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Executive Summary

Volume VI: Building Collaboration in Systems of Care

Introduction

This monograph was developed for the purpose of describing promising practices in interagency collaboration at sites funded by the federal Center for Mental Health Services as part of the Comprehensive Community Mental Health Services Program for Children and Their Families. Traditionally, services for the estimated 3.5 million children and adolescents in the United States who are affected by serious emotional disturbance have been delivered categorically by individual agencies, leaving the service delivery system fragmented, costly and often unavailable to those most in need. Interagency collaboration, the process of child-serving agencies joining together for the purpose of improving services, represents a fundamental reform in the way services to children with serious emotional disturbance and their families are delivered.

The nine sites participating in this study are actively building collaborative processes into their service delivery systems. In spite of the differences in mandate, funding and structure among child-serving agencies, these sites have found the benefits of collaboration far outweigh the investment it requires in time and energy.

They are finding that collaboration helps bridge the complexities of their work, allowing them to be more responsive and effective. As one respondent commented, "Partnerships aren’t a luxury, they’re essential because the problems are too big and too complex."
They are finding that when child-serving agencies focus on the needs of children and families that the agencies share more similarities than differences. As another respondent observed, "the bottom line…is that there is no distinction; the needs of children and families [in different agencies] are not significantly different."
And they are finding that collaboration produces results. Not only are relationships improved among child-serving agencies, but the services they offer are more individualized, less restrictive and anchored in their community. Another respondent, commenting on a documented 48 percent reduction in out-of-home placements that is attributed to their collaborative efforts, made the observation, "Collaboration works for kids and families. And it is cost effective."

Although the sites in this study spoke of their efforts to build interagency collaboration, many referenced "true collaboration" as their real mission. True collaboration is distinguished from collaboration based on rules and mandates that exists in name only. The sites described true collaboration as embodying:

role clarity for families and service providers;
interdependence and shared responsibility among collaborating partners;
striving for vision-driven solutions; and
a focus on the whole child in the context of the child’s family and community.

This study investigates the experience of service providers, administrators, families and community members involved in the Comprehensive Community Mental Health Services Program for Children and Their Families as it relates to their efforts to establish collaborative practice in their service delivery system. The study and its findings are described in more detail below.

Study Design

This study began with a preliminary review of literature about collaboration which pointed out why there is a need for collaboration; summarized attempts to define, characterize and create a framework for collaboration; described common barriers to the process; and described components of successful collaboration. The literature review helped to shape the questions used to interview participants at each of the sites for the purpose of defining, describing, characterizing and creating a framework to describe the process of collaboration at each site.

Ninety-eight interviews were conducted by phone or in person in order to capture participants’ experiences, successes, hopes and concerns for collaborative practice. Respondents included service providers, administrators, families and community members. Participating sites were chosen to reflect the variety of contexts in which systems reform is occurring, including rural, small counties and urban sites.

Five questions guided this research:

What are the components of strong and effective collaboration?
What structural and relational factors contribute to increased collaboration?
How has increased collaboration changed service to children and families?
What supports and impediments have been experienced in building collaboration?
Has collaboration changed the way stakeholders perceive children’s mental health?

Findings

The findings of this study have been clustered into three categories: 1) the foundations of collaboration; 2) strategies for implementing collaborative processes; and 3) the results of collaboration. These clusters represent individual chapters in this monograph and are summarized below.

The Foundations of Collaboration section provides context surrounding early efforts to build collaborative practice. The foundations chapter includes a discussion of strengths upon which collaboration has been built; these include the desire to change and the emergence of strong leadership. This section also presents the challenges faced in building collaboration; these include blame and distrust among child-serving agencies, inflexibility and the fear of change.

The Strategies for Implementing Collaborative Processes section focuses on the strategies that were identified by the sites as the most promising tools for building collaborative practice. These strategies are grouped into three broad categories: 1) structural elements, which include cross-agency governance, formal collaborative groups at supervisory and service levels, formal interagency agreements and collaborative specific staff, the availability of a pool of funds for flexible use, and a commitment to group decision making and joint problem solving; 2) relationship-building strategies, which include starting with a small core group and building strategically from that point, recognizing strengths and limitations of participating agencies, nurturing collaboration by creating win-win situations, providing opportunities for informal networking such as retreats, exerting peer pressure to urge collaboration and encouraging innovation and risk; 3) engaging families and the community in collaborative processes, which includes strategies for increasing the participation of families in service planning and delivery as full partners both at the system level and at the individual case level, and tying the mission and goals of the collaborative to local community issues and concerns.

The Results of Collaboration section identifies positive results of collaboration that can be clustered into five broad categories: 1) improved relationships among child-serving agencies; 2) increased understanding of system-of-care principles; 3) increased relevance of mental health services; 4) improved service delivery; and 5) improved relationships between families and service providers.

Collaboration as a Developmental Process

Stage I: Individual Action

Stage II: One-on-One

Stage III: New Service Development

Stage IV: Professional Collaboration

Stage V: True Collaboration

The Implications For Building Collaboration

This study of collaboration offers the opportunity to consider implications for building collaborative processes in other communities that are striving to build systems of care for children with serious emotional disturbance and their families. The implications of this study can be summarized in three broad statements about the process of building interagency collaboration.

Collaboration must occur at multiple administrative levels within a child-serving agency and across the multiple agencies that provide services for children and families.
Building collaboration is a developmental process that takes time and considerable effort.
The emergence of families as full partners in systems of care is the key to true and lasting collaboration.

Multi-level participation in collaborative efforts. Feedback from the sites participating in this study emphasized the necessity of involving multiple levels of agency personnel in collaborative efforts. Three levels of involvement were identified: agency-level participation, usually involving agency heads in collaborative activity; program-level participation, involving the mid-level managers who direct programs and services; and practice-level involvement for the purpose of ensuring that collaboration is established in the context of day-to day service delivery.

Collaboration as a developmental process. As the sites involved in this study described their experiences in building interagency collaboration, they emphasized the developmental nature of this process. Five stages of development were identified as part of this process, each having defining characteristics and collaborative activities associated with that stage. Although the sites described their movement through these stages as uneven rather than linear, the stages illustrate the move away from individual action and toward collaborative processes.

Families as full partners. Alongside this model of collaboration as a developmental process is a description of the stages of family involvement in the process of collaboration, beginning with families being viewed as clients of the system of care and progressing to the involvement of families as full partners. The stages of development illustrate a move away from considering family members as outsiders to the service delivery process and toward involving families in a collaborative effort. Participants in this study report that this is an uneven process of development and that successfully involving families in decisions that affect service design and policy does not assure family involvement at the level of the individual child.

True Collaboration

The results of this study indicate that the developmental process of interagency collaboration must be interwoven with the process of developing the participation of families as full partners in their system of care and that family involvement must occur at all three levels of interagency collaboration: the agency level, the program level and the practice or direct service level. It is through the emergence of the family as full partner in a system of care that true collaboration can be achieved. The figure on the next page illustrates the four essential components that come together around the whole child for the purpose of improving services for children with serious emotional disturbance.

Essential Components of True Collaboration

Sites that have begun to involve families as full collaborative partners have come to believe that families are the key to sustaining their collaborative efforts. Respondents indicate that family involvement ensures a constancy and consistency in collaborative efforts regardless of administrative, staff and funding changes that affect all child-serving agencies over time. Respondents also indicate that family involvement makes the service system accountable to the family and community in ways that would not otherwise be possible.

Family Involvement as a Developmental Process

Family as Client

Family as Guest

Family as Participant

Family as Full Partner