1. Systems of Care Fundamentals
[Adapted from Sheila A. Pires, Building Systems of Care: A Primer (second edition, 2010)]

2. Systems of Care
A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations so services and supports are effective, build on the strengths of individuals, and address each person’s cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life.
Gary Blau, Child, Adolescent and Family Branch, CMHS, SAMHSA

3. Family-Driven, Youth-Guided Systems of Care Look Like This 
It was in 1986 that Beth Stroul and Bob Friedman wrote the system of care monograph in which they used this venn diagram to articulate what was meant by the phrase ‘system of care.’
The system of care concept says that all life domains and needs should be considered rather than addressing mental health treatment needs in isolation, and so it is organized around eight overlapping dimensions. Each dimension represents an area of need for children and families.
It’s been more than twenty years since this visual representation was developed and we have learned much. What remains consistent is the importance of youth and family being at the center.
What is significantly different is our evolutionary understanding of what youth and family involvement looks like - from that of passive observer to active participant to shared decision-maker.
A family-driven and youth-guided system of care is more than a pretty diagram or a theoretical construct. I want to share with you just a few examples of what I think of when I think of a system of care that has strong potential to make a difference. You may even recognize a few of these examples.

4. SOC Development, Expansion Focuses on…
Policy Level (e.g. vision, financing, regulations)
Management Level (e.g., data; quality improvement; human resource development; 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)
Individual Level – How can I participate? What am I willing to contribute?
Adapted from Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

5. Recovery, Resilience and Transformation
What is involved?
Rethinking traditional approaches
Strengths-based
Family driven & youth guided
Embracing culture
Who is involved?
Youth
Adults
Families
Providers
Communities
One way to further help you visualize how the work you are doing fits with the overall effort to transform mental health in America is through this diagram.
I think of Systems of Care as surrounded by three key components – Recovery, Resilience and Transformation.
– The work being done in the area of Recovery - creating an environment where consumers of services can find hope, can think of recovery not as a cure, but as an opportunity to live a productive life is so important to infusing a sense of life and future into Systems of Care.
– The work being done in the area of Resiliency, learning from youth and adults their management and coping strategies, and then incorporating those into better service delivery designs, brings a sense of vibrancy to Systems of Care.
– And finally, the work being done to transform mental health in America, rethinking categorical funding streams, bridging age groups, such as you are doing here today, and doubling efforts to operate in a family-driven, youth-guided quality improvement way, offers a clarity of vision for making communities stronger.
CLICK
Transformation
Systems of Care
Recovery
Resilience
Fulfilling Potential

6. Values and Principles for a System of Care
Family-driven and youth-guided
Home and community based
Strength-based and individualized
Culturally and linguistically competent
Integrated across systems
Connected to natural helping networks
Data-driven, outcomes oriented
Adapted from 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. Family-Driven Means…
Families have a primary decision making role in the care of their own children, as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation.
The first area for “Stars” to focus on is how your efforts are being driven by the opinions and guidance from families. Over the past 20 years we have moved from knowing that we needed to involve families to recognizing today that if the transformation is to be successful, families must drive what is developed and delivered.
In one of our system of care communities in Missouri, the target population being served are youth involved in the child welfare system. Many of the birth parents have relinquished custody or have had their parental rights terminated. One might think that in this case, “family driven” would be defined as foster parents or guardians.
Not so - there is just as strong an effort to identify strategies for involving birth parents in decision-making processes as there is for the foster parents and guardians.
Easy to do? Not a chance, as you might expect. But we don’t fund system of care communities to do things that are easy. We are talking about transformational change - change that will require rethinking on all of our parts about traditional roles, attitudes, and assumptions.

8. Family-Driven Means That Families Take the Lead
Choosing supports, services, and providers; Setting goals; Designing and implementing programs;
Monitoring outcomes; Managing the funding for services, treatments and supports; and Determining the effectiveness of all efforts to promote the mental health and well being of children and youth.
Within this definition is the understanding that family driven means that families take the lead in
Choosing supports, services, and providers;
Setting goals;
Designing and implementing programs;
Monitoring outcomes; and
Determining the effectiveness of all efforts to promote the mental health and well being of children and youth.
A current example comes from a funded community in the West that has changed the way it goes about making decisions about which services will be funded in a local community each year. Instead of Department of Mental Health leadership making the decision, family led community councils are making the decisions about what to fund. The process was scary at first but the buy in they are seeing from families and community has been extraordinary. Families are taking the lead in driving decisions about the type of services to be funded.
As you think about the efforts you are involved with in your local communities, ask yourselves the question, “In what ways are families driving the development of a system of care in my community?” in what ways are families involved in discussions about the type of services residential care centers should provide?

9. Youth-Guided Means… Youth have rights.
Youth are utilized as resources.
Youth have an equal voice and are engaged in developing and sustaining the policies and systems that serve and support them.
Youth are active partners in creating their individual support plans.
Youth have access to information that is pertinent.
Youth are valued as experts in creating systems transformation.
Youth’s strengths and interests are focused on and utilized.
Adults and youth respect and value youth culture and all forms of diversity.
Youth are supported in a way that meets their individual needs.
The second area of focus is Youth Guided.
Our efforts do not end with family-driven discussions. There is a tremendous amount of positive energy right now around better defining what youth guided care means and should look like. In the past six months I have established a national youth advisory board to help with the discussion. The definition of “Youth Guided” on the screen comes from the work they are doing. It’s not done yet, but as you can see, they are putting serious work into the development of a statement that can help guide system of care planning efforts across the country.
Many of the youth I meet with in national policy discussions have spent time in the residential care centers you represent. They, as you would expect, have strong opinions about what they received. Not all negative I should add, and that is important for you to hear. But I think you can begin to see that when we talk about transforming mental health by not only opening the discussion of what is needed to families and youth, but having them drive the discussion; we are seeing a different type of discussion with new and innovative ideas coming forth.
Systems of care is about rethinking how we do business. The youth guided focus that is emerging will impact policy. You need to be a part of the discussion.

10. Youth Involvement in Systems of Care
A starting point for understanding youth involvement and engagement in order to develop and fully integrate a youth-directed movement within local systems of care. (see
A wonderful resource for you to identify specific strategies for fully developing your Youth Guided component of your transformation strategy is to review the recently produced monograph - Youth Involvement in Systems of Care, put out by the Technical Assistance Partnership.
You can download it for free at

11. Examples of Shifts in Roles and Expectations for Family Members and Youth
-Recipient of information
re: child’s service plan
Passive partner in service planning process
Service planning team leader
-Unheard voice in program evaluation
Participant in program evaluation
Partner (or independent) in developing and conducting program evaluations
-Recipient of services
Partner in planning and developing services
Service providers
-Uninvited key stakeholders
in training initiatives
-Anger, adversity &
resistance
Participants in training initiatives
Self-advocacy
Partners and independent trainers
Advocacy & peer support
Lazear, K. & Conlon, L. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

12. Cultural and Linguistic Competence: Definitions
Culture
A broad concept that reflects an integrated pattern of a wide range of beliefs, values, practices, customs, rituals, and attitudes that make up an
individual, family, organization, or community.
Cultural Competence
Accepting and respecting diversity and difference in a continuous process of self assessment and reflection on one’s personal and organizational perceptions of the dynamics of culture.
Linguistic Competence
The capacity of an organization and its personnel to communicate effectively and convey information in a way that is easily understood by diverse audiences, including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. 
Adapted from Youth Involvement in Systems of Care: A Guide to Empowerment (2006) and Goode & Jones (modified 2004). National Center for Cultural Competence, Georgetown University Center for Child & Human Development.

13. Why Develop Cultural and Linguistic Competence?
To respond to current and projected demographic changes in the United States
To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds
To improve access to services and outcomes
To improve the quality of services and health outcomes
To meet legislative, regulatory, and accreditation mandates
The third area of primary focus for Transformation Stars is cultural and linguistic competence – specifically in the areas of reducing disparities and enhancing cultural and linguistic competence among policy-makers, administrators and service providers.
Specific ways to do this include:
Enhancing organizational capacity for cultural and linguistic competence.
Increasing awareness and knowledge of factors that contribute to disparities.
Developing specific approaches that contribute to the goal of eliminating disparities.
Folks, as you well know, the system of care family is a wonderfully rich mosaic of cultures and ethnicities. We transform nothing if we do not recognize this and learn how to ensure that we do all we can to embrace all parts of the mosaic. We emphasize this at the Branch and with those communities we are involved with.
As you all know, residential treatment, historically, has been viewed as a “placement of last resort”, and for many something that was utilized “at the end”, and therefore a bit unknown. Cultural competence is about many things, but definitely about making the unknown known, learning about the cultures of the youth being served, the culture of the providers providing the service, and the culture of the community that is impacted by both.
As you think about the work you are doing in your own community ask yourselves if your organization is reflective of those you serve.
We know that much more needs to be done in the area of reducing disparities and enhancing cultural and linguistic competence among policy-makers, administrators and service providers.
We must develop specific approaches that contribute to the goal of eliminating disparities across issues of race, ethnicity, geography, and socio-ecomic status.
And, as communities across the country continue to tell us, we must continue our efforts to address disparities in services to lesbian, gay, bisexual and transgender youth.
What are the areas that you are most proud of in your work that bring out a strong exhibition of cultural and linguistic competence?

14. Wraparound Process
Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports, individualized for that child and family to achieve a positive set of outcomes. Wraparound does not equal a “complete” system of care. It is only one component.
Individualized care plan refers to the procedures and activities that are appropriately scheduled and used to deliver services, treatments, and supports to the child and family.

15. Operational Characteristics
System of Care
Operational Characteristics
Collaboration across agencies
Partnership with families and youth
Cultural and linguistic competence
Blended, braided, or coordinated financing
Shared governance across systems and with families and youth
Shared outcomes across systems
Organized pathway to services & supports
Child and family teams
Staff, providers, families, youth trained and mentored in a common practice model
Single plan of care
One accountable care manager
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

16. Current Systems Problems
Lack of home and community-based services and supports
Patterns of utilization; racial/ethnic disproportionality and disparities
Cost
Administrative inefficiencies
Knowledge, skills and attitudes of key stakeholders
Poor outcomes
Rigid financing structures
Deficit-based/medical models, limited types of interventions
Pires, S. (1996). Human Service Collaborative, Washington, D.C.

17. 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/youth 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/youth within families
Community-based ownership
Creation of “self-help”
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

18. Youth in SOC Achieve Positive Education Outcomes
Only 8% of youth in SOC for 12 months had repeated a grade, compared to nearly twice as many American students in the general public (15%)
The percentage of youth receiving passing grades (C or better) increased from 55% upon entry into services to 66% after 12 months of services (20% increase in the proportion of youth who received passing grades)
Within one year of entering SOC services, the percentage of youth attending school regularly increased from 75% to 81% (this improvement means that school attendance for youth with mental health needs in SOC approached the national school attendance average of 83%)

19. Youth in SOC Achieve Positive Education Outcomes
There was a 22% reduction in the percentage of youth who changed schools due to emotional and behavioral reasons after receiving SOC services for 12 months.
Expulsions from school decreased by 2/3 (from 15% at intake to 5%) within 12 months of entering SOC services
12 months after beginning SOC services, 16% of youth reported significant lower levels of depression and 21% reported significant lower levels of anxiety than when they entered services
Youth suicide attempts decreased significantly within the first 6 months of services, from 13% to 6%. Within 12 months, only 5% of youth had reported suicide attempts (62% reduction after starting services)
US Department of Health and Human Services (

20. Frontline Practice Level
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, Schools, Community Colleges/Universities, Physical Health, Juvenile Justice, Child Welfare)
What dollars/resources do they control?
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? (e.g., culturally diverse providers)
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 be put in place to provide opportunities for youth to contribute and feel a part of the larger community?
Pires, S Building systems of care..Human Service Collaborative. Washington, D.C.

21. Fundamental Challenge and Rationale for Building Systems of Care
No one system controls everything.
Every system controls something.
Pires, S Human Service Collaborative. Washington, D.C.

22. to obtain goals and objectives.”
Strategic Planning
“The science and art of mobilizing all forces – political, economic, financial, psychological –
to obtain goals and objectives.”
Pires, S., Lazear, K., Conlan, L.(2003). “Primer Hands On”: A skill building curriculum. Adapted from Webster’s Dictionary. Washington, D.C. Human Service Collaborative

23. Building Local Systems of Care: Strategically 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.

24. Core Elements of an Effective System-Building Process
The Importance of Being Strategic
A strategic mindset
A shared vision based on common values and principles
A clear population focus
Shared outcomes
Community mapping—understanding 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 mechanisms—being opportunistic
Opportunity for reflection
Adequate time
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative

25. Core Elements of an Effective System-Building Process
The Importance of Leadership & Constituency Building
A core leadership group
Evolving leadership
Effective collaboration
Partnership with families and youth
Cultural and linguistic 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.