BUILDING SYSTEMS OF CARE: CRITICAL STRUCTURES AND PROCESSES Presentation by: Sheila A. Pires Human Service Collaborative N...
Purpose and Structure of the Training <ul><li>Increase knowledge about what is involved in building  </li></ul><ul><li>sys...
A system of care incorporates a broad array  of services and supports for a defined population that is organized into a co...
Pires, S. (2002)  Building systems of care: A primer.  Washington, D.C.:  Human Service Collaborative. National System of ...
System of care is, first and foremost, a set of  values and principles that provides an organizing  framework for systems ...
Values and Principles  for the System of Care <ul><li>CORE VALUES </li></ul><ul><li>Child centered and family focused  </l...
Values and Principles  for the System of Care <ul><li>Comprehensive array of services/supports </li></ul><ul><li>Individua...
Values and Principles for the System of Care <ul><li>Care management or similar mechanisms  </li></ul><ul><li>Early identi...
Principles of Family Support Practice <ul><li>Staff & families work together in relationships based on equality and respec...
Youth Development Principles <ul><li>Adolescent Centered </li></ul><ul><li>Community Based </li></ul><ul><li>Comprehensive...
System of Care: Operational Characteristics <ul><li>Collaboration across agencies </li></ul><ul><li>Partnership with famil...
System of Care: Operational Characteristics Pires, S. (2002).  Building systems of care: A primer.  Washington, D.C.: Huma...
Current Systems Problems <ul><li>Lack of home and community-based services and supports </li></ul><ul><li>Patterns of util...
Characteristics of Systems of Care as  Systems Reform Initiatives FROM Fragmented service delivery Categorical programs/fu...
SYSTEMS CHANGE FOCUSES ON: <ul><li>Policy Level (e.g., financing; regs; rates) </li></ul><ul><li>Management Level (e.g., d...
Frontline Practice Shifts Control by professionals   Partnerships with  families Only professional services   Partnership ...
Examples of Family Members: Shifts in Roles and Expectations Lazear, K.  (2004).  “Primer Hands On” for Family Organizatio...
Categorical vs. Non-Categorical  System Reforms Categorical  System  Reforms Non-Categorical  Reforms Pires, S. (2001).  C...
The Total Population of Children and Families Who Depend on Public Systems <ul><li>Children and families eligible for Medi...
2 - 5% 15% 80% More  complex  needs Systems of Care Less  complex  needs Intensive Services Accessible high-quality servic...
Child Welfare Population Issues <ul><li>All children and families involved in child welfare? </li></ul><ul><li>If subsets,...
Example:  Transition-Age Youth <ul><li>Policy Level:  </li></ul><ul><li>What systems need to be involved? </li></ul><ul><l...
<ul><li>Management Level: </li></ul><ul><li>How do we create a locus of system management  </li></ul><ul><li>accountabilit...
Example:  Transition-Age Youth <ul><li>Community Level: </li></ul><ul><li>What are the partnerships we need to build with ...
Child Welfare Outcomes <ul><li>Safety </li></ul><ul><li>Permanency </li></ul><ul><li>Well-Being </li></ul>Difficult to ach...
Examples of Sources of Funding for Children/Youth  with Behavioral Health Needs in the Public Sector Pires, S. (1995).  Ex...
WHO CONTROLS POLICY AND DOLLARS? <ul><li>Key  </li></ul><ul><li>State Medicaid Agencies </li></ul><ul><li>State/Local Chil...
OTHER CRITICAL PLAYERS <ul><li>“ Gatekeepers” (e.g., managed care organizations,  </li></ul><ul><li>judges, interagency te...
Local Ownership State Commitment Pires, S. (2002).  Building systems of care: A primer.  Washington, D.C.: Human Service C...
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) <ul><li>Most evidence of efficacy: Intensive case manage...
Evidence-Based Practices  And Promising Approaches Evidence-based practices Show evidence of effectiveness through careful...
Examples of Evidence-Based Practices <ul><li>Multisystemic Therapy (MST) </li></ul><ul><li>Multidimensional Treatment Fost...
Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available ...
Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available ...
Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available ...
KAUFFMAN BEST PRACTICES PROJECT AND NATIONAL CHILD TRAUMATIC STRESS  NETWORK <ul><li>Trauma Focused-Cognitive Behavioral T...
Shared Characteristics of  Evidence-Based (and Promising) Interventions <ul><li>Function as service components within syst...
“ The current need is …for building efficacious treatment interventions within effective, compassionate, and competent sys...
EXAMPLES OF SYSTEMS OF CARE
Wraparound Milwaukee   Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Hea...
OUTCOMES (Milwaukee Wraparound) <ul><li>60% reduction in recidivism rates for delinquent </li></ul><ul><li>youth from one ...
Next Phase of Milwaukee Wraparound <ul><li>Partnership with HMO to become “medical/clinical” </li></ul><ul><li>home for al...
Dawn Project Cost Allocation How Dawn Project is Funded DAWN Project Indianapolis, IN Management Entity: Non profit behavi...
More Dawn Features <ul><li>Service coordination plans, including safety and crisis plan </li></ul><ul><li>Broad array of t...
Dawn Service Array Psychiatric Assessment Medication follow-up/psychiatric review Nursing services Mentor Community case m...
Dawn Service Array, Continued Discretionary Activities Automobile repair Childcare/supervision Clothing Educational expens...
NJ Children’s System of Care Initiative CHILD Screening with Uniform Protocols Child  Welfare JJC Court School Referral Co...
El Paso County, Colorado Pires, S. (1999).  El paso county, colorado risk-based contracting arrangement . Washington, DC: ...
Types of Outcomes Achieved by Systems Of Care <ul><li>Reduction in inpatient hospitalization and residential </li></ul><ul...
Data on Outcomes Available From (Among Others): <ul><li>Burns & Hoagwood,  Community Treatment for Youth: </li></ul><ul><l...
Process How system builders conduct themselves Structure What gets built (i.e., how functions are organized) Pires, S. (20...
Structure “ Something Arranged in a Definite Pattern of Organization” <ul><li>I. Distributes </li></ul><ul><ul><li>Power <...
Goal: One plan of care; one care manager Children in  out-of-home  placements <ul><li>Child Welfare </li></ul><ul><li>Fami...
System of Care Functions Requiring Structure <ul><li>Planning </li></ul><ul><li>Decision Making/Policy Level Oversight </l...
Core Elements of an Effective System-Building Process <ul><li>A core leadership group </li></ul><ul><li>Evolving leadershi...
Core Elements of an  Effective System-Building Process <ul><li>A strategic mindset </li></ul><ul><li>A shared vision based...
Challenges to Collaboration “Barrier Busters” Wraparound Milwaukee. (1998).  Challenges to collaboration/“barrier busters....
Cross-Cutting Characteristics <ul><li>Cultural and linguistic competence , that is, processes and structures that support ...
How Systems of Care are Structuring Family Involvement at Various  Levels of the System   Pires, S. (1996). Human Service ...
Why Culture Matters <ul><li>Because it affects… </li></ul><ul><li>Attitudes and beliefs about services and systems </li></...
BUILDING SYSTEMS OF CARE: STRATEGICALLY MANAGING COMPLEX CHANGE Human Service Collaborative. (1996).  Building local syste...
Elements of Effective Planning Processes <ul><li>Are staffed </li></ul><ul><li>Involve key stakeholders </li></ul><ul><li>...
A Planning Process for Family and Children’s Service Reform Friedman, M. (1994). Washington, D.C.: Center for the Study of...
Strategies for Involving Parents in Planning <ul><li>Providing special orientation and training and ongoing assistance; co...
Strategies for Involving  Parents in Planning  (continued) <ul><li>Using parents who work regularly with other parents to ...
Definition of Governance Decision making at a policy level that has legitimacy, authority, and accountability. Pires, S. (...
System Management Day-to-day operational  decision making Pires, S. (2002).  Building systems of care: A primer.  Washingt...
Key Issues for  Governing Bodies <ul><li>Has authority to govern </li></ul><ul><li>Is clear about what it is governing </l...
System Management:  Day-to-Day  Operational Decision Making <ul><li>Key Issues </li></ul><ul><li>Is the reporting relation...
Pires, S. (1996).  Contracted system management structure . Washington, DC: Human Service Collaborative. Example of Govern...
Pires, S. (1996).  Evolving governance structure . Washington, DC: Human Service Collaborative . BRING THE CHILDREN HOME S...
Examples of Types of Family Partnership in System Governance and Management Conlan, L. (2003).  Implementing family involv...
Distinctions Among  Screening, Assessment and  Evaluation, and Care Planning <ul><li>Screening </li></ul><ul><li>1 st  ste...
Distinctions Among  Screening, Assessment and  Evaluation, and Care Planning Pires, S. (2002).  Building systems of care: ...
Life Domain Areas Adapted from. Dennis, K, VanDenBerg, J., & Burchard, J. (1990).  Life domain areas . Chicago: Kaleidosco...
<ul><li>Definition of Wraparound </li></ul><ul><li>Wraparound is “ . . . a definable planning process that results in a un...
Wraparound and System of Care Wraparound is an important approach to care planning and service provision within a system o...
Examples of What You’d Want to Provide Based on  Effectiveness Literature <ul><li>Outpatient Models : </li></ul><ul><li>Co...
Examples of Other Home and Community-Based Services You’d Want to Provide Based on  Practice/Family Experience & Outcomes ...
What You Don’t See Listed as Evidence-Based Practice <ul><li>Traditional office-based “talk” therapy </li></ul><ul><li>Res...
What Natural  Helpers Can Provide <ul><li>Emotional support </li></ul><ul><li>System navigation  </li></ul><ul><li>Resourc...
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 T...
Service Array Focused on  a Total Eligible Population <ul><li>Family Support Services </li></ul><ul><li>Youth Development ...
Where Family Organizations Fit Into Service Array <ul><li>As technical assistance providers & consultants </li></ul><ul><l...
Comparison of Case Management  and Care Management <ul><li>Case Management </li></ul><ul><li>Little authority over resourc...
Care Management  Continuum Pires, S. (2001).  Case/care management continuum . Washington, DC: Human Service Collaborative...
Care Management/Service Coordination  Structure Principles <ul><li>Support a  unitary  (i.e., across agencies) care manage...
Utilization Management Concerns <ul><li>Who is using services? </li></ul><ul><li>What services are being used? </li></ul><...
Principles for  Utilization Management <ul><li>UM must be understood and embraced by all  key stakeholders </li></ul><ul><...
Purposes of UM/Evaluation Data:  Examples <ul><li>Planning and Decision Support (Day-to-Day and  </li></ul><ul><li>Retrosp...
Evaluation & Data Gathering <ul><li>To eliminate disparities, disproportionalities, and improve quality of care, we need t...
Financing Strategies to Support Improved Outcomes for Children & Families <ul><li>FIRST PRINCIPLE: </li></ul><ul><ul><li>S...
Financing Strategies to Support Improved Outcomes   <ul><li>RAISING OTHER REVENUE TO SUPPORT FAMILIES AND  </li></ul><ul><...
Where to Look for Money  and Other Types of Support Pires, S. (1994).  Where to look for money and other types of support ...
Milwaukee Wraparound Wraparound Milwaukee. (2002).  What are the pooled funds?  Milwaukee, WI: Milwaukee Count Mental Heal...
How to Finance/Implement Systems of Care <ul><li>Adopt a Population Focus:  Who are the populations </li></ul><ul><li>of y...
Examples of Incentives to Various  Child-Serving Systems Medicaid:  slowing rate of growth in “deep end” services Child We...
Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices District of Columbia...
New Mexico - MST Medicaid managed care  pays for service costs of MST Juvenile Justice  pays for training/coaching/fidelit...
Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices New Jersey – In-Home...
Characteristics of  Effective Provider Networks <ul><li>Responsive to the population that is the focus of the system of ca...
Examples of  Incentives to Providers <ul><li>Decent rates </li></ul><ul><li>Flexibility and control </li></ul><ul><li>Time...
Purchasing/Contracting Options <ul><li>Pre-Approved Provider Lists : </li></ul><ul><li>Flexibility for system of care + </...
Progression of Risk by  Contracting Arrangement RISK TO SYSTEM OF CARE HIGHEST RISK LOWEST RISK RISK TO PROVIDER LOWEST RI...
Human Resource  Development Functions <ul><li>Assessment of workforce requirements (i.e., What skills are needed, what typ...
Staffing Systems of Care Re-deploy  and Retrain Existing  Staff Contract Out Hire  New  Staff Partner  with Others Pires, ...
A Developmental Training Curriculum TRADITIONAL   MODIFIED INTEGRATED UNIFIED SYSTEM PROGRAM State systems develop trainin...
A Developmental  Training Curriculum TRADITIONAL   MODIFIED INTEGRATED UNIFIED PRACTICE Participation in professional conf...
Summary: Common Elements of Re-Structured Systems <ul><li>Values-based systems/Family and youth partnership </li></ul><ul>...
Summary:Common Elements of Re-Structured Systems <ul><li>Flexible financing and contracting arrangements  </li></ul><ul><l...
Summary: Common Elements of Re-Structured Systems <ul><li>Utilization management </li></ul><ul><li>Mobile crisis capacity ...
Transformation <ul><li>Need to connect related reforms in child-serving systems </li></ul><ul><li>and Medicaid needs to be...
“ The world that we have made as a result of the level of thinking we have done thus far creates problems that we cannot s...
The measure of success is not whether you have a tough problem to deal with, but whether it’s the same problem you had las...
To Obtain Copies of  Building Systems of Care: A Primer Contact:   Mary Moreland, Publications Manager Georgetown Universi...
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  • Good listening Housing information Child care Transportation Access to services Person to trust A bridge to services – the intermediary
  • This network analysis looked at the relationship among a group of natural helpers, community residents and providers in the EQUIPO. The pre-EQUIPO network is composed of 33 sets of disconnected cluster in the EQUIPO. This shows how it looked for 13 persons who participated during one summer.
  • In the post EQUIPO network there are many more relationships, so the network has a much higher density. It is a complete network of 204 person. Although clusters can be found, there are no more clusters isolated from tall the others. Decrease in social isolation.
  • Building Systems of Care: Critical Structures and Processes

    1. 1. 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
    2. 2. Purpose and Structure of the Training <ul><li>Increase knowledge about what is involved in building </li></ul><ul><li>systems of care: critical structures, essential process </li></ul><ul><li>elements, examples – Didactic, Questions/Discussion </li></ul><ul><li>Assess system-building progress and stage of </li></ul><ul><li>development – Break out by County/Facilitated Discussion </li></ul><ul><li>Develop specific action agendas to advance </li></ul><ul><li>system-building efforts – Break out by County/Facilitated </li></ul><ul><li>Discussion/Technical Assistance </li></ul><ul><li>Peer Learning – Reporting Back/Large Group Discussion </li></ul>
    3. 3. 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.
    4. 4. Pires, S. (2002) Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. National System of Care Activity <ul><li>CASSP </li></ul><ul><li>RWJ MHSPY </li></ul><ul><li>CASEY MHI </li></ul><ul><li>CMHS GRANTS </li></ul><ul><li>CSAT GRANTS </li></ul><ul><li>ACF GRANTS </li></ul><ul><li>CMS GRANTS </li></ul><ul><li>PRESIDENT’S NEW FREEDOM MENTAL HEALTH COMMISSION </li></ul><ul><li>STATE INFRASTRUCTURE GRANTS </li></ul>
    5. 5. 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.
    6. 6. Values and Principles for the System of Care <ul><li>CORE VALUES </li></ul><ul><li>Child centered and family focused </li></ul><ul><li>Community based </li></ul><ul><li>Culturally competent </li></ul>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.
    7. 7. Values and Principles for the System of Care <ul><li>Comprehensive array of services/supports </li></ul><ul><li>Individualized services guided by an individualized service plan </li></ul><ul><li>Least restrictive environment that is clinically appropriate </li></ul><ul><li>Families and surrogate families and youth full participants in all aspects of the planning and delivery of services </li></ul><ul><li>Integrated services </li></ul><ul><li>Continued … </li></ul>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.
    8. 8. Values and Principles for the System of Care <ul><li>Care management or similar mechanisms </li></ul><ul><li>Early identification and intervention </li></ul><ul><li>Smooth transitions </li></ul><ul><li>Rights protected, and effective advocacy efforts promoted </li></ul><ul><li>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 </li></ul>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.
    9. 9. Principles of Family Support Practice <ul><li>Staff & families work together in relationships based on equality and respect. </li></ul><ul><li>Staff enhances families’ capacity to support the growth and development of all family members. </li></ul><ul><li>Families are resources to their own members, other families, programs, and communities. </li></ul><ul><li>Programs affirm and strengthen families’ cultural, racial, and linguistic identities. </li></ul><ul><li>Programs are embedded in their communities and contribute to the community building. </li></ul><ul><li>Programs advocate with families for services and systems that are fair, responsive, and accountable to the families served. </li></ul><ul><li>Practitioners work with families to mobilize formal and informal resources to support family development. </li></ul><ul><li>Programs are flexible & responsive to emerging family & community issues. </li></ul><ul><li>Principles of family support are modeled in all program activities. </li></ul>Family Support America. (2001). Principles of Family Support Practice in Guidelines for Family Support Practice (2 nd ed.). Chicago, IL.
    10. 10. Youth Development Principles <ul><li>Adolescent Centered </li></ul><ul><li>Community Based </li></ul><ul><li>Comprehensive </li></ul><ul><li>Collaborative </li></ul><ul><li>Egalitarian </li></ul><ul><li>Empowering </li></ul><ul><li>Inclusive </li></ul><ul><li>Visible, Accessible, and Engaging </li></ul><ul><li>Flexible </li></ul><ul><li>Culturally Sensitive </li></ul><ul><li>Family Focused </li></ul><ul><li>Affirming </li></ul>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.
    11. 11. System of Care: Operational Characteristics <ul><li>Collaboration across agencies </li></ul><ul><li>Partnership with families </li></ul><ul><li>Cultural & linguistic competence </li></ul><ul><li>Blended, braided, or coordinated financing </li></ul><ul><li>Shared governance across systems & with families </li></ul><ul><li>Shared outcomes across systems </li></ul><ul><li>Organized pathway to services & supports </li></ul><ul><li>Interagency/family services planning teams </li></ul><ul><li>Interagency/family services monitoring teams </li></ul><ul><li>Single plan of care </li></ul><ul><li>One accountable care manager </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .
    12. 12. System of Care: Operational Characteristics Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative <ul><li>Cross-agency care coordination </li></ul><ul><li>Individualized services and supports “wrapped around” </li></ul><ul><li>child/family </li></ul><ul><li>Home- & community-based alternatives </li></ul><ul><li>Broad, flexible array of services and supports </li></ul><ul><li>Integration of clinical treatment services & natural </li></ul><ul><li>supports, linkage to community resources </li></ul><ul><li>Integration of evidence-based and effective practices </li></ul><ul><li>Cross-agency MIS </li></ul>
    13. 13. Current Systems Problems <ul><li>Lack of home and community-based services and supports </li></ul><ul><li>Patterns of utilization </li></ul><ul><li>Cost </li></ul><ul><li>Administrative inefficiencies </li></ul><ul><li>Knowledge, skills and attitudes of key stakeholders </li></ul><ul><li>Poor outcomes </li></ul><ul><li>Financing structures </li></ul><ul><li>Pathology-based/medical models, deficit-oriented, punitive systems </li></ul> Pires, S. (1996). Human Service Collaborative, Washington, D.C.
    14. 14. 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.
    15. 15. SYSTEMS CHANGE FOCUSES ON: <ul><li>Policy Level (e.g., financing; regs; rates) </li></ul><ul><li>Management Level (e.g., data; QI; HRD; system </li></ul><ul><li>organization) </li></ul><ul><li>Frontline Practice Level (e.g., assessment; care planning; </li></ul><ul><li>care management; services/supports provision) </li></ul><ul><li>Community Level (e.g., partnership with families, youth, </li></ul><ul><li>natural helpers; community buy-in) </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    16. 16. 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
    17. 17. 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
    18. 18. 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.
    19. 19. The Total Population of Children and Families Who Depend on Public Systems <ul><li>Children and families eligible for Medicaid </li></ul><ul><li>Children and families eligible for the State Children's Health Insurance Program (SCHIP) </li></ul><ul><li>Poor and uninsured children and families who do not qualify for Medicaid or SCHIP </li></ul><ul><li>Families who are not poor or uninsured but who exhaust their private insurance, often because they have a child with a serious disorder </li></ul><ul><li>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. </li></ul>Pires, S. (1997). The total population of children and families who depend on public systems . Human Service Collaborative: Washington, D.C.
    20. 20. 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
    21. 21. Child Welfare Population Issues <ul><li>All children and families involved in child welfare? </li></ul><ul><li>If subsets, who? </li></ul><ul><li>Demographic: e.g., infants, transition-age youth </li></ul><ul><li>Intensity of System Involvement: e.g., out of home placement, </li></ul><ul><li>multi-system, length of stay </li></ul><ul><li>At risk: e.g., </li></ul><ul><li>Children with natural families at risk of out of home placement? </li></ul><ul><li>Children in permanent placements that are at risk of disruption ? </li></ul><ul><li>(e.g., subsidized adoption, kinship care, permanent foster care) </li></ul><ul><li>Level of severity: e.g., </li></ul><ul><li>Children with serious emotional/behavioral disorders, serious </li></ul><ul><li>physical health problems, developmental disabilities, </li></ul><ul><li>co-occurring </li></ul>Pires, S.A. 2004. Human Service Collaborative. Washington, D.C.
    22. 22. Example: Transition-Age Youth <ul><li>Policy Level: </li></ul><ul><li>What systems need to be involved? </li></ul><ul><li>e.g., Housing, Vocational Rehabilitation, Employment </li></ul><ul><li>Services, Mental Health and Substance Abuse, Medicaid, </li></ul><ul><li>Community Colleges/Universities, Physical Health, Juvenile </li></ul><ul><li>Justice, in addition to Child Welfare </li></ul><ul><li>What dollars/resources do they control? </li></ul>What outcomes do we want to see for this population? Continued
    23. 23. <ul><li>Management Level: </li></ul><ul><li>How do we create a locus of system management </li></ul><ul><li>accountability for this population? </li></ul><ul><li>E.g., In-house? Lead community agency? </li></ul><ul><li>Frontline Practice Level: </li></ul><ul><li>Are there evidence-based/promising approaches targeted </li></ul><ul><li>to this population? </li></ul><ul><li>What training do we need to provide and for whom to </li></ul><ul><li>create desired attitudes, knowledge, skills about this </li></ul><ul><li>population? </li></ul><ul><li>What providers know this population best in our </li></ul><ul><li>community? </li></ul>Example: Transition-Age Youth Continued
    24. 24. Example: Transition-Age Youth <ul><li>Community Level: </li></ul><ul><li>What are the partnerships we need to build with </li></ul><ul><li>youth and families? </li></ul><ul><li>How can natural helpers in the community play a role? </li></ul><ul><li>How do we create larger community buy-in? </li></ul><ul><li>What can we put in place to provide opportunities </li></ul><ul><li>for youth to contribute and feel a part of the larger </li></ul><ul><li>community? </li></ul>What does our system design look like for this population?
    25. 25. Child Welfare Outcomes <ul><li>Safety </li></ul><ul><li>Permanency </li></ul><ul><li>Well-Being </li></ul>Difficult to achieve without taking a system of care approach
    26. 26. 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. <ul><li>Medicaid </li></ul><ul><li>Medicaid In-Patient </li></ul><ul><li>Medicaid Outpatient </li></ul><ul><li>Medicaid Rehabilitation Services Option </li></ul><ul><li>Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) </li></ul><ul><li>Targeted Case Management </li></ul><ul><li>Medicaid Waivers </li></ul><ul><li>Katie Beckett Option </li></ul><ul><li>Substance Abuse </li></ul><ul><li>SA General Revenue </li></ul><ul><li>SA Medicaid Match </li></ul><ul><li>SA Block Grant </li></ul><ul><li>Juvenile Justice </li></ul><ul><li>JJ General Revenue </li></ul><ul><li>JJ Medicaid Match </li></ul><ul><li>JJ Federal Grants </li></ul><ul><li>Mental Health </li></ul><ul><li>MH General Revenue </li></ul><ul><li>MH Medicaid Match </li></ul><ul><li>MH Block Grant </li></ul><ul><li>Child Welfare </li></ul><ul><li>CW General Revenue </li></ul><ul><li>CW Medicaid Match </li></ul><ul><li>IV-E (Foster Care and Adoption Assistance) </li></ul><ul><li>IV-B (Child Welfare Services) </li></ul><ul><li>Family Preservation/Family Support </li></ul><ul><li>Education </li></ul><ul><li>ED General Revenue </li></ul><ul><li>ED Medicaid Match </li></ul><ul><li>Student Services </li></ul><ul><li>Other </li></ul><ul><li>WAGES </li></ul><ul><li>Children’s Medical Services/Title V– Maternal and Child Health </li></ul><ul><li>Mental Retardation/ Developmental Disabilities </li></ul><ul><li>Title XXI-State Children’s Health Insurance Program (SCHIP) </li></ul><ul><li>Vocational Rehabilitation </li></ul><ul><li>Supplemental Security Income (SSI) </li></ul><ul><li>Local Funds </li></ul>
    27. 27. WHO CONTROLS POLICY AND DOLLARS? <ul><li>Key </li></ul><ul><li>State Medicaid Agencies </li></ul><ul><li>State/Local Child Welfare Agencies </li></ul><ul><li>State/Local Mental Health Authorities </li></ul><ul><li>Public Health and Primary Care </li></ul><ul><li>State/Local Education Agencies </li></ul><ul><li>State and Local Juvenile Justice Systems </li></ul><ul><li>Some Others </li></ul><ul><li>Commercial Insurers </li></ul><ul><li>Employment Services </li></ul><ul><li>State/Local Substance </li></ul><ul><li>Abuse Agencies </li></ul><ul><li>Housing </li></ul>Pires, S. (2004). Human Service Collaborative, Washington, D.C.
    28. 28. OTHER CRITICAL PLAYERS <ul><li>“ Gatekeepers” (e.g., managed care organizations, </li></ul><ul><li>judges, interagency teams) </li></ul><ul><li>Providers </li></ul><ul><li>Natural Helpers and Community Resources </li></ul><ul><li>Families </li></ul><ul><li>Youth </li></ul>Pires, S. (2004). Human Service Collaborative, Washington, D.C.
    29. 29. Local Ownership State Commitment Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
    30. 30. Converging Trends Pires, S. (2003). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .
    31. 31. Efficacy of Research (Barbara Burns’ Research at Duke University) <ul><li>Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care </li></ul><ul><li>Weaker evidence ( because not much research done ): Crisis services, respite, mentoring, family education and support </li></ul><ul><li>Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .
    32. 32. 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 .
    33. 33. Examples of Evidence-Based Practices <ul><li>Multisystemic Therapy (MST) </li></ul><ul><li>Multidimensional Treatment Foster Care (MDTFC) </li></ul><ul><li>Functional Family Therapy (FFT) </li></ul><ul><li>Cognitive Behavioral Therapy (various models) </li></ul><ul><li>Intensive Care Management (various models) </li></ul>Examples of Promising Practices <ul><li>Family Support and Education </li></ul><ul><li>Wraparound Service Approaches </li></ul><ul><li>Mobile Response and Stabilization Services </li></ul>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)
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. KAUFFMAN BEST PRACTICES PROJECT AND NATIONAL CHILD TRAUMATIC STRESS NETWORK <ul><li>Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) </li></ul><ul><li>Abuse Focused-Cognitive Behavioral Therapy (AF-CBT) </li></ul><ul><li>Parent Child Interaction Therapy (PCIT) </li></ul>
    38. 38. Shared Characteristics of Evidence-Based (and Promising) Interventions <ul><li>Function as service components within systems of care </li></ul><ul><li>Provided in the community </li></ul><ul><li>Utilize natural supports, parents, with training and supervision provided by those with formal mental health training </li></ul><ul><li>Operate under the auspices of all child-serving systems, not just mental health </li></ul><ul><li>Studied in the field with “real world” children and families </li></ul><ul><li>Less expensive than institutional care (when the full continuum is in place) </li></ul>Burns, B. and Hoagwood, K. 2002. Community treatment for youth. New York: Oxford University Press.
    39. 39. “ 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 .
    40. 40. EXAMPLES OF SYSTEMS OF CARE
    41. 41. 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) <ul><li>Mental Health </li></ul><ul><li>Crisis Billing </li></ul><ul><li>Block Grant </li></ul><ul><li>HMO Commercial </li></ul><ul><li>Insurance </li></ul>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
    42. 42. OUTCOMES (Milwaukee Wraparound) <ul><li>60% reduction in recidivism rates for delinquent </li></ul><ul><li>youth from one year prior to enrollment to one year </li></ul><ul><li>post enrollment </li></ul><ul><li>Decrease in average daily RTC population from 375 </li></ul><ul><li>to 50 </li></ul><ul><li>Reduction in psychiatric inpatient days from 5,000 days </li></ul><ul><li>to less than 200 days per year </li></ul><ul><li>Average monthly cost of $4,200 (compared to $7,200 </li></ul><ul><li>for RTC, $6,000 for juvenile detention, $18,000 for </li></ul><ul><li>psychiatric hospitalization </li></ul>
    43. 43. Next Phase of Milwaukee Wraparound <ul><li>Partnership with HMO to become “medical/clinical” </li></ul><ul><li>home for all children in foster care in the county – </li></ul><ul><li>Locus of accountability for managing physical, </li></ul><ul><li>dental, and behavioral health care to achieve ASFA </li></ul><ul><li>well-being outcomes </li></ul>
    44. 44. Dawn Project Cost Allocation How Dawn Project is Funded DAWN Project Indianapolis, IN Management Entity: Non profit behavioral health organization
    45. 45. More Dawn Features <ul><li>Service coordination plans, including safety and crisis plan </li></ul><ul><li>Broad array of treatment and supportive services </li></ul><ul><li>Extensive provider network, paid fee for service </li></ul>Health/medical Safety/crisis Family/relationships Educational/vocational Psychological/emotional Substance abuse Social/recreational Daily living Cultural/spiritual Financial/legal Life Domains
    46. 46. 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
    47. 47. 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
    48. 48. NJ Children’s System of Care Initiative CHILD Screening with Uniform Protocols Child Welfare JJC Court School Referral Community Agencies Family & Self Other <ul><li>Contracted </li></ul><ul><li>Systems </li></ul><ul><li>Administrator CSA </li></ul><ul><ul><li>Registration </li></ul></ul><ul><ul><li>Screening for self-referrals </li></ul></ul><ul><ul><li>Tracking </li></ul></ul><ul><ul><li>Assessment of Level of Care Needed </li></ul></ul><ul><ul><li>Care Coordination </li></ul></ul><ul><ul><li>Authorization of Services </li></ul></ul><ul><li>Community </li></ul><ul><li>Agencies </li></ul><ul><li>Uncomplicated Care </li></ul><ul><li>Service Authorized </li></ul><ul><li>Service Delivered </li></ul><ul><li>CMO </li></ul><ul><li>Complex Multi-System </li></ul><ul><li>Children </li></ul><ul><li>ISP Developed </li></ul><ul><li>Full Plan of Care </li></ul><ul><li>Authorized </li></ul>FSO Family to Family Support
    49. 49. 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
    50. 50. Types of Outcomes Achieved by Systems Of Care <ul><li>Reduction in inpatient hospitalization and residential </li></ul><ul><li>treatment placements and lengths of stay </li></ul><ul><li>Reductions in detention rates </li></ul><ul><li>Reductions in out-of-home placements and lengths of </li></ul><ul><li>stay </li></ul><ul><li>Improved clinical and functional outcomes </li></ul><ul><li>Higher family and youth satisfaction </li></ul><ul><li>Lower costs per child served for total system if </li></ul><ul><li>a range of home and community-based is in place </li></ul>
    51. 51. Data on Outcomes Available From (Among Others): <ul><li>Burns & Hoagwood, Community Treatment for Youth: </li></ul><ul><li>Evidence-Based Interventions for Severe Emotional and </li></ul><ul><li>Behavioral Disorders , Oxford University Press </li></ul><ul><li>Kaufman Foundation, Closing the Quality Chasm in Child </li></ul><ul><li>Abuse Treatment: Identifying and Disseminating Best </li></ul><ul><li>Practices, www.kauffmanfoundation.org </li></ul><ul><li>Wraparound Milwaukee (bkamrad@wrapmilw.org) </li></ul><ul><li>Dawn Project (krotto@choicesteam.org) </li></ul><ul><li>Coordinated Care Services, Inc. ( [email_address] ) </li></ul><ul><li>Massachusetts Mental Health Services Program for Youth </li></ul><ul><li>( [email_address] ) </li></ul><ul><li>Youth Villages (tim.goldsmith@youthvillages.org) </li></ul>
    52. 52. 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 .
    53. 53. Structure “ Something Arranged in a Definite Pattern of Organization” <ul><li>I. Distributes </li></ul><ul><ul><li>Power </li></ul></ul><ul><ul><li>Responsibility </li></ul></ul><ul><li>II. Shapes and is shaped by </li></ul><ul><ul><li>Values </li></ul></ul><ul><li>III. Affects </li></ul><ul><ul><li>Practice and outcomes </li></ul></ul><ul><ul><li>Subjective experiences (i.e., how participants feel) </li></ul></ul>Pires, S. (1995). Structure . Washington, DC: Human Service Collaborative.
    54. 54. Goal: One plan of care; one care manager Children in out-of-home placements <ul><li>Child Welfare </li></ul><ul><li>Family Group Decision Making </li></ul><ul><li>CW Case Worker </li></ul>EXAMPLE <ul><li>Mental Health </li></ul><ul><li>Individualized WrapAround Approach </li></ul><ul><li>Care manager </li></ul><ul><li>MCO </li></ul><ul><li>Prior Authorization </li></ul><ul><li>Clinical Coordinator </li></ul><ul><li>Education </li></ul><ul><li>Child Study Team </li></ul><ul><li>Teacher </li></ul>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.
    55. 55. System of Care Functions Requiring Structure <ul><li>Planning </li></ul><ul><li>Decision Making/Policy Level Oversight </li></ul><ul><li>System Management </li></ul><ul><li>Benefit Design/Service Array </li></ul><ul><li>Evidence-Based Practice </li></ul><ul><li>Outreach and Referral </li></ul><ul><li>System Entry/Access </li></ul><ul><li>Screening, Assessment, and Evaluation </li></ul><ul><li>Decision Making and Oversight at the Service Delivery Level </li></ul><ul><ul><li>Care Planning </li></ul></ul><ul><ul><li>Care Authorization </li></ul></ul><ul><ul><li>Care Monitoring and Review </li></ul></ul><ul><li>Care Management or Care Coordination </li></ul><ul><li>Crisis Management at the Service Delivery and Systems Levels </li></ul><ul><li>Utilization Management </li></ul><ul><li>Family Involvement, Support, and Development at all Levels </li></ul><ul><li>Youth Involvement, Support, and Development </li></ul><ul><li>Staffing Structure </li></ul><ul><li>Staff Involvement, Support, Development </li></ul><ul><li>Orientation, Training of Key Stakeholders </li></ul><ul><li>External and Internal Communication </li></ul><ul><li>Provider Network </li></ul><ul><li>Protecting Privacy </li></ul><ul><li>Ensuring Rights </li></ul><ul><li>Transportation </li></ul><ul><li>Financing </li></ul><ul><li>Purchasing/Contracting </li></ul><ul><li>Provider Payment Rates </li></ul><ul><li>Revenue Generation and Reinvestment </li></ul><ul><li>Billing and Claims Processing </li></ul><ul><li>Information Management </li></ul><ul><li>Quality Improvement </li></ul><ul><li>Evaluation </li></ul><ul><li>System Exit </li></ul><ul><li>Technical Assistance and Consultation </li></ul><ul><li>Cultural Competence </li></ul>Pires, S. (2002). Building Systems of Care: A Primer . Washington, D.C.: Human Service Collaborative.
    56. 56. Core Elements of an Effective System-Building Process <ul><li>A core leadership group </li></ul><ul><li>Evolving leadership </li></ul><ul><li>Effective collaboration </li></ul><ul><li>Partnership with families and youth </li></ul><ul><li>Cultural competence </li></ul><ul><li>Connection to neighborhood resources and natural helpers </li></ul><ul><li>Bottom-up and top-down approach </li></ul><ul><li>Effective communication </li></ul><ul><li>Conflict resolution, mediation, and team-building mechanisms </li></ul><ul><li>A positive attitude </li></ul>Leadership and Constituency Building Pires, S. (2002). Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative .
    57. 57. Core Elements of an Effective System-Building Process <ul><li>A strategic mindset </li></ul><ul><li>A shared vision based on common values and principles </li></ul><ul><li>A clear population focus </li></ul><ul><li>Shared outcomes </li></ul><ul><li>Community mapping—understanding strengths and needs </li></ul><ul><li>Understanding and changing traditional systems </li></ul><ul><li>Understanding of the importance of “de facto” mental health providers (e.g., schools, primary care providers, day care providers, head start) </li></ul><ul><li>Understanding of major financing streams </li></ul><ul><li>Connection to related reform initiatives </li></ul><ul><li>Clear goals, objectives, and benchmarks </li></ul><ul><li>Trigger mechanisms—being opportunistic </li></ul><ul><li>Opportunity for reflection </li></ul><ul><li>Adequate time </li></ul>Being Strategic Pires, S. (2002). Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative
    58. 58. 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 . <ul><li>Infuse values into all meetings, training, and workshops </li></ul><ul><li>Share documentation and include parents in as many meetings as possible </li></ul><ul><li>Strength-based cross training </li></ul><ul><li>Develop QA measures based on values </li></ul>Sharing value base <ul><li>Invest in relationships with partners in collaboration </li></ul><ul><li>Share literature and workshops </li></ul><ul><li>Track and provide meaningful outcomes </li></ul>Maintaining investment from stakeholders <ul><li>Document safety plans </li></ul><ul><li>Develop protocol for high-risk kids </li></ul><ul><li>Demonstrate adherence to court orders </li></ul><ul><li>Maintain communication with District Attorneys </li></ul><ul><li>Myths of “bricks and mortar” </li></ul>Addressing issues of community safety <ul><li>Set up a common data base </li></ul><ul><li>Share organizational charts/phone lists </li></ul><ul><li>Share paperwork </li></ul><ul><li>Promote flexibility in schedules to support attendance in meetings </li></ul>Information sharing among systems <ul><li>Family driven/accountability </li></ul><ul><li>Team development training </li></ul><ul><li>Job shadowing </li></ul><ul><li>Communication channels </li></ul><ul><li>Share myths and realities </li></ul>Role definition: “Who’s in charge?” <ul><li>Cross training </li></ul><ul><li>Share each other’s turf </li></ul><ul><li>Share literature </li></ul>Language differences: Mental health jargon vs. court jargon BARRIER BUSTERS CHALLENGE
    59. 59. Cross-Cutting Characteristics <ul><li>Cultural and linguistic competence , that is, processes and structures that support capacity to function effectively in cross-cultural situations; </li></ul><ul><li>Meaningful partnership with families , including family organizations, and youth in system building processes and structural decision making, design, and implementation; </li></ul><ul><li>A cross-agency perspective , that is, processes and structures that operate in a non-categorical fashion. </li></ul><ul><li>State and local partnership and shared commitment. </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington D.C.: Human Service Collaborative .
    60. 60. 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
    61. 61. Why Culture Matters <ul><li>Because it affects… </li></ul><ul><li>Attitudes and beliefs about services and systems </li></ul><ul><li>Expression of symptoms </li></ul><ul><li>Coping strategies </li></ul><ul><li>Help-seeking behaviors </li></ul><ul><li>Utilization of services </li></ul><ul><li>Appropriateness of services and supports </li></ul><ul><li>Disparities in access </li></ul>Lazear, K., (2003) “Primer Hands On”; A skill building curriculum . Washington, D.C.: Human Service Collaborative.
    62. 62. 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.
    63. 63. Elements of Effective Planning Processes <ul><li>Are staffed </li></ul><ul><li>Involve key stakeholders </li></ul><ul><li>Involve families early in the process and in ways that are meaningful </li></ul><ul><li>Ensure meaningful representation of racially and ethnically diverse families </li></ul><ul><li>Develop and maintain a multi-agency focus </li></ul><ul><li>Build on and incorporate related programmatic and planning initiatives </li></ul><ul><li>Continually seek ways to build constituencies, interest, and investment </li></ul><ul><li>Pay attention to sustainability and growth of system changes from day one </li></ul>Pires, S. (1991). State child mental health planning . Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center of Children’s Mental Health.
    64. 64. 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
    65. 65. Strategies for Involving Parents in Planning <ul><li>Providing special orientation and training and ongoing assistance; consulting with parents before meetings. </li></ul><ul><li>Having more than token representation. </li></ul><ul><li>Contracting with community-based and parent organizations to develop/sustain process. </li></ul><ul><li>Working through parent organizations. </li></ul><ul><li>Asking agencies that work with parents to recommend parents to participate in planning. </li></ul><ul><li>Paying stipends, transportation, child care. </li></ul><ul><li>Holding planning meetings in the evenings or on weekends, in locations such as schools. </li></ul><ul><li>Conducting surveys to elicit views of many parents. </li></ul><ul><li>Continued … </li></ul>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.
    66. 66. Strategies for Involving Parents in Planning (continued) <ul><li>Using parents who work regularly with other parents to conduct focus groups. </li></ul><ul><li>Working with family support groups to tap into informal networks. </li></ul><ul><li>Working with home visiting programs and health clinics to reach out to parents. </li></ul><ul><li>Working with family preservation and family reunification programs. </li></ul><ul><li>Conducting sessions for planning group members with trained facilitators to explore attitudes about race, culture, families. </li></ul><ul><li>Publicly acknowledging the contributions of parents. </li></ul>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.
    67. 67. 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.
    68. 68. System Management Day-to-day operational decision making Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    69. 69. Key Issues for Governing Bodies <ul><li>Has authority to govern </li></ul><ul><li>Is clear about what it is governing </li></ul><ul><li>Is representative </li></ul><ul><li>Has the capacity to govern </li></ul><ul><li>Has the credibility to govern </li></ul><ul><li>Assumes shared liability across systems for target population </li></ul>Pires, S. (2000). Key issues for governing bodies . Washington, DC: Human Service Collaborative.
    70. 70. System Management: Day-to-Day Operational Decision Making <ul><li>Key Issues </li></ul><ul><li>Is the reporting relationship clear? </li></ul><ul><li>Are expectations clear regarding what is to be managed and what outcomes are expected? </li></ul><ul><li>Does the system management structure have the capacity to manage? </li></ul><ul><li>Does the system management structure have the credibility to manage? </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    71. 71. Pires, S. (1996). Contracted system management structure . Washington, DC: Human Service Collaborative. Example of Governance/Management Structure Care Management Entity
    72. 72. 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
    73. 73. 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 . <ul><li>Input/evaluation of key management </li></ul><ul><li>Input/evaluation of quality of services and programs </li></ul><ul><li>Local system of care input </li></ul><ul><li>Resource allocation </li></ul><ul><li>Service planning and implementation </li></ul><ul><li>Policies and procedures </li></ul><ul><li>Grievance and resolution procedures </li></ul>
    74. 74. Distinctions Among Screening, Assessment and Evaluation, and Care Planning <ul><li>Screening </li></ul><ul><li>1 st step, triage, identify children at high risk, link to appropriate assessments </li></ul><ul><li>Assessment </li></ul><ul><li>Based on data from multiple sources </li></ul><ul><li>Comprehensive </li></ul><ul><li>Identify strengths, resources, needs </li></ul><ul><li>Leads to care planning </li></ul><ul><li>Continued … </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
    75. 75. Distinctions Among Screening, Assessment and Evaluation, and Care Planning Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. <ul><li>Evaluation </li></ul><ul><li>Discipline-specific, e.g., neurological exam </li></ul><ul><li>Closer, more intensive study of a particular or suspected </li></ul><ul><li>clinical issue </li></ul><ul><li>Provides data to assessment process </li></ul><ul><li>Care planning </li></ul><ul><li>Individualized decision making process for determining services </li></ul><ul><li>and supports </li></ul><ul><li>Draws on screening, assessment, and evaluation data </li></ul>
    76. 76. Life Domain Areas Adapted from. Dennis, K, VanDenBerg, J., & Burchard, J. (1990). Life domain areas . Chicago: Kaleidoscope.
    77. 77. <ul><li>Definition of Wraparound </li></ul><ul><li>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.”* </li></ul><ul><li>*Burns, B. & Hoagwood, K. (Eds.) Community-Based Interventions for Children and Families . Oxford: Oxford University Press. </li></ul>
    78. 78. 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.
    79. 79. Examples of What You’d Want to Provide Based on Effectiveness Literature <ul><li>Outpatient Models : </li></ul><ul><li>Cognitive Behavior Therapy (various models) </li></ul><ul><li>Functional Family Therapy (FFT) </li></ul><ul><li>Parent Child Interaction Therapy (PCIT) </li></ul><ul><li>Intensive In-Home Models : </li></ul><ul><li>Multisystemic Therapy (MST) </li></ul><ul><li>Out-of-Home Model: </li></ul><ul><li>Multidimensional Treatment Foster Care </li></ul><ul><li>Intensive Care Management </li></ul>Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
    80. 80. Examples of Other Home and Community-Based Services You’d Want to Provide Based on Practice/Family Experience & Outcomes Data <ul><li>Intensive in-home services (not just MST) </li></ul><ul><li>Child respite services </li></ul><ul><li>Mobile response and stabilization services </li></ul><ul><li>Mental health consultation services </li></ul><ul><li>Independent living skills and supports </li></ul><ul><li>Family/youth education and peer support </li></ul>Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
    81. 81. What You Don’t See Listed as Evidence-Based Practice <ul><li>Traditional office-based “talk” therapy </li></ul><ul><li>Residential Treatment </li></ul><ul><li>Group Homes </li></ul><ul><li>Day Treatment </li></ul>
    82. 82. What Natural Helpers Can Provide <ul><li>Emotional support </li></ul><ul><li>System navigation </li></ul><ul><li>Resource acquisition </li></ul><ul><li>Concrete help </li></ul><ul><li>Decrease social isolation </li></ul><ul><li>Greater understanding of community </li></ul><ul><li>Community navigation </li></ul><ul><li>Effective intervention or support strategies </li></ul>Lazear, K., (2003). “Primer Hands On”; A skill building curriculum . Human Service Collaborative: Washington, D.C.
    83. 83. Pre-Equipo Network Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.
    84. 84. Post –EQUIPO Network Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.
    85. 85. 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
    86. 86. Service Array Focused on a Total Eligible Population <ul><li>Family Support Services </li></ul><ul><li>Youth Development Program/Activities </li></ul><ul><li>Coordinated Intake Assessment & Treatment Planning </li></ul><ul><li>Intensive Case Management/Care Coordination </li></ul><ul><li>Wraparound Services & Supports </li></ul><ul><li>Clinical Services </li></ul>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
    87. 87. Where Family Organizations Fit Into Service Array <ul><li>As technical assistance providers & consultants </li></ul><ul><li>Training </li></ul><ul><li>Evaluation </li></ul><ul><li>Research </li></ul><ul><li>Support </li></ul><ul><li>Outreach </li></ul><ul><li>As direct service providers </li></ul><ul><li>Family Liaisons </li></ul><ul><li>Care Coordinators </li></ul><ul><li>Family Educators </li></ul><ul><li>Specific Program Managers (respite, etc) </li></ul>Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
    88. 88. Comparison of Case Management and Care Management <ul><li>Case Management </li></ul><ul><li>Little authority over resources </li></ul><ul><li>Child centered </li></ul><ul><li>Reactive </li></ul><ul><li>Service provided to placement </li></ul><ul><li>Organization of existing services </li></ul><ul><li>Uses current system </li></ul><ul><li>Care Management </li></ul><ul><li>More control over resources </li></ul><ul><li>Family centered </li></ul><ul><li>Proactive </li></ul><ul><li>Unconditional care </li></ul><ul><li>Creation of services when not available </li></ul><ul><li>Family and community supports </li></ul>Adapted from: Community Care Systems. (2000). Comparison of case management and care coordination . Madison, WI.
    89. 89. 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
    90. 90. Care Management/Service Coordination Structure Principles <ul><li>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. </li></ul><ul><li>Support the goals of continuity and coordination of care across multiple services and systems over time. </li></ul><ul><li>Encompass families and youth as partners in the process of managing/coordinating care. </li></ul><ul><li>Incorporate the strengths of families and youth, including the natural and social support networks on which families rely. </li></ul>Pires, S. (20O2). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    91. 91. Utilization Management Concerns <ul><li>Who is using services? </li></ul><ul><li>What services are being used? </li></ul><ul><li>How much service is being used? </li></ul><ul><li>What is the cost of the services being used? </li></ul><ul><li>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?) </li></ul>Pires, S. (2001). Utilization management concerns . Washington, DC: Human Service Collaborative. UM
    92. 92. Principles for Utilization Management <ul><li>UM must be understood and embraced by all key stakeholders </li></ul><ul><li>UM must concern itself with both the cost and quality of care </li></ul><ul><li>The UM structure needs to be tied to the quality improvement structure </li></ul>Pires.. S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    93. 93. Purposes of UM/Evaluation Data: Examples <ul><li>Planning and Decision Support (Day-to-Day and </li></ul><ul><li>Retrospectively) </li></ul><ul><li>Quality Improvement </li></ul><ul><li>Cost/Benefit Monitoring </li></ul><ul><li>Research </li></ul><ul><li>Marketing </li></ul><ul><li>Accountability </li></ul>Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
    94. 94. Evaluation & Data Gathering <ul><li>To eliminate disparities, disproportionalities, and improve quality of care, we need to collect data. </li></ul><ul><li>Questionnaires </li></ul><ul><li>Surveys </li></ul><ul><li>Interviews </li></ul><ul><li>Focus groups </li></ul><ul><li>Clinical outcome data </li></ul><ul><li>Using a participatory evaluation framework </li></ul><ul><li>Lazear, K. (2003). “Primer Hands On” A skill building curriculum. Washington. D.C. </li></ul>
    95. 95. Financing Strategies to Support Improved Outcomes for Children & Families <ul><li>FIRST PRINCIPLE: </li></ul><ul><ul><li>System Design Drives Financing </li></ul></ul><ul><li>REDEPLOYMENT: </li></ul><ul><ul><li>Using the Money We Already Have </li></ul></ul><ul><ul><li>The Cost of Doing Nothing </li></ul></ul><ul><ul><li>Shifting Funds from Treatment to Early Intervention </li></ul></ul><ul><ul><li>Moving Across Fiscal Years </li></ul></ul><ul><li>REFINANCING: </li></ul><ul><ul><li>Generating New Money by Increasing Federal Claims </li></ul></ul><ul><ul><li>The Commitment to Reinvest Funds for Families and Children </li></ul></ul><ul><ul><li>Foster Care and Adoption Assistance (Title IV-E) </li></ul></ul><ul><ul><li>Medicaid (Title XIX) </li></ul></ul>Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children . Center for the Study of Social Policy: Washington, D.C..
    96. 96. Financing Strategies to Support Improved Outcomes <ul><li>RAISING OTHER REVENUE TO SUPPORT FAMILIES AND </li></ul><ul><li>CHILDREN: </li></ul><ul><ul><li>- Donations </li></ul></ul><ul><ul><li>- Special Taxes and Taxing Districts for Children </li></ul></ul><ul><ul><li>- Fees and Third Party Collections Including Child Support </li></ul></ul><ul><ul><li>- Trust Funds </li></ul></ul><ul><li>FINANCING STRUCTURES THAT SUPPORT GOALS: </li></ul><ul><ul><li>- Seamless Services: Financial claiming invisible to families </li></ul></ul><ul><ul><li>- Funding Pools: Breaking the lock of agency ownership of funds </li></ul></ul><ul><ul><li>- Flexible Dollars: Removing the barriers to meeting the unique </li></ul></ul><ul><ul><li>needs of families </li></ul></ul><ul><ul><li>- Incentives: Rewarding good practice </li></ul></ul>Friedman, M. (1995). Financing strategies to support improved outcomes for children . Center for the Study of Social Policy: Washington, D.C.
    97. 97. 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
    98. 98. Milwaukee Wraparound Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.
    99. 99. How to Finance/Implement Systems of Care <ul><li>Adopt a Population Focus: Who are the populations </li></ul><ul><li>of youth for whom you want to change practice/outcomes </li></ul><ul><li>Adopt a Cross-Systems Approach: What other systems </li></ul><ul><li>serve these youngsters; who controls potential or actual </li></ul><ul><li>match dollars; which systems now spend a lot on </li></ul><ul><li>restrictive levels of care with poor outcomes or on deficit- </li></ul><ul><li>based assessments not linked to effective services – </li></ul><ul><li>Opportunities for re-direction </li></ul><ul><li>Identify Incentives to Finance/Implement Systems of Care </li></ul>Pires, S. 2005. Human Service Collaborative. Washington, D.C.
    100. 100. 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.
    101. 101. 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.
    102. 102. 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.
    103. 103. 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.
    104. 104. Characteristics of Effective Provider Networks <ul><li>Responsive to the population that is the focus of the system of care. </li></ul><ul><li>Encompass both clinical treatment service providers and natural, </li></ul><ul><li>social support resources, such as mentors and respite workers. </li></ul><ul><li>Include both traditional and non traditional, indigenous providers. </li></ul><ul><li>Include culturally and linguistically diverse providers. </li></ul><ul><li>Include families and youth as providers of services and supports. </li></ul><ul><li>Are flexible, structured in a way that allows for additions/deletions. </li></ul><ul><li>Are accountable, structured to serve the system of care. </li></ul><ul><li>Have a commitment to evidence-based and promising practices. </li></ul><ul><li>Encompass choice for families. </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    105. 105. Examples of Incentives to Providers <ul><li>Decent rates </li></ul><ul><li>Flexibility and control </li></ul><ul><li>Timely reimbursements </li></ul><ul><li>Back up support for difficult administrative and clinical challenges </li></ul><ul><li>Access to training and staff development </li></ul><ul><li>Capacity building grants </li></ul><ul><li>Less paperwork </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative .
    106. 106. Purchasing/Contracting Options <ul><li>Pre-Approved Provider Lists : </li></ul><ul><li>Flexibility for system of care + </li></ul><ul><li>Choice for families + </li></ul><ul><li>Could disadvantage small indigenous providers – </li></ul><ul><li>Could create overload on some providers – </li></ul><ul><li>Risk-Based Contracts (e.g., capitation, case rates) </li></ul><ul><li>Flexibility for providers + </li></ul><ul><li>Individualized care for families + </li></ul><ul><li>Potential for under-service – </li></ul><ul><li>Potential for overpaying for services – </li></ul><ul><li>Fixed Price/Service Contracts </li></ul><ul><li>Predictability and stability for providers + </li></ul><ul><li>Inflexible-families have to “fit” what is available – </li></ul>Pires, S. (2002). Building systems of care: A primer . Human Service Collaborative: Washington, D.C..
    107. 107. Progression of Risk by Contracting Arrangement RISK TO SYSTEM OF CARE HIGHEST RISK LOWEST RISK RISK TO PROVIDER LOWEST RISK HIGHEST RISK <ul><li>TYPE OF CONTRACTING </li></ul><ul><li>ARRANGEMENT </li></ul><ul><li>Grant </li></ul><ul><li>Fee-for-Service </li></ul><ul><li>Case Rate </li></ul><ul><li>Capitation </li></ul>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.
    108. 108. Human Resource Development Functions <ul><li>Assessment of workforce requirements (i.e., What skills are needed, what types of staff, how many staff) in the context of systems change </li></ul><ul><li>Recruitment, retention, staff distribution </li></ul><ul><li>Education and training (pre-service and in-service) </li></ul><ul><li>Standards and licensure </li></ul>Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
    109. 109. 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.
    110. 110. 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 place- ments 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.
    111. 111. 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.
    112. 112. Summary: Common Elements of Re-Structured Systems <ul><li>Values-based systems/Family and youth partnership </li></ul><ul><li>Identified target population, costs associated with </li></ul><ul><li>population, funders </li></ul><ul><li>Locus of accountability (and risk) for target population </li></ul><ul><li>Organized pathway to services for target population </li></ul><ul><li>Strengths-based and individualized service planning </li></ul><ul><li>and care monitoring (e.g., wraparound approach) </li></ul><ul><li>Intensive care management </li></ul><ul><li>continued … </li></ul>Pires, S. 2004. Human Service Collaborative. Washington, D.C.
    113. 113. Summary:Common Elements of Re-Structured Systems <ul><li>Flexible financing and contracting arrangements </li></ul><ul><li>(e.g., case rates, qualified provider panel – fee-for-service ) </li></ul><ul><li>Broad provider network: sufficient types </li></ul><ul><li>of services and supports (including natural helpers) </li></ul><ul><li>Combined funding from multiple funders (e.g., Medicaid, </li></ul><ul><li>child welfare, mental health, juvenile justice, education) </li></ul><ul><li>Real time data across systems to support clinical decision- </li></ul><ul><li>making, utilization management, quality improvement </li></ul><ul><li>Outcomes tracking – child/family level, systems level </li></ul><ul><li>continued… </li></ul>Pires, S. 2004. Human Service Collaborative. Washington, D.C.
    114. 114. Summary: Common Elements of Re-Structured Systems <ul><li>Utilization management </li></ul><ul><li>Mobile crisis capacity </li></ul><ul><li>Judiciary buy-in </li></ul><ul><li>Re-engineered residential treatment centers </li></ul><ul><li>Shared governance/liability </li></ul><ul><li>Training and technical assistance </li></ul>Pires, S. 2004. Human Service Collaborative. Washington, D.C.
    115. 115. Transformation <ul><li>Need to connect related reforms in child-serving systems </li></ul><ul><li>and Medicaid needs to be a partner in reform: </li></ul><ul><li>SAMHSA Transformation Grants, Infrastructure Grants, </li></ul><ul><li>System of Care Grants </li></ul><ul><li>Child Welfare System of Care Grants, Program </li></ul><ul><li>Improvement Plans </li></ul><ul><li>Juvenile Justice MH/SA Initiatives </li></ul><ul><li>CMS Feasibility and Real Choice Grants </li></ul>Pires, S. 2005. Human Service Collaborative. Washington, D.C.
    116. 116. “ 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.
    117. 117. 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
    118. 118. 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

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