Designing an Outcomes Rate Card Approach in Connecticut to Better Serve Families

Having a child changes your life. For many families, extra support during the transition into parenthood is critical. Home visiting programs, like those funded by the Connecticut Office of Early Childhood (OEC), help new parents navigate pregnancy, birth, and early parenting by connecting them with trained home visitors. During visits, home visitors provide guidance on various topics, such as child health, postpartum mental health, and infant developmental milestones. Home visitors can also provide transformative support to families.

When Jazmin (name redacted for privacy), a new mom participating in OEC’s home visiting program, shared with her home visitor that she dreamed of going back to school to become a nurse, the home visitor helped her develop a plan to make her dream happen. Even though home visiting is not a job training or education service, the home visitor ultimately helped Jazmin take classes, obtain a job as a Certified Nursing Assistant, and gain acceptance to nursing school. For supporting Jazmin’s employment and education goals, the home visiting provider received an incentive payment from OEC through an outcomes rate card.

An outcomes rate card lists high-priority metrics in a given service contract and ties a specific payment to each metric if it is achieved. Since 2017, Social Finance has worked with OEC to launch outcomes-focused projects, with the goal of strengthening the state’s early childhood system—a system that funds nearly $20 million in maternal and infant health and education services to approximately 3,000 caregivers who qualify as low-income each year. From 2018 to 2020, OEC developed five rate cards across its home visiting system to strengthen service delivery, improve performance, and reward providers for achieving priority outcomes.

Read more about how a rate card works and Social Finance’s partnership with OEC in Part 1 of this series →

Following three years of rate card implementation and an extensive review process (including statewide community listening sessions, provider interviews, family focus groups, a needs assessment, and analysis of rate card data), Social Finance and OEC determined that future versions of the rate card would be more impactful and easier to implement if they were more clearly aligned with OEC’s overall goals and strategy for home visiting. The home visiting system itself had evolved over those three years of partnership and stepping back to set the overall strategy would establish a foundation on which all future initiatives could grow. Fortunately, OEC was on the cusp of a new RFP intended to unify and re-articulate the system’s overall goals. Social Finance partnered with OEC (as well as the University of Connecticut School of Social Work and the Government Performance Lab at the Harvard Kennedy School) to define the RFP strategy, informed in part by some of the tactical lessons of the early rate cards. The RFP ultimately stated three core goals for home visiting: i) improve healthy births, ii) improve child development and parenting practices, and iii) reduce child maltreatment. These goals served as the foundation for not only the 2021 Rate Card design but also all aspects of the next set of home visiting contracts.

Building on the strategy stated in the RFP, OEC and Social Finance adjusted the design process in four ways for the 2021 Rate Card, which launched in Summer 2021 as the initiative’s sixth iteration:

1. Aligned the 2021 Rate Card across state and federally funded providers in a single, cohesive system (prior rate cards tended to be separated by home visiting model type).
2. Chose metrics that reinforce OEC’s vision. The rate card built upon the three aforementioned goals for home visiting that OEC articulated in its RFP.
3. Incorporated feedback from service providers and OEC staff. Social Finance interviewed several providers and the OEC home visiting team to understand their rate card implementation experiences. The most common recommendation was that OEC should improve rate card payment processes.
4. Leveraged historical data to inform metric selection and pricing. For example, Social Finance considered depression screening as a metric, but when 2020 data showed that home visiting providers already complete screens at high rates, OEC felt this would not meaningfully challenge providers. While this remains an important metric that providers are responsible for, it was not included in the rate card. OEC and Social Finance also used 2020 data to price the four selected metrics.

The adjusted design process resulted in three changes to the 2021 Rate Card:

1. Commit to simple metric definitions: The four metrics focus on easy-to-measure metrics that can be achieved quickly or routinely. The goal is for providers to be rewarded for strong delivery and receive payments quickly—not necessarily to complicate data collection or define the “perfect” metric.
2. Shift to payments every six months: Since payment lags persist, OEC will shift to paying every six months, instead of every three months as in prior rate cards. The less frequent timing should help OEC to verify data and make payments in a timely, predictable manner.
3. Enhance performance management: To strengthen the data feedback loop between OEC and the home visiting network, Social Finance will support OEC to consolidate, analyze, and visualize 2021 Rate Card data to determine how each provider performs and how results should influence operations.

The 2021 Rate Card includes four metrics, as seen in Figure 1. For every family achieving a metric, the provider receives a payment and can keep receiving payments up to 4% above existing fee-for-service contracts.

1. Key Population Enrollment: OEC encourages home visitors to serve families with birth outcomes that differ the most versus all population groups in Connecticut. The COVID-19 pandemic and national racial reckoning elevated OEC’s focus on serving families who have been systemically disadvantaged by racism. OEC also encourages enrolling teenage caregivers who need additional support.
2. Prenatal Enrollment: OEC rewards providers for enrolling caregivers before 32 weeks of pregnancy. OEC’s RFP articulated a focus on upstream and prevention services, and prenatal enrollment is one way to reach families early.
3. Caregiver Education and Training or Employment: Home visitors can help families to obtain and sustain employment and education as COVID-19 weakens families’ economic security.
4. Prenatal and Postpartum Care: This metric builds upon the Prenatal Enrollment metric by incentivizing early enrollment and encouraging timely perinatal services.

The rate card is a tool we are using to reflect OEC’s policy priorities and strategy. OEC and Social Finance look forward to collaborating with home visiting providers to improve service delivery for families and mothers—like Jazmin—in Connecticut over the next three years.

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