Indicator #2 - Early Intervention Services - Provided Predominately in Home or in Community Settings

Early Intervention Services - Provided Predominately in Home or in Community Settings

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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.

Illinois authorization system is centralized in the Cornerstone data system. The state subsequently pays all bills through its Central Billing Office. Each month a report is run based on the same logic used for the federal 618 setting report. This reflects where services are authorized. In theory this will perfectly reflect the recommendations of the IFSP team. However, the current data system does not allow for a perfect reflection. In some cases, Individual Family Service Plans may call for services to be delivered in natural settings but authorizations reflect that services are actually being delivered in non-natural settings because no providers are available to deliver services off-site. The IFSP must include a justification for this, along with a plan to transition to a natural setting, when available. Authorizations are for the delivery setting, not the IFSP recommendation. This is a significant issue in only a few areas of the state, most notably Peoria. While the current data system includes detail that shows what setting the IFSP team recommends, it is not stored in a way we can query. Planning has been underway for some time to replace the current system that would correct this problem but that is at least several years away.

The monthly predominate settings report provides both statewide and service coordination area (CFC) level data. This detail is reflected in the monthly statistical reports. The performance contracting system grants incentive funding to the 12 CFCs (of 25) with the highest proportion of cases served predominately in natural settings at the end of each quarter. CFCs who served less than 85% of their cases in natural settings at the end of a quarter are penalized. The state program has deemed 85% a minimum standard to demonstrate local compliance with state and federal rules regarding the delivery of service in natural settings.

Natural settings performance also plays a part in determinations in two ways. It is one of the ten performance measures that factor into determining a CFCs average performance ranking and receipt of a penalty, even if in just one quarter, is a mark against the CFC.

Because settings data is reported every month, it is constantly being evaluated by the program centrally and is an ongoing concern to all 25 CFCs. In addition, as outlined under Indicator 1, the program has implemented a more aggressive, standardized method of reporting service delay. Several elements were incorporated into this process that go beyond what is required by OSEP. One of these elements

is to include information on services being delivered in a non-natural setting when the IFSP calls for a natural setting. The hope is that this will provide both state and local leaders with a new tool to recruit providers willing to deliver services in natural settings in areas where that has been a significant and chronic problem.

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 programs for typically developing children.
(20 U.S.C. 1416(a)(3)(A) and 1442)

Measurement:

Percent = [(# of infants and toddlers with IFSPs who primarily receive early intervention services in the home or programs for typically developing children) divided by the (total # of infants and toddlers with IFSPs)] times 100.

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

Measurable and Rigorous Target: At least 88.0% of all children with IFSPs active on June 30, 2008 will have their services provided predominately in the home or in community settings.

Actual Target Data for FFY 07/SFY 08: On June 30, 2008, 89.9% of all children with IFSPs have their services provided predominately in the home or in community settings.(16,607/18,467)*100= 89.9%

Correction of Noncompliance

Five of the six uncorrected findings of noncompliance for Indicator 2 noted in the FFY06 Illinois APR were identified and documented through the program's monitoring process. Documentation of correction of noncompliance was made during the subsequent annual monitoring visit in which it was identified that there is evidence that the previous fiscal year corrective action plan had been implemented and continued to address areas of violation. The final uncorrected finding of noncompliance was identified based upon system data. Subsequently, the CFC has submitted a corrective action plan regarding this indicator. This plan was reviewed and approved and implementation strategies were successfully implemented, verifying that the noncompliance had been corrected.

Actual Target Data for FFY 07/SFY 08:

Predominate Settings History	Nov. 30 2005	Oct. 31 2006	Jun. 30 2007	Oct. 31 2007	Jun. 30 2008	Oct. 31 2008
Dev. Centers	2.8%	NA	NA	NA	NA	NA
Typically Developing	4.0%	4.2%	4.4%	4.6%	4.4%	4.6%
Home	83.8%	85.1%	84.8%	84.9%	85.5%	87.2%
Provider Location/Other *	9.5%	10.8%	10.8%	10.5%	10.1%	8.1%
% Natural Settings	87.7%	89.3%	89.2%	89.5%	89.9%	91.9%
Client Count	16,175	16,613	17,654	17,486	18,467	18,597
Centers & Provider Locations	1,982	1,784	1,908	1,841	1,860	1,511

* Provider locations & developmental centers merged to meet new OSEP definitions

FFY 07/SFY08 saw continued improvement in the proportion of children with IFSP services authorized predominately in natural settings. Statewide the proportion of children served predominately in natural settings increased from 89.2% at the end of June 2007 to 89.9% at the end of June 2008:

All three of the larger geographic regions of the state improved between the 619 reporting periods and measured from June 2007 to June 2008. Besides the underlying trend, the notable jump between June 30, 2008 and October 31, 2008 was caused by two factors. First, the Joliet CFC found that coordinators had been issuing authorizations for center-based services in a number of instances, even though it was not part of the IFSP, due to a long outdated agreement with a provider. These services were not being used but it left the false impression in the data system that a large number of kids were being served predominately in centers. Second, a review of the programming logic that determines predominate setting found that translation services that take place outside of the delivery of direct service were inappropriately being counted as direct services. These two changes produce a more accurate picture of the settings situation in Illinois.

The issue of natural settings continues to be a problem in a few areas but progress is being made. The only large-scale systemic resistance to the idea of natural settings is found in the Peoria area. However, we continue to see progress even there. There is some residual resistance to the idea in pockets of northeastern Illinois but it has diminished to the point where it does not represent a threat to implementation of the EI philosophy, including the delivery of services in natural settings.

A bigger problem stems from a lack of providers delivering service in natural settings. This is discussed in more detail under the service delay indicator (#1). A lack of providers creates the dilemma of insisting on services being delivered in natural settings, which means service delays, or getting services started in non-natural settings. State financial problems are contributing to the shortage of providers in more and more areas. This makes it harder to deliver services in natural settings. In recognition of the interaction between service delay and settings, the Illinois Interagency Council on Early Intervention (IICEI) Service Delay Workgroup has addressing settings issues as a secondary mission.

Besides Peoria, there has been progress in other areas of the state. The Rockford area has shown dramatic improvement under difficult conditions and has recently moved to having more than 85% of its cases served predominately in natural settings for the first time. The state has deemed being below 85% to be a sign of non-compliance with the principle of service being delivered in natural settings. As noted, the problem Joliet had meeting the state compliance minimum appears to have been at least partially artificial. They now are above the state average.

CFC 3 (Northwest Illinois) is the only area with a systemic problem that has not been resolved. This is because they have the state's most severe provider shortages. On-site therapies are often the only services available. Since they serve a largely rural area, some families do not even have a center or a provider office as an alternative. The IICEI Service Delay Workgroup is working with a subgroup in the Rockford-Freeport area to develop recommendations to improve both the service delay and settings issues.

As was discussed in detail under Indicator 1 - Service Delay, the system for reporting service delays includes reporting on service delivery problems beyond what is required for APR reporting. This includes reporting on instances where services are being delivered in a non-natural setting because no provider is available to deliver services in a natural setting and the number of hours needed. This allows the program to produce a cumulative number of hours a CFC, or a contiguous group of CFCs, is looking to fill for each service. The program has started to share those reports with stakeholders as a means of facilitating discussions regarding how to resolve both local and statewide problems.

As noted previously, the Peoria CFC has the greatest problem with the delivery of services in non-natural settings. They do not have service delay problems but the service delay reporting system records that more than half of children in the Peoria region have IFSPs that recommend services be delivered in natural settings but that is not happening because service providers are not available.

Another systemic problem continues to be some resistance to the delivery of services in natural settings in the wealthier areas where some assume services in a facility are better. A consistent message over time regarding the value of delivering services in natural settings, as well as state and federal rules, have resulted in significant improvement. The inclusion of natural settings in the performance-contracting framework, as both a penalty and a reward, had some impact. Guidance letters from the Bureau clarifying policy had an even bigger impact.

Overall, as of June 30, 2008, nine CFCs met or exceeded the federal 95% substantial compliance standard, 13 were under 95% but above the state establish minimum standard of 85%, and three were below 85%. However, since June 30 the Rockford area has moved past the 85% state compliance standard. That leaves just Peoria and Freeport below the 85% standard.

There was less improvement downstate in FFY07/SFY08 than in the Chicago areas, particularly the collar counties. However, most downstate agencies have among he highest rates of children served predominately in natural settings. Peoria and the two Rockford area agencies pull down the average for downstate. 

Cases Predominately in Natural Settings
By CFC & Geographic Regions

CFC # & Name	5-Dec	6-Oct	7-Jun	7-Oct	8-Jun	8-Oct
Cook County
#6 N. Suburbs	90.40%	92.10%	92.00%	89.70%	88.30%	92.00%
#7 W. Suburbs	89.40%	92.40%	89.20%	91.10%	88.60%	91.90%
#8 SW Chicago	94.80%	97.50%	96.60%	97.30%	94.90%	97.50%
#9 Central Chicago	86.90%	85.30%	85.80%	86.60%	89.60%	92.80%
#10 SE Chicago	89.40%	87.40%	91.90%	91.80%	91.10%	90.50%
#11 N. Chicago	87.40%	87.50%	84.60%	84.90%	86.70%	88.00%
#12 S. Suburbs	91.60%	93.90%	93.00%	92.50%	96.80%	98.90%
Collar Counties
#2 Lake County	93.80%	95.80%	94.00%	94.50%	90.50%	91.40%
#4 Kane-Kendall	85.80%	89.80%	87.50%	84.10%	86.20%	93.80%
#5 DuPage County	90.60%	93.90%	94.40%	94.80%	96.10%	98.00%
#15 Joliet	84.50%	81.00%	85.20%	87.30%	91.30%	94.10%
#25 McHenry Co.	86.80%	95.60%	92.20%	92.10%	93.50%	96.90%
Downstate
#1 Rockford	73.50%	78.10%	79.40%	80.90%	82.60%	87.40%
#3 Freeport	76.20%	75.60%	79.40%	79.10%	76.20%	78.50%
#13 Macomb	96.20%	96.50%	96.80%	96.60%	97.60%	94.10%
#14 Peoria	31.60%	31.70%	34.10%	38.70%	40.80%	42.70%
#16 Bloomington	90.20%	90.40%	91.40%	93.80%	90.90%	92.60%
#17 Quincy	97.20%	94.00%	95.10%	96.30%	91.00%	91.40%
#18 Springfield	96.10%	94.40%	94.30%	93.60%	92.50%	90.80%
#19 Decatur	93.70%	95.40%	93.60%	95.00%	97.10%	97.60%
#20 Effingham	99.70%	99.20%	99.70%	99.40%	99.50%	100.00%
#21 Belleville	95.00%	95.30%	98.40%	98.10%	97.90%	97.40%
#22 Centralia	97.50%	99.10%	99.40%	98.90%	97.80%	98.80%
#23 Norris City	99.50%	100.00%	100.00%	100.00%	100.00%	100.00%
#24 Carbondale	99.30%	99.30%	98.60%	100.00%	100.00%	99.40%
Summary
Total	88.10%	89.20%	89.20%	89.50%	89.90%	91.90%
Cook County	89.60%	90.50%	89.60%	89.50%	90.10%	92.40%
Collar Counties	88.20%	89.90%	90.30%	90.40%	90.70%	94.90%
Downstate	85.80%	86.60%	87.60%	88.50%	88.90%	88.60%

NOTE:
Red cells = below 85% state established minimum standard,
Green cells = below federal 95% substantial compliance standard,
Bold cells = Above federal 95% substantial compliance standard

Discussion of Improvement Activities Completed and Explanation of Progress or Slippage that occurred for FFY 06/SFY 07:

The increase in the percentage of children with open IFSPs who are served predominately in natural settings exceeded the established goal of at least 88%. The following steps contributed to this progress:

• The program's continued and consistent message about the meaning of state and federal rules regarding the preference for the delivery of services in natural settings.
• The program's continued and consistent message about the definition of what constitutes natural settings.
• Consistent training on natural settings and what is necessary to document ANY services delivered in other than natural settings.
• Reinforcement of the memos to field staff (CFCs) and to providers on the meaning and importance of natural settings and how rules should be implemented.
• Continued inclusion of a natural settings performance element in the CFC performance contracting system, providing incentive funding to the 12 CFCs with the highest level of IFSPs authorized predominately in natural settings at the end of each quarter.
• Enforcement of a performance-contracting penalty on any CFC with less than 85% of IFSPs authorized predominately in natural settings at the end of each quarter.
• Adjustment to the program that calculates predominate setting to treat translation services differently.
• Correction of an outdated and inappropriate policy in the Joliet area that falsely caused some children to be found to be served predominately in a natural setting.
• New attention brought to the issue by the IICEI Services Delay workgroup, which has a secondary mission to help address settings issues.

Revisions, with Justification, to Proposed Targets / Improvement Activities/Timelines/ Resources for FFY08/SFY09

Illinois did exceed its goal for FFY07/SFY08. However, we are concerned that the states financial problems will make it even harder to recruit and retain enough providers willing to deliver services in natural settings. Fewer providers will mean more service delays and more need to start service in non-natural settings. As mentioned previously, part of the problem is that while IFSP teams suggest that services should be delivered in a natural (off-site) setting our data system can only track where they are authorized. If we had the means to accurately reflect IFSP team recommendations things would look different. For instance, Peoria would probably be at about 90% predominately in natural settings instead of 40.8%.

So, the program does not propose to change the FFY08/SFY09 goal of 89.0% or any of the other goals in the State Performance Plan. This would still reflect a long-term upward trend. Apart from the impact of financial problems all signs point to continued steady progress.