Vice President for Business Development and Communications (860) ext. 241

Transcription

1 Response to DCF RFI Social Impact Bonds and Pay for Success Contracts for Children and Families Impacted by Substance Abuse CHR (Community Health Resources) Service Provider 995 Day Hill Road Windsor, CT Contact: Alyssa Goduti Vice President for Business Development and Communications (860) ext. 241

2 A. Describe Yourself and Explain Your Interest in this RFI CHR (Community Health Resources) is the leading provider of mental health, substance use, supportive housing, foster care and recovery support services. Our name embodies our commitment to community based care, utilizing all available resources to achieve change, and instill hope for a healthy happy future. CHR provides over 80 programs and has 32 locations where we provide services to more than 16,000 children, adults and families. We engage with children and families to identify issues that are most important to them to provide real hope for improvement in their lives. CHR is expert in serving children, families and adults; providing multiple evidence-based models; focusing on trauma and gender informed care; addressing addictions, mental illness and domestic violence; providing basic needs services and service coordination; and routinely managing high risk. CHR s vision is to be the first choice for high quality mental health and addiction services and supportive housing in Connecticut. Known for clinical excellence, exceptional customer service and a culture of flexibility, CHR will be a valued partner in the healthcare system. Our goal for every individual and family member served by CHR is to restore hope, provide care and celebrate progress. In concert with our mission and vision, we are always looking to achieve the best outcomes for clients using the most efficient and cost effective service delivery models. Quality data and outcome-based service delivery has been paramount to the way CHR manages and delivers a complex system of care. This focus on data and outcomes is essential in the increasingly competitive market. Our state funders, foundations, corporate donors, and individual donors depend on data to make key funding decisions. CHR s demonstrated dedication to performance-based management and use of data to drive towards outcomes coupled with our success in delivering evidence-based models and unwavering commitment to the Page 2

3 delivery of high-quality services, make CHR is well-positioned to partner with DCF to develop social impact bonds. B. General Areas for Response 1.Programs and Potential Service Delivery Models: Please describe the range of interventions (social service programs) that could target improved social outcomes for children and families involved in the child welfare system who are also impacted by substance abuse. In particular, please address the following points: 1.1.What evidence based interventions currently exist that have demonstrated success? Do these interventions have the potential to be implemented more broadly through a social impact bond? CHR s services include over 80 programs, meeting a range of mental health and addiction treatment needs of over 16,000 children, families, adolescents and adults. Among these interventions, CHR provides addiction treatment services for families, children and adolescents including: Family Based Recovery (FBR), Multidisciplinary Family Therapy (MDFT), Functional Family Therapy (FFT) and Adolescent Community Reinforcement Approach and Assertive Continuing Care (A-CRA/ACC). Each of these models are rooted in evidence, emphasize outcomes and have clear measures of success. However, the successes of all of these models hinges on the support, engagement and buy-in of a variety of stakeholders. Providers have the ability to impact these stakeholders, but creating a pay for performance system around a program with outcomes that are deeply impacted by stakeholders other than the provider proves complicated. If a social impact bond model would be used to broaden the service array for families with addiction treatment needs, the model with the most potential to work effectively would be the A- CRA/ACC model. CHR applied to provide this model three years ago because of the evidence of its effectiveness in treating youth substance use, its focus on individualized, flexible behavioral approaches, its emphasis on the development of coping skills for both youth and their primary Page 3

4 caregivers, the continuing care approach through the ACC model for youth who have received treatment using the A-CRA protocol, in addition to being a cost-efficient alternative to MDFT. CHR also welcomed the emphasis on enhancing youth strengths and protective factors, integrating the use of non-clinical supports, and offering in-home and community supports. This program, originally funded through a three year grant from SAMHSA, has been proven successful and has clearly established and measurable outcomes. There is extensive data on the societal cost and impact of substance abuse on families. This program uses a positive treatment model that focuses on developing alternatives to substance abuse, along with improving decision making, communication skills, handling peer pressure and creating better relationships with family members. The A-CRA/ACC model includes both office-based and community based services, engages the family as well as the youth and addresses the need to provide services and follow up services over an extended timeframe. For these reasons, CHR s data has shown that the model has been successful in meeting desired outcomes. The A-CRA/ACC approach to substance abuse treatment is well-researched with documentation of its effectiveness with youth and young adults. Adolescent substance abuse is understood as occurring in a social and environmental context where the positive reinforcement of non-using behaviour is less that the immediate short-term reward of the abusing behaviour. Behaviour treatment recognizes that the youth s complete environment contains many known and potential re-enforcers of non-using behaviour. This is most often discussed in the substance abuse treatment field as the existence of risk and protective factors. Treatment approaches must act to enhance and support protective factors while reducing or, in the instance of A-CRA, replacing the risk factors. Additional dynamic contributions to the model are research on resiliency in youth which emphasizes the importance of self-efficacy (the belief that one can Page 4

5 succeed), the importance of consistent, accepting relationships, and opportunities to be useful or helpful. Families are also validated as a major protective factor in the form of deliberately structuring positive and supportive experiences. The model emphasizes the teaching of essential skills both needed for successful development and in reducing stress and conflict that often leads to substance abuse. Data has shown the prevalence of need for substance use services for youth and the value of long-term engagement in services, promoted by the A-CRA/ASAT model. Of the 3.87 million (13.5%) youth age currently enrolled in school with SUD (Substance Use Dependency), only 141,000 (4%) or 1 in 25 received treatment in a SUD or MHD program. In fact only 298,800 (8%) or 1 in 12 reported receiving any kind of intervention, including (with overlap): treatment in an SUD or MHD program (141,000; 4%), a self-help program (99,000; 3%), a medical office (36,000; 1%), emergency room (34,000; 0.9%), or juvenile detention (27,000; 0.7%). Among youth with SUD, the rate of unmet need for any intervention (92.3% overall) is similar by gender but significantly worse for those under age 15 (96.3%) and for African American youth (95.0%) and for minority girls vs. boys within several minority groups. Thus there is a great need to increase access to care and reduce health disparities in access. (The Need and Opportunity to Expand Substance Use Disorder (SUD) Treatment in School-Based Settings, Michael Dennis, Ph.D., Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, and Larke Huang, Ph.D.) Even among those admitted to specialized treatment (SAMHSA, 2013), less than half are discharged successfully or stay in treatment for the 90 days recommended by experts (Brannigan, Schackman, Falco, & Millman, 2004; NIDA, in press). A recent analysis found that publicly funded programs met only 6 of 14 indicators of quality treatment 80% or more often Page 5

6 (Hunter, Griffin, Booth, Ramchand, & McCaffrey, 2013). The same analysis showed that the introduction of evidence-based assessment called the Global Appraisal of Individual Needs (GAIN, Dennis et al 2003) significantly improved scores in 6 indicators with a trend (p<.10) in two more. Thus IOM (2006) recommended the increased use of evidenced based screening, clinical assessment, prevention, treatment and care coordination for SUD and co-occurring MHD. The most recent meta-analysis of adolescent treatment (Tanner-Smith, Wilson, & Lipsey, 2013) shows that relapse is common and that treatment as usual does no better than no treatment. The same meta-analysis, however, also shows that a wide range of more recent evidence-based treatments (EBTs) do significantly better. These practices are characterized by being developmentally appropriate, using cognitive and behavioral modification theory, and in the best cases, involving families. While many EBTs had similar outcomes, they varied substantially in costs and, consequently, in their cost-effectiveness (Dennis et al., 2004; French et al., 2003). Thus, it is not enough to just increase initial access to treatment; as a field, we need to keep them engaged there, to identify/address co-occurring issues, and to use EBTs associated with better effectiveness and cost-effectiveness. (The Need and Opportunity to Expand Substance Use Disorder (SUD) Treatment in School-Based Settings, Michael Dennis, Ph.D., Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, and Larke Huang, Ph.D.) 1.2.Are there innovative interventions that may lack a strong evidence base (for example, due to nascent program models or models that are currently undergoing evaluations) but that may be appropriate for incorporation in the program due to potential for high net benefits? Describe the intervention(s) in detail, including the target population, program goals, existing evidence of success, and current implementation strategies. None that we are familiar with at this point Describe the social outcomes that the intervention(s) target. What level of impact can be expected from the intervention(s)? Page 6

7 This model focuses on reducing the prevalence of substance use both in the short-term and long-term, improved behaviors, maintaining stability in the family, educational success and a range of secondary benefits derived from addressing the substance abuse. CHR data has shown the ability to impact these outcomes through our implementation of the program. We are optimistic about the program expansion and its potential to impact these issues on a much broader scale. Data clearly shows a need for this kind of service. Research demonstrates a high prevalence of substance abuse among youth and adolescents. According to the figures for the North Central portion of Connecticut in the National Survey on Drug Use and Heath (NSDUH), 9.9% percent of youths between 12 and 17 had used illicit drugs within the 30 days preceding the survey with 17% using marijuana within the last year. Seventeen and one half percent (17.5%) had used alcohol in the 30 days prior to the survey. Connecticut as a whole has consistently had rates of unmet treatment need for substance abuse that are at or above the national average, particularly among youth This gap in available services is evident in the north central region, where lack of drug treatment results in almost 4% of youths needing but not receiving treatment for drug dependence or abuse. NSDUH estimates are that approximately 4.8% of youth in the area need but do not receive treatment for alcohol treatment or dependence. The data from Connecticut s population surveys on adults also show that substance use and abuse is widely prevalent in the state (Babor et al, 2000, Ungemack et al., 1999; Ungemack et al., 2001; Ungemack et al., 2005). The 2003 survey found that approximately 1-in-5 adults were risky drinkers and 1-in-12 had used illicit drugs in the past year, putting them at risk of substance-related problems. Marijuana accounts for the largest proportion of both use and dependence among Connecticut adults who use illicit substances. Comparison of the 1995 and Page 7

8 2003 showed a disturbing finding: reported use of illicit drugs and misuse of prescription drugs increased over the past decade. For instance, lifetime marijuana use among adults rose from 32% in 1995 to 39% in Rates of risky drinking and illicit drug use, especially marijuana, tend to be inversely related to socioeconomic level of the community with the highest levels of use found in less affluent towns/cities. In FY 2009, a total of 41,872 unduplicated individuals, ages 18 and older, were served in Connecticut substance abuse treatment programs, accounting for over 69,680 admissions. Forty percent (40%) of individuals admitted to treatment reported alcohol use; 35% heroin; 23% marijuana; 20% cocaine; 13% crack; and 9% other opiates. Eighteen percent (18%) of individuals were aged 18-25; 49% were years of age; and 31% were years of age. In terms of ethnicity, while the majority were non-hispanic White (58%), over 40% included persons of African (18%) or Latino (22%) origin. This model aims to address a highly prevalent and costly societal problem through thoughtful and creative engagement of both youth and families. The procedures of these models are designed to enhance participation and success. For example, the use of the Happiness Scale and Goal Setting both serve to identify targets for treatment in a client-centered manner, and also communicate clearly that we are concerned with their happiness. This directly contrasts with many youth s perception of treatment that we are here to make their lives miserable and to take things away from them. Starting with the idea that we are both concerned about how happy they are with different aspects of their lives and plan to help them with things about which they could be happier. Inherent in the presentation of A-CRA/ACC procedures to youth/young adults is showing them how they will benefit from learning or trying a new skill, or engaging in the process of treatment. Most youth seem to enjoy their A-CRA/ACC involvement, responding positively to learning procedures and to their therapist. CHR has noted this in the experiences of Page 8

9 the therapists, in supervisory review of recorded sessions, and in youth feedback in the follow up interviews. We would recommend a certain level of flexibility while implementing the model, while adhering to the models fidelity, has also contributed to its successful implementation. For example, although ACC has been seen as an aftercare component, it has demonstrated to be beneficial to provide active case management, outreach, and engage to youth/young adults early in the A-CRA process, in addition to having ACC staff check-in with youth/young adults in between sessions. Originally, CHR looked at implementing A-CRA for thirteen weeks followed by ACC for thirteen weeks. In practice, and in consultation with Chestnut Health Systems, we have found that many if not most youth/young adults were not making it to the office-based sessions for thirteen weeks in a row. Many required some level of outreach and engagement much sooner in order to stay involved. Collaborating with other community and professional resources, such as youth service bureaus, schools, probation officers, as well as, having program staff be more available through flexibility or through outreach in the community assures that youth/young adults are seen more often. CHR has received overwhelming positive response from several schools and alternative school programs in respect to the A-CRA/ACC Program. Once we are able to demonstrate that a youth/young adult is working on improving their life, and they are able to use some of the skills (particularly communication and problem solving), school personnel are quite willing to be flexible and extend themselves to our clients. In one instance a youth had an extended suspension for his drug use, but the school offered to give him credit for attending and completing treatment. A number of schools have welcomed program staff to see clients in the school and even to complete follow-up GAIN administration in the school. We have seen quite a few of our clients achieve academic success, including graduating from high Page 9

10 school when they had been at high-risk of dropping out or failing pre-treatment. We attribute positive outcomes to youth/young adults identifying their own personal goals and beginning to apply skills learned to achieve them. We can confidently say that the majority of youth/young adults who participated in the A-CRA/ACC Program made substantial changes in their behavior, including substance use, in order to accomplish their goals. Since the commencement of federal funding, the CHR A-CRA/ACC Program has enrolled 68 youth who have had an average length of stay of 210 days. Sixty-six percent (66%) of youth have remained enrolled and engaged in the program for 6 months or longer. Seventy-four percent (74%) of youth served have been White; 6% Hispanic; 5% African American; and 15% multiracial. Eighty percent (80%) of youth were between 15 and 17 years of age and 20% were 14 years old or younger. In the 90 days prior to entering the program, 87% of youth reported using some substance for at least 13 days during the quarter; 61% reported being high or drunk for most of the day during 13 or more days; and 84% reported experiencing moderate to severe impairments in their day-to-day functioning. Along with issues of substance use, most youth were diagnosed with other emotional/mental health issues, including 18% of youth diagnosed with depression; 8% with anxiety disorders; 28% with various other internalizing disorders; 39% with attention, hyperactivity, and impulsive disorders; and 20% with serious trauma. Approximately 5% of youth reported seriously contemplated suicide. At treatment conclusion, substance use more frequently than 13 days per quarter had dropped dramatically from 73% at intake to 44% at discharge. Significant improvement in seriously or moderately impaired functioning at home, school or community was also documented, where 84% of youth were assessed as seriously or moderately impairment at intake and 59% of youth assessed as moderately impaired and no youth were assessed as having serious impairments post Page 10

11 intervention. Additionally, 50% of discharged youths reported no problems with mental health symptoms and youth reporting serious problems dropped by 10%. By the end of the federal project period, CHR fully anticipates meeting/exceeding all CSAT grant expectations Describe the type and amount of any governmental savings that could be achieved as a result of implementing the program outlined above. It is very challenging to put a monetary value on the savings created due to prevention of long-term addictions, the benefits of helping a student graduate from high school or the savings created by maintaining a youth living with his/her family in their home. Many benefits of this treatment are not quantifiable in terms of dollars, but have a tremendous societal impact. Estimates of the total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs exceed $600 billion annually. This includes approximately $193 billion for illicit drugs, $193 billion for tobacco, and $235 billion for alcohol. As staggering as these numbers are, they do not fully describe the breadth of destructive public health and safety implications of drug abuse and addiction, such as family disintegration, loss of employment, failure in school, domestic violence, and child abuse. (National Institute on Drug Abuse, Understanding Drug Abuse and Addiction) Describe potential outcome(s) that could be measured and used to evaluate the success of the interventions, along with a process for collecting the required data. CHR has complied with a rigorous research and outcomes-oriented process specific to the A- CRA/ACC SAMHSA funded program. The data collected and used within the program is based upon SAMSHA AAFT grant requirements and CHR s own internal performance monitoring system policies. The protocols for the program call for collection of four waves (Intake, 3-, 6-, and 12-month) of various data, including 1) Results from the Global Appraisal of Individual Needs (GAIN) which is a research validated instrument; 2) Basic demographic and status data at Page 11

12 the same intervals; 3) Routine recordings of program interventions, and 4) Data concerning treatment satisfaction. CHR program staff has found these data collection processes helpful to the development of clear diagnostic impressions and to clinical interventions planning; supervisors use the case information produced to guide supervision; and managers have found the analyzed data useful to program outcome management and performance improvement. It would be important to collect and submit data to external sources; to benchmark that data statewide and nationally; to maintain data internally and secure data from external sources; and to continue to analyze, review, and use within quality improvement efforts the rich data coming from the program. Currently, data collection is administered by a designated Data Manager within the program. This individual, in conjunction with clinical staff, conducts the periodic assessments. The Data Manager develops and updates program contact logs, maintains interview schedules and notifies clinical staff of upcoming interview waves, enters data into both the Chestnut system as well as in the federally mandated Government Performance and Results system (GPRA) through the Service Accountability and Improvement System (SAIS) and conducts data quality edits. Data Reporting. CHR produces multiple reports based upon clinical and service data within its EHR system, Credible Behavioral Health. Using the Business Informatics capability of the system, data support and IT staff within the agency produce reports for all programs within CHRs Child and Family Division. Routine reports include utilization reports, service efficiency and responsiveness reports, and outcome reports. Data within this system is also used for ad hoc reporting on timely issues that arise within the agency, for performance improvement, and for reports to funders with contractually required information. In addition, Credible allows for Page 12

13 automated processing of batched data reports to external providers. CHR is preparing to implement such electronic batch reporting before the end of the current quarter. CHR uses the quarterly report systems from Chestnut Associates with Participant Profiles and Outcomes from the GAIN, and quarterly copies of databases with service fidelity data, satisfaction data, and all GAIN assessment data included. When combined with internal electronic medical record data such as diagnostic, support effort, and service intensity information, the data provides enormous insight into the characteristics and outcomes of the youth we serve, as well as linkages to services related to the outcomes achieved Describe potential evaluation strategies. The CHR Children s Services Division engages in a quality improvement process established through agency policy. The Division s Professional Services Committee (PSC) meets monthly to review performance for all children s services. Composed of staff and managers, this committee reviews process data from every program each month, and selected outcome indicators every quarter for all programs on a revolving basis. The PSC is charged with identifying areas for improvement, initiating system changes based upon the analyses, and monitoring the results of changes after implementation. All deliberations and actions of the PSC s are reported to and monitored by the agency s Senior Management staff sitting as the Quality Assurance Committee. Reports concerning all programs are communicated by managers to supervisory staff, who are responsible for communicating results as well as changes made to their staff. A similar process would be used for this proposed A-CRA/ACC program. Monthly process and utilization reviews, including the monitoring of outcomes for the program, would occur. Outcome reviews will include indicators based upon the goals and objectives of the project, namely substance use status, outcomes and satisfaction. Page 13

14 A three-person Quality Management Unit provides the primary support for the PSC. This division of the agency carries out all data maintenance and analysis of programming for the agency including Professional Services Committees. This staff also will perform these functions for the initiative. The Service Effectiveness Coordinator from CHR, who serves as the evaluator for the CSAT grant, is responsible for merging and maintaining all data sources. 2. SERVICE DELIVERY CAPACITY 2.1 What are the barriers that service providers face in becoming ready for implementation of a pay for success service delivery model? Pay for Success and Social Impact Bonds (PFS/SIB) have emerged as potential mechanisms for investing in effective social interventions by focusing on results and outcomes, in addition to changing the way state agencies allocate and invest its resources. Fundamental to the PFS/SIB service delivery model is the delivery and measurement of positive outcomes for children, families, and communities served. With demonstrated dedication to performance-based management and use of data to drive towards outcomes, in addition to CHR s experience with replication of evidence-based models and unwavering commitment to the delivery of highquality services, CHR is well-positioned to partner with the Connecticut Department of Children and Families (DCF) in implementing PFS/SIB approaches. While CHR is wellpositioned to operate programs under an outcomes-based framework, the introduction of PFS/SIBs, as a new mechanism to fund services/programs, will require pre-implementation capacity building both at the state and provider levels. For example, DCF, in partnership with community providers, will need to: 1) Identify which interventions are best positioned for PFS/SIB and which ones are not. The literature recommends that PFS/SIB should not been used as a substitute for meeting statutorily mandated services or obligations in child protection and child/family support. Additionally, the literature suggests use of PFS/SIB for prevention and Page 14

15 early intervention services with a need for further analysis of whether more complex evidencebased practices are suitable for delivery under a PFS/SIB model. 2) Pre-determine definitions and measures for outcomes that are specifically tailored for each targeted intervention and for the child and family populations to be served. Entities that have undertaken this work, have found this process of accurately and fairly defining and measuring outcomes to be extremely challenging. 3) Create a PFS/SIB financing structure that provides safeguards for financial risk and return. The development of this new financing structure will require significant collaboration from DCF, the provider system, and the potential investors. Successful adoption and implementation of PFS/SIB in Connecticut will require careful analysis of the following questions: a) What social issue are we proposing to address, including the target population, the intervention recommended, the possible outcomes and the cost savings that may be achievable?; b) What is proposed structure, both at the state and provider levels, to achieve the desired outcome of PFS/SIB?; c) What potential private sector investors will be targeted for this initiative?; d) What safeguards will be provided to ensure limited risk to providers?; and e) What mechanisms are in place or need to be developed to track and evaluate outcomes for the purposes of determining overall success of the initiative? Fundamental to the success of a PFS/SIB initiative is DCF leadership s role in spearheading the development of public/private partnerships, including obtaining financial commitment from external investors to support targeted interventions. Strong business, philanthropic and government support is needed to establish and maintain the PFS/SIB capital financing structure. DCF and providers will jointly need to: a) identify the high-priority, unmet social needs, including defining the target populations and interventions of interest and demonstrating the net benefits of investing in there services/program. Analysis on whether more complex evidence- Page 15

16 based practices avail themselves to PFS/SIB model will also need to be conducted; b) identify outcome measures that are achievable for the child and family populations of focus and can be easily measured within existing data systems; c) develop a financing model that limits financial risk and ensures availability of needed services and support to children and families of focus; and d) Develop capabilities in administering and evaluating the PFS/SIB program performance. In summary, barriers specific for service providers may include: 1) Financial Model: Developing a feasible financial model for PFS/SIB that includes safeguards to limit providers financial risk, in addition to ensure the availability of programs/services as needed by children and families to be served. The financial model should include availability of up front funding to aid providers in meeting significant operating costs, particularly while ramping up the PFS/SIB model. 2) Loss of Flexibility: Work with children and family needs to be a fluid and ever evolving process. It is unclear from the literature if the PFS/SIB model, which will include new public/private funding mechanisms, allows for continuously reassessing the needs of children and families and adjusting services appropriately. Loss of providers flexibility to make programmatic adjustments that best meets the needs of children and families served will be detrimental to successful outcomes for these children and families. 3) Targeted Interventions: The targeted interventions must avail themselves for broad use with the PFS/SIB model and must have sufficiently high net benefits to allow investors to earn their required rates of return. 4) Measurable Outcomes: The targeted interventions must have measurable outcomes that can be evaluated by reliable performance measures What technical assistance and support would service providers need to become ready to participate in a pay for success service delivery model? Page 16

17 CHR recommends that intensive technical assistance and supports be made available to support implementation of the PFS/SIB model. Areas of technical assistance include but are not limited to: a) understanding fidelity of the PFS/SIB financing approach; b) use of PFS/SIB to fund services; c) engagement of private sources of working capital and/or risk capital to finance these services; d) developing internal capabilities to financially function within a PFS/SIB environment; e) utilization of outcome measures to document achievement of cost-effective, positive outcomes for children and families; and f) understanding risks associated with PFS/SIB financing and embedding solutions to eliminate these risks in the Connecticut PFS/SIB model. 3. Description of Potential Governance Structure Describe the use of intermediaries and/or other advisors, service providers, investors, and evaluators, and the process for selecting and establishing relationships between DCF and each of these types of entities. Explain the role that each entity would play during the development and implementation of the program. CHR recommends the use of experienced service providers to serve as the intermediaries in the PFS/SIB model. The literature demonstrates that robust intermediaries are key to overcoming many of the implementation barriers that are needed to make PFS/SIBs work. The intermediaries will serve as specialists with expertise in the targeted intervention models and will be key in representing providers in the public-private-nonprofit partnerships. Intermediaries must also convince investors that the intervention will achieve the desired outcomes. CHR has the existing expertise and capacity to be effective in this role. A number of states, including Massachusetts and New York, have opted to use this model versus bringing in external intermediaries Are there alternative models that DCF should consider, including contracting directly with service providers? Page 17

18 CHR recommends that DCF begin with a small-scale PFS/SIB pilot for implementation with a small number of providers. This pilot will offer DCF the opportunity to develop or acquire the capacity for PFS/SIB performance contracting; assess the potential investor market; and evaluate the outcomes associated with PFS/SIB. Evaluation findings and lessons learned, as warranted, can be implemented on a larger-scale with other interventions and populations of focus. CHR also recommends piloting a hybrid PFS/SIB model, which includes DCF contracting directly with providers to limit financial risk and ensuring children and families continued access to services/programs. Page 18