Paper
Interventions for children with multiple needs: severity, effectiveness and costs
- issue: Issue 3 / 2008
- authors: Maria Bezze
- keywords: Italy, cost analysis, effectiveness, severity
- views: 3352
- downloaded: 0
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abstract
Background and research goals. The scenario of social politics is characterised by scarce resources and rapid increase of demands. Furthermore, within Italian welfare system, resources are devoted mainly to the care of elderly people (retirements, 68%) and health care (health, 24%), rather than to social care (social services, 8%). The latter represents only 1.8% out of the whole gross domestic product.
Regarding the expenses in support of children and families, Italy places penultimate according to the EU15 because of its 4.4% of expenses out of the whole gross domestic product. The expenses that local municipalities - which are the main responsible for social services - devote to children and families were in 2004 only little more than 2 billion €, i.e. 36 € per capita; significant differences were noticed if comparing in particular North and South Italy (minimum 24€, maximum 282€). Such resources are very limited and little is known about whether they are related to social needs, if they are used efficiently and to provide effective services. Indeed, all these must be taken into greater consideration and deepened.
This paper takes into consideration this background, and its main goal is to answer the following questions:
- Does a relation exist between the severity of children's needs - supported by services - and the costs of interventions provided?
- Does a relation exist between costs and effectiveness of the interventions provided?
These are questions policy makers rarely ask themselves in regard to social politics, particularly in Italy, also because of the lack of systematic and strict information on these aspects. This contribution goes beyond the theme of evidence-based research, by comparing needs and effectivess, costs and interventions provided.
Theoretical framework. A cost analysis considers the use of resources spent for caring people, and in particular in this paper children belonging to multiproblematic families. There are different levels of studies on costs. In our case the focus is on the analysis of the resources used to support children in a given area (Chieti).
In order to determine costs, a bottom-up approach was used, i.e. a way to find the resources directly used to implement each care process supporting the child. This is a costly technique than the top-down one, but it is essential to answer the questions this works derive from. Moreover, the use of the bottom-up approach was made possible because professionals experimented this working method with personalised care projects, that imply the analysis of needs, the definition of the problems and the related care plan with reference to expected goals to reach. The care plan, indeed, contains information on: type of intervention (for example home visits), type of professional involved (such as social workers), quantity (for example 8 hours per week) and length (for example 3 months). Activities were valued on the basis of information available in the area of Chieti; therefore no standard costs but real costs were used.
Method. This contribution derives from an experimental study aimed at finding clinical and organizational solution in regard to the care of multiproblematic families with children located in the area of Chieti (Gioga e Pivetti, 2008). Due to the complexity of this study, research considered a small sample composed of 15 families, including 27 children. These, however, represent only 30% of all who are in a multiproblematic situation that were found in the area of the Chieti Municipality.
As already pointed out, these are all children belonging to multiproblematic families, i.e. families where there is:
- co-presence of several socio and health problems,
- the need of interventions provided by different services,
- inadequate parenting role,
- one or more child/chidren facing vulnerabilities, deprivation and maladjustments.
Various information were available about these children on: their needs at the moment of admission to care; interventions provided according to care plan defined by professionals and their condition at the end of care plan.
The quality of information made it possible to consider only half of the children explored. This allowed us to present results only in a descriptive way.
Findings. The severity of needs was classified according to a range 0-5 (maladjustment-wellbeing), with reference to 3 domains: cognitive-behavioural, functional-organic and socio-environmental domains. At the entrance in care, children showed in general a medium severity (3,24 out of 5). The costs of the interventions during the 1st period after children's admission in care were 1.500€ on average. Figure 1 shows the relationship between child' need severity and costs of interventions provided, thus enabling us to answer the 1st question: Does a relation exist between the severity of children's needs - supported by services - and the costs of interventions provided?
Even though data were limited, the graphic shows there is a positive relationship, that is the more need severity increases, the more intervention costs increase, too. This leads to two different ways of considering this evolution. If this relation between child's need severity and costs of intervention is confirmed by other studies and on a wider case sample, then policy makers should take it into consideration when managing social services. In other words, if children present a great severity within their community, then - under similar conditions - it will be necessary to devote more resources to such interventions than to other age, such as the older people.
The second consideration must be made in regard to professionals' behaviour. The existence or lack of the relationship between need severity and costs of intervention provided can provide useful elements to evaluate choices made during the care process. for example, if specifically considering this study, professional behaved in an equal way, since they devoted most of resources to the most severe children.
If for example the relation had been negative - higher costs for less severe cases - then the professionals evaluation would have been completely opposing, with consequences even from an ethics point of view.
The effectiveness of interventions provided derives from the comparison between need severity evaluated before and after the intervention. It is important to remember that these children belong to multiproblematic families and that, given their condition, have problems that sometimes can impact only in a mid and long term period. As a consequence, further improvements (positive outcomes) in the short-term can have nothing but reduced values. This has happened in our case: need severity reduced of 0,12 out of 5 on average from the moment of entrance to the 1st evaluation.
For example, children with a great severity index at the entrance in care kept the same level even after the 1st evaluation of the assistance project. Contrarily to this, among those children with a mid index, there were some who improved their condition from great severity to a mild one, even after a short-term care.
In order to answer the 2nd question, which inspired this contribution, I used a graph, too.. Figure 2 shows a positive relationship between costs of intervention and level of effectiveness reached (in terms of evaluation of need severity): the more a child is given, the greater the effectiveness reached will be. In other words, to have efficient interventions it is necessary to spend money. This aspect, however, is strictly related to a specific case: children belonging to multiproblematic families which require a long-term care. Therefore results might be different according to different population groups experiencing different living conditions (hospitalized children, children with serious disabilities, etc.).
Conclusions. Data shows the existence of a relationship between needs severity and the amount of resources needed to provide effective interventions. As a consequence, in order to plan and organise services, this aspect must be taken into account when allocating resources and when thinking about the need to introduce an evidence-based evaluation.
Scarse resources will force to follow this direction in order to guarantee the survival of out welfare systems. But it is necessary to invest on research that compare needs, effectiveness and costs. It is not only an issue of sustainability (scarce resources and increase of demand) but it is also and mainly related to transparency and equality when manging public resources.
Key references
Beecham, J. and Sinclair, I. (2006), Costs and Outcomes in Children's Social Care: Messages from Research, Jessica Kingsley Press, London.
Gioga, G. and Pivetti, M. (2008), Progetti personalizzati capaci di considerare congiuntamente i bisogni della persona e della famiglia. I risultati di una sperimentazione con 15 famiglie multiproblematiche con minori, in this volume.
Contacts: Maria Bezze, Fondazione "E. Zancan" Onlus, via Vescovado, 66. 35141 Padova, Italia, E-mail: mariabezze@fondazionezancan.it, Phone 049663800.