Constraints and Benefits of Child Welfare Contracts with Behavioral Health Providers: Front Line Worker Perceptions

Background and Purpose: This paper explores worker perceptions of how public child welfare agencies’ purchase of service contracts with regional private behavioral health organizations both constrain and facilitate referral making, and children’s access to services outside of the child welfare system. To promote well-being among children who have experienced maltreatment, child welfare agencies often sub-contract with local behavioral health providers for specialized behavioral health treatment.  Although sub-contracting is intended to facilitate referrals and access to specialty treatment, the scope, terms, requirements, and compensation specified in sub-contracts may also constrain workers’ ability to link children and youth with appropriate services. Understanding how contractual relationships influence linkages to appropriate care is key for informing how child welfare agencies procure services and manage relationships with contracted providers.

Methods: Five, 90-minute focus groups were conducted with workers (n=50) from an urban public child welfare agency in the Midwest.  Participants were selected purposefully to ensure group composition reflected expertise in collaborating with the behavioral health system and variation in caseworker functions. A semi-structured interview guide focused discussion on linkage to behavioral health treatments for child welfare-involved youth. Focus groups were audio-recorded and professionally transcribed. Using the constant comparative method, at least two coders independently analyzed each transcript and arrived at consensus regarding coding schemes and definitions using an iterative review and revision process. 

Results: Contracts were perceived to facilitate service access in two ways. First, workers perceived that contracts reduce wait time for services if the contracts included language that reserved treatment slots for child-welfare involved youth. Second, workers discussed how having a network of contracted providers narrows the number of agencies with which workers need to be familiar (in terms of services, procedures, paperwork), thus reducing some of their work burden. However, workers may be most familiar and refer to only a subset of contractors, as discussion suggested workers were unaware of the full set of contracted agency providers. Contracts were perceived to constrain workers’ ability to tailor a referral to the unique needs of the child, especially when the treatment needs were complex, costly, and beyond the scope of the negotiated master contract. Although workers described processes for working around these constraints to refer to non-contracted providers, the workload was perceived as prohibitive.

Conclusion: Although sub-contracts may expedite service linkages, these benefits may be conditioned upon on the unique service needs of the child. For children who have complex service needs that are costly, workers may need to refer to specialized providers who do not have existing child welfare contracts, which may delay service access. Findings suggest the need for contracts between child welfare and behavioral health agencies to be modifiable to accommodate changing service needs. Additionally, communication between purchasing departments and line-workers about the scope of services delivered by both contracted and non-contracted behavioral health providers may help facilitate service referrals and access for children with complex treatment needs, and buffer over-dependence on a subset of contractors.