This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Annual Report to Congress on the Evaluation of the Comprehensive Community Mental Health Services Program for Children and Their FamiliesYear 3 System Assessment Findings: Partnerships in ActionSystem-of-care development can best be described as a process of developing partnerships and collaborations (Bruner, 1991). Because of this, findings from the Year 3 system-level assessment focus on the issue of partnerships. Partnerships are made up of relationships between service providers, families, teachers, and others who care for a child. These partnerships engage in building systems of care based on a set of guiding principles and a theoretical foundation. Since systems of care, by definition, are tailored to make use of a community’s particular resources to meet that community’s specific needs, the relationships built in each system will be varied. Each must form partnerships within the context and diversity of their communities, and each system formed will reflect the considerable diversity among the communities. Similarly, the developmental trajectory of each system of care will be unique, but through the evaluation process, similarities in the stages of maturation among grantees have been identified. Research on partnership development describes three stages that characterize collaborative relationships: formation, growth, and evaluation (Kagan, 1991). Some of the underlying characteristics of community-based systems of care had already formed and were in periods of growth prior to funding in many grantee sites. The awarding of Federal funding marked the beginning of new opportunities to re-form old relationships and to engage and develop buy-in with newly formed community partners as Federal resources became available to enhance system growth. The 3 years of annual visits during the system assessment process show that the grantees have generally followed these stages of development, and that the length of time they are supported by grant funds influences progress along this continuum. Formation. The first stage, generally observed in the first year of grant funding, was a time of formation. Some of the sites had previous CASSP grants, which allowed them to develop a few collaborative services and tenuous management structures. The CMHS services initiative grant supported these sites to continue to expand the scale of these efforts with the ultimate goal of creating a system of care. For most grantees, the first year was used as time to plan and organize an entire system. They began to create the structures needed to support a system of care and to design and develop comprehensive service systems. At the time of the system assessment site visits in 1995, when grantees had been funded for 9 to 12 months, nine of the systems of care were completing the planning stages and had not yet begun serving children and families. Several other grantees had just begun to enroll children into services and were providing care to a small number of children they planned to continue to serve in the system of care. Growth. During the second year, most grantees entered the growth stage, as they were beginning to operate as systems of care with processes in place. The newly formed structures and services were serving children and families in all sites. System-of-care goals and principles were being implemented, and grantees were learning to work with families and communities in ways they never had before. Many participants’ enthusiasm for the system-of-care principles was evident during the site visits, and efforts were made to implement changes focused on utilizing these principles. Creative ideas were generated and growth was apparent—interagency, community-based structures were formed; new programs were crafted; and successes were occurring. For example, in Napa County, representatives from the public agencies met with family groups to assess and revise existing services and operating policies as well as to develop new services. Common intake processes were initiated, support groups were formed, and services such as driving classes were started.
Evaluation. During the third year after the grant award, most grantees had created services and were in the process of implementing, expanding, and evaluating the need for refining the system of care. Tasks that everyone agreed upon and those clearly stated in the grant application, such as starting a family organization and establishing a case management system, were completed. While agreement remained on general ideas, divergent opinions began to emerge as substantive changes in policies, procedures, and operations were faced. Through their continued participation, the participants recognized they had different perspectives on issues, and roles and responsibilities were questioned. For example, in at least three systems of care, questions arose regarding overtime pay for teachers attending interagency meetings after school or during the summer. The participants recognized that just being present was not enough; they had to form working partnerships among agency representatives, families, and community members. As suggested in the literature on collaboration (Himmelman, 1993), by the third year of working together, grantees found that building partnerships required that each partner share resources and trust the other partners to accomplish system-of-care goals. Further, with each step they took towards creating partnerships, the more they realized that more extensive efforts would be needed to nurture and sustain those relationships. Agencies must give up turf and change traditions, professionals must give up authority, and families must put aside past experiences and be willing to risk forming alliances (Abbott, Jordan, & Murtaza, 1993).
Also by the third year, most systems of care recognized the need to add new partners to grow and develop. As the systems of care were first forming, some of the child-serving agencies and community organizations were willing participants, but others were not. The systems of care were able to build on this voluntary participation to a certain extent, but eventually the missing agencies caused gaps in services for some families. For example, sites found that many of the school systems operating in the catchment area were not fully participating. The system grantees recognized the need to expand outreach to develop these partnerships. By the third year, most systems of care had begun reaching out to add new partners.
In addition, the need to forge partnerships became more critical to the grantees in the third year since the Federal grant funds would be decreasing over the years to come. To sustain the new programs and ideas, they needed to have effective partnerships to share the costs. Partnerships were recognized as key to accomplishing the tasks necessary to improve efficiency, such as reducing cross-agency duplication. For example, in several California sites, social service and juvenile justice programs providing counseling to youth were merged as a result of system-of-care initiatives.
All of the sites visited in 1997 were in the process of partnership building, working toward their goal of creating a fully developed system of care. Few systems of care began new large-scale programs, though several restructured their operations. Developmental changes occurred. Findings from system development site visits reflect the successes and challenges grantees faced in creating and developing partnerships among agencies, with families, and with their communities. They also highlight the creative relationships grantees have developed through their local efforts and with the support of the CMHS initiative. This section of the report examines how partnerships have formed the basis for a strong infrastructure and improved service delivery, the two overarching domains that comprise systemness. Within each domain, selected attributes are discussed that best highlight how these partnerships have become established and developed over time. Building Infrastructure Through Partnerships The infrastructure domain includes the organizational arrangements and processes that together provide the overall framework and foundation of the system. These arrangements and processes illustrate the strengths of the partnerships created through the system of care. According to Macbeth (1993), strong partnerships will create a stable but flexible infrastructure that is able to withstand changes and support growth, whereas weak relationships will result in fragmentation and rigidity, and thus limit the provision of comprehensive services. Ten attributes comprise the system-level infrastructure. Infrastructure is driven by a set of goals shared among the core child-serving agencies, service providers, and families. These partners share a defined target population that is comprised of children and families in need of services, and the geographic catchment area to be served. The system is community based and governed by an empowered interagency structure whose members work as partners to develop a service array that is both comprehensive and tailored to build on the strengths of families and the community. Human resources, trained staff and volunteers, are developed among the partners to meet these goals, and case review occurs to ensure that a broad array of community-based services are provided for the children and families. Partners establish and share information through communication networks. In addition, funding patterns are established that pool and share resources to support integrated, individualized services. Finally, evaluation is used to monitor system development and progress in order to provide continuous quality improvement.
During the course of the 3 years of this evaluation, grantees have made significant progress in developing their infrastructures. Two attributes of infrastructure have been selected to illustrate how partnerships manifest in systems of care; interagency structure and service array are highlighted on the following pages. Interagency structures embody many of the other attributes, as they are often the central mechanism for establishing goals, target population, and communication patterns, and are the forum for decisionmaking related to human resources, funding, case review, and use of evaluation data. The service array attribute shows how partnerships manifest in comprehensive unified program development. Interagency Stuctures In a system of care, an interagency structure is the most direct embodiment of the principles of partnership. An interagency structure is defined as a consortium of core child-serving agencies, providers, families, and community representatives to provide governance, program planning, budgetary authority, and evaluation. In a mature system of care, the interagency structure operates in a systematic manner (e.g., holds regular meetings, has formal by-laws). Participant roles and functions are defined and institutionalized as specified in formal interagency agreements (The National Network for Collaboration, 1995). By the second year of operation, all of the grantees had established some type of interagency structure that had at least an ostensible family presence. While the establishment of a structure was notable, the effect of the newly formed groups was often nominal. Participants were at the table, but often were not making decisions that resulted in system development. Respondents reported that meetings were often dominated by issues relating to a single family situation, rather than changes in policy. In almost all cases, their roles and responsibilities were unclear. Participants described the meetings as information-sharing events, often led and directed by the project director. While this increase in communication was important to them, it was not achieving the role needed to support a system of care. Some participants expressed frustration at the inaction, and in a few instances, the entire structure was disbanded and reorganized.
By the third year, however, several changes had occurred in most grantee sites. Groups had been meeting and participants remained committed to the system-of-care ideal. These systems progressed into the growth-and-implementation stage, as they built relationships and began to understand each other’s perspectives. Similar progressions have been reported in the literature (Magrab, Young, & Waddell, 1985). These groups of diverse individuals with different missions and agendas had decided to take on more active roles in governance and had begun the transition into partnerships. Over time, in many sites the concept of partnership became institutionalized, reflective of changes that occurred within the leadership of the interagency structure. Initially it was common for a key leader to spearhead the efforts to bring the participants together. This key person gave direction and vision. However, as the relationships developed and strengthened, the dependance on a single leader lessened and other leaders emerged. These leaders, having come from a shared framework, tended to work collaboratively with their partners in reshaping and detailing the vision. By the third year of the grant, several systems of care had instituted processes for sharing management responsibilities among the partners, such as rotating the leadership positions among the agencies and creating committees and subcommittees with different leaders. The success and strength of these organizations is evidenced by the fact that in several sites key leaders left the system, but the system of care continued to develop its interagency structure. Agency Partnerships In most of the sites, the relationships among public agencies have continued to develop in two significant ways. First, the depth of the involvement of the existing partners continues to grow. Partner agencies move from attending meetings to obtain information, to nominally supporting specific activities, to substantively changing their operating procedures to reflect system-of-care values, to sharing resources, including funding. Consistent with theories of system integration (Konrad, 1996), as the level of partnership increases, more members of the partner agency staff at all levels are affected, which, in turn, results in more changes and the development of more relationships.
Another way interagency relationships have grown is the inclusion of more agencies as partners. Almost all systems of care report adding new agency partners to the system of care during their third to fourth year of funding. Typically, sites report adding representatives to the interagency structure from substance abuse agencies, education, and juvenile justice. By Year 3, all systems of care had at least one representative from education on the structure, almost all had a representative from juvenile justice, and almost half had participation from a substance abuse agency. Involving these agencies has often required concentrated outreach efforts. For example, in COMCARE, in Wichita, Kansas, system-of-care representatives repeatedly met with staff from the juvenile court system. By educating the court staff about services offered by the system of care, they worked together to develop a partnership. In another example, in the Multiagency Integrated System of Care (MISC) in Santa Barbara County, California, only one school system joined the system of care initially, thereby limiting services to children in other areas of the county. The system of care worked with the other school systems, showing through evaluation data reports, that children benefit from the services. Additional school partnerships were forged, and services expanded.
Over time, public agency participation on interagency structures increased, but respondents also became more aware of the need for all child-serving agencies to participate to serve children fully. Most systems of care report that they need to strengthen relationships with certain agencies and organizations, particularly to involve schools fully. Although some sites, for example, the Three Townships in Illinois, show that effective collaborations with education are occurring, several other sites continue to struggle with developing partnerships with education. Multiple school district issues are part of the problem in many places, but often there are additional barriers. The different hours and school year schedules affect the willingness of education staff to participate in system governance. The high financial cost of special education services, which cannot be supported or sustained by CMHS grant funds, is also seen as a barrier for some. While relationships among agencies have been increasing, agency representatives often report that they face conflicts in agency mandates that limit their abilities to develop partnerships. For example, in some systems, the child welfare agency may see its charge to protect children as difficult to reconcile with the system-of-care approach to involve families fully. Similarly, agencies such as juvenile justice and law enforcement have a mandate to protect the public, and the need to confine or incarcerate can conflict with system-of-care values such as providing services in the least restrictive environment possible. In most systems of care, the public health department has no existing programs to serve school-age children, and thus, health departments are frequently seen as marginal to the systems. As other studies have shown, these barriers can be difficult for systems of care to overcome (Skiba, Polsgrove, & Nasstrom, 1996). Family Partnerships According to theory, governance structures within systems of care should include families as partners. Reflecting this, the CMHS grant requirements mandated a family presence on the interagency structure. However, in some systems of care, the idea of including families in system-level decisionmaking was new. Initially, for many grantees, a single family member was drafted to serve as the sole family representative at meetings. Most agency managers had not worked as peers with family members before, and this often created discomfort for both. Building meaningful, respectful partnerships with families, in which their perspectives are valued and their voices are heard, takes long periods of time. In some sites, even agency managers who believed in empowering families found it difficult to find a common language and fully understand how to work with families. In one site, respondents reported that they even created a policy that eliminated acronyms from meetings since acronyms were not familiar to family representatives. As other research shows (Quinn & Cumblad, 1994), before relationships could be developed, agency leaders and families had to take time to work together to translate ideas, define roles, and build, or rebuild, relationships based on common goals and objectives. At the same time agency managers were learning to work with families as peers, families were learning about the roles they can play in the system and what rights they should expect. Family organizations, many of which had not existed prior to the grant, developed and grew stronger. Helped in part by the networks created through this grant, and supported by technical assistance provided by national organizations such as the Federation of Families for Children’s Mental Health, leaders in the family organizations emerged, and the organizations began to involve families more fully in the system of care. These organizations began to play key roles by providing services and advocacy.
Despite slow beginnings, by the third year of operation, the majority of interagency structures had instituted mechanisms to solicit and integrate family input. These mechanisms included holding evening meetings so that more family members could attend, postponing meetings when families were not there, banning the use of professional jargon, providing an orientation to the interagency structure for new members, pairing new family members with more experienced members, establishing ground rules for interaction to ensure that all participants have equal input, and offering child care. Some grantees, including the South Philadelphia Family Partnership in Pennsylvania, Wings for Children and Families in Maine, FRIENDS in Mott Haven, New York, and Olympia in Las Cruces, New Mexico, acknowledge the value of family members’ time by providing case stipends for attendance at interagency structure meetings. Further, through the grant, family representatives attended training events and conferences, building their skills to be full, active partners. Families and their system-level partners often describe how they have begun a continual learning process, valuing their partnerships as they find new ways to expand the system of care.
Over time, roles for the family organizations have grown in the systems of care. For example, family organizations offer trainings for families in issues related to systems of care in almost half of the sites. Families provide training to professional staff in over a third of the sites. Families also participate in hiring decisions in some sites, and in Minot, North Dakota, families are present during the provider-contract review process. The family organization in Sonoma County, California, is an excellent example of the evolution of a family organization from a new entity to a full partner. Families of children with serious emotional disorders did not have an active organization in Sonoma County at the time of the CMHS grant award. The system of care initiated a Family/Professional Partnership Development Plan, with the goals of involving families as full partners in every aspect of the system of care and ensuring that family participation reflects the diversity within the community. The plan created a committee composed of agency staff and families whose mandate is to promote family-centered services and family empowerment as well as to evaluate the plan. Supported by grant funds, a parent of a child in the system was hired to start a support group, and as the support group grew, it helped advocate for families. Family members, youth, and family advocates are now represented on the Mental Health Board, and families are included in all levels of policymaking, including the interagency structure and the grievance structure. There are also training opportunities for parents in system-of-care principles, policies, and procedures. In response to the growing need, five family advocates have been hired. Their offices are located at mental health agencies, but they have their own direct telephone lines so families can reach them directly, without speaking to an agency staff member. The advocates work closely with mental health and probation agency staff to provide services to families. As the partnerships forming interagency structures recognized the need to broaden agency participation, they also recognized the need to involve more families. Most systems of care now include more than one family representative. In addition to increasing the presence of families overall on the structure, more representatives are better able to represent the diversity of families served by the systems, which protects against overburdening and overwhelming individual family members.
While family involvement at the system level has been increasing over time, challenges remain. Families are advisors in some systems of care, while they are full voting members in others. Many families with different cultural needs are excluded from participation, as will be discussed below. A few systems of care continue to have a narrow definition of family involvement and limit participation on the interagency structure to a few carefully selected family members who will not create conflict or disagreements. In these systems families and family organizations are still struggling to establish their role as full partners. Community Partnerships Another goal of many of the systems of care was to extend their partners beyond the core public agencies. While this goal expands the system-of-care principles beyond their original intent, these systems wanted to involve the entire community in caring for their children. To this end, systems had to create relationships with private agencies and providers, civic groups, businesses, communities of faith, and other community-based organizations (The National Assembly of National Voluntary Health and Social Welfare Organizations, 1991). During the first years after the grant award, only a few systems of care even nominally included community participants on the interagency structures, and then typically only organizations that had a direct stake in the system of care. By the third year, the partners on the interagency structures had recognized this gap and were actively soliciting more community involvement.
During their third year of operation, over half of the sites reported that they had made concentrated efforts to develop community partnerships. For example, seven sites now work with the Boys and Girls Clubs to offer services to children and their families. Six sites partner with the United Way to expand the service options for families, and three sites have forged new relationships with Big Brothers and Big Sisters to provide services to children. In most of these sites, a family organization played an important role in conducting these outreach efforts. For example, in Lane County and Solano County, family organizations have organized speakers who share their experiences with civic and community groups. Both Providence, Rhode Island, and Mott Haven, New York, have focused presentations to churches, bringing them in as formal partners in the system of care. In North Carolina, system-of-care representatives have made presentations to local businesses to invite them to become partners in and provide resources for the system of care. In Solano County, a collaboration with the Private Industry Council has resulted in a vocational counselor being hired at the system of care’s alternative high school. A few systems of care have created comprehensive programs with community partners. In Providence, Project REACH Rhode Island is a partnership built on and centered at the John Hope Settlement House, a United Way agency community center that offers an array of educational programs, recreational activities and social services. Through the initiative, the system of care added services such as behavioral services for preschool children to complement existing services. In Philadelphia, the Kinship Family Center at McDaniel School is a partnership of the mayor’s office, the schools, the family organization, and other child-serving agencies. Managed by the family organization, the Kinship Family Center is located in the school and offers integrated services on site, including family support, parent education, child development, physical and mental health services, early-intervention case management, and community/volunteer services. In Mott Haven, the system of care’s partnership with the community organization Banana Kelly has created a youth leadership program. Participants in the program attend training sessions on major issues facing youth today. In turn, they become trainers and role models to other youth. The FRIENDS project provides a stipend to all youth who participate. Although much progress in building relationships has been made, more progress is needed. Even in the most developed systems, the relationship-building process is ongoing and requires flexibility to adapt to larger community changes. Further, as a system, each decision made by the governance structure or by any partner can directly or indirectly affect the other partners. For example, when the State education policy changed in Hawai‘i, the system of care’s referral and intake process changed dramatically, affecting the mental health agency and providers, families, community outreach, and all of the other public agencies. Similarly, in Philadelphia, the reorganization of the schools into clusters forced the governance structure to regroup and create new partnerships around and within the cluster system. The privatization of child welfare services in Kansas and the subsequent changes to agency-level participation profoundly affected both the Wichita and Parsons systems of care. Service Array One of the main reasons for systems of care to establish interagency partnerships has been to offer a full array of comprehensive, community-based services with adequate capacity to meet the need. No single agency is able to offer a full array of services needed in a system of care and to serve all in need, so partnerships must be formed to provide such services. Range of Services
During the first years of system-of-care development, almost all sites reported several gaps in services. By the third year, most of the sites were offering a full array of services, although about a third of the sites report critical gaps in their service continuum, often related to transition services and day treatment. Over time, partnerships have developed to expand the array of services far beyond the required continuum of care. By the third year of operation, over half of the sites had developed relationships with substance abuse service providers to add these services to the array. Six sites had formed associations with Head Start to offer early intervention services, and another seven sites had formed relationships to address the needs of young children. (Charleston, South Carolina’s exceptional program is highlighted in chapter IV.) Four sites had developed partnerships with agencies to offer job training programs. In Santa Barbara County, MISC is working with the Department of Vocational Rehabilitation to explore ways to create employment opportunities for children and their family members. Several of the partnerships with family organizations have led to the family organizations becoming direct service providers, thus filling a community need. For example, in Ventura County, the family organization holds the contract for providing respite care. Wraparound Milwaukee hires family partners to provide mentor services. By the third year of operation, most of the system-of-care sites were operating collaborative programs among agencies. Some of the most exciting and promising programs have emerged from relationships with juvenile justice. Some of these programs are highlighted below.
Sites are also creating new relationships with education agencies. School-based partnerships provide therapeutic support to children within the context of the school day, promoting social interactions and academic development. The following systems of care are examples of some of the collaborative projects being implemented.
Service Capacity In addition to adding to their service array, all sites made progress in expanding their capacity during the first 3 years of funding. This was accomplished primarily by hiring additional staff, contracting with community providers, and partnering with other agencies to respond to the growing demand for selected services that were available but already at or over capacity. Although sites have expanded service capacity in general, respondents in all of the sites report that additional children are in need of services. A few sites have reached the capacity for entry into the system of care. In these sites, priorities have been set and some families in need of services are often put on waiting lists or told to apply later. These sites have ceased public outreach and are concentrating on serving those already in the system, while seeking to develop relationships with other agencies and organizations to enable them to continue services after the grant ends. Respondents in virtually all of the sites report the need to expand capacity for selected services. Respite services are in very short supply in most communities, and most of the sites need additional therapeutic foster care services. In several sites, system-of-care managers are working to develop additional partnerships with family organizations and social service agencies to develop these services; however, barriers must be overcome to provide adequate capacity. For example, several respondents cited State-level policies regarding liability and licensing issues as barriers to developing these programs. To address such State-level challenges, an additional level of relationships must be cultivated. Improving Service Delivery Through Partnerships System-of-care partnerships at the service delivery level are formed around each child and family to address their individual needs. Research has shown that these multi-level collaborations are needed for effective system building (Bruner, 1991; Quinn et al., 1994) and that relationships at the infrastructure level support and promote teamwork at the service delivery level by providing staff and resources that can be accessed when needed by the families (Nelson & Pearson, 1991). System-level partnerships define who will be partners and what resources the partners can access in serving the families. For this analysis, the service delivery domain focuses on the actual provision of care to children and their families. Service delivery at the child and family level is characterized by six attributes. Service delivery is managed through a case management process that assures coordination of services, monitors progress, and facilitates a match between the individual needs of children and families and the types and intensity of services available to them. Services are accessible to the children and families, and service delivery coordination occurs systematically across agencies. Services are provided in a family-centered manner, such that families are involved in all decisionmaking processes. Services are individualized, and service planning is tailored to each family’s unique strengths and needs. Finally, culturally competent services are provided, showing sensitivity and respect to the cultural differences of children and families. While sites have generally made improvements in all of the attributes related to service delivery, the following section highlights the improvements in the coordination of services through the use of case management systems, interagency planning processes, and shared mechanisms for providing services, and the increases in family involvement and cultural competence. Case Management
At the service delivery level, partnerships among families and service providers are often facilitated by the case manager. In systems of care, the case management process links families with services, ensuring good communication among the multiple providers. Case management also supports families and helps them identify their particular strengths and existing resources (Skiba et al., 1996). Since the case manager in many ways embodies the system of care for each child and family, as interagency partnerships have broadened and deepened, the role for the case manager has expanded. When the grant was initially awarded, case management approaches had to be redefined and enhanced to be responsive to system-of-care principles. Over time, these case management systems have become more sophisticated as the overall system of care expanded. First, as the partnerships at the system level broadened, case mangers had more access to programs and services offered through the partner agencies. Second, as relationships deepened, the authority of the case managers became more recognized by the partnering agency staff, enabling the case manager to have a lead role in coordinating services. In addition, over time, the staff members working in case management systems learned to build their own networks. Several systems of care have promoted this growth through training and through internal meetings where case managers share information. Sites have implemented a variety of strategies for improving partnerships through the case management process. To promote relationship building at the staff level, several sites have outstationed case management staff to partner agencies. For example, in Bismarck, North Dakota, case managers have offices in the juvenile justice agency, the social services agency, and the schools.
In other sites, such as Santa Barbara County, case management staff from different partner agencies are co-located in a central office. In Wai‘anae Coast, Hawai‘i, the project promotes family partnerships by encouraging them to drive the service provision process and to serve as the facilitators of their wraparound meetings. Similarly, Project REACH Rhode Island hires family members to fill all case management positions. Another way to promote partnerships has been to create formal case management teams. In addition to providing families with more support and continuity, case management teams give the staff members a designated backup, thus reducing stress. Sites are exploring different models of case management teams. Napa County, for example, is creating multidisciplinary teams to work with families to efficiently and effectively provide families with the diverse expertise the disciplines provide. In this county, a child involved in the juvenile justice system may have a case management team consisting of a parole officer and a mental health provider who together would provide links to the resources for counseling and juvenile justice services. Another model is to create teams of professionals and paraprofessionals that provide continuity of care as the families’ needs change. For example, in Baltimore, the team member who is a therapist will work intensely with the family during crises and when mental health needs are most critical, but as the family stabilizes, the paraprofessional team member emerges as the primary contact, working with the family to connect them with community supports. Teams on the Navajo Nation consist of a case manager, a therapist, a family support specialist, and a traditional healer who work together to provide a blend of Western and traditional services to families in their homes. Each team is also supported by a dedicated administrative liaison who facilitates the coordination and communication among the public systems. Individualized Service Planning
The service planning process shows the extent of partnerships in a system of care. Creating a comprehensive, individualized service plan for a family requires all partners to work together well. By the third year of the grant, most of the sites had instituted a cross-agency service planning process that was used with many families. In most of the sites, the individualized service planning process creates a relationship among representatives from many agencies, the family, and sometimes community representatives to work with an individual family. Through this process, representatives from agencies involved with the family (or those who should be involved with the family), service providers, family members, and others selected by the families sit down together and develop a plan of care. In over half of the sites, the family selects who will attend the meetings. Several sites, such as Napa County; Solano County; San Mateo County; Charleston; Burlington, Vermont; and Hawai‘i, have family advocates who accompany the family to the meeting and help them through the process.
Sites have found that developing a service planning format that promotes interagency participation and system-of-care values has been particularly helpful. Some sites have recently developed forms and processes to systematically address a wide range of issues affecting a child’s life, rather than just focus on a single problem, and to specifically involve all of the partners serving on the team. By going through these processes, the partners at the table look at many issues and find strengths to build on as well as needs to be met, and discuss the resources each partner has to address these issues. For example, several sites have developed formats that encourage the service planning team to focus on the family’s strengths and address a range of life domains such as psychological, educational, housing, recreation, spiritual, and financial. Each domain is then assigned to the partner or partners that can best accomplish the goals. Sites developing these types of format include Napa County, Maine, Solano County, Milwaukee, and North Carolina. The format of the service plan in Minot allows partners to indicate whether they agree with the provisions of the plan, potentially increasing buy-in to the process as providers are "allowed" to disagree and record that disagreement.
By accessing the resources and programs offered by the expanding base of partner agencies and organizations, sites have been better able to individualize care. For example, in Milwaukee, dozens of community-based organizations are in the provider network. The resources of these organizations can be accessed through the service planning process. Supplementing the resources of current partners and helping to forge relationships with additional providers and organizations is the use of flexible funds. Often, these funds have been used to access resources from providers offering special services needed by individual children and families. Sites have found that using flexible funds can be a way of introducing the system-of-care philosophy to the community and cultivating partnerships. For example, a karate teacher initially paid by flex funds donated services later. In another example, an art class that originally was paid to teach one student, developed into a series of classes with an art therapy component attached.
Despite the successes of these individualized service planning processes, not every family received coordinated, individualized care tailored to their specific needs. Many children and families in the sites still were not receiving system-of-care services. Some site respondents explained that, due to limited capacity of nontraditional services, tailoring services for each family was not possible. Other respondents explained that not all case managers were aware of the full array of services and therefore did not access them for the children and families they serve. Further, some families had not received needed services because the system of care failed to involve the necessary partner. For example, one child received coordinated, planned, comprehensive services in eighth grade, but the school she attended in the ninth grade was not a system-of-care participant and thus school-based services were no longer possible. Coordinated Process One of the best illustrations of how partnerships are manifested is through cross-agency coordination of a child and family’s services. The research shows that such coordination efforts reduce barriers to services (Nelson et al., 1991) and initially, when systems of care began, the idea of coordinating processes among core agencies was seen as an ideal. Over time, the complexity of implementing this ideal has tested relationships. But by Year 3, over half of the sites had developed routine processes and mechanisms that enabled them to deliver services in a coordinated manner. Several sites have developed specific mechanisms to improve coordination among partner agencies. Solano County’s common, over-the-phone intake process is cited as being family friendly as well as being a one-stop coordinated process. In the past year, the capacity of their intake system has increased significantly. In Baltimore, a universal intake form is used at all the partner agencies, facilitating cross-agency communication and reducing duplication. Mott Haven uses a uniform case record format, which ensures that assessments and service plans are consistent, documented, and uniformly developed and include elements such as families’ strengths. Bismark and Charleston currently use a common service planning form in all of the system-of-care agencies, and Napa County is in the process of designing such a form. Similarly, the system of care in St. Johnsbury uses a multi-agency release form that enables partners to share information easily. In several sites, the partner agencies have created staff positions to increase coordination. In Baltimore, special positions were created in each of the partner agencies. Outstationed individuals holding these positions acted as liaisons with the agencies, working with cross-agency staff and managers to solve problems and help coordinate services. In North Carolina, a staff person had been designated to solve cross-agency coordination issues at the system level. Using information obtained from the intensive quality assurance process that identifies coordination problems, the person then works with the agencies to eliminate the barriers. Although these mechanisms were cited as useful, developing an institutionalized system for multi-agency coordination has been difficult. Agency patterns for service delivery were firmly established in policy as well as in agency culture. As one respondent described it, the "agency processes are entrenched." To help increase coordination, sites such as Lane County, Napa County, and Santa Barbara County had physically relocated staff from a variety of participating agencies into one central area. In other sites, such as Ventura County, outstationing system-of-care staff into other agencies had been used as a strategy to improve coordination. Both of these strategies were praised for facilitating informal and ad hoc information sharing. Family-Focused Partnerships In some sites, the movement to include families at the service delivery level predates the implementation of the system-of-care model, and the emphasis on family involvement has been growing substantially through the course of this grant. By Year 3, virtually all sites reported an ongoing shift in philosophy that has resulted in families becoming increasingly involved in their child’s care.
Family respondents across almost all of the sites report a major change in the respect they receive from at least some professionals in the system of care. Although problems remain, the families repeatedly praised the changes that have been made over time. Families report being listened to and not blamed. Many families acknowledge that their strengths are addressed as well as their problems. Families are often given choice in services. They feel supported and they like having a case management system as the central point of contact. Often, the continued problems families report are focused on agencies and professionals that have not been integrated as partners in the system of care.
One of the most significant changes that has occurred through this initiative has been the emphasis on in-home services. By working in families’ homes, professionals see what the family sees and share the experience. This creates a common, equal ground for relationships to develop. Bringing services to the home also increases access for families and reduces concerns regarding transportation.
Another significant change over time has been the expansion of the definition of "family." As system-of-care principles have been implemented, sites recognized that the former definition of family, typically limited to the child in treatment and a legal parent (usually the mother), was inadequate. Systems of care began to ask families who should be included as "family." Grandparents, uncles, aunts, stepparents, siblings, cousins, and even close family friends emerged as family, creating new challenges and new opportunities to forge partnerships. Some sites report noncustodial parents being invited to join as partners in their child’s care. The existence of these extended family systems forced systems of care to redefine "family" in order to capitalize upon the strengths, resourcefulness, and resilience of the more complex, nontraditional model. Most systems of care responded to the expanding definitions of family by implementing services designed to address the needs of the whole family. Family therapy and respite care are commonly offered, as are parenting classes. The majority of sites routinely include siblings and extended family members are routinely included in social and recreational activities. Several grantees have addressed the service needs of the whole family by creating special ways to incorporate extended families as partners. Philadelphia offers special services to grandparents, Solano County offers support groups for siblings, and the Navajo Nation extends the concept of family to include support through clan relationships.
Support groups and services for families have also increased as a result of the CMHS grant. Well over half of the sites have active family support organizations. All offer group meetings, and many offer special events. For example, in Hawai‘i, the family organization hosts social dinners that are attended by hundreds of families. In Bismarck, the family organization holds family support group meetings and monthly pot-luck dinners that are open to families who are involved with the system of care as well as other families with similar concerns. Similarly, family picnics are held in Solano County. These activities are essential to helping families connect with each other and establish their own support networks. However, many families still report they are unaware of such support. Families with special cultural needs often find these needs are not currently met.
Cultural Competence System-of-care theory requires services to be delivered in a culturally competent manner, and all sites acknowledge that goal. Initially, in most of the sites the goal was interpreted vaguely and little action was taken. Over time, the understanding of this principle emerged as sites recognized the importance of culture in providing individualized care for families. By building relationships with families and with community-based organizations, most of the sites have improved their cultural competence.
One of the major changes has been the recognition of the complexities of culture. In sites with a racially diverse target population, cultural issues were more obvious, but as systems of care began operating more fully, the diversity of cultures within the same racial and ethnic groups became more apparent. Sites began to recognize additional dimensions of culture such as gender, language, acculturation, and economics. Although the needs of each community differ, sites have developed a variety of ways to build partnerships that have addressed cultural competence needs. Two sites, the Navajo Nation and Wai‘anae Coast, include community elders as full partners on their interagency structures. Recognizing the need to build relationships with communities, seven sites have hired a designated liaison who serves as a link to specific communities. For example, in Parsons, cultural liaisons provide outreach to cultural communities. The liaisons try to destigmatize mental illness by sharing information about mental health and available mental health services. They also display posters and provide pamphlets in the mental health centers that positively emphasize cultural strengths and history (for example, posters of African American leaders and historical figures). They visit local schools to raise awareness about cultural strengths and to identity and host support groups in communities. Similarly, New Opportunities in Lane County has a staff person devoted to multicultural issues. This person has done outreach with organizations in the Hispanic community, provided staff training on cultural sensitivity, and served as a resource person for direct-care staff members. Most of the sites offer cultural competence trainings. For example, the FRIENDS Initiative in Mott Haven has sponsored training efforts that focused on issues such as developing a better understanding of aspects of Hispanic and Caribbean cultures regarding healing and well-being, with a discussion of the role of spiritual healers. Both families and staff were invited to participate in that training. Later in the year, the staff applied what they had learned by inviting a spiritual healer to work with a child and family unit. Similarly, ACCESS in Burlington has worked with its community partners to develop training events on cultural diversity. In conjunction with partners such as Refugee Resettlement Program of Catholic Charities and the Empowerment Zones, many trainings have been held to address the health needs of different cultural groups. Many of the systems of care now offer services, especially case management, in multiple languages. Several sites have established arrangements with community groups to obtain translation services and to recruit new bilingual, bicultural providers. For example, Wraparound Milwaukee uses its extensive provider network to access needed services. A voucher system allows providers with special skills to be integrated into the service system as needs arise. Sonoma County sought and obtained a special grant to collaborate with Southeast Asian and African community organizations to obtain translation services. Several sites have developed special partnerships to improve their ability to meet cultural needs. One example is the collaboration with California State University–San Bernadino on a 20/20 Masters of Social Work program for minority students. This program, which recruits local community members, was developed to ensure a supply of qualified social workers who understand the mental health issues within their community. Through the program, the mental health agency pays the students a full salary; the students attend classes 20 hours a week and work 20 hours a week. Riverside County has also developed a relationship with the University of California to help provide culturally appropriate services. Through the partnership, university students work in a mentoring program with youth at risk for serious emotional disorders. Students also offer a "Saturday School" tutoring program, a tutorial lab for teen mothers, and dance and karate enrichment programs. In addition, a summer academy for 174 ethnically diverse minority children between the ages of 5 and 12 gives them the opportunity to attend a summer program at the university. Mental health agency staff members assist the tutoring/mentoring program by offering individual counseling and direct services to students in crisis. The system of care in Solano County has partnered with the Omega Boys and Girls Club to provide mentoring services. Volunteers experienced in working with youth (especially youth with emotional or behavioral problems) are recruited from the African American community and are trained to serve as mentors to youth enrolled in the project. If possible, mentors and youth are matched by gender. Mentors participate in an intensive 10-hour training event to prepare them to work with the special population that the project serves. Training topics include serious emotional disorders, medications, mentoring skills, conflict resolution, physical education, recreational activities, confidentiality, and drugs (what they look like, street names, and so forth). Mental health agency staff members give presentations to new volunteers, and the family organization provides training to Omega volunteers to give them insight into working with families. Drawing on the strength of the Hawai‘ian culture, the ‘Ohana Project in Hawai‘i, through a Department of Education grant, has established a unique partnership among community organizations that provides funding for the recruitment and training of natural caregivers (community professionals). These caregivers provide culturally competent support to teachers and parents to assist in creating school and family environments designed to foster the psychosocial and intellectual development of Native Hawai‘ian students at risk for serious emotional disorders.
Although these efforts are promising and successes have been reported, most respondents recognize the need to strengthen relationships that reflect the diversity of their communities. Few sites have achieved appropriate diversity among representatives serving on their system-level interagency structures, which affects the overall system of care. Several sites report exceptional difficulties in establishing relationships with their growing Asian and Middle Eastern communities. Virtually all of the sites report difficulties in recruiting and retaining bilingual and, more importantly, bicultural staff, which directly affects service delivery. Although some sites have made progress in addressing these issues, as described above, much more needs to be done. Sustaining Systems of Care Through Partnerships The CMHS grant provides funding for 5 years, with an increased match in the last 2 years of the grant. As the grantees reach the third year of funding, they must focus on how to meet the increased match and how to sustain programs. Although some sites planned for sustainability from the beginning, for most of the grantees, issues of sustainability were becoming critical by the third year and respondents were concerned that services would have to be cut. Respondents were less concerned about their future in only two sites, Riverside and Ventura Counties, where grant funds make up only a small percentage of their overall budgets. Sites have found that partnerships are essential to sustaining the system of care and maintaining value-based services when specific grant funds end. Almost all of the sites have relied on donated staff time and in-kind donations from partner agencies as part of their match. However, as grant funds decrease in the final years, increased commitment from the partner agencies is important. One of the keys to partnerships is thought to be the sharing of resources. However, only a few sites—Stark County, Philadelphia, South Carolina, Alexandria, and Illinois—have been able to blend and pool funds from multiple partner agencies. Several sites, including Milwaukee, St. Johnsbury, Santa Barbara County, the North Dakota sites, and Napa County, are currently accessing family preservation or foster care funds through relationships with their partners. Napa County also receives funds through its partnership with the Department of Probation. Santa Barbara County, Solano County, and Rhode Island receive funds through their partnerships with the public health agencies. Similarly, Hawai‘i and the California sites receive education funds. In the other sites, funding remains basically categorical and thus beyond the control of the system of care’s governance structures. The lack of long-term shared funding is beginning to have an effect in some sites, as the reduced grant funds are affecting long-term decisions. To reduce the long-term funding issues and increase services, several systems of care have created arrangements among partner agencies that were designed to sustain some positions or programs. Several of the sites, including Illinois, Philadelphia, and the North Dakota sites, have instituted cross-staffing of services. Through this plan, two or more agencies agree to fund a staff position that will focus on system-of-care activities. Grant funds are often used to help establish and support these positions at first, allowing the agency to learn how system-of-care principles can help the children and families served. Over time, the agency will assume the full cost of the position, thus ensuring that it will continue. From its inception, the system of care in Santa Barbara County built an approach that expands upon this idea. Partner agencies and schools designate staff to work as care coordinators in the system of care, but remain employed by their respective agencies. The care coordinators have the authority to gain access to the services of any of the partner agencies to provide services to children and their families. Almost all of the sites are planning to use Medicaid reimbursements to help sustain their programs. In order to do this, the systems of care must establish relationships with the State Medicaid agencies. To maximize reimbursements, cross-agency services need to be billable. To this end, two sites described ways they have accomplished this. In North Carolina, an innovative arrangement with the mental health agency allows credentialed coordinators in all of the partner agencies to bill Medicaid for their services through the PEN-PAL Project. Similarly, in Illinois, partner agencies are working together to define services to make it possible to bill Medicaid. In several sites, Medicaid is transitioning to managed care systems, offering some sites opportunities for sustainability. For example, Milwaukee’s system of care became a Medicaid managed care program and receives a capitated monthly cost per child for all services related to mental health and substance abuse. Milwaukee will also receive additional funds to provide services for children in State custody, including the delinquent population of youth with serious emotional disorders. State funds are also critical to sustaining the majority of the systems of care. Several sites have applied for or are receiving State grants. For example, in Maine, Wings was recently awarded a demonstration grant from the State to develop school-linked/school-based mental health services. The grant is a collaborative effort between Wings, a community mental health center, a local hospital, and a local school that entails a small amount of funding for wraparound dollars and donated wraparound facilitator time from each collaborator. Through a program called "realignment," the California sites already receive funds for reducing their out-of-community placement and hospitalization rates. Mott Haven and Rhode Island are working with their State legislatures to establish a similar system. The two grantees in Kansas, COMCARE in Wichita and KanFocus in Parsons, work as partners with the State of Kansas, which established a waiver to support home-based and community-based services by using fund that would otherwise be used to place the child in a residential or inpatient setting. These funds will help sustain both systems of care and promote the development of community-based services throughout the State.
As the need to address sustainability issues has grown, sites have found they need information to present to outside sources, such as their State legislatures and partner agencies. Evaluation data often fills this need. Research has shown the use of evaluation data is effective for sustainability (Friend & Cook, 1990), and several of the sites report that they have used evaluation data in their own efforts. For example, respondents in Kansas, North Dakota, Maine, and Ohio have used evaluation data when making presentations to their State legislatures. Many respondents routinely share evaluation information with partner agencies to show the progress of the system of care and to reinforce continued efforts. |
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