Abstract
The articles in this Special Issue on system change within systems of care (SOCs) provide guidance regarding strategies for modifying SOCs to address the needs of different populations, and ways for changing systems to support more positive child and family outcomes. This paper frames central needs, unanswered questions, and issues that remain for those working to implement SOCs. Specific needs and new directions considered include: (1) rigorous implementation-focused research to identify the necessary and sufficient elements of SOCs and the primary practice approach currently used in SOCs, wraparound; (2) applied research to assess SOCs and document their effectiveness in non-standard or non-traditional settings (i.e., non-mental health settings, including child welfare, juvenile justice, local housing authorities); (3) controlled outcome studies for school-based wraparound initiatives; (4) research to document the effectiveness of the family support efforts that are part of most SOCs; and (5) attention to context, for families, service providers, and collaborative implementation efforts, by researchers and providers alike. Progress in these areas can inform well-targeted system change efforts in the context of SOCs, a critical need given changes in federal funding for these initiatives.
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The implementation of the system of care (SOC) philosophy continues to expand in diverse communities across the country. It has become so widespread that many states currently frame the SOC philosophy as reflecting best practice for their human service systems and have instituted practice recommendations, required documentation, and mandated system structures consistent with SOCs. In fact, SOCs have been described as the central element of the United States’ child mental health policy (Hodges et al. 2010).
However, in the time since the call for proposals for this Special Issue was disseminated in February, 2010, much has changed, and the landscape for systems of care has shifted substantively. Of greatest salience, changes at the federal level have led to the discontinuation of the multi-year, multi-million dollar Substance Abuse and Mental Health Services Administration (SAMHSA) Child Mental Health Initiative grants to communities to establish and implement systems of care. Instead, the current federal SOC funding consists largely of smaller ($300,000–$800,000), 1-year “expansion planning grants” that states, tribal organizations, or other units of government can use for “improving and expanding services provided by systems of care” (SAMHSA 2011). This change highlights the need for a better understanding of the components of SOCs that communities should implement to maximize the benefits for youth and families. While this Special Issue provides guidance regarding ways that SOCs can be modified to address the specific needs of different populations, and ways that systems might be changed to result in better outcomes, a number of unanswered questions remain for those working to implement SOCs.
Lower levels of funding for SOC implementation suggest that communities will need to be more targeted and resource efficient in their efforts. At the same time, SOCs are being implemented in new settings and with a growing set of populations. Consequently, there is a growing need for applied research efforts designed to understand which core elements of SOCs are most essential for improving child and family outcomes. The sections that follow identify central issues, needs, and directions for SOC work.
To inform well-targeted system change, rigorous implementation-focused research is needed to identify the necessary and sufficient elements of SOCs and of the primary practice approach used in SOCs, wraparound. While a significant literature has identified issues in the implementation of SOCs (e.g., Center for Mental Health Services 2003; Cook and Kilmer 2004; Holden et al. 2003; Kilmer et al. 2010b; Kutash et al. 2011; Lunn et al. 2011; Pandiani et al. 1996) and wraparound (e.g., Bertram et al. 2011; Bruns et al. 2011; Cook et al. 2007; Epstein et al. 2003; Palamaro Munsell et al. 2011; Walker et al. 2003; Walker and Schutte 2005), including a Special Issue (Bruns and Walker 2011a) focusing on wraparound services and wraparound implementation, there is scant knowledge regarding the particular elements of wraparound, or the specific characteristics of SOCs, that contribute to more positive outcomes for children and their families.
Wraparound has been described as “put[ting] into practice the values and principles of a system of care at the service delivery (i.e., child and family) level” (Stroul and Friedman 2011, p. 16). Despite the long history of wraparound implementation since the late 1980s (VanDenBerg et al. 2003) and the fact that wraparound initiatives are found in nearly every state (Bruns and Walker 2011b), the authors of a recent review found just 36 published wraparound outcome studies, with only seven using comparison groups (a later review found two more; see Suter and Bruns 2008; Bruns and Suter 2010). Moreover, of the 9 controlled outcome studies in the literature, only one also attempted to assess implementation (Suter and Bruns 2008; Bruns and Suter 2010). At the same time, an emerging literature suggests that, when wraparound is implemented well, better outcomes result (see, e.g., Bruns et al. 2005a, b, 2006b, 2008a; Haber et al. 2010; Hemphill et al. 2010; Rast et al. 2007). Focused applied research and evaluation efforts, assessing fidelity of implementation and employing control groups, are requisite. Overall, research is needed that can clarify the circumstances under which wraparound contributes to more positive outcomes, to help guide system change efforts.
Given the central role of child and family teams in developing and implementing plans of care in wraparound (Bruns et al. 2008b; VanDenBerg and Grealish 1996), particular attention should focus on the practice and processes of these teams and their meetings. Many assessments of wraparound fidelity involve team member interviews regarding team functioning over a period of time (e.g., 3 months); however, assessments of the processes occurring at team meetings have been found to be important indicators of wraparound implementation (e.g., Haber et al. 2012; Palamaro Munsell et al. 2011) that have also been found to relate to better child outcomes (e.g., Haber et al. 2010; Hemphill et al. 2010). Given increasing use of wraparound to address a wide range of problems experienced by children and families (Bruns et al. 2011; Bruns and Walker 2011b), better understanding of the systemic factors that lead to better wraparound fidelity and more positive outcomes is imperative. Discerning the role of CFTs and the contribution of team meeting processes to outcomes is one important means of doing so.
More broadly, the lack of understanding regarding the implementation factors or elements of SOCs that contribute to positive outcomes is a critical gap. Given that SOCs are essentially system change initiatives, designed to change the way systems, agencies, and practitioners “do business”, it is crucial to know the nature of the changes to systems, policies, and practices that will support optimal outcomes. This is a core unanswered question, particularly given the diverse efforts being made around the country to sustain SOCs after sites’ federal funding ends; policymakers, administrators, agency directors, and professionals all need to know how to institute change to support effective practices and how to make informed choices regarding the allocation of limited resources. Rigorous evaluation efforts can help identify targets for emphasis in future SOC system change work.
Applied research is also needed to assess SOCs and document their effectiveness in non-standard or non-traditional settings. While SOCs are intended to be coordinated systems, integrated across the major service sectors (i.e., mental health, health, juvenile justice, child welfare), given their intent and target populations (i.e., children and youth with severe emotional disturbance), they are often based in mental health systems, and cross-sector partnerships are not always realized (see, e.g., Cocozza and Skowyra 2006; Office of Juvenile Justice and Delinquency Prevention 2000). Furthermore, although research has examined wraparound implementation within SOC initiatives in the child welfare and juvenile justice systems, this research base is more limited than that focusing on mental health (see, e.g., Bruns et al. 2006a; Clark et al. 1996; Erickson 2012).
SOC principles are being implemented in a growing number of different types of settings. For example, in Charlotte, the city’s housing authority is piloting a SOC initiative using a wraparound model to provide care coordination and supportive services for families in public housing. Our university-based research team is evaluating the effort, and the partnership is using data-driven feedback to support the implementation of high fidelity wraparound. As SOCs are implemented in a growing array of different settings with different populations, it is critical to examine the factors that contribute to successful change efforts within those systems.
Controlled outcome studies are also needed for school-based wraparound initiatives. Although efforts in other non-mental health service systems (child welfare, juvenile justice) or via other agencies (local housing authorities) have noteworthy potential, school-based wraparound initiatives hold particular promise, especially given the growing role that schools play in addressing the mental health needs of youth. Increasingly the loci for wraparound initiatives (e.g., Eber et al. 2002; Scott and Eber 2003), schools have become important “partners in the mental health care of our children” (New Freedom Commission on Mental Health 2003, p. 58) and have been found to provide a higher proportion of mental health services for youth than any other service sector (Burns et al. 1995; Costello et al. 1996). Notably, however, although wraparound in school-based contexts has garnered considerable attention, the extant literature includes no outcome studies of school-based wraparound services that have used a comparison group (Suter and Bruns 2008, 2009; Bruns and Suter 2010).
Research is needed to examine wraparound’s impact relative to more typical school-based intervention approaches received by matched comparison children, and the change strategies needed to implement wraparound effectively in schools. Implementation of wraparound in school settings has the potential to change the ways that schools and their personnel interact with families and communities, and it is important to examine the factors contributing to those changes. Such research can inform community partnerships to meet the needs of children and families, integrating services and supports that extend beyond the walls of the school. In fact, to the degree that evaluation supports their effectiveness, school-based models of wraparound could be fruitfully targeted by communities seeking to sustain work guided by the SOC philosophy.
In addition to work investigating SOC implementation and wraparound initiatives, research is also needed to document the effectiveness of family support efforts that are part of most SOCs (Briggs 1996; Friedman 1994; see Slaton et al. 2012 and Wenz-Gross et al. 2012). Family organizations and other family support models emphasize (1) the development of family capacities and strengths that empower families to make decisions and exercise control over the care of their children, and (2) the creation of structures and the provision of resources that enable families to exert influence over the development and implementation of SOCs. These goals are central to a SOC philosophy, and family support programs using paraprofessional parents as mentors and advocates continue to grow (Illback 1997). In fact, family support efforts have been required elements in SAMHSA-funded SOC initiatives. Family support programs, designed to increase family strengths, stability, and well-being, have used diverse means to accomplish these goals, including parent education, social and emotional support, counseling or referral to services and case management, other support services (e.g., transportation, respite, play groups), health care for parents and children, center-based early childhood education, leadership/advocacy training, and adult basic education and/or job skills (see Layzer et al. 2001). In general, family support programs have been found to have modest effects on children and families (Layzer et al. 2001), but they vary tremendously in their nature and scope, target population, and impact. The literature supporting their effectiveness evidences notable gaps, and it is critical to ascertain the nature of their impact on children and families, particularly in the context of SOCs.
For instance, growing numbers of family support programs, often within SOCs, are grass-roots efforts, operated by parents of youths with special needs; these types of programs are also the least likely programs to be evaluated (Layzer et al. 2001). Programs that target families in which youth have behavioral challenges, such as those in SOCs, have been particularly effective (Layzer et al. 2001; Vostanis 2006), but work is needed to (a) discern the specific elements of family support (e.g., dose, types of support) that contribute to youth and family outcomes and the mechanisms of these effects, and (b) identify the systemic elements that can foster and sustain these family support efforts. Programs run by nonprofessionals, which are common in SOCs, tend to be less effective than professional-run programs; however, they are rarely subject to rigorous evaluation (Layzer et al. 2001). Thus the evaluation of these family-run family support programs is particularly critical. Similarly, examination of the impact of nascent efforts to secure reimbursement for the services and supports provided by family peer support specialists, family partners, and those in similar roles (see Slaton et al. 2012; Wenz-Gross et al. 2012) is needed to increase systemic efforts to support families in SOCs.
Critical to system change in SOCs is attention to context, for families, service providers, and collaborative implementation efforts (see, e.g., Cook and Kilmer 2010a, b; Farmer and Farmer 2001; Tolan and Dodge 2005). While a major tenet of both the SOC philosophy and the wraparound practice model is that plans of care address the broad needs of youth and their families (e.g., Bruns et al. 2008b; VanDenBerg and Grealish 1996), all too often the focus remains on the mental health needs of the identified child, not the full range of needs experienced by a family (Kilmer et al. 2008, 2010b; Strater et al. 2012; Tolan and Dodge 2005). In addition to a focus on the family context of the youth, an important focus in wraparound is on building and maintaining families’ connections with natural support networks and community resources. Given evidence that wraparound teams often focus on professional resources to the exclusion of informal, community supports (see, e.g., Cook and Kilmer 2010b; Cook et al. 2007; Epstein et al. 2003; Walker and Schutte 2005), an examination of mechanisms for engaging other critical resources and supports in families’ contexts is clearly warranted.
In addition to the family context, service providers in SOCs exist within organizational contexts that have been found to relate to access to mental health care and mental health outcomes; however, this literature is not well developed (see, e.g., Bertram et al. 2011). For example, organizational climate, operationalized as employees’ views of their work environment as beneficial versus detrimental to their well-being, predicted improvements in children’s functioning (Glisson and Hemmelgarn 1998) more than interorganizational services coordination for children in state custody. Furthermore, organizational culture, the organization’s behavioral expectations of its employees and the patterns and ways in which things are done in the organization, and organizational climate have been found to relate to both access to mental health services (Glisson and Green 2006) and staff turnover and new program sustainability (Glisson et al. 2008). Moreover, climate has been found amenable to change in case management teams, with improvements leading to lower turnover rates among the staff (Glisson et al. 2006). Organizational context, only rarely examined as a variable of interest in predicting outcomes in SOCs or as an important factor in creating effective SOCs and, at a more proximal level, their care coordinating teams, warrants greater attention in system change efforts and research.
The broader community context of SOCs is also of interest for establishing and studying SOCs. Communities developing a SOC are likely to mobilize multiple community organizations and groups to address the needs of children and families with mental health challenges. Through this mobilization of effort, which might include joint training of staff from different organizations, creation of a family organization, enlisting businesses and other groups to provide tangible support for families, or other community-building strategies, segments of the community can come together. When communities become organized and pull together to accomplish a task, there are likely benefits to youth in the community, regardless of the focus of the task (Flaspohler et al. 2011). Consistent with this would be the findings of Bickman et al. (1999), who found that youth who did not receive formal services within a SOC improved in symptoms and mental health functioning at the same rate as (or, in some instances, a greater rate than) those who received comprehensive SOC services. This suggests that the community’s collaborative efforts to create and support a SOC might contribute to improvements in youth and families separate from and in addition to the provision of formal services as part of the SOC. That is, while infrastructure reform and formal treatment may not directly impact child and family outcomes (e.g., Bickman and Heflinger 1995), if broader changes are occurring that bring the community together, these changes might contribute to functional improvements for children and families. Thus, to understand system change in SOCs going forward, it will be important to identify the relevant contextual factors in the broader community and how they might influence outcomes for children and families.
Recent efforts (see Strater et al. 2012) highlight the far-ranging needs of families served within SOCs and point to the potential benefit of an ecologically-grounded approach that accounts for the varied proximal and distal influences on child and family functioning (Cook and Kilmer 2010a; Farmer and Farmer 2001; Tolan and Dodge 2005). Children and families would benefit from services and supports implemented to build on the families’ resources and address their needs, with plans of care that utilize community-based resources, foster networks of support, and extend beyond formal mental health treatment and professionals’ billable hours (see, e.g., Brashears et al. 2012; Cook and Kilmer 2010b; Melton 2010).
Addressing the broad needs of families, particularly given that those served by the public mental health system are also likely to be living in poverty, is certainly consistent with the tenets of the SOC philosophy. However, in light of current practices, it would reflect considerably more than “tweaking the mechanisms of quality improvement and assurance” (Melton, 2010, p. 174); rather, it would require more concerted efforts to change the systems that are designed to address the needs of children with severe emotional disturbances and their families. SOC professionals, administrators, and organizations should work to address adversities and issues that fall outside of most traditional mental health interventions (e.g., assistance in securing quality housing or living wage employment) and, critically, seek to engage and partner with community resources such as faith-based communities and other entities with the potential to serve as “natural” helpers and supports (Cook and Kilmer 2010b; Farmer and Farmer 2001; Kilmer et al. 2010a; Melton 2010). This latter step would help build needed social connections and supports for families and provide means of accessing needed resources that extend beyond the interventions typically delivered within traditional mental health “treatment” approaches.
Conclusions. Although strides have been made in SOC development and implementation, it is clear that further progress is necessary for SOCs to reach their potential and function optimally to benefit the children and families served. In light of their competencies, values, and systems orientation, community psychologists can play a substantive role in these efforts (Cook and Kilmer 2012). As one core area for emphasis, research is needed to enhance targeted implementation processes and change (see Foster-Fishman and Watson 2012) in SOC initiatives broadly, with specific efforts also needed in non-traditional contexts, including child welfare, juvenile justice, and, in particular, the schools.
Wraparound is increasingly referenced as a practice model that can facilitate integration of care for people of all ages who have complex problems (Bruns and Walker 2011b), and some wraparound programs have been cited as improving quality, access to care, and cost savings (Chong 2009). Wraparound service providers have been characterized as the functional equivalent of the “medical home” (Sia et al. 2004), an option for Medicaid beneficiaries in the Affordable Care Act (Center for Medicare and Medicaid Services 2010), or as a “mental health home” (Schoenwald et al. 2010). Consequently, the SOC framework and the wraparound practice approach can fit well within the national context, particularly among ongoing considerations for health care reforms, including the Medicaid health home option (see Wotring and Stroul 2011).
Consistent with these notions, Brashears et al. (2012) delineate several macro-level system and social change recommendations, including integrating SOC principles and values into health care reform (see also Miller et al. 2012). These recommendations are well-founded, as the SOC philosophy and the wraparound practice model fit well with increasing efforts at developing models of co-located or integrated primary medical and mental health care (see, e.g., American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics—Task Force on Mental Health 2009; Stroul 2006; Tolan and Dodge 2005; Wotring and Stroul 2011). For instance, when implemented well, wraparound focuses on the range of needs of the child and the family, not just narrowly-defined mental health needs of the child, resulting in a greater potential for addressing health disparities in these children and families (Cook and Kilmer 2010a; Kilmer et al. 2010a; Tolan and Dodge 2005).
Other actionable recommendations put forth by Brashears et al. (2012), such as modifying Medicaid policy and regulations, also align with similar calls to expand the range of reimbursable services (e.g., Cook and Kilmer 2010a; Tolan and Dodge 2005). In addition, Kilmer et al. (2010a) recommended shifting the definition of “patient” from the individual child to the family within the Medicaid system and broadening the terms of the system, so that “medical necessity” does not function as the main criterion for accessing needed services and supports. Community psychologists (and others interested in social justice and social issues) can advocate and work to support such “big picture” and longer-range changes in policy, funding mechanisms, and system function.
In the interim, given the proliferation of SOCs and wraparound-based initiatives around the country—and the fact that the extant literature includes notable gaps regarding the “active” components of SOCs, strategies for attending to families’ larger contexts, and the qualities, characteristics, and practices that are necessary and sufficient to support positive child and family outcomes—it is crucial to enhance the functioning of those systems by providing data-driven feedback to guide training and workforce development, resource allocation, and practice-relevant policies and procedures ‘on the ground’. Such work is imperative to appropriately serve, support, and meet the needs of children and families.
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Kilmer, R.P., Cook, J.R. Moving Forward with Systems of Care: Needs and New Directions. Am J Community Psychol 49, 580–587 (2012). https://doi.org/10.1007/s10464-012-9513-y
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DOI: https://doi.org/10.1007/s10464-012-9513-y