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/FacilitatedDiscussion/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.

Values and Principles for the System of Care

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 servicesContinued …

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

Values and Principlesfor the System of Care

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

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.

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 (2nd 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


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”


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)


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.

Recipient of information

re: child’s service plan

Passive partner in service planning process

Service planning team leader

Unheard voice in program evaluation

Participant in program evaluation

Partner (or independent) in developing and conducting program evaluations

Recipient of services Partner in planning and developing services

Service providers

Uninvited key stakeholders

in training initiatives

Participants in training initiatives

Partners and independent trainers

Advocacy & peer support Advocacy & peer support Advocacy & peer support

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

IntensiveServices

Accessiblehigh-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, EmploymentServices, Mental Health and Substance Abuse, Medicaid, Community Colleges/Universities, Physical Health, JuvenileJustice, 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 targetedto 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?


Continued


Community Level:•What are the partnerships we need to build withyouth 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 opportunitiesfor 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 withouttaking 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 OwnershipLocal Ownership

State CommitmentState Commitment


Converging Trends


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 practicesShow evidence of effectiveness through carefully controlled

scientific studies, including random clinical trials

Promising approachesShow evidence of effectiveness through experience of key

stakeholders (e.g., families, youth, providers, administrators) and by data collected by program/system


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

Problem Area Best Support

Good Support

Moderate

SupportAnxious or Avoidant Behaviors

Cognitive Behavior Therapy (CBT);

Exposure Modeling

CBT with Parents; Group CBT; CBT for Child & Parent;

Educational Support

None

Depressive or Withdrawn Behaviors

CBT CBT with Parents; Inter-

Personal Tx.

(Manualized);

Relaxation

None

HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd


Problem Area Best Support

Good Support Moderate

SupportDisruptive & Oppositional Behaviors

Known Risks:

Group Therapy

Parent & Teacher Training; Parent Child Interaction Therapy

Anger Coping Therapy; Assertiveness Training; Problem Solving Skills Training, Rational Emotive Therapy, AC-SIT, PATHS & FAST Track Programs

Social Relations Training; Project Achieve

Juvenile Sex Offenders

None None Multisystemic Therapy



Problem Area

Best Support

Good Support Moderate

SupportDelinquency & Willful Misconduct Behavior

Known Risks: Group Therapy

None Multisystemic Therapy; Functional Family Therapy

Multi-

Dimensional

Treatment Foster Care; Wraparound Foster Care

Substance Use

Known Risks:

Group Therapy

CBT Behavior Therapy; Purdue Brief Family Therapy

None


KAUFFMAN BEST PRACTICES PROJECT ANDNATIONAL 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


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 WelfareFunds thru Case Rate

(Budget for InstitutionalCare 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

ProviderNetwork

240 Providers85 Services

CareCoordination

Plans of Care

9.5M 2.0M10M8.5M

Per Participant Case Rate

Mngt. Entity: County Agency

OUTCOMES (Milwaukee Wraparound)

•60% reduction in recidivism rates for delinquentyouth from one year prior to enrollment to one yearpost enrollment•Decrease in average daily RTC population from 375 to 50•Reduction in psychiatric inpatient days from 5,000 daysto less than 200 days per year•Average monthly cost of $4,200 (compared to $7,200for RTC, $6,000 for juvenile detention, $18,000 forpsychiatric 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 ASFAwell-being outcomes

Dawn Project Cost Allocation

How Dawn Project is Funded

DAWN Project Indianapolis, IN

Management Entity:Non profit behavioralhealth 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

Life DomainsHealth/medical

Safety/crisis

Family/relationships

Educational/vocational

Psychological/emotional

Substance abuse

Social/recreational

Daily living

Cultural/spiritual

Financial/legal

Dawn Service Array

Behavioral HealthBehavior managementCrisis interventionDay treatmentEvaluationFamily assessmentFamily preservationFamily therapyGroup therapyIndividual therapyParenting/family skills trainingSubstance abuse therapy, individual and groupSpecial therapy

PsychiatricAssessmentMedication follow-up/psychiatric reviewNursing services

MentorCommunity case management/case aideClinical mentorEducational mentorLife coach/independent living skills mentorParent and family mentorRecreational/social mentorSupported work environmentTutorCommunity supervision

Dawn Service Array, Continued

PlacementAcute hospitalizationFoster careTherapeutic foster careGroup home careRelative placementResidential treatmentShelter careCrisis residentialSupported independent living

RespiteCrisis respitePlanned respiteResidential respite

Service CoordinationCase managementService coordinationIntensive case management

OtherCampTeam meetingConsultation with other professionalsGuardian ad litemTransportationInterpretive services

DiscretionaryActivitiesAutomobile repairChildcare/supervisionClothingEducational expensesFurnishings/appliancesHousing (rent, security deposits)MedicalMonitoring equipmentPaid roommateSupplies/groceriesUtilitiesIncentive money

NJ Children’s System of Care Initiative

CHILD

Screening with Uniform Protocols

Child Welfare

JJCCourt

SchoolReferral

Community Agencies

Family

& SelfOther

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

FSOFamily 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 WelfareServices & 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 SystemsOf Care

•Reduction in inpatient hospitalization and residentialtreatment placements and lengths of stay•Reductions in detention rates•Reductions in out-of-home placements and lengths ofstay•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 andBehavioral Disorders, Oxford University Press•Kaufman Foundation, Closing the Quality Chasm in ChildAbuse Treatment: Identifying and Disseminating Best Practices, www.kauffmanfoundation.org•Wraparound Milwaukee ([email protected])•Dawn Project ([email protected])•Coordinated Care Services, Inc. ([email protected])•Massachusetts Mental Health Services Program for Youth([email protected])•Youth Villages ([email protected])

mailto:[email protected]


ProcessProcessHow system builders conduct themselves

StructureStructureWhat gets built (i.e., how functions are

organized)


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

TutoringParent Support,

etc.

Treatment Foster Care

In-HomeServices

Crisis Services

Out-patient services

Primary Care

Alternative School

EH ClassroomRelated 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


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”CHALLENGE BARRIER BUSTERS

Language differences: Mental health jargon vs.

court jargon

• Cross training• Share each other’s turf

• Share literature

Role definition: “Who’s in charge?”

• Family driven/accountability• Team development training

• Job shadowing• Communication channels• Share myths and realities

Information sharing among systems

• Set up a common data base• Share organizational charts/phone lists

• Share paperwork• Promote flexibility in schedules to support attendance in

meetings

Addressing issues of community safety

• Document safety plans• Develop protocol for high-risk kids

• Demonstrate adherence to court orders• Maintain communication with District Attorneys

• Myths of “bricks and mortar”

Maintaining investment from stakeholders

• Invest in relationships with partners in collaboration• Share literature and workshops

• Track and provide meaningful outcomes

Sharing value base • 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 valuesWraparound Milwaukee. (1998). Challenges to collaboration/“barrier busters.” Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch.

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


LEVEL STRUCTUREPolicy 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 ProcessesAre staffedInvolve key stakeholdersInvolve families early in the process and in ways that are meaningfulEnsure meaningful representation of racially and ethnically diverse

familiesDevelop and maintain a multi-agency focusBuild on and incorporate related programmatic and planning initiativesContinually seek ways to build constituencies, interest, and investmentPay 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 CommunityCross Agency

The System As It Is Now

Outcomes For

ChildrenThe

System As It Should

Be

Principles

ReinvestmentCommitment

Financing Options

Combined Fiscal Program Strategy

------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------

GovernanceStrategy

StateCounty

Community

Action Plan Political Strategy

Multi Year Steps

Strategies for InvolvingParents 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 andsupport 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


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 DirectorsFamily/Youth Reps.

Providers Forum

SOC Team Leader

“Bring the Children Home”Interagency Care Management Team

“Bring the Children Home”Care Managers

Families/Youth ServedOther 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 PlanningScreening

• 1st 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 …


Distinctions Among Screening, Assessment and

Evaluation, and Care Planning


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 careplanning 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 ServicesYou’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

Number ofScheduled

Office Visits

Number ofHours

Spent inOffice Visits

Number ofHours Spent

Traveling to andfrom Office Visits

Number ofMiles

Traveledfor Care

69:6

105:8

29:6

1250:180Time 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.

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 managementNo “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 SupportImproved 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.

ee

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 populationsof youth for whom you want to change practice/outcomes

•Adopt a Cross-Systems Approach: What other systemsserve these youngsters; who controls potential or actualmatch dollars; which systems now spend a lot onrestrictive 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


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


Examples of Cross-System Partnerships to Financeand Implement Evidence-Based and Promising Practices

District of Columbia – MST, Mobile Response, In-HomeMedicaid Rehab Option pays for MST, Intensive Home-Based Services (Ohio model), Mobile Responseand Stabilization Services (NJ model)Child Welfare provides match and paid for initialtraining, coaching, provider capacity development;Mental health/child welfare share costs of outcomes trackingJuvenile Justice now paying match, training costs as wellMedicaid HMO expressing interest in Mobile Crisis


New Mexico - MSTMedicaid managed care pays for service costs of MSTJuvenile Justice pays for training/coaching/fidelitymonitoring


Hawaii – Range of EBPsMedicaid managed care, Education special ed, mental health general revenue/block grant pay for range ofEBPs, training, monitoring



New Jersey – In-Home, Mobile Response, Intensive CaseManagement, Family Support Medicaid Rehab Option pays for in-home, MobileResponse and Stabilization, intensive case management,family supportChild welfare contributed match dollars

Tennessee – MST, Multi-Dimensional TreatmentFoster CareMedicaid managed care and mental health GR pay forMST and MDTFCPires, 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 OptionsPre-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 TOSYSTEMOF CARE

HIGHESTRISK

LOWESTRISK

RISK TOPROVIDER

LOWESTRISK

HIGHESTRISK

TYPE OF CONTRACTINGARRANGEMENT

•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


A Developmental Training Curriculum

TRADITIONAL MODIFIED INTEGRATED UNIFIED

SYSTEM

PROGRAM

State systemsdevelop trainingalong specialtyguild lines –Promotion of stronger specialtyfocus

Communityagencies anduniversitiesoperate in isolation

Disciplines trainin isolation fromone another

Instruction isdidactic, “expert” No support for cross-training

State systemsindependentlyadopt similarphilosophy,promotingCollaboration

Communityagencies andUniversitiesbegin jointresearch andevaluation

Pre-servicetraining remainsseparate fromthe field

State systemsbegin sharingtraining calendars

Promotion ofcross-training; joint funding

Communityagencies anduniversities beginto integrate fieldstaff/families intopre-service training

Student field place-ments cross agencyboundaries

Cross-agency training gains support

State systemspool trainingstaff, mergetraining events

Communityagencies anduniversitiescollaboratewith largercommunity, e.g. families as co-instructors;curricula reflectpractice goals

Training gearedto 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 Participationin professionalconferences onindividual basiswithin agencyboundaries

Services areprovided withinagency boundaries

Staff receivetraining thatpromotescollaboration,but receive itwithin agencyboundaries Specialty focuspredominant

Services remainwithin agencyboundaries

Serviceteaming ispromotedthrough cross-agency training

Service teamswith full familyinclusion are thenorm

Redefined specialtypractice roles developto supportprofessional identitywhile promotingcollaboration

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

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

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 systemsand 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


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 PrimerContact:

Mary Moreland, Publications ManagerGeorgetown University National Technical Assistance Center for Children’s Mental Health202 687-8803E-mail: [email protected]

For Further Information About Building Systems of Care, Contact:

Sheila A. PiresHuman Service Collaborative202 333-1892E-mail: [email protected]


building systems of care: critical structures and processes

Documents

building systems of

care planning

system of carepires

system of carecare management

service delivery

severe emotional disturbances

childrens mental health

national origin