Systems of Care Fundamentals

• [Adapted from Sheila A. Pires, Building Systems of Care: A Primer (second edition, 2010)]

Systems of Care

A system of care is a coordinated network of community-based

services and supports that are organized to meet the challenges

of children and youth with serious mental health needs and

their families. Families and youth work in partnership with

public and private organizations so services and supports are

effective, build on the strengths of individuals, and address

each person’s cultural and linguistic needs. A system of care

helps children, youth and families function better at home, in

school, in the community and throughout life.Gary Blau, Child, Adolescent and Family Branch, CMHS, SAMHSA

Family-Driven, Youth-Guided Systems of Care Look Like This

4

SOC Development, Expansion Focuses on…

• Policy Level (e.g. vision, financing, regulations)• Management Level (e.g., data; quality improvement;

human resource development; system organization)• Frontline Practice Level (e.g., assessment; care

planning; care management; services/supports provision)

• Community Level (e.g., partnership with families, youth, natural helpers; community buy-in)

• Individual Level – How can I participate? What am I willing to contribute?

Adapted from Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Systems of Care

Recovery, Resilience and Transformation

Recovery

Transformation

Resilience

What is involved?

Rethinking traditional approaches

Strengths-based

Family driven & youth guided

Embracing culture

Who is involved?

Youth

Adults

Families

Providers

Communities

Fulfilling Potential

6

Family-driven and youth-guided Home and community based Strength-based and individualized Culturally and linguistically competent Integrated across systems Connected to natural helping networks Data-driven, outcomes oriented

Adapted from Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. Reprinted by permission.

Values and Principles for a System of Care

Family-Driven Means…

Families have a primary decision making role in the care of their own children, as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation.

Family-Driven Means That Families Take the Lead

Choosing supports, services, and providers;

Setting goals;

Designing and implementing programs;

Monitoring outcomes;

Managing the funding for services, treatments and supports;

and

Determining the effectiveness of all efforts to promote the

mental health and well being of children and youth.

Youth-Guided Means…

• Youth have rights.

• Youth are utilized as resources.

• Youth have an equal voice and are engaged in developing and sustaining the

policies and systems that serve and support them.

• Youth are active partners in creating their individual support plans.

• Youth have access to information that is pertinent.

• Youth are valued as experts in creating systems transformation.

• Youth’s strengths and interests are focused on and utilized.

• Adults and youth respect and value youth culture and all

forms of diversity.

• Youth are supported in a way that meets their individual needs.

Youth Involvement in Systems of Care

A starting point for understanding youth

involvement and engagement in order to develop and fully integrate a youth-directed

movement within local systems of care.

(see www.tapartnership.org)

11

Examples of Shifts in Roles and Expectations for Family Members and Youth

Lazear, K. & Conlon, L. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

-Recipient of information

re: child’s service plan

Passive partner in service planning process

Service planning team leader

-Unheard voice in program evaluation

Participant in program evaluation

Partner (or independent) in developing and conducting program evaluations

-Recipient of services Partner in planning and developing services

Service providers

-Uninvited key stakeholders

in training initiatives

-Anger, adversity &

resistance

Participants in training initiatives

Self-advocacy

Partners and independent trainers

Advocacy & peer support

12

CultureA broad concept that reflects an integrated pattern of a wide range of beliefs, values, practices, customs, rituals, and attitudes that make up anindividual, family, organization, or community.

Adapted from Youth Involvement in Systems of Care: A Guide to Empowerment (2006) and Goode & Jones (modified 2004). National Center for Cultural Competence, Georgetown University Center for Child & Human Development.

Cultural CompetenceAccepting and respecting diversity and difference in a continuous process of self assessment and reflection on one’s personal and organizational perceptions of the dynamics of culture.

Cultural and Linguistic Competence: Definitions

Linguistic Competence

The capacity of an organization and its personnel to communicate effectively and convey information in a way that is easily understood by diverse audiences, including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities.

Why Develop Cultural and Linguistic Competence?

To respond to current and projected demographic changes in the United States

To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds

To improve access to services and outcomes To improve the quality of services and

health outcomes To meet legislative, regulatory, and

accreditation mandates

Wraparound Process

• Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports, individualized for that child and family to achieve a positive set of outcomes. Wraparound does not equal a “complete” system of care. It is only one component.

• Individualized care plan refers to the procedures and activities that are appropriately scheduled and used to deliver services, treatments, and supports to the child and family.

15

• Collaboration across agencies• Partnership with families and youth• Cultural and linguistic competence• Blended, braided, or coordinated financing• Shared governance across systems and with families

and youth• Shared outcomes across systems• Organized pathway to services & supports• Child and family teams• Staff, providers, families, youth trained and

mentored in a common practice model• Single plan of care• One accountable care manager

System of CareOperational Characteristics

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

16

Current Systems Problems• Lack of home and community-based services and

supports• Patterns of utilization; racial/ethnic

disproportionality and disparities• Cost• Administrative inefficiencies• Knowledge, skills and attitudes of key stakeholders• Poor outcomes• Rigid financing structures• Deficit-based/medical models, limited types of

interventions

Pires, S. (1996). Human Service Collaborative, Washington, D.C.

17

Characteristics of Systems of Care as Systems Reform Initiatives

FROM

Fragmented service delivery

Categorical programs/funding

Limited services

Reactive, crisis-oriented

Focus on “deep end,” restrictive

Children/youth out-of-home

Centralized authority

Creation of “dependency”

TO

Coordinated service delivery

Blended resources

Comprehensive service array

Focus on prevention/early

intervention

Least restrictive settings

Children/youth within families

Community-based ownership

Creation of “self-help”

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Youth in SOC Achieve Positive Education Outcomes

• Only 8% of youth in SOC for 12 months had repeated a grade, compared to nearly twice as many American students in the general public (15%)

• The percentage of youth receiving passing grades (C or better) increased from 55% upon entry into services to 66% after 12 months of services (20% increase in the proportion of youth who received passing grades)

• Within one year of entering SOC services, the percentage of youth attending school regularly increased from 75% to 81% (this improvement means that school attendance for youth with mental health needs in SOC approached the national school attendance average of 83%)

Youth in SOC Achieve Positive Education Outcomes

• There was a 22% reduction in the percentage of youth who changed schools due to emotional and behavioral reasons after receiving SOC services for 12 months.

• Expulsions from school decreased by 2/3 (from 15% at intake to 5%) within 12 months of entering SOC services

• 12 months after beginning SOC services, 16% of youth reported significant lower levels of depression and 21% reported significant lower levels of anxiety than when they entered services

• Youth suicide attempts decreased significantly within the first 6 months of services, from 13% to 6%. Within 12 months, only 5% of youth had reported suicide attempts (62% reduction after starting services) US Department of Health and Human Services (www.samhsa.gov)

20

Example: Transition-Age YouthWhat outcomes do we want to see for this population?

Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.

Policy Level •What systems need to be involved? (e.g., Housing, Vocational Rehabilitation, Employment Services, Mental Health and Substance Abuse, Medicaid, Schools, Community Colleges/Universities, Physical Health, Juvenile Justice, Child Welfare)•What dollars/resources do they control?

Management Level•How do we create a locus of system management accountability for this population? (e.g., in-house, lead community agency)

Frontline Practice Level•Are there evidence-based/promising approaches targeted to this population?•What training do we need to provide and for whom to create desired attitudes, knowledge, skills about this population?•What providers know this population best in our community? (e.g., culturally diverse providers)

Community Level•What are the partnerships we need to build with youth and families? •How can natural helpers in the community play a role?•How do we create larger community buy-in?•What can be put in place to provide opportunities for youth to contribute and feel a part of the larger community?

21

Fundamental Challenge and Rationale for Building Systems of Care

No one system controls everything.

Every system controls something.

Pires, S. 2004. Human Service Collaborative. Washington, D.C.

22

Strategic Planning

“The science and art of mobilizing all forces – political, economic, financial, psychological –

to obtain goals and objectives.”

Pires, S., Lazear, K., Conlan, L.(2003). “Primer Hands On”: A skill building curriculum. Adapted from Webster’s Dictionary. Washington, D.C. Human Service Collaborative

23

Building Local Systems of Care: Strategically Managing Complex Change

Human Service Collaborative. (1996). Building local systems of care: Strategically managing complex change. [Adapted from T. Knosler (1991), TASH Presentations]. Washington: DC.

24

Core Elements of an Effective System-Building Process

• A strategic mindset• A shared vision based on common values and principles• A clear population focus• Shared outcomes• Community mapping—understanding strengths and needs• Understanding and changing traditional systems• Understanding of the importance of “de facto” mental health providers

(e.g., schools, primary care providers, day care providers, Head Start)• Understanding of major financing streams• Connection to related reform initiatives• Clear goals, objectives, and benchmarks• Trigger mechanisms—being opportunistic• Opportunity for reflection• Adequate time

The Importance of Being Strategic

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative

25

Core Elements of an Effective System-Building Process

• A core leadership group• Evolving leadership• Effective collaboration• Partnership with families and youth• Cultural and linguistic competence• Connection to neighborhood resources and natural helpers• Bottom-up and top-down approach• Effective communication• Conflict resolution, mediation, and team-building mechanisms• A positive attitude

The Importance of Leadership & Constituency Building

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.