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“Creative Financing”: Funding Evidence-Based Interventions in Human Service Systems - PMC As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. .

Author manuscript; available in PMC: 2020 Jul 1. Published in final edited form as: J Behav Health Serv Res. 2019 Jul;46(3):366–383.

doi: 10. 1007/s11414-018-9644-5 “Creative Financing”: Funding Evidence-Based Interventions in Human Service Systems Elise Trott Jaramillo , Ph. D.

1 Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, 851 University Blvd SE, Suite 101, Albuquerque, NM, 87106, USA 3 Department of Anthropology, University of New Mexico, MSC01-1040, Anthropology 1, Albuquerque, NM 87131, USA Find articles by Elise Trott Jaramillo 1, 3 , Cathleen E Willging Cathleen E Willging , Ph. D.

1 Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, 851 University Blvd SE, Suite 101, Albuquerque, NM, 87106, USA 3 Department of Anthropology, University of New Mexico, MSC01-1040, Anthropology 1, Albuquerque, NM 87131, USA Find articles by Cathleen E Willging 2 Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (8012) La Jolla, CA 92093-0812, USA Find articles by Amy Green 1 Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, 851 University Blvd SE, Suite 101, Albuquerque, NM, 87106, USA 3 Department of Anthropology, University of New Mexico, MSC01-1040, Anthropology 1, Albuquerque, NM 87131, USA Find articles by Lara Gunderson Danielle L Fettes , Ph.

D.

2 Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (8012) La Jolla, CA 92093-0812, USA Find articles by Danielle L Fettes 2 Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (8012) La Jolla, CA 92093-0812, USA Find articles by Gregory A Aarons 1 Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, 851 University Blvd SE, Suite 101, Albuquerque, NM, 87106, USA 2 Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (8012) La Jolla, CA 92093-0812, USA 3 Department of Anthropology, University of New Mexico, MSC01-1040, Anthropology 1, Albuquerque, NM 87131, USA ✉ Corresponding author: etrott@pire.

org PMCID: PMC6816239 NIHMSID: NIHMS1051740 PMID: 30535899 The publisher's version of this article is available at J Behav Health Serv Res Implementation and sustainment of evidence-based interventions (EBIs) is influenced by outer (e.g., broader environments in which organizations operate) and inner (e.g., organizations, their administrators, and staff) contexts.

One important outer-context element that shapes the inner context is funding, which is complex and unpredictable. There is a dearth of knowledge on how funding arrangements affect sustainment of EBIs in human service systems and the organizations delivering them, including child welfare and behavioral health agencies.

This study uses qualitative interview and focus group data with stakeholders at the system, organizational, and provider levels from 11 human service systems in two states to examine how stakeholders strategically negotiate diverse and shifting funding arrangements over time.

Study findings indicate that, while diverse funding streams may contribute to flexibility of organizations and possible transformations in the human service delivery environment, a dedicated funding source for EBIs is crucial to their successful implementation and sustainment. Keywords: Evidence-Based Interventions, Community-Based Organizations, Funding, Policy, Sustainment “How many millions of times do we need to say ‘the funding?

’ That’s been our main challenge, our main accomplishment, our main headache. Everything has been around that. ” (Government Human Services Agency Administrator) Implementing and sustaining evidence-based interventions (EBIs) in human service systems involves pairing an effective intervention with effective implementation.

1 Factors associated with the outer context (e.g., systems and environments) and the inner context (e.g., organizations and their administrators and staff) affect implementation and sustainment, individually and in interaction with one another. 2 A key outer-context element shaping the inner context is funding.

As this study shows, the shifting and unpredictable nature of funding significantly affects the implementation and sustainment of human service EBIs. Funding human services is complex, as the community-based organizations (CBOs) that are often contracted to deliver them have not historically operated according to the market logic governing other financial relationships, in which clients are considered “customers.

” Instead, CBOs are accountable to multiple funders, subject to contractual constraints and to federal, state, and local policies and standards, and obligated to meet the needs of a growing and diverse client base, while maintaining organizational stability and staff morale.

3 Increasingly, CBOs must also accommodate a shift away from relatively stable, predictable, and long-term funding arrangements and towards more competitive, short-term, and performance-based contracts. 4 – 6 Funding Human Services in the United States Funding for human services in the United States (U.S.) has evolved over time to reflect changing sociopolitical priorities.

For decades, U.S. human service agencies were funded primarily by private donors and charities. However, motivated by the War on Poverty and other policy initiatives in the 1960s, the federal government expanded social services by contracting with non-government agencies.

Although government contracts are still the most prevalent form of funding for human services, large-scale funding cutbacks in the 1980s have resulted in an environment in which such services, including child welfare and behavioral health, are provided largely by nonprofit CBOs financed through combinations of public and private funding.

5 , 7 Sociologist Kirsten Gronbjerg points out that public-sector funding sources “differ in their underlying structures, in the nature of interorganizational funding relationships they set in motion, and in the range and contingencies they impose. ” 3 (p. 8) These factors affect how CBOs operate, from the tasks and services they can bill for, to the way they track, measure, and report outcomes.

Providers choose between different sources depending on these contingencies, as well as the amount of funding, and its timing, length, and prospects for renewal.

3 As government contracts are affected by reduced funding and increased emphasis on competition and for-profit options, CBOs must look elsewhere for funding and embrace increased “marketization” of government contracting, including fee-for-service and performance-based contracting, the consequent shifting of risk onto providers, and increased emphasis on financial management and outcomes.

5 Nonetheless, contracting for human services remains uniquely complex as human service CBOs tend to be under-capitalized, to operate in a limited field of competition, and to face difficulties delivering labor-intensive and costly services to diverse clients. 5 , 8 The current funding environment for human services is multifaceted.

Human services increasingly rely on Medicaid to fund mental health care, substance use treatment, and social services, including child welfare. 9 In addition, other government tools, such as tax credits, vouchers, waivers, and tax-exempt bonds contribute to funding CBOs. 5 While private sources, such as foundations and donors, appeal to CBOs because of their independence from government mandates, they tend to be fragmented and unstable.

10 Provider CBOs may also rely on earned income, such as endowments or the sale of products or services. Several studies have examined how nonprofits evaluate funding sources 11 and respond to shifts in funding. 12 – 15 However, little research has examined the effects of funding on specific innovations, like those derived from research bases of effectiveness (i.e., EBIs), or on the service systems implementing them.

Although scholarship on system-level EBI instantiation suggests that funding is an important element of the implementation environment, 2 , 16 , 17 there is a dearth of knowledge on how diverse funding arrangements influence sustainment of EBIs delivered by CBOs.

Understanding these influences specifically on sustainment of EBIs (i.e., maintenance of core elements of an intervention with fidelity over time) is a pressing need as many EBIs are not continued after preliminary implementation, wasting their often costly start-up processes. 18 , 19 Scholars describe EBI implementation as a dynamic multi-stage process involving the interplay of systems, organizations, providers, and clients.

2 , 16 , 20 To understand the effects of funding on these dimensions, we employ the EPIS framework, which conceptualizes four phases in the implementation of EBIs: Exploration, Preparation, Implementation, and Sustainment. Each phase centers on inner- and outer-context factors that influence EBI implementation.

Key inner-context factors concerning funding are CBO leadership, costs of EBIs, and organizational factors (e.g., billing procedures, administrative work to apply for and maintain funding). Outer-context factors shaping funding arrangements include the priorities of national, state, and private funders, state-level decisions about federal funds, leadership in government systems, contracts, and inter-organizational relationships.

2 , 3 , 5 , 16 For this study, the EPIS model elucidates how inner- and outer-context factors influence funding for EBIs over time.

This study features data that are longitudinal, multi-level, and multi-sited to elucidate the ways that funding arrangements influenced the implementation of a child welfare EBI: (1) at every stage, from the decision to implement the intervention to its sustainment over several years; (2) in inner and outer contexts from the perspectives of system and CBO stakeholders; and (3) in a variety of settings, including established and publicly-funded CBOs as well as smaller agencies, some of which had limited access to, or flexibility in, public funding.

The depth and breadth of this research into a specific EBI thus represents an important contribution to understanding the central influence of funding priorities, processes, and decision making on the provision of EBIs more generally, especially in the current environment of emphasizing market-based competition and both public and private financial uncertainty.

5 This study draws on interviews and focus groups with system, organizational, and frontline stakeholders from one statewide and 10 countywide child welfare systems in two states. Each service system delineated a government human service agency and the CBOs tasked with delivering child welfare services under its purview.

This substantial and descriptive dataset documents how these actors strategically arranged funding to implement and sustain SafeCare®, an evidence-based in-home parenting intervention for families reported or deemed at-risk for child maltreatment. 21 – 23 The dataset was compiled over more than 10 years from three iterative studies of implementation 24 – 26 and follow-up research on sustainment.

27 With the exception of one county, SafeCare was delivered by CBOs contracted by state or county government agencies (many of which also delivered behavioral health services and worked with clients receiving such services), and was funded by a variety of public and private sources.

Initial training was supported by federal grant funding; the responsibility for funding service provision and subsequent training and coaching then fell upon the state or county. Data Collection and Analysis This study utilizes secondary analysis of preexisting data collected during a series of mixed-method studies of SafeCare implementation readiness, actual implementation, and sustainment in multiple service systems.

2 ,25, 28 Individual semi-structured interviews ( n= 175), small group interviews with an average of three participants ( n= 13), and focus groups with an average of six participants ( n= 80) were conducted with a wide range of stakeholders involved in SafeCare in each system.

System-level stakeholders were government administrators (e.g., directors of state- or county-run child welfare agencies), CBO administrators (e.g., executive directors and program managers), academic collaborators, and funders (e.g., administrators of public and private funding agencies). Frontline stakeholders were home visitors tasked with delivering SafeCare and their supervisors and coaches.

Systems were classified according to their EBI sustainment status: “fully-” ( n =7); “partial-” ( n =1); and “non-” ( n =3). 29 Fully-sustaining systems maintained core elements of SafeCare at a sufficient level of fidelity after initial implementation support had ended, and adequate capacity existed (e.g., training for new staff; ongoing fidelity monitoring and coaching) to maintain these elements.

Partial-sustaining systems met only some of the core elements (e.g., did not conduct model-required fidelity monitoring and coaching) after withdrawal of initial support. In non-sustaining systems, SafeCare was no longer being implemented by any home visitors.

Data were collected at three time points that varied according to when SafeCare began in each system: Time 1 (T1; initial Implementation phase for two sites; 2006–2008), Time 2 (T2; initial Implementation phase for nine sites, later Implementation/Sustainment phase for first two sites; 2009–2011), and Time 3 (T3; Sustainment phase for all sites; 2012–2014).

Data were collected data in at least one system each year across all time periods. The majority of data collection for this analysis occurred in T3 when systems had all been implementing SafeCare for a minimum of 2 years and were in the Sustainment phase. Several stakeholders with long tenures in their positions were interviewed multiple times during the study.

Interview and focus group guides examined factors pertinent to the EPIS phases of SafeCare in each service system. Interviews in T1 asked about the Exploration, Preparation, and early Implementation phases (i.e., perceptions of SafeCare; development of implementation procedures; prospective inner- and outer-context factors affecting implementation, including system leadership, contracting processes, and funding).

Interviews in T2 further investigated the Implementation phase (i.e., successes and challenges of implementation; how SafeCare was working within each service system). Interviews in T3 focused on the later Implementation and Sustainment phases (i.e., inner- and outer-context factors influencing implementation success and sustainment of SafeCare). Separate guides were developed for system-level, CBO, and frontline stakeholders.

Table 1 details questions pertaining specifically to the financing of SafeCare. Notably, however, funding and billing issues arose as topics of particular concern in participant responses throughout the interviews (e.g., in response to general questions about challenges of SafeCare implementation or factors that may affect SafeCare sustainment).

An iterative process was used to develop guides to ensure consistency of topic areas and questions. Interview/Focus Group Questions on Financing Exploration, Preparation, and early Implementation Phases (T1) Implementation Phase (T2) Later Implementation and Sustainment Phases (T3) System and CBO Administrators What factors do you believe to be critical in facilitating or hindering the implementation of SafeCare? (Probe: Policies?

Funding? Within the agency?) What changes to existing agency policies or procedures does SafeCare require?

Why? What costs and benefits have been encountered by you or your agency in implementing SafeCare? What factors do believe to be critical in facilitating or hindering the implementation of SafeCare?

(Probe: Policies? Funding? Within the agency?)

What challenges have there been delivering the SafeCare model? (Probe: Challenges with staff? Challenges with clients?

Challenges in meeting contractual obligations?) Can you explain to me how the current SafeCare contracts work? How do contracts support the use of SafeCare?

How do contracts undermine the use of SafeCare? What types of contract changes are needed to better support SafeCare?) What could prevent the contract from supporting ongoing use of SafeCare?

How? What policies are in place to support the use of SafeCare? How do they support Safecare?

How might these same policies undermine the use of SafeCare? What other types of policies are needed to better support SafeCare? What could prevent these policies from supporting ongoing use of SafeCare?

How? What types of information are used to make decisions regarding the contract or policies that support use of SafeCare? What changes have occurred in your agency over the past year?

(Probe: Changes in personnel? Changes in policies and procedures? Changes in resources?)

In what ways have the changes you mentioned made it harder or easier to provide services? How? What issues outside of your organizations (such as policy, funding, transportation, etc.) have made it harder or easier to provide services?

How? What changes have occurred in your agency over the past year? (Probe: Changes in personnel?

Changes in policies and procedures? Changes in resources?) In what ways have the changes you mentioned made it harder or easier to provide services?

How? What issues outside of your organizations (such as policy, funding, transportation, etc.) have made it harder or easier to provide services? How?

How have changes within your agency affected how you use SafeCare? Changes might have to do with personnel, policies, and resources. (Probe: What were the changes?

How did these changes impact your own ideas, opinions, or attitudes about SafeCare?) How did these changes impact you all as employees of the agency? (Probe: How did they affect your morale, for example?)

How did these changes impact your clients? (Probe: How did they affect their satisfaction with services?) What do you need to provide effective SafeCare services on an ongoing basis?

(Probe: What type of support did you and your coworkers receive in the past year? How useful was this support?) Interviews and focus groups were digitally recorded, professionally transcribed, and checked for accuracy.

We utilized NVivo 10 qualitative data analysis software 30 in a process of repeated review and analysis. In the primary analysis of these studies, the data were coded by research assistants and condensed into analyzable units. Codes were assigned to segments of text based a priori on topic areas and interview questions.

31 For the secondary analysis in this study, the first author created additional codes based on key sensitizing concepts from the implementation literature, including funding, budget, contract, and billing. These concepts provided “a general sense of reference” 31 (p.

545) and supplied descriptive data based in the words of participants, enabling the research team to examine their salience and meaning for different stakeholders over time. Open and focused coding were then used to locate new themes and issues related to funding (e.g., “creative financing,” “billing problems,” “funding insecurity”), and to determine which themes emerged frequently or represented particular concerns.

32 The first author independently coded the transcripts, created detailed memos that described and linked codes to each theme, and shared this work with the larger team to be reviewed and checked for accuracy. Discrepancies in analysis were discussed and resolved by the entire research team.

Through comparing and contrasting codes generated by multiple coders in the primary and secondary analysis of the data, codes with similar content were grouped into broad themes linked to segments of text. 32 , 33 Final themes illuminate the role funding played in implementing and sustaining SafeCare. Themes are divided into outer-context (i.e., system-level) and inner-context (i.e., CBO-level) perspectives.

Table 2 organizes results by EPIS phase and sustainment status. Results by EPIS Phase and Sustainment Status Exploration (T1) and Preparation (T1) Outer Context: Funders and government administrators negotiate training and implementation of SafeCare. Funders are interested because of shift toward funding EBIs.

CBO administrators are involved in negotiations. Initial problems include reimbursement rates, cost of SafeCare, and government demands to serve more families with little additional funding. Government and CBO leadership balance different funding streams, accommodate unforeseen funding changes, plan for future changes.

Inner Context: Providers feel pressured to serve more clients and work more hours, express dissatisfaction with emphasis on quantity over quality. They report inability to bill for some aspects of their work. CBOs subsidize supplies for SafeCare and weather fluctuations in funding by maximizing existing CBO resources.

Outer Context: CBO administrators continue to look for other funding streams. Some competition between CBOs for SafeCare contracts. Participants report that contracts specifying SafeCare funding levels and phases ensure implementation.

Inner Context: Providers feel that the pressure to make billable hours may compromise fidelity, having to “be creative” (e.g., doing drop-by visits instead of planned visits) to serve families when not all services are billable. CBOs support implementation with supplies and resources using other funding. Outer Context: Government and CBO administrators engage in “creative financing” to fund SafeCare.

They anticipate initial funding ending and having to look for more funding elsewhere. Inner Context: CBO pursues EBIs due to more funding. Outer Context: CBO experiences problems getting enough referrals for SafeCare.

Inner Context: Some resources provided for SafeCare by CBO fundraising. Providers feel cut off from government budget decisions. Contract is cut because not enough referrals are being made to SafeCare.

Government experiences budget cuts. Inner Context: Providers like the program but worry about future of SafeCare. Outer Context: Government agencies invite CBOs to be trained in SafeCare.

No additional funding provided for training or implementation. No formal contracts to provide SafeCare. No exploration of other possible funding streams.

Inner Context: Providers attempt to absorb SafeCare into existing caseloads with no additional money. Outer Context: One CBO encounters difficulty billing for SC; government agency attempts to leverage multiple funding to make up the difference but eventually reverts to services as usual. In other systems, non-specific contract leads to non-sustainment.

Inner Context: Providers’ attempts to integrate SafeCare into existing caseloads are unsuccessful. Funding a Home Visitation EBI In the majority of fully-sustaining systems, SafeCare was funded by blended streams of federal, state, and county money. These included state discretionary funds for child welfare, state funds for mental health services, and county general funds.

In most cases, systems contracted with CBOs or other existing home visitation programs to implement SafeCare. For example, in one system, CBOs were contracted to deliver SafeCare using special funding for prevention and early intervention via a state ballot proposition for mental health services.

In another, public health nurses were trained to deliver SafeCare using county general funds for child welfare and social services with the help of federal matching funds. In a third system, a private charitable organization funded initial implementation, after which SafeCare was supported by federal, state, and county money.

Several fully-sustaining systems received support from a statewide initiative to use tobacco taxes to fund early childhood programs. Partial-sustaining Systems In the partial-sustaining system, the local child welfare agency contracted with CBOs using state funding dedicated to home visitation services and a federal child welfare block grant. Funding from these sources decreased over time.

In the non-sustaining systems, SafeCare was added to the existing caseloads of government social workers or CBO staff. No new funding streams were found to support SafeCare. In one case, government administrators hoped to fund SafeCare as part of the “select” child welfare services eligible for Medicaid dollars; however, they were unable to get all of the SafeCare modules to fit reimbursement rules.

Although they tried to leverage other funding streams to make up the difference, the CBO reverted to services as usual. Outer-Context Perspectives Securing and Maintaining Funding For administrators of government agencies and CBOs, efforts to find, secure, and maintain adequate funding were a nearly constant activity.

Across all service systems, these administrators characterized their efforts to leverage various funding streams to cover the costs of service provision as a necessary but challenging aspect of human services. One CBO administrator commented, “If it was just me as a social worker, I love [SafeCare].

We love the results it gets, but … I feel the pressure to maintain peoples’ jobs and quality of services, so money always comes up, unfortunately. ” Other CBO administrators agreed that the need to prioritize funding was regrettable, yet inseparable from service provision. While funding concerns were commonplace, government and CBO administrators in fully-sustaining systems were proactive, strategic, and creative in pursuing funding.

When asked about their roles in planning and contracting for SafeCare, several government administrators used the term “creative financing” to characterize their efforts in prioritizing programs, exploring financing streams, and strategically applying often fluctuating funds to serve clients and meet outcomes.

This also involved recognizing the often disparate goals of funders and determining how best to demonstrate to them that their goals were indeed aligned. Government administrators in fully-sustaining systems managed an added layer of complexity by foreseeing future program and funding changes.

For example, early in the Implementation phase in a system where SafeCare was delivered partly by federal civil service program volunteers, government administrators were already planning how to sustain the EBI when the volunteers ended their tenures a year or two in the future.

In another system, administrators limited home visitor caseloads, despite a substantial in-flow of implementation funding, to prevent future cuts when funding returned to normal. In these cases, administrators planned for changes months or years ahead. In contrast, sustainment was compromised in partial- and non-sustaining systems by unanticipated issues.

For example, in one system, unforeseen difficulties in billing Medicaid for SafeCare resulted in home visitors not getting paid. For their part, CBO administrators engaged in similar types of negotiations around funding at the organizational level. For several CBOs with broad service portfolios not limited to SafeCare, this took the form of juggling funding among different programs.

For example, one program manager in the partial-sustaining system recounted the “creative financing” involved: There’s about four different contracts that we’re working under to support [a program]. … One contract was taken away, but then we got some other funding, a small $10,000 one, where we were able to put that in. … With [another program], we found some money [but] we went from six to three caseworkers.

… It was on the verge of being taken away. Challenges and Opportunities of Funding EBIs Stakeholders across the systems reported opportunities and challenges associated with funding an EBI. There was a widespread perception that EBIs attracted more funding than programs lacking an evidence base.

While discussing policies affecting SafeCare, a CBO director observed, “I believe that there’s a paradigm shift happening … [with] funders in general. Our RFPs [Requests for Proposals] now are specifically requesting those evidence-based programs. ” This was confirmed by an individual from a funding agency: “The more attractive it is to donors, the more money we’re gonna raise, the more money we can invest in the community.

And so we did feel that SafeCare would really offer that. ” Accordingly, in the Exploration and Preparation phases, the perception that EBIs were attractive to funders played a significant role in the decision to implement SafeCare in multiple systems. However, stakeholders also reported challenges in funding the EBI.

One barrier was that SafeCare was initially omitted as an approved evidence-based model on a list of federal grant opportunities. Government and CBO administrators reported trouble paying for coaching, outreach to referral agents, training, and materials. After a competitive contract bidding process, a CBO director recalled worrying that commitment to SafeCare might result in the CBO “pricing themselves out” of consideration.

In the Exploration and Preparation phases, administrators confirmed that the cost and reduced caseload of SafeCare were reflective of the program’s quality; yet, they worried that securing adequate funding posed a challenge to sustainment. System-level stakeholders reported that SafeCare integration in contracts played a significant role in sustainment.

In fully-sustaining systems, SafeCare contracts were clear and detailed, setting out funding levels for the aspects and stages of service delivery, including training, coaching, reimbursement rates, and referral sources. Stakeholders cited the inclusion of such details as important for success. In the Preparation phase, the development of detailed contracts involved extensive negotiation by funders, government agencies, and CBOs.

In contrast, contracts in non-sustaining systems tended to be minimal and non-specific. In two non-sustaining systems, government agencies attempted to incorporate SafeCare into existing structures for service delivery and billing, without additional contract specifications.

In a third non-sustaining system, a government administrator pointed to lack of detail in the SafeCare contract as a reason implementation failed, “I think the contract … really didn’t encapsulate implementation of an evidence-based practice. What we know now, we would have put explicit language in there in terms of expectations around implementation, [and] different components of the SafeCare project.

” In these systems, the contract’s lack of detail concerning funding and staffing, chains of authority, goals, and outcomes, prevented administrators from dealing with contingencies, including changes in referral sources and obstacles with billing. The most consistent theme underlying interviews was funding insecurity.

When asked about factors affecting sustainment of SafeCare, one CBO director echoed others, explaining, “Every traditional pot of funding has a little bit of a question mark by it. ” Public funding was perceived as frequently changing. A second CBO director worried that SafeCare’s status as a social program made it a target of funding cuts in a conservative political climate.

Private funding was also perceived as subject to economic downturn or changing priorities. System-level stakeholders nearly universally agreed throughout all EPIS phases that funding ultimately determined the future of the intervention, and most were resigned to the possibility that it could change at any moment.

A government administrator from a fully-sustaining system stated, “If you don’t have money, you don’t have SafeCare, honestly. It’s fiscal year to fiscal year. ” Another expanded, “Any government contract is contingent upon funding.

So if funding gets pulled at any level, those contracts are gone. ” Funding fluctuations that might endanger sustainment were accepted as a possibility even in systems that had made substantial financial and organizational commitments to SafeCare. For at least one non-sustaining system, lack of funding represented an insuperable barrier.

A government administrator explained, “This is going on in the middle of the worst economic downturn we’ve faced in my career. Sometimes as important as initiatives [like SafeCare] are, the bottom line is we have to get our mandates done. ” While stakeholders in this system believed in the benefits of SafeCare, this belief was not enough to protect it from funding insecurity.

Inner-Context Perspectives Billing, Caseloads, and Fidelity In discussing SafeCare, frontline staff reported that billing for services was a frequent concern. In one system, CBOs had transitioned from cost reimbursement to a fee-for-service contract delineating billable activities, which home visitors worried precluded them from being paid for necessary work, like making calls, preparing for home visits, and doing paperwork.

While these concerns pre-dated SafeCare, early implementation of the EBI reinforced home visitors’ apprehensions. One group discussed drop-by visits to check on a family, “At this point, if you’re doing a SafeCare module, it’s like I have to sneak in a drop-by … [but] it’s not billable. So the billing is kind of … conflicting with [fidelity].

” Home visitors also reported feeling pressure to serve as many clients as possible, while still maintaining fidelity to SafeCare. A CBO director commented, “I think there’s a little tension between taking the time you need … and the drive for billable hours.

” Fully-sustaining systems relied on CBO administrators and mid-level staff, such as coaches and supervisors, to buffer frontline staff from the demand to serve more clients and make more billable hours. For example, a second CBO director described the need to “[start] a dialogue” with the government agency about, “If this is how much money you give us, then this is the maximum number of cases we can carry with that