Systems of Care Fundamentals

1. Systems of Care Fundamentals • [Adapted from Sheila A. Pires, Building Systems of Care: A Primer (second edition, 2010)]

2. Systems of Care A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations so services and supports are effective, build on the strengths of individuals, and address each person’s cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life. Gary Blau, Child, Adolescent and Family Branch, CMHS, SAMHSA

3. Family-Driven, Youth-Guided Systems of Care Look Like This 

4. SOC Development, Expansion Focuses on… • Policy Level (e.g. vision, financing, regulations) • Management Level (e.g., data; quality improvement; human resource development; 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) • Individual Level – How can I participate? What am I willing to contribute? Adapted from Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

5. Recovery, Resilience and Transformation What is involved? • Rethinking traditional approaches • Strengths-based • Family driven & youth guided • Embracing culture Who is involved? • Youth • Adults • Families • Providers • Communities Transformation Systems of Care Recovery Resilience Fulfilling Potential

6. Values and Principles for a System of Care • Family-driven and youth-guided • Home and community based • Strength-based and individualized • Culturally and linguistically competent • Integrated across systems • Connected to natural helping networks • Data-driven, outcomes oriented Adapted from Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. Reprinted by permission.

7. Family-Driven Means… Families have a primary decision making role in the care of their own children, as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation.

8. Family-Driven Means That Families Take the Lead Choosing supports, services, and providers;Setting goals;Designing and implementing programs; Monitoring outcomes; Managing the funding for services, treatments and supports; andDetermining the effectiveness of all efforts to promote the mental health and well being of children and youth.

9. Youth-Guided Means… • Youth have rights. • Youth are utilized as resources. • Youth have an equal voice and are engaged in developing and sustaining the policies and systems that serve and support them. • Youth are active partners in creating their individual support plans. • Youth have access to information that is pertinent. • Youth are valued as experts in creating systems transformation. • Youth’s strengths and interests are focused on and utilized. • Adults and youth respect and value youth culture and all forms of diversity. • Youth are supported in a way that meets their individual needs.

10. Youth Involvement in Systems of Care A starting point for understanding youth involvement and engagement in order to develop and fully integrate a youth-directed movement within local systems of care.(see www.tapartnership.org)

11. Examples of Shifts in Roles and Expectations for Family Members and Youth Lazear, K. & Conlon, L. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

12. Cultural and Linguistic Competence: Definitions Culture A broad concept that reflects an integrated pattern of a wide range of beliefs, values, practices, customs, rituals, and attitudes that make up an individual, family, organization, or community. Cultural Competence Accepting and respecting diversity and difference in a continuous process of self assessment and reflection on one’s personal and organizational perceptions of the dynamics of culture. Linguistic Competence The capacity of an organization and its personnel to communicate effectively and convey information in a way that is easily understood by diverse audiences, including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities.  Adapted from Youth Involvement in Systems of Care: A Guide to Empowerment (2006) and Goode & Jones (modified 2004). National Center for Cultural Competence, Georgetown University Center for Child & Human Development.

13. Why Develop Cultural and Linguistic Competence? • To respond to current and projected demographic changes in the United States • To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds • To improve access to services and outcomes • To improve the quality of services and health outcomes • To meet legislative, regulatory, and accreditation mandates

14. Wraparound Process • Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports, individualized for that child and family to achieve a positive set of outcomes. Wraparound does not equal a “complete” system of care. It is only one component. • Individualized care plan refers to the procedures and activities that are appropriately scheduled and used to deliver services, treatments, and supports to the child and family.

15. System of Care Operational Characteristics • Collaboration across agencies • Partnership with families and youth • Cultural and linguistic competence • Blended, braided, or coordinated financing • Shared governance across systems and with families and youth • Shared outcomes across systems • Organized pathway to services & supports • Child and family teams • Staff, providers, families, youth trained and mentored in a common practice model • Single plan of care • One accountable care manager Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

16. Current Systems Problems • Lack of home and community-based services and supports • Patterns of utilization; racial/ethnic disproportionality and disparities • Cost • Administrative inefficiencies • Knowledge, skills and attitudes of key stakeholders • Poor outcomes • Rigid financing structures • Deficit-based/medical models, limited types of interventions Pires, S. (1996). Human Service Collaborative, Washington, D.C.

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

18. Youth in SOC Achieve Positive Education Outcomes • Only 8% of youth in SOC for 12 months had repeated a grade, compared to nearly twice as many American students in the general public (15%) • The percentage of youth receiving passing grades (C or better) increased from 55% upon entry into services to 66% after 12 months of services (20% increase in the proportion of youth who received passing grades) • Within one year of entering SOC services, the percentage of youth attending school regularly increased from 75% to 81% (this improvement means that school attendance for youth with mental health needs in SOC approached the national school attendance average of 83%)

19. Youth in SOC Achieve Positive Education Outcomes • There was a 22% reduction in the percentage of youth who changed schools due to emotional and behavioral reasons after receiving SOC services for 12 months. • Expulsions from school decreased by 2/3 (from 15% at intake to 5%) within 12 months of entering SOC services • 12 months after beginning SOC services, 16% of youth reported significant lower levels of depression and 21% reported significant lower levels of anxiety than when they entered services • Youth suicide attempts decreased significantly within the first 6 months of services, from 13% to 6%. Within 12 months, only 5% of youth had reported suicide attempts (62% reduction after starting services) US Department of Health and Human Services (www.samhsa.gov)

20. Example: Transition-Age Youth What outcomes do we want to see for this population? • Policy Level • What systems need to be involved? (e.g., Housing, Vocational Rehabilitation, Employment Services, Mental Health and Substance Abuse, Medicaid, Schools, Community Colleges/Universities, Physical Health, Juvenile Justice, Child Welfare) • What dollars/resources do they control? • Management Level • How do we create a locus of system management accountability for this population? (e.g., in-house, lead community agency) • Frontline Practice Level • Are there evidence-based/promising approaches targeted to this population? • What training do we need to provide and for whom to create desired attitudes, knowledge, skills about this population? • What providers know this population best in our community? (e.g., culturally diverse providers) • Community Level • What are the partnerships we need to build with youth and families? • How can natural helpers in the community play a role? • How do we create larger community buy-in? • What can be put in place to provide opportunities for youth to contribute and feel a part of the larger community? Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.

21. Fundamental Challenge and Rationale for Building Systems of Care No one system controls everything. Every system controls something. Pires, S. 2004. Human Service Collaborative. Washington, D.C.

22. Strategic Planning “The science and art of mobilizing allforces – political, economic, financial, psychological – to obtain goals and objectives.” Pires, S., Lazear, K., Conlan, L.(2003). “Primer Hands On”: A skill building curriculum. Adapted from Webster’s Dictionary. Washington, D.C. Human Service Collaborative

23. Building Local 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.

24. Core Elements of an Effective System-Building Process The Importance of Being Strategic • 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 Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative

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