This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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1999 Annual Report to Congress on the Evaluation
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CHAPTER SUMMARY In summary:
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Seven grant communities received their awards in February 1994 in the second cycle of funding under the Comprehensive Community Mental Health Services for Children and their Families Program. These grant communities completed their fifth and final year of funding in FY 1998.
During the 5-year period covered by the grant, 11 systems of care were established in the 7 grant communities. These included five counties in California (Riverside, San Mateo, Santa Cruz, Solano, Ventura) that established separate systems of care under one grant; a statewide program serving eight catchment areas in the State of Rhode Island; a four-county region in Maine; a three-county program in eastern North Carolina; and county-level systems of care in Kansas, New Mexico, and Wisconsin.
Each of these systems of care served unique populations and developed in accordance with the needs of these diverse communities. The grant communities also reflected considerable differences in terms of their histories of interagency collaboration prior to implementing the grant, the effects of State-level policies such as Medicaid managed care reforms, and their ability to sustain and expand the system of care during the life of the grant.
A brief description of each system of care follows, highlighting some of the distinctive characteristics that evolved across the 5 years of grant funding. These include overviews of the background and history of each system of care; its target population; how the system of care is organized; approaches to service delivery, family involvement and cultural competence; unique features, strengths and challenges faced by the system of care; sustainability after the grant period; and lessons learned. Information is drawn from system-of-care assessment site visit reports as well as descriptive and outcome data obtained from each grant community.
Grant communities are presented according to their geographical hub: urban, small city or county, and rural. The urban hub includes the systems of care in Kansas, Rhode Island, and Wisconsin. The five California grant communities are each classified as small city or county systems. The Maine, New Mexico, and North Carolina grant communities lie within the rural hub. Descriptive information about the children and families served at each grant community and changes in clinical indicators are also presented by hub.
CMHS-funded grant communities included in the urban hub are those with a predominating metropolitan area, and who self-identified with issues relevant to urban populations. Three system-of-care grants were awarded to urban communities: Sedgewick County, Kansas, the State of Rhode Island, and Milwaukee County, Wisconsin. While the Sedgewick County, Kansas, system of care serves the entire county, the population is centered in the city of Wichita which is located in this county. Milwaukee County, as one of two counties within which the city of Milwaukee is located, is entirely encompassed by the city. In Rhode Island, funding was provided to the State to develop systems of care in eight catchment areas. System-of-care assessments were conducted at two of these sites, Washington County and the city of Providence, and are reflected in the narrative.
Table 19 presents the demographic characteristics of the children participating in the evaluation in the three urban grant communities. The children who participated in system-of-care services among the three grant communities were predominately male. Children in Milwaukee were slightly older, predominately African-American, and came from families with a slightly higher income than those in Wichita and Rhode Island. In comparison to the national aggregate data, more White children were enrolled in services in Wichita, and more than three times as many African-American children received services in Milwaukee. Slightly more than half of all children lived with their mothers as caregivers, and almost twice as many children lived with two parents in Wichita and Rhode Island than in Milwaukee. Children in Milwaukee were also somewhat less likely to reside in impoverished families.
Referral to services differed at each grant community. In Wichita, most children were referred to system-of-care services by mental health agencies, followed by physician and social service agency referrals. In Rhode Island, most children were referred by mental health agencies; however, school and parent referrals were also important. The juvenile justice system in Milwaukee, including referrals by the court and corrections, accounted for close to 60 percent of all children who participated in the system of care, and social service agencies also referred a significant proportion of children. In comparison to the national aggregate data, four times as many children in Milwaukee were referred to services by the juvenile justice system.
At all grant communities the three primary diagnoses were conduct-related disorders, attention-deficit/hyperactivity disorder (ADHD), and depression. Children in Milwaukee were more likely to have received a primary diagnosis of conduct-related disorder, while a higher percentage of children in Rhode Island were diagnosed with ADHD, and children in Wichita had a higher incidence of depression. Family history of mental illness, family violence, and substance abuse were present in a significant proportion of families. In comparison to the national figures, children in Milwaukee had a higher incidence of child and family risk factors across all categories. Children in Wichita had a greater incidence of previous psychiatric hospitalization and were less likely to have run away or used drugs or alcohol, and their siblings were less likely to be institutionalized. In Rhode Island and Wichita, the history of family mental illness was greater and felony conviction of caregivers was lower than national figures (see Table 20).
Changes in child functional status and child behavior are reported in Figures 54 and 55. Children participating in the system of care in Rhode Island were least functionally and behaviorally impaired at intake, and child behavior problems as assessed by parents dropped below clinical levels at 1 year. In Milwaukee and Wichita, where children who entered services had greater functional impairment, considerable functional improvement was seen for children who were assessed at 6 months and 1 year. In Wichita, the 19 children who remained in services up to 1 year and participated in the national evaluation approached normal functional levels.
History. Wichita's system of care had its origins in a program launched in 1992 by the city's Family and Children's Community Services (FCCS) agency, using State mental health reform funds. Two years later, FCCS became the CMHS grant community and expanded services of the Comprehensive Community Care of Sedgwick County (COMCARE).
Catchment Area. The FCCS system of care covers Sedgwick County, which includes the city of Wichita. The county's population of children under the age of 18 is approximately 110,500.
Target Population. The target population is children with serious emotional disorders who are at risk of hospitalization or residential care. Assessment of children who encountered the juvenile justice system has been placed under FCCS. Social and Rehabilitative Services (SRS), the child welfare agency participating in the system of care, conducts protective investigations of children placed in protective custody.
Management and Organization. Several public agencies form the core of the system of care: FCCS, the child welfare agency (SRS), two juvenile justice agencies, and the county school system. In addition, several private, nonprofit agencies participate. A Children's Mental Health Coalition, representing a broad range of providers, advocacy organizations, parents' organizations, and public agencies, also participates. This group serves as an information-sharing body, and is a structure that is to remain in place beyond the life of the grant. Finally, three parent organizations represent the parents of children with serious emotional disturbance. Parent advocates have a strong voice and participate in hiring, training, and policy decisions for the system of care. Relationships between public and private agencies, particularly at the management level, bring strong collaboration on behalf of families.
A major influence on the system of care's management and organization was a 1997 State-level reorganization that led to the privatization of many child welfare functions, including foster care, adoptions, and in-home services for families involved with child protective services. Among other effects, this change removed many children who would have been in the system of care's target population from the system's network of services and case management according to system-of-care principles. Changes in funding sources and in child- and family-serving agencies affected interagency and collaborative approaches to services; however, these changes also presented new opportunities for collaboration that would be influenced in part by allocation of State funds.
Service Delivery Approaches. A "quick assignment" strategy assigns children to a case manager, who attends intake with the child, the family, and a parent support representative to help determine the appropriate range of services. Case reviews occur weekly at two different levels to ensure appropriate referrals to services. The child and family are involved in developing the service plan; family team meetings bring together service providers for planning and coordination. Case managers make service decisions and are respected by agency staff and families. Children receive individualized services, and flexible funding is available to meet specific family needs. Services are available in convenient locations, including homes and schools, and assistance with transportation, a particular problem for those in outlying areas, is often provided. Intensive in-home services, respite care, and attendant care are provided under contract by several private providers.
Family Involvement. At the system level, family advocates from Families Act and the Mental Health Association participate on coalitions and committees and take part in weekly case review meetings. In addition, parent advocates participate as case managers. Funding is being sought to maintain the family organizations with hopes of expanding staff positions to full-time. Two family organizations, NAMI-CAN and Keys for Networking, have played a peripheral role in the system of care. Both organizations were involved in some educational activities and expressed interest in further involvement. Family input is respected, families are very involved in service planning, and families are able to enlist support of case managers or advocates as needed.
Cultural Competence. The Mental Health Association and FCCS regularly provide cultural competence training. While few specific cultural needs arise among participants in the system of care, assistance in addressing the needs of Spanish-speaking families is available through a case manager who is fluent in Spanish. In addition, parent support is available for families of Hispanic origin, and the Mental Health Association applied for additional funding to work with Hispanic families. The YMCA and the Boys and Girls Club, by involvement in service planning, also serve as resources to address cultural needs.
Unique Features. Once children and families reach a point where less intensive assistance is required, they are transitioned to aftercare case managers who are trained and employed by the Mental Health Association, one of three parent support organizations involved in the system of care. Collaboration with the adult mental health system provides transition to the adult system.
Strengths include an effective case management system, strong public-private partnerships, an established commitment to family involvement, and an ability to sustain the system-of-care philosophy in a managed care environment.
Continuing challenges include an uneven (but improving) relationship with the school and juvenile justice system, the lack of an evaluator (who left the program and has not been replaced), and some fragmentation among the three parent organizations.
Despite the effects of State-level reorganization, it was anticipated that COMCARE would continue to exist through other funding streams. Successful changes to system-of-care approaches in agencies were brought about by the grant. It was anticipated that these changes toward a community-based, individualized, family-friendly philosophy of services would continue to shape service delivery over time.
Lessons learned included the importance of developing a better understanding of what motivates families to follow through on treatment and parental responsibilities, establishing partnerships with parents to meet children's needs, and sharing information with families.
History. The State of Rhode Island applied for and received a CMHS grant to implement a statewide system of care. The city of Providence is one of eight catchment areas across the State to which funding was allocated through the State Department of Children, Youth, and Families (DCYF) for the implementation and maintenance of a comprehensive system of care for children and youth with serious emotional disturbance and their families. Funding to local sites began in August 1994.
Catchment Area. The catchment area for this system of care is the city of Providence, the major urban area in Rhode Island. The city's population is diverse and includes Hispanic, African-American, and Southeast Asian families, all served by the system of care. Each year, the Providence system of care serves approximately 155 children and families, the majority of whom are eligible for Medicaid.
Target Population. The target population is defined as children at risk of out-of-home placement or those who were placed out-of-home due to their emotional and behavioral problems and are returning home.
Management and Organization. Unlike other local systems of care in Rhode Island for which the local mental health agency serves as the lead agency, the Providence system of care is administered by John Hope Settlement House, a community-based agency that has been in operation since the early 1920s. The city's community mental health center is part of the system of care, along with juvenile justice, education, child welfare, and parent organizations. A public health representative was being recruited at the time of the last system-level assessment visit.
Like the other Rhode Island systems of care, the Providence system of care is administered at the local level by a Local Coordinating Council (LCC), which provides guidance for policy and service delivery decisions.
Service Delivery Approaches. Family Service Coordinators (FSCs), who are parents of children with behavioral or emotional challenges, work with children and families to set up initial service planning meetings, referred to as case reviews. The FSCs combine a case management role with a parental support role, with emphasis on the latter. Although the FSCs may help families identify services, they do not track the provision or quality of services over time.
Interagency case reviews can include representatives of numerous agencies involved with a child, including staff from the mental health agency, the school system, juvenile justice, or other agencies. In addition to initial case reviews, additional reviews occur within 1 to 3 months of program involvement as a quality control function, and subsequently as needed. However, the high volume of cases creates long intervals between reviews—up to 4 months.
Family Involvement. Project REACH RI, along with other grants and contracts, financially supports the statewide family organization, the Parent Support Network (PSN). This network is a resource for family support and advocacy at the individual and system levels, and serves as a partner in local policymaking. The Rhode Island Parent Information Network works in partnership with PSN and is active in the system of care. Involvement by these organizations includes education, training, and technical assistance, in addition to family advocacy and support. Providers have shown support for family organizations, and recognition of families as decisionmakers has progressed. FSCs are involved in a family's entry into the system of care and provide support through the case review process, and for other parent concerns.
Cultural Competence. Providence has a culturally diverse population. Among families participating in Project REACH RI in Providence, many are African-American and some are of Hispanic origin. Available staff among the PSN and FSCs are ethnically diverse. FSCs are predominantly African-American, and one FSC who is fluent in Spanish is available to work with Hispanic families. Additional ethnic groups are represented among PSN staff. There is considerable awareness of the need to address the cultural diversity of the community. Culturally diverse service providers are actively recruited in the community for activities such as mentoring children and providing respite.
Unique Features. The Providence system of care stationed a Family Service Coordinator within a juvenile justice facility for young law offenders and dedicated a separate case review team to this population, to facilitate youths' transitions from the juvenile justice setting to their homes and communities. Since FSCs are all parents, they are better able to support and guide families entering the system of care.
The project's strengths include achieving active and successful family involvement at all levels. FSCs form an important part of service delivery. Advocates of the parent organization support system-level change. Project strengths also include securing a strong commitment from the LCC and changing service delivery philosophies among partner agencies.
Challenges for the future include meeting a steadily increasing demand for services, incorporating children and families who are not eligible for Medicaid into the full spectrum of system-of-care services, improving record keeping, and increasing the use of evaluation data for program planning and service delivery.
State support for institutionalizing the system of care throughout the State is under way. The Governor and Legislature have appropriated enough funds to carry Project REACH RI (which includes both Providence and Washington County) through June 2000. Support for the budget for FY 2001 is also anticipated, given the strong support shown by both the Governor and the Legislature. In addition, the State of Rhode Island has funded a demonstration project to pilot the LCC as the primary administrative body for the system of care in two catchment areas. Separate grants for better serving the needs of youth involved with the juvenile justice system have been secured and will help expand the system-of-care philosophy and outcomes to this population.
Lessons learned include the importance of involving families in service planning and using the Local Coordinating Council to enhance providers' knowledge of each others' efforts and services. Collaboration through the LCC has assisted in expanding services available in Providence.
History. Washington County's system of care is one of eight funded by a statewide system-of-care project, Project REACH, which combines State and CMHS funds to implement systems of care throughout the State. In Washington County, as in six other catchment areas, the grant is administered through a local mental health center.
Catchment Area. Washington County's system of care covers the entire county, a relatively rural area south of Providence with a largely White population. In the last year of the current grant, the program served 131 children and their families. (Twelve of these cases were not active, but were left open in case the families needed further assistance.)
Target Population. The target population is defined as children at risk of out-of-home placement or those who were placed out-of-home due to their emotional and behavioral problems and are returning home.
Management and Organization. The county mental health center is the lead agency for the system of care. A Local Coordinating Council (LCC) meets monthly to provide guidance to the system of care regarding policy and service delivery decisions. Its composition includes public child-serving agencies, the local education agency, a family support organization, community-based providers, and parents. LCC subcommittees take on more specific tasks, such as educating the community, exploring alternative funding sources, or working with State agencies. An Advisory Committee helps coordinate activities between monthly LCC meetings.
Service Delivery Approaches. Case review teams review each referral to determine eligibility. Once deemed eligible, children and families are referred to a Family Service Coordinator (FSC), who is a trained parent of a child who received services through the system of care. Each FSC specializes in working with children referred from different agencies, such as the mental health center or the school system. The system of care does not offer therapeutic foster care, but does offer a wide variety of therapeutic recreation and respite services. Services are provided in homes or schools whenever possible.
The system of care has worked very creatively with Medicaid to provide a full array of services and to enhance individualized services for children who are eligible for Medicaid. Consequently, there has been a substantial increase in resources available to children eligible for Medicaid. In contrast, privately insured children may not be able to access as broad an array of services due to restrictions placed on service plans by managed care.
Family Involvement. Family members are an integral part of the LCC, which recognizes the need for parent involvement and family-focused services. As in Providence, the PSN serves as a resource for family support. Additional support for families is available through parent support groups, and a monthly newsletter, produced by the FSCs, updates families about system-of-care activities. Additional recognition by schools of the value of family involvement may still be needed. Families participate in service planning, receive advocacy support at case review meetings, and generally express positive opinions of their interactions with staff.
Cultural Competence. Even though there is little ethnic diversity in Washington County, efforts to address cultural issues have been made. These efforts include the review of service plans by interracial teams, respecting families' preferences for the ethnicity or gender of their service provider, and the inclusion of ethnically diverse perspectives in training programs.
Unique Approaches. Family Service Coordinators, who initiate contacts with children and families and coordinate their services, are parents who have successfully negotiated the system of care for their own children and families. In addition, LCCs have worked effectively with many local school districts to design and sustain day treatment programs.
Strengths include strong family involvement in the system of care and a supportive, effective Local Coordinating Council. Challenges include extending services to children who are not eligible for Medicaid, integrating evaluation data in a more useful way, and transitioning to a new and challenging role as a pilot site for an emerging State-managed behavioral health care system.
Strong State support and a vote of confidence in designating Washington County as a pilot site for a managed care demonstration suggest that the system of care created through the CMHS grant will be sustained in the future. The Governor and Legislature have appropriated enough funds to carry Project REACH RI (which includes both Providence and Washington County) through June 2000. Support for the budget for FY 2001 is also anticipated, given the strong support shown by both the Governor and the Legislature.
Lessons learned include looking to existing community supports for families, proactively identifying resources for those who are not eligible for Medicaid, and recognizing that staffing positions with family members is a cost-effective, successful strategy throughout the system of care.
History. Wraparound Milwaukee, Milwaukee County's system of care, had its origins in a State grant awarded to the county's Child and Adolescent Services Division in 1990 to develop intensive in-home and case management services. When the CMHS grant was awarded in 1994, the model was expanded to include care coordination, a mobile crisis service, and an extensive provider network. In 1997, Wraparound Milwaukee was approved as a publicly operated managed care system, becoming the administrative arm for the system of care. It is now one of the largest system-of-care programs in the United States, with an operating budget of over $26 million per year.
Catchment Area. The program's catchment area is the county of Milwaukee, which also includes the city of Milwaukee.
Target Population. Wraparound Milwaukee's target population originally included children through 19 years of age with serious emotional disorders who were either in residential care or at risk of residential placement, and whose needs involved multiple agencies. In 1998, the target population was redefined in response to State-level changes in child welfare and juvenile justice policies. These policy changes, in effect, created a new target population of children referred to the program by court order from either the child welfare or the juvenile court system. This included youth ready to return home after spending time in a residential placement and those at immediate risk of out-of-home placement.
In 1999, 60 percent of the 650 enrolled children were referred by juvenile justice, with the rest referred by child welfare. The majority (63 percent) of families served were African-American. The remainder included Caucasian families (28 percent), Hispanic families (7 percent), and American Indian or Asian families (2 percent).
Management and Organization. Wraparound Milwaukee functions mainly as an administrative services organization. It contracts for the provision of case management services and has created a Provider Network to provide an array of over 60 mental health, social, and other supportive services. It is a direct provider of the county's children's mobile crisis services. Housed within the county's Child and Adolescent Services Division, the organization functions much like a behavioral health care company or specialized HMO. In addition to its two sources of court-ordered referrals (child welfare and juvenile justice), Wraparound Milwaukee maintains a network of 160 providers throughout the county. In addition, a full-time family advocate and coordinator represents family issues within the organization and its committees.
A Partnership Council serves in an advisory role, fostering interagency communication and information-sharing. Its members include representatives from the provider network, parent advocates, and representatives from child welfare, juvenile justice, education, and public health.
Unique in the Wraparound Milwaukee Program has been its ability to pool over $26 million from child welfare, juvenile justice, and Medicaid. A single decategorized and flexible funding pool was created to meet the individualized needs of children and their families. No new State or local funding was required to form the pool. The monies moved from reducing the utilization of residential treatment and psychiatric inpatient care in favor of supporting community-based care.
Service Delivery Approaches. Once clients are referred from child
welfare or juvenile justice, a multi-agency team of professionals and
parents (the Wraparound Review and Intake Team, or WRIT) reviews each
case and assigns the child and family to a trained care coordinator in
one of 19 community agencies. The care coordinator then works with the
child, the family, and their designated support team to develop a service
plan.
In addition to the network of 160 providers, Wraparound Milwaukee provides a mobile crisis team, the Mobile Urgent Treatment Team. This team serves both enrolled children and others who are at risk of being removed from their homes or schools because of a mental health crisis.
Family Involvement. The full-time family advocate is involved in the Partnership Council, WRIT, and the Peer Review Group, and also attends project management meetings. Other family involvement includes volunteers who serve as advocates and support for families new to the system. In addition, family members are actively involved in child and family service planning teams.
Cultural Competence. The large provider network is very diverse and offers a broad array of community-based services. Care coordinators reflect the diversity in the community. The provider network is actively recruiting minority and bilingual care coordinators.
Unique Features. A new early intervention program called Safe Now, modeled on Wraparound Milwaukee and using the same provider network, provides services to families where there has been evidence of child abuse or neglect and there is a risk of removal of the child from the home. Safe Now provides support services, including mental health services designed to stabilize the family and keep the child safe. This $6 million program is extending the system-of-care approach to a different target population.
Strengths include the active use of data and feedback for decisionmaking and program improvement, a diverse provider network, fiscal strength and sustainability, extensive care coordinator training, limited use of restrictive out-of-home placements, and a family-centered planning process.
Challenges include incorporating other agencies into the system of care (particularly education and public health, which are currently only peripherally involved), involving neighborhood and grassroots organizations (particularly for supporting youth as they transition out of the program), ensuring continuity of care for youth exiting the program, retaining and monitoring providers and care coordinators, and supporting a family advocacy organization to enhance family representation in the system of care's governance. (A local Federation of Families chapter is planned but has not yet been formed.)
There has been a 60 percent reduction in the utilization of residential treatment care, from 360 to under 140 children in care per day, and a 70 percent reduction in the use of psychiatric inpatient services. The reduced use of institutional care has allowed $13 million to be shifted to serve more children in the system. For delinquent children served, there has been a 40 percent reduction in the commission of delinquent acts from 1 year prior to enrollment, to 1 year post enrollment.
Wraparound Milwaukee's managed care designation strengthens its ability to sustain the system of care that has been created, regardless of State and Federal funding shifts.
Evaluation and quality data could have been used more effectively, particularly to communicate successes and promote the program's positive outcomes. Although interagency collaboration is strong at the highest levels, more attention to mid-level managers' involvement might have yielded stronger and earlier buy-in. Newly contracted agencies and newly hired care coordinators required extensive training and support, particularly at first. Expertly trained crisis staff were critical for diverting placement that results from crisis situations.
The system-of-care programs located in Wichita, Rhode Island, and Milwaukee, while each considered urban grant communities, are situated in different geographical areas and serve different populations. While both Wichita and Milwaukee are funded at the county level, Sedgewick County, Kansas, includes a rural area in addition to Wichita, whereas Milwaukee County is primarily urban. The ethnic composition of children and families served at each grant community differs, yet each program has made efforts to address the cultural diversity of its community. Active participation from key child-serving agencies and family organizations has characterized these systems of care. Each grant community has been impacted by State-level decisions that have implications for sustainability of the systems of care. In Kansas, changes that have increased the privatization of many child welfare services have implications for continued accessibility of services through the existing system of care. In both Milwaukee and Rhode Island, State-level decisions have positive implications for sustainability, particularly in Rhode Island where the State has allocated funds for the continuation of the system of care.
System-of-care grant communities included under the small
city or county hub designation encompassed smaller metropolitan areas.
System-of-care funding was provided to five counties in California under
one grant. These counties—Riverside, Santa Cruz, San Mateo, Solano,
and Ventura—were identified as small city or county communities.
CMHS funding to these counties was provided as a supplement to State and
local resources for the provision of services to children with serious
emotional disturbance. As a result, funds provided by the CMHS grant contributed
to the support of most children enrolled in system-of-care services within
these communities, but other sources contributed to supporting service
delivery.
Among the five communities served in California, the average age of children served was 12.4 years, and more boys than girls were enrolled in services. Approximately half of all children were White, and one-third were of Hispanic origin, compared to the national aggregate, in which one-fourth of the children were Hispanic. Children enrolled in system-of-care services were by and large proportionally representative of the ethnic mix of their respective communities, although Hispanic and African-American children were overrepresented in some grant communities, and Asian children were less likely to be enrolled in services across all grant communities. Slightly more than one-fourth of children had a primary diagnosis of depression, and one-fourth received a primary diagnosis of a conduct-related disorder. Other primary diagnoses included attention-deficit/hyperactivity disorder and anxiety disorders. Approximately one-third of the children served in California system-of-care grant communities were dually diagnosed. Substance abuse and conduct disorder were the most frequent secondary diagnoses. (see Table 21).
While limited descriptive information was collected on a large number of children across the five California communities, a much smaller number of children participated in the longitudinal outcome study in California. Children who remained in the system of care in California and also participated in the study improved in their functional and behavioral status from entry into services to 1 year. For those children who remained in services and were assessed at 1 year, total CAFAS scores improved. Child behavior problems, as reported by parents on the CBCL for children who were assessed at 1 year, fell to below the clinical range overall (see Figures 56 and 57).
History. Like its counterparts in other California counties, the Riverside County Interagency System of Care was initially funded through California Assembly Bill 377 in 1989. A 5-year grant from CMHS was obtained in 1994.
Catchment Area. Riverside County is a relatively large and diverse county experiencing rapid population growth, especially among minorities and migrant workers. The county includes an urban area centered around the city of Riverside, a mid-county area, and a desert area several hours' drive from Riverside.
Target Population. The Riverside County system of care defines its target population as "children who are, or who are at risk of being, emotionally disturbed, and who are at risk for out-of-home placement."
To date, the system of care has served 36,372 children, 6,000 of whom were served during FY 1998. Of these, 49 percent were White, 13 percent were African-American, 35 percent were Mexican American, and the remaining 3 percent were either Filipino, American Indian, Cambodian, or Laotian.
Management and Organization. The Riverside system of care is operated primarily by the county's mental health agency, with input from other child-serving agencies. Two councils—the Executive Council for Children and Families (ECCF) and the Interagency Council—set and implement policies for the system of care. The ECCF is comprised of senior agency leaders who meet monthly to coordinate services and identify and address service gaps. The Interagency Council includes mid-level management representatives from the departments of probation, mental health, education, and health. This group is responsible for service planning, implementation, and monitoring.
Service Delivery Approaches. Thirteen sites throughout the county provide access to mental health services to children and families, along with school-based settings and Department of Public Social Services (DPSS) offices. The Department of Probation, schools, and DPSS are the major referral sources for the system of care. Each child is assigned a case manager, who may be a clinician or a full-time case manager, depending on the child's service needs. In either case, the clinical or case manager coordinates the child's care with other agencies. An Interagency Screening Committee reviews the cases of most children who are being considered for placement into group home facilities, State hospitals, and specialized foster care.
Family Involvement. Parent advocates are employed at each mental health clinic to provide support and information to parents, to attend meetings with schools and other agencies, and to attend case planning and review meetings. Parents are also involved in advisory committees, in a liaison capacity with mental health, and in family-professional partnerships. Additional involvement in clinical staffing decisions is planned. Two family organizations are involved providing parent support groups, parent education and training, a telephone support network, and support for parents who attend local, State, and national conferences.
Cultural Competence. One of Riverside County's top priorities is to have a culturally appropriate system for delivering mental health services. Measures taken to address cultural competence include the allocation of resources to enhance existing efforts led by two staff members who coordinate services for minorities. Additional efforts include an ethnic services committee to addresses relevant cultural issues, and recruitment of diverse and bilingual staff and parent advocates. A cultural competence plan to address the needs of the county's ethnically diverse community was developed for the countywide managed care program. This plan will be integrated into the philosophy of the children's mental health unit. In addition, informational materials about programs for ethnic minorities have been developed, outreach to minority communities has expanded through the development of community advisory groups, and students from the local university have provided culturally appropriate services as mentors and tutors.
Unique Features. Three in-home programs provide a combination of intensive case management and behavioral specialist services, including parenting sessions, behavioral assessments, linkage to various resources, and both individual and group therapy.
A popular system-of-care feature is a program linking students from the University of California at Riverside with youth at risk through a mentoring and tutoring program. Clinicians are assigned to each DPSS office to consult, assess, and refer children and families to mental health resources when needed.
The Riverside County system of care's strengths include a well-organized managed care system that is culturally competent, community based, and user friendly; strong ties with parent organizations and active involvement of families in advocacy, program development, evaluation, and service delivery; a strong collaborative relationship among senior administrators of the agencies serving the target population; and individualized services reflecting the creativity and flexibility of case managers and therapists.
Challenges include increased demand (and limited capacity) for specific services such as childcare, 24-hour crisis services, and child psychiatrists to provide services for residents of group homes. Some services—such as the mentoring program and intensive in-home services—are already referring clients to waiting lists. Transportation problems are also expected to increase along with the demand for services. Other service gaps include transition services for youth aging out of the system of care and a crisis team that can respond to the needs of youth who need help, but who do not necessarily require hospitalization, child protective services, or some type of custody.
A combination of county and State funds will ensure a long-term commitment to the system of care, beyond the 5-year CMHS grant period. Other features that the system of care expects to sustain include using evaluation results to drive activities, including families as partners in decisionmaking regarding the system of care, and incorporating cultural competence into the mental health service delivery system.
Lessons learned include the following:
History. The services that evolved into the San Mateo system of care were originally created in 1986 through California Assembly Bill 3632, which made children who need special education eligible for mental health services. In 1989, major system reform was initiated through a State initiative to develop an interagency system of mental health care at the county level. In 1994, San Mateo was one of five California counties that jointly applied for and received CMHS funding. Since then, three other State-funded programs have affected San Mateo's system of care. These include (a) a pilot program funded in 1995 to prevent nonpublic school placements for special education students, (b) a bill mandating that mental health screening and assessment be provided for all children in group homes in counties receiving system-of-care funding, and (c) a State wraparound services bill that selected San Mateo County as a pilot program to reinvest State foster care dollars into community-based options to help the highest risk youth (30 targeted youth per year) avoid out-of-home placement or return home or to homelike settings.
Catchment Area. The catchment area includes the entire county of San Mateo, which contains the cities of San Mateo and Redwood City. The county has a diverse ethnic population. Of those under 18 years of age, approximately 20 percent are Asian, 25 percent of Hispanic origin, and 7 percent African-American.
Target Population. The target population is defined as children at risk of out-of-home placement or who have a serious emotional disorder. In 1997–98, 1,871 children and youth who met this definition received services. Of these, 29 percent were referred by the criminal justice system, 6 percent were referred by social services, and 16 percent were referred by schools. The remaining 49 percent were referred by other sources, including unknown or unrecorded sources.
Approximately 40 percent of the client population was Caucasian, 32 percent was Hispanic, 16 percent was African-American, 6 percent was Asian or Pacific Islander, and 0.5 percent was American Indian. The remaining 5.5 percent were of other racial or ethnic backgrounds.
Management and Organization. The San Mateo system of care is administered by the county's mental health agency. The system of care's interagency structure was recently reorganized, with the System of Care Advisory Committee (CYSOC) folded into an existing Children's Executive Council Action Team (CECAT). This group includes high-level county leaders, community members, consumers, family members, and child-serving agency representatives.
An interagency executive team, consisting of the directors, deputies,
and other key managers from child-serving agencies in the system of care,
addresses policy and budget issues affecting the system of care.
Service Delivery Approaches. The San Mateo County system of care follows a decentralized model in which mental health staff are outstationed in collaborating public child-serving agencies. All youth entering the system of care have a designated care coordinator, typically the lead therapist.
There are two major interagency case review structures whose decisions are considered binding across all the participating agencies. These are a placement review committee (whose voting members include program managers or directors from mental health, child welfare, special education, and juvenile probation, and family partnership representatives) and a case assistance committee (with broader membership and a broader mandate for brainstorming and troubleshooting).
Family Involvement. A Family Partnership Team (FPT) operates as a unit within the county mental health agency and is managed by a full-time county employee (augmented by volunteers and contractual staff). While most staff are not family members themselves, this group offers support and "bridgework" or linkage services for families and tries to promote family and professional partnerships. The FPT staff developed handbooks for facilitators, participants, and families. Recent accomplishments include development of a family-centered service planning approach called Family and Community Together. Once implemented, this approach will supplement and expand the generic care coordination plan currently required by the mental health agency.
Cultural Competence. In compliance with a State requirement, the system of care has developed a detailed cultural competence plan. The plan requires the agency to examine the distribution of ethnic groups across the county, identify which types of translation services are available, and assess the diversity of staff. Although interpreters are available under private contracts, additional training and orientation is needed to educate them about the system-of-care approach to working with families. In addition, staff identified a need to improve efforts to address the needs of the county's African-American population.
Unique Features. In an effort to emphasize early intervention and prevention, the system-of-care agencies participate in an initiative called "Pre-to-3." This program is an intensive, in-home program that provides mental health assessments, treatments, and referrals for women and children enrolled in California's Medicaid managed care program (Medi-Cal). The system of care's action team led an effort to develop a strengths-based children's health report card to identify benchmarks and raise awareness about the status of youth in the county.
Strengths include committed staff and volunteers who value a team approach to service delivery, a rich array of services, an ongoing commitment to using evaluation and quality assurance data for decisionmaking, and system-of-care principles diffused across participating agencies.
Challenges include developing a clear direction and set of goals for the recently reorganized interagency structure, continuing to promote system-of-care values throughout participating organizations, and addressing staff burnout and leadership development issues.
The system of care in San Mateo has been in place in various forms for over a decade and is supported by multiple sources of local, State, and Federal funding. Most, if not all, services currently funded by the CMHS grant are expected to continue after the grant ends.
Lessons learned include the following:
History. The Santa Cruz County system of care reflects a decade of changes in State and county mental health funding that affected agencies and systems throughout California. The system of care was initially funded through California Assembly Bill 377 in 1989 and was based on an interagency collaborative model developed by Ventura County, California. In 1991, responsibility for allocating mental health funds shifted from the State level to local, county-level agencies. In 1994, Santa Cruz County joined with four other California counties to apply for CMHS funding to expand systems of care. Although the State mental health agency was designated as the lead agency for the grant, each of the five county agencies was responsible for local implementation.
Catchment Area. The county of Santa Cruz is located in Northern California on the Monterey peninsula. Its population of 240,000 includes 20 to 50 percent Hispanic residents. In the southern part of the county, the Hispanic population is 50 percent of the total.
Target Population. The Santa Cruz County system of care targets children and adolescents 18 years of age or younger with serious emotional disturbance (SED) who either need or are at risk of out-of-home placement. Children whose academic performance is jeopardized by their mental health needs are also priorities for the system of care. In FY 1998, the Santa Cruz system of care served 1,000 children and youth.
Management and Organization. The Santa Cruz County system of care is governed by a Steering Committee that includes high-level representation from key youth-serving agencies, including mental health, probation, social services, and education. The committee also includes family representatives and a cultural competence coordinator. In addition to overseeing the CMHS funding, the Steering Committee provides input and guidance to all the county's mental health funds. In that capacity, the committee has served as a mechanism for collaboration across agencies for planning grants and other joint efforts.
Staff are organized into eight teams that respond to particular needs among children and youth:
Service Delivery Approaches. The service delivery approach is anchored by the client's therapist, who serves as care coordinator and is responsible for developing and monitoring a service plan. Clients enter the system of care through four main gateways: probation (26 percent), social services (20 percent), schools (22 percent), and the general public (11 percent). About 17 percent of children enter services through the dual diagnosis team, and 4 percent through the transition team. The probation, social services, and school teams conduct their own intake into the system of care. Children and youth who have "other serious emotional disorders" and who are not identified through one of these gateways, are triaged by mental health intake workers who make referrals to the appropriate team. If children do not meet system-of-care criteria and are eligible to participate in the California managed care program, they may be referred there.
Family Involvement. Family involvement in governance includes representation on the Steering Committee and the monthly children's management team, but there is agreement that involvement at the governance level could be strengthened. Grant funds were used to contract for two part-time parent liaisons who work with clinicians to bring a family perspective, serve as advocates for families, and organize a support group. Other paraprofessionals help families negotiate the system. Clinicians have received training on family-based care, and some have been trained in the Family Unity Conference model.
Cultural Competence. A cultural competence coordinator initiated the development of an action plan that addresses the enhancement of cultural competence along multiple dimensions from policy to operations of the system of care. A cultural competence steering committee is another avenue for addressing this issue. Santa Cruz has focused its efforts into recruiting a culturally diverse staff who are both bilingual and bicultural. Program materials are translated into Spanish, and outreach efforts have been targeted to the Hispanic population. Training in cultural competence is provided to all staff.
Unique Features. The Santa Cruz system of care has developed an interagency management information system (MIS), called the KIDS Database System, that links the mental health, child protection, and juvenile probation systems, and tracks Aid to Families with Dependent Children–Foster Care (AFDC–FC) costs, and placements. A Family Unity Conference (based on a model developed in Oregon) is another innovation for the program that allows families to identify the people they wish to include in their support network and include them in services planning.
Strengths include instituting family liaison positions, recruiting culturally competent staff, fostering interagency collaboration and coordination (through co-located services and interaction on service delivery teams), developing simple intake procedures, and providing access to clinicians through expanded evening and weekend hours. The program has succeeded in reducing residential placements for clients.
Persistent challenges include the lack of respite care, drug treatment programs, and a 24-hour crisis facility; the absence of transition services for all youth aging out of the system of care; the lack of family involvement in the system of care's governance; outreach to immigrant populations with services; and the need to strengthen the education system's role in the system of care.
A strong State mental health initiative and mental health coverage through California's Medicaid system suggest that the system of care will continue to expand, even without CMHS funds.
Lessons learned include
History. The Solano County Comprehensive System of Care was formally launched in 1994 with the award of the 5-year CMHS grant. In preparation for implementing a comprehensive system of care, the county conducted a needs assessment process prior to obtaining the grant that included input from mental health, social services, education, juvenile justice, health care agencies, parents, and consumers. As a result of efforts to identify, improve, and augment services for children with serious emotional disturbance, the Solano County Comprehensive System of Care was established.
Catchment Area. Solano County is located north of the San Francisco Bay. Its ethnically diverse population, spread across seven small cities, is approximately 13 percent African-American, 13 percent Hispanic, 59 percent Caucasian, 8 percent Filipino, 4 percent other Asian and Pacific Islanders, and 1 percent American Indian. The county's children are even more diverse than the general population, with 45 percent being members of minority groups.
Target Population. The system of care's target population is children and adolescents with serious emotional disorders who have a DSM–IV diagnosis, are at high risk for out-of-home placement or psychiatric hospitalization, are involved with multiple agencies, and experience impairment in more than one area of their lives.
A total of 750 new cases were opened during FY 1998. Referrals to the system of care come from mental health clinics, schools, parents, hospitals, other child-serving agencies including child welfare and juvenile justice, and private contractors.
Management and Organization. Solano County's mental health agency is the lead agency for the system of care. Other public agencies involved in the system of care include child protection and social services, probation, special education, and the school districts. A number of nonprofit agencies are also partners in the system of care. These include an organization that provides in-home support and sponsors a parent network, an organization that offers youth-to-adult transition services, a mentoring organization, an outpatient organization, and an infant and early childhood mental health program. Families are represented through two organizations—one internal to the system of care, and an external Parent Advocacy Network. Two councils fulfill policy and planning functions at the agency department head-level, and system-of-care coordination (at the mid-level manager level).
Service Delivery Approaches. Outpatient mental health services are available through 21 school sites and two neighborhood service centers, located in an African-American community and a Hispanic community.
Case managers or therapists work with families to coordinate care for youth who are not at risk of out-of-home placement or who are in foster care. A Multi-Agency Interdisciplinary Team (MIT) and intensive in-home intervention teams have been developed to help the system of care provide intensive wraparound services for youth with more complex, extensive service needs. Typically, children or youth served by these teams are involved with multiple agencies, are dependents of the county, have been arrested and have extensive mental health problems, or are wards of the court.
Family Involvement. The family organization, Solano Parent Network (SPN), is community based and accessible to families, serving to empower parents as partners and advocates within the system of care. SPN provides information, resources, and support services, and is represented at committee and management levels. Parent aides provide support services to parents in a variety of ways, including presence on treatment planning teams, and are accepted as partners by system-of-care staff. Through SPN and the parent aides, there is a strong family presence throughout the county. Additional efforts are being made to provide support groups to families in outlying areas. Families are involved in service planning and treatment decisions, and find that staff draw on family strengths and tailor services to meet their child's needs. While additional support for transportation is needed, wraparound funds have been used for this purpose and also to address recreational needs.
Cultural Competence. Solano County's strong commitment to culturally competent service delivery is demonstrated by efforts to heighten staff awareness through workshops and training, to diversify case management staff, to employ bilingual staff, to match clients with appropriate staff, and to provide outreach services to ethnically diverse populations.
Unique Features. To reach children as early as possible, the system of care added infant mental health services for children under the age of 5 through a contract with a private organization, Child Haven. Child Haven provides neurological assessments, risk assessments, developmental services, speech and art therapy, parenting classes, and family groups. At the other end of the age spectrum, the system of care added an enhanced youth-to-adult transition services program for young people between the ages of 17 and 22 that includes linkages to local college programs.
The Solano system of care's strengths include strong relationships between core agencies and the system's two parent organizations, the employment of parents as staff within the system of care, the expansion of services to reach families from all the county's communities and involve small community-based agencies, the strong collaborative relationships that are fostered among agencies, a commitment to cultural diversity and competence, and the use of evaluation data for program development.
Challenges include the uncertain impact of an ongoing reorganization of the county department of health and social services (within which the lead mental health agency is housed), a need for continued outreach to communities of color, continuing efforts to recruit culturally competent staff to work with Asian and African-American youth, and the need to secure strong commitments to system-of-care principles from child welfare staff.
With county- and State-level support, the Solano County system of care will remain intact. No changes are anticipated in core agencies or partnerships with contractor agencies. State-level sources of funding are expected to be available to assist increasing numbers of children.
Lessons learned include the critical importance of the following:
History. Ventura County's system of care, one of the first, was launched in 1985, following an interagency model of joint planning and blended resources to serve children and adolescents who are in or at risk of out-of-home placement. In 1994, the county was one of five California counties that jointly received funding through a 5-year CMHS grant.
Catchment Area. The catchment area is Ventura County, located north of Los Angeles in southern California. The cities of Simi Valley, Oxnard, and Ventura, with populations totaling approximately 350,000, are included in the service area. The entire county population is approximately 720,000. Ethnic composition is estimated to be 66 percent Caucasian, 26 percent Hispanic, 2 percent African-American, and 2 percent Asian.
Target Population. The system of care's target population includes children and youth who are in or at risk of out-of-home placement, children and families eligible for Medi-Cal (the California Medicaid system), and children in special education who have mental health needs. Children served by the system of care must have a DSM–IV diagnosis with functional impairment or indication that further problems are likely to lead to out-of-home placement. Approximately 2,000 children are served each year, of whom 53 percent are Caucasian and 39 percent are Hispanic.
Management and Organization. The county mental health department, the Ventura County Behavioral Health Department (VCBHD) is the lead agency for the system of care. Mental health staff are stationed both in regional clinics and within partner agencies, where they provide services and act in a liaison capacity. This arrangement includes child welfare agencies, probation sites, schools, Head Start, and the county's child health and disability prevention program. United Parents, a support organization that provides some respite and crisis services as well as support groups for parents, is the official parent partner.
Several cross-agency task forces meet at the senior department level to coordinate funding and to respond to Federal and State initiatives. At the mid-management level, a Lead Team includes the program managers and the children's medical director from mental health programs. This group meets weekly to discuss policy implementation, collaboration with other systems, referrals, quality improvement, and personnel issues.
Service Delivery Approaches. Services are available throughout the county at decentralized program sites. Available services span a broad spectrum, including efforts to intervene earlier in children's lives through connections to the Head Start and EPSDT programs, and assistance to older youth with transitions to independent living. Children enter the system of care through individual agencies. Key sources of referrals are the special education portion of the school system, juvenile justice, and child welfare.
Case management varies by the child's level of need, as well as the subsystem through which they enter services. Efforts are made to avoid placing children in residential care and to return children to the community as soon as possible when residential placement is necessary. Formal case management is provided for all children who are hospitalized or in residential care. Case managers work closely with children and families to assure the appropriateness of placement and plan the transition back to the community. Not all children have formally designated case managers; for many children services are coordinated by their primary provider—usually a therapist, probation officer, or child welfare case worker. Initial case planning meetings are limited to the youth, the parent, and the mental health worker. Case managers meet regularly with supervisors and providers to agree on services and approaches to treatment, and can address families' needs with flexible funds. An interagency review team meets to review the case of any child recommended for residential placement (unless the child is already within the juvenile justice system), identify the child's strengths and needs, and review service options.
Family Involvement. Parent involvement occurs primarily through United Parents, a parent support organization that provides family support and parenting groups, a parent newsletter, in-home crisis services, and respite care. Members will stay with families at their homes until a crisis is resolved, helping families avoid unnecessary hospital admissions. Representatives attend system-of-care meetings occasionally but do not take an active role in system-of-care administration; however, members are to some extent involved in the hiring and training of new mental health employees. Other local family support organizations are specific to children's disorders and have not been involved in the system of care.
Cultural Competence. The system of care has made consistent efforts to recruit an ethnically diverse staff. Bilingual and bicultural employees can be found among juvenile justice, Head Start, and clinic-based acute case management staff. There is a continuing need for additional minority mental health staff as well as parent advocacy groups representing minorities. A successful juvenile justice initiative in Oxnard that is based in community centers, focuses on youths' strengths and provides a broad array of services, support groups, workshops, recreation, and training. All service teams are bilingual and are staffed by neighborhood residents.
Unique Features. The system of care's parent organization, United Parents, administers a Hospital Alternative Treatment Team (HATT) that responds to family crises either by telephone or in person. The team tries to help families avoid unnecessary hospital admissions, staying with them until the crisis is resolved.
The Ventura County system of care has largely succeeded in keeping families and services within the community and has supported families struggling with the problems that bring them into the system of care. In addition, the system of care appears to be widely incorporated through long-standing principles and practices, rather than through the directives of specific individuals.
Challenges include the lack of access to evaluation data (because there is no evaluator on the staff), uneven family support (particularly for families of color), different intake procedures for each agency, and waiting lists for some services. Some managerial challenges include the lack of success in recruiting bilingual and bicultural staff, administrative funding and support that has not kept pace with expanded program and clinical activities, and a lack of training opportunities for staff.
Despite significant challenges, the Ventura County system of care appears to be firmly entrenched within the county and supported by State initiatives that endorse the system-of-care approach.
Key infrastructure functions (such as administration, clerical, and evaluation services) did not keep pace with expanded service capacity. This placed a burden on the administrative staff and severely compromised the system of care's ability to collect and use evaluation data.
There are many similarities across the California grant communities. In each of these grant communities, the mental health agency takes a lead role, interagency structures serve an integral function, and parent organizations have a strong voice. Access to services is available throughout the counties at local agencies, although concerns about transportation to services remain. Addressing needs of the ethnically diverse families, of which approximately one-third are of Hispanic origin, has led to active consideration of the cultural competence of the system of care, and of managed care in general. Hiring ethnically diverse staff, bilingual speakers, and translators has been an important consideration, as has offering cultural competence training. Given strong State and county support of the systems of care, as well as involvement with the California Medicaid managed care program, sustainability of established systems of care is expected in each community.
Those grant communities included in the rural hub—Maine, North Carolina, and Doña Ana County, New Mexico—were communities in largely rural counties that may have included smaller towns, but for whom issues relevant to rural populations predominated. In the State of Maine, a four-county area in the northeastern half of the State (Piscatquis, Hancock, Penobscot, and Washington Counties) received system-of-care funding under one grant. Bangor, where program services are based, is the largest community in this largely rural area. A system-of-care assessment took place in Bangor and is reported in this section. In North Carolina, a three-county area received system-of-care funds. These counties, Pitt, Nash, and Edgecombe, and including also the towns of Rocky Mount and Greenville, are located toward the northeastern portion of the State and are largely rural. System-of-care assessments occurred in each of these counties. Doña Ana County in New Mexico is a sizable area in the southern part of the State bordering Mexico. The system-of-care assessment took place in the town of Las Cruces, where services were based.
Table 22 presents the demographic characteristics of children participating in the national evaluation in these rural communities. Among the three grant communities included in the rural hub, a greater number of boys were enrolled in system-of-care services. This was particularly the case in Las Cruces, where almost three-fourths of the children who received services were boys. The average age of children receiving services at two of the grant communities was below age 11, about 1 year younger than the average for the national aggregate sample. In accordance with regional demographic distributions, representation by ethnic groups varied across these grant communities. In Maine most children were White or American Indian, in North Carolina most were African-American, and in New Mexico most were of Hispanic origin. Most of the children across the grant communities were in the custody of their mothers, with those in New Mexico and North Carolina more likely to be in the custody of their mother only than the average for those participating in the national evaluation. Children were more likely to be in the custody of two parents in Maine when compared to the national average. In North Carolina, more than 20 percent of children were either in the custody of a guardian or a ward of the State. Income levels varied across the grant communities, with families in Maine having a slightly higher income, and families in New Mexico having the lowest incomes, with almost 80 percent below the poverty threshold.
Referrals to system-of-care services in all three locations were made primarily from mental health agencies; mental health referrals were twice as likely in Maine and 3.5 times as likely in North Carolina when compared to the national sample. In New Mexico, a larger number of referrals also came from schools, juvenile justice, and social services. Referrals from juvenile justice were less likely in the Maine and North Carolina grant communities than national figures. Across the three rural communities, the greatest percentage of children with conduct-related disorders and ADHD as their primary diagnosis were in North Carolina, where children were also least likely to be diagnosed as depressed. Across all three communities, ADHD diagnoses were more frequent than found in the national aggregate data; and anxiety disorders were higher in Maine and lower in the other two grant communities. Depression was diagnosed more often in New Mexico and less often in North Carolina. More children in Maine and New Mexico had previous psychiatric hospitalizations, or had been physically or sexually abused. More children in New Mexico had used alcohol or drugs, or had run away from home; these risk factors were less prevalent in North Carolina than across the national data set. Family history of mental illness, family violence, and substance abuse exceeded national figures in Maine, and were considerably lower than the national average in North Carolina (see Table 23).
Functional and behavioral status of children served by the three rural system-of-care grant communities improved from intake to 1 year among children who remained in services and were assessed at 1 year. Among these children, those enrolled in the system of care in Maine entered services with the most behavioral and functional challenges, while those in North Carolina entered with the fewest challenges. Functional improvement occurred from intake to 6 months for all children in the rural communities, and child behavior continued to improve to 1 year. Changes in child functional status and child behavior are reported in Figures 58 and 59.
History. Maine's system of care was created in 1994 after the State mental health agency successfully applied for CMHS grant funding. A regional interagency body was given responsibility for implementing the grant in a four-county area. It was this organization that made the decision to create a nonprofit agency, independent of the State and county public child-serving agencies, to create a system of care. The new organization, Wings for Children and Families, began operations in 1995.
Recent legislative changes affecting the system of care include a State law that makes the State mental health agency responsible for instituting a statewide system of care that includes case managers outstationed in other public agencies as well as 24-hour crisis services. In addition, the settlement of a class action lawsuit stipulated that the State cannot limit State matching funds for case management and behavioral aide services for children who are eligible for Medicaid. This means that Wings can bill Medicaid for these services.
Catchment Area. Wings was originally designed to serve a four-county region in Maine (Piscatquis, Hancock, Penobscot, and Washington Counties), but a fifth county (Aroostoock County) was added when the State regions were redrawn. The majority (97 percent) of the population in this region is Caucasian.
Target Population. The target population is defined as children 18 years of age or younger with either a DSM–IV diagnosis or a condition that indicates such a diagnosis, who live in the five-county catchment area, who are at risk of out-of-home placement, who are involved with at least two public child-serving agencies, and who have difficulty maintaining stability at school, at home, or in the community. (Students aged 20 or younger who are still in school are also eligible.) Approximately 250 children were served during the first 3 years of the grant; in the most recent year, 150 children and their families were served.
Management and Organization. Wings is a private, nonprofit agency whose policies are set by a board of directors. At least 55 percent of the board's members must be parents of children with serious emotional disturbance. Although there has been tension between Wings and the region's public child-serving agencies in the past, more collaboration has evolved in the past year. In particular, Wings has outstationed case managers in the Department of Corrections and at a homeless shelter. Two regional groups affect the system of care's operations: the regional Children's Cabinets (which represent staff from five core child-serving agencies in each region of Maine) and local Case Resolution Committees (which assist local agencies with families that have needs that are difficult to meet).
Service Delivery Approaches. Wings employs 17 case managers and 6 parent resource coordinators to provide case management services to approximately 150 children. As noted above, case managers are also stationed in the Department of Corrections and at a homeless shelter. Wings recently formed a partnership with a local provider and successfully bid on a contract to provide case management services for the five-county area that will be reimbursable under the State Medicaid program. Although a wide array of services are offered, capacity problems limit the number of children and families that Wings can serve. The program's waiting list included 80 families, which translates into a 6-month wait for services.
Family Involvement. Family members are actively involved in the governance of Wings and several parents have been hired as parent resource coordinators. Another parent has been hired as the agency evaluator. The State Department of Mental Health has contracted with Wings to hire two parent advocates in each of its regional offices to ensure that families have a voice in the operations of the service system. Families are very involved in treatment planning and service selection decisions.
Cultural Competence. The region has a large American Indian population, and the system of care has made great strides to serve American Indian families. An example of the kind of emphasis that Wings has given to American Indian mental health needs is reflected in the funding it provides for a full-time case manger in the mental health center that serves the Passamaquoddy reservation.
Unique Features. Wings' case managers use a strengths-based wraparound approach, and develop service plans with individualized goals and objectives. Other agencies have drawn on Wings' experience for training in wraparound approaches to treatment and in the development of collaborative individualized plans for families. Efforts to link with the American Indian community have resulted in the support of a case manager on the Passamaquoddy reservation. Wings conducts its own internal quality assurance and assesses family satisfaction. The organization's bylaws require at least 55 percent of the members of the board of directors to be parents of children with serious emotional disturbance.
Wings' strengths include strong leadership, qualified and skilled staff, effective family involvement, and low administrative overhead costs (approximately 14 percent). Challenges include overcoming a history of mistrust and competition with public agencies, reducing the consistent waiting list for services by increasing capacity or transitioning families to less-intensive case management, using evaluation data, fostering unity among disparate parent organizations and representatives, and finding new sources of funding, particularly for flexible funds.
The system of care will be sustained as a result of a legislatively mandated, statewide system of care, but some staffing and funding cuts (particularly for flexible funds) are anticipated.
It was extremely difficult for a newly created private agency to assume a leadership role among established public agencies. Staff suggested that grant programs begin planning toward sustaining themselves without grant funds as soon as grant funds are received. Similarly, a ratio of 1-year planning grants for 5 years of operational funds was suggested. Another area that warranted more attention was the design of a useful, timely, and accessible data and evaluation system. Technical assistance, particularly regarding parent involvement, would have helped the program avoid a trial-and-error approach to implementing this component.
History. New Mexico's State-level Children, Youth, and Families Department (CYFD) administers the CMHS grant. When the grant was awarded in 1994, the local agency partner was the Doña Ana County Child and Adolescent Collaborative (DACCAC). This entity became a private, nonprofit agency in 1995. In 1996, the organization assisted in the development of a new entity, the Olympia Health Management Alliance, in order to bid for State Medicaid behavioral health care services contracts to be awarded to regional provider networks as part of the State's Medicaid managed care reform efforts. The regional behavioral health care contract for Doña Ana County was, however, awarded to a rival organization in 1997, shifting services for children eligible for Medicaid from Olympia to that organization. To improve competitiveness as a full-service behavioral health care provider, DACCAC and Olympia subsequently merged into a provider network also called Olympia.
Catchment Area. The catchment area for this project is Doña Ana County, a very large, rural county adjacent to the U.S.–Mexican border that encompasses 1,300 square miles. Most of the county's population resides in Las Cruces and the surrounding area, and is largely poor. Fifty-eight percent of residents are Hispanic; many are native Spanish speakers. Thirty-eight percent of the county's residents are Caucasian and 2 percent are African-American.
Target Population. The target population is school-aged children with serious emotional disturbance who are at risk for out-of-home placement and who are involved with two or more public agencies. Referrals are made from juvenile justice, child welfare, schools, private agencies, and other providers. With the shift in Medicaid-reimbursable services to another entity, the population served by Olympia changed to children and families who have neither private insurance nor Medicaid; however, efforts are underway to resume provision of services to children eligible for Medicaid through referrals from the authorized provider.
Management and Organization. Olympia's board of directors includes parents and the directors of participating agencies. A parent currently serves as board chairperson, and more parents are being recruited to bring parent representation up to 55 percent of the total board membership. The board provides oversight to the grant, and has responsibility for policymaking, personnel, and budget decisions. It is also involved in the development of a local and statewide provider network. Although there is no collaborative interagency body associated with the grant, the Community Team serves this function for child-serving public and private agencies in the county. This county interagency body had oversight for the CMHS grant until DACCAC became a private nonprofit agency; it continues to serve as a forum for the exchange of information between child-serving agencies. Olympia continues to work with the Community Team to foster cross-agency collaboration in areas such as the promotion of the development of a cross-agency management information system. The shift in Medicaid services also impacted the function of the Community Team as Olympia and the other agency are both members of this interagency body.
Service Delivery Approaches. Olympia follows an intensive case management model that values a wraparound approach to services, and increasingly focuses on family strengths to guide interventions. Case managers meet weekly as a group to review cases; however, families and other agencies are not involved in this process. Other mental health services are provided by Olympia or private service providers in the Olympia network, thereby ensuring close collaboration with case managers. Additional services needed by families such as outpatient therapy, respite care, and behavioral aides are available through Olympia.
Flexible funds have been an important resource for families, particularly in relation to the accomplishment of specific service plan goals. More recently, family empowerment, the use of community resources, and informal family supports have emerged as critical alternatives to reliance on case managers and the use of flexible funds to address family needs.
Efforts have been made to streamline access to services through Olympia; however, access has been limited to families without Medicaid or private insurance. Service options for families in rural areas as well as continuity of services have been influenced by issues such as provider reimbursement, transportation difficulties for families, and provider affiliations with managed care.
Family Involvement. Family representation on the board of directors and the Community Team means that families have a voice, although variably heard, in system management. Involvement at the child and family level is strong. Case managers are credited with a strong strengths-based and family-centered approach. Families are involved in all aspects of the treatment process, including assessment, planning, service selection, and service monitoring. This strong family focus has caused other providers in the network to become more family friendly.
Cultural Competence. Most of Olympia's staff and its network of agencies are bilingual and bicultural with a respect for the many Hispanic cultures found in the county and a sensitivity to the complex issues with which many Hispanic families must contend.
Unique Approaches. Olympia case managers are currently being trained and certified as substance abuse counselors to help address the alcohol and drug use problems among their clients.
Olympia's strengths include flexibility in responding to different community needs, highly regarded case management services that have been critical to families served by the organization, a commitment to involving parents, and cultural competence demonstrated through bilingual, bicultural staff and the trust and respect earned from families.
Challenges include calming the continuing tensions with the rival organization that won the Medicaid managed behavioral care contract, overcoming a legacy of distrust between Olympia and public child-serving agencies, finding new sources of funds to replace the CMHS grant, improving interagency collaboration at the system and case levels, and affecting deficiencies (particularly the lack of wraparound services and intensive case management) in the current provision of managed behavioral health care for residents of the catchment area.
Olympia is pursuing several strategies to sustain itself, although in the short term these may not support system-of-care principles. Strategies include developing new, niche services to obtain referrals from the Medicaid managed behavioral care organization (which currently does not refer clients to Olympia despite an agreement to do so), providing services (such as an after-school program for court-involved youth) to the juvenile justice system, obtaining State funds from Olympia's designation as a community mental health center, seeking new sources of funding, and building provider networks in other parts of the State.
Lessons learned include the following:
History. PEN–PAL, the North Carolina system of care, originated in a State-level Child Mental Health Plan that was adopted by the State legislature in 1987. Three counties in eastern North Carolina—Pitt, Edgecombe, and Nash Counties—were selected as demonstration sites for a system of care because of their history of interagency cooperation and their proximity to East Carolina University (ECU), and because the eastern part of the State was viewed as lagging behind other regions in terms of program development.
Catchment Area. The system of care's catchment area includes Pitt, Edgecombe, and Nash Counties. Three adjacent counties have also participated in some system-of-care activities such as training. All three counties have largely rural and poor populations who are approximately 60 percent White and 40 percent African-American. Each county is experiencing rapid growth of Hispanic migrant families.
Target Population. PEN–PAL's target population includes children who are experiencing serious emotional or behavioral problems or mental illness, who are separated from their families or at risk for being removed from their homes, and who have complex needs that require a variety of services from multiple agencies. Approximately 300 children and families were served during FY 1998. Social services, schools, mental health centers, and juvenile justice represent the major sources of referrals.
Management and Organization. The system of care is managed at two levels. At the State level, an oversight committee comprised of the directors of State child-serving agencies meets quarterly to provide overall guidance. Day-to-day management and operations take place at the local county level, with the county mental health/developmental disabilities/substance abuse services agencies taking the lead.
Two counties, Edgecombe and Nash, have a joint executive committee, while Pitt County has a project management committee. The Edgecombe–Nash executive committee meets monthly and includes representatives from both counties' school systems, social services departments, juvenile courts, county mental health centers, and the local parent organization.
The Pitt County committee meets informally and includes the child-serving directors from mental health, public health, schools, and social services.
Both systems are allied with a training and technical assistance program
at East Carolina University. A local affiliate of the Federation of Families
for Children's Mental Health exists, but has reduced its staff and activities
in response to funding cuts.
Service Delivery Approaches. Coordinators based in the local, county mental health centers serve as the point of entry into the system of care. The coordinators review referrals, determine the intensity of case management required, assign children and families to case managers, and lead weekly case review meetings. Case managers operate from various agencies and try to provide services in homes, schools, and community settings as much as possible.
Family Involvement. Families are involved in the oversight of PEN–PAL and serve on State-level committees. At the local level, at least one family member serves on the Executive Committee. The local affiliate of the Federation of Families, WE CARE, conducted an assessment of families' needs and shared findings with the Executive Committee to develop additional strategies for working with families. The executive director of WE CARE works closely with the State Department of Mental Health and the local-level agencies to assist
