Indicator #1 - Early Intervention Services - Received in A Timely Manner

Early Intervention Services - Received in A Timely Manner

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Part C State Annual Performance Report (APR) for FFY 07/SFY 08

Overview of the Annual Performance Report Development:

The Illinois APR documents performance data on State targets for each Child and Family Connections (CFC) office and documents CFC and state progress or slippage toward measurable and rigorous targets. The Illinois Early Intervention (EI) Program makes the Illinois APR and State Performance Plan (SPP) available on its web site and through links from the other EI web sites (the Illinois Early Intervention Training Program; Provider Connections, the Early Intervention credentialing office; and the Early Childhood Intervention Clearinghouse). The APR and SPP documents are also available to the public at each of the 25 CFC offices.

The APR is part an ongoing process of performance measurement and strategic planning for the Illinois Early Intervention Program. For a number of years, Illinois has been reporting performance data to key stakeholders including the Illinois Interagency Council on Early Intervention (IICEI), the Child and Family Connections (CFC) offices, and the general public through various reporting mechanisms. Work groups of the IICEI have been formed to address specific indicators (Service Delay Work Group and Transition Work Group) and overall operation issues (Finance Work Group). These work groups have helped analyze data and suggest improvement strategies.

During FFY 06/SFY 07, the program carefully reviewed secondary factors that seemed to point to higher levels of service delay than were being reported. This was followed by an extensive discussion with CFC Managers about the issue. It was pointed out that while service delays are bad, if they are underreported neither the CFCs nor the Bureau of Early Intervention have documentation of the problem and that makes it difficult to recruit providers to fill the gaps. Attention focused on the existing service delay reporting system that had been used for many years. It was a paper system with submissions by CFCs to the Bureau of Early Intervention once a month. These data were entered into a database that maintained the history of delays for the full year. The monthly totals were accumulated and compared to the number of IFSPs for the same periods.

Discussions led to the decision to upgrade the delay reporting system effective January 2007, although it took until April 2007 to work out the problems. These discussions and the new system have led to more accurate and uniform reporting and it has improved the program's ability to identify and respond to service delays. The new system allows the program to sort off family delays and treat them differently. Although for state oversight purposes CFCs are expected to do everything they can to limit family delays. The new system also allows the program to include shortages of service and instances where service is being delivered in non-natural settings because no provider is available to provide service in a natural setting. This allows the program to compile a total shortfall calculation that can be translated into FTEs from the Zip code level all the way up to statewide summary reports.

The month of April is used for making local determinations and for this report. The program decided that it would not use service delay reporting in performance contracting, although it is a non-incentive funded measure on monthly reports. Service delay will be considered in setting determination scorecards if an agency fails to submit a credible corrective action plan or fails to make good faith efforts to complete corrective action steps. Experience shows that service delay is highly seasonal. It is low in the first seven or eight months of the state fiscal year then grows in sync with the annual spring jump in the caseload. April is near the annual peak in delays.

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 U.S.C. 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.

FFY:

2007 (7/1/07-6/30/08)

Measurable and Rigorous Target: 100 percent of infants and toddlers with IFSPs will receive the early intervention services on their IFSP within 30 days.

Actual Target Data for FFY07/SFY08: On June 30, 2008, 95.31% of infants and toddlers with IFSPs received the early intervention services on their IFSP within 30 days.((18,246-855)/18,246)*100=95.31%

Actual Target Data for FFY 07/SFY 08:	FFY06/ SFY07 Actual	FFY06/ SFY07 Goal	FFY07/ SFY08 Actual	FFY07/ SFY08 Goal
Children With No Delays	96.52%	100%	95.31%	100%

The table below shows performance for the state and for each of the state's 25 service coordination agencies in April 2008, followed by statewide performance for April 2007. It calculates performance both including and excluding delays for family reasons. Statewide, 95.31% of children with IFSPs were experiencing no delays at the end April 2008, excluding family delays. Five agencies had no delays. Eleven CFCs had at least 95% of their cases with no delays. However, nine CFCs had less than 95% of their open cases with no delays. All nine serve areas north of Interstate 80, which runs just south of Chicago.

The situation in April 2008 reflects an increase in service delay problems. In April 2007, 96.52% of cases had no service delays and just five CFC areas were below 95%. The causes of delay problems will be discussed in more detail later. However, there are two main causes. First, continued strong caseload growth combines with an already competitive environment for the limited number of available providers, particularly speech therapists. This problem is far greater in the greater Chicago area, where multiple job opportunities are close at hand, compared to downstate where opportunities are more dispersed.

Competition for resources has been a chronic problem for many years and is almost unavoidable. However, a greater problem during FFY06/SFY07 was due to weak state finances. Although providers did receive a 3% rate increase on January 1, 2008, that was not enough to reverse the corrosive impact of rates that had been flat for ten years. This was made worse when EI provider payments were delayed briefly for the first time. That has caused a few providers to leave the system or cut-back on the amount of service they deliver. It has increased the reluctance of new providers to enter the system.

The financial problems of the state have worsened existing problems in northwest Illinois and in the rapidly growing suburbs of Chicago. It also has started to create problems in other areas that previously have been able to identify enough service when it was needed.

Almost all service delays for system reasons are due to problems identifying a qualified and willing provider within 30 days of an initial IFSP or within 30 days of a disruption in services during an IFSP. The lowest rate of problems is downstate, where growth is slower and where the EI provider community is more stable, with fewer alternative employment opportunities. Most downstate areas report few problems. The area around Rockford (CFC 1 & CFC 3) has the most chronic problems. They accounted for 72.8% of the downstate service delays. Within Chicago, there also is competition for qualified providers and that is complicated by economic factors. Three of the four Chicago CFCs experienced increased problems in FFY07/SFY08 but the wealthiest area of Chicago, CFC 11, at 96.4% compliance was right at the state average. A rapidly emerging problem in the suburbs is of great concern and is going to be difficult to address with current financial constraints on the state.

While delays for this report are reported in with family delays removed from the calculations, the program generally treats all delays as problems that need to be looked into and addressed. Many family delays are for obvious and unavoidable issues, such as child or parent health issues. Others are due to problems it is difficult for the CFC to address.

The following nine agencies had system delays of more than 5%:

#2 - Lake County/North of Cook County,
#25 - McHenry County/Northwest of Cook County &
#6 - Northern Cook County Suburbs
- Strong population growth has increased competition for scarce resources, part of the Elgin problem area.

#3 - Freeport/Northwest Illinois
- This area has had significant problems identifying enough providers to deliver services in natural settings and in identifying enough providers in general. Problems have been greatest in particular rural areas where the availability or lack of availability of one provider makes a big difference.

#4 - Kane & Kendall Counties/Outer Western Chicago Suburbs
- This is a rapidly growing area with great competition for qualified professionals. The program has identified an area around the suburb of Elgin as the focal point for a new and growing service delay problem encompassing several other CFCs as well.

#10 - Southeast Chicago,
#9 - Central Chicago &
#8 - Southwest Chicago
- These CFC areas comprise one of the poorest areas in the state. In SFY2008, an average of 83.7% of kids served by CFC 10 were on Medicaid and only 4.6% had enough income for the families to owe fees, 185% of poverty. The averages for CFC 8 were 71.2% with Medicaid and 15.6% with fees. For CFC 9, 83.3% of kids had Medicaid and fees were required in just 5.4% of cases. This compares to a statewide average of 58.3% of cases with Medicaid in SFY 08 and 30.3% required to pay fees. Fewer qualified professionals live in the area and it is difficult to recruit providers from outside to work in the area when there are many work opportunities in the Chicago area.

#15 - Joliet/Southwest Chicago Suburbs
- This is a rapidly growing area with great competition for qualified professionals. Their problems are further complicated because it includes large rural areas that present the problems of low client density, and thus longer travel distances, yet within reach of Joliet and other suburban centers that offer an array of job opportunities.

	IFSPs	Family Delays	Net IFSPs	System Delays	No Delays	No Delays	No System Delays
April 2008
#1 ROCKFORD	614	14	600	29	571	93.0%	95.2%
#2 LAKE COUNTY	834	13	821	49	772	92.6%	94.0%
#3 FREEPORT	337	1	336	70	266	78.9%	79.2%
#4 KANE-KENDALL	852	27	825	96	729	85.6%	88.4%
#5 DUPAGE COUNTY	1,241	10	1,231	25	1,206	97.2%	98.0%
#6 N. SUBURBS	1,540	6	1,534	82	1,452	94.3%	94.7%
#7 W. SUBURBS	1,012	6	1,006	36	970	95.8%	96.4%
#8 SW CHICAGO	809	18	791	58	733	90.6%	92.7%
#9 CENTRAL CHICAGO	1,050	3	1,047	89	958	91.2%	91.5%
#10 SE CHICAGO	805	5	800	45	755	93.8%	94.4%
#11 N. CHICAGO	2,023	48	1,975	90	1,885	93.2%	95.4%
#12 S. SUBURBS	1,158	21	1,137	23	1,114	96.2%	98.0%
#13 MACOMB	359	-	359	-	359	100.0%	100.0%
#14 PEORIA	532	1	531	15	516	97.0%	97.2%
#15 JOLIET	1,373	4	1,369	74	1,295	94.3%	94.6%
#16 BLOOMINGTON	654	-	654	14	640	97.9%	97.9%
#17 QUINCY	229	-	229	1	228	99.6%	99.6%
#18 SPRINGFIELD	364	-	364	1	363	99.7%	99.7%
#19 DECATUR	341	-	341	-	341	100.0%	100.0%
#20 EFFINGHAM	430	-	430	4	426	99.1%	99.1%
#21 BELLEVILLE	636	-	636	-	636	100.0%	100.0%
#22 CENTRALIA	372	-	372	-	372	100.0%	100.0%
#23 NORRIS CITY	244	-	244	2	242	99.2%	99.2%
#24 CARBONDALE	142	-	142	-	142	100.0%	100.0%
#25 MCHENRY CO.	481	9	472	52	420	87.3%	89.0%
State	18,432	186	18,246	855	17,391	94.35%	95.31%
Cook County	8,397	107	8,290	423	7,867	93.69%	94.90%
Collar Counties	4,781	63	4,718	296	4,422	92.49%	93.73%
Downstate	5,254	16	5,238	136	5,102	97.11%	97.40%
April 2007
State	17,588	182	17,406	606	16,800	95.52%	96.52%
Cook County	7,968	116	7,852	346	7,506	94.20%	95.59%
Collar Counties	4,559	48	4,511	172	4,339	95.17%	96.19%
Downstate	5,061	18	5,043	88	4,955	97.91%	98.26%

Discussion of Improvement Activities Completed and Explanation of Progress or Slippage that occurred for FFY 07/SFY 08:

During FFY07/SFY08 the program poured an unprecedented amount of time and resources into the effort to reduce service delay but problems resulted in slippage. Particular activities undertaken included the following:

1. More attention was placed on circulating and understanding the monthly service delay reports,
2. The IICEI established a Service Delay Workgroup, whose charge also includes fostering the delivery of service in natural settings,
3. A Service Delay sub-group was established for the Rockford-Freeport area to develop a package of recommendations to reduce service delay in that area, with the expectation that piloted strategies might be recommended for use in other areas of the state, and
4. Notification of findings letters to the CFC offices now require corrective action plans even if there is only one identified delay and even if that delay is for family reasons.

Unfortunately, the underlying root causes of service delays in Illinois worsened, as outlined below, particularly due to the problem of low rates and weakening state finances.

Problem #1: Caseload growth continues to present a challenge in identifying enough providers to fill the need for services. The number of active IFSPs was almost 5% higher at the end of April 2008 than it was a year earlier. This situation is made worse by the seasonal nature of caseload growth. The caseload is generally flat between July and January and then grows rapidly through May or June. It takes awhile to catch-up with that growth. Illinois' system of any "able and willing" providers is more responsive than systems that centralize service delivery but it is still difficult for supply to meet demand when demand increases, particularly when it increases quickly.

This does not fully explain problems in areas with systemic problems that need to be addressed, such as Northwest Illinois and south and central portions of Chicago, but it does explain why delay rates are higher in April-June than in the rest of the year. In areas without systemic problems, supply generally catches up with demand. The good news is that the new reporting system provides the program and local agencies with data that can better identify systematic problems and that can be used for recruitment. Also, the program is now building a history that will help us project the growth in demand. The program has not taken full advantage of this system yet but expects to do more in the coming year.

Problem #2: On January 1, 2008, providers received a 3% rate increase. It was hoped that this would provide some relief but it was the first increase in a decade and it may have been too small to make any difference. It is difficult to tell if it did due to other factors.

EI rates have been based on Medicaid rates and they are much lower than the rates paid by insurance. Low rates continue to lead some providers to leave the program or limit how much EI work they accepted. Low rates make others reluctant to enter the system.

An increasingly important problem is that Illinois has started to experience significant financial problems. Other social and medical service programs experienced significant delays in FFY07/SFY08 but EI was mostly immune due to the fact there was always a balance in the EI Revolving fund. However, there were some brief delays and that was enough to unsettle some providers. Unfortunately, since the end of FFY07/SFY08 things have gotten much worse. While delays remain short relative to those experienced by most service providers it has been very upsetting to the EI community, particularly independent therapists. The program has had to spend a great deal of time dealing with rumors and misinformation. While much of what people are hearing is incorrect it still creates a negative environment and detracts from efforts to address service delays.

Problem #3: When the state statute was amended to require the use of private health insurance for SFY 02, large providers pushed successfully to require providers to bill insurance first. They can only get paid if they have a valid denial from the insurance company. Large providers who are well versed in billing insurance, and who have staff dedicated to billing, like the system because they realize getting paid by insurance means higher rates. However, small agencies and independent providers do not like the requirement to bill insurance first. Some providers have left in frustration and others will not enter. The program has created a central insurance billing unit that providers may choose to use to process insurance claims. It is believed this will help in the long run but utilization of this service is starting slowly. More assistance and education in the field is still needed.

Problem #4: The Bureau is considering strategies to improve program efficiency and effectiveness through the EI Program Integrity Project, which would expand responsibilities of the EI Monitoring Program to include a System Ombudsman function and focus activities of Pediatric Consultative Service contracts, currently in place from all CFC offices, to address specific system compliance issues. Guided by data reviews, Developmental Pediatric Consultants and the System Ombudsman will review the systems utilized at the local level for conformity with the spirit of Early Intervention rules, laws and principles. The Developmental Pediatric Consultant will review clinical activities while the Ombudsman will review systems through data analysis, interviews, personal observation and other appropriate means. Developmental Pediatric Consultants and the Ombudsman will issue reports intended to foster the most efficient and effective local program administration and uniform statewide program administration.

Revisions, with Justification, to Proposed Targets / Improvement Activities / Timelines / Resources for FFY 07-10/SFY 08-11

As required, the targets for service delays will remain to have none. Additional improvement activities will be added as follows:

• 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.