Indicator 2: Percent of infants and toddlers with IFSPs who primarily receive early intervention services in the home or community-based settings.

Helping Families. Supporting Communities. Empowering Individuals.

Overview of the State Performance Plan Development: See Indicator 1 for a description of this process.

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

Monitoring Priority Early Intervention Services In Natural Environments
Indicator 2 Percent of infants and toddlers with IFSPs who primarily receive early intervention services in the home or community-based settings.
Measurement Percent = [(# of infants and toddlers with IFSPs who primarily receive early intervention services in the home or community-based settings) divided by the (total # of infants and toddlers with IFSPs)] times 100.

Overview of Issue/Description of System or Process:

In 1998, Illinois' Part C program was moved from the State Board of Education to the new Department of Human Services. At that time, the program moved from a system that provided grants to 101 local agencies, which then paid for all client services, and replaced it with a fee-for-service system that allows all willing and qualified providers to deliver services. The grant-funded providers were all operators of developmental centers. They had a natural preference towards the delivery of services in those facilities. Large numbers of the new providers delivered services in the home or community. In a related step, a new service coordination system was put in place that utilized a central entity to serve defined geographies. Finally, with the move to DHS, the tracking of client data was centralized in a single system (Cornerstone) for the first time. Cornerstone affords the program the ability to measure the delivery of services by settings on a regular basis.

Starting in SFY 04/FFY 03, the program began to report how much service was paid for in natural settings by region (CFC) and made it an item that carried incentive funding for CFCs who delivered the highest levels of services in natural settings. Unfortunately, paid service analysis included evaluation and assessment as well as IFSP development. At that time the program could not regularly measure the proportions of services authorized on IFSPs to be delivered in natural settings.

The program increased the emphasis on the natural settings issue, noting the law and the fact Illinois lagged behind the rest of the country in the delivery of services in natural settings. However, little, if any progress was made in SFY 04/FFY 03. So, for SFY 05/FFY 04, the program added a penalty clause to its CFC performance contracts to promote greater compliance with the rules. Then, early in SFY 05/FFY 04, the program found that changes implemented to make the billing systems HIPAA compliant also allowed monthly measurement of services authorized in natural settings. This matched OSEP guidance of how this should be measured. These changes allowed the program to exclude evaluation, assessment and IFSP development, also in conformance with guidance from OSEP. Effective with the September 2004 monthly reports, all reporting and the assessment of incentives and penalties converted to this system. As a follow-up to training on the issue guidance letters on the issue were sent by the EI Bureau to both CFCs and providers on July 1, 2005. These steps appear to have had more impact than the previous systems and guidance.

It is important to understand the history of the program when considering the delivery of services in natural settings. When the EI program was based on grants, all funds were funneled through developmental centers. When the system moved to one based on any willing and qualified providers, there was a rapid movement towards the delivery of service in homes and community settings. This was initially due to an increased emphasis on family choice and the fact they had more home and community options to choose from. Families chose to have services delivered in natural settings, primarily the home. Initially, the program did not put a heavy emphasis on rules regarding natural settings.

By the end of SFY 2003/FFY 02, it became clear that progress on meeting natural settings requirements had slowed. In addition, important segments of the Illinois EI community still had not embraced the concept that services must be delivered in natural settings unless there is a justification that explains why a child's outcomes cannot be achieved in a natural setting. Starting in SFY 04/FFY 03, the program has increasingly emphasized the law and the value of services being delivered in natural settings. This has been done through the use of data, training and, more recently, through monitoring. The issue is discussed at almost every IICEI meeting and CFC and statewide-level performance data is posted quarterly on the EI program internet site.

In SFY 04/FFY 03, the program added a measure of services delivered in natural settings to the list of data items that carried incentive funding for top performers. This did not change behavior in some parts of the State as much as desired. Objective analysis of the differences between regions and comparisons of Illinois' performance to other states made it clear that the law regarding the delivery of services in natural environments was not being consistently and uniformly followed. Therefore, for SFY 05 penalty floors were introduced that set minimum standards for the proportion of IFSPs with services authorized predominately in natural settings. That floor has been rising each quarter to allow areas to improve compliance and find adequate resources to meet demand. By the end of December 2005 the floor will reach 85% of open IFSPs.

Objective comparisons and analysis indicate that even a standard of 85% of children in any given area being served predominately in natural settings does not indicate full compliance with the law in any area. Some states have effectively set much higher standards. Illinois' floor is intended to set a minimum level to assure equity in program administration. If the laws are followed appropriately, there should be no impact on any individual IFSP decision. More complete analysis of conformity with the law related to the delivery of services in natural environments depends on the monitoring of case records. That process started with the establishment of the EI Monitoring Program as the chief monitoring agent for SFY 05.

Baseline Data for FFY 2004 (2004-2005):

Predominate Settings

Dec. 1

1999

Dec. 1

2000

Dec. 1

2001

Dec. 1

2002

Dec. 1

2003

Nov. 30

2004

Jun. 30

2005

Developmental Centers 32.6% 18.6% 13.8% 11.7% 6.9% 3.9% 3.5%
Typically Developing & Other 8.8% 4.6% 3.1% 3.4% 3.8% 4.4% 4.0%
Home 45.6% 64.8% 75.0% 76.5% 78.3% 77.9% 80.8%
Provider Location 13.0% 11.9% 8.2% 8.4% 11.0% 13.8% 11.6%
% Natural Settings 54.4% 69.5% 78.0% 79.9% 82.1% 82.3% 84.8%
Client Count 7,756 10,930 10,021 10,906 13,140 15,486 16,647
Centers & Provider Locations 3,537 3,338 2,200 2,192 2,352 2,717 2,525

Cases Predominately in Natural Settings -By CFC & Geographic Regions

CFC & Number 4-Sep 4-Dec 5-Mar 5-Jun
#1 - LOVES PARK 61.70% 60.80% 61.10% 64.70%
#2 - Lake County 90.80% 91.40% 93.30% 93.20%
#3 - FREEPORT 85.10% 77.60% 76.50% 73.80%
#4 - Kane & Kendall Counties 69.70% 73.40% 73.70% 77.20%
#5 - Du Page County 83.70% 86.60% 87.30% 87.60%
#6 - N. Suburbs 74.30% 76.70% 75.60% 83.30%
#7 - W. Suburbs 77.80% 81.30% 81.60% 85.80%
#8 - SW Chicago 91.90% 91.10% 92.90% 91.20%
#9 - Central Chicago 83.00% 83.20% 84.50% 85.90%
#10 - SE Chicago 89.10% 89.50% 87.50% 88.80%
#11 - N. Chicago 83.10% 84.40% 83.60% 84.50%
#12 - S. Suburbs 79.60% 82.30% 86.00% 87.80%
#13 - MONMOUTH 95.80% 94.80% 92.50% 94.00%
#14 - PEORIA 19.20% 23.50% 25.60% 27.20%
#15 - Joliet 82.40% 84.20% 85.00% 84.30%
#16 - DANVILLE 72.50% 72.10% 74.30% 73.60%
#17 - QUINCY 95.30% 97.20% 98.20% 98.20%
#18 - SPRINGFIELD 91.90% 93.00% 93.20% 93.30%
#19 - DECATUR 92.30% 94.00% 92.50% 93.70%
#20 - EFFINGHAM 97.20% 97.30% 98.30% 98.60%
#21 - BELLEVILLE 93.70% 92.50% 92.80% 94.00%
#22 - CENTRALIA 98.40% 97.50% 97.40% 97.80%
#23 - NORRIS CITY 99.50% 99.50% 100.00% 99.60%
#24 - CARBONDALE 100.00% 100.00% 100.00% 100.00%
#25 - McHenry County 81.80% 81.10% 81.50% 80.00%
Total 81.90% 83.10% 83.60% 84.80%
Cook County 82.10% 83.60% 84.00% 86.30%
Collar Counties 82.00% 83.90% 84.90% 85.30%

Discussion of Baseline Data:

When Early Intervention services moved from block grants to center-based providers to a fee-for-service basis open to all willing and qualified providers, the bulk of services were provided in developmental centers and provider offices. This changed rapidly through 2001, as families quickly took advantage of the chance to have services delivered at home. However, by the end of 2002 progress had stalled. Analysis and monitoring cast doubts about compliance with rules regarding preference for services delivered in natural settings. However, at that point the programs monitoring capacity was limited.

Sharp regional differences lend credence to this assessment. Regions (CFCs) that on the surface look similar diverge sharply in the percentage of children whose services are being delivered predominately in natural settings. The most notable of these is Peoria. On the surface, it seems they would be similar to Springfield, Bloomington/Champaign or Rockford. However, while significant progress has been made in Peoria, they continue to be the only area of the state with less than 60% of services being provided predominately in a natural setting and they are at less than half that rate. The provider community continues to resist the concept that natural settings are to be favored as better for children and families than centers and clinics. With such a preponderance of services still being delivered in non-natural settings, the Peoria area also faces an uphill battle in terms of building capacity to deliver needed services in the home and community.

The only other area of the state with an obvious capacity issue is Rockford. As was noted under the section on service delays (Indicator 1), Rockford is the only part of the state where there is a significant, chronic problem in identifying providers in a timely manner, particularly speech therapists. The two issues are related. It is difficult to identify enough providers in the area and many of those who are providing services will only do so in clinic settings.

Three other areas were below 80% of children being served predominately in natural settings at the end of SFY 05/FFY 04: Freeport, Batavia, and Bloomington. The Freeport CFC (Northwest Illinois) serves a completely rural area. Until recently they served children in natural settings at rates above the state average. They believe their slide through SFY 05/FFY 04 was due to the loss of individual providers who were providing home and community based services and their difficulty in replacing those providers, at least in the short-tem.

The Batavia CFC (Kane and Kendall counties west of Chicago), along with the DuPage County CFC and CFC 6 (North suburban Cook County), all faced provider communities resistant to delivering services in natural settings. However, each has worked very hard to educate their communities on the issue and to build capacity. While the Batavia CFC still has problems, it improved more than any other CFC in the state during SFY 05.

The Bloomington/Champaign/Danville CFC borders the Peoria area. They share some of the providers and some of the institutional resistance to the delivery of services in natural settings. The agency that serves this region took over from another agency for SFY 05/FFY 04. They had to overcome a very difficult transition period, including almost complete staff turnover. Early in the year, this hurt their performance in many areas but they improved sharply on most measures in the second half of SFY 05/FFY 04. They recently were able to turn their attention to the issue of natural settings. They are now working closely with their providers to educate them about the issue and the program requirements.

Until SFY 05/FFY 04, the program was generally able to assess that compliance with the rules regarding the authorization of services in natural settings was weak but it lacked the capacity to systematically demonstrate this. However, for SFY 05/FFY 04, the EI Monitoring Program was established as the program's main monitoring agent. This allows the program to monitor program compliance on such issues as natural settings much more closely.

Measurable and Rigorous Target

FFY Measurable and Rigorous Target

2005

(2005-2006)

At least 86% of all children with IFSPs active on June 30, 2006 will have their services provided predominately in the home or in community settings.

2006

(2006-2007)

At least 87% of all children with IFSPs active on June 30, 2007 will have their services provided predominately in the home or in community settings.

2007

(2007-2008)

At least 88% of all children with IFSPs active on June 30, 2008 will have their services provided predominately in the home or in community settings.

2008

(2008-2009)

At least 89% of all children with IFSPs active on June 30, 2009 will have their services provided predominately in the home or in community settings.

2009

(2009-2010)

At least 89.5% of all children with IFSPs active on June 30, 2010 will have their services provided predominately in the home or in community settings.

2010

(2010-2011)

At least 90% of all children with IFSPs active on June 30, 2011 will have their services provided predominately in the home or in community settings.

2011

(2011-2012)

At least 90% of all children with IFSPs active on June 30, 2012 will have their services provided predominately in the home or in community settings.

2012

(2012-2013)

At least 90% of all children with IFSPs active on June 30, 2013 will have their services provided predominately in the home or in community settings.

Proposed target values for FFY2011 and FFY2012 reflect a maintenance level when compared to the FFY2010 target value of 90%. Based upon recent years' data, it appears that the program may have reached a plateau in the proportion of children served predominately in natural settings. In addition, the proportion children served predominately in natural settings may be negatively impacted by circumstances that impact service delays. (See Indicator 1.)

Improvement Activities/Timelines/Resources:

  • The program will continue to report the proportion of children being served predominately in natural settings by program/region (CFC) on its monthly statistical reports.
  • The program will continue to grant quarterly incentive funding to CFCs quarterly through its performance contracting system for the programs providing the highest levels of services in natural settings.
  • The program shall continue to impose penalties quarterly on any CFC failing to provide a minimum percentage of services predominately in natural settings. The minimum shall be 80% for the end of September 2005 and 85% at the end of December 2005 and it shall be maintained at 85% for the remainder of the plan period. The intent of this floor is to assure a minimum level of program equity and compliance with law and rule.
  • The program shall provide targeted technical assistance to all CFCs failing to provide services predominately in natural settings to at least 85% of children with IFSPs through June 2006 and as needed after that date.
  • A guidance letter on the natural setting requirements was issued to providers (see Attachment 2) on July 1, 2005.* A guidance letter on the natural settings requirements was issued to CFCs (see Attachment 3) on July 1, 2005.
  • Special efforts will be made to recruit providers willing to deliver services in natural settings in the Rockford, Peoria, Freeport, and Bloomington/Champaign/Danville areas during SFY 06/FFY 05 and SFY 07/FFY 06. Other areas will be added as deemed necessary and as requested by local communities.
  • Annual monitoring of CFCs will include a review of cases where services were authorized in other than natural settings to determine if proper documentation of why such services were in the best interest of the child is present. 
  • The program feels that diligent implementation of existing rules and procedures, monitoring efforts, performance contracting incentives and penalties and the other steps outlined previously will result in compliance with rules related to the deliver of services in natural environments. However, we will continuously monitor performance throughout the term of this plan and make additional adjustments as needed and appropriate.
  • Effective with January 2007, the new service delay reporting system will include all instances where a CFC is looking for services to comply with the provisions of an IFSP, including instances where services are being delivered in a setting other than the one authorized in the IFSP because a provider is not available to deliver services in a natural setting. The new reporting system allows services delivered in incorrect settings to be added to other kinds of service delays to provide a fuller picture of service delays. This can be used both locally and by the EI Bureau to aid in provider recruitment.

The improvement activities described in the SPP are ongoing efforts. The following are new improvement activities to be implemented through FFY12/SFY13.

New Improvement Activity Timelines & Resources
As part of the CFC 14 pilot project, develop and implement a training plan targeting strategies to increase the proportion of children served predominately in natural settings. Other strategies for FFY10/SFY11 include the following: hold a provider recruitment fair, distribute recruitment letters to area licensed professionals; and continue discussions with CFC office staff, EI providers and parents. Strategies will be shared with other CFC offices.

The pilot project training and technical assistance plan and other listed strategies will be completed by June 30, 2011. Through June 30, 2013, ongoing strategies will be shared with CFC offices through updates at monthly managers' meeting and through additional pilot projects, when applicable.

Resources include the Bureau of Early Intervention, the EI Training Program, EI System Ombudsman, and the EI Monitoring Program.

Continue to track CFC office performance on services provided predominately in the home or in community settings, but discontinue the practice of issuing findings based strictly upon data. 

Effective with the issue of findings in the first quarter of FFY11/SFY12.

Resources include the Bureaus of Early Intervention and Performance Support Services.