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Title: Integrating system components: Resisting Distractions and Embracing Change


1
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

2
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
    Care Transforming Childrens Services Through
    Family and Community Partnerships

3
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

4
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 813-974-4640
  • Email hernande_at_fmhi.usf.edu

5
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

6
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

7
Role of System of Care
  • To provide access to effective services for a
    large and diverse population within a specified
    community!
  • Friedman, 2008

8
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

9
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

10
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

11
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

12
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

13
  • 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

14
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

15
  • Systems are generally considered to be a
    collection of parts that, through their
    interactions, function as a whole (Ackoff
    Rovin, 2003 Maani Cavana, 2000)

16
  • 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

17
  • 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
18
Intentionality
  • Planning and providing services was directly tied
    to the local communitys knowledge of their local
    population of concern

19
  • 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.

20
  • 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.

21
  • 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.

22
  • 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.

23
  • 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.

24
  • 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

25
  • 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.

26
  • 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.

27
  • 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.

28
  • 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.

29
  • The theory of change process links community
    outcomes with planned activities and the
    assumptions or principles that underlie the
    community planning efforts.

30
  • 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).

31
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

32
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.

33
Family Voices Network of Erie County
  • Marie Morilus-Black
  • Family Voices Network of Erie County
  • Buffalo, NY
  • Phone 716-858-2697
  • Email Morilusm_at_erie.gov

34
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

35
How FVN defined community in the context of
system stakeholders
36
Erie County Buffalo, NY
New York City
37
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
38
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

39
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

40
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

41
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

42
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

43
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

44
How Erie began a development process to allow
system stakeholders to take ownership in system
change

45
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

46
Family Voices Network
  • SOME Committee
  • Families, youth
  • Social Marketer
  • Evaluator

Ongoing Training for FVN and Partner Agencies
47
How FVN put theory to action to accomplish system
change and shared responsibility for outcomes.
48
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
49
Family Voices Network Achieve Cross-system
Cultural Change Enhance Existing Infrastructure
of Care Coordination Individualized
Services Achieve Fiscal Stability October 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
50
Group Activity
  • Group Activity
  • In your group, rank order these three items
  • Coaching_________
  • Training__________
  • Monitoring________

51
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

52
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

53
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

54
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.

55
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56
Critical Indicators Data Dashboard
57
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

58
Wraparound Values Tool 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

59
Fiscal Integration
  • Strategies to integrate funding with System of
    Care Reform Values and Principles

60
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

61
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

62
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

63
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
Care Transforming Childrens Services
  • Twenty-Two Years of Evolution
  • 1986-2008

65
State of California
66
County of Placer
67
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68
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69
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70
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71
1986 The Beginning
  • Video Judge Colleen Nichols in her own words.

72
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?

73
Array of Categorical Child and Family Service
Agencies
74
Array of Categorical Child and Family Service
Agencies
Child Welfare
Child Protection
Social workers
Abuse and neglect
75
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
81
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.
82
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
83
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 Cs Communication
Agency A
Agency B
Agency D
Agency C
99
The Four Cs Coordination

Agency A
Agency B
Agency D
Agency C
100
Assessment, Intervention and Authorization Team
  • Mental Health
  • Probation
  • Child Welfare
  • Education

101
SMART Policy Board 1988
  • 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 Cs Collaboration

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 Cs Consolidation

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
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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
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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 813-974-6460
  • 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
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