BUILDING SYSTEMS OF CARE:
CRITICAL STRUCTURES AND PROCESSES
Presentation by:
Sheila A. Pires
Human Service Collaborative
November 3, 2005
Sponsored by the Pennsylvania Child Welfare Training Program
Purpose and Structure of the Training
•Increase knowledge about what is involved in building
systems of care: critical structures, essential process
elements, examples – Didactic, Questions/Discussion
•Assess system-building progress and stage of
development – Break out by County/Facilitated Discussion
•Develop specific action agendas to advance
system-building efforts – Break out by County/Facilitated
Discussion/Technical Assistance
•Peer Learning – Reporting Back/Large Group Discussion
Definition of a System of Care
A system of care incorporates a broad array
of services and supports for a defined population
that is organized into a coordinated network,
integrates care planning and management across
multiple levels, is culturally and linguistically
competent, and builds meaningful partnerships
with families and youth at service delivery,
management, and policy levels.
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
National System of Care Activity
• CASSP
• RWJ MHSPY
• CASEY MHI
• CMHS GRANTS
• CSAT GRANTS
• ACF GRANTS
• CMS GRANTS
• PRESIDENT’S NEW FREEDOM
MENTAL HEALTH COMMISSION
• STATE INFRASTRUCTURE GRANTS
Pires, S. (2002) Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
System of care is, first and foremost, a set of
values and principles that provides an organizing
framework for systems change on behalf of
children, youth and families.
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
Values and Principles
for the System of Care
CORE VALUES
• Child centered and family focused
• Community based
• Culturally competent
Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC:
Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. Reprinted by permission.
Values and Principles
for the System of Care
 Comprehensive array of services/supports
 Individualized services guided by an individualized
service plan
 Least restrictive environment that is clinically
appropriate
 Families and surrogate families and youth full
participants in all aspects of the planning and
delivery of services
 Integrated services
Continued …
Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC:
Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. Reprinted by permission.
Values and Principles
for the System of Care




Care management or similar mechanisms
Early identification and intervention
Smooth transitions
Rights protected, and effective advocacy efforts
promoted
 Receive services without regard to race, religion,
national origin, sex, physical disability, or other
characteristics and services should be sensitive and
responsive to cultural differences and special needs
Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC:
Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. Reprinted by permission.
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.
Youth Development Principles
•
•
•
•
•
•
Adolescent Centered
Community Based
Comprehensive
Collaborative
Egalitarian
Empowering
• Inclusive
• Visible, Accessible,
and Engaging
• Flexible
• Culturally Sensitive
• Family Focused
• Affirming
Pires, S. & Silber, J. (1991). On their own: Runaway and homeless youth and the programs that serve them. Washington, D.C.: Georgetown University
Child Development Center.
System of Care: Operational Characteristics
•Collaboration across agencies
•Partnership with families
•Cultural & linguistic competence
•Blended, braided, or coordinated financing
•Shared governance across systems & with families
•Shared outcomes across systems
•Organized pathway to services & supports
•Interagency/family services planning teams
•Interagency/family services monitoring teams
•Single plan of care
•One accountable care manager
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
System of Care: Operational Characteristics
•Cross-agency care coordination
•Individualized services and supports “wrapped around”
child/family
•Home- & community-based alternatives
•Broad, flexible array of services and supports
•Integration of clinical treatment services & natural
supports, linkage to community resources
•Integration of evidence-based and effective practices
•Cross-agency MIS
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
Current Systems Problems
• Lack of home and community-based services and supports
• Patterns of utilization
• Cost
• Administrative inefficiencies
• Knowledge, skills and attitudes of key stakeholders
• Poor outcomes
• Financing structures
• Pathology-based/medical models, deficit-oriented, punitive
systems
Pires, S. (1996). Human Service Collaborative, Washington, D.C.
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 service array
Reactive, crisis-oriented
Focus on prevention/early
intervention
Focus on “deep end,” restrictive
Least restrictive settings
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.
SYSTEMS CHANGE FOCUSES ON:
•Policy Level (e.g., financing; regs; rates)
•Management Level (e.g., data; QI; HRD; system
organization)
•Frontline Practice Level (e.g., assessment; care planning;
care management; services/supports provision)
•Community Level (e.g., partnership with families, youth,
natural helpers; community buy-in)
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Frontline Practice Shifts
Control by professionals
Only professional services
Multiple case managers
Multiple service plans for child
Family blaming
Deficits
Mono Cultural
Partnerships with
families
Partnership between
natural and professional
supports and services
One service coordinator
Single plan for child and
family
Family partnerships
Strengths
Cultural Competence
Orrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to Strengthen Our Community
Examples of Family Members:
Shifts in Roles and Expectations
Recipient of information
re: child’s service plan
Passive partner in service
planning process
Service planning
team leader
Unheard voice in program
evaluation
Participant in program
evaluation
Partner (or
independent) in
developing and
conducting program
evaluations
Recipient of services
Partner in planning and
developing services
Service providers
Uninvited key stakeholders
in training initiatives
Participants in training
initiatives
Partners and
independent trainers
Advocacy & peer support
Advocacy & peer support
Advocacy & peer
support
Lazear, K. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
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.
The Total Population of Children and Families
Who Depend on Public Systems
• Children and families eligible for Medicaid
• Children and families eligible for the State Children's Health
Insurance Program (SCHIP)
• Poor and uninsured children and families who do not qualify for
Medicaid or SCHIP
• Families who are not poor or uninsured but who exhaust their
private insurance, often because they have a child with a serious
disorder
• Families who are not poor or uninsured and who may not yet
have exhausted their private insurance but who need a particular
type of service not available through their private insurer and
only available from the public sector.
Pires, S. (1997). The total population of children and families who depend on public systems. Human Service Collaborative: Washington, D.C.
Systems of Care
More
complex
needs
2 - 5%
15%
Less
complex
needs
80%
Intensive
Services
Accessible
high-quality
services
and
supports
Assessment,
Prevention
and Universal
Health
Promotion
Child Welfare Population Issues
•All children and families involved in child welfare?
If subsets, who?
•Demographic: e.g., infants, transition-age youth
•Intensity of System Involvement: e.g., out of home placement,
multi-system, length of stay
•At risk: e.g.,
Children with natural families at risk of out of home placement?
Children in permanent placements that are at risk of disruption ?
(e.g., subsidized adoption, kinship care, permanent foster care)
• Level of severity: e.g.,
Children with serious emotional/behavioral disorders, serious
physical health problems, developmental disabilities,
co-occurring
Pires, S.A. 2004. Human Service Collaborative. Washington, D.C.
Example: Transition-Age Youth
What outcomes do we want to see for this population?
Policy Level:
•What systems need to be involved?
e.g., Housing, Vocational Rehabilitation, Employment
Services, Mental Health and Substance Abuse, Medicaid,
Community Colleges/Universities, Physical Health, Juvenile
Justice, in addition to Child Welfare
•What dollars/resources do they control?
Continued
Example: Transition-Age Youth
Management Level:
•How do we create a locus of system management
accountability for this population?
E.g., In-house? Lead community agency?
Frontline Practice Level:
•Are there evidence-based/promising approaches targeted
to this population?
•What training do we need to provide and for whom to
create desired attitudes, knowledge, skills about this
population?
•What providers know this population best in our
community?
Continued
Example: Transition-Age Youth
Community Level:
•What are the partnerships we need to build with
youth and families?
•How can natural helpers in the community play a role?
•How do we create larger community buy-in?
•What can we put in place to provide opportunities
for youth to contribute and feel a part of the larger
community?
What does our system design look like for this population?
Child Welfare Outcomes
•Safety
•Permanency
•Well-Being
Difficult to achieve without
taking a system of care approach
Examples of Sources of Funding for Children/Youth
with Behavioral Health 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
• Katie Beckett Option
Mental Health
• MH General Revenue
• MH Medicaid Match
• MH Block Grant
• 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
Substance Abuse
• SA General Revenue
• SA Medicaid Match
• SA Block Grant
Education
Juvenile Justice
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants
Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public
sector. Washington, DC: Human Service Collaborative. Revised 2005.
• WAGES
• 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)
• Local Funds
WHO CONTROLS POLICY AND DOLLARS?
Key
•State Medicaid Agencies
Some Others
•Commercial Insurers
•State/Local Child Welfare Agencies
•Employment Services
•State/Local Mental Health Authorities
•State/Local Substance
Abuse Agencies
•Public Health and Primary Care
•State/Local Education Agencies
•State and Local Juvenile Justice Systems
•Housing
OTHER CRITICAL PLAYERS
“Gatekeepers” (e.g., managed care organizations,
judges, interagency teams)
Providers
Natural Helpers and Community Resources
Families
Youth
Pires, S. (2004). Human Service Collaborative, Washington, D.C.
Local Ownership
State Commitment
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
Converging Trends
Pires, S. (2003). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Efficacy of Research
(Barbara Burns’ Research at Duke University)
• Most evidence of efficacy: Intensive case
management, in-home services, therapeutic foster
care
• Weaker evidence (because not much research
done): Crisis services, respite, mentoring, family
education and support
• Least evidence (and lots of research): Inpatient,
residential treatment, therapeutic group home
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Evidence-Based Practices
And Promising Approaches
Evidence-based practices
Show evidence of effectiveness through carefully controlled
scientific studies, including random clinical trials
Promising approaches
Show evidence of effectiveness through experience of key
stakeholders (e.g., families, youth, providers, administrators)
and by data collected by program/system
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Examples of Evidence-Based Practices
•Multisystemic Therapy (MST)
•Multidimensional Treatment Foster Care (MDTFC)
•Functional Family Therapy (FFT)
•Cognitive Behavioral Therapy (various models)
•Intensive Care Management (various models)
Examples of Promising Practices
•Family Support and Education
•Wraparound Service Approaches
•Mobile Response and Stabilization Services
Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidencebased interventions for severe emotional and behavioral disorders. Oxford
University Press and State of New Jersey BH Partnership (www.njkidsoc.org)
Examples from Hawaii’s List of Evidence Based Practices
Problem Area
Anxious or
Avoidant
Behaviors
Depressive or
Withdrawn
Behaviors
Best
Support
Cognitive
Behavior
Therapy
(CBT);
Exposure
Modeling
CBT
Good
Support
Moderate
Support
CBT with
None
Parents; Group
CBT; CBT for
Child & Parent;
Educational
Support
CBT with
None
Parents; InterPersonal Tx.
(Manualized);
Relaxation
HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd
Examples from Hawaii’s List of Evidence Based Practices
Problem Area
Disruptive &
Oppositional
Behaviors
Best
Support
Good Support
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
None
Known Risks:
Group Therapy
Juvenile Sex
Offenders
None
Moderate
Support
Social
Relations
Training;
Project
Achieve
Multisystemic
Therapy
HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd
Examples from Hawaii’s List of Evidence Based Practices
Problem Area
Delinquency &
Willful
Misconduct
Behavior
Best
Support
Good Support
Moderate
Support
None
Multisystemic
Therapy;
Functional Family
Therapy
MultiDimensional
Treatment
Foster Care;
Wraparound
Foster Care
CBT
Behavior Therapy; None
Purdue Brief
Family Therapy
Known Risks:
Group Therapy
Substance Use
Known Risks:
Group Therapy
HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd
KAUFFMAN BEST PRACTICES PROJECT AND
NATIONAL CHILD TRAUMATIC STRESS
NETWORK
•Trauma Focused-Cognitive Behavioral Therapy (TF-CBT)
•Abuse Focused-Cognitive Behavioral Therapy (AF-CBT)
•Parent Child Interaction Therapy (PCIT)
Shared Characteristics of
Evidence-Based (and Promising)
Interventions
• Function as service components within systems of care
• Provided in the community
• Utilize natural supports, parents, with training and
supervision provided by those with formal mental health
training
• Operate under the auspices of all child-serving systems,
not just mental health
• Studied in the field with “real world” children and families
• Less expensive than institutional care (when the full
continuum is in place)
Burns, B. and Hoagwood, K. 2002. Community treatment for youth. New York: Oxford University Press.
“The current need is …for building
efficacious treatment interventions
within effective, compassionate, and
competent systems of care”
Peter Jensen, M.D.
Building Community Treatment for Youth
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
EXAMPLES OF SYSTEMS OF CARE
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
Mental Health
•Crisis Billing
•Block Grant
•HMO Commercial
Insurance
10M
2.0M
Management Entity:
Wraparound Milwaukee
Management Service Organization (MSO)
$30M
Per Participant Case Rate
Care
Coordination
Child and Family Teams
Provider
Network
240 Providers
85 Services
Plans of Care
Mngt. Entity: County Agency
Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division,
Child and Adolescent Services Branch
OUTCOMES (Milwaukee Wraparound)
•60% reduction in recidivism rates for delinquent
youth from one year prior to enrollment to one year
post enrollment
•Decrease in average daily RTC population from 375
to 50
•Reduction in psychiatric inpatient days from 5,000 days
to less than 200 days per year
•Average monthly cost of $4,200 (compared to $7,200
for RTC, $6,000 for juvenile detention, $18,000 for
psychiatric hospitalization
Next Phase of Milwaukee Wraparound
Partnership with HMO to become “medical/clinical”
home for all children in foster care in the county –
•Locus of accountability for managing physical,
dental, and behavioral health care to achieve ASFA
well-being outcomes
DAWN Project
Indianapolis, IN
How Dawn Project is Funded
Dawn Project
Cost Allocation
Management Entity:
Non profit behavioral
health organization
More Dawn Features
Life Domains
Health/medical
Safety/crisis
Family/relationships
Educational/vocational
Psychological/emotional
Substance abuse
Social/recreational
Daily living
Cultural/spiritual
Financial/legal
• Service coordination
plans, including safety
and crisis plan
• Broad array of treatment
and supportive services
• Extensive provider
network, paid fee for
service
Dawn Service Array
Behavioral Health
Psychiatric
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
Assessment
Medication follow-up/psychiatric review
Nursing services
Mentor
Community case management/case aide
Clinical mentor
Educational mentor
Life coach/independent living skills
mentor
Parent and family mentor
Recreational/social mentor
Supported work environment
Tutor
Community supervision
Dawn Service Array, Continued
Placement
Acute hospitalization
Foster care
Therapeutic foster care
Group home care
Relative placement
Residential treatment
Shelter care
Crisis residential
Supported independent
living
Respite
Crisis respite
Planned respite
Residential respite
Service
Coordination
Case management
Service coordination
Intensive case management
Other
Camp
Team meeting
Consultation with other
professionals
Guardian ad litem
Transportation
Interpretive services
Discretionary
Activities
Automobile repair
Childcare/supervision
Clothing
Educational expenses
Furnishings/appliances
Housing (rent, security
deposits)
Medical
Monitoring equipment
Paid roommate
Supplies/groceries
Utilities
Incentive money
NJ Children’s System of Care Initiative
CHILD
Child
Welfare
Other
JJC
Court
School
Referral
Family
& Self
Community
Agencies
Screening with Uniform Protocols
Contracted
Systems
Administrator CSA
CMO
•Complex Multi-System
Children
•ISP Developed
•Full Plan of Care
Authorized
•Registration
•Screening for self-referrals
•Tracking
•Assessment of Level of Care Needed
•Care Coordination
•Authorization of Services
FSO
Family to Family Support
Community
Agencies
•Uncomplicated Care
•Service Authorized
•Service Delivered
El Paso County, Colorado
State-Capped Out of Home Placement Allocation
County DHS acts as MCO (contracting, monitoring, utilization review)
Child Welfare $$
Case rate contract with CPA
BH Tx $$ matched by Medicaid.
Capitation contract with BHO
with risk-adjusted rates for child
welfare-involved children
Joint treatment planning approved by DHS
Child Placement Agencies (CPA)
Responsible for full range of Child Welfare
Services & ASFA (Adoption and Safe
Families ACT) related outcomes
Mental Health Assessment and Service
Agency (BHO)
Responsible (at risk) for full range
of MH treatment services & clinical
outcomes & ASO functions
Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.
Types of Outcomes Achieved by Systems
Of Care
•Reduction in inpatient hospitalization and residential
treatment placements and lengths of stay
•Reductions in detention rates
•Reductions in out-of-home placements and lengths of
stay
•Improved clinical and functional outcomes
•Higher family and youth satisfaction
•Lower costs per child served for total system if
a range of home and community-based is in place
Data on Outcomes Available From (Among Others):
•Burns & Hoagwood, Community Treatment for Youth:
Evidence-Based Interventions for Severe Emotional and
Behavioral Disorders, Oxford University Press
•Kaufman Foundation, Closing the Quality Chasm in Child
Abuse Treatment: Identifying and Disseminating Best
Practices, www.kauffmanfoundation.org
•Wraparound Milwaukee (bkamrad@wrapmilw.org)
•Dawn Project (krotto@choicesteam.org)
•Coordinated Care Services, Inc. (jlevison-johnson@ccsi.org)
•Massachusetts Mental Health Services Program for Youth
(katherine_grimes@nhp.org)
•Youth Villages (tim.goldsmith@youthvillages.org)
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.
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.
EXAMPLE
Goal: One plan of care; 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.
MCO
•Prior Authorization
•Clinical Coordinator
Out-patient
services
Primary
Care
Crisis
Services
Children in
out-of-home
placements
Med. Mngt.
Treatment
Foster Care
In-Home
Services
Education
•Child Study Team
•Teacher
Alternative
School
EH Classroom
Related Services
Result: Multiple plans of care; multiple care managers
Pires, S. (2004).Building Systems of Care: A Primer. Human Service Collaborative: Washington, DC
System of Care Functions Requiring Structure
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Planning
Decision Making/Policy Level Oversight
System Management
Benefit Design/Service Array
Evidence-Based Practice
Outreach and Referral
System Entry/Access
Screening, Assessment, and Evaluation
Decision Making and Oversight at the
Service Delivery Level
– Care Planning
– Care Authorization
– Care Monitoring and Review
Care Management or Care Coordination
Crisis Management at the Service
Delivery and Systems Levels
Utilization Management
Family Involvement, Support, and
Development at all Levels
Youth Involvement, Support, and
Development
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Staffing Structure
Staff Involvement, Support, Development
Orientation, Training of Key Stakeholders
External and Internal Communication
Provider Network
Protecting Privacy
Ensuring Rights
Transportation
Financing
Purchasing/Contracting
Provider Payment Rates
Revenue Generation and Reinvestment
Billing and Claims Processing
Information Management
Quality Improvement
Evaluation
System Exit
Technical Assistance and Consultation
Cultural Competence
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.
Core Elements of an Effective SystemBuilding Process
Leadership and Constituency Building
•
•
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•
•
•
•
•
•
•
A core leadership group
Evolving leadership
Effective collaboration
Partnership with families and youth
Cultural competence
Connection to neighborhood resources and natural helpers
Bottom-up and top-down approach
Effective communication
Conflict resolution, mediation, and team-building mechanisms
A positive attitude
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.
Core Elements of an
Effective System-Building Process
Being Strategic
•
•
•
•
•
•
•
•
•
•
•
•
•
A strategic mindset
A shared vision based on common values and principles
A clear population focus
Shared outcomes
Community mapping—understanding strengths and needs
Understanding and changing traditional systems
Understanding of the importance of “de facto” mental health providers (e.g.,
schools, primary care providers, day care providers, head start)
Understanding of major financing streams
Connection to related reform initiatives
Clear goals, objectives, and benchmarks
Trigger mechanisms—being opportunistic
Opportunity for reflection
Adequate time
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative
Challenges to Collaboration “Barrier Busters”
CHALLENGE
Language differences:
Mental health jargon vs.
court jargon
BARRIER BUSTERS
• Cross training
• Share each other’s turf
• Share literature
Role definition: “Who’s in
charge?”
• Family driven/accountability
• Team development training
• Job shadowing
• Communication channels
• Share myths and realities
Information sharing among
systems
• Set up a common data base
• Share organizational charts/phone lists
• Share paperwork
• Promote flexibility in schedules to support attendance in
meetings
Addressing issues of
community safety
• Document safety plans
• Develop protocol for high-risk kids
• Demonstrate adherence to court orders
• Maintain communication with District Attorneys
• Myths of “bricks and mortar”
Maintaining investment
from stakeholders
• Invest in relationships with partners in collaboration
• Share literature and workshops
• Track and provide meaningful outcomes
Sharing value base
• 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
Wraparound Milwaukee. (1998). Challenges to collaboration/“barrier busters.” Milwaukee, WI: Milwaukee County
Mental Health Division, Child and Adolescent Services Branch.
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, including family
organizations, and youth in system building processes and
structural decision making, design, and implementation;
• A cross-agency perspective, that is, processes and
structures that operate in a non-categorical fashion.
• State and local partnership and shared commitment.
Pires, S. (2002).Building systems of care: A primer. Washington D.C.: Human Service Collaborative.
How Systems of Care are Structuring
Family Involvement at Various
Levels of the System
LEVEL
STRUCTURE
Policy
At least 51% vote on governing bodies; as
members of teams to write and review RFPs
and contracts; as members of system design
workgroups and advisory boards
Management
As part of quality improvement processes; as
evaluators of system performance; as trainers
in training activities; as advisors to selecting
personnel
Services
As members of team for own children; as
family support workers, care managers, peer
mentors, system navigators for other families
Pires, S. (1996). Human Service Collaborative, Washington, D.C.
Why Culture Matters
Because it affects…
• Attitudes and beliefs about services and systems
• Expression of symptoms
• Coping strategies
• Help-seeking behaviors
• Utilization of services
• Appropriateness of services and supports
• Disparities in access
Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.
BUILDING 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.
Elements of Effective Planning Processes
Are staffed
Involve key stakeholders
Involve families early in the process and in ways that are
meaningful
Ensure meaningful representation of racially and ethnically
diverse families
Develop and maintain a multi-agency focus
Build on and incorporate related programmatic and planning
initiatives
Continually seek ways to build constituencies, interest, and
investment
Pay attention to sustainability and growth of system changes
from day one
Pires, S. (1991). State child mental health planning. Washington, DC: Georgetown University Child Development Center, National Technical Assistance
Center of Children’s Mental Health.
A Planning Process for Family and Children’s Service Reform
The
System As
It Is Now
Outcomes
For
Children
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
Strategies for Involving
Parents in Planning
• Providing special orientation and training and ongoing
assistance; consulting with parents before meetings.
• Having more than token representation.
• Contracting with community-based and parent
organizations to develop/sustain process.
• Working through parent organizations.
• Asking agencies that work with parents to recommend
parents to participate in planning.
• Paying stipends, transportation, child care.
• Holding planning meetings in the evenings or on
weekends, in locations such as schools.
• Conducting surveys to elicit views of many parents.
Continued …
Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and support services program.
Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.
Strategies for Involving
Parents in Planning (continued)
• Using parents who work regularly with other parents to
conduct focus groups.
• Working with family support groups to tap into informal
networks.
• Working with home visiting programs and health clinics to
reach out to parents.
• Working with family preservation and family reunification
programs.
• Conducting sessions for planning group members with
trained facilitators to explore attitudes about race, culture,
families.
• Publicly acknowledging the contributions of parents.
Emig, C., Farrow, F. & Allen, M. (1994). A guide for planning: Making strategic use of the family preservation and
support services program. Washington, D.C.: Center for the Study of Social Policy & Children’s Defense Fund.
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.
System Management
Day-to-day operational
decision making
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
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.
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.
Example of Governance/Management Structure
Care Management Entity
Pires, S. (1996). Contracted system management structure. Washington, DC: Human Service Collaborative.
Example of Governance/Management Structure
BRING THE CHILDREN HOME STATE LEGISLATION
COUNTY EXECUTIVE
Local Governing Board
Agency Directors
Family/Youth Reps.
Providers Forum
SOC Team Leader
“Bring the Children Home”
Interagency Care Management Team
“Bring the Children Home”
Care Managers
Families/Youth Served
Other Agency Workers
Pires, S. (1996). Evolving governance structure. Washington, DC: Human Service Collaborative.
Examples of Types of Family Partnership in
System Governance and Management
• Input/evaluation of key management
• Input/evaluation of quality of services and programs
• Local system of care input
• Resource allocation
• Service planning and implementation
• Policies and procedures
• Grievance and resolution procedures
Conlan, L. (2003). Implementing family involvement. Burlington, VT: Vermont Federation of Families for Children’s Mental Health.
Distinctions Among
Screening, Assessment and
Evaluation, and Care Planning
Screening
• 1st step, triage, identify children at high risk, link to
appropriate assessments
Assessment
• Based on data from multiple sources
• Comprehensive
• Identify strengths, resources, needs
• Leads to care planning
Continued …
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative
Distinctions Among
Screening, Assessment and
Evaluation, and Care Planning
Evaluation
• Discipline-specific, e.g., neurological exam
• Closer, more intensive study of a particular or suspected
clinical issue
• Provides data to assessment process
Care planning
• Individualized decision making process for determining services
and supports
• Draws on screening, assessment, and evaluation data
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Life Domain Areas
Adapted from. Dennis, K, VanDenBerg, J., & Burchard, J. (1990). Life domain areas. Chicago: Kaleidoscope.
Definition of Wraparound
•Wraparound is “ . . . a definable planning
process that results in a unique set of
community services and natural supports that
are individualized for a child and family to
achieve a positive set of outcomes.”*
*Burns, B. & Hoagwood, K. (Eds.) Community-Based Interventions for Children and
Families. Oxford: Oxford University Press.
Wraparound and System of Care
Wraparound is an important approach to care
planning and service provision within a system of care
But ….
It does not, in and of itself, constitute a system of care!
Pires., S. 2005. Human Service Collaborative. Washington, D.C.
Examples of What You’d Want to Provide Based on
Effectiveness Literature
Outpatient Models:
•Cognitive Behavior Therapy (various models)
•Functional Family Therapy (FFT)
•Parent Child Interaction Therapy (PCIT)
Intensive In-Home Models:
•Multisystemic Therapy (MST)
Out-of-Home Model:
•Multidimensional Treatment Foster Care
•Intensive Care Management
Examples of Other Home and Community-Based Services
You’d Want to Provide Based on
Practice/Family Experience & Outcomes Data
•Intensive in-home services (not just MST)
•Child respite services
•Mobile response and stabilization services
•Mental health consultation services
•Independent living skills and supports
•Family/youth education and peer support
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
What You Don’t See Listed as Evidence-Based Practice
•Traditional office-based “talk” therapy
•Residential Treatment
•Group Homes
•Day Treatment
What Natural
Helpers Can Provide
•
•
•
•
•
•
•
•
Emotional support
System navigation
Resource acquisition
Concrete help
Decrease social isolation
Greater understanding of community
Community navigation
Effective intervention or support strategies
Lazear, K., (2003). “Primer Hands On”; A skill building curriculum. Human Service Collaborative: Washington, D.C.
Pre-Equipo Network
Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.
Post –EQUIPO Network
Gutierrez-Mayka, M & Wolfe, A. (2001). EQUIPO Neighborhood Family Team: Final Evaluation Report.
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
Lazear, K. (2003). Family Experience of the Mental Health System, Research and Training Center for Children’s Mental Health, Tampa, FL.
Service Array Focused on
a Total Eligible Population
Universal
Core Services
Targeted
Prevention
Early Intervention
Intensive Services
 Family Support
Services
 Youth Development
Program/Activities
 Coordinated Intake
Assessment &
Treatment Planning
 Intensive Case
Management/Care
Coordination
 Wraparound Services
& Supports
 Clinical Services
Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of
Trainers Conference]. Washington, DC: Human Service Collaborative.
Where Family Organizations Fit
Into Service Array
As technical assistance
providers & consultants
As direct service
providers
 Training
 Family Liaisons
 Evaluation
 Care Coordinators
 Research
 Support
 Outreach
 Family Educators
 Specific Program
Managers (respite, etc)
Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.
Comparison of Case Management
and Care Management
Case Management
• Little authority over
resources
• Child centered
• Reactive
• Service provided to
placement
• Organization of existing
services
• Uses current system
Care Management
• More control over
resources
• Family centered
• Proactive
• Unconditional care
• Creation of services
when not available
• Family and community
supports
Adapted from: Community Care Systems. (2000). Comparison of case management and care coordination.
Madison, WI.
Care Management
Continuum
Children needing
only brief shortterm services and
supports
UM-type care
management
No “caseloads”
Children needing
intermediate level of
services and supports
Service
coordination
Large caseloads
Children needing
intensive and
extended level of
services and
supports
Intensive care
management
Very small
caseloads
Pires, S. (2001). Case/care management continuum. Washington, DC: Human Service Collaborative.
Care Management/Service Coordination
Structure Principles
• Support a unitary (i.e., across agencies) care
management/coordination approach even though multiple
systems are involved, just as the care planning structure
needs to support development of one care plan.
• Support the goals of continuity and coordination of care
across multiple services and systems over time.
• Encompass families and youth as partners in the process
of managing/coordinating care.
• Incorporate the strengths of families and youth, including
the natural and social support networks on which families
rely.
Pires, S. (20O2). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Utilization Management
Concerns
Who is using services?
What services are being used?
How much service is being used?
UM
What is the cost of the services
being used?
What effect are the services
having on those using them? (i.e.,
Are clinical/functional outcomes
improving? Are families and
youth satisfied? Are children
returning home?)
Pires, S. (2001). Utilization management concerns. Washington, DC: Human Service Collaborative.
Principles for
Utilization Management
• UM must be understood and embraced by all
key stakeholders
• UM must concern itself with both the cost and
quality of care
• The UM structure needs to be tied to the quality
improvement structure
Pires.. S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Purposes of UM/Evaluation Data: Examples
•Planning and Decision Support (Day-to-Day and
Retrospectively)
•Quality Improvement
•Cost/Benefit Monitoring
•Research
•Marketing
•Accountability
Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.
Evaluation & Data Gathering
To eliminate disparities, disproportionalities, and
improve quality of care, we need to collect data.
• Questionnaires
• Surveys
• Interviews
• Focus groups
• Clinical outcome data
Using a participatory evaluation framework
Financing Strategies to Support Improved
Outcomes for Children & Families
•FIRST PRINCIPLE:
•System Design Drives Financing
•REDEPLOYMENT:
•Using the Money We Already Have
•The Cost of Doing Nothing
•Shifting Funds from Treatment to Early Intervention
•Moving Across Fiscal Years
•REFINANCING:
•Generating New Money by Increasing Federal Claims
•The Commitment to Reinvest Funds for Families and Children
•Foster Care and Adoption Assistance (Title IV-E)
•Medicaid (Title XIX)
Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Center for the Study of Social Policy: Washington, D.C..
Financing Strategies to Support
Improved Outcomes
RAISING OTHER REVENUE TO SUPPORT FAMILIES AND
CHILDREN:
- Donations
- Special Taxes and Taxing Districts for Children
- Fees and Third Party Collections Including Child Support
- Trust Funds
FINANCING STRUCTURES THAT SUPPORT GOALS:
- Seamless Services: Financial claiming invisible to families
- Funding Pools: Breaking the lock of agency ownership of funds
- Flexible Dollars: Removing the barriers to meeting the unique
needs of families
- Incentives: Rewarding good practice
Friedman, M. (1995). Financing strategies to support improved outcomes for children. Center for the Study of Social Policy: Washington, D.C.
Where to Look for Money
and Other Types of Support
e
e
Pires, S. (1994). Where to look for money and other types of support. Human Service Collaborative: Washington, D.C.
Milwaukee Wraparound
Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services
Branch.
How to Finance/Implement Systems of Care
•Adopt a Population Focus: Who are the populations
of youth for whom you want to change practice/outcomes
•Adopt a Cross-Systems Approach: What other systems
serve these youngsters; who controls potential or actual
match dollars; which systems now spend a lot on
restrictive levels of care with poor outcomes or on deficitbased assessments not linked to effective services –
Opportunities for re-direction
•Identify Incentives to Finance/Implement Systems of Care
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
Examples of Incentives to Various
Child-Serving Systems
Medicaid: slowing rate of growth in “deep end” services
Child Welfare: meeting Adoptions and Safe Families Act
outcomes; reducing out-of-home placements
Juvenile Justice: creating alternatives to incarceration;
reducing detention costs
Mental Health: more effective delivery system
Education: reducing special education expenditures
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
Examples of Cross-System Partnerships to Finance
and Implement Evidence-Based and Promising Practices
District of Columbia – MST, Mobile Response, In-Home
Medicaid Rehab Option pays for MST, Intensive
Home-Based Services (Ohio model), Mobile Response
and Stabilization Services (NJ model)
Child Welfare provides match and paid for initial
training, coaching, provider capacity development;
Mental health/child welfare share costs of outcomes tracking
Juvenile Justice now paying match, training costs as well
Medicaid HMO expressing interest in Mobile Crisis
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
Examples of Cross-System Partnerships to Finance
and Implement Evidence-Based and Promising Practices
New Mexico - MST
Medicaid managed care pays for service costs of MST
Juvenile Justice pays for training/coaching/fidelity
monitoring
Hawaii – Range of EBPs
Medicaid managed care, Education special ed, mental
health general revenue/block grant pay for range of
EBPs, training, monitoring
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
Examples of Cross-System Partnerships to Finance
and Implement Evidence-Based and Promising Practices
New Jersey – In-Home, Mobile Response, Intensive Case
Management, Family Support
Medicaid Rehab Option pays for in-home, Mobile
Response and Stabilization, intensive case management,
family support
Child welfare contributed match dollars
Tennessee – MST, Multi-Dimensional Treatment
Foster Care
Medicaid managed care and mental health GR pay for
MST and MDTFC
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
Characteristics of
Effective Provider Networks
• Responsive to the population that is the focus of the system of care.
• Encompass both clinical treatment service providers and natural,
social support resources, such as mentors and respite workers.
• Include both traditional and non traditional, indigenous providers.
• Include culturally and linguistically diverse providers.
• Include families and youth as providers of services and supports.
• Are flexible, structured in a way that allows for additions/deletions.
• Are accountable, structured to serve the system of care.
• Have a commitment to evidence-based and promising practices.
• Encompass choice for families.
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Examples of
Incentives to Providers
•
•
•
•
Decent rates
Flexibility and control
Timely reimbursements
Back up support for difficult administrative
and clinical challenges
• Access to training and staff development
• Capacity building grants
• Less paperwork
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
Purchasing/Contracting Options
Pre-Approved Provider Lists:
•Flexibility for system of care +
•Choice for families +
•Could disadvantage small indigenous providers –
•Could create overload on some providers –
Risk-Based Contracts (e.g., capitation, case rates)
•Flexibility for providers +
•Individualized care for families +
•Potential for under-service –
•Potential for overpaying for services –
Fixed Price/Service Contracts
•Predictability and stability for providers +
•Inflexible-families have to “fit” what is available –
Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C..
Progression of 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.
Human Resource
Development Functions
• Assessment of workforce requirements (i.e., What
skills are needed, what types of staff, how many
staff) in the context of systems change
• Recruitment, retention, staff distribution
• Education and training (pre-service and in-service)
• Standards and licensure
Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.
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.
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
cross-training
UNIFIED
State systems
pool training
staff, merge
training events
Promotion of
cross-training;
joint funding
Cross-agency
training gains
support
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.
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.
Summary: Common Elements of Re-Structured Systems
Values-based systems/Family and youth partnership
Identified target population, costs associated with
population, funders
Locus of accountability (and risk) for target population
Organized pathway to services for target population
Strengths-based and individualized service planning
and care monitoring (e.g., wraparound approach)
Intensive care management
Pires, S. 2004. Human Service Collaborative. Washington, D.C.
continued …
Summary:Common Elements of Re-Structured Systems
Flexible financing and contracting arrangements
(e.g., case rates, qualified provider panel – fee-for-service )
 Broad provider network: sufficient types
of services and supports (including natural helpers)
Combined funding from multiple funders (e.g., Medicaid,
child welfare, mental health, juvenile justice, education)
Real time data across systems to support clinical decisionmaking, utilization management, quality improvement
Outcomes tracking – child/family level, systems level
continued…
Pires, S. 2004. Human Service Collaborative. Washington, D.C.
Summary: Common Elements of Re-Structured Systems
Utilization management
Mobile crisis capacity
Judiciary buy-in
Re-engineered residential treatment centers
Shared governance/liability
Training and technical assistance
Transformation
Need to connect related reforms in child-serving systems
and Medicaid needs to be a partner in reform:
•SAMHSA Transformation Grants, Infrastructure Grants,
System of Care Grants
•Child Welfare System of Care Grants, Program
•Improvement Plans
•Juvenile Justice MH/SA Initiatives
•CMS Feasibility and Real Choice Grants
Pires, S. 2005. Human Service Collaborative. Washington, D.C.
“The world that we have made as a
result of the level of thinking we
have done thus far creates
problems that we cannot solve at
the same level at which we created
them.”
Albert Einstein
Pires, S. (2002).Building Systems of Care: A Primer. Washington, D.C.: Human Service Collaborative.
The measure of success is not
whether you have a tough
problem to deal with, but
whether it’s the same problem
you had last year.
John Foster Dulles
To Obtain Copies of Building Systems of Care: A Primer
Contact:
Mary Moreland, Publications Manager
Georgetown University National Technical Assistance
Center for Children’s Mental Health
202 687-8803
E-mail: deaconm@georgetown.edu
For Further Information About Building Systems of Care,
Contact:
Sheila A. Pires
Human Service Collaborative
202 333-1892
E-mail: sapires@aol.com