1. Sustaining Systems Of Care Beth A. Stroul, M.Ed. June, 2007

2. What do we mean by the “sustainability” of systems of care?

3. Defining Sustainability Long-term survival of services and programs that were initiated with grants or other specialized funding, including policy, philosophical, structural, and service delivery changes: Maintenance of systems of care over time Services, Infrastructure, and Philosophy Maintenance of systems of care after federal funding has terminated

4. Array of Effective Community-Based Services & Supports Cultural & Linguistic Competence Local Infrastructure Sustaining Systems of Care State Infrastructure Strategic Financing Improved Service Coordination/Integration Political & Economic Support Evaluation VISION/PHILOSOPHY/PRINCIPLES Education & Training Social Marketing Youth & Family Involvement

5. Sustainable Systems of Care Have: Policies, practices, structures, finances and philosophy in place in order to provide the services and supports that increase the capacity for children with serious emotional disturbances and their families to live, work, learn and participate fully in their community. (Sustainability Tool Kit) Policies, practices, structures, finances and philosophy in place in order to provide the services and supports that increase the capacity for children with serious emotional disturbances and their families to live, work, learn and participate fully in their community. (Sustainability Tool Kit)

6. How can sustainability be assessed?

7. Special Study on Sustainability in National Evaluation Explore extent to which systems of care are maintained after federal funding Identify features more likely to be sustained and those less likely Identify factors that affect sustainability Identify successful strategies for sustainability Explore extent to which systems of care are maintained after federal funding Identify features more likely to be sustained and those less likely Identify factors that affect sustainability Identify successful strategies for sustainability

8. Methodology of Sustainability Study Literature review, focus groups Sample selection –Graduated Sites 4-5 Years Post Grant (N=26) –Nearly Graduated Sites in 6 th Year (N=11) Web survey –Current or former project director –Mental health system rep –Family member –Rep of another child serving system Telephone interviews –Current or former project director –Family member –State children’s mental health director Literature review, focus groups Sample selection –Graduated Sites 4-5 Years Post Grant (N=26) –Nearly Graduated Sites in 6 th Year (N=11) Web survey –Current or former project director –Mental health system rep –Family member –Rep of another child serving system Telephone interviews –Current or former project director –Family member –State children’s mental health director

9. Array of Services and Supports Comparison of: Degree to which each of the services and supports in the array was available during period of grant funding Degree to which each of the services and supports was available during the current period (last 12 months) Comparison of: Degree to which each of the services and supports in the array was available during period of grant funding Degree to which each of the services and supports was available during the current period (last 12 months)

10. System of Care Philosophy Comparison of degree of implementation of principles during the grant period and during the current period: Individualized care Interagency coordination - system and service levels Service accessibility Family involvement - system and service levels Cultural competence - system and service levels Comparison of degree of implementation of principles during the grant period and during the current period: Individualized care Interagency coordination - system and service levels Service accessibility Family involvement - system and service levels Cultural competence - system and service levels

11. System of Care Goals Comparison of goal achievement (including infrastructure goals) during the grant period and during the current period: Minimizing need to leave the community for services Reducing services in overly restrictive settings Ensuring sufficient service capacity Using evaluation to inform policy and program decisions Maintaining focal point for system management Maintaining an active family organization Achieving general acceptance of system of care philosophy among system managers/leaders and service providers Comparison of goal achievement (including infrastructure goals) during the grant period and during the current period: Minimizing need to leave the community for services Reducing services in overly restrictive settings Ensuring sufficient service capacity Using evaluation to inform policy and program decisions Maintaining focal point for system management Maintaining an active family organization Achieving general acceptance of system of care philosophy among system managers/leaders and service providers

12. What do we know about sustainability in “graduated” communities?

13. Sustainability of Services Increased Availability from Grant to Current Period Decreased Availability from Grant to Current Period Behavioral aide services Transition - residential to community Transition to adult services Medication treatment/monitoring Substance abuse treatment Case management Therapeutic group homes Independent living After school/summer programs Flexible funds Transportation Respite care Family preservation/home-based Family support services Recreation Tutoring Professional consultation Vocational services Mentoring

14. Sustainability of Services Small differences Pattern suggests decreased availability of “supportive” services Difficult to replace grant resources for flexible funds and other supportive services Differences attributable to graduated sites Challenging to maintaining services developed with grant funds at same level Small differences Pattern suggests decreased availability of “supportive” services Difficult to replace grant resources for flexible funds and other supportive services Differences attributable to graduated sites Challenging to maintaining services developed with grant funds at same level

15. Availability of Services No services judged extensively available in either time period (rating of 5) Only case management and outpatient individual counseling rated very available (rating of 4) Most others rated somewhat or moderately available (rating of 2 – 3) Communities have struggled to build service capacity commensurate with need, even with investment of grant funds No services judged extensively available in either time period (rating of 5) Only case management and outpatient individual counseling rated very available (rating of 4) Most others rated somewhat or moderately available (rating of 2 – 3) Communities have struggled to build service capacity commensurate with need, even with investment of grant funds

16. Sustainability of Philosophy Increased Implementation from Grant to Current Period Decreased Implementation from Grant to Current Period Family involvement in the service planning and delivery process (services level) Cultural competence of services (services level) Cultural competence of system policy and management (system level) Individualized care approach Interagency coordination in system policy and management (system level) Interagency coordination in planning and delivering services (services level) Family involvement in system policy and management (system level) Services accessibility (times, locations) ) Shared administrative processes among agencies

17. Sustainability of Philosophy Small differences Implementation of most features declined Differences attributable to graduated sites Suggests difficulty maintaining principles at same level without visible presence of grant related requirements and activities Small differences Implementation of most features declined Differences attributable to graduated sites Suggests difficulty maintaining principles at same level without visible presence of grant related requirements and activities

18. Implementation of Principles Several rated as very much implemented (rating of over 3.5 in both time periods) –Family involvement at the system level –Family involvement at the services level –Individualized care Despite largest declines, these three remained the most highly implemented principles Other principles implemented “moderately” in both time periods Several rated as very much implemented (rating of over 3.5 in both time periods) –Family involvement at the system level –Family involvement at the services level –Individualized care Despite largest declines, these three remained the most highly implemented principles Other principles implemented “moderately” in both time periods

19. Achievement of Goals Increased Achievement from Grant to Current Period Decreased Achievement from Grant to Current Period Minimizing need to leave community for services (community-based care) Reducing services in overly restrictive settings (least restrictive setting) Achieving general acceptance of SOC philosophy among system/program managers Achieving general acceptance of SOC philosophy among service providers Ensuring sufficient service capacity Using evaluation data to inform program and policy decisions Maintaining a focal point for management of the system of care (agency, office, or entity) Supporting and maintaining an active family organization in the community

20. Achievement of Goals “Infrastructure” goals declined in achievement Suggests infrastructure goals pose more challenges without federal funds and accompanying mandates Differences attributable to graduated sites “Infrastructure” goals declined in achievement Suggests infrastructure goals pose more challenges without federal funds and accompanying mandates Differences attributable to graduated sites

21. Level of Goal Achievement None achieved with complete or substantial success (ratings of 4 or 5) Most approached substantial success in both time periods (ratings over 3.5) –Achieving general acceptance of SOC philosophy –Maintaining designated focal point for system management –Reducing use of unnecessarily restrictive settings –Minimizing need to leave the community for services Others achieved with moderate success in both time periods None achieved with complete or substantial success (ratings of 4 or 5) Most approached substantial success in both time periods (ratings over 3.5) –Achieving general acceptance of SOC philosophy –Maintaining designated focal point for system management –Reducing use of unnecessarily restrictive settings –Minimizing need to leave the community for services Others achieved with moderate success in both time periods

22. Factors Affecting Sustainability Many factors affect sustainability Some in control of communities, others by political/economic environment Factors most present in sites: –Local commitment to the SOC approach –Increased utilization/reliance on Medicaid –Existence of ongoing administrative leadership –Interagency partnerships –Inclusion of key stakeholders at all levels Many factors affect sustainability Some in control of communities, others by political/economic environment Factors most present in sites: –Local commitment to the SOC approach –Increased utilization/reliance on Medicaid –Existence of ongoing administrative leadership –Interagency partnerships –Inclusion of key stakeholders at all levels

23. Impact of Factors on Sustainability Factors with Negative Impact Changes in larger economic climate Changes in elected or appointed officials Factors with No Impact Implementation of managed care

24. Impact of Factors on Sustainability Factors with Most Positive Impact Inclusion of key stakeholders at all SOC levels Interagency partnerships Local commitment to SOC approach Existence of ongoing leadership Provision on ongoing training Existence of constituency advocating for SOC approach Presence of a “champion” with power/influence Infusion of SOC into larger system, not separate Existence of evaluation data on effectiveness of SOC State commitment to SOC approach and involvement Existence of formal policies supportive of systems of care Engagement of political and policy leaders State financial support Increased utilization of Medicaid for financing services

25. Strategies for Sustainability None rated completely or very effective (rating of 4 or 5) Some approached very effective level (rating of over 3.5) –Cultivating strong interagency relationships –Involving stakeholders –Establishing a strong family organization –Using evaluation results –Creating an ongoing focal point for SOC management None rated completely or very effective (rating of 4 or 5) Some approached very effective level (rating of over 3.5) –Cultivating strong interagency relationships –Involving stakeholders –Establishing a strong family organization –Using evaluation results –Creating an ongoing focal point for SOC management

26. Strategies for Sustainability All others were rated moderately effective –Making policy and regulatory changes supportive of SOCs –Infusing the SOC into the broader service system –Providing training –Creating an advocacy base –Generating political support Making policy/regulatory changes and infusing SOCs into broader system were rated higher by graduated communities Creating ongoing focal point and establishing strong family organization were goals achieved less effectively, but were rated among most effective sustainability strategies Ratings varied with ability to implement the strategy well All others were rated moderately effective –Making policy and regulatory changes supportive of SOCs –Infusing the SOC into the broader service system –Providing training –Creating an advocacy base –Generating political support Making policy/regulatory changes and infusing SOCs into broader system were rated higher by graduated communities Creating ongoing focal point and establishing strong family organization were goals achieved less effectively, but were rated among most effective sustainability strategies Ratings varied with ability to implement the strategy well

27. Financing Strategies Strategies Used Most Frequently: Increasing ability to obtain Medicaid reimbursement for services Operating more efficiently (cutting costs) Creating partnership with other non-mental health child-serving systems Obtaining grants Coordinating categorical funds Obtaining new/increased state funds Leveraging funding sources Strategies Used Most Frequently: Increasing ability to obtain Medicaid reimbursement for services Operating more efficiently (cutting costs) Creating partnership with other non-mental health child-serving systems Obtaining grants Coordinating categorical funds Obtaining new/increased state funds Leveraging funding sources

28. Most Effective Financing Strategies Increasing ability to obtain Medicaid reimbursement –Collaboration with state mental health and Medicaid agency –Changing state plan by adding new definitions and service codes –Use of multiple Medicaid options Obtaining new/increased state funding (general revenue, block grant) Obtaining funds from partner child-serving agencies Redeploying funds from higher to lower cost services Increasing ability to obtain Medicaid reimbursement –Collaboration with state mental health and Medicaid agency –Changing state plan by adding new definitions and service codes –Use of multiple Medicaid options Obtaining new/increased state funding (general revenue, block grant) Obtaining funds from partner child-serving agencies Redeploying funds from higher to lower cost services

29. State Perspectives Crucial role of state agencies in providing leadership and resources Cannot sustain SOCs without policy and financial support from states Support of state agencies, in partnership with communities, is necessary condition for sustainability State role essential for statewide SOC development State involvement with SOC communities is critical Crucial role of state agencies in providing leadership and resources Cannot sustain SOCs without policy and financial support from states Support of state agencies, in partnership with communities, is necessary condition for sustainability State role essential for statewide SOC development State involvement with SOC communities is critical

30. State Role Working with state Medicaid agency to amend state Medicaid plans and rules to finance the services within SOCs Providing funds from state mental health agencies to finance SOCs and their component services Negotiating agreements with other child-serving systems to support the SOC approach, enhance interagency coordination, and provide funding for services Implementing statewide programs (e.g., wraparound or crisis programs) that provide mechanisms for sustaining SOCs and services Building on the system development in funded communities for statewide SOC development by using them as pilots, models, and sources of experience, information, and training Working with state Medicaid agency to amend state Medicaid plans and rules to finance the services within SOCs Providing funds from state mental health agencies to finance SOCs and their component services Negotiating agreements with other child-serving systems to support the SOC approach, enhance interagency coordination, and provide funding for services Implementing statewide programs (e.g., wraparound or crisis programs) that provide mechanisms for sustaining SOCs and services Building on the system development in funded communities for statewide SOC development by using them as pilots, models, and sources of experience, information, and training

31. State Role, Continued Enacting legislation that supports statewide SOC implementation Implementing mechanisms to provide TA and training on SOC philosophy and approach Creating entities to provide leadership, coordination, and support for SOCs at state, regional, and/or local levels Incorporating the SOC philosophy and approach in policy documents, plans, licensing requirements for provider agencies, and contracts with provider agencies and managed care organizations Removing barriers in policy, regulations, and financing that are identified by local communities in sustaining SOCs Monitoring compliance with the SOC philosophy and approach in communities and evaluating the outcomes of SOCs and services Enacting legislation that supports statewide SOC implementation Implementing mechanisms to provide TA and training on SOC philosophy and approach Creating entities to provide leadership, coordination, and support for SOCs at state, regional, and/or local levels Incorporating the SOC philosophy and approach in policy documents, plans, licensing requirements for provider agencies, and contracts with provider agencies and managed care organizations Removing barriers in policy, regulations, and financing that are identified by local communities in sustaining SOCs Monitoring compliance with the SOC philosophy and approach in communities and evaluating the outcomes of SOCs and services

32. Lessons Learned from Sites Establish a strong link between local SOCs and state agencies Engage top policy makers and system administrators Incorporate SOC approach into written plans and documents Understand and create partnerships with other child-serving systems Involve and strengthen family advocates and family organizations Use outcome data and personal stories to advocate sustaining SOCs Conceptualize grants as part of larger state strategy for SOCs “Refinance” SOC grants from outset with multiple funding streams Collaborate with state Medicaid agency Cultivate leaders/champions to “carry the mantle” over time Establish a strong link between local SOCs and state agencies Engage top policy makers and system administrators Incorporate SOC approach into written plans and documents Understand and create partnerships with other child-serving systems Involve and strengthen family advocates and family organizations Use outcome data and personal stories to advocate sustaining SOCs Conceptualize grants as part of larger state strategy for SOCs “Refinance” SOC grants from outset with multiple funding streams Collaborate with state Medicaid agency Cultivate leaders/champions to “carry the mantle” over time

33. More Lessons Learned Incorporate key elements of SOCs into contracts with providers Implement mechanisms to pay providers for interagency coordination and service planning processes Use effective social marketing approaches to disseminate information and garner supports Provide extensive training on SOCs and services Use first year of grant for implementation and sustainability planning Use multiple strategies for sustainability Adapt to changing circumstances Learn from experience of graduated communities Incorporate key elements of SOCs into contracts with providers Implement mechanisms to pay providers for interagency coordination and service planning processes Use effective social marketing approaches to disseminate information and garner supports Provide extensive training on SOCs and services Use first year of grant for implementation and sustainability planning Use multiple strategies for sustainability Adapt to changing circumstances Learn from experience of graduated communities

34. What are the implications for currently funded communities?

35. Implications for Systems of Care Need for greater focus on maintaining supportive services (flexible funds, respite, family support, mentoring) Greater attention to increasing service capacity Increased emphasis on maintaining principles at the system level (family involvement and interagency coordination), as well as service level Need for greater focus on maintaining supportive services (flexible funds, respite, family support, mentoring) Greater attention to increasing service capacity Increased emphasis on maintaining principles at the system level (family involvement and interagency coordination), as well as service level

36. More Implications Attend to infrastructure elements in sustainability planning (e.g., focal point for system management, evaluation capacity, maintaining family organization) Maximize factors that enhance sustainability (e.g., nurture state partnerships) Use multiple sustainability strategies Use lessons learned to address challenges and pitfalls Attend to infrastructure elements in sustainability planning (e.g., focal point for system management, evaluation capacity, maintaining family organization) Maximize factors that enhance sustainability (e.g., nurture state partnerships) Use multiple sustainability strategies Use lessons learned to address challenges and pitfalls

37. Strategic Framework for Sustainability Planning Sustainability Strategies 1.Ongoing Locus of Accountability –Create a viable, ongoing focal point for system management 2.Family Organization and Advocacy Base –Establish a strong family organization –Create an effective advocacy base 3.Evaluation/Accountability Data –Use evaluation/accountability results to “make the case” for sustainability 4.Interagency Partnerships –Cultivate strong interagency relationships and partnerships for service delivery and coordination –Cultivate strong interagency partnerships for ongoing financing of services

38. Strategic Framework, Continued 5.Infusion of System of Care Approach into Larger System –Make state-level and local-level policy and regulatory changes that support SOCs –Make the SOC philosophy/approach the way the community’s larger service system operates 6.Training –Provide ongoing training and coaching re SOC philosophy and approach –Provide ongoing training re effective services 7.Commitment and Support for System of Care Approach –Generate political and policy level support for the SOC approach –Generate state involvement and commitment –Generate local involvement and commitment –Cultivate ongoing leaders and champions for SOC philosophy and approach

39. Strategic Framework, Continued Financing Strategies for Sustainability 1.Medicaid –Increase ability to obtain Medicaid reimbursement for services 2.State Mental Health Funds –Obtain new or increased state mental health funds 3.Other Child Service Systems Funds –Obtain new or increased funds from other child-serving agencies –Coordinate, blend, or braid funds with other child-serving agencies 4.Redeploying Funds –Redeploy/shift funds from higher to lower cost services 5.Local Funds –Obtain new or increased local funds (e.g., taxing authorities)