Integrating system components: Resisting Distractions and Embracing Change

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Integrating system components Resisting
Distractions and Embracing Change

• 2008 Behavioral Health Collaborative Conference
• A Place in the Communityand Beyond
• Albuquerque, NM December 2-5, 2008

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Presenters

• Mario Hernandez, Ph.D.
• Professor/Chair
• Department of Child and Family Studies
• Louis de la Parte Florida Mental Health Studies
• School of Mental Health Studies
• Sharon Hodges, Ph.D.
• Director-Division of TREaD
• Department of Child and Family Studies
• Louis de la Parte Florida Mental Health Studies
• School of Mental Health Studies

• Marie Morilus-Black
• Family Voices Network of Erie County
• Buffalo, NY
• Cynthia Brundage, LCSW
• CSOC Program Manager
• Placer County SMART Childrens System of
  CareTransforming Childrens Services Through
  Family and Community Partnerships

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Learning Objectives

• The value of thinking holistically
• Strategies for being concrete about values,
  flexible in system response, and proactive in
  system development
• The importance of linking system development
  strategies to the strengths and needs of local
  populations
• Strategies for creating a shared vision that is
  concrete enough to operationalize and powerful
  enough to inspire and guide you through the rough
  times
• The value of engaging the community in the change
  process
• Critical factors that support system development

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The Foundation for Community Inspired Strategies

• Mario Hernandez, Ph.D.
• Professor/Chair
• Department of Child and Family Studies
• Louis de la Parte Florida Mental Health Studies
• School of Mental Health Studies
• Phone [phone]
• Email hernande_at_fmhi.usf.edu

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What Is A System of Care?

• Original Definition
• A system of care is a comprehensive spectrum of
  mental health and other necessary services which
  are organized into a coordinated network to meet
  the multiple and changing needs of children and
  adolescents with severe emotional disturbances
  and their families
• Stroul Friedman, 1986

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What System Conditions Led to Development of
Systems of Care?

• Inadequate range of services and supports
• Failure to individualize services
• Fragmentation of system
• Children with special needs in many systems
• Lack of clear values/principles for system
• Lack of clarity about population of concern
• Inadequate accountability
• Lack of adequate responsiveness to cultural
  differences.
• Friedman, 2008

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Role of System of Care

• To provide access to effective services for a
  large and diverse population within a specified
  community!
• Friedman, 2008

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Key Principles/Values of a System of Care

• Services should be based on needs and strengths
  of child and family
• Partnerships between families and professionals
  is critical
• Collaboration between multiple service sectors is
  essential
• Services should be culturally competent
• System performance should be evaluated on an
  ongoing basis for purposes of continuous
  improvement
• Friedman, 2008

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What Should A System of Care Be Based Upon?

• A vision and set of values developed and agreed
  upon by community stakeholders
• A clear definition of the population to be
  served, and a thorough understanding of the needs
  and strengths of the population
• A set of goals and desired outcomes, developed by
  community stakeholders
• Friedman, 2008

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What Should A System of Care Be Based Upon?

• Best available evidence on effectiveness of
  system mechanisms and services
• A theory of change that makes explicit the link
  between interventions at the system,
  organization, program, provider, and child/family
  levels, and desired outcomes.
• Friedman, 2008

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Major Changes New Concepts

• Individualized care
• Family voice and choice
• Family-driven and youth-guided
• Cultural competence
• Collaboration across sectors
• Strength and need-based
• Systemic
• Data-based
• Friedman, 2008

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Systems of Care

• From differentiation to integration
• From focus on one aspect of a system to focus on
  all aspects and their interrelationship
• Are we there yet?
• How do we get there?
• A key to our success!!
• Friedman, 2008

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• Systems Change
• Refers to an intentional process designed to
  alter the status quo by shifting and realigning
  the form and function of a targeted system
• In most system change endeavors, the underlying
  structures and supporting mechanisms that operate
  within a system are altered, such as policies,
  routines, relationships, resources, power
  structures and values.
• Foster-Fishman, 2002

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To Do So Requires

• Understanding different perspectives concerning
  the problem situation
• Locating root causes to systemic problems by
  identifying system parts and their patterns of
  interdependency that explain the status quo
• Using this information to identify leverage
  points that will cultivate second-order change
• Foster-Fishman, Nowell, Yang 2007

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• Systems are generally considered to be a
  collection of parts that, through their
  interactions, function as a whole (Ackoff
  Rovin, 2003 Maani Cavana, 2000)

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• Began our work searching for sites that were
  exceptional at collecting and using outcome
  information
• What we learned about these exceptional sites
  changed our thinking about outcome information
  and how exceptional sites actually operate and
  use information

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• We found that sites doing a great job of
  collecting and using outcome information also did
  a great job of knowing who they were serving,
  what services they were offering, what
  system/policy changes they were making in support
  of their service strategies, and, of course,
  whether they were reaching their intended goals.

Ecology of outcomes
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Intentionality

• Planning and providing services was directly tied
  to the local communitys knowledge of their local
  population of concern

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• To be successful, system implementation efforts
  must be responsive to the needs, strengths and
  wishes of a local population of children and
  families in the context of the federal, state,
  and local policies of the multiple child-serving
  agencies responsible for this population.

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• Defining the local population of concern remains
  a critical aspect of local system change
  strategies.
• The system of care movement initially identified
  the population of focus as children with serious
  emotional disturbance (Knitzer, 1982 Stroul
  Friedman, 1986) describes this population as
  children and youth under 22 years of age who have
  a diagnosable mental health disorder that
  results in reduced functioning in home, school or
  community settings or requires multi-agency
  intervention, and whose disability must have been
  present or is expected to be present for at least
  one year.

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• This definition is actually a broad grouping of
  children that only provide basic parameters to
  guide local planning.
• Communities are expected to identify their own
  population of children and families with these
  parameters.
• Initially, a community may choose to define the
  population of focus as a smaller subgroup of
  children within juvenile justice, child welfare
  or education who are of particular local concern.
• Additionally, communities must make strategic
  decisions about where to begin their efforts and
  with which part of their local population of
  concern.

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• When community planning is based upon the
  knowledge of its own children and families, then
  planners are more likely to select appropriate
  services and to impact the associated system
  structures and processes that influence the
  provision of services.
• What this means is that a local system of care
  must be built upon a foundation of local
  population information.
• This foundation is what should drive system
  building and sustainability.

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• Without this core knowledge of context, system
  planners are likely doomed to work in a manner
  that is disconnected from the needs, strengths
  and wishes of their local children and families,
  and to proceed in a business as usual manner
  while espousing system of care values and
  principles.

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• The impact of holistic thinking, informed
  decision making, and the consideration of context
  in system implementation are strengthened when
  system planners and implementers can clearly
  articulate goals with their local population of
  concern and strategies with achieving their goals

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• The expectation is that systems of care can meet
  the unique population needs of communities by
  adapting the application of the values and
  principles to the complex and constantly changing
  conditions that characterize local service
  delivery environments.

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• One tool for addressing this challenge is to
  develop a logic model for system of care
  implementation using a theory of change approach
  to planning
• This process can bring consensus among
  interagency partners and other stakeholders for a
  shared overall strategy for stem development.

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• The goal of the theory of change approach is to
  provide a process for expressing and monitoring
  the link between the ideas or plans for system
  implementation to the corresponding actions taken
  by planners and implementers regarding how
  services and supports are actually deployed.

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• The theory of change approach challenges key
  stakeholders to be clear about who they intend to
  serve, what they want to achieve and how they
  believe they can accomplish their goals.

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• The theory of change process links community
  outcomes with planned activities and the
  assumptions or principles that underlie the
  community planning efforts.

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• When complete, a theory of change logic model can
  serve as a guide for implementation, ensuring
  that community plans for service delivery remain
  true to their intent (Hernandez Hodges, 2005).

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Conclusion

• Just like SOC-driven service delivery should be
  based on a clear understanding of the needs,
  strengths, and wishes of children and their
  families System planning should be anchored on a
  clear knowledge of the need, strengths, and
  wishes of the local population of concern

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References

• Ackoff, R. L., Rovin, S. (2003). Redesigning
  Society. Stanford, CA Stanford Business Books.
• Foster-Fishman, P. G. (2002). How to create
  systems change. Lansing, MI Michigan
  Developmental Disabilities Council.
• Foster-Fishman, P., Nowell, B., Yang, H.
  (2007). Putting the system back into systems
  change A framework for understanding and
  changing organizational and community systems.
  American Journal of Community Psychology, 39(3),
  197-215.
• Friedman, R. M., Hernandez, M., Morilus-Black,
  M., Brundage, C., Hodges, S. (2008, July).
  Integrating system components Resisting
  Distractions and Embracing Change. Symposium
  conducted at the 2008 Georgetown University
  Training Institutes Developing Local Systems of
  Care for Children and Adolescents with Mental
  Health Needs and Their Families, Nashville, TN.
• Hernandez, M., Hodges, S. (2005). Crafting
  logic models for systems of care Ideas into
  action (rev. Ed.). Tampa, FL University of South
  Florida, Louis de la Parte Florida Mental Health
  Institute.
• Hernandez, M., Hodges, S., Cascardi, M. (1998).
  The ecology of outcomes System accountability in
  children's mental health. Journal of Behavioral
  Health Services Research, 25(2), 136.
• Knitzer, J. (1982). Unclaimed children The
  failure of public responsibility to children and
  adolescents in need of mental health services.
  Washington, DC Children's Defense Fund.
• Maani, K. E. Cavana, R. Y. (2000). Systems
  thinking and modeling Understanding change and
  complexity. Auckland, New Zealand Pearson
  Education New Zealand Limited.
• Stroul, B., Friedman, R. M. (1986). A system of
  care for children and youth with severe emotional
  disturbances. Washington, DC Georgetown
  University Child Development Center, CASSP
  Technical Assistance Center.

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Family Voices Network of Erie County

• Marie Morilus-Black
• Family Voices Network of Erie County
• Buffalo, NY
• Phone [phone]
• Email Morilusm_at_erie.gov

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Presentation Objectives

• Process to defining Community in the context of
  system stakeholders at the local level and to
  ensure ownership
• Strategies to Put Theory to action to accomplish
  system change and shared responsibility for
  outcome
• Strategies to integrate funding with System of
  Care Reform Values and Principles

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How FVN defined community in the context of
system stakeholders
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Erie County Buffalo, NY
New York City
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Albright Knox Art Gallery
Buffalo from Lake Erie
Buffalo 1st city of lights
Anchor Bar Home of Buffalo Chicken Wings
Ellicott Square Bldg.
Olmsted Park System
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Demographics of Erie County and the City of
Buffalo

• Erie Countys population is estimated at 950,000
• Buffalo, within Erie County, is the second
  largest city in the state of New York, population
  approximately 290,000
• Buffalo Public Schools approximate population is
  37,000 students

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Needs Assessment of Children with Serious
Emotional Behavioral Challenges

• Collaboration with Departments of Social
  Services, Juvenile Justice, Mental Health and
  Families
• Interviewed 134 key family contacts including
  case managers, or those who worked directly with
  youth
• Interviewed 32 parents/caregivers of youth with
  Serious Emotional Challenges

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Needs Assessment of Children with Serious
Emotional Behavioral Challenges

• Results of Needs Assessment
• Youth present from across all areas of system
• Needs of youth and families are universal across
  the system
• Recommendations to County
• System transformation to integrate child-serving
  systems
• Expand community-based and individualized services

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Focus Groups

• Family members of youth with mental health
  challenges included diverse cultures and
  ethnicities
• Representatives from faith-based groups covering
  the diverse population of Erie County
• Youth group representatives from organizations in
  support of youth with mental health and
  challenging behaviors

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Focus Groups

• Recommendations to County
• Eliminate barriers to access for families
• Simplify referral and shorter wait lists
• Community-based alternatives to residential care
• Individualized plan of care to meet needs of
  family youth

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Focus Groups

• Community
• MH, SS, JJ representatives participated in Pilot
  Program
• Focus group attendees, faith-based, child-serving
  organizations invited to Implementation Team
  meeting
• All those interested in childrens mental health
  transformation became our community
  stakeholders

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How Erie began a development process to allow
system stakeholders to take ownership in system
change

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Continuous Engagement of Stakeholders

• The Logic Model is the tool used by Family Voices
  Network to transform the system of care in Erie
  County
• All levels of Governance participated in the
  development of our communitys plan for the
  system of care
• All levels of Governance use the same framework
  to guide their strategic planning process
• The resulting plan, as depicted in our Logic
  Model, is the primary tool used in all system
  level outreach and education

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Family Voices Network

• SOME Committee
• Families, youth
• Social Marketer
• Evaluator

Ongoing Training for FVN and Partner Agencies
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How FVN put theory to action to accomplish system
change and shared responsibility for outcomes.
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Family Voices Network
Mission Family Voices Network will provide
individualized, integrated, comprehensive,
culturally competent and cost-effective community
based services that support and promote
self-sufficiency of children and families
experiencing serious emotional and/or behavioral
challenges.
Vision Erie County will have a family-driven,
strength based integrated system of care that
responds with appropriate coordinated services
and effective partnering to support
self-sufficiency. Services will be timely,
flexible, individualized and reduce the need for
out-of-home placement as well as shortening the
length of stay when there is the need for
placement.
Outcomes
Strategies
Context
Goals
Family, Youth Child Involvement at Each Level
of SOC

• Population of Concern
• Children 5-17 and Youth 18-21 in transition,
  with serious emotional or behavioral challenges
• At Imminent Risk for Out of Home, School or
  Community Placement,
• And with severe functional impairments, with one
  or more of the following
• Hx of multiple Institutional stays complex
  multi-service system involvement unsuccessful
  Tx. -OR-Current RTC/RTF resident with extended
  LOS
• System Issues/Strengths
• Categorical funding staff attrition waiting
  lists access barriers racial ethnic service
  disparities knowledge deficit
• Committed system leaders that effect reform
• Community Issues/Strengths
• Rigid mandates service system role confusion
• Centralized Intake committed community
  stakeholders that embrace system reform

• System Level
• Infrastructure
• System-wide sustainability
• System fiscal reform at local, state, federal
  levels
• Fully developed local SOC infrastructure
• Increased community SOC knowledge, decreased
  stigma
• Service Delivery
• Reduced length of stay and of placements in out
  of home care
• Efficient use of resources
• Least restrictive/most appropriate placements

System Strategies

• Infrastructure
• Work with Families CAN to develop youth family
  involvement
• Provide training in SOC principles, to become
  culturally relevant
• Service Delivery
• Embrace Wraparound philosophy principles values
  into daily practice
• Develop Integrated Point of Access
• Identify gaps, barriers capacity service issues
  

• Achieve Cross-system Cultural Change
• Achieve Fiscal Stability
• Enhance Existing Infrastructure of Care
  Coordination Individualized Services

• Executive Committee
• Management Team

Governance, Management Coordination

• Intake Committee
• Cultural Competency Team
• Social Marketing Team

Family, Youth Child Team Process
Community Strategies

• Advocate for local statewide funding
  organizational support
• Promote cultural competency plan and system
  reform thru the development of community
  relationships
• Use social marketing/education to inform
  community stakeholders
• Work with community groups to increase
• knowledge involvement of family, youth and
  children

• Family, Youth Child Level
• Increased appropriate Care Coordination referrals
  
• Increased stability within the community
• Increased school attendance
• Increased natural community supports
• Increased family participation and empowerment
  

Evaluation, Reporting and Continuous Quality
Improvement
Logic Model Macro Level
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Family Voices Network Achieve Cross-system
Cultural ChangeEnhance Existing Infrastructure
of Care Coordination Individualized
ServicesAchieve Fiscal StabilityOctober 2004
September 2010
Long-Term Indicators (3-5 yrs)
Short-Term Indicators (12-24 months)

• System Level
• Infrastructure
• SOC framework established inc. state, county
  leaders, Youth Council Families CAN
• Indicators cross-systems governance structure in
  place with decision making ability, family and
  youth equal partners in decisions, Sustainability
  Plan developed
• Standards of practice developed
• Indicator Wraparound principles adherence
• Out-of-home placements / Length of Stay
  benchmarked
• Indicator Measure residential community
  placements, LOS
• System-wide sustainability plan created
• Indicator Sub-committee formed to develop
  relationships and future funding sources
• Youth care coordinators active in SOC
  transformation
• Indicator Youth Council is active in committee
  work, Care coordinators trained in principles of
  wraparound, fidelity measures are developed by
  Outcomes Committee
• Cultural competence and system reform thru
  education Social Marketing
• Indicator Social Marketing measurements TBD
• Service Delivery
• Improved referral pathways incorporated for JJ,
  DSS and schools
• Indicator Integrated Point of Access fully
  functioning with all stakeholders participating
  weekly
• Benchmark individualized services and fidelity to
  the wraparound model
• Indicator Parent/Caregiver survey indicates
  parent approval of plan of care (4.8/5.0 scale)

• System Level
• Infrastructure
• Local infrastructure for SOC fully developed
• Indicator pre and post benchmarks of
  cross-system governance, collaborative
  relationships developed with community
• System-wide sustainability accomplished
• Indicators 25 Residential funding is diverted
  to SOC, transition to non-Samhsa funding from
  diverse arenas
• Families CAN is self-supporting, includes
  diverse membership
• Indicator Full 501-C3 status, with independent
  funding, membership matches closely to the SOC
  population served
• Youth council is diverse, self-sustaining
• Indicator Youth membership matches SOC
  ethnic/racial population, greater than 25 members
  
• Community meetings held in diverse settings
• Indicator meetings held at least 2x year in
  community to match SOC population
• Knowledge of SOC. paradigm shift and decreased
  stigma accomplished throughout county
• Indicator CMHAD, KE survey, CSWI, Dashboard
• Service Delivery
• Child and Family screenings disposition are
  timely
• Indicator assignments are made w/i 10 days
• Referrals to SOC match characteristics of SOC
  population by race ethnicity

• Standards of practice developed
• Indicator Wraparound principles adherence

• Knowledge of SOC. paradigm shift and decreased
  stigma accomplished throughout county
• Indicator CMHAD, KE survey, CSWI, Dashboard

Evaluation, Reporting and Continuous Quality
Improvement
Logic Model Indicators
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Group Activity

• Group Activity
• In your group, rank order these three items
• Coaching_________
• Training__________
• Monitoring________

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2005 Emerging Challenges to the Achievement of
Valued Wraparound Outcomes

• Critical Practice Area 1 Rapid Assessment
  Assignment of Cases
• Time from Referral to FVN SPOA to Assignment of
  Family to Wraparound normatively 6 to 8 Weeks
• Barriers to Timely Case Assignment
• SPOA Processing of Referrals
• Onus on Referral Source to get Referral Package
  Completed
• Steps in Assignment Process including meeting
  with all Care Coordination Providers

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2005 Emerging Challenges to the Achievement of
Valued Wraparound Outcomes

• Critical Practice Area 2 Timely Access to
  Wraparound Services Capacity
• Waiting List throughout 2005 that significantly
  contributed to the above
• Primary Barriers to Timely Access
• Wraparound Staff Turnover 23 of contracted
  staff days unfilled
• Length of Stay in Wraparound (Agencies with 2
  Years of Care Coordination) 20 of Families had
  LOS gt than 14

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2005 Emerging Challenges to the Achievement of
Valued Wraparound Outcomes

• Critical Practice Area 3 Successful Engagement
  in Care Coordination (Normative LOS 11 to 13
  Months) 8.4 of Families Enrolled in Services
  but Discharged in less than 90 Days
• Critical Practice Area 4 Achievement of Valued
  Outcomes
• At 12 Months, a 20 Point or Greater Improvement
  in Overall Level of Functioning as Measured by
  CAFAS occurred for 55 of enrolled Youth.
• 39 of Families Achieved Service Plan Objectives

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FVN Wraparound Critical Indicators Data Dashboard

• A real time data report structure that supports
  ongoing goal setting and monitoring of
  performance milestone achievement, learning
  opportunities for improvements in the efficacy of
  practice, and identification of and adjustment to
  emerging challenges.

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Critical IndicatorsData Dashboard
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Clinical Administrative/Management Applications
of Critical Data Dashboard

• Group and Individual Practitioner Supervision
• Program Monitoring and Quality Improvement
• Supervisors Learning Community
• FVN Management Team
• Commissioners Executive Director Group
• Contracted Services Resource Allocation
• Home and Community Based Waiver Slots
• Blended Wraparound Care Coordination Slots

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Wraparound ValuesTool for Practical Change

• Family Youth Role in Practice Change
• Training Coaching Strategies
• Value-Based Single Standard of Care
• Using Objective Practice-Based Evidence
• Monitor Practice Change
• Critical Indicators Dashboard
• Provider Supervision
• Inter-Agency Learning Communities

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Fiscal Integration

• Strategies to integrate funding with System of
  Care Reform Values and Principles

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Resource Allocation Sustainability

• Inter-Agency Tactical Strategic Planning
• Inter-Agency Resource Sharing
• Reallocation of Institutional Care Savings to
  expand Community-Based Resources
• Using Data to Guide Resource Allocation

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2005 2007 System Outcomes

• 5,800,000 Annualized Reinvestment of Blended
  Funding into Community-Based Services
• 16,400,000 Sustainable Annual Funding Available
  to the System of Care

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2005 2007 System Outcomes

• 34 Reduction in RTC Bed Days
• Inpatient Census Reduced to 56 of Capacity
• 70 Reduction in Non-Secure Detention
• 37 Reduction in Secure Detention
• 76 Reduction of PINS Youth on Probation
• 44 Reduction of PINS Petitions
• 85 of the Children are remaining in the
  Community long term

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Placer County SMART Childrens System of Care

• Transforming Childrens Services
• Albuquerque, New Mexico
• December 2, 2008
• Presented by Cynthia Brundage, LCSW

64
Placer County SMART Childrens System of
CareTransforming Childrens Services

• Twenty-Two Years of Evolution
• 1986-2008

65
State of California
66
County of Placer
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1986 The Beginning

• Video Judge Colleen Nichols in her own words.

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Is the SMART Childrens System of Care a natural
consequence of the public funded system?

• Or
• Is it the result of unnatural acts of
  collaboration by risk takers?

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Array of Categorical Child and Family Service
Agencies
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Array of Categorical Child and Family Service
Agencies
Child Welfare
Child Protection
Social workers
Abuse and neglect
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Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Counseling therapy medication
Child Protection
Social workers
Doctors therapists technicians
Abuse and neglect
Psychiatric/ emotional problems
76
Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Social Services
Counseling therapy medication
Child Protection
Income and employability
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Abuse and neglect
Psychiatric/ emotional problems
Poverty
77
Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
78
Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Injuries and illness
79
Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Learning barriers and disabilities
Injuries and illness
80
Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
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Array of Categorical Child and Family Service
Agencies
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
Child and family service agencies are organized
categorically to promote specialization,
concentrate funding, and prevent duplication of
services.
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The Problem With Categorical Services
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
Agencies deliver single categorical services
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The Problem With Categorical Services
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
but families experience multiple inter-related
problems.
84
For Families Fragmented Maze of Disconnected
Services
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
No single agency can address the familys full
set of needs, and agencies cannot work together
to solve them.
85
For Families Fragmented Maze of Disconnected
Services
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
Because the system is organized categorically,
children and families cannot get all the help
they need.
86
Failure By Fragmentation
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
Gains achieved through single services will be
undermined by unaddressed multiple needs.
87
Categorical System Failure
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Criminal Justice
Counseling therapy medication
Child Protection
Income and employability
Treatment counseling prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Doctors therapists technicians
Eligibility workers and specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses workers
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
Even though it delivers many excellent services,
the categorical system fails to meet the
comprehensive needs of the people it is supposed
to serve.
88
Silos Within Silos
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Probation
Every agency administers multiple categorical
silo programs, each with its own rules and
funding.
89
Silos Within Silos at Multiple
Levels
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Probation
PREVENTION
The disciplines are further categorized into
prevention, early intervention and treatment.
90
Silos Within Silos at Multiple
Levels
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Probation
PREVENTION
EARLY INTERVENTION
The disciplines are further categorized into
prevention, early intervention and treatment.
91
Silos Within Silos at Multiple
Levels
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Probation
PREVENTION
EARLY INTERVENTION
TREATMENT
The disciplines are further categorized into
prevention, early intervention and treatment.
92
Categorical Programs and Categorical Dollars
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Probation





































































































































































































































































































































































Every categorical program comes with its own
rules, its own roles, and its own funds.
93
Private Sector Fragmentation
Child Welfare
Mental Health
Social Services
Alcohol and Drug Programs
Health
Education
Probation
Counseling therapy medication
Child Protection
Income and employability
Treatment and prevention
Treatment and health promotion
Special and alternative education
Enforcement and supervision
Social workers
Psychiatrists therapists technicians
Eligibility workers / job specialists
Counselors and specialists
Officers
Teachers and resource specialists
Physicians nurses educators
Abuse and neglect
Psychiatric/ emotional problems
Poverty
Substance abuse
Delinquency and crime
Learning barriers and disabilities
Injuries and illness
The public agencies are surrounded by hundreds of
categorical community-based agencies.
94
How did Placer transform from Silos to
Comprehensive Outcomes and Integrated Services?
95
The Four Cs of Integration

• Communication
• Coordination
• Collaboration
• Consolidation

96
The Four Cs of Integration

• Communication Agencies share information about
  themselves and learn about each other, but
  funding, mission and authority remain completely
  separate and often in competition with each
  other.
• Coordination Agencies communicate and align
  their services to eliminate the gaps between
  them.
• Collaboration Agencies now work together in one
  multi-service program.
• Consolidation Agencies transfer a portion of
  their authority, resources, and services to a
  create a new agency with its own budget,
  management structure, resources and staff with
  shared authority over the entire spectrum of
  outcomes.

97
The Four Cs
Agency A
Agency B
Agency D
Agency C
David Gray 2005
98
The Four CsCommunication
Agency A
Agency B
Agency D
Agency C
99
The Four CsCoordination

Agency A
Agency B
Agency D
Agency C
100
Assessment, Intervention and Authorization Team

• Mental Health
• Probation
• Child Welfare
• Education

101
SMART Policy Board1988

• Special Multidisciplinary Advocacy and
  Resource Team
• Presiding Juvenile Court Judge
• Welfare Director
• Chief Probation Officer
• Mental Health Director
• Superintendent of the Office of Education

102
The Four CsCollaboration

Agency A
Agency B
Agency C
Agency D
103
Placement Prevention Intervention Collaborative

• Co-location of Staff from each agency
• Transdisciplinary shared approach
• Family Preservation Model
• Family-Centered Team
• Integrated budgets

104
The Four CsConsolidation

Agency A
Agency B

Agency E
Agency D
Agency C
105
SMART POLICY BOARD

• In 1994 the Special Multidisciplinary Advocacy
  and Resource Team was changed to Systems
  Management, Advocacy, and Resource Team.
• The SMART Policy Board, chaired by the Presiding
  Juvenile Court Judge, met weekly from 1994 to
  2006 and bi-weekly from 2006 to present.
• SMART Policy has joint authority and
  accountability over all publically funded
  childrens services.

106
(No Transcript)
107
The Mission

• The SMART Policy Board shall ensure that all
  public programs for children and families will
  provide services in a comprehensive way and
  integrated manner, regardless of the agency door
  by which they enter.

108
The Vision

• All children, adults and families in Placer
  County will be self-sufficient in keeping
  themselves, their children and their families
• SAFE, HEALTHY, AT HOME,
• IN SCHOOL/EMPLOYED,
• OUT OF TROUBLE/BEHAVING WELL
• and ECONOMICALLY STABLE.

109
Going to Scale

• Threats and Opportunities
• The Only Constant is Change
• Tools for Survival

110
HOW CSOC IS ORGANIZED
111
Who Shares the Authority and the Responsibility
112
Why is Placer County CSOC Organized the Way It Is?
113
Rick Saletta

• In his own words..

114
Service System Integration At Multiple Levels
Criminal Justice
Child Welfare
Mental Health
Social Services
Health
Education
Alcohol and Drug Programs
Outcomes Measure comprehensive outcomes for all
children and families
Leadership Share joint authority
and decision-making
Financing Move and use funds where
they are needed
Service Delivery Work together to address the
full set of family needs
115
Comprehensive Child and Family Outcomes
Criminal Justice
Child Welfare
Mental Health
Social Services
Health
Education
Alcohol and Drug Programs
All families will be self-sufficient in keeping
their children Safe Healthy At
Home In School Behaving
Well
The outcomes span the full array of services.
116
Access
Family Centered Service Teams
Data-Driven Decision Making
SMART / HHS Policy Board
Family Centered Support Teams
Outcome Accountability
Integrated Services
Integrated Information System
Family Centered Technical Teams
SMART Management Team
Unified Service Plan
Vision All children, adults, and families in
Placer County will be self-sufficient in keeping
themselves, their children, and their
families SAFE, HEALTHY, AT HOME, IN
SCHOOL/EMPLOYED, OUT OF TROUBLE, and ECONOMICALLY
STABLE Mission The SMART Policy Board shall
ensure that all public programs for children and
families will provide services in a comprehensive
way and integrated manner, regardless of the
agency door by which families enter.
Placement Review Team
Evidence-based Practices
Childrens System Of Care
Community Partnerships
Comprehensive Outcomes
Family / Client / Youth Driven
Private Provider Network
Culturally Competent and Welcoming
CBO Contracts
Integrated Budget CWS Redesign SAMHSA MHSA
Strengths-Based / Recovery Oriented
Collaborative Relationships
Family-Centered Practice
Family Team Decision Making
Supportive Initiatives
117
Placer Outcomes

• Holistic Approach is appreciated by families
• Able to serve more children with a greater array
  of services
• Resources and families needs are matched more
  appropriately
• System is more confusing to workers than to
  families
• Group Home placements rise, then fall
• Over time outcomes for children improve

• Though population nearly doubles, Group Home
  placements are reduced by 75
• Administration costs increase due to categorical
  demands
• Challenges to sustainability are constant
• Only one Parent Advocate is sustained
• Underserved populations remain underserved
• Lacking in cultural competency

118
(No Transcript)
119
Are They Threats or Opportunities?
120
Cooperative Agreement MISSION STATEMENT

• Placer County Childrens System of Care and
  Partners will transform by supporting, honoring,
  and valuing all youth and families to achieve
  their own goals within their own terms, culture
  and world view.

121
Sustainability Our Future

• Unified Vision and Mission
• Shared Values and Principles
• Visionary Leaders and Passionate Partners
• Creative Financing
• Succession Planning
• The Role of the Court
• The Local Governing Body
• Knowing when to resist influences and when to
  embrace them
• Hold on to the Theory of Change
• NO WRONG DOOR

122
Keep Your Eyes on the Prize!
123
Connecting with our families
and working towards strength and resilience
124
Is the SMART Childrens System of Care a natural
consequence of the public funded system?

• Or
• Is it the result of unnatural acts of
  collaboration by risk takers?

125
Thank you!
126
System Development Lessons Learned Thinking
Holistically

• Sharon Hodges, Ph.D.
• Director-Division of TREaD
• Department of Child and Family Studies
• Louis de la Parte Florida Mental Health Studies
• School of Mental Health Studies
• Phone [phone]
• Email hodges_at_fmhi.usf.edu

127
National Study of System Implementation

• 6 Participating Systems
• Long-standing, established systems
• Identified population of children and families
• Clearly articulated goals and strategies for that
  population
• Documented outcomes
• Placer County, CA
• Santa Cruz County, CA
• Region 3, NE
• State of Hawaii
• Westchester County, NY
• Marion County, IN

128
Local Experience of System Development

• Significant variations in local context
• Demographics
• Political and economic climates
• Triggering conditions
• Shared experience of critical factors

129
What Factors Were Most Critical?

• Willingness to Change
• Shared Commitment to Values
• Shared Accountability
• Delegation of Authority
• Strategic Resource Use
• Family Empowerment
• Information-Based Decision Making

130
Willingness to Change

• Commitment to change Courage to change.
• Incorporates concept of readiness.
• Based on shared belief that improvement is
  needed.
• Develops from shared conviction that something
  has to change.
• Whatever it takes.
• Fosters risk taking and creativity.

Partners make an implicit agreement to face
challenges together, take risks to achieve goals,
and support one another throughout the process.
(WC)
131
Shared Commitment to Values

• Grounded in SOC values individualized, family
  focused, culturally competent, community-based.
• Drives the kinds of system goals that are set.
• Articulation and reinforcement.
• Serve as checks and balances
• Widely held wildly held.

Shared Vision --a strong desire to achieve
better outcomes for children and families that is
based on a common belief that system of care
principles will benefit children and their
families. (R3)
132
Shared Accountability

• To children and families, to one another as
  partners, and to the community.
• Clarity around roles.
• Curtails finger pointing.
• Makes public both challenges and successes.

The goal of accountability motivates people and
helps us see how our individual efforts have been
an impact on the systems as a whole. (HI)
133
Delegation of Authority

• Leadership diffused across system partners and
  within system agencies.
• Horizontal organizations.
• Built upon trust.

Delegation of power and authority involves clear
delineation of tasks, cross-system leadership and
responsibility, and the support of managers and
line staff to act in a family-focused manner to
create desired outcomes. (PC)
134
Strategic Resource Use

• Involves fiscal and non-fiscal resources.
• No one model.
• Creative solutions.
• Blended, Braided, or Not.
• Tends to be a structural solution.

Structural change is difficult because of
territorial thinking, language, fears of
incompetence, fear of change, fear of loss of
identity (professional identity) . . . it has
taken a long time, but great progress has been
made. (PC)
135
Family Empowerment

• Direct service level ask families what they
  need.
• System level engaged in system planning and
  implementation.
• Valued participants.

Family participation at all levels of the system
is considered a key aspect of valuing
partnerships. (HI)
136
Information-Based Decision Making

• Grounded in values, driven by goals.
• Theory-based approach.
• Self-reflection.
• Timely and relevant
• Results-oriented CQI approach.
• Accountability rather than blame.
• Formal and Informal.

Outcome focus is used to develop services for
targeted population and to ensure that system
response is in line with system values. (SC)
137
Maximize Return on System Implementation

• Create focus on values and beliefs
• Translate shared beliefs into action
• Recognize that opportunities are not linear
• Know that concrete does not mean static
• Be realistic about the impact of structural
  change
• Remember the system emerges from stakeholder
  choices and actions