Technical Assistance Resource Guide

for the *Comprehensive Community Mental Health for Children and Their
Families Program*

##### 

**This Resource Guide provides information and resources to assist
states and communities in developing, implementing, evaluating and
sustaining systems of care to benefit children and youth with serious
emotional disturbances and their families.**

##### Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Department of Health and Human Services

**[Table of Contents]{.underline}**

Preface....3

1\. History and Philosophy of Systems of Care...4

2\. Target Population....6

Additional Special Populations....6

3\. Overarching Goals....7

4\. Infrastructure Development....9

Key Administrative Structures and Procedures....9

5\. Key Activities and Concepts.....13

6\. Elements of Sustainability.....18

7\. Evaluation Details....21

8\. Definitions....22

9\. References....26

**Preface**

This document is a Resource Guide, providing information about
community-based systems of care for children and adolescents with
serious emotional disturbances and their families, such as those
supported under the Federal ***Comprehensive Community Mental Health
Services for Children and Their Families Program***. This Guide updates
some areas of knowledge within the system-of-care field, provides a
variety of suggestions about building successful systems of care, and
identifies some basic key resources from the field.

Community-based systems of care are developed on a foundation of shared
values and beliefs about how to best to meet the myriad needs of
children and youth with a serious emotional disturbance and their
families. The children and youth themselves, and the families and
caregivers who care for them, hold the greatest interest in achieving
successful outcomes and the community as a whole benefits when those
outcomes lead to productive adult citizens who have overcome barriers
and obstacles to reach maturity. This Guide provides detail to assist
communities to identify and involve all appropriate partners, to build
consensus about the vision and steps toward achieving the vision, and to
build effective systems of care.

This Resource Guide also identifies various additional resources and
sources of information that can be explored by interested communities.
Many communities have worked for decades to build effective systems that
care for the special needs of children and their families, and much of
their learning has found its way into literature of all types, from
professional journals to local newsletters. Communities will benefit by
exploring resources identified in this Guide, while also seeking and
using other system-of-care resources.

**History and Philosophy of Systems of Care**

The System of Care model is in many ways simple and direct, while in
other ways quite complex. The first system-of-care definition was
published in 1986:

> *A comprehensive spectrum of mental health and other necessary
> services which are organized into a coordinated network to meet the
> multiple and changing needs of children and their families.*[^1]

A system of care stands strongly on a foundation of *shared values*
about how we -- society -- care for children with special needs and
their families. A system of care is *community-oriented*, respecting
community differences and linking together the many individuals and
organizations interested in the well-being of children, adolescents, and
their families. A system of care is *planned and deliberate*, carefully
building an infrastructure to maximize the positive, effective impact of
all community services. A system of care employs up-to-date knowledge
about *effective practices*, respecting family choices, culture and
abilities, and monitors its effect, *adapting constantly* to new
information about impact and satisfaction. A system of care is a
*[system]{.underline}* -- many components, each bringing something of
value -- wherein all participants hold a common goal of effective care
for children and families.

Much has been learned as communities across the country worked to
realize this definition of effective care. In the "Annual Report to
Congress on the Evaluation of the Comprehensive Community Mental Health
Services for Children and Their families Program" (1998), prepared by
Macro International, the following "hallmarks of the system of care
approach" were presented:

-   The mental health service system is driven by the needs and
    preferences of the child and family, using a strengths-based
    perspective.

-   Family involvement is integrated into all aspects of service
    planning and delivery.

-   The locus and management of services are built on multi-agency
    collaboration and grounded in a strong community base.

-   A broad array of services and supports is provided in an
    individualized, flexible, coordinated manner and emphasizes
    treatment in the least restrictive, most appropriate setting.

-   The services offered, the agencies participating, and the programs
    generated are responsive to the cultural context and characteristics
    of the populations that are served.

At the simplest level, this model promotes common sense and bringing
community members, organizations and helping systems together to nurture
all children and adolescents towards productive, satisfying adulthoods.
A successful system of care, however, requires complex, long-term
strategies, including: 1) commitment to a set of shared values across
all system components; 2) a planned infrastructure to link and
coordinate system functions; 3) a broad set of flexible service and
support options; and 4) the full and meaningful participation of those
children and families the system serves.[^2]

The Program builds on a well-documented history of efforts to promote
effective, community-based care for children and adolescents
experiencing serious emotional disturbances (also known as severe
emotional disturbances, mental illnesses or behavioral disorders) and
their families. The Federal Child and Adolescent Service System Program
(CASSP) established the first national public focus on community-based
care of children and adolescents with serious emotional disturbances in
1983, eventually providing federal grants to all 50 states to begin
developing effective service systems to better meet their needs. The key
principles behind these state-level systems were: 1) involvement of the
mental health authority for the State, county, and/or city; 2)
collaboration of child-serving agencies on behalf of children and
adolescents with a serious emotional disturbance and their families; 3)
involvement of families as partners in planning, implementation and
maintenance; 4) system support for interventions that are culturally
relevant and competent; 5) individualized services for each child and
family; 6) child and family assessments that are strength-based; and 7)
delivery of a broad array of services in the home and community.

In 1989 the Robert Wood Johnson Foundation established the Mental Health
Services Program for Youth and supported a set of communities as they
built functional systems of care and reported on their development
experiences. In 1992 Congress authorized SAMHSA to fund an initial set
of communities as system-of-care development demonstration sites. Seven
different cohorts of sites have now been funded under the CMHI over the
past decade, resulting in 96 funded communities, including 2 territories
and 10 American Indian/Alaska Native tribes or tribal organizations.

The Children's Mental Health Initiative provides an opportunity for
communities to gain support to build necessary system-of-care
components. To illustrate, communities can:

-   Draw together system partners to deepen their shared understanding
    of the values foundation upon which the system of care is built;

-   Establish or expand system infrastructure elements to link together
    all helpers within the community, promoting information
    dissemination, shared decision-making, collaborative partnerships,
    and effective care of children;

-   Expand capacity across the full array of community-based services
    and supports needed by children and adolescents with serious
    emotional disturbances and their families;

-   Promote system workforce development and increase the use of best
    practices (evidence-based and promising practices) across all
    aspects of care, supporting each direct care provider; and

-   Learn to use finite resources more effectively, attaining improved
    outcomes for children with mental health needs and their families at
    the lowest viable cost.

-   Empower families to have a decision making role in the care of their
    own children as well as the policies and procedures governing care
    for all children in the community, state, and nation.

As published recently in [Building Systems of Care: A
Primer]{.underline}:

> Building systems of care is a multifaceted, multilevel process. It
> involves making changes at state, local, and even neighborhood levels.
> It entails changes at policy and services delivery levels. Effective
> system builders are multidimensional, strategic thinkers. They
> recognize the complexities of system building and tend to be
> stimulated rather than discouraged by the process. They also are
> realistic. They recognize that system building takes time, is
> developmental, and proceeds in both a linear and circular fashion.
> They weigh strategically which aspects of system building to tackle at
> which developmental stage and guard against exhausting themselves by
> trying to take on 'everything at once.' They also constantly are
> looking for allies to engage in system building to spread the workload
> and maximize the resources.[^3]

All efforts towards system building under this cooperative agreement can
lay groundwork to sustain the resulting improvements far beyond the
grant period, substantially reforming the community's care of children
with serious emotional needs and their families.

##### Target Population

The target population for the Program is all children and adolescents
who have a diagnosable mental disorder (also called a "serious emotional
disturbance") that has negatively impacted their functioning at home, in
school, and/or in the community for a year or more (or can be expected
to last at least that long) and who are involved (or need to be
involved) with two or more of the separate public service systems
(including the education, child welfare, juvenile justice, health,
mental health and/or substance abuse systems). A focus on children and
adolescents who already manifest serious disorders assures that their
needs are met in the most effective ways possible. The development of
system-of-care components to care for this group of children and
adolescents must also lead to system changes that benefit a wider set of
children and families, including those with less serious needs, those
involved with only one helping system, younger children, and members of
sub-populations that are historically underserved or inadequately served
by publicly funded systems. System of Care communities will work to
serve children and adolescents in the target population, knowing that
these efforts, along with building an enduring infrastructure, will
positively touch additional children and families outside that
population.

**Additional Special Populations**

Communities have selected to focus on building systems of care that
serve any of several sub-populations of children, including:

-   *Youth with co-occurring serious emotional disturbances and
    substance abuse disorders*;

    -   Evidence from the National Evaluation of this Program suggests
        that nearly 50 percent of all adolescents receiving services
        through funded systems of care have a co-occurring serious
        emotional disturbance and substance use disorder, suggesting
        that implementing communities should be aware of and seek to
        address the substance abuse treatment needs of any child or
        adolescent enrolled.

    -   Cooperative agreements funded under the Program are encouraged
        to use the "window of opportunity" during the pre-adolescent
        years to link the system of care with effective substance abuse
        prevention interventions for children identified with a serious
        emotional disturbance, such as those promoted through he
        National Registry of Effective Programs and Practices (NREPP) of
        SAMHSA's Center for Substance Abuse Prevention. (See
        [www.samhsa.gov](http://www.samhsa.gov/).) While dollars under
        this Program will not be used to purchase substance abuse
        treatment services, the successful system of care must address
        these needs when they co-occur with serious emotional
        disturbances.

-   *Infants and young children with serious emotional disturbances*;

    -   Infants and young children, birth to age 5, may experience
        treatable serious emotional or behavioral disturbances but these
        needs are often ignored and/or inadequately addressed.
        System-of-care linkages to health care, child care, and
        pre-school providers for children this age are planned and
        deliberate.

    -   Cooperative agreements funded under the Program are encouraged
        to propose systems of care that effectively serve children from
        birth to age 5, as a focus of system development or included as
        part of a larger effort to serve children from birth to
        adulthood.

-   *Young adults with serious emotional disturbances*;

    -   Young adults, particularly those 18-21, experiencing a serious
        emotional disturbance may be inadequately served in both the
        child and adult mental health systems, and linkages and
        coordination between those two systems are not routine.

    -   Cooperative agreements funded under the Program are encouraged
        to propose systems of care that effectively deliver services to
        young adults through increased coordination and the development
        of community supports among all helping systems.

*Youth involved with the Child Welfare System.*

-   There is clear evidence that youth in the foster care system are at
    greater risk for the development of serious emotional disturbances.
    Linkages with child welfare agencies are critical if mental health
    systems of care are to expand impact and create a broader approach
    to service delivery.

-   Many Program communities have proposed service delivery models that
    incorporate child welfare systems and agencies.

*Youth involved with the Juvenile Justice System*.

-   Estimates suggest that between 60-80% of youth in the juvenile
    justice system already experience significant mental health
    challenges, many of these qualifying as a youth with a serious
    emotional disorder. In addition, involvement in the juvenile justice
    system serves as a predictor variable for future mental health
    issues.

-   System of care communities have already begun to document
    preliminary evidence indicating that this approach not only improves
    mental health outcomes, it also reduces recidivism and increases
    functioning at school. Communities are therefore creating more
    system of care models that link directly with the juvenile justice
    system, developing working partnerships to provide adequate service
    delivery to this population.

**Overarching Goals**

The primary goals for the CMHI Program are to:

-   Expand community capacity to serve children and adolescents with
    serious emotional disturbances and their families;

-   Provide a broad array of effective services, treatments and
    supports;

-   Create a care management team with an individualized service plan
    for each child;

-   Deliver culturally and linguistically competent services for racial
    and ethnic populations represented in communities; and

-   Promote full participation of families and youth in service planning
    and in the development of local services.

*Expand community capacity*: Currently, many communities lack adequate
capacity across a wide range of community-based services and supports to
care for a substantial portion of the population needing care. Service
and support capacity expansion occurs as the result of deliberate and
careful planning within the community, involving all relevant partners,
including state-level decision-makers.

*A broad array of services and supports*: Effective care is highly
individualized for each child and family, requiring a wide set of
service and support options to be available within the community.
Further, all options are designed for flexible application to each child
and family, in response to their strengths and needs. Flexibility may be
obtained by offering services at multiple locations and across all hours
of family life (including evenings and weekends), by utilizing service
and support providers who represent broad diversity in preparation and
life experience, and by many other locally-determined methods.

*Care management team and individualized service plan*: Children with
complex and challenging needs are best served when a team is formed
around the child to plan and monitor care. Such teams are unique for
each child and family, including professional and non-professional
helpers, as well as caregivers and others important in the child's life,
and they work in partnership to identify the best options for effective
care. A team's work is guided by an individualized service plan, created
uniquely for each child and family, and changed as often as necessary to
reflect changes in the child, the family, and/or their circumstances.
Such plans should treat the family as a unit and seek to coordinate
service efforts across all family members.

*Culturally and linguistically competent services and supports*:
Communities contain diversity across many racial, ethnic, cultural and
economic groups, and children and adolescents of all backgrounds and
experience, or are at risk of, serious emotional disturbances. Effective
systems of care are prepared to learn about community diversity and
respond with care that respects and is sensitive to the traditions,
values and beliefs of each child and family, with services and supports
accessible in languages other than English, as appropriate to each
community.

*Full participation of families and youth*: No other goal is more
important to system-of-care development than to create effective and
positive partnerships among helpers and caregivers of children and
adolescents with serious emotional disturbances. Advances in
understanding of brain development and functioning demonstrate that many
serious emotional disturbances are based on biological processes,
requiring care strategies with biological or medical elements. A system
of care strives to view parents and other caregivers as the child's
"best experts", positively engaging them in all aspects of care
planning, delivery and evaluation about their child and supporting their
efforts to successfully raise their own child. Likewise, children and
youth are invited and encouraged to participate in guiding their own
care to the fullest extent possible, considering each child's age,
development, and clinical needs. The importance of family-driven care
and the inclusion of youth as part of decision making is a hallmark of
this approach and are demonstrated in all aspects of the Program's
model.

**Infrastructure Development**

The Program supports the development of 16 key administrative
[structures]{.underline} and [procedures]{.underline} in its
implementing communities. The importance of infrastructure development
in building systems of care cannot be overstated -- each of these
structures and procedures plays an important role in effective system
functioning, as explained below. Planners will want to pay substantial
attention to items in this list, taking advantage of already existing
elements, perhaps adapted for particular populations, and determine how
to create elements not yet in place.

Key Administrative Structures and Procedures

-   ***Establishment of governance body*** refers to a group of
    individuals with the authority to make policy decisions for the
    system of care. The group includes representatives of the public
    entity that is awarded the Federal funds and also representatives of
    collaborating state or community child-serving agencies (such as
    education, health, child welfare, juvenile justice, mental health,
    and substance abuse), family members, youth, and other community
    representatives, including representation from racial or ethnic
    minority populations. This governing body may be organized as a
    board of directors of a newly incorporated system of care or as a
    committee, task force, workgroup or other such decision-making body
    of an existing human service agency. This body develops and upholds
    formal agreements and memoranda of understanding between the
    collaborating child-serving agencies, including those from all
    relevant political subdivisions of the State. It also holds the
    system of care accountable for meeting high standards of care,
    including standards for cultural responsiveness and family
    involvement, as well as standards of practice that have been shown
    to be effective through research and evaluation studies.

-   ***Systems integration*** is the organization and coordination of
    resources available through Federal, State, and local human service
    systems responsible for serving children with serious emotional
    disturbances and their families. Strategic planning, consolidation
    of funding streams, and policy formation are examples of tools that
    promote integration efforts.

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-   As part of systems integration, the Program requires that the local
    system of care develop formal relationships with the State, tribal,
    or territorial mental health authority to increase the likelihood of
    sustaining the local community-based system of care, and also to
    provide an effective system-of-care model that can be replicated
    across the State. All relevant State agencies, in collaboration with
    the State child and adult mental health authorities, will
    collaboratively implement the local system of care approach through
    statewide policies and fiscal initiatives to increase the likelihood
    of sustainability. Local system of care development should generally
    be described in the goals of the State's Community Mental Health
    Services Block Grant Plan, submitted under Public Law 102-321. The
    State mental health authority also should ensure that the local
    system of care is a Medicaid provider, as required in Section
    561(a)(2)(b)(2) of the Public Health Service Act.

-   In addition, under the Program states or communities are asked to
    provide a plan on how the State mental health authority intends to
    replicate the system-of-care model across the State. The replication
    plan from the State mental health authority may include approaches
    at various levels of effort, including replication of the
    system-of-care model:

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-   During the 6 years, through a phased and strategic approach across
    one or more counties within the State.

-   After the 6 years of Federal funding; and

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-   ***Interagency collaboration*** is defined as formal arrangements
    between child-serving agencies that describe planning, provision,
    and evaluation of the broad array of services. ***Child-serving
    agencies*** include those that deliver services and supports in the
    areas of mental health, education, child welfare, child protection,
    juvenile courts, juvenile corrections, primary health care, and
    specialty services such as substance abuse treatment and prevention,
    vocational counseling, and rehabilitation. They are located in the
    community or have the capacity and authority to provide services in
    the community. Formal arrangements for collaboration must be stated
    clearly in memoranda of agreement, policy manuals, board minutes, or
    other documents shared among the agencies. These documents should
    specify the role(s) that each agency plays in the system of care. At
    a minimum, they should specify each agency's financial or in-kind
    contribution, official representation in the governance structure,
    and participation in strategic planning, delivery of relevant
    services, and evaluation. They also should specify whether the
    agency is a local or State entity and indicate any special
    requirements that must be met for participation of the local or
    State agency. A staff person within each entity should be designated
    to implement the above arrangements.

-   ***Service integration*** refers to the efforts of a care manager,
    together with an individualized care team, to organize and
    coordinate multiple services and arrange for their efficient and
    effective delivery to each child with a serious emotional
    disturbance and the child's family. An individualized service plan
    is a tool that the care manager and the individualized care team use
    for service integration. Service integration takes place on behalf
    of each child and family, and the system must be organized to
    support integration activities. One goal of service integration is
    to eliminate and avoid duplication of efforts, especially when
    services are delivered through collaborating child-serving agencies.
    More important, however, is the goal to give each child and family a
    unified, efficient, and supportive service experience.

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-   ***Wraparound process*** is defined as an approach to care planning
    and service provision that organizes and manages the delivery of
    multiple services, treatments, and supports to a child and the
    child's family in ways that are flexible, individualized,
    strengths-based, family-driven, culturally responsive, and
    effective. Such services, treatments, and supports are aimed at
    meeting the unique needs of each child and family and are driven by
    the goals of the child and family. Wraparound processes are
    organized around all key life domains (home, school, and community
    living). Some services may be delivered through formal agency
    procedures, while others may be delivered through informal
    arrangements in the community. Like the individualized service plan,
    the wraparound process is a powerful tool for service integration.

-   ***Flexible funds*** are service monies that can be used for service
    and support activities that are outside traditional funding streams
    and, when purchasing those items are non-reimbursable by State and
    Federal fund streams. For example, flexible funds may be used to pay
    for horseback riding lessons for a child with a serious emotional
    disturbance who expresses a strong interest in this recreational
    activity, if this activity has the potential for a positive
    therapeutic effect on the child. Generally, the individualized care
    team determines when it is appropriate to use flexible funds for an
    individual child and family, and the system maintains accountability
    procedures regarding the use of those funds.

-   ***Care review*** is a deliberate process used by a designated
    interagency group to examine how well services are being delivered
    to individual children and their families. The purpose of such
    examination is to develop recommendations for improving the system
    adequacy, appropriateness, quality of service and the procedures for
    delivery of services. Special attention is given to how well each
    child-serving agency is contributing to meeting the individual needs
    of children. Communities often use experienced supervisors and
    family members from child-serving systems to conduct ongoing care
    review procedures.

-   ***Access*** refers to the ease with which eligible children and
    their families are able to receive needed services. Children and
    their families are provided with clear and comprehensible
    eligibility criteria. Procedures for determining eligibility and
    entry into services are efficient and timely, with limited paperwork
    demands. Services are located within distances that make it
    relatively easy for children and families to reach and at times
    flexible enough to meet the needs and schedules of families.

-   ***Financing approach*** refers to the community's capacity to
    fulfill the non-federal match requirements and to obtain necessary
    funding to maintain and enhance the system of care beyond the 6-year
    Federal funding period of this Program. Specifically, it refers
    to: (1) funding for services from collaborating State and community
    child-serving agencies; (2) access to existing categorical service
    funds from public and private sources for which children with a
    serious emotional disturbance and their families are eligible, such
    as Medicaid, the Child Health Insurance Program, and private
    insurance; and (3) other public and private funds to support
    system-of-care activities and structures, other than services such
    as training, research, and equipment. A system of care uses
    financial resources strategically to accomplish its vision, values,
    and priorities, ensuring that "the program drives the dollars."
    Grant communities will consider what approach or combination of
    approaches best supports the types of development planned within the
    system of care, engaging multiple fund streams to meet the
    non-federal match requirements and to sustain system development
    after the grant ends. The system of care also implements methods to
    assure fiscal accountability to each funding source.

-   ***Workforce development*** refers to the strategies used by the
    system of care to ensure that there are adequate numbers of staff
    with the attitudes, knowledge and skills to successfully manage the
    system of care and deliver the services to children and families,
    including traditional human resource activities (e.g., recruitment;
    retention; incentives) and staff development (e.g., training;
    educational supports; supervision). Training strategies may include
    in-service educational opportunities such as seminars, workshops,
    institutes, and continuing education units. Family members and/or
    staff may be given scholarships or time-off awards to participate in
    formal educational experiences such as certification programs and
    professional degree programs, adding competencies to system care.
    Workforce development partnerships with higher education
    institutions in the community are encouraged, particularly those
    that help to ensure that the workforce reflects the diversity of the
    community.

-   ***Support from community leaders*** is defined as the endorsement
    of system-of-care goals and activities given by community leaders
    (e.g., judges, mayors, clergy, business executives, presidents of
    educational institutions), including leaders from racial and ethnic
    minority populations. Such endorsements may be given through public
    statements, financial contributions, or direct representation in the
    governing body of the system of care. Ongoing activities to inform
    and involve community leadership are expected in effective systems
    of care.

-   ***The clinical network*** is defined as the set of services,
    treatments, and supports that exist and are available within the
    system of care to serve children with a serious emotional
    disturbance and their families. Each awardee is urged to enhance and
    develop its clinical network to the highest possible level of
    quality, aiming to serve as a model of system reform in the State.
    Awardees should implement to the greatest possible extent Federal or
    professional practice standards and guidelines for the delivery of
    children's mental health services. These standards and guidelines
    may focus on the delivery of specific clinical interventions, and
    they may address the delivery of system-of-care services such as
    intensive care management, therapeutic foster care, and home-based
    crisis intervention. Awardees are required to include in their
    clinical network one (or more) evidence-based service or treatment
    that has been shown to be effective in research studies.

-   ***The administrative team*** is the group of individuals
    responsible for developing, implementing, and managing the system of
    care within this project. Specifically, this team will:

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-   Develop a strategic plan that includes a component for social
    marketing, local-level evaluation, and sustainability.

-   Coordinate services delivered through collaborating child-serving
    agencies;

-   Budget, manage, and expend service funds for required services;

-   Integrate funding streams, as appropriate;

-   Award and manage contracts for service delivery, training, technical
    assistance, evaluation, and social marketing, as appropriate;

-   Use findings from the National Evaluation and any local evaluation
    to shape future program direction, decisions about practices and
    policies that work, and to develop a quality improvement plan;

-   Implement care review procedures;

-   Monitor the extent and quality of implementation of individualized
    service plans;

-   Examine the extent to which service decisions for children utilize
    the least restrictive, most normative, and safest environments that
    also are clinically appropriate, focusing especially on decreasing
    the need for out-of-home and out-of-community placements;

-   Monitor the degree to which care management and other services
    enhance the strengths, resilience, protective factors, and
    well-being of children and families;

-   Comply with the rules and regulations for electronic exchange of
    information and for confidentiality of care records, as required by
    the Health Insurance Portability and Accountability Act (HIPAA).

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-   ***Training capacity*** is an important element of workforce
    development, defined as the ongoing strategies used by the system of
    care to ensure that there are adequate numbers of staff with the
    attitudes, knowledge and skills to successfully manage the system of
    care and deliver the services to children and families. Adequate
    training capacity may be achieved by budgeting specific dollars to
    hire trainers and consultants with specific expertise in areas such
    as system leadership, fiscal management, personnel management,
    implementation of clinical interventions and the wraparound process,
    quality improvement, and evaluation. Systems of care strive to
    include parents and other caregivers, as well as youth, in training
    activities, both as participants and trainers. Systems of care seek
    and utilize cross-system training strategies, coordination of
    training resources (e.g., IV-E training resources), and maximum
    opportunities for interagency staff and the children and families
    they serve to teach each other.

-   ***Performance standards*** are defined as the criteria or
    benchmarks that are established to measure the degree to which the
    system of care meets quality and effectiveness goals. These goals
    may describe areas such as access, capacity, clinical outcomes,
    service provision, family and youth satisfaction, infrastructure
    development, workforce development, and others. Child and family
    outcomes are the most important system of care standards. In
    addition, system-level outcomes (e.g., reducing out-of-home
    placements) and process outcomes (e.g., increasing the number of
    front-line and supervisory staff active in collaboration activities)
    must also be included as part of the evaluation and monitoring
    functions of the system of care.

-   ***Management information system*** (MIS) refers to a computerized
    system for the electronic collection, storage, management, and
    exchange of information within the system of care. At a minimum, the
    MIS should be used to record the type, amount, and cost of services
    delivered to each child and family in the system of care. These
    services should include those reimbursed by Medicaid and also those
    covered by cooperative agreement funds and by any other State or
    private funding streams. There should be a close correspondence
    between the services delivered as part of the individualized care
    plan and the services recorded in the MIS. As much as possible, the
    MIS should be integrated across the collaborating child-serving
    agencies and be used as a tool for the coordination of service
    delivery. In addition, the MIS should have the capacity to integrate
    child and family outcome data from the National Evaluation. The MIS
    procedures must be compliant with HIPAA specifications.

**Key Activities and Concepts**

Systems of care for children with a serious emotional disturbance and
their families emphasize a set of key activities and concepts that are
generally addressed by communities under the Program. System-of-care
planning processes will lead to the development of strategies to promote
each of these activities and concepts.

***Delivery of Clinical Interventions*.** The system of care must ensure
that children with a serious emotional disturbance have access to the
most effective clinical interventions. A ***clinical intervention***
refers to a service, treatment, or therapy that is used to assess or
treat a specific diagnosable emotional, behavioral, or mental disorder,
or a combination of co-occurring disorders, and is delivered by trained
and qualified personnel. The system of care should, at a minimum:

1.  Implement one (or more) *evidence-based intervention*, defined as an
    intervention that has been scientifically studied and found to
    produce positive outcomes for children and families. Typically, an
    evidence-based intervention includes:

-   A written manual that serves as a procedural guide for implementing
    and replicating the intervention. The purpose of the manual is to
    ensure adherence to a specific set of intervention procedures
    referred to as the *intervention protocol.* Manualized care promotes
    the delivery of an *effective intervention* that results in positive
    individual outcomes that are better than the outcomes from
    conventional, untested interventions, or better than the absence of
    any intervention and a *quality intervention*, delivered efficiently
    and producing high satisfaction and acceptability from the child and
    family.

-   Several research studies that, as a set, produce reliable, valid,
    and generalizable findings about the effectiveness of the
    intervention. These findings demonstrate that the intervention
    results in consistent positive outcomes across children and/or for a
    specific population for whom the intervention was intended (e.g.,
    children experiencing major depression). Findings also show that the
    outcomes of the intervention can be replicated consistently across
    population groups (e.g., racial or ethnic) or in different settings
    (e.g., rural, urban).

-   Specification of a clinical population for which the treatment
    applies, such as children with depression, attention
    deficit/hyperactivity disorder, or oppositional defiant
    disorder.[^4]

2.  Ensure that procedures for diagnosis and treatment planning match
    the individual and unique mental health needs of the child with the
    most appropriate treatment or combination of treatments.

3.  Encourage implementation of state-of-the-art, community-based
    treatment methodologies.

4.  Make necessary adaptations to innovative evidenced-based
    interventions for the target populations, particularly for racial
    and ethnic minority populations in the specific communities served
    by the program.

5.  Conduct clinical assessments in a manner that recognizes gender and
    cultural differences in the diagnosis of overt behaviors and the
    evaluation of presenting problems.

6.  Address the training needs of clinicians in several areas, including
    the delivery of evidenced-based treatments and appropriate
    application of DSM-IV diagnostic categories.

***Delivery of Care Management Services***. Care management services
(also known as care coordination or case management), tailored to the
needs of each individual child, are required for all children and
adolescents who are offered access to the system of care under this
Program. ***Care management*** represents the procedures used by a
trained service provider to access and coordinate services for a child
with a serious emotional disturbance and the child's family. These
procedures establish an identifiable point of accountability between the
child and family and all helping systems.

The system of care will provide each child in the target population with
a level of care management appropriate to the child and family's
strengths and needs. Care management services should, at a minimum:

1.  Unify and coordinate services provided to the child and the child's
    family, including those specified in the individualized service plan
    and any other services or supports.

2.  Establish eligibility of the child and the child's family for
    financial assistance and services under Federal, State, and local
    programs, and document that such services and supports are received.

3.  Reassess the needs of the child and the child's family at regularly
    established intervals, and modify the individualized service plan
    accordingly.

4.  Provide the family with information on progress made toward the
    objectives in the individualized service plan.

5.  Create intensive or therapeutic care management services for
    children with the most severe emotional disturbances at a ratio of
    no more than 10 children for every one intensive care manager.

6.  Create care management services for children with a serious
    emotional disturbance whose needs are less complex than those with
    severe needs, but who still require regular monitoring or
    coordination of service delivery. The ratio of assigned children to
    this type of care manager should be no more than 15 to one.

***Development of an Individualized Service Plan.*** Each child or
adolescent served within systems of care under the Program must have an
individualized service plan developed by an interagency team that
includes the child's parents or caregivers and, unless clinically
inappropriate, the child. The ***individualized service plan*** defines
in writing the procedures and activities that are appropriately
scheduled and used to deliver services, treatments, and supports to a
child and the child's family. These procedures and activities must fit
the unique strengths and needs of the child and the child's family. The
group that assists the care manager, family members and child to design
and implement the individualized service plan is the ***individualized
care team***, comprised of representatives from child-serving agencies
that provide services to the child and the family, as well as informal
but significant individuals in the community who relate closely to the
child and family, such as a minister, friend, or community leader.

Development of the *individualized service plan* must include:

1.  An emphasis on identifying and building upon the existing strengths
    of the child and the child's family.

2.  Coordination with services available under parts B and H of the
    Individuals with Disabilities Education Act (IDEA), including
    consistency and coordination with the Individualized Education Plan
    (IEP).

3.  Coordination with services available through the U.S. Department of
    Health and Human Services, Administration for Children, Youth and
    Families' Family Preservation and Support Program (Title IV-B,
    Subpart 2, Social Security Act).

4.  Inclusion and implementation of the following components of the
    plan:

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a.  Identification of existing strengths of the child and the child's
    family and how the strengths will used in support of the
    individualized plan;

b.  Description of the service and support needs;

c.  Development of objectives that build upon the existing strengths and
    meet the needs of the child and the child's family;

d.  Description of methodologies for meeting these objectives, including
    all necessary services and supports;

e.  Provision of non-mental health services, as appropriate; and,

f.  Designation of the lead agency responsible for care management
    services.

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```
5.  Regular review of the appropriateness of services in the
    individualized service plan, and revisions when necessary, but at
    least quarterly (every 90 days).

***Family driven and youth-guided care.*** Family-driven means families
have a decision making role in the care of their own children as well as
the policies and procedures governing care for all children in the
community, state, and nation. This includes choosing supports, services,
and providers; setting goals; designing and implementing programs;
monitoring outcomes; and determining effectiveness of all efforts to
promote the mental health of children and youth.

# Guiding Principles

1.  Families and youth have accurate, understandable, and complete
    information necessary to make choices for improved planning for
    individual children.

2.  Families and youth are organized to collectively use their knowledge
    and skills as an engine for systems change.

3.  Families and youth embrace the concept of sharing decision-making
    and responsibility for outcomes with providers.

4.  Providers embrace the concept of sharing decision-making authority
    and responsibility for outcomes with families and youth.

5.  Providers take the initiative to change practice from
    provider-driven to family-driven.

6.  Administrators allocate staff, training, and support resources to
    make family-driven practice work at the point where services and
    supports are delivered to children, youth, and families.

7.  Peer support reduces isolation and strengthens family and youth
    voice.

8.  Community attitude change removes barriers created by stigma.

# Conditions that exist in family-driven care model

1.  Administrators and staff actively demonstrate their partnerships
    with all families and youth by sharing power, resources, authority,
    and control with them.

2.  Family and youth experiences, their visions and goals, their
    perceptions of strengths and needs, and their guidance about what
    will make them comfortable steer decision making about all aspects
    of service and system design, operation, and evaluation.

3.  Meetings and services happen in culturally and linguistically
    responsive environments where family and youth voices are heard and
    valued, everyone is respected and trusted, and it is safe for
    everyone to speak honestly.

4.  Families and youth have access to useful, usable, and understandable
    information and data, as well as sound professional expertise so
    they have good information on which to base the choices they make.

> ***Youth-Guided***. Activities to support active youth participation
> include:

-   Designation of an individual to serve as *youth coordinator* in the
    system of care. Duties of the youth coordinator should, at a
    minimum, include: helping to form an organized group among youth
    receiving services; advocating for youth who are receiving services;
    reaching out to eligible youth who are not receiving services; and
    representing youth on the governance body.

***Cultural and Linguistic Competence***. Each child and family served
by a system of care comes with unique strengths, needs and
circumstances, including what they believe, what they value, and the
traditions they choose to practice. Cultural and linguistic
responsiveness is demonstrated when individual service providers possess
the attitudes, knowledge, and skills to effectively serve children with
a serious emotional disturbance and their families coming from racial or
ethnic minority groups in the community. The attitudes, knowledge, and
skills of all system helpers collectively reflect system respect for
community diversity and contribute to the well being of all children and
families. Cultural and linguistic responsiveness also refers to the
policies and practices of the system of care that have a positive effect
on the well being of all children and their families.[^5]

Cultural competence requires that organizations:

-   Have a defined set of values and principles, and demonstrate
    behaviors, attitudes, policies, and structures that enable them to
    work effectively cross-culturally.

-   Have the capacity to: 1) value diversity, 2) conduct
    self-assessment, 3) manage the dynamics of difference (through tools
    such as negotiation, mediation, or conflict resolution), 4) acquire
    and institutionalize cultural knowledge, and 5) adapt to diversity
    and the cultural context of communities served.

-   Incorporate the above in all aspects of policy-making,
    administration, practice and service delivery, and systematically
    involve consumers, families and communities.

Communities supported under the Program generally implement the
following activities, designed to enhance the cultural responsiveness of
a system of care:

1.  Compliance with Title VI of the Civil Rights Act.

2.  Application of cultural competence standards, as suggested in
    documents such as the Culturally and Linguistically Appropriate
    Standards (CLAS) in Health Care, published by the U.S. Department of
    Health and Human Services, or those included in CMHS's "Cultural
    Competence Standards" publication.

3.  Identify and address disparities in access and utilization, quality
    of mental health services, availability of effective clinical
    interventions, clinical and functional outcomes, satisfaction with
    services and supports, and other system-of care outcomes of
    children, youth and families from culturally and linguistically
    diverse groups.

4.  Incorporation of culturally appropriate practices in each
    individualized service plan, such as: using the preferred language
    of the child and the child's family during service delivery;
    nurturing the strengths, customs and traditions of the child and the
    child's family that reflect their cultural or religious heritage;
    and respecting behaviors and beliefs of the child and the child's
    family that are culturally accepted -- in [their]{.underline}
    culture.[^6]

5.  Individuals from racial or ethnic minority groups in the community
    are invited and supported to participate meaningfully in activities
    of such system-of-care entities as the governing body,
    administrative team, care review group, and individualized care
    teams. Such individuals may serve as effective advocates for
    children and families from those cultural groups.

6.  Provide evidence that the management plan, staffing pattern, project
    organization, and projected resources are appropriate and adequate
    for carrying out all aspects of the proposed project, including
    practice models that incorporate culture and language in the
    delivery of services and supports to diverse groups.

7.  Expand services available through the system of care to include
    service providers reflecting the cultural and linguistic diversity
    of the community.

8.  System-of-care services are (1) planned in the cultural context
    preferred by the child and the child's family, and (2) provided
    without discrimination against the child or the child's family on
    the basis of race, religion, national origin, gender, sexual
    orientation, disability, or age (i.e., for the child, age 21 years
    or younger).

*Racial or ethnic minority groups*, as used in this Program, refer to
the four primary racial or ethnic groups that have been found nationally
to be underserved in the area of health care, including the African
American, Hispanic, American Indian and Alaska Native, and Asian
American and Pacific Islander groups. These groups also include
underserved immigrant and refugee groups who have recently arrived in
the United States from other countries of the world, as identified by
local community leaders.

***Early Intervention.*** A system of care that effectively responds to
the needs of infants and preschoolers with a serious emotional
disturbance and their families must include, at a minimum:

1.  Appropriate assessments (designed for use with infants and young
    children) for the identification of infants and preschoolers with a
    serious emotional disturbance.

2.  Collaborative arrangements with the primary health care sector
    (e.g., family physicians, pediatricians, public health nurses) to
    provide linkages between early health care and the treatment of
    mental health needs. These arrangements may include a system for
    referrals to system-of-care services for children and their families
    and/or guidelines for treatment of these children, especially when a
    serious emotional disturbance co-occurs with a chronic illness.

3.  Integration of services provided through the childcare provider,
    early childhood education, and infant and early childhood public
    health systems. Such integration should occur across Federal and
    state programs, including Head Start, Early Head Start, and Healthy
    Families.

**Elements of Sustainability**

Communities supported under this Program are pursuing long-term
system-of-care development. From the beginning, planning aims towards
sustaining all gains made under the Program after Federal and other
grant funds have ended. Ten years of experience with this Program in
multiple communities has led to the identification of ***key elements of
sustainability*** to which grant communities attend, in planning,
implementation, and evaluation.

-   Vision

Local project leaders set the *vision* for system-of-care development,
describing how the system should be functioning when fully developed,
and then monitor actual growth against the vision on a recurring basis,
also evolving the vision as needed. The vision guides development at all
levels, at all times, which requires deliberate strategies to both
disseminate and update the vision. Effective system-of-care communities
keep the vision alive through active discussion and ongoing
consideration of its local implications.

-   Results Orientation and Key Indicators of Success

The Program seeks *measurable improvements* in the experience of
children with serious emotional disturbances and their families -- these
are the results that matter. While it is also important to seek
measurable improvements in system functioning, the primary desired
results are found in the experiences of children and families and the
quality-of-life improvements they attain as the result of system
activities. Grant communities will be oriented towards constant
improvement, establishing the intended outcomes and *key indicators of
success* that demonstrate improvement, monitoring progress across those
outcomes and indicators, and utilizing evaluation findings to constantly
adjust program operations. In the simplest terms, when planned
strategies do not obtain the intended outcomes (at the individual child
level [or]{.underline} the system level), planners use that information
to change the strategies being employed.

-   Strategic Financing

A system of care *uses financial resources strategically* to accomplish
its vision, values, and priorities, ensuring that "the program drives
the dollars." Some communities will choose to shift dollars from
traditional uses to more flexible, community-based activities; some will
seek to maximize the use of major funding streams (e.g., Medicaid, Title
IV-E); some will implement changes in how dollars are allocated to
services, employing strategies such as pooled funding, capitation or
case rate financing, or family budgeting approaches. Grant communities
will consider what approach or combination of approaches best supports
the types of development planned within the system of care, engaging
multiple fund streams to sustain system development after the grant
ends.

-   Key Champions and Leadership

System-of-care communities seek and support *leadership* from across the
community, including but not limited to service system leaders. From
conception through implementation, *key champions* are likely to emerge,
serving both to broaden community support and to increase understanding
of community-based care of children with emotional disturbances and
their families. At different stages of system development, different
types of leadership may be required, with leaders reflecting the major
strategies needed at each stage. Successful grant communities will plan
to identify and develop leadership among all stakeholders in the system
of care, with special attention given to leadership from family members
and youth served within the system. It is appropriate for system-of-care
planners to nurture leadership through deliberate program activities.

-   Family and Youth Advocacy

In the Program model, everyone connected with the system serves as an
advocate, and a critical area of advocacy is support for the meaningful
participation of children and adolescents and their families. This model
rebalances the power within helping systems to ensure that families are
equal partners in the care of their children and to support youth to be
actively involved in their own care and recovery. Primary caregivers of
children are considered to be the "best experts" regarding their
children. System-of-care communities support the development of *family
and youth advocacy*, linking with family and youth advocacy
organizations and offering training that includes caregivers and youth,
both in giving and receiving training. Systems provide tangible
supports, such as transportation, translation, or childcare assistance,
to enable caregiver and youth participation. Beyond such supports,
communities strive to recognize the multiple roles that can be played by
families, caregivers and youth, including, but not limited to: guiding
care of their own children; participation on steering committees;
delivering services to other children and families, such as care
management, mentoring, and peer support; evaluation activities, such as
gathering data, determining the meaning of data gathered, and reporting
to the community; and serving in key system roles, based on
competencies, credentials and experience.

-   Community Support

The system of care is not separate from the *community* but is an
integral part of the community as it responds to the needs of community
members. Community members are educated by the system and given avenues
for involvement in support of the ongoing care of children and their
families. Leaders and others active in the system of care constantly
educate and involve additional community members to create a climate
that nurtures community-based care of children and their families. The
community is recognized as the repository of everything needed to
successfully care for children with special needs through advocacy,
organization, and mobilization.

-   Adaptability to Changing Conditions

The environment surrounding a system of care continues to change and
evolve in response to, and regardless of, system activities, demanding
*adaptability to changing conditions*. In particular, circumstances at
the state level strongly impact local decision-making, yet local
decision-makers may feel powerless to impact state circumstances. As
circumstances evolve, systems of care look constantly for opportunities
to put in place new policies and practices that lead to the vision
becoming reality. When stressors press against the system, it finds ways
to maintain the most necessary system functions. Change is expected
throughout the life of this Program and beyond, and systems are prepared
to respond.

-   Strong Governance and Interagency Collaboration

Systems of care require *strong governance*, which is exploring,
deciding, and monitoring policy and implementation. Governance is
necessarily an *interagency* process because various components of child
and family care and the respective resources are lodged in different
agencies, as defined by Congress and State legislatures. Likewise,
governance is an important function in which children and families
affected by system activities must participate, fully and meaningfully.
It is important for local governance bodies to consider: 1) the extent
and limitations of its authority; 2) its responsibilities; 3) its
credibility in the community; 4) its capacity to govern; 5) its shared
liability; and 6) its representation of all appropriate system
stakeholders. Separate agencies must also work together to build trust
and communication so that the strengths and voices of all stakeholders
can impact system success. System planners will regularly revisit these
and other questions to keep interagency governance processes
representative and relevant.

-   Political and Legislative Advocacy

This Program is aimed at developing systems of care within communities
that can then demonstrate their methods of success to the broader
systems in which they operate. Just as the political climate impacts
each community's ability to implement systems of care, such local
systems can and do impact the political climate, demonstrating how to
effectively care for children with challenging needs and keep the public
cost of care within manageable limits. Through *political and
legislative advocacy*, each State legislature is informed regarding
project activities and outcomes, using grantee experience to guide
relevant legislation in support of the system of care approach.

-   Clear Sustainability Plan

Each of these sustainability elements (and others, as determined
locally) should be addressed in a long-term *Sustainability Plan*. The
plan should begin when the project begins and continue to grow
throughout the project's life. Gains made under this Program will not
survive without deliberate efforts in each community to support and
institutionalize necessary changes in practice, policy, and oversight.

**Evaluation Details**

Implementing communities under this Program are expected to comply with
the requirements of the National Evaluation, conducted under contract by
SAMHSA, and participate in the collection of descriptive and outcome
data.

Applicants agree to participate in the development and implementation of
quality improvement methods and to work with the Project Officer and
other contractors to identify benchmarks (i.e., targets/goals) that will
determine project progress. These benchmarks will be consistent with
system-of-care principles and the outcomes contained in the President's
New Freedom Commission Report. Examples include movement towards a
family driven system of care, the reduction of ethnic, racial and
geographic disparities in care, and improvements in functional
behaviors.

Implementing communities will ensure that adequate resources are
included for local level evaluation, including analysis of ethnic,
cultural, and linguistic disparities in service development, and
evaluation of strategic plans that focus on long-term sustainability.

Regular training and technical assistance sessions will be conducted
on-site, during awardee meetings, and at other scheduled times
throughout the 6-year Federal funding period for implementing
communities under this Program. Evaluation staff and other
system-of-care staff will be asked to participate in these training and
technical assistance sessions.

To meet the requirements of the National Evaluation, communities will be
required to:

1.  Adhere closely to the design of the National Evaluation.

2.  Implement procedures for collection, entry, management, and storage
    of data.

3.  Comply with National Evaluation data collection and reporting
    requirements.

4.  Transmit data to the National Evaluation contractor on a scheduled
    basis.

5.  Report evaluation findings on the local system of care to the
    stakeholders of the system of care, including family members,
    personnel of collaborating child-serving partner agencies, clinical
    staff, members of the governing body, and others.

6.  Use evaluation findings to inform system-of-care development
    efforts, including improvement of management procedures, adoption of
    new system and service policies, attainment of new sources of public
    and private financing, and others.

7.  Involve youth who are receiving services and their family members in
    the implementation of the National Evaluation.

8.  Obtain written assurances from each participating agency indicating
    a willingness to cooperate with the required activities of the
    National Evaluation.

9.  Hire at least two full-time equivalent (FTE) evaluation staff. One
    FTE must have an earned Ph.D. in public health, psychology, social
    work, or other relevant area of human services. At least one of the
    full-time evaluation staff should have an office located in the
    awardee community. Evaluation staff must have knowledge of and
    experience with coordinating and implementing longitudinal data
    collection activities, including tracking individuals, data
    management, data analysis, basic quantitative and qualitative
    evaluation methods, and report writing.

10. Participate in an annual 2- to 3-day site visit conducted by the
    National Evaluation contractor to assess development of the
    awardee's system of care. During this annual site visit, structured
    interviews will be conducted with persons representing service
    recipients and their families, service providers, partner systems
    and agencies (from management to front-line service delivery), and
    evaluation staff. Applicants must secure an agreement from each
    collaborating child-serving agency that staff will be available for
    and participate in the site visits.

11. Obtain approval from an Institutional Review Board (IRB) associated
    with the system of care to perform the data collection strategies
    required by the National Evaluation.

In addition, implementing communities are encouraged to enhance the
National Evaluation with their own local evaluation activities. These
local evaluation activities help ensure that the unique needs for
system-of-care development within each community are being met. Data and
findings from local evaluation efforts do not need to be transmitted to
the National Evaluation contractor, unless arrangements are made for a
special study that can be valuable for the development of systems of
care across the nation. However, critical findings from local evaluation
efforts may be reported in cooperative agreement re-applications and
quarterly reports.

**Definitions**

**[Best Practice:]{.underline}** *Best practices* are practices that
incorporate the best objective information currently available from
recognized experts regarding effectiveness and acceptability. Best
practices include, but are not limited to, *evidence-based* (defined as
practice knowledge "obtained through carefully implemented scientific
methods about the prevalence, incidence, or risks for mental disorders,
or about the impact of treatment or services on mental health
problems"[^7]) and *promising approaches* (defined as practice knowledge
supported by evidence of effectiveness through the experiences of key
stakeholders, such as families and direct-care providers).

**[Catchment Area:]{.underline}** A *catchment area* is the geographic
area from which the functioning system of care will draw the target
population to be served.

**[Community:]{.underline}** Under this Program, *community* is any
discrete geographic entity that is defined by an applicant. The scope
and size of the community is left to State or local discretion. States
and non-State applicants may choose to create systems in communities as
small as a single school district or as large as a county or a group of
contiguous counties. A State with a sparse population may wish to
develop a system to cover the entire State, but it is expected that this
will be the exception. The amount of funds requested by a community will
be proportional to the number of children in the community, and
communities must ensure that sufficient funds are requested and
available to develop a comprehensive system of care with sufficient
service capacity in the designated target community.

**[Cooperative Agreement:]{.underline}** A *cooperative agreement* is a
form of Federal grant. Cooperative agreements are distinguished from
other grants in that, under a cooperative agreement, substantial
involvement is anticipated between the awarding office and the recipient
during performance of the funded activity. This involvement may include
collaboration, participation, or intervention in the activity. HHS
awarding offices use grants or cooperative agreements (rather than
contracts) when the principal purpose of the transaction is the transfer
of money, property, services, or anything of value to accomplish a
public purpose of support or stimulation authorized by Federal statute.
The primary beneficiary under a grant or cooperative agreement is the
public, as opposed to the Federal Government.

**[Cost Sharing or Matching:]{.underline}** *Cost-sharing* refers to the
value of allowable non-Federal contributions toward the allowable costs
of a Federal grant project or program. Such contributions may be cash or
in-kind contributions. For SAMHSA grants, cost-sharing or matching is
not required, and applications will not be screened out on the basis of
cost-sharing.  However, communities often include cash or in-kind
contributions as evidence of commitment to the proposed project.

**[Family Involvement:]{.underline}** *Family involvement* refers to the
identification of, outreach efforts to, and meaningful engagement of
diverse families ("diverse" is an inclusive term to describe families of
various races, ethnicities, gender orientations, socioeconomic
backgrounds, and family structures reflective of the community being
served) receiving services from the proposed system-of-care community
and of the target population, so that their collective experiences and
perspectives meaningfully drive the planning, implementation, and
evaluation of the system of care.

**[Family Member:]{.underline}** Families who have children, youth, or
adolescents with a serious emotional disturbance are organized in a wide
variety of configurations, regardless of social or economic status.
Families may include biological parents and their partners, adoptive
parents and their partners, foster parents and their partners,
grandparents and their partners, siblings and their partners, kinship
caregivers, friends, and others, *as defined by the family*. A family
may include any primary caregiver for a child, youth, or adolescent with
a serious emotional disturbance, and the primary caregiver may receive
significant support from extended family members.

**[Family-run Organization:]{.underline}** A *family-run organization*
is a private, nonprofit entity that meets the following criteria: 1) its
explicit purpose is to serve families who have a child, youth, or
adolescent with a serious emotional disturbance (an emotional,
behavioral, or mental disorder, age 0-18, or to age 21 if served by an
Individualized Education Plan); 2) it is governed by a board of
directors containing a majority (at least 51%) of individuals who are
family members; 3) it gives preference to family members in hiring
practices; and, 4) it is incorporated as a private, nonprofit entity
(i.e., 501(c)3 status).

**[Fidelity:]{.underline}** *Fidelity* is the degree to which a specific
implementation of a program or practice resembles, adheres to, or is
faithful to the evidence-based model on which it is based. Fidelity is
formally assessed using rating scales of the major elements of the
evidence-based model. A toolkit on how to develop and use fidelity
instruments is available from the SAMHSA-funded Evaluation Technical
Assistance Center at [http://tecathsri.org](http://tecathsri.org/) or by
calling (617) 876-0426.

**[Grant:]{.underline}** A *grant* is the funding mechanism used by the
Federal Government when the principal purpose of the transaction is the
transfer of money, property, services, or anything of value to
accomplish a public purpose of support or stimulation authorized by
Federal statute. The primary beneficiary under a grant or cooperative
agreement is the public, as opposed to the Federal Government.

**[In-Kind Contribution]{.underline}**: *In-kind contributions* toward a
grant project are non-cash contributions (e.g., facilities, space,
services) that are derived from non-Federal sources, such as State or
sub-State non-Federal revenues, foundation grants, or contributions from
other non-Federal public or private entities.

**[Logic Model:]{.underline}** A *logic model* is a diagrammatic
representation of a theoretical framework. A logic model describes the
logical linkages among program resources, conditions, strategies,
short-term outcomes, and long-term impact.

**[Practice]{.underline}:** A *practice* is any activity, or collective
set of activities, intended to improve outcomes for people with or at
risk for mental illness and/or substance abuse. Such activities may
include direct service provision (e.g., therapy, day treatment),
supportive activities (e.g., mentoring, respite), and efforts to improve
access to and retention in services, organizational efficiency or
effectiveness, community readiness, collaboration among stakeholder
groups, education, awareness, training, or any other activity that is
designed to improve outcomes for people with or at risk for mental
illness or substance abuse.

**[Practice Support System]{.underline}:** This term refers to
*contextual factors* that affect practice delivery and effectiveness in
the pre-adoption phase, delivery phase, and post-delivery phase, such as
a) community collaboration and consensus building, b) training and
overall readiness of those implementing the practice, and c) sufficient
ongoing supervision for those implementing the practice.

**[Community Partner:]{.underline}** A *community partner* is an
individual, organization, constituent group, or other entity that has an
interest in and will be affected by a proposed grant project. Community
partners in cooperative agreements under this Program may include a wide
variety of community representatives, as well as the children and
families themselves, each with an interest in the impact or
effectiveness of the system of care.

**[Sustainability:]{.underline}** *Sustainability* is the ability to
continue a program or practice after SAMHSA grant funding has ended.
Grantees should make all efforts to sustain any and all practices
established or enhanced through this project.

**[Target Population:]{.underline}** The *target population* is the
specific population of people a particular program or practice is
designed to serve or reach.

# [Wraparound Process:]{.underline} *Wraparound* process is an approach to treatment that has evolved over the past 15 years through efforts to help families with the most challenging children function more effectively in the community. More specifically, it is a definable planning process that results in a unique set of community services and natural supports that are individualized for a child and family to achieve a positive set of outcomes. 

# *Essential Elements of Wraparound*

1.         Wraparound must be based in the community.

2.         The wraparound approach must be a team-driven process
involving the family, child, natural supports, agencies, and community
services working together to develop, implement, and evaluate the
individualized plan.

3.         Families must be full and active partners in every level of
the wraparound process.

4.         Services and supports must be individualized, built on
strengths, and meet the needs of children and families across life
domains to promote success, safety, and permanence in home, school and
community.

5.         The process must be culturally competent, building on the
unique values, preferences and strengths of children and families, and
their communities.

6.         Wraparound child and family teams must have flexible
approaches and adequate and flexible funding.

7.        Wraparound plans must include a balance of formal services and
informal community and family supports.

8.         There must be an unconditional commitment to serve children
and their families is essential.

9.         The plans should be developed and implemented based on an
interagency, community-based collaborative process.

**References**

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[^1]: Stroul, B.A. & Friedman, R.M. (Revised, 1994). A system of care
    for children and youth with severe emotional disturbances, (revised
    edition) Washington, DC: National Technical Assistance Center for
    Children's Mental Health, Georgetown University Child Development
    Center.

[^2]: For an explicit and detailed description of the System of Care
    model, see Stroul & Friedman.

[^3]: Pires, S.A. (2002). Building systems of care: a primer.
    Washington, DC: National Technical Assistance Center for Children's
    Mental Health, Georgetown University Child Development Center (pg.
    10).

[^4]: For more detailed resources, see the National Registry of
    Effective Programs and Practices (NREPP) (at the
    [www.samhsa.gov]{.underline} web site.), the *Blueprint for Change:
    Research on Child and Adolescent Mental Health* (National Advisory
    Mental Health Council Workgroup on Child and Adolescent Mental
    Health Intervention Development and Deployment, 2001; at
    http://www.nimh.nih.gov/child/blueprint.cfm.), and the *Mental
    Health: A Report of the Surgeon General* (U.S. Department of Health
    and Human Services, 1999).

[^5]: For a detailed discussion of cultural competence in a system of
    care, see Cross, T.L., Bazron, B.J., Dennis, K.W., and Isaacs, M.R.
    (1989). *Towards a culturally competent system of care: A monograph
    on effective services for minority children who are severely
    emotionally disturbed*. Washington, DC: National Technical
    Assistance Center for Children's Mental Health, Georgetown
    University Child Development Center; with two subsequent volumes in
    1991 and 1998.

[^6]: For additional information, see "Planning for cultural and
    linguistic competence in systems of care for children and youth with
    social-emotional and behavioral disorders and their families,"
    developed by the National Center for Cultural Competence, which can
    be found at http://gucchd.georgetown.edu/nccc/products.html.

[^7]: For a detailed discussion, see Burns, B. & Hoagwood, K. (Eds.).
    (2002). *Community treatment for youth: Evidence-based interventions
    for severe emotional and behavioral disorders.* New York: Oxford
    University Press.