Independent Living Coordinators’ Effects on Intangible Domains in an Independent Living Program

Purpose This study involved an evaluation of the role of the Independent Living Coordinator (ILC) in a. Email multi-domain Independent Living program (ILP). It focused on the intangible domains of health/mental health, support, and prevention. Method One hundred and nineteen ILP plans from 97 foster youth were coded to determine which goals were achieved for foster youth between the ages of 14 and 21. Quotations from case notes and IL plans were selected to illustrate the role of the ILC. Results Results demonstrated that ILCs were effective in achieving goals regarding mental health counseling and medication management and practical support for finances and transportation. ILCs struggled to promote peer support, romantic relationships, and use of birth control. Discussion ILCs play roles in supporting foster youths’ transition into adulthood. ILCs were successful based on the types of goals, their understanding of developmental needs, and access to resources. Future research should involve randomized control trial evaluations.

Foster youth experience difficulties across multiple domains when transitioning to adulthood. Thirty-three percent of foster youth perceive the transition as difficult or very difficult (Sulimani-Aidan, 2014). These difficulties occur in tangible and intangible domains. Tangible domains include education, employment, housing, and life skills while intangible domains include health/mental health, support (relational and practical), and prevention. Courtney and Dworsky (2006) summarized the findings of the Midwest Evaluation of the Adult Functioning of Former Foster Youth study, the largest study conducted of transition age foster youth. They reported that more than one-third of foster youth had neither a high school diploma nor a GED. Another study found that 57% of foster youth had a high school diploma or GED by age 19 (Children's Bureau, 2017). In the area of employment, only 9% of foster youth in transition were employed full-time and 14% part-time at age 19 (Children's Bureau, 2017). Most foster youth never completed job training and only 16% had part-time jobs (Mitchell et al., 2015). Hook and Courtney (2011) reported that at age 24 only half of former foster youth who aged out of the system were employed. Addtionally, Shpiegel and Cascardi (2015) found that only 13% of foster youth were employed full-time or part-time. Regarding housing outcomes for foster youth, 20% of foster youth were homeless at least once in their lives (Children's Bureau, 2017;Mitchell et al., 2015). Shpiegel and Cascardi (2015) reported that 16% of foster youth reported a period of homelessness. Youth needed help learning about financial matters such as planning a budget and savings (Hojer et al., 2013). Courtney and Dworsky (2006) found that only half of foster youth had a savings or checking account. Twenty percent of foster youth in college acknowledged the need to improve their life skills in the area of finance (Kinarsky, 2017). Life skills training was needed in a number of areas including money management, housing, transportation, self-care issues, work and study habits, and problem-solving skills (Haggman-Laitila et al., 2018).
Foster youth also experience challenges in intangible domains. Mental health issues are of concern for foster youth aging out. The lifetime prevalence for mental health disorders for foster youth between the ages of 17 and 18 was 61-66% (Havlicek et al., 2013). The twelve-month prevalence rate was 37% (Havlicek et al., 2013). One-third of foster youth suffered from depression, dysthymia, PTSD, social phobia, alcohol abuse, alcohol dependence, substance abuse, or substance dependence (Courtney & Dworsky, 2006). Seventy-seven percent of 19-year-old foster youth reported having Medicaid (Children's Bureau, 2017).
Regarding support, foster youth have needs for both practical and relational support. Many reported experiencing one or more recent indicators of economic hardship for which they could use practical support. According to Courtney and Dworsky (2006), one-quarter of foster youth were food insecure. More than twice as many of the foster youth as nonfoster youth did not have enough money to pay their rent or mortgage. Twice as many foster youth as non-foster youth were unable to pay a utility bill. Foster youth were 1.5 times more likely to report having their phones disconnected. Foster youth were more likely to report being evicted. Eighty-nine percent of foster youth reported having a positive connection to an adult at age 19 (Children's Bureau, 2017). Collins et al. (2010) reported that foster youth range from having no connections to a wide variety of connections.
The intangible domain of prevention includes topics such as pregnancy and substance use. By age 19, nearly half of females transitioning out of care had been pregnant and the young adults were twice as likely as 19-year-olds in the general population to have at least one child (Courtney & Dworsky, 2006). Four percent of males and 10% of female foster youth have children by the age of 17 (Shpiegel & Cascardi, 2015). Regarding substance use, Vaughn et al. (2007) reported that more than one-third of the foster youth met the criteria for a substance use disorder. Forty percent of foster youth in an independent living program reported using alcohol, 36% reported using marijuana, and 25% reported using both in the past six months (Thompson & Auslander, 2007).
In order to assist foster youth in addressing these challenges during the transition to adulthood, several individuals must collaborate, including program staff, administrators, funders, and any other professionals who can impact intervention success (Salazar et al., 2016). One type of other professional is an Independent Living Coordinator (ILC). ILCs possess a great deal of knowledge regarding policy and practice (Tao et al., 2013). An ILC works in an Independent Living Program (ILP) to engage older foster youth in transition planning and offer support with addressing key life domains when preparing to enter adulthood.
This study will explore the effectiveness of the ILC in offering services to foster youth in a comprehensive ILP. This ILP is referred to as a "multi-domain ILP" because it encompasses seven domains in its programming: (a) education, (b) employment, (c) housing, (d) health/mental health, (e) support, (f) prevention, and (g) life skills. The seven domains can be divided into two groupings: the "tangible" domains or supports, which consist of (a) education, (b) employment, (c) housing, and (d) life skills (hard skills), and the "intangible" domains, which consist of (a) health/mental health, (b) support, and (c) prevention (soft skills). This paper will focus on the intangible domains of intervention. The study's major research questions are as follows: 1) What was the role of the ILC in providing interventions in each of the intangible domains? 2) How effective was the ILC in providing interventions in each of the intangible domains? 3) How did the ILCs' interventions in each of the intangible domains impact the effectiveness of the ILP?
Health/Mental Health Goodkind et al. (2011) found that one of the greatest difficulties for foster youth is mental health challenges. There are more mental health diagnoses and greater experiences of trauma for former foster youth in comparison with the general population (Greeno et al., 2019a). The most common problem among foster youths tended to be externalizing disorders (Kerker & Dore, 2006). The most common diagnoses of children in foster care were ODD/Conduct Disorder, Major Depressive Disorder, PTSD, and Reactive Attachment Disorder (Engler et al., 2022). There was twice the rate of PTSD among foster youth at ages 17-18 than in the general population (Havlicek et al., 2013). There was also four times the rate of conduct disorder among foster youth in this age group (Havlicek et al., 2013). Foster youth were three times likely to have ADD/ADHD, five times as likely to have anxiety, six times as likely to have behavior problems, and seven times as likely to have depression as the general population (Turney & Wilderman, 2016). Additionally, foster youth were prescribed psychotropic medications at a higher rate than other Medicaideligible youth (Lee & Morgan, 2017). Foster youth need treatment for mental health issues and trauma when they are preparing to exit from foster care (Greeno et al., 2019a), which ILCs should support (Katz & Courtney, 2015). Social workers play an important role in helping foster youth address their mental health issues. Training for caseworkers need to address the topic of trauma, separation, and loss, and to help ILCs develop skills to reduce the negative impact of foster care experiences such as placement moves (Unrau et al., 2008). Child welfare professionals need to implement interventions that assist foster youth with managing negative emotions (Haggman-Laitila et al., 2018). Child welfare professionals also are able to advocate for foster youths' mental health needs, provide access to behavioral health history, and assist in coordinating and collaborating with mental health professionals for foster youths' care (Lee & Morgan, 2017;Park et al., 2019).
Foster youth also struggle to receive adequate general medical care. Children in foster care were twice as likely to have learning disabilities, developmental delays, asthma, obesity, and speech problems, and three times as likely to have hearing and vision problems as the general population (Turney & Wilderman, 2016). Foster youths often have gaps in medical care (Massinga & Pecora, 2004;Merdinger et al., 2005), as well as dental, vision, and hearing services (Massinga & Pecora, 2004). Support services are needed in the areas of how to use health services (Haggman-Laitila et al., 2019) and address physical and mental health needs (Haggman-Laitila et al., 2018). Merdinger et al. (2005) noted that 45% of foster youths did not have medical insurance.

Support-Relational
Foster youth's greatest difficulties are with social and emotional support from family members, current and former romantic relationships, and the other parent of children (Goodkind et al., 2011). Foster youth transitioning to adulthood have greater success in achieving independence when they have established relationships with adults who will support them over time. Dinisman (2016) reported that all youth exiting care in Israel should have a relationship with an adult that will support them through the transition to adulthood, whether it be a family member, professional, or mentor. Sixty-nine percent of foster youth indicated that they had one supportive adult in their life (Collins et al., 2010).
Caseworkers such as ILCs play a significant role in bolstering support for foster youth (Ahrens et al., 2011). ILCs need to develop and utilize specific interventions that help older youth find and develop permanent and committed relationships with responsible adults prior to aging out of foster care (Yampolskaya et al., 2014). This is twofold in that sometimes the caseworkers provide support and at other times they link foster youth to other relational supports. Collins et al. (2010) found that over a third of foster youths reported that a child welfare professional was an important support in their life. The majority of foster youth reported relatively high levels of relationship quality with their caseworkers (Jaramillo & Kothari, 2021). Rosenwald et al. (2013) noted that foster youth need emotional support from ILCs. Emotional support from caseworkers is experienced in the forms of openness to foster youths' experiences and an expressed sense of care (Strolin-Goltzman et al., 2016). ILCs provide instrumental and appraisal in addition to emotional support (Singer et al., 2013). Foster youth on average reported high levels of emotional and instrumental support from caseworkers (Jaramillo & Kothari, 2021). The caseworker must have time with the foster youth to develop a positive relationship based on regular personal and phone contact (Charles & Nelson, 2000). Open and honest communication is foundational to maintaining these relationships in both Ireland and the United States (Glynn & Mayock, 2019;Salazar et al., 2020). Collins et al. (2010) found that adults in the child welfare system such as caseworkers were described as accepting of foster youth, encouraging, reliable, and able to aid when needed. Conversely, Blakeslee and Best (2019) found that inconsistent or challenging relationships with caseworkers negatively impacted foster youths' connection to transition supports and support networks. Many foster youth maintain these supports after the child has exited the foster care system (Singer et al., 2013). Hokanson et al. (2020) reported that foster youth reported more positive relationships with social workers than any other type of relationship. Foster youth who reported more positive relationships with their social workers reported higher satisfaction with their care (Richardson & Yates, 2019).
Social workers and caseworkers should assist foster youth in building informal support networks and strengthen use of current relationships (Singer et al., 2013). Antle et al. (2009) noted that child welfare workers need to identify relational supports for older foster youth exiting care. For example, child welfare workers can aid foster youths in determining who they want to participate in family support systems and how they want to build relationships with family members (Lee et al., 2016). Overall, the role of the caseworker such as the ILC must encompass assessment, initiation, and continuation of relationships as well as relationship skills (Charles & Nelson, 2000) and monitoring and assistance to support relationships (Johnson & Mendes, 2014).

Support-Practical
According to Rosenberg (2019), foster youth reported missing support in key areas including transportation and instrumental support. Foster youth often lacked financial support, including in South Africa (Shaw et al., 2020). Caseworkers provided financial support to foster youth across several European countries (Jackson & Cameron, 2012). By age 19, foster youth received at least one type of financial assistance such as Social Security, financial aid, or other forms of significant, periodic financial support (Children's Bureau, 2017). Even foster youth who go on to attend postsecondary education reported some financial difficulty upon exiting the foster care system (Merdinger et al., 2005). In order to live independently, foster youths needed transportation (Shaw et al., 2020). Foster youths also needed transportation to increase educational stability (Strolin-Goltzman et al., 2016). Successful ILPs must provide transportation (Massinga & Pecora, 2004) and implement other creative means to address concrete barriers to foster youths' successful transition (Wells & Zunz, 2009). Lastly, caseworkers in a Zimbabwe community played a role in providing foster youths transitioning out of foster care with vital documents such as birth certificates that enabled them to pursue independent living goals (Dziro, 2020).

Prevention
Foster youths are at increased risk of challenges in the areas of teen pregnancy (Putnam-Hornstein & King, 2014;Shpiegel et al., 2017), increased STD/STIs (Ahrens et al., 2016;King & Van Wert, 2017), and substance use and abuse (Greeno et al., 2019a(Greeno et al., , 2019bTraube et al., 2012). ILCs provide prevention services for foster youth in these areas. Traube et al. (2012) reported that 47.7% of their sample reported having consumed social drugs within the last 30 days, 18 months, or 36 months into the study. Additionally, 17.4% reported using hard drugs within the last 30 days, 18 months, or 36 months into the study. Greeno et al., 2019aGreeno et al., , 2019b indicated 99% of foster youth in their study were indicated for hazardous drinking and 96% of youth drank between 5 and 6 drinks when consuming alcohol, which is considered binge drinking. Caseworkers should deliver substance abuse prevention services nonjudgmentally, empathetically, and in ways that are empowering (Salazar et al., 2018). Training for child welfare workers to address substance abuse with foster youth is strongly recommended (Braciszewski et al., 2018).
Sexual health and education are important topics for foster youth since they encompass prevention information related to STD/STI, reproductive health, and pregnancy prevention. Foster youth had challenges accessing and effectively utilizing services related to reproduction and sexual health (King & Van Wert, 2017). Some foster youth had inaccurate beliefs like condoms are not necessary with steady partners, youth have the ability to tell that someone is trustworthy or has an STI by they way they look, and early pregnancy is inevitable (Ahrens et al., 2016). All youth with child welfare involvement were at risk of pregnancy and parenting (Combs et al., 2018). Shpiegel et al. (2017) found in the National Youth in Transition Database that the cumulative rate of childbirth by for foster youth at age 19 was 21%. Between the ages of 17 and 19, the rate was 17% and for foster youth ages 17 or earlier, the rate was 9%. Putnam-Hornstein and King (2014) reported that in California, 11.4% of foster youth had a first birth before age 18 and 28.1% had a birth before age 20. For those girls who had a first birth before age 18, 41.2% had a repeat teen birth. Child welfare workers have-to have clearly defined roles regarding sexual and reproductive health with the foster youth (Harmon-Darrow et al., 2020). Caseworkers have stated they are fearful and unprepared to address these topics with foster youth (King & Van Wert, 2017). Harmon-Darrow et al. (2020) explained that child welfare workers should be aware of resources and services, understand their own values and issues on this topic, and establish trust with the foster youth. They also noted that child welfare workers felt more at ease talking with foster youth about these issues after receiving more education and training.
Foster youth who participate in extracurricular activities are able to build supportive relationships with people outside of the foster care system. These activities provide foster youth with a sense of achievement and self-efficacy, as found with foster youth from Australia and the United Kingdom (Martin & Jackson, 2002). Foster youths often do not get the chance to participate in extracurricular activities due to multiple placement moves (Day et al., 2012). ILCs can encourage foster youths to participate in extracurricular activities that are of interest to them (Moyer & Goldberg, 2020). Refaeli et al. (2017) noted that Israeli caseworkers within care institutions should discuss foster youths' participation in extracurricular activities. These activities can help facilitate the transition to independent living. 65.7% of former foster youth reported participating in extracurricular activities in high school (White et al., 2018)

Program Description
The ILP evaluated in this study is located in a Northeastern urban area. The ILP bases its programming on the stateproduced bulletin and supplemental appendix that outlines the responsibilities of the ILP and the Independent Living Coordinators (ILCs). ILCs provide coordinated and comprehensive services that are individualized to meet the specific needs of foster youth who have been in care on or after their 14 th birthday through their 21st birthday to assist them with the transition from out-of-home placement and adolescence to adulthood.
The ILP employs a "Joint Case Management" approach to help foster youth achieve their goals. The Joint Case Management approach joins certified child welfare caseworkers with ILCs, who are also certified child welfare workers, to increase continuity of care and independent living service planning for foster youth. This approach also provides workers with the opportunity to interchangeably attend important meetings such as mental health multidisciplinary meetings, permanency team meetings, Family Group Decision Making conferences, and other meetings important to both placement/permanency planning and transitioning to adulthood.
Independent living coordinators in this program implement several central elements that impact the delivery of services. These include: -Teaming across multiple systems through a local Independent Living Collaborative, -Being trained in trauma-informed care and using this training to guide their interactions with foster youth, -Developing a trusting relationship with the foster youth as a foundation for the work they do together, -Incorporating permanency work into the Independent Living Program, -Expanding opportunities for normalcy in the foster youths' lives.
Independent living coordinators perform typical case management functions such as conducting a Casey Life Skills Assessment, scheduling, and attending family court hearings, arranging for various meetings, and completing required paperwork for the delivery of services and case assessment. ILCs create IL plans with each foster youth that address the seven domains and are updated every six months. ILCs meet with foster youth monthly, or more as needed, to implement the plan with the foster youth by creating short-term goals and next steps each month. Additionally, ILCs do everything from making referrals to services including health and mental health services, requesting stipends for goal support, and helping to identify social support systems while also being part of the foster youths' social support network, creating and funding opportunities for foster youth to participate in extracurricular activities, and identifying and helping remove barriers for foster youth to achieve their goals in all domains.

Method
This study involved coding 119 IL plans from 97 foster youths between the ages of 14 and 21 years old involved in an IL Program. The majority of the sample was female and Caucasian. Demographic information is contained in Table 1.
This study was approved by the Institutional Review Board of the Pennsylvania State University. Since this study involved secondary data analysis no consent forms were obtained from participants. Confidentiality of participants was protected by de-identifying all documents prior to the first author's review of them and keeping them stored in a locked file cabinet in the first author's office. The second author had personal knowledge of all study participants due to her role as the former coordinator of the ILP, so it was not necessary to de-identify data provided to the second author. The second author attempted to conduct this research objectively, by basing all decisions on case records and data analysis. However, her personal knowledge of all participants may have influenced the way she perceived the data and could have been a potential conflict of interest in that she wanted the program to appear successful because of her role as the former ILP supervisor. However, the second researcher attempted to adhere strictly to the data when drawing conclusions regarding the data and goal achievement.
This study involved a mixed methods analysis conducted by two researchers. Independent Living (IL) Plans were obtained from the case records of the ILP. Analysis of IL plans involved development of an inventory of goals for the seven domains. Goals were generated based on the researchers' knowledge of the program's activities to provide services within the seven domains. Developing the inventory in this way may have introduced bias by neglecting to add goals and activities that other programs may prioritize or by narrowing focus to only those goals and activities identified within this particular ILP. Goals from the inventory included in the prevention domain, "Obtain birth control," and in the health/ mental health domain, "Begin individual mental health counseling." Initially, both researchers coded plans and updated the inventory until a final version of the inventory was developed. Both researchers then coded IL plans until reliability was established. Initial percent agreement was 71% on the first version of the inventory. On the second version, percent agreement was 73%. After establishing reliability, one of the two researchers coded each plan with the inventory. The former ILP director determined if goals were achieved, which were validated by case note quotes. If the ILP director was uncertain if the foster youth had achieved a goal, the IL coordinator who worked with the foster youth was contacted to provide this information. Totals of goals and achievements were calculated.
Percentages were computed of total number of foster youths who achieved the goals out of total number of foster youths who worked toward the goal. The number of unknown achievements due to foster youths' attrition in the program and the number of foster youths who were not yet of age to complete a goal were not included in calculations of what percentage of foster youth achieved a goal. Goal achievement was rated at three levels. If a goal was achieved by 70% or more of the participants who identified this goal, it was rated as substantial achievement. If the goal was achieved by 40-69% of participants who identified this goal, it was rated as moderate achievement. If the goal was achieved by less than 40% of the participants who identified this goal, it was rated as minimal achievement. This scale was applied across analyses of both tangible and intangible domains. Within the intangible domains, there were no codes rated as minimal achievement.
For both IL plans and case notes, the first author coded for themes based on the goals in the inventory in the text of the documents. The first author coded all IL plans used in the study and 50 cases of case notes. She selected quotes that represented examples of each of the goals on the inventory that were part of substantial and moderate achievement categories from both IL plans and case notes.
A second coding sheet was used to capture the role of the Independent Living Coordinator in helping foster youth achieve their identified goals. This sheet was based on a section of the Independent Living Plans. Plans were structured such that after foster youths' goals were written, the ILC's role in attaining that goal was outlined. Themes were coded for all major roles that the ILC was identified as fulfilling in each of the seven domains of the plans. A section of each plan denoted how the ILC would assist the foster youth with achieving each goal for each of the seven domains. Thematic analysis (Braun & Clarke, 2006) was employed to code each of the statements addressing ILC assistance with foster youth goal achievement. Initially, thematic codes were developed, such as, "ILC assistance with obtaining medical insurance," to represent the areas of help that the ILCs provided the foster youths in achieving their goals. Codes were grouped into broader themes that encompassed areas of intervention that ILCs provided to foster youth in the IL program.

Results
The results from this study demonstrated multiple ways that ILCs provide services to older foster youth. They also showed several weaknesses in interventions provided across the three domains. The results are described by explaining substantial or moderate achievement in each domain. Codes were labeled as substantial achievement if the goal was achieved 70% or greater of participants who identified the goal achieved it. Codes were labeled as moderate achievement if 40-69% of the participants who identified the goal achieved it. Codes were labeled as minimal achievement if less than 40% of the participants who identified the goal achieved it. Within the intangible domains, no codes were rated as minimal achievement. Quotes from case notes and IL plans as well as ILC themes were used to show ways in which ILCs supported foster youths' achievement of goals in each domain.

Health/Mental Health
Independent living coordinators showed substantial achievement in supporting foster youth in all three areas of the health/mental health domains of beginning (76.47%) and participating (77.14%) in individual mental health counseling and maintaining psychotropic medication (86.36%). They did not show any moderate or minimal achievements in this domain. These results were reflected in the theme, "ILC assistance with receiving psychotherapeutic interventions." Independent living coordinators successfully supported foster youth in beginning and participating in individual mental health counseling (see Table 2): "CW [Name]will make the counseling appointment at [Agency Name] and will follow up with [Equine Therapy Name]" (case note) (Table 3). ILCs also provided support for youth maintaining their psychotropic medication regimens: "ILC [Name] assisted Youth with scheduling an appointment at a place that will do med management where she can receive weekly counseling" (case note).

Support-Relational
Independent living coordinators demonstrated substantial achievement in building support systems with themselves, family members, and foster parents. ILCs supported foster youth building relationships and potential relational permanency with family members, including siblings (90.91%), birth mothers (90.00%), and other relatives (90.63%) such as grandparents, aunts, uncles, and cousins. These relationships were shown in the theme, "ILC assistance with relationships with family members." A second theme related to Support-Relational was, "ILC assistance with relationships with nonkin supports," which was reflected in ILCs' relationships with foster youth (100%) and interventions to sustain relationships between foster youths and foster parents (81.82%). See Table 4 for percentages and Table 7 for ILC assistance themes.
Case notes and IL Plans verified ILCs' support of the above themes including building relationships with family members: "Worker asked about his sister. Youth stated that they talk weekly, she is in a group home, is a senior and is joining the   Other trusted adults ILC will work with youth SS in forming positive supportive relationships Where she needs some work is finding a permanent support system. She does not plan on staying with carol or maintaining contact, after she graduates from high school. She also does not know where she wants to end up. She lists her sister. M., as her support system, but there are some serious issues with their relationship, at this time. ILC will continue to help Youth's sister find a support system, as this is an integral part of transitioning into a successful adult Support-practical-substantial achievement Agency social support IL staff is currently SQ's support. She needs assistance identifying additional support people informed them that there must be something that they are saying or doing that is having an impact on him" (case note). Independent living coordinators showed moderate achievement in supporting foster youth in building relationships between themselves and peers (68.75%), romantic partners (63.64%), and other trusted adults (58.82%). The theme "ILC assistance with relationships with peers" reflected the ILCs' somewhat limited role in foster youths' friendships and romantic relationships.
Case notes demonstrated that ILCs experienced some difficulty fostering social support in youths' relationships with friends: "CW [Name] discussed the friends that Youth keeps and advised her to be mindful of who she is hanging around" (case note). Case notes indicated that ILCs attempted to support healthy romantic relationships between youth and partners, despite efforts to provide education on healthy relationships: "ILC [Name] discussed group with Youth. She said that she really liked last night's topic, which was relationships with a panel of staff member's significant others" (case notes). ILCs demonstrated moderate achievement in developing relationships between youth and other trusted adults, such as mentors, family friends, and parents of significant others.

Support -Practical
Independent living coordinators showed substantial achievement in providing referrals for foster youth to other agencies (100%), financial support (100%), transportation (100%), and obtaining IDs (94.44%) and vital documents (100%). There were no areas of moderate or minimal achievement in this domain. ILCs were highly successful in making referrals for foster youth to other agencies and services, such as the Office of Vocational Rehabilitation, mental health agencies, arts programs, educational services, employment services, and housing services (see Table 5) as reflected in the codes: "ILC referral to educational counseling," "ILC referral to vocational assessment," and "ILC referral to drug and alcohol counseling." These linkages with other systems were captured in the theme, "ILC assistance with systemic support." The theme, "ILC assistance with tangible support," reflected the fact that ILCs provided several tangible supports to youth. First, ILCs provided financial support to use in a wide variety of areas, including purchasing books for school, obtaining clothing and uniforms, assistance with insurance payments, housing start-up costs and rental assistance, savings matches and stipends to encourage goal achievement. ILCs frequently provided transportation for youth to achieve various goals, including obtaining and maintaining employment, attending mental health appointments and GED classes, obtaining IDs, visiting colleges, and participating in IL Group. ILCs assisted youth in obtaining IDs and vital documents, such as birth certificates and social security cards. IL Plans and case notes demonstrated ILCs' efforts in supporting foster youths' achievement of these goals. An IL Plan showed an example of a referral: "[ILC will] Send a referral to [local university] for a vocational assessment" (IL plan). An example of financial support in a case note was: "She continues to work at [local restaurant] and has held that job for over a year. She recently received a savings match. lL CW [Name] will submit a goal support stipend for $200 for her continued work" (case note). An example of ILC support for transportation was: "ILC [Name] picked up Youth A. at school and transported him to [local college] for a campus tour and then returned him to school" (case note). A case note indicated ILC assistance with vital documents: "CW [Name] and CW [Name] will work with Youth to obtain her birth certificate and social security card over spring break" (case note).

Prevention
In prevention, the ILCs showed substantial achievement in providing pregnancy prevention services (87.50%) and engaging foster youth in extracurricular activities (70.00%) and moderate achievement in supporting foster youths' continued use of birth control (55.56%). The ILCs demonstrated substantial achievement in providing youth with information and education surrounding pregnancy prevention, such as birth control use, accessing birth control and gynecology appointments, and practicing safe sex (see Table 6). ILCs showed some difficulties in facilitating foster youth continuing to use birth control. The theme, "ILC assistance with reproductive health," captured ILCs efforts. The ILCs showed substantial achievement in engaging foster youth in extracurricular activities. The theme, "ILC assistance with participation in extracurricular activities" reflected ILCs' work with engaging youth in school activities and community clubs.
Case note quotes supported the themes in demonstrating ILCs' substantial achievement with pregnancy prevention and extracurricular activities. A case note quote for pregnancy prevention showed that, "Youth's Sister reported to [ILC] that she has a boyfriend. IL CW [Name] will discuss prevention and pregnancy/STDs with Youth's Sister" (case note). A case note quote for extracurricular activities demonstrated that, "ILC finalized the baking plans for the Art Exhibit with him" (case note) (Table 7).

Discussion and Applications to Practice
Independent living coordinators used specific strategies to help foster youth address their health and mental health needs. ILCs understood the trauma of placement in foster care and encouraged foster youth to address their mental health concerns as part of IL planning for their transition to adulthood. This supported Greeno et al's (2019a) findings that there was a need to provide support and services regarding mental health and trauma for foster youth exiting care. ILCs used their knowledge of the mental health system and partnerships developed through the IL Collaborative to help foster youth gain access to individual mental health counseling. Park et al. (2019) stressed the importance of coordinating mental health services across the child behavioral health care system. ILCs helped to overcome the structural barrier of lack of access to transportation that can prevent appropriate psychotropic  (Park et al., 2019) and assisted foster youth in obtaining insurance to cover the cost of medications. ILCs also discussed medication management and reminded foster youth to continue taking their medications at home visits. Independent living coordinators showed effectiveness in the domain of Support-Relational. ILCs successfully offered social support to foster youth because they understood the role of the therapeutic alliance, building trust, the need for foster youth to have advocates within the foster care system, and participate in the planning process. Marion et al. (2017) highlighted the need for building and maintaining trusting relationships with foster youth in order to achieve successful interventions. Trust should be built slowly through such strategies as validation of foster youths' feelings (Salazar et al., 2020). Glynn and Mayock (2019) found that in Ireland foster youths participated in transition planning when caseworkers communicated respectfully with them. Kang-Yi and Adams (2015) highlighted the importance of early transition planning such as that conducted by ILCs with youth in the ILP. Foster youths noted that discussing strengths, needs, and goals with them enabled caseworkers to provide effective support and understanding (Salazar et al., 2020). ILCs built relationships with foster youths that gave them the support and confidence to believe that they could accomplish tasks independently (Piel & Lacasse, 2017). Jaramillo and Kothari (2021) found that caseworkers' responsiveness to foster youths' needs, which ILCs met effectively in this study, was the characteristic most correlated with the overall quality of the relationship between the caseworker and foster youth.
Independent living coordinators successfully built relationships with family members, including siblings, birth mothers, and other relatives because they believed it was important to establish permanent and supportive relationships for foster youths' successful transition into adulthood. Lee et al. (2016) noted that child welfare workers play an important role in helping foster youths address family relationships during their transition out of foster care. ILCs worked within a permanency-driven child welfare organization, which was necessary for individual workers to adopt a philosophy of permanency (Roberts et al., 2018). Permanent family relationships were built over time, requiring consistent monitoring and support from ILCs (Johnson & Mendes, 2014). Havlicek (2021) noted a need to better support foster youths in understanding the strengths, weaknesses, and risks of maintaining relationships with their birth parents. In Austria, ILCs needed to support the level of relationships they developed with birth families (Sting & Groinig, 2020). They also needed to process past and present conflicts with birth family members (Sting & Groinig, 2020).
Independent living coordinators were successful in building relationships between foster youth and foster parents. They recognized the importance of placement stability on many other IL goals, such as graduating high school, obtaining employment, relational permanency, and experiencing normalcy.
Independent living coordinators were somewhat effective in supporting foster youths in establishing relationships and social support within the peer group, such as friends and significant others. Zinn et al. (2017) stressed the importance of child welfare agencies' development of programs and policies that create opportunities to process and educate foster youths regarding romantic relationships as well as provide ongoing support for these relationships. Moyer and Goldberg (2020) noted the importance of social workers building positive relationships between foster youths and peers. Mann-Feder (2018) also highlighted the importance of active intervention from adult figures to help foster youths develop peer relationships both inside and outside of the foster care system in Canada. Staff in residential foster care viewed their roles as encouraging positive peer relationships and discouraging negative peer relationships (Mann-Feder, 2018). ILCs could benefit from increased training regarding the important developmental milestones related to foster youths' dependence on peer groups and in order to adequately address these issues in IL plan goals or service provision. ILCs were also  moderately effective in incorporating other significant adults, such as mentors, teachers, and coaches into the foster youths' support systems (Singer et al., 2013). Greeson (2013) recommended integrating natural mentoring into child welfare services and development of programs that allowed older foster youth to build relationships with supportive nonparental adults. Independent living coordinators successfully provided practical support in a variety of areas. ILCs' relationships with agencies built through the IL Collaborative allowed for them to quickly identify services needed and make referrals in a timely manner. The ILCs were able to identify financial needs and request funding from the agency through the dedicated funding stream provided by the state. Similarly, in South Africa, the foster youth were able to meet basic needs when they received a social grant in foster care but were not when they did not receive funding after leaving care (Shaw et al., 2020).
Independent living coordinators were able to provide transportation or to arrange for transportation for foster youth through the agency's transportation aides (Massinga & Pecora, 2004). Armstrong-Heimsoth et al. (2020) described how caseworkers could provide transportation to foster youth. ILCs also overcame transportation barriers to and from school, which were common (Day et al., 2012;Wells & Zunz, 2009). Foster youths needed to access transportation to and from school to facilitate educational stability (Strolin-Goltzman et al., 2016). ILCs were required to ensure that all foster youth in the program obtained their vital documents and photo IDs because these were necessary to achieve various other goals, such as obtaining employment, enrolling in school or postsecondary education, and applying for housing. Independent living coordinators showed success in the domain of prevention. ILCs were successful in providing pregnancy prevention through education at home visits at younger ages as suggested by Combs et al. (2018) in addition to setting up and transporting foster youth to medical appointments to obtain birth control. Futris et al. (2019) were able to successfully increase contraception use of foster youth through a combination of relationship education and sex education. ILCs successfully engaged foster youth in extracurricular activities by encouraging them to pursue activities they enjoyed, referring them to arts programs provided by the agency, providing transportation, and paying entrance fees. Paying fees was a particularly important service, as policy recommendations of former foster youth include child welfare agencies spending more money on extracurricular activities (White et al., 2018). White et al. (2018) noted that child welfare workers are "uniquely situated" (p. 7) to support foster youths' involvement in extracurricular activities.
Independent living coordinators in the evaluation provided a wide array of services in a comprehensive program addressing the needs of IL foster youth across seven domains. This study revealed a variety of successes and challenges for ILCs. ILCs needed to do better at understanding and meeting the developmental needs of foster youth in the areas of normalcy and peer relationships, which could be accomplished through training and innovative programs surrounding adolescent needs. Additionally, this ILP focused on a system of care approach that included teaming and collaboration. ILCs had a strength in teaming, collaboration, and knowledge of other systems that allowed them to help foster youth navigate systems and access services that were needed to help them achieve their goals. Barnow et al. (2015) highlighted the need for a multisystemic approach to service provision for foster youths that involved several areas of community services, including education, employment, juvenile justice, housing, and mental health, in addition to child welfare. Woodgate et al. (2017) also noted the importance of interagency collaboration between service providers to provide multi-domain interventions that supported the transition process out of foster care. Due to the strength and flexibility of the funding for the ILP, ILCs were able to remove tangible barriers, such as transportation and financial barriers. Finally, the fact that research from other countries reflected similar strengths regarding the ILC's role in transition planning, financial support, development of peer relationships, and development of relationships with birth families, illustrated that ILCs play a significant role in the transition to adulthood internationally. There were several limitations to this study. ILCs inconsistently documented goals in the IL plans. Each IL plan must inquire about the seven domains, however, there is not a set method of capturing the foster youths' goals. For example, a foster youth may identify obtaining birth control as a goal, but one ILC may not capture it and another one will. Also, there were different versions of the IL plan during the time documents were reviewed for the study.
Only one perspective was considered to determine whether or not the foster youth achieved the goals-that of the IL Supervisor. We did not account for the perspectives of the foster youth, foster parents, birth relatives, or other professionals involved with the foster youth.
There were weaknesses in the design of the study. A pretest/post-test design was not used to determine change over time in goal attainment. An experimental design with random assignment to the ILP or a control group was not used to support that the ILP caused changes in goal achievement.
Generalizability of the study was limited for three reasons. First, the ILP was a complex, multi-domain program that is likely different from other ILPs. Second, the ILP served a unique geographic location. Third, the ILP served primarily white foster youth and may not produce the same results with youth of color.
This study had several implications for research. The role of the caseworker and ILC in multi-domain ILPs needs to be further assessed and evaluated to determine their impact on foster youth's success in transitioning to adulthood. Future research should include evaluations of caseworkers and other professionals in this type of role with attention to the types of training they receive and how they interact with child welfare caseworkers. Qualitative studies that explore the perspective of the caseworkers or ILCs regarding their job responsibilities and interactions with foster youth are needed to assess how the ILCs and caseworkers impact foster youths' outcomes related to health/mental health, prevention, and support. Similarly, there should be qualitative studies conducted to explore the foster youths' perspective regarding their experience of staff and staff cooperation in IL programs. Quantitative studies should be conducted that explore the relationship between the therapeutic alliance between the ILC and foster youth and outcomes for foster youth during the transition to adulthood. Finally, research in other countries that have independent living programs can be conducted to compare findings and determine similarities and differences with programs such as this one.
This study had several implications for practice. ILCs play an important role in addressing intangible domains related to foster youths' successful transition into adulthood. ILCs should complete a comprehensive assessment of social support across multiple domains such as family, peer, and other adults to better identify a foster youth's social support system, to identify gaps, and develop plans to address gaps in social support. ILCs should participate in training on the significance of the peer group and how to foster mentoring relationships for older foster youth and implement strategies with older foster youth to improve relationships with their peer groups. ILCs should continue to assist youth with engaging in health/mental health and substance abuse treatment services and help youth who are resistant to these types of services to see their value and impact on a successful transition to adulthood. Finally, ILCs should expand methods of assisting youth in prevention related activities by providing resilience-and strength-building opportunities for youth, such as participating in normalcy activities, creating leadership groups, and promoting self-care among foster youth. These implications may have relevance for programs internationally.
This study had several implications for policy. Policies often address the overall program goals related to serving older foster youth. The findings from this study indicate that policy should address the roles of those working with older foster youth-Independent Living Program staff, such as ILCs, and child welfare caseworkers. ILCs and child welfare caseworkers need specific training surrounding the developmental needs of older foster youth along with understanding the impact of trauma on foster youths' health, mental health, and potential substance use/abuse. Current policies that provide federal dollars to states that are dedicated to meeting the unique needs of older foster youth should remain in place and be expanded as more is learned about what will help older foster youth transition successfully into adulthood. Policies should be developed that encourage the participation of the ILCs in any permanency discussions so that they can advocate for and with youth and can incorporate permanency planning into the IL planning process and interactions with youth.
In conclusion, ILCs have many areas of strength in providing services to foster youth in an independent living program, including assisting foster youth with obtaining and participating in individual mental health counseling and medication management, building social supports with relatives, and pregnancy prevention. Their weaknesses included: building social supports with members of foster youths' peer group and romantic partners and helping foster youth remain on birth control. ILCs successes were based on their teaming approach to helping foster youth navigate multiple systems, their knowledge of community resources and programs, their ability to assess for and remove barriers, specifically tangible barriers such as finances and transportation, and building rapport with foster youth. Areas for improvement included a need for training in the area of adolescent development, specifically around the role of peer groups, deeper assessment, and building of social support systems.