BUILDING SYSTEMS OF CARE:

1
BUILDING SYSTEMS OF CARE CRITICAL STRUCTURES AND
PROCESSES
Presentation by Sheila A. Pires Human Service
Collaborative November 3, 2005
Sponsored by the Pennsylvania Child Welfare
Training Program
2
Purpose and Structure of the Training

• Increase knowledge about what is involved in
  building
• systems of care critical structures, essential
  process
• elements, examples Didactic, Questions/Discussio
  n
• Assess system-building progress and stage of
• development Break out by County/Facilitated
  Discussion
• Develop specific action agendas to advance
• system-building efforts Break out by
  County/Facilitated
• Discussion/Technical Assistance
• Peer Learning Reporting Back/Large Group
  Discussion

3
Definition of a System of Care
A system of care incorporates a broad array of
services and supports for a defined population
that is organized into a coordinated network,
integrates care planning and management across
multiple levels, is culturally and
linguistically competent, and builds meaningful
partnerships with families and youth at service
delivery, management, and policy levels.
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
4
National System of Care Activity

• CASSP
• RWJ MHSPY
• CASEY MHI
• CMHS GRANTS
• CSAT GRANTS
• ACF GRANTS
• CMS GRANTS
• PRESIDENTS NEW FREEDOM MENTAL HEALTH COMMISSION
• STATE INFRASTRUCTURE GRANTS

Pires, S. (2002) Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
5
System of care is, first and foremost, a set of
values and principles that provides an
organizing framework for systems change on
behalf of children, youth and families.
Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
6
Values and Principles for the System of Care

• CORE VALUES
• Child centered and family focused
• Community based
• Culturally competent

Stroul, B., Friedman, R. (1986). A system of
care for children and youth with severe emotional
disturbances (Rev. ed.) Washington, DC
Georgetown University Child Development Center,
National Technical Assistance Center for
Children's Mental Health. Reprinted by permission.
7
Values and Principles for the System of Care

• Comprehensive array of services/supports
• Individualized services guided by an
  individualized service plan
• Least restrictive environment that is clinically
  appropriate
• Families and surrogate families and youth full
  participants in all aspects of the planning and
  delivery of services
• Integrated services
• Continued

Stroul, B., Friedman, R. (1986). A system of
care for children and youth with severe emotional
disturbances (Rev. ed.) Washington,
DC Georgetown University Child Development
Center, National Technical Assistance Center for
Children's Mental Health. Reprinted by permission.
8
Values and Principlesfor the System of Care

• Care management or similar mechanisms
• Early identification and intervention
• Smooth transitions
• Rights protected, and effective advocacy efforts
  promoted
• Receive services without regard to race,
  religion, national origin, sex, physical
  disability, or other characteristics and services
  should be sensitive and responsive to cultural
  differences and special needs

Stroul, B., Friedman, R. (1986). A system of
care for children and youth with severe emotional
disturbances (Rev. ed.) Washington,
DC Georgetown University Child Development
Center, National Technical Assistance Center for
Children's Mental Health. Reprinted by permission.
9
Principles of Family Support Practice

• Staff families work together in relationships
  based on equality and respect.
• Staff enhances families capacity to support the
  growth and development of all family members.
• Families are resources to their own members,
  other families, programs, and communities.
• Programs affirm and strengthen families
  cultural, racial, and linguistic identities.
• Programs are embedded in their communities and
  contribute to the community building.
• Programs advocate with families for services and
  systems that are fair, responsive, and
  accountable to the families served.
• Practitioners work with families to mobilize
  formal and informal resources to support family
  development.
• Programs are flexible responsive to emerging
  family community issues.
• Principles of family support are modeled in all
  program activities.

Family Support America. (2001). Principles of
Family Support Practice in Guidelines for Family
Support Practice (2nd ed.). Chicago, IL.
10
Youth Development Principles

• Adolescent Centered
• Community Based
• Comprehensive
• Collaborative
• Egalitarian
• Empowering

• Inclusive
• Visible, Accessible, and Engaging
• Flexible
• Culturally Sensitive
• Family Focused
• Affirming

Pires, S. Silber, J. (1991). On their own
Runaway and homeless youth and the programs that
serve them. Washington, D.C. Georgetown
University Child Development Center.
11
System of Care Operational Characteristics

• Collaboration across agencies
• Partnership with families
• Cultural linguistic competence
• Blended, braided, or coordinated financing
• Shared governance across systems with families
• Shared outcomes across systems
• Organized pathway to services supports
• Interagency/family services planning teams
• Interagency/family services monitoring teams
• Single plan of care
• One accountable care manager

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
12
System of Care Operational Characteristics

• Cross-agency care coordination
• Individualized services and supports wrapped
  around
• child/family
• Home- community-based alternatives
• Broad, flexible array of services and supports
• Integration of clinical treatment services
  natural
• supports, linkage to community resources
• Integration of evidence-based and effective
  practices
• Cross-agency MIS

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative
13
Current Systems Problems

• Lack of home and community-based services and
  supports
• Patterns of utilization
• Cost
• Administrative inefficiencies
• Knowledge, skills and attitudes of key
  stakeholders
• Poor outcomes
• Financing structures
• Pathology-based/medical models, deficit-oriented,
  punitive systems

Pires, S. (1996). Human Service Collaborative,
Washington, D.C.
14
Characteristics of Systems of Care as Systems
Reform Initiatives
FROM Fragmented service delivery Categorical
programs/funding Limited services Reactive,
crisis-oriented Focus on deep end,
restrictive Children out-of-home Centralized
authority Creation of dependency
TO Coordinated service delivery Blended
resources Comprehensive service array Focus on
prevention/early intervention Least restrictive
settings Children within families Community-based
ownership Creation of self-help
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
15
SYSTEMS CHANGE FOCUSES ON

• Policy Level (e.g., financing regs rates)
• Management Level (e.g., data QI HRD system
• organization)
• Frontline Practice Level (e.g., assessment care
  planning
• care management services/supports provision)
• Community Level (e.g., partnership with families,
  youth,
• natural helpers community buy-in)

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
16
Frontline Practice Shifts
Control by professionals Partnerships
with families Only professional services
Partnership between
natural and professional
supports and services Multiple case managers
One service coordinator Multiple
service plans for child Single plan for child
and family Family blaming Family
partnerships Deficits Strengths Mono
Cultural Cultural Competence
Orrego, M. E. Lazear, K. J. (1998) EQUIPO
Working as Partners to Strengthen Our Community
17
Examples of Family Members Shifts in Roles and
Expectations
Lazear, K. (2004). Primer Hands On for Family
Organizations. Human Service Collaborative
Washington, D.C.
18
Categorical vs. Non-Categorical System Reforms
Categorical System Reforms
Non-Categorical Reforms
Pires, S. (2001). Categorical vs. non-categorical
system reforms. Washington, DC Human Service
Collaborative.
19
The Total Population of Children and Families Who
Depend on Public Systems

• Children and families eligible for Medicaid
• Children and families eligible for the State
  Children's Health Insurance Program (SCHIP)
• Poor and uninsured children and families who do
  not qualify for Medicaid or SCHIP
• Families who are not poor or uninsured but who
  exhaust their private insurance, often because
  they have a child with a serious disorder
• Families who are not poor or uninsured and who
  may not yet have exhausted their private
  insurance but who need a particular type of
  service not available through their private
  insurer and only available from the public sector.

Pires, S. (1997). The total population of
children and families who depend on public
systems. Human Service Collaborative Washington,
D.C.
20
Systems of Care
More complex needs
IntensiveServices
Accessiblehigh-quality services and supports
2 - 5
Assessment, Prevention and Universal Health
Promotion
15
80
Less complex needs
21
Child Welfare Population Issues

• All children and families involved in child
  welfare?
• If subsets, who?
• Demographic e.g., infants, transition-age youth
• Intensity of System Involvement e.g., out of
  home placement,
• multi-system, length of stay
• At risk e.g.,
• Children with natural families at risk of
  out of home placement?
• Children in permanent placements that are
  at risk of disruption ?
• (e.g., subsidized adoption, kinship care,
  permanent foster care)
• Level of severity e.g.,
• Children with serious emotional/behavioral
  disorders, serious
• physical health problems, developmental
  disabilities,
• co-occurring

Pires, S.A. 2004. Human Service Collaborative.
Washington, D.C.
22
Example Transition-Age Youth
What outcomes do we want to see for this
population?

• Policy Level
• What systems need to be involved?
• e.g., Housing, Vocational Rehabilitation,
  Employment
• Services, Mental Health and Substance Abuse,
  Medicaid,
• Community Colleges/Universities, Physical Health,
  Juvenile
• Justice, in addition to Child Welfare
• What dollars/resources do they control?

Continued
23
Example Transition-Age Youth

• Management Level
• How do we create a locus of system management
• accountability for this population?
• E.g., In-house? Lead community agency?
• Frontline Practice Level
• Are there evidence-based/promising approaches
  targeted
• to this population?
• What training do we need to provide and for whom
  to
• create desired attitudes, knowledge, skills about
  this
• population?
• What providers know this population best in our
• community?

Continued
24
Example Transition-Age Youth

• Community Level
• What are the partnerships we need to build with
• youth and families?
• How can natural helpers in the community play a
  role?
• How do we create larger community buy-in?
• What can we put in place to provide opportunities
• for youth to contribute and feel a part of the
  larger
• community?

What does our system design look like for this
population?
25
Child Welfare Outcomes

• Safety
• Permanency
• Well-Being

Difficult to achieve without taking a system of
care approach
26
Examples of Sources of Funding for Children/Youth
with Behavioral Health Needs in the Public
Sector

• Education
• ED General Revenue
• ED Medicaid Match
• Student Services

• Mental Health
• MH General Revenue
• MH Medicaid Match
• MH Block Grant

• Medicaid
• Medicaid In-Patient
• Medicaid Outpatient
• Medicaid Rehabilitation Services Option
• Medicaid Early Periodic Screening, Diagnosis and
  Treatment (EPSDT)
• Targeted Case Management
• Medicaid Waivers
• Katie Beckett Option

• Other
• WAGES
• Childrens Medical Services/Title V Maternal and
  Child Health
• Mental Retardation/ Developmental Disabilities
• Title XXI-State Childrens Health Insurance
  Program (SCHIP)
• Vocational Rehabilitation
• Supplemental Security Income (SSI)
• Local Funds

• Child Welfare
• CW General Revenue
• CW Medicaid Match
• IV-E (Foster Care and Adoption Assistance)
• IV-B (Child Welfare Services)
• Family Preservation/Family Support

• Substance Abuse
• SA General Revenue
• SA Medicaid Match
• SA Block Grant

• Juvenile Justice
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants

Pires, S. (1995). Examples of sources of
behavioral health funding for children families
in the public sector. Washington, DC Human
Service Collaborative. Revised 2005.
27
WHO CONTROLS POLICY AND DOLLARS?

• Key
• State Medicaid Agencies
• State/Local Child Welfare Agencies
• State/Local Mental Health Authorities
• Public Health and Primary Care
• State/Local Education Agencies
• State and Local Juvenile Justice Systems

• Some Others
• Commercial Insurers
• Employment Services
• State/Local Substance
• Abuse Agencies
• Housing

Pires, S. (2004). Human Service Collaborative,
Washington, D.C.
28
OTHER CRITICAL PLAYERS

• Gatekeepers (e.g., managed care organizations,
• judges, interagency
  teams)
• Providers
• Natural Helpers and Community Resources
• Families
• Youth

Pires, S. (2004). Human Service Collaborative,
Washington, D.C.
29
Local OwnershipState Commitment
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative
30
Converging Trends
Pires, S. (2003). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
31
Efficacy of Research(Barbara Burns Research at
Duke University)

• Most evidence of efficacy Intensive case
  management, in-home services, therapeutic foster
  care
• Weaker evidence (because not much research done)
  Crisis services, respite, mentoring, family
  education and support
• Least evidence (and lots of research) Inpatient,
  residential treatment, therapeutic group home

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
32
Evidence-Based Practices And Promising Approaches
Evidence-based practices Show evidence of
effectiveness through carefully controlled
scientific studies, including random clinical
trials Promising approaches Show evidence of
effectiveness through experience of key
stakeholders (e.g., families, youth, providers,
administrators) and by data collected by
program/system
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
33
Examples of Evidence-Based Practices

• Multisystemic Therapy (MST)
• Multidimensional Treatment Foster Care (MDTFC)
• Functional Family Therapy (FFT)
• Cognitive Behavioral Therapy (various models)
• Intensive Care Management (various models)

Examples of Promising Practices

• Family Support and Education
• Wraparound Service Approaches
• Mobile Response and Stabilization Services

Source Burns Hoagwood. 2002. Community
treatment for youth Evidence- based
interventions for severe emotional and behavioral
disorders. Oxford University Press and State of
New Jersey BH Partnership (www.njkidsoc.org)
34
Examples from Hawaiis List of Evidence Based
Practices
HA Dept. of Health, Child Adolescent Division
(2005). Available from http//www.hawaii.gov/heal
th/mentalhealth/camhd
35
Examples from Hawaiis List of Evidence Based
Practices
HA Dept. of Health, Child Adolescent Division
(2005). Available from http//www.hawaii.gov/heal
th/mentalhealth/camhd
36
Examples from Hawaiis List of Evidence Based
Practices
HA Dept. of Health, Child Adolescent Division
(2005). Available from http//www.hawaii.gov/heal
th/mentalhealth/camhd
37
KAUFFMAN BEST PRACTICES PROJECT AND NATIONAL
CHILD TRAUMATIC STRESS NETWORK

• Trauma Focused-Cognitive Behavioral Therapy
  (TF-CBT)
• Abuse Focused-Cognitive Behavioral Therapy
  (AF-CBT)
• Parent Child Interaction Therapy (PCIT)

38
Shared Characteristics of Evidence-Based (and
Promising)Interventions

• Function as service components within systems of
  care
• Provided in the community
• Utilize natural supports, parents, with training
  and supervision provided by those with formal
  mental health training
• Operate under the auspices of all child-serving
  systems, not just mental health
• Studied in the field with real world children
  and families
• Less expensive than institutional care (when the
  full continuum is in place)

Burns, B. and Hoagwood, K. 2002. Community
treatment for youth. New York Oxford University
Press.
39
The current need is for building efficacious
treatment interventions within effective,
compassionate, and competent systems of care
Peter Jensen, M.D. Building Community Treatment
for Youth
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
40
EXAMPLES OF SYSTEMS OF CARE
41

• Mental Health
• Crisis Billing
• Block Grant
• HMO Commercial
• Insurance

Child Welfare Funds thru Case Rate (Budget for
Institutional Care for CHIPS Children)
Medicaid Capitation (1557 per Month per Enrollee
Juvenile Justice (Funds Budgeted for Residential
Treatment for Delinquent Youth)
9.5M
10M
8.5M
2.0M
Wraparound Milwaukee Wraparound
Milwaukee. (2002). What are the pooled funds?
Milwaukee, WI Milwaukee County Mental Health
Division, Child and Adolescent Services Branch
Management Entity Wraparound Milwaukee Management
Service Organization (MSO) 30M
Per Participant Case Rate
Provider Network 240 Providers 85 Services
Care Coordination
Child and Family Teams
Plans of Care
Mngt. Entity County Agency
42
OUTCOMES (Milwaukee Wraparound)

• 60 reduction in recidivism rates for delinquent
• youth from one year prior to enrollment to one
  year
• post enrollment
• Decrease in average daily RTC population from 375
  
• to 50
• Reduction in psychiatric inpatient days from
  5,000 days
• to less than 200 days per year
• Average monthly cost of 4,200 (compared to
  7,200
• for RTC, 6,000 for juvenile detention, 18,000
  for
• psychiatric hospitalization

43
Next Phase of Milwaukee Wraparound

• Partnership with HMO to become medical/clinical
• home for all children in foster care in the
  county
• Locus of accountability for managing physical,
• dental, and behavioral health care to achieve
  ASFA
• well-being outcomes

44
DAWN Project Indianapolis, IN
How Dawn Project is Funded
Dawn Project Cost Allocation
Management Entity Non profit behavioral health
organization
45
More Dawn Features

• Service coordination plans, including safety and
  crisis plan
• Broad array of treatment and supportive services
• Extensive provider network, paid fee for service

46
Dawn Service Array
47
Dawn Service Array, Continued
48
NJ Childrens System of Care Initiative
Other
School Referral
Family Self
CHILD
Child Welfare
JJC Court
Community Agencies
Screening with Uniform Protocols

• Contracted
• Systems
• Administrator CSA
• Registration
• Screening for self-referrals
• Tracking
• Assessment of Level of Care Needed
• Care Coordination
• Authorization of Services

• Community
• Agencies
• Uncomplicated Care
• Service Authorized
• Service Delivered

• CMO
• Complex Multi-System
• Children
• ISP Developed
• Full Plan of Care
• Authorized

FSO Family to Family Support
49
El Paso County, Colorado
State-Capped Out of Home Placement Allocation
County DHS acts as MCO (contracting, monitoring,
utilization review)
BH Tx matched by Medicaid. Capitation contract
with BHO with risk-adjusted rates for child
welfare-involved children
Child Welfare Case rate contract with CPA
Joint treatment planning approved by DHS
Child Placement Agencies (CPA) Responsible for
full range of Child Welfare Services ASFA
(Adoption and Safe Families ACT) related
outcomes
Mental Health Assessment and Service Agency
(BHO) Responsible (at risk) for full range of
MH treatment services clinical outcomes ASO
functions
Pires, S. (1999). El paso county, colorado
risk-based contracting arrangement. Washington,
DC Human Service Collaborative.
50
Types of Outcomes Achieved by Systems Of Care

• Reduction in inpatient hospitalization and
  residential
• treatment placements and lengths of stay
• Reductions in detention rates
• Reductions in out-of-home placements and lengths
  of
• stay
• Improved clinical and functional outcomes
• Higher family and youth satisfaction
• Lower costs per child served for total system if
• a range of home and community-based is in place

51
Data on Outcomes Available From (Among Others)

• Burns Hoagwood, Community Treatment for Youth
• Evidence-Based Interventions for Severe Emotional
  and
• Behavioral Disorders, Oxford University Press
• Kaufman Foundation, Closing the Quality Chasm in
  Child
• Abuse Treatment Identifying and Disseminating
  Best
• Practices, www.kauffmanfoundation.org
• Wraparound Milwaukee (bkamrad_at_wrapmilw.org)
• Dawn Project (krotto_at_choicesteam.org)
• Coordinated Care Services, Inc.
  (jlevison-johnson_at_ccsi.org)
• Massachusetts Mental Health Services Program for
  Youth
• (katherine_grimes_at_nhp.org)
• Youth Villages (tim.goldsmith_at_youthvillages.org)

52
Process How system builders conduct
themselves Structure What gets built (i.e., how
functions are organized)
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
53
Structure Something Arranged in a Definite
Pattern of Organization

• I. Distributes
• Power
• Responsibility
• II. Shapes and is shaped by
• Values
• III. Affects
• Practice and outcomes
• Subjective experiences (i.e., how participants
  feel)

Pires, S. (1995). Structure. Washington, DC
Human Service Collaborative.
54
EXAMPLE
Goal One plan of care one care manager

• Mental Health
• Individualized WrapAround Approach
• Care manager

• Child Welfare
• Family Group Decision Making
• CW Case Worker

Kinship Care
Subsidized Adoption
Permanent Foster Care
Tutoring Parent Support, etc.
Treatment Foster Care
In-Home Services
Crisis Services
Children in out-of-home placements

• MCO
• Prior Authorization
• Clinical Coordinator

• Education
• Child Study Team
• Teacher

Out-patient services
Primary Care
Alternative School
EH Classroom Related Services
Med. Mngt.
Result Multiple plans of care multiple care
managers
Pires, S. (2004).Building Systems of Care A
Primer. Human Service Collaborative Washington,
DC
55
System of Care Functions Requiring Structure

• Planning
• Decision Making/Policy Level Oversight
• System Management
• Benefit Design/Service Array
• Evidence-Based Practice
• Outreach and Referral
• System Entry/Access
• Screening, Assessment, and Evaluation
• Decision Making and Oversight at the Service
  Delivery Level
• Care Planning
• Care Authorization
• Care Monitoring and Review
• Care Management or Care Coordination
• Crisis Management at the Service Delivery and
  Systems Levels
• Utilization Management
• Family Involvement, Support, and Development at
  all Levels
• Youth Involvement, Support, and Development

• Staffing Structure
• Staff Involvement, Support, Development
• Orientation, Training of Key Stakeholders
• External and Internal Communication
• Provider Network
• Protecting Privacy
• Ensuring Rights
• Transportation
• Financing
• Purchasing/Contracting
• Provider Payment Rates
• Revenue Generation and Reinvestment
• Billing and Claims Processing
• Information Management
• Quality Improvement
• Evaluation
• System Exit
• Technical Assistance and Consultation
• Cultural Competence

Pires, S. (2002).Building Systems of Care A
Primer. Washington, D.C. Human Service
Collaborative.
56
Core Elements of an Effective System-Building
Process
Leadership and Constituency Building

• A core leadership group
• Evolving leadership
• Effective collaboration
• Partnership with families and youth
• Cultural competence
• Connection to neighborhood resources and natural
  helpers
• Bottom-up and top-down approach
• Effective communication
• Conflict resolution, mediation, and team-building
  mechanisms
• A positive attitude

Pires, S. (2002).Building Systems of Care A
Primer. Washington, D.C. Human Service
Collaborative.
57
Core Elements of an Effective System-Building
Process
Being Strategic

• A strategic mindset
• A shared vision based on common values and
  principles
• A clear population focus
• Shared outcomes
• Community mappingunderstanding strengths and
  needs
• Understanding and changing traditional systems
• Understanding of the importance of de facto
  mental health providers (e.g., schools, primary
  care providers, day care providers, head start)
• Understanding of major financing streams
• Connection to related reform initiatives
• Clear goals, objectives, and benchmarks
• Trigger mechanismsbeing opportunistic
• Opportunity for reflection
• Adequate time

Pires, S. (2002).Building Systems of Care A
Primer. Washington, D.C. Human Service
Collaborative
58
Challenges to Collaboration Barrier Busters
Wraparound Milwaukee. (1998). Challenges to
collaboration/barrier busters. Milwaukee, WI
Milwaukee County Mental Health Division, Child
and Adolescent Services Branch.
59
Cross-Cutting Characteristics

• Cultural and linguistic competence, that is,
  processes and structures that support capacity to
  function effectively in cross-cultural
  situations
• Meaningful partnership with families, including
  family organizations, and youth in system
  building processes and structural decision
  making, design, and implementation
• A cross-agency perspective, that is, processes
  and structures that operate in a non-categorical
  fashion.
• State and local partnership and shared commitment.

Pires, S. (2002).Building systems of care A
primer. Washington D.C. Human Service
Collaborative.
60
LEVEL STRUCTURE Policy At least 51 vote on
governing bodies as members of teams to
write and review RFPs and contracts as
members of system design workgroups and
advisory boards Management As part of quality
improvement processes as evaluators of system
performance as trainers in training
activities as advisors to selecting
personnel Services As members of team for
own children as family support workers, care
managers, peer mentors, system navigators for
other families
How Systems of Care are Structuring Family
Involvement at Various Levels of the System
Pires, S. (1996). Human Service
Collaborative, Washington, D.C.
61
Why Culture Matters

• Because it affects
• Attitudes and beliefs about services and systems
• Expression of symptoms
• Coping strategies
• Help-seeking behaviors
• Utilization of services
• Appropriateness of services and supports
• Disparities in access

Lazear, K., (2003) Primer Hands On A skill
building curriculum. Washington, D.C. Human
Service Collaborative.
62
BUILDING SYSTEMS OF CARESTRATEGICALLY MANAGING
COMPLEX CHANGE
Human Service Collaborative. (1996). Building
local systems of care Strategically managing
complex change. Adapted from T. Knosler (1991),
TASH Presentations. Washington DC.
63
Elements of Effective Planning Processes

• Are staffed
• Involve key stakeholders
• Involve families early in the process and in ways
  that are meaningful
• Ensure meaningful representation of racially and
  ethnically diverse families
• Develop and maintain a multi-agency focus
• Build on and incorporate related programmatic and
  planning initiatives
• Continually seek ways to build constituencies,
  interest, and investment
• Pay attention to sustainability and growth of
  system changes from day one

Pires, S. (1991). State child mental health
planning. Washington, DC Georgetown University
Child Development Center, National Technical
Assistance Center of Childrens Mental Health.
64
A Planning Process for Family and Childrens
Service Reform
The System As It Is Now
Outcomes For Children
The System As It Should Be
Principles
Reinvestment Commitment Financing Options
Multi Year Steps
Leadership and Professional Development
Strategy Cross Community Cross Agency
Governance Strategy State County Community
Combined Fiscal Program Strategy ---------------
--------------------------------------------------
--------------------------------------------------
--------------------------------------------------
---------------
Friedman, M. (1994). Washington, D.C. Center for
the Study of Social Policy
65
Strategies for InvolvingParents in Planning

• Providing special orientation and training and
  ongoing assistance consulting with parents
  before meetings.
• Having more than token representation.
• Contracting with community-based and parent
  organizations to develop/sustain process.
• Working through parent organizations.
• Asking agencies that work with parents to
  recommend parents to participate in planning.
• Paying stipends, transportation, child care.
• Holding planning meetings in the evenings or on
  weekends, in locations such as schools.
• Conducting surveys to elicit views of many
  parents.
• Continued

Emig, C., Farrow, F. Allen, M. (1994). A guide
for planning Making strategic use of the family
preservation and support services program.
Washington, D.C. Center for the Study of Social
Policy Childrens Defense Fund.
66
Strategies for Involving Parents in Planning
(continued)

• Using parents who work regularly with other
  parents to conduct focus groups.
• Working with family support groups to tap into
  informal networks.
• Working with home visiting programs and health
  clinics to reach out to parents.
• Working with family preservation and family
  reunification programs.
• Conducting sessions for planning group members
  with trained facilitators to explore attitudes
  about race, culture, families.
• Publicly acknowledging the contributions of
  parents.

Emig, C., Farrow, F. Allen, M. (1994). A guide
for planning Making strategic use of the family
preservation and support services program.
Washington, D.C. Center for the Study of Social
Policy Childrens Defense Fund.
67
Definition of Governance
Decision making at a policy level that has
legitimacy, authority, and accountability.
Pires, S. (1995). Definition of governance.
Washington, DC Human Service Collaborative.
68
System Management Day-to-day operational
decision making
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
69
Key Issues for Governing Bodies

• Has authority to govern
• Is clear about what it is governing
• Is representative
• Has the capacity to govern
• Has the credibility to govern
• Assumes shared liability across systems for
  target population

Pires, S. (2000). Key issues for governing
bodies. Washington, DC Human Service
Collaborative.
70
System Management Day-to-Day Operational
Decision Making

• Key Issues
• Is the reporting relationship clear?
• Are expectations clear regarding what is to be
  managed and what outcomes are expected?
• Does the system management structure have the
  capacity to manage?
• Does the system management structure have the
  credibility to manage?

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
71
Example of Governance/Management Structure
Care Management Entity
Pires, S. (1996). Contracted system management
structure. Washington, DC Human Service
Collaborative.
72
Example of Governance/Management Structure
BRING THE CHILDREN HOME STATE LEGISLATION
COUNTY EXECUTIVE
Local Governing Board
Agency Directors Family/Youth Reps.
Providers Forum
SOC Team Leader
Bring the Children Home Interagency Care
Management Team
Bring the Children Home Care Managers
Families/Youth Served Other Agency Workers
Pires, S. (1996). Evolving governance structure.
Washington, DC Human Service Collaborative.
73
Examples of Types of Family Partnership in System
Governance and Management

• Input/evaluation of key management
• Input/evaluation of quality of services and
  programs
• Local system of care input
• Resource allocation
• Service planning and implementation
• Policies and procedures
• Grievance and resolution procedures

Conlan, L. (2003). Implementing family
involvement. Burlington, VT Vermont Federation
of Families for Childrens Mental Health.
74
Distinctions Among Screening, Assessment and
Evaluation, and Care Planning

• Screening
• 1st step, triage, identify children at high
  risk, link to appropriate assessments
• Assessment
• Based on data from multiple sources
• Comprehensive
• Identify strengths, resources, needs
• Leads to care planning
• Continued

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative
75
Distinctions Among Screening, Assessment and
Evaluation, and Care Planning

• Evaluation
• Discipline-specific, e.g., neurological exam
• Closer, more intensive study of a particular or
  suspected
• clinical issue
• Provides data to assessment process
• Care planning
• Individualized decision making process for
  determining services
• and supports
• Draws on screening, assessment, and evaluation
  data

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
76
Life Domain Areas
Adapted from. Dennis, K, VanDenBerg, J.,
Burchard, J. (1990). Life domain areas. Chicago
Kaleidoscope.
77

• Definition of Wraparound
• Wraparound is . . . a definable planning
  process that results in a unique set of community
  services and natural supports that are
  individualized for a child and family to achieve
  a positive set of outcomes.
• Burns, B. Hoagwood, K. (Eds.) Community-Based
  Interventions for Children and Families. Oxford
  Oxford University Press.

78
Wraparound and System of Care
Wraparound is an important approach to
care planning and service provision within a
system of care But . It does not, in and of
itself, constitute a system of care!
Pires., S. 2005. Human Service Collaborative.
Washington, D.C.
79
Examples of What Youd Want to Provide Based on
Effectiveness Literature

• Outpatient Models
• Cognitive Behavior Therapy (various models)
• Functional Family Therapy (FFT)
• Parent Child Interaction Therapy (PCIT)
• Intensive In-Home Models
• Multisystemic Therapy (MST)
• Out-of-Home Model
• Multidimensional Treatment Foster Care
• Intensive Care Management

Pires, S. 2005. Building systems of care. Human
Service Collaborative. Washington, D.C.
80
Examples of Other Home and Community-Based
Services Youd Want to Provide Based on
Practice/Family Experience Outcomes Data

• Intensive in-home services (not just MST)
• Child respite services
• Mobile response and stabilization services
• Mental health consultation services
• Independent living skills and supports
• Family/youth education and peer support

Pires, S. 2005. Building systems of care. Human
Service Collaborative. Washington, D.C.
81
What You Dont See Listed as Evidence-Based
Practice

• Traditional office-based talk therapy
• Residential Treatment
• Group Homes
• Day Treatment

82
What Natural Helpers Can Provide

• Emotional support
• System navigation
• Resource acquisition
• Concrete help
• Decrease social isolation
• Greater understanding of community
• Community navigation
• Effective intervention or support strategies

Lazear, K., (2003). Primer Hands On A skill
building curriculum. Human Service Collaborative
Washington, D.C.
83
Pre-Equipo Network
Gutierrez-Mayka, M Wolfe, A. (2001). EQUIPO
Neighborhood Family Team Final Evaluation Report.
84
Post EQUIPO Network
Gutierrez-Mayka, M Wolfe, A. (2001). EQUIPO
Neighborhood Family Team Final Evaluation Report.
85
Travel Miles
1250180
Time and Travel (Ten Month Period)
Study Family
Comparison Family
Office Hours
1058
Visits
696
Travel Hours
296
Lazear, K. (2003). Family Experience of the
Mental Health System, Research and Training
Center for Childrens Mental Health, Tampa, FL.
86
Service Array Focused on a Total Eligible
Population
Universal
Targeted
Core Services
Prevention Early Intervention
Intensive Services

• Family Support Services
• Youth Development Program/Activities
• Coordinated Intake Assessment Treatment
  Planning
• Intensive Case Management/Care Coordination
• Wraparound Services Supports
• Clinical Services

Pires, S. Isaacs, M. (1996, May) Service
delivery and systems reform. Training module for
Annie E. Casey Foundation Urban Mental Health
Initiative Training of Trainers Conference.
Washington, DC Human Service Collaborative.
87
Where Family Organizations Fit Into Service Array

• As technical assistance providers consultants
• Training
• Evaluation
• Research
• Support
• Outreach

• As direct service providers
• Family Liaisons
• Care Coordinators
• Family Educators
• Specific Program Managers (respite, etc)

Wells, C. (2004). Primer Hands On for Family
Organizations. Human Service Collaborative
Washington, D.C.
88
Comparison of Case Management and Care Management

• Case Management
• Little authority over resources
• Child centered
• Reactive
• Service provided to placement
• Organization of existing services
• Uses current system

• Care Management
• More control over resources
• Family centered
• Proactive
• Unconditional care
• Creation of services when not available
• Family and community supports

Adapted from Community Care Systems. (2000).
Comparison of case management and care
coordination. Madison, WI.
89
Care Management Continuum
Children needing intensive and extended level of
services and supports
Children needing only brief short-term services
and supports
Children needing intermediate level of services
and supports
UM-type care management No caseloads
Service coordination Large caseloads
Intensive care management Very small caseloads
Pires, S. (2001). Case/care management continuum.
Washington, DC Human Service Collaborative.
90
Care Management/Service Coordination Structure
Principles

• Support a unitary (i.e., across agencies) care
  management/coordination approach even though
  multiple systems are involved, just as the care
  planning structure needs to support development
  of one care plan.
• Support the goals of continuity and coordination
  of care across multiple services and systems over
  time.
• Encompass families and youth as partners in the
  process of managing/coordinating care.
• Incorporate the strengths of families and youth,
  including the natural and social support networks
  on which families rely.

Pires, S. (20O2). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
91
Utilization Management Concerns

• Who is using services?
• What services are being used?
• How much service is being used?
• What is the cost of the services being used?
• What effect are the services having on those
  using them? (i.e., Are clinical/functional
  outcomes improving? Are families and youth
  satisfied? Are children returning home?)

UM
Pires, S. (2001). Utilization management
concerns. Washington, DC Human Service
Collaborative.
92
Principles for Utilization Management

• UM must be understood and embraced by all key
  stakeholders
• UM must concern itself with both the cost and
  quality of care
• The UM structure needs to be tied to the quality
  improvement structure

Pires.. S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
93
Purposes of UM/Evaluation Data Examples

• Planning and Decision Support (Day-to-Day and
• Retrospectively)
• Quality Improvement
• Cost/Benefit Monitoring
• Research
• Marketing
• Accountability

Pires, S. 2005. Building systems of care. Human
Service Collaborative. Washington, D.C.
94
Evaluation Data Gathering

• To eliminate disparities, disproportionalities,
  and improve quality of care, we need to collect
  data.
• Questionnaires
• Surveys
• Interviews
• Focus groups
• Clinical outcome data
• Using a participatory evaluation framework
• Lazear, K. (2003). Primer Hands On A skill
  building curriculum. Washington. D.C.

95
Financing Strategies to Support Improved Outcomes
for Children Families

• FIRST PRINCIPLE
• System Design Drives Financing
• REDEPLOYMENT
• Using the Money We Already Have
• The Cost of Doing Nothing
• Shifting Funds from Treatment to Early
  Intervention
• Moving Across Fiscal Years
• REFINANCING
• Generating New Money by Increasing Federal Claims
• The Commitment to Reinvest Funds for Families and
  Children
• Foster Care and Adoption Assistance (Title IV-E)
• Medicaid (Title XIX)

Adapted from Friedman, M. (1995). Financing
strategies to support improved outcomes for
children. Center for the Study of Social Policy
Washington, D.C..
96
Financing Strategies to Support Improved Outcomes

• RAISING OTHER REVENUE TO SUPPORT FAMILIES AND
• CHILDREN
• - Donations
• - Special Taxes and Taxing Districts for Children
• - Fees and Third Party Collections Including
  Child Support
• - Trust Funds
• FINANCING STRUCTURES THAT SUPPORT GOALS
• - Seamless Services Financial claiming invisible
  to families
• - Funding Pools Breaking the lock of agency
  ownership of funds
• - Flexible Dollars Removing the barriers to
  meeting the unique
• needs of families
• - Incentives Rewarding good practice

Friedman, M. (1995). Financing strategies to
support improved outcomes for children. Center
for the Study of Social Policy Washington, D.C.
97
Where to Look for Money and Other Types of
Support
e
e
Pires, S. (1994). Where to look for money and
other types of support. Human Service
Collaborative Washington, D.C.
98
Milwaukee Wraparound
Wraparound Milwaukee. (2002). What are the pooled
funds? Milwaukee, WI Milwaukee Count Mental
Health Division, Child and Adolescent Services
Branch.
99
How to Finance/Implement Systems of Care

• Adopt a Population Focus Who are the
  populations
• of youth for whom you want to change
  practice/outcomes
• Adopt a Cross-Systems Approach What other
  systems
• serve these youngsters who controls potential or
  actual
• match dollars which systems now spend a lot on
• restrictive levels of care with poor outcomes or
  on deficit-
• based assessments not linked to effective
  services
• Opportunities for re-direction
• Identify Incentives to Finance/Implement Systems
  of Care

Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
100
Examples of Incentives to Various Child-Serving
Systems
Medicaid slowing rate of growth in deep end
services Child Welfare meeting Adoptions and
Safe Families Act outcomes reducing out-of-home
placements Juvenile Justice creating
alternatives to incarceration reducing
detention costs Mental Health more effective
delivery system Education reducing special
education expenditures
Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
101
Examples of Cross-System Partnerships to
Finance and Implement Evidence-Based and
Promising Practices
District of Columbia MST, Mobile Response,
In-Home Medicaid Rehab Option pays for MST,
Intensive Home-Based Services (Ohio model),
Mobile Response and Stabilization Services (NJ
model) Child Welfare provides match and paid for
initial training, coaching, provider capacity
development Mental health/child welfare share
costs of outcomes tracking Juvenile Justice now
paying match, training costs as well Medicaid HMO
expressing interest in Mobile Crisis
Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
102
Examples of Cross-System Partnerships to
Finance and Implement Evidence-Based and
Promising Practices
New Mexico - MST Medicaid managed care pays for
service costs of MST Juvenile Justice pays for
training/coaching/fidelity monitoring
Hawaii Range of EBPs Medicaid managed care,
Education special ed, mental health general
revenue/block grant pay for range of EBPs,
training, monitoring
Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
103
Examples of Cross-System Partnerships to
Finance and Implement Evidence-Based and
Promising Practices
New Jersey In-Home, Mobile Response, Intensive
Case Management, Family Support Medicaid Rehab
Option pays for in-home, Mobile Response and
Stabilization, intensive case management, family
support Child welfare contributed match dollars
Tennessee MST, Multi-Dimensional
Treatment Foster Care Medicaid managed care and
mental health GR pay for MST and MDTFC
Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
104
Characteristics of Effective Provider Networks

• Responsive to the population that is the focus
  of the system of care.
• Encompass both clinical treatment service
  providers and natural,
• social support resources, such as mentors and
  respite workers.
• Include both traditional and non traditional,
  indigenous providers.
• Include culturally and linguistically diverse
  providers.
• Include families and youth as providers of
  services and supports.
• Are flexible, structured in a way that allows
  for additions/deletions.
• Are accountable, structured to serve the system
  of care.
• Have a commitment to evidence-based and
  promising practices.
• Encompass choice for families.

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
105
Examples of Incentives to Providers

• Decent rates
• Flexibility and control
• Timely reimbursements
• Back up support for difficult administrative and
  clinical challenges
• Access to training and staff development
• Capacity building grants
• Less paperwork

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
106
Purchasing/Contracting Options

• Pre-Approved Provider Lists
• Flexibility for system of care
• Choice for families
• Could disadvantage small indigenous providers
• Could create overload on some providers
• Risk-Based Contracts (e.g., capitation, case
  rates)
• Flexibility for providers
• Individualized care for families
• Potential for under-service
• Potential for overpaying for services
• Fixed Price/Service Contracts
• Predictability and stability for providers
• Inflexible-families have to fit what is
  available

Pires, S. (2002). Building systems of care A
primer. Human Service Collaborative Washington,
D.C..
107
Progression of Risk by Contracting Arrangement

• TYPE OF CONTRACTING
• ARRANGEMENT
• Grant
• Fee-for-Service
• Case Rate
• Capitation

RISK TO SYSTEM OF CARE HIGHEST RISK LOWEST RIS
K
RISK TO PROVIDER LOWEST RISK HIGHEST RISK
Adapted from Broskowski, A. (1996). Progression
of providers risks. In Managed care Challenges
for children and family services. Baltimore, MD
Annie E. Casey Foundation.
108
Human Resource Development Functions

• Assessment of workforce requirements (i.e., What
  skills are needed, what types of staff, how many
  staff) in the context of systems change
• Recruitment, retention, staff distribution
• Education and training (pre-service and
  in-service)
• Standards and licensure

Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
109
Staffing Systems of Care
Re-deploy and Retrain Existing Staff
Contract Out
Hire New Staff
Partner withOthers
Pires, S. (2002). Building systems of care A
primer. Washington, D.C. Human Service
Collaborative.
110
A Developmental Training Curriculum
TRADITIONAL MODIFIED INTEGRATED UNIFIED
SYSTEM PROGRAM
State systems develop training along
specialty guild lines Promotion of stronger
specialty focus Community agencies
and universities operate in isolation Disciplines
train in isolation from one another Instruction
is didactic, expert No support for
cross-training
State systems independently adopt
similar philosophy, promoting Collaboration Comm
unity agencies and Universities begin
joint research and evaluation Pre-service trainin
g remains separate from the field
State systems begin sharing training
calendars Promotion of cross-training joint
funding Community agencies and universities
begin to integrate field staff/families
into pre-service training Student field
place- ments cross agency boundaries Cross-agency
training gains support
State systems pool training staff, merge training
events Community agencies and universities col
laborate with larger community, e.g. families as
co- instructors curricula reflect practice
goals Training geared to system goals
Meyers, J., Kaufman, M. Goldman, S. (1991).
Training strategies for serving children with
serious emotional disturbances and their families
in a system of care. Promising Practices in
childrens mental health. 5. Washington, D.C.
American Institutes for Research.
111
A Developmental Training Curriculum
TRADITIONAL MODIFIED INTEGRATED UNIFIED
PRACTICE
Participation in professional conferences
on individual basis within agency boundaries Serv
ices are provided within agency boundaries
Staff receive training that promotes collaboration
, but receive it within agency boundaries
Specialty focus predominant Services
remain within agency boundaries
Service teaming is promoted through cross- agency
training
Service teams with full family inclusion are
the norm Redefined specialty practice roles
develop to support professional identity while
promoting collaboration
Meyers, J., Kaufman, M. Goldman, S. (1991).
Training strategies for serving children with
serious emotional disturbances and their families
in a system of care. Promising practices in
childrens mental health. 5. Washington, D.C.
American Institutes for Research.
112
Summary Common Elements of Re-Structured Systems

• Values-based systems/Family and youth partnership
• Identified target population, costs associated
  with
• population, funders
• Locus of accountability (and risk) for target
  population
• Organized pathway to services for target
  population
• Strengths-based and individualized service
  planning
• and care monitoring (e.g., wraparound approach)
• Intensive care management
• continued

Pires, S. 2004. Human Service Collaborative.
Washington, D.C.
113
SummaryCommon Elements of Re-Structured Systems

• Flexible financing and contracting arrangements
• (e.g., case rates, qualified provider panel
  fee-for-service )
• Broad provider network sufficient types
• of services and supports (including natural
  helpers)
• Combined funding from multiple funders (e.g.,
  Medicaid,
• child welfare, mental health, juvenile justice,
  education)
• Real time data across systems to support clinical
  decision-
• making, utilization management, quality
  improvement
• Outcomes tracking child/family level, systems
  level
• continued

Pires, S. 2004. Human Service Collaborative.
Washington, D.C.
114
Summary Common Elements of Re-Structured Systems

• Utilization management
• Mobile crisis capacity
• Judiciary buy-in
• Re-engineered residential treatment centers
• Shared governance/liability
• Training and technical assistance

Pires, S. 2004. Human Service Collaborative.
Washington, D.C.
115
Transformation

• Need to connect related reforms in child-serving
  systems
• and Medicaid needs to be a partner in reform
• SAMHSA Transformation Grants, Infrastructure
  Grants,
• System of Care Grants
• Child Welfare System of Care Grants, Program
• Improvement Plans
• Juvenile Justice MH/SA Initiatives
• CMS Feasibility and Real Choice Grants

Pires, S. 2005. Human Service Collaborative.
Washington, D.C.
116
The world that we have made as a result of the
level of thinking we have done thus far creates
problems that we cannot solve at the same level
at which we created them. Albert Einstein
Pires, S. (2002).Building Systems of Care A
Primer. Washington, D.C. Human Service
Collaborative.
117
The measure of success is not whether you have a
tough problem to deal with, but whether its the
same problem you had last year.
John Foster Dulles
118
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Pri