Levels of Care

The original committee, composed of Department of Health and Human Services (DHHS) staff, was convened in December 2000 to look at ways to assess each child in the care of DHHS, as well as children entering care. That group met bi-monthly and looked at several systems from other states. Information from Massachusetts, Washington, Wisconsin, Texas and Illinois was explored to determine if any of these systems would match the goals of the committee. Several members of the committee were trained to perform the CALOCUS assessment (a standardized assessment instrument). This instrument was then piloted on a sample of 100 children in different levels of placement to determine if it would be feasible to use with Maine's child welfare population. A primary drawback was that this instrument could only be used on school age children leaving a population of children from birth to age 5 that would need to be assessed separately.  The instrument also did not account for issues specific to children in a child welfare system.

On March 21, 2002, the committee added new members from the stakeholder community. This was done to enhance collaboration with the foster parent and provider community who are affected by the decisions made by this committee. The committee meets twice a month.  In addition, several subcommittees were developed: to work on the initial screening tool, to review assessment tools and make recommendations to the full committee, to develop the levels of care child functioning definitions, to define the expectations of providers, to perform pilot assessments and policy development. Subcommittee work was brought to the full committee for review and comment. The issue of reimbursement rates was discussed in the full committee with Karen Westburg, Director of the Bureau of Child and Family Services, setting proposed rates for the committee to consider. This proposal was: Level 1=$16.50, Level 2=$30.00, Level 3=$45.00, Level 4=$60.00, Level 5=$70.00. The rates would not be lower than these proposed rates but might be higher after the pilot assessment was completed and data was analyzed. 

Once reimbursement was proposed, a plan was developed to begin communication with the foster parent and provider community. A letter was sent to foster parents and agencies in January 2003 explaining the level system and proposed reimbursement rates. In February 2003, twelve foster parent informational meetings were scheduled statewide to discuss the proposed changes to the foster home reimbursement system. Penny Dineen, Levels of Care project management, and Martha Proulx, foster care and licensing manager, moderated these meetings and other committee members attended as well. Three hundred and forty foster parents, in addition to staff from DHHS Child and Family Services and private therapeutic foster care agencies, attended these statewide meetings. Feedback from those meetings was used to develop levels of care policy and modifications to the system.

Pilot Assessment 

During the month of March 2003, 95 randomly selected cases of children in foster home placements statewide were chosen to be part of the pilot assessment process. Six people were trained to conduct these assessments. All six assessors to establish inter rater reliability reviewed six initial cases together. The child assessment system that was designed by the committee was tested on all 95 cases. 

The child assessment process includes an interview with the foster parent using caregiver questionnaires designed by the state of Illinois that include tested assessment instruments. These interviews took anywhere from 30 - 60 minutes to conduct, with an average time of 45 minutes. Information was gathered from caseworkers and agencies regarding treatment plans, case plans, medical/developmental information, psychiatric/psychological/neurological evaluations, case manager and foster parent notes, and any other pertinent information that would provide detail to the child assessment process.

The CAFAS (Child and Adolescent Functional Assessment Scale) was completed for children aged 7 and older. A younger version of this assessment tool, the PECFAS (Preschool and Early Childhood Functional Assessment Scale) was completed for children between the ages of 4 and 7. Each tool was scored individually and then converted to one of the five Levels of Care. Data was gathered on each case and entered into a database. An outcome of the data indicated that the assessors all performed the assessments similarly. The population of the selected pilot sample is a representation of the whole population of children in foster home placements. 

Among the 95 children assessed, 29% were at Level 1, 25% were at Level 2, 32% were at Level 3, 9% were at Level 4 and 5% were at Level 5. Preliminary figures indicate approximately more than half of the children would receive an increase in reimbursement rate and less than half of the children would receive a decrease in reimbursement rate. It is important, however, to acknowledge those rate decreases. Grandfathering of current placements for 15 months was developed because it was understood that some foster families would see a decreased rate. In addition, the Levels of Care Committee has prioritized higher need cases with higher rates for early assessment so foster families have specific information about possible reimbursement decreases as early as possible.

Grandfathering Provision

The committee developed a grandfathering provision that covers 15 months for current placements. All children in their current foster home placement, who were placed prior to May 19, 2003, will be covered by the grandfathering policy. Children in these homes would be exempt from changes in reimbursement rates for a 15-month period ending August 19, 2004. If a child leaves their current placement they would no longer be grandfathered. Exceptions to this grandfathering policy would be children in therapeutic foster homes that are a part of the voluntary extended care (V9) program for older youth. Children that come into care or change placements after May 19, 2003 will be subject to the new levels of care system.

The new system has begun conducting child assessments on children in treatment foster care placements that are in the voluntary extended care (or V9) program and children who are presently receiving the higher reimbursement rates. The reason for reviewing children receiving the higher rates is to give the foster family early notice of the rate that will be provided for the children after August 19, 2004.

In addition, in May the final proposed rates were set. The Level 5 rate increased to $75. The full set of rates is Level 1=$16.50, Level 2=$30.00, Level 3=$45.00, Level 4=$60.00, Level 5=$75.00.

Rule Making

Public hearings on proposed rules in the Levels of Care system were held on June 16 and June 20. The proposed rules describe the five levels. Foster and adoptive families received proposed rules and information on submission of public comment. The Levels of Care system was implemented under emergency rules on May 19, pending adoption of final rules.

The Levels of Care Committee has a commitment to the well being of children. We believe that generally children are best served by their families and therefore services are provided to support the preservation of the family unit. However, the safety of children is paramount and as such at times it is necessary for them to be removed from the home. In these cases, a placement will be selected which promotes the highest level of independent functioning the child is able to achieve. The Department will offer a continuum of care by which children in need of placement outside their homes will enter the most appropriate, normalized living environment. Preferably this placement will be in close proximity to the child's home community. In this respect, it is hoped that not only will their needs be met but at the same time the disruption and trauma to them minimized. Substitute care for children ranges from the most normalized setting of relative and family foster care through therapeutic care; group home care, residential treatment centers and hospitalization.

The purpose of all substitute care settings, in addition to ensuring a child's safety and well being, is to effect positive change enabling the child to live in a permanent family setting, independently or in the most normalized community setting. In order to ensure that children in the care and custody of the Department are placed in the most normalized setting that meets their needs, the Department shall assess each child in order to determine the appropriate level of care and services to meet that child's needs as indicated above. This assessment process will work toward insuring the child's initial placement meets the above criteria. It will also be a continuing process whereby the child moves to the most normalized living environment where well being and permanency needs of the children will be periodically reassessed.

Carol Armour Department of Health and Human Services Manager, Residential Services Bureau of Child and Family Services 11 SHS Augusta, Maine 04333 287-5283 287-5282 fax Carol.Armour@maine.gov	Janice Koshiol Foster Care Developer PO Box 313 Greenville Junction 04442 695-4457 home 945-4240 work 745-6387 cell 990-3660 fax jkoshiol@caredev.org jkoshiol@prexar.com Foster Parent Community Representative Treatment Foster Care Provider
Penny Dineen Department of Health and Human Services Manager, Program Placement & Utilization Bureau of Child and Family Services 11 SHS Augusta, Maine 04333 287-5060 287-5282 fax Penny.M.Dineen@maine.gov DHHS OCFS lead person for this initiative.	Dulcey Laberge Quality Assurance Program Manager Bureau of Child and Family Services 11 SHS Augusta, Maine 04333 287-5060 287-5282 fax dulcey.laberge@maine.gov
Martha Proux Department of Health and Human Services Program Specialist, Children's Services & Foster Care Licensing Bureau of Child and Family Services 11 SHS Augusta, Maine 04333 287-5075 287-5282 fax Martha.A.Proulx@maine.gov	Marie Laverriere-Boucher-Maine Legislator 69 Foss St Biddeford, Me 04005 284-6701 marielb@gwi.net
Leslie Rozeff Co-Director Child Welfare Training Institute 295 Water Street Augusta, Maine 04330 626-5218 626-5210 leslie.rozeff@maine.gov	Julie Levitz Department of Health and Human Services Quality Assurance Bureau of Child and Family Services 208 Graham Street Biddeford, Maine 04005-3350 286-2485 2862408 fax Julie.levitz@maine.gov
Mattew Ruel Department of Health and Human Services MACWIS Program Manager Bureau of Child and Family Service 11 SHS Augusta, Me 04333 287-3690 287-5252 fax Matthew.R.Ruel@maine.gov	Jeannie Lucas Project Assistant Child Welfare Training Institute 295 Water Street Augusta, Me. 04330 626-5014 jeannie.lucas@maine.gov
Frances Ryan Department of Health and Human Services Special Projects Director Office of the Commissioner 161 Marginal Way Portland, Maine 04101 822-2316 822-2226 fax Frances.Ryan@maine.gov	Joyce Pringle 20 Gabradak Lane Chelsea, Me. 04330 582-4034 joycepringle@aol.com Foster Parent President Maine Association of Foster and Adoptive Parents Board Member, National Foster Parent Association
Gary Vavra KidsPeace 343 Gorham Rd So. Portland, Me 04106 771-5700 gvavra@kidspeace.org	Delia Saintcross Department of Health and Human Services Casework Supervisor Bureau of Child and Family Services 161 Marginal Way Portland, Maine 04101 822-2204 822-2226 fax Delia.P.Saintcross@maine.gov
Karen Westburg Department of Health and Human Services Director Bureau of Child and Family Services 11 SHS Augusta, Maine 04333 287-5060 287-5282 fax Karen.M.Westburg@maine.gov	Deb Schaedler Maine Caring Families Bureau of Child and Family Services #11 SHS Augusta, Maine 04333-0011 287-5060 287-5282 fax Deb.schaedler@maine.gov
Michael Norton Director, Division of Public Affairs/Quality Assurance Bureau of Child and Family Services #11 SHS Augusta, Maine 04333-0011 287-5060 287-5282 fax Michael.Norton@maine.gov	Wayne Walker Community Health & Counseling Services Assistant Director of Children's Services P.O. Box 425 Bangor, Maine 04402-0425 947-0366 947-2825 fax mwwalker99@hotmail.com Maine Association of Mental Health Service Providers Representative
Doug Wright 620 Headtide Road Whitefield, Maine 04353 549-7325 Dwright667@aol.com Therapeutic Foster Parent Foster Parent Community Representative	Bette Hoxie President Adoptive and Foster Families of Maine 294 Center Street, Unit 1 Old Town, Maine 04468 827-2331 bette@affm.net Foster and Adoptive parent