strategies for expanding the system of care approach · child, adolescent and family branch center...

Beth A. Stroul, M.Ed.Robert M. Friedman, Ph.D.

Child, Adolescent and Family BranchCenter for Mental Health Services

Substance Abuse of Mental Health Services AdministrationU.S. Department of Health and Human Services

SEPTEMBER 2011

I S S U E B R I E F

Strategies FOR Expanding THE

System of Care Approach

AcknowledgmentsThis issue brief summarizes the findings from a study on effective strategies for expanding the system of care approach that was undertaken as part of the national evaluation of the federalComprehensive Community Mental Health Services for Children and Their Families Program. Thisstudy could not have been conducted out without the input and assistance of many people. Thedirectors of children’s mental health in the nine states that were included in the study not onlyshared their perspectives, but also enlisted others to participate. In total, 52 individuals wereinterviewed, and the authors are most appreciative of their time and contributions.

At each stage of the study, leaders in children’s mental health from around the country contributedtheir ideas and feedback. Local, state, and federal policy makers and administrators; serviceproviders; family members; youth; researchers; and technical assistance providers all offered valuableand much appreciated input. Special appreciation is due to Gary Blau, Ph.D., chief of the Child,Adolescent and Family Branch of the Federal Center for Mental Health Services, and BrigitteManteuffel, Ph.D., of ICF Macro, principal investigator for the national evaluation, for theirguidance and thoughtful review.

Twenty-five years ago, we were privileged to have the opportunity to present a vision for a system ofcare to better serve children, youth, and families. We were again privileged to have had this newopportunity to gather and present what we believe to be very helpful information to expand theimplementation of the system of care approach. Throughout this study, we were impressed by theoutstanding work and commitment of so many people across the country. We hope that the studydoes justice to their work and will enhance efforts to improve services and outcomes for children,youth, and young adults with mental health challenges and their families.

Suggested Citation:Stroul, B. A., & Friedman, R. M. (2011). Issue brief: Strategies for expanding the system of careapproach. Washington, DC: Technical Assistance Partnership for Child and Family Mental Health.

Available at: www.tapartnership.org

This product was developed with support from the Child, Adolescent and Family Branch (CAFB),Center for Mental Health Services (CMHS), Substance Abuse and Mental Health ServicesAdministration (SAMHSA). The content of this publication does not necessarily reflect the views,opinions or policies of CAFB, CMHS, SAMHSA or the Department of Health and Human Services.

Background and Context ..................................................................................................................................................2Children’s Mental Health Initiative ....................................................................................................................................2Expanding the System of Care Approach ......................................................................................................................3Conceptual Framework for System Change ................................................................................................................3

Effective Strategies for Expanding the System of Care Approach ................................7Implementing Policy, Administrative, and Regulatory Changes ..................................................................7

Most Effective Strategies ....................................................................................................................................................8Underutilized Strategies ......................................................................................................................................................9

Developing or Expanding Services and Supports Based on the System of Care Philosophy and Approach ..................................................................................9

Most Effective Strategies ....................................................................................................................................................9Underutilized Strategies ....................................................................................................................................................10

Creating or Improving Financing Strategies..............................................................................................................11Most Effective Strategies ..................................................................................................................................................11Underutilized Strategies ....................................................................................................................................................11

Providing Training, Technical Assistance, and Coaching ..............................................................................12Most Effective Strategies ..................................................................................................................................................12Underutilized Strategies ....................................................................................................................................................13

Generating Support........................................................................................................................................................................13Most Effective Strategies ..................................................................................................................................................13Underutilized Strategies ....................................................................................................................................................14

Additional Information to Guide Expansion ..........................................................................................15Most Significant Strategies ......................................................................................................................................................15Most Significant Underutilized Strategies....................................................................................................................17State-Community Partnerships for Expanding the System of Care Approach..............................19Challenges to Expanding Systems of Care..................................................................................................................20

Lessons for Expanding the System of Care Approach ..............................................................20Lessons Learned................................................................................................................................................................................20Conclusion ............................................................................................................................................................................................22

References ........................................................................................................................................................................................22

Issue Brief: Strategies for Expanding the System of Care Approach

Table of Contents

2 Issue Brief: Strategies for Expanding the System of Care Approach

BACKGROUND AND CONTEXT

Background and ContextSince 1992, the federal ComprehensiveCommunity Mental Health Services for Childrenand Their Families Program (or the Children’sMental Health Initiative, CMHI) has investedresources in implementing the system of careapproach in communities across the nation. With astrong history of demonstrating the effectiveness ofthis approach, the Substance Abuse and MentalHealth Services Administration (SAMHSA) isturning its attention to strategies for expandingsystems of care throughout states, tribes, andterritories (hereafter referred to as “states”;SAMHSA, 2011). To support this new focus, astudy was undertaken to identify lessons that canbe learned from a diverse group of states that havemade significant progress in promoting thewidespread adoption of systems of care. This issuebrief is based on the study results and is anoutgrowth of efforts across the country to achievethe large-scale systemic changes that are requiredto expand the system of care approach.

The children’s mental health field took a majorstep forward in the mid-1980s with the initiationof the Child and Adolescent Service SystemProgram (CASSP) and the introduction of theconcept of a “system of care.” Originally definedas a “comprehensive spectrum of mental healthand other necessary services which are organizedinto a coordinated network to meet the multipleand changing needs of children and their families”(Stroul & Friedman, 1986, p. 3), the approach hasgained broad acceptance. In fact, the system ofcare approach has reshaped children’s mentalhealth services to the extent that at least someelements of the system of care philosophy andapproach can be found in nearly all communitiesacross the nation (Stroul, Blau, & Friedman,2010). The approach has also been adopted bychild welfare, juvenile justice, education, and

substance abuse systems; early childhoodprograms; systems designed to serve youth andyoung adults in transition to adulthood; and evenmany adult-serving systems.

Although the system of care approach continues toevolve to reflect advances in research and servicedelivery, the core values of community-based,family-driven, youth-guided, and culturally andlinguistically competent services are widelyaccepted. The guiding principles calling for abroad array of effective services, individualizedcare, and coordination across child-serving systemsare extensively used as the standards of carethroughout the nation. A recently updateddefinition of the system of care concept and philosophy is shown in Table 1 (Stroul et al., 2010).

Children’s Mental Health InitiativeThe CMHI is designed to provide funding forcommunities to implement systems of care (Stroul,Blau, & Sondheimer, 2008). As of 2011, theCMHI has invested nearly $1.6 billion in grants to173 communities in all 50 states, Puerto Rico,Guam, the District of Columbia, and 21 AmericanIndian/Alaska Native communities. Initiallyproviding funding in the form of 5-yeardemonstration grants, the legislation was revisedto add a 6th year of funding, and the fundingsubsequently took the form of cooperativeagreements (hereafter referred to collectively asgrants). In addition to the program’s time-limitedgrants to support system reform and build servicecapacity, an increasingly explicit goal has been todevelop systems of care that are sustained after thegrants end and that have an impact oncommunities around the country whether or notthey actually receive a grant. Such an impact hasbeen achieved through developing effectivestrategies for implementing systems of care,collecting outcome data that demonstrate positiveeffects, building strong constituencies for systemsof care, and widely disseminating the informationthat has been gathered.

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DEFINITIONA system of care is: A spectrum of effective, community-based services and supports for children and youth with orat risk for mental health or other challenges and their families, that is organized into a coordinated network, buildsmeaningful partnerships with families and youth, and addresses their cultural and linguistic needs, in order to helpthem to function better at home, in school, in the community, and throughout life.

CORE VALUESSystems of care are:1. Family driven and youth guided, with the strengths and needs of the child and family determining the types and

mix of services and supports provided.2. Community based, with the locus of services as well as system management resting within a supportive, adaptive

infrastructure of structures, processes, and relationships at the community level.3. Culturally and linguistically competent, with agencies, programs, and services that reflect the cultural, racial, ethnic,

and linguistic differences of the populations they serve to facilitate access to and utilization of appropriate servicesand supports.

GUIDING PRINCIPLESSystems of care are designed to:1. Ensure availability of and access to a broad, flexible array of effective, evidence-informed, community-based

services and supports for children and their families that addresses their physical, emotional, social, and educationalneeds, including traditional and nontraditional services as well as informal and natural supports.

2. Provide individualized services in accordance with the unique potential, strengths, and needs of each child andfamily, guided by an individualized, “wraparound” service planning process and an individualized service plandeveloped in true partnership with the child and family.

3. Deliver services and supports within the least restrictive, most normative environments that are clinically appropriate.4. Ensure that families, other caregivers, and youth are full partners in all aspects of the planning and delivery of their

own services and in the policies and procedures that govern care for all children and youth in their community,state, territory, tribe, and nation.

5. Ensure cross-system collaboration, with linkages among child-serving systems and mechanisms for system-levelmanagement, coordination, and integrated management of service delivery and costs.

6. Provide care management or similar mechanisms to ensure that multiple services are delivered in a coordinated andtherapeutic manner and that children and their families can move through the system of services in accordancewith their changing needs.

7. Provide developmentally appropriate mental health services and supports that promote optimal social-emotionaloutcomes for young children and their families in their homes and community settings.

8. Provide developmentally appropriate services and supports to facilitate the transition of youth to adulthood and tothe adult service system as needed.

9. Incorporate or link with mental health promotion, prevention, and early identification and intervention to improvelong-term outcomes, including mechanisms to identify problems at an earlier stage and mental health promotionand prevention activities directed at all children and adolescents.

10. Incorporate continuous accountability mechanisms to track, monitor, and manage the achievement of system ofcare goals; fidelity to the system of care philosophy; and quality, effectiveness, and outcomes at the system level,practice level, and child and family level.

11. Protect the rights of children and families and promote effective advocacy efforts.12. Provide services and supports without regard to race, religion, national origin, gender, gender expression, sexual

orientation, physical disability, socio-economic status, geography, language, immigration status, or othercharacteristics, and services should be sensitive and responsive to these differences.

TABLE 1SYSTEM OF CARE CONCEPT AND PHILOSOPHY

Expanding the System of Care ApproachExtensive evaluation and research havedocumented the effectiveness of the system of careapproach (Manteuffel, Stephens, Brashears,Krivelyova, & Fisher, 2008). The nationalevaluation of the CMHI has consistently foundthat implementing the approach at the system andservice delivery levels results in positive outcomes.With changes in service delivery and frontlinepractice, children and youth have demonstratedimprovements in clinical and functional outcomes,increases in behavioral and emotional strengths,reductions in suicide attempts, improvements inschool performance and attendance, fewer contactswith law enforcement, reductions in reliance oninpatient care, and more stable living situations.Data also have shown that caregivers of childrenand youth served within systems of care experiencereduced strain associated with caring for a child oryouth who has a serious mental health condition,more adequate resources, fewer missed days ofwork due to the mental health needs of their child,and improvement in overall family functioning(Manteuffel et al., 2008).

At the system level, the evaluation of the CMHIhas shown that grantees change their policies,infrastructure, and services in accordance with thesystem of care philosophy. The evaluation has alsoshown that the system of care approach is a cost-effective way of investing resources by redirectingfunds from deep-end services (inpatient andresidential treatment) to home- and community-based services and supports (Gruttadaro, Markey,& Duckworth, 2009; Maine Department of Healthand Human Services, 2011; Maryland Child &Adolescent Innovations Institute, 2008; Manteuffelet al., 2008). As a result of these positiveoutcomes, SAMHSA launched a new effort tofurther this progress by providing funds to statesto develop comprehensive strategic plans forwidespread expansion of the system of careapproach so that more children and families canbenefit (SAMHSA, 2011).

The system of care expansion initiative isconsistent with SAMHSA’s theory of change,which takes an innovation—in this instance, thesystem of care approach—through the stages ofconceptual development, implementation asdemonstrations, dissemination, capacity buildingfor broader implementation, and finally towidespread adoption (Blau, 2011). With thedemonstration of the system of care approach instates and communities across the nation, and withthe documented positive results, the approach hasreached the stage of readiness for broad-basedimplementation in service delivery systems.SAMHSA’s System of Care Expansion PlanningGrant program is intended as a step towardachieving the ultimate objective in SAMHSA’stheory of change. This study on strategies forexpanding the system of care approach will informthe work of states as they develop and implementsystem of care expansion plans.

Conceptual Framework for System ChangeAt its broadest level, the framework for the studyconceptualized systems of care as having threemajor, interrelated components—an array ofservices, a supportive infrastructure, and anunderlying philosophy that guides the system andits component services, as shown in Figure 1.Specifically, these encompass: (1) a set of valuesand principles; (2) an infrastructure (includinggovernance structures; financing for a wide rangeof services and supports; partnerships amongchild-serving agencies, providers, families, andyouth; provider networks; and capacity forplanning, evaluation, and quality improvement);and (3) actual interactions with children, youth,and families at the service delivery level that areconsistent with the system of care philosophy. Thestudy focused on the expansion of these majorelements of the system of care approach.

A conceptual framework was then developed thatfocused specifically on expanding systems of care.The framework was built on prior research on



making and sustaining systemic changes andincludes five “core strategy areas” (Stroul &Manteuffel, 2007, 2008). Within each of thesecore strategy areas, a number of more specific sub-strategies were identified. For example, specificsub-strategies for creating or improving financingapproaches include increasing the use of Medicaid,increasing the use of federal grants, increasing theuse of funds from other child-serving systems, andredeploying funds from higher-cost services tolower-cost services. Table 2 shows the core strategyareas with the corresponding sub-strategies. Inseveral instances, new sub-strategies to include inthe strategic framework were identified throughinterviews with study informants and throughdiscussions with expert advisors. Where applicable,those sub-strategies are included in the table.

To explore effective strategies for expanding thesystem of care approach, nine states wereidentified that had made significant progress instatewide system of care expansion and wereselected for inclusion in the study (Stroul &Friedman, 2011). Each of these states has received

at least one prior system of care grant as part ofthe federal CMHI. New Jersey is at the low end ofthis range, having received only 1 grant; Michiganis at the high end, having received 6 grants. In all,31 grants have been awarded across all states.

Based on the conceptual framework comprised ofthe five core strategy areas, an interview protocolwas developed to determine which strategies hadbeen used in each state and which were judged tobe effective. Interviews were conducted with fourto seven individuals in each state, includingrepresentatives of state and community leadagencies, families and youth, and others identifiedas important to system of care expansion withineach state. Information was then analyzed toidentify effective expansion strategies and lessonslearned. These findings establish a research basefor implementing the high-level systemic changesneeded to move toward widespread adoption ofthe system of care approach and are intended toassist other states in their efforts to expand theirsystems of care statewide.

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Infrastructure

Philosophy

Services&

Supports

FIGURE 1

ELEMENTS OF THE SYSTEM OF CAREAPPROACH I. Implementing Policy, Administrative, and

Regulatory Changes

II. Developing or Expanding Services and SupportsBased on the System of Care Philosophy and Approach

III. Creating or Improving Financing Strategies

IV. Providing Training, Technical Assistance, and Coaching

V. Generating Support

CORE STRATEGY AREAS

Arizona Maryland North CarolinaHawaii Michigan OklahomaMaine New Jersey Rhode Island

STATES STUDIED



I. Implementing Policy, Administrative, and Regulatory Changes

Making state-level policy and regulatory changes that infuse and “institutionalize” the system of carephilosophy and approach into the larger service system to support expansion of the system of care approach

Sub-Strategies• Establishing an organizational locus of system of care management and accountability at state and local levels• Developing and implementing strategic plans• Developing interagency structures, agreements, and partnerships for coordination and financing• Promulgating rules, regulations, guidelines, standards, and practice protocols• Incorporating the system of care approach as requirements in requests for proposals and contracts• Enacting legislation that supports the system of care approach• Incorporating the system of care approach in protocols to monitor compliance with system of care requirements• Incorporating the system of care approach into data systems for outcome measurement and quality improvement• Linking with and building on other system change initiatives (e.g., health reform, parity legislation, reforms in other systems)

II. Developing or Expanding Services and Supports Based on the System of Care Philosophy and Approach

Implementing the systemic changes needed to develop and expand a broad array of home- and community-based services and supports that are individualized, coordinated, family driven, youth guided, and culturallyand linguistically competent to support expansion of the system of care approach

Sub-Strategies• Creating or expanding the array of home- and community-based services and supports• Creating or expanding an individualized, wraparound approach to service delivery• Creating care management entities• Creating or expanding care coordination and care management• Implementing family-driven, youth-guided services and expanding family and youth involvement at the servicedelivery level

• Creating, expanding, or changing the provider network with new providers and by retooling and aligning communityand residential providers

• Creating or expanding the use of evidence-informed and promising practices and practice-based evidence approaches• Improving the cultural and linguistic competence of services• Reducing racial, ethnic, and geographic disparities in service delivery• Implementing or expanding the use of technology (e.g., electronic medical records, telemedicine, videoconferencing, e-therapy)

III. Creating or Improving Financing Strategies

Creating or improving financing mechanisms and using funding sources more strategically to support theinfrastructure and services comprising systems of care to support expansion of the system of care approach

Sub-Strategies• Increasing the use of Medicaid• Increasing the use of federal system of care grants, Mental Health Block Grants, and other federal grants• Redeploying funds from higher-cost to lower-cost services• Implementing case rates or other risk-based financing approaches• Increasing the use of state mental health and substance use funds• Increasing the use of funds from other child-serving systems• Increasing the use of local funds• Increasing the use of federal entitlements other than Medicaid• Accessing new financing structures and funding streams (e.g., health reform, parity legislation)

TABLE 2STRATEGIC FRAMEWORK FOR EXPANDING THE SYSTEM OF CARE APPROACH: FIVE CORESTRATEGY AREAS AND SUB-STRATEGIES

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EFFECTIVE STRATEGIES FOR EXPANDING THE SYSTEM OF CARE APPROACH


IV. Providing Training, Technical Assistance, and Coaching

Implementing workforce development mechanisms to provide ongoing training, technical assistance, and coaching to ensure that providers are prepared and skilled to provide effective services and supports consistentwith the system of care philosophy and approach to support expansion of the system of care approach

Sub-Strategies• Providing training, technical assistance, and coaching on the system of care approach• Creating ongoing training and technical assistance capacity• Providing training, technical assistance, and coaching on evidence-informed and promising practices and practice-based evidence approaches

V. Generating Support

Generating support among families and youth, high-level decision makers at state and local levels, providers,managed care organizations, and other key leaders to support expansion of the system of care approach

Sub-Strategies• Establishing strong family and youth organizations to support expansion of the system of care approach• Generating support among high-level policy makers and administrators at state and local levels• Using data on outcomes and cost avoidance to promote expansion of the system of care approach• Cultivating partnerships with providers, provider organizations, managed care organizations, and other key leaders• Generating support through social marketing and strategic communications• Cultivating leaders and champions for the system of care approach

Cross-Cutting Themes Across All Core Strategy Areas

• Family-driven, youth-guided approaches to services and systems• Cultural and linguistic competence in services and systems• Cross-system collaboration in services and systems• Social marketing and strategic communications

TABLE 2CONTINUED STRATEGIC FRAMEWORK FOR EXPANDING THE SYSTEM OF CARE APPROACH: FIVE CORE

STRATEGY AREAS AND SUB-STRATEGIES

Effective Strategies forExpanding the Systemof Care ApproachEach core strategy area is discussed below. Themost effective strategies and those found to be underutilized are described. The study team defined underutilized strategies as those that have thepotential to have an impact on system of careexpansion but were not used in most states. Stateshave used strategies selectively, choosing those that they considered to be the most appropriate for their particular contexts. Examples of how each strategywas implemented in the states studied are included.

Implementing Policy,Administrative, and Regulatory Changes

The first core strategy area involves a range ofsystem changes that are directed at making state-level policy and regulatory changes that infuse and“institutionalize” the system of care philosophyand approach into the larger service system tosupport expansion of the system of care approach.

Most Effective StrategiesEstablishing an Ongoing Locus of Managementand Accountability for Systems of CareCreating or assigning a viable, ongoing focal pointof accountability and management at the state and

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local levels (e.g., agency, office, staff) to supportsystem of care expansion proved to be essential inproviding continuous leadership and managementfor systems of care. In most states in the studysample, a state-level agency has taken the lead forsystem of care development and has had majorresponsibility for both policy and systemmanagement and oversight. A number of stateshave interagency entities serving as policy-makingbodies; however, those states also have a focalpoint of management and accountability within anagency that manages system of careimplementation. An example of this dual approachcan be seen in Maryland, where the administrativelocus of accountability is in the Office of Childand Adolescent Services of the Mental HygieneAdministration, and policy leadership is providedby a Children’s Cabinet at the governor’s level thatcomprises executives from child-serving agencies.

At the local level, focal points of management andaccountability for system of care implementationvary. Regional behavioral health entities, cross-system bodies, community collaboratives, mentalhealth agencies, and care management entities(CMEs) have all been used as local managementstructures. For example, Regional BehavioralHealth Authorities (RBHAs) are responsible inArizona, cross-system entities are used in Maine,mental health agencies are assigned in Michiganand Hawaii, and CMEs are used in New Jerseyand Maryland.

Developing and Implementing Strategic PlansDeveloping and implementing plans that establishthe system of care philosophy and approach asgoals for the state’s service delivery system werefound to be essential to guide expansion efforts.Most of the states have used a strategic plan,whether formal or informal, as a blueprint forsystem of care expansion. A formal strategic planfor statewide systems of care was created inresponse to a class action settlement in Arizona,and Maryland has followed an interagencystrategic plan created at the Children’s Cabinetlevel with extensive community and stakeholder

input. New Jersey used a concept paper to guidestatewide system of care implementation, andOklahoma has used action plans and logic models.

Strengthening Interagency CollaborationCultivating strong interagency partnerships wasseen as a critical strategy for system of careexpansion, particularly in cases where suchpartnerships have led to cross-agency financing ofsystem of care infrastructure and services. Suchrelationships were seen in interagency structures,interagency agreements that incorporate the systemof care approach, and interagency partnerships forcoordination and/or financing. In several states(e.g., Arizona, North Carolina, Oklahoma),partnerships with the state Medicaid agency haveresulted in coverage for a broader range of servicesand supports. A partnership between the mentalhealth and child welfare agencies in Michigan hasbeen instrumental in system of care expansion bycreating system of care pilots in eight areas, withplans for eventual statewide implementation.

Promulgating Rules, Regulations, Standards,Guidelines, and Practice ProtocolsPromulgating rules, regulations, standards,guidelines, or practice protocols that requireelements of the system of care philosophy andapproach is another important component of anoverall expansion strategy. Rules and regulationshave been used as a strategy in some states, forexample, Medicaid rules in Maryland andOklahoma. Other states have relied more onstandards and guidelines to promote expansion,such as practice protocols in Arizona andstandards for lead agencies in Rhode Island.

Incorporating the System of Care Approach in Requests for Proposals and ContractsRequirements for the various elements of the system of care approach in requests for proposals (RFPs)and contracts with providers, lead agencies, andmanaged care organizations have been used widelyto support expansion efforts. Interviewees notedthat requirements are best used in combinationwith other strategies, including incentives such as

financing and training, to generate commitment tothis approach. Contractual requirements have beenused effectively to ensure that all systemparticipants are aligned with the system of careapproach and with the state’s system of careexpansion goals. For example, in Maine, allproviders receiving state funds are required toapply system of care principles. In Michigan,health plans under the managed care system mustcontractually implement systems of care, and inNew Jersey there are performance requirements incontracts related to the system of care philosophy.

Underutilized StrategiesIncorporating the System of Care Approach in Monitoring ProtocolsThe use of monitoring protocols as a mechanismfor assessing the implementation of system of carerequirements was not identified as a frequentlyused strategy. However, some states foundmonitoring to be an effective strategy. Forexample, in New Jersey, site reviews, reviews ofperformance data, and audits make up animportant expansion strategy, and data dashboardsprovide local and statewide information on systemof care development. Oklahoma uses annual sitevisits and monthly reports on system performanceto monitor the implementation of the system ofcare approach. Other states were in early stages ofdeveloping capabilities in this area.

Enacting LegislationLegislation has not been used as an expansionstrategy in most states studied. An exception isRhode Island where several pieces of legislation areseen as instrumental in establishing the basis forstatewide expansion of the system of careapproach, such as legislation requiring blendedfunding to support system of care developmentand legislation requiring collaboration and jointplanning with the state Medicaid agency. InMaryland, legislation was passed in 2011 toremove barriers to family-driven care and to alignthe state’s service delivery system with the systemof care approach set forth in its interagencystrategic plan. Several informants in other states

indicated that legislation would be helpful inlending “weightiness” to expansion goals.

Developing or ExpandingServices and Supports Basedon the System of CarePhilosophy and Approach

The second core strategy area involvesimplementing the systemic changes needed todevelop and expand a broad array of home- and community-based services and supports thatare individualized, coordinated, family driven,youth guided, and culturally and linguisticallycompetent to support expansion of the system of care approach.

Most Effective StrategiesCreating or Expanding a Broad Array of Services and SupportsAll the states have broadened their service array tooffer a comprehensive range of home- and community-based services and supports, which is an inherent characteristic of systems of care.Expanded coverage under Medicaid has been aprimary vehicle for accomplishing this goal. Newservices and supports include respite, family andyouth peer support, intensive care management,intensive home-based services, therapeuticbehavioral aide services, skills training, therapeuticfoster care, mobile crisis services, crisisstabilization, specific evidence-based practices, and mentoring among others.

Creating or Expanding an IndividualizedApproach to Service DeliveryAn individualized or wraparound approach toservice planning and delivery has been a centralcomponent of the expansion efforts in all the statesand has been the primary mechanism foroperationalizing the system of care approach at theservice delivery level. Most of the states requirechild and family teams for youth with the mostserious and complex service needs, with full familyand youth involvement, individualized service

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II.

plans, care coordination, and flexible funds topurchase services and supports not covered byother funding sources. Extensive training in thewraparound approach is provided in many states.Wraparound fidelity is often measured using toolsfrom the National Wraparound Initiative, which isa consortium of individuals and organizationsseeking to promote high-fidelity wraparound implementation and evaluation (www.nwi.pdx.edu).

Creating or Expanding CMEs and CareManagement ServicesAnother important system change involves creatingor expanding CMEs to serve as the focal point ofaccountability and responsibility for managing theservices, costs, and care management for childrenwith intensive service needs and their families. Anumber of the states have created CMEs.Examples include Arizona’s RBHAs, New Jersey’sCare Management Organizations in each county,and Maryland’s CMEs that cover the entire state.These CMEs are an important expansion strategyand a significant service system innovation. Inaddition, some of the states have expandedintensive care management services, such asArizona’s high-need care management services and Maine’s extensive use of targeted case management.

Implementing Family-Driven, Youth-GuidedServices and Expanding Family and YouthInvolvement in Service DeliveryThe states view the expansion of family and youthinvolvement at the service delivery level as a basictenet of systems of care, with the core value of family-driven and youth-guided services. Family and youth involvement is also a fundamental principleof the wraparound approach and is considered animportant strategy for supporting system of careexpansion. Some states, such as Arizona, requirefamily and youth involvement in contracts withRBHAs and providers. Nearly all states havefamily support partners who help families navigateservice systems and provide peer support. In somecases, peer support is funded through a contractwith a family organization. In New Jersey, aFamily Support Organization is tied to each CME

and facilitates family engagement and involvementin services through peer-to-peer support providedby parent partners. Each of these Family SupportOrganizations also houses a Youth Partnership.

Underutilized StrategiesCreating or Expanding the Use of Evidence-Informed and Promising Practices and Practice-Based Evidence ApproachesA number of states are supporting theimplementation of specific evidence-informedpractices, such as Trauma-Focused CognitiveBehavior Therapy in Maine and ParentManagement Training-Oregon Model in Michigan. Others are implementing or exploring the “common elements” approach that identifies practicecomponents across evidence-based interventionsand provides training to clinicians in using theseapproaches. Other than in Maine, however, thestates did not identify implementation of evidence-informed practices as a specific expansion strategy.

Creating, Expanding, or Changing the Provider NetworkAlthough expanding the provider network for theexpanded array of services and supports is anunderutilized strategy, several states found it to bean effective strategy. Arizona, for example, added anew type of provider agency for direct support andrehabilitation services, and Rhode Island expandedthe provider network beyond community mentalhealth centers through its newly created FamilyCare Community Partnerships. Others haveexpanded their networks by adding providers fornew services such as respite, mentoring, andtherapeutic behavioral aide services.

Improving the Cultural and LinguisticCompetence of ServicesActivities are under way in the states to enhance the cultural and linguistic competence of their services,although these activities were generally not definedas strategies for expanding the system of careapproach. The states described strategies including incorporating culture-specific services in their service array (as in Hawaii), recruiting culturally diverse



providers (as in Maryland), and training (as in Oklahoma). In Arizona, a culture discovery process is seen as an integral part of the wraparoundapproach, and the cultural and linguisticcompetence of services at the practice level is measured using the System of Care Practice Reviewtool. This tool measures how well the system of careapproach is applied at the service delivery level.

Reducing Racial, Ethnic, and GeographicDisparities in Service DeliverySimilar to improving the cultural and linguisticcompetence of services, reducing disparities wasidentified as an important goal but was notgenerally defined as a strategy for system of careexpansion. Several of the states have receivedgrants that specifically target rural areas orcommunities of color; for example, Maine’s effortsto serve its Somali population. Interviewees notedthat geographic disparities are reduced simply byexpanding the system of care approach statewide.

Creating or ImprovingFinancing Strategies

Financing is indispensable to expanding the systemof care approach, and the states are creating orimproving financing mechanisms and usingfunding sources more strategically to support the infrastructure and services comprising systems of care.

Most Effective StrategiesIncreasing the Use of MedicaidIncreasing the use of Medicaid to finance servicesand supports was unequivocally the primary andmost effective financing strategy that the stateshave used. Three major approaches were used:

• Expanding the array of covered services byadding new service codes and definitions and byrevising existing service definitions to cover suchservices as intensive home-based services,intensive outpatient substance use services,respite, family and peer support, treatmentplanning, the wraparound process, therapeuticfoster care, supported housing and employment,mobile crisis response, crisis stabilization,

therapeutic behavioral aide services, skillstraining, traditional Native healers, specificevidence-based practices, assertive communitytreatment, and targeted care management

• Using multiple Medicaid options and waivers tofinance services and supports as seen in theoptions and waivers implemented in Michigan

• Generating Medicaid match with funds from both mental health and other child-serving systems to draw down increased federal Medicaid funds, as in New Jersey where funds are pooled across mental health, child welfare, and Medicaid to draw down additional federal funds including funds fromresidential and group home services to be redirected to home and community-based services

Increasing the Use of Federal Grants to Finance Systems of CareFederal grants, especially system of care grantsthrough the CMHI, have been used to supportstatewide expansion of systems of care. Thesegrants have been used strategically as vehicles forleveraging other long-term financing sources.Maine and Rhode Island are examples of statesthat have used system of care grants to put in placestructures and long-term financing for statewidesystem of care implementation. In Maryland,multiple federal grants have been linked and havebuilt on one another to move statewide expansionforward. Federal Mental Health Block Grants havealso been used to fund activities that supportstatewide expansion. For example, counties inMichigan can apply for Mental Health BlockGrant funds to support system of care planning.

Underutilized StrategiesIncreasing the Use of State Mental Health and/or Substance Use FundsThe strategy of obtaining new or increased statemental health funds has not been used forexpansion primarily because of the lack ofavailability of these funds in the context of statebudget crises. Although some mental healthgeneral revenue funds may have been usedpreviously to support services not covered under

11



III.

Medicaid, budget cuts have had a dramatic effecton their current availability. In North Carolina,however, state mental health funds have been usedfor statewide conferences on the system of careapproach, support of Local Management Entities and their system of care coordinators, school-based system of care coordinators, and collaborativeactivities. State funds in Maryland pay for crisisresponse and respite services for children who donot qualify under their Psychiatric ResidentialTreatment Facility Medicaid Waiver. No statereported using state substance abuse funds as a strategy for expanding the system of care approach.

Increasing the Use of Funds from Other Child Serving SystemsUsing funds from partner child-serving systems hasworked well in several states, but overall is anunderutilized expansion strategy. For example, inMichigan, child welfare funds are currently used tosupport systems of care in eight counties, withplans for statewide expansion. Child welfare andjuvenile justice funds have supported bothwraparound and specific evidence-informedinterventions in Maine. In Rhode Island, fundsacross child-serving systems are being used tosupport statewide system of care implementation,and in Maryland, the Children’s Cabinet is avehicle for blending resources across agencies tofund the services provided by CMEs.

Redeploying FundsThe process of redeploying funds from high-costresidential and inpatient services to home- andcommunity-based services is underutilized,although this strategy has proven effective in statessuch as Maine, Michigan, and New Jersey. In somecases, savings from reduced utilization of inpatientand residential services have had to be returned tostate treasuries in the current fiscal environment,rather than be reinvested in community-basedservices and supports. In Rhode Island, a cap onbeds has been established; 50 percent of thesavings is reinvested in home- and community-based services, and the other 50 percent is returnedto the state’s treasury.

Increasing the Use of Local FundsLocal funds are not being used as an expansionstrategy in most states studied. In Michigan, thechild welfare system has county child care funds,and decision-making power about the use of thosefunds is at the local level. With approval from thestate child welfare agency, counties can redirectthese funds and blend them with mental healthfunds to draw down additional Medicaid funds.One Michigan community has a juvenile justicemillage (i.e., property tax) that funds some systemof care activities, such as an alternative school andrecreation programs. Other communities may beconsidering the idea of a millage.

Increasing the Use of Federal Entitlements Other Than MedicaidNo state reported using other federal entitlements as a source of funding for system of care infrastructure or services. There was consensus among keyinformants that this was not a viable financing strategy for expanding the system of care approach.

Providing Training, TechnicalAssistance, and Coaching

The system of care approach cannot be expandedwithout a skilled workforce to provide services andsupports consistent with this framework, and thelack of a workforce was identified as a barrier in some states. Several effective strategies for addressing workforce development needs were identified.

Most Effective StrategiesProviding Training, Technical Assistance, andCoaching on the System of Care ApproachTraining has been a vital expansion strategy in allthe states studied, and substantial resources havebeen invested in providing training and technicalassistance on the system of care approach. Outsideconsultants, partnerships, and contracts withuniversities, state staff, and system of carecommunities have all provided vehicles andresources for developing a workforce that is skilledand prepared to work within a system of careframework. For example, Arizona brought



IV.

consultants into the state to provide training inwraparound. In Maine, a federally funded systemof care community provides training to othercommunities on the system of care approach andevidence-informed practices. Partnerships withuniversities have been used in North Carolina,Hawaii, and Maryland. Michigan includes a state-employed wraparound trainer on staff.

Creating Training and Technical Assistance CapacityProviding training alone does not meet long-termworkforce development needs. The capacity for ongoing training and technical assistance on systems of care is also needed and was seen as a highlyeffective strategy. Particularly given the turnoveramong administrators, managers, and providers, ongoing training is considered key to expansion and to continued development and improvement of theworkforce. Potential structures include institutes,centers of excellence, technical assistance centers,intermediary organizations, and partnerships withhigher education. Both Maryland and New Jerseyhave established centers at universities that provideongoing training, while capacity has been createdat local system of care sites and provider agenciesin Michigan, Maine, and Oklahoma.

Underutilized StrategiesProviding Training, Technical Assistance, andCoaching on Evidence-Informed and Promising Practices and Practice-Based Evidence ApproachesTraining on effective practices has generally notbeen used systematically as a strategy to supportsystem of care expansion. This strategy has thepotential to improve outcomes and thereby garner support for expansion efforts but was generally not used for expansion purposes. Exceptions are foundin Maryland, where the Innovations Institute is thehub for statewide training on evidence-informedservices, and in Michigan, where communityagencies provide training on the specific evidence-informed practices that are being implementedstatewide. Training is also provided in Maine on effective services such as Trauma-Focused CognitiveBehavior Therapy and Multisystemic Therapy.

Generating Support

System of care expansion cannot occur without thesupport of high-level policy and decision makers.In addition, expansion efforts can be derailed iffamilies, youth, providers, managed careorganizations, and other state and communityleaders do not buy into the approach and supportits expansion. Thus, this core strategy area focuses on strategies to generate support forsystem of care expansion.

Most Effective StrategiesEstablishing Strong Family and Youth OrganizationsA highly effective strategy identified by the states issupporting the development of strong familyorganizations that take a leadership role insupporting and becoming closely involved instatewide expansion efforts. Typically, this strategy is accomplished through state contracts with family organizations that support family involvement atthe system level. The role of family organizationshas been instrumental in most states. For example,in Maryland, the statewide family coalition iscredited with having a significant impact onmaintaining expansion efforts in the face ofchanges of administration and budget deficits.

The development and role of youth organizationsis considerably behind that of family organizationsin all the states. Youth organizations are sometimesembedded in family organizations, such as inHawaii, Michigan, and New Jersey. The nationalyouth organization Youth M.O.V.E. (YouthMotivating Others through Voices of Experience)is becoming increasingly involved in nationalpolicy and in the development of state and localyouth organizations. Youth organizations are inearly stages of assisting with system of careexpansion efforts through public education andoutreach to key constituencies.

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V.

Generating Support Among High-Level Policyand Decision MakersSupport among high-level decision makers wasidentified as a requirement for statewide expansionof the system of care approach. Efforts to garnersupport have focused on state-level policy anddecision makers. A variety of approaches are used,including providing data, educational briefings,concept papers, plans, reports, and meetings withfamilies and youth. In Michigan, high-leveldecision makers have been included in delegationsto federal meetings (e.g., system of care traininginstitutes, policy academies) to engage them inexpansion efforts. The Children’s Cabinet inMaryland has been fully engaged in system of careexpansion, and its members have becomechampions for the approach. Support from thelegislature and governor was reported to be criticalfor system of care expansion in Rhode Island, andsystem of care leaders thought strategically abouthow to involve key policy makers in opportunitiesto support system change. A focus on gaining thesupport of local decision makers was identified inRhode Island, where concept papers were used toengage local leaders. In North Carolina andOklahoma, local collaboratives work to garnersupport among local decision makers.

Using Outcome DataData on outcomes at both the system and servicedelivery levels are important components ofsecuring the support of decision makers forstatewide expansion. In Maine and Oklahoma, forexample, data are presented to legislators andother policy makers. In Maryland, effectivenessdata from various pilots helped promote statewideimplementation. North Carolina has used outcomedata from federally funded system of carecommunities to generate support for expansion.

Underutilized StrategiesUsing Cost Avoidance DataAn approach used less frequently involves usingdata on cost avoidance across systems and/orcomparisons with high-cost services to make the

case for statewide expansion. Given the difficulteconomic situation in most states and the lack ofnew monies, it is important to demonstrate thatthe system of care approach results in reducedutilization of inpatient and residential treatmentplacements while showing positive clinical and functional outcomes. Oklahoma and Michigan have been able to demonstrate cost avoidance based onreducing the utilization of residential treatmentcenters and other out-of-home services. Otherstates studied did not report using this approach.

Cultivating Partnerships With Providers and Other Key LeadersTo some extent, states have intentionally pursuedpartnerships with providers, provider agencies, andmanaged care organizations to engage them inexpansion efforts, but this generally has been anunderutilized strategy. One exception is inMichigan, where the state works closely with thechildren’s mental health leaders in each communitymental health agency on system of careimplementation issues. Also, Rhode Island seeksinput from community providers on all plans and policy documents, creating buy-in and commitment to the system of care approach. Work to generatesupport from various types of civic leaders wasgenerally not cited as an expansion strategy.

Generating Support Through Social Marketingand Strategic CommunicationsAlthough social marketing activities were reported,most states did not characterize social marketingas an important strategy for expanding the systemof care approach. Despite not being cited as aspecific expansion strategy, social marketing andstrategic communications have, in fact, permeatedmany of the expansion strategies reported aseffective. An example of the effective use of socialmarketing is found in Maryland, where the firstlady became a spokesperson for children’s mentalhealth, generating strong support for statewidesystem of care implementation.



15

ADDITIONAL INFORMATION TO GUIDE EXPANSION


Cultivating LeadersCultivating leaders was generally not noted as anapproach for system of care expansion. However,in Rhode Island, efforts to cultivate leaders forsystems of care involve providing training andcoaching to community lead agencies. InMaryland, leadership academies and other nationalmeetings have been used as vehicles to developleaders for the system of care approach. Inaddition, the Maryland Coalition of Families offersa Family Leadership Institute to support familymembers to become system of care leaders in theircommunities, in the state, and nationally.

Additional Informationto Guide ExpansionIn addition to the findings on the effectiveness ofthe strategies discussed above, the study identified:

• The strategies judged to be most effective acrossall five core areas

• The most significant underutilized strategies thathave the potential to have an impact on systemof care expansion

• The roles of system of care communities aspartners for system of care expansion

• Challenges and barriers to expansion efforts

Most Significant StrategiesOf all the strategies explored through this study,eight were identified across states as the mostsignificant and effective strategies overall forexpanding the system of care approach. This list of strategies should not be interpreted to mean that these are the only strategies that were effectiveor the only strategies that should be used. Eachstate studied used many strategies as part of acomprehensive, multipronged approach to system change.

Incorporating Requirements in RFPs, Contracts, and RegulationsIncorporating various types of requirements was afrequently used strategy and was considered veryimportant and effective. Actions that were takeninclude requiring that RFPs and contracts withproviders mandate the use of the system of careapproach, inserting system of care language inMedicaid regulations, and developing providermanuals and practice protocols based on thesystem of care approach.

Creating or Assigning a State and Local Locus ofManagement and AccountabilityWithin this sample of states, there was a clearlocus of accountability for efforts to implementsystems of care at the state level and at theregional or local level. This does not diminish theimportance of governance groups, coalitions, andinteragency policy bodies but rather speaks to thevalue of having a clear and strong focal point ofmanagement and accountability.

Providing Training on the System of Care ApproachMost states in this study have mounted robustprograms of training and technical assistance,particularly for providers but also for other keyleaders. Training was believed to be significant forimproving practice and for creating meaningful,sustainable change. In some states, neworganizational entities were created to enhancetheir capacity to provide ongoing training.Examples of topics covered in training and

• Incorporating requirements in RFPs, contracts, and regulations

• Creating or assigning a state and local locus ofmanagement and accountability

• Providing training on the system of care approach• Expanding the array of services and supports• Expanding an individualized, wraparound approachto service delivery

• Expanding family and youth involvement in services• Creating and supporting strong family organizations• Increasing the use of Medicaid financing

MOST SIGNIFICANT STRATEGIES

technical assistance include system of care valuesand principles, partnerships with families andyouth, cultural and linguistic competence, thewraparound process, and the use of specificevidence-informed practices. Training has alsofocused on what it takes to develop theinfrastructure, organizational supports, andgovernance structures for effective systems of care.

Expanding the Array of Services and SupportsTo be consistent with the system of care approach,a service delivery system must offer a wide array ofservices and supports. During the past 25 years,the breadth of the service arrays in communitiesand states across the country has expanded toinclude home- and community-based services andmany additional supports such as respite care,therapeutic behavioral aide services, andmentoring. Each state in this study madeconsiderable progress in expanding the range ofavailable services and supports. This clearly helpedenhance outcomes for children, youth, and familiesand, as a consequence, build support for expansionamong a wide range of stakeholders.

Expanding an Individualized, WraparoundApproach to Service DeliveryThe wraparound approach puts into practice thevalues and principles of a system of care at theservice delivery (i.e., child and family) level. It isnot surprising, therefore, that the states in thisstudy invested heavily in providing training inwraparound approaches and funding for theirimplementation and that they found this to be ahighly significant and effective strategy in theirexpansion efforts. Closely related to this approach,many states expanded their care managementservices and created CMEs to provide and manageindividualized, coordinated services and supports.

Expanding Family and Youth Involvement in ServicesParticipation by families in the service deliveryprocess has increased over time in this sample ofstates and was considered to be essential. Families

were key drivers in the development ofindividualized service plans and were involved inproviding peer support and education, oftenthrough family organizations. There wereindications that youth involvement in services wasincreasing as well, although this is not as yet at thesame level of development as family involvement.

Creating and Supporting Strong Family OrganizationsIn addition to their service delivery roles, familyorganizations have played a critical role insupporting the expansion of the system of careapproach. Each of these states has a strong familyorganization, and, in most cases, the state hassupported their development and sustainabilitythrough contracts. These organizations have beenvital to the states’ ability to sustain their effortsduring difficult economic times. Through theiroutreach efforts to leaders in the legislative andexecutive branches, family organizations havesuccessfully kept the issue of children’s mentalhealth in the forefront, helped educate groupsabout the seriousness of mental health challengesin children and youth, and provided concreteexamples of the value of systems of care in helpingfamilies address these problems.

Increasing the Use of Medicaid FinancingAlthough the specific strategies used by statesdiffered, a strong and consistent finding was thatstates increased their ability to support anextensive array of services and supports throughthe use of Medicaid. Medicaid funding was asignificant element in bringing about andsustaining system change in difficult budgetarytimes. States used different waivers, differentoptions, and different service definitions, but allwere successful in capitalizing on the opportunitiesthat Medicaid offered to fund important servicesand supports for children and youth with mentalhealth challenges and their families.



Most Significant Underutilized StrategiesOther strategies considered to be underutilized alsohave the potential to have an impact on statewideexpansion of systems of care but were not utilizedextensively by most states in this sample. As noted,states selected those strategies that were mostappropriate in their particular environments,although respondents acknowledged that otherscould also be helpful. Those strategies deemedparticularly promising are discussed below.

Incorporating the System of Care Approach in Monitoring ProtocolsIt is noteworthy that respondents reported a highrate of incorporating the system of care approachin rules, regulations, standards, RFPs, andcontracts, but less focus on monitoring compliancewith these requirements. In addition to assessinggeneral adherence to the system of care approach,such monitoring can determine fidelity to variousaspects of the approach. Specific areas can then betargeted for improvement. States in this studyrecognize this and are beginning to enhance theirmonitoring efforts.

Creating or Expanding the Use of Evidence-Informed and Promising Practices and Practice-Based Evidence ApproachesLess activity was reported for implementingevidence-informed practices than for expanding abroad array of services, care management, and anindividualized approach—the essence of a systemof care since its beginning. However, theimportance of interventions that have empiricalsupport has increasingly been emphasized. Theevidence base for specific services and supports hasincreased dramatically over the past decade, andthere are indications in the states studied ofgrowing efforts to incorporate evidence-informedpractices into their service array. States are likelyto increasingly integrate evidence-informed care toimprove the effectiveness of services and,ultimately, child, youth, and family outcomes.

Creating or Expanding the Provider NetworkCommunities and states continue to struggle withworkforce issues. One approach has been to reachout to a broader range of providers, leading to alarger number of service providers on a fee-for-service basis. This expansion allows families tohave a choice of providers as well as a choice ofservices. The expansion of provider networks andthe emphasis on choice are consistent with thesystem of care core value of family-driven, youth-guided services. Expanding provider networks canbe an effective approach for addressing workforceneeds, creating the capacity to provide the broadarray of services and supports that is characteristicof systems of care, and offering meaningful choicesto families and youth. The movement towardCMEs is another illustration of this approachbecause these entities typically have the flexibilityto expand their provider networks in order to offera wide range of services and supports.

Improving the Cultural and LinguisticCompetence of ServicesTrue system of care development cannot beaccomplished without attention to the diversity ofthe population of children, youth, and families inneed of services and to the need for cultural andlinguistic competence. The children’s mental healthfield has been a pioneer in framing this issue andin developing approaches to address cultural and

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• Incorporating the system of care approach inmonitoring protocols

• Creating or expanding the use of evidence-informedand promising practices and practice-based evidence approaches

• Creating or expanding the provider network• Improving the cultural and linguistic competence of services

• Redeploying funds and using data on cost avoidance• Increasing the use of state mental health funds, fundsfrom other child-serving systems, and local funds

• Generating support through social marketing andstrategic communications

• Cultivating ongoing leaders and champions for thesystem of care approach

MOST SIGNIFICANT UNDERUTILIZED STRATEGIES

linguistic competence. A next step in system ofcare implementation is to demonstrate that culturaland linguistic competence will improve outcomesand, ultimately, support system of care expansion.

Redeploying Funds and Using Data on Cost AvoidanceThe states in this study have had substantialsuccess in reducing the use of residential care at asizeable cost savings; however, they have had lesssuccess in redeploying these funds to home- andcommunity-based services that will further reducethe need for expensive residential care. To someextent this is understandable because the data forthe study were collected during difficult economictimes. Nevertheless, this economic environmentmay provide opportunities to divert funds fromexpensive out-of-home care into home- andcommunity-based services. If data are collected onthe costs avoided through reducing the use ofresidential care, in combination with data onoutcomes for children and families served withinsystems of care, such savings can be used tosupport statewide expansion. This type of datacollection and analysis is complex; respondentsindicated that they could benefit from resourcesand technical assistance in this area.

Increasing the Use of State Mental Health Funds, Funds From Other Child-Serving Systems,and Local FundsThe public sector children’s mental health systemhas increased dramatically its dependence onMedicaid funding over the past 20 years. Thefindings from this study indicate that the states inthe sample have become very knowledgeable aboutMedicaid funding and very skilled in using theopportunities provided by Medicaid to supportand expand systems of care. However, it is clearthat other sources of funding are also needed tosupport systems of care. The study found onlymodest uses of state mental health funds, fundsfrom other systems, and local funds. It is achallenge to effectively reach out to these potentialsources of funding while also capitalizing on newopportunities created by such changes as health

reform and parity legislation and maintaining theuse of Medicaid that has been demonstrated in thisstudy. Several states have begun to developinteragency funding strategies and to do jointbudgeting across systems. Those states that areable to leverage their existing funds by creatingopportunities for new fiscal partnerships that cutacross service systems at the state and local levelsare poised to be successful.

Generating Support Through Social Marketingand Strategic CommunicationsRespondents at the state level rarely identifiedsocial marketing as an expansion strategy.However, as noted, social marketing and strategiccommunications cut across most strategiesidentified as effective. For example, cultivatingsupport among high-level policy and decisionmakers has been accomplished with targetedinformation highlighting outcomes along withpersonal stories to demonstrate the value of thesystem of care approach for youth and families. Ifsystem of care expansion is to be accomplishedand sustained, social marketing and strategiccommunications are needed to support action onbehalf of this population. States that have donethis well have fared better in these difficultfinancial times than states that have not.

Cultivating Ongoing Leaders and Champions for the System of Care ApproachLooking to the future, new leaders must beidentified and prepared at state and local levels for systems of care. Leaders are needed who are skilled in the system change process, knowledgeable aboutthe system of care approach, able to generatesupport at the highest levels, and able to createpartnerships across systems to improve services forchildren, youth, and families. Further, states andcommunities must cultivate champions who areable to communicate convincingly about thesystem of care approach and have sufficientinfluence to make a difference. In the past, systemsof care have relied heavily on family members andyouth to fulfill this role, but champions can also behighly visible individuals from the political, civic,



faith, sports, entertainment, or media arenas.States may wish to consider how best to identifysuch champions and how to cultivate them asadvocates for systems of care.

State-Community Partnerships for Expanding the System of Care ApproachPrevious work on sustainability underscored theimportance of state-community partnerships toaccomplish the goal of widespread adoption of thesystem of care approach (Stroul & Manteuffel,2007, 2008). With state involvement, the policiesand financing mechanisms necessary to sustain andexpand systems of care can be put in place.However, there was also consensus as to theimportance of community involvement becausecommunity members are an invaluable source ofexperience and expertise that can both inform andfacilitate expansion efforts. Ideally, both a top-down approach with policies, goals, and system-level supports for system of care implementation and a bottom-up approach involving the innovation, commitment, and expertise at the community levelcreate the synergy needed to achieve wide-scaleadoption. Thus, both states and communities arecentral players and have important roles to play inexpanding the system of care approach. The studyfound that communities can and do play a vitaland strategic role in the areas described below.

Testing, Piloting, and Demonstrating Approaches for Statewide ImplementationA frequent and effective role that grantees playedwas serving as a test site for new approaches,including interventions both at the system level

and at the service delivery level, such asimplementing CMEs or child and family teams forservice planning and delivery. This, then, facilitatedthe broader implementation of these approaches inother communities throughout the state.

Providing DataA number of states indicated that data on theeffectiveness of systems of care, collected throughboth the national and local evaluations, werehelpful in building a case for the expansion ofsystems of care among high-level policy anddecision makers at the state level. System of caregrants provided more resources for evaluation thanwere typically available, and this was very helpfulwithin states. The availability of national datathrough the evaluation was also cited as beinghelpful to states in demonstrating that systems of care not only are effective, but are a national model.

Providing Training and Technical AssistanceA number of states have been able to harness theexpertise of system of care communities to providetraining and technical assistance to othercommunities statewide. In some instances, statesinitiated training activities and enlisted current or graduated communities to provide training to other communities. In other cases, local grantees reachedout to other communities or were sought out fortraining elsewhere in their states. The states in which this occurred found it to be extremely helpful and were actively working to sustain this enhancedtraining and technical assistance capacity.

Contributing to the Development of Family and Youth OrganizationsThrough system of care grants, increased supportwas provided to family organizations, which arecritical to expansion efforts. This support hasincluded funding and opportunities to participateon planning councils, attend state and nationalmeetings, and become service providers. Thesefamily organizations are critical to expansion efforts. Also, CMHI grant resources have been used to support the development of youth leadershipand youth organizations within the states.

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• Testing, piloting, and demonstrating approaches for statewide implementation

• Providing data• Providing training and technical assistance• Contributing to the development of family and youth organizations

ROLES FOR COMMUNITIES AS PARTNERS INSYSTEM OF CARE EXPANSION

Challenges to Expanding Systems of CareAlthough the states studied have made significant progress, they have also encountered challenges and barriers to expanding systems of care. Two barriers stood out as major concerns across states: the fiscal crises in many of the states with accompanyingbudget cuts and changes in administration thatcould potentially result in policy changes.

Although it is not unusual for states to have periodic budget problems, the fiscal challenges experiencedby states in recent years have been exceptional andhave threatened both current and future financing for system of care implementation. It is noteworthy, however, that several states indicated that theywere able either to avoid cuts or to minimize thecuts through the support they had from family organizations, support across child-serving systems, data on effectiveness, and ongoing education of key leaders. In addition, some states described budgetproblems as both a challenge and an opportunity,noting that policy makers and child-serving agencypartners are more amenable to such approaches asblending or braiding funds, redeploying resourcesfrom higher-cost to lower-cost services, and usingother strategies for better investing scarceresources in difficult economic times.

Similarly, states in the study sample have hadconsiderable success in maintaining their gainsthrough various administration changes. This isattributed to the institutionalization of the systemof care approach in policy, financing, and practice.In addition, intentional outreach and educationalefforts with high-level decision makers in newadministrations by system of care leaders andfamily organizations have helped these statessuccessfully work through such changes.

Lessons for Expandingthe System of CareApproachEach state in the study took a different approachto system of care expansion, building on its uniquecontext, opportunities, needs, and strengths.However, a number of consistent themes aresummarized below to provide guidance to otherstates, tribes, territories, and communities in theirexpansion efforts.

Lessons LearnedEstablish a Strong Value BaseThe states in this study had a strong foundation insystem of care values and principles that they wereable to build on in their expansion efforts. As theamount of funding changes, and as individualleaders come and go, it is clear that one of the keyfactors in keeping systems of care alive andexpanding in these states has been a deepcommitment by diverse stakeholders, includingpolicy makers, family advocates, and providers, tosystem of care values and principles.

Create a Plan With Multiple StrategiesAll the states in the study followed some type ofplan that included multiple strategies to achievetheir expansion goals. Some states had formalstrategic plans that were reviewed and updatedperiodically. Other states proceeded withoutformal strategic plans but always had a clearvision and some type of document to help guidethe effort. The plans followed by these states all



• Fiscal crises and budget cuts• Changes in administration with new directions and policy changes

CHALLENGES

• Establish a strong value base• Create a plan with multiple strategies• Cultivate effective leadership• Be opportunistic and adaptive• Adhere to high standards of quality• Partner with families and youth

LESSONS LEARNED FOR SYSTEM OF CARE EXPANSION

included multiple strategies to achieve theirexpansion goals. Interviewees underscored theimportance of ensuring that the multiple strategiesin their plans are aligned with one another so thatthe service expansion, data collection, new fundingdevelopment, and workforce development effortsall promote system of care expansion. TheSAMHSA System of Care Expansion Grantprogram is designed to support state efforts todevelop strategic plans specifically focused onstatewide system of care expansion.

Cultivate Effective LeadershipEach state in the study had strong leadership, bothindividual and collective, with a vision of what toaccomplish and a plan to get the process going.Leadership consisted of formal leaders, such asstate directors of children’s mental health, directorsof family organizations, and directors of otherchild-serving agencies at the state and local levels.Leadership also came from leaders without directauthority, such as community members and thespouses of key officials. Most important, theleadership, whether individual or collective, wasstrategic and tactical, flexible and adaptive, andinclusive and persistent.

Be Opportunistic and AdaptableStates in this study had strong planning. However,there are always unexpected developments, andthese states were also strong at leveraging positiveopportunities that emerged unexpectedly andminimizing the negative impact of anyunanticipated barriers. Some of the positiveopportunities included new grant programs, newwaiver opportunities through Medicaid, and evenopportunities provided by settlement agreementsrelated to class-action lawsuits. Contextually, it isalso important to remember that data collectionfor this study took place during a time of greatbudgetary challenges in all these states. Thesuccessful states had sound data on the outcomesof their work and powerful partnerships, and theirpreparation and ability to adapt helped keep thedamage to a minimum. In fact, in several states thetight budgets created opportunities to demonstrate

that cost-effective, individualized care approachescould reduce the need for more expensive andrestrictive residential placements. This is a primeexample of converting a potentially seriousproblem into a positive outcome.

Adhere to High Standards of QualityConsistent with the emphasis on systems ascomplex entities with many parts interacting inoften unpredictable ways, the system of care grantprogram and the overall system of care approachhave increased the focus on continuous qualityimprovement and performance measurement. Thislesson was clearly reflected in the work of thestates in this study. They recognized thatexpanding systems of care without maintainingadherence to strong quality standards couldpotentially harm the system of care movement andtheir states’ expansion efforts. The establishmentof high standards for quality and theimplementation of efforts to monitor adherence tothem was considered essential. Often aided bynational and local evaluations related to theCMHI, these activities not only provide a basis forquality improvement, but also provide informationto support system of care expansion.

Partner With Families and YouthA strong and consistent theme across these stateshas been the important role of family members andyouth in supporting the expansion of the system ofcare approach. The role of family organizationshas been particularly notable because they are at amore advanced stage of development in thesestates than are youth organizations. Familyorganizations have educated key stakeholdersabout the needs of children and youth with seriousmental health challenges; about system of carevalues and principles; and about the benefits of anindividualized, culturally and linguisticallycompetent, strength-based approach to care. Theyhave been enormously valuable advocates inpromoting the system of care approach. Familyorganizations have targeted leaders in legislativeand executive branches and have been credited bystate leaders for securing new resources and for

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LESSONS FOR EXPANDING THE SYSTEM OF CARE APPROACH


minimizing the loss of resources during budgetarychallenges. Several of the states also have strongyouth leaders and organizations. Their impact hasbeen extremely positive, and the overall impact ofyouth leaders and organizations is anticipated onlyto grow over the coming years.

ConclusionAs the findings from this study indicate, there is nosingle formula or strategy for expanding thesystem of care approach statewide. The key is forstates to incorporate lessons learned from the fieldand to develop and implement expansion plansthat build on their strengths, create partnerships,and capitalize on opportunities. The states studiedhave made very encouraging progress and havemaintained that progress in the face of extremefinancial challenges. They also have recognizedthat many challenges remain.

SAMHSA’s System of Care Expansion PlanningGrant program to promote widespread adoptionof the approach provides a new opportunity toenhance progress that has already been achievedand to support new expansion efforts across thenation. Other changes, such as health reform andmodifications in the federal Mental Health BlockGrant program and Medicaid, may also facilitatethe process so that more states can truly achieve atipping point for broad implementation of thesystem of care approach. These changes and new initiatives all provide additional opportunitiesfor continuous learning about the critical butcomplex task of bringing about system change inindividual communities and throughout a state,tribe, or territory.

It is hoped that the lessons learned through thisstudy will assist states in their efforts to expandthe system of care approach in the coming yearsand that these efforts will, in turn, further advancethe knowledge base about how to achievewidespread adoption of innovative approaches.

REFERENCESBlau, G. (2011, March). SAMHSA theory of change model.Presentation at the Services Evaluation Committee Meeting forthe National Evaluation of the Comprehensive CommunityMental Health Services for Children and Their Families Program.Gaithersburg, MD.

Gruttadaro, D., Markey, D., & Duckworth, K. (2009).Reinvesting in the community: A family guide to expandinghome and community-based services and supports. Arlington,VA: National Alliance on Mental Illness.

Maine Department of Health and Human Services, Office ofContinuous Quality Improvement Services (2011, July).Wraparound Maine: A mental health service use and cost study.QI Data Snapshot, 3(3).

Manteuffel, B., Stephens, R., Brashears, R., Krikelyova, A., & Fisher, S. (2008). Evaluation results and systems of care: A review. In B. Stroul & G. Blau (Eds.), The system of care handbook:Transforming mental health services for children, youth, andfamilies (pp. 25-69). Baltimore: Paul H. Brookes Publishing Co.

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LESSONS FOR EXPANDING THE SYSTEM OF CARE APPROACH

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