What strategies support effective implementation of the system of care approach?

Introduction

In the system of care (SOC) approach, leaders work across funding and service systems to improve behavioral health and related outcomes for children and their families. System transformation requires long-term commitment, which can be challenging in the context of shifting priorities and administration changes. Without a sustained focus on changes at the structural, philosophical, and resource levels, leadership teams and systems may react to the needs, news headlines, or crises of the moment and revert to silos and the status quo.

This brief focuses on lessons learned from successful implementation of the SOC approach, including strategies that have helped promote commitment, leadership, funding, coordinated infrastructure, partnerships with families, and collaboration with providers and other stakeholders.

To identify strategies for effective SOC implementation, the Center for Health Care Strategies, drawing heavily on the seminal work of Sheila Pires and Beth Stroul, conducted a literature review and a series of interviews with 24 stakeholders, including national experts, state agency representatives from New Hampshire, New Jersey, Ohio, and Oklahoma, and individuals with lived experience.¹ While there are geographic, political and other variations across the four jurisdictions, their approaches share an explicit and sustained commitment to meeting the needs of families involved with child welfare, and each includes ensuring the availability of key home- and community-based services statewide.

Implementation lessons learned

Research identified six key strategies that can support successful implementation of the SOC approach.

Build trust with families, providers, and other stakeholders

A core principle of the SOC approach is that all system partners (Medicaid, behavioral health, education, child welfare, juvenile justice, health care, developmental disabilities, community providers, among others) collaborate and involve children, families, and communities in planning, implementation, and evaluation. Partners may have different opinions or perspectives on how best to address problems and improve outcomes, but ultimately all are guided by a shared commitment to ensure child safety and enhance overall child and family well-being. Each partner brings expertise, some of it informed through lived experiences, that can be leveraged to better understand and address child, family, and community needs.

Partnering can lead to macro-level solutions instead of fragmented or piecemeal efforts, allowing systems to work more effectively and efficiently, and address common family challenges more comprehensively. De Lacy Davis, a national expert and educator on the traumas associated with police brutality, said it is important to “take ‘no’ off the table” to encourage solution-focused thinking and planning. Cross-sector partners with different perspectives are likely to generate innovative ideas through teams or committees. Without trust, however, partnerships can recede at every level. Julie Collins, vice president of practice excellence at Child Welfare League of America, said taking action to address challenges faced by system partners can demonstrate that “you hear what your partners are saying, and you are willing to help solve things that matter to them. Then they know that you heard them, and they’ll be more likely to do something about what matters to you.”

In Oklahoma, the Department of Mental Health and Substance Abuse Services works together with other agencies, including the state Department of Human Services, to meet the needs of children and families involved with child welfare. “Our child welfare and juvenile justice partners have been part of the conversation from the very beginning, and through the years, our relationships have developed, which makes it easier to accomplish things,” said Kelly Perry, senior director of Child and Adolescent Systems and Crisis Services. “Those relationships allow child welfare to call us and say, ‘This model doesn’t work for children and youth in group homes’ and then we say ‘OK, what do we need to do so that this service is available to any child or youth in Oklahoma?’ This doesn’t mean everything has been easy, but we don’t give up and we keep working to find our common ground.” As an example, the SOC team advanced the implementation of an Enhanced Foster Care program to provide services to children with behavioral health needs in their foster care or kinship homes, in collaboration with child welfare partners.

Advance a paradigm shift

Responsive, proactive engagement of children, families, and communities is foundational to the effective implementation of the SOC approach. This is a paradigm shift from a professional-driven model to one that centers children, older youth, families, and communities as experts on their own experiences within the systems they encounter. Children, families, and communities are key decision-makers in both the planning and design of services, programs, and system-level changes. This paradigm shift empowers individuals, families, and communities, and advances more equitable systems. It requires constant attention from all system partners to succeed.

To facilitate these partnerships, state agencies and other service providers must work with children, families, and communities to identify what matters most to them and strive to create environments that support better outcomes. According to a recent study, outcomes that ranked most important to families include: accessible services; provider collaboration with caregivers and other providers/systems; knowledge, resources, and tools to support children’s mental health needs; and effective communication between caregiver, child, and service systems.²

As a demonstration of this evolution, Oklahoma includes the following statement as part of its SOC practice framework: “The family is the primary decision maker. …No planning sessions occur without the family’s involvement, input, voice and choice.” Oklahoma also incorporates system of care principles into its provider manuals and contracts for community-based services, including those for high fidelity wraparound, mobile response and stabilization services, and family and youth peers.

In Ohio, state officials bring a summary of the SOC philosophy to meetings with system partners. Maureen Corcoran, Ohio’s director of Medicaid, explained that educating colleagues and the need to align and avoid duplication never stops, especially given staff turnover. “You must be continuous, aggressive, and keep educating people on system of care,” she said. “Bringing frameworks together and keeping them aligned is an ongoing priority in this work.”

Embrace shared decision-making

Partners engaged in design or implementation of the SOC approach benefit from clearly defined roles and responsibilities. Children, families, and communities should be included in decision-making, policymaking, and accountability processes, as well as program design, implementation, and evaluation to ensure that systems function as intended. System partners should establish leadership and advisory mechanisms to ensure that decision-making on design and implementation is shared among all stakeholders.

It is essential to clearly outline the functions and roles of each group or team involved with design and implementation, and to not confuse system governance with system management. Both are important, but governance involves big-picture policy and oversight, while system management involves day-to-day operations. The entity charged with governance must have ultimate authority on decisions, which are informed and influenced through the various SOC partners, children and families in particular.

New Hampshire, New Jersey, Ohio, and Oklahoma each has a designated lead agency for SOC implementation and governance, and advisory teams comprised of all system partners including child welfare, juvenile justice, education, mental health, Medicaid, community providers, families, and youth. Other states have established interagency councils guided by advisory groups to lead and govern SOC work in their jurisdiction.

In New Hampshire, a state law codified a comprehensive system of care for children’s mental health and established the purpose, roles, and responsibilities for all partners involved, including commissioners of the Department of Health and Human Services and the Department of Education, as well as a system of care advisory committee. This coincided with the establishment of a dedicated state entity, the New Hampshire Bureau for Children’s Behavioral Health, which is under the purview of Health and Human Services.

Communicate with intention

System partners often use different terminology to describe or communicate about similar concepts. Along with establishing shared values and principles, partners can promote seamless communication through training and refinement of terminology. This requires a shared commitment among SOC partners to provide consistent language across child welfare, behavioral health, Medicaid, health and managed care, and other child- and family-serving systems.

To ensure standardized, jargon-free assessment tools and language, it can be helpful to communicate in ways that all partners and families understand. In New Jersey, SOC agencies shifted away from referring to “cases” and “patients” toward using more humanistic terms like “youth” and “families.” This shift may seem small, but when implemented by all system partners, it can alter mindsets and behaviors. Another example is replacing pedantic terminology such as “home visit” with more hospitable descriptions like “a child going home to spend time with family.” The latter acknowledges that the child’s home is with family and not in a treatment setting. Framing communication in these ways convey respect and dignity, and prioritize the needs and feelings of the children and families being served.

As part of its paradigm shift to the SOC approach, Ohio reframed how it communicated around governance and service delivery by describing through multiple venues and media what system transformation would look and feel like from the perspectives of children, families, and communities, as well as for system partners.

Prioritize home- and community-based services

To help prevent child welfare involvement and out-of-home placement, states should ensure access to a broad and coordinated array of home- and community-based services for children and families.³ The Centers for Medicare & Medicaid Services’ (CMS) Psychiatric Residential Treatment Facilities Demonstration Program and the Children’s Mental Health Initiative paved the way for this by demonstrating the effectiveness of several key home- and community-based services.

A federal joint informational bulletin outlines key service components, including mobile crisis response and stabilization services, intensive care coordination using the wraparound model, intensive in-home mental health treatment, respite care, parent and youth peer support, flexible funds, and treatments addressing trauma. Updated guidance reinforces this. States currently are offering home- and community-based services through multiple Medicaid authorities and also can consolidate services under a single state plan authority.

Continuously monitor and evaluate

Ongoing monitoring and evaluation are essential to success of the SOC approach. Establishing clear, shared performance metrics in collaboration with children, families, and communities ensures that the evaluation is aligned with their priorities and that results are relevant and meaningful. Metrics should encompass both quantitative data, such as service utilization and outcome rates, and qualitative insights, like children and family satisfaction and engagement. A feedback loop also can incorporate the perspectives of state and local policymakers for designing ongoing improvements.

System partners often capture data on the same population, but opportunities to share information are limited due to confidentiality and operational barriers. Addressing data-sharing questions and challenges requires effective teaming at both the system level and among individual staff, with children, families, and community stakeholders involved. Establishing mechanisms for data sharing through memorandums of understanding or interagency agreements can facilitate access to data, a more comprehensive understanding of the needs of children and families, and monitoring progress. “Families need the facts and the stats on their own communities to be able to mobilize and address issues collectively,” said Sheamekah Williams, president and CEO of the Evolution Foundation and former director of Children, Youth, and Family Services at the Oklahoma Department of Mental Health and Substance Abuse Services.

The system of care in New Jersey has a public-facing database maintained by Rutgers University that features trend tracking on various services. New Jersey also makes available a statewide and county level dashboard that shares additional information on service access and utilization.

Sustainability and scale

The Innovations Institute at the University of Connecticut School of Social Work supports states and communities that are implementing the SOC approach. Michelle Zabel, the institute’s executive director, said that for an SOC to be sustainable and make gains, the approach needs to be customizable and actionable. Research reveals five key elements for achieving scale and sustainability.

Commitment, trust, and patience

To sustain the SOC approach in a state or community, system partners must continuously work to garner support from state leadership. This can be easier said than done, as state leaders are juggling many competing priorities, but their support can be foundational at all stages of design and implementation, from building cross-system relationships to executing data-sharing agreements and maintaining collaboration across partners. “For a successful system of care, you need top leadership to have buy-in, but many times, unless something is wrong, doing things with other child-serving systems doesn’t necessarily get traction,” said David Miller, senior operations and project director of the National Association of State Mental Health Program Directors. State leaders, while key players, are not the only drivers of the work. Other champions in the state and community can help advocate for and sustain the SOC approach.

Regardless of their role, champions who “have a willingness to listen to the folks on the ground” are critical, said Julie Collins, vice president of practice excellence at Child Welfare League of America. Maintaining open communication and building trust with children, families, and direct service providers will help state agencies address challenges earlier and more nimbly.

Partnership with children and families

Children and families should be included in system-level decision-making and implementation to ensure sustainability of the SOC approach. While state officials and providers may change jobs or locations, children and families remain constant and bring vital expertise to design and implementation. “Families have the solutions and should be part of every conversation,” said Millie Sweeney, director of learning and workforce development of the Family-Run Executive Director Leadership Association. It is notable that a key to system of care sustainability in New Jersey has been family strength and advocacy through multiple administrations.⁴

Financing

New Hampshire has maximized funding from several sources to support system of care implementation, including state funds from the Department of Education and the Department of Health and Human Services, as well as state general funds and federal sources like Title IV-A, Title IV-B, Title IV-E, Medicaid, and the Substance Abuse and Mental Health Services Administration (SAMHSA). Katja Fox, director of the division for behavioral health at the Department of Health and Human Services, said that while it can “get complicated, we do our best to be payer agnostic,” teasing apart payment mechanisms on the back end to make the provision of services seamless for children and families. Recently, the New Hampshire Department of Insurance also has been brought to the table to help achieve parity in behavioral health services between Medicaid and commercial insurance plans.

The SOC approach is aligned with broader health care system reform goals to improve outcomes and reduce avoidable costs by increasing access to necessary and quality care. “Systems of care have demonstrated that the availability of a broad range of treatment and support services for children’s behavioral health is effective in preventing more serious problems and in mitigating overall health care system costs,” said a 2011 report from Georgetown University’s Center for Child and Human Development. “Systems of care have demonstrated that there are, in fact, cost-reducing and cost-effective alternatives to serving children in hospitals, residential treatment centers, and other institutional settings, which is especially important during this time of fiscal challenges.”⁵

Capacity building

Centers of Excellence, which help governing bodies implement evidence-based and promising practices, can be key partners in helping to infuse SOC values and principles in training, capacity building efforts, and coaching for community providers, system partners, and families. Ohio relies on its strong partnerships with Centers of Excellence to train and educate the workforce and advance the sustainability of the framework. There are three entities in Ohio that play unique roles: the Child and Adolescent Behavioral Health Center of Excellence, which helps create access to home and community-based services to keep families together; the Center for Innovative Practices, which supports community-based organizations that implement interventions for youth and families; and the Center for Evidence-Based Practices, which offers technical assistance through skills training, consultation, and program evaluation.

Accountability

Once leaders and champions are identified, it also is important to document, celebrate, and share incremental gains and stories of success with partners, including legislators, advocates, providers, and agency leadership. This can help create momentum and maintain support for system reform. Establishing SOC advisory committees and councils, like those in New Hampshire, New Jersey, Ohio, and Oklahoma, comprised of cross system partners — including government agencies, youth- and family-run organizations, community-based organizations, and universities — facilitates communication and helps ensure accountability to the shared mission and vision.

1 The content of this brief was informed by interviews with Joe Ribsam, Director, Child Welfare and Juvenile Justice Policy, Annie E. Casey Foundation, August 30, 2024; Michelle Zabel, Executive Director, Deborah Harburger, Director of Policy and Financing, and Marlene Matarese, Deputy Director, Innovations Institute at the University of Connecticut, August 29, 2024; David Miller, Senior Operations and Project Director, National Association of State Mental Health Program Directors, August 28, 2024; Pat Hunt, Executive Director, and Millie Sweeney, Director of Learning and Workforce Development, Family-Run Executive Director Leadership Association, August 9, 2024; Tara Reynon, Senior Program Director, and David Simmons, Director of Government Affairs and Advocacy, National Indian Child Welfare Association, August 27, 2024; Julie Collins, Vice President of Practice Excellence, Child Welfare League of America, August 29, 2024; Dr. De Lacy Davis, Executive Director, Alliance of Family Support Organizations, August 14, 2024; Sheamekah Williams, President and CEO, Evolution Foundation, August 15, 2024; Mollie Green, Assistant Commissioner, and Wyndee Davis, Assistant Director, New Jersey Children’s System of Care, Department of Children and Families, and Valery Bailey, Executive Director, and Alexandra Morales, Clinical Director, PerformCare, September 10, 2024; Marisa Wiesel, Deputy Director, Bridget Harrison, Deputy Director, and Maureen Corcoran, Director, Ohio Department of Medicaid, August 22, 2024; Morissa Henn, Deputy Commissioner; Marie Noonan, Interim Director of the Division for Children, Youth and Families; Daryll Tenney, Bureau Chief, Bureau for Children’s Behavioral Health; and Katja Fox, Director, Division for Behavioral Health, New Hampshire Department of Health and Human Services, August 26, 2024; and Kelly Perry, Senior Director of Child and Adolescent Systems and Crisis Services, Oklahoma Department of Mental Health and Substant Abuse Services, August 28, 2024.

2 Graaf, G., Kitchens, K., Sweeney, M., & Thomas, K.C. (2024). Behavioral health services outcomes that matter most to caregivers of children, youth, and young adults with mental health needs. International Journal of Environmental Research and Public Health, 21(172).

3 For a description of a comprehensive service array to help stabilize families and prevent child removal, see page 18 of The evolution of the system of care approach.

4 Stroul, Beth and Gary Blau (eds). (2008). The system of care handbook: Transforming mental health services for children, youth and their families, p. 269. Baltimore, MD: Brookes Publishing.

5 Wotring, J., & Stroul, B. (2011). Issue brief: The intersect of health reform and systems of care for children’s behavioral health care. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Center for Children’s Mental Health.