Primer Hands On-Child Welfare
THE SKILL BUILDING CURRICULUM
Developed by:
Sheila A. Pires
Human Service Collaborative
Washington, D.C.
In partnership with:
Katherine J. Lazear
Research and Training Center for Children’s Mental Health
University of South Florida, Tampa, FL
Lisa Conlan
Federation of Families for Children’s Mental Health
Washington, D.C.
Primer Hands On - Child Welfare (2007)
1
Primer Hands On-Child Welfare
PURPOSE
• Build a network of individuals grounded in a
common strategic framework for building systems
of care
• Support one another’s efforts
• Advance the larger field
Pires, S., Lazear, K., Conlan, L. (2003). “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
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Ways to Use
Primer Hands On-Child Welfare
• As a self-contained, intensive two-day
training covering all Modules: provides an
overall strategic framework;
• As separate training sessions on individual
Modules: allows in-depth focus on a given
area;
• As material that can be drawn on by
technical assistance providers/consultants:
supports targeted technical assistance.
Pires, S., Lazear, K., Conlan, L. (2003). “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
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Primer Hands On-Child Welfare
COMPONENTS
• Capacity-building sessions, or topical training
sessions on individual modules, or materials for
targeted technical assistance, based on Building
Systems of Care: A Primer
• Skill building curriculum, including curriculum,
case scenarios, exercises, handouts, Power Point
slides, and Primer
• Network for peer support and technical assistance,
linked by list-serve
Pires, S., Lazear, K., Conlan, L. (2003). “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
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Primer Hands On-Child Welfare
TARGET AUDIENCE
System Builders: All stakeholders providing
leadership in building systems of care for children,
youth and families involved, or at risk for
involvement, in the child welfare system.
E.g., families, youth, County managers and
State administrators, providers, CASA
volunteers, law enforcement personnel,
judges, frontline workers, supervisors,
researchers, natural helpers, guardian ad
litems, etc.
Pires, S., Lazear, K., Conlan, L. (2006). Primer Hands On-Child Welfare: A skill building curriculum. Washington, D.C.: Human Service
Collaborative.
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Primer Hands On-Child Welfare
OBJECTIVES
• To strengthen the knowledge base and skills of
system of care leaders to operate strategically in
system building
• To give system of care leaders teaching tools to use
in their respective communities
Pires, S., Lazear, K., Conlan, L.( 2003). “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
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Primer Hands On-Child Welfare
METHODS
• Didactic
• Case method
• Peer-to-peer exchange and team work
• On-going coaching and peer support
•Technical assistance on specific modules
Pires, S., Lazear, K., Conlan, L.(2007). “Primer Hands On”- Child Welfare. Washington, D.C.: Human Service Collaborative.
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Strategic Planning
“The science and art of mobilizing all forces –
political, economic, financial, psychological,
social – 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
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Elements of Strategic Planning
• Strategic planning is a continual process for
improving organizational performance by
developing strategies to produce results.
• Planning is strategic when it focuses on what the
agency wants to accomplish (outcomes) and on how
to move the agency towards these larger goals.
• Strategic planning involves engaging all
stakeholders.
• Strategic planning communicates the agency’s
mission and goals to the public.
Source: National Child Welfare Resource Center for Organizational Improvement, Child and Family Services Review Technical Assistance.
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Definition of a System of Care
A system of care incorporates a broad, flexible array
of services and supports for a defined population(s)
that is organized into a coordinated network,
integrates service planning and service coordination
and management across multiple levels, is culturally
and linguistically competent, builds meaningful
partnerships with families and youth at service
delivery, management, and policy levels, and has
supportive management and policy infrastructure.
Pires, S. (2006). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
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ACF System of Care Sites
• Contra Costa County, CA
• State of Kansas
• Bedford-Stuyvesant, Brooklyn, NY
• Jefferson County, CO
• Clark County, NV
• State of North Carolina
• State of Oregon
• State of Pennsylvania
• Tribal Sites in North Dakota
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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Retrospective:
National System of Care Activity
• CASSP - Child and Adolescent Service System Program
• RWJ MHSPY – Robert Wood Johnson Mental Health Services Program
for Youth
• CASEY MHI – Annie E. Casey Foundation Urban Mental Health
Initiative
• STATEWIDE FAMILY NETWORK GRANTS
• CMHS GRANTS – Center for Mental Health Services
• CSAT GRANTS – Center for Substance Abuse Treatment
• ACF GRANTS – Administration for Children and Families
• CMS GRANTS – Center on Medicare and Medicaid Services
• Child and Family Services Reviews (CFSRs)
• CLARK FOUNDATION – Community Partnerships for Protecting
Children
• NEW FREEDOM MENTAL HEALTH COMMISSION
• YOUTH MOVES - Center for Mental Health Services
Pires, S. (2006). Primer Hands On-Child Welfare. Washington, D.C.: Human Service Collaborative.
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Recent Child Welfare Sponsored
System of Care Activities
• 9 ACF System of Care Grants
• SOC Technical Assistance through Caliber Associates
• ACF Region III Policy Academy
• Primer Hands On-Child Welfare Training of Trainers
Pires, S. (2006). Primer Hands On-Child Welfare. Washington, D.C.: Human Service Collaborative.
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Organizing Framework
System of care is, first and foremost, a set of
values and principles that provides an
organizing framework for systems reform on
behalf of children, youth and families.
Stroul, B.( 2002). Issue brief-Systems of care: A framework for system reform in children’s mental health. Washington, D.C.: Georgetown
University Child Development Center
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Values and Principles
for the System of Care
CORE VALUES
Child, Youth and Family - Centered
Community Based
Culturally and Linguistically Competent
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.
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Values and Principles
for the System of Care
• Comprehensive array of services and supports
• Individualized services and supports guided by an
individualized services and supports plan
• Least restrictive environment that is most appropriate
• Families, surrogate families and youth full
participants in all aspects of the planning and delivery
of services and supports
• Integrated services and supports
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.
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Values and Principles
for the System of Care
• Services and supports coordination and management
accountability across multiple systems
• Early identification and intervention
• Smooth transitions
• Rights protected, and effective advocacy efforts
promoted
• Receive services without regard to race, religion, national
origin, gender, sexual orientation, physical disability, or
other characteristics and services and supports should be
sensitive and responsive to cultural and linguistic
differences and special needs
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.
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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.
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Youth Development Principles
•
•
•
•
•
•
•
•
•
•
•
•
Child and Youth 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.
• Embrace total youth
involvement
• Create a healthy and safe
environment
• Promote healthy relationships
• Create community
partnerships
• Realize interdependence
takes time
• Value individual strengths
• Build feedback and selfassessment
• Learn by doing
Child Welfare League of America, DeWitt Wallace
Grant, 1995
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CFSR Child Welfare Principles
Family-centered practice
Community-based services
Strengthening the capacity of families
Individualizing services
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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PRIMER HANDS ON- CHILD WELFARE
HANDOUT 2.1
Alabama’s R.C. Goals and Principles
Bazelon Center for Mental Health Law
Making Child Welfare Work: How the R.C. Lawsuit Forged New
Partnerships to Protect Children and Sustain Families Washington D.C.
1998
Primer Hands On - Child Welfare (2007)
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System of Care Operational Characteristics
• Collaboration across agencies
• Partnership with families/youth
• Cultural & linguistic competence
• Blended, braided, or coordinated financing
• Shared governance across systems & with
families and youth
• Shared outcomes across systems
• Organized pathway to services & supports
• Child and family teams
• Single plan of services and supports
• Staff, providers, and families trained and
mentored in a common practice model
• One accountable service manager
• Cross-agency service
coordination
• Individualized services &
supports "wrapped around" child
& family
• Home- & community-based
alternatives
• Broad, flexible array of services
& supports for children &
families
• Integration of formal services &
natural supports, and linkage to
community resources
• Integration of evidence-based
and promising practices
• Data-driven focus on Continuous
Quality Improvement (CQI)
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
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CFSR Systemic Factors
1. Statewide Information System
2. Case Review System
3. Quality Assurance System
4. Staff and Provider Training
5. Service Array
6. Agency Responsiveness to the Community
7. Foster and Adoptive Licensing, Recruitment and
Retention
Primer Hands On - Child Welfare (2007)
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Resonance Between CFSR and SOC Outcomes
Child & Family Services Review
System of Care
Children are protected from abuse and
neglect.
Build safety plans into service/support
plans.
Children are safely maintained in their
homes whenever possible and appropriate.
Prevent out-of-home placements, keep
families intact.
Children have permanency and stability in
their living arrangements.
Minimize disruption in children’s lives and
promote continuity and smooth transitions.
The continuity of family relationships and
connections is preserved for children.
Core value - family focus
Families have enhances capacity to care for Strengthen the resiliency of both families
their families’ needs.
and youth and enhance natural helping
networks.
Children receive appropriate services to
meet their educational needs
Focus on all life domains, including
education.
Children receive adequate services to meet
their physical and mental health needs
Holistic approach, broad array of services
and supports.
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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Major Issues Identified Through Child and
Family Services Reviews
Safety
Inconsistent services to protect children at home
Inconsistent monitoring of families
Insufficient risk or safety assessment
Permanency
Inconsistent concurrent planning efforts
Adoption studies, court proceedings take too long
Well-Being
Inconsistent match of services to needs
Lack of support services to foster and relative caregivers
Parents not involved in case planning
Lack of health and mental health assessments
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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Examples of State Successes in Program
Improvement Plan Implementation
•Changing the culture of agencies
•Aligning child welfare, juvenile justice and mental
health through communications and common practice
•Improving collaboration with community partners
•Using best practices
•Reorganizing child welfare as a “learning organization”
through a Continuous Quality Improvement structure
•Using data to inform decision-making and improve
quality.
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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Current Systems Problems
• Lack of home and community-based services and
supports
• Patterns of how children, youth and families use
services and supports
• Cost
• Administrative inefficiencies
• Knowledge, skills and attitudes of key stakeholders
• Poor outcomes
• Financing structures
• Deficit-based, pathology-based, limited types of
interventions
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Pires, S. (1996). Human Service Collaborative, Washington, D.C.
Fundamental Challenge to Building a
System of Care
No one system controls everything.
Every system controls something.
Pires, S. (2004). Human Service Collaborative. Washington, D.C.
28
Characteristics of Systems of Care as
Systems Reform Initiatives
FROM
TO
Fragmented service delivery
Coordinated service delivery
Categorical programs/funding
Blended resources
Limited services
Comprehensive services/supports array
Reactive, crisis-oriented
Focus on prevention/early intervention
Focus on out-of-home placements
Individualized services & supports in least
restrictive, normalized environments
Children out-of-home
Children within families
Centralized authority
Community-based ownership
Creation of “dependency”
Creation of “self-help”
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
29
Frontline Practice Shifts
Given power imbalance
“I’m in charge” attitude
Controlling
Law enforcement approach
Multiple case managers
Multiple service plans for child
Family blaming
Deficit-Based
Mono Cultural
Acknowledgment of power
imbalance with family and that
their fears and concerns are real
Positive engagement
Collaborative
Helping/Social worker
approach
One service manager
Single plan for child and family
Family partnerships
Strengths Focused
Sensitivity to culture/linguistics
and family ritual
Conlon, L. Federation of Families for Children’s Mental Health and Orrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to
Strengthen Our Community. Tampa, FL: University of South Florida
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How Families Become Involved with
Child Welfare
• Based on safety concerns, families are investigated for their
parenting and abuse and neglect is founded.
• Families are in need of services and supports to increase their
parenting skills and preserve their family.
• The needs of parents can be serious when they are dealing with
their own childhood traumatic experiences, violence, mental
health, cognitive, and substance abuse concerns.
• The child or youth within a family may display harmful or
delinquent behaviors and become court ordered to placement.
• Families are unable to access the necessary services needed to
meet their child or youth’s serious emotional disturbance.
The majority of families involved with the system of care through
child welfare become involved involuntarily.
Conlan, L., Federation of Families for Children’s Mental Health
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Family Centered Practice in Child Welfare
• The family unit is the focus of attention.
• Strengthening the capacity of families to function
effectively is emphasized.
• Families are linked with more comprehensive,
diverse, and community-based networks of supports
and services.
• Families are engaged in designing all aspects of the
policies, services, and program evaluation.
National Resource Center for Family Centered Practice and Permanency Planning, Hunter College School of Social Work.
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Examples of Family and Youth
Shifts in Roles and Expectations
-Recipient of information &
requirements (esp. if
abuse/neglect)
Passive partner in services Service and supports
and supports planning
planning team leader
process
-Unheard voice in program
evaluation
Participant in program
evaluation
Partner (or
independent) in
developing and
conducting program
evaluations
-Recipient of services/supports
Partner in planning and
developing services and
supports
Services and supports
providers
-Uninvited key stakeholders
in training initiatives
-Anger, adversity & resistance
Participants in training
initiatives
Partners and
independent trainers
Self-advocacy & peer
support
Systems advocacy &
peer support
Lazear, K. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
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Partnering with Families in Child
Welfare: Fundamental Shifts in
Decision-Making Practice
Child Welfare
Families
Child Welfare
Extended family networks
Community resources
Other child-serving systems
Team decision making
Family group conferencing
Wraparound
Partnerships with
neighborhood resources:
- Family-to-family
- Community partnerships
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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System Change Focuses On
Policy Level
(e.g., financing; regs; rates)
Management Level
(e.g., data; Quality Improvement; Human Resource Development;
system organization)
Frontline Practice Level
(e.g., assessment; services and supports planning; service coordination;
services and supports provision)
Community Level
(e.g., partnership with families, youth, natural helpers; community buy-in)
Pires, S. (2006). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
35
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.
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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 at home at risk of out of home placement?
Children in permanent placements 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
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Pires, S (2004.) Human Service Collaborative. Washington, D.C.
Prevalence and Utilization
More
complex
needs
2 - 5%
15%
Less
complex
needs
Out of
Home
Placements
Intensive
Services –
60% of $$
Early
Intervention
and Family
Preservation
services and
supports –
35% of $$
80%
Pires, S.( 2006). Human Service Collaborative. Washington, D.C.
Primary
Prevention
and Universal
Well-Being
Promotion –
5% of $$
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Example: Transition-Age Youth
What outcomes do we want to see for this population?
(e.g. connection to caring adults, employment, education, independence)
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., inhouse, lead community agency)
Frontline Practice Level
-Are there evidence-based/promising approaches targeted to this population? (e.g., Family
Finding) -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 we put in
place to provide opportunities for youth to contribute and feel a part of the larger community? -What does out system look like for this population?
Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.
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Local Ownership
State Commitment
Tribal Ownership/Partnership
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
40
Evidence-Based Practices
And Promising Approaches
Evidence-Based Practices
Show evidence of effectiveness through carefully controlled
scientific studies, including random clinical trials
Practice-Based Evidence/Promising Approaches
Show evidence of effectiveness through experience of key
stakeholders (e.g., families, youth, providers, administrators)
and outcomes data
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
41
Examples
Examples of Evidence-Based Practices
• Multisystemic Therapy (MST)
• Multidimensional Treatment Foster Care (MDTFC)
• Functional Family Therapy (FFT)
• Cognitive Behavioral Therapy (various models)
• Intensive Case Management (various models)
Examples of Promising Practices
• Family Support and Education
• Wraparound Service Approaches
• Mobile Response and Stabilization Services
• Family Group Decision Making
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)
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Kauffman Foundation Best Practices Project/
National Child Traumatic Stress Network
Evidenced-Based Practices for Children in Child Welfare
• Trauma Focused-Cognitive Behavioral Therapy (TF-CBT)
• Abuse Focused-Cognitive Behavioral Therapy (AF-CBT)
• Parent Child Interaction Therapy (PCIT)
Contact: www.kauffmanfoundation.org
• California Evidence-Based Clearinghouse for Child Welfare
Contact: www.cachildwelfareclearinghouse.org
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
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Effectiveness Research
(Burns & Hoagwood, 2002)
• Most evidence of efficacy: Intensive case
management, in-home services, therapeutic foster
care
• Less 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
Burns & Hoagwood. (2002). Community Treatment for Youth. New York: Oxford University Press
44
Shared Characteristics of Evidence-Based
(and Promising) Interventions
• Function as service components within systems of care
• Provided in the community
• Utilize natural supports, partner with parents, with training
and supervision provided by those with formal training
• Operate under the auspices of all child-serving systems, not
just child welfare
• Studied in the field with “real world” children and families
• Less expensive than institutional care (e.g., residential
treatment, hospitals) (when the full continuum is in place)
Burns, B. and Hoagwood, K.( 2002). Community treatment for youth. New York: Oxford University Press.
45
3 Lessons in Values
• People come with established values
• These values are constantly tested by situations
that arise
• These values and the news ones formed are
constantly shaped by the situations that play out
Lazear, K. (2004). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
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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.
47
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.
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Example
Goal: One service & support plan; one service manager
Mental Health
Child Welfare
•Individualized Wraparound Approach
•Care manager
•Family Group Decision Making
•CW Case Worker
Kinship
Care
Subsidized
Adoption
Permanent
Tutoring
Foster
Parent Support,
Care
etc.
Juvenile Justice
Children in &
at risk for
out-of-home
placements
•Screening & Assessment
•Probation officer
Community Services
MCO
•Prior Authorization
•Clinical Coordinator
Out-patient
services
Crisis
Services
Primary
Care
Treatment
Foster Care
In-Home
Services
Education
•Child Study Team
•Teacher
Alternative
School
EH Classroom
Related Services
Med. Mngt.
Result: Multiple service & support plans; multiple service manager
Pires, S. (2004). Primer Hands On. Human Service Collaborative: Washington, DC
49
Wraparound Milwaukee
CHILD WELFARE
Funds thru Case Rate
(Budget for Institutional
Care for CHIPS Children)
JUVENILE JUSTICE
(Funds budgeted for
Residential Treatment for
Delinquent Youth)
9.5M
MEDICAID CAPITATION
(1557 per month
per enrollee)
8.5M
10M
MENTAL HEALTH
•Crisis Billing
•Block Grant
•HMO Commercial Insurance
2.0M
Wraparound Milwaukee
Management Service Organization (MSO)
$30M
Per Participant Case Rate
Service
Coordination
Child and Family Team
Families United
$300,000
Provider Network
240 Providers
85 Services
Plan of Services & Supports
Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent
Services Branch.
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Truisms About Structure
• Certain functions must be structured and not
left to happenstance
• Structures need to be evaluated and
modified if necessary over time
• New structures replace existing ones; some
existing ones are worth keeping; some are
more difficult to replace than others
• There are no perfect or “correct” structures
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
51
System of Care Functions Requiring Structure
• Planning
• Decision Making/Policy Level
Oversight
• System Management
• Service & Supports Array
• Evidence-Based & Promising Practices
• Outreach and Engagement
• System Entry/Access
• Screening, Assessment, & Evaluation
• Decision Making & Oversight at the
Service Delivery Level
– Services & Supports Planning
– Services & Supports Authorization
– Service Monitoring & Review
• Service Coordination
• Crisis Management at the Service
Delivery & Systems Levels
• Utilization Management
• Family Involvement, Support, &
Development at all Levels
• Youth Involvement, Support, &
Development
• Human Resource Development/Staffing
• Staff Involvement, Support,
Development
• Orientation, Training of Key
Stakeholders
• External & Internal Communication
• Provider Network
• Protecting Privacy
• Ensuring Rights
• Transportation
• Financing
• Purchasing/Contracting
• Provider Payment Rates
• Revenue Generation & Reinvestment
• Billing & Claims Processing
• Information Management
• Quality Improvement
• Evaluation
• System Exit
• Technical Assistance & Consultation
• Cultural & Linguisrtic Competence
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.
52
Core Elements of an
Effective System-Building Process
The Importance of Leadership & Constituency Building
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•
•
•
•
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.
53
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 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
54
The 5Cs of
Core Leadership
Constituency (representativeness)
Credibility
Capacity
Commitment
Consistency
Pires, S. (2005). The 5Cs of core leadership. Washington, DC: Human Service Collaborative.
55
Examples of Leadership Styles
Charismatic
Facilitative
Managerial
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
56
Partnership Involves
• Team Building
• Communication
• Negotiations
• Conflict Resolution
• Leadership Development
• Mutual Respect
• Skill Building
• Information Sharing
Pires, S. (1996). Partnership involves. Washington, DC: Human Service Collaborative.
57
Principles to Guide Collaboration
• Build, maintain trust so collaborative partners are able to share
information perceptions, feedback and work as a cohesive team.
• Agree on core values that each partner can honor in spirit & practice.
• Focus on common goals that all will strive to achieve.
• Develop a common language so all partners can have a common
understanding of terms (i.e., “family involvement,” “culturally
competent services.”
• Respect the knowledge and experience each person brings.
• Assume the best intentions of all partners.
• Recognize strengths, limitations, and needs; and identify ways to
maximize participation of each partner.
• Honor all voices by respectfully listening to each partner and attending
to the issues they raise.
• Share decision making, risk taking and accountability so that risks are
taken as a team and the entire team is accountable for achieving the
goals.
58
Stark, D. (1999). Collaboration basics: Strategies from six communities engaged in collaborative efforts among families, child welfare, and children’s
mental health. Washington, DC: Georgetown Child Development Center, National Technical Assistance Center for Children’s Mental Health
Challenges to Collaboration “Barrier Busters”
CHALLENGE
Language differences:
Mental health jargon vs.
court jargon
Role definition: “Who’s
in charge?”
Mandated service vs.
requested services
Information sharing
among systems
Addressing issues of
child and community
safety
Maintaining investment
from stakeholders
Sharing value base
BARRIER BUSTERS
• Cross training
• Share each other’s turf
• Share literature
• Family driven/accountability
• Team development training
• Job shadowing
• Communication channels
• Share myths and realities
• Set up a common data base
• Share organizational charts/phone lists
• Share paperwork
• Promote flexibility in schedules to support attendance in meetings
• Document safety plans
• Develop protocol for high-risk kids
• Demonstrate adherence to court orders
• Maintain communication with District Attorneys
• Myths of “bricks and mortar”
• Invest in relationships with partners in collaboration
• Share literature and workshops
• Track and provide meaningful outcomes
• Infuse values into all meetings, training, and workshops
• Share documentation and include parents in as many meetings as
possible
• Strength-based cross training
• Develop QA measures based on values
Adapted from Wraparound Milwaukee. (1998). Challenges to collaboration/“barrier busters.” Milwaukee, WI: Milwaukee County Mental Health
Division, Child and Adolescent Services Branch.
59
Catalyst/Trigger Mechanisms
• Legislative mandates (new or existing)
• Study findings (needs assessments, research, or
evaluation)
• Judicial decisions - Class action suits
• Charismatic/powerful leader
• Outside funding sources (federal, foundations)
• Funding changes
• Local “scandals” and other tragedies
• Coverage of successes
• CFSR findings/Program Improvement Plans
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative
.
60
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.
61
Example: Cuyahoga County (Cleveland)
Cuyahoga Tapestry System of Care
Administrative Services Organization
+
Training and Coaching for Wraparound Fidelity
PEP Connections
___
700 kids
and families
PEP Tapestry
___
240 kids
and families
System of Care
Initiatives
--800 kids
and families
SCY
--60 kids
and families
300 kids =
Child Welfare
300 kids =
Juvenile Justice
200 kids =
Help Me Grow
(Birth to 3 years)
Family to Family
Community
Wraparound
--500 kids
and families
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
62
Cuyahoga County (Cleveland)
System of Care Oversight Committee
County
Administrative
Services
Organization
}
Neighborhood Collaboratives &
Lead Provider Agency
Partnerships
State
FCFC $$
Early Intervention and
Fast/ABC $$
Family Preservation
Residential Treatment Center $$$$
Therapeutic Foster Care $$$
“Unruly”/shelter care $
Tapestry $$ System of Care Grants
SCY $$
}
Reinvestment of savings
Community Providers and Natural Helping Networks
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
63
Cross-Cutting Characteristics
• Cultural and linguistic competence, that is, processes and
structures that support capacity to function effectively in crosscultural situations;
• Meaningful partnership with families and youth, including
family and youth organizations, 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, local and tribal partnership and shared commitment.
Pires, S. (2002).Building systems of care: A primer. Washington D.C.: Human Service Collaborative.
64
Defining Family and Youth
• Parents and guardians
• Grandparents
• Kin-relatives
• Youth who have been involved with child welfare
• Foster parents
• Adoptive parents
Conlan, L., Federation of Families for Children’s Mental Health.
65
How Systems of Care Are Structuring Family
Involvement at Various Levels of the System
Level
Structure
Policy
As voting members on governing bodies; as members
of teams to write/review Request For Proposals (RFPs)
and contracts; as members of system design workgroups
and advisory boards; raising public awareness
{
{
{
Management
Services
As administrators; part of quality improvement
processes; as evaluators of system performance;
as trainers in training activities; as advisors in
selecting personnel
As members of team for own children; service providers,
such as family support workers, respite providers, service/
support managers, peer mentors, system navigators
66
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
American Humane Association
Ethical Standards
“Families should have a meaningful role at both the
case level – in assessing, planning and evaluating
their own needs and services – and the systems
level – in setting eligibility criteria, determining
service offerings, selecting managed care
intermediaries and providers, etc. This will require
training and support for families.”
American Humane Association. 1997. Ethical standards for the implementation of managed care in child welfare.
67
Issue of Court-Involved Families
“It is important to address the issue of court involvement, which
makes services involuntary for many families and thus affects
their desire – and legal ability – to choose services. There is more
danger of under-service (in child welfare) than in other
systems…because child welfare clients are unlikely to advocate on
their own behalf for services. Families may be fully capable,
physically and mentally, to make good choices about what
services and what particular providers could be of most assistance
to them, but because of court involvement, these families may not
be permitted to exercise any choices. The challenge for familydriven…service models is to bring judicial stakeholders into the
discussion of how much choice a particular family should have,
given the circumstances of the court’s involvement.
Kimmich & Feild. 1999. Partnering with families to reform services: Managed care in the child welfare system. American Humane Association
68
Example: Court-Involved Families
in System of Care – Wraparound Milwaukee
• Participating families are court-involved
• Participating families are partners on Child and
• Family Teams
• Judges overwhelmingly concur with Child and
Family Team decisions
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
69
Issue of Families’ Lacking
Capacity to Partner
“Critics argue that family-driven systems have greater potential than
traditional approaches for exploitation or ill-informed decisionmaking by families. While it is true that some families may be
limited in their ability to manage their own resources, the
difficulty some may have in making decisions is no justification
for circumscribing the decision-making authority of all
participants. Indeed, there will be some families who, because
of legal involvement and safety issues, will not have the option of
controlling service decisions. However, many families are quite
capable of making (or learning to make) key decisions concerning
their lives, and systems must be structured to promote and to support
such capability from the start.”
Kimmich & Feild. 1999. Partnering with families to reform services: Managed care in the child welfare system. American Humane Association
70
Example: Child Welfare SOC Partnering
with Families in Jefferson County, CO
Supported by Parent Coordinator
Parent
Partners
Child Welfare
Workers
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
71
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 4.1
How Family-Centered Are You?
The Rhode Island Coalition for Family Support and Involvement
• Focus on the strengths of the child, youth and family?
• Support relationship building and community membership?
• Foster mutual trust and respect between families and program staff
and/or administration?
• Promote family choice and control?
• Offer families good information and access to information?
• Include families in policy decisions and program planning?
Primer Hands On - Child Welfare (2007)
72
Youth - Guided
• 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 is developmentally targeted to
their individual needs.
Technical Assistance Partnership
73
Roles for Youth: Infusing Youth
Voice in All Levels!
• Engage youth in the CFSR
process
• Include on Program
Improvement Plan
workgroups
• Youth advisory boards
• Youth group development
• Peer mentors
• Educators/trainers/evaluators
Adapted From Materese, M., Technical Assistance Partnership & National Child Welfare Resource Center for Youth Development
74
Barriers to Youth Participation
As Identified by Adults
•Time
•Funding
•Staffing
•Access to youth
•Lack of training (in how to
work with youth)
•Politics
•Parents
•Adult staff not empowered
•Program evaluation
requirements
•Weak leadership
•Racism
As Identified by Youths
•Ageism/Adultism
•Money
•Racism, sexism, homophobia
•Stereotyping by appearance
•Time
•Transportation
•Language
•Lack of access to information
•Lack of access to opportunities
•Lack of support from adults
•Few role models
•Lack of motivation
Politz, B. (1996). Barriers to youth participation. Washington, DC: Academy for Educational Development. The Center for Youth
Development.
75
Family and Youth Networks of Support
and Advocacy
• Information and referral
• Support groups
• Coaching and mentoring
• Training and education
• Community forums
• Advocacy
• Social opportunities
Conlon, L. Primer Hands On - Child Welfare
76
Creating Family- and Youth-Directed
Organizational Capacity
• Build a new, or contract with an existing, national, state, or local
family or youth directed organization (e.g., Foster Parents
Associations, Adoptive Parents Associations, Grandparents
Resource Centers, Parents Anonymous, Federation of Families
for Children’s Mental Health, Foster Youth Associations,
YouthMOVE; Parents & Friends of Lesbians and Gays-PFLAG)
• Mutually create clear expectations for the organization and for
system partners
• Ensure representation from diverse families involved in child
welfare
• Mutually agree on performance expectations and evaluation
criteria
• Provide fair compensation for the work
Conlon, L. , Lzear, K, Pires, S. (2007) Primer Hands On - Child Welfare
77
Role of Family- & Youth-Directed
Associations and Organizations
• Mobilize family and youth voice
• Provide a structure for implementing family and youth partnership
with the system of care
• Engage and support families, youth, and family members who may
feel disenfranchised from or distrustful of child welfare and other
systems (e.g., birth parents whose children have been removed;
fathers; racially/ethnically diverse families; LGBTQ youth or
caregivers)
• Create ties to the larger community and other family and youth
organizations. (e.g., Federation of Families for Children’s Mental
Health; Foster Parents Association; Adoptive Resource Center;
Parents Anonymous; Grandparents Resource Center).
Conlon, L., Pires, S., & Lazear, K. (2007) Primer Hands On - Child Welfare
78
Why Culture Matters
Culture can be defined as a broad concept that reflects
an integrated pattern of a wide range of beliefs,
practices, and attitudes that make up an individual.
It affects…
• Parenting and child rearing
• Coping strategies
• Help-seeking behaviors; Help-giving behaviors
• Expression of symptoms
• Attitudes and beliefs about services; social support; kinship
support
• Utilization of services and social support
• Appropriateness of services and supports (i.e., retraumatization)
• Setting priorities
Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
79
Why Develop Cultural & Linguistic
Knowledge and Skills: Realities
• To respond to demographic changes in the United States
• To address issues of disproportionality in child welfare systems.
-
are over-represented in restrictive levels of care child welfare systems and in out-of-home
placements
• To eliminate disparities and disproportionality in access to
services and supports.
-
have less access to and availability of services
are underrepresented in research (e.g., Evidence Based Practice)
• To improve the quality of services and outcomes.
-
are less likely to receive appropriate services
often receive a poorer quality of services and supports and less likely to achieve
permanency outcomes
• To meet legislative and regulatory mandates.
• To decrease the likelihood of class action lawsuits.
• To achieve Child and Family Services Review outcomes.
Lazear, K. Primer Hands On – Child Welfare (2007). Adapted from the National Center for Cultural Competence, Georgetown University Center for
Child and Human Development, Washington, DC. & Mental Health: Culture, Race, and Ethnicity - Executive Summary - A Supplement to the Mental
Health Report: A Report of the Surgeon General, 2001.
80
Disproportionality in Child Welfare
“…all states have a disproportionate representation of African
American children in foster care. As of 2000, the child welfare
system in 16 states had extreme rates of disproportionality that
were more than three and one-half times the proportion of
children in color in the state’s total child population.”
-Robert B. Hill, Overrepresentation of Children of Color in Foster Care in 2000 – Revised Working Paper, March 2005 –
“In states where there is a large population of Native Americans,
this group can constitute between 15% to 65% of the children in
foster care.”
-Casey Family Programs, Framework for Change (April, 2005) –
“Hispanic/Latino children may be significantly over-represented
based on locality (e.g., Santa Clara County, CA: Latino
children represent 30% of child population, but 52% of child
welfare cases).”
- Congressional Research Service. August 2005. Race/Ethnicity and Child Welfare Places to Watch: Promising Practices to Address Racial Disproportionality in Child Welfare. The Center for Community Partnerships in Child
Welfare of the Center for the Study of Social Policy (2006).
81
Disparity in Child Welfare
“African Americans are investigated for child abuse and neglect
twice as often as Caucasians.”
- Yaun, J. J. Hedderson and P. Curtis, Disproportionate representation of Race and Ethnicity in Child Maltreatment: Investigation
and Victimization , Children and Youth Services Review, 25 (2003): 359-373 – Places to Watch.
“African American children who were determined to be victims
of child abuse were 36% more likely than Caucasian children
to be placed into foster care.”
- U.S. Department of Health and Human Services (2005) -
First round of CFSRs shows that white children achieve
permanency outcomes at a higher rate than children of color.
- National Child Welfare Resource Center (2006) -
Primer Hands On – Child Welfare 2007
82
Disproportionality Theories: From Researchers
More likely to be in poor,
single parent homes – risk
factors for maltreatment
Have less access
to services that
prevent placement
and hasten
permanency
Children of color
More likely to come into
contact with social
service or other workers
who notice and report
maltreatment
More likely to be reported and
less likely to be reunified due to
biased decision making
Adapted from Congressional Research Service. August 2005. Race/Ethnicity and Child Welfare
83
Disproportionality Theories: From
Child Welfare Administrators, Supervisors, Workers
Greater visibility of
minority families
for reporting of
maltreatment
Lack of familiarity with
other cultures and with
what
constitutes abusive
behavior
Poverty and related
issues, such as
homelessness
Media
pressure to
remove
children
Lack of community
resources to address a
range of issues,
such as substance abuse
and domestic violence
84
Congressional Research Service. August 2005. Race/Ethnicity and Child Welfare
Examples of Partnerships to Address
Disproportionality in Child Welfare
Iowa Children of Color Project
Linking families to neighborhood
organizations offering culturally
appropriate services/training for
child welfare workers
The Collaborative Circle for the Well-Being
of South Dakota’s Native Children –
Partnership to reduce the number of Native
American children in foster care; increase the
number of available Native foster homes; and,
to achieve better outcomes for Native children
and families
Texas/Casey Family Programs Community Advisory
Committees on Disproportionality
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
85
Example: Outcomes of Work to Address Racial
Disparity in Child Welfare
Wake County, NC
Initiatives: Family to Family; Racial Disparities Workgroup;
Believe in a Child Campaign; Child Welfare Faith Community
Partnership; Legal Services
Outcomes: When the racial disparity work began in 2002, African American
families reported to the Wake County Human Services Hotline were slightly
more likely to be substantiated for maltreatment than Caucasian families. By
2004, the substantiation rate had been reversed. African American families
were being substantiated less often (22%) than Caucasian families (26%);
the percentage of African American children entering foster care is
decreasing as is the overall percentage of Wake County’s African American
foster children. (Although the disproportionality rate continues to be high
with respect to the percentage of African American children in the total
population, progress is occurring.)
Places to Watch: Promising Practices to Address Racial Disproportionality in Child Welfare. The Center for Community Partnerships in Child
Welfare of the Center for the Study of Social Policy (2006).
86
Cultural Competence Continuum
Cultural competence is a developmental process that
evolves over an extended period. Individuals and
organizations are at various levels of awareness,
knowledge and skills along the cultural competence
continuum. (NCCC adapted from Cross et al., 1989)
Cross, T., Bazron,B., Dennis, K., & Isaacs, M. (1989) Towards a culturally competent system of care Vol. 1,.
87
Culturally Competent Organizations
Cultural competence requires that organizations:
• have a defined set of values and principles, and demonstrate
behaviors, attitudes, policies and structures that enable them to
work effectively cross-culturally.
• have the capacity to (1) value diversity, (2) conduct selfassessment, (3) manage the dynamics of difference, (4) acquire
and institutionalize cultural knowledge and (5) adapt to
diversity and the cultural contexts of the communities they
serve.
• incorporate the above in all aspects of policy making,
administration, practice, service delivery and involve
systematically consumers, key stakeholders and communities.
Adapted from Cross, T., Bazron,B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care Vol. 1, National Technical
Assistance Center for Children’s Mental; Health, Georgetown University Child Development Center, Washington DC. & NWICWA, (1993).
88
Cultural and Linguistic Competence:
Definitions
A Definition of Cultural Competence
Culture competence is 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.
A Definition of Linguistic Competence
Linguistic competence is 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.
Lazear, K. (2006). Human Service Collaborative: Washington, D.C. 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.
89
Core Elements of a Culturally and Linguistically
Competent System of Care
 Commitment from top leadership; agency resources
 Data collection: Organizational self-assessment; evaluation and
research activities that provide ongoing feedback about progress,
needs, modifications, and next steps
Identification and involvement of key diverse persons in a
sustained, influential, and critical advisory capacity
 Mission statements, definitions, policies, and procedures reflecting
the values and principles
 Strategic plan; Internal capacity to oversee and monitor the
implementation process; targeted service delivery strategies
 Recruitment and retention of diverse staff; training and skill
development
Certification, licensure, and contract standards
Isaacs, M., Benjamin, M., et al. (1989-1998). Towards a culturally competent system of care (Vols 1-3). Washington, DC: Georgetown
University Child Development Center, National Technical Assistance Center for Children’s Mental Health.
90
Factors
Influencing
Group
Process
Norms
Participation
Feelings
Influence
Membership
Group
Process
Style
of
Leadership
DecisionMaking
Procedures
Adapted from The Pheiffer Book of Successful Team-Building
Tools, Edited by Elaine Biech. 2001 by John Wiley & Sons, Inc.
Group
Atmosphere
Task
Functions
Maintenance
Functions
91
Coming together is a beginning.
Keeping together is progress.
Working together is success.
H. Ford
Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative. (2004)
92
Planning Structure Issues
• Leadership
• Staffing
• Time and place of meetings
• Stakeholder involvement
• Committees or work groups
• Communication or dissemination of information
• Outreach to broader constituencies
• Outreach to and involvement of diverse and disenfranchised
constituencies
• Linkage to related reform/planning initiatives
• Resources
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
93
Stages of Planning For Systems of Care
STAGE 1: Form workgroup
STAGE 2: Articulate mission
STAGE 3: Identify goals and guiding principles
STAGE 4: Develop the population context
STAGE 5: Map resources and assets
STAGE 6: Assess system flow
STAGE 7: Identify outcomes and measurement parameters
STAGE 8: Define strategies
STAGE 9: Create and fine-tune the framework
STAGE 10: Elicit feedback
STAGE 11: Use framework to inform, plan evaluation, and technical assistance
STAGE 12: Use framework to track progress and revise theory of change
Hernandez, M. & Hodges, S. (2003). Crafting logic models for systems of care: Ideas into action. Tampa, FL: University of South Florida
94
A Planning Process for Family and Children’s Service Reform
The
System As
It Is Now
Outcomes
For
Children
and Families
The
System As
It Should
Be
Principles
Reinvestment
Commitment
Financing
Options
Combined Fiscal Program Strategy
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Action Plan
Multi Year
Steps
Governance
Strategy
Leadership and
Professional
Development Strategy
State
County
Community
Cross Community
Cross Agency
Political Strategy
Friedman, M. (1994). Washington, D.C.: Center for the Study of Social Policy
95
Elements of Effective Planning Processes
 Are staffed
 Involve key stakeholders
 Involve families and youth early in the process and in ways that
are meaningful
 Ensure meaningful representation of racially and ethnically
diverse families and youth
 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 Children’s Mental Health.
96
Strategies for Involving Families and Youth in Planning
• Share information about planning meetings by working with family/youth
organizations and community agencies, such as Big Brothers/Big Sisters, Boys and
Girls Clubs, Family Organizations, Family Preservation services agencies, etc.
• Provide orientation/training for families/youth about current policies, plans and
workgroups (i.e., CFSR plan, PIP workgroups).
• Have involved family/youth leaders engage other families/youth to be involved.
• Provide on-going mentorship/support (i.e., Family Service Workers engage
youth/family to become involved in planning).
• Hold planning meetings in the evenings/weekends, at community centers, schools,
and recreation centers.
• Conduct focus groups/interviews/surveys to solicit views of many families/ youth.
• Pay stipends, transportation, child care; provide food.
• Conduct facilitated sessions for planning group to explore attitudes about race,
culture, families and youth.
• Publicly acknowledge the contributions of individual families and youth.
Adapted from: 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 & Children’s Defense Fund.
97
Cultural and Linguistic Competence
in Planning
• Conduct on-going assessments of the environment
• Build support for change
• Identify, acknowledge, engage, and partner with formal and
informal leadership
• Identify and develop needed resources and enhance leadership
capacity
• Articulate values, establish a mission, and set goals
• Plan action steps in partnership with diverse families/youth
and communities
• Develop strategies to sanction or mandate the incorporation of
cultural knowledge into policy making, infrastructure and
practice.
Adapted from Cross, T., Bazron, B., Dennis, K., & Issacs, M. (1989). Towards a Culturally Competent System of Care Vol. 1. & NCCC
98
Cuyahoga County Planning Process Structure
System of Care Oversight Committee
Chaired by Deputy County Administrator for Human Services
Includes a Broad Representative Stakeholder Group, e.g., major child serving
systems, families and youth, Neighborhood Collaboratives, providers,
researchers
Cultural &
Linguistic
Competence
Social
Marketing
Family &
Youth
Involvement
Sustainability
Evaluation &
Research
Training &
Coaching
Staffed by
System of Care Office
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
99
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.
100
Definition of System Management
Day-to-day operational
decision making
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
101
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.
102
Examples of
Types of Governance Structures
State and/or local interagency body
Non profit board of directors
Quasi governmental entity
Tribal government
Hybrids
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
103
Evolving Governance Structure
Illustration 1.2A
Policy Level
Local Governing Board
Operational Level
Agency Directors
Family Advocacy
Organizational Representative
DSS Director
“Bring the Children Home”
SOC Supervisor and Staff
“Bring the Children Home”
Service Managers
Illustration 1.2B
Families Served
Other Agency Workers
BRING THE CHILDREN HOME STATE LEGISLATION
COUNTY EXECUTIVE
Local Governing Board
SOC Team Leader
Agency Directors
Family/Youth Reps.
DSS Director
Providers Forum
“Bring the Children Home”
Interagency Service Management Team
“Bring the Children Home”
Service Managers
Families/Youth Served
Other Agency Workers
104
Pires, S. ( 2006). Evolving governance structure. Washington, DC: Human Service Collaborative.
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.
105
Examples of Types of System
Management Structures
• State and/or local interagency body
• Quasi-governmental entity
• Non profit lead agency
• Public sector lead agency
• For profit commercial managed care entity
• Coalition management
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
106
Examples of Management Accountability
Cuyahoga County Management
Structure
Sarasota Co. and Milwaukee Co.
Management Structures
Deputy County Administrator for Human Services
Sarasota County
Coalition for
Families & Children
System of Care Office
Subsets of Children & Families
Involved in Child Welfare
Children in or at
risk for residential
Children with serious
placement
behavioral health
challenges
Youth who are
status
offenders
Milwaukee Co.
Division of Child
Mental Health
All children involved
in child welfare
Subset of cw population
0-3 population Early
Intervention
engagement
challenges
Children in/at risk for
RTCs
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human
Service Collaborative.
107
Examples of Relationships Between Governance and
Management Structures
Sarasota County, FL
Cuyahoga County, OH
Locally-Based, Representative Governance Board
& State/District Office
Interagency
Governing Body
Contract
Lead Public Agency:
SOC Office
Coalition Management Entity
108
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
Example of Governance/Management Structure
State Funding Pool
Local Allocation
County Alliance
Case Rate for each
enrolled child
Provider
Financer/
Payers
Purchaser
Care Management Entity
• Organize and manage provider network
• Staff and manage child and family team process
• Care management, including case management
and utilization management/utilization review
• Quality assurance
• Outcomes management /monitoring
• Management Information System (tracks
children, services, dollars)
Provider
Pires, S. (1996). Contracted system management structure. Washington, DC: Human Service Collaborative.
Provider
109
Examples of Types of Family/Youth 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 Children’s Mental Health.
110
Culturally Competent Management Structures
 Hire from diverse communities
 Incorporate quality improvement that addresses
issues important to racial and ethnic communities
(e.g., disparity and disproportionality)
 Outreach to and engage racially/ethnically diverse
stakeholders, other “minority populations”
 Conduct cultural “self assessments”
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
111
Outreach and Engagement Issues
Who is it we are trying to reach?
- How will we reach and engage the population of
focus and subsets within it?
- How will we structure outreach to culturally
diverse constituencies?
- How will we partner with families, youth, and
culturally diverse constituencies in reaching out to
different target groups?
- Who are the system partners we need to engage?
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
112
Roles for Families and Youth in
Outreach and Engagement
• Strategically providing information booths with diverse family
leaders (e.g., protective service offices, family court, health
clinics, youth correction facilities during visiting hours)
• Building formal and informal environments of trust, including
communication between foster parents and birth family (focus
groups, education forums, support and social events, etc.);
• Contracting to provide outreach, support and education services
to assist systems in understanding population needs and diverse
cultures.
• Creating methods for families/youth to connect with each other
for information (phone trees, list serves, chat rooms, newsletters)
• Sponsoring conferences and summits; designing and delivering
workshops to create bridges of confidence between families/youth
and the system.
113
L. Conlon, Federation of Families for Children;s Mental Health
Principles of Culturally Competent
Community Engagement
• Working with natural, informal supports
• Communities’ determining their own strengths, assets
and needs
• Partnership in decision-making
• Meaningful benefit from collaboration
• Reciprocal transfer of knowledge and skills
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
114
Example of Community Outreach
and Engagement
Everglades Health Center
• Signs in 3 languages: Spanish, English, and Creole
Haitian
• Literacy programs
• Audio cassettes in Spanish, English, Creole,
Honduran dialect, 3 Mexican dialects, 2
Guatemalan dialects
• Mini soap operas for the radio (with follow-up by
health care workers going in homes and
community centers)
Everglades Health Center, Community Health Centers of Dade County, Florida. Funded by the Bureau of Primary Health Care, U.S.
Department of Health and Human Services.
115
Example of Community Outreach & Engagement
Abriendo Puertas Family Center
East Little Havana, Miami, FL
• Governing board composed of 51% residents;
• Family Council to nurture leadership in decision-making;
• Natural helpers (Madrinas/Padrinos) to provide informal supports;
• Time Dollar Bank barter program to track volunteer hours given
in exchange for services received;
• Extensive collaboration among providers, including co-location of
services to create a continuum of service and supports
• Frontline practice service delivery approach (EQUIPO del Barrio)
that partners the natural helpers with formal service providers
• Family Resource Center as the hub for accessing services and
supports and for promoting the development of social support
networks among neighborhood families.
Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Human Service Collaborative: Washington, D.C.
116
Caseworker’s Role in Outreach and Engagement:
Shift in Home Visit Focus
Examining only the
performance of the
family (e.g., did the
parent attend the
substance abuse
treatment offered?).
Assessing both the performance of
the agency and caseworker (e.g.,
did the agency ensure that the
treatment matched the needs, age
and gender of the intended
recipient and was available at a
time and location appropriate to
the family’s schedule?) and how
well the family is functioning
relative to the support and services
provided by the agency.
National Conference of State Legislatures. (2006) Child Welfare: Case Caseworker Visits with Children and
Families. www.ncsl.org/programs/cyf/caseworkervisits.htm.
117
Characteristics of a Caseworker to Successfully
Engage a Family
Understands and agrees with the principle of appreciating strengths
and the culture of children, youth and their families;
Understands the concepts of using the child’s safety, attachment and
other needs to engage a family;
Appreciates a family’s expertise on their child’s needs;
Finds common ground;
Gives the family the opportunity to tell their story;
Is empathetic while being honest and straight forward, while
communicating unmet safety and attachment issues;
Is confident, persistent, creative, thinking beyond traditional services;
Is comfortable taking risks and working with traditional and nontraditional providers to begin providing different services;
Has a positive and goal oriented philosophy; Is solution-based rather
than seeing problems as barriers that cannot be overcome.
118
Adapted from the Oregon Manual
Organized Pathway to Services and Supports
While the court is the pathway for many families into the child
welfare system, there still needs to be an organized pathway for
families once involved in the system – or at risk for involvement
– to access needed services and supports.
Multiple Entry Points
One Access Point
+ more accessible
- loss of entry control
- loss of quality control
+
-
+ less confusing
+ more entry
control
- inaccessible
Can create virtual single pathway through integrated MIS
Pires, S. (2007). Adapted from Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
119
Pathways to Services and Supports for Families
At Risk for Involvement in Child Welfare
Cuyahoga County, OH
11 Neighborhood Collaboratives
+
Lead Provider Agencies
County MIS System
Sarasota County, FL
Milwaukee County, WI
Collaboration for Families & Children
Milwaukee Wraparound
120
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
Travel Miles
1250:180
Time and Travel
(Ten Month Period)
Study Family
Comparison Family
Office Hours
105:8
Visits
69:6
Travel Hours
29:6
Number of
Scheduled
Office Visits
Number of
Hours
Spent in
Office Visits
Number of
Number of
Hours Spent
Miles
Traveling to and
Traveled
from Office Visits
for Care
121
Lazear, K. (2003). Family Experience of the Mental Health System, Research and Training Center for Children’s Mental Health, Tampa, FL.
Distinctions Among Screening, Assessment
and Evaluation, and Service Planning
Screening
• 1st step, triage, identify children and families at high
risk, link to appropriate assessments
Assessment
• Based on data from multiple sources
• Comprehensive
• Identify strengths, resources, needs
• Leads to services/supports planning
Continued …
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
122
Distinctions Among Screening, Assessment
and Evaluation, and Service Planning
Evaluation
• Discipline-specific, e.g., neurological exam
• Closer, more intensive study of a particular or suspected
issue
• Provides data to assessment process
Services/Supports Planning and Placement Planning
• Individualized decision making process for determining
services, supports, with goals and timeframes
• Draws on screening, assessment, and evaluation data
• Utilizes a child and family team approach/System of Care
values
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
123
Screening and Assessment in Child Welfare
Question #1: Does the family need child welfare services?
Screening #1: Does preliminary information suggest that a child
has been a victim of or is at risk for child abuse and/or neglect?
Assessment and Plan #1: Safety/Strengths. Is the child at
imminent risk of harm and if so what needs to be in place to
ensure safety (e.g., services, placement).
Assessment and Plan #2: Risk assessment/strengths assessment
– identifies concerns about future risk and family’s strengths to
mitigate these.
Question #2: What/which services would help the family?
Assessment: Based on data from multiple sources;
Comprehensive; Identify strengths, resources, needs; Leads to
services/supports planning.
Pires, S. & Berdie, J. (2007). Primer Hands On – Child Welfare
124
Comprehensive Family Assessment
• Recognizes patterns of parental behavior over time;
• Examines the family strengths and protective factors to identify
resources that can support the family’s ability to meet its needs
and better protect the children;
• Addresses the overall needs of the child and family that affect the
safety, permanency, and well-being of the child;
• Considers contributing factors such as domestic violence,
substance abuse, mental health, chronic health problems, and
poverty; and
• Incorporates information gathered through other assessments and
focuses on the development of a service plan or plan for
intervention with the family. The service plan addresses the major
factors that affect safety, permanency and child well-being over
time.
Comprehensive Family Assessment Guidelines for Child Welfare. (2006). Children’s Bureau Safety, Permanency
and Well-Being, Us. Department of Health and Human Services Administration for Children and Families.
125
Importance of Caseworker’s Role
in Assessment and Service Planning:
CFSRs Findings - Home Visits
• When state child welfare agencies do well on the caseworker
visits, they are…
-better positioned to assess children’s risk of harm and need for
alternative permanency options;
-Better able to identify and provide needed services, and;
-Better able to engage children and parents in planning for their
future.
• Concerns include…
- insufficient face-to-face contacts with children or parents to
address their safety and well-being, and;
- an inconsistent focus on issues regarding case plans and goals
during visits.
Child and Family Services Review (2001-2004)
126
Psychological/Emotional
Life Domains
Safety
(protected from neglect and abuse/free from crime and violence)
Family/Surrogate Family
Cultural/Ethnic
(protective/capable)
(positive self-esteem & identity)
Medical
Income/Economics
(healthy/free of disease)
Educational/Vocational
Legal
(competent/productive)
(protection of rights/custody)
Spiritual
Living Arrangements
(a place to live)
Social/Recreational
(basic beliefs/values about life)
(friends, contact with other people)
127
Adapted from. Dennis, K, VanDenBerg, J., & Burchard, J. (1990). Life domain areas. Chicago: Kaleidoscope.
Problem Oriented to Strengths-Based Approach
Models developed by Ted Bowman, Associate Director, Community Care Resources, A Program of the Wilder Foundation, St. Paul, MN. In
Guide to developing neighborhood family centers. (1993). Cleveland, OH: Federation for Community Planning.
128
Definitions of Two Services Planning Processes
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.” The wraparound process is
strengths-based and culturally and linguistically competent.
Bruns, B. & Hoagwood, K. (Eds.) Community-Based Interventions for Children and Families. Oxford: Oxford University Press.
FAMILY GROUP DECISION (FGDM) is a “non-adversarial
process in which families, in partnership with child welfare and
other community resources, develop plans and make decisions
to address issues of safety, permanence and wellbeing…Reflecting the principles of family-centered practice,
FGDM is strengths-oriented, culturally adapted, and
community-based.’’
National Child Welfare Resource Center for Family-Centered Practice. 2005. http://www.cwresource.org/services
129
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 6.1
Arizona Department of Health Services:
A Comparison of Six Practice Models
Frank Rider, (2005) Arizona Department of Health Services
Primer Hands On - Child Welfare (2007)
130
Essential Elements of Wraparound, Family Group
Decision Making (FGDM) & Related Approaches
•
•
•
•
•
•
•
•
•
•
Family/youth voice and choice
Team-driven
Community-based
Individualized
Strengths-based and focused across life domains
Culturally competent
Flexible approaches, flexible funding
Informal community and family supports
Interagency, community-based collaboration
Outcome-based
Goldman, S. & Faw, L. (1991). Three wraparound models as promising approaches. In B.J. Burns & S.K. Goldman (Eds.). Promising
practices in wraparound for children with severe emotional disturbance and their families. Systems of care: Promising practices in children’s
mental health (1998 series). 4. Washington, D.C.: American Institutes for Research and the National Wraparound Initiative (2005)
131
Examples of Systems of Care That Incorporate
A Wraparound Approach for the Child Welfare
Population or Subsets
• Milwaukee Wraparound (Milwaukee Co., WI)
• Dawn Project (Marion County, IN)
• Central Nebraska
• Westchester County, New York
• Sacred Child Project, South Dakota
• Cuyahoga County, OH
• States of Alabama, Nevada, North Carolina
Pires., S. 2005. Human Service Collaborative. Washington, D.C.
132
Example: Using Both Family Group
Decision Making (FGDM) and Wraparound in the
Kansas Child Welfare System
Family Group
Decision Making
All children in child welfare
Wraparound
Children with
intensive needs
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
133
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 6.2
Kansas Department of Social and
Rehabilitation Services
Family Centered Practice
www.srskansas.org/CFS/FCSOC/whatissoc.htm
Primer Hands On - Child Welfare (2007)
134
Example of Developing a Comprehensive Plan
IFSP Framework
Orrego, M., & Lazear, K. (1998). Equipo training manual. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute,
Research and Training Center for Children’s Mental Health. Adapted from: Bennett, T, Lingerfelt, B., Nelson, D. Developing individualized
support plans-a training manual.
135
Individualized Service and Support Plan
Components
•
•
•
•
•
•
Strengths/Culture Discovery
Crisis/Safety Plan
Vision
Family Narrative
Needs Statements
Strategies (who, what, when, how) based on
strengths (including transition out of formal
services)
Adapted from Meyers, MJ. Wraparound Milwaukee, Milwaukee County Behavioral Health Division, Child and Adolescent Services Branch
136
A Well Documented Services and
Support Plan…
• Tells the family story in a way you would want your
own story told
• Is written from strengths
• Uses family-friendly language
• Reflects what was actually said in the service planning
meeting
• Is specific and concise
• Addresses mandates while staying family focused
Meyers, MJ. Wraparound Milwaukee, Milwaukee County Behavioral Health Division, Child and Adolescent Services Branch
137
Being Part of a Team Means…
• Appreciating strengths and the culture of children,
youth and their families;
• Being creative and thinking beyond traditional
services;
• Listening;
• Being honest and empathetic;
• Being comfortable taking risks and working with
traditional and non-traditional providers;
• Being confident and persistent;
• Having a positive and goal oriented philosophy;
• Finding solutions rather than seeing problems as
barriers that cannot be overcome.
Adapted from the Oregon Manual for System of Care
138
Eco-Mapping
Exercise
Partners/
Companeros
de ejercicio
Extended
Family/
Familiares
Friends/
Amigos
Work/
Trabajo
Health
Care/
Servicios de
Salud
Social
Services/
Servicios
Sociales
Neighbors/
Vecinos
Me/Yo
School/
Escuela
Strong connections
Tenuous connections
Stressful connections
Flow of energy
Faith
Organizations/
Organizacion
religiosa
Orrego, M.E. Lazear, K. J. EQUIPO: University of South Florida, Tampa, FL
Adapted from Markiewicz, J. Eco-Map
139
The Importance of Accessible Information
in Outreach and Engagement
www.gucchd.georgetown.edu
Information and material that
involves all stakeholders can
provide everyone a better
understanding of the child welfare
system and help families, agencies
and communities reach positive
solutions for children, youth and
families.
A Family’s Guide to the Child Welfare System (2003). Georgetown University Center for Child and Human Development,
Washington, DC
140
When a Parent Has a Physical or Mental Illness
Parents with mental illness may be quite vulnerable to losing custody of their children.
Some studies have reported as many as 70% of parents have lost custody.
To promote positive outcomes
• Recognize the strengths of parents;
• Identify the specific service needs of parents;
• Battle the stigma of mental illness;
• Attend to custody and visitation issues;
• Attend to termination of parental rights issues;
• Attend to the legal issues of parents;
• Provide supports for children of parents with mental illness;
• Educate professionals to the needs of parents;
• Identify/provide peer support for parents;
• Coordinate services for parents;
• Provide family-centered care;
• Multiple systems must work together.
Adapted from Nicholson, J., Biebel, K., Hinden, B., Henry, A., and Stier, L. (2001) – Critical issues for parents with mental illness and their families. 141
Department of Psychiatry, University of Massachusetts Medical School and Strengthening family fact sheet, National Mental Health Association
Steps to Responding: Families with Repeat
Involvement with Child Welfare
• Develop a better understanding of the phenomenon;
• Make needed change in management, staffing, and training in
the child welfare agency and in the court;
• Assess and enhance the services and supports needed to
address families holistically, recognizing and responding to
the multiplicity and complexity of family needs;
• Listen to the voices of families and youth;
• Heighten attention to the impact of trauma on children and
youth to met children’s physical, cognitive, emotional, social,
and behavioral needs;
• Build stronger community responses;
• Use local, county, and state resources more cohesively and
effectively.
Families with Repeat Involvement with Child Welfare Systems: The Current Knowledge Base and Neded Next Steps (2006) The Center for
Community Partnerships in Child Welfare of the Center for the Study of Social Policy.
142
Examples:
Use of Common Screening and Assessment Tools
Across Systems to Guide Decisions
Child and Adolescent Needs and Strengths (CANS) tools
(www.buddinpraed.org/cans)
New Jersey (www.njkidsoc.org)
Philadelphia
Child and Adolescent Functional Assessment Scale
(Hodges, K., Wong, M.M., & Latessa, M. (1998). Use of the Child and Adolescent
Functional Assessment Scale (CAFAS) as an outcome measure in clinical settings.
Journal of Behavioral Health Services and Research, 25 (3), 325-336.
Michigan
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
143
Service Decision Making in Child Welfare
Who/What Drives Decisions
judges, guardians ad litem, court-appointed special advocates, outside
clinicians
Who/What Doesn’t Drive Decisions
child welfare professionals, families’ needs, evidence of what works
Result: “Treatment for child welfare consumers lacks
individualized plans or services”
Washington University Center for Mental Health Services Research Grant. 2005
Related Finding: Investigations by CASA volunteers
associated with higher rates of removal, less kinship care,
less reunification
Caliber Associates. 2004
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
144
The Role of Supervision and Coaching
• Supervisors must play an active role as practice change agents
(and thus be provided opportunities and be required to participate
in workshops/trainings, etc. that reflect new approaches and/or
philosophies).
• Supervisors are the link between administration and frontline
staff.
• Supervisors can use their knowledge and understanding of
agency data to provide frontline practice change supervision and
proactively direct the achievement of outcomes.
• Supervisors play a critical role in selecting the best candidates
(e.g., those skilled in system of care practices) for an agency
vacancies.
Primer Hands On-Child Welfare (2007) and NCWRCOI Focus Area III
145
Supervising Strengths/Needs Based Practice
• Experienced supervisors comment that supervising strengths/needs
based practice requires a different, disciplined approach to
coaching workers.
• The goal is deepening the worker’s empathy for the child, youth,
family and foster family.
• It takes time to reflect with workers on their cases and coach them
on engaging families more effectively.
• Appreciate workers’ strengths at developing collaborative
relationships with families.
• Help workers have the patience to help families over time to get a
better understanding of their child’s needs and to see how they can
build on their strengths.
• Encourage workers to help families design interventions that are
most likely to meet needs, rather than being limited to programs
146
that already exist. Adapted from Englander, B. Oregon Manual for System of Care
Why Focus on Medicaid Managed Care?
Medicaid is the primary source for health/mental
health care for children in child welfare.
Most states (86%) are applying managed care
approaches to their Medicaid programs.
Health Care Reform Tracking Project 2003 State Survey. Research and Training Center for Children’s Mental Health,
University of South Florida, Tampa, FL
147
Children in Child Welfare in Medicaid
Managed Care
Source: CMS/MSIS State Summary Data, FY 2003
53% - 72% of foster care population is enrolled
in Medicaid managed care –
HMO Enrollment: 245,313
BHO Enrollment: 174,584
________________________
Total Enrollment: 419,897
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
148
State Coverage of Child Welfare Population
in Medicaid Managed Care
Source: Health Care Reform Tracking Project 2003 State Survey
26 states include the child welfare population in
Medicaid managed care –
• 22 with mandatory enrollment
• 4 with voluntary enrollment
Pires, S. (2002). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
149
NRCOI Framework for a Full Service
Array in Child Welfare
“Collaborative, strategic, population-focused process,
guided by set of tools, to identify array of practices, services,
and supports needed in a SOC for child welfare populations”
1.
2.
3.
4.
Assessment of Current Practices in the Jurisdiction as They Relate to
Building Specified, Needed Child Welfare Capacities.
Assessment of Current Leadership and Systemic Culture in the Jurisdiction
as They Relate to Building Specified, Needed Child Welfare Capacities.
Assessment of Current Services in the Jurisdiction as They Relate to Building
Specified, Needed Child Welfare Capacities.
Assessment of the Need for Other Services Not Currently Available in the
Jurisdiction as They Relate to Building Specified, Needed Child Welfare
Capacities.
Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National
Child Welfare Resource Center for Organizational Improvement
150
Purposes of NRCOI Framework
• Create a service directory
• Prepare for the CFSR, the Statewide Assessment, and in
developing the PIP re the service array
• Meet CAPTA requirement to conduct annual inventory
• Help define array of services needed in SOC when
specific target population has been chosen
• Identify gaps and strategies to improve service array
• Can lead to better collaboration among providers and
a better functioning community collaborative
Examples
Pulaski, Co., Virginia
Nebraska – 14-county rural area
Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource
Center for Organizational Improvement
151
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 7.1
National Child Welfare Resource Center for
Organizational Improvement:
Service Array Framework
www.nrcoi.org
Primer Hands On - Child Welfare (2007)
152
Dawn Services & Supports
Behavioral Health
•Behavior management
•Crisis intervention
•Day treatment
•Evaluation
•Family assessment
•Family preservation
•Family therapy
•Group therapy
•Individual therapy
•Parenting/family skills
training
•Substance abuse therapy,
individual and group
•Special therapy
Placement
•Acute hospitalization
•Foster care
•Therapeutic foster care
•Group home care
•Relative placement
•Residential treatment
•Shelter care
•Crisis residential
•Supported independent living
Psychiatric
Other
•Assessment
•Camp
•Medication follow-up/psychiatric
•Team meeting
review
•Consultation with other
•Nursing services
professionals
Mentor
•Guardian ad litem
•Community case management/case
•Transportation
aide
•Interpretive services
•Clinical mentor
Discretionary
•Educational mentor
•Activities
•Life coach/independent living skills •Automobile repair
mentor
•Childcare/supervision
•Parent and family mentor
•Clothing
•Recreational/social mentor
•Educational expenses
•Supported work environment
•Furnishings/appliances
•Tutor
•Housing (rent, security
•Community supervision
deposits)
Respite
•Medical
•Crisis respite
•Monitoring equipment
•Planned respite
•Paid roommate
•Residential respite
•Supplies/groceries
Service Coordination
•Utilities
•Case management
•Incentive money
153
•Service coordination
2005 CHIOCES, Inc., Indianapolis, IN
•Intensive case management
Examples of Evidence Based Practices Related to CFSR Outcomes
Programs Addressing Safety
- Abuse-Focused Cognitive Behavioral Therapy (AF-CBT) - AMEND, Inc. (Abusive Men Exploring New
Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Project
Connect - Child Parent Psychotherapy for Family Violence (CPP-FV) – Trauma Treatment Rated - Project
SafeCare - Domestic Abuse Intervention Project (DAIP) - Nurturing Parenting Programs - Project SUPPORT
- Intensive Reunification Program (IRP) Motivational Interviewing (MI) - Nurturing Program for Families in
Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Self-Motivation
Group (SM Group) - Shared Family Care (SFC) - Supported Housing Program (SHP) - The Community
Advocacy Project - Triple P – Positive Parenting Program
Programs Addressing Permanency
HOMEBUILDERS - Intensive Reunification Program (IRP) - Project CONNECT - Shared Family Care
Programs Addressing Well-Being
1-2-3 Magic: Effective Discipline for Children 2-12 - Abuse-Focused Cognitive Behavioral Therapy Alcoholics Anonymous (A.A.) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent
Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Child Parent Psychotherapy for
Family Violence (CPP-FV): Trauma Treatment Rated - Community Reinforcement + Vouchers Approach
(CRA + Vouchers) - Community Reinforcement Approach - Domestic Abuse Intervention Project (DAIP) Eye Movement Desensitization and Reprocessing (EMDR) - Intensive Reunification Program (IRP) Motivational Interviewing (MI)Nurturing Parenting Programs - Nurturing Program for Families in Substance
Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Parenting Wisely - Project
CONNECT - Project SUPPORT - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - STEP:
Systematic Training for Effective Parenting - Supported Housing Program (SHP) - The Community
Advocacy Project - The Incredible Years – Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - Triple
P – Positive Parenting Program
154
California Evidence-Based Clearinghouse at: http://www.cachildwelfareclearinghouse.org
Examples of Other Services
You’d Want to Provide Based on
Practice/Family Experience & Outcomes Data
• Family Group Decision Making
• Wraparound
• Integration of natural helping networks
• Intensive in-home services (not just MST)
• Respite services
• Mobile response and stabilization 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.
155
Examples of What You Don’t See Listed as
Evidence-Based Practice
(though they may be standard practice)
• Residential Treatment
• Group Homes
• Day Treatment
• Traditional office-based “talk” therapy
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
156
Examples from Hawaii’s List of Evidence Based Practices
Problem Area
Anxious or Avoidant
Behaviors
Depressive or Withdrawn
Behaviors
Disruptive & Oppositional
Behaviors
Best Support
Good Support
Cognitive Behavior
Therapy (CBT);
Exposure Modeling
CBT with Parents; Group CBT;
CBT for Child & Parent;
Educational Support
CBT
CBT with Parents; Inter-Personal
Tx. (Manualized); Relaxation
Parent & Teacher
Training; Parent
Child Interaction
Therapy
Anger Coping Therapy;
Assertiveness Training; Problem
Solving Skills Training, Rational
Emotive Therapy, AC-SIT, PATHS
& FAST Track Programs
Juvenile Sex Offenders
None
None
Delinquency & Willful
Misconduct Behavior
Known Risks: Group
Therapy
None
Multisystemic Therapy; Functional
Family Therapy
Substance Use
Known Risks:
Group Therapy
CBT
Behavior Therapy; Purdue Brief
Family Therapy
Known Risks:
Group Therapy
Moderate
Support
None
None
Social Relations
Training; Project
Achieve
Multisystemic
Therapy
MultiDimensional
Treatment Foster
Care;Wraparound
Foster Care
None
157
HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 7.2
Examples of Potentially Harmful Programs
and Effective Alternatives
Source: Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer
Influences in Intervention and Public Policy for Youth,” Social Policy
Report, Vol. XX, No. 1, January 2006. As published in Youth Today: The
Newspaper on Youth Work, Vol. 15, No. 7. www.youthtoday.org
Primer Hands On - Child Welfare (2007)
158
Challenges to Financing and Implementing
Evidence-Based/Promising Practices
Financing & Infrastructure needed for:
Training
Consultation
Coaching
Provider Capacity Development
Fidelity Monitoring
Outcomes Tracking
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
159
How to Finance/Implement Evidence-Based
and Promising Practices
Adopt a Population Focus: Who are the populations of families
and youth for whom you want to change practice/outcomes?
Adopt a Cross-Systems Approach: What other systems serve
these children and families? Who controls potential or actual
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 and Supports to finance/implement evidence
based practices
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
160
Examples of Incentives to Various Systems
Serving Children and Families
Medicaid: slowing rate of growth in inpatient, emergency
room, residential treatment and pharmacy costs
Child Welfare: meeting Adoptions and Safe Families Act
outcomes; reducing out-of-home placements
Juvenile Justice: creating alternatives to incarceration
Mental Health: more effective delivery system
Education: reducing special education expenditures
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
161
Examples of Cross-System Partnerships to Finance
and Implement Evidence-Based and Promising Practices
District of Columbia
Multi Systemic Therapy (MST), Mobile Response, In-Home
Medicaid Rehab Option
to pay for MST, Intensive Home-Based
Services (Ohio model), Mobile Response
and Stabilization Services (NJ model)
Child Welfare
provided match and paid for initial
training, coaching, provider
capacity development;
Mental health/child welfare to share costs of outcomes tracking
Juvenile Justice
also to pay match, training costs as well
Medicaid HMO
expressing interest in Mobile Crisis
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
162
Service Array Focused on a Total Population
Universal
Core Services
Prevention
Targeted
Early Intervention
Intensive Services
 Family Support
Services
 Youth Development
Program/Activities
 Service Coordination
 Intensive Service
Management
 Wraparound Services
& Supports; Family
Group Decision
Making
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.
163
Characteristics of a Culturally and Linguistically
Competent Service Design & Practice
•
•
•
•
Driven by family/youth-preferred choices;
Understands the needs/help-seeking behaviors of youth/families;
Embraces principles of equal access/non-discriminatory practices;
Designs/implements services and supports that are tailored or
matched to the unique needs of children, youth, families,
organizations and communities served;
• Recognizes well-being crosses life domains;
• Understands that cultural competence must be defined and
required for Evidence Based Practices (EBP), and that Practice
Based Evidence (PBE) must be taken into consideration as a
critical component of EBPs in communities of color.
Lazear, K. J Primer Hands On Human Service Collaborative, Washington, DC. 2006
164
Families and Youth Provide Valuable
Services and Supports
As technical assistance
providers & consultants
As direct service providers
Training
 Foster Parents
Evaluation
 Mentors
Research
 Service Coordinators
Support
 Family Educators
Outreach
 Specific Program
Managers (respite, etc)
Adapted from Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
165
Family and Youth Roles in Building
Evidence-Based Practice (EBP)
• Advocate for ethical, culturally sensitive research
• Participate in the development and analysis of
research to support EBP
• Assist in data collection to support EBP
• Educate families, family leaders and youth about
EBP
Wells, C. & Pires, S. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
166
Examples of Strategies to Address Lack of
Home and Community-Based Services
•
•
•
•
•
Support family and youth movements
Engage natural helpers and culturally diverse communities
Implement a meaningful Medicaid rehab option
Write child and family appropriate service definitions
Collapse out-of-home and home and community-based budget
structures
• Re-direct dollars from out-of-home to home and communitybased
• Implement flexible rate structures (e.g., bundled rates/case
rates)
• Implement pilots or phase in system change
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
167
Examples of Strategies to Address Lack of
Home and Community-Based Services
•
•
•
•
•
•
•
•
Implement capacity-building grants
Implement performance-based contracts
Develop practice and implementation guidelines
Train providers, judges, families, etc. – use training resources
across systems
Implement quality and utilization management
Apply for federal demonstration grants
Collect data on child and family outcomes, family/youth
satisfaction, and cost/benefits
Educate key constituencies (e.g., legislators, Governor’s Office,
State Insurance Commissioner)
Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.
168
Examples of Sources of Funding for Children/Youth
with Individualized Needs in the Public Sector
Medicaid
• Medicaid In-Patient
• Medicaid Outpatient
• Medicaid Rehabilitation
Services Option
• Medicaid Early Periodic
Screening, Diagnosis and
Treatment (EPSDT)
• Targeted Case
Management
• Medicaid Waivers
• TEFRA Option
Substance Abuse
• SA General Revenue
• SA Medicaid Match
• SA Block Grant
Mental Health
• MH General Revenue
• MH Medicaid Match
• MH Block Grant
Education
• ED General Revenue
• ED Medicaid Match
• Student Services
Other
Child Welfare
• CW General Revenue
• CW Medicaid Match
• IV-E (Foster Care and
Adoption Assistance)
• IV-B (Child Welfare
Services)
• Family
Preservation/Family
Support
Juvenile Justice
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants
Pires, S. (1995). Examples of sources of funding for children & families in the public sector. Washington,
DC: Human Service Collaborative.
• TANF
• Children’s Medical
Services/Title V–
Maternal and Child
Health
• Mental Retardation/
Developmental
Disabilities
• Title XXI-State
Children’s Health
Insurance Program
(SCHIP)
• Vocational
Rehabilitation
• Supplemental Security
Income (SSI)
169
• Local Funds
Major Child Welfare Funding Streams
• Child Welfare Services – Title IV-B
• Foster Care & Adoption Assistance – Title IV-E
• Social Services Block Grant
• Temporary Assistance to Needy Families (TANF)
• Medicaid – Title IX
• State and local general revenue
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
170
Advantages and Drawbacks of Specific Child Welfare
Financing Streams
Type
IV-B
Advantages
Flexible, includes family
preservation and support $$
Capped allocation from federal government
to states and represents a relatively small
percentage of available $$
Uncapped entitlement $$
Can be used only for room/board costs for
eligible children in out-of-home
placements and certain administrative and
training costs
Important source of revenue
for health and behavioral
health services for children in
or at risk for child welfare
involvement
Medicaid agencies are concerned about
increasing costs and assuming too much
responsibility for “high-cost” populations;
Adult family members may not be eligible
Important source of
emergency funds for families
Capped
IV-E
Medicaid
TANF
Drawbacks
SS Block Grant Flexible
Capped and shrinking
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
171
Creating “Win-Win” Scenarios
Child Welfare
Alternative to out-of-home care
high costs/poor outcomes
Medicaid
Alternative to
Inpatient/Emergency Roomhigh cost
System of Care
Alternative to detentionhigh cost/poor outcomes
Juvenile Justice
Alternative to out-of-school
placements – high cost
Special Education
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
172
Thinking Across Systems Serving Children,
Youth and Families
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
173
Financing Strategies to Support Improved
Outcomes for Children, Youth and Families
FIRST PRINCIPLE: System Design Drives Financing
REDEPLOYMENT
Using the money we already have
The cost of doing nothing
Shifting funds from treatment to prevention
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)
RAISING OTHER REVENUE TO SUPPORT
FAMILIES AND CHILDREN
Donations
Special taxes and taxing districts for
children
Fees & 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. Washington, DC: Center for the Study of Social Policy.
174
What Are the Pooled Funds?
CHILD WELFARE
Funds thru Case Rate
(Budget for Institutional
Care for CHIPS Children)
JUVENILE JUSTICE
(Funds budgeted for
Residential Treatment for
Delinquent Youth)
9.5M
MEDICAID CAPITATION
(1557 per month
per enrollee)
8.5M
10M
MENTAL HEALTH
•Crisis Billing
•Block Grant
•HMO Commercial Insurance
2.0M
Wraparound Milwaukee
Management Service Organization (MSO)
$30M
Per Participant Case Rate
Care
Coordination
Child and Family Team
Provider Network
240 Providers
85 Services
Plan of Care
Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and
Adolescent Services Branch.
175
Example: Pooled Funds for
Nebraska’s Integrated Care Coordination Units
Child Welfare
State General Revenue,
IV-E, IV-B
Juvenile Justice
State General Revenue
Federal Mental Health
Block Grant
Case Rate
Integrated Care Coordination Unity
Services and supports for
children in state custody
with complex needs
Families Care
8% of Case Rate
Pires, S. (2007) Primer Hands On - Child Welfare
176
Financing – Cuyahoga County (Cleveland)
System of Care Oversight Committee
County
Administrative
Services
Organization
}
Neighborhood Collaboratives &
Lead Provider Agency
Partnerships
State
Early Intervention and
Family Preservation
FCFC $$
Fast/ABC $$
Residential Treatment Center $$$$
Therapeutic Foster Care $$$
“Unruly”/shelter care $
Tapestry $$
System of Care Grants
SCY $$
}
Reinvestment of savings
Community Providers and Natural Helping Networks
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
177
Example of Redirecting Funds
Youth who are at-risk of
entering a RTC
Medicaid
DHR and DJS
Federal and State
(MHS Match Mental Hygiene
Block Money
Youth referred to a
local management
entity
Local
Management
Entity
Controls the
management of
treatment services,
support services, and
housing/placements.
Money form the three
funding sources are
streamlined into the
local management
entity
$
At risk pool
is created
for the local
managemen
t entities
$
$
$
The three sources of funding stream into the
local management entity from the state and
federal government. The local management
entity is held accountable to the state. The three
sources of funding are from Medicaid, Mental
Hygiene, and a combination of DHR and DJS.
Treatment services (in patient
(treatment facility) and out-patient
(in-home) services)
Support services (respite,
behavioral supports, nutrition, etc.)
Housing/Placement services
(foster care, group home, adoption,
etc.)
Adapted from State of Maryland, 2004
178
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. Washington, DC: Human Service Collaborative.
179
Diversity of Federal Grant Sites Funding
SOURCE
State
SYSTEM
DESCRIPTION
Mental Health
General fund, Medicaid (including FFS/managed care/waivers),
federal mental health block grant, redirected institutional funds,
and funds allocated as a result of court decrees
Child Welfare
Title IV-B (family preservation), Title IV-B (foster care
services), Title IV-E (adoption assistance, training,
administration), and technical assistance and in-kind staff
resources
Juvenile Justice
Federal formula grant funds to states for juvenile justice
prevention, state juvenile justice appropriations, and juvenile
courts.
Education
Special education, general education, training, technical
assistance, and in-kind staff resources
Governor’s Office/Cabinet
Special children’s initiatives, often including interagency
blended funding
Social Services
Title XX funds and realigned welfare funds (TANF)
Bureau of Children with
Special Needs
Title V federal funds and state resources
Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising
practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.
180
Diversity of Federal Grant Sites Funding (continued)
SOURCE
SYSTEM
CMHS GRANT
State
Local
SITES FUNDINGDESCRIPTION
DIVERSITY
Health Department
State funds
Public Universities
In-kind support, partner in activities
Department of Children
In states where child mental health services
are the responsibility of child agency, not
mental health, sources of funds similar to
above
Vocational Rehabilitation
Federal- and state-supported employment
funds
Housing
Various sources
County, City, or Local
Township
General fund
Juvenile Justice
Locally controlled funds
Education
Courts, probation department, and community
corrections
County
May levy tax for specific purposes (mental
health)
Food Programs
In-kind donations of time and food
Health
Local health authority-controlled resources
Public Universities and
Community Colleges
Substance Abuse
In-kind support
Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s
mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.
181
Diversity of Federal Grant Sites Funding (continued)
SOURCE
Private
SYSTEM
DESCRIPTION
Third Party Reimbursement
Private insurance and family fees
Local Businesses
Donations and in-kind support
Foundations
Robert Wood Johnson, Annie E. Casey, Soros
Foundation, and various local foundations
Charitable
Lutheran Social Services, Catholic Charities, faith
organizations, homeless programs, and food
programs (in-kind)
Family Organizations
In-kind Support
Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care:
Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and
Practice.
182
Example: Diversified Funding Sources & Approaches
at the Parent Support Network, RI
CHILD
WELFARE
IVB FUNDS
STATE
APPROPRIATION
FUNDS
BEHAVIORAL
HEALTH
DEPARTMENT OF
EDUCATION
DISCRETIONARY
FUNDS
FEDERAL GRANTS
&
PRIVATE
DONATIONS
Administrative Infrastructure (4.0 FTE)
Executive Director, Assistant Director, Administrative Assistant, and Data and
Technology Specialist
Peer Mentor Program (3.25 FTE)
Information & Referral
Child & Family Teams
Education Planning
Support Groups/ Youth Speaking Out
Training
Family & Youth Leadership Program
(2.50 FTE)
System Reform Training & TA
Placement on Policy Boards
Focus Groups
Social Marketing/ Presentations
Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.
183
Examples of Medicaid Options States Use to Cover Evidence-Based and
Promising Community-Based Practices (1)
Medicaid Option
Advantages
Issues
Example
Rehabilitation
Services Option
•Flexibility to cover a
broad array of services and
supports provided in
different settings (e.g.,
home, school)
•Service definitions often
adult-oriented
•Provider-service mismacth
•OH – developing new
service definitions and
case rates for intensive
home-based services and
Multisystemic Therapy
Managed Care
Demos and
Waivers - 1115
and 1915 (b)
•Accountability and
management of cost
through risk
structuring/sharing
•Flexibility to cover wide
range of services and
populations
•Managed care not without
risks/challenges
•Federal waiver process can
be challenging
•Cost neutrality issues
•NM – covering
Multisystemic Therapy
•AZ – covering family
support and urgent
response for child
welfare
Home and
CommunityBased Waivers 1915 (c)
•Flexibility, broader
coverage, waiver of
income limits and
comparability
•Alternative to hospitallevel of care but PRTF (i.e.,
residential tx.) may be issue
•Cost and management
concerns/limited to small
number
•KS, NY, VT, IN, WI – have
HCBS Waivers
•AK, FL, GA, IN, KN, MD,
MS, MT, SC, VA – have
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
community alternatives
to psychiatric residential
treatment facilities
demonstration grant
184
Examples of Medicaid Options States Use to Cover Evidence-Based and
Promising Community-Based Practices (2)
Medicaid
Option
Advantages
Issues
Example
Early and
Periodic
Screening,
Diagnosis and
Treatment EPSDT
•Broadest entitlement
•Supports holistic
assessments and services
•No waiver or state plan
amendment requirements
•Management mechanism
critical because of cost
concerns
•Oriented more to physical
health in practice
•RH
•PA
Targeted Case
Management
•Can be targeted to high
need populations, such as
child welfare
•Supports small case load
focus (e.g., 1-10)
•Not sufficient without
other services
•Federal attention
•VT
•NY
Administrative
Case
Management
•Ability to cover basic case
management services to
support enrollment access
•Not sufficient without
other services
•NJ – covering
some activities of
family-run
organizations
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
185
Examples of Medicaid Options States Use to Cover Evidence-Based and
Promising Community-Based Practices (3)
Medicaid
Option
Advantages
Issues
Tax Equity and
Fiscal
Responsibility
Act of 1982
(TEFRA)
•Avenue to eligibility to
community-based services
for children who meet SSI
disability criteria – allows
disregard of family income
•SSI criteria not easy to
meet for children with SED
•Does not expand types of
covered services
•Cost issues, so generally
small program
•MN
•WI
Medicaid as
Part of a
Blended or
Braided
Funding
Approach
(without a
waiver)
•Holistic, integrated
(across systems) financing,
supports broad array of
services, natural supports
and individualized care
•Involves significant
restructuring
•Milwaukee
Wraparound
•DAWN Project
•Massachusetts
Mental Health
Services Program
for Youth
•New Jersey
Partnership
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
Example
186
Bottom Line
State Medicaid agencies are cobbling together a
variety of Medicaid options in attempt to cover and
contain community-based services for children and
families - often without involvement of other systems
serving children and families.
What is needed is a more integrated, strategic
financing approach across systems.
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
187
If you have answered the questions:
Financing For Whom?
Financing for What?
I.E.,
Identified your population(s) of focus
Agreed on underlying values and intended outcomes
Identified services/supports and practice model to achieve outcomes
Identified how services/supports will be organized
(so that all key stakeholders can draw the system design)
Identified the administrative/system infrastructure needed to support
the delivery system
Costed out your system of care
Then You Are Ready To
Talk About Financing!
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
188
Strategic Financing Analysis
1. Identify state and local agencies that spend dollars on the identified
population(s). (How much each agency is spending and types of
dollars being spent, e.g., federal, state, local, tribal, non-governmental)
2. Identify resources that are untapped or under-utilized (e.g., Medicaid).
3. Identify utilization patterns and expenditures associated with high
costs/poor outcomes, and strategies for re-direction.
4. Identify disparities and disproportionality in access to
services/supports, and strategies to address.
5. Identify the funding structures that will best support the system
design (e.g., blended or braided funding; risk-based financing; purchasing
collaboratives).
6. Identify short and long term financing strategies (e.g., Federal revenue
maximization; re-direction from restrictive levels of care; waiver; performance
incentives; legislative proposal; taxpayer referendum, etc.).
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
189
Example: Program Budget for a Neighborhood-Based System of Care
Cost
Categories
Proposed
Total
Costs
Neighborhood
Governance
Family
Leadership
Family
Service/
Support
Removal
of Barriers
Community
Organizing
School
Linkage
Tracking
&
Evaluating
Volunteers
Partnership
Building
Exec.
Direction
&Support
Salaries
446,000
21,000
29,000
190,000
21,000
26,000
35,000
15,000
30,000
18,000
63,000
Fringe
133,000
6,300
8,700
57,000
6,300
7,800
10,500
3,900
9,000
5,400
18,900
Building
Occupancy
93,600
8,700
12,300
36,800
2,400
4,300
4,000
2,500
4,300
2,500
15,800
Professional
Services
109,000
17,600
22,100
32,400
3,600
2,700
2,700
18.600
2,700
2,900
3,700
Travel
43,700
12,300
5,300
10,300
9,000
1,200
3,000
500
500
500
1,600
Equipment
6,000
600
600
600
600
600
600
600
600
600
600
Food
Services
25,000
0
4,000
1,000
18,000
0
1,000
0
1,000
0
0
Subcontract
89,000
0
0
89,000
0
0
0
0
0
0
0
Operating
Supplies &
Expenses
21,500
1,800
700
8,600
200
1,300
2,100
500
1,500
4,100
4,100
Other
(stipends,
transport,
child care)
84,000
0
40,000
9,000
35,000
0
0
0
0
0
0
Equipment
Lease
25,000
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
Property
25,000
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
2,500
Insurance
13,500
2,700
1,200
1,200
1,200
1,200
1,200
1,200
1,200
1,200
1,200
125,900
459,900
64,100
45,800
GRAND TOTALS: 1,115,100 80,000
84,300
51,100
55,300
Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.
36,800
190
113,900
Example: Program Budget for a Neighborhood-Based System of Care
(continued)
Proposed
Total
Costs
Neighborhood
Governance
Family
Leadership
Revenue
Totals
Across
Sources
Family
Service/
Support
Removal
of
Barriers
Community
Organizing
School
Linkage
Tracking
&
Evaluating
Volunteers
Partnership
Building
Exec.
Direction
&Support
Revenue Allocation By Program
Foundation
217,100
40,000
30,000
25,000
28,300
24,000
0
22,800
12,000
15,000
20,000
State Mental
Health &
Substance
Abuse
258,800
2,500
28,400
157,900
3,000
20,000
0
5,000
12,000
5,000
25,000
CountyChild
Welfare
124,900
20,000
30,000
30,000
10,000
5,000
0
3,000
12,000
2,000
12,900
Dept of
Education
70,100
2,500
1,600
0
0
0
60,000
0
0
0
6,000
State Family
Preservation
Grant
373,400
5,000
20,000
230,000
35,000
0
0
12,000
18,000
14,000
39,400
In-Kind
29,300
0
10,000
10,000
5,000
1,000
0
0
800
0
2,500
Donations
21,300
5,000
900
5,000
1,000
100
2,100
3,000
500
800
5,000
Other
Grants
20,200
5,000
900
5,000
1,000
100
2,100
3,000
0
0
3,100
GRAND
TOTALS
1,115,100
80,000
125,900
459,900
84,300
51,100
64,100
45,800
55,300
36,800
113,900
Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas
Family Center.
191
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 7.3
The “Matrix” from Oregon
How to Fund the Service Array and How to Process
Includes:
Client Related Expenditures
Resource Priorities
Payment Documents
Primer Hands On - Child Welfare (2007)
192
Pros and Cons of Some Particular
Provider Network Structures
Allows for greater quality control over the network
May disenfranchise some providers who do not get selected
May reduce the choice of providers available to families
May give families considerable choice of providers
May be difficult for the system of care to exercise sufficient
quality control over providers
May give families and service planners considerable choice of providers
May be difficult for some providers to manage too much or
too little service volume
193
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
Characteristics of
Effective Provider Networks
• Responsive to the population that is the focus of the system of care.
• Encompass both formal 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 and youth.
Pires, S. (2006). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
194
Essential Elements of Trauma-Informed Child
Welfare Practice and Provider Network
• Maximize the child’s sense of safety.
• Connect children and youth with providers who can assist
them in reducing overwhelming emotions.
• Connect children with providers who can help them
integrate traumatic experiences and gain mastery over their
experiences.
• Address ripple effects in the child’s behavior, development,
relationships, and survival strategies following a trauma.
• Provide support and guidance to the child’s family.
• Ensure that caseworkers manage their own professional and
personal stress.
Focal Point: Traumatic Stress/Child Welfare. Winter 2007. Research and Training Center on Family Support and Children’s Mental Health,
Portland, OR.
195
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. (2006). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
196
Natural Helping Networks and
Social Supports
•
•
•
•
Family and friends
Neighbors
Volunteers
Individuals in the community, e.g. mail carrier,
minister, storekeeper, etc.
• People with similar experiences or problems
• Faith-based organizations
Lazear, K. Reyes, D. & Sanchez, M. (2004). Natural Helpers: Partnerships in Latino Communities, Training Institutes. San Francisco, CA.
197
What Natural Helpers/Social Supports
Can Provide
•
•
•
•
•
•
•
•
•
Emotional support; moral & spiritual guidance
System navigation
Resource acquisition & education
Concrete help & advocacy
Decrease social isolation
Greater understanding of community
Community navigation
Effective intervention or support strategies
Identify potential foster and adoptive parents or leads
Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
198
3 Child Welfare Initiatives to Build
Natural Supports
• Family-to-Family (F2F) Neighborhood Collaboratives –
neighborhood resources are mobilized to support families at risk for
involvement in child welfare (Cuyahoga County with 11 Neighborhood
Initiatives)
• Community Partnerships for Protecting Children (CPPC)
focuses on changing child protective service through family-centered
practice supported by neighborhood networks (Cedar Rapids, Jacksonville,
Louisville and St. Louis all employ CPPC strategies such as locating CPS
workers in neighborhoods and enlisting neighborhood partners to provide
supports to at risk families, such as new mothers)
• “Family Finding” – uses Internet search engines to locate extended
family members for children and youth in care (Washington State and
Santa Clara County, CA)
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
199
Other Examples of Initiatives to
Build Natural Supports
• Community Partnerships in Child Welfare: San Antonio, Texas
– to involve the community in developing a network of support for at-risk
families, change the culture, policies and practices of the child welfare
agency to more family-centered
• EQUIPO: Abriendo Puertas Family Center, East Little Havana,
Miami, Florida – focused on developing a partnership between formal
and informal helpers in the community through a curriculum based training
initiative to strengthen neighborhood supports and services.
Lazear, K. (2007). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
200
Pre-Equipo Network
Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.
201
Post –EQUIPO Network
Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.
202
Families and Youth as Providers
•
•
•
•
•
•
•
•
Active outreach in the community
First to connect with family upon intake
Respects other families’ experiences
Reflective of the families to be served culturally,
linguistically, and socio-economically
Supports the family to have active voice and choice
Works collaboratively to connect families together as a
network of support to one another
Work within or in partnership with family organizations
(training, system reform, etc.)
Build trust & bridge relationships between families, youth
and system
Conlan, L. Primer Hands On, 2007
203
Provider Roles for Families and Youth
• Explaining how the system works.
• Helping families to contribute in a meaningful way to each
stage of their involvement in child welfare, including the
assessment of concerns and strengths, developing the
service plan (e.g., thinking through and voicing what kinds
of services they want), and assessment of progress.
• Helping locate resources.
• Advocating for the family when resources are scarce.
• Supporting family and youth throughout the process.
• Providing system navigation, and information and referral
assistance.
Focus Area IVC: Engaging Birth Parents, Family Caregivers and Youth. National Child Welfare Resource Center For Organizational Improvement. (2007)
204
Examples of Infrastructure Considerations to
Support Families and Youth as Providers
• Co-locations to create family-driven working
environment and culture
• Realistic and clear job descriptions
• Fair compensation for work
• Flexible agency policies and procedures for all
employees (flex schedule, release time, etc.)
• Equal partnerships across agency roles, not
performance hierarchy
• Co-supervision models
• Credentialing/continued learning
Conlan, L. Primer Hands On, 2007
205
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
•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. Washington, D.C.: Human Service Collaborative.
206
Capitation and Case Rate Distinctions
Capitation: Pays Managed Care Organizations (MCOs) or
providers a fixed rate per eligible user
Incentive:
#1: Prevent eligible users from becoming actual users (e.g., make
it difficult to access services; engage in prevention)
#2: Control the type and volume of services used
Case Rate: Pays Managed Care Organizations (MCOs) or
providers a fixed rate per actual user
Incentive:
#1: Control the type and volume of services used
Pires, S. Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
207
Risk-Based Contracting Arrangement
State-Capped Out of Home Placement Allocation
County DHS acts as Managed Care Organization (contracting, monitoring, utilization review)
Child Welfare $$
Case rate contract with Child
Placement Agency (CPA)
BH Tx $$ matched by Medicaid.
Capitation contract with
Behavioral Health Organization
(BHO)
with risk-adjusted rates for child
welfare-involved children
Joint service planning required
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 and management functions
Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.
208
Progression of Financial Risk by
Contracting Arrangement
RISK TO
SYSTEM
OF CARE
RISK TO
PROVIDER
TYPE OF CONTRACTING
ARRANGEMENT
HIGHEST
RISK
LOWEST
RISK
•Grant
•Fee-for-Service
•Case Rate
LOWEST
RISK
HIGHEST
RISK
•Capitation
Adapted from Broskowski, A. (1996). Progression of provider’s risks. In Managed care: Challenges for children and family services.
Baltimore, MD: Annie E. Casey Foundation.
209
Move from a mentality of “funding programs”
to one of “purchasing quality care”
What do you want to buy that will really make a
difference for your identified population(s)?
How do you want to use your dollars to promote
practice change?
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
210
Massachusetts Purchasing Strategy to
Support System Goals
State Child Welfare System
CQI Structure
Performancebased contracts
Objective
Integrated
continuum of
placement and
non-placement
services
GOAL:
Improved
permanency
outcomes
Case rates
•Increase funding for home and
community-based services
•Bring children back or divert
them from residential placement
•Redirect dollars to home and
Strategies
community-based care
Strategies
Designated Lead Agencies
Regional Resource Centers
Network of Providers
CQI Process
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
211
Connecticut Purchasing Strategy Using Title IV-E Waiver
Child Welfare Agency
Case
Rates
Lead Agencies
Continuum of Home and
Community-Based Services
Reduced Out-of-Home
Placements =
Redirected Dollars
FINDINGS FROM EVALUATION OF WAIVER
•
•
•
•
•
Lengths of stay in restrictive placements reduced
Children returned to in-home placements sooner
Use of care management, crisis stabilization and family
support services increased
Well-being of children improved
Costs were lower
Adapted from from Holden, W., et.al., Outcomes of a randomized trial of continuum of care services for children in a child
welfare system. ORC MACRO.
212
Definition of Terms
Service Coordinator
Assists families with basic to intermediate needs to
coordinate services and supports, usually has other
responsibilities and/or is assisting large numbers of
families.
Care Manager
Primary job is to be the accountable care manager for
families with serious and complex needs; works with
small number of families (e.g., 8-10), has authority to
convene child/family team as needed and often has
control over resources.
Pires. S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
213
Example of Care Management:
Nebraska Integrated Care Coordination Units
Care Manager:
10 Families
Formal Services &
Informal Supports
Decreasing time to meet
permanency goals
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
214
Care Management/Coordination
Structure Principles
• Support a unitary (i.e., across agencies) care
management/coordination approach even though multiple
systems are involved, just as the service/supports planning
structure needs to support development of one service/supports
plan.
• Support the goals of continuity and coordination of
service/supports 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.
215
EXAMPLE
Goal: One plan of services/supports; one care manager
Mental Health
Child Welfare
•Individualized WrapAround Approach
•Care manager
•Family Group Decision Making
•CW Case Worker
Kinship
Care
Subsidized
Adoption
Permanent
Tutoring
Foster
Parent Support,
Care
etc.
Children in
out-of-home
placements
Juvenile Justice
•Screening & Assessment
•Probation officer
Community Services
MCO
•Prior Authorization
•Clinical Coordinator
Out-patient
services
Crisis
Services
Primary
Care
Treatment
Foster Care
In-Home
Services
Education
•Child Study Team
•Teacher
Alternative
School
EH Classroom
Related Services
Med. Mngt.
Result: Multiple plans of services/supports; multiple service coordinators
216
Pires, S. (2004).Building Systems of Care: A Primer. Human Service Collaborative: Washington, DC
Care Management Continuum
Children &
families needing
only brief shortterm services and
supports
No formal
service
coordination
Children & families
needing intermediate
level of services and
supports
Service
coordination
Larger
staff:family
ratios
Children & families
needing intensive
and extended level
of services and
supports
Intensive care
management
Very small
staff:family
ratios
Pires, S. (2001). Case/care management continuum. Washington, DC: Human Service Collaborative.
217
Examples of Types of Care Coordinators
• Re-assigned case workers
• Paraprofessional care managers
• Clinical care managers
• Family members as care coordinators
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
218
Examples of Care Management Structures
Structure #1
MH Care Managers
“Bring the Children Home” Project
Interagency Care Planning Team
CW Care Managers
JJ Care Managers
ED Care Managers
Structure #3
Structure #2
Care Managers
hired/contracted
by pooled funds
Care Managers on
loan from agencies
but report to Project
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
219
Utilization Management (UM) Concerns
Who is using services & supports?
What services/supports are being
used?
How much service is being used?
UM
What is the cost of the
services/supports being used?
What effect are the services having
on those using them? (i.e.,
Achieving permanency? Increased
safety? Are clinical/functional
outcomes improving? Are families
and youth experiencing the system
as empowering?)
Pires, S. (2001). Utilization management concerns. Washington, DC: Human Service Collaborative.
220
Principles for
Utilization Management (UM)
• UM must be understood and embraced by all key
stakeholders, such as child welfare workers,
providers, families, managers)
• UM must concern itself with both the cost and
quality of services and supports
• The UM structure needs to be tied to the quality
improvement structure
• The UM structure needs to address/integrate CFSR
and PIP objectives
Pires.. S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
221
Shared Utilization Management Structures Among
Care Managers and Child and Family Teams
• Service/support plans build in “trigger” dates
or events for review
• Service/support plans have scheduled review
dates
• Service/support plans require regular “report
backs” from providers
• Families and youth provide review of services
• Family and youth voice drives monitoring and
reviews
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
222
PRIMER HANDS ON- CHILD WELFARE
HANDOUT 9.1
Massachusetts Department of Social Services
Continuous Quality Improvement Program
(Discussion Guide for Learning Forums)
and
CQI Process Scenario
Deveney, W., Nicholson, J., &
Massachusetts Department of Social Services and CQI Staff (2006)
Using Organizational Data to Create the Essential Context for
System Transformation in Child Welfare.
Primer Hands On - Child Welfare (2007)
223
Example: Utilizing Data to Drive Quality
Contra Costa County’s CQI Structure
Internal Evaluators
University-based Evaluator
Evaluation Subcommittee
(diverse partners, including families)
•Developing activities to
ensure CQI for:
-Youth with multiple
placements
-Transition-aged youth
-Multi-jurisdiction youth
-Youth at-risk for multiple
placements
•Developing and Tracking
Quality and outcome
measures:
I.E. reduction in number of
youth with 3 or more
placements; linkage to
needed resources upon
emancipation
Pires, S (2006) Primer Hands On for Child Welfare. From Caliber, Building the Infrastructure to Support Systems of Care.
224
Types of Data Reports and Their Use
• Resource focused
– Workloads (case/client lists); length of stay
• Policy focused (provide feedback to managers on adherence to
agency policies and procedures, i.e., compliance)
– Approved foster homes; adoptive homes, etc.; staff rosters; budgets
• Family focused
– Repeat maltreatment within 6 months; maltreatment of children in care;
children achieving permanency within 12 months (reunification), or 24
months (adoption/guardianship); children re-entering care within 12
months; multiple placement - no more than 2 within 12 months)
• Service response (results of actions taken that contribute to
achieving outcomes)
– Reduction in residential placements; stability in placement; placement of
children in proximity to their homes; parent-child visitation (unless
detriment to the child)
225
Focus Area V Using Information and Data in Planning and Measuring Progress. CFSR Comprehensive Training and Technical Assistance
Package. National Resource Center for Child Data and Technology, National Child Welfare Resource Center for Organizational Improvement
Purposes of Utilization and Quality
Management Data
• Planning and decision support (day-to-day and
retrospectively)
• Quality improvement
• Cost monitoring
• Research
• Marketing and media
• Accountability
• Changing casework practice
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
226
Example: Statewide Quality Improvement Initiative
Michigan: Uses data on child/family outcomes (CAFAS) to:
• Focus on quality statewide and by site
• Identify effective local programs and practices
• Identify types of youth served and practices associated with
good outcomes (and practices associated with bad outcomes)
• Inform use of evidence based practices (e.g., Cognitive
Behavior (CBT) for depression)
• Support providers with training informed by data
• Inform performance-based contracting
QI Initiative designed and implemented as a partnership among
State, University and Family Organization
Hodges. K. & J. Wotring. 2005. State of Michigan.
227
Example: Proposed Outcomes Measurements of
Success for a System of Care in Oregon
1.
2.
The array of services available to children and families will increase and there
will be evidence in case records that the community is collaborating to
provide wraparound services.
The number of parents actively involved in planning for reunification or
preservation of their families will increase.
(i.e., the number of Family Meetings will increase; more voluntary agreements; earlier
compliance; increase in staff and partners trained to facilitate Family Meetings;
parents will be able to articulate their child’s needs and understand how to meet those
needs; increase in direct family contact; when a child is re-abused or at risk for reabuse, parents will be able to recognize the need for assistance and make a voluntary
request for services)
3.
There will be an increase of foster care beds in targeted recruitment areas of
minority and medically fragile providers.
4.
Every child entering foster care will have a full physical and mental health
assessment by two weeks time in placement.
Case records will clearly document practice change that supports identified
child needs (i.e., children will make fewer moves in care; the Service Plan
clearly reflects children’s needs and is based on sound assessment practices.
5.
Englander, B. System of Care, Oregon
continued…228
Example: Proposed Outcomes Measurements of
Success for a System of Care in Oregon
6.
Reasonable efforts will always be made to prevent placements in foster care
and attachment will always be considered as a factor in placement (i.e., law
enforcement will place children in care after hours with consultation from SCF;
children will be placed with kinship providers unless safety is an issue; children will
be placed in their neighborhood of origin, or the SOC plan will address a desired
permanency outcome for transient children and their parents that establishes a stable
environment; length of stay in care will reduce; length of time to the initial visit will
decrease considerably; school age children will remain in their current school)
7.
The focus of visitation practice will continue to shift toward a fully
therapeutic model and there will be an increase in the number/types of tools
used to promote visitation.
8. Every case worker will have cases meeting SOC criteria designated as such.
9. There will be fewer Termination of Parental Rights (TPRs) and more
relinquishments, when the presumed alternate plan is adoption and must be
implemented
10. Foster Parent will be involved with case planning
11. Children will be placed in compliance with the agreement.
Englander, B. System of Care, Oregon
229
Example: Outcomes of Nebraska’s Integrated Care
Coordination Unit and Early Integrated Care
Coordination Unit
Integrated Care Coordination Unit
• At enrollment, 35.8% of children served were living in group or residential
care; at disenrollment, 5.4% were in group or residential care
• At enrollment, 2.3% of children were living in psychiatric hospitals; at
disenrollment, no children were hospitalized
• At enrollment, 7% of youth served were in juvenile detention or correctional
facilities; at disenrollment, no youth were in these facilities
• At enrollment, 41.4% of children were living in the community (at home –
4.4%; with a relative – 1.5%; in foster care – 35.5%); at disenrollment, 87.1%
were living in the community (at home – 53.5%; with a relative – 7.6%; in
foster care – 14.5%; independent living – 11.5%).
• Improvement in Child and Adolescent Functional Assessment Scale scores
• Generation of $900,000 in cost savings (by reducing cost per child served)
Early Integrated Care Coordination Unit
• Prevention of placement in state custody for 88.1% of children referred.
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative. From Nebraska’s Integrated Care
Coordination Unit
230
Example: Outcomes for Milwaukee Wraparound
• Reduction in placement disruption rate from 65% to 30%
• School attendance for child welfare-involved children improved
from 71% days attended to 86% days attended
• 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)
Milwaukee Wraparound. 2004. Milwaukee, WI.
231
Example: Family/Caregiver Experience
Wraparound Milwaukee
*Nearly half had previous CPS referral
91% felt they and their child were
treated with respect (n=191)
91% felt staff were sensitive to their
cultural, ethnic and religious needs
(n=189)
Not At All 4%
Somewhat
5%
Not At All 4%
Somewhat
5%
Very Much So
Somewhat
Not At All
Very Much
So 91%
72% felt there was an adequate
crisis/safety plan in place (n=172)
Not At All
15%
Very Much
So 91%
64% reported Wrap Milwaukee empowered them
to handle challenging situations in the future (n=188)
Somewhat
29%
Somewhat
13%
Very Much
So 72%
Not At All
7%
Very Much
So 64%
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
232
System of Care Functions Requiring Structure
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Planning
Decision Making/Policy Level Oversight
System Management
Service & Supports Array
Evidence-Based & Promising Practices
Outreach and Engagement
System Entry/Access
Screening, Assessment, and Evaluation
Decision Making and Oversight at the
Service Delivery Level
– Services & Supports Planning
– Services & Supports Authorization
– Service Monitoring and Review
Service 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
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Human Resource Development/Staffing
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 and Linguisrtic Competence
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.
233
Human Resource Development Functions
• Assessment of workforce requirements (i.e., what
skills are needed, what types of staff/providers,
how many staff/providers) 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.
234
Culturally Competent, Family-Driven and Youth Guided
Human Resource Development (HRD) Strategies
• Assessing workforce requirements through a culturally diverse
lens
• Developing requirements for job announcements and having
input on hiring
• Hiring family members and youth in paid staff roles
• Engaging leaders from culturally diverse communities to assist
in recruitment
• Partnering with historic Black and Hispanic colleges
• Utilizing families, youth and culturally diverse communities to
develop questions in interview protocols that reflect cultural
awareness and understanding of family-centered practice
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
235
Staffing Systems of Care
Re-deploy
and Retrain
Existing
Staff
Hire
New
Staff
Contract
Out
Partner
with
Others
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
236
A Developmental Training Curriculum
TRADITIONAL
SYSTEM
PROGRAM
MODIFIED
INTEGRATED
State systems
develop training
along specialty
guild lines –
Promotion of
stronger specialty
focus
State systems
independently
adopt similar
philosophy,
promoting
Collaboration
State systems
begin sharing
training calendars
Community
agencies and
universities
operate in isolation
Community
agencies and
Universities
begin joint
research and
evaluation
Community
agencies and
universities begin
to integrate field
staff/families into
pre-service training
Pre-service
training remains
separate from
the field
Student field placements cross agency
boundaries
Disciplines train
in isolation from
one another
Instruction is
didactic, “expert”
No support for crosstraining
Promotion of
cross-training;
joint funding
Cross-agency
training gains
support
UNIFIED
State systems
pool training
staff, merge
training events
Community
agencies and
universities
collaborate
with larger
community, e.g.
families as coinstructors;
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 children’s mental health. 5. Washington, D.C.: American Institutes for Research.
237
A Developmental Training Curriculum
TRADITIONAL
PRACTICE
Participation
in professional
conferences on
individual basis
within agency
boundaries
Services are
provided within
agency boundaries
MODIFIED
Staff receive
training that
promotes
collaboration,
but receive it
within agency
boundaries
Specialty focus
predominant
Services remain
within agency
boundaries
INTEGRATED
Service
teaming is
promoted
through crossagency training
UNIFIED
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 children’s mental health. 5. Washington, D.C.: American Institutes for Research.
238
Examples of Cross-System Training
St. Mary’s County, MD and Clark County, NV
Training CPS investigators, permanency staff,
mental health clinicians, probation staff,
providers, families in a strengths-based,
State of North Carolina
culturally competent, individualized,
System of Care Child and
child and family team approach
Family Team Curriculum
and Training Workgroup
with goal of developing a
consistent practice model to
support system of care
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
239
Example: Communication Mechanisms in
the State of North Carolina
Meeting calendar
Website
Local Collaborative
Communication Committee
Regional meetings
Brochures
Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.
240
Examples: Social Marketing
Kansas Family Centered Systems of Care Marketing Strategy Goals
1. increased interagency collaboration
2. Increased involvement and interest of stakeholders in the outcomes of all children in
community.
3. Increased family involvement in the development and influence of policy making decisions
that affect children and families
4. The development of a sustainable infrastructure that supports families and children on the
community level and less on the state level. (www.ctb.ku.edu)
Oregon’s SOC Goals and Performance Measures: Goal 8 Public Pride
The public knows about and takes pride in Oregon’s record of child safety and permanency.
SOC Activities
•Develop citizen advisory boards for implementing counties
Performance Measures
•Increase percentage of customers expressing satisfaction with SCF service.
•Decrease percentage of cases on which a (formal) complaint about services is filed.
Illinois’s Don’t Write Me Off: Foster Kids Are Our Kids Campaign
Provided a seminar for Program Ambassadors, Foster Home Recruiters, Communication
and/or Development Directors about media opportunities for Illinois child welfare agencies
and the placements of billboard, transit and other advertisements of the Don’t write Me Off
Campaign throughout the state. ([email protected])
241
Primer Hands On: Child Welfare (2007)
Child Welfare and the Media
10 Questions You’ll Want to Answer
1.
2.
3.
4.
5.
6.
7.
8.
9.
Why do you want the media attention?
What is your “news?”
What types of media coverage do you want?
Whom will you contact in the media?
How will you contact the media?
What do you have to offer?
How will you respond when the media calls you?
Which media strategy can your available resources support?
What other sources of free publicity are available in your
community?
10. How will you know if you’ve been effective?
Weinreich, N.K. (National Clearinghouse on Child Abuse and Neglect Information, National Clearinghouse on Child Abuse and Neglect,
U.S. Department of Health and Human Services.
242
Common Elements of Re-Structured Systems
• Values-based systems/family and youth partnership
• Identified population(s) of focus, costs associated with
population, funders
• Locus of accountability (and risk) for target population(s)
• Organized pathway to services for population(s) of focus
• Strengths-based, family-driven, youth-guided,
individualized, culturally competent practice model
• Intensive care management/service coordination
• Flexible financing and contracting arrangements (e.g., case
rates, qualified provider panel – fee-for-service)
• Combined funding from multiple funders (e.g., Medicaid,
child welfare, mental health, juvenile justice, education)
Pires, S. 2004. Human Service Collaborative. Washington, D.C.
continued … 243
Common Elements of Re-Structured Systems
(continued)
• Broad provider network: sufficient types of services and
supports, including natural helpers
• Real time data across systems to support service decisionmaking, utilization management, quality improvement
• Outcomes tracking – child/family level, systems level
• Utilization and quality management
• Mobile crisis capacity
• Judiciary buy-in
• Re-engineered residential treatment centers
• Shared governance/liability
• Strategic use of training and technical assistance
Pires, S. 2004. Human Service Collaborative. Washington, D.C.
244
“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.”
A. Einstein
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.
245
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