 days.

Improvement Activities/Timelines/Resources:

  • Effective FFY06/SFY07 CFCs will be required to submit a corrective action plan whenever service delays exceed 2.0% of children with IFSPs during April of the previous fiscal year. [This step reflects a modification more in line with the determination process. It has been implemented.]
  • With FFY 06/SFY 07, CFCs with more than 5% of open cases in April experiencing service delays will be found in non-compliance. Agencies with more than 5% delays excluding family delays will be found in federal non-compliance. Agencies with more than 5% will be deemed in state non-compliance. [This is to be inline with the determination letter process and has been implemented.]
  • The corrective action plans of agencies found in either federal or state non-compliance will be forwarded to the Bureau of Early Intervention for incorporation into the state corrective action plan.
  • An Illinois Interagency Council on Early Intervention (IICEI) workgroup will be formed to address the following problems: 1) the systemic problem in Rockford, 2) how to respond to demand in rural areas, 3) the expectations on both CFCs and the EI Bureau for addressing service delays, and 4) the potential use of incentives and penalties to improve compliance (example: 1% incentive payment for each quarter a CFC goes without needing more than 30 days to find a service authorized within an IFSP). An initial report will be issued by April 30, 2008 with action steps to be implemented during SFY 07/FFY 06. [This reflects minor adjustments in line with the determination letter process.]
  • Through regular meetings provider groups will be asked to assist in closing existing gaps in availability and in helping to quickly address new problems when they arise. These meetings will include the sharing of data on areas where the program is having difficulty meeting the demand and trends in the caseload and use of services. Meetings will start by July 2007.
  • The IICEI workgroup will recommend additional steps to eliminate service delays not covered previously, as deemed necessary after the April 30, 2008 report noted previously.
  • Starting no later than July 2007, a new item will be added to the programs monthly statistical reporting to highlight service delays by CFC.
  • Starting no later than January 31, 2008, delays will be added to the statistics provided to the IICEI as part of each of their meetings.
  • Starting no later than July 2007, delays by CFC will be added as part of the statistical report posted quarterly to the DHS website. The monthly CFC reports on delays will be adjusted to better reflect the requirements of the State Performance Plan. This will include more emphasis on service delays, compared to other kinds of delays that can be tracked in other ways. Reporting also will follow delays for up to 12-months as necessary, compared to the current six-months. (This would be in accordance with OSEP expectations, although few delays ever go beyond six-months.)
  • The traditional service delay reporting system will be replaced with one that will provide much more actionable details for both CFCs and the EI Bureau, effective January 2007.
  • Before the end of FFY 07/SFY 08 the program will implement an option for providers to have insurance billing done by the program as a means of lessening the burden on small providers and encouraging more providers to work within the program.
  • The program hopes that the steps outlined will result in the elimination of service delays. However, we will continue to utilize our monthly reporting system, monitoring, and meetings with provider groups to find additional ways to assure service availability through the period of the plan.
  • Effective with the notification of findings letters issued to CFC offices during FFY07/SFY08 from the central data system, any finding of non-compliance will require a corrective action plan.
  • The Northwest Illinois Service Delay subgroup will recommend a package of steps to address service delay issues by March 31, 2009.
  • The IICEI Service Delay Workgroup will work with the Bureau of Early Intervention and the EI Training Program to develop a plan to train on selected strategies be piloted in Northwest Illinois statewide no later than July 1, 2009.
  • The program will expand responsibilities of the EI Monitoring Program to include a System Ombudsman function and focus activities of Pediatric Consultative Service contracts to utilize statistical reports to assess conformity with program standards and principles and minimize inefficient use of scarce resources that lead to service delays no later than March 1, 2009.
  • The program hopes that the steps outlined will result in the elimination of service delays. However, we will continue to utilize our monthly reporting system, monitoring, and meetings with provider groups to find additional ways to assure service availability through the period of the plan.
  • In FFY09/SFY10, expand Program Integrity Pilot to include three additional targeted CFC areas.
  • Effective February 15, 2010, a system ombudsman position will be added to the Early Intervention Training Program to support the Program Integrity Project.
  • In FFY09/SFY10, the program will work with the IICEI and its Service Delay Work Group to finalize recommendations regarding an Integrated Team Approach and pilot this strategy in a target area.