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

System of Care Development

This section highlights selected attributes of the five graduating sites in the two domains that comprise a system of care: infrastructure and service delivery. As noted in earlier discussions about the evolution of systems of care, each attribute overlaps with others. The result, as documented below, is that as each attribute of a system of care is enhanced, it in turn strengthens other attributes as well. For example, greater family involvement strengthens ties to communities, reinforcing two separate but related goals underlying systems of care.

Infrastructure

Like any other partnership among organizations, system of care development evolves along a continuum that spans the formation of a new partnership, moves through growth and expansion of the partnership, and then continues with an evaluation or assessment of the partnership’s activities. Because they received the earliest funding, the five graduating sites have had the greatest opportunities to move into the latter stages of partnership development.

Precursors to the Current Systems of Care

The term "formation" is somewhat misleading when applied to systems of care, since most grantees have used grant funding to solidify and/or expand existing networks. In varying degrees, this was the case for all five of the graduating sites. For example, in some cases, grantees built on a previous infrastructure development initiative, the Child and Adolescent Service System Program (CASSP). This was the case for the statewide Families First Initiative in Vermont, commonly known as ACCESS Vermont. Other examples of councils or partnerships that pre-dated the CMHS grants include the Stark County Family Council and the Southern Consortium for Children in Ohio, both launched during the 1980s.

The Village Project in Charleston, South Carolina and the East Baltimore Mental Health Partnership both created new interagency structures in response to the 1993 CMHS grant funding. The Village Project structure, while new, enjoyed close ties to a more established coalition devoted to children and family issues, housed in the Mayor’s Office in Charleston.

Of the graduating sites, the East Baltimore project had perhaps the greatest distance to travel in terms of creating a new system of care partnership from scratch. The partnership that evolved included a range of public and private agencies, and is run by a local nonprofit organization that administers the grant. The staff and services are provided by Johns Hopkins Hospital under contract to the nonprofit agency.

Geographic Scope

Although all five sites served children and adolescents with serious emotional disturbance and their families, they differed markedly in the geographic scope of their efforts. East Baltimore focused on a neighborhood in a "pilot" approach, with the goal of solidifying its focus on community and family involvement before expanding to other parts of the city. Vermont’s program, on the other hand, is a statewide and State-run initiative that melds statewide priorities for child and adolescent mental health with local priority services. As its name suggests, the Stark County Family Council focuses its system of care throughout a single county, while the Southern Consortium encompasses a 10-county area in rural Ohio. The Village Project, originally focused on the city of Charleston, has expanded to include families living on a more isolated island community off of South Carolina’s coastline.

Interagency Structures

Each of the five graduating sites strengthened or created partnerships among different types of agencies engaged in various aspects of child and adolescent health. The basic configuration included:

• public agencies, particularly State mental health agencies; departments of juvenile justice, education, and welfare; and State and local health departments;
  
• private and not-for-profit organizations, including businesses, churches, health care organizations, and community-based organizations; and
  
• family advocacy groups.

To coordinate the varying agendas and systems represented by these different types of organizations, grantees created interagency councils that functioned at several levels. For example, several of the graduating sites created two levels of interagency coordination: one representing the agency director level for decisions about the system overall, and another representing operational or managerial levels, for day-to-day case coordination. As discussed below in the section on family involvement, family members were included in the councils at both levels.

The interagency meetings among system of care participants served several purposes. At the most global level, some grantees reported that contact with representatives from other agencies helped them understand the perspective of groups with whom they were less familiar. In addition, frequent contact helped system of care participants develop a shared sense of goals and responsibilities. Each month, for example, weekly meetings of The Village Project’s consultation team are led by a different agency representative.

Some grantees reported another important byproduct of interagency contacts: gradually spreading the system of care philosophy and values to other organizations within the system of care. For example, staff in one site noted that over time, family involvement, modeled by some organizations within the system of care, had become a standard feature of other agencies’ work—including some (such as juvenile justice) with little prior history of family involvement.

At a more concrete level, the contact among the organizations that comprised systems of care allowed participants to identify and reduce barriers more efficiently—especially with the feedback provided by family representatives. At this level, interagency coordination led to efficiencies such as universal intake forms that could be used consistently by all the organizations within a system of care.

Service Array

Fulfilling the goals of systems of care, the five graduating sites offered children and families a mix of traditional and nontraditional services. Each site included some type of clinical center that provided outpatient care such as counseling. In some cases, these services were also provided in other settings (such as schools) to improve access.

Children and families were referred to traditional clinical care through a range of non-medical organizations, including schools, juvenile justice systems, law enforcement, churches, and by families themselves. (The various sources of referrals are discussed in greater detail in the Outcomes section below.)

Adding another dimension of services, community organizations and family support networks provided wraparound services (such as transportation and respite care) to help meet the non-clinical, but equally compelling, needs of children, adolescents, and families.

These three elements—traditional mental health care, intake and referral sources, and wraparound services—were features of all five graduating sites. Their coexistence illustrates how each new layer of services that is added to a system of care helps increase responsiveness to children and families. At the same time, new services led to additional partnerships, extending systems of care into communities. For example, in East Baltimore, the system of care developed a violence prevention and response program called Community Oriented Partnership Services (COPS) with a local police district.

Service Delivery Approaches

Service Coordination

Systems of care represent a response, in part, to the fragmentation and unnecessary duplication of services for children and adolescents with severe emotional disturbance. The coordination of formerly fragmented services occurs at several levels. As described above, interagency contacts and agreements pave the way for increased coordination that may take the form of concrete changes in agency policies, such as common use of a universal intake form across all agencies involved in a system of care. For example, public and private providers in The Village Project’s system of care adopted a single application form for residential services, and cross-agency intake forms and service plans were also under development.

Additional service coordination occurred through the formal role of case managers and through the efforts of trained family advocates, particularly to coordinate nontraditional services such as transportation, housing, and respite care.

Another important byproduct of service coordination is greater accountability among all participants in a system of care. For example, one of the systems of care in Vermont has responsibility for tracking data on trends such as the number of children placed in residential facilities and protective custody, or problems with access to services identified by providers. These data are presented at quarterly management meetings to help track the system of care’s efforts and potential barriers for families. Similarly, in Stark County, the interagency group identified performance requirements for each family so that providers and families can jointly monitor progress.

Family Involvement

Among the graduating sites, family involvement occurred at many levels. First, in keeping with system of care principles, families were included in service planning for their own families as partners, rather than passive recipients of services. In East Baltimore and Stark County, family members are invited to include others with ties to the child or adolescent receiving services, such as teachers or ministers, in service planning sessions.

In each site, families were involved to some degree in formal governance bodies, such as the interagency councils described above. In several of the sites, parent and family organizations had become more formal over time, whether as chapters of the national Federation of Families for Children’s Mental Health or by creating a separately staffed organization. These organizations have undertaken a variety of activities, including service coordination for wraparound services, training providers, sponsoring a fair where families and providers could learn about each other, and organizing social activities for families.

Informal family advocacy groups also evolved in some sites. In East Baltimore, for example, the project’s neighborhood catchment area was further divided into four "clusters." Project staff helped launch social events—such as picnics and holiday parties—in each cluster, to help families meet one another and develop their own support networks. Over time, the families in each cluster began organizing their own activities, without involvement from project staff.

Trained family advocates provided important services for other family members who were newly involved in the system of care, supplementing existing case management services. For example, in Stark County, families were contacted by family advocates as soon as they were referred for formal mental health services, even if they were still on the waiting list for mental health services. In several graduating sites, family representatives also helped facilitate and organize support groups for parents and grandparents. Family advocates who participate in The Village Project in South Carolina formed a telephone support network to augment face-to-face meetings.

In addition to supporting one another, families also have been involved in shaping the system of care attributes in the graduating sites. For example, in one site, family members participated in training of system of care providers and had input into hiring decisions.

Another important role played by family representatives and advocates in the graduating sites was extending and strengthening ties to communities. For example, in The Village Project in Charleston, family advocates forged a link between the project and families living on St. John’s Island. In Stark County, family advocates and representatives from the project’s family organization were stationed in various community locations to assist families as they negotiated the system of care. 

Cultural Competence

The graduating sites illustrate many approaches to improving cultural competence within the systems of care. Intake forms for The Village Project’s system of care specifically asked about families’ cultural beliefs and values, so that these could be incorporated into service planning. In Stark County, the project’s Family Council included a minority outreach parent coordinator, who helped minority children and adolescents tap into community resources such as mentoring programs.

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