Trajectories of child protective services contact among Alaska Native/American Indian and non-Native children

BackgroundContact with child protective services (CPS) functions as an independent marker of child vulnerability. Alaska children are an important population for understanding patterns of CPS contact given high rates of contact overall and among specific demographic groups.ObjectiveWe aimed to identify longitudinal trajectory classes of CPS contact among Alaska Native/American Indian (AN/AI) and non-Native children and examine preconception and prenatal risk factors associated with identified classes.Participants and settingWe used data from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a linkage of 2009–2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) births with administrative data including CPS records.MethodsWe conducted growth mixture modeling to identify trajectory classes of CPS contact from birth to age five years. We used Vermunt’s three-step approach to examine associations with preconception and prenatal risk factors.ResultsAmong AN/AI children, we identified three classes: 1) no/low CPS contact (75.4%); 2) continuous CPS contact (19.6%), and 3) early, decreasing CPS contact (5.0%). Among non-Native children, we identified four classes: 1) no CPS contact (81.3%); 2) low, increasing CPS contact (9.5%); 3) early, rapid decline CPS contact (5.8%); and 4) high, decreasing CPS contact (3.3%). Maternal substance use had the largest impact on probabilities of class membership, increasing the probability of membership in classes characterized by CPS contact, among both AN/AI and non-Native children.ConclusionsResults reveal heterogeneity in longitudinal patterns CPS contact across early childhood among Alaska children and identify maternal substance use as an important target for primary prevention.     

Prenatal substance exposure diagnosed at birth and infant involvement with child protective services

Infants have the highest rates of maltreatment reporting and entries to foster care. Prenatal substance exposure is thought to contribute to early involvement with child protective services (CPS), yet there have been limited data with which to examine this relationship or variations by substance type. Using linked birth, hospital discharge, and CPS records from California, we estimated the population prevalence of medically diagnosed substance exposure and neonatal withdrawal disorders at birth. We then explored the corresponding rates of CPS involvement during the first year of life by substance type after adjusting for sociodemographic and health factors. Among 551,232 infants born alive in 2006, 1.45% (n = 7994) were diagnosed with prenatal substance exposure at birth; 61.2% of those diagnosed were reported to CPS before age 1 and nearly one third (29.9%) were placed in foster care. Medically diagnosed prenatal substance exposure was strongly associated with an infant’s likelihood of being reported to CPS, yet significant variation in the likelihood and level of CPS involvement was observed by substance type. Although these data undoubtedly understate the prevalence of prenatal illicit drug and alcohol use, this study provides a population-based characterization of a common pathway to CPS involvement during infancy. Future research is needed to explicate the longer-term trajectories of infants diagnosed with prenatal substance exposure, including the role of CPS.     

Neighborhood inequality in the prevalence of reported and substantiated child maltreatment

BackgroundPrior research documents spatial concentration in the incidence of child maltreatment reported to and confirmed by Child Protective Services (CPS), but without estimates of the prevalence of such reports, the extent of CPS contact in different communities is unknown.ObjectiveTo estimate the prevalence of CPS reports during early childhood and substantiated investigations during childhood for children living in different types of neighborhoods.Participants and settingChildren who experienced CPS reports and substantiated investigations in Connecticut.MethodsThis study uses synthetic cohort life tables to estimate the cumulative risk of CPS reports before age five and substantiated CPS investigations before age 18, by neighborhood poverty rate and neighborhood racial composition.ResultsThe analysis reveals substantial stratification in the prevalence of CPS contact by the demographic characteristics of children’s residential neighborhoods. For example, while 7% of children in low-poverty neighborhoods (under 10% poor) experience a substantiated CPS investigation at some point during childhood at 2014 and 2015 rates, this risk more than doubles to 17% for their peers in moderate-poverty neighborhoods (10–20% poor) and more than triples to 26% for their peers in high-poverty neighborhoods (over 20% poor). Similar trends emerge when examining CPS reports in early childhood as well as when comparing neighborhoods with different proportions of White residents.ConclusionsCPS reports and substantiated investigations are a widespread and disproportionately experienced life event for children in poor neighborhoods and children in non-White neighborhoods.     

Infant removals: The need to address the over-representation of Aboriginal infants and community concerns of another ‘stolen generation’

ObjectivesThe removal of a child from their parents is traumatising, particularly in Aboriginal communities where a history of child removals has led to intergenerational trauma. This study will determine where disparities in child protection involvement exist among Aboriginal and non-Aboriginal children and characteristics associated with infant removals. Challenges faced by child protection and other agencies, and opportunities for overcoming these, are discussed.MethodsData from both the Australian Institute of Health and Welfare and linked Western Australian government data was used to examine disparities between Aboriginal and non-Aboriginal children in the child protection and out-of-home care system.ResultsNationally, Aboriginal children are ten times more likely to be placed in out-of-home care than non-Aboriginal children and this disparity starts in infancy. Infants were removed from parents with high levels of risk. Aboriginal infants were at increased risk of being removed from women with substance-use problems and had greater proportions removed from remote, disadvantaged communities than were non-Aboriginal infants.ConclusionsAboriginal infants have a high rate of removal. Although there are many complexities to be understood and challenges to overcome, there are also potential strategies. The disparity between Aboriginal and non-Aboriginal infant removals needs to be seen as a priority requiring urgent action to prevent further intergenerational trauma.     

Paternity establishment at birth and early maltreatment: Risk and protective effects by maternal race and ethnicity

BackgroundMinority race/ethnicity, low socioeconomic status, and lack of established paternity have been identified in previous research as risk factors for child maltreatment. However, given vastly different patterns of income distribution, single parenting and co-parenting across racial and ethnic populations, it is difficult to know which of these factors contribute most to maltreatment risk.ObjectiveThe current study explores whether the odds of maltreatment differ across race/ethnicity when paternity is not established at birth after controlling for maternal socioeconomic status.MethodsUsing merged birth certificate and child protective services records for children born between 2009 and 2011 in Texas (N = 1,175,804), we conducted multiple logistic regression analyses testing the main effects of maternal race and lack of established paternity, as well as the interaction of the two, on substantiated maltreatment.ResultsResults show that children of black mothers were less likely to have established paternity and more likely to experience maltreatment compared with other groups. However, the odds of maltreatment were lower for children of black mothers without established paternity compared to children of white mothers without established paternity (OR = .71, 95% CI [0.67,0.75]). Alternatively, the odds of maltreatment were higher when paternity was not established at birth for Hispanic mothers (OR = 1.13, 95% CI [1.08,1.18]) and mothers of other race/ethnicities (OR = 1.35, 95% CI [1.11,1.65]) compared to white mothers.ConclusionResearch and prevention programming must consider that the processes and pathways linking paternity establishment and maltreatment may differ within and between racial/ethnic groups.     

Child maltreatment and risk patterns among participants in a child abuse prevention program

The relationship between risk factors and Child Protective Services (CPS) outcomes in families who participate in home visiting programs to prevent abuse and neglect and who are reported to CPS is largely unknown. We examined the relationship between parental risk factors and the substantiation status and number of CPS reports in families in a statewide prevention program. We reviewed CPS reports from 2006 to 2008 for families in Connecticut's child abuse prevention program. Six risk factors (histories of CPS, domestic violence [DV], mental health, sexual abuse, substance abuse, and criminal involvement) and the number of caregivers were abstracted to create risk scores for each family member. Maltreatment type, substantiation, and number of reports were recorded. Odds ratios were calculated. Of 1,125 families, 171 (15.6%) had at least one CPS report, and reports of 131 families were available for review. Families with a substantiated (25.2%) versus unsubstantiated (74.8%) first report had a high number of paternal risk factors (OR = 6.13, 95% CI [1.89, 20.00]) and were more likely to have a history of maternal DV (OR = 8.47, 95% CI [2.96, 24.39]), paternal DV (OR = 11.23, 95% CI [3.33, 38.46]), and maternal criminal history (OR = 4.55; 95% CI [1.32, 15.60]). Families with >1 report (34.4%) versus 1 report (65.6%) were more likely to have >3 caregivers, but this was not statistically significant (OR = 2.53, 95% CI [0.98, 6.54]). In a prevention program for first-time families, DV, paternal risk, maternal criminal history, and an increased number of caregivers were associated with maltreatment outcomes. Targeting parental violence may impact child abuse prevention.     

Lifetime risk of child protection system involvement in South Australia for Aboriginal and non-Aboriginal children, 1986–2017 using linked administrative data

BackgroundChild protection services exist to reduce potential harms from child maltreatment. Many jurisdictions produce annual data on child protection system (CPS) involvement, leaving a gap in knowledge of lifetime involvement.ObjectiveTo describe lifetime involvement in CPS, by type of contact.ParticipantsAll 608,547 children born in South Australia (SA), Australia between 1986 and 2017.MethodsA retrospective cohort design using linked administrative data to report cumulative incidence of CPS involvement from birth to age <18 (or June30 2017) by Aboriginal status. CPS involvement was categorised into notifications (3 levels), investigations, substantiations and out-of-home care (OOHC). Cumulative incidence curves were derived for 5 birth cohorts.ResultsAcross childhood (to age <18 years), substantiated maltreatment was experienced by 3.2–3.6% of non-Aboriginal and 19–25% of Aboriginal children, 7 times reported annual substantiation rates. For most CPS categories CPS involvement increased until 2010, and was occurring earlier in life. By age 3, 0.5% of non-Aboriginal and 4.5% of Aboriginal children born 1986–1991 were the subject of a substantiation compared with 1.9% and 15% of non-Aboriginal and Aboriginal children, respectively, born 2010–2017. Incidence rates beyond age 3 were similar. OOHC contact was similar across cohorts, with ˜1.5% of non-Aboriginal and 12.7% of Aboriginal children ever-placed in care.ConclusionsData linkage is an essential tool for understanding life course involvement with the CPS and describing trends not observable from annual snapshots. Such information is critical for burden of disease estimates, informing policy and monitoring CPS performance.     

Using time-to-event analysis to identify preconception and prenatal predictors of child protective services contact

We examined preconception and prenatal predictors of time to first child protective services (CPS) contact among Alaska children. Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a population-representative data source linking 2009–2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data with administrative data sources through 2015. We examined the incidence CPS contact using the Kaplan-Meier method and predictors of CPS contact using Cox proportional hazards regression. Using data from the Alaska Permanent Fund Dividend and Child Death Review, we censored children who emigrated out-of-state or died during the study period. Significant predictors included low socioeconomic status (HR = 2.23, 95% CI 1.68, 2.96), maternal smoking during pregnancy (HR = 1.87, 95% CI 1.55, 2.24), unmarried maternal marital status (HR = 1.62, 95% CI 1.31, 1.99), urban residence (HR = 1.59, 95% CI 1.32, 1.92), lower maternal education (HR = 1.54, 95% CI 1.24, 1.92), maternal experience of intimate partner violence in the 12 months before childbirth(HR = 1.32, 95% CI 1.01, 1.74), Alaska Native/American Indian race (HR = 1.40, 95% CI 1.15, 1.71), a greater number of living children (HR = 1.20, 95% CI 1.13, 1.29), a greater number of stressful life eventsin the 12 months before childbirth (HR = 1.16, 95% CI 1.11, 1.21), and younger maternal age at childbirth (HR = 0.95, 95% CI 0.93, 0.97). Use of multiple linked data sources and time-to-event analysis methods adds to the growing literature regarding predictors of CPS contact. Results suggest that assessing for and addressing clinical, social, and environmental indicators during the prenatal period may aid prevention efforts in mitigating family need for involvement with CPS.     

Child protection cases,one size fits all? Cluster analyses of risk and protective factors

BackgroundTo provide effective tailor made case management in Child Protection Services (CPS) a insight is needed into the specific characteristics of the target group. Using the ecological perspective of maltreatment, this study explored poorly known characteristics of the CPS population.ObjectiveTo distinguish CPS subgroups based on risk and protective factors enables tailor made case management that fits the specific needs of these subgroups.Participants and settingWe studied 250 Dutch CPS cases of family supervision by court order that had completed the LIRIK and Action Plan checklists in August 2014–March 2015.MethodsThis quantitative study analyzed risk and protective factors for children and parents reported in client files. Subgroups were identified by two-step cluster analyses. Chi-square analyses identified relations between parental risk subgroups and other groups.ResultsBuilding on the interplay between risk and protective factors on the levels of child, parent and environment, we found five distinct subgroups in the CPS population. The most vulnerable is parents with multiple problems (31%) or socio-economic problems (13%). Parts of both subgroup have limited protective factors. Parents with major life events (16%) or poor parenting (13%) are characterized by single-level problems. One subgroup (28%), the unaccepted, has no parental risk factors registered.ConclusionsStudying client files can lead to a better understanding of the healthcare needs of the CPS population. To develop and implement more effective case management requires constant dialogue between science, policy, and the experiences of both clients and professional.     

Timing and chronicity of child neglect and substance use in early adulthood

BackgroundNeglect is the most common form of child maltreatment with consequences that appear to be as serious as for abuse. Despite this, the problem has received less than its due attention.ObjectiveTo examine the relationship between the timing and chronicity of neglect during childhood and substance use in early adulthood.Participants and settingThe sample consisted of a subset of 475 participants from the prospective Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) consortium from five geographic areas around the U.S.MethodNeglect was assessed using abstracted information from CPS reports (birth-18) and self-reports of neglect (12–18). Participants completed a follow-up online survey (mean age of 24 years) that probed their use of substances.ResultsThe prevalence of substance use during the past year was comparable in this high-risk sample to the general population. Latent class analysis supported the presence of three groups related to the presence and timing of neglect: Chronic Neglect, Late Neglect and Limited Neglect. Late Neglect was the pattern most strongly linked to substance use in early adulthood.ConclusionsHigh-risk youth experiencing neglect beginning in mid- adolescence are especially vulnerable to later substance use. Those working with such youth and their families can play a valuable role helping ensure their basic needs are adequately met, and recognizing early signs of substance use and abuse.     

Substance-exposed newborn infants and public health law: Differences in addressing the legal mandate to report

Prenatal exposure to illicit substances is a finding that typically requires reporting to a child protective services agency. We examine whether there is differential reporting to two public agencies, and whether it varies by race/ethnicity and region. We also study predictors of indicating a maltreatment report as credible. Data on positive neonatal toxicology reports were obtained from the Illinois Department of Public Health (IDPH) and the Illinois Department of Children and Family Services (DCFS). Variation in reporting rates by race/ethnicity and region were compared with Pearson chi-square analysis. Multivariate logistic regression examined factors related to the likelihood of DCFS indicating a report as credible for maltreatment. IDPH recorded 1838 reports of substance-exposed newborn infants while DCFS only recorded 459 reports. There was a greater percentage of whites than blacks reported to DCFS as compared to those reported to IDPH (p < 0.001). There was a greater percentage of whites than blacks found to be indicated by DCFS as compared to those reported to IDPH (p < 0.001). Infants reported in rural areas were indicated less often (OR:0.34, 95% CI:0.17–0.67, p = 0.002) than those from urban areas. In conclusion, there was variation in reporting patterns between the two agencies. To optimize health outcomes for substance-exposed newborn infants (SEIs), the law should be clarified to provide clear standards for reporting and managing SEIs. Clinicians should ensure they are acting within the confines of existing law, and should engage in an interprofessional process with a broad array of stakeholders to develop statewide drug testing and reporting protocols.     

Identifying children at high risk for a child maltreatment report

Objective

To help professionals identify factors that place families at risk for future child maltreatment, to facilitate necessary services and to potentially help prevent abuse and neglect.

Method

The data are from a prospective, longitudinal study of 332 low-income families recruited from urban pediatric primary care clinics, followed for over 10 years, until the children were approximately 12 years old. Children with prior child protective services involvement (CPS) were excluded. The initial assessment included sociodemographic, child, parent and family level variables. Child maltreatment was assessed via CPS reports. Risk ratios (RRs) and their 95% confidence intervals (CIs) were estimated using Cox regression models.

Results

Of the 224 children without a prior CPS report and with complete data who were followed for an average of 10 years, 97 (43%) later had a CPS report. In a multivariate survival analysis, 5 risk factors predicted CPS reports: child's low performance on a standardized developmental assessment (RR = 1.23, 95% CI = 1.01-1.49, p = .04), maternal education ≤ high school (RR = 1.55, CI = 1.01-2.38, p = .04), maternal drug use (RR = 1.71, CI = 1.01-2.90, p < .05), maternal depressive symptoms (RR per one standard deviation higher score = 1.28, CI = 1.09-1.51, p < .01), and more children in the family (RR per additional child = 1.26, CI = 1.07-1.47, p < .01).

Conclusions

Five risk factors were associated with an increased risk for later maltreatment. Child health care and other professionals can identify these risk factors and facilitate necessary services to strengthen families, support parents and potentially help prevent child maltreatment.     

The efficacy of family reunification practices: reentry rates and correlates of reentry for abused and neglected children reunited with their families

OBJECTIVE: Since the 1980s Child Protective Services has increasingly relied on family reunification for abused/neglected children rather than long term foster care or adoption. While family reunification practices are controversial, little research is available to inform the debate. This research explores the efficacy of these practices. METHODS: This study utilizes two CPS data sources and both quantitative and qualitative methodologies to identify reentry rates and correlates of reentry for abused and neglected children returned to their families by CPS. RESULTS: System reentry due to additional maltreatment is considerable. Thirty-seven percent of the children reunited with their families reenter the system within 3 1/2 years. Correlates of reentry are identified as; abuse type, CPS history, parental competency, race, criminal history, substance abuse, and social support. Notably, assessments of risk made by caseworkers are found to be unrelated to reentry. CONCLUSIONS: The high reentry rate and the limitations of current risk assessment procedures suggest that CPS family reunification practices have not been entirely successful. The identification of specific risks of reentry, such as those revealed in this study, will be helpful in assessing risk on cases. In addition, future studies should explore the systemic deficiencies that contribute to the additional maltreatment that occurs for a sizable proportion of the children served by the system.     

Risk of re-report: A latent class analysis of infants reported for maltreatment

A key challenge facing child protective services (CPS) is identifying children who are at greatest risk of future maltreatment. This analysis examined a cohort of children with a first report to CPS during infancy, a vulnerable population at high risk of future CPS reports. Birth records of all infants born in California in 2006 were linked to CPS records; 23,871 infants remaining in the home following an initial report were followed for 5 years to determine if another maltreatment report occurred. Latent class analysis (LCA) was used to identify subpopulations of infants based on varying risks of re-report. LCA model fit was examined using the Bayesian information criterion, a likelihood ratio test, and entropy. Statistical indicators and interpretability suggested the four-class model best fit the data. A second LCA included infant re-report as a distal outcome to examine the association between class membership and the likelihood of re-report. In Class 1 and Class 2 (lowest risk), the probability of a re-report was 44%; in contrast, the probability in Class 4 (highest risk) was 78%. Two birth characteristics clustered in the medium- and highest-risk classes: lack of established paternity and delayed or absent prenatal care. Two risk factors from the initial report of maltreatment emerged as predictors of re-report in the highest-risk class: an initial allegation of neglect and a family history of CPS involvement involving older siblings. Findings suggest that statistical techniques can be used to identify families with a heightened risk of experiencing later CPS contact.     

An examination of child protective service involvement among children born to mothers in foster care

ObjectiveThis study identified children born to mothers in foster care and documented Child Protective Service (CPS) involvement among children.MethodsProbabilistically linked birth and CPS records from California (2009–2012) were used to identify all mothers in foster care on or after conception. Children were followed prospectively using linked records to identify CPS involvement occurring during the first three years of life. Differences between reported and unreported children were examined using χ2 tests. The Latent Class Analysis (LCA) identified classes of children born to mothers in care who were at increased risk of CPS involvement. Model fit was assessed using the Bayesian Information Criterion, entropy, and likelihood ratio tests. For each of the classes, the relationship to the distal outcome (i.e., a maltreatment report by age three), was examined.ResultsFindings indicate that 53% of children born to mothers in care were reported. The proportion of children reported to CPS for maltreatment declined over time, from 63% of children born to mothers in foster care in 2009, to 46% in 2012. The LCA documented three distinct classes of mother-child dyads with varying risk of report. More than one third of children in Class 1 and nearly 70% of children in Class 3 were reported.ConclusionsThis study was the first to develop multi-dimensional class profiles of two-generation CPS involvement among mother-child dyads. This study documents that mothers’ experiences in care and mental health conditions vary widely, underscoring the importance of providing services that fit the needs of dyads.     

Child protective services' response to prenatal drug exposure: results from a nationwide survey.

OBJECTIVE: This survey was conducted to: (1) document child protective services (CPS) agencies' actual practices regarding prenatal drug exposure; (2) examine urban and rural differences in CPS responses; (3) explore whether CPS practices varied as a function of county median income, birth rate, population size, or percent minority births; and (4) assess respondent satisfaction with their county's current responses. METHOD: Data were collected via a nationwide telephone survey of child welfare supervisors from two urban and two rural counties in every state (N = 200). RESULTS: Ninety percent of counties (100% of urban and 80% of rural) reported receiving referrals of infants with prenatal drug exposure. Among those receiving referrals, extreme variations in practice were found; all possible response options (from very inactive to very aggressive) were equally represented on key questions (e.g., filing court petitions, taking custody). Rural counties tended to have stronger responses than urban counties (t[175] = -2.26, p = .024). County response did not vary with county-level median family income, percent minority births, or birth rate. Despite wide variations in practice, the majority of respondents (69%) felt their county's response was appropriate. Of respondents who did indicate that their county's response was inappropriate, most (85%) felt that the county needed to do more to protect children. CONCLUSIONS: There is currently tremendous variation across US counties in CPS responses to, and beliefs regarding, the issue of prenatal drug exposure. Some of this variation is due to differences between urban and rural counties, with little variation explained by differences in median income or percent minority births at the county level. There is a need for research-based guidance and consensus building in CPS practice in this area.     

Adverse childhood experiences and preschool suspension expulsion: A population study

BackgroundPreschool suspension and expulsion rates are typically based on teacher reports, and don’t simultaneously account for adverse childhood experiences (ACEs).ObjectiveTo examine estimates in the United States of parent-reported preschool suspension and expulsion rates, in the context of ACEs.Participants and settingParents of children aged 3–5 years old (N = 6,100) in the 2016 National Survey of Children’s Health dataset.MethodWe reported the prevalence estimates of preschool suspension and expulsion, and estimated the unique variance of ACEs as risk factors using weighted sequential logistic regression.ResultsAn estimated 174,309 preschoolers (2.0%) were suspended, and 17,248 (0.2%) children were expelled annually. If divided by 36 school weeks, the instances of weekly suspension and expulsion were at least 4,842 and 479 respectively. Controlling for previous risk factors (i.e., age, gender, race, ethnicity), the odds ratio increased by 80% for every unit of ACEs increment. Children were more likely to be suspended or expelled if they had domestic violence (OR = 10.6, p < .001), living with mental illness (OR = 9.8, p < .001), adult substance abuse (OR = 4.8, p < .001), and victim of violence (OR = 4.5, p = .004), living in high poverty (OR = 3.9, p = .001), divorced parents (OR = 3.3, p = .001), and parent incarceration (OR = 3.0, p = .009).ConclusionThe alarming suspension and expulsion rates call for more comprehensive outreach prevention and response efforts in preschool settings. Cross system collaboration and family support are essential to this work.     

What does effectiveness mean?: A qualitative assessment of two child protection systems

BackgroundChild Protective Services (CPS) systems have not historically conducted system effectiveness research. More information is needed about the long-term outcomes of children and families served by the systems.ObjectiveTo investigate how workers within CPS systems in Colorado and the Netherlands measure and perceive the effectiveness of their CPS system.Participants and settingCPS administrators and workers in Colorado and the Netherlands from August 2015 through May 2016. At both sites, interviewees included front line employees with deep knowledge of daily mechanics and processes, as well as experts and thought leaders who possessed historical memory and perspective about their site’s CPS system.MethodsIn-depth, semi-structured interviews were conducted with 77 participants. In Colorado (n = 36), 8 participants were state experts and 28 held county-level roles. In the Netherlands (n = 41), 17 participants were national experts and 24 worked at Veilig Thuis agencies.ResultsParticipants in both sites reported that they did not know if their system had empirical evidence to support its effectiveness, and had difficulty identifying how they would measure the effectiveness of their system.ConclusionsBoth systems lack the ability to collect data on the quality of their services and the longitudinal outcomes for the children and families they serve. Measures of good outcomes must be developed. Without longitudinal outcome data, CPS systems cannot assess the effectiveness of their practice. CPS systems might partner with the healthcare system, where the infrastructure and culture are already in place to look at quality and longitudinal outcomes.