Building Systems of Care: Critical Structures and Processes

BUILDING SYSTEMS OF CARE: CRITICAL STRUCTURES AND PROCESSES Presentation by: Sheila A. Pires Human Service Collaborative November 3, 2005 Sponsored by the Pennsylvania Child Welfare Training Program

Purpose and Structure of the Training
Increase knowledge about what is involved in building
systems of care: critical structures, essential process
elements, examples – Didactic, Questions/Discussion
Assess system-building progress and stage of
development – Break out by County/Facilitated Discussion
Develop specific action agendas to advance
system-building efforts – Break out by County/Facilitated
Discussion/Technical Assistance
Peer Learning – Reporting Back/Large Group Discussion

A system of care incorporates a broad array of services and supports for a defined population that is organized into a coordinated network, integrates care planning and management across multiple levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery, management, and policy levels. Definition of a System of Care Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Pires, S. (2002) Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. National System of Care Activity
CASSP
RWJ MHSPY
CASEY MHI
CMHS GRANTS
CSAT GRANTS
ACF GRANTS
CMS GRANTS
PRESIDENT’S NEW FREEDOM MENTAL HEALTH COMMISSION
STATE INFRASTRUCTURE GRANTS

System of care is, first and foremost, a set of values and principles that provides an organizing framework for systems change on behalf of children, youth and families. Pires, S. 2005. Human Service Collaborative. Washington, D.C.

Values and Principles for the System of Care
CORE VALUES
Child centered and family focused
Community based
Culturally competent
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.

Comprehensive array of services/supports
Individualized services guided by an individualized service plan
Least restrictive environment that is clinically appropriate
Families and surrogate families and youth full participants in all aspects of the planning and delivery of services
Integrated services
Continued …

Care management or similar mechanisms
Early identification and intervention
Smooth transitions
Rights protected, and effective advocacy efforts promoted
Receive services without regard to race, religion, national origin, sex, physical disability, or other characteristics and services should be sensitive and responsive to cultural differences and special needs

Principles of Family Support Practice
Staff & families work together in relationships based on equality and respect.
Staff enhances families’ capacity to support the growth and development of all family members.
Families are resources to their own members, other families, programs, and communities.
Programs affirm and strengthen families’ cultural, racial, and linguistic identities.
Programs are embedded in their communities and contribute to the community building.
Programs advocate with families for services and systems that are fair, responsive, and accountable to the families served.
Practitioners work with families to mobilize formal and informal resources to support family development.
Programs are flexible & responsive to emerging family & community issues.
Principles of family support are modeled in all program activities.
Family Support America. (2001). Principles of Family Support Practice in Guidelines for Family Support Practice (2 nd ed.). Chicago, IL.

Youth Development Principles
Adolescent Centered
Community Based
Comprehensive
Collaborative
Egalitarian
Empowering
Inclusive
Visible, Accessible, and Engaging
Flexible
Culturally Sensitive
Family Focused
Affirming
Pires, S. & Silber, J. (1991). On their own: Runaway and homeless youth and the programs that serve them. Washington, D.C.: Georgetown University Child Development Center.

System of Care: Operational Characteristics
Collaboration across agencies
Partnership with families
Cultural & linguistic competence
Blended, braided, or coordinated financing
Shared governance across systems & with families
Shared outcomes across systems
Organized pathway to services & supports
Interagency/family services planning teams
Interagency/family services monitoring teams
Single plan of care
One accountable care manager
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .

System of Care: Operational Characteristics Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
Cross-agency care coordination
Individualized services and supports “wrapped around”
child/family
Home- & community-based alternatives
Broad, flexible array of services and supports
Integration of clinical treatment services & natural
supports, linkage to community resources
Integration of evidence-based and effective practices
Cross-agency MIS

Current Systems Problems
Lack of home and community-based services and supports
Patterns of utilization
Cost
Administrative inefficiencies
Knowledge, skills and attitudes of key stakeholders
Poor outcomes
Financing structures
Pathology-based/medical models, deficit-oriented, punitive systems
Pires, S. (1996). Human Service Collaborative, Washington, D.C.

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 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 within families Community-based ownership Creation of “self-help” Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

SYSTEMS CHANGE FOCUSES ON:
Policy Level (e.g., financing; regs; rates)
Management Level (e.g., data; QI; HRD; 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)
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Frontline Practice Shifts Control by professionals Partnerships with families Only professional services Partnership between natural and professional supports and services Multiple case managers One service coordinator Multiple service plans for child Single plan for child and family Family blaming Family partnerships Deficits Strengths Mono Cultural Cultural Competence Orrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to Strengthen Our Community

Examples of Family Members: Shifts in Roles and Expectations Lazear, K. (2004). “Primer Hands On” for Family Organizations . Human Service Collaborative: Washington, D.C. Advocacy & peer support Advocacy & peer support Advocacy & peer support Partners and independent trainers Participants in training initiatives Uninvited key stakeholders in training initiatives Service providers Partner in planning and developing services Recipient of services Partner (or independent) in developing and conducting program evaluations Participant in program evaluation Unheard voice in program evaluation Service planning team leader Passive partner in service planning process Recipient of information re: child’s service plan

Categorical vs. Non-Categorical System Reforms Categorical System Reforms Non-Categorical Reforms Pires, S. (2001). Categorical vs. non-categorical system reforms . Washington, DC: Human Service Collaborative.

The Total Population of Children and Families Who Depend on Public Systems
Children and families eligible for Medicaid
Children and families eligible for the State Children's Health Insurance Program (SCHIP)
Poor and uninsured children and families who do not qualify for Medicaid or SCHIP
Families who are not poor or uninsured but who exhaust their private insurance, often because they have a child with a serious disorder
Families who are not poor or uninsured and who may not yet have exhausted their private insurance but who need a particular type of service not available through their private insurer and only available from the public sector.
Pires, S. (1997). The total population of children and families who depend on public systems . Human Service Collaborative: Washington, D.C.

2 - 5% 15% 80% More complex needs Systems of Care Less complex needs Intensive Services Accessible high-quality services and supports Assessment, Prevention and Universal Health Promotion

Child Welfare Population Issues
All children and families involved in child welfare?
If subsets, who?
Demographic: e.g., infants, transition-age youth
Intensity of System Involvement: e.g., out of home placement,
multi-system, length of stay
At risk: e.g.,
Children with natural families at risk of out of home placement?
Children in permanent placements that are at risk of disruption ?
(e.g., subsidized adoption, kinship care, permanent foster care)
Level of severity: e.g.,
Children with serious emotional/behavioral disorders, serious
physical health problems, developmental disabilities,
co-occurring
Pires, S.A. 2004. Human Service Collaborative. Washington, D.C.

Example: Transition-Age Youth
Policy Level:
What systems need to be involved?
e.g., Housing, Vocational Rehabilitation, Employment
Services, Mental Health and Substance Abuse, Medicaid,
Community Colleges/Universities, Physical Health, Juvenile
Justice, in addition to Child Welfare
What dollars/resources do they control?
What outcomes do we want to see for this population? Continued

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?
Example: Transition-Age Youth Continued

Example: Transition-Age Youth
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 we put in place to provide opportunities
for youth to contribute and feel a part of the larger
community?
What does our system design look like for this population?

Child Welfare Outcomes
Safety
Permanency
Well-Being
Difficult to achieve without taking a system of care approach

Examples of Sources of Funding for Children/Youth with Behavioral Health Needs in the Public Sector Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector . Washington, DC: Human Service Collaborative. Revised 2005.
Medicaid
Medicaid In-Patient
Medicaid Outpatient
Medicaid Rehabilitation Services Option
Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT)
Targeted Case Management
Medicaid Waivers
Katie Beckett Option
Substance Abuse
SA General Revenue
SA Medicaid Match
SA Block Grant
Juvenile Justice
JJ General Revenue
JJ Medicaid Match
JJ Federal Grants
Mental Health
MH General Revenue
MH Medicaid Match
MH Block Grant
Child Welfare
CW General Revenue
CW Medicaid Match
IV-E (Foster Care and Adoption Assistance)
IV-B (Child Welfare Services)
Family Preservation/Family Support
Education
ED General Revenue
ED Medicaid Match
Student Services
Other
WAGES
Children’s Medical Services/Title V– Maternal and Child Health
Mental Retardation/ Developmental Disabilities
Title XXI-State Children’s Health Insurance Program (SCHIP)
Vocational Rehabilitation
Supplemental Security Income (SSI)
Local Funds

WHO CONTROLS POLICY AND DOLLARS?
Key
State Medicaid Agencies
State/Local Child Welfare Agencies
State/Local Mental Health Authorities
Public Health and Primary Care
State/Local Education Agencies
State and Local Juvenile Justice Systems
Some Others
Commercial Insurers
Employment Services
State/Local Substance
Abuse Agencies
Housing

OTHER CRITICAL PLAYERS
“ Gatekeepers” (e.g., managed care organizations,
judges, interagency teams)
Providers
Natural Helpers and Community Resources
Families
Youth

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

Converging Trends Pires, S. (2003). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .

Efficacy of Research (Barbara Burns’ Research at Duke University)
Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care
Weaker evidence ( because not much research done ): Crisis services, respite, mentoring, family education and support
Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home

Evidence-Based Practices And Promising Approaches Evidence-based practices Show evidence of effectiveness through carefully controlled scientific studies, including random clinical trials Promising approaches Show evidence of effectiveness through experience of key stakeholders (e.g., families, youth, providers, administrators) and by data collected by program/system Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .

Examples of Evidence-Based Practices
Multisystemic Therapy (MST)
Multidimensional Treatment Foster Care (MDTFC)
Functional Family Therapy (FFT)
Cognitive Behavioral Therapy (various models)
Intensive Care Management (various models)
Examples of Promising Practices
Family Support and Education
Wraparound Service Approaches
Mobile Response and Stabilization Services
Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidence- based interventions for severe emotional and behavioral disorders. Oxford University Press and State of New Jersey BH Partnership (www.njkidsoc.org)

Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd None CBT with Parents; Inter- Personal Tx. (Manualized); Relaxation CBT Depressive or Withdrawn Behaviors None CBT with Parents; Group CBT; CBT for Child & Parent; Educational Support Cognitive Behavior Therapy (CBT); Exposure Modeling Anxious or Avoidant Behaviors Moderate Support Good Support Best Support Problem Area

Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd Multisystemic Therapy None None Juvenile Sex Offenders Social Relations Training; Project Achieve Anger Coping Therapy; Assertiveness Training; Problem Solving Skills Training, Rational Emotive Therapy, AC-SIT, PATHS & FAST Track Programs Parent & Teacher Training; Parent Child Interaction Therapy Disruptive & Oppositional Behaviors Known Risks: Group Therapy Moderate Support Good Support Best Support Problem Area

Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd None Behavior Therapy; Purdue Brief Family Therapy CBT Substance Use Known Risks: Group Therapy Multi- Dimensional Treatment Foster Care; Wraparound Foster Care Multisystemic Therapy; Functional Family Therapy None Delinquency & Willful Misconduct Behavior Known Risks: Group Therapy Moderate Support Good Support Best Support Problem Area

KAUFFMAN BEST PRACTICES PROJECT AND NATIONAL CHILD TRAUMATIC STRESS NETWORK
Trauma Focused-Cognitive Behavioral Therapy (TF-CBT)
Abuse Focused-Cognitive Behavioral Therapy (AF-CBT)
Parent Child Interaction Therapy (PCIT)

Shared Characteristics of Evidence-Based (and Promising) Interventions
Function as service components within systems of care
Provided in the community
Utilize natural supports, parents, with training and supervision provided by those with formal mental health training
Operate under the auspices of all child-serving systems, not just mental health
Studied in the field with “real world” children and families
Less expensive than institutional care (when the full continuum is in place)
Burns, B. and Hoagwood, K. 2002. Community treatment for youth. New York: Oxford University Press.

“ The current need is …for building efficacious treatment interventions within effective, compassionate, and competent systems of care” Peter Jensen, M.D. Building Community Treatment for Youth Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .

EXAMPLES OF SYSTEMS OF CARE

Wraparound Milwaukee Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch Child Welfare Funds thru Case Rate (Budget for Institutional Care for CHIPS Children)
Mental Health
Crisis Billing
Block Grant
HMO Commercial
Insurance
Medicaid Capitation (1557 per Month per Enrollee Juvenile Justice (Funds Budgeted for Residential Treatment for Delinquent Youth) Management Entity: Wraparound Milwaukee Management Service Organization (MSO) $30M Child and Family Teams Provider Network 240 Providers 85 Services Care Coordination Plans of Care 9.5M 2.0M 10M 8.5M Per Participant Case Rate Mngt. Entity: County Agency

OUTCOMES (Milwaukee Wraparound)
60% reduction in recidivism rates for delinquent
youth from one year prior to enrollment to one year
post enrollment
Decrease in average daily RTC population from 375
to 50
Reduction in psychiatric inpatient days from 5,000 days
to less than 200 days per year
Average monthly cost of $4,200 (compared to $7,200
for RTC, $6,000 for juvenile detention, $18,000 for
psychiatric hospitalization

Next Phase of Milwaukee Wraparound
Partnership with HMO to become “medical/clinical”
home for all children in foster care in the county –
Locus of accountability for managing physical,
dental, and behavioral health care to achieve ASFA
well-being outcomes

Dawn Project Cost Allocation How Dawn Project is Funded DAWN Project Indianapolis, IN Management Entity: Non profit behavioral health organization

More Dawn Features
Service coordination plans, including safety and crisis plan
Broad array of treatment and supportive services
Extensive provider network, paid fee for service
Health/medical Safety/crisis Family/relationships Educational/vocational Psychological/emotional Substance abuse Social/recreational Daily living Cultural/spiritual Financial/legal Life Domains

Dawn Service Array Psychiatric Assessment Medication follow-up/psychiatric review Nursing services Mentor Community case management/case aide Clinical mentor Educational mentor Life coach/independent living skills mentor Parent and family mentor Recreational/social mentor Supported work environment Tutor Community supervision Behavioral Health Behavior management Crisis intervention Day treatment Evaluation Family assessment Family preservation Family therapy Group therapy Individual therapy Parenting/family skills training Substance abuse therapy, individual and group Special therapy

Dawn Service Array, Continued Discretionary Activities Automobile repair Childcare/supervision Clothing Educational expenses Furnishings/appliances Housing (rent, security deposits) Medical Monitoring equipment Paid roommate Supplies/groceries Utilities Incentive money Service Coordination Case management Service coordination Intensive case management Other Camp Team meeting Consultation with other professionals Guardian ad litem Transportation Interpretive services Placement Acute hospitalization Foster care Therapeutic foster care Group home care Relative placement Residential treatment Shelter care Crisis residential Supported independent living Respite Crisis respite Planned respite Residential respite

NJ Children’s System of Care Initiative CHILD Screening with Uniform Protocols Child Welfare JJC Court School Referral Community Agencies Family & Self Other
Contracted
Systems
Administrator CSA
Registration
Screening for self-referrals
Tracking
Assessment of Level of Care Needed
Care Coordination
Authorization of Services
Community
Agencies
Uncomplicated Care
Service Authorized
Service Delivered
CMO
Complex Multi-System
Children
ISP Developed
Full Plan of Care
Authorized
FSO Family to Family Support

El Paso County, Colorado Pires, S. (1999). El paso county, colorado risk-based contracting arrangement . Washington, DC: Human Service Collaborative. State-Capped Out of Home Placement Allocation County DHS acts as MCO (contracting, monitoring, utilization review) Child Welfare $$ Case rate contract with CPA BH Tx $$ matched by Medicaid. Capitation contract with BHO with risk-adjusted rates for child welfare-involved children Joint treatment planning approved by DHS Child Placement Agencies (CPA) Responsible for full range of Child Welfare Services & ASFA (Adoption and Safe Families ACT) related outcomes Mental Health Assessment and Service Agency (BHO) Responsible (at risk) for full range of MH treatment services & clinical outcomes & ASO functions

Types of Outcomes Achieved by Systems Of Care
Reduction in inpatient hospitalization and residential
treatment placements and lengths of stay
Reductions in detention rates
Reductions in out-of-home placements and lengths of
stay
Improved clinical and functional outcomes
Higher family and youth satisfaction
Lower costs per child served for total system if
a range of home and community-based is in place

Data on Outcomes Available From (Among Others):
Burns & Hoagwood, Community Treatment for Youth:
Evidence-Based Interventions for Severe Emotional and
Behavioral Disorders , Oxford University Press
Kaufman Foundation, Closing the Quality Chasm in Child
Abuse Treatment: Identifying and Disseminating Best
Practices, www.kauffmanfoundation.org
Wraparound Milwaukee (bkamrad@wrapmilw.org)
Dawn Project (krotto@choicesteam.org)
Coordinated Care Services, Inc. ( [email_address] )
Massachusetts Mental Health Services Program for Youth
( [email_address] )
Youth Villages (tim.goldsmith@youthvillages.org)

Process How system builders conduct themselves Structure What gets built (i.e., how functions are organized) Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .

Structure “ Something Arranged in a Definite Pattern of Organization”
I. Distributes
Power
Responsibility
II. Shapes and is shaped by
Values
III. Affects
Practice and outcomes
Subjective experiences (i.e., how participants feel)
Pires, S. (1995). Structure . Washington, DC: Human Service Collaborative.

Goal: One plan of care; one care manager Children in out-of-home placements
Child Welfare
Family Group Decision Making
CW Case Worker
EXAMPLE
Mental Health
Individualized WrapAround Approach
Care manager
MCO
Prior Authorization
Clinical Coordinator
Education
Child Study Team
Teacher
Kinship Care Subsidized Adoption Permanent Foster Care Tutoring Parent Support, etc. Treatment Foster Care In-Home Services Crisis Services Out-patient services Primary Care Alternative School EH Classroom Related Services Result: Multiple plans of care; multiple care managers Pires, S. (2004). Building Systems of Care: A Primer . Human Service Collaborative: Washington, DC Med. Mngt.

System of Care Functions Requiring Structure
Planning
Decision Making/Policy Level Oversight
System Management
Benefit Design/Service Array
Evidence-Based Practice
Outreach and Referral
System Entry/Access
Screening, Assessment, and Evaluation
Decision Making and Oversight at the Service Delivery Level
Care Planning
Care Authorization
Care Monitoring and Review
Care Management or Care Coordination
Crisis Management at the Service Delivery and Systems Levels
Utilization Management
Family Involvement, Support, and Development at all Levels
Youth Involvement, Support, and Development
Staffing Structure
Staff Involvement, Support, Development
Orientation, Training of Key Stakeholders
External and Internal Communication
Provider Network
Protecting Privacy
Ensuring Rights
Transportation
Financing
Purchasing/Contracting
Provider Payment Rates
Revenue Generation and Reinvestment
Billing and Claims Processing
Information Management
Quality Improvement
Evaluation
System Exit
Technical Assistance and Consultation
Cultural Competence
Pires, S. (2002). Building Systems of Care: A Primer . Washington, D.C.: Human Service Collaborative.

Core Elements of an Effective System-Building Process
A core leadership group
Evolving leadership
Effective collaboration
Partnership with families and youth
Cultural 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
Leadership and Constituency Building Pires, S. (2002). Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative .

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

Challenges to Collaboration “Barrier Busters” Wraparound Milwaukee. (1998). Challenges to collaboration/“barrier busters.” Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch .
Infuse values into all meetings, training, and workshops
Share documentation and include parents in as many meetings as possible
Strength-based cross training
Develop QA measures based on values
Sharing value base
Invest in relationships with partners in collaboration
Share literature and workshops
Track and provide meaningful outcomes
Maintaining investment from stakeholders
Document safety plans
Develop protocol for high-risk kids
Demonstrate adherence to court orders
Maintain communication with District Attorneys
Myths of “bricks and mortar”
Addressing issues of community safety
Set up a common data base
Share organizational charts/phone lists
Share paperwork
Promote flexibility in schedules to support attendance in meetings
Information sharing among systems
Family driven/accountability
Team development training
Job shadowing
Communication channels
Share myths and realities
Role definition: “Who’s in charge?”
Cross training
Share each other’s turf
Share literature
Language differences: Mental health jargon vs. court jargon BARRIER BUSTERS CHALLENGE

Cross-Cutting Characteristics
Cultural and linguistic competence , that is, processes and structures that support capacity to function effectively in cross-cultural situations;
Meaningful partnership with families , including family organizations, and youth in system building processes and structural decision making, design, and implementation;
A cross-agency perspective , that is, processes and structures that operate in a non-categorical fashion.
State and local partnership and shared commitment.
Pires, S. (2002). Building systems of care: A primer. Washington D.C.: Human Service Collaborative .

How Systems of Care are Structuring Family Involvement at Various Levels of the System Pires, S. (1996). Human Service Collaborative, Washington, D.C. LEVEL STRUCTURE Policy At least 51% vote on governing bodies; as members of teams to write and review RFPs and contracts; as members of system design workgroups and advisory boards Management As part of quality improvement processes; as evaluators of system performance; as trainers in training activities; as advisors to selecting personnel Services As members of team for own children; as family support workers, care managers, peer mentors, system navigators for other families

Why Culture Matters
Because it affects…
Attitudes and beliefs about services and systems
Expression of symptoms
Coping strategies
Help-seeking behaviors
Utilization of services
Appropriateness of services and supports
Disparities in access
Lazear, K., (2003) “Primer Hands On”; A skill building curriculum . Washington, D.C.: Human Service Collaborative.

BUILDING 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.

Elements of Effective Planning Processes
Are staffed
Involve key stakeholders
Involve families early in the process and in ways that are meaningful
Ensure meaningful representation of racially and ethnically diverse families
Develop and maintain a multi-agency focus
Build on and incorporate related programmatic and planning initiatives
Continually seek ways to build constituencies, interest, and investment
Pay attention to sustainability and growth of system changes from day one
Pires, S. (1991). State child mental health planning . Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center of Children’s Mental Health.

A Planning Process for Family and Children’s Service Reform Friedman, M. (1994). Washington, D.C.: Center for the Study of Social Policy Leadership and Professional Development Strategy Cross Community Cross Agency The System As It Is Now Outcomes For Children The System As It Should Be Principles Reinvestment Commitment Financing Options Combined Fiscal Program Strategy ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Governance Strategy State County Community Multi Year Steps Action Plan Political Strategy

Strategies for Involving Parents in Planning
Providing special orientation and training and ongoing assistance; consulting with parents before meetings.
Having more than token representation.
Contracting with community-based and parent organizations to develop/sustain process.
Working through parent organizations.
Asking agencies that work with parents to recommend parents to participate in planning.
Paying stipends, transportation, child care.
Holding planning meetings in the evenings or on weekends, in locations such as schools.
Conducting surveys to elicit views of many parents.
Continued …
Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and support services program. Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.

Strategies for Involving Parents in Planning (continued)
Using parents who work regularly with other parents to conduct focus groups.
Working with family support groups to tap into informal networks.
Working with home visiting programs and health clinics to reach out to parents.
Working with family preservation and family reunification programs.
Conducting sessions for planning group members with trained facilitators to explore attitudes about race, culture, families.
Publicly acknowledging the contributions of parents.
Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and support services program. Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.

Definition of Governance Decision making at a policy level that has legitimacy, authority, and accountability. Pires, S. (1995). Definition of governance . Washington, DC: Human Service Collaborative.

System Management Day-to-day operational decision making Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Key Issues for Governing Bodies
Has authority to govern
Is clear about what it is governing
Is representative
Has the capacity to govern
Has the credibility to govern
Assumes shared liability across systems for target population
Pires, S. (2000). Key issues for governing bodies . Washington, DC: Human Service Collaborative.

System Management: Day-to-Day Operational Decision Making
Key Issues
Is the reporting relationship clear?
Are expectations clear regarding what is to be managed and what outcomes are expected?
Does the system management structure have the capacity to manage?
Does the system management structure have the credibility to manage?

Pires, S. (1996). Contracted system management structure . Washington, DC: Human Service Collaborative. Example of Governance/Management Structure Care Management Entity

Pires, S. (1996). Evolving governance structure . Washington, DC: Human Service Collaborative . BRING THE CHILDREN HOME STATE LEGISLATION COUNTY EXECUTIVE Local Governing Board Agency Directors Family/Youth Reps. Providers Forum SOC Team Leader “ Bring the Children Home” Interagency Care Management Team “ Bring the Children Home” Care Managers Families/Youth Served Other Agency Workers Example of Governance/Management Structure

Examples of Types of Family Partnership in System Governance and Management Conlan, L. (2003). Implementing family involvement. Burlington, VT: Vermont Federation of Families for Children’s Mental Health .
Input/evaluation of key management
Input/evaluation of quality of services and programs
Local system of care input
Resource allocation
Service planning and implementation
Policies and procedures
Grievance and resolution procedures

Distinctions Among Screening, Assessment and Evaluation, and Care Planning
Screening
1 st step, triage, identify children at high risk, link to appropriate assessments
Assessment
Based on data from multiple sources
Comprehensive
Identify strengths, resources, needs
Leads to care planning
Continued …
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

Distinctions Among Screening, Assessment and Evaluation, and Care Planning Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Evaluation
Discipline-specific, e.g., neurological exam
Closer, more intensive study of a particular or suspected
clinical issue
Provides data to assessment process
Care planning
Individualized decision making process for determining services
and supports
Draws on screening, assessment, and evaluation data

Life Domain Areas Adapted from. Dennis, K, VanDenBerg, J., & Burchard, J. (1990). Life domain areas . Chicago: Kaleidoscope.

Definition of Wraparound
Wraparound is “ . . . a definable planning process that results in a unique set of community services and natural supports that are individualized for a child and family to achieve a positive set of outcomes.”*
*Burns, B. & Hoagwood, K. (Eds.) Community-Based Interventions for Children and Families . Oxford: Oxford University Press.

Wraparound and System of Care Wraparound is an important approach to care planning and service provision within a system of care But …. It does not, in and of itself, constitute a system of care! Pires., S. 2005. Human Service Collaborative. Washington, D.C.

Examples of What You’d Want to Provide Based on Effectiveness Literature
Outpatient Models :
Cognitive Behavior Therapy (various models)
Functional Family Therapy (FFT)
Parent Child Interaction Therapy (PCIT)
Intensive In-Home Models :
Multisystemic Therapy (MST)
Out-of-Home Model:
Multidimensional Treatment Foster Care
Intensive Care Management
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

Examples of Other Home and Community-Based Services You’d Want to Provide Based on Practice/Family Experience & Outcomes Data
Intensive in-home services (not just MST)
Child respite services
Mobile response and stabilization services
Mental health consultation services
Independent living skills and supports
Family/youth education and peer support

What You Don’t See Listed as Evidence-Based Practice
Traditional office-based “talk” therapy
Residential Treatment
Group Homes
Day Treatment

What Natural Helpers Can Provide
Emotional support
System navigation
Resource acquisition
Concrete help
Decrease social isolation
Greater understanding of community
Community navigation
Effective intervention or support strategies
Lazear, K., (2003). “Primer Hands On”; A skill building curriculum . Human Service Collaborative: Washington, D.C.

Pre-Equipo Network Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.

Post –EQUIPO Network Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.

Study Family Comparison Family 69 : 6 105 : 8 29 : 6 1250 : 180 Time and Travel (Ten Month Period) Visits Office Hours Travel Hours Travel Miles Lazear, K. (2003). Family Experience of the Mental Health System, Research and Training Center for Children’s Mental Health, Tampa, FL. Number of Scheduled Office Visits Number of Hours Spent in Office Visits Number of Hours Spent Traveling to and from Office Visits Number of Miles Traveled for Care

Service Array Focused on a Total Eligible Population
Family Support Services
Youth Development Program/Activities
Coordinated Intake Assessment & Treatment Planning
Intensive Case Management/Care Coordination
Wraparound Services & Supports
Clinical Services
Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform . [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative. Core Services Prevention Early Intervention Intensive Services Universal Targeted

Where Family Organizations Fit Into Service Array
As technical assistance providers & consultants
Training
Evaluation
Research
Support
Outreach
As direct service providers
Family Liaisons
Care Coordinators
Family Educators
Specific Program Managers (respite, etc)
Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

Comparison of Case Management and Care Management
Case Management
Little authority over resources
Child centered
Reactive
Service provided to placement
Organization of existing services
Uses current system
Care Management
More control over resources
Family centered
Proactive
Unconditional care
Creation of services when not available
Family and community supports
Adapted from: Community Care Systems. (2000). Comparison of case management and care coordination . Madison, WI.

Care Management Continuum Pires, S. (2001). Case/care management continuum . Washington, DC: Human Service Collaborative. Children needing only brief short-term services and supports Children needing intermediate level of services and supports Children needing intensive and extended level of services and supports UM-type care management No “caseloads” Service coordination Large caseloads Intensive care management Very small caseloads

Care Management/Service Coordination Structure Principles
Support a unitary (i.e., across agencies) care management/coordination approach even though multiple systems are involved, just as the care planning structure needs to support development of one care plan.
Support the goals of continuity and coordination of care across multiple services and systems over time.
Encompass families and youth as partners in the process of managing/coordinating care.
Incorporate the strengths of families and youth, including the natural and social support networks on which families rely.
Pires, S. (20O2). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Utilization Management Concerns
Who is using services?
What services are being used?
How much service is being used?
What is the cost of the services being used?
What effect are the services having on those using them? (i.e., Are clinical/functional outcomes improving? Are families and youth satisfied? Are children returning home?)
Pires, S. (2001). Utilization management concerns . Washington, DC: Human Service Collaborative. UM

Principles for Utilization Management
UM must be understood and embraced by all key stakeholders
UM must concern itself with both the cost and quality of care
The UM structure needs to be tied to the quality improvement structure
Pires.. S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Purposes of UM/Evaluation Data: Examples
Planning and Decision Support (Day-to-Day and
Retrospectively)
Quality Improvement
Cost/Benefit Monitoring
Research
Marketing
Accountability

Evaluation & Data Gathering
To eliminate disparities, disproportionalities, and improve quality of care, we need to collect data.
Questionnaires
Surveys
Interviews
Focus groups
Clinical outcome data
Using a participatory evaluation framework
Lazear, K. (2003). “Primer Hands On” A skill building curriculum. Washington. D.C.

Financing Strategies to Support Improved Outcomes for Children & Families
FIRST PRINCIPLE:
System Design Drives Financing
REDEPLOYMENT:
Using the Money We Already Have
The Cost of Doing Nothing
Shifting Funds from Treatment to Early Intervention
Moving Across Fiscal Years
REFINANCING:
Generating New Money by Increasing Federal Claims
The Commitment to Reinvest Funds for Families and Children
Foster Care and Adoption Assistance (Title IV-E)
Medicaid (Title XIX)
Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children . Center for the Study of Social Policy: Washington, D.C..

Financing Strategies to Support Improved Outcomes
RAISING OTHER REVENUE TO SUPPORT FAMILIES AND
CHILDREN:
- Donations
- Special Taxes and Taxing Districts for Children
- Fees and Third Party Collections Including Child Support
- Trust Funds
FINANCING STRUCTURES THAT SUPPORT GOALS:
- Seamless Services: Financial claiming invisible to families
- Funding Pools: Breaking the lock of agency ownership of funds
- Flexible Dollars: Removing the barriers to meeting the unique
needs of families
- Incentives: Rewarding good practice
Friedman, M. (1995). Financing strategies to support improved outcomes for children . Center for the Study of Social Policy: Washington, D.C.

Where to Look for Money and Other Types of Support Pires, S. (1994). Where to look for money and other types of support . Human Service Collaborative: Washington, D.C. e e

Milwaukee Wraparound Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

How to Finance/Implement Systems of Care
Adopt a Population Focus: Who are the populations
of youth for whom you want to change practice/outcomes
Adopt a Cross-Systems Approach: What other systems
serve these youngsters; who controls potential or actual
match dollars; which systems now spend a lot on
restrictive levels of care with poor outcomes or on deficit-
based assessments not linked to effective services –
Opportunities for re-direction
Identify Incentives to Finance/Implement Systems of Care
Pires, S. 2005. Human Service Collaborative. Washington, D.C.

Examples of Incentives to Various Child-Serving Systems Medicaid: slowing rate of growth in “deep end” services Child Welfare: meeting Adoptions and Safe Families Act outcomes; reducing out-of-home placements Juvenile Justice: creating alternatives to incarceration; reducing detention costs Mental Health: more effective delivery system Education: reducing special education expenditures Pires, S. 2005. Human Service Collaborative. Washington, D.C.

Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices District of Columbia – MST, Mobile Response, In-Home Medicaid Rehab Option pays for MST, Intensive Home-Based Services (Ohio model), Mobile Response and Stabilization Services (NJ model) Child Welfare provides match and paid for initial training, coaching, provider capacity development; Mental health/child welfare share costs of outcomes tracking Juvenile Justice now paying match, training costs as well Medicaid HMO expressing interest in Mobile Crisis Pires, S. 2005. Human Service Collaborative. Washington, D.C.

New Mexico - MST Medicaid managed care pays for service costs of MST Juvenile Justice pays for training/coaching/fidelity monitoring Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices Hawaii – Range of EBPs Medicaid managed care, Education special ed, mental health general revenue/block grant pay for range of EBPs, training, monitoring Pires, S. 2005. Human Service Collaborative. Washington, D.C.

Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices New Jersey – In-Home, Mobile Response, Intensive Case Management, Family Support Medicaid Rehab Option pays for in-home, Mobile Response and Stabilization, intensive case management, family support Child welfare contributed match dollars Tennessee – MST, Multi-Dimensional Treatment Foster Care Medicaid managed care and mental health GR pay for MST and MDTFC Pires, S. 2005. Human Service Collaborative. Washington, D.C.

Characteristics of Effective Provider Networks
Responsive to the population that is the focus of the system of care.
Encompass both clinical treatment service providers and natural,
social support resources, such as mentors and respite workers.
Include both traditional and non traditional, indigenous providers.
Include culturally and linguistically diverse providers.
Include families and youth as providers of services and supports.
Are flexible, structured in a way that allows for additions/deletions.
Are accountable, structured to serve the system of care.
Have a commitment to evidence-based and promising practices.
Encompass choice for families.

Examples of Incentives to Providers
Decent rates
Flexibility and control
Timely reimbursements
Back up support for difficult administrative and clinical challenges
Access to training and staff development
Capacity building grants
Less paperwork

Purchasing/Contracting Options
Pre-Approved Provider Lists :
Flexibility for system of care +
Choice for families +
Could disadvantage small indigenous providers –
Could create overload on some providers –
Risk-Based Contracts (e.g., capitation, case rates)
Flexibility for providers +
Individualized care for families +
Potential for under-service –
Potential for overpaying for services –
Fixed Price/Service Contracts
Predictability and stability for providers +
Inflexible-families have to “fit” what is available –
Pires, S. (2002). Building systems of care: A primer . Human Service Collaborative: Washington, D.C..

Progression of Risk by Contracting Arrangement RISK TO SYSTEM OF CARE HIGHEST RISK LOWEST RISK RISK TO PROVIDER LOWEST RISK HIGHEST RISK
TYPE OF CONTRACTING
ARRANGEMENT
Grant
Fee-for-Service
Case Rate
Capitation
Adapted from Broskowski, A. (1996). Progression of provider’s risks. In Managed care: Challenges for children and family services. Baltimore, MD: Annie E. Casey Foundation.

Human Resource Development Functions
Assessment of workforce requirements (i.e., What skills are needed, what types of staff, how many staff) in the context of systems change
Recruitment, retention, staff distribution
Education and training (pre-service and in-service)
Standards and licensure

Staffing Systems of Care Re-deploy and Retrain Existing Staff Contract Out Hire New Staff Partner with Others Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

A Developmental Training Curriculum TRADITIONAL MODIFIED INTEGRATED UNIFIED SYSTEM PROGRAM State systems develop training along specialty guild lines – Promotion of stronger specialty focus Community agencies and universities operate in isolation Disciplines train in isolation from one another Instruction is didactic, “expert” No support for cross-training State systems independently adopt similar philosophy, promoting Collaboration Community agencies and Universities begin joint research and evaluation Pre-service training remains separate from the field State systems begin sharing training calendars Promotion of cross-training; joint funding Community agencies and universities begin to integrate field staff/families into pre-service training Student field placements cross agency boundaries Cross-agency training gains support State systems pool training staff, merge training events Community agencies and universities collaborate with larger community, e.g. families as co- instructors; curricula reflect practice goals Training geared to system goals Meyers, J., Kaufman, M. & Goldman, S. (1991). Training strategies for serving children with serious emotional disturbances and their families in a system of care. Promising Practices in children’s mental health. 5. Washington, D.C.: American Institutes for Research.

A Developmental Training Curriculum TRADITIONAL MODIFIED INTEGRATED UNIFIED PRACTICE Participation in professional conferences on individual basis within agency boundaries Services are provided within agency boundaries Staff receive training that promotes collaboration, but receive it within agency boundaries Specialty focus predominant Services remain within agency boundaries Service teaming is promoted through cross- agency training Service teams with full family inclusion are the norm Redefined specialty practice roles develop to support professional identity while promoting collaboration Meyers, J., Kaufman, M. & Goldman, S. (1991). Training strategies for serving children with serious emotional disturbances and their families in a system of care. Promising practices in children’s mental health. 5. Washington, D.C.: American Institutes for Research.

Summary: Common Elements of Re-Structured Systems
Values-based systems/Family and youth partnership
Identified target population, costs associated with
population, funders
Locus of accountability (and risk) for target population
Organized pathway to services for target population
Strengths-based and individualized service planning
and care monitoring (e.g., wraparound approach)
Intensive care management
continued …

Summary:Common Elements of Re-Structured Systems
Flexible financing and contracting arrangements
(e.g., case rates, qualified provider panel – fee-for-service )
Broad provider network: sufficient types
of services and supports (including natural helpers)
Combined funding from multiple funders (e.g., Medicaid,
child welfare, mental health, juvenile justice, education)
Real time data across systems to support clinical decision-
making, utilization management, quality improvement
Outcomes tracking – child/family level, systems level
continued…

Summary: Common Elements of Re-Structured Systems
Utilization management
Mobile crisis capacity
Judiciary buy-in
Re-engineered residential treatment centers
Shared governance/liability
Training and technical assistance

Transformation
Need to connect related reforms in child-serving systems
and Medicaid needs to be a partner in reform:
SAMHSA Transformation Grants, Infrastructure Grants,
System of Care Grants
Child Welfare System of Care Grants, Program
Improvement Plans
Juvenile Justice MH/SA Initiatives
CMS Feasibility and Real Choice Grants

“ The world that we have made as a result of the level of thinking we have done thus far creates problems that we cannot solve at the same level at which we created them.” Albert Einstein Pires, S. (2002). Building Systems of Care: A Primer . Washington, D.C.: Human Service Collaborative.

The measure of success is not whether you have a tough problem to deal with, but whether it’s the same problem you had last year. John Foster Dulles

To Obtain Copies of Building Systems of Care: A Primer Contact: Mary Moreland, Publications Manager Georgetown University National Technical Assistance Center for Children’s Mental Health 202 687-8803 E-mail: [email_address] For Further Information About Building Systems of Care, Contact : Sheila A. Pires Human Service Collaborative 202 333-1892 E-mail: sapires@aol.com

Building Systems of Care: Critical Structures and Processes

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