Follow-up Report

DEPARTMENT OF HUMAN SERVICES' EARLY INTERVENTION PROGRAM

Released: April 2002

This report is also available on the worldwide web at:
http://www.state.il.us/auditor

• Child Find and Public Awareness: The percentage of children participating in the EI Program has increased in recent years; however, rates of participation varied across the State. Additional outreach and public awareness efforts are necessary.
• Availability of Providers: In response to our survey, CFCs reported shortages of some types of EI providers; however, monthly reports filed by CFCs with DHS listed few children not receiving services due to the lack of providers. Also, the number of EI providers has increased.
• Children Delayed in Receiving Services: As of October 31, 2001, CFCs reported 1,196 children who were delayed in receiving services. Many of these children did not have an Individualized Family Service Plan (IFSP) prepared within the required 45 days. Family delays, such as parents not responding to inquiries, were reported as the primary reason for the delay in 52 percent of the cases.
• Service Coordinator Caseloads: Service coordinators' caseloads varied widely among CFCs, from a low of 34 to a high of 82 cases per service coordinator.

While DHS has taken steps to improve Program planning, an overall long-term strategic plan for the Program has not yet been developed.

In 1993, the Office of the Auditor General released an evaluation of the EI Program. Public Act 92-307 required a follow-up evaluation be completed.

Over the past two and one-half years, the number of children with active Individualized Family Service Plans (IFSPs) authorizing them to receive EI services, such as speech language therapy, developmental therapy, and physical therapy, has increased.

Changes have resulted in Program improvements since our 1993 audit. There remain, however, areas where further improvements are warranted. DHS is in the process of working toward addressing many of these areas.

Illinois' participation rate has increased significantly since 1998. In December 1998, Illinois' statewide participation rate was .9 percent; in December 2001, it was 1.8 percent.

By December 2001, the number of cases with active IFSPs declined to 9,910, or an 18 percent decrease since May 2001. DHS officials attributed some of the decline to Program changes associated with insurance and family fees.

The EI annual report for the year ending September 30, 1998, reported that approximately 2,200 providers had enrolled in the Program; as of January 2002, the EI Bureau reported that approximately 4,200 providers were credentialed to provide early intervention services.

Twenty of the 25 CFCs we surveyed responded that there was a severe shortage in at least 1 of the 16 types of service providers for which we inquired.

As of October 31, 2001, CFC monthly reports identified 1,196 children as delayed in receiving services.

During the first six months of Fiscal Year 2002, approximately 50 percent of the IFSPs were not completed within the required 45 days, according to EI staff; IFSPs were completed an average of 75 days after the initial referral, or 30 days longer than required by law.

There were wide variations in the average caseloads of service coordinators across the 25 CFCs. As of October 31, 2001, the average caseloads ranged from 34 cases to 82 cases.

The annual report issued by DHS and the Council for the year ending September 1999 did not contain the statutorily required information on program participants and cost.

The U. S. Department of Education's Office of Special Education Programs (OSEP) raised concerns regarding the QE process because the IFSP team was not developing the IFSP which details the type and amount of care a child and family will receive.

DHS has taken steps to implement many of the requirements of Public Act 92-307, which became effective on August 9, 2001.

REPORT CONCLUSIONS

The Early Intervention (EI) Program provides services to children, birth to 36 months of age, who have disabilities due to developmental delay, have a medically diagnosed mental or physical condition that typically results in developmental delay, or have been determined to be at risk of a substantial developmental delay. The EI Program is administered by the Department of Human Services (DHS). DHS contracts with various entities to provide most Program components, including case coordination, public awareness, billing, provider credentialing, and training functions. In Fiscal Year 2001, DHS reported EI Program expenditures totaling $96 million, $74.8 million of which was paid to providers of early intervention services. As of December 31, 2001, 9,910 children had Individualized Family Service Plans (IFSPs) authorizing them to receive EI services, such as speech language therapy, developmental therapy, and physical therapy.

In 1993, the Office of the Auditor General completed an audit of the Early Intervention Program. The 1993 audit found that although the framework being established for the EI Program should be capable of providing services under State and federal laws, several areas needed to be addressed.

Public Act 92-307, effective August 9, 2001, directed the Auditor General to conduct a follow-up evaluation of the Early Intervention Program. In addition, the Legislative Audit Commission adopted Resolution Number 122 in June 2001 directing the Auditor General to conduct an audit of the EI Program examining the adequacy of its management information systems and contractor monitoring. We are issuing two reports on our audit of the Early Intervention Program: this first report follows up on issues raised in the 1993 audit; a second report, to be issued during the summer of 2002, will examine issues specifically identified in Legislative Audit Commission Resolution Number 122.

The operation of the Early Intervention Program has changed significantly since our 1993 audit. In 1997, Child and Family Connections offices (CFCs) were established statewide to carry out intake and service coordination responsibilities. Responsibility for the Program was transferred to the Department of Human Services in January 1998. Also in 1998, the method for funding early intervention services changed from a grant program to a fee-for-service system. In 1999, DHS contracted with a vendor to operate the Central Billing Office (CBO) to process all payments related to the Early Intervention Program. In 2001, DHS implemented many new program changes.

These changes have resulted in Program improvements since our 1993 audit. There remain, however, areas where further improvements are warranted. DHS is in the process of working toward addressing many of these areas:

• Child Find and Public Awareness: The percentage of children participating in the EI Program increased in recent years, but began to decline during the summer of 2001. DHS officials attributed some of the decline to Program changes associated with insurance and family fees. Rates of participation in the Program varied across the State. Additional outreach and public awareness efforts are necessary, especially in counties with low participation rates.

• Availability of Providers: In response to a survey we sent asking whether there were a sufficient number of providers so that services were not delayed, 20 of the 25 CFCs noted a severe shortage in one or more early intervention provider types. However, monthly reports filed by CFCs listed relatively few children who were not receiving services due to a lack of early intervention service providers. Also, the number of providers enrolled in the Program increased from 2,200 in September 1998 to approximately 4,200 by January 2002, according to DHS officials.

• Children Delayed in Receiving Services: As of October 31, 2001, CFCs reported 1,196 children who were delayed in receiving services. Most of these children were not receiving services because an IFSP had not been prepared within the required 45 days. Family delays, such as parents not responding to inquiries, were reported as the primary reasons for the delay in 52 percent of the cases. System delays, such as high CFC caseloads or providers not completing assessments in a timely manner, accounted for the remaining 48 percent of the cases. In cases where there were system delays, 85 percent of the children were reported delayed two months or less for services.

• Service Coordinator Caseloads: Service coordinators' average caseloads varied widely among CFCs, from a low of 34 to a high of 82. DHS officials noted that some of the variations were caused by funded vacancies that the CFCs did not fill or by projected caseloads which did not materialize. High caseloads were cited by several CFCs as a primary reason why IFSPs were not completed within the required 45 days. Some CFCs with high caseloads, however, implemented IFSPs on a more timely basis than did CFCs with lower caseloads.

• Cost and Client Information: In August 1995, the Early Intervention Services System Act was amended to require the Illinois Interagency Council on Early Intervention's annual report to include information on the estimated number of eligible children and the estimated cost of providing services to all eligible infants and toddlers in the State. The annual report issued jointly by DHS and the Council for the year ending September 1999 did not include the statutorily required information. The annual report for the year ending September 2000 had not been issued as of January 2002.

In June 2001, the Department implemented the Quality Enhancement (QE) process, which was established to ensure that all eligible children and their families receive appropriate, consistent, and quality interventions. According to DHS officials, the U. S. Department of Education's Office of Special Education Programs (OSEP) raised concerns regarding the QE process because the IFSP team was not developing the IFSP which details the type and amount of care a child and family will receive. OSEP has not yet made its Part C grant award of approximately $16.6 million to Illinois for federal fiscal year 2001 pending revision of the QE process. DHS has begun to undertake revisions to the QE process.

Public Act 92-307, effective August 9, 2001, made significant changes to the Early Intervention Program. These changes included: establishing new eligibility requirements; mandating changes in the credentialing and training of EI providers; setting new insurance and family fee requirements; and requiring the bidding of certain EI contracts. The Department has implemented many of the new requirements; implementation of others is still underway.

The EI Program has taken steps to improve planning. In late 2001, the EI Bureau began to develop performance measures for some aspects of the EI system, as well as an Operations Plan that contains goals and objectives to improve the Program's operations and management. DHS has also developed an Improvement Plan to address issues raised as part of the Continuous Improvement Monitoring Process. In 2001, the Illinois Interagency Early Intervention Council developed a Vision and Mission Statement and established Principles of Early Intervention. While key planning efforts have been initiated, DHS has not developed an overall long-term strategic plan for the EI Program. (pages 1-3)

BACKGROUND

On August 9, 2001, Public Act 92-307 was signed into law. In addition to making significant changes in the Department of Human Services' operation of the Early Intervention Program, it also contained a requirement that the Office of the Auditor General conduct a follow-up evaluation of the Early Intervention Program. In 1993, the Office of the Auditor General released an evaluation of the EI Program. The Public Act required the follow-up evaluation be completed by April 30, 2002.

In addition, the Legislative Audit Commission adopted Resolution Number 122 in June 2001 directing the Auditor General to conduct an audit of the EI Program examining the adequacy of its management information systems and contractor monitoring. We are issuing two reports on our audit of the Early Intervention Program: this first report follows up on issues raised in the 1993 audit; a second report, to be issued during the summer of 2002, will examine issues specifically identified in Legislative Audit Commission Resolution Number 122.

The Early Intervention (EI) Program provides services to children, birth to 36 months of age, who have disabilities due to developmental delay, have a medically diagnosed mental or physical condition that typically results in developmental delay, or have been determined to be at risk of a substantial developmental delay. The EI Program is administered by the Department of Human Services (DHS).

DHS contracts with various entities to provide most Program components, including case coordination, public awareness, billing, provider credentialing, and training functions. In Fiscal Year 2001, DHS reported EI Program expenditures totaling $96 million, $74.8 million of which was paid to providers of early intervention services.

Over the past two and one-half years, the number of children with active Individualized Family Service Plans (IFSPs) authorizing them to receive EI services, such as speech language therapy, developmental therapy, and physical therapy, has increased. As shown in Digest Exhibit 1, in September 1999, DHS reported there were 7,769 children with active IFSPs. As of December 2001, the number of children with active IFSPs was 9,910. The number of children with active IFSPs has decreased since the spring of 2001. DHS attributed some of the decline to Program changes associated with insurance and family fees.

The Office of the Auditor General 's 1993 audit of the Early Intervention Program found that although the framework being established for the EI Program should be capable of providing services under State and federal laws, several areas needed to be addressed. These included: services were not available in all parts of the State; some eligible children were not being served and were on waiting lists; IFSPs were not being completed within the required 45 days; and State agencies were not collecting information on the number of children eligible for services, the number served by all programs, or the cost of services per child.

The operation of the Early Intervention Program has changed significantly since our 1993 audit. In 1996, the U. S. District Court in the Northern District of Illinois found that the State was violating the federal Individuals with Disabilities Education Act (IDEA). The Court's Order required the State to undertake numerous actions to address system deficiencies (Marie O. v. Edgar case). In March 2000, the Court terminated its supervision of the State's actions noting it had "observed substantial improvement" in the State's compliance with the IDEA.

In 1997, Child and Family Connections offices (CFCs) were established statewide to carry out intake and service coordination responsibilities. Responsibility for the Program was transferred from the State Board of Education to the Department of Human Services in January 1998. Also in 1998, the method for funding early intervention services changed from a grant program to a fee-for-service system. In 1999, DHS contracted with a vendor to operate the Central Billing Office to process all payments related to the Early Intervention Program.

These changes have resulted in Program improvements since our 1993 audit. There remain, however, areas where further improvements are warranted. DHS is in the process of working toward addressing many of these areas. (pages 3-15)

CHILD FIND AND PUBLIC AWARENESS

For the EI Program to be effective, eligible children and their families need to be identified and provided information about the Program. State and federal laws require the EI Program to establish Child Find and public awareness efforts. Child Find includes activities to ensure that all infants and toddlers in the State who are eligible for EI services are identified, located, and evaluated. Public awareness activities are intended to disseminate information about the Program to primary referral sources, such as hospitals, physicians, and child care programs.

There are indications that Child Find and public awareness efforts have improved in recent years, but there remain additional areas for improvement. One measure to ascertain the effectiveness of the EI Program’s Child Find and public awareness efforts is the participation rate. The participation rate is the percentage of children in the age group from 0 to 3 years who are receiving services through the EI Program in a given geographic area. The higher the participation percentage, the greater the indication that the public is aware of the Program and is accessing it. Areas with low participation rates may indicate that additional outreach is needed to educate the public about the EI Program.

Illinois' participation rate has increased significantly since 1998. In December 1998, Illinois' statewide participation rate was .9 percent; in December 2001, it was 1.8 percent.

While the Illinois rate has improved, there are still areas of concern. The first is that there are significant differences in participation rates among the 102 counties in Illinois. As shown in Digest Exhibit 2, in July 2001, Calhoun County and Carroll County had the lowest participation rates at .7 percent. Wabash County had the highest rate at 7.6 percent. DHS followed-up with CFCs in counties with low participation rates. Appendix C in the report lists all Illinois counties and their participation rates.

A second area of concern regarding Illinois' participation rate is that the number of cases with IFSPs has been decreasing since May 2001. The number of active IFSPs is used to calculate the participation rate. In May 2001, the number of cases with an active IFSP was 12,034. By December 2001, the number of cases with active IFSPs declined to 9,910, or an 18 percent decrease since May 2001. Illinois' statewide participation rate declined from 2.2 percent in December 2000 to 1.8 percent in December 2001. DHS officials attributed some of the decline to Program changes associated with insurance and family fees.

We surveyed the 25 CFCs and asked if there were areas where improvements could be made in the outreach activities of the EI Program. Twenty-one of the 25 CFCs responded that improvements could be made. Some of the suggestions included: improving connections with physicians and nurses; providing additional funding for promotional ads and more outreach activities; and more effectively dealing with language issues (such as in Hispanic areas where English is a second language).

In late 2001, the EI Bureau began the development of the Early Intervention Operations Plan. The Plan contains goals, objectives, and action steps covering a wide range of Early Intervention Program areas. The Operations Plan contains an objective to develop action plans to increase participation in areas with low participation rates. We recommended that the Department should continue efforts to increase public awareness of the Early Intervention Program, specifically focusing such efforts in areas of the State with low EI Program participation rates. (pages 19-23)

AVAILABILITY OF PROVIDERS

An effective early intervention system requires an adequate number of providers to deliver services. The Auditor General's 1993 audit found that there was a shortage of early intervention service providers. The audit reported that there were 99 providers of early intervention services, many of which were community or local government agencies that provided a variety of services.

Since the 1993 audit, the early intervention delivery system changed. In 1993, funding for EI services was paid to local service providers in the form of grants. In 1998, the service delivery system changed to a fee-for-service system. The Illinois Interagency Council on Early Intervention's annual report for the year ending September 30, 1998, reported that approximately 2,200 early intervention providers had enrolled in the Program. As of January 2002, the EI Bureau reported that approximately 4,200 providers were credentialed to provide early intervention services.

Monthly reports submitted by CFCs reported that relatively few children were not receiving services because a provider was unavailable. In the June 2001 monthly reports, CFCs reported 54 cases that were delayed due to providers being unavailable, which accounted for only 4 percent of all children reported delayed for services that month.

While the CFCs’ monthly reports contained relatively few instances where services were delayed due to a lack of providers, CFCs' responses to our November 2001 survey identified a more prevalent problem. Twenty of the 25 CFCs responded that there was a severe shortage in at least 1 of the 16 types of service providers for which we inquired. Generally, the CFCs in the Cook County area reported fewer severe shortages of providers than CFCs located elsewhere in the State.

Transportation was the service most frequently cited as having a severe shortage -- 12 of the 25 CFCs. Ten CFCs reported shortages in vision services, while nine cited shortages in speech and language therapy. We recommended that the Department of Human Services should follow-up with the CFCs that reported shortages of providers and develop strategies to recruit additional providers where needed. (pages 24-26)

CHILDREN DELAYED IN RECEIVING SERVICES

Our 1993 audit reported that there were 1,048 children waiting for services to be provided, as of November 1, 1992. Providers surveyed as part of the 1993 audit reported that children waited anywhere from 2 weeks to 12 months for services. In 1993, providers received a set amount of grant funds to pay for services. According to DHS officials, when providers' grant funds were expended, children had to wait for services. The 1994 Marie O. class action complaint noted that the State's decision to provide mandated services only as appropriated funds became available "has resulted in serious and systematic unavailability and inadequacy of services in the State of Illinois."

While there continued to be children delayed in receiving services, there are important differences between the numbers reported for 1993 and 2001. Whereas in 1993 services were not available due to a lack of State funding, in 2001, funding was available for needed services. A major reason why children were not receiving services in 2001 (52 percent of the cases in October 2001) was delays reported to be due to family reasons, such as the parent was unable to be contacted or did not respond to inquiries. The CFCs' ability to process cases and arrange for services is limited if there are delays associated with the parents.

As of October 31, 2001, CFC monthly reports identified 1,196 children as delayed in receiving services. We identified instances where CFCs did not include in their monthly reports all the cases where children did not have an IFSP within the required 45 days. Our review of the EI Program's management information will be examined in greater detail in our report covering matters included in Legislative Audit Commission Resolution Number 122, to be issued in the summer of 2002.

As shown in Digest Exhibit 3, delays due to family reasons were cited as the primary reason for a child not receiving services in 52 percent (618 of 1,196) of the cases. Provider delays comprised the second largest reason (239 cases) why children were not receiving services. Provider delays included instances where the provider was untimely in completing evaluations and assessments. The third largest reason for service delays was CFC delays. CFC delays also accounted for 20 percent (234 cases) of the cases where children were not receiving services.

In reporting children delayed in receiving services, DHS distinguishes between children delayed in receiving services due to family reasons (such as parent delays) versus system delays (such as CFC delays, lack of provider, etc.). As of October 31, 2001, of the 578 children not receiving services due to system delays, 493 (85 percent) were reported to be delayed in receiving services for two months or less; 71 were delayed for three to four months, and 14 were delayed for five or more months.

Our 1993 audit reported that IFSPs were not being completed within the required 45 days. The preparation of IFSPs within the 45 day time period continues to be a problem. Of the 1,196 children CFCs reported as delayed in receiving services as of October 31, 2001, 891 (74 percent) were over 45 days without an initial IFSP. During the first six months of Fiscal Year 2002, approximately 50 percent of the IFSPs were not completed within the required 45 days, according to EI staff. A DHS report run at our request showed that IFSPs were completed an average of

75 days after the initial referral, or 30 days longer than required by law. The average number of days CFCs took to complete the IFSPs ranged from a low of 50 days to a high of 106 days, according to DHS.

The potential effectiveness of the EI Program is diminished if services are not received in a timely manner. An important step in receiving needed services in a timely manner is the preparation of the Individualized Family Service Plan within the required 45 days. We recommended that the Department of Human Services should continue to monitor and follow-up on cases where children are not receiving services in a timely manner. When EI system delays are the cause for the delays, action should be taken to address such causes. (pages 26-29)

SERVICE COORDINATOR CASELOADS

There were wide variations in the average caseloads of service coordinators across the 25 CFCs. As of October 31, 2001, the average caseloads ranged from 34 cases to 82 cases. Six CFCs had average caseloads under 40, while 3 had average caseloads that exceeded 70 cases per service coordinator.

High caseloads were cited by several CFCs as a primary reason why IFSPs were not completed within the required 45 days. Some CFCs with high caseloads, however, implemented IFSPs on a more timely basis than CFCs with lower caseloads.

As part of the funding formula for CFCs, DHS based CFC funding on a caseload of approximately 50 IFSP cases per service coordinator. In some instances, projected caseloads did not materialize, according to EI officials; in other instances, CFCs had funded vacancies that they chose not to fill. The Bureau does not have any service coordinator caseload standards.

Service coordinators play a key role in the early intervention system. Excessive caseloads can have a detrimental effect on children and families receiving timely, comprehensive services. We recommended that the Department of Human Services should review the appropriateness of CFC caseloads. (pages 29-31)

PROGRAM INFORMATION AND ANNUAL REPORTS

Our 1993 audit found that the State did not have complete information on the number of eligible children, the number of children served, or the cost of services. The audit recommended that State agencies collect this information and noted that the General Assembly may wish to consider establishing a requirement that such information be reported by the Illinois Interagency Council on Early Intervention (IICEI) on an annual basis. Effective August 11, 1995, the Illinois Early Intervention Services System Act was amended to require that the annual report prepared by the IICEI include this information.

The annual report issued by DHS and the Council for the year ending September 1999 did not contain the statutorily required information on program participants and cost. DHS officials stated that the information required by Section 4 of the Early Intervention Services System Act will be included in the 2001 annual report. Also, the most recent EI annual reports have not been issued in a timely manner. The annual report for the year ending September 1998 was issued in November 1999; the report for the year ending September 1999 was issued in November 2001; and the annual report for the year ended September 2000 had not been issued as of January 2002.

We recommended that the Department of Human Services and the Illinois Interagency Council on Early Intervention should issue the annual report required by the Illinois Early Intervention Services System Act in a timely manner. Furthermore, the annual report should contain the information required by Section 4 of the Act. (pages 33-34)

QUALITY ENHANCEMENT PROCESS

In June 2001, the Department implemented the Quality Enhancement (QE) process, which was established to ensure that all eligible children and their families receive appropriate, consistent, and quality interventions. The QE team (comprised of a developmental pediatrician, an Illinois Medical Diagnostic Network coordinator, the child's CFC service coordinator, the CFC parent liaison, and two local providers) reviews the child's evaluation and assessment.

According to DHS officials, the U. S. Department of Education's Office of Special Education Programs (OSEP) raised concerns regarding the QE process because the IFSP team was not developing the IFSP which details the type and amount of care a child and family will receive. OSEP noted that, "A State may neither confer the final determination of the early intervention services on a body that does not meet those requirements, nor require a parent to initiate mediation or an administrative proceeding . . . in order to secure the early intervention services determined necessary by the IFSP team."

OSEP directed DHS to revise the State's IFSP procedures to make them consistent with the requirements of Part C of the federal IDEA. OSEP has not yet made its Part C grant award of approximately $16.6 million to Illinois for federal fiscal year 2001 pending revision of the QE process. In February 2002, DHS proposed a revised QE process to OSEP for review. DHS plans to implement a revised procedure in some parts of Illinois in spring 2002, with full implementation by July 1, 2002. (pages 35-36)

IMPLEMENTATION OF PUBLIC ACT 92-307

DHS has taken steps to implement many of the requirements of Public Act 92-307, which became effective on August 9, 2001. The Public Act makes significant changes to the Early Intervention Program, including: establishing new eligibility requirements; mandating changes in the credentialing and training of EI providers; setting new insurance and family fee requirements; and requiring the bidding of certain EI contracts. Appendix D in the report contains a summary of the status of DHS' implementation of the requirements of Public Act 92-307. Given that the changes required by Public Act 92-307 have only been recently implemented, the scope of this audit did not include assessing the impact

of these changes or whether changes made to rules, policies, and procedures have actually been implemented in practice. We recommended that the Department of Human Services should continue its efforts to implement all the requirements of Public Act 92-307. (pages 36-37)

STRATEGIC PLANNING

The EI Program has undergone significant changes in recent years. In such a changing Program environment, formal planning is critical to ensure that the changes are consistent with, and supportive of, the main Program goals and objectives.

The Early Intervention Program has taken steps to improve Program planning. In late 2001, the EI Bureau began to develop performance measures for some aspects of the EI system, as well as an Operations Plan that contains goals and objectives to improve the Program's operations and management. DHS developed an Improvement Plan as part of the federal Continuous Improvement Monitoring Process.

In 2001, the Illinois Interagency Early Intervention Council developed a Vision and Mission Statement and established Principles of Early Intervention. While key planning efforts have been initiated, DHS has not developed an overall long-term strategic plan for the EI Program. Such a plan would allow Program managers to assess the degree to which the Program is having its intended effect.

We recommended that the Department of Human Services should establish a formal plan for the Early Intervention Program which establishes goals and objectives, as well as performance measures to determine whether desired outcomes are being achieved. (pages 37-38)

AGENCY RESPONSE

The Department of Human Services agreed with the eight recommendations made in the audit report. The Department's written response can be found in Appendix E of the report.

 

 

WILLIAM G. HOLLAND

Auditor General

WGH\JS

April 2002