Alcance Obras Subterráneas

abused or are likely to be abused and so are at high risk of being placed in foster care or some other protective institutional arrangement. The somewhat controversial assump- tions behind the strategy are that even the most disturbed families often "want to d o right for their kids" and that foster care or other institutional arrangements are often psycho- logically detrimental (Schuerman, Rzepnicki, and Littell, 1994, p. 5). The theory of inter- vention emphasizes family-centeredness, family empowerment, a community orienta- tion, use of the home as the primary service site, and the opportunity that crisis presents to promote positive change (p. 19).

deliver services directly or contract out. Of the state funds deemed saved by avoiding out-of-home placements, 75 percent were to be turned over to these local entities for the purpose of developing community-based services. The other 25 percent were to be retained by state agencies and used for prevention. The Systems Reform Initiative office, which had already emerged within the governor's Office for Children, Youth, and Families, undertook to promote the aims of the legislation.

Whether or not the family preservation strategy contributed to the result, out of state placements decreased in the July to October 1992 period by 51 percent relative to the same period a year earlier.36 In fiscal year 1993, 39 percent fewer children entered out of state placement, and $1.14 million was returned to the local planning entities for local capacity building.37

Progress was slow, however. During the course of hammering out the fiscal 1997 state budget, a variety of interests expressed the feeling that system reform was not proceeding rapidly enough. Despite the leg- islative mandate, a substantial minority of counties had not yet created an official local management board. The performance and potential of some existing boards were seen as inadequate.38 A task force chaired by the lieutenant governor was created to review the entire process. It rec- ommended a new state Commission on Children and Families made u p of diverse stakeholders with substantial powers—for example, set- ting reimbursement rates for providers, conducting program audits of state agencies and local service systems, and recommending to the gov- ernor which individual, state agency, nonprofit organization, or for- profit organization would negotiate annual funding agreements with the localities. Neither the governor nor the legislature officially accepted the report's recommendations, however.

Tennessee Children's Plan (Medium)

The reforming discourse in Tennessee in the late 1980s and early 1990s was not so much about the evils of fragmentation as it was about

36. Maryland Subcabinet for Children, Youth, and Families. 1994. "Status of Systems Reform Fiscal Year 1993," p. 3.

37. Maryland Subcabinet for Children, Youth, and Families. 1994. "Status of Systems Reform Fiscal Year 1994, p. 23.

38.1 rated this Maryland case as a high success. However, I simply felt unable to judge whether the delay for a project of this scale was or w a s not within the bounds of "nor- malcy." I decided to err on the side of tolerance.

the excesses, both humanitarian and fiscal, of having too many children in custody and of treating them poorly while they were in custody. Between fiscal years 1985 and 1989, commitments grew by 28 percent, and a 1989 study by the state Department of Finance and Admini- stration found that 31 percent of those children in custody were in an overly restrictive placement, only 12 percent of the need for family preservation services was being met, and only 31 percent of the need for family mental health therapy was being met.39

The director of Finance and Administration who instigated the study, David Manning, was a personal friend of the Republican governor and had strong ties to leaders of the Democrat-controlled legislature as well. He is said to be a man of great intelligence, drive, and charisma. From his position at Finance and Administration controlling the state's dol- lars, and in conjunction with allies at the top of the state Health Department, he created TennCare, a medicaid-managed care plan, one of the first in the nation. Manning decided to make almost as big a rev- olution in children's services. He called it the Children's Plan and in February 1991 presented it to the legislature's Select Committee on Children and Youth.

The logic of managed care was to be exported, to the extent possible, to this client population as well. Funds hitherto used by the separate departments for custodial services would be pooled into a single account. Interdisciplinary Assessment and Care Coordination Teams (ACCTs) were to manage the cases of each child, and they would use the account to purchase services, if necessary, from any of a variety of private sector vendors.40 The key managerial component in the whole system was to be the twelve regional Community Health Agencies (CHAs), which had been created in October 1989 as part of the TennCare initiative to develop community-based health resources.

By early 1995, although it was not clear that service quality was improving, the system was able to demonstrate average daily costs declining: Whereas in mid-1991 approximately 18 to 22 percent of first admissions were to private psychiatric hospitals, by 1995 these were down to 2 percent.41

39. Tennessee State Department of Finance and Administration (1990, pp. iii-v).