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Creating a System of Care:A Partnership Between Title V and SAMHSA
Susan StrombergChild, Adolescent, and Family Branch, SAMHSA
Jeffrey Lobas, MDChild Health Specialty Clinics
Gary LippeDept. of Human Services, NE Iowa
Comprehensive Community Mental Health Services for Children and Their Families(Systems of Care)
Susan Stromberg
October 16, 2007
The Comprehensive Community Mental Health Services for Children and Their Families Program
(Children’s Program) Encourages the development of home and
community-based systems of care SOCs meet the needs of children and
adolescents with serious emotional disturbances and their families
SOC communities are administered in States, political subdivisions of States, Native American tribes or tribal organizations, and U.S. territories
Systems of care are developed on the premise that the mental health needs of children, adolescents, and their families can be met within their home, school, and community environments.
These systems are developed around the following principles:
• child-centered• family-driven• strength-based• culturally competent
Additionally, interagency collaboration is embedded within these systems.
Systems of Care
Systems of Care Program Framework Accountability through
outcome evaluation Comprehensive array
of services Cross-agency
coordination Cultural competence Early identification and
intervention
Family partnerships Home and community-
based services Least restrictive service
environments Strength-based
individualized service planning
System of Care Model
CHILDAND
FAMILY
MENTALHEALTH
SERVICES
EDUCATIONAL SERVICES
HEALTH SERVICES
SUBSTANCEABUSE
SERVICES
VOCATIONAL SERVICES
RECREATIONAL SERVICES
OPERATIONAL SERVICES SOCIAL
SERVICES
Children’s Mental Health suffering from a lack of: services for children & adolescents
non-restrictive settings
full community-based service array
interagency coordination
family involvement
cultural competence
Need for SYSTEMS OF CARE!!+
System of Care Core Values
Community based
Child and family focused (family driven and youth guided)
Culturally and linguistically competent
System of Care Guiding Principles
Comprehensive array of services
Individualized care
Least restrictive setting
Family and youth involvement
Service integration
System of Care Guiding Principles
Care coordination Early identification and early
childhood intervention Smooth transitions Rights protection and
advocacy Nondiscrimination
System of Care Concept is…
A framework and guide, not a prescription
Flexible and creative
Adaptive to family and community needs
Consistent in philosophy
Systems of Care
Systems of Care Resilience, Leadership &
Transformation
Leadership
Transformation
Resilience
What is involved? Rethinking traditional
approaches
Strengths-based
Family driven & youth guided
Embracing culture
Who is involved? Youth
Adults
Families
Providers
Communities
Fulfilling Potential
Systems of Care
Systems of Care Resilience, Leadership &
Transformation
Leadership
Transformation
Resilience
What is involved? Rethinking traditional
approaches
Strengths-based
Family driven & youth guided
Embracing culture
Who is involved? Youth
Adults
Families
Providers
Communities
Fulfilling Potential
Eastern Kentucky
North Carolina (10 counties)
California 5 (Santa Cruz,San Mateo, Riverside Ventura, &
Solano Counties)
Vermont 1 (statewide)
Lyons, Riverside, & Proviso, IL
Bismarck, Fargo, & Minot, ND
Northern Arapaho Tribe, WY
Sault Ste. Marie Tribe, MI
Rhode Island 2 (statewide)
Hillsborough County, FL
Charleston, SC
King County, WA
Clark County, WA
Clackamas County, OR
Vermont 2 (statewide)
Passamaquoddy Tribe, ME
Rhode Island 1 (statewide)
Maine (4 counties)
Edgecombe, Nash, & Pitt Counties, NC
Alexandria, VA
Baltimore, MD
South Philadelphia, PA
Mott Haven, NY
Detroit, MI
Northwoods Alliance, WIMilwaukee, WI
Navajo Nation
Sacred Child Project, ND
San Diego County, CA
Napa & Sonoma Counties, CA
Lane County, OR
Santa Barbara County, CA
Greenwood, SC
West Palm Beach, FL
Contra Costa County, CA
Birmingham, AL
North Carolina (11 counties)
Oglalla Sioux Tribe, SD
Lancaster County, NEWillmar, MN
Pima County, AZ
Marion County, IN
Charleston, WV
Montgomery County, MD
Delaware (statewide)
Burlington County, NJWestchester County, NY
Worcester, MANew Hampshire (3 regions)
Gwinnett & Rockdale Counties, GA
System-of-Care Communities of the Comprehensive Community Mental Health Services for Children and Their Families Program
United Indian Health Service, CA
Nebraska (22 counties)
San Francisco, CA
Clark County, NV
Rural Frontier, UT
Denver, CO
Las Cruces, NM
Wichita, KS
Parsons, KS
Travis County, TX
Sacramento County, CAGlenn County, CA
Colorado (4 counties)El Paso County, TX
Oklahoma
Ft. Worth, TX
Choctaw Nation, OK
St. Charles County, MOMissouri
Broward County, FL
Connecticut (statewide)
Washington, DC
New York, NY
Lake County, INIllinois (Chicago area)
Idaho
Wai'anae & Leeward, HI
Fairbanks, AK
Yukon Kuskokwim Delta Region, AK
Guam
Puerto Rico
Oakland, CA
Monterey County, CA
Four Counties, OR
Allegheny County, PA
Southern Consortium& Stark County, OH
Cuyahoga County, OH
Jackson, MSSt. Louis, MO
Nashville, TNLouisiana (5 parishes)
3 counties & Catawba Nation, SC
9-1-93 42-1-94 79-1-94 9
11-1-94 29-1-97 9
10-1-98 13 11-1-98 1
Date Number
Funded Communities
9-30-99 205-1-00 17-1-00 1
10-1-02 189-30-03 79-30-04 4
Date Number
Erie County, NY
Albany County, NY
Montana & Crow Nation
Kentucky(8 counties)
Systems of Care as a Transformation Strategy
• Customer focused
• Family driven
• Bridging Systems
Vision & Beliefs + Actions x (CQI)2
FamilyInvolvement
Moving from family involvement to family driven
Fully embracing youth involvement
Opening the data setEstablishing key benchmarks
Sustainability - defining how systems of care contribute
Integrating technical assistance activities
Moving from concept to reality. Tools & strategies
YouthInvolvement
TechnicalAssistance
Research
System of CareTransformation
CulturalCompetence
National Wraparound Initiative
Setting standards
Developing materials that are user-friendly
Embracing CQI and the Benchmarking Initiative
Continuous Quality Improvement
National T.A.Community ProgramAdministrators
ImprovementContinuous
Quality
Strategies to ImproveCultural Context
Program Performance
CQI Feedback
Indicator 32 - Caregiver and Other Family
Involvement in Service Plan Increase family involvement in developing the service plan, either through attending planning meetings or approving treatment plans. Benchmark: 100%
Source and Item(s)
Enrollment and Demographic Information Form (EDIF): Item 14
Definition Percentage of cases where the caregiver participated in developing the child’s service plan.
Time period Intake into services
Calculation Number responding yes to edif14a or edif14c/# responses to edif14a and edif14c
Systems of Care Work! Reductions in use of restrictive levels of care
and residential placements across systems
Cost reductions and cost avoidance
Improved clinical and functional status
Decreased juvenile recidivism and incarceration
Improved school attendance and achievement
Family driven means…
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.
Beginnings
Youth MOVE
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. http://www.tapartnership.org/
Transformation Resources
Got a question about a family-driven, youth-guided system of care?
Start here
www.systemsofcare.samhsa.gov
Work togetherThere is strength in numbers…
System of Care: Partnership between SAMHSA, DHS,
and CHSC Jeffrey Lobas, MD, EdD.
Iowa’s Title V Agency for Children with Special Health Care Needs
Funded through IDPH, categorical grants, contracts, reimbursement for services
Administratively housed in the Dept. of Pediatrics at the University of Iowa
Direct Services
Enabling Services
Population Based Services
Infrastructure Building
Title V Children with Special Health Care NeedsChild Health Specialty Clinics (CHSC)
The Child Health Specialty Clinics (CHSC) mission is to improve the health, development, and well-being of children and youth with special health care needs in partnership with families, service providers, communities and policy makers.
Creston
Council Bluffs
Carroll
Sioux City
Ft. Dodge
Spencer
Mason City
Oelwein
Ottumwa Burlington
Davenport
Iowa City
DubuqueWaterloo
Child Health Specialty Clinics
Regional Centers Satellite Centers Central Office
Sioux Center
Shenandoah
Des Moines
Elkader
Chariton
ABCD II Project Birth to Five Services Health and Disease Management Continuity of Care Program Family to Family Support Integrated Evaluation and Planning
Clinics Regional Autism Services Program Telehealth Iowa Medical Home Initiative Early ACCESS
1997-Needs Assessment 1999-Future Search 2001-Governor’s White Paper 2002-Creston Project 2003-Magellan and CHSC 2004-CHSC Statewide Implementation 2005-Oversight Committee 2007-SAMHSA System of Care
Evaluation of Statewide Services Research on a Delivery Model Statewide Implementation “Spread Strategy” Collaborative approach
Focus Groups Structured Interviews with Families and
Community Leaders Outcome Research Flow and Time Studies Satisfaction Surveys
Patients seen July 2004 – June 2005
Burlington 85 Carroll 84
Council Bluffs 119 Creston 196
Davenport 20 Dubuque 71
Fort Dodge 219 Mason City 555
Ottumwa 175 Sioux City 150
Spencer 631 Waterloo 16
Total 2321
ADHD (all types) 63%
Conduct / Oppositional Defiant Disorders 7%
Reaction Attachment Disorders 5%
Developmental Disorders 4%
PDD Spectrum and other Child Psychosis 3%
Total with behavioral or mental health diagnosis 93%
Key Components of Intervention Model Multidisciplinary Team Enhanced care coordination.
Initial on-site psychiatric assessments, if indicated by intake procedures;
Telehealth/telepsych patient follow-ups; Telehealth consultations to primary care and other
service providers; Educational events targeting service providers; Best practice/care guidelines; Systemic data collection regarding patient/family
outcomes and service delivery processes; and A community advisory board and consumer
participation
Care Plan development Arrangement of Service Delivery Alignment of advocacy across systems Collaboration with family and physicians Crisis intervention plan Follow-up with family and team
Degree of Clinical Change (percent) at Discharge for Children who Received CBHP vs. Usual Care
Enhanced Program Dimensions Key Components (1-8) Usual
Care (N=25)
(N=34) Problems* 4% -30% Mental health* 3% -23% Substance use* 22% -56% Risk Behaviors 10% -4% Functioning* 24% -18% Caregiver capacity* 11% -7% Strengths 9% -9%
*significant difference between groups (p<.05)
Children who received CBHP services were more severe from children who received usual care across several factors including:
Being more often abused (68% v. 8%) Had used psychiatric inpatient care (24% v.
0%)
This increasing identification of children with complex behavioral health needs significantly affected the potential degree of clinical change at discharge.
As a result, the CBHP was the most effective model in improving both the functional and strengths/supports dimensions in CANS-MH scores.
CANS-MH score results from the CBHP data is comparable to a recent comprehensive review of level of care needs across the New York state system of mental health utilizing the CANS instrument.
Data suggests that IEPC is similar to the intensity of services provided by the Intensive Case Management levels of care in New York.
A multidisciplinary team approach was very effective
Care coordination and follow-up of services was important to patient outcomes
Appropriate triage at intake yielded greater efficiency and more effective results to patients
Tele-health is an extremely valuable tool in providing services to underserved areas of the state
Clinical guidelines enhance care
There is great variability among regional centers in many areas which makes quality assurance difficult to achieve
The role and methods of triage has to be standardized and more training needs to be provided
Increased cost efficiency can be gained through standardized methods of triage, appropriate use of team, standardization of forms and dictation methods and gaining reimbursement for services by non-physician providers
Highest level of unmet need was identified as availability of child psychiatry
A standardized approach is needed at all centers which would include:
Comprehensive triage and follow-up plan
Availability of a multidisciplinary team at each regional center
Utilization of standardized history forms and clinical tools - Vanderbilt; CHSC Med Hx; Beh Hx; Social Hx: and School Hx forms
Standardized dictation methods into the PEDS centralized transcription and issuance of reports
Inadequate Resources (Long-waiting lists) Minimal services available Emergency and Crisis Intervention Wrap-around Services Social Marketing and Outreach
Oversight Committee Discussions between CHSC, DHS, SAMHSA Development of Proposal SAMHSA System of Care
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Multidisciplinary Team
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Outreach/Lighthouse
Multidisciplinary TeamNavigator Team Navigator Team
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Outreach/Lighthouse
Evaluation
and Dx
Rx and and Care
Plan
Family Team
Meeting
Care Coordination
(Process)
Navigator Team
Intake/
Triage
Monitor and
Feedback
Multidisciplinary Team Navigator Team
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Subspecialty and Primary Care
Outreach/Lighthouse
Evaluation
and Dx
Rx Care Plan
Family Team
Meeting
Care Coordination
(Process)
Navigator Team
Intake/
Triage
Monitor and
Feedback
Multidisciplinary Team Navigator Team
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Subspecialty and Primary Care
Community Based Wraparound Services
Outreach/Lighthouse
Evaluation
and Dx
Rx and Care Plan
Family Team
Meeting
Care Coordination
(Process)
Navigator Team
Intake/
Triage
Monitor and
Feedback
Multidisciplinary Team Navigator Team
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Subspecialty and Primary Care
Community Based Wraparound Services
Emergency and Crisis Management
Outreach/Lighthouse
Evaluation
and Dx
Rx and Care Plan
Family Team
Meeting
Care Coordination
(Process)
Navigator’s Team
Intake/
Triage
Monitor and
Feedback
Multidisciplinary Team Navigator’s Team
Early
Identification
Children’s Mental Health System of Care
Primary Care
Schools
Mental HealthAgencies
JuvenileJustice
Child Welfare/DHS
Community
Families
Family/YouthAdvocacy Orgs
Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation
and Coordination
Monitor and
Follow-Up
Community Circle of Care
Child Health Specialty Clinics
Subspecialty and Primary Care
Community Based Wraparound Services
Emergency and Crisis Management
Quality Assurance and Evaluation
Outreach/Lighthouse
Evaluation
and Dx
Treatment and Care
Plan
Family Team
Meeting
(Local)
Care Coordination
(Process)
Navigator Team
Intake/
Triage
Monitor and
Feedback
Multidisciplinary Team Navigator Team
Partnership, Collaboration, Integration
DHSIowa Department of Human
Services
Community Circle of Care
Systems of Care Work
ACCESS
Navigation
COORDINATION
INDIVIDUALIZED SUPPORTS
Systems of Care Professionals and Families
Share Common Goals
• We want children and youth to be in safe and stable homes
• We want to assist families to meet their children’s needs
• We seek family preservation or reunification if the child has been removed
Meeting the mental health needs of children, youth, and families is critical to achieving these goals
What Works?
• When children and youth with serious mental health needs receive coordinated services, their functioning substantially improves at school, at home, and in their community.
*Data Trends #104, September 2004, University of South Florida
A System of Care Is…A community partnership among families,
youth, schools, and public and private organizations which provide coordinated
mental health services. Our partners include:
• Families• Education• Provider Agencies• Mental health and substance
abuse professionals
• Juvenile justice• Primary health care• Faith community• Other community
organizations• Child welfare
• Family-driven and youth-guided• Researched and evidenced based• Supports Individualized for each family• Wrap around services provided• Culturally and linguistically competent• Community-based
A System of Care Is…Guided by Core Values
Benefit: Homes Are Stable
• The percentage of children and youth who lived in multiple settings decreased by 11 percent over 12 months.
Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005
• Caregiver strain is reduced in many families.
• More than a quarter of families had higher functioning after 30 months; more than half remained stable.
Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005
Benefit: Families Are Stronger
• Caregiver job, vocational, and educational skills improve.
• Incomes increase.• Families have more time and support.
Sources: CMHS National Evaluation: Updates from the National Evaluation, Services Evaluation Committee Meeting, 2004CMHS National Evaluation: Aggregate Data Profile Report, 2004
Benefit: Families Have More Resources
Community Circle of Care
A care coordination, wrap around
system of care
Community Circle of Care
• Decisions about services are made based on what the family needs; funding is secured through the care coordinator which eliminates time and effort for the family.
• Services are identified and service gaps are filled whenever possible.
Outcome: Improved Access to Needed Services
• Decisions about services are family driven.
• Parent voice is integral to the developing system and to system change at the local and state level
• Families have access to other caregivers who have experience parenting a child with mental health and behavioral challenges.
Outcome: Empowered Caregivers
• Child welfare, health care, education, and mental health professionals work closely together.
• Mental health services are introduced in homes by system of care representatives including parents who have caregiver experience with a child who has mental health and behavioral challenges.
• Professionals who work in the system of care are offered technical assistance to better understand and serve their clients in a family centered approach.
• Needed child and family services are more accessible.
Outcome: Coordinated Services
• Early mental health intervention helps children, youth, and families stay together.
• Early mental health intervention reduces the length of time for out-of-home placement.
Outcome: Decreased Out-of-Home Placements
• Supports based on family needs• Wrap around services• Services developed in response to needs
Outcome: Individualized services and supports for each family
What Our Partnership Could Accomplish
• Coordinated, community-based services that support families in need
• Collaborative, individualized plans of action for families in their local community
• A community support structure that is accessible and family-focused
AMCHP Association of Maternal & Child Health Programs
Mental Health: Perspective of State Title V
AMCHP Association of Maternal & Child Health ProgramsTitle V Performance MeasuresSummary Numbers 200
12006
% Change
# of States with>1 perf. Measure relevant to mental health
24 36 50%
Total perf. Measures relevant to mental health across States/Territories
30 57 90%
# States/Territories with>1 priority need relevant to mental health
30 49 63%
Total # priority needs relevant to mental health across States/Territories
39 101 159%
AMCHP Association of Maternal & Child Health Programs AMCHP’s Role• AMCHP’s 2005-2009 strategic plan identified
emotional behavioral health as a priority focus area
• Develop Key Partnerships- Public Health, Mental Health Systems, Private Sector
• AMCHP in partnership working for policy and legislative reforms
• 2006 - AMCHP convened a series of meetings with NASHP, SAMHSA, MCHB to produce “roadmap”
• Developing common set of principles
AMCHP Association of Maternal & Child Health Programs Key Partners• Maternal and Child Health Bureau• Substance Abuse and Mental
Health Services Administration• National Academy of State Health
Policy• Georgetown Child Development
Center• Family Voices• Federation of Families
AMCHP Association of Maternal & Child Health ProgramsA Common Set of Principles• A continuum of services relating to
mental health;• Strengthening the interface between
public health and mental health, including prevention
• Increasing protective factors and risk reduction.
• Mental Health and Primary Care (Medical Home)
AMCHP Association of Maternal & Child Health ProgramsCurrent Activities
• Developing A Public Health Approach to Mental Health
• Collecting and Disseminating Best Practice Models
• Development of Monograph– Conceptual Framework for PH
approach– Continuum of Services– Common language
AMCHP Association of Maternal & Child Health ProgramsNext Step: Engagement• Strategies to Engage Stakeholders
formally and informally– Stakeholder Meeting– Focus Groups– Interviews– Document Review– Surveys– Presentations
AMCHP Association of Maternal & Child Health ProgramsChallenges for Leadership• Dialogue between cultures• Trust and understanding• Value
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