Developing and Maintaining System Coordination

Systems of Care 1

Running Head: DEVELOPING AND MAINTAINING COLLABORATION

Developing and Maintaining Collaboration in Systems of Care for Children and Youth with Emotional and Behavioral Disabilities and Their Families

Jeffrey A. Anderson Indiana University

Janet S. McIntyre Knute I. Rotto Indiana Behavioral Health Choices and the Dawn Project

David C. Robertson Indiana University

Address correspondence to: Jeffrey Anderson, Assistant Professor and Area Coordinator for Special Education, School of Education at IUPUI, Indiana University, 902 West New York St., Indianapolis, IN 46202-5155; (317) 274-6809; [email protected]

Systems of Care 2

Abstract Many communities have implemented systems of care in an effort to better coordinate and integrate mental health and other social services for children and youth, while simultaneously managing existing funding sources more effectively. Systems of care represent a fundamentally different way of delivering mental health services and accordingly require new approaches for both developing and sustaining collaboration. This paper examines obstacles to collaboration and addresses key factors required to build and sustain collaboration.

KEYWORDS Systems of care Children's mental health Emotional and behavioral disabilities Interagency collaboration Family centered practices

Systems of Care 3 Developing and Maintaining Collaboration in Systems of Care for Children and Youth with Emotional and Behavioral Disabilities and Their Families Some of the major reform efforts designed to improve children’s mental health and other social services have focused on creating methods for coordinating the variety of systems and agencies that provide services to children with multisystem needs and their families (e.g., child welfare, special education, juvenile justice, health, mental health). Many of these efforts can be attributed to the 1984 enactment of the Child and Adolescent Service System Program (CASSP), which provided support for communities to develop mechanisms for coordinating services among the agencies that serve children with multi-system needs and their families (Stroul & Friedman, 1986). CASSP laid the groundwork for the development of systems of care, which are defined as comprehensive spectrums of “mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of children and adolescents with severe emotional disturbances and their families" (Stroul & Friedman, 1986, p. 3). Stroul and Friedman (1986) also identified several core values and attributes that should be incorporated into these care systems, including (a) child centered and family focused services, such that the strengths and needs of the child and family dictate the types and mix of services provided; (b) community based services in which the responsibility for the locus of services, management, and decision making occur at the community level; and (c) culturally competent services such that all agencies, programs, and services reflect policies, behaviors, and attitudes that are cross-culturally appropriate (Benjamin & Isaacs-Shockley, 1996; Isaacs & Benjamin, 1991). During the past decade, the number of systems of care operating in this country has increased and some literature has described how these systems function (e.g., see Anderson,

Systems of Care 4 2000; Epstein, Kutash, & Duchnowski, 1998; Stroul, 1996; Vinson, Brannan, Baughman, Wilce, & Gawron, 2001). The purpose of this paper is to provide information about how to develop and sustain collaboration and coordination in systems of care. We begin by describing how systems of care can be created and proceed to describe barriers to interagency collaborative efforts and methods for overcoming such challenges. Throughout the paper, examples from the Dawn Project, a system of care located in Marion County (which includes the city of Indianapolis), Indiana, are provided to illustrate how interagency collaborative efforts can be initiated and sustained to improve service provision to young people with multi-system needs and their families. The Dawn Project: An Example of a System of Care The Dawn Project, a public sector system of care that began serving families in 1997, was created out of the recognition that increasing numbers of children with serious emotional and behavioral problems were being placed out of their homes, including out of county and out of state. These concerns had both ethical and financial origins, leading stakeholders to seek cost effective, community-based alternatives to the use of highly restrictive, expensive out-of-home placements. Subsequently, the Dawn Project was formed to provide a coordinated, system of services for children and youth and their families in which costs are contained and services are provided in the community (Indiana Division of Mental Health, 1999). To implement this project, stakeholders agreed that Dawn would adhere to system of care principles (Stroul & Friedman, 1986) within a care management environment, by establishing a case rate of $4,256.00 per participant, per month. This rate covers all behavioral health care, including acute hospitalization, residential care, mentoring, family and individual therapy, respite care etc. Dawn, which is funded jointly by county and state government, is administered through a

Systems of Care 5 contract with Indiana Behavioral Health Choices, non-profit care management organization (Anderson, 2000; Indiana Division of Mental Health, 1999). The Dawn Project employs service coordinators (see Stroul, 1996 for a discussion of service coordination) whose role is to implement the system of care philosophy within the parameters of the capitated rate. Upon enrollment in Dawn, a service coordinator is assigned to work with the family. Coordinators first form a child and family service coordination team, in which families are the key members. Teams are made up of practitioners from all agencies involved with a family and individuals who support the family (e.g., extended family members, religious advisors, neighbors). Under the guidance of the service coordinator, the team uses a strengths-based orientation (Rapp, 1998) to develop a multi-agency service plan that incorporates (a) the family's strengths and addresses their needs, (b) other services with which a family may be involved, and (c) existing informal and natural supports available to the family. Caregivers are empowered to become equal partners in the development of the service plan and in all decisionmaking related to service provision for their child. Teams also use or create nontraditional types of services when needed (e.g., educational mentoring). An essential principle for these teams is that if the family is not present, the meeting does not take place (Anderson & Matthews, 2001). To date, the Dawn Project has served over 500 children and their families. Children and youth can be referred to Dawn primarily from three sources: Marion County Office of Family and Children, Indiana Division of Special Education, and Marion Superior Court Juvenile Division (Russell, Rotto, Matthews, 1999). In addition, youth also can enter Dawn through one of several pilot projects recently implemented as part of a six-year grant awarded to Marion County in October 1999 by the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA). Specifically, this grant has allowed Dawn to

Systems of Care 6 expand its service capacity to include Marion County youth who are: (a) sent to the Department of Correction, (b) in State hospitals, and (c) at-risk for developing more serious emotional disturbances; however, the core program continues to be supported by the original public payers: the Marion County Office of Family and Children, the Indiana Division of Special Education, and Indiana Division of Mental Health and Addiction (see Figure 1 for more information about the organizational structure of the Dawn Project). We will refer to the Dawn Project throughout the paper in an effort to exemplify processes and procedures related to systems of care. Creating a System of Care The creation of a system of care requires a commitment to collaborate from individuals, public and private agencies, family members, and government funders (Epstein et al., 1993). True collaboration is difficult to achieve “because it is both the process and the product of building systems of care” (Hodges, Nesman, & Hernandez, 1999, p.2). It requires collaborating partners to share responsibilities and to develop a commitment to find solutions to the inevitable conflicts that accompany collaboration (Friend & Cook, 1990; Harvey, 1995). According to Kagan (1991), true collaboration also requires participants to join in full commitment to a common mission with well-defined communication channels working at all levels. Collaboration in a system of care must also include genuine family participation in all aspects of the system, including creation, implementation, and evaluation (Simpson, Koroloff, Friesen, & Gac, 1999; Osher, Kammen, & Zaro, 2001). Furthermore, because systems of care represent a significant change in how services are delivered, successful collaboration also requires strong leadership across system partners (Duchnowski, Kutash, & Knitzer, 1997). Needs Assessment. It is important for collaborators to gather as much information about the population they intend to serve as possible (Epstein et al., 1993). For example, possible

Systems of Care 7 questions for a needs assessment might include: How are children and youth with the most serious needs being served in the current structure? What are the outcomes and costs of existing services? Who are the primary providers? Are certain groups or subpopulations of children being excluded from receiving services? (e.g., see Illback, Nelson, & Sanders, 1998). It is difficult to plan for the future without having a clear, shared understanding of the present environment. However, it also can be illuminating for representatives of different systems to recognize that in fact, at least some of the same children and families are being served in the different systems in ways that overlap, causing costly duplication and confusion for both the providers and families being served. Additionally, needs assessments can uncover gaps in current service structures, as well as identify underserved groups (e.g., see Epstein et al., 1995). To address the escalating costs and ethical implications of out of home services in Marion County, officials from the Office of Family and Children, Juvenile Court, Indiana University School of Social Work, the Mayor’s office, and several children’s services providers came together to examine the current structure and status of child welfare. They found that education, child welfare, and mental health each had separate funding streams and administrative structures, which made it extremely difficult for agencies to coordinate activities and also created gaps and overlap in service provision (Indiana Division of Mental Health, 1999). These findings led to the submission of a proposal to the Robert Wood Johnson Foundation for a Mental Health Services Program for Youth (MHSPY) replication planning grant. The goals of MHSPY included building a family-focused, community-based, capitated managed care system of services for children with serious emotional disabilities and their families. Upon receipt of the grant, serious planning to implement such a system began.

Systems of Care 8 Common Values. For a system of care to coalesce, collaboration must be grounded in common values and set of goals. While some stakeholders may press for early action, it is critical for child-serving agencies, schools, families, and community members to first become fluent in the core values of systems of care, as previously described (Schoenberg, 1994; see Stroul & Friedman, 1986). Within this context, the local creators of the care system should communicate those values in language that is understandable, meaningful, and relevant to members of their community. For example, early in the planning stages, the Dawn Project Consortium was formed by key stakeholders, and included both service provider representatives and family members. Initially, the Consortium created a cross-system task force to craft a mission statement, guiding philosophy, and core values and principles. In turn, these were reviewed, amended and ultimately approved by the Consortium. A great deal of time was spent by many people to make sure that these statements were jargon-free, easy to understand, and both acceptable and believable for all stakeholders. Entire meetings were devoted to gaining consensus about the language and substance of these belief statements; family members played an integral part in the process. Leadership. To embark upon creating a family-centered, community-based, culturally sensitive system of care, it is critical that strong cooperative relationships exist or are developed among the leaders of the child-serving systems in the community (e.g., see Epstein, et al, 1993; Duchnowski et al., 1997). Representatives from parent and family advocacy groups, child welfare, juvenile justice, mental health (including Community Mental Health Centers and Mental Health Associations), and special education must have the opportunity and ability to communicate openly and proactively on behalf of youth and their families (Indiana Division of Mental Health, 1999). Additionally, some collaborative efforts may include Public Health and/or

Systems of Care 9 Medicaid agencies. Rifts or conflicts in any of these relationships need to be addressed and repaired before beginning to develop a system of care. Ideally, all leaders and critical stakeholders should share in developing a vision for the system of care. For example, Dawn has benefited from a strong cadre of leaders from state and local government, advocacy organizations, service agencies, and families, who make up the Dawn Project Consortium. Furthermore, and as previously described, long before any children were admitted to the Dawn Project, the Consortium created and agreed on written statements defining mission, core values and guiding philosophy and principles (Indiana Division of Mental Health, 1999). The leadership also agreed that finding ways in which to better and more effectively serve children and families was paramount. When the inevitable disagreements arise, Consortium workgroups or task forces are formed to address issues and find solutions acceptable to everyone. For example, surveys of system participants, conducted in 1999, identified disagreements around the implementation of a strengths-based philosophy and uses of financial resources (Sullivan, 2001). These issues were aired through Consortium meetings, which led to the formation of workgroups, with broad stakeholder representation, designed to address the concerns. What is noteworthy is that despite inherent system differences nearly all of the founding leaders are still members of the Consortium and continue to be committed to making the Dawn Project collaboration successful. Theory-based Frameworks. At the outset, leaders from each system need to be committed to a common theory of change that both delineates how each system defines “success” for the children it serves and illuminates why they believe system of care reform will lead to success for participating children and families. Hernandez, Hodges, and Worthington (2000) have developed a 12 step process in which community leaders work together to develop a theory-based

Systems of Care 10 framework for clearly linking the ideas, actions and outcomes that will drive the emerging care system. Defining the populations to be served, strategies to accomplish goals, and desired outcomes can collectively help to illuminate the interrelationships among these elements. By stating the beliefs, assumptions, and expectations that collaborators hold, leaders can build a foundation for strategic planning and outcome evaluation. The Dawn Project began with wellcrafted belief statements that all stakeholders endorsed. Leaders also clearly defined the population to be served and created a referral process that was acceptable to everyone involved (Anderson, 2000; Indiana Division of Mental Health, 1999). Taking the time to develop a theory of change ensures that all stakeholders in the system of care are able to reach consensus about system operations. Everyone involved must be open to the idea that systems of care can lead to better outcomes for children with serious emotional difficulties and their families; otherwise, success will be short-lived or difficult to achieve (e.g., see Hernandez, Hodges, & Worthington, 2000). Stakeholders also need to realize that risks will always exist because multiple individuals and systems are contributing both their resources and reputations to the implementation process; consequently, however, everyone also is able to share in successes (Kagan, 1991). The Dawn Project, for example, strives to begin every meeting with success stories, so that even those who have responsibility for policymaking but do not work directly with the children and their families can take ownership of the good work that is occurring. Family Involvement. In outlining the principles for the system of care, Stroul and Friedman stress that the system must be “child centered and family focused” (1986, p. 16). Family involvement encompasses both a philosophical framework underlying treatment and a commitment to include family members in all decisions that affect their children. The Dawn

Systems of Care 11 Project involves families in decision making as members of the child and family service coordination team (see Anderson & Matthews, 2001), through involvement in the Consortium, and through Families Reaching for Rainbows, a local chapter of the Federation of Families for Children’s Mental Health. Moreover, the Dawn Project Consortium has had family representation since its inception. Family members were instrumental in naming the project and creating its mission and values statements. Every cross-system child and family team that creates a service coordination plan has family participation and, sometimes, family leadership. A hallmark of Dawn is that no meeting is held without family members present. Through the active support of Families Reaching for Rainbows, the Dawn Project has been able to identify family members to participate on its Evaluation Team, Diversity Team, Outcomes Workgroup, and numerous other ad hoc committees and workgroups. In addition, the president of Families Reaching for Rainbows is a member of the Dawn Project Consortium and can thus, both raise family issues with the consortium, as well as communicate consortium activities to families. Challenges to Successful Collaboration According to Hodges, Nesman, and Hernandez (1999), barriers to collaboration can be put into three categories: personal, systemic, or environmental. Personal barriers are those resulting from basic American beliefs in competition and independence that make it difficult for individuals from different systems to work cooperatively (Lippitt & Van Til, 1981). These traits may cause people to fear and resist change and collaborative efforts. Agency staff members may feel their professional integrity is threatened when they are required to participate in shared decision-making and differences in treatment philosophy and goals can create friction among those who are charged with working together (Skiba, Polsgrove, & Nasstrom, 1996). For example, a probation officer who views behavior from a public safety perspective and a therapist

Systems of Care 12 who views the same behavior from a mental health perspective may face difficulty in finding common ground when working with the same child or youth (Anderson, 2000). System barriers can be created by the scarcity of resources that often exists in the social services, including limitations in time, staff, technology, money, or experience with collaboration (Hodges et al., 1999). The need for complex coordination in addition to the normal duties of service providers also can hinder cooperation. Normal workloads already may be overwhelming, and staff may not have the skills, experience, desire, or time to coordinate activities among and across agencies and systems. Moreover, change often is difficult for both people and organizations. Organizations typically resist change via built-in processes designed to preserve stability (Robbins, 2000); bureaucracies, by their nature, are especially adept at maintaining the status quo. People may resist change because of aforementioned issues (e.g., scarcity of resources, lack of training, etc.). Over time, the Dawn Project service coordinators and administrators have learned strategies to help partners come together. For example, thorough training in conflict resolution helps workers learn to build empathy and give voice to those who might otherwise subvert or avoid collaboration; disagreements that are spoken out loud are possible to mediate, whereas, unspoken issues can tear a team apart. Dawn Project managers frequently emphasize to staff that “change agents must change first,” thereby setting an example for others. Other system-level barriers may stem from poor internal and external communication, due to professional language, turfism, training, or high employee turnover. If new organizational structures are not created and communication links established and maintained, agencies may be unable to move beyond turfism, which can obviate cooperation and pooling of resources. For example, if the child welfare system views a child’s challenges as school related, caseworkers

Systems of Care 13 may not intervene because they believe the situation is the school’s responsibility. Moreover, some professionals may have been trained to believe that they alone hold the expertise in all areas related to a child’s functioning, without regard for the experience and knowledge of the child’s family members, and with little understanding of the mandates of other public systems with which the child and family may be involved (e.g., see Malysiak, 1997; 1998). Cross system training may greatly increase the chances for collaborative success by enabling workers to gain empathy for each other’s work challenges. For example, the Dawn Project has facilitated cross training with the Department of Correction and with Special Education. In addition, the Dawn Project has allowed system partners to attend national meetings where they get to know each other better and have the opportunity to meet others, from both their own fields and other disciplines, who collaborate in systems of care. Similarly, Dawn management has learned that sharing food and insight with supervisors who work for the project’s partners on a regular basis helps tremendously to keep the lines of communication open. Confidentiality issues also can produce barriers to open communication among participating agencies. Designed to protect families and children, confidentiality can be used as a reason to refuse to cooperate and share information. The Dawn Project utilizes a broad “Authorization for Release and Exchange of Information,” which children’s caregivers sign at intake in order to facilitate information sharing at the team level. Families may choose not to release specific information to specific agencies, but generally, they are happy to sign in the hope that service providers will work both together and with them to provide one plan rather than many fragmented ones.

Systems of Care 14 Environmental barriers can exist in communities, as well as at state and national levels (Hodges et al., 1999). For example, political rivalries can produce obstacles that have no direct relationship to the collaborative effort necessary to create a system of care. Competing or contradictory mandates for state agencies that serve children also create threats to cooperation. Additionally, variations in how different agencies define emotional and behavioral disabilities and use these definitions to establish service eligibility criteria can also obstruct system of care implementation (Anderson, 2000; Friedman, Kutash, & Duchnowski, 1996; Kutash & Duchnowski, 1997). Like most collaborative efforts, the Dawn Project has suffered from its share of turfism and power struggles as it engages bureaucracies in new ways of delivering services. For example, even with the changes that have occurred, the underlying funding mechanisms used by various systems appear to continue encouraging cost shifting (i.e., trying to move children to different agencies so the services are funded out of somebody else’s budget). Moreover, during times of stress, organizations and individuals often revert to traditional modes of behavior. In order to sustain change, it is critical that lines of communication remain open and constructive. In the Dawn Project, information sharing happens frequently and at multiple levels, including regular meetings at the child and family team level and the agency supervisory level, and Consortium meetings at the executive level. The Project’s System Coordinator and the Community Resource Manager are charged with facilitating these exchanges and responding promptly to any and all concerns of collaborating partners and providers. Overcoming Barriers to Sustain System Collaboration In spite of the challenges inherent in creating and maintaining coordinated systems of care for and with children and families, many states and communities are moving in this

Systems of Care 15 direction (NRN for Child & Family Mental Health Services of WBGH, Ed., 1999). A growing body of preliminary research points to successful outcomes of systems of care, both in the lives of children and families and in containing or reducing costs of services (e.g., see Anderson, Wright, Kooreman, Mohr, & Russell, in press; Center for Mental Health Services, 1997; 1998; Lourie, Stroul, & Friedman, 1998; Rosenblatt, Wyman, Kingdon, & Ichinose, 1998; Schoenberg, 1994; NRN, 1999). The potential for positive results may be starting to create an atmosphere in which communities are more willing to embark on the difficult work of developing unique local systems of care. While resistance to change is common and pervasive in all organizations (Robbins, 2000), there are some proven tools and techniques that can help sustain and renew collaborative reform efforts. A key learning in the Dawn Project was the realization that perceptions and values varied within individual agencies, which in turn, necessitated ongoing communications across all levels of the organization. Second, it became critical that child and family teams identify and resolve all cross-system conflicts in a professional manner, elevating larger structural issues to the Consortium on a timely basis so that such issues can be understood and addressed. Third, when difficult issues have arisen, the Dawn Project Consortium has assigned responsibility for their resolution to work teams or task forces that include representation across stakeholder groups and at a variety of levels within stakeholder organizations. Evaluation. In addition to strong leadership, theory of change approaches, and needs assessments, system of care development can be enhanced by funding and conducting careful and meaningful evaluation, and disseminating findings (Anderson, Kooreman, Mohr, Wright, & Russell, 2002; Rosenblatt et al., 1998). Evaluation activities can start with open dialogue among leadership, staff, and families about what is working and what is not. It is important to create a

Systems of Care 16 culture that values cooperation among individuals and recognizes the importance of feelings and opinions related to continued progress. Spending time to develop an agreed upon, explicit evaluation plan and process provides a framework from which system of care progress can be monitored and, when necessary, changes made. Including the voices of all stakeholders in developing evaluation priorities is important for making evaluation activities meaningful and credible because these are the people who know the system best and can propose important questions. Additionally, those involved in developing evaluation activities are more likely to be interested in the results of these activities and use results to improve system operations (e.g., see Cousins & Earl, 1992; Garaway, 1995). Moreover, constantly reviewing the degree to which the care system is progressing is critical to both the survival and maintenance of a system of care (Winer & Ray, 1997). Comprehensive evaluation efforts require data collection from all of the agencies and systems that are part of the system of care. While the difficulties in obtaining data from a variety of systems are many, evaluation results are essential for sustainability. Findings from a wellconstructed evaluation can help inform decision-making in the system of care, such as how best to allocate scarce resources or whether certain patterns of service usage are more effective than others (Woodbridge & Huang, 2000). In addition, policymakers, legislators, and other stakeholders increasingly require evidence that public dollars are being spent wisely. Evaluation findings also can be used by program managers to develop priorities and improve practice (Goldman, 1994). Schoenberg (1994) suggests that evaluation must be approached at three levels: systemic (agency or community wide indicators), program (efficacy of treatment), and client (satisfaction and progress). Winer and Ray (1997) propose a two-pronged evaluation process involving process (how the collaboration functions) and results (what has been

Systems of Care 17 achieved). However, the methodology and specific tools used for evaluation are probably less important than the collaborative agreement among partners as to what outcomes are expected and how to monitor the degree to which they have been achieved. The Dawn Project leaders understood the need for common frames of reference for outcomes among the systems involved and in 1998 created a set outcome measures for program participants and for the system of care itself. The Consortium is revising and updating these measures in 2002, using the knowledge, experience, and data that are now available. There also is an extensive external evaluation being conducted. Utilizing funding from its Federal grant, the Dawn Project participates in a national evaluation required of all grantees, and is also involved in an external local evaluation conducted by a cross-disciplinary team of researchers (including academic faculty from education, sociology, economics, psychiatric nursing, psychology, and others), family members, practitioners, program administrators, system representatives, and other stakeholders. The Dawn Project Evaluation Study (DPES) is organized around six general areas: (1) profiles and outcomes of participants, (2) patterns and costs of service usage, (3) service coordination team functioning, (4) overall program effectiveness, (5) development of the Families Reaching for Rainbows family advocacy group, and (6) systems level changes related to the implementation of a system of care (Anderson, Kooreman et al., 2002). All DPES activities were planned collaboratively and are designed to inform policymakers about the project’s performance, as well as to assist program administrators in improving the project. To accomplish these tasks, an evaluation advisory board, consisting of multiple stakeholders, was established to review the work of the evaluation team on a quarterly basis. Moreover, to increase the usefulness of evaluation findings, each year the evaluators hold

Systems of Care 18 a public “annual briefing” for Dawn Project stakeholders and other interested persons (see http://kidwrap.org/template.asp?PAGE=64 for further information). As a result of these activities, preliminary findings about Dawn Project participation have been reported, including improved clinical functioning over time for participants and reduced recidivism rates for those who successfully complete Dawn (Anderson, Wright et al., in press). In addition, evaluators have compared the Dawn Project’s monthly case rate to service costs for non-Dawn youth in the Marion County child welfare system. Data for this study included all Marion County youth involved in child welfare and who were in residential treatment at some time during the 12-month study period. Because this group accessed some level of residential services during the course of a year, they were used as a comparison group for Dawn. Findings revealed that over 12 months, the non-Dawn comparison group had an average monthly cost of $6,017 per child, which obviously exceeds Dawn’s case rate of $4,256.00 per child per month (Warner, Ziska, Anderson, & Wright, 2002). Although all of these findings are preliminary, early evidence suggests that not only is Dawn improving outcomes for its participants, it also is less costly. Communication. The importance of open lines of communication within and among all systems cannot be overemphasized. Stakeholders at all levels, from executives through middle management, to line staff, need to understand and support the system of care. Simultaneously, relationships with family members must be carefully cultivated, maintained, and equally valued. All stakeholders must feel fully informed in a way that is jargon-free, clear, and completely understandable to them. A system coordinator or facilitator can help immensely with the task of keeping everyone up to date and informed (Indiana Division of Mental Health, 1999). This individual must be able to look beyond a unidimensional point of view to understand the whole

Systems of Care 19 system of care “picture.” A dynamic understanding of the system enables system coordinators to facilitate communication and build and maintain trust among system partners. The Dawn Project employs a systems coordinator whose role is to facilitate written and oral communication among all the stakeholders in the project, including line staff, families, consortium members, payer/executive members, and community members. This person’s role involves organizing monthly consortium meetings, disseminating minutes of these meetings, convening workgroups as necessary to study needs and propose solutions, writing quarterly updates for various payers, and attending community meetings to educate and inform the community about Dawn. Moreover, the coordinator works closely with family members and acts as a liaison between Dawn and the local chapter of the Federation of Families for Children’s Mental Health. The coordinator is also responsible for ensuring that the federal grant goals and objectives are achieved, coordinating with new stakeholders, and communicating with the federal grantor about progress. Training and Technical Assistance. Cross system training should be provided for individuals who will work across agencies and systems to engender the attitude that “we are all in this together.” Learning the legal mandates and local practices of each participating service system can help to bridge gaps and create common understanding. Often, for example, mental health providers do not understand how the special education system works; nor do teachers understand the legal mandates of the child welfare system (Anderson, 2000). Vocabulary and jargon specific to each system can be defined and a new language common to the emerging system of care developed. Additionally, it can be difficult for people who have worked in traditional service systems to conceptualize a seamless system of care that transcends funding

Systems of Care 20 and professional “silos.” Typically, differences in philosophy and agency policies create barriers to collaboration (e.g., see Anderson, 2000) that proactive and ongoing training can alleviate. Technical assistance can help system of care development and maintenance in several ways. First, it brings into the community outside experts who have experience and knowledge in system of care development. Through its Federal grant and the national Technical Assistance Partnership, Dawn has been assigned family and professional peer mentors and has access to other system of care experts at the national level. Additionally, national and local experts occasionally have provided local system partners with training about systems of care. By sharing their experiences and skills, national and local experts credibly demonstrate to community stakeholders that the venture is a positive undertaking for children and families and provide new perspectives from outside of the community. An outside consultant can mediate among stakeholders in ways that local leaders may not, in order to move system of care development and implementation processes forward. For example, system payers need to collaborate to calculate a blended services rate that represents the costs to all systems for children and families. This is the rate that stakeholders will decide is necessary to serve children and youth with emotional and behavioral problems in the community. However, the individuals involved in calculating and setting this rate typically will not have had experience in implementing the blended funding mechanisms that are used to fund systems of care. Likewise, new management information systems must be created or purchased, provider networks created or enhanced, and clinical operations defined. Often, it is wise to enlist outside help for these tasks because, as communities set out to develop care systems, these tend to be activities that will be familiar to few, if any, stakeholders.

Systems of Care 21 Under its RWJF grant, the Dawn Project received technical assistance from a variety of sources across a variety of areas of expertise. For example, the Washington Business Group on Health (WBGH) liaison was available for phone and in person consultation. Additionally, consultants from North Carolina suggested that the Dawn Project Consortium form five task forces in order address issues that needed to be decided before implementation of the project. A Wisconsin consultant helped with rate setting and other financial questions. The grant also allowed funding for a local consultant who had extensive hands-on experience with the Portland, Oregon MHSPY site. Collectively, these supports probably moved Dawn development and implementation forward much faster than if the local leadership had not had access to these kinds of expertise. Governing Structures. To avoid misunderstandings, a governing structure including procedures for conflict resolution, should be clearly delineated and agreed upon by all stakeholders at the beginning of the development process (Cumblad, Epstein, Keeney, Marty, & Soderlund, 1996). The roles and responsibilities of everyone involved must be clearly articulated. Everyone must understand who is responsible for any given task and additionally, what happens when there are disagreements among stakeholders or grievances from service participants. Obviously, the work of maintaining the care system should be shared equally, as much as possible (Lippitt & Von Til, 1981). Additionally, continuous communication and feedback among the governing body members is critical. Specific methods of formalized communication can include monthly community committee meetings, regular newsletters, annual reports from the system of care, executive leadership meetings and annual reviews of the progress of the community. Since 1996, the Dawn Project has instituted many of these approaches. Monthly Consortium meetings, annual reports from Choices, the manager of the

Systems of Care 22 project, and executive payer meetings have occurred since the beginning. More recently, a quarterly newsletter and Website highlighting activities of Dawn were implemented. Finally, creating a climate that celebrates successes is vital for keeping enthusiasm and morale high for families, line staff, and leaders. Periodic renewal, reinvention, and rededication need be built into these collaborative efforts in order to sustain their viability. It may be necessary for some members to “move on,” and new individuals to join the process throughout the development of the system of care (Winer & Ray, 1997), so that collaborators have the necessary energy and skills to continue toward sustainability. It also is important to acknowledge both those who are leaving and those who are staying and recognize that creating and maintaining systems of care for children with serious mental and emotional problems and their families is challenging and difficult work which requires considerable dedication and advanced practical skills. The Dawn Project has always valued celebrating success. Every Dawn staff meeting and every child and family team meeting begin with the enumeration of “successes.” Upon “graduation” from the project, every child and family is again celebrated. Additionally, the Dawn Project Consortium undertook a “Rededication Retreat” facilitated by outside consultants in December 2000 in order to encourage leaders to take a look back and review successes and lessons learned during the first 3 1/2 years. Conclusion This paper has explored how community agencies can collaborate to improve the coordination of services for children with emotional and behavioral disabilities and their families. Obstacles for developing and maintaining systems of care were discussed, methods for creating interagency collaboratives and frameworks were presented, and a relatively new system of care, the Dawn Project in Indiana, was described. Early findings from research exploring the

Systems of Care 23 impact that systems of care have on children and their families have been encouraging. By fully involving families in “treatment” processes, care systems appear to be able to overcome many of the limitations of traditional, uncoordinated services systems which, for the most part, were created to address “pathology” or “dysfunction” in children and families. Traditionally, professionals often have viewed themselves as experts who know best, implementing approaches in which treatments are applied to people instead of developed in partnership with people (Anderson, 2000). Historically, services for this population of children often have failed to produce positive outcomes. Systems of care, on the other hand, espouse collaboration both among systems, agencies, and professionals, and most importantly, with families. Central to a system of care is a specific focus on cross-agency service coordination, blended policy and funding initiatives, and effective and clearly articulated structures for communication among stakeholders. Successful care systems create mechanisms to assure these core constructs are in place and maintained. For example, in the Dawn Project, oversight of processes to build and sustain collaboration is the specific responsibility of the technical assistance and systems coordinator. Systems of care are both developed out of and maintained through these collaborative relationships. An important potential outcome of this reform movement is the discovery of innovative methods for working across systems and agencies and with families to build service and resource capacity, strengthen community support, and develop new approaches to service provision. The Dawn Project and similar efforts around the country continue to generate novel and unique ways to involve families in service delivery. These efforts are also creating collaborative opportunities for all stakeholders to improve the allocation of scarce resources, as well as how services are provided to children and youth with emotional and behavioral challenges and their families.

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Systems of Care 31

Author Note Jeffrey A. Anderson, Ph.D., Assistant Professor and Area Coordinator for Special Education. Department of Teacher Education, School of Education at IUPUI, Indiana University, 902 West New York Street, Indianapolis, IN 46202-5155. Janet S. McIntyre, M.P.A. Systems Coordinator, Indiana Behavioral Health Choices. 4701 North Keystone Ave. Suite 150. Indianapolis, IN 46205. Knute I. Rotto, ACSW, Chief Executive Officer, Indiana Behavioral Health Choices. 4701 N. Keystone Avenue, Suite 150. Indianapolis, Indiana 46205. David C. Robertson, M.A., Research Associate and Doctoral Student. Indiana University. Bloomington.

Systems of Care 32 Community Consortium Family representatives Rainbow s members Funding Partners MHA of Marion County Juvenile Court IUPUI Choices Mayor's Office State Hospital Corrections School corporations

Adv ocacy

Health & Hospital Corporation (Application & Fiscal agent) CMHS Initiative $$

Families Reaching for Rainbows Family support and advocacy group

Grant ov ersight

Adv ocacy & Support

Daw n Proj ect Funding Partners Office of Family & Children Juvenile Court Division of Special Education Division of Mental Health Department of Corrections Federal Grant - CMHS

Dawn Project Intensive coordination w/ community teams for multi-need families

Gov ernance

Administer s blended $$

Serv ices Ev aluate Community Provider Network Behav ioral Health Serv ices Alternativ e serv ices Therapy Residential Treatment Foster care Mentoring Crisis Interv ention Respite Substance Abuse serv ices Community Serv ice Prov iders

Indiana Consortium for Mental Health Services Research Indiana University (Ev aluation Team)

Contracts with IBHC

Indiana Behavioral Health Choices, Inc. 501 (C)(3)

Ev aluator

Contracts f or serv ices

Figure 1. Structural Overview of Dawn Project Administration and Organization