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Sustaining Systems Of CareSustaining Systems Of Care
Beth A. Stroul, M.Ed.June, 2007
Beth A. Stroul, M.Ed.June, 2007
What do we mean by the “sustainability” of systems of care?
What do we mean by the “sustainability” of systems of care?
Defining SustainabilityDefining Sustainability
Long-term survival of services and programs that were initiated with grants or other specialized funding, including policy, philosophical, structural, and service delivery changes:
• Maintenance of systems of care over time
Services, Infrastructure, and Philosophy
• Maintenance of systems of care after federal funding has terminated
Array of Effective Community-Based Services & SupportsArray of Effective Community-Based Services & Supports Array of Effective Community-Based Services & SupportsArray of Effective Community-Based Services & Supports
Cultural & LinguisticCompetence
Cultural & LinguisticCompetence
LocalLocalInfrastructureInfrastructure
LocalLocalInfrastructureInfrastructure
Sustaining Systems of Care
StateStateInfrastructureInfrastructure
StateStateInfrastructureInfrastructure
Strategic FinancingStrategic Financing
Improved ServiceCoordination/Integration
Improved ServiceCoordination/Integration
Political & EconomicSupport
Political & EconomicSupport
EvaluationEvaluation
VVIISSIIOONN
//
PPHHIILLOOSSOOPPHHYY
//
PPRRIINNCCIIPPLLEESS
Education & TrainingEducation & Training
Social MarketingSocial Marketing
Youth & Family Involvement
Sustainable Systems of Care Have:Sustainable Systems of Care Have:
Policies, practices, structures, Policies, practices, structures, finances and philosophy finances and philosophy
in place in order to provide the services in place in order to provide the services and supports that increase the capacity and supports that increase the capacity for children with serious emotional for children with serious emotional disturbances and their families to live, disturbances and their families to live, work, learn and participate fully in their work, learn and participate fully in their community.community.
(Sustainability Tool Kit)(Sustainability Tool Kit)
Policies, practices, structures, Policies, practices, structures, finances and philosophy finances and philosophy
in place in order to provide the services in place in order to provide the services and supports that increase the capacity and supports that increase the capacity for children with serious emotional for children with serious emotional disturbances and their families to live, disturbances and their families to live, work, learn and participate fully in their work, learn and participate fully in their community.community.
(Sustainability Tool Kit)(Sustainability Tool Kit)
How can sustainability be assessed?How can sustainability be assessed?
Special Study on Sustainabilityin National Evaluation
Special Study on Sustainabilityin National Evaluation
• Explore extent to which systems of care are maintained after federal funding
• Identify features more likely to be sustained and those less likely
• Identify factors that affect sustainability
• Identify successful strategies for sustainability
• Explore extent to which systems of care are maintained after federal funding
• Identify features more likely to be sustained and those less likely
• Identify factors that affect sustainability
• Identify successful strategies for sustainability
Methodology of Sustainability StudyMethodology of Sustainability Study
• Literature review, focus groups• Sample selection
– Graduated Sites 4-5 Years Post Grant (N=26)– Nearly Graduated Sites in 6th Year (N=11)
• Web survey– Current or former project director– Mental health system rep– Family member– Rep of another child serving system
• Telephone interviews– Current or former project director– Family member– State children’s mental health director
• Literature review, focus groups• Sample selection
– Graduated Sites 4-5 Years Post Grant (N=26)– Nearly Graduated Sites in 6th Year (N=11)
• Web survey– Current or former project director– Mental health system rep– Family member– Rep of another child serving system
• Telephone interviews– Current or former project director– Family member– State children’s mental health director
Array of Services and SupportsArray of Services and Supports
Comparison of:• Degree to which each of the
services and supports in the array was available during period of grant funding
• Degree to which each of the services and supports was available during the current period (last 12 months)
Comparison of:• Degree to which each of the
services and supports in the array was available during period of grant funding
• Degree to which each of the services and supports was available during the current period (last 12 months)
System of Care PhilosophySystem of Care Philosophy
Comparison of degree of implementation of principles during the grant period and during the current period:
• Individualized care• Interagency coordination -
system and service levels• Service accessibility• Family involvement -
system and service levels• Cultural competence -
system and service levels
Comparison of degree of implementation of principles during the grant period and during the current period:
• Individualized care• Interagency coordination -
system and service levels• Service accessibility• Family involvement -
system and service levels• Cultural competence -
system and service levels
System of Care GoalsSystem of Care Goals
Comparison of goal achievement (including infrastructure goals) during the grant period and during the current period:
• Minimizing need to leave the community for services• Reducing services in overly restrictive settings• Ensuring sufficient service capacity• Using evaluation to inform policy and program decisions• Maintaining focal point for system management• Maintaining an active family organization• Achieving general acceptance of system of care philosophy
among system managers/leaders and service providers
Comparison of goal achievement (including infrastructure goals) during the grant period and during the current period:
• Minimizing need to leave the community for services• Reducing services in overly restrictive settings• Ensuring sufficient service capacity• Using evaluation to inform policy and program decisions• Maintaining focal point for system management• Maintaining an active family organization• Achieving general acceptance of system of care philosophy
among system managers/leaders and service providers
What do we know about sustainability in “graduated” communities?
What do we know about sustainability in “graduated” communities?
Sustainability of ServicesSustainability of Services
Increased Availability from Grant to Current Period
Decreased Availability from Grant to Current Period
Behavioral aide services
Transition - residential to community Transition to adult services
Medication treatment/monitoring
Substance abuse treatment
Case management
Therapeutic group homes
Independent living
After school/summer programs
Flexible fundsTransportation Respite care Family preservation/home-basedFamily support servicesRecreationTutoringProfessional consultationVocational servicesMentoring
Sustainability of ServicesSustainability of Services
• Small differences• Pattern suggests decreased availability of
“supportive” services• Difficult to replace grant resources for
flexible funds and other supportive services• Differences attributable to graduated sites• Challenging to maintaining services
developed with grant funds at same level
• Small differences• Pattern suggests decreased availability of
“supportive” services• Difficult to replace grant resources for
flexible funds and other supportive services• Differences attributable to graduated sites• Challenging to maintaining services
developed with grant funds at same level
Availability of ServicesAvailability of Services
• No services judged extensively available in either time period (rating of 5)
• Only case management and outpatient individual counseling rated very available (rating of 4)
• Most others rated somewhat or moderately available (rating of 2 – 3)
• Communities have struggled to build service capacity commensurate with need, even with investment of grant funds
• No services judged extensively available in either time period (rating of 5)
• Only case management and outpatient individual counseling rated very available (rating of 4)
• Most others rated somewhat or moderately available (rating of 2 – 3)
• Communities have struggled to build service capacity commensurate with need, even with investment of grant funds
Sustainability of Philosophy Sustainability of Philosophy
Increased Implementation from Grant to Current Period
Decreased Implementation from Grant to Current Period
Family involvement in the service planning and delivery process (services level)
Cultural competence of services (services level)
Cultural competence of system policy and management (system level)
Individualized care approachInteragency coordination in system policy and management (system level)Interagency coordination in planning and delivering services (services level)Family involvement in system policy and management (system level)Services accessibility (times, locations) )Shared administrative processes among agencies
Sustainability of PhilosophySustainability of Philosophy
• Small differences
• Implementation of most features declined
• Differences attributable to graduated sites
• Suggests difficulty maintaining principles at same level without visible presence of grant related requirements and activities
• Small differences
• Implementation of most features declined
• Differences attributable to graduated sites
• Suggests difficulty maintaining principles at same level without visible presence of grant related requirements and activities
Implementation of PrinciplesImplementation of Principles
• Several rated as very much implemented (rating of over 3.5 in both time periods)– Family involvement at the system level– Family involvement at the services level– Individualized care
• Despite largest declines, these three remained the most highly implemented principles
• Other principles implemented “moderately” in both time periods
• Several rated as very much implemented (rating of over 3.5 in both time periods)– Family involvement at the system level– Family involvement at the services level– Individualized care
• Despite largest declines, these three remained the most highly implemented principles
• Other principles implemented “moderately” in both time periods
Achievement of GoalsAchievement of Goals
Increased Achievement from Grant to Current Period
Decreased Achievement from Grant to Current Period
Minimizing need to leave community for services (community-based care)
Reducing services in overly restrictive settings (least restrictive setting)
Achieving general acceptance of SOC philosophy among system/program managers
Achieving general acceptance of SOC philosophy among service providers
Ensuring sufficient service capacityUsing evaluation data to inform program and policy decisionsMaintaining a focal point for management of the system of care (agency, office, or entity)Supporting and maintaining an active family organization in the community
Achievement of GoalsAchievement of Goals
• “Infrastructure” goals declined in achievement
• Suggests infrastructure goals pose more challenges without federal funds and accompanying mandates
• Differences attributable to graduated sites
• “Infrastructure” goals declined in achievement
• Suggests infrastructure goals pose more challenges without federal funds and accompanying mandates
• Differences attributable to graduated sites
Level of Goal AchievementLevel of Goal Achievement
• None achieved with complete or substantial success (ratings of 4 or 5)
• Most approached substantial success in both time periods (ratings over 3.5)– Achieving general acceptance of SOC philosophy– Maintaining designated focal point for system management– Reducing use of unnecessarily restrictive settings– Minimizing need to leave the community for services
• Others achieved with moderate success in both time periods
• None achieved with complete or substantial success (ratings of 4 or 5)
• Most approached substantial success in both time periods (ratings over 3.5)– Achieving general acceptance of SOC philosophy– Maintaining designated focal point for system management– Reducing use of unnecessarily restrictive settings– Minimizing need to leave the community for services
• Others achieved with moderate success in both time periods
Factors Affecting SustainabilityFactors Affecting Sustainability
• Many factors affect sustainability
• Some in control of communities, others by political/economic environment
• Factors most present in sites:– Local commitment to the SOC approach
– Increased utilization/reliance on Medicaid
– Existence of ongoing administrative leadership
– Interagency partnerships
– Inclusion of key stakeholders at all levels
• Many factors affect sustainability
• Some in control of communities, others by political/economic environment
• Factors most present in sites:– Local commitment to the SOC approach
– Increased utilization/reliance on Medicaid
– Existence of ongoing administrative leadership
– Interagency partnerships
– Inclusion of key stakeholders at all levels
Impact of Factors on SustainabilityImpact of Factors on Sustainability
Factors with Negative Impact
Changes in larger economic climate
Changes in elected or appointed officials
Factors with No Impact
Implementation of managed care
Impact of Factors on SustainabilityImpact of Factors on Sustainability
Factors with Most Positive ImpactInclusion of key stakeholders at all SOC levels
Interagency partnerships
Local commitment to SOC approach
Existence of ongoing leadership
Provision on ongoing training
Existence of constituency advocating for SOC approach
Presence of a “champion” with power/influence
Infusion of SOC into larger system, not separate
Existence of evaluation data on effectiveness of SOC
State commitment to SOC approach and involvement
Existence of formal policies supportive of systems of care
Engagement of political and policy leaders
State financial support
Increased utilization of Medicaid for financing services
Strategies for SustainabilityStrategies for Sustainability
• None rated completely or very effective (rating of 4 or 5)
• Some approached very effective level (rating of over 3.5)– Cultivating strong interagency relationships
– Involving stakeholders
– Establishing a strong family organization
– Using evaluation results
– Creating an ongoing focal point for SOC management
• None rated completely or very effective (rating of 4 or 5)
• Some approached very effective level (rating of over 3.5)– Cultivating strong interagency relationships
– Involving stakeholders
– Establishing a strong family organization
– Using evaluation results
– Creating an ongoing focal point for SOC management
Strategies for SustainabilityStrategies for Sustainability
• All others were rated moderately effective– Making policy and regulatory changes supportive of SOCs– Infusing the SOC into the broader service system– Providing training– Creating an advocacy base– Generating political support
• Making policy/regulatory changes and infusing SOCs into broader system were rated higher by graduated communities
• Creating ongoing focal point and establishing strong family organization were goals achieved less effectively, but were rated among most effective sustainability strategies
• Ratings varied with ability to implement the strategy well
• All others were rated moderately effective– Making policy and regulatory changes supportive of SOCs– Infusing the SOC into the broader service system– Providing training– Creating an advocacy base– Generating political support
• Making policy/regulatory changes and infusing SOCs into broader system were rated higher by graduated communities
• Creating ongoing focal point and establishing strong family organization were goals achieved less effectively, but were rated among most effective sustainability strategies
• Ratings varied with ability to implement the strategy well
Financing StrategiesFinancing Strategies
Strategies Used Most Frequently:• Increasing ability to obtain Medicaid
reimbursement for services• Operating more efficiently (cutting costs)• Creating partnership with other non-mental health
child-serving systems• Obtaining grants• Coordinating categorical funds• Obtaining new/increased state funds• Leveraging funding sources
Strategies Used Most Frequently:• Increasing ability to obtain Medicaid
reimbursement for services• Operating more efficiently (cutting costs)• Creating partnership with other non-mental health
child-serving systems• Obtaining grants• Coordinating categorical funds• Obtaining new/increased state funds• Leveraging funding sources
Most Effective Financing StrategiesMost Effective Financing Strategies
• Increasing ability to obtain Medicaid reimbursement– Collaboration with state mental health and Medicaid agency– Changing state plan by adding new definitions and service codes– Use of multiple Medicaid options
• Obtaining new/increased state funding (general revenue, block grant)
• Obtaining funds from partner child-serving agencies
• Redeploying funds from higher to lower cost services
• Increasing ability to obtain Medicaid reimbursement– Collaboration with state mental health and Medicaid agency– Changing state plan by adding new definitions and service codes– Use of multiple Medicaid options
• Obtaining new/increased state funding (general revenue, block grant)
• Obtaining funds from partner child-serving agencies
• Redeploying funds from higher to lower cost services
State PerspectivesState Perspectives
• Crucial role of state agencies in providing leadership and resources
• Cannot sustain SOCs without policy and financial support from states
• Support of state agencies, in partnership with communities, is necessary condition for sustainability
• State role essential for statewide SOC development• State involvement with SOC communities is critical
• Crucial role of state agencies in providing leadership and resources
• Cannot sustain SOCs without policy and financial support from states
• Support of state agencies, in partnership with communities, is necessary condition for sustainability
• State role essential for statewide SOC development• State involvement with SOC communities is critical
State RoleState Role
• Working with state Medicaid agency to amend state Medicaid plans and rules to finance the services within SOCs
• Providing funds from state mental health agencies to finance SOCs and their component services
• Negotiating agreements with other child-serving systems to support the SOC approach, enhance interagency coordination, and provide funding for services
• Implementing statewide programs (e.g., wraparound or crisis programs) that provide mechanisms for sustaining SOCs and services
• Building on the system development in funded communities for statewide SOC development by using them as pilots, models, and sources of experience, information, and training
• Working with state Medicaid agency to amend state Medicaid plans and rules to finance the services within SOCs
• Providing funds from state mental health agencies to finance SOCs and their component services
• Negotiating agreements with other child-serving systems to support the SOC approach, enhance interagency coordination, and provide funding for services
• Implementing statewide programs (e.g., wraparound or crisis programs) that provide mechanisms for sustaining SOCs and services
• Building on the system development in funded communities for statewide SOC development by using them as pilots, models, and sources of experience, information, and training
State Role, ContinuedState Role, Continued
• Enacting legislation that supports statewide SOC implementation • Implementing mechanisms to provide TA and training on SOC
philosophy and approach • Creating entities to provide leadership, coordination, and support
for SOCs at state, regional, and/or local levels • Incorporating the SOC philosophy and approach in policy
documents, plans, licensing requirements for provider agencies, and contracts with provider agencies and managed care organizations
• Removing barriers in policy, regulations, and financing that are identified by local communities in sustaining SOCs
• Monitoring compliance with the SOC philosophy and approach in communities and evaluating the outcomes of SOCs and services
• Enacting legislation that supports statewide SOC implementation • Implementing mechanisms to provide TA and training on SOC
philosophy and approach • Creating entities to provide leadership, coordination, and support
for SOCs at state, regional, and/or local levels • Incorporating the SOC philosophy and approach in policy
documents, plans, licensing requirements for provider agencies, and contracts with provider agencies and managed care organizations
• Removing barriers in policy, regulations, and financing that are identified by local communities in sustaining SOCs
• Monitoring compliance with the SOC philosophy and approach in communities and evaluating the outcomes of SOCs and services
Lessons Learned from SitesLessons Learned from Sites
• Establish a strong link between local SOCs and state agencies• Engage top policy makers and system administrators• Incorporate SOC approach into written plans and documents• Understand and create partnerships with other child-serving
systems• Involve and strengthen family advocates and family organizations• Use outcome data and personal stories to advocate sustaining SOCs• Conceptualize grants as part of larger state strategy for SOCs• “Refinance” SOC grants from outset with multiple funding streams• Collaborate with state Medicaid agency• Cultivate leaders/champions to “carry the mantle” over time
• Establish a strong link between local SOCs and state agencies• Engage top policy makers and system administrators• Incorporate SOC approach into written plans and documents• Understand and create partnerships with other child-serving
systems• Involve and strengthen family advocates and family organizations• Use outcome data and personal stories to advocate sustaining SOCs• Conceptualize grants as part of larger state strategy for SOCs• “Refinance” SOC grants from outset with multiple funding streams• Collaborate with state Medicaid agency• Cultivate leaders/champions to “carry the mantle” over time
More Lessons LearnedMore Lessons Learned
• Incorporate key elements of SOCs into contracts with providers• Implement mechanisms to pay providers for interagency
coordination and service planning processes• Use effective social marketing approaches to disseminate
information and garner supports• Provide extensive training on SOCs and services• Use first year of grant for implementation and sustainability
planning• Use multiple strategies for sustainability• Adapt to changing circumstances• Learn from experience of graduated communities
• Incorporate key elements of SOCs into contracts with providers• Implement mechanisms to pay providers for interagency
coordination and service planning processes• Use effective social marketing approaches to disseminate
information and garner supports• Provide extensive training on SOCs and services• Use first year of grant for implementation and sustainability
planning• Use multiple strategies for sustainability• Adapt to changing circumstances• Learn from experience of graduated communities
What are the implications for currently funded communities?What are the implications for
currently funded communities?
Implications for Systems of CareImplications for Systems of Care
• Need for greater focus on maintaining supportive services (flexible funds, respite, family support, mentoring)
• Greater attention to increasing service capacity
• Increased emphasis on maintaining principles at the system level (family involvement and interagency coordination), as well as service level
• Need for greater focus on maintaining supportive services (flexible funds, respite, family support, mentoring)
• Greater attention to increasing service capacity
• Increased emphasis on maintaining principles at the system level (family involvement and interagency coordination), as well as service level
More ImplicationsMore Implications
• Attend to infrastructure elements in sustainability planning (e.g., focal point for system management, evaluation capacity, maintaining family organization)
• Maximize factors that enhance sustainability (e.g., nurture state partnerships)
• Use multiple sustainability strategies
• Use lessons learned to address challenges and pitfalls
• Attend to infrastructure elements in sustainability planning (e.g., focal point for system management, evaluation capacity, maintaining family organization)
• Maximize factors that enhance sustainability (e.g., nurture state partnerships)
• Use multiple sustainability strategies
• Use lessons learned to address challenges and pitfalls
Strategic Framework for Sustainability Planning
Strategic Framework for Sustainability Planning
Sustainability Strategies1. Ongoing Locus of Accountability
– Create a viable, ongoing focal point for system management
2. Family Organization and Advocacy Base– Establish a strong family organization
– Create an effective advocacy base
3. Evaluation/Accountability Data– Use evaluation/accountability results to “make the case” for sustainability
4. Interagency Partnerships– Cultivate strong interagency relationships and partnerships for service delivery
and coordination
– Cultivate strong interagency partnerships for ongoing financing of services
Strategic Framework, ContinuedStrategic Framework, Continued
5. Infusion of System of Care Approach into Larger System– Make state-level and local-level policy and regulatory changes that support SOCs
– Make the SOC philosophy/approach the way the community’s larger service system operates
6. Training– Provide ongoing training and coaching re SOC philosophy and approach
– Provide ongoing training re effective services
7. Commitment and Support for System of Care Approach– Generate political and policy level support for the SOC approach
– Generate state involvement and commitment
– Generate local involvement and commitment
– Cultivate ongoing leaders and champions for SOC philosophy and approach
Strategic Framework, ContinuedStrategic Framework, Continued
Financing Strategies for Sustainability1. Medicaid
– Increase ability to obtain Medicaid reimbursement for services
2. State Mental Health Funds– Obtain new or increased state mental health funds
3. Other Child Service Systems Funds– Obtain new or increased funds from other child-serving agencies
– Coordinate, blend, or braid funds with other child-serving agencies
4. Redeploying Funds– Redeploy/shift funds from higher to lower cost services
5. Local Funds– Obtain new or increased local funds (e.g., taxing authorities)
