Areas of Concern

A.  The in-home aide supervisor has serious responsibilities and continues to need relief.  The consequences of errors in judgment can be very serious when working with a frail, dependent population.

B.  Residential respite resources continue to be needed for frail adults.

C.  While services have improved, the problems of substance abuse continue to devastate many in the community.

D.  Chronically mentally ill adults have difficulty locating private resources for treatment and usually do not have transportation to other areas or family support.  Many of our most dependent clients have been impacted by divestment and reorganization of the mental health system.

E.  There is a critical lack of psychiatric beds available in the state, resulting at times in clients being released from the hospital before receiving treatment or having to wait long periods of time in the Emergency Department before being transferred to a more appropriate facility that can meet their needs.

F.  Essential transportation needs, whether to local services or out of the county for specialist services, are often not being met by the current county plan.  Social workers and aide staff continue to spend far too much time being transportation aides when their time is needed to fulfill their primary duties.

Recommendations

A.  Create a second in-home aide supervisor position.

B.  Research the development of institutional respite services in other areas and try to develop these services locally.

C.  Continue to educate our staff about substance abuse problems, support local treatment resources, and support the further development of urgent residential options for clients with a critical need.

D.  Work closely with East Carolina Behavioral Health (or another LME the county might choose to oversee local mental health services) to ensure that the problems that mental health has experienced over the last year in particular be rectified and that needed services be made available and accessible as soon as possible to severely mentally ill adults who are difficult to treat.  This would include the availability of mobile crisis services, and also specialty services for geriatrics and others with severe and chronic needs.

E.  Continue to advocate at the state level for improved services for the mentally ill, including adding sufficient psychiatric beds statewide to meet the needs of this population.

 
Children's Services
 

Overview

Children’s Services includes Child Protective Services, In Home Family Services, Foster Care and Adoptions.  State performance indicators show that Dare County is doing a good job of protecting children, working with families, and finding permanence for children that are unable to stay in their biological home.  The unit has experienced four vacancies this year, two due to retirement and two due to personnel issues.  One worker was off for three months on maternity leave, requiring the hiring of an experienced contract social worker to fill her position.  These staffing shortages placed a considerable strain on staff; however, the unit has maintained its sense of cohesiveness and professionalism.

The Multiple Response approach to reports of child abuse, neglect and dependency continues to offer more options to social workers working with families.  Reports of serious neglect and abuse are slightly down from last year, with 97 investigative assessments involving 199 children in calendar year 2009 resulting in only 4 individuals being placed on the Responsible Individuals List.  Family assessments encompassing all other reports totaled 164, involving 229 children. The complexity of all reports and in home services cases has drastically increased. High unemployment has exacerbated the difficulties many of these families face. Lack of resources or lack of money available to access those resources is prevalent.  Social workers have had to become more creative and the hours spent working with individual families is compounded.

In addition to more hours being spent with each family, state and federal documentation and assessment requirements continue to increase. Three and one half hours is the minimum amount of time required to complete the forms for an investigation or assessment.  In December alone, there were 43 of these cases open. Currently, the agency employs only two social workers to handle the majority of these cases. North Carolina state standard is 10 cases per worker. This has forced the utilization of both foster care and in home case managers to assist with these investigations and assessments.  As the requirements for these positions have also increased, workers feel they are barely treading water.  This agency has not added a new position to conduct investigations and assessments in 18 years.

During calendar year 2009, averages of 18 cases per month were served by In Home Case management  Services.  The primary goal of is to provide involuntary child protective services that are designed to ensure the children’s safety, permanence, and well being while helping the parent/caretaker resolve the issues that brought them to the attention of the department.  The contract facilitator for Child and Family Team meetings, a component of In Home Services recently reported that, “the meeting process has been refined so that requirements can be satisfied with a minimum of effort and resources. Family consumers have appeared to embrace the idea as well as real work seems to be going on during the meetings. Dare County is isolated geographically but their CFTs are as leading edge as anyone actually practices in the state”.  This positive feedback shows how well the unit has adapted to significant changes in the way child protective services was offered only three short years ago.

Currently, there are 30 children in foster care, 13 less than last year this time.  In 2009, the number of children in foster care has averaged 36, 10 fewer than the average in 2008.  The services we have been able to provide since July of 2008, with the Flexible Funding provided by the county, have been instrumental in preventing foster care placements and in reunifying families.

Of the children currently in foster care, nine are in licensed foster home placements.  Ten are placed in the homes of relatives.  Two are placed with their parents.  One child is placed at the Wright Place for Youth Group Home and two are placed in out-of-county foster homes.   Four teenagers are in therapeutic placements which provide them specialized services designed to address their mental health issues and needs.  Two children are currently in adoptive placements; one of the adoptions will be finalized very soon and the other will be completed upon resolution of the appeal.

Of the 30 children in foster care at of the close of 2009, 14 have been in agency custody for over one year.  There are a number of factors that have led to this.  Two children living in their adoptive homes remain in agency custody because of legal appeals filed by their biological parents.  A 12 year old boy who is legally free for adoption has not yet been adopted due to his behavioral issues, however, he is currently placed with a foster parent who is interested in adopting him in the near future.  Others have been in agency custody just over one year and will be adopted or placed in the guardianship of relatives, when legally possible for them to do so.  Three children with special needs requiring group home/therapeutic placement have been in agency custody for over one year and are older teenagers (17 years of age) not likely to be adopted or placed in the guardianship of family members.  We have a unique situation involving a teenage mother and her two year old child.  Both have been in agency custody for over one year which has been necessary in order to allow them to live together in the same therapeutic foster home while ensuring the needs of both are met.

Currently, there are 19 licensed foster homes in the county.  There was one foster parent training held in 2009.  The agency has continued to contract with a former foster/adoptive parent to recruit, train and license families and this continues to go well. This contracted position is funded by the Special Children Adoption Fund.

Because we have a sufficient number of foster families interested in providing care to younger children, the agency has made the decision to target our current recruitment efforts to train and license families interested in providing care to older children, ages 8 to 18 years of age.  A senior social worker continues to work with our foster and adoptive families, in addition to her duties as the agency adoption worker.  She has provided ongoing training and support for the foster families, which is crucial in maintaining the stability of placements for children in foster care.

During 2009, there was an average of five children in foster care found eligible for IV-E reimbursement, which significantly increases the amount of reimbursement the agency receives from the state for their care.  Although we started out with a very small number of these cases in the early part of the year, the number has increased monthly, to a current total of ten.  This classification requires specific criteria to be met for initial eligibility and compliance for continued eligibility.  In a review done of these cases in 2009 by state reviewers, we were found to be in compliance for these cases.

The foster care unit was faced with some unique challenges in 2009.  Two children came into the legal custody of the agency with needs beyond those we normally see.  One of these is a seventeen year old with a spinal cord injury resulting in paralysis.  The other is a severely mentally retarded thirteen year old.  In the cases of both, they have required extensive services and advocacy to ensure their needs have been met, to include arrangements for specialized placements, education, medical services and equipment.  Both of these children remain in agency custody and will most likely remain in agency custody long-term.

In 2009, a total of 36 children left foster care.  Twenty of these children were reunified with their parents.  Twelve were adopted by their foster families or relatives.  Four children were placed in the guardianship of relatives or other caretakers, and one former foster child that had been adopted by a grandmother previously was readopted by an aunt when the grandmother died.

The Special Children Adoption Fund is a vital resource in the placement of special needs children. The money is used to enhance adoption programs and secure permanent homes for hard to place children.  The agency received $4,500.00 last year before the fund was exhausted and no other funds were available.  This money has been used primarily for training foster/adoptive parents.

The Special Children Adoption Incentive Fund, a second and separate fund, was allocated by the General Assembly to financially support the adoption of children that had a need for daily supervision due to behavioral and emotional diagnosis or children with a serious medical condition. The funding is a 50% county and 50% state funded program. Currently we have six children that participate.

A new law that became effective in January, 2008 allows for licensed child placing agencies to act as confidential intermediaries between adult adoptees, adult lineal descendants of a deceased adoptee, parents of adoptees under the age of 21, and biological parents. The agency elected to serve individuals that have been adopted through this agency. Two inquiries, both from adults adopted as infants were handled in 2009. Unfortunately neither search was successful.

The Wright Place for Youth, the county group home operated by the Methodist Home for Children as an emergency shelter, provides care to children in the custody of the county, and, on a smaller scale, neighboring counties.  Eleven children, ten from Dare County and one from a neighboring county, were placed at the Wright Place in 2009. 

The Methodist Home for Children continues to provide Intensive Family Preservation Services and Reunification Services, through the state contract.  Additionally, in July, 2008, Family Services became available through this agency to work with our at-risk families.  Family Services provides parent education and independent living skills training and has been especially effective in working with adolescents and their caregivers.  In 2009, six families received In-home Family Preservation Services, seven families received Reunification Services and seven families received Family Services.

Child Protective Services Flexible Funding, provided by the County, has been instrumental in preserving families, reunifying families and providing placement stability for children in foster care.  With this funding, we have been able to provide parent training, mental health counseling services and meet other needs that have arisen in the families with whom we work.  Forty-three families have benefitted from the services made available through this funding.

 Identified Strengths

A.  The staff is very dedicated to protecting children and is dependable, diligent and hard working.

B.  Children’s services staff have a good working relationship with school personnel, law enforcement, the local domestic violence program and local mental health providers.

C.  The legal counsel for the agency is very experienced in children’s services.

D.  Two social workers in the Family Services unit currently provide services for high risk cases. These services has been effective in preventing some cases from becoming child protective services cases and is valuable resource for families who no longer require child protective services, but need support and advocacy.

Areas of Concern

A.  East Carolina Behavioral Health has currently authorized only one agency provider in area with psychiatric services. This not sufficient to meet the needs of our clients.     

B.  Demands continue to be placed on the agency to assist families in dealing with very aggressive behavior or children with unmet mental health needs, when few interventions are provided by other agencies.

C. There are no therapeutic services available to Latino families within a two hour radius of Dare County. Clients have had to travel as far as Greenville for therapeutic evaluation.

D. The current staffing level for the Children’s Services Unit is insufficient to meet state and federal standards. Protection of children is compromised when staffing levels are not sufficient.

Recommendations

A.  Encourage political support for the addition of a family court in this district.

B. Continue the Child Protective Services Flexible funding used for preserving and reunifying families. This funding provides parent training, mental health counseling services and in home services to families.

C.  Continue to advocate for the addition of Spanish speaking therapeutic services for Dare County Latino population.

D.  Create a third Social Worker position to do investigative and family assessments.

On Call Services Unit
 

Overview

The On Call Unit was formed in February 2002 and is currently comprised of four social workers and four supervisors. An additional supervisor will be added in May. The unit provides after hours coverage for emergencies for the department, to include child, adult, family and emergency services reports. Unit members, scheduled on a rotating basis, are available after normal work hours, weekends and holidays, and are dispatched through Dare Central. There were 55 calls concerning adult protective services, medically fragile adults or mentally ill adults, 175 calls concerning child protective services and 10 calls concerning emergency services for families.

The unit continues to function well. Decisions concerning serious child or adult abuse or neglect, all petitions, and court hearings are handled by the respective units. New tracking procedures have allowed supervisors to review specific information about calls. There have been no significant problems within the unit and everyone seems comfortable with the process.

Identified Strengths

A.    The unit is composed of experienced staff and there have been few changes in workers.

Area of Concern

A.  There are only four child protective services social workers that staff on call.  It would be beneficial  to have more diversity in the staff.

B.  There has not been an increase in monetary compensation for eight years. This has made it difficult to attract additional staff.

Recommendations

1. Continue to provide training as needed.

2. Conduct recruitment in the spring and encourage other workers to apply.

  Family Services
 

Overview  

Family Services includes a number of programs and services aimed at supporting family life.  These include:  Food & Nutrition Services, Work First, Family & Children’s Medicaid, coordination of Medicaid Transportation, North Carolina Health Choice, Child Day Care, Employment Services, Medicaid At-Risk Services, Prevention Services, Supportive Services and Emergency Services intake.  An overview by program follows.

Work First Benefits

Effective October 1, 2009, Work First Benefits (WFB) was implemented for all work eligible families with at least one adult in the case receiving Work First.  WFB participants must complete all aspects of their Mutual Responsibility Agreement (MRA) Core Requirements and MRA Plan of Action before receiving a Work First cash assistance check, unless there is good cause.  This includes completing the required hours of work, training, education, or other activities.

Work First families that include an adult are subject to a Federal 60-month lifetime limit of assistance under the Temporary Assistance for Needy Families Block Grant.   They are also subject to a 24-month time limit of Work First assistance in North Carolina.

With the Deficit Reduction Act of 2005 , there is an increased emphasis on meeting the federal requirements for Participation Rates.  Failure to meet these rates can result in financial penalties and the loss of a portion of the state’s TANF Block Grant.

In calculating the federal participation rate (currently 50%), only certain activities “count” in the calculation.  Work eligible individuals must participate in work activities on a full-time basis as outlined in their specific MRA Plan of Action.  A participant’s number of required hours will vary depending on the age of their youngest child and whether the household includes two parents. 

Individuals claiming incapacity (with medical documentation) are not required to meet regular work requirements; however, they do count against the county’s monthly participation rate.  An average of one participant per month has claimed incapacity from 2005 to 2009.

Dare County’s YTD all families participation rate is 55.96%, exceeding the federal goal of 50%.  At this time last year, Dare County’s rate was 47.22%.  YTD, Dare County ranks 2^rd in Team 8 which includes the following counties:  Beaufort, Carteret, Craven, Dare, Greene, Hyde, Jones, Lenoir, Onslow, Pamlico, Pitt and Wayne. The state’s YTD all families participation rate is 44.08%.

The WFB social workers collaborate with community partners to provide opportunities, services and resources to WFB participants.  Many participants in the program are referred to alternative work opportunities while they search for viable employment.  Numerous participants have volunteered at Endless Possibilities, the weaving project operated by Outer Banks Hotline, while others have worked in their thrift shops to obtain countable participation hours and valuable employment skills.   Alternative work experiences have also been offered within the department doing office related tasks such as copying, preparing packets, or assisting with mass mailings.   

In addition to partnering with Outer Banks Hotline, the social workers also work closely with the Employment Security Commission, Coastal Staffing Agency, College of the Albemarle, Vocational Rehabilitation, the Northeastern Workforce Development group, and East Carolina Behavioral Health to assist families in removing barriers to reach their goals. 

The monthly average number of WFB services recipients remained at 16   participants in 2009 – compared to the same number in 2008. 

Services Intake/Crisis Programs

There are four social workers who provide emergency intake services for Dare County.  Three are permanently housed in the Manteo office and the fourth is located in the Hatteras Island Satellite Office.   

Due to the current economic situation, the request for emergency services in both locations has risen substantially.  At the Manteo location, social workers assisted 1,509 individuals with emergency needs in 2008; however in 2009 that number increased to 1,902, representing a 26% increase from 2008 to 2009.  At the Hatteras Island location, 509 clients were seen for emergency services.  This significant increase has dictated the focus of the social workers this year, sometimes resulting in less attention to clients open for ongoing services.  There have been occasions when two other social workers have been needed to assist the three ongoing social workers in order to meet the demands of the community.    

Many individuals applying for emergency services are in economic crisis.  The majority of emergencies are related to a reduction in income or other unforeseen event.  This results in a need for food, heating or cooling assistance, housing assistance in the form of rent or mortgage for those facing eviction, emergency shelter to prevent homelessness, medication assistance, and transportation to medical appointments.  To help resolve these issues, social workers frequently utilize available community resources such as Community Care Clinic, Interfaith Community Outreach, New Horizons, Community Development Corporation, Outer Banks Hotline, Room In The Inn, Cape Hatteras Methodist Men, Cape Hatteras Electric Membership Corporation, the Outer Banks Relief Foundation, and local food pantries.  The Albemarle Food Bank is now serving the area with food distribution to residents in need twice monthly.   

An ongoing challenge for the department is the homeless population in the area.  In January 2009, Room In The Inn began meeting some of this need by offering shelter and food for those needing assistance.  The program is a collaborative effort of several local churches.  They can serve up to twelve people per night and both men and women can be accommodated.  If families are in need of shelter, the program has special funding to pay for short-term emergency shelter in a local motel.  Last year they operated from January 4, 2009 - March 15, 2009.  To assist program coordinators, the emergency services social workers screen potential residents and make requests for transportation to the shelter as needed.    

Adequate mental health services continue to be an ongoing concern throughout the county.  In July 2009, East Carolina Behavioral Health (ECBH) assumed the role once performed by Albemarle Mental Health Center.  They have attempted to be proactive in this role, organizing focus groups and holding community meetings to gauge area needs and concerns.  Clinical services are still limited, with CNC Access/Res Care providing care to those who are uninsured.  The only psychiatrist in the county is housed with that mental health provider.  Many of the individuals seen through emergency intake require or receive mental health services, particularly psychiatry services, so this issue continues to be of concern to the department.  There is still uncertainty about the future of mental health in the county as the contract with ECBH will expire on June 30, 2010.  Without adequate mental health services, including medication access and management, many of the individuals with mental health needs will be at risk. 

Hatteras Island is geographically challenged for transportation and access to specialty medical care, particularly mental health. This challenge is particularly felt for our children and families who must spend more than four hours going to a weekly or bi-weekly mental visit. For families without Medicaid (e.g., NC Health Choice or private insurance), the financial burden is added as well. Dare County Transportation has not always been reasonable alternative as vans typically leave Hatteras early in the morning and return late in the afternoon, resulting in a child missing an entire day of school.  When needed, the Hatteras Island Satellite Office social worker will provide transportation for clients open for prevention services, but this service must be limited due to workload constraints and time out of the office.

Due to the ongoing economic crisis, social workers are still reporting that they are seeing many individuals who are first time visitors to the agency.  This was also the case last year.  In 2009, it is estimated that approximately 35% of the emergency intake clients were requesting assistance for the first time.  This is a decrease from last year but may be because those new to the agency last year are now returning clients.  Many individuals seen were previously in the workforce but are currently unemployed and not eligible for unemployment benefits, receiving unemployment benefits, or underemployed.  This was even applicable during the summer months when tourism was at its peak.  The social workers encountered many situations where individuals were working, but not full time.  It was reported that several large employers were only scheduling their employees to work part time schedules to avoid paying benefits.  Social workers were also told that some employers in the retail industry had their employees “on call” rather than on a weekly work schedule.  Those employees reported that they were called when the weather was poor and business owners expected the tourists to be shopping rather than on the beaches.  The majority of new individuals seen by the social workers continue to be those affiliated with the construction industry; however, there was also an increase in the number of people working in the restaurant industry and other tourist related business. 

The emergency services social workers have also reported that they continue to see an increase in the number of residents affected by foreclosure.  Last year most of those clients were facing foreclosure, but this year more individuals had already been through the foreclosure process. These situations continue to be extremely challenging for the social workers as the available options are very limited due to the severity of their situation.  It is not unusual for these clients to have unrealistic expectations about the amount of assistance available to help them.  The social workers have reported that clients are increasingly frustrated and sometimes hopeless about their current economic crisis.  As a result, in addition to making referrals for economic relief, social workers are making more referrals for mental health services to ensure that clients are connected with all appropriate and available community resources.       

Due to the increased demand but fixed funding sources, emergency services social workers are monitoring funding levels closely and are making conscientious attempts to identify unique and creative ways to assist individuals and families.  Some examples include making payment arrangements with landlords and electric companies or requiring clients to pay a portion of the payment, with the DSS assisting with the balance.  Social workers are completing a budget worksheet with every emergency services client to discuss income and expenses and to brainstorm ways to conserve or reallocate resources to meet their basic needs.  Social workers are making a conscious effort to work with each client to develop a plan for self-sufficiency and set goals to avoid future crisis driven needs.   

The Hatteras Island Satellite Office opened in March 2009.  Since that time, emergency intake numbers have consistently increased as residents have become aware that a social worker is permanently housed at that location.  On Hatteras Island, service requests vary widely and often require collaboration with the income maintenance caseworker to ensure that client needs are met. Because the office is now fully staffed, both the Methodist Men and Cape Hatteras Electric Foundation refer clients to the department for initial screening before they assist clients.  Both organizations indicate an increased use of services this year, in part due to increased access to programs available at the department.  The screenings also assist clients in utilizing available agency programs before community funds are used.

In addition to emergency services, the social workers also provide 200% services to families whose income is below 200% of the poverty level but are not receiving Work First benefits.  The program can provide assistance with work-related expenses such as training, uniforms, car repairs, and car insurance.  Like Work First, the goal is to provide supportive and financial services to keep individuals in the workforce and promote self sufficiency.  This program has continued to grow as families are motivated to remain employed but are facing more financial challenges.  Families who request emergency assistance are evaluated for potential enrollment in this program to meet needs that are related to maintaining their employment. 

Additional services provided by Family Services include Individual & Family Adjustment Services, Health Support Services, Medicaid Transportation, and Problem Pregnancy Services.  Individual & Family Adjustment Services provide services to strengthen the home environments of individuals and families.  Health Support Services assist individuals and families to recognize and address health needs related to alcohol and/or drug abuse, disability, incapacity, or aging.  These services connect recipients with supportive community resources.  Medicaid Transportation services assists Medicaid clients who have no transportation or who cannot afford the cost of transportation to their medical providers.  Problem Pregnancy services are provided to individuals with a complicated or undesired pregnancy. 

Medicaid Transportation is extremely complex and requires considerable attention to detail.  The social workers and other designated staff members spend considerable time reviewing requests for reimbursement in an effort to prevent fraud and to insure only Medicaid covered services are being reimbursed with Medicaid dollars.  When clients have out-of town medical appointments on a day when transportation is not available, they are referred to social services.  This process is extremely lengthy for social workers because they must contact the volunteers from Dare County Transportation to arrange the transportation for the out-of-town medical appointments.  Many times out-of-town non-emergency appointments must be rescheduled in order to utilize Dare County’s Transportation System or because a volunteer driver is not available.  Frequently, social workers bear the brunt of disgruntled clients who don’t understand the limitations of the existing transportation system.   We are working with Dare County Transportation System representatives to more creatively and effectively utilize volunteers for transportation.

When a client receives Medicaid, social workers or the department transportation coordinator must complete transportation assessments for each individual prior to receiving medical transportation services.  Additionally, whenever a client adds a new provider, a modified assessment must be completed.  Some of the factors complicating Medicaid transportation are:  lack of available transportation, both locally and long distance; the considerable geographical distances clients must travel for medical care; lack of local specialists; the current out-of-town schedule Dare County Transportation maintains; and the clients’ lack of understanding and desire to utilize the service.  

Prevention Services

The first prevention social worker was hired in 2005 and a second in 2008 to serve the needs of Hatteras Island.  Both work with families who are at an increased risk for abusing or neglecting their children.  The goal of the program is to prevent abuse or neglect of children by strengthening families.  To accomplish this, the prevention social workers work closely with families to provide referrals, advocacy, and services.  Goals and activities are developed to strengthen the family unit and then the social worker engages with the family to accomplish those goals. 

The majority of the referrals continue to come from the Child Protective Services Unit, Dare County Schools, and the Dare County Health Department.  Some referrals have been received by private therapists and several families have self-referred when they learned about the program and its purpose.  The prevention program is voluntary, primarily consisting of Individual & Family Adjustment services. 

The prevention social workers work with many families who are affected by mental illness, a continuing need for families in our community.  In order to meet the various needs of the families and children in this program, the recommended ongoing caseload is 10-12 cases.  Demand has exceeded availability in recent months, so a waiting list for services was implemented.  There are currently sixteen families on the waiting list; twelve who reside in Northern Dare County and four on Hatteras Island.  The community’s response to the prevention concept continues to be extremely supportive.

In addition to Individual and Family Adjustment Services, these social workers also provide Medicaid At-Risk Services to families who are receiving Medicaid and the children are at risk for abuse or neglect.  To qualify for this service, the child or parent must have a physical or mental deficiency or disability that prevents the child’s needs from being met or the child must have been previously neglected or abused and the factors that led to that treatment are still present.  The goal of this service is to locate, coordinate, and monitor services that are needed or being received by the family to prevent future abuse or neglect.   

In 2009, the northern Dare County prevention social worker served 41 children in 21 families and the Hatteras Island social worker served 29 children in 14 families.  A few of the interventions include:

·     Facilitated mental health evaluations and ongoing care for six families residing on Hatteras Island (three adults and four children).  Social worker collaborated with community and utilized agency resources to provide care at no cost to the clients who were currently ineligible for Medicaid. The resources included the Yellow House Ministry and CPS Flexible Funds as well as pro bono sessions from two private local mental health providers.

·     Worked with an extended family to reunite a mother and her three-year old child.  The mother participated in outpatient substance abuse treatment, parenting classes and became gainfully employed. She was accepted at Grace Court, an intensive long-term residential substance abuse program in Robeson County where she is receiving not only substance treatment, but also education, parenting skills and related support services for her child.

• Assisted four families in finding and arranging residential placement for their children when their mental health needs could not be met in our community

• Assisted several families in psychiatric hospitalizations after their children exemplified homicidal and/or suicidal behaviors.

• Assisted disabled mother and her children in moving to the Hotline Shelter and then on to her own home after being a victim of domestic violence for many years.  She is now self-sufficient and residing independently with her children.

Child Day Care Services

The current allocation for direct services for fiscal year 2009-2010 is:

        $  1,065,469           Subsidy Child Care funds

               151,931           Smart Start funds

               162,727           ARRA funds

        $ 1,380,127           Total funding

For service months June 2009 through December 2009, a total of $ 786,707 has been utilized to assist families through the Child Day Care Subsidy Program, a spending coefficient of 98%.  This is a 31% increase over the same period in 2008, with a spending coefficient of 89%..

On June 1, 2009 the subsidy program initiated a waiting list for new applicants, based on several factors:

·   An increase in the cost of care was anticipated when several child care facilities would earn a higher star-rated license, which increases the subsidy payment rate. 

·    Knowledge that one or two subsidy children would be approved for an additional monthly payment for a one-on-one special needs aide to assist them in the child care setting. 

·    As more Smart Start funds were being utilized to pay the Enhancement Bonuses, less of these funds would be available to pay for child care.

In October 2009, funds from The American Recovery and Reinvestment Act of 2009 were released, and Dare was given $ 162,727.  Initially, these funds were spent along with regular subsidy funds to alleviate any potential overspending.  As spending began to decrease in November, and additional Smart Start funds were received, the decision was made to utilize ARRA funding through Time Limited Vouchers.  Parents on the waiting list were contacted, and if they met subsidy criteria, were approved for assistance through May 31, 2010.  As of February 1^st, 19 children have been approved for care using Time Limited Vouchers.  All parents on the waiting list will continue to remain on the list awaiting regular funding, regardless of whether they were served with the Time Limited Vouchers or not.  There are currently 187 children on the waiting list.

It is apparent that changes in the economy continue to affect the demand for child care assistance.  Some families indicate that the mother is working one or more jobs while the father is home with the children, because construction-related jobs are not available.  Other families with working parents have found relatives, friends or unlicensed providers to watch their children, with little or no cost to them, rather than use subsidy care.  Several families have moved out of Dare County to seek job opportunities and/or be near family who can help with child care. 

In December 2009, the subsidy program served 259 children, a 13% decrease from the 292 children served in December 2008.  This is a 33% decrease from the 344 children served in December 2007.

Subsidy staff has been spending more time screening families to determine if they qualify under other criteria if they are unable to find employment, referring parents to jobs that may not be advertised, and giving job search/interviewing advice.  Parents are referred to the community college to enroll in GED or college courses, the local Employment Security Office, and websites listing jobs.  Guidance is given to parents with part-time employment to assist in either finding part-time child care, or finding additional employment. 

Dare County continues to have six More at Four classrooms that currently serve 108 children.  More at Four is a preschool program that offers a high quality, pre-kindergarten education for at-risk four year olds who meet the eligibility guidelines.  Many subsidy parents and parents on the subsidy waiting list have been able to place a child in this program, or Headstart, at no cost to the parent. 

The subsidy program continues to administer payment of the Smart Start Enhancement Bonus Program initiated by the Children & Youth Partnership, which is a bonus paid to child care providers with 3-5 star licenses, and for children aged birth through two.  Smart Start funds are also used to pay for child care, along with regular subsidy funds. 

Subsidy parents continue to struggle with their payment to providers who charge more than the state market rate, primarily child care home providers.  When the provider charges more than the rate paid by the subsidy program, the parent must pay the difference between the two amounts, in addition to their DSS parent fee.  For example, a licensed two star center charges $672 per month for an infant, however, the subsidy rate is $445 (a difference of $227).  This issue is compounded if the parent has multiple children in child care.  Several providers have agreed to temporarily waive this fee for children served by Time Limited Vouchers.

Identified Strengths

1. Family services staff are dedicated to providing quality services to those in need, in a caring,  compassionate manner. This unit has 173 years of experience in Social Services.

2. The family services unit includes social workers and income maintenance caseworkers providing an environment that encourages sharing  of ideas, sharing of important information, and “ownership” in the well-being of the individuals served by both types of these workers. 

3. Family services works well as a team.  There is a great deal of cross training and staff back each other up as demand indicates.

4. The addition of a prevention services/emergency services social worker for Hatteras Island has enabled the department to better serve families with children who are at risk of abuse and/or neglect in southernmost Dare County, and to provide emergency services intake more efficiently. 

5. Members of the family services unit are involved in various agency and community committees and boards,   including the   

6. Dare County Board of Education’s  Exceptional Children Advisory Committee, local Interagency Coordinating Committee, Parenting   Enrichment Partnership, DSS Permanency Planning Team, Outer Banks Community Development Corporation-Emergency Housing Committee, Dare County Interagency Coordinating Council, 4-H & Youth Foundation Board, Child Care Resource and Referral Early Learning Task Force, and the More at Four Selection Committee.

7. The agency continues to receive positive feedback from school officials, local mental health workers, private therapists, and various community entities concerning our prevention services program.   The successes of the program have been met with suggestions of hiring additional prevention social workers to provide these valuable services. 

 Areas of Concern

1. Providing emergency services intake has become more complex and time consuming due to the severity of the financial and emotional burdens carried by the clients.  The social workers have reported that clients are increasingly frustrated and hopeless as a result of their current economic crisis.  In addition to making referrals for economic relief, social workers are making more referrals for mental health services to ensure that clients are connected with all appropriate community resources.       

2. The cost of child care in Dare County exceeds the market rates approved by the Division of Child Development, thus forcing subsidy parents to pay over and beyond the recommended fees. 

3. The need for an additional prevention services social worker for Northern Dare County is apparent by the full caseload of the current prevention services social worker.  New referrals to the program are made almost weekly and twelve children are currently on a waiting list.

4. The prevention services social worker spends a great deal of time transporting children to and from necessary appointments with counselors and doctors due to parents having conflicting work schedules or lack of transportation.  The Dare County Transportation Program cannot transport individuals under the age of 18 without an accompanying adult.  Although the time with a client is always time well spent, many transportation needs could be met by someone other than the social worker.

5. The challenge of assisting incapacitated Work First recipients continues to be problematical for the WFB social workers.

6. The inflexibility of the current Dare County Transportation Program as it relates to Medicaid recipients makes it difficult for all clients to obtain needed transportation. Hatteras Island is geographically challenged for transportation and access to specialty medical care, particularly mental health. This challenge is particularly felt for our children and families who must spend more than 4 hours going to a weekly or bi-weekly mental health visit.

Recommendations

1. Support the development of approved child care facilities.

2. Explore means of assisting subsidy parents with paying the cost of day care exceeding the local market rate.

3. Hire an additional prevention social worker to serve families in northern   

4. Dare County. 

5. Hire a social worker assistant to assist in transporting children to their required appointments. This person could also assist Work First employment recipients when transportation is a barrier to obtaining and maintaining employment. 

6. Continue to support the creation of avenues with which the department may work with incapacitated Work First parents.

7. Encourage daily out-of-town transportation routes through the Dare County Transportation  Program for Medicaid recipients.

Economic Services
 

Overview  

The Economic Services Unit is responsible for assessing an individual/family’s need for temporary assistance offered by one or more public assistance programs administered by social services.  Dare County is unique in their approach to this process in that staff assigned to this unit are knowledgeable in all program areas.  The benefit is a more customer friendly approach allowing an individual/family to share their situation with one expert caseworker to evaluate their situation and, if necessary, refer them to agency social workers and/or community resources.  The structure of this unit has been particularly beneficial with the increase in new applicants over the past year. 

Persons applying for assistance today are often individuals that once had a year or more of household expenses saved up and have depleted their savings due to lack of work, mostly in the construction or real estate industry .  They are watching their assets dwindle as they go into foreclosure or items such as vehicles, boats, work trailers and campers are repossessed.  Individuals that once invested in real estate as a means to have a secure retirement are now moving from home to home as they go into foreclosure.  Families are being forced to live apart in one parent’s efforts to seek work elsewhere while the other parent tries to maintain the home while children attend school in Dare County.  Staff throughout the agency has demonstrated tremendous caring and compassion as they go through the lengthy process of explaining programs and processes to individuals new to this experience.

The programs individual/families are assessed for include; Work First Family Assistance, Benefit Diversion Assistance, Food and Nutrition Services (formerly known as food stamps), Medicaid, North Carolina Health Choice and Special Assistance. These are means tested programs that assist with the prevention of a crisis or the provision of nutritional, medical or financial support to remedy a situation when a family is already in crisis.  Work First Family Assistance provides temporary cash assistance and Medicaid to qualifying families with children age 18 and younger.  Benefit Diversion Assistance is a short-term money payment intended to assist families that are temporarily out of work.  Food and Nutrition Services help low income individuals/families purchase food.  Medicaid provides individuals/families with a means to access needed health care.  North Carolina Health Choice provides health coverage for children under age 19 whose parental countable income is at or below 200% of the federal poverty level.  Special Assistance provides assistance to persons living in adult care homes (rest homes) that have a financial need and are age 65 or older or between the ages of 18 and 65 and meet the Social Security definition of disabled or blind.   

There were a total of 5,291 applications registered for these programs during calendar year 2009, a 13.8% increase from the 4,651 applications received in 2008.  More significantly if you compare the 3,891 applications received in 2007 this reflects a 36% increase in applications received since 2007. The Food and Nutrition Services (FNS) program alone saw an increase from 1,460 applications in 2008 to 1,747 in 2009, a 19.7% increase. If you compare this increase to the 1,015 FNS applications received in 2007 there is a staggering 72.1% increase.  This program is very responsive to local economic conditions.  The staff have done an incredible job keeping up with the dramatic increases in demand for services offered.

Individual case situations have become more complex with people seeking assistance in multiple programs.  Additionally, there has been an increase in the number of referrals being made to agency socials workers and/or community resources.  Income maintenance caseworkers and social work staff completed 1,114 referrals to the food pantries in 2009, a 45.25% increase over the 767 in 2008.

By far the largest number of applications received is for Medicaid.  The agency has seen many new individuals seeking assistance as family incomes have decreased due to lack of employment opportunities.  Typically one of the first things a family cuts from their budget, when they experience decreases in income, is health insurance.  In 2009, the agency received 3,326 applications for some type of medical assistance through one of the many Medicaid and Special Assistance programs.  This compares to 2,999 in 2008, reflecting a 10.9% increase in applications in these program areas. When comparing the 2,399 applications received in 2007 this is an increase of 38.6%. Likewise there was an increase in Medicaid expenditures.  In 2009, $23,438,489 was billed to Medicaid for Dare County residents.  This is a 7.2% increase from the $21,868,309 in 2008.  The numbers in part reflect individuals that once had health coverage but were forced to drop it when their income decreased due to lack of employment. 

One of the biggest changes that occurred in all Medicaid programs in 2009 was the implementation of the NC Medicaid Program issuing only one Medicaid card per year to each participant.   This change became effective September 8, 2009. With this change also came the requirement that providers, i.e. doctors, therapists, etc. now verify a person’s eligibility, either through electronic means or by an automated voice response system.  Both of these changes deviated drastically from years past in that the Medicaid card has historically been issued once a month and the Department of Social Services was responsible for verifying eligibility should a provider need assistance.  The agency did an outstanding job networking with local health care providers through meetings and conferences to explain how this change might impact their practice.

Economic Services has a full time case worker located in Frisco at the Hatteras Island Satellite Office. Since opening its doors March 15, 2009, that caseworker has registered 346 applications for individuals/families in one of the many public assistance programs offered.  The presence of a full time caseworker has had a positive impact for residents on Hatteras Island.

An additional caseworker was hired in November 2009 to be positioned at the Outer Banks Hospital.  This position is funded in part by the hospital to take Medicaid applications at that location. 

A more detailed overview by program follows.

Work First Family Assistance

Work First Family Assistance provides temporary cash assistance to families with children who are either in a crisis or have the potential to be in crisis.  In addition to cash assistance, eligible families receive Medicaid and frequently receive Food and Nutrition Services. The adults included in the assistance unit are required to work with an employment social worker to develop a plan of action that will remedy their situation, allowing them to become self-supporting. Effective 10-1-09 the Federal Final Rule from the Deficit Reduction Act of 2005 along with legislative mandates now requires individuals to complete all aspects of their Mutual Responsibility Agreement and Plan of Action each month prior to receiving a check.  This excludes child only cases. 

The application caseworker completes all the necessary paperwork, including an appointment time for the employment social work staff and, if needed, registers the applicant for work with the Employment Security Commission. Work First Family Assistance saw an increase in requests for assistance in 2009 with 218 applications received. This is an increase of 13.5% over the 192 applications received in 2008.  Of those applicants, there was a significant decrease in those requiring registration for employment.  During the January – December 2009 period there were 63 applicants registered for work through First Stop with the Employment Security Commission.  This is a significant decrease from the 106 in 2008. 

The average monthly number of Work First cases increased by 16% when comparing calendar year 2009 to calendar year 2008, with a monthly average of 51 households in 2009 and 44 in 2008.  Although only a difference of seven cases, this is the first increase since 2006, when the average number of cases was 50.  We attribute this to the downturn in the economy.

The number of Work First adult households remained the same when comparing calendar year 2009 to calendar year 2008, with a monthly average of 16 households. The number of Work First child only cases increased by 33% when comparing calendar year 2009 to calendar year 2008, with a monthly average of 35 in 2009 compared to 27 cases in 2008.  The largest increase is in the undocumented alien population, where only children born in the United States are included in the benefit amount.  Total expenditures for Work First cash assistance averaged $11,018 per month during the 2009 calendar year, a 13.7% increase from the monthly average of $9,693 during calendar year 2008.

Benefit Diversion Assistance allows for three months of cash assistance in the form of a lump sum payment.  The family’s situation is evaluated to determine if short term assistance will help keep a family from a crisis situation.   There was a 72% increase with 43 cases approved for Benefit Diversion Assistance during 2009 compared to 25 cases approved in 2008.  In part this is due to the increase in request for assistance by individuals that cannot qualify for unemployment benefits due to citizenship requirements but have a child born in the United States and are in need of some short term help until they are able to return to work.  With the increase in layoffs individuals that qualify for unemployment have been able to receive help through benefit diversion assistance during the waiting period for unemployment benefits.

Food and Nutrition Services

Food and Nutrition Services (formerly referred to as food stamps) helps individuals and families increase their purchasing power to provide more nutritious meals, promoting better health.  Individuals or families must meet income guidelines (at or below 130% of the Federal Poverty Level), and asset, citizenship and work requirements in order to be eligible to participate. Applications are available in various locations throughout the county and can be requested by phone, allowing for more accessibility to the program.

There were a total of 1,747 applications received for Food and Nutrition Services during calendar year 2009.  This is a 19.6% increase from the 1,460 applications received during in 2008.  There was a significant increase in food stamp mail-in and drop-off applications with the department receiving 374 in 2009; a 39.5% increase from the 268 applications received in 2008. Out of the 1,747 applications received in 2009, 21.4% were mail-in applications.  There were 595 applications by first time applicants in 2009, a 62.1% increase from the 367 applications received in 2008.

There was a 48.7% increase in the monthly average number of households receiving food assistance when comparing calendar year 2009 to calendar year 2008, with 1,020 receiving in 2009 and 686 receiving in 2008. The monthly average number of individuals participating in the food and nutrition services program was 2,154 in 2009, a 51.2% increase from the monthly average of 1,425 individuals in calendar year 2008.   Average expenditures per month in calendar year 2009 were $267,018 compared to $143,206 in 2008, an increase of 86.5%.

    Food and Nutrition Services Activity

The tremendous growth in food assistance over the past five years is evidenced by reviewing

the statistics below.  Applications have increased by 93.7% during this period and the number of first time applicants has increased by 134.3%. There has been a 175.7% increase in the number of households receiving assistance, a 189.1% increase in the number of individuals receiving assistance, and a 349.7% increase in average monthly expenditures. 

The Food and Nutrition Services staff assigned to processing and ongoing responsibilities remained at two workers for many years.  In April of 2008, these two workers accepted the additional responsibility of interviewing clients whose Food & Nutrition applications were received in the mail, to expedite possible emergency applications.  Although very beneficial to the clients, it was very demanding for these two workers. 

The average Food & Nutrition Services caseload was 343 per worker in calendar year 2008.  By April 2009, the average caseload had grown to 500 cases per worker. A great deal of overtime was necessary and customer service – in particular, returning phone calls, declined.  In June of 2009, an additional Food & Nutrition Services worker was hired with Funds from the American Recovery and Reinvestment Act.    

Food and Nutrition state representatives recognize that workers who take applications, process, and maintain Food & Nutrition cases begin making errors when caseloads exceed 275 cases.  At the present time, caseloads are averaging 398 per worker.  It is important to note that if an agency Food & Nutrition Services caseworker makes an error causing an overpayment to the recipient, the recipient must pay the overpayment back to the Food & Nutrition Service Program.  Many times, this can cause extreme hardship to the client.

Family Medicaid and North Carolina Health Choice for Children

Family Medicaid programs allow children, families and pregnant women to access emergency and routine preventative health care.  The family Medicaid programs have become increasingly complex to administer.  Policy changes resulting from the Deficit Reduction Act continue to be the most cumbersome to deal with when interviewing and processing applications for medical assistance.  Mandates that went into effect September 1, 2006, required that all applicants for Medicaid must provide proof of citizenship and identity.  In the past, proof of citizenship was required only if the individual’s statement was questionable.  The state has taken measures to try to alleviate this problem by automatically validating social security numbers with the Social Security Administration once the application is registered with the state and a valid social security number is entered.

There were 2,612 applications received for Family Medicaid in 2009.  This is a 7.2% increase over the 2,437 received in 2008. 

Included in the Family Medicaid programs is Presumptive Medicaid which provides short-term medical coverage to pregnant women who would not otherwise be eligible to receive assistance due to citizenship.  Eligibility for this program is determined by the Dare County Department of Public Health. There were 238 applications authorized in January through December 2009; this was a 9.2% decrease from the 262 applications authorized for the same time period in 2008. 

The number of average Family and Children’s Medicaid households increased 12.4% when comparing calendar year 2009 to calendar year 2008, with 1,771 households in 2009 and 1,576 in 2008.  The number of individuals increased by 14.2%.

North Carolina Health Choice is a health insurance program for children that are not eligible for Medicaid due to family income.  All applications received for this program are received as Medicaid.  Once income is provided and budgets are completed the caseworker will either approve the child for Medicaid or North Carolina Health Choice depending on the countable income that has been determined through the budgeting process. There was a slight increase in the number of North Carolina Health Choice applications approved.  During January through December 2009, 256 Medicaid applications were approved for North Carolina Health Choice.  This is a 20% increase from the 213 that were approved in 2008. 

When comparing calendar year 2009 to calendar year 2008, the number of households receiving NC Health Choice assistance increased by 4.5%, with an average of 327 households receiving assistance in calendar year 2009, and 313 households receiving assistance in 2008.   Over the same months, an average of 477 children received assistance in 2009 and an average of 429 children received assistance in 2008, an 11.2% increase.

In reviewing the total number of Family & Children Medicaid and North Carolina Health Choice households, there was a 11% increase when comparing calendar year 2009 to calendar year 2008.  

 Family Medicaid and North Carolina Health Choice

There are three caseworkers assigned to process all Family Medicaid and North Carolina Health Choice applications received through the mail, from re-enrollments (case reviews) or office visits.  These applications tend to be complex in that there are so many programs to evaluate for; Medicaid for Pregnant Women, Medicaid for Infants and Children, Medicaid for Families and Family Planning Medicaid.  Each program has slightly different income and resource guidelines and requires multiple budgets before reaching the appropriate program of eligibility.  This process is required on most all of the applications received seeking some type of medical coverage.

In the Family Services unit, four workers are Medicaid and Work First case managers and one worker is a lead worker for Food & Nutrition Services, Work First cash assistance and Family & Children’s Medicaid.  This lead worker also carries a caseload of approximately 100 -110 foster care Medicaid cases. The four Medicaid and Work First case manager’s average caseloads have increased by 16.5% when comparing calendar years 2009 and 2008.  In 2009 the average monthly caseload was 515 compared to 442 cases in 2008.  Currently, the average caseload is 549 cases.  According to Family & Children’s Medicaid/NC Health Choice staffing recommendations, caseworkers should carry a maximum of 350-400 cases.  An additional worker is needed if current case numbers continue or increase.

On October 24, 2000 President Clinton signed into law the Breast and Cervical Cancer Prevention and Treatment Act of 2000.  This act gave states the option to provide medical assistance through Medicaid to eligible women who were screened for and found to have breast or cervical cancer including precancerous conditions.  The North Carolina General Assembly approved funding for this option in Senate Bill 1005.  In North Carolina the program is known as Breast and Cervical Cancer Medicaid (BCCM).   

Once accessed, BCCM provides wonderful coverage for the diagnosis and treatment of breast and/or cervical cancer.  The woman’s income must be at or below 250% of the Federal Poverty Level and she must not been enrolled in Medicare Part B or have any creditable medical insurance coverage.  

Accessing this program is cumbersome, at best, in that in order to gain coverage in BCCM the woman must be screened through the Breast and Cervical Cancer Control Program (BCCCP).  In Dare County the Department of Public Health administers BCCCP.  In collaboration with the Department of Public Health, the agency has helped to educate physicians’ offices regarding how to advise their patients to gain access to this program.  The agency hosted a health coverage conference in September with 32 attendees representing various health care providers.  Additionally the agency continues to attend quarterly physician’s breakfast meetings at the Outer Banks Hospital to present general information about this and other Medicaid programs.  

The agency is represented on the Healthy Carolinians Breast Cancer Task Force. The task force is busy working with state staff to advocate for easier access to this much needed health coverage program for women facing breast or cervical cancer.  

Adult Medicaid

The Adult Medicaid programs encompass Medicaid for Aged, Blind and Disabled of any age.  It also includes assistance with the costs of Medicare premiums, deductibles and coinsurance for low income recipients.

Total cases rose 15.3% during the year from 671 in December 2008 to 718 at the end of December 2009. A total of 690 applications were made this year to Adult Medicaid. 

The three caseworkers in the Adult Services Unit are responsible for processing all applications for Medicaid for the Aged, Blind and Disabled and for Special Assistance for the Aged and Disabled and for maintaining all ongoing cases.  They have again done an outstanding job with these complex cases which often require research into policy, verification of many types of resources that are available to the client, and the ability to understand and navigate the complex processes that enable clients to receive long term or continuing services to meet their health and mental health needs.  Adult clients are more likely to own property, trusts, annuities, and insurance policies – resources that may be countable in the adult programs.  These clients are also more likely to have multiple health problems and need extensive or long term medical services.  The caseworkers must often rely on representatives for information due to the advanced age or incapacity of the client to provide information.

The Department was notified in late 2009 that automatic applications for the Medicaid for Qualified Beneficiaries (MQB) program will be generated from Medicare Low Income Subsidy applications, applied for through Social Security.  The department is then responsible for processing the application to determine whether the person qualifies for the Medicaid for Qualified Beneficiaries program.  This change was effective January 1, 2010, and it is estimated that there are 48 persons potentially eligible for the MQB program which could cause in an increase in the MQB caseloads.

Medicaid to the Aged Blind and Disabled – Medicaid for Qualified Beneficiaries Activity

Within the Medicaid aid categories of Aged Blind and Disabled, the largest numbers of applications received are for Medicaid to the Disabled, requiring a disability determination.  Case record documentation is more in-depth for this program than in most others, stating detailed physical and mental medical symptoms to assist the Disability Determination examiner with their decision.  These applications are received from individuals or from area hospitals.  Most hospitals will not allow an uninsured individual to apply for charity funds unless they have first been determined ineligible for Medicaid.  Mental health providers and substance abuse counselors often require uninsured individuals to seek Medicaid coverage to help off set the cost of the individuals’ treatment plan.  Of the 690 adult Medicaid applications received, 466 were for Medicaid to the Disabled; of those 304 or 53.5% were denied with the bulk of those denials being determined not under a disability by the Disability Determination Section.

State/County Special Assistance

The Special Assistance program provides a monthly benefit check to clients who are residing in Adult Care Homes such as Spring Arbor. The benefits help pay the cost of care if their other income is less than the set rate.  The NC General Assembly sets the rate each year that such facilities may charge public assistance clients.  In addition to the basic room and board rate, homes may bill Medicaid a daily rate for basic personal care assistance and an enhanced rate for more intense personal care if provided.  There is also a component of this program that helps clients at risk of placement remain in their own home if there are documented services that, if provided, enable them to have a sufficiently safe environment and other services.  This is called the Special Assistance In-Home program. Counties are given a limited number of slots for this second category.  Dare County currently has 24 slots with no vacancies. To qualify for the program, the client’s doctor must provide diagnostic and patient care information that indicates a need for care in an adult care home.  An in-depth evaluation is done in the home by a social worker using the Resident Assessment Instrument for Home Care.  If essential unmet needs are identified that can be met given funding, the social worker completes a detailed budget recommending an amount to meet those needs and submits it to the caseworker.  The check amount is then authorized and the support identified by the social worker to help the client obtain the needed items, move to a safer environment, make repairs or adaptations to his home, etc., is provided.  The needs most often paid for are housing, food and nutritional supplements, medical supplies or equipment; many of these clients also receive help with budgeting or receive payee services.  An SA-In-home client will never receive a check that is more than 75% of the amount he would be eligible for if placed in a facility.  At the end of December 2008, the average SA payment for Dare County clients living in Adult Care Homes was $479.00.  The average payment for SA In-Home clients was $365.00.           

This table shows the applications and monthly average caseload activity in State County Special Assistance for 2008 and 2009:

Program Integrity

Referrals for investigation are received through many sources:  the community, employers, friends and relatives and case reviews.  This position works closely with staff throughout the agency in trying to ensure individuals and families are receiving benefits at the appropriate level.  Since the state has changed their reporting requirements so food stamp recipients are no longer required to report a change in income unless it causes them to be ineligible, it has reduced the number of claims established due to unreported income.  If a recipient is receiving from more than one program all records are reviewed for consistency of information and what effect the reported information might have on past and future eligibility. 

Due to economic conditions, the agency was forced to move the investigator to an intake position to assist with the increasing number of requests for assistance.  The chart below reflects a decrease in the number of referrals being made and decreases in the agency’s ability to investigate, collect claims or refer individuals to court.  While we had hoped the increased demand for services would have leveled off, the continued down turn in our economy has caused the program integrity investigator to continue assisting with applications; leaving little time to investigate referrals.  The agency is out of compliance with state mandated timeliness of referral status of case either being substantiated or unsubstantiated.

In chart below the decrease in collections is directly related to the dramatic decrease in collection from either state or federal tax intercept.  There was a 78% decrease in monies received through tax intercept of $698 in 2009 compared to $3,250 in 2008.  It should also be noted that the stimulus checks issued in August 2008 contributed to the money collected in 2008.  With the increase in unemployment most individuals have either not filed a return or are not due for a tax refund. 

Identified Strengths

A.  Caseworkers throughout the agency are experienced and professional, performing at a very high standard. They compassionately advocate for those individuals in need of services and are dedicated to meeting or exceeding state standards.

B.  The co-location of caseworker staff with social work staff has deepened their understanding of the range of problems and needs that face individuals seeking assistance.  They are able to work more effectively with social workers to access available resources more efficiently.

C.  The structure of the initial assessment process allows for better customer service and expert evaluation of available programs and services offered.

D.  Agency staff serves on state level committees allowing for input to affect change in some policy areas.  Additionally, the agency is represented on many local boards and tasks forces creating effective communication with sister agencies; addressing many medical and mental health issues in Dare County. 

Areas of Concern

1. The number of households receiving Food & Nutrition Services has increased 175.75% over the past five years.  Although an additional case worker was hired in June 2009, current caseloads average 398 per worker.  As discussed earlier, state representatives recognize that workers with these responsibilities begin making errors when caseloads exceed 275 cases.

2. The number of households receiving Family & Children Medicaid/NC Health Choice has increased 11% when comparing calendar year 2008 to 2009.  According to Family & Children’s Medicaid/NC Health Choice staffing recommendations, caseworkers should carry a maximum of 350-400 cases.    Currently, the average caseload is 549 and an additional staff person is needed now if current numbers continue or increase.   

3. The lead worker for the Economic Intake Processing Unit has been forced to assume responsibility for processing Work First Family Assistance applications in addition to processing Presumptive Medicaid applications, Breast and Cervical Cancer and some other Medicaid cases leaving little time to provide direct staff training or case reviews.  The lead worker for adult Medicaid programs has also had to carry a significant caseload.

4. Due to increase demands in applications for economic services programs; the program integrity caseworker has not been able to pursue the duties of program integrity full time.  This has caused the agency to be out of compliance with state mandates in timeliness of substantiating/unsubstantiating fraud referrals.

Recommendations

1. Monitor the Food & Nutrition Services caseloads to assure a manageable workload.
2. Explore the possibility of securing an additional Family & Children Medicaid/NC Health Choice case worker to create manageable caseloads.
3. Monitor adult Medicaid caseloads and add staff as required.

 Administration
 

Overview

In general, the administrative side of the department functions at a high level.  In particular, fiscal and personnel matters are well managed.  The department is extremely fortunate to be able to utilize automation to the extent we do.

Facilities

The new Hatteras Island Satellite Building, which included Social Services offices, was completed in 2009.  This facility should meet our needs for many years.

Recruitment/Retention

In FY 08-9 the agency had a turnover rate of 14%.  This is up from the 6% turnover rate from FY 07-08. 

             Total #                                         Total %

Unit                  of Position        Term                 of Turnover       Avoidable         Unavoidable

Clerical                         8              4                           50%                 100%                      0%

Income Main.             23              2                             5%                    50%                   50%               

Social Work               22              1                           14%                   66%                   34%               

Other Admin.             14               1                             7%                     0                     100%         

So far in 09-10 the agency turnover rate is 7%.

Interpretation

We continue to see a significant number of non-English speaking clients.  We are fortunate to have several bi-lingual staff as well as a full-time Interpreter.  We also contract with a telephone interpreter service.

File Management

The department’s file room is close to being filled to capacity.  We are unable to purge many records due to federal audits.  We are exploring expanding our modular filing system.  It will soon be necessary to transition to an imaging system.

Fiscal Management

The department’s fiscal life continues to be excellent.  We are collecting all available federal and state revenues.  We have experienced some state budget reductions and others may be forthcoming.

Organization

The Family Services Unit is currently comprised of 17 staff members, with the need for at least two additional positions.  A normal span of control for a supervisor is 8 – 10 supervisees.  This unit may need to be split which may lead to some departmental reorganization. The Adult Services Unit has similar issues.

Leadership

Most of the department’s management team are baby boomers and the potential exists for a number of leaders to retire in a short period of time.  Our adult services supervisor did retire this year and was replaced with an experience, external candidate.  In most units, emerging leaders have been identified.

Automation

The process of documenting workers time for state purposes was automated so that workers enter their day sheet information into the global database and then the data is uploaded to the state’s legacy system for processing.  This enhancement to our Global Database eliminated double entry of day sheet information.

A preventive services database was designed and implemented for the social workers that work with clients that require preventive services.  This database gives workers a better method of organizing their client data.

DSS email spam blocker was switched from Hexamail to Postini to enable email archival as required.  Postini had already been implemented by the County and we were able to “piggyback” their system with no cost to DSS.

Hatteras Island Satellite Office was set up so that the workers in Frisco can access data on our network in Manteo.  This gives us the ability to share information more efficiently.

Identified Strengths

1. The Department’s administrative staff is very strong.  The financial life of the department is well-managed.

2. Our ability to provide interpretation services is still sufficient.

3. Turnover is at a manageable level.

4. Automation continues to be on the leading edge within the agency.  The ability to customize our databases in-house gives us more flexibility than most other agencies.

 Areas of Concern

A.     We have insufficient file capacity.

B.     Two units have grown very large.

Recommendations

1. Explore imaging systems and expansion of current modular filing system.

2. Explore reorganization of Family Services/Department as funds permit