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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2000 Annual Report to Congress on the Evaluation
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CHAPTER SUMMARY In summary:
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During the 5-year period covered by the grant, 15 system-of-care sites were established in the 11 grant communities. These system-of-care sites were established in Napa County, California; Santa Barbara County, California; Sonoma County, California; Leeward O'ahu, Hawai'i; Wai'anae Coast, Hawai'i; Lyons, Riverside, and Proviso Townships, Illinois; Navajo Nation; Southeast Kansas; Mott Haven, New York; Bismarck, North Dakota; Fargo, North Dakota; Minot, North Dakota; Lane County, Oregon; Philadelphia, Pennsylvania; and Alexandria, Virginia.
Each of these systems of care served unique populations and developed in accordance with the needs of these diverse communities. The grant communities also reflect 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 systems of care during the life of the grant.
Grant Communities Funded Fall 1994
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Information in this chapter is drawn from two primary sources:
Key findings are drawn from the last year of system-of-care assessment site visits and represent a snapshot of the system at the time of the last site visit. Descriptive information about the children and families served at each grant community is also presented. Following the individual community profiles, findings are noted from a cross-community analysis of the lessons learned, strengths, and challenges. Although 15 system-of-care sites were established in 1993-94, only 14 are described below. For the purpose of the system-of-care assessments, only one to two sites per grant community were visited and assessed.
History. The Napa County System of Care was part of the Sonoma-Napa Comprehensive System of Care (SNCSC). While each county operated its own system, the two counties worked together by sharing resources and jointly conducting training and evaluation. Sonoma County's program is presented after this discussion. In Napa County, funds from the two-county grant were channeled through an umbrella agency, the Napa County Health and Human Services Agency (HHSA), which included mental health, public health, drug and alcohol services, and social services. The co-location of the core agencies facilitated collaboration and coordination. The Napa County Behavioral Health Care Unit in the Children and Family Services Section of HHSA administered the CMHS grant.
Catchment Area. Napa County is located about 1 hour north of San Francisco in northern California. The primarily rural county consists of five incorporated cities, with about half of its 121,000 residents within the city of Napa. The geographic area served by the Napa County System of Care included four major regions: American Canyon, Calistoga, St. Helena, and Napa. The system of care served a growing number of Hispanic and Filipino families.
Target Population. Eligible children were residents of Napa County between the ages of birth and 18 with a DSM-IV diagnosis. The children either were at risk of out-of-home placement or were referred through the schools. Characteristics of the children served by this community are shown in Table 22.
Management and Organization. The Napa County System of Care had a three-tiered management structure: (a) a community-based collaborative with broad, diverse representation to discuss general issues, (b) a multi-agency committee of mid-level managers to implement key decisions, and (c) an executive committee to make final decisions on matters of policy and procedure. The Executive Committee consisted of department administrators of the public child-serving agencies, administrators from the county schools, representatives from Matrix (the local family organization), and the director of the nonprofit coalition (a community group of nonprofit organizations). The System of Care Policy Group, the official interagency structure, consisted of representatives from Child Protective Services, Juvenile Probation, Napa Valley Unified School District, and Matrix. Representatives were mid-level management staff members who had decisionmaking authority in their agencies. The Policy Group's primary role was to resolve procedure and policy issues as they related to the system-of-care grant. Problems that were not resolved at System of Care Policy Group meetings were addressed by the Executive Committee. The System of Care Collaborative, the third coordinating structure, included all nonprofit agencies, supervisory line staff of the various child-serving agencies, and parent partners. The primary function of this group was to deal with the day-to-day issues (i.e., determining effective components of the system of care, discussing agenda items to be presented to the Executive Committee, and structuring the future direction of the system of care after the grant ended). The collaborative offered open attendance at its meetings, and participation varied. No formal contracts were initiated among the partnering agencies in the Napa County System of Care, but there were memoranda of understanding.
Matrix, the family organization, participated in multiple interagency groups and was viewed as a true partner and strength in the system of care. |
Service Delivery Approaches. Parent advocates made initial contact with families and provided them with information on the system of care, the role of families, and service delivery structure and options. They also assisted the family in completing forms. To determine eligibility for the system of care, the assigned intake case manager completed the intake process by conducting a brief assessment of the child's and family's needs. Once eligibility was established, the child and family were assigned to the system of care for mental health services. The supervisory case manager assigned the case to a case manager who scheduled a service planning meeting. Coordinated service plans were developed for all youth in the system of care. Depending upon the needs of the youth, children and families within the system of care were provided with appropriate levels of case management services. Mental health and probation staff provided case management in a wide range of settings, such as the child's home, the school, and Juvenile Hall.
Family Involvement Strategies. The system of care had extensive family involvement throughout its structure, and there were written policies on involving families in the system of care. In addition, Matrix, the family organization, was highly involved in the Napa County System of Care. Matrix participated in multiple interagency groups and was viewed as a true partner and strength in the system of care. Its members provided training for families that included advocacy, participating in Individualized Education Plan (IEP) meetings, and using wraparound services. Parent advocates facilitated wraparound service meetings, attended IEP meetings at the schools with families, mediated IEP meetings, and served as the initial point of contact for new families who entered the system of care.
Cultural Competence. The Napa County target population has grown in diversity to include increasing numbers of Hispanic families. Two bilingual/bicultural staff provided services in the mental health agency, but this was not sufficient to meet the needs of the Hispanic and Filipino communities. Because a large percentage of staff in the public health agency were bilingual/bicultural and were located in the same office complex with the mental health agency, families received occasional assistance from them. Resources also existed for American Sign Language and Spanish translation. In addition, Matrix established a Spanish-speaking hotline to communicate with Hispanic families and employed one parent advocate who was bilingual/bicultural to work with Hispanic families.
Sustainability. Strategies for fiscally sustaining the system of care included maximizing Medicaid reimbursement, increasing the level of financial support from the county, and applying for a State system-of-care grant. Several providers and staff indicated that the collaborative cross-agency relationships; family involvement; and multidisciplinary, multi-agency approach to service delivery would continue beyond the grant funding because these system-of-care principles were accepted and incorporated into its service delivery structure.
History. The Sonoma-Napa Comprehensive System of Care was supported by a two-county grant that served both Sonoma and Napa Counties, whereby each county operated a separate system of care. The Sonoma County Mental Health Services Division (under the County of Sonoma Department of Health Services) was the lead agency for Sonoma County Youth and Family System of Care (SCYFS). Other agencies involved in the system of care included juvenile justice, education, special education, child welfare, public health, and DHS/Alcohol, Drug and Tobacco Services Division. The County Board of Supervisors provided grant oversight with input from the citizens of the Mental Health Board.
Catchment Area. Sonoma County Youth and Family System of Care served the entire county, which was primarily rural with three medium-sized urban centers north of San Francisco. With a population of 430,000, the ethnic mix of the county was 72 percent Caucasian, 18 percent Latino, 5 percent African-American, and 4 percent American Indian.
Target Population. The target population was children who were Sonoma County residents with a diagnosis of serious emotional disorders, who were served by multiple agencies and at risk for out-of-home placement. The children also had to be special education students in need of mental health treatment or had to have a DSM-IV diagnosis that impairs life functioning. Characteristics of the children served by this community are shown in Table 23.
Management and Organization. The Sonoma County Youth and Family Services Partnership (SCYFSP) consisted of representatives from public, private, nonprofit, and community-based child-serving agencies, and four family members. SCYFS had two interagency management structures. An interagency structure developed policy and made decisions related to system-of-care issues. Since the directors of the child-serving agencies were members of the interagency structure, decisions made by the structure were binding. The SCYFSP Mid-Level Management Council was composed of representatives appointed by the department heads of five public child-serving agencies and two parent representatives. Its purpose was to provide a forum for mid-level, cross-system communication and implementation of the cross-system vision developed by the SCYFSP and to facilitate discussions of coordination efforts and problem-solving.
There were interagency agreements among several of the child-serving agencies and a memorandum of understanding with nine agencies, mainly public child-serving agencies (e.g., for the purposes of information sharing, formulation of integrated service plans, and referral for services).
Service Delivery Approaches. The Mental Health Services Division was the central point of entry for the system of care and was divided into five geographic teams across the county (south, west, south central, north central, and north). Each team consisted of case management specialists, a family partner, a psychiatrist, licensed mental health clinicians, and administrative support staff. These teams were primarily responsible for serving children with significant service needs (e.g., to maintain them in a home setting). Children in crisis were served by a designated emergency services program, while children with minimal services needs generally were referred to other providers in the community.
All referrals were processed by the lead clinician at one of the geographical teams to determine the appropriate linkages and/or agency for services. Each child was assigned a service coordinator (a case manager or mental health clinician). After completing a thorough mental health assessment with the child and family and obtaining from the family authorization to share information, the service coordinator met with other involved core agencies on an as-needed basis to develop a plan of care for the child. Case management services depended upon the level of care needed. Families with intensive service coordination needs had a case manager specialist in addition to their service provider, and other families had a service provider who also provided service coordination.
Family Involvement Strategies. At the system level, family members served on the Mental Health Board, the Mid-Level Management Council, and other policymaking committees within the Mental Health Services Division as well as the Family Partnership Committee that discussed issues related to families. In addition, family partners and the family advocate were hired by the grant to provide guidance and direction by (a) coordinating and developing the parent support systems, (b) acting as liaisons between families and the mental health system, (c) coordinating parent participation in the treatment of their children, and (d) providing a family perspective in policy development and management decisions. The family partner positions were dispersed throughout the system of care, with one parent assigned to each of the geographical teams, one assigned to day treatment, one assigned to Juvenile Hall, and one assigned to work with the evaluator. At the child and family level, families worked collaboratively with the case management staff to develop individualized treatment plans for their children.
Cultural Competence. Hispanic, African-American, and American Indian children and families composed culturally distinct populations in the system-of-care catchment area. The decentralized, region-based approach to service delivery allowed staff to be more responsive to community characteristics and the needs of the families they served. Other methods to improve cultural competence included the provision of training in cultural competence.
Sustainability. As Federal dollars decreased, the system of care developed new funding strategies through collaboration with the child welfare agency; the maximization of Medicaid and Early Periodic Screening, Diagnosis, and Treatment (EPSDT) dollars; and the use of funds recovered from the reallocation of hospitalization monies. The community expected to sustain other aspects of the system of care, including the buy-in and commitment from other core child-serving agencies and front-line staff to the system-of-care principles, strong family involvement, extensive use of evaluation data for program enhancements, and the ability of the core child-serving agencies and key partners to solve problems creatively.
History. The Multiagency Integrated System of Care (MISC) was a partnership that consisted of a wide array of public and private child-serving agencies and families. The grant from CMHS was administered by the Santa Barbara County Department of Mental Health Services, one of the MISC public partners. A basic concept of MISC management was the "redirection" and outstationing of staff from participating child-serving agencies and schools in the county. Through this arrangement, the redirected staff remained employed by their respective agencies but were co-located in Santa Barbara, Santa Maria, and Lompoc, the three MISC regional centers.
Catchment Area. To serve the entire county of Santa Barbara, MISC had three regional centers located in the cities of Santa Barbara, Santa Maria, and Lompoc. In 1998, the population of children living in Santa Barbara County was about 52 percent Caucasian, 40 percent Latino, 3 percent African-American, and 5 percent Asian/Pacific Islander.
Target Population. The target population of MISC was youth of Santa Barbara County who were involved with two or more partner agencies. Each doorway agency determined the criteria for enrolling children in MISC, and each agency developed its own priorities designed to ensure that children with the most serious emotional disorders received MISC services. Characteristics of the children served by this community are shown in Table 24.
Management and Organization. The Family Advisory Council (formerly called the MISC Advisory Council) consisted of representatives from partner agencies, community-based organizations, the evaluation team, and family members. Its role was to suggest and provide guidance about the service system policy changes. The fiscal aspects and brief descriptions of services that partners of MISC shared were documented in memoranda of understanding.
MISC became the county's primary vehicle for providing a wide range of children's services, with a scope far beyond that which could be supported by a single grant. |
Services Delivery Approaches. Responsibility for serving children and families was shared and provided by several interrelated mechanisms: multi-agency assessment teams, care coordination teams, and treatment teams. Each team was each dedicated to a set of responsibilities, and all worked together to serve MISC youth and families. All children receiving MISC services had care coordinators who were the first point of contact for families with the system. Care coordinators, in addition to coordinating services and facilitating wraparound, made referrals for mental health and other types of services. To meet the needs of children and families efficiently and appropriately, MISC established specialized positions to provide intensive care coordination. The intensive care coordinator positions were grant funded, had small caseloads, and worked with families having more acute needs. Children with less acute needs were assigned another type of care coordinator.
Family Involvement. To promote family involvement, each regional office had a Family Resource Center, which was led by a family mentor. Family mentors were primarily responsible for convening and facilitating parent support groups and providing other forms of assistance as needed. To increase family members' participation in the Family Advisory Council, MISC contracted with the Community Action Commission (CAC), a community-based organization, to recruit and train family members (three from each region) to become members of the council. Family mentors conducted a training for Family Advisory Council members on parliamentary language and procedure so they could participate more effectively in the meetings. Challenges to family involvement at the system level included resistance to advocacy from public child-serving agencies and turnover in family representation positions. Family involvement increased as a result of the incorporation of family strengths and the involvement of families in developing their service plans.
Cultural Competence. During the grant-funded period, MISC had difficulty keeping pace with the growing need for bilingual/bicultural staff members. Although many new staff were hired to meet these needs, the demand was very high. Every attempt was made to assign Spanish-speaking families to bilingual/bicultural staff members, but it was more difficult to meet the needs of the growing Asian communities. Language and cultural barriers made it difficult to involve these families fully in MISC.
Sustainability. MISC wisely developed a system to sustain and expand funding. MISC became the county's primary vehicle for providing a wide range of children's services, with a scope far beyond that which could be supported by a single grant. It used and will continue to use a variety of funding sources, including State and county funds (i.e., realignment dollars), insurance reimbursements (i.e., Medicaid), and other sources (i.e., Family Preservation funds). All of the partner agencies contributed staff and resources, which were combined to finance the system of care. Financial sustainability was assured and the system of care will continue to grow in Santa Barbara County.
History. The Hawai'i State Department of Health received funding from CMHS for the Hawai'i 'Ohana Project. The University of Hawai'i Affiliated Program fiscally administered the grant through a memorandum of understanding with the Department of Health, Children and Adolescent Mental Health Division (CAMHD). With funding and resources provided through the 'Ohana Project, the Wai'anae Coast Community Mental Health Center (WCCMHC) and the Susannah Wesley Community Mental Health Center (which served the Leeward Coast)1 began expanding the service capacity of the system of care in 1994.
A Federal court ruling (Felix Consent Decree) in a class action lawsuit filed against the Departments of Health and Education in 1991 required the State to implement a statewide system of care for children with serious emotional disorders based on Child and Adolescent Service System Program (CASSP) principles. Toward the end of the grant-funded period, CAMHD was reorganized in response to the suit, spawning major changes in the referral and delivery of children's mental health services. Creating a single point of entry, the new children's mental health system required referrals to be initiated by the school system and then directed to Family Guidance Centers located throughout the State. The Family Guidance Centers were charged with reviewing referrals and authorizing and monitoring service plans. The Leeward Family Guidance Center (LFGC) served both the Wai'anae Coast and the Leeward Coast.
Catchment Area. The Wai'anae Coast, on the Leeward side of O'ahu, is comprised of the communities of Nanakuli, Ma'ili, Wai'anae, Makaha, and Makua. The majority of residents in the community were Native Hawaiian.
Target Population. Under the Felix decree, children aged 3 to 21 who had serious emotional disorders and multi-agency involvement and a Section 5042 (mainstream class with special supports) or an IDEA3 (special education class) designation (made by the schools) were eligible for services. Children whose emotional problems had not affected their academic functioning were no longer eligible for mental health services from the State, as a result of the decree. Characteristics of the children served by this community are shown in Table 25.
Management and Organization. The Governing Council for the Hawai'i 'Ohana Project and the Governing Board of the WCCMHC served as the two oversight bodies for the Wai'anae system of care during the final year of funding. The Governing Council provided oversight to the 'Ohana Project, including the WCCMHC, and had broad representation from stakeholders, including the local child-serving agencies as well as families, youth, and members of the community. The Governing Board was the entity that developed policies and programs for the WCCMHC, providing oversight for all children's and adult programs.
After the Felix Consent Decree, subsequent legislation required each community to be responsible for establishing a Community Children's Council (CCC) to assess community needs, to shape policy, and to oversee and monitor the development of the system of care in that community. To encourage their autonomy, the CCCs operated under the auspices of a separate office outside the other State departments. Each CCC required 30 percent of its representation to come from families and caregivers, and each had to include representatives from the core child-serving agencies. The co-chairs of the Wai'anae CCC were community representatives and also participated on the Governing Council for the 'Ohana Project.
Service Delivery Approaches. The Leeward Family Guidance Center (LFGC) authorized service plans for children in both of the grant catchment areas, Leeward and Wai'anae Coasts. The LFGC care coordinators received referrals from the schools. If appropriate, they then referred the child to a provider in the community for psychological evaluation. If the evaluation found that mental health services were needed, a case/IEP (Individualized Education Plan) conference was held to develop the service plan with the authorizing care coordinator, staff from a variety of agencies, the family, and other involved parties. The plan outlined both the specific services to be delivered and the actual units of service (i.e., number of hours or days) to be delivered. Care coordinators at the Family Guidance Center conducted additional meetings if the child became at risk for out-of-home placement or if the child's needs became complicated.
In the WCCMHC (which was the locus of grant-funded service delivery before the decree), case managers were the primary means for providing culturally appropriate, community-based services. The paraprofessional service coordinators served in several roles, including helping caregivers and children navigate the child-serving system, coordinating services they received, collecting data, and providing supportive counseling to children and their families. The case managers reportedly used a strengths-based model to assess the needs of children and their families and to determine the type and level of services they needed. A review of randomly selected case records showed increased documentation of child and family strengths over time, but less evidence of the way their strengths were incorporated into service delivery plans. For children entering the service system through the Leeward Family Guidance Center, services were received through WCCMHC only if approved by the child's care coordinator at the center.
Family Involvement Strategies. Family members or community representatives constituted approximately half of the Governing Council. Families were included in all major project decisions—their input was solicited and valued, and they were seen as essential to the implementation of project efforts. Family involvement was considered vital to effective service delivery. WCCMHC practices that enhanced family involvement included having caregivers participate in service planning, building on child and family strengths, visiting and providing services in the home, and offering support services to caregivers and siblings. Caregivers also reported being involved and feeling respected by WCCMHC and 'Ohana Project staff. However, family involvement continued to be a challenge for some providers and staff in certain child-serving agencies.
Cultural competence was evidenced by the diversity of community representatives on the Governing Council, the use of indigenous paraprofessionals, and utilization of the traditions of the Native Hawaiian culture to enhance the self-esteem and self-efficacy of children. |
Cultural Competence. The Wai'anae Coast community has always been racially and ethnically diverse. The guiding philosophy of the 'Ohana Project was that services must be developed that provided an understanding of and a sensitivity to the cultural norms of the community served. This was evidenced by the diversity of community representatives on the Governing Council, the use of indigenous paraprofessionals, and utilization of the traditions of the Native Hawaiian culture to enhance the self-esteem and self-efficacy of children. Efforts to address cultural needs of the Native Hawaiian population were more successful than for other minority populations such as the Filipino, Japanese, and other Asian communities.
Sustainability. Although the Felix Consent Decree posed many challenges to the project, it also brought the prospect of sustained funding for key children's mental health services beyond the grant-funded period. The 'Ohana Project planned to continue working to influence State mental health policy in order to broaden the array of reimbursable services. The project was also committed to supporting the local CCCs to maximize their impact on the continuing development of the system. The involvement of families in the governance of the system was supported by the project and the State under the consent decree.
History. In 1994 the Illinois State Department of Mental Health and Developmental Disabilities divided the State into 62 State-designated local area networks (LANs) to facilitate the planning and coordination of service systems for children with severe emotional disorders and their families. In 1994 Lyons and Riverside Townships (LAN 57) and Proviso Township (LAN 60) joined to create the InterLAN Council, the governance body for the grant program, the Community Wraparound Initiative (CWI). CWI consisted of a core project management and administrative staff, and other staff (i.e., wraparound facilitators, family resource developers, supervisory staff, and an individual supports coordinator) were outstationed in partner agencies.
Catchment Area. Lyons, Riverside, and Proviso Townships are located in the western section of Cook County and roughly cover a 10-mile by 10-mile geographic area with a population of about 270,000. The Lyons/Riverside area (LAN 57) was a relatively homogeneous area with a strong neighborhood orientation. This area is divided by a canal, and the area south of the canal was more racially diverse, has fewer resources, and had not been as well served as the area north of the canal. Proviso Township (LAN 60) was a more racially diverse area.
Target Population. CWI defined its target population as children aged 3 to 21 years who resided in the townships, had serious emotional disorders, had multi-agency involvement, and were at risk for out-of-home placement. Characteristics of the children served by this community are shown in Table 26.
Participating agencies on the InterLAN Council had formal relationships with CWI and with each other through written interagency agreements established at the inception of the grant. |
Management and Organization. At the system level, there were several structures in place designed to serve various management and leadership roles related to both the grant and the overall system of care in Lyons, Riverside, and Proviso Townships. Foremost was the InterLAN Council, which served primarily as a guidance and advisory group to the co-principal investigators of the grant. The InterLAN Council met monthly and included five representatives from the mental health sector, two representatives from the child welfare sector, four representatives from education, one parent organization representative, one representative from the juvenile justice system, and CWI staff, including the project director and evaluators. Participating agencies on the InterLAN Council had formal relationships with CWI and with each other through written interagency agreements established at the inception of the grant.
Service Delivery Approaches. CWI's approach to coordinating and providing services focused on implementing a wraparound approach. Facilitators convened multi-agency child and family teams to plan and monitor services for children and families. Through the efforts of this team, services were planned, coordinated, delivered, and monitored for a child and family throughout their involvement with the system of care. Intake procedure consisted of a multistep process that involved obtaining information from the referring agency(ies) and the family, primarily through telephone discussions but sometimes through in-home visits. This early information-gathering culminated in a child and family team meeting to develop a service plan. The intake and service planning processes tended to blend together and were not always distinct.
Family Involvement Strategies. At the system level, family involvement was a key focus of CWI's goals and vision throughout the grant period and was identified as a hallmark of the CWI approach. The family perspective was represented on the InterLAN Council by the director of the Illinois Federation of Families (IFF). In addition to hiring and employing the family resource developers, IFF's role in the system was that of a collaborator. At the child and family level, family involvement in the planning and provision of their services was the centerpiece of the wraparound approach. The children and youth were also very involved in their own service planning, and families reported that their viewpoints were respected.
Cultural Competence. To address the needs of minority populations appropriately, staffing included African-American and Hispanic direct service providers, although additional efforts were needed to meet the unique needs of the Hispanic and Middle Eastern communities. At the service delivery level, staff worked to understand and be responsive to families' cultural preferences and values. Family members reported feeling that their family's culture was respected by their providers.
Sustainability. CWI implemented several strategies to assure a strong future for the philosophies and functions that were put into place during the grant-funded period. Major sources of supplemental funds will include the State of Illinois and local sources (primarily to fund nontraditional services and flexible funding for wraparound services). Certain key roles and responsibilities were transferred to the service provider agencies from the core CWI staff in hopes that these roles and functions would continue. In addition, training and technical assistance (e.g., on the wraparound approach) and strategic planning for the future governance structure were carried out to help insure that key functions of CWI would not end with the Federal grant.
History. The Kansas Department of Mental Health and Developmental Disabilities applied for and received grant funds. KanFocus was administered by the Labette Center for Mental Health Services in Parsons, Kansas, one of the five community mental health centers in southeastern Kansas that comprised KanFocus.
Catchment Area. The catchment area for the five centers covered a 13-county region in southeastern Kansas: Labette, Cherokee, Crawford, Wilson, Elk, Chautauqua, Montgomery, Anderson, Woodson, Allen, Bourbon, Neosho, and Linn. Some centers covered only one to two counties, while some covered several counties. This region is rural with wide geographic distances between the centers.
Target Population. KanFocus targeted children with or at risk of developing serious emotional disorders and children at risk of out-of-home or out-of-community placement. Characteristics of the children served by this community are shown in Table 27.
Management and Organization. KanFocus was a mental health agency project and was not directly governed by an interagency structure. KanFocus did, however, actively engage in cross-agency collaboration through county Children's Coalitions (see below), task forces, and other committees. In an effort to promote collaboration between the public child-serving agencies, the Kansas legislature passed HB3113 in 1992, which required regional interagency coalitions to be formed to address the needs of children with emotional and behavioral problems. The development of Children's Coalitions in southeast Kansas established a commitment among agencies to a system-of-care approach to services. The coalitions were the primary interagency structures for each of the 13 counties in southeast Kansas. Membership on the coalitions was open to core public, child-serving agencies; private providers; family members; and community agencies and organizations. The coalitions acted on issues such as the administration of KanFocus flexible funds, case review and planning for difficult-to-serve families, finding resources to meet the service needs of specific families, grant writing, and information sharing.
Service Delivery Approaches. KanFocus staff provided intensive case management for children and families who met the target population characteristics for the grant. Referrals to KanFocus came from a variety of providers, including schools, mental health centers, and private therapists. Case managers developed wraparound service plans with the child and family and often held team meetings with all involved agencies. Other child-serving agency staff complied with these plans.
Family Involvement Strategies. At the system level, family involvement in the Children's Coalitions was weak, and agencies had not effectively incorporated family input into their operations and management. During the last year of funding, KanFocus ended the contract with the family organization for family advocates because they lacked adequate supervision and training. However, all of the family advocates who previously were hired as contractors became employees of KanFocus. Some of these advocates were being moved into case management positions at some of the mental health centers as the grant was ending.
At the service delivery level, KanFocus actively involved families in wraparound planning, the selection of services, and the monitoring of the effectiveness of services. Over the course of the grant, KanFocus services became more family centered and less focused on only the individual child. Families, parent advocates, and case managers all found that public school and juvenile justice staff had become better at listening to and respecting the opinions of caregivers over time.
The full-time cultural liaison staff did significant amounts of outreach into minority communities and had positively impacted the sensitivity of mental health center staff to cultural and ethnic differences. |
Cultural Competence. While the population of southeast Kansas was quite homogenous (over 92 percent Caucasian), many direct care staff identified nonracial subcultures in the region such as those of substance abuse, sexual abuse, poverty, and rural life. Race and ethnicity were generally not considered significant issues in this region despite a strong concentration of African-Americans in urban areas such as the town of Parsons. Two of the five community mental health centers had full-time cultural liaison staff. These two staff members did significant amounts of outreach into minority communities and had positively impacted the sensitivity of mental health center staff to cultural and ethnic differences through staff training and case consultations.
Sustainability. Some reductions in services in the five community mental health centers were expected when Federal grant funds ended. However, several strategies were identified to raise enough revenue to maintain the system of care, including Kansas mental health reform dollars, county mill levies for Medicaid, Medicaid reimbursements, and third-party payments. The Children's Coalitions, interagency collaboration around specific programs, and mental health's system-of-care approach to services and family involvement are all likely to continue.
History. Prior to the CMHS grant initiative, very few children's mental health services were offered on the Navajo Nation. CMHS grant funds were used to develop a system of care that builds on Navajo cultural traditions of k'é and integrates them with Western mental health assessment and intervention strategies. The project was reorganized in 1996 to become a private, nonprofit organization with its own 501(c)(3) status. As part of its reorganization, the project was moved from the ABN Foundation (part of a local school board) to the Children and Families' Advocacy Corporation (CFAC), with an independent board of directors to provide oversight to the K'é Project on the Navajo Nation. The name of the project, K'é, is a Navajo word for the way of life: ensuring the health and well-being of the family, clan, and community by defining how an individual relates to the world.
Catchment Area. Structurally, the K'é Project consisted of a central office and six regional service areas throughout the Navajo Nation: three in Arizona (Fort Defiance, Dilkon, and Chinle) and three in New Mexico (Crownpoint, Gallup, and Shiprock). K'é Project staff consisted of administrative staff at the central office in Tohatchi, New Mexico, and the service teams at the six regional service areas. A seventh service area in Tuba City, Arizona, was closed in 1997. While there were no service areas located in the Utah areas of the Nation, children and their families in Utah could access K'é Project services in Shiprock, New Mexico.
Target Population. The target population for the K'é Project was Navajo children with severe emotional disorders and their families. Approximately two-thirds of the Navajo population reside in Arizona and one-third live in New Mexico, with a much smaller proportion of the population living in Utah. Characteristics of the children served by this community are shown in Table 28.
Management and Organization. The board of directors for the K'é Project was comprised of three representatives from child-serving agencies and one family member from each region. The board made all funding decisions. The board also made decisions such as the closing of a service area and supervised the executive director of the project. Although no formal interagency agreements existed through the K'é Project, regional staff met with staff and management from other agencies in their communities. These meetings were used to help coordinate services and service development in the community.
Service Delivery Approaches. Families were referred to the project from a variety of sources, including schools, hospitals and residential treatment facilities, social services, Indian Health Service, community-based organizations, judicial services, and their own families. Once enrolled in the project, the service team from one of the six regional service areas provided intensive in-home services to the entire family (e.g., individual and family therapy, parenting instruction in Western and Navajo traditions, child advocate services, traditional Navajo counseling, case management services, family support services). Each team consisted of a therapist, a case manager, a Traditional Behavioral Management Specialist (TBMS) who provided educational services in k'é and coordinated traditional treatments, a family support specialist, and an administrative liaison. The integration of Western mental health services and traditional healing services was key to the service approach taken by each team. Although each family determined the degree to which traditional and Western services would be combined, all families participated in some Navajo traditions and cultural practices. Providing services based on k'é involved the entire family as defined by the family served. This meant that service teams usually worked with extended families which often included grandparents, uncles, and aunts. For each child, an average of five family members were actually served by the team.
Family Involvement. At the system level, families were involved on the board of directors. At the time of the visit, the six family members (one for each region) were all new to the board and thus their effectiveness as a voice for family issues was unclear. Since these family members did not have an established means to communicate information back and forth from their home communities, their representation and effectiveness in community-level advocacy may have been limited. No active grassroots family organizations on the Nation were identified by the providers and family members interviewed, and the lack of telephones and transportation made it difficult for family support groups and advocacy groups to flourish. In accordance with k'é philosophy, families were treated as a unit, with siblings and extended family included in the provision of services. Families were always included in service planning meetings. Family choices and values were respected, especially with regard to traditional education and treatments. Many families reported that having their goals acknowledged and heard was a positive experience for them. Families also reported being pleased that services occurred in their homes and at the times they chose.
Cultural Competence. The site structured services with attention to family preferences and religious and spiritual beliefs. Families reported that cultural instruction, including traditional teachings and support of the use of the Navajo language, had been very important to their care. Interviews with families and a review of case records showed that all families received traditional (k'é) services. Most direct service staff were both bilingual (fluent in Navajo) and bicultural. Several therapists who were not Navajo worked in teams with bilingual staff to ensure complete services to families regardless of their primary language preferences.
In addition, a three-page cultural self-assessment was done with each family entering K'é Project services, providing basic information about their level of understanding of and involvement in traditional beliefs and practices. The information collected was used to develop the service plan and determine the role the of the TBMS in providing services.
Sustainability. Medicaid was expected to be the key new source of funds after the grant ended, with the project devising systems to bill the Medicaid system in New Mexico as well as in Arizona. To conserve existing funds, the central office reduced administrative overhead by more than 10 percent. Certain aspects of the system of care and k'é philosophy were likely to be sustained through the work of other community-based programs that have modeled their efforts on the K'é Project and its services (e.g., home- and community-based care involving families).
History. Mott Haven's Families Reaching In Ever New Directions (FRIENDS) Initiative began with CMHS funding. The Research Foundation for Mental Hygiene, Inc. and the New York State Office of Mental Health (OMH) Bureau of Children and Families monitored the FRIENDS Initiative. Although FRIENDS functioned as an administrative hub for community service system reform efforts for much of the grant-funded period, at the time of the last site visit, FRIENDS was attempting to establish itself as a not-for-profit service provider.
Catchment Area. The FRIENDS Initiative served Community District 1 of the Bronx Borough of New York City. The majority of children and families in the Mott Haven community were Puerto Rican, Dominican, and African-American.
Target Population. The target population included Mott Haven residents younger than 21 years with serious emotional disorders who experienced continuous, substantial, year-long impairment of functioning or who exhibited severe symptoms within the past 30 days coupled with substantial impairments in functioning. Priority for acceptance into FRIENDS was given to children who were being served by three or more agencies. The majority of children and families served were Latino—more specifically, Puerto Rican and Dominican—and the second-largest group served was African-American. These demographic proportions reflected the racial and ethnic composition of the Mott Haven community itself. Characteristics of the children served by this community are shown in Table 29.
Management and Organization. At the local level, FRIENDS had a two-tiered management structure. The Planning Board consisted of several public sector agencies such as mental health, probation, juvenile justice, education, Administration for Children Services (ACS), and family representatives. The Board was responsible for making policy and budgetary decisions relating to FRIENDS' daily operations. The second level, the Management Team, consisted of the assistant executive director, program directors, and staff from the contractual agencies and addressed day-to-day operations in service delivery. The team also made recommendations that were passed to the board for final approval.
These two groups were to be replaced by the Board of Directors once FRIENDS became a nonprofit organization. The new structure would consist of community and family representatives. FRIENDS planned to recruit additional family representatives to constitute a majority of the board. The Board of Directors would still make budgetary and policy decisions for FRIENDS, but without active representation from public child-serving agencies it would no longer serve as a vehicle for fostering interagency collaboration. Instead, representatives from public child-serving agencies would serve in an advisory capacity to the Board of Directors.
Service Delivery Approaches. FRIENDS' system coordinators determined whether a child met the eligibility criteria. Children with an existing DSM-IV diagnosis were enrolled into FRIENDS and assigned the appropriate level of case management services (e.g., as provided through a contract agency). FRIENDS contracted with three private agencies to provide (a) crisis intervention through the Mobile Community Support Team (MCST), (b) intensive and supportive case management services via Steinway Child and Family Services, and (c) family support services and youth leadership training through Banana Kelly, Incorporated. Case management consisted of supportive and intensive case managers and community linkage workers. Case managers worked with the child, the family, and, if available, representatives from public child-serving agencies to design an individualized service plan (ISP) at the child and family team meeting.
Family Involvement. At the system level, families were voting members of the Planning Board but not of the Management Team. FRIENDS was challenged to recruit adequate numbers of family members to participate in system-level activities (e.g., participating on the Planning Board). Families were also employees of FRIENDS (i.e., parent research assistants) and the contract agencies (i.e., community linkage workers and parent advocates).
In lieu of a formal family advocacy organization, the Family Support Forum (a meeting of parent advocates and community activists) and the Family Learning Circle (educational meetings for families) remained the primary vehicles to educate families about the different services and resources available and to train families to advocate for themselves with different child-serving systems. The FRIENDS parent consultant also played a critical role in empowering families to advocate for themselves.
At the service delivery level, family advocates were available 24 hours per day to children and families in need, and family strengths typically were solicited as part of the service planning process. Despite these positive efforts to support and involve families, not all case managers and mental health providers were considered responsive to family needs.
Cultural Competence. Although over two-thirds of families served by the project were Latino, approximately 50 percent of agency staff at FRIENDS were African-American, most of whom were not bilingual. Despite this disparity, once families were accepted into FRIENDS, efforts were made to match families who spoke primarily Spanish with bilingual staff. As an innovative attempt to insure cultural competence, FRIENDS used an instrument designed to assess a family's cultural background, ethnicity, religious beliefs, migration experiences, linguistic background and proficiency, language use, and language environment so that service plans developed could be more culturally sensitive and appropriate.
As part of its plans for long-term sustainability, FRIENDS was moving toward incorporation as a nonprofit 501(c)(3) organization. |
Sustainability. As part of its plans for long-term sustainability, FRIENDS moved toward incorporation as a nonprofit 501(c)(3) organization. FRIENDS also maximized Medicaid reimbursements for case management services and progressed toward its goal of improving its relationships with other child-serving agencies that might refer families to FRIENDS.
History. In 1987, North Dakota passed legislation that established a State-level Children's Services Coordinating Committee (CSCC) to plan and coordinate delivery of human services for children and adolescents across the State. CSCCs were expanded to each of the eight North Dakota Human Services Center regions in 1993 and, later, on four American Indian reservations. In 1994, the Division of Mental Health and Substance Abuse Services of the North Dakota Department of Human Services, working with three of the regional CSCCs, applied for and received a Federal CMHS grant. The North Dakota Partnerships Project was established by the three CSCCs that received grant funds. The State Department of Human Services retained ultimate control over the grant, but each of the three Partnerships Project regions administered its portion of the grant.4 The Partnerships Project grant was originally administered by the Region VII CSCC; however, in 1995 State legislation was passed that prohibited the CSCCs from providing direct services. Administration of grant funds was turned over to the West Central Human Services Center (WCHSC), the local mental health agency.
Catchment Area. The North Dakota Partnerships Project for Region VII covered 10 counties: Burleigh, Oliver, Mercer, Morton, Kidder, Grant, McClean, Sheridan, Sioux, and Emmons. Sioux County includes the Standing Rock American Indian reservation. The population of Region VII was predominately White (97 percent). American Indians comprised approximately 80 percent of the population of Sioux County and 3 percent of the overall population of the region. Approximately 11 percent of the children and families served by the Partnerships Project were American Indian.
Target Population. The target population for the North Dakota Partnerships Project was children under age 21 and with a DSM-IV diagnosis, a GAF below 51, problems lasting a year or more, and multi-agency involvement. Children also had histories of out-of-home placements or were at risk for out-of-home placements or care. Characteristics of the children served by this community are shown in Table 30.
Management and Organization. The North Dakota Partnerships Council was the interagency structure for the Partnerships Project. Membership on the council included WCHSC, Burlington County Social Services, Region VII CSCC, juvenile courts, Department of Corrections, Police Youth Bureaus, Professional Association of Therapeutic Homes, Mandan and Bismarck Public Schools, and family members of children with serious emotional disorders. Partnerships Council by-laws stipulated that family members comprise 51 percent of the membership; however, the council struggled to recruit enough family members. A parent served as the chairperson of the council. The council used a committee structure to address system-of-care issues such as management, eligibility/flexible funds, intensive support, and out-of-home care. The committees facilitated communication and operations across agencies. The Partnerships Council served an advisory role and made recommendations on policy and the use of grant funds to the director of WCHSC. It was hoped that the council would in the future expand its role to become an advisor to all of its children's services. The council was involved in drafting a proposed Medicaid waiver during the last year of the grant.
Service Delivery Approaches. Care coordinators carried caseloads of 12 children and worked with paraprofessional case aides and contract in-home therapists to provide a broad range of services to families. Referrals to the Partnerships Project were made through the care coordinators who were outstationed in all core public agencies to facilitate access to services. One care coordinator was also stationed in rural parts of the catchment area, and one was stationed on the Standing Rock reservation to ensure that families in those geographic areas received services. The Partnerships Project had contracts with several private providers for in-home therapy, case aides, trackers (behavioral aides working with youth involved with the juvenile justice system), school aides, safe beds, respite care, and crisis response.
Care coordinators carried caseloads of 12 children and worked with paraprofessional case aides and contract in-home therapists to provide a broad range of services to families. |
A centralized process was used for entry into the system of care. The eligibility committee, consisting of representatives of the core public child-serving agencies and families, screened all applications to ensure that eligibility criteria were met, prioritized children's and families' needs, and determined the level of care the family would receive using a point system developed for this purpose. The clinical care coordinator assigned cases to care coordinators. An initial child and family team that included the child and family was formed to decide which services were needed and who would be included in the next meeting. Typically, agency representatives involved with the child and family, professional providers, noncustodial family members, friends, and the child and family attended the second team meeting. During this meeting, the individualized care plan and a crisis plan were developed and implementation of the wraparound process was begun. However, waiting lists were common for some services such as in-home therapy, trackers, and respite care. Access to access inpatient and outpatient addiction services for adolescents was difficult.
Family Involvement. At the system level, the State Division of Mental Health and Substance Abuse Services provided grant funds to support the North Dakota Federation of Families. This support allowed the Federation to develop an infrastructure at each of the three regionally based Partnerships Project communities, including that in Region VII. The Federation provided support and advocacy for families who had children with emotional disorders. Despite earlier tension between the Federation and the Partnerships Council, the Federation became a partner in the Partnership Project and encouraged family members to participate on the Partnerships Council (which stipulated that family members comprise 51 percent of its membership). Although recruitment of enough family members to fulfill this goal was difficult, family members on the council contributed to committees.
At the service level, families were involved in planning services for their children. Participation on care plan teams was excellent, and families felt they had input into all decisions and were treated with respect. Some expressed concern that the care planning process was too family driven and encouraged family dependency on care coordinators and flexible funds. Consequently, some family members may not have learned to advocate for themselves and may have stayed in services longer than necessary.
Cultural Competence. The Partnerships Project did not place a strong emphasis on system-level activities to achieve cultural competence, but project staff worked with families on an individual basis to address the cultural needs of families and to ensure that families' values were respected. Some training on cultural sensitivity was offered to all staff. A care coordinator, outstationed on the Standing Rock reservation, worked well with tribal leaders and other service providers. Another care coordinator was outstationed in rural areas to address these families' particular needs.
Sustainability. The North Dakota Partnerships Project was to continue for at least 2 years beyond the grant period using carryover Federal grant funds, funds contributed from other core agencies, Medicaid reimbursements, and other resources sought by the Partnerships Project. Strengths of the Partnerships Project that were expected to be sustained were the expanded services developed through the grant and the outstationing of care coordinators in other agencies. The grant also had lasting impacts on the operations of the partner agencies, including philosophical buy-in to the system-of-care approach to services. Collaboration, commitment to community services to keep children at home, wraparound approaches, family involvement, and the use of a wider array of nontraditional services were expected to continue.
History. Region II was one of the three Partnership Project regions. The State Department of Human Services retained control over the grant, but each of the three Partnerships Project regions administered its portion of the grant.5 Although the Partnerships Project grant was originally administered by the Region II CSCC, in 1995 State legislation was passed that prohibited the CSCCs from providing direct services. In 1996, administration of grant funds was transferred to the North Central Human Services Center (NCHSC), the public mental health agency.
Catchment Area. The North Dakota Partnerships Project for Region II covers seven counties: Bottineau, Burke, McHenry, Mountrail, Pierce, Renville, and Ward. Many of the families served by the project live in the Minot area.
Target Population. The target population for the Partnerships Project was children under age 21 with a DSM-IV diagnosis, a GAF of 50 or below, problems lasting at least a year, and multi-agency involvement. Children also had histories of out-of-home placements or were at risk for out-of-home placement. Characteristics of the children served by this community are shown in Table 30 (see previous community profile for Bismarck, North Dakota).
Management and Organization. The core public participating agencies in the Partnerships Project included North Central Human Services Center, Renville County Social Services, Ward County Social Services, Ward County Juvenile Court, Northern Plains Special Services (special education), Souris Valley Special Services (special education), First District Public Health, and Region II CSCC. Most of the agencies participating in the Partnerships Project were clustered around Minot. Only a few agencies from nearby counties were represented. Several family members from the regional Federation of Families chapter participated in the Partnerships Project. Participating private agencies included the Dakota Boys Ranch, Village Family Service Center, Lutheran Social Services, UniMed Hospital, and Trinity Hospital. The Partnerships Board functioned as the interagency structure and served as a coordinating mechanism among agencies. Membership on the board, which met monthly, mirrored the participants in the system of care, and most were from the Minot area. The Partnerships Board functioned as an advisory body, making recommendations to NCHSC on the use of grant funds and policies affecting grant operations. NCHSC usually followed the board's recommendations. The Partnerships Board served as a coordinating mechanism among agencies.
Service plans developed through interagency team meetings showed individualization and a family focus to services. |
Service Delivery Approaches. All families who were found eligible for the Partnerships Project were assigned a care coordinator. Care coordinators were stationed in several counties (i.e., Bottineau, Renville) to work specifically with rural families in outlying areas, and many contract service providers traveled into the counties to provide services. Care coordinator caseloads ranged from 12 to 20 families. The care coordinators worked with families to develop treatment plans, held interagency team planning meetings, made referrals for services, and monitored progress. In addition, care coordinators, trackers, and case aides often provided transportation for families. Treatment plans were usually updated every 3 months. Service plans developed through interagency team meetings showed individualization and a family focus to services. Goals and objectives were specific and achievable. Although family strengths were noted in the plans, they were not tied to strategies to implement case plan objectives.
Family Involvement. At the system level, the Partnerships Project made extensive efforts to include family members on the Partnerships Board. Members of the Federation of Families were represented on the board and its committees; however, family members attended irregularly. Family involvement on the board shifted to a less adversarial relationship with agencies over time. Parents were at times unsure of their roles and responsibilities on the board and would have found a more thorough orientation helpful. Care coordinators encouraged families to join the Federation of Families. Parents also participated on committees addressing screening and flexible funds, interviewed new staff, and provided input to human resource decisions.
At the service level, families were very involved as members of their child and family team. The service planning process was family focused, and family members reported feeling listened to and respected in the process. Parents had extensive input into service decisions and felt they could be open and honest with care coordinators. Agency staff had some concerns that the process was too family driven and needed to move toward greater partnership among all the entities involved with a child and family.
Cultural Competence. The Partnerships Project did not place a strong emphasis on system-level cultural competence activities, but project staff were sensitive to the cultural needs of families and worked individually with families to ensure that they felt comfortable and respected. Sensitivity to the cultures of rural families was incorporated into the work of project staff. No specific service adaptations were made for working with American Indian families in this region.
Due to the hard work of the Partnerships Project to involve families at the system and direct services levels, the impact of the project on services was expected to continue in a number of areas. |
Sustainability. The Region II North Dakota Partnerships Project was to continue to operate for 2 years with carryover Federal grant funds. Continuation of project services was expected to be dependent upon the success of several financing strategies; however, continued operation of the Partnerships Board beyond grant funding was uncertain during the last year of funding. The North Dakota Federation of Families was faced with a major challenge to locate additional funding. Further, the Federation needed to develop more strategies to maintain strong and informed family voices among agencies.
Due to the hard work of the Partnerships Project to involve families at the system and direct services levels, the impact of the project on services was expected to continue in a number of areas. The project was committed to individualizing services for children and families, and it had begun to address long-range problems that would affect service provision beyond the grant. These included reviewing cases for quality assurance, setting more measurable treatment objectives, and providing services for children who were just beginning to present behavioral and emotional problems. Strengths of the Partnerships Project that expected to be sustained included the positive effect of the grant on opening communications across agencies; the system's family friendliness; the efforts of some local agency staff to listen, involve, and respect families; expanded services that have had a major impact on treatment of children and families, including care coordination, in-home therapy, case aides, trackers, and Help Funds; family involvement in care planning; communication and cooperation among direct care staff from the agencies; commitments to using wraparound services to avoid out-of-home placements; and provision of services in rural areas using creative community resources.
History. New Opportunities (NOPS) was a demonstration project managed by the Child and Adolescent Behavioral Health Services (CABHS) within Lane County Health and Human Services. NOPS was primarily organized around the outstationing of Family Support Workers (FSWs) in partner child-serving agencies. Staff, trained by NOPS in system-of-care service delivery approaches, served as intensive service coordinators, wraparound service planning facilitators, and promoters of cross-agency coordination and the dissemination of the system-of-care philosophy. Initially supported with grant funds, NOPS worked with the host agencies to transfer fiscal responsibility for the FSWs from NOPS to the host agencies where the FSWs were outstationed.
During the 5-year grant-funded period, Medicaid managed care was implemented through the Oregon Health Plan (OHP). In Lane County, OHP was administered through LaneCare, a partnership of Lane County DHHS and a local organization called PeaceHealth. Although the change to managed care significantly reduced the funds available for children's mental health, many of the principles of systems of care were incorporated in the managed care model. NOPS became a part of LaneCare.
Catchment Area. The catchment area for the grant included Lane County and the primary urban center for the county, the town of Eugene.
Target Population. The original target population for NOPS (children and adolescents aged 0 to 19 with multi-agency involvement) shifted with the implementation of Medicaid managed care. NOPS expanded its umbrella of services to provide services to more children and families with mental health needs, not just those with serious emotional and behavioral disorders. Characteristics of the children served by this community are shown in Table 31.
Service System and Approach
Management and Organization. The system of care was managed by a two-tiered structure consisting of the GIRBLs (Government Incremental Revolutionary Bureaucratic Leaders, an executive-level interagency group) and the M&Ms (Middle Managers, a mid-level managers interagency group).
The GIRBLS consisted solely of directors from lead county agencies. This executive-level committee was primarily responsible for policy development and had ultimate approval over program activities and funding. M&Ms consisted of mid-level managers from child-serving agencies. Their efforts focused primarily on gaining approval from the GIRBLS for system-of-care activities and demonstration projects and gaining full support for FSWs at all levels of the community service system.
The main written "agreement" among the core system-of-care agencies and New Opportunities was the system-of-care work plan, which was reviewed and revised annually. Once the fiscal responsibility for FSWs was transferred to each host agency, Lane County developed formal interagency agreements between the mental health and social services agencies and the school systems outlining the role of FSWs in each agency. As part of the transition to Medicaid managed care, formal budget arrangements were also established between mental health agencies (DHHS, CABHS, and NOPS), LaneCare, and Peace Health.
Family Support Workers brokered services, coordinated care, and facilitated wraparound service planning. They acted as outreach and resource providers, offering referrals to community resources, counseling, or mediation services. |
Service Delivery Approaches. The process of entry into the services depended upon the portal of entry (e.g., juvenile justice system, schools, mental health agency). For families requiring behavioral health services through Medicaid managed care, there was an organized entry process under the OHP. At the time of the last site visit, 14 FSWs were outstationed in a variety of host agencies. FSWs brokered services, coordinated care, and facilitated wraparound service planning; they acted as outreach and resource providers, offering referrals to community resources, counseling, or mediation services as appropriate. For children who required more intensive wraparound planning, FSWs acted as community consultants who provided administration, training, and supervision to facilitate the group wraparound process and delivery of services to families through local multi-agency and multidisciplinary "triage committees."
Family Involvement. Agencies, especially mental health, were committed to promoting family involvement at all levels of service delivery and to embracing family input at the system level. Family participation on the interagency structure was limited, however. One member of the M&Ms was a family member, but no family representatives took part in GIRBLs meetings. Oregon Family Support Network (OFSN) staff members were instrumental in promoting family involvement through agency partnerships. While their representation was widespread on agency boards, family members expressed concerns that many agencies still did not fully embrace family involvement. At the child and family level, family members became intimately involved with wraparound planning and service delivery processes. The full support and formal commitment of family members was required for wraparound to proceed. OFSN also worked at the child and family level to provide support and advocacy training, to reduce isolation, and to meet family respite care needs.
Cultural Competence. While Lane County was primarily White, both racial as well as cultural issues needed to be addressed. New Opportunities staff and volunteers were aware of the importance of cultural diversity and were sensitive to the diverse needs of children and their families. Case coordinators addressed individual cultural needs and preferences of each child and family member as part of each wraparound plan, but noted that plans sometimes could be difficult to implement without acceptance of cultural and ethnic diversity by the broader community. A multicultural advisory committee, which was in transition at the time of the visit, addressed cultural competence concerns in the past; the committee will focus specifically on children and families in the future.
Sustainability. While many Lane County agencies were beginning to adopt the system-of-care model, New Opportunities recognized it must gain buy-in for the system-of-care philosophy from all the child-serving agencies and garner support for pooling of funds to carry out system-of-care initiatives. To this end, GIRBLs members worked collaboratively to expand services to children and families, and they decided to pool funds for research projects to demonstrate the effectiveness of the system of care. Regardless of fiscal outcomes, however, New Opportunities clearly helped initiate a paradigm shift in the Lane County community. This resulted in increased interagency cooperation and collaboration and the spread of a wraparound, strengths-based approach to service delivery, all of which were likely to be sustained past the grant-funded period.
History. The State of Pennsylvania received early CMHS funding through the CASSP grant, which initiated considerable progress toward incorporating CASSP principles and developing a system of care. Upon receiving the CMHS grant in 1994, South Philadelphia Family Partnership (SPFP) focused on expanding existing services and networks and creating new services. This collaborative of the mental health agency, schools, family advocates, specialized children's service agencies, and child-serving community agencies began serving children and families in late 1995. In 1998, through a mental health carve-out from Medicaid managed care, the Office of Mental Health created Community Behavioral Health, Inc. (CBH), a nonprofit, quasi-governmental organization serving as the managed care provider of Medicaid mental health services in Philadelphia County. CBH became fully responsible for providing mental health and related services to children and families served by SPFP during the final grant year. Remaining grant dollars were used to fund programs and services not covered by CBH (e.g., summer camp, respite, advocacy, some school-based services). Development of school-linked mental health services was continued to support a base of services in the schools after the grant ended, and a behavioral health care coordinator, jointly funded by the School District of Philadelphia and the Office of Mental Health, was hired to direct this effort.
Catchment Area. The system of care served the nine south Philadelphia school districts, a community of about 150,000 residents. Of the residents in this densely populated, urban community, 56 percent were Caucasian, 37 percent were African-American, 5 percent were Asian, 2 percent were Latino, and less than 1 percent were American Indian. Approximately 37,000 residents were children under 18 years of age.
Target Population. SPFP served children and adolescents 0 to 18 years of age (up to 22 years of age if enrolled in special education) residing within south Philadelphia who had a serious emotional disorder, at high risk of severe emotional disturbance, or had a DSM-IV diagnosis and had previously received services from the mental health system or other child-serving agencies were eligible for services. The majority of children and families (approximately 80 percent) served through SPFP were African-American. Characteristics of the children served by this community are shown in Table 32.
Management and Organization. The project was administered through the Children's Mental Health Services Unit of the Office of Mental Health and Retardation (OMH/MR), part of the Philadelphia Department of Public Health. The Commissioner of Health provided oversight to the project. SPFP's grant administrator reported to the director of the Children's Mental Health Services Unit and was responsible for the daily operations of the project as well as the management of the Federal grant, supervision of expenditures, program implementation, development of contracts for services, and program sustainability. OMH/MR also provided oversight to CBH and its activities and functions. The grant's Advisory Board became the Advisory Board for CBH. The primary participating agencies in SPFP included the School District of Philadelphia (the nine public elementary schools in south Philadelphia), Citizens Acting Together Can Help, Inc. (CATCH), Eighteenth Street Development/Raising Others' Children (ROC), Parents Involved Network (PIN), Community Behavioral Health, Inc. (CBH), and the Office of Mental Health. The secondary partners involved with SPFP were the Department of Public Welfare, the Department of Human Services (local child welfare agency), the Department of Human Services (juvenile justice system), and the Department of Recreation.
Service Delivery Approaches. CBH provided services through a network of 12 community-based mental health centers, 6 hospital systems, 20 community providers, and 60 providers of wraparound services. The majority of children were referred to services through the school-based Comprehensive Support Process (CSP), which coordinates services of professional school staff trained to provide assessment and intervention to students experiencing trouble in school. Children with existing or new DSM-IV diagnoses were referred to a school-based intensive case manager (ICM), while children without a DSM-IV diagnosis were referred to consultation and education (C&E) specialists. The C&E specialists provided prevention and early intervention services and supports, along with basic resource coordination, to children and their families. Referrals to either C&E specialists or intensive case managers were made regardless of eligibility for Medicaid; however, those children eligible for Medicaid were also eligible for all services provided through CBH. Children and families served under Medicaid managed care entered the CBH service system by directly contacting CBH or through one of the network providers. An appointment was scheduled and an in-depth intake and evaluation assessment were conducted, and services were assigned based on the child's diagnosis and the family's needs. Those families not eligible for Medicaid were referred by CBH intake staff to OMH/MR, which could access funds to provide services to uninsured and underinsured children and families. Children with a DSM-IV diagnosis who also required more intensive, long-term service coordination were assigned to an ICM, who conducted needs assessments, developed service plans, linked families with needed services, monitored families' progress, coordinated services, and provided 24-hour (7 days a week) crisis resolution and crisis response services. Children and families receiving wraparound/EPSDT services (most of whom were receiving intensive case management services) were also assigned a wraparound coordinator, and State-mandated interagency team meetings were held every 3 months to monitor care and coordinate services. Immediate and daily reviews of children placed in more restrictive settings were also conducted, and designated staff were in daily contact with the hospital and visited children in placement once a week to meet with providers, the family, and other involved parties. Families were particularly positive about this level of staff involvement.
Family Involvement. At the system level, family members were actively involved. They served as one-third of the membership of the CBH Advisory Board, and they had strong ties through the parent organizations (PIN and ROC) with SPFP and CBH. Through these relationships, family members participated in program development, allocation of finances, and guidance activities related to the service delivery system. Their strong presence had a significant impact on provider and professional behavior, and this enabled family advocacy. As the grant ended, family advocate and family resource coordinator positions, previously funded by the grant, were absorbed by other agencies such as OMH and PIN in an effort to sustain family involvement. The influence of PIN and ROC extended into other agencies such as child welfare, which contributed funds to support family support activities.
At the system level, family members had a strong voice and served as one-third of the membership of the CBH Advisory Board. |
At the service level, PIN staff lobbied CBH to include respite as a part of its service array in the organization's request to the State for upcoming funding, and they also lobbied SPFP to support the development of a summer camp for children served by the grant project. Then they changed the summer camp program to be a therapeutic program so that Medicaid funding could be secured as CMHS grant dollars decreased. The PIN director of Kinship Programs persuaded Grand Central, a resource center for kinship care families (headed by grandparents or "kin" other than the biological parents), to incorporate five support groups for kinship care families with mental health needs. Families also were integrally involved in staffing the Family Help Line, an information and referral line operated by PIN.
Cultural Competence. Agencies affiliated with SPFP conducted outreach campaigns to culturally diverse neighborhoods, and staff in the provider network received training in cultural competence. Increased hiring of diverse staff among providers was promoted, and efforts were made to match case managers to children and families that took into consideration racial and ethnic backgrounds. Two programs that were particularly successful in delivering culturally competent services to children and families were the minority-owned provider agency, Youth Advocate Program, and the multicultural therapeutic summer camp, which brought together children with serious emotional disorders and families from a range of racial and ethnic backgrounds. Plans were implemented to promote continued cultural competence of staff after the grant ended, and attention was given to cultural competence and sensitivity in service delivery.
Difficulties in promoting cultural competence included perceptions that the younger, less experienced staff had difficulties being sensitive and responsive to the needs of families of color and families of lower socioeconomic status. In addition, the SPFP had difficulties in hiring ethnically diverse or appropriate staff, particularly in important positions such as case management, C&E specialists, and wraparound positions. More importantly, the geographic location of CATCH in an historically Italian American neighborhood and poor relations between African-Americans and Italians in the area sometimes kept African-American families from accessing services.
Sustainability. SPFP achieved its grant match through the Medicaid managed care system and, as a result, were expected to cease to exist once grant funds were depleted. Children and families enrolled in SPFP would be served completely through CBH and OMH/MR (for those families not on Medicaid). A wide range of services, including those solely supported by the grant, would continue due to the development of the Medicaid managed care system. Through the work of SPFP project administrative and management staff, the grant project continued to have an impact on the development of the service array by providing input on the allocation of reinvestment dollars. CBH asked for State authorization to pay for respite services once supported by the grant, and several school clusters assumed funding of the C&E specialist positions. Reinvestment dollars, along with CMHS carryover grant funds, were expected to fund the family advocate positions only partially. OMH and PIN were jointly funding family advocate positions, and the Department of Human Services (the child welfare agency) contributed $100,000 to ROC to support the project's work with kinship care families. In addition, the Department of Human Services contributed $100,000 to support Grand Central in its efforts. Availability of flexible funds were expected to end with the grant; however, the wraparound/EPSDT program offered some level of flexibility to provide needed services once paid for through flexible funds. No agencies or organizations were expected to cease their involvement in the children's mental health arena when grant funding ended.
History. The State of Virginia passed the Comprehensive Services Act (CSA) in 1992. This act created a cross-agency pool of categorical funds from the five major, public child-serving agencies. It also established community-level policy and management teams (CPMT) designed to manage funds, reduce duplication of services, and reduce the number of residential or out-of-community placements for children with serious emotional disorders. Grant funds were used primarily to develop a specialized constellation of services (e.g., intensive case management [ICM]/home-based services, family support and advocacy, Latino outreach, outpatient services for juvenile offenders and victims of sexual abuse, respite services, and therapeutic foster care) to expand the already existing system of care. The specialized services were delivered through a program called ACCESS. Grant funds were managed through the local mental health agency, the Alexandria Community Services Board (ACSB).
Catchment Area. The catchment area was limited to the city of Alexandria, located on the west bank of the Potomac River, 6 miles south of Washington, DC.
Target Population. The system of care as a whole served children placed in foster care, at risk for out-of-home placement, or receiving special education services through an IEP, and other children such as those in the mental health or juvenile justice systems. Children in the system of care who needed services from two or more agencies and who had pressing service needs were referred to a special service planning committee. This committee assessed their eligibility for specialized services such as those delivered through the grant program, ACCESS. Characteristics of the children served by this community are shown in Table 33.
Service System and Approach
Management and Organization. Alexandria's community policy and management team served as the interagency structure for the local system of care. Members included key child-serving agencies, a representative of private providers, and a volunteer family representative. The policy and budgetary review structure's main functions included managing the pool of funds created by the State act, facilitating cross-agency communication, and guiding and making recommendations to the individual agencies and the projects they oversaw. Although the group was composed of agency directors and recommendations were made by the group to member agencies, ultimate decisionmaking authority for each agency rested within that agency, and decisions were made according to each agency's respective mandates. Interagency agreements existed among core agencies, as legally required by the State act. However, there were no additional agreements that were specific to the system-of-care philosophy (e.g., which detailed how shared system-of-care goals within the system of care and grant program would be operationalized and met).
Service Delivery Approaches. Each participating agency in the system of care completed intake into services according to its own eligibility criteria and processes. Within ASOC's framework, however, children who needed services from two or more agencies (e.g., those children requiring intensive services, creative service solutions, or a higher level of service coordination) were referred to one of four local Family Assessment and Planning Teams (FAPT). The FAPT process was a service planning process completed by standing teams of agency and family representatives. FAPTs were responsible for decisions related to service planning and resource provision, and they represented the primary structure for interagency coordination at the child and family level. Once the FAPT service plan was approved, responsibility for ongoing service coordination generally remained with the initial referring agency and case manager. When an intensive case manager (ICM) from ACCESS was assigned to work with the family, however, the ICM generally assumed responsibility for case management. ACCESS ICMs were generally seen as major facilitators in the coordination of services.
Family Involvement. Although many positive family-oriented changes to ASOC occurred in the final years of funding, ASOC continued to struggle with involving families at the system level. There were two family representative positions on the policy and management committee (only one position was filled at the time of the final site visit); however, the family representative position had not functioned as a full partner in ASOC's decisionmaking process. With the development of several new family groups and committees, there was hope that family involvement at the system level could be accomplished in several ways. For example, a new coordinator and four local family advocates were hired by a local family interest group, Families for Families. Family involvement in service planning varied by the type of planning process. Changes were made during the last year of funding to provide better support to families during FAPT meetings; family members whose services were being reviewed in the FAPT process were offered the assistance of a trained family advocate to aid them prior to, during, and following their FAPT meeting. Service planning meetings between families and ACCESS intensive case managers were more interactive, focusing on identifying needs and designing individualized service plans for each child. Family involvement with the ICMs and the service planning process was generally positively reported.
Cultural Competence. Alexandria has a racially and ethnically diverse population. During the last year of funding, ASOC was making particular efforts to address the needs of the growing Latino community, in part by hiring additional staff. To fill staff positions, ASOC needed to hire many staff who lived outside the city and had never been residents of Alexandria. While some recognized the necessity of this situation, other community members explained that hiring from outside the community meant that providers often had limited familiarity with specific Alexandria neighborhoods and cultural traditions (even when providers shared the same racial or ethnic background as local residents).
Sustainability. The future of ASOC was largely tied to the existing CSA mandate in the State of Virginia. The ACCESS program seemed most in danger of losing services and staff because no additional State or local funds specifically earmarked for ACCESS had been secured for use after the grant. As a regular vendor to ASOC, however, ACCESS was expected to have access to some CSA funds, a resource created by mandated public agencies' contributions to a central fund to provide services to children with serious emotional disorders. However, the ACCESS programs would compete with other private contract providers for those funds.
Although several strengths were identified for each graduating grant community, three emerged as the most commonly observed strengths across grant communities:
Interagency collaboration as a system-of-care value took root at the system and service delivery levels and influenced many changes in the system of care. Particularly at the service delivery level, collaboration of child and family providers became widely accepted across staff. The growing number of children with multi-agency involvement, combined with an emphasis on reducing duplication and costs, led to widespread recognition of the importance of bringing together all involved parties to serve children and families. Grant communities used several mechanisms to plan and deliver interagency services, including multi-agency service teams, case review structures, outstationing of personnel, co-funding and co-location of staff, and joint training efforts. Collaboration at the infrastructure or system level was not as common but nonetheless facilitated some interagency service delivery (i.e., service provider co-location or outstationing). Several grant communities noted that even if some aspects of the system of care were not sustained beyond the grant funding, agencies would continue to work together and maintain the relationships created. The expanded communication, deepened understanding of different agency roles and missions, and increased willingness to collaborate across service sectors are vital legacies of the grant and are likely to result in future and ongoing improvements to the community service system.
System-of-care communities actively involved families in their children's service planning and delivery in various ways. Families were the ultimate sources for identifying their needs and strengths, selecting appropriate services and providers, and identifying convenient times and locations for services. Increasing numbers of agencies, organizations, and individual providers came to view families as integral partners in service planning as well as critical resources for identifying and tailoring services to meet the unique needs of each child. Some grant communities hired families as staff to support other families in the system of care (e.g., by acting as peer mentors, advocates, or respite providers).
The incorporation of system-of-care principles into service delivery was another strength observed among the grant communities. Although grant communities did not necessarily implement service delivery according to the system-of-care approach in the same way within a community, or across the various grant communities, communities experienced notable success in diffusing key system-of-care principles across partner agencies at the local level. Service coordinators, especially when co-located or outstationed with other agency staff, were quite effective at modeling attitudes and practices reflecting the system-of-care philosophy (e.g., respecting and soliciting family input, involving a wide range of participants to help plan services for a family, focusing on strengths). For many agencies and staff originally indoctrinated in a deficits-based, medical model approach to assessment and service delivery, introduction of the system-of-care approach led to significant paradigm shifts in conceptualizing service determination and delivery.
For example, a strengths-based approach was consistently used to identify child and family needs, areas of strength and resiliency, and other natural supports and resources. As a result, both needs and strengths were incorporated into the child and family service plan. Providers, especially service coordinators (i.e., case managers, care coordinators), were specifically trained to collect detailed information from youth and families about their individual needs, preferences, strengths, and interests. Using a "wraparound" approach to service planning resulted in highly customized service plans individualized to the youth and inclusive of specific family needs and input. The diverse array of services and suppo
