Context Setting and Non Negotiable Characteristics of System of Care Processes and Structures Sheila A. Pires Human Service Collaborative Lisa Conlan Parent

Context Setting and Non Negotiable Characteristicsof System of Care Processes and Structures

Sheila A. PiresHuman Service Collaborative

Lisa ConlanParent Support Network of Rhode Island

Ashley KeenanParent Support Network of Rhode Island

2

Historic and Current Systems Problems

• Lack of home and community-based services and supports; deficit-based models

• Patterns of utilization• Cost• Administrative inefficiencies• Knowledge, skills and attitudes of key stakeholders• Poor outcomes; racial, ethnic and geographic

disparities and disproportionality• Rigid financing structures

Pires, S. (1996). Human Service Collaborative, Washington, D.C.

3

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

Foster “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

Build on strengths and resiliency

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

4

Categorical vs. Non-Categorical System Reforms

Categorical

System Reforms

Non-Categorical

Reforms

Pires, S. (2001). Categorical vs. non-categorical system reforms. Washington, DC: Human Service Collaborative.

5

Cross-System System Reform/Transformation Focuses

On…

• Policy Level (e.g., financing; regulations; rates)

• 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)


6

ProcessProcessHow system builders conduct themselves

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


7

Core Elements of an Effective System-Building Process

• A core leadership group• Evolving leadership• Effective collaboration• Partnership with families and with 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

The Importance of Leadership & Constituency Building

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.

8

Core Elements of an Effective System-Building Process

• A strategic mindset• A shared vision based on common values and principles• A clear population focus• Shared outcomes• Community mapping—understanding strengths and needs• Understanding and changing traditional systems• Understanding the importance of “de facto” mental health providers (e.g.,

schools, primary care providers, child care providers, Head Start)• Understanding of major financing streams• Connection to related reform initiatives• Clear goals, objectives, and benchmarks• Catalyst mechanisms—being opportunistic• Opportunity for reflection and adequate time

The Importance of Being Strategic

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative

9

Truisms About Structure

• Certain functions must be structured and not left to happenstance

• Structures need to be evaluated and modified if necessary over time

• New structures replace existing ones; some existing ones are worth keeping; some are more difficult to replace than others

• There are no perfect or “correct” structures


System of Care Functions Requiring Structure

• Planning• Governance-Policy Level Oversight• System Management• Benefit Design/Service Array• Evidence-Based Practice• Outreach and Referral• System Entry/Access• Screening, Assessment, and Evaluation• Decision Making and Oversight at the

Service Delivery Level– Care Planning– Care Authorization– Care Monitoring and Review

• Care Management or Care Coordination• Crisis Management at the Service

Delivery and Systems Levels• Utilization Management• Family Involvement, Support, and

Development at all Levels• Youth Involvement, Support, and

Development at all Levels

• Staffing Structure• Staff Involvement, Support, Development• Orientation, Training of Key Stakeholders• External and Internal Communication• Social Marketing• Provider Network• Protecting Privacy• Ensuring Rights• Transportation• Financing• Purchasing/Contracting• Provider Payment Rates• Revenue Generation and Reinvestment• Billing and Claims Processing• Information Management &

Communications Technology• Quality Improvement• Evaluation• System Exit• Technical Assistance and Consultation• Cultural and Linguistic Competence

Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.

11

Cross-Cutting Characteristics of System of CareProcesses and Structures

• Cultural and linguistic competence, that is, processes and structures that support capacity to function effectively in multi- or cross-cultural situations;

• Meaningful partnership with families, including family-run organizations in system building processes and structural decision making, design, and implementation;

• Meaningful partnership with youth, including youth-run or youth guided organizations;

• A cross-agency perspective, that is, processes and structures that operate in a non-categorical fashion;

• State, Territory, Tribal, and local partnership and shared commitment.

Pires, S. (2002).Building systems of care: A primer. Washington D.C.: Human Service Collaborative.

Developing Capacity for Cultural and LinguisticCompetence

•Cultural and linguistic self assessment – of system, of system building leaders, of system planners

For guidance in designing and implementing aculturally and linguistically competent system…

•Partnerships with cultural leaders in the community•Outreach to and engagement of culturally andlinguistically diverse families and youth•Partnerships with culturally and linguisticallydiverse community organizations•Build on related efforts; use technical assistance

13

Family Members and Youth - Shifts in Roles and Expectations

Lazear, K. & Conlon, L. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

Recipient of information

re: child’s service plan

Passive partner in service planning process

Service planning team leader

Unheard voice in program evaluation

Participant in program evaluation

Partner (or independent) in developing and conducting program evaluations

Recipient of services Partner in planning and developing services

Service providers

Uninvited key stakeholders

in training initiatives

Anger, adversity & resistance

Participants in training initiatives

Self-advocacy

Partners and independent trainers

Advocacy & peer support

14T. Osher, D. Osher and Blau, FFCMH and CMHS, SAMHSAT. Osher, D. Osher and Blau, FFCMH and CMHS, SAMHSA.

Family Driven Definition

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. This includes:o Choosing culturally and linguistically competent supports, services, and providers;o Setting goals;o Designing, implementing and evaluating programs;o Monitoring outcomes; ando Partnering in funding decisions.

Family Organization Structure

Stage 1• Advisory group of

families

• Vision and mission

• In-kind services and supports

• Fiscal agents/501c3 status

• Emerging Board of Directors

(families at least 51%)

• Building support and investment

Stage 2• Committed leadership• Established board• Roles/family member

preference• Policies & procedures• Needs assessment • Allies/champions• Membership• Fund development• Fiscal management

systems

15

Family Organization Structure

Stage 3 • Fiscally and legally

responsible Board• Programs established• Financial and program

experts• Diversified funding• Public awareness/ social marketing• Fiscal and data

information systems

Stage 4• Strong organizational

infrastructure • Pulse on the community need

and programs• Management and cross

training• Market-focused and strategic• Diversified stable income-

working capital• Public policy• Continuous quality assurance

16

Agencies: Strategies to Support the Growth of Family Organizations

• Contract with community-based and parent organizations to develop/sustain processes, i.e. trainings, curriculum, special programs, etc.

• Work through parent organizations. Get to know your local family support groups and advocacy organizations.

• Offer to sign/write letters of support for organization’s grant proposals.

• Collaborate, co-write grant proposals. • Pay stipends, transportation, child care for parent and youth

participation on committees.• Co-sponsor an event or conference.• Work with family support groups to tap into informal

networks.

18

Definition of Youth Guided

Substance Abuse and Mental Health Services Administration, Systems of Care, 2007

“Youth guided means to value youth asexperts, respect their voice, and to treat them as equal partners in creating system change at the individual, state, and national level.”

www.youthmove.us

19

Youth initiated and directedYouth initiated, shared decisions with adultsYouth and adult initiated and directedAdult initiated, shared decisions with youthConsulted and informedAssigned and informedTokenismDecorationManipulation

Adapted from System of Care Start-up Webinar Series 2006-2007

Ladder of Young People’s Participation

Maximum Youth Participation

Minimum Youth Participation

Barriers to Youth Participation

20

As Identified by Adults• Time• Funding• Staffing• Access to youth• Lack of training (how to work

with youth)• Politics• Parents• Adult staff not empowered• Program evaluation requirements• Weak leadership• Racism

As Identified by Youths• Ageism/Adultism• Money• Racism, sexism, homophobia• Stereotyping by appearance• Time• Transportation• Language/ jargon• Lack of access to information• Lack of access to opportunities• Lack of support from adults• Few role models• Lack of motivation• Being called “Kids”

Adapted from Politz, B. (1996). Barriers to youth participation. Washington, DC: Academy for Educational Development. The Center for Youth Development.

21

How Systems of Care Are Structuring Family and Youth Involvement at Various

Levels of the System

Level Structure

Policy At least 51% vote on governing bodies; as membersof teams to write/review request for proposals and contracts; as members of system design workgroups and advisory boards; raising public awareness; state and local committees

Management As administrators; part of quality improvementprocesses; as evaluators of system performance;as trainers; as advisors in selecting personnel; full time youth coordinator

Services As members of team for own children/youth; servicedelivery providers, such as family support workers,care managers, peer mentors, youth group development,system navigators


Youth Partnerships • Youth Involvement takes time and planning.• What do you want your youth partnerships to look

like?• “Scan your environment” for youth groups and

organizations that are doing similar work.• Assess the landscape of youth involvement in your

community. What are the strengths and gaps of those partners?

• Values check- where do you and your partners stand in regard to partnering with youth at all levels?

23

Characteristics of Family and Youth Organizations

• Strong ties to community; linkages with other family and youth groups

• Sensitivity to infrastructure development (e.g., clear expectations, performance criteria, assessment processes for both the family and youth organizations and the system of care; clear contracting relationships)

• Fair compensation for the work

• Natural family and youth leaders representative of the cultural and linguistic background of the population of focus

• Adequately funded

• Families and youth decide mission, goals, structure and activities

• Engaged in strategic planning for sustainability of family and youth voice

Conlan, L., Federation of Families for Children’s Mental Health.

Planning for Sustainability



25

Planning Structure Issues

• Leadership• Staffing• Time and place of meetings• Stakeholder involvement and supports• Committees, work groups, focus groups• Communication and dissemination of information• Outreach to and involvement of families and youth• Outreach to and involvement of diverse and disenfranchised constituencies• Linkage to related reform/planning initiatives• Resources•Attention to sustainability


26

Strategies for Addressing Cultural and Linguistic Competence in Planning

• Identify, engage and partner/contract with formal and informal community organizations, leaders and cultural brokers

• Engage diverse families and youth in planning

• Conduct sessions for planning group members with trained facilitators to explore attitudes about culture and diversity (e.g., race, “isms”)

• Provide culturally and linguistically appropriate invitations, outreach materials and other information

• Incorporate specific strategies for cultural and linguistic competence in system of care plans

• Utilize cultural competence coordinator to support effective planning Lazear, K. University of South Florida. Primer Hands On (2008)

27

Cuyahoga County Planning Process Structure

System of Care Oversight CommitteeChaired by Deputy County Administrator for Human Services

Includes a Broad Representative Stakeholder Group, e.g., major child serving systems, families and youth, Neighborhood Collaboratives, providers, researchers

Cultural & Linguistic

CompetenceEvaluation &

Research

Family & Youth

InvolvementSocial Marketing

Design &Sustainability

Training & Coaching

Staffed bySystem of Care Office

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

28

Example: Communication Mechanisms in the State of North Carolina

Local Collaborative Communication Committee

Website

Regional meetings

Brochures

Meeting calendar


29Pires, S. 2006. Human Service Collaborative. Washington, D.C.

Identify your population(s) of focus. Agree on underlying values and intended outcomes. Identify services/supports and practice model to

achieve outcomes. Identify how services/supports will be organized (so

that all key stakeholders can draw the system design). Identify the administrative/system infrastructure

needed to support the delivery system, including the structure for family/youth partnership.

Cost out the system of care. Develop a strategic financing and sustainability plan.

Critical Steps in a Planning Process

30

The Total Population of Children, Youth and Families Who Depend on Public Systems

Pires, S. (1997). The total population of children and families who depend on public systems. Washington, DC: Human Service Collaborative.

Children/youth/families eligible for Tribal Authority funding.

Children/youth/familieseligible for the State Children's

Health Insurance Program (SCHIP)

Poor and uninsured children/youth/families who do not qualify for

Medicaid or SCHIP.

Families who are not poor or uninsured but who exhaust

their private insurance, often because they have a

child with a serious emotional/behavioral challenge.

Families who are not poor or uninsured and who may not yet

have exhausted their private insurance but who need a particular type

of service not available through their private insurer and only

available from the public sector.

Children/youth/families eligible for Medicaid.

31

2 - 5%

15%

80%

More complex

needs

Less complex

needs

Intensiveservices – 60% of $$

Home and community services and supports; Early intervention -35% of $$

Prevention and Universal Health Promotion – 5% of $$

Prevalence/Utilization Triangle

Pires, S. 2006. Human Service Collaborative. Washington, D.C.

32

Example: Transition-Age YouthWhat outcomes do we want to see for this population?

Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.

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 we put in place to provide opportunities for youth to contribute and feel a part of the larger community?

Crafting Logic Models: Phases of Theory Development For Systems of Care

STAGE 1: Form workgroup

STAGE 2: Articulate mission

STAGE 3: Identify goals and guiding principles

STAGE 4: Develop the population context

STAGE 5: Map resources and assets

STAGE 6: Assess system flow

STAGE 7: Identify outcomes and measurement parameters

STAGE 8: Define strategies

STAGE 9: Create and fine-tune the framework

STAGE 10: Elicit feedback

STAGE 11: Use framework to inform, plan evaluation, and technical assistance

STAGE 12: Use framework to track progress and revise theory of change

Hernandez, M. & Hodges, S. (2003). Crafting logic models for systems of care: Ideas into action. Tampa, FL: University of South Florida

The more that planning is directed to making systemic or structural change, the more sustainable the changes will be.

Example #1: Launching a newsletter for families – good goal, not a structural changeAmend the State Medicaid Plan to cover family peer support – good goal anda structural change

Example #2:One-time legislative appropriation to expand home and community services – goodgoal, not a structural changeAmend the State Medicaid Plan to cover an array of home and community-basedservices and pool or braid dollars across systems – good goal and a structural change

Example #3: Educating providers about partnering with families and with youth – good goal, not a structural changeContractual requirements for child/family teams – good goal and structural change

Planning for Sustainable Change

Pires, S. (2002).Building systems of care: A primer. Washington D.C.: Human Service Collaborative.

Strategies for Involving Families and Youth in Planning

35

• Disseminate invitations/outreach flyers

• Engage families and youth who work regularly with other families and youth

• Contract with family organizations to develop and sustain process for providing participant supports

• Offer stipends, transportation, food, child care, interpretation, translation

• Hold planning meetings at flexible times and accessible locations

• Conduct focus groups, interviews and surveys

• Provide ongoing training and mentoring

• Have more than token representation

• Publicly acknowledge the contributions of families and youth

Adapted from: Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and support services program. Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.

36

Roles for a Full Time Youth Engagement Specialist / Youth Coordinator

• Coordinate and foster a youth-guided system and youth-driven movement

• Coach• Raise awareness of the importance of youth voice at all levels of the

system of care• Build bridges and partnerships between the youth and professional

worlds• Foster a youth-guided system and youth-driven movement• Reconnect youth with the community• Educate adults and professionals on the importance of youth

involvement• Work with youth to create a strategic plan of the movement that ties into

the community logic model

Adapted from System of Care- Start Up Webinar Series 2006-2007

Governance and System Management



38

Definition of Governance

Decision making at a policy level that has legitimacy, authority, and accountability.

Definition of System ManagementDay-to-day operational decision making

Pires, S. (1995). Definition of governance. Washington, DC: Human Service Collaborative.

39

Key Issues for Governing Bodies

Has authority to govern Is clear about what it is governing Is representative Has the capacity to govern Has the credibility to govern Assumes shared liability across systems for

the population(s) of focus

Pires, S. (2000). Key issues for governing bodies. Washington, DC: Human Service Collaborative.

40

Examples of Types of Governance Structures

• State and/or local interagency body

• Non profit board of directors

• Quasi governmental entity

• Tribal governance

• Hybrids


41Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

System Management: Day-to-Day Operational Decision Making

Key Issues

• Is the reporting relationship clear?

• Are expectations clear regarding what is to be managed and what outcomes are expected?

• Does the system management structure have the capacity to manage?

• Does the system management structure have the credibility to manage?

42

Examples of Types of SystemManagement Structures

• State and/or local interagency body

• Quasi-governmental entity

• Non profit lead agency

• Public sector lead agency

• For profit commercial managed care entity

• Shared management structure/hybrid

• Tribal authorityPires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

43

New Jersey - Contracted Management Structure

CHILD

Screening with Uniform Protocols

Child Welfare

Juvenile Justice/Court

SchoolReferral

Community Agencies

Family & Self

Other

Contracted Systems Administrator CSA

•Registration•Screening for self-referrals•Tracking•Assessment of level of care needed•Care coordination•Authorization of services

Community Agencies•Uncomplicated care•Service authorized•Service delivered

Care Management Organization•Complex multi-system involved children•Individualized plan developed•Full plan of care authorized

Family Support OrganizationFamily to Family Support

Adapted from NJ System of Care

Youth Support Organizations

44

Wraparound Milwaukee - Lead Public Agency Management Structure

Child WelfareFunds thru Case Rate

(Budget for InstitutionalCare for CHIPS Children)

Mental Health•Crisis Billing•Block Grant

•HMO Commercial Insurance

Medicaid Capitation(1557 per Month

per Enrollee

Juvenile Justice(Funds Budgeted for

Residential Treatment for Delinquent Youth)

Management Entity:Wraparound Milwaukee

Management Service Organization (MSO)$30M

Child and Family Teams

ProviderNetwork

240 Providers85 Services

CareCoordination

Plans of Care

9.5M 2.0M10M8.5M

Per Participant Case Rate

Family Organization$300,000

Mgt. Entity: Co. BH Div.

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

45

Deputy County Administrator for Human Services

System of Care Office*

Children in or at risk for residential

placement

Youth with status offenses

Children with serious behavioral health

challenges

0-3 population Early Intervention engagement challenges

Subsets of Children & Families –Focus of Care Coordination

Partnerships


Cuyahoga County OH - In-House Management Structure

System of Care Oversight Committee

*Functions as anAdministrative ServicesOrganization

Lead Family Coordinator

Lead Youth Coordinator

{

{

4646

Regional CareManagement Entities

•Ensure child & family team plan of care**•Ensure intensive care coordination•Manage utilization at servicelevel

**Plans of Care (w/priority on community-based/naturalsupports) determine medicalnecessity, except inpatient, residential/group, which require prior authorization

DCHMCO MCO MCO

MHDDAD

ASO TPA

DFCS

DJS

DOE

Care Management Entities:Locus of management accountability for children

with complex, multi-system involvement

Use Same Decision Support Tool –CANS – to determine need for CME

Pires, S. 2008. Washington, D.C.: Human Service Collaborative

47

• At the Youth & Family Level:– Child Family Team (CFT) Facilitation using Wraparound Model – Care Coordination with assessment tools– Care Monitoring and Review– Peer Support Partners

• At the Systems Level:– Information Management & Web-based Information System – Provider Network Recruitment and Management– Utilization Review – Evaluation, Outcomes and Continuous Quality Improvement

• Financing Model- Case Rate

Maryland Specific Supports & Functions of a Care Management Entity

48

Pires, S. (1996). Contracted system management structure. Washington, DC: Human Service Collaborative.

Example of Governance/Management Structure

State Funding Pool

Local Allocation

County Alliance

Case Rate for each enrolled child

Provider ProviderProvider

Financer/Payers

Purchaser

Care Management Entity – Lead Non Profit•Organize and manage provider network•Staff and manage child and family team process• Intensive care management •Utilization management•Quality assurance•Outcomes management /monitoring•Management Information System (tracks children, services, dollars)

State Interagency

Body

Natural Supports Natural Supports

49

BOARD POLICY STATEMENTThe Governing Board of All Children System of Care, in recognition of the growing diversity in the population of children and youth needing behavioral health services, seeks to create and maintain a culturally responsive helping environment capable of comprehensively addressing the unique needs of children of color. Children of color have historically been under referred to treatment and specifically in Alden County. It is the responsibility of ACSC to not only make its services accessible to all, but to affirm by policy and action its commitment to children of all cultures.

It is the policy of ACSC to develop and maintain: links with key referral sources in our state’s communities of color; standards for providing services to ethnically, culturally diverse children; a culturally competent work force, reflective of the cultural diversity of the service population; intake procedures, treatment planning, and therapeutic interventions which recognize, enhance and strengthen cultural identity, dignity, and esteem; a treatment milieu in which racism, stereotyping, bigotry and prejudices are inappropriate and not tolerated.

Example: Board Policy Statement Addressing Cultural and Linguistic Competence

Adapted from: People of Color Leadership Institute and Day, P.A. Cultural Competence Materials for MSW Students, Staff, Faculty and the CommunityUniversity of Minnesota, Duluth

50

• Input/evaluation of key management• Input/evaluation of quality of services and

programs• Local system of care input• Resource allocation• Service planning and implementation• Policies and procedures• Grievance and resolution procedures

Examples of Types of Family/Youth Partnership in System Governance and Management

Conlan, L. (2003). Implementing family involvement. Burlington, VT: Vermont Federation of Families for Children’s Mental Health.

Outreach and Engagement

Organized Pathway to Service System

Intake and Referral



52Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

Outreach and Engagement Issues

• Who is it we are trying to reach?• How will we reach and engage the population of

focus and subsets within it?• How will we structure outreach to culturally and

linguistically diverse constituencies?• How will we partner with families, youth, and

culturally diverse constituencies in reaching out to different populations of focus?

• Who are other constituencies we need to engage, such as judges, legislators, other systems?

53

Example of Community Outreach and Engagement Everglades Health Center, Dade County, FL

• Signs in 3 languages: Spanish, English, and Creole Haitian

• Literacy programs• Audio cassettes in Spanish, English, Creole, Honduran

dialect, 3 Mexican dialects, 2 Guatemalan dialects• Mini soap operas for the radio (with follow-up by

health care workers going in homes and community centers)

Everglades Health Center, Community Health Centers of Dade County, Florida. Funded by the Bureau of Primary Health Care, U.S. Department of Health and Human Services.

54

Referral Issues

• Who can refer?• Can families and youth self-refer?• Where are referrals made?• Will the system have a narrow or broad referral

base?• Will there be waiting lists?• What role will families, youth, family and youth

organizations, and culturally and linguistically diverse constituencies play in the referral process?

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

55

Organized Pathway to Care

Multiple Entry Points

+ more accessible- loss of entry control- loss of quality control+-

One Access Point

+ less confusing+ more entry control- inaccessible--


Can create virtual single pathway through an integrated Management Information System (MIS)

56

Examples of Pathways to Care for Families

Cuyahoga County, OH

Milwaukee County, WI

11 NeighborhoodCollaboratives

+

Lead Provider Agencies

County MIS System

Milwaukee Wraparound


Early Intervention

57

New Jersey - Contracted Management Structure

CHILD

Screening with Uniform Protocols

Child Welfare

Juvenile Justice/Court

SchoolReferral

Community Agencies

Family & Self

Other

Contracted Systems Administrator CSA

•Registration•Screening for self-referrals•Tracking•Assessment of level of care needed•Care coordination•Authorization of services

Community Agencies•Uncomplicated care•Service authorized•Service delivered

Care Management Organization•Complex multi-system involved children•Individualized plan developed•Full plan of care authorized

Family Support OrganizationFamily to Family Support

Adapted from NJ System of Care

Youth Support Organizations

58

Distinctions Among Screening, Assessment and Evaluation, and Care Planning

Screening: 1st step, triage, identify children at high risk, link to appropriate assessments

Assessment: Based on data from multiple sources; Comprehensive; Identify strengths, resources, needs; Leads to care planning

Evaluation: Discipline-specific, e.g., neurological exam; Closer, more intensive study of a particular or suspected clinical issue; Provides data to assessment process

Care Planning: Individualized decision making process for determining services and supports; Draws on screening, assessment, and evaluation data

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

59

Phases of Wraparound

Time

Engagement and team preparation

Transition

Implementation

Plan development

Bruns, E. Ensuring high quality wraparound

Wraparound is “a definable planning process that results in a unique set of community services and natural supports that are individualized for a child and family to achieve a positive set of outcomes.”

Bruns, B. & Hoagwood, K. (Eds.) Community-Based Interventions for Children and Families. Oxford: Oxford University Press and National Wraparound Initiative,.

www.rtc.pdx.edu/nwi

60

What Wraparound is Not

• A system of care

• A new funding source

• A “service”

• A way to get “stuff” – services that are not typically reimbursable

• Only for a small group of children

• Case management

• A specific intervention or program

• A categorical approach where services reflect what’s available rather than what’s really needed

Adapted from Bruns, E. (2004). Ensuring high quality wraparound. Technical Assistance Partnership Webinar and Meyers, MJ. Wraparound Milwaukee, Milwaukee County Behavioral Health Division, Child and Adolescent Services , & S. Pires, Building System sof Care: A Primer

61

Developing a Culturally and Linguistically Competent Service Array

Connecting Circles of Care, Butte County, CA

WRAPAROUND TEAMS

ClinicianFamily Support Worker

Family Partner

Native American Team

Latino American Team

Hmong American Team

African-American Team

Rural/Mountain Team

Family-Directed Outreach and Engagement

• Toll-free helpline for support, information and referral

• Outreach presentations to diverse provider agencies and groups and tracking of referrals

• Informational booth/family contact during visiting hours at corrections

• Information/family contact at family court for emergency petitions/child welfare involvement

• Information/family contact at the hospital emergency rooms to support families with children in acute psychiatric needs.

62Conlan, L. RI Primer Hands On. 2008

63

Roles for Families & Youth in Outreach, Engagement, Referral

• Building formal and informal environments of trust (focus groups, education forums, support and social events, etc.).

• Contracting to provide outreach, support and education services to assist systems in understanding population needs and diverse cultures.

• Creating methods for families and youth to connect with each other for information (phone trees, list serves, chat rooms, newsletters, social events, etc.)

• Sponsoring conferences and summits; designing and delivering workshops to create bridges of confidence between families, youth and the system.

L. Conlon, Federation of Families for Children;s Mental Health

Being Data-Driven



65

Systems of Care are data driven.

Pires, S. (2001). Utilization management concerns. Washington, DC: Human Service Collaborative.

66

• Planning and Decision Support (Day-to-Day and

Retrospectively)• Utilization Management• Quality Improvement• Cost Monitoring• Research• Evaluation• Social Marketing• Accountability• Education and Advocacy

Examples of How to Use Data

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

67

Utilization Management (UM) Concerns

Who is using services?

What services are being used?

How much service is being used?

What is the cost of the services being used?

What effect are the services having on those using them? (i.e., are clinical/functional outcomes improving? Are families and youth satisfied?)

Pires, S. (2001). Utilization management concerns. Washington, DC: Human Service Collaborative.

UM

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Continuous Quality Improvement: Utilizing Data to Drive Quality

Contra Costa County, CA

Internal Evaluators

University-based Evaluator

Evaluation Subcommittee(diverse partners, including families)

Pires, S (2006) Primer Hands On for Child Welfare. From Caliber, Building the Infrastructure to Support Systems of Care.

•Developing activities to ensure CQI for: -Youth with multiple placements -Transition-aged youth -Multi-jurisdiction youth -Youth at-risk for multiple placements

•Developing and Tracking Quality and outcome measures: I.E. reduction in number of youth with 3 or more placements; linkage to needed resources upon emancipation

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Example of Statewide Quality Improvement Initiative

Michigan: Uses data on child/family outcomes (CAFAS) to:

• Focus on quality statewide and by site• Identify effective local programs and practices• Identify types of youth served and practices associated withgood outcomes (and practices associated with bad outcomes)• Inform use of evidence-based practices (e.g., CBT for depression)• Support providers with training informed by data• Inform performance-based contracting

QI Initiative designed and implemented as a partnership among State, University and Family Organization

K. Hodges. & J. Wotring. 2005. State of Michigan.

Social Marketing

Using commercial marketing practices and techniques topromote social change

Example: Marketing system of care to legislatures – mightuse cost/benefit data

Marketing system of care to diverse families – might use stories of other diverse families who have experienced thesystem as effective

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Social Marketing/Communications Activities and Resources

• On-call/on-site consultation• Communication listserv• Bimonthly conference calls• Resource center• Tip sheets• Workshops• Training academies• Excellence in Community Communications and Outreach

(ECCO) Recognition Program • Education Products

systemsofcare.samhsa.gov/TechnicalAssistance/smc.aspx

Caring for Every Child’s Mental Health Campaign; NASMHPD/Vanguard Communications/FFCMH;

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Examples of How to Collect Data

• Questionnaires• Surveys• Interviews• Focus groups• Clinical outcome data• Record reviews • Participatory Action Research• Network analyses • Financial analyses

Lazear, K. (2003). “Primer Hands On” A skill building curriculum. Washington. D.C. Quote: Warren Bennis, Leadership Institute, University of Southern California

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Example of Quantitative Outcomes - Milwaukee Wraparound

•Reduction in placement disruption rate from 65% to 30%

•School attendance for child welfare-involved children improved

from 71% days attended to 86% days attended

•60% reduction in recidivism rates for delinquent youth from one year prior to enrollment to one year post enrollment

•Decrease in average daily RTC population from 375 to 50

•Reduction in psychiatric inpatient days from 5,000 days to less than 200 days per year

•Average monthly cost of $4,200 (compared to $7,200 for RTC, $6,000 for juvenile detention, $18,000 for psychiatric hospitalization)

Milwaukee Wraparound. 2004. Milwaukee, WI.

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Example of Qualitative Outcomes:Family/Caregiver Experience Milwaukee Wraparound

Very Much So 64%

Not At All 7%

Somewhat 29%

64% reported Wrap Milwaukee empowered them to handle challenging situations in the future (n=188)

72% felt there was an adequate crisis/safety plan in place (n=172)

91% felt staff were sensitive to their cultural, ethnic and religious needs (n=189)

91% felt they and their child were treated with respect (n=191)

Very Much So 72%

Somewhat 13%

Not At All 15%

Very Much So 91%

Somewhat 5%

Not At All 4%

Very Much So

Somewhat

Not At All


Very Much So 91%

Somewhat 5%

Not At All 4%

7575

Information Management Systems

Importance of web-based, real time datato support care managers, administrators,policymakers, families and youth

Synthesis, The Clinical Manager (TCM), Others

Information and Communications Technology

Information technology – use of electronic computers and software to store, process and transmit information – e.g., electronichealth records

Communications technology – electronic systems used for communication between individuals or groups who are notphysically present at the same location – e.g., video conferencing,Twitter

Telehealth

Using communications technology to provide access to health/behavioral health assessment, diagnosis, intervention,consultation, supervision, education, peer support acrossdistance

Example: Kansas Center for Telemedicine and Telehealth atUniversity of Kansas Medical Center using technology for -

• child psychiatric consultation in remote areas of the state• individual and group therapy; care management• consultation to schools, group homes, and child careprograms in inner city communities

Youth Participation

• Make the process worthwhile for youth• Needs to be a priority during all phases of planning• Access to information in an engaging and

developmentally appropriate way• Young people need support to be involved

Services and Supports Array

Provider Network

Natural Helpers

FinancingSheila A. PiresHuman Service Collaborative


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Types of Medicaid Services in Systems of Care

• Assessment and diagnosis

• Outpatient psychotherapy

• Medical management

• Home-based services

• Day treatment/partial hospitalization

• Crisis services – mobile & residential

• Behavioral aide services

• Behavioral management skills training

• Therapeutic foster care

• Therapeutic group homes

• Inpatient hospital services

• Case management services

• School-based services

• Respite services

• Wraparound

• Family peer support/education

• Youth peer support

• Transportation

• Mental health consultation

• Early intervention and prevention services

• Supported independent living

• Residential treatment centers

Stroul, B.A., Pires, S.A., Armstrong, M.I. (2001). Health care reform tracking project: Tracking state managed care reforms as they affect children and adolescents with behavioral health disorders and their families-2000 State Survey. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, Department of Child and Family Studies, Division of State and Local Support.

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Example: Broad Service Array - Dawn Services & Supports

Behavioral Health•Behavior management•Crisis intervention•Day treatment•Evaluation•Family assessment•Family preservation•Family therapy•Group therapy•Individual therapy•Parenting/family skills training•Substance abuse therapy, individual and group•Special therapy

Placement•Acute hospitalization•Foster care•Therapeutic foster care•Group home care•Relative placement•Residential treatment•Shelter care•Crisis residential•Supported independent living

Psychiatric•Assessment•Medication follow-up/psychiatric review•Nursing services

Mentor•Community case management/case aide•Clinical mentor•Educational mentor•Life coach/independent living skills mentor•Parent and family mentor•Recreational/social mentor•Supported work environment•Tutor•Community supervision

Respite•Crisis respite•Planned respite•Residential respite

Service Coordination•Case management•Service coordination•Intensive case management

Other•Camp•Team meeting•Consultation with other professionals•Guardian ad litem•Transportation•Interpretive services

Discretionary•Activities•Automobile repair•Childcare/supervision•Clothing•Educational expenses•Furnishings/appliances•Housing (rent, security deposits)•Medical•Monitoring equipment•Paid roommate•Supplies/groceries•Utilities•Incentive money

2005 CHIOCES, Inc., Indianapolis, IN

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Service Array Focused on a Total Population

Family Support Services

Youth Development Program/Activities

Coordinated Intake Assessment & Treatment Planning

Service Coordination Intensive Care

Management Clinical Services

Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative.

Core Services Prevention Early Intervention Intensive Services

Universal Targeted

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Evidence-Based Practices

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. Examples - Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders. Oxford University Press and State of New Jersey BH Partnership (www.njkidsoc.org)

Show evidence of effectiveness through carefully controlled scientific studies, including random clinical trials. For example, Multisystemic Therapy, Functional Family Therapy

Promising Approaches or Practice-Based Evidence

Show evidence of effectiveness through experience of key stakeholders (e.g., families, youth, providers, administrators) and outcomes data. For example, Wraparound, MobileResponse and Stabilization, Family Peer Support

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Effectiveness Research(Barbara Burns’ Research at Duke University)

• Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care

• Less evidence (because not much research done): Crisis services, respite, mentoring, family education and support

• Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home


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Examples of What You Don’t See Listed as Evidence-Based Practice

(though they may be standard practice)

• Traditional office-based “talk” therapy• Residential Treatment• Group Homes• Day Treatment_______________________________________________

Examples of Potentially Harmful Programs and Effective Alternatives in Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer Influences in Intervention and Public Policy for Youth,” Social Policy Report, Vol. XX, No. 1, January 2006. Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7.

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

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Implications for How RTCs are Utilized

• Movement away from “placement” orientation and long lengths of stay

• Residential as part of an integrated continuum, connected to community

• Shared decision making with families/youth and other providers and agencies

• Individualized treatment approaches through a child and family team process

• Trauma-informed care

For more information, go to Building Bridges Initiative:1) www.systemsofcare.samsha.gov2) Click on Hot Topics3) Click on Issues in Residential Treatment

Data Trends #127, February 2006,University of South Florida.

http://www.systemsofcare.samsha.gov/

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Characteristics of Effective Provider Networks

• Responsive to the population that is the focus of the system of care.

• Encompass both clinical treatment service providers and natural, social support resources, such as mentors and respite workers.

• Include both traditional and non traditional, indigenous providers.

• Include culturally and linguistically diverse providers.

• Include families and youth as providers of services and supports.

• Are flexible, structured in a way that allows for additions/deletions.

• Are accountable, structured to serve the system of care.

• Have a commitment to evidence-based and promising practices.

• Encompass choice for families and youth.


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The Role of Natural Helpers

•Emotional support; moral & spiritual guidance

•System navigation

•Concrete help & advocacy

•Decrease social isolation

•Community navigation

•Resource acquisition & education

•Greater understanding of intervention or support strategies

•Create Time Banks

Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.

Natural Helpers are…•Family and friends

•Neighbors•Volunteers

•Individuals in the community, e.g. mail carrier, minister,

storekeeper, etc. •People with similar experiences

•Faith-based organizations

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Examples of Sources of Funding for Children/ Youth with Behavioral Health Needs in the Public Sector

Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

Medicaid• Medicaid In-Patient• Medicaid Outpatient• Medicaid

Rehabilitation Services Option

• Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT)

• Targeted Case Management

• Medicaid Waivers• TEFRA Option

Substance Abuse• SA General Revenue• SA Medicaid Match• SA Block Grant

Juvenile Justice• JJ General Revenue• JJ Medicaid Match• JJ Federal Grants

Mental Health• MH General Revenue• MH Medicaid Match• MH Block Grant

Child Welfare• CW General Revenue• CW Medicaid Match• IV-E (Foster Care and

Adoption Assistance)• IV-B (Child Welfare

Services)• Family

Preservation/Family Support

Education• ED General Revenue• ED Medicaid Match• Student Services

Other• WAGES• Children’s Medical

Services/Title V– Maternal and Child Health

• Mental Retardation/ Developmental Disabilities

• Title XXI-State Children’s Health Insurance Program (SCHIP)

• Vocational Rehabilitation

• Supplemental Security Income (SSI)

• Local Funds

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Financing Strategies and Structures to Support Improved Outcomes for Children, Youth and Families

FIRST PRINCIPLE: System Design Drives Financing

Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

REDEPLOYMENTUsing the money we already haveThe cost of doing nothingShifting funds from treatment to early intervention and preventionMoving across fiscal years

REFINANCINGGenerating new money by increasing federal claimsThe commitment to reinvest funds for families and childrenFoster Care and Adoption Assistance (Title IV-E)Medicaid (Title XIX)

RAISING OTHER REVENUE TO SUPPORT FAMILIES AND CHILDRENDonationsSpecial taxes and taxing districts for childrenFees & third party collections including child supportTrust funds

FINANCING STRUCTURES THAT SUPPORT GOALSSeamless services: Financial claiming invisible to families Funding pools: Breaking the lock of agency ownership of fundsFlexible Dollars: Removing the barriers to meeting the unique needs of familiesIncentives: Rewarding good practice

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Redirection

Where are you spending resources onhigh costs and/or poor outcomes?

Residential Treatment?Group Homes?Detention?Hospital admissions/re-admissions?Too long stays in therapeutic foster care?Inappropriate psychotropic drug use?“Cookie-cutter” psychiatric and psychologicalevaluations?

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Wraparound Milwaukee – Example of Redirection

Child WelfareFunds thru Case Rate

(Budget for InstitutionalCare for CHIPS Children)

Mental Health•Crisis Billing•Block Grant

•HMO Commercial Insurance

Medicaid Capitation(1557 per Month

per Enrollee

Juvenile Justice(Funds Budgeted for

Residential Treatment for Delinquent Youth)

Management Entity:Wraparound Milwaukee

Management Service Organization (MSO)$30M

Child and Family Teams

ProviderNetwork

240 Providers85 Services

CareCoordination

Plans of Care

9.5M 2.0M10M8.5M

Per Participant Case Rate

Family Organization$300,000

Mgt. Entity: Co. BH Div.

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

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Examples of Refinancing

Milwaukee County, WI Schools and child welfare contributed $450,000 each to expand mobile response and stabilization services(prevent placement disruptions in child welfare, prevent school expulsions) Is a Medicaid-billable service; contributions fromschools and child welfare generate $180,00 to theschool contribution and $200,000 to child welfare’s inFederal Medicaid match dollars

Cuyahoga County, OHCross-walked 93 wraparound skill sets to Medicaidbilling categories

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Raising New Revenue

•Prop 63 in California (1% income tax on millionaires)

•Spokane Co., WA – 0.1% sales tax for mental health

•Jackson Co., KN – 1.3% per $100 property tax formental health

•Florida counties – children’s trust funds

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Creating “Win-Win” Scenarios

System of Care

Child Welfare

Alternative to out-of-home care high costs/poor outcomes

Juvenile Justice

Alternative to detention-high cost/poor outcomes

Medicaid

Alternative to IP/ER-high cost

Special Education

Alternative to out-of-schoolplacements – high cost


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The Cost of Doing Nothing

If Milwaukee County had done nothing: the $18m.spent by child welfare ten years ago on residentialtreatment would be $48m. today

Project Bloom “Cost of Failure Study” – Early childhoodservices at an average cost per child of $987/year save$5,693/year in special education

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The Cost of Doing Nothing:Racial & Ethnic Disparities/Disproportionality

“…youths of color were less likely to receive outpatient therapy…and more likely to receiveresidential services.” (Source: McMillen, J., Scott, L.et. al. Use of Mental Health Services Among Older Youths In Foster Care. 2004.Psychiatric Services 55:811-817. American Psychiatric Association)

“The study finds greater use of residential treatmentcenters by black persons and Hispanic persons thatis attributable in part to (public sector) managed care”(Source: Snowden, L., Cuellar, E. & Libby, A. Minority Youth in Foster Care: Managed Care and Access to Mental Health Treatment. 2003. Med Care. 41(2): 264-74). University of California Berkley)

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Strategic Financing Analysis1) Identify state and local agencies that spend dollars on children’s behavioral health services/supports.

- how much each agency is spending

- types of dollars being spent (e.g., federal, state, local, Tribal, non-governmental)

2) Identify resources that are untapped or under-utilized (e.g., Medicaid).

3) Identify utilization patterns and expenditures associated with high costs/poor outcomes, and strategies for re-direction.

4) Identify disparities and disproportionality in access to services/supports, and strategies to address.

5) Identify the funding structures that will best support the system design (e.g., blended or braided funding; risk-based financing; purchasing collaboratives).

6) Identify short and long term financing strategies (e.g., Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum, etc.).

Pires, S. 2006. Human Service Collaborative. Washington, D.C.

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Where Families, Youth and Family and Youth Organizations Fit Into the Service Array

As technical assistance providers & consultants

Training

Evaluation

Research

Support

Outreach/Dissemination

As direct service providers

Family Liaisons

Care Coordinators

Family Educators

Specific Program Managers (respite, etc)

Youth Peer MentorsWells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

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Rhode Island Time Bank Initiative

• TimeBank Coordinator

• TimeBank Ambassadors

• Community Outreach

• Exchanges

• Special Projects

• Database

• Advisory Board

• Website

Time Bank Core Values: Assets-Redefining Work-Reciprocity-Community-Respect

Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.

Family Organization Sustainability Strategies

• Increase public awareness and acceptance of your organization and/or initiative.

• Develop a fund development plan for sustainability.

• Learn about all the different potential funding sources that could support your mission and family involvement work.

• Build relationships and trust with community and state agency partners and other potential funders.

• Develop a base of knowledge and evaluative results that supports your family involvement efforts in meeting the needs of children, youth, families, community and partners.

Example - Family Involvement CenterPhoenix, AZ

Contract with State Behavioral Health Agency

Medicaid managed care “administrative functions” contract

Medicaid managed care contract as provider in network

Contract with State child welfare agency

Financed initially by foundation grant; nowfinanced by State general revenue (MH), tobacco settlement,federal MH block grant, federal discretionary grant, Medicaidbillable services, and child welfare (GR and IV-E waiver)

Documents

Context Setting and Non Negotiable Characteristics of System of Care Processes and Structures Sheila A. Pires Human Service Collaborative Lisa Conlan Parent