Unmet Need, Safety Net Services, and Research

The popular and professional presses abound with news of system deficiencies and unmet human need. In June 2003, the largest and most comprehensive report of health care quality revealed that Americans receive the care recommended for their health conditions only about half the time, whether they receive chronic, acute, or preventive care and whether they seek screening, diagnosis, treatment, or follow-up care (McGlynn et al., 2003). This unsettling report on the quality of health care follows, by just weeks, several new reports that decry the condition of our child welfare system. Reports from the General Accounting Office (2003, http://www.gao.gov/), the Brookings Institution (Light, 2003, http://www. brookings.org/gs/cps/humanservices.pdf), and Annie E. Casey Foundation (2003, www.aecf. org/publications/hswip.pdf) identify a litany of problems, including heavy workloads, poor training and preparation of caseworkers, high staff turnover, and lack of tracking systems. The Institute of Medicine recently characterized the nation's "safety net"--the health, social, and mental health system that cares for Medicaid, uninsured, and other vulnerable populations--as a "patchwork" structure of institutions in precarious financial straits (Lewin & Altman, 2000). Of course this is not news to social workers, who administer, train the workforce, shape policy, and provide frontline services in public systems of care. Nor does unmet need surprise social workers in the private sector where lack of insurance keeps clients from paying for, and hence too often from receiving, the care they need. What is new is that the dire straits of our service delivery systems have become front-page stories for the public at large. With more than 40 million people in the United States lacking health insurance (Institute of Medicine, n.d.), the safety net of publicly funded services has become even more critical. Such times and conditions accentuate the need for data--data about need, unmet need (for example, the gap between need and care provided), and factors associated with less than optimal system performance. Such data make system performance transparent, help mobilize change, and have the potential to inform quality improvement (Clancey, 2003). The Institute of Medicine has called for data that can monitor the structure, capacity, and financial stability of systems of care in the safety net (Lewin & Altman, 2000). A Safety Net Monitoring Collaborative has been established to support the accrual of baseline information about public systems of care, their environments, and the populations they serve (Agency for Health Care Research and Quality, 2003, http://www.ahrq. gov/data/safetynet). The goal of the collaborative is to inform policy, help service providers design interventions, and develop a research agenda on issues of access for low-income populations. As foundations and federal agencies call attention to the dire straits of systems of care in which we work, social workers and social work researchers need to contribute actively to such data. This issue's lead article contributes data about the performance of an indispensable part of the nation's safety net--the child welfare system. A perennial problem in providing quality foster care is retaining an adequate pool of foster families. Rhodes, Orme, Cox, and Buehler's longitudinal study addresses factors associated with attrition. Their sample reflects the magnitude of the dropout problem: Of 131 families studied who completed training, nearly half had already discontinued or planned to discontinue six months later. Attrition is a costly problem for the system, given the time and costs associated with assessing, recruiting, and training of foster families. This study indicates that resources play a key role in retaining foster families. Those with more resources, especially income, were more likely to continue as foster families. These findings suggest that agencies need to help families overcome resource barriers that threaten their ability to serve as caregivers, especially during the first year. …