linking records to advance child protection: a california case study emily putnam-hornstein, phd...

LINKING RECORDS TO ADVANCE CHILD

PROTECTION: A CALIFORNIA CASE STUDY

Emily Putnam-Hornstein, PhD

University of Southern California

Barbara Needell, PhDUniversity of California at Berkeley

3rd Annual State of Health Care Conference

BACKGROUND

California Child Welfare Indicators Project longstanding university/agency partnership longitudinal configuration of state’s child protective services data

technical assistance to California counties & state

consultation services to other state child welfare agencies

publicly available website for tracking outcomes and performance indicators (interactive queries)

data available for research…

In 2011, more than 6 million children were referred for possible maltreatment in the United States; nearly 700,000 were substantiated as victims

Estimated lifetime cost of child maltreatment is $124 billion each year (Fang, et al., 2012)

A growing body of research indicates that children who experience abuse or neglect are at heightened risk of adverse health outcomes, including: Obesity, cancer, strokes (Felitti, et al., 1998) Teen pregnancy (Noll & Shenk, 2013) Self-injurious behaviors (Rhodes, et al., 2013)

WHAT WE KNOW (NATIONAL)

WHAT WE KNOW (CALIFORNIA)

010

2030

4050

Rat

e

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Referrals Substantiations Entries to Foster Care

(per 1,000 children)Rates of CPS Involvement in California

WHAT WE DO

Birth

Maltreatment

Referral

Investigation

Services

CPS involvement

A “SNAPSHOT” OF MALTREATED CHILDREN

before CPS Data

after

Children not Reported for Maltreatment

MOVING AWAY FROM DATA SILOS…

birth data

death data

population-based information

child protective

service records

before CPS Data

after

Children not Reported for Maltreatment

RECORD LINKAGES 101

File A File BSSNSSN

First Name

First Name

Middle Name Middle InitialLast Name Last Name

Date of Birth

Date of Birth

Address Zip Code

deterministic match

probabilistic match

LINKED DATASET

birth records

LINKED DATA

birth cps contact birth no cps contact

4.3 million

514,000

cps records

EXPANDED INFORMATION

vital birth

records

population-based information

child protective

service records

California Birth Cohort

Child A

Child B

Child C

Child D

Referral by

Age 5

“Risk factor”: a term used in epidemiology to define a characteristic that is either directly or indirectly associated with risk of disease or other adverse health outcomes Stable / Fixed at birth (e.g., male gender is a risk

factor for injury) Time varying – developing through exposure to

adversities in the social or physical environment

This information can be used to identify individuals/groups/communities particularly vulnerable to a given adverse outcome in order to strategically target prevention and intervention programs and policies

LANGUAGE

sex• female• male

birth weight• 2500g+• <2500g

prenatal care

• 1st trimester• 2nd trimester• 3rd trimester• no care

birth abnormality

• present• none

maternal birth place

• US born• non-US born

race

• Native American• black• Hispanic• white• Asian/Pacific Islander

maternal age

• <=19• 20-24• 25-29• 30+

maternal education

• <high school• high school• some college• college+

pregnancy termination

hx

• prior termination• none reported

named father

• missing• named father

# of children in the family

• one• two• three+

birth payment method

• public/med-cal• other

BIRTH RECORD VARIABLES

SELECTED FINDINGS…

14% of children in birth cohort were reported to CPS by age 5 Lower bound estimate…could not match 16% of CPS records Cumulative rate of CPS involvement 3x higher than single year

estimates suggest

11 of 12 variables were signifi cantly associated with CPS contact Crude risk ratios >2 were observed for 7 variables

Contact with CPS is hardly a rare event for certain groups 34% children without paternity established 25% of children born to teen mothers

missing paternity paternity medi-cal coverage private insurance

34%

12%

21%

9%

Percentage of Children Reported for Maltreatment by Age 5:California's 2002 Birth Cohort, by paternity & birth payment

none third trimester second trimester first trimester

48.9

25.4 22.3

12.3

Percentage of Children Reported for Maltreatment by Age 5:California's 2002 Birth Cohort, by prenatal care

<20 yrs 20-24 yrs 25-29 yrs 30+ yrs

25.719.0

12.6 9.3

Percentage of Children Reported for Maltreatment by Age 5:California's 2002 Birth Cohort, by maternal age at birth

AN EPIDEMIOLOGIC RISK ASSESSMENT TOOL?

(“BACK OF THE ENVELOPE” CALCULATIONS…)

We classified as “high risk” any child with three or more of the following (theoretically modifiable) risk factors at birth:

late prenatal care (after the first trimester) missing paternity <=high school degree 3+ children in the family maternal age <=24 years Medi-Cal birth for a US-born mother

Think of this as a means of “sorting” children – looking for proxy indicators that give us additional information about an infant’s likelihood of referral

RISK ASSESSMENT TOOLS

ADMINISTERED AT BIRTH?

15% 50%

Full Birth Cohort Children Reported to CPS

RECOGNIZING THE RISK ASSOCIATED WITH THE PRESENCE OF MULTIPLE RISK FACTORS…

High Risk on Every Modifiable Risk Factor: 89% probability of CPS reportLow Risk on Every Modifiable Risk Factor: 3% probability of CPS report

CONCLUDING THOUGHTS…

Data that are universally collected at birth can be used to identify those children that are at greatest risk of later CPS involvement

Compared with the demographics of the birth cohort as a whole, these young children are defi ned by the presence of multiple risk factors

A standardized assessment tool can never replace more comprehensive assessments of a family’s strengths and risks, but against an invariable backdrop of limited resources, the ability to prioritize investigations and adjust levels of case monitoring in order to meet the greater needs of a targeted swath of at-risk children and families has the potential for cost-savings to be realized, while also improving child well-being

“Each person in the world creates a Book of Life. This Book starts with birth and ends with death. Its pages are made up of the records of the principal events in life. Record linkage is the name given to the process of assembling the pages of this Book…” (Dunn, 1946)

RECORD LINKAGES

Government

University Partners

Ongoing Collaboration

QUESTIONS?ehornste@usc.edu

bneedell@berkeley.edu

http://cssr.berkeley.edu/ucb_childwelfare /

Thank you to our colleagues at the Center for Social Services Research and the California Department of Social Services

Ongoing support for research arising from the California Performance Indicators Project and related activities is generously provided by CDSS, the Stuart Foundation, and Casey Family Programs

Record linkages funded by the Harry Frank Guggenheim Foundation, the Conrad N. Hilton Foundation, and First 5 LA

ACKNOWLEDGEMENTS