Systems of care: Twenty years down the road
 The idea of systems of care has been with us for almost 20 years now. A new review* examines what has been learned in those 20 years about systems of care, and asks the question "Is this a viable program model?"
The impetus for systems of care came from recognition of the problems that plagued existing services for children with emotional and behavioral disorders. These problems included uncoordinated and ineffective services, an over-reliance on restrictive settings, and a lack of family participation and cultural competence. In contrast, systems of care are intended to provide a wide array of services and supports, with an emphasis on serving children and families in their home communities and in least restrictive environments. In systems of care, child- and family-serving agencies collaborate and coordinate their efforts, providing individualized, culturally competent care. Systems of care encourage the full participation of families and youth consumers in planning, evaluating, and delivering services and supports.
According to the review, the evidence for the effectiveness of systems of care is still somewhat unclear. It appears that systems of care do actually increase access to and use of services. Family satisfaction also appears to be higher when services are received through systems of care, and use of inpatient hospitalization appears to decrease. However, the impact on costs and outcomes is less clear. Some studies have shown increased costs under systems of care, but the review cites evidence that systems of care, under specific operating conditions, may at least not cost more than traditional services. Some studies have shown improved outcomes with systems of care, while other, more rigorous studies, have not shown improved outcomes.
We are interested in hearing your perspectives on systems of care-your ideas, opinions, and reactions. The questions below may help you get started:
- What do you think about systems of care?
- Have you worked in or with a system of care, or received services from a system of care? Was it different from "treatment as usual" or work as usual?
- Is development of systems of care a realistic goal for "average" communities around the country?
- Once developed, can systems of care be sustained?
As always, we look forward to hearing from you!
* Kutash, K., Duchnowski, A. J., & Friedman, R. M. (2005). The system of care 20 years later. In M. Epstein & K. Kutash & A. J. Duchnowski (Eds.), Outcomes for children and youth with emotional and behavioral disorders and their families: Programs and best practices . Austin, TX: Pro-ed.
Your thoughts…
Comments:
 SOC is a huge challege. Coordination of effort, let alone integration of effort, is very difffcult to achieve, and seems to be a problem in many aspects of our government/society, e.g.,consider what we're trying to do with the FBI, CIA, NSC, etc. Yet, with enlightened, insightful, and motivated leaders SOC can be developed. I have seen islands of success in the county in which I have been working for 33 years. To make progress one must have a positive attitude and never give up (learned optimsim and continuous improvement approaches). Posted Monday, March 21, 2005 at 05:24 AM
In those systems of care that seem to be making an impact and are not watered down - why is it working? I would love to hear from people where the system of care is not watered down and what specific things can be referenced to that have made a difference. Is the difference an administrator, legislature, advocates within the system, family advocate groups? Posted Wednesday, February 23, 2005 at 12:14 PM
As is true with many new ideas that emerge in any field, we have seen the term "system of care" get very watered down in practice. Our state has had several different federal funding sources to build systems of care, but I see a real lack of knowledge about what SOC really is. Posted Wednesday, February 23, 2005 at 09:08 AM
I find reason for optimism if what this review says is true. Even as "beginners" in understanding how to make systems of care work, we seem to be achieving systems that increase access to services and increase family satisfaction, with costs and "outcomes" possibly the same. At the very worst, that is an improvement and something to build on. I think the picture may even be more favorable than that when you think about the kinds of outcomes that are usually measured-- mostly they do not tap into family overall well-being and measure child functioning in ways that may not reflect the positive results that are being achieved (for example looking at symptoms and deficits rather than strengths and connections to community). Posted Friday, February 18, 2005 at 08:03 AM
System of care is a long term goal. It may not be widely achieved so far, but it is now seen very commonly as what we are striving for. We are learning more and more each year. Not just about how hard it is to do system of care, which it is, but also about how to overcome the challenges. Now it is not rare to hear about the need for cultural competence, family voice and choice, or meeting family and child needs in an individualized way. This was all way out there twenty years ago. We have come a long way. Posted Thursday, February 17, 2005 at 08:50 PM
I believe that one of the problems that tend to arise with systems of care is an unwillingness-- or lack of overall political will-- to take a big leap to do things differently. Trying for piecemeal change while clinging to the old ways of doing things for security blunts the motivation to achieve real change. So we have a sort of veneer of SOC over the same old stuff. The veneer is not very durable, and maintaining it costs money, so it inherently unsustainable. At the service level, I think this translates into doing everything we were doing before plus the "extras" that give luster to the veneer. For example, rather than dediding we're really going to provide the services and supports families want, we provide what the "old" system wants to give PLUS any extra stuff we think fits with the "New" system ideology. Naturally this will cost more, and people within the system experience "change" as one more bogus fad to be ridden out. Still, I think it's a sort of chicken and egg paradox: most places are not willing to take a big leap on faith alone, and are waiting for good evidence. But as long as we only attempt reform in timid ways, the evidence for real change won't be there. Posted Wednesday, February 16, 2005 at 12:12 PM
A great deal of discussion surrounding system of care has been philosophically based. Unless we move beyond philosophy and values into concrete actions and processes we will, I believe, continue to struggle to assist youth and families. The philosophical basis of system of care has allowed many systems to state that they have a system of care when very little has changed within the system. I believe that this is a great dis-service to families and youth. I do believe that a system of care is beneficial and have seen little glimpses but it is still not the 'culture'. Posted Wednesday, February 16, 2005 at 10:58 AM
When looking at how the Systems of Care philosophy has evolved over the last twenty years, it is apparent that some progress is being made to more effectively meet the needs of children and families who are often the targeted population for these services. There is no question that programs like Wrap Aroung Milwaukie have made a huge impact in providing quality intensive mental health services in a cost effective manner. The Systems of Care (CASSP)principles have been adopted by numerous states as children's mental health policy, setting the tone for which services are to be provided, and how best to provide them.
On a more local note, however, it seems that this level of change in service delivery is less of a reality for many families. If one happens to live in a community where the political and professional leadership buy into a Systems of Care framework for children's mental health service delivery, then it is more likely that this model can be achieved.
Too many SOC programs have folded, especially in recent years when funding at state and local levels have been more scarce. It appears that the only incentive these communities have to fund SOC is by threat or pending lawsuit. There may be exceptions across the country to this, however I live in Oregon, and recently our State Legislature has mandated that the state Office of Mental Health and Addictions services carve out residential dollars to fund a comprehensive service array, that is consistent with CASSP, at the local level for children with serious mental health disorders. Along with this mandate is another, that requires local communities to more effectively engage and involve families at the advisory/policy, planning and treatment level. The Legislature took this action to avoid a lawsuit. The lawsuit, initiated by state and local advocacy organizations.
While this could be considered policy advocacy, at it's best - it is also disheartening that our local and state public elected officials are less focused on doing what is good for our children and families because it is the right thing to do.
It is encouraging that services are moving toward a SOC framework in Oregon, however we still have a lot of work to do here!!! Posted Tuesday, February 15, 2005 by S. Bumpus - Portland, Oregon at 03:35 PM
An interesting thing about the reviews of systems of care is that they don't tend to look too hard at sustainability. I think many of the communities that have tried to develop systems of care have failed. They seem to have initial energy, and also usually initial funding, but after that early enthusiasm and money is gone, the whole thing crumbles. Posted Tuesday, February 15, 2005 at 03:32 PM
In July 2001 The Tennessee Department of Mental Health and Developmental Disabilities awarded federal block grant funding to fund two demonstration projects serving children age birth through third grade. The objective was to develop a system of care for children with behavioral and mental health issues and their families.
I serve as coordinator of the Maury County Early Childhood Network. Centerstone is the agency through whom these funds are received. Members of the Early Childhood Network include parents, providers, and community members. We meet as a group on a monthly basis. During these meetings networking, collaboration, and information regarding various services available to the target population is provided.
The other component of our program is providing wraparound services to families who are willing to go through the wraparound process. This process include the initial assessment, the development of the child and family team, and defining the goals the family wishes to address.
From my perspective the Early Childhood Network has proven beneficial to the families served, the providers, and to our community at large. I feel that persons who attend our meetings received information that they might not have otherwise received. Persons who participate on Child and Family teams learn about the family needs and have contribute to meeting those needs in ways that might not have been utilized if the team consisted of only the case manager and the family member.
As one parent recently wrote, "I would like to thank ECN for the opportunity given to my child and I to put a team together from our own community that has helped us with everyday needs. ECN has helped me get everything inmy life organized enough to start college, get glasses that I've needed for 3 years now, has helped with our membership with the YMCA for my son to get extra therapy he needs, and to apply for the much needed help from respite. Thank you!" Posted Tuesday, February 15, 2005 at 02:34 PM
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