Beth A. Stroul, M.Ed.
4th Annual DC Summit
Now is the Time: Promoting and Implementing
Evidence-Based Solutions for Mental Health
October 8, 2014
What are states and communities doing to improve
outcomes and investments, why they’re doing it, and
how they’re doing it……..
 What?
Expanding the system of care approach
 Why?
Evidence-based practice with documented positive
outcomes
 How?
Developing and implementing strategies for wide-scale
system change

20% with diagnosable mental health condition

2-5% serious condition with functional impairment,
one of most expensive populations across systems

New Medicaid data on 29 million children (Pires, et al)
› For children using behavioral health services, mean physical and
behavioral health care expenditures $8,520/year – 5 times higher
than Medicaid children in general ($1,729/year)
› Expenditures driven by behavioral health services used

Substantial resources still being invested in highend, high-cost services across systems over and
above Medicaid

High cost of doing nothing (Pires)
Pyramid of Population of
Children and Service Needs
More
complex
needs
2 - 5%
Intensive MH
Services +Supports
Intermediate MH
Services + Supports
15%
Less
complex
needs
Pires, 2006
80%
Basic MH
Services
or
No MH
Services
Universal MH
Promotion and
Prevention
Universal
Screening or for AtRisk Populations
Early Identification

Poor outcomes
› School dropout
› Substance use
› Suicide
› Poor vocational success
› Correctional system involvement
› Inability to live independently

High financial costs across state
systems, high social costs to
families and nation
What?
The System of Care
Approach

Framework and philosophy for children’s
mental health services

Shaped the work of states, communities, tribes, and
territories – some elements in nearly all communities

Shaped national policy (Surgeon General’s Report,
President’s New Freedom Commission Children’s
Sub-Committee)

Used as framework for reform by partner child-serving
and some adult systems

Broader application than for youth with serious mental
health conditions (e.g., recovery-oriented SOCs for
substance use conditions)
“A spectrum of effective, community-based
services and supports for children and youth
with or at risk for mental health or other
challenges and their families, that is
organized into a coordinated network, builds
meaningful partnerships with families and
youth, and addresses their cultural and
linguistic needs, in order to help them to
function better at home, in school, in the
community, and throughout life.”
Home and Community-Based Treatment and
Support Services
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Assessment and evaluation
Individualized “wraparound” service
planning
Intensive care management
Outpatient therapy – individual, family,
group
Medication management
Intensive home-based services
Substance abuse intensive outpatient
services
Mobile crisis response and stabilization
Family peer support
Youth peer support
Respite services
Therapeutic behavioral aide services
Therapeutic mentoring
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Behavior management skills training
Youth and family education
Mental health consultation
Therapeutic nursery/preschool
School-based behavioral health services
Supported education and employment
Supported housing
Transportation
Out-of-Home Treatment Services
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Therapeutic foster care
Therapeutic group home care
Residential treatment services
Inpatient hospital services
Inpatient medical detoxification
Crisis stabilization services
Specific evidence-informed interventions and culture-specific
interventions can be included in each type of service
1.
Family driven and youth guided
2.
Community based
3.
Culturally and linguistically
competent
1.
2.
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4.
5.
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7.
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Broad array of evidence-informed services and supports
Individualized services
Least restrictive, clinically appropriate setting
Families and youth as full partners at all levels
Cross-system collaboration at system level
Care management for coordination at services level
Services and supports for young children and their families
Services and supports for youth and young adults in transition
to adulthood
Incorporate or link with mental health promotion, prevention,
and early identification and intervention
Continuous accountability mechanisms
Rights protection and advocacy
Nondiscrimination

Not a “model” to be “replicated” like a
manualized treatment
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Not a single “program,” but a coordinated
network of services across agencies

Not a “treatment or clinical intervention” that directly
improves child and family outcomes without
accompanying changes at the practice level to provide
effective services and supports to achieve positive child
and family outcomes
System Change + Practice Change = Improved Outcomes
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Paradigm shift, vision, value base

Organizational framework for system reform

Not a prescription, but a guide with flexibility to implement
in a way that fits each state, tribe, territory, community

Adapt the approach based on context
(political, administrative, fiscal)

Multilevel intervention – Changes at state,
local system, and practice levels
Why?
Evidence of
Improved Outcomes and
Investments

Federal Children’s Mental Health Initiative established by
Congress in 1992 to fund communities, tribes, and
territories to implement the SOC approach

National evaluation of the CMHI and other studies have
found:
› Positive outcomes for children and families
› Improvements in systems and services
› Better investment of limited resources

Results have led to efforts to expand implementation of
the approach so more children and families benefit
Stroul, Goldman, Pires, & Manteuffel, 2012
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Decrease behavioral and emotional
problems (depression, anxiety,
aggression)
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Decrease suicide rates
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Decrease substance use
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Improve school attendance and grades

Decrease involvement with juvenile
justice
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Increase stability of living situations

Increase strengths
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Decrease caregiver strain

Increase capacity to handle their child’s
challenging behavior
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Improve problem-solving skills
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Increase ability to work
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Increase peer-to-peer support
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Increase family education and supports
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Improve the service experience of caregivers and youth
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Improve system management
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Create interagency partnerships (structures,
agreements, braided funding)
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Result in systematic development and implementation of
strategic plans to improve services
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Improve requirements in contracts with
MCOs, providers, regulations, Medicaid
rules, standards, practice protocols

Improve accountability and use of data
for quality improvement and decision
making

Expand services to broad array of home and
community-based services

Customize services with individualized, wraparound
approach to service planning and delivery

Improve care management and coordination (especially
for youth with most complex, costly problems)
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Increase family-driven, youth-guided services
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Increase cultural and linguistic competence of services
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Increase use of evidence-informed practices
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Increase training of children’s mental health workforce
Redeploy resources from higher cost restrictive
services to lower cost home- and community-based
services and supports
 Increased utilization of home- and communitybased treatment services and supports
 Decreased admissions and lengths of stay in out-of-home
treatment settings (e.g., psychiatric hospitals, residential
treatment, juvenile justice, and out-of-school placements)
 Cost data demonstrating impact on costs across systems
(e.g., reduced out-of-home placements in child welfare and
juvenile justice with substantial per capita savings)
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New ROI document shows savings in short term and future
Stroul, Pires, Boyce, Krivelyova, & Walrath, 2014
Outcome
Cost Savings
Reduced Inpatient Use
Average cost/child reduced by 42%
$37 million saved when applied to all children in
funded SOCs
Reduced ER Use
Average cost/child reduced by 57%
$15 million saved when applied to all children in
funded SOCs
Reduced Arrests
Average cost/child reduced by 39%
$10.6 milling saved when applied to all children in
funded SOC
Reduced School
Dropout
Fewer school dropouts in SOCs (8.6%) than national
population (20%)
Potential $380 million saved when applied to all
children in funded SOCs (Based on monetizing
average annual earnings and earnings over lifetime)
Reduced Caregiver
Missed Work
Estimated 39% reduction in average cost of lost
productivity (Based on imputed average daily wage
of caregivers)
Outcome
Cost Savings
Oklahoma
41% reduction in average total behavioral health charges vs.
17% reduction for control group
60% reduction in average inpatient charges vs. 17% for control
group
Savings of $357 per youth per month, projected $18 million
savings if all youth in study participated in SOC
Wraparound
Milwaukee
$3,200 average total all-inclusive cost per child per month vs.
$6,083 group home, $8,821 correctional facility, $9,460
residential treatment, $39,100 inpatient
Massachusetts,
Mental Health
Services
Program for
Youth (MHSPY)
Total per child per month Medicaid claims expense less than
half for SOC group vs. comparison group (both physical and
behavioral health)
Claims 31% lower for ER, 73% lower for inpatient
Child Welfare – Alternatives to out-of-home care with
high costs and poor outcomes
 Medicaid – Alternatives to inpatient and PRTFs
 Juvenile Justice – Alternatives to detention and
correction facilities with high costs and poor outcomes
 Education – Alternatives to out-of-school placements and
high special education costs
 Substance Use – Alternatives to out-of-home treatment,
improved outcomes for youth with co-occurring
conditions
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Pires, 2006
Evidence-Based
Practice Approach
In Systems of Care
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Team-based, collaborative process for implementing
individualized, tailored care plans
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Primary strategy for operationalizing the SOC approach at
service delivery level
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Typically for children with complex needs and their families,
but can be applied for all levels of need
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Evidence-based “process” that cuts across all clinical
interventions and formal and informal supports
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Resources from National Wraparound Initiative
 Child and Family Team – Family members (and youth as
appropriate), involved providers, members of the family’s support
network collaborate to create a customized care plan
 Intensive Care Coordination – Dedicated wraparound
facilitator/care coordinator organizes and manages process
across systems (small ratio)
 Individualized Service Plan – Includes and coordinates the
entire array of needed services and supports require
 Partnership with Families and Youth – experts in analyzing the
issues in their lives and potential strategies to address them
 Peer Support – Peer support for families with “family partners”
with lived experience and increasingly youth peer support
 Collaboration – All agencies and providers work together to
reduce fragmentation and ensure coordination
 Strengths Based – Incorporates strengths and assets to build
on, enhances engagement and resiliency
 Ecological Perspective – Addresses multiple life domains
Mental
Health
Family/
Surrogate
Family
Educational/
Vocational
Living
Arrangement
Social/
Recreational
Crisis/Safety
Cultural/
Linguistic
Substance Use
Medical
Income
Legal
Spiritual
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Move to less restrictive environments
Improved functioning based on CAFAS scores
Improved school attendance and grades, fewer disciplinary
actions
Fewer out-of-home placements and days in placements
Fewer arrests, less detention, lower recidivism rates
Improvement on standardized measures of behavioral and
emotional problems
ROI, such as 29% reduction in Medicaid spending, 74% lower
inpatient costs, 32% lower ER costs, 29% lower residential
treatment costs, expenditures half of comparison group
Bruns & Suter, 2010
How?
Strategies for Expanding
Systems of Care
Innovation to Widespread Adoption

Purpose to expand the SOC approach statewide and
throughout territories and tribes
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Planning grantees develop strategic plans for expansion
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Implementation grants provide up to $1million per year for
4 years to support implementation of the SOC approach
statewide
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Informed by a study of expansion strategies
that identified five core strategy areas for
SOC expansion (implications for widespread
adoption of any innovation)
System of Care Expansion Planning and Implementation
Need and Inputs
Need
Need for wide-scale
adoption of SOCs:
• SOCs are in selected
communities but not
yet implemented
broadly
• Positive outcomes for
SOCs documented
• More children, youth,
and young adults and
their families could
benefit
State-Community
Partnerships
Expansion Planning
Activities
Expansion
Implementation Activities
State, tribes, or
territorial systems
and community
system(s) create
partnerships for twolevel expansion
strategy including:
States, tribes, territories,
and communities
develop comprehensive
strategic plans for SOC
expansion including:
States, tribes, territories,
and communities
implement SOC expansion
strategies at system and
community levels
including:
State, tribal and
territorial grantees
identify and link with
communities for focus
of expansion efforts
Inputs
Federal lnputs:
• SOC Expansion
Grants for TwoPhase Process of
Planning and
Implementation
• Federal TA
• National Evaluation
Jurisdiction Inputs:
• Previously
developed SOC
expansion plans
• Previous
community-level
SOC grants
• Previous SOC
expansion efforts
• Resources
committed to SOC
expansion
Community grantees
link with lead state
agency for youth with
mental health
conditions for systemic
changes to support
SOC expansion efforts
• Create SOC Expansion
Team
• Conduct self-assessment
and determine areas to
be addressed to expand
SOCs
• Determine goals for
expansion at state, tribal,
and territorial system
level and at community
level
• Determine overall
approach to expanding
SOCs with two-level
strategy
• Identify expansion
strategies in core
strategy areas of policy,
services, financing,
training, and strategic
communications
• Complete a strategic plan
that includes key
elements
• Establish priority goals
and strategies
• Develop a financing plan
Systemic changes in:
• Policy and partnerships
• Services and supports
• Financing
• Training and workforce
development
• Generating support
through strategic
communications
• Evaluation/CQI
SOC implementation:
• Develop SOC
infrastructure
• Develop treatment services
and supports based on
SOC philosophy
• Provide services
• Collaborate across childserving systems
• Incorporate family-driven,
youth-guided approaches
to systems and services
• Incorporate cultural and
linguistic competence into
systems and services and
address disparities
Evaluation/CQI – Refine Expansion Strategies
Outcomes
Outcomes are achieved at the state,
tribal, and territorial system level, the
community level, and the child and family
level including:
State, Tribal, and Territorial Level
Systemic changes are implemented:
• Changes in policy, requirements,
interagency partnerships, evaluation/CQI
• Changes to develop/expand services and
supports based on the SOC philosophy
• Changes in financing and resource
investment
• Changes in training, TA, and workforce
development
• Changes in support for SOC expansion
Community Level
SOC approach is implemented:
• SOC values/principles are implemented
• Home- and community-based services
and supports are implemented
• SOC infrastructure is implemented
• Resources are invested in home- and
community-based services and supports
• Services and supports are provided to
increasing numbers of children with SOC
approach
Child and Family Level
Children and families benefit:
• Children and families receive effective
home- and community-based services
and supports with the SOC approach
• Children and families experience positive
clinical and functional outcomes
• Children and families are satisfied with
their service experience
Five Core Strategy Areas:
1. Implementing Policy, Regulatory and Partnership
Changes
2. Developing or Expanding Services and Supports
Based on the SOC Philosophy and Approach
3. Creating or Improving Financing
Strategies
4. Providing Training, TA, and Coaching
5. Generating Support
Overlapping and Interrelated
Organizational locus of accountability for SOCs (state and
local)
 Interagency structures, agreements, and partnerships for
coordination and financing
 Rules, regulations, guidelines, standards, and practice protocols
 SOC requirements in requests for proposals and contracts
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SOC approach in data systems and monitoring protocols for
outcome measurement and quality improvement
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Linking with and building on other system change initiatives
(e.g., health reform, reforms in other systems)
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Expanding family and youth involvement at policy level
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Improving cultural and linguistic competence at policy level
Array of home- and community-based services and supports
 Individualized, wraparound practice approach to services
 Family-driven, youth-guided services
 Care coordination and care management
 Care management entities
 Provider network with new providers and retooled residential
providers
 Evidence-informed and promising practices and practice-based
evidence approaches
 Cultural and linguistic competence of services
 Reduce racial, ethnic, and geographic disparities in service
delivery
 Use of technology (e.g., electronic medical records, telemedicine,
videoconferencing, e-therapy)
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Intensive care coordination, wraparound approach
 Intensive in-home services
 Mobile crisis response and stabilization
 Parent and youth peer support services
 Respite
 Flex funds
 Specific evidence-based practices
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Medicaid
Mental Health Block Grants
Redeploying funds from higher cost to lower cost services
Funds from partner child-serving systems
Federal SOC grants and grants to create sustainable
financing
Case rates or other risk-based financing
State mental health and substance use funds
Use of federal entitlements other than Medicaid
New financing structures and funding streams
(e.g., health reform)
Local funds
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Training, TA, and coaching on the SOC approach
Ongoing training and TA capacity, training and TA
institutes, centers or other structures and processes
Training, TA, and coaching on evidence-informed and
promising practices and practice-based evidence
approaches
Strategies to prepare future workforce to work within
SOC framework
Establishing strong family and youth organizations to
support SOC expansion
 Generating support among high-level policy makers
and administrators at state and local levels
 Using data on outcomes and return on investment to
promote SOC expansion
 Partnerships with providers, provider organizations,
managed care organizations, and other key leaders
 Social marketing and strategic communications directed
at key audiences
 Cultivating leaders and champions for the SOC
approach
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Family-driven, youth-guided approaches to services and
systems
Cultural and linguistic competence in services and
systems and addressing disparities
Cross-system collaboration in services and systems
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Offers tested models for many ACA provisions to address unique
needs of children with behavioral health challenges
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Essential benefits for Medicaid and Health Insurance Exchanges
Medicaid and CHIP expansion
Health homes
1915(i) state plan amendments
Money Follows the Person
ACOs
Systems of care and their care management entities can be
health homes – Improve quality and manage costs for populations with
serious disorders, provide intensive care management, individualize
care, link to needed services and supports across systems
Wotring & Stroul; Pires et al – Center for Health Care Strategies
Useful Tools
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Complete as a group exercise or
leadership group
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Invite multiple stakeholders to
complete the self-assessment
individually
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Tabulate results across stakeholders
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Not an evaluation, but a diagnostic tool
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Assess areas of progress and areas that need attention
in SOC work
4. Promulgating Rules, Regulations, Standards, Guidelines, and Practice
Protocols
a) Promulgating rules and regulations that require elements of the system of care
philosophy and approach to support expansion of the system of care approach
Rating of Progress: 0=None 1=Some
2=Moderate 3=Significant 4=Extensive
Notes:
5. Incorporating the System of Care Approach in Requests for Proposals
(RFPs) and Contracts
Incorporating requirements for elements of the system of care philosophy and approach
in RFPs and contracts with providers and managed care organizations to support
expansion of the system of care approach
Rating of Progress: 0=None 1=Some
2=Moderate 3=Significant 4=Extensive
Notes:
SOC values and principles are implemented
 Services and supports consistent with SOC
approach are implemented
 SOC infrastructure is implemented
 Resources are invested in home- and
community-based services
 Services and supports are provided to
increasing numbers of children with SOC
approach
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1.
SOC values and principles are implemented
› Individualized, wraparound approach
› Family-driven approach
› Youth-guided approach
› Coordinated approach
› Culturally and linguistically competent approach
› Evidence-informed approach
› Least restrictive approach
› Broad array of home and community-based services
› Data-driven continuous quality improvement and accountability
approaches
2.
Services and supports consistent with SOC approach
are implemented
› Availability of specific treatment services and supports
provided in SOCs (non-residential)
› Availability of out-of-home treatment services for short-term
treatment goals that are linked to home- and communitybased services and supports
3.
SOC infrastructure is implemented
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Point of accountability structure for SOCs
Financing strategies for SOC infrastructure and services
Structure/process to manage care for high-need populations
Interagency partnerships/agreements
Structure/process for partnerships with family organizations/leaders
Structure/process for partnerships with youth organizations/leaders
Structure/process to advance culturally and linguistically competent
services and address disparities
Defined access/entry points to care
Provider network to deliver comprehensive service array
Structure/process for training, TA, and workforce development
Structure/process for measuring and monitoring quality, outcomes,
and costs and using data for continuous quality improvement
Structure/process for strategic communications/social marketing
Structure/process for strategic planning and resolving barriers
4.
Resources are invested in home- and community-based
services
› Increased utilization of home- and community-based services and
supports
› Decreased admissions and lengths of stay in out-of-home treatment
settings (e.g., psychiatric hospitals, residential treatment centers,
juvenile justice placements, out-of-school placements)
› Cost data demonstrating impact on costs across systems by
utilizing home- and community-based services and supports
5.
Services and supports are provided to increasing
numbers of children with the SOC approach
› Identification of areas within the jurisdiction that have high levels of
SOC implementation
› Increased number and description of children with serious
mental/behavioral health challenges and their families served with
the SOC approach within the jurisdiction

Developed to assess progress in implementing the SOC
approach
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Provides “snapshot” of implementation of key elements of
SOCs at a point in time

Method to derive an estimate of the “level” of implementation of
the SOC approach

Identify areas of strength and areas needing improvement
Use as progress assessment/evaluation across multiple
communities/regions in a larger jurisdiction (state, tribe, territory, large
geographic area)
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Use at regular intervals to track progress (e.g.,annually)
Level 1 –No Implementation
Level 2 – Some Implementation
Level 3 – Moderate Implementation
Level 4 – Substantial Implementation
Level 5 – Extensive Implementation
Designed for approximately 10+ respondents
per community or region – scores are averaged
 Can be customized to each community re number and
type of respondent
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› Local Community- or Regional-Level Director or Manager of
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Services for Children with Behavioral Health Challenges
Lead Provider Agency Director or Manager
Family Organization Director or Family Leader
Youth Organization Director or Youth Leader
Local Community- or Regional-Level Director or
Manager of Services for Children with Behavioral Health
Challenges from a Partner Agency
Other Key Stakeholders Identified by Lead Contact Person
for a Community or Region
LEVEL OF IMPLEMENTATION RATING
(0)
Score
LEVEL I
NO IMPLEMENTATION
LEVEL II
SOME IMPLEMENTATION
(1 – 100)
(1% – 25%)
LEVEL III
MODERATE IMPLEMENTATION
(101 – 200)
(26% – 50%)
LEVEL IV
SUBSTANTIAL IMPLEMENTATION (201 – 300)
(51% – 75%)
LEVEL V
EXTENSIVE IMPLEMENTATION
(76% – 100%)
(301 – 400)
TOTAL SCORE
STRATEGIC PLAN SCORE (MAX = 4)
PRINCIPLES SCORE (MAX = 152)
SERVICES SCORE (MAX = 136)
INFRASTRUCTURE SCORE (MAX = 48)
COMMITMENT SCORE (MAX = 60)
TOTAL SCORE (MAX = 400)
%
(0%)
Score
%
To improve outcomes for children, youth, and
young adults with serious mental health conditions
and their families through systems of care