Introduction Federal Programs for Child Mental Health Services Principles for a Successful Funding Strategy Blending or Braiding Federal Funds Using Federal Funds Effectively Entitlements and Permanent Authorities How States Use Federal Entitlement and Block Grant Funds Discretionary Programs Plug the Gaps Matrix of Federal Entitlement and Block Grant Programs to Support Systems of Care for Children with Serious Mental and Emotional Disorders Collaborations for Interagency Systems of Care Who Collaborates? First Steps to Take Getting Down to Business Barriers to Overcome Keeping Collaborations Going Managing Change in Difficult Times Conclusion Notes Further Readings Tables 1. Purposes of and Constraints in Major Federal Programs 2. Discretionary Federal Programs Supporting Services and Activities of Interagency Systems of Care for Children with Mental Health Needs Principles for a System of Care for Child and Adolescent Services

Collaborations For Interagency Systems Of Care

Those interviewed for this study have had considerable success in forging interagency collaborations and they offered tips and suggestions for colleagues who are struggling to find the resources and political will in their states to establish collaborations that promote effective systems of care. Although the interviewees did not feel that a single model for establishing a system of care could be uniformly applied in all cases, they believe their experiences can guide others seeking to develop such systems.

Several excellent publications also discuss in detail how systems of care can be organized (see resources section). Building Systems of Care: A Primer, by the Human Services Collaborative for the Georgetown University National Technical Assistance Center for Children’s Mental Health, is particularly informative.

Who Collaborates?

Leadership has been a key factor in every collaboration that has achieved long-term viability and success in improving child outcomes.

All of the agencies are jointly committed to the best care for each child... commitment of the agencies at middle management (responsible bureaucrats near the top of each of the child agencies) is what worked in our state. (State juvenile justice official)

Finding and supporting people who will play these leadership roles is not always easy. Participants at the meeting identified three key barriers that must be overcome:

• Leadership in an agency may be turf-oriented and self-protective.
• The system could be about to lose critical leadership or leadership combinations.
• Personnel shortages may limit the time that can be devoted to the required meeting/planning for system change or individual child/family planning.

To overcome these barriers, commitment from a high level of government has generally been necessary. The officials interviewed for this study stressed that top leaders must either buy into the concept or, at a minimum, support the collaboration’s broad goals and empower agency personnel to collaborate in new and effective ways.

Some states establish separate committees, task forces or a children’s cabinet to bring about high-level collaboration. Other states have less formal, but nonetheless effective, strategies.

Find champions to carry the message and exemplify it. (State juvenile justice official)

Leaders must remain engaged. In the experience of those interviewed, the greatest success was achieved when high-level leadership stayed informed on progress and had regular contact with those who were designing and implementing the system of care. At the same time, leaders must allow agency personnel the flexibility to think creatively and “out-of-the-box” in order to develop new ways of doing business.

The interviewees also stressed the importance of identifying individuals who can act as effective leaders within each agency (such as the state mental health authority’s children’s staff or the child welfare staff responsible for foster care), in family groups and in the stakeholder community. These individuals must do the actual work of collaboration on a month-by-month basis. In a few states, leaders at this level have achieved long-lasting and effective collaboration despite minimal involvement of higher-level leadership.

You need people who have informal leadership, not necessarily formal leadership, to be engaged—people who are on your wavelength. (State mental health official)

While the exact structure varies to suit state dynamics, generally a core leadership group has formed in all successful states to sustain the collaboration through changes in political leadership. Another large, inclusive group often exists as well, to keep everyone informed and to collect feedback from a broad group of stakeholders.

You can’t be dependent on one person. It must be a culture of collaboration. (State child welfare official)
Collaborative relationships are built on trust among people who have shared ideas of system needs. According to the officials interviewed for this study, one way to assess who will be a strong partner is to look for willingness to make compromises when necessary. Rigid thinking will undermine collaborative efforts. People in the collaboration should be accessible to their colleagues and be ready to give up some control in order to further the collaboration.

The skills you need to look for (in agency personnel) are facilitation skills, not diagnostic skills. (State mental health official)

Those interviewed felt strongly that family members need to be brought into such collaborations at the earliest possible stage, to work alongside agency personnel and help guide the collaboration so that outcomes are acceptable to families. This is unlikely unless public agencies provide resources for family members to participate, such as payment for their time and reimbursement for travel or other related costs and child care.

What works is having families as allies...this enhances the vision that kids belong in communities and reduces turf issues. (State child welfare official)

All parties must make a real commitment, not just give lip-service to collaboration. The group needs to be action-oriented to avoid promoting reforms that will exist only on paper. Participants pointed out that each participating agency must be willing to commit to the collaboration in a meaningful way so as to purchase results.

The ingredients that make the system work are leadership and money as an incentive. If you play (collaborate) you get the money/resources to have your children served; if you don’t, you don’t. (State mental health official)

First Steps to Take

Leaders must subscribe to the same important values. In particular, they must agree that children’s and families’ needs must be prioritized and must always override agency issues and staff needs.

What brings people together is a shared commitment to do the right thing. (State juvenile justice official)

This philosophy should be clarified in a collaborative process and be in writing. An important aspect of the mission, and one that should be dealt with by the highest level of leadership, is the definition of children to be served. Is it all children, all children with mental health care needs, children of all ages, children with serious mental or emotional disorders? Decisions on system-building vary greatly depending on this choice. Regardless of this decision, leaders must also focus on how the most complex cases will be resolved without disputes, because a failure to deal with the most difficult cases will undermine agencies’ commitments to work together in the future.

We have state review teams for very complex children. The directors of all agencies come together to deal with these children’s issues. (State juvenile justice official)

Collaborators need to be clear not only on their mission and purpose but how they will accomplish their goals and the timeline for making the various changes needed. It is unreasonable to expect quick results.

To build long-lasting collaborations, the proposed system must both address children’s and families’ needs and serve each agency’s goals. Participants believed that no single solution could guide collaborators, but that it is possible in each case to determine how the system of care will help agencies stay true to their basic mission. For example, many agency goals can be satisfied in a system of care whose articulated objectives include preventing children’s involvement with juvenile justice, helping children behave appropriately in school or improving their academic performance, and keeping children safe either in their own home or in an alternative placement when necessary.

Experience has shown participants that systems of care can readily be marketed to all agencies—and to legislators or senior policy officials who oversee such agencies—by showing how the collaboration will satisfy each agency’s existing goals and improve outcomes. They stress that successful collaborations do not result from mental health agencies’ dictating to other child-serving systems what must be done by the group, but from mental health agencies’ learning what other agencies require better to serve children with mental health care needs in their systems.

What’s clear from this is that the system’s objections to change were taken seriously and dealt with effectively from the beginning, so they were invested in the process. (State child welfare official)

Child welfare has been relieved of the sole responsibility for deep end kids’ mental health issues. (State child welfare official)

Getting Down to Business

The process must begin with individuals’ spending time to learn about each of the other systems—their language and goals, the data they collect and the products they want. This enables the group to acknowledge and respect the differences between agencies and to identify commonalities.

The group should share detailed information about each agency, including budget information. Planning groups should be mixed, with policy experts, administrators and direct-care staff.

Frequent contact and a willingness to respond to problems of colleagues can facilitate this process. In time, informants had found, the group will begin to share power and control as well as the burden of running overextended systems with too few resources. All agencies may not be prepared to “play” and the collaboration must be prepared to proceed.

Our primary systems are mental health, child welfare and Medicaid. Juvenile justice is a partner, but no funds yet. Education is involved to a lesser degree and substance abuse has a long way to go. (State mental health official)

Policy changes should allow for some top-down reform, such as a state’s setting broad policy reform goals, designing new initiatives and providing funding, infrastructure and training. But they also should allow for bottom-up reform through local design and built-in flexibility at the local level, within the framework established by the state.

Particularly successful strategies to foster closer working relationships between mental health and other agencies are:

• Mental health staff volunteer to work on other agency committees—for example, to help write state regulations on IDEA regarding mental health issues.
• Mental health line staff are outplaced into other child-serving agencies.
• Cross-agency job shadowing is arranged for those working in all the collaborating agencies.

Mental health staff are co-located in [the] child welfare agency to resolve issues quickly. We co-fund certain services and share supervisory responsibility and jointly certify wraparound coordinators. (State child welfare official)

Collecting good data is critical for monitoring, evaluating and demonstrating success. Interviewees urged collaborations to address data-system issues early in the reform process. Unless it is clear what is happening to children and families from the outset, the effect of the collaboration will be difficult to determine. Without evidence that collaboration makes a real difference, resistance to change and other obstacles may soon overwhelm reform efforts. Collaborators must continue to evaluate the outcomes achieved by the system of care and must constantly work to improve its responsiveness and effectiveness.

We use Medicaid MIS now for some non-Medicaid services so we can identify all the funds for the child in one place. (State mental health official)

Data should focus on outcomes and speak for itself. That is, collaborations should avoid over-interpretation. Data might include:

• drop outs/school discipline incidents;
• child welfare residential-placement rates;
• use of inpatient psychiatric hospitals or residential treatment centers (RTCs);
• family views on services;
• number of children in juvenile justice because mental health services are inaccessible elsewhere.

As system reform is designed, it is critical to address the broad range of issues raised by the families who are to benefit from the provision of more effective services for their child. Each reform will need to infuse cultural competence throughout its systems of care.

Barriers to be Overcome

Long-standing suspicions, misunderstandings and different views of children and families in different systems can work against collaboration. Participants reported that the organizational culture in some agencies can also work against collaboration. They point out that these barriers should be recognized, so they can be addressed and agencies can remain focused on the child and family.

Different values, beliefs, funding, “blaming and shaming” need to be dealt with early in the collaboration process and gotten out of the way. (State child welfare official).

Teachers are invested in the status quo. A system of cross-agency staff training has been used to assist in implementing the [new] system. (State special education official.)

Keeping Collaborations Going

In addition to having formal processes for discussing key issues, participants reported, collaborations are often most successful when people get to know each other in less formal ways. Deliberate plans to get together outside meetings—over lunch, for example—enhance the sense that all are engaged in a common task and walk the same path. This can help a group overcome the inevitable and difficult clashes of agency needs. Accordingly, said the officials interviewed, a sense of shared ownership, shared burden and shared leadership must exist within the group.

In spite of legislation and policy, we were able to build strong relationships based on trust. (State education official)

Consultants can be helpful in developing and implementing these steps, according to participants. Outside experts can create trust when, as often happens, people within the state know each other too well and are unable to hear new ideas from their in-state colleagues. To get the most value from such outside consultants, it is best to work with only one or two individuals over time, so that the consultant becomes familiar with state-specific issues and problems.

An ongoing training program for administrators and direct staff is necessary to ensure success and maintain collaboration at both state and local levels. Cross-training is the most effective approach. Training must be ongoing, due to staff turnover and because the pressures of everyday work can overwhelm staff. If that happens, collaborative work, despite its long-term payoff, will be dropped.

We have had wraparound training universally. Even correctional officers in the juvenile justice institution have received wraparound training (State juvenile justice official)

Two trainers train staff from mental health, child welfare, juvenile justice and education with families for a week. (State mental health official)

Family engagement at the implementation stage is key, according to the officials interviewed. Family engagement can help maintain constant pressure for real improvement. It can also help motivate policymakers and legislators to support a process that may not immediately demonstrate its efficacy.

As time passes, participants warned, it is easy to allow day-to-day pressures to reduce the time spent continuing to build and nurture the collaboration process and the essential relationships. Strong collaborations are built on frequent contact and must involve individuals who are willing to spend time going beyond their normal responsibilities.

Managing Change in Difficult Times

Managing change is the difficult task facing a collaborative effort at systems reform. Those interviewed stressed that it is critically important to be strategic about what can be changed, and not to overreach in the early stages of reform. This is an evolutionary process and there will inevitably be stages to the relationships between agencies.

Interviewees reported that they had faced and overcome several challenges to successful interagency system-of-care reforms, including:

• resource issues—a continuing and sometimes overwhelming barrier;
• changes in leadership, particularly at the highest levels;
• lack of advocacy and support from child agencies, families or various other child advocates in the state; and
• already overworked staff’s becoming overwhelmed.

Those interviewed also highlighted four specific resource issues of concern:

• To be successful, systems of care must be able to serve all children who qualify, regardless of the funding source. Currently, mental health and, increasingly, other state systems focus almost exclusively on Medicaid-eligible children.
• Short-range cost concerns too often drive state and local rulemaking. This creates difficulties for the system of care and hampers long-range improvements in outcomes for children and families.
• Reformers are constantly threatened by potential funding cuts—a problem that is particularly acute as this study goes to print.
• Different values between the systems about what should be funded can lead to cost-shifting and blaming.

  Less money can cause more gate guarding and people retrenching. (State child welfare official)

Participants reported that funding constraints are often created by one system or another either out of ignorance of a particular program’s spending rules or out of a desire to limit spending in a particular agency’s budget. For example, there is great confusion over the use of Medicaid funds and some state officials may erroneously believe that federal rules prohibit certain types of spending. Those interviewed urged efforts to overcome bureaucratic resistance to examining all funding streams and devising ways to use existing funds appropriately in a collaborative manner to achieve the same goals and outcomes for children.

Escalating costs can result in cost-monitoring and cost-containment measures. When this is a motive and drives rulemaking, the less the system is oriented to child services and therefore the less effective it is. (State education official)

On the other hand, some interviewees pointed out that budget crises have often driven successful reforms and that the lack of resources can help advance reforms. Resource shortages force officials to think out of the box and devise more cost-efficient ways of using limited funds. Interagency systems of care are efficient and, if appropriately designed and implemented, can reduce wasted expenditures and improve child outcomes, resulting in significant future savings for many state systems. In times of fiscal crises, policymakers are often open to such new ideas.

Economic downturn is an asset in that it forces more efficiency and effectiveness in planning and execution. In our state it caused entities to come together and blend whatever they had to contribute. (State juvenile justice official)

A strategy that might be used in difficult fiscal times would be for agencies to join together on major initiatives, such as applications for a federal waiver. An application in one system (Medicaid or child welfare) could involve partner agencies who would make policy changes in their own systems to support the waiver. In this way, the waiver can be designed to support the interagency system-of-care goals and objectives, and working together strengthens the collaboration as well as the system of care.

Besides the obvious opportunities presented by demonstrating successful outcomes, positive resource benefits can result for every agency once a system of care begins to show results. Individual agency budgets may be increased as policymakers see the success of this approach. Data sharing and improved data infrastructure can produce information to help policymakers view the total costs of serving children. Cost-savings can then be appropriately considered to include savings in various other state systems.
When state administrations change and new high-level leadership takes over, the value, goals and objectives and system-of-care outcomes must be explained all over again. This can be done successfully, but must be a focus for those engaged in the reform initiative; collaborators cannot assume that new leadership will buy into the principles underlying reform.

A split among agency-level participants over key issues, such as reform goals, is a constant threat to collaborative efforts and can reduce agencies’ commitment to the process. The officials interviewed for this study repeatedly emphasized that these reforms are constant and evolving processes and that collaborators need to remain focused on how each agency can gain from the collaboration and to work at building relationships within the collaboration.

Finding time for sustained collaboration can be difficult. The commitment to carve out the hours necessary for interagency discussions and new planning can become burdensome.

Many states have developed successful local collaborations in some areas of the state, but have had great difficulty in stimulating similar reforms in others. An examination of why these areas are doing so much better in collaboration can be useful. For example, is it due to better collaborative structures, personnel or other factors? Other strategies might include states’ supporting local collaborations by forging common approaches to children’s and families’ needs. For example, state-level collaborations can design core competencies across child-serving systems. They can arrange a common schedule for training (and retraining) to reorient direct-care staff to a systems-of-care approach. States can also assist local system-of-care sites by providing technical assistance directly and furnishing flexible funds that can be used locally for planning or training.

Another threat identified by the group is lack of advocacy to create pressure for a single agenda. This, it was observed, has undermined many reforms. Lack of advocacy also affects the ability of reformers to sell their approach to the state’s political leadership. If families are fully involved and committed to the system-of-care reforms, they must also recognize their important role as advocates and spend time and resources to learn how to present a case to policymakers. To do so, families and advocates need access to key information and data and should be fully engaged in a meaningful, ongoing way in the design and implementation of reform.

Those interviewed pointed out that working first to solve a specific problem or to provide useful, timely information to others can be helpful in creating a sense early on of the successes that can come from collaboration.

Next: Conclusion