Annual Report to Congress on the Evaluation of the Comprehensive Community Mental Health Services Program for Children and Their Families

Variations in Approaches to System of Care Development

While all systems of care share the same goals of providing comprehensive, community-based, individualized, family-focused, and culturally competent services, achieving these goals requires each system of care to be unique to its community’s needs and resources. Community-specific environmental factors, including geography, socio-political structures, cultural influences, and economic resources, have significant effects on system development (The National Assembly of National Voluntary Health and Social Welfare Organizations, 1991). Recognizing and distinguishing the variation among the system-of-care approaches implemented by the grantees is critical to understanding how systems of care develop. The sites studied in this evaluation vary on several key characteristics that affect their development and operation. These site-level differences give context to all findings in this report.

First, the catchment areas of the communities served by the grantees vary. Grants were purposely directed to ensure that systems of care operated in a variety of geographic configurations, including urban, small city/county, rural, and Native American settings. Some systems of care operate in small areas within larger communities. For example, the East Baltimore Mental Health Partnership operates in one section of Baltimore, Maryland. Other systems of care operate in huge expanses, such as the service regions encompassing many counties (e.g., the Partnerships Projects centered in Minot, Bismarck, and Fargo, North Dakota). In Rhode Island and Vermont, systems of care operate statewide. Each approach to defining the catchment area brings different challenges. In Baltimore, the challenge is to inspire the core agencies to develop a comprehensive collaborative relationship when the grant-defined system of care only encompasses a small part of the agencies’ entire target population and total service area. In North Dakota, the challenge is to get the multiple counties, which often compete for State resources, to work together and cooperate.

Second, the management of the system varies. In many grantee sites, public agencies run the system. In other sites, nonprofit agencies are in the lead, and changes in public and private status are occurring. In the majority of sites, the mental health agency has been the driving force behind the system. For example, at the PEN-PAL project in North Carolina, the State agency of mental health is the lead agency and is involved in setting the direction for the system of care. In other sites, such as the Riverside County (California) Interagency System of Care, the local mental health agency is the grantee. The Napa County, California, site represents a different approach in which an umbrella agency, Sonoma-Napa Comprehensive System of Care, unifies many public family-serving agencies under one administrative unit. Within these varying types of administrative approaches, staff structures vary. In some sites, public agencies run programs and public employees provide most of the services to children and families. In other sites, private agencies are contracted to provide services. In most of the sites, a combination of public and private providers exists.

In sites where nonprofit entities are directly responsible for the management of the system of care, such as Olympia (formerly known as the Doña Ana County Child and Adolescent Collaborative) in Las Cruces, New Mexico, and the Stark County Family Council in Ohio, nonprofit organizations bring community direction to system management. In yet another model, the New Opportunities program in Lane County, Oregon, a public-private consortium is the leadership body.

Third, the history of the approaches to serving children and the relationships among the core agencies in the communities in which systems of care operate vary. In sites such as the Ventura County (California) System of Care, the basic structure and service array had existed for over a decade before the infusion of CMHS grant funds. In contrast, on the Navajo Nation, very few public services existed to help children with serious emotional disorders and their families before the K’é Project. Many sites built services on the foundation laid by earlier CASSP initiatives. For example, Stark County used its CASSP grant to provide State-level staffing and technical support to create coalitions among the child-serving agencies. Similarly, in the Three Townships in Illinois, Department of Education grant funds and CASSP values created school-based teams to address the needs of children with serious emotional disorders. Further, specific legislative mandates have been shown to have major effects on system-of-care development (Lourie, 1994), and this is true for the grantee sites. For example, the consent decree in the State of Hawai‘i requires comprehensive services for children, directing system-of-care implementation. The Children’s Services Act in Virginia and Act 264 in Vermont requiring interagency coordination have had major effects on the system-of-care development for the sites in these States.

Finally, the pre-existing resources vary across the communities. Some communities, for example, St. Johnsbury, Vermont, and Milwaukee, Wisconsin, had a strong base of existing services and resources to draw upon, such as not-for-profit organizations and community-based organizations. Other communities had little to tap into and had to build services from scratch. Each of these situations creates different benefits and challenges, and requires building relationships among different partners.

Despite the variation in approaches, analysis of the findings over the last 3 years has revealed many similarities in the system-of-care sites. However, the variances give insight as to how sites focused their system development, how priorities were set, and how choices were made to pursue some aspects of systemness over others. Throughout this report, taking into account these differences provides context for assessing the relative value of any given initiative; for example, a program serving 10 families in 1 community can be just as effective as 1 serving 100 families in another.

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