Improving Child Welfare 

Outcomes through Systems of 

Care: Building the Infrastructure

A GUIDE FOR COMMUNITIES

U.S. Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

Children’s Bureau

Improving Child Welfare 

Outcomes through Systems of 

Care: Building the Infrastructure

A GUIDE FOR COMMUNITIES

Gary DeCarolis, M.Ed.

Luanne Southern, M.S.W.

Fern Blake, L.C.S.W.

Improving Child Welfare Outcomes through Systems of Care: Building the 

Infrastructure was developed by the National Technical Assistance and 

Evaluation Center for Systems of Care with support from the Children’s Bureau, 

Administration on Children, Youth and Families, Administration for Children and 

Families in the U.S. Department of Health and Human Services.

U.S. Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

Children’s Bureau

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities i

Tab le of Contents

ACKNOWLEDGMENTS .......................................................................................................................... iii

CHAPTER 1: INTRODUCTION ................................................................................................................ 1

CHAPTER 2: SYSTEMS OF CARE .......................................................................................................... 3

CHAPTER 3: SYSTEMS OF CARE AND CHILD WELFARE.................................................................... 5

The Infrastructure Development Process ............................................................................... 8

CHAPTER 4: INFRASTRUCTURE ......................................................................................................... 11

CHAPTER 5: Infrastructure Components............................................................................... 13

Planning ................................................................................................................................ 15

Governance........................................................................................................................... 20

System Management............................................................................................................ 24

Coordination of Services and Service Array......................................................................... 30

Communication..................................................................................................................... 39

Policy..................................................................................................................................... 44

Finance.................................................................................................................................. 49

Continuous Quality Improvement......................................................................................... 53

Human Resources and Staff Development .......................................................................... 57

CONCLUSION........................................................................................................................................ 61

ENDNOTES............................................................................................................................................ 63

APPENDICES......................................................................................................................................... 65

A: Governance Structure for Contra Costa County, CA Systems of Care Effort ................. 67

B: Interagency Liaison/Administrative Coordinator ............................................................. 69

C: Example of Who to Involve in a Local Systems of Care Governance Structure ............. 71

D: Example of the Management Structure of a Systems of Care (SOC) Effort ................... 73

E: Service Coordination Processes Used in Systems of Care Communities...................... 75

F: Kansas Family Centered Systems of Care Marketing Strategy ...................................... 79

G: State of Kansas Family Centered Systems of Care Social Marketing Campaign........... 83

H: Planning a Systems of Care Conference: Lessons Learned in North Carolina .............. 91

I: Milwaukee Wraparound ................................................................................................. 107

J: Steps for Implementing a Refinancing Initiative ............................................................ 111

K: Lessons Learned: Michigan’s Integrated Funding Effort ............................................. 113

WORKSHEETS .................................................................................................................................... 115

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities iii

ACKNOWLEDGMENTS1

Contributing Authors and 

Reviewers

We also would like to thank the following individuals who contributed their expertise to this project:

Duren Banks, Ph.D.

Nicole Bossard, M.A.

Jennifer Brooks, Ph.D.

Dan Cantillon, Ph.D.

Susan Chibnall, Ph.D.

Danielle Fox, Ph.D.

John Glover, M.A.

Janet Griffith, Ph.D.

Shauna Harps, Ph.D.

Tanya Howell, M.S.W.

Ethleen Iron Cloud Two Dogs, M.S.

Pamela Johnson

Lisa Lunghofer, Ph.D.

Michelle Zabel, M.S.S.

Additional 

Acknowledgments

Improving Child Welfare Outcomes through Systems 

of Care: Building the Infrastructure was developed 

under the guidance, support, and direction of 

Janice P. Shafer, Director, Division of Research and 

Innovation, Children’s Bureau.

The authors would like to recognize the work being 

done by child welfare agencies to build the infrastructure to support systems of care at the State, 

county, city, and tribal levels by thanking the nine 

grantees involved in the Improving Child Welfare 

Outcomes through Systems of Care program. 

They contributed significantly to this document by 

participating in its review, content development, 

formatting, and dissemination.

Clark County Family Services

333 North Rancho Drive, Suite 200

Las Vegas, NV 89106

Contra Costa County Employment and Human 

Services

40 Douglas Avenue

Martinez, CA 94553

Jefferson County Department of 

Human Services

900 Jeffco Parkway, Room 295

Golden, CO 80401

Kansas Department of Social and 

Rehabilitation Services

Docking State Office Building

915 SW Harrison, Room 515-South

Topeka, KS 66612

Local grant sites: Cherokee, Reno, and Riley counties

Native American Training Institute

4007 State Street, Suite 103

Bismark, ND 58504

Tribal sites: Three Affiliated, Standing Rock, Turtle 

Mountain, and Spirit Lake

New York City Administration for 

Children’s Services

150 William Street, 5th floor

New York, NY 10038

Neighborhood site: Bedford-Stuyvesant, Brooklyn
iv

North Carolina Department of Health and 

Human Services

325 N. Salisbury Street

2439 Mail Service Center

Raleigh, NC 27699-2439

Local grant sites: Alamance, Bladen, and 

Mecklenburg counties

Oregon Department of Human Services

500 Summer Street, NE, Room E-69

Salem, OR 97301-1066

Local grant sites: Clackamas, Lake, and Umatilla/

Morrow counties

Pennsylvania Department of Public Welfare

Office of Children, Youth and Families

4th Floor Bertolino Building

P.O. Box 2675

Harrisburg, PA 17105-2675

Local grant sites: Dauphin and Northumberland 

counties

Acknowledgments
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

Background

This guide was developed after a review of the 

initial-year strategic plans of the nine grantees 

who received Federal funds through the Improving 

Child Welfare Outcomes through Systems of Care

program. The Children’s Bureau determined 

that more information on a systems of care infrastructure would be beneficial to the grantees as 

well as to professionals in the child welfare field, 

families with whom they partner, and community 

agencies representing education, mental health, 

juvenile justice, substance abuse treatment, and 

other organizations with an interest in child welfare 

driven systems of care. 

The work group that developed this guide included staff of the Children’s Bureau and the National 

Technical Assistance and Evaluation Center 

for the grant program. Each of the grantees of 

the Improving Child Welfare Outcomes through 

Systems of Care program also had the opportunity to review, comment on, and contribute to the 

content of the guide.

Purpose 

This guide originally was designed to clarify for 

grantees the various activities that Federal funds 

could support during the 5-year grant cycle. While 

it was developed in response to a need identified 

through the Improving Child Welfare Outcomes 

through Systems of Care program, the guide also 

provides useful information to other State, tribal, 

county, city, or neighborhood agencies providing 

services to children, youth, and families who are 

involved in the child welfare system.

Using This Guide

This guide is organized into nine parts that correspond to the fundamental components of the 

infrastructure needed to support systems of care:

z Planning

z Governance

z System management

z Coordination of services and service array

z Communication

z Policy

z Finance

z Continuous quality improvement 

z Human resources and staff development

The parts are divided into sections that outline the 

definitions, goals, activities, personnel, and expected outcomes related to each component. The 

flexible format allows users of the guide to review 

all facets of a particular infrastructure component 

CHAPTER 1

INTRODUCTION

1
2

or, alternatively, refer to all goal-setting discussions, 

for example, across infrastructure components. In 

addition, the guide provides resources that illustrate further the topics covered in the discussion of 

the infrastructure components. 

The guide includes examples from the field to 

highlight the variety of activities undertaken by the 

grantees. While the examples reflect the activities of 

only a limited number of systems of care initiatives, 

the experiences of these grantees shed significant 

light on the current and emerging systems of care 

issues confronting communities across the country 

CHAPTER 1 Introduction

and offer direction for systems of care planning, 

implementation, and evaluation. 

The guide is intended to be a customizable 

document and features a set of worksheets that 

correspond to the nine systems of care infrastructure components. These worksheets can be used 

to spark discussion and decision-making by those 

leading and participating in systems of care development and implementation, making the guide a 

valuable and practical resource for enhancing the 

capacity of communities to foster a collaborative 

environment for ensuring safety, permanency, and 

well-being for children, youth, and families. 
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 3

CHAPTER 2

SYSTEMS OF CARE

Since the 1980s, there have been numerous national efforts to provide States and communities with innovative approaches 

that address the multiple needs of children and 

families accessing services from public agencies. 

Several of these initiatives support principles that 

show promise for improving child, youth, and family 

outcomes. Systems of care is an initiative that 

incorporates a core set of principles that combine 

to meet the diverse needs of children, youth, and 

families. The system of care concept provides a 

framework that States, tribes, counties, and cities 

can utilize as they develop the infrastructure to 

support the following guiding principles:

Interagency Collaboration 

State, tribal, county, city, or neighborhood agencies 

providing services to children, youth, and families 

must work together to plan, develop, and coordinate care. These agencies are in the public, private, 

and faith-based sectors, and include child welfare, 

juvenile justice, behavioral health, education, 

substance abuse, primary health, early childhood, domestic violence, law enforcement, judicial 

system, and (if separate) agencies that serve Native 

American families. 

Individualized, Strengths-based 

Services 

Every child, youth, or family receiving services 

from agencies that are part of a State, tribal, 

county, city, or neighborhood system of care 

must be equal participants in a planning process 

to develop an individualized service plan which 

links their unique needs and strengths with 

services and supports. 

Cultural Competence

State, tribal, county, city, or neighborhood 

systems of care must have policies, structures, 

practices, and services that are responsive to 

the cultural, ethnic, linguistic, and racial diversity of children, youth, and families and the 

communities in which they reside.

Youth and Family Involvement 

Children, youth, and families must be equal 

participants in the planning, development, implementation, and governance of the State, tribal, 

county, city, or neighborhood system of care. 
4

Community-based Services

Services and supports that are part of a system of 

care must be home- and community-based and 

comprehensive enough to address holistically 

each child, youth, and family’s needs. 

Accountability 

Data must be used to evaluate the effectiveness and 

quality of services provided to children, youth, and 

families, as well as the impact of agency policies, 

procedures, and processes on sustaining systems 

of care principles. The data should inform State, 

CHAPTER 2 Systems of Care

tribal, county, city, or neighborhood stakeholders 

about project progress as part of a continuous 

quality improvement process and sustainability 

plan.

According to Stroul (2002), who was one of 

the developers of the systems of care concept, 

service coordination, interagency collaboration, 

family involvement, and cultural competence are 

key elements of the systems of care philosophy. 

However, Stroul notes that none of these elements 

is the sole focus of systems of care development.2

The following chart illustrates this point.

System of Care Concept

Services 

and 

Supports

Infrastructure

Philosophy
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 5

CHAPTER 3

SYSTEMS OF CARE AND 

CHILD WELFARE

The child welfare system has undergone 

tremendous change during the past 

decade. Federal law has stimulated much 

of this change through the Adoption and Safe 

Families Act of 1997; amendments to the Social 

Security Act, which authorized reviews of Title IVB and IV-E compliance; the Multi-Ethnic Placement 

Act; 1996 amendments to the Child Abuse 

Prevention and Treatment Act; and the Children’s 

Health Act of 2000. Among the most significant 

changes were 1994 amendments to the Social 

Security Act, which mandated in-depth reviews of 

State child and family services programs, resulting 

in Child and Family Service Reviews (CFSRs). 

Child and Family Service Reviews

In 2000, the Federal Government implemented 

the CFSR process, a results-oriented, comprehensive monitoring system designed to assist States 

with continuous quality improvement of outcomes 

for children, youth, and families who come into 

contact with public child welfare agencies. The 

CFSR focus reflects the Federal emphasis on child 

welfare principles such as family-centered practice, 

community-based services, individualized case 

planning and service delivery, and finally strengthening the capacity of parents to care safely for 

their children whenever possible and appropriate. 

CFSRs also consider the extent to which States 

are achieving the outcomes of safety, permanency, 

and well-being for the children, youth, and families 

who come in contact with the child welfare system. 

The goal of the reviews is to help States improve 

child welfare services and achieve the following 

outcomes for families, youth, and children who 

receive services:

Safety

z Children are, first and foremost, protected from 

abuse and neglect.

z Children are maintained safely in their homes 

whenever possible and appropriate.

Permanency

z Children have permanency and stability in their 

living situations.

z The continuity of family relationships and 

connections is preserved.

Well-being

z Families have enhanced capacity to provide for 

their child’s needs.

z Children receive appropriate services to meet 

their educational needs.

z Children receive adequate services to meet 

their physical and behavioral health needs.

The CFSR process includes three phases:

1. The State involves numerous stakeholders 

and interagency partners in a comprehensive 

self-assessment of its child welfare system and 

submits the findings to the Children’s Bureau 

for review. 

2. The Children’s Bureau conducts an extensive, 

onsite review of the State’s child welfare 

practice, focusing on three jurisdictions within 

the State, as well as on the State child welfare 

agency. This assessment includes record 

reviews of foster care and in-home services 

case records, and in-depth interviews or focus 

groups with parents, children, and youth (when 

age-appropriate), foster and adoptive parents, 

private service providers, child welfare agency 
6

caseworkers and supervisors, State and local 

child welfare agency administrators, and other 

local and State stakeholders. A detailed report 

of review findings is compiled and provided to 

the State. 

3. The State develops a Program Improvement 

Plan (PIP), which includes areas identified in the 

State’s self-assessment as needing improvement 

and the findings of the onsite review to enhance 

safety, permanency, and well-being outcomes for 

children, youth, and families. 

The results of the first round of CFSRs indicated 

that a majority of States are challenged to achieve 

consistently positive outcomes in safety, permanency, and well-being for children and families, 

with particular need for:

z More effective services to protect children and 

prevent removal from their homes.

z More comprehensive and consistent needs 

assessments of family members and 

appropriate matching of services to needs.

z More active involvement of children and 

parents in case planning.

z Increased attention to the educational needs

of children.

z Increased attention to the physical health 

needs of children.

z Increased attention to the behavioral health 

needs of children and families.

States found to need improvement in one or more 

areas must develop and implement a 2-year PIP. 

At the end of the 2-year period, States undergo a 

new review since the CFSR process is designed to 

promote continuous quality improvement. 

System Change

Many States are using the CFSR process, and 

especially PIP development, as an opportunity 

to generate system change. They recognize that, 

because of policy, programmatic, or fiscal limitations, no single agency can provide all the necessary 

services and supports for families with children who 

are vulnerable to child abuse and neglect. Because 

the safety, permanency, and well-being of children 

and families served by child welfare agencies are 

affected by many systems in addition to child 

welfare, agencies are building more collaborative 

relationships with behavioral health, substance 

abuse, domestic violence, education, and judicial 

systems, as well as with the private sector. 

States must change day-to-day practice in the field 

and agency infrastructure, both of which affect 

outcomes for children and families. Such change 

requires considerable time, strategic thinking, 

and resources, which must be balanced with the 

responsibility of ensuring the safety, permanency, 

and well-being of children in the agency’s care. 

While many changes focus on State child welfare 

systems, others target child-serving partners in 

education, domestic violence, behavioral health, 

primary health, juvenile justice, and substance 

abuse to make similar reforms. Many Federal, State, 

and local initiatives feature interagency structures 

to maximize resources and coordinate services. 

To achieve, manage, and sustain lasting change, 

State child welfare agencies must determine an 

internal course toward systemic change, including appropriate investments of time and funds, 

and work collaboratively with partner agencies to 

ensure the safety, permanency, and well-being of 

children, youth, and families.

Improving Child Welfare Outcomes 

through Systems of Care

Since the 1990s, the Center for Mental Health 

Services of the Substance Abuse and Mental 

Health Services Administration has managed the 

Comprehensive Community Mental Health Services 

for Children and Their Families Program (P.L.102-

321). This Federal initiative targets children with 

severe emotional disturbance and applies systems 

of care principles to their treatment. Outcomes for 

families and children served by this program have 

been promising, with improvement in the following areas:

z Placement stability. 

z School grades. 

z Contacts with the juvenile justice system. 

z Behavioral health status. 

z Parent and youth satisfaction.

z Costs associated with serving children who 

have the highest level of need.

In 2003, the Children’s Bureau funded the Improving 

Child Welfare Outcomes through Systems of Care 

initiative, designed to test the effectiveness of 

applying systems of care principles and infrastructure to the child welfare population. This effort 

was sparked by the promising outcomes of the 

CHAPTER 3 Systems of Care and Child Welfare
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 7

Comprehensive Community Mental Health Services 

for Children and Their Families Program and the 

need for more effective collaboration among childserving agencies at the State and local levels, as a 

means to improve CFSR outcomes. 

The notion of community-based, interagency 

systems of care has shown merit in effectively 

meeting the needs of children within their home, 

community, and school. Whether this approach has 

merit in helping to achieve positive outcomes for 

children and families involved with the child welfare 

system remains unanswered. The Children’s 

Bureau’s Improving Child Welfare Outcomes 

through Systems of Care initiative is designed to 

answer the following questions:

z Do the underlying values and principles of 

the systems of care concept support needed 

systemic changes throughout child welfare 

agencies?

z How can a child welfare agency provide 

leadership in systems of care that involve the 

commitment of colleagues in other child and 

family service agencies?

z What features would a child welfare system of 

care have?

z How effective will systems of care be in 

addressing the needs of various populations 

within the child welfare system?

z Can families be partners in a child welfare-led 

system of care?

z How might a child welfare-led system of care 

address children needing services prior to, or 

without coming into, State custody?

According to the Children’s Bureau, a number 

of compelling issues have emerged in the child 

welfare system that might be affected positively 

by a move to an interagency, community-based, 

systems of care approach. These issues and 

associated assumptions and questions, which are 

to be tested through the Improving Child Welfare 

Outcomes through Systems of Care program, are 

highlighted in the chart below.

Compelling Child Welfare Issue Assumption/Question

Many children receiving child welfare services have been 

placed in multiple out-of-home placements.

Can individualizing care to children within the system of care increase placement 

stability?

Successful reunification of children with their birth families 

remains an issue with no clear understanding of when, 

why, or with whom it succeeds or fails.

When children are reunified with their biological parents after being in out-of-home 

placement, can their involvement in systems of care increase the success rate of 

family reunification, maintaining safety, and permanency?

Most States need to focus on how to address the health, 

behavioral health, education, and well-being of children in 

their custody.

Systems of care offer a range of service options and supports to meet the individualized needs of children and families. Do systems of care offer solutions to identify 

children, youth, and families with these needs and develop case plans that address 

them?

Comprehensive, strength-based assessments and ongoing 

needs assessments have been challenging to implement 

routinely in child welfare.

Can systems of care have relevance for the child welfare system in this area?

Child welfare practice has incorporated family-based 

approaches to service delivery.

What can be learned from integrating these approaches with others that are used 

within systems of care?

Engaging youth in the design and implementation of their 

case plans is an important step in building services and 

supports that address their needs.

What can be learned from current practices within child welfare and systems of 

care to give full voice and participation to youth?

Rural communities have presented the child welfare 

system with challenges in accessing services and offering 

a broad array of service options.

What lessons can be learned from developing systems of care in rural areas to 

address issues such as service availability, transportation, and cultural barriers?

Supervision of caseworkers needs improvement in many 

child welfare systems.

How can models of supervision that use systems of care principles contribute to 

worker skill and positive outcomes for children, youth, and families?

Flexibility in child welfare visitation policies and practice 

has been a cause of concern noted in CFSRs.

Can the flexibility of child and family team approaches used in systems of care help 

child welfare agencies become more flexible in where, when, and how safe visitation occurs for the child, parents, and child protective services (CPS) caseworker?

Using data to help the child welfare system develop policy, 

improve or replace services, and better understand the 

children and families served has been problematic.

Can systems of care provide solid evidence to ensure high-quality services and 

increased levels of satisfaction, compliance, and retention for children, youth, and 

families?
8

Challenges and Opportunities

Implementation of systems of care principles in 

child welfare practice within local communities and 

States can present challenges, despite lessons 

learned from the behavioral health system. A few 

of these challenges are discussed below.

Resources

Many families involved in the child welfare system 

also are involved with other agencies, such as 

substance abuse, domestic violence, behavioral 

health, juvenile justice, and education. Yet Federal 

and State funding streams are allocated to these 

agencies categorically, which often poses challenges for integrating and coordinating resources. 

Identifying and coordinating funding streams of 

involved agencies is an important step toward 

efficiently using public funds, reducing duplicated 

effort, and maximizing Federal matching funds. For 

sustainable interagency partnerships to emerge, 

each partner must understand the benefits they 

can expect in return for contributing resources.

Family involvement

Historically, child welfare has identified the 

“dysfunctional family’s” problems and offered 

a professional plan for “fixing” those problems. 

Frequently, the service plan has been a pre-printed 

document, presented to each family for signature, 

which does not recognize differences in families 

and their needs. Viewing family members as 

experts in determining their own service needs, 

identifying and building on their strengths, and 

meaningfully involving them in the development of 

service plans, strategic planning, and policy development often require a paradigm shift for families, 

agency staff, and administrators. A similar change 

is required for agency policies, practices, and 

services to acknowledge the cultural, ethnic, and 

racial diversity of children, youth, families, and the 

community. 

Infrastructure development

To address these challenges, a strong, supportive infrastructure is essential to systems of care. 

Infrastructure includes a number of components: 

planning; governance; system management; 

coordination of services and service array; 

communication; policy; finance; continuous quality 

improvement; and human resources and staff 

development. Planning must be community-wide 

and include relevant stakeholders, families, youth, 

interagency partners, and the private sector. To 

build interagency collaboration, the governance 

body must represent families as well as the service 

delivery system. A solid management structure can 

support systems of care development and implementation, and ensure coordination of services to 

families, youth, and children by multiple agencies. 

Evaluation and training 

Safety, permanency, and well-being outcomes for 

child welfare involved families must be monitored and 

evaluated continuously. In addition, ongoing training 

and technical assistance must be provided to staff 

to give them the tools to carry out their duties and 

responsibilities in a systems of care environment.

The Infrastructure

Development Process

Stakeholder Involvement 

Creating the infrastructure to support systems 

of care requires the engagement of State, tribal, 

county, city, or neighborhood stakeholders. In his 

book, Leading Change, Kotter (1996) identified 

four essential characteristics for building coalitions 

to lead change:

1. Position Power: Are all key people on board, 

especially program managers, supervisors, 

and direct line staff, so those left out cannot 

easily block progress?

2. Expertise: Are there various points of view, in 

terms of discipline, work experience, culture, 

and ethnicity, adequately represented so 

informed decisions can be made?

3. Credibility: Does the group include people 

with positive reputations in the agency, 

community, or neighborhood so others will 

respect the group’s findings?

4. Leadership: Does the group include veteran 

leaders who can direct the change process? 

(Leadership and management skills must work 

in tandem, with managers keeping the process 

under control and leaders driving change.)3

For forming a group responsible for leading a 

change effort, Kotter identifies certain personality 

CHAPTER 3 Systems of Care and Child Welfare
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 9

characteristics and qualities that should be avoided 

or managed. These include:

z People “with large egos that fill up a room, 

leaving no space for anyone else.” 

z People “who create enough mistrust to kill 

teamwork.”

z People “who are reluctant players.”4

The following exhibit illustrates Kotter’s ideas.

Building a Coalition That 

Can Make Change Happen

Find the Right People

z With strong position power, broad 

expertise, and high credibility

z With leadership and management skills, 

especially the former

Create Trust

z Through carefully planned off-site events

z With lots of talk and joint activities

Develop a Common Goal

z Sensible to the head

z Appealing to the heart5

Once individual members have been identified, 

it is important to assess whether the group, as a 

whole, reflects systems of care principles. Given 

the importance of family involvement and cultural 

competence, membership should include those 

who have received services from participating 

agencies and represent the diversity of the State, 

tribal community, county, city, or neighborhood 

population. Service providers, faith-based organizations, private and public agencies, providers 

of informal supports, and other key constituents 

unique to the State, tribe, county, city, or neighborhood also should be represented. 

The following chart, from Building Systems of 

Care: A Primer,

6

 offers guidance for effective 

collaboration. 

Principles to Guide 

Collaboration

z Build and maintain trust so collaborative 

partners are able to share information, 

perceptions, and feedback and work as 

a cohesive team.

z Agree on core values that each partner 

can honor in spirit and practice.

z Focus on common goals that all 

partners will strive to achieve.

z Develop a common language so 

all partners can have a common 

understanding of terms such as “family 

involvement” and “cultural competence.”

z Respect the knowledge and experience 

each person brings.

z Assume the best intentions of all partners.

z Recognize strengths, limitations, and 

needs, and identify ways to maximize 

participation of each partner.

z Honor all voices by respectfully listening 

to each partner and attending to the 

issues they raise.

z Share decision-making, risk taking, 

and accountability so that risks are 

taken as a team and the entire team is 

accountable for achieving the goals.

Understanding Ambiguity

The infrastructure development process has 

been described as messy, ambiguous, and time 

consuming work that requires perseverance and 

patience. Consequently, a clear understanding of 

the complex and ambiguous nature of the work 

is needed. This will help to sustain commitment 

and maintain a focus on inter- and intra-agency 

relationships. 

Developing a Theory of Change

To build systems of care, communities can follow 

a theory of change that incorporates interagency 

planning and allows participants to understand 

their role in the infrastructure development plan.7

Hernandez and Hodges (2003) provide the following chart, which depicts how a theory of change 

can be organized in three phases.
10

When developing the infrastructure to support 

systems of care, interagency collaboration, family 

involvement, and cultural competence provide a 

solid foundation for planning and building. Creating 

a theory of change also enables participants to 

understand their roles. Other important considerations throughout the developmental process 

include: 

1. How will the effort be marketed to constituents? 

2. How will the efforts and changes made by the 

group be sustained over time? 

3. What strengths can be built upon, and what 

structural components should be created or 

modified? 

4. What interagency groups, coalitions, or 

commissions with similar goals are in place or 

legislatively mandated? Can the infrastructure 

developed on behalf of systems of care be 

integrated into and benefit these broader 

efforts? 

5. Does the effort have the full support of funders, 

policymakers, agency directors, and other 

leaders?

CHAPTER 3 Systems of Care and Child Welfare

6. What is the level of influence the systems 

of care effort may have on other priority 

areas within the State, tribe, county, city, or 

neighborhood? 

7. Are the roles, expectations, responsibilities, 

and levels of authority clearly defined for 

individuals involved in the effort?

8. What shifts in attitudes, assumptions, and 

beliefs must be made to meet the challenges 

of systemic change and sustaining systems of 

care?

9. What policies, procedures, processes, tasks, 

activities, and functions must be developed, 

modified, or eliminated to address technical 

challenges associated with systemic changes 

needed to sustain systems of care?

10. What personal or professional values or 

philosophies are challenged, and how will 

individuals accept change and be open to 

fresh ideas? 

These considerations can be the basis for addressing the infrastructure components described in 

detail in the following section.

Phases of Theory Development for Systems of Care

Phase I

Pre-planning

Phase II

Theory of Change Development

Phase III

Implementation

Stage 1: Form Interagency Work Group

Stage 2: Articulate Mission

Stage 3: Identify Goals and Guiding Principles

Stage 4: Develop the Population Context

Stage 5: Map Resources and Assets

Stage 6: Assess System Flow

Stage 7: Identify Outcomes and Measurement Parameters

Stage 8: Define Strategies

Stage 9: Create and Fine-tune the Framework

Stage 10: Elicit Feedback

Stage 11: Use Framework to Inform Planning, Evaluation, and Technical

 Assistance Efforts

Stage 12: Use Framework to Track Progress and Revise Theory of Change
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 11

CHAPTER 4

INFRASTRUCTURE

An infrastructure is multi-faceted and 

 complex and can include a central office 

 staff, interagency standing and ad hoc 

committees, an advisory board, and administrative support.8

 In systems of care, the complexity 

is intensified by the need to identify, develop, or 

modify agency organizational structures and align 

functions, processes, and policies while ensuring 

systems of care principles are incorporated into 

all aspects of infrastructure development. Despite 

guidance from these principles, a community’s 

unique history, demographics, cultural and ethnic 

diversity, and government and administrative 

structures will shape infrastructure components. 

In addition, changing political, legislative, financial, and administrative contexts will affect the 

infrastructure development process. The following 

exhibit highlights these divergent, yet interrelated 

components.

Organizational Context

Inter- and Intra-Agency 

Organizational Structure, 

Policies, Practice, and 

Administrative and Business 

Functions

Community Context

State, Tribal, County, City, 

or Neighborhood Structures, 

Business Practices, and Culture

Program and Practice

Coordination of Services and 

Service Array

•	 Competing priorities

•	 Political environment

•	 Legislation

•	 Policies, procedures, and

processes

•	 Agency mandates

•	 Fiscal stability

•	 Leadership

•	 Personnel changes

•	 Existing legal issues

•	 Changing population

demographics

•	 Current and evolving social

problems

•	 Sustainability

•	 Other major initiatives of

similar focus

Are principles evident in these 

areas? If not, how will this be 

addressed?

What areas are strengths that 

can be built upon to support 

and sustain systems of care?

What challenges in these 

areas need to be addressed?

Structures to Assess 

and Address at the State 

or Local Level

Systems of Care 

Principles

Strengths, Weaknesses, 

Opportunities, Threats

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 13

CHAPTER 5

INFRASTRUCTURE 

COMPONENTS

Infrastructure (noun) 1: the underlying foundation or basic framework (as of a system or organization); 

2: the system of public works of a country, State, or region; and 3: the resources (personnel, buildings, 

or equipment) required to conduct functions, tasks or activities.9

I

mplementing infrastructure development in 

child welfare requires knowledge of the administrative parameters of the system. Some child 

welfare agencies are State-supervised and countyadministered, while others are State-administered 

and county-supervised. Further, some State-administered agencies have strong county structures, 

with local discretion. In addition, child welfare is 

administered differently in tribal communities. 

The majority of child welfare agencies, about twothirds, are units within larger agencies rather than 

freestanding units.10

The following map and summary of States highlight 

the differing child welfare agency structures found 

across the United States.11 Understanding the 

dynamics of these organizational structures is 

essential when building the child welfare agency 

infrastructure to support systems of care.

State-Administered = AK, AZ, CT, DC, DE, FL, HI, IA, ID, IL, KS, KY, LA, MA, ME, MI, MS, MT, NE, NH, NJ, NM, OR, RI, SD, TN, TX, 

UT, WA, and WY. 

State-Supervised, County-Administered = CA, CO, GA, MD, MN, NC, ND, NV, NY, OH, PA, VA, and WI. 

State-Administered with Strong County Structure and Discretion = AL, AR, IN, MO, OK, SC, VT, and WV.

Administrative Structure

State Administered (30)

State Supervised/County Administered (13)

State Administered/Strong County Discretion (8)

DC

Administrative Structure of Child Protective Services12
14

Assessing Effectiveness

Identifying and developing outcomes that reflect infrastructure reforms at various levels are important for 

building systems of care. Stroul illustrates this point in the following chart.13

Infrastructure components that support systems of 

care include:

z Planning

z Governance

z System management 

z Coordination of services and service array

z Communication

z Policy

z Finance

z Continuous quality improvement

z Human resources and staff development

Following are examples of how to address each 

infrastructure component as part of a systems of 

care development and implementation strategy. 

The examples include definitions, goals, systems 

of care principles and values, activities and tasks, 

personnel, questions to consider, and additional 

resources to stimulate ideas. Activities in the preplanning, planning, and implementation phases 

are described, and details about how an Improving 

Child Welfare Outcomes through Systems of Care 

program grantee addressed each infrastructure 

component are provided.

Assessing Progress

As child welfare agencies and their partners, plan, 

develop, and build systems of care, they must 

continually assess progress toward short- and longterm goals and recognize milestones to maintain 

the commitment and enthusiasm of participants. 

Example

The following chart was created by a systems of 

care community in a tribal site to chart its progress 

in developing systems of care.14 The center of the 

circle represents the core, center, or Nagi (Lakota 

term for spirit) of the system of care. Communities 

can chart their progress on the dotted lines, with 

the dashes on the lines of the innermost circle 

representing milestones. The pattern of dashes 

provides a visual representation of the consistency or variation in the progress the community has 

made on the different infrastructure components. 

For example, if the line connecting the dashes is a 

circle, it indicates consistency across components 

on the level of progress achieved.

CHAPTER 5 Infrastructure Components

Levels of Systems of Care Development

State-Level Outcomes

Local System-Level 

Outcomes

Child and Family-Level 

Outcomes

State Policy Reforms

Local System-Level 

Reforms

Service Delivery-Level 

Reforms
Planning Governance

System

M

a

n

ag

ement

F

ni a

n

c

e

Policy

Staffng

Principles

Interagency Collaboration

Ac

c

o

u

ntability

nI

d vi

di

ualized

Stre

n

gth

s-Based

Care

Community-Based Services

INFRASTRUCTURE

Quality Assurance Communications

Service Array

Youth and Family Involvement Cultural Competence

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 15

PLANNING

Definition

Planning is defined as the dynamic process of 

gathering information from stakeholder groups, 

including youth, parents, provider organizations, 

public and private agencies, and the communityat-large, to develop a shared mission and vision 

for children and families within the systems of care 

infrastructure.

The information is used to formulate a plan to guide 

infrastructure development activities. Agreed upon 

indicators of organizational and individual child 

and family outcomes are critical to success.

Resources

Systems of Care: A Guide for Planning. 

http://www.childwelfare.gov/systemwide/

service/soc/build/socinfrastructure.cfm

Strategic Planning for Child Welfare 

Agencies. http://muskie.usm.maine.edu/

helpkids/rcpdfs/strat.plan.pdf

Building Systems of Care: A Primer. http://

childwelfare.gov/systemwide/

service_array/soc/soc-pubs-list.cfm

Systems of Care Development

SOC
16

z Planning documents include language that 

focuses on family-driven, community-focused, 

and strength-based approaches to service 

delivery and the organizational processes that 

support them.

z Youth, families, and other stakeholders are 

responsible for accomplishing tasks outlined in 

the planning document.

z Outcome measures and performance 

expectations are specified in the planning 

document, as is the method for collecting 

baseline data.

Activities and Tasks

Planning activities and tasks in your community 

might include:

Pre-Planning Phase

z Determine the entity charged with planning. 

Is there an existing group that can serve this 

purpose or will a new planning group need to 

be formed?

z Embrace a “planning to implement” strategy. 

z Identify stakeholders. If an existing group is 

relied upon, who needs to be added to fulfill 

the purpose of the systems of care work?

z Identify ways to address the question, “What’s 

in it for me?” 

z Make certain agency administrators, judges, 

and other key decision-makers are aware of 

the planning and its potential impact on their 

system and the community as a whole. Make 

sure they are supportive of, and committed to, 

the effort and have opportunities to participate.

z Seek out tested strategies, tools, 

methodologies, and experts on planning.

z Identify fiscal, personnel, and consultant 

resources to support the planning. 

z Ensure planning group members are 

representative of the target population.

Goals

Your community might establish systems of care 

planning goals such as:

z Stakeholder groups have maximum input into 

the planning process.

z The planning process creates a shared vision 

of the system of care.

z Stakeholders recognize planning as an 

evolutionary process.

z Planning is used to inform program and 

system development.

z Planning documents are created to guide 

activities.

z Planning documents are culturally and 

linguistically competent.

z Planning documents are disseminated across 

a wide spectrum of stakeholders.

z The planning process and subsequent 

strategic planning document reflect the phases 

of systems of care work from development to 

implementation through sustainability.

Systems of Care Principles 

and Values

The following are just a few ways that systems of 

care principles and values might be evident in your 

community’s planning:

z Families and youth in the target population 

who have received services are actively 

engaged in the planning process.

z Stakeholders involved in planning activities 

represent a spectrum of agencies, 

organizations, and individuals with knowledge 

of the target population and the geographic 

area. 

z Planning meetings are conducted at times, 

places, and on dates that respect the time of 

all participants. Special accommodations are 

made for participants who are non-English 

speaking, have physical disabilities, or are 

visually or hearing impaired.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 17

Planning Phase

z Identify appropriate neutral locations for 

planning.

z Determine the cultures of the community, 

families, and institutional structures.

z Define the reason for existing as a planning 

body and as a project.

z Establish an internal and external 

communication plan.

z Conduct public hearings.

z Conduct a needs assessment or asset 

mapping with multiple groups such as other 

organizations and direct service providers. 

z Conduct a Strengths, Weaknesses, 

Opportunities, Threats (SWOT) analysis.

z Use focus groups, surveys, and interviews to 

collect data from multiple groups on areas 

such as needs, assets, values, and priorities.

z Conduct an orientation on planning for 

stakeholder participants.

z Develop consensus among stakeholders. 

z Develop a common language, including 

overcoming use of acronyms and systemspecific jargon that may not be familiar to all 

stakeholders. 

z Assess evaluation tools, cultural competence 

issues, and other factors that affect the effort.

z Develop shared goals, vision, and mission 

based on values and principles of systems 

of care.

z Define shared outcomes to be achieved 

through systems of care.

z Write the strategic plan for implementing 

systems of care.

z Provide copies of the plan to key decisionmakers and make certain the agencies and 

constituents they represent have approved 

the plan, support it, and understand and are 

committed to their role in its implementation.

z Distribute the plan to all interested parties. 

Implementation Phase

z Conduct a needs assessment of the knowledge, 

technical skills, and experience of the systems of 

care team that will implement activities.

z Establish communication protocols with 

external and internal constituents.

z Create workgroups such as interagency and 

policy groups.

z Assemble an effective systems of care team 

and add members as the project grows.

z Conduct sustainability planning.

z Use focus groups, surveys, and interviews 

to collect data from multiple groups on 

implementation activities, including progress, 

barriers, facilitators, and lessons learned. 

z Develop methods for learning about each 

member’s agency, policies, procedures, and 

processes. 

z Determine what resources are needed to 

efficiently and effectively carry out activities 

and meet deadlines.

z Assign tasks, activities, and functions to 

individuals, agencies, and groups as outlined 

in the plan.

z Develop reporting mechanisms for informing 

decision-makers about progress.

z Review the implementation plan routinely and 

make changes as needed. 

Personnel

The people who perform planning duties in your 

community might include:

z Project director

z Evaluator (staff position or consultant) 

z Administrative assistant

z Planner (staff position or consultant)

z Representatives of families and the community, 

such as a family member hired as a 

coordinator

Questions to Consider

As systems of care planning evolves in your 

community, keep in mind questions such as:
18

z Have all key stakeholders been identified and 

involved in the planning process?

z Has a SWOT analysis been conducted? 

z Has a needs assessment been conducted?

z Have various methods for collecting 

information from key stakeholder groups been 

used (focus groups, interviews, surveys, public 

forums)?

z Has an exercise been conducted to map out 

resources (fiscal, personnel) and services?

z Have the policies, funding mechanisms, 

mandates, and procedures of key interagency 

partners been assessed?

z Have stakeholders agreed upon a short- and 

long-term action plan? If so, is it being used to 

guide systems of care development?

z Does the planning relate to State CFSR 

outcomes and the PIP?

z Is other planning being conducted by the State 

or local child welfare agency? How does this 

work relate to broader efforts?

z Have existing child welfare boards, advisory 

groups, or advocacy groups been considered 

for involvement? How does the work of these 

groups relate to planning for systems of care? 

How will these groups be kept informed of 

progress toward goals and objectives?

z Are representatives of the judicial system, 

attorneys, and law enforcement represented in 

the planning? How will they be kept informed 

of the potential impact?

z Does the planning require authorization or 

approval from any agency boards of directors, 

State commissioners, advisory groups, city 

council, tribal leaders, county boards, or 

school boards? If so, what is the strategy for 

securing a place on their agendas? Who will 

present the information? What is the process 

for approval? How will these groups gain 

information about progress in implementing 

the plan and building systems of care? 

CHAPTER 5 Infrastructure Components

Example from the Field

Site

Department of Human Services, Jefferson County, Colorado

Strategy/Approach

What Was Done and Who Was Involved

One aspect of infrastructure development we considered important was to recognize and utilize the 

substantial resources already available within Jefferson County to support and sustain implementation of systems of care principles. Communication about systems of care principles and anticipated 

activities across the various Jefferson County Divisions and Departments by project staff in the first 

grant year led to the identification of a number of potential collaborative projects. One such opportunity, a community needs assessment, was initiated in the third year of the grant. 

The referral address geomapping project mapped the areas of greatest need in Jefferson County, 

based on the geographic concentration of child abuse and neglect referrals. The Systems of Care 

Research Analyst presented this proposal to “Family to Family” staff within child welfare and to 

the Global Information Systems geomapping expert at Jefferson County’s Long-Range Planning 

Department. The “Family to Family” initiative in Jefferson County is currently involved in strategic 

planning for the Building Community Partnerships component of the project. Systems of care is 

collaborating with and supporting these efforts, as we are also initiating targeted community outreach 

activities. “Family to Family” staff agreed to collaborate and assist in verifying referral address data in 

the Statewide Automated Child Welfare Information System (SACWIS) in preparation for geomapping. 
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 19

The Research Analyst met with the mapping expert on map formatting and map overlay possibilities 

(from already existing county census data). 

Time Frame

Initial meetings took place in the latter part of year two and the first maps of child welfare child 

abuse and neglect referral addresses by ethnicity of children in the home were produced at the 

beginning of year three. The first set of maps showing two key areas of high need (Lakewood and 

Arvada, overlaid on census income data and showing ethnicity of children) have been presented to 

various groups by the Systems of Care Project Manager and Research Analyst, and by child welfare 

Program Managers to generate discussion about how we may collaborate to address the needs of 

these communities. Presentation audiences include those within child welfare and the Department 

of Human Services, as well as community groups.

Why This Approach Was Selected

The referral address geomapping project provides both systems of care and “Family to Family” with 

a valuable tool to identify high need areas of the county in which to target efforts in building community partnerships. Such maps will also enhance future planning on the assignment of child welfare 

caseworkers according to geographic area and ethnicity. In addition, the original maps (based on 

year two data) will serve as a baseline of the density of greatest need in the county (and ethnic diversity of the referrals), against which future geo-maps could be compared to evaluate the effectiveness 

of systems of care and “Family to Family” based services.

Systems of Care Principles 

The systems of care team has always been attentive to potential interagency collaboration opportunities. 

Such opportunities, when realized in concrete collaborative planning and implementation, are much 

more likely to result in long-term sustainability, as multiple parties have a stake in their success and 

benefit from their products. In addition, translating the wealth of available child welfare data into usable 

accountability products is a challenge, but when wedded to creative community thinking and feedback, 

can be among the most productive and sustainable elements of systems of care grant activities. 

Lessons Learned

Facilitators

Facilitators to this process included frequent, concise, and in-depth communication between interested parties that helped to distinguish what the benefits of collaboration would be for each. This 

helped representatives of each party to take the message back to their respective units and managers to facilitate buy-in at different levels of the organization.

Barriers

Once maps were produced and presented, some initial misconceptions developed regarding what 

they represented and the ease with which they could be produced. The Systems of Care Research 

Analyst created an informational letter that summarized key details. This letter was given to all 

potential presenters and the details were reviewed individually with them to ensure that the map 

information was not misrepresented and was utilized appropriately. The Research Analyst then 

gathered feedback from stakeholders about additional elements that could be overlaid or added 

to the maps to tailor them to specific planning efforts (e.g., school attendance areas, child welfare 

service providers). We hope to continue the geomapping project beyond the life of the grant.
20

GOVERNANCE

Definition

Governance refers to the interagency entity and 

operating structure authorized to make decisions 

and set strategic direction for activities, tasks, and 

functions associated with building, implementing, 

and sustaining systems of care, and providing 

oversight for their implementation. This body is 

responsible for developing interagency solutions 

to address the needs and challenges of a specific 

target population or geographic area. 

The governance body is composed of local, county, 

State, tribal, or neighborhood administrators, 

family members, program specialists, and service 

delivery staff. For the infrastructure to operate effectively, members must demonstrate a commitment 

to systems of care principles and develop rules, 

procedures, roles, and expectations for members, 

committees, staff, and other individuals involved in 

the systems of care effort. 

Resources

Memorandum of agreement used in 

systems of care work. http://www.dhhs.state.

nc.us/mhddsas/announce/moa_state3-31-

03_child02-03.pdf 

Bylaws for a governance structure leading 

systems of care work. http://www.systemofcareillinois.com/lan_39_bylaws.htm 

Promising practice monograph on 

interagency collaboration. http://cecp.air.org/

promisingpractices/1998monographs/vol6.pdf

Toolkit on building community systems. 

http://ctb.ku.edu/tools/

See Appendix A for an example of the 

organizational structure of the governance 

body conducting systems of care work in 

Contra Costa County, California.

See Appendix B for an example of a job 

description for an interagency liaison/

administrative coordinator position that 

provides support to the governance body. 

See Appendix C for an example of who 

to involve on the governance body of a 

systems of care effort addressing the needs 

of families involved in child welfare. 

Goals

Your community might establish systems of care 

governance goals such as:

z Interagency staff, family members, faithand community-based organizations are 

represented on the governance body and its 

committees.

z The governance body has the authority, 

capacity, and credibility to govern.15 

z The governance body and its committees 

operate efficiently and effectively, utilizing the 

strengths and resources of members. 

z The governance body operates in a manner 

that ensures timely disposition of unresolved 

issues, including those that directly affect 

children, youth, and families.

z Members of the governance body demonstrate 

a continuous learning community approach 

to systems of care development and 

implementation.

CHAPTER 5 Infrastructure Components

z Members of the governance body are 

authorized to make decisions about policy, 

funding, service delivery system design, and 

other issues. 

z Members of the governance body define their 

roles and responsibilities as a group, as well as 

individually.

z The governance body evolves over time to 

accommodate changes in agency structures, 

service populations, or other environmental 

factors.

z Consensus among members is the desired 

method for decision-making. 
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 21

Systems of Care Principles 

and Values

The following are just a few ways systems of care 

principles and values might be evident in your 

community’s governance:

z Members of the governance body are able to 

incorporate systems of care principles in verbal 

and written communications, and demonstrate 

them within their agencies. 

z The governance body conducts business at 

times, locations, and dates that are accessible 

to all interested parties, including families, 

youth, non-English speaking constituents, and 

individuals with physical disabilities or who are 

hearing or visually impaired.

z The governance body conducts business 

operations through an open, public process 

available to all interested parties.

z The governance body is representative of a 

wide variety of stakeholder groups, cultures, 

youth, and family members.

z The governance body utilizes data and 

outcomes to inform decision-making 

processes (fiscal, policy, service delivery) and 

to modify operations as needed.

Activities and Tasks 

Governance activities and tasks in your community 

might include:

Pre-Planning Phase

If no interagency governance body exists:

z Identify interagency resources available to 

support development of the governance body.

z Identify what processes need to be followed to 

receive administrative or policy approval for the 

body. (Do State or county administrators, tribal 

leaders, or commissioners need to approve 

and authorize the work?)

z Develop materials to present to officials 

authorized to approve creation of the 

governance body.

z Identify members. (The governance body 

should be composed of decision-makers 

and policymakers from the public and private 

service delivery sectors, as well as family 

members, youth, and service providers).

z Contact member agencies and individuals 

to determine commitment and availability to 

participate. 

z Agency staff must determine the process for 

authorizing them to represent their agency on 

the governance body.

z Provide orientation and training to members.

z Develop Memorandum of Understanding/

Memorandum of Agreement (MOU/MOA) to 

formalize interagency relationships, roles, and 

responsibilities.

z Develop bylaws.

z Provide members with the MOU/MOA to 

present to their agencies for approval and 

authorization of their involvement. 

z Seek signatures for the MOU/MOA from 

individuals who can authorize and approve the 

work of the governance body.

z Once signatures are received, send copies 

of the document to all agencies, individual 

members, and interested parties.

If a governance body already exists:

z Determine whether the existing body 

addresses issues of similar focus and scope.

z Determine whether the existing body, with 

expanded capacity, can incorporate systems of 

care into its vision, mission, and operations. 

z Determine the requirements to build on the 

work already accomplished by the body.

Planning Phase

z Establish a communications plan for 

governance structure members to inform their 

internal agency staff about their involvement in 

the effort.
22

z County structures should inform State 

stakeholders, and vice versa. 

z Structures should be sensitive to the way in 

which the responsible child welfare system is 

administered.

z Establish methods for disseminating 

information to interested parties. 

z Determine who needs progress reports and 

establish communication with them. 

z If applicable, integrate existing governance 

bodies.

z Identify individuals to manage the governance 

body and lead committee work.

z Determine financial oversight if money is 

involved.

z Identify committees and other administrative 

support for the governance structure. 

z Establish a committee structure.

z Pinpoint areas in which the policies and 

practices of partner agencies might contradict 

or conflict with one another, and establish 

methods for addressing these issues. 

Implementation Phase

z Approve the strategic plan.

z Approve funding requests.

z Continue to assess and address issues that 

arise in the geographical area and within the 

target population. (This could include reducing 

foster care or out-of-state placements.)

z Develop and implement a social marketing 

plan that provides the community with 

information about systems of care. 

z Recommend changes to legislation or agencyspecific policies in order to support systems of 

care principles.

z Recommend funding to support new or 

expanded services within the existing service 

delivery system.

z Conduct ongoing assessment of community 

needs. 

Personnel

The people who perform governance duties in your 

community might include:

z Administrative assistant/coordinator

z Interagency partners (administrators and 

program directors)

z Family members 

z Project director

Questions to Consider

As systems of care governance evolves in your 

community, keep in mind questions such as:

z Has a governance structure that features 

interagency and family involvement been 

established?

z Does the governance body and its committees 

meet regularly?

z Does the governance body exist at the State, 

territorial, tribal, county, and/or local level?

z Does the governance body resolve barriers 

(policies, program gaps, and funding) for 

implementing individual service plans? 

z Does the governance body support a variety 

of subcommittee activities, including training, 

program development, policy development, 

finance, social marketing, and information 

systems? 

z Does the governance body have the authority 

and responsibility to make essential decisions 

for building, implementing, operating, and 

sustaining the system of care?

z Is the membership of the governance 

body representative of the system of care 

stakeholders?

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 23

Example from the Field

Site 

Alamance County, North Carolina

Goal

To provide leadership in the integration of agency service in establishing a system of care approach 

to working with children and families in Alamance County.

Strategy/Approach

Alamance County developed a Children’s Executive Oversight Committee to coordinate five statutorily mandated child-serving committees, including the Community Child Protection Team, the Juvenile 

Crime Prevention Council, the School Based Child and Family Team Support Initiative, Community 

Collaborative for Children and Families, and Smart Start Board. These committees actively engage in 

work to ensure that services are provided to children and families identified as high risk. Each committee has designated administrative membership (e.g., the superintendent of schools, the District Court 

judge, the Department of Social Services director) that overlaps with each of the other committees. 

Given the time commitment, each of the administrators was sending designees to represent them. 

This committee will bring the administrators together three or four times per year to get updates on 

the work of each committee, to continue to work toward better integration of community systems, and 

to provide ongoing leadership and advocacy for children and families across systems. Committee 

members include: the chief district court judge, the superintendent of schools, the county commissioner, the director of the Department of Social Services, the director of the Health Department, the 

director of the Mental Health Center, the chief court counselor, and the chief of police. Bringing people 

together was a slow process of building relationships over one year as it became clear that we 

needed to bring decision-makers together to provide leadership for this change process. 

Systems of Care Principles

Developing this leadership committee is a collaboration between community-based agencies and, 

just as importantly, their respective administrators.

Lessons Learned

Building relationships takes time.

Barriers

z Administrators do not always know or understand how they are interdependent.

z Territory is difficult to share.

What Might Have Been Done Differently

z Start earlier in this process.

z Conduct trust building exercises.

z Define self-interest (individual and mutual).
24

SYSTEM MANAGEMENT

Definition

System management refers to conducting or 

supervising day-to-day operations associated 

with developing, implementing, and sustaining a 

system of care. The management structure developed to support systems of care features positions 

responsible for carrying out activities, tasks, and 

functions that support the vision and mission. In 

addition to personnel, the management structure includes operational functions that support 

systems of care.

Goals

Your community might establish systems of care 

system management goals such as:

z The capacity of existing management 

structures has been strengthened to support 

and sustain systems of care.

z Innovative approaches are applied to the 

management of day-to-day activities and 

reflect the values and principles of systems of 

care.

z Families are involved meaningfully and 

represented fairly in day-to-day operations and 

meetings that address operational issues.

z Individuals responsible for day-to-day 

operations are trained in, and committed to, 

systems of care values and principles. 

z Family members are hired, either as staff or 

contract consultants, for the systems of care 

management team.

z The systems of care management team 

operates with the support of employers and 

agency administration.

z The systems of care management team has 

the support of the governance body and other 

authorizing officials to plan for and implement 

system change.

z The system managers of partner agencies are 

trained in, and committed to, the values and 

principles of systems of care.

Resources

See Appendix D for an example of the 

management structure of a systems of care 

community.

See the links below for examples of management information systems that are used in 

systems of care communities to track service 

and fiscal utilization and provide electronic 

records of child and family team processes, 

integrated service plans, and interagency case 

planning: 

c Harmony Information Systems. http://

www.harmonyis.com/

c Qualifacts Information Systems. http://

www.qualifacts.com/

c The Clinical Manager. http://www.choicesteam.org

Quality Assurance Mission Statement, 

Quality Assurance Flow Chart, Quality 

Improvement Plan, Quality Assurance Plan, 

and an overview of a Quality Assurance 

Program for Wraparound Milwaukee, 

a systems of care effort in Milwaukee, 

Wisconsin. http://www.county.milwaukee.gov/

display/router.asp?docid=10151

How the State of New Jersey has structured 

the management of its systems of care effort, 

which integrates resources from multiple 

public agencies. http://www.state.nj.us/

humanservices/dcbhs/archives.htm

http://www.state.nj.us/humanservices/dcbhs/

publications.htm

CHAPTER 5 Infrastructure Components

z The management structure is adaptable to 

emerging issues and needs.

z Management information systems track data 

and outcomes and manage fiscal and service 

utilization across agencies.

z A smooth, efficient process develops and 

implements individualized multi-agency case 

plans.

z Clear procedures for developing case plans 

include a process for utilizing interagency 

administrative teams, grievance procedures, 

and confidentiality protocols.
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 25

Systems of Care Principles 

and Values

The following are just a few ways systems of care 

principles and values might be evident in your 

community’s system management structure:

z Meetings are scheduled at convenient times 

for all team members.

z Family members who are not agency 

employees are reimbursed for attending 

meetings.

z Family members are compensated with 

salaries comparable or equal to agency 

positions of similar scope.

z Childcare is provided or requisite costs 

reimbursed for family team members who 

are participating in the systems of care 

collaborative or advisory council but are not 

agency employees.

z Consensus is a decision-making goal.

z Staff can follow a flexible schedule for the 40-

hour work week.

z Supervision follows a strength-based approach 

or is applied through a positive performance 

process.

z Individuals representing diverse cultures, 

ethnicities, and ideas manage the system.

z Children, youth, and families are regarded 

as a community responsibility rather than 

the responsibility of a single department or 

agency.

z The use of strength-based, family-driven, 

community-based care is evident. 

z Data and outcomes are collected, analyzed, 

and used to make decisions and manage the 

system.

z Data are reported to all interested parties, 

funders, and the governance body, and are 

linked to a formalized continuous quality 

improvement structure.

z Management information systems incorporate 

data fields that reflect systems of care 

principles.

Activities and Tasks

System management activities and tasks in your 

community might include:

Pre-Planning Phase

z Identify staffing needs to manage the work 

(administrative assistants, systems of care 

director, work groups).

z Identify data collection, tracking, and 

assessment needs. 

z Identify other resources to manage work 

(money, staff, training).

Planning Phase

z Determine the positions responsible for day-today management.

z Identify entities responsible for managing work.

z Identify full-time employees to conduct grant 

activities to support and sustain the work over 

the funding period and post-funding.

z Determine State, county, tribal, and community 

system management. 

z Assess existing management structures and 

determine if they should be modified or have 

their capacity expanded.

z Determine ways to inform agency leaders 

about progress to maintain their commitment 

and support.

Implementation Phase

z Create interagency committees that focus 

on training, communications, finance, policy 

development, information systems, resource 

development, service delivery system design, 

and quality improvement to organize the tasks, 

activities, and functions associated with building, 

implementing, and sustaining systems of care.

z Link the tasks, activities, and functions of the 

management structure directly to the systems 

of care strategic plan.

z Coordinate planning, communications, and 

operations.

z Manage resources.

z Maintain a management information system.
26

z Guide interagency teams.

z Continuously inform agency leaders and 

decision-makers about progress to ensure 

their continued support and commitment. 

z Develop a plan for sustaining the system of 

care after the grant ends.

Personnel

The people who perform system management 

duties in your community might include:

z Project director

z Administrative assistant

z Agency directors involved in interagency 

teams

z Program directors involved in interagency 

teams

z Interagency administrative and program 

committees 

z Family members involved in interagency teams

z Service delivery staff 

Questions to Consider 

As systems of care system management evolves in 

your community, keep in mind questions such as:

z Is there an identified lead person to oversee 

the day-to-day operation of the systems of care 

effort?

z Is there adequate administrative support to 

ensure timely execution of all governance 

activities and procedures, including resolution 

of barriers to implementing individualized case 

plans?

z Are families involved meaningfully in all 

systems of care activities?

z Are families properly reimbursed for their time?

z Are governance meetings scheduled so all 

participants can attend regularly?

z Do governance meetings follow an open 

meetings process so interested parties are 

informed and can choose to attend?

z Is there a sustainability plan?

CHAPTER 5 Infrastructure Components

Examples from the Field

Site

New York City

Strategy/Approach

What Was Done

In the middle of year three, we found ourselves at a pivotal point given the mission and the increasingly complex and rapidly changing environment in which we operate. There are a multitude of needs 

both within the field office in which the staff works as well as within the community as a whole. We are 

constantly called upon to provide community resource information, make linkages between agencies 

and families, coordinate trainings, participate in Family Team Conferences and other requests, and it 

is imperative that the team have clear roles and responsibilities that keep us on track both individually 

and as a team. After many months of planning, we completed our strategic plan at the end of year 

three. The strategic plan document provided us with a road map and focus for the next 2 years that 

includes clear goals, objectives, and strategies that would produce concrete outcomes.

One of the first tasks in building the system management structure was to establish a clear sense 

of leadership hierarchy with separate lines of authority and responsibility. The staff titles reflect 

the responsibilities that each person is assigned, i.e., training and development manager, family 

engagement specialist, and community consultant. The staff now has a clear knowledge of the 

responsibilities in which they are engaged within the project.
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 27

Who Was Involved

The training and development manager is the person responsible for developing a strong infrastructure of interagency collaboration by identifying agencies in the community to partner and develop an 

MOA agreement with, coordinating trainings and workshops with community-based organizations 

and city agencies on issues of relevance to the community, as noted in earlier needs assessments, 

and participating in Family Team Conferences to provide families with information on the services 

available in the community. 

The family engagement specialist is responsible for the child and family involvement aspect of the 

work, which includes building family representation on the various committees engaged in the 

systems of care work; coordinating family activities within the community; serving as the liaison 

with community groups, parent leaders within the neighborhood schools, and child care/Head Start 

partners to engage them in the systems of care work; and serving as the point person for the 

partnership with the Child Welfare Organizing Project, the agency we have partnered with to train 

parents to become parent advocates in the community. 

The community consultant is charged with executing the realization of a community where culturally competent services and supports are provided to families, as well as engaging key community 

stakeholders such as the churches, police department, and elected officials. 

Management and supervision are carried out by the project director and deputy director. The need 

to identify a person who has the ability to multitask and has experience in systems building was 

critical in hiring the new deputy director. We were fortunate to hire a person who has expertise in 

systems building in the not-for-profit context. 

The deputy director is charged with managing day-to-day activities, which include keeping the team 

on track with key strategic priorities. One activity she has developed is leading weekly meetings with 

the team to discuss priorities for the week and to check in on what was accomplished, identifying 

roadblocks that may exist for activities that were not carried out, and strategizing how to remedy 

the issue or bring it to the steering committee for resolution, if appropriate. The project director has 

overall responsibility for ensuring the smooth operation of the entire structure.

Why This Approach Was Selected

The team’s work is guided by our network in various forms. The steering committee is the body that 

assesses and ensures that we are on track with our strategic goals. Roles and responsibilities of 

the committee were created, voted upon, and accepted. A chair has been selected to facilitate the 

steering committee meetings (a co-chair will be voted upon at the next committee meeting). The 

CRADLE (Community Taking Responsibility in Assisting in Developing Life and Empowerment) team 

reports accomplishments and activities to the committee and presents issues for discussion that 

were uncovered at the team’s staff meetings. For issues that may require longer or more in-depth 

discussion and the development of specific protocols, an ad hoc committee, the implementation 

work group, was created. Families are represented on the Bedford Stuyvesant Activists committee 

(formerly called the Bedford Stuyvesant Stakeholders Committee), which is made up of families in 

the community who want to be involved with building and sustaining a family voice in Bed-Stuy. 

They set goals for the year in recruitment of additional families and coordinate activities. 

Systems of Care Principles

Because the creation of a system of care is an intricate process, the roles and responsibilities of each 

staff member had to be carefully thought through. We particularly wanted to emphasize the systems 

of care guiding principles and have them infused within the tasks of each staff person. We also took 

into account each person’s past experience, expertise, and area of interest. While all members of the 
28

team are responsible for committing to and carrying out all of the systems of care guiding principles, 

each person has direct responsibility for key areas of the system building process. 

Lessons Learned

Facilitators

Ongoing process meetings (including the weekly check-ins, monthly staff meetings, and monthly 

one-on-one meetings with team members and the deputy director) are necessary for the group to 

be informed of and record all the activities that the team is engaged in, both in terms of new relationships among agencies and within the infrastructure itself. 

Better tools such as the creation of Tasks and Standards (evaluation) and a monthly Activity Log 

(which documents the daily activities of each team member) were put in place to monitor staff 

performance and outcomes. We contracted with a consultant who focused on team building activities and the team was assessed and given a professional development plan. Training was also given 

to staff on implementing tasks and producing outcomes. 

Barriers

Most of the barriers encountered with system management revolved around strategically developing roles and responsibilities for staff, the various members involved in systems of care work, and in 

engaging and sustaining member involvement in the work. By creating roles and responsibilities for 

each of the committees and identifying key projects and tasks, everyone is clear and by incorporating these key system-building activities, people remain committed to the work. 

Site

Dauphin and Northumberland counties, Pennsylvania

Goal

The implementation of the Locally Organized Systems of Care for Children in Pennsylvania demonstration grant is focusing on two principal counties, Dauphin County and Northumberland County. 

Through the vision of the Secretary of the Department of Public Welfare, the State has focused on 

the implementation of integrated services through the Integrated Children’s Services Plan Initiative 

for each county in the Commonwealth. These plans focus on the principles of systems of care and 

will be used to integrate services throughout the counties and their child-serving agencies. 

Strategy/Approach

Who Was Involved

To assist in advising the State on the issues of support integration, an Integrated Children’s Services 

Advisory Board has been created. This Advisory Board is composed of members of the State, county, and 

family partners. They will ensure that the process of integrating services throughout the Commonwealth, 

and providing quality supports to each child and family that needs them, is realized. 

A cross section of agency members involved in the Office of Mental Health and Substance Abuse 

Services, the Department of Public Welfare, and the University of Pittsburgh are committed to the 

systems of care process and the infrastructure development that will arise as a result of this cultural 

change. Each partner is involved in many aspects of this project as resource and change agent. 

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 29

What Was Done 

In Dauphin County, systems and community partners are actively engaged in various aspects of the 

systems of care initiative at all levels. Within the county agencies, partners from each department have 

an opportunity to participate on a practice team. This team assists in guiding the agency collaborations 

and identifying resources as they pertain to the support provided to the children and families of Dauphin 

County. Strong community outreach is a focus in Dauphin County. Five subcommittees have been developed to focus on the community implementation of systems of care: Faith Based, Community Based, 

Parent Advisory, Youth, and Outreach subcommittees. Each subcommittee is composed of community 

members, school district officials, and members from supporting service agencies. During this summer, 

the member of the subcommittees designed and implemented a camp program which was initiated by 

the Faith Based Subcommittee as they realized that there are a limited number of supports available 

to children in their adolescence. As a result of the limited resources, there is an increase in violence 

and substance abuse. A task group, consisting of volunteers, was established and was instrumental 

in the day-to-day running of the camp. The Harrisburg School District provided space for the camp, 

buses for transportation to field trips, breakfast and lunch, and school personnel to assist with hands on 

educational support. Penn State University’s 4-H Club, the YMCA, Hamilton Health Center, Harrisburg 

Police Department, Harrisburg Parks and Recreation, and the Dauphin County Executive Commission 

on Drugs and Alcohol all collaborated to provide programming for the camp. Goodwill also provided a 

6-week job training program for children 14 years of age and older. A preliminary survey was conducted. 

The results were informative and enlightening. Many of the children felt they learned more at the camp 

than in the school year through one-on-one instruction, entrepreneurial skills, and invaluable peer-topeer relationship building.

Systems of Care Principles

Both Dauphin and Northumberland counties have designed their services plan to reflect the principles of systems of care and apply these principles to serving families in a collaborative way. In the 

first year of the grant, Northumberland County suffered a death of a child as a result of domestic 

violence. This tragic event has sparked a movement to eradicate domestic violence in the county. 

With the Integrated Children’s Services Plan as a guide, Northumberland County has established 

core principles that directly relate to the principles of systems of care: integrated intake, integrated 

case management, integrated data management, integrated prevention, Domestic Violence Steering 

Committee, Family Group Decision Making Implementation Committee, and the Systems of Care 

Family Advisory Committee. Each principle is represented by a team from each of the children’s 

service agencies in the county, as well as parent representation to develop a service system that 

will ensure families receive comprehensive services. A significant method used in the success of 

this movement is Family Group Decision-Making. Within the first 8 months that the county has 

offered Family Group Decision-Making, they have conducted 30 conferences, trained 10 facilitators, 

and empowered countless families to take control of their lives before accessing formal services. 

Informally, the county has surveyed families after they have participated in a conference. Only two 

families have returned to formal services. 

Lessons Learned

The results of committed collaboration have been dynamic for both counties but it has not developed without a lot of patience and hard work from every stakeholder. Involving community and 

cross-agency partners from the beginning might have made infrastructure change easier. The time 

it takes to gather committed partners is worth the time it takes to clearly convey the desire for long 

lasting change. As long as partners are a part of the process, no matter the time frame, systemic 

change will occur.
30

COORDINATION OF 

SERVICES AND SERVICE 

ARRAY

Definition

Coordination of services refers to the centralized 

process by which multiple services and supports, 

often provided by multiple agencies, are synchronized to address the needs and strengths of each 

child, youth, or family. This process commonly 

follows a strength-based, child and family team 

approach to develop a service plan. Coordination 

of services for families involved with child welfare 

may occur through methods such as Family 

Group Decision-Making, Team Decision-Making, 

Wraparound, case management, and care 

coordination. 

CHAPTER 5 Infrastructure Components

Service array refers to the range of service options, 

including methods for coordinating services available to address holistically the individual needs of 

children, youth, and families, as determined by a 

thorough assessment, within a geographic area. 

Services should include family preservation and 

case management services, out-of-home placement, and permanency planning. The service 

array consists of the network of all local public, 

private, faith-based, and nonprofit communitybased organizations designed to ensure the safety, 

permanency, and well-being of children, youth, and 

families.

The service array, including child and family team 

processes, must be supported by other infrastructure components, as illustrated in the following 

visual developed by Portland State University.16

Three Levels of Supports for Child 

and Family Teams

Effective Team 

(family, youth, others)

Supportive Organization

(lead and partner agencies)

Hospitable System

(policy and funding context)
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 31

Resources

See Appendix E for examples of service coordination processes used in communities to 

address the needs of children, youth, and families involved with the child welfare system.

Family to Family/Team Decision-Making

Annie E. Casey Foundation. http://www.aecf.org

Family to Family tools to rebuild foster care. http://www.aecf.org/initiatives/familytofamily/

Implementing Family Group Decision-Making

http://www.aecf.org/initiatives/mc/tarc/peermatch/reports/indianapolis.pdf

National Center on Family Group Decision Making, American Humane.

http://www.americanhumane.org/site/PageServer?pagename=pc_fgdm

Child and Family Teams and Wraparound

Partnership for Children of Essex, New Jersey. http://www.altrue.net/site/pcenjweb/section.

php?id=9863

Stark County, Ohio Family Council. http://www.starkfamilycouncil.org/wrap/FamilyTeams_bot.html

Child and Family Teams. http://www.childandfamilyteams.com/world/home.htm

Wraparound process. http://www.cscn.on.ca/WrapAround/wraparound.htm

Wraparound Fidelity Index. http://depts.washington.edu/wrapeval/

Wraparound in systems of care. http://www.wraparoundsolutions.com/

Promising and Evidence-based Practice

Promising Practices Network. http://www.promisingpractices.net

Federal Substance Abuse and Mental Health Services Administration. http://www.mentalhealth.

samhsa.gov/cmhs/ChildrensCampaign/practices.asp

Multi-Systemic Therapy. http://www.mstservices.com

Functional Family Therapy. http://www.fftinc.com/index.php

Blueprint. http://www.colorado.edu/cspv/blueprints/model/overview.html

Best Practice Brief, Michigan State University. http://outreach.msu.edu/bpbriefs/

Mental health publications. http://nmhicstore.samhsa.gov/:

Promising practices monographs. http://cecp.air.org/promisingpractices/default.asp

Child Trends data bank What Works section. http://www.childtrendsdatabank.org/index.cfm

Kauffman Report on best practices for the treatment of child abuse and neglect. 

http://www.musc.edu/cvc/kauffmanfinal.pdf

Chapin Hall Center for Children at the University of Chicago. http://www.chapinhall.org/

The Research Network on Transitions to Adulthood at the University of Pennsylvania (funded by 

the MacArthur Foundation). http://www.pop.upenn.edu/transad/

The Jordan Institute for Families at the University of North Carolina. http://ssw.unc.edu/jif/index.html

The National Center on Youth Transition. http://ntacyt.fmhi.usf.edu/index2.cfm

The National Governor’s Association Center for Best Practices. http://www.nga.org/center/

The Casey Center for Effective Child Welfare Practice. http://161.58.58.2/pr_casey_center.html
32

Goals

Your community might establish systems of care 

coordination of services and service array goals 

such as:

z A comprehensive set of services and supports 

are available and accessible to the target 

population.

z The interagency network of service providers 

works on behalf of all children and families in 

the target population.

z Each child, youth, and family participates in 

coordinating services as part of the case plan.

z All children, youth, and families receive a 

comprehensive, strength-based, familyfriendly assessment that is accepted by all 

participating agencies prior to development 

of a case plan. Cultural needs are part of the 

assessment.

z All service providers and the family are part of 

the service-planning process to produce one 

individualized, multi-agency, service plan per 

family, regardless of the number of agencies 

involved.

z Flexible funds are available to purchase 

services that meet the unique needs of a 

child, youth, or family, and may fall outside the 

normal menu of services offered.

z Services and supports are arranged for a 

child, youth, or family to optimize efficient and 

effective delivery.

z Models for coordinating services are 

recognized as part of the broader service array 

available to children, youth, and families in the 

system of care.

z Agencies that fund services allocate revenue 

to the system of care to support, purchase, 

or develop services for the target population, 

including methods for coordinating care.

z Agencies and organizations support the 

service array and service coordination 

methods fiscally and through policies and 

procedures.

CHAPTER 5 Infrastructure Components

Systems of Care Principles 

and Values

The following are just a few ways systems of care principles and values might be evident in your community’s 

coordination of services and service array:

z Services and supports directly address the 

needs and strengths of the child, youth, or family.

z Families and youth take part in coordinating 

services and developing service plans.

z Culture, race, class, and gender factor into the 

design and implementation of service or support.

z Service providers use strength-based, 

culturally competent needs assessments to 

guide case planning.

z Children, youth, and families are not subject 

to multiple interviews or invasive, exhaustive 

questionnaires from multiple sources.

z Individual service plans include service 

providers who represent diverse agencies and 

organizations.

z Establishing and using community-based 

services and reducing out-of-home placements 

are emphasized.

z When children and youth must be placed 

out of their homes, placements are in close 

proximity to their homes, communities, and 

schools. 

z Service outcomes and utilization data are 

tracked monthly, provided to interested parties, 

and used to determine if services should be 

changed, created, or eliminated.

z Service coordination is essential for case 

planning and service delivery for all children, 

youth, and families in the target population.

z The community, agency funders, and key 

leaders support the array of services available 

and methods for coordinating services.

An example of how systems of care principles are 

evident in a service array that follows an integrated, 

interagency community approach is reflected in the 

following graphic. 
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 33

Activities and Tasks

Coordination of services and service array activities and tasks in your community might include:

Pre-Planning Phase

z Provide a process for the agency and 

community to describe the existing community 

service array and detail the resources and 

services available.

z Identify the way in which child welfare 

services are delivered to the target 

population. (Are they privatized, contracted, 

or provided by the agency?)

z Identify the methods for coordinating services 

to the target population (family group decisionmaking, wraparound, team decision-making).

z Identify service providers to participate in 

systems of care activities (governance body, 

committees, planning group).

z Identify service recipients to participate in 

the assessment and development of the 

service array, which includes assessment and 

development of service coordination methods.

Families 

Involved in Child 

Welfare

Strengths

B- ased

a

n

d In

dividualized

Community-Based Approach

Inter-Agency Collaboration

Cultural Co

m

p

ete

n

ce

Community-Based 

 Organizations

Child 

 Advocates

Faith-Based

 Providers

 Relative/

 Peer 

Support

 Other Service

Providers

Family 

Partners

Mental Health

Child Welfare

 Housing 

 and Urban 

Development

Education

Juvenile

 Justice

Health

TANF

Substance 

Abuse

Principles

Family Involvement

Accountability

System

Providers

System

Partners

System

Activities Social

Policy

D

e

v

elopment

Allocation

Planning

Sustainability

Management

Marketing

Developm

ent

Staff

Finance

Strategic
34

z Determine what policies, rules, and regulations 

need to be created, revised, or eliminated 

to support changes in the way services are 

coordinated and delivered.

Implementation Phase

z Create case plans that link strengths and 

needs with services and supports.

z Continuously assess the quality and 

accessibility of services.

z Conduct family risk and safety assessments. 

z Require service providers to receive annual 

training in systems of care.

z Consider requiring service providers to receive 

ongoing staff development and training 

in systems of care principles and service 

coordination methods as a condition of 

employment or funding.

z Implement processes for monitoring and 

addressing out-of-home placement rates.

z Implement processes for conducting child and 

family team meetings and developing case 

plans.

z Implement processes for documenting, 

monitoring, and tracking child and family team 

meetings. 

z Implement processes for accessing, using, 

and monitoring flexible funds, if applicable.

Personnel

The people who perform coordination of services 

and service array duties in your community might 

include:

z Culturally diverse and competent service 

providers

z Individuals responsible for coordinating 

services

z Agency leaders responsible for funding 

services and making policy

z Directors of agencies responsible for 

developing services

z Individuals responsible for training service 

providers

z Invite community service providers, agency 

staff providing services to children, youth, and 

families, and service recipients to participate in 

systems of care activities.

Planning Phase

z Outline the process for assessing community 

needs and resources, assessing child and 

family needs and strengths, and coordinating 

services.

z Assess the existing service delivery system 

and identify service gaps.

z Assess how families receive multiple services.

z Assess service utilization by service type.

z Assess outcomes associated with each service 

type. 

z Develop assessment tools that are used 

throughout all agencies.

z Address culture, language, and accessibility 

issues, considering where services are 

delivered, by whom, for whom, and when they 

are offered.

z Train service providers, service coordinators, 

and service recipients in systems of care and 

service coordination methods.

z Select assessment tools that are 

comprehensive, integrated, culturally 

appropriate, and non-burdensome.

z Define integrated or coordinated care, case 

management, or service coordination. 

z Conduct outreach to nontraditional providers 

of services and support, such as communityand faith-based organizations.

z Develop tools to measure service effectiveness 

and customer satisfaction. 

z Define processes for monitoring and 

addressing out-of-home placement rates.

z Develop tools for assessing the effectiveness 

of child and family team meetings 

(wraparound, family group decision-making, 

“Family to Family,” team decision-making). 

z Determine how services will be funded.

z Develop procedures for accessing, using, 

and monitoring the flexible fund account, if 

applicable.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 35

z Supervisors of staff providing direct services to 

children, youth, and families

Questions to Consider 

As systems of care coordination of services and 

service array evolve in your community, keep in 

mind questions such as:

z Are all relevant agencies involved in 

developing and supporting case plans?

z Do case plans address the child’s needs at 

home, in school, and in the community?

z Are staff assigned to ensure the service plan is 

coordinated, realized, and flexible enough to 

adjust to changing needs?

z Is the service plan strength-based?

z Was the family a partner in designing the 

service plan?

z Are case plans culturally competent?

z Do agency decision-makers support services 

available to the target population fiscally and 

through agency policies and practices?

z Are there processes to assess the 

effectiveness of services delivered?

z Are service providers aware of systems of care 

principles and expectations for service delivery 

based on those principles?

z How accessible are court-ordered services for 

parents?

z Are judges, legal system representatives, 

advocates, and law enforcement personnel 

involved in identifying service gaps and needs?

Examples from the Field

Site

Medicine Moon Initiative (MMI) to Improve Tribal Child Welfare Outcomes through Systems of Care, 

Spirit Lake, Standing Rock, Fort Berthold, and Turtle Mountain Reservations, North Dakota 

Goal

To develop a culturally competent, locally administered, tribal system of care for child welfare 

involved families that integrates natural and cultural supports into the child welfare service array and 

includes cultural well-being as part of the quality improvement process.

Strategy/Approach

What Was Done 

To enhance culturally competent services, expand the service/support array, and develop a culturally appropriate, quality improvement process, the MMI conducted seven group interviews with elders 

and community members from the four reservations and seven tribal groups of Dakota, Lakota, 

Mandan, Hidatsa, Arikara, and Chippewa tribal people to identify cultural supports, values, and 

protocols that could improve the cultural appropriateness of services, identify values that can be 

used to enhance child welfare practice, and identify elements/indicators that can be used as part of 

the development of a culturally relevant quality improvement process.

Who Was Involved

The approach involved community members and elders from each tribal group from the four reservations, child welfare staff, Native American Training Institute MMI staff, a University of North Dakota 

graduate and intern, a local community member who facilitated the meetings, and the MMI evaluation team composed of key stakeholders.
36

Time Frame

The initial conceptualization of the cultural interview process began at the end of the first year of the 

grant and was finally ready for implementation by the middle of year two. The group interviews were 

conducted in the latter half of year two. It took approximately 15 months to develop and conduct the 

group interviews.

Why This Approach Was Selected

z Recognition that cultural well-being and identity are protective factors for Native American 

youth. 

z Many Native American families do not know their cultural values and history, and had identified 

this on a survey to determine training needs for Native American parents and foster parents. 

z There are many Native American youth in the North Dakota State child welfare system; it is 

difficult to find cultural information and/or cultural supports for these children and the Native 

American families who are involved in their system. 

z Many reservation-based child welfare practitioners, even if they are Native American, do not 

necessarily know what cultural supports, values, and protocols are in the communities where 

they reside or practice.

Systems of Care Principles

The principle of strength-based care is incorporated because it recognizes culture as a strength of 

Native American communities. To be culturally competent, you have to know what those competencies are. It was necessary to involve community members who are knowledgeable about how 

community-based strengths can be utilized. Accountability to Native American children and families 

must include identification of issues of cultural well-being. Enhancement of services and supports to 

Native American children and families that can be sustained over time is also critical to the system 

of care because they are ingrained and part of the community. 

Lessons Learned

Facilitators 

There needed to be additional training provided to local community facilitators. It was difficult to stay 

focused on the purpose of the interview when some of the elders reminisced or had a need to socialize. You need adequate time to discuss cultural issues because sometimes it will be said in a story or 

roundabout way. There needs to be patience of the group facilitation, selection of competent facilitators with good people and communication skills, and basic knowledge of cultural protocols.

Barriers 

While valuable information was gained, the group was not as diverse as they could have been due 

to all being from the same community and often related. Unforeseen circumstances prevented a 

large turnout in one group. Initial resistance by some child welfare staff who were involved in the 

process was a barrier, partly due to divergent perspectives among staff about how to best address 

issues of cultural well-being.

What Might Have Been Done Differently

The MMI central staff may do another round of interviews and consult with local community members 

about who should be interviewed instead of relying solely on the local child welfare staff. The first 

groups were still good in and of themselves, but conducting another round of interviews could be 

used to validate the findings from the first interviews.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 37

Site 

Clackamas, Umatilla/Morrow, and Washington counties, Oregon

Goal 

Our goal is to improve permanency outcomes for children in the care and custody of child welfare 

by integrating systems of care values into child welfare practice, engaging families more inclusively at all levels, and increasing interagency partnership. 

Strategy/Approach

What Was Done

While some aspects of family involvement in service planning and interagency cooperation 

were identified as strengths in the Child and Family Services Review, areas needing attention 

included improving permanency outcomes for children and increasing the service array. Building 

on a decade of statewide practice improvement through a strength-based system of care and 

wraparound implementation in all county branches as well as use of Title IV-E waiver funds, the 

State Department of Human Services applied for and, once approved, began participating in the 

Federal grant program, Improving Child Welfare Outcomes through Systems of Care in order to 

pilot new strategies to improve permanency outcomes. This grant program bridges a decade of 

strength-based practice through family decision meetings with increased attention to child safety 

through engagement of families and increasing interagency and community involvement through 

local and State advisory boards.

Local child welfare branches are conducting a 30-day, 4-month and/or 8-month case review to 

ensure services are appropriate to meet the child’s safety, permanency, and well-being needs and 

that a viable plan is in place. Systems of care funds are used to meet the individual needs of the child 

(e.g., mediation, adoption preparation services, skills training, and therapeutic supports). Children 

in substitute or in-home care are eligible for these funds as long as there is funding and the service 

request meets the safety and attachment, permanency, or well-being needs of the child.

In Washington County, there were gaps in the advisory board membership and in an effort to fill 

those gaps and enlist new members, the coordinator provided an overview of systems of care 

principles and child welfare goals and objectives. This put members on an equal footing and 

raised awareness of our goals. As a result, membership increased from 3–5 participants to 25–30 

members. Parent leaders are now sitting on the board for the first time and are more assertive 

in their role, as are some other community leaders. Members are committed to continuing what 

is working well in the county and refining areas that need improvement. This collaboration has 

evolved to discussions of increasing strength-based and family-involved practice.

The development of parent leaders and parent partners in the child welfare system is a key component of the grant. A contract with a local community agency recently was activated to provide 

consultation and training and support of parent leadership to the sites participating in the grant. 

Areas of training and consultation include: parent engagement strategies to both project and child 

welfare staff; presentations for parent leaders at monthly meetings; semi-annual training on parent 

leadership/shared leadership; and weekly support groups for parent participants in the grant. 

Who Was Involved

The State Department of Human Services applied for the grant in cooperation with Portland State 

University’s Graduate School of Social Work as the local evaluation contractor. Paring down the 
38

number of sites participating in the initial pilot to three (Clackamas, Umatilla/Morrow, and Washington 

counties), the State refocused its effort by hiring county system of care coordinators to develop and 

improve family involvement, build family leadership in the grant program, and improve advisory 

board participation in order to maintain and sustain innovations through sustainable cross-agency 

commitment. Permanency facilitators in each county work to identify internal barriers to permanency and make recommendations for practice changes. 

Time Frame 

The work began in earnest in the third year of the grant with the addition of systems of care coordinators. Many aspects of the work are ongoing and predated this grant but the coordination and 

refocusing aspects of the grant program hope to show improved permanency outcomes by the 

fourth year of the grant.

Why This Approach Was Selected 

Child and Family Services Review results provided some impetus, as did other evaluation of State 

practice and its outcomes. The State desired to integrate previous systems of care practice to 

increase child safety and demonstrate that increased engagement of families in all aspects of child 

welfare practice improves child safety, permanency outcomes, and worker satisfaction.

Systems of Care Principles 

Systems of care practice encourages family involvement, a strength-based approach to planning 

and service delivery, and an interagency team approach to service planning, delivery, and evaluation. 

These values are being integrated into practice by developing family leadership, partnerships at local 

and State levels, and increasing interagency partnership in county and State advisory boards.

Lessons Learned

Facilitators

A chain of communication and “command” from the State advisory board to the local advisory 

boards and including staff and families were essential. Our permanency facilitators were initially 

helpful in identifying strategies to improve outcomes but lacked reporting mechanisms and support 

and we were unable to demonstrate effectiveness. Practice change must be addressed in policy if 

it is to be sustained; communication of effectiveness and efficacy are essential to elevate practice 

improvement from a value to an outcome and eventually into policy and system change.

Barriers

Initially we had too many counties participating with insufficient oversight and lines of communication. We addressed this by refocusing the target of the grant on three sites (four counties), increasing 

communication and accountability at the State and local levels, and identifying clearer expectations 

and reporting mechanisms. 

What Might Have Been Done Differently

We would have been better served by greater discussion and commitment across line staff, supervisors, 

and administrators at the county branches and at administrative levels in the State office to ensure that we 

were all committed to the goals of the grant and knew our individual roles in their accomplishment.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 39

COMMUNICATION

Definition

Communication is a strategic activity to raise awareness, inform, enlighten, and guide stakeholders and 

key decision-makers in understanding, supporting, and sustaining a system of care. According to 

Pires,17 both external and internal communication 

strategies are important. External communication 

informs the public about the system of care and 

generates support, while internal communication 

ensures ongoing exchange of information among 

key stakeholders within the system of care, including staff at all levels of each agency involved.

Areas of focus include: 

z The service array and coordination of services 

to children and families. 

z Infrastructure components to support systems 

of care.

z Increased understanding of the needs of the 

target population.

z The effectiveness of systems of care in 

improving child and family safety, permanency, 

and well-being. 

Goals

Your community might establish systems of care 

communication goals such as:

z The community has a greater understanding of 

the target population and the system, services, 

and supports needed to address their needs 

effectively.

z There is increased cooperation among 

agencies on behalf of the target population.

z The community has increased knowledge of 

how the system of care addresses the safety, 

permanency, and well-being of children, youth, 

and families.

z A demonstrated administrative, policy, and 

financial commitment is evident to support and 

sustain the system of care.

z A social marketing and communications plan 

is developed and implemented.

z Data and outcomes are used to inform the 

community about the success of the initiative 

and to encourage fiscal support to sustain it.

z The child welfare agency and interagency 

partners are committed to supporting and 

sustaining systems of care for the target 

population.

z At all levels of the child welfare agency (e.g., 

caseworkers, supervisors, administrators), 

staff are aware of and understand the systems 

of care principles and how they apply to their 

work.

z Processes are in place to inform agency staff, 

children, and families about progress in the 

system of care. 

Systems of Care Principles 

and Values

The following are just a few ways systems of care 

principles and values might be evident in communication in your community:

z Communication materials: 

{ Are culturally and linguistically competent. 

Resources

See Appendix F for an example of a social 

marketing strategy used in Kansas as part 

of its systems of care work.

See Appendix G for an example of a social 

marketing campaign developed in Kansas 

for its systems of care work. 

See Appendix H for an example from North 

Carolina about the steps it takes to plan a 

conference to inform people about systems 

of care, and the lessons learned in the 

process. 

System of Care Promising Practice 

Monograph, Using Evaluation Data to 

Manage, Improve, Market and Sustain 

Children’s Services. http://media.shs.net/

ken/pdf/2000monographs/vol2.pdf 
40

{ Reflect the views of stakeholder groups, 

especially families in the target population. 

{ Address the target audience.

{ Are written to be understood easily.

z Messages:

{ Feature people-people language.

{ Have consistency and articulate the goals 

and outcomes of systems of care.

{ Contribute to the work’s positive reputation, despite changes in leadership or 

personnel.

Activities and Tasks

Communication activities and tasks in your community might include:

Pre-Planning Phase

z Resources such as revenue, staff, and 

consultants are identified to support the 

development and implementation of a social 

marketing and communications plan. 

z A committee or workgroup is established 

to develop a social marketing and 

communications plan.

Planning Phase

z Target audiences are determined.

z A plan that focuses on benefits to the target 

population and results expected from the 

system of care (market analysis) is developed.

z Structures are developed for communication 

throughout the system of care and among 

stakeholder groups and constituents 

(interagency, intra-agency, internal to project 

staff and the governance body, external to the 

broader community).

z An internal communications plan is designed 

to ensure staff at all levels of an agency (e.g., 

frontline workers, supervisors) understand the 

initiative and their role in its success.

z Customer satisfaction surveys are developed.

z Needs assessments are developed.

z Establish culturally appropriate communication 

protocols. 

z Internal (agency) and external (public) focus 

groups are conducted. 

z Community meetings are held. 

z Individual and group meetings with 

stakeholder groups occur.

z Media markets are identified.

z Communication media are identified 

(newsletters, brochures, print articles, radio, 

television, flyers).

z A social marketing and communications plan 

is developed.

Implementation Phase

z Develop media relations protocols.

z Conduct needs assessments. 

z Write newsletters. 

z Write letters to editors. 

z Administer routine customer satisfaction 

surveys. 

z Prepare press releases.

z Hold press conferences.

z Implement marketing strategies. 

z Develop relationships with contacts in the 

media (television, radio, print).

z Listen to and learn from others.

z Consider the tone of communication with 

families and youth.

z Consider the tone of communication with staff 

within each agency.

Personnel

The people who perform communication duties in 

your community might include:

z Communications director

z Public information officer

z Interagency communications committee

z Intra-agency communications committee

z Social marketing consultant or agency 

(contracted)

z Neighborhood leader

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 41

Questions to Consider

As systems of care communication evolves in your 

community, keep in mind questions such as:

z Is there a communications committee with 

interagency and family involvement? 

z Has a communications plan been developed?

z Are messages developed by soliciting input 

from stakeholder groups? 

Example from the Field

Site

Kansas

Goal

The goal of the social marketing strategy was that the image of child welfare would be changed so 

it would be seen positively rather than negatively, and that the Kansas Department of Social and 

Rehabilitation Services, namely child welfare, would be controlling the message that goes out to 

educate people about the services that are available to keep families together. The big dream is that 

those working for the department will have a sense of pride in their work for the community and the 

community sees the agency as an asset. 

Strategy/Approach

What Was Done

The first task was “marketing” social marketing to the grant team to get them on board. Educating 

them about the basics of social marketing and its importance for child welfare were key. They 

needed to know social marketing basics to develop and implement a social marketing strategy, and 

the entire grant team had to be able to justify to intra- and interagency partners why social marketing 

was a good investment of resources. Next, we developed the following. 

z A social marketing concept paper to help justify putting resources into social marketing 

versus direct services or staff development/retention and to help people understand the 

concept, its importance, and its plan. The paper included examples of how others are using 

social marketing to create good will and good buzz. The site looked to local public healthcare 

social marketing efforts, examples, and advice, such as when we spoke with the marketing 

director for other health services (Healthwave) who provided examples that bolstered our 

claims for including social marketing in the Improving Child Welfare Outcomes through Systems 

of Care effort.

z A strategic social marketing implementation plan was collaboratively created by the grant 

team, with participation from other stakeholders when possible. When someone with marketing 

z Are data incorporated into messages? 

z Are social marketing principles used to 

develop and target message points?

z Have target audiences been identified, and 

have messages been tailored to reach them?
42

skills is not on staff, either bring someone on with these skills or locate staff who regard social 

marketing as a good idea.

z Promotional items, such as a website, brochures, posters, and giveaways to market systems 

of care principles and services. Use staff trainings and presentations to educate people about 

the information and concepts on the promotional items to create more ambassadors for the 

initiative.

Key Points to Remember:

z Design a plan, including staff assignments, for social marketing and do not assume it will just 

get done somehow.

z Think big!

z Make learning about systems of care fun.

z Know the culture of your child welfare agency because incorporating this knowledge into 

marketing plans will help to get them noticed.

Who Was Involved

The grant team was involved in all phases of the social marketing strategy. One team member did 

the initial research and conceptualizing and brought those ideas and plans back to the grant team 

for input and approval. Every item in the plan was collaboratively approved by the team. Team 

members included the project director, assistant program manager, project manager, family service 

coordinator, and administrative assistant. 

Key Points to Remember:

z For the team to buy in, there has to be a plan. The concept paper and strategic plan were 

crucial and generated investment and ownership by the team.

z The Department of Social and Rehabilitation Services developed the Public Awareness Work 

Team and Charter, charged with informing legislators and consumers of the department’s work 

and services in order to secure buy-in from legislators and the community.

z There must be good follow-up; consider how to keep people engaged long-term.

z Find ways to operationalize good ideas; a good idea is just the beginning, so be prepared with 

possibilities for how to turn the idea to reality.

z Leadership must buy in since they have the authority to assign resources to make the plan 

move ahead.

Time Frame

Work started on social marketing almost from the beginning of the grant when we began planning 

the logo, website, and other components. The logo was created and approved with considerable 

input and guidance from the interagency Statewide Steering Committee. In the fall of the second 

year, we wrote the social marketing concept paper and strategic social marketing plan. To benefit 

from more voices in the creative development and discussion, we review and update the plan, as 

well as certain materials such as the website and brochure, on an ongoing basis with input from a 

diverse interagency work team. 

Key Points to Remember:

z Social marketing is a long-term endeavor, not a quick fix.

z Social marketing requires resources.

z The best social marketing involves diverse stakeholders throughout the process.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 43

Why This Approach Was Selected

We recognized that we had to help people see social marketing as a need in the agency versus a 

luxury. We had to start convincing agency staff that social marketing was a requirement for doing 

business, including child welfare.

Key Points to Remember:

z Know the agency culture so you can communicate the most relevant information effectively.

z Educate child welfare staff on the ways social marketing is good for the agency and the staff.

Systems of Care Principles

The Department of Social and Rehabilitation Services used social marketing to help people within 

the agency work collaboratively rather than in silos. The grant team used this strategy and plan to 

educate people within the department about the comprehensive services they provided, as well 

as other agencies and community providers to highlight services that could be starting places for 

collaborative service delivery. The strategy’s intent is to have systems of care principles discussed 

at staff meetings and be incorporated into supervision.

Lessons Learned 

Facilitators

Facilitators should engage as many people in leadership, from diverse backgrounds as frequently as 

possible, as this will assist with buy-in and sustainability; cast a wide net to get multiple perspectives 

to avoid the “great leader” syndrome—when the leader goes away, everything stops. Developing 

the skills and capacity of multiple leaders is a pivotal part of the work to keep the process moving 

forward. 

Barriers

Limited monetary resources for social marketing, a child welfare departmental culture that minimizes 

success and achievement, as well as a tendency in child welfare to avoid marketing until there is a 

crisis or tragedy to address were significant barriers to our progress. Communication is often reacting to the issues raised by others or in a crisis rather than the agency proactively reaching out as a 

community resource. The Kansas family-centered system of care addressed these barriers through 

the development of its social marketing concept paper and strategic plan to justify the marketing 

approach, the allocation of resources, and its relevance as a complement to the work of the agency. 

Additionally, presentations within and outside of the agency were integral to the marketing strategy 

to educate others about the core concepts of systems of care and to get people invested in the 

initiative.

What Might Have Been Done Differently

From day one, we would have formed a social marketing committee made up of internal and external partners, including family members, with different levels of expertise. They would have been 

ambassadors in the community for the initiative, as well as enriching the social marketing development process with diversity of opinion and experience.
44

POLICY

Definition

Policy is defined as a plan or course of action, as of 

a government, political party, or business, intended 

to influence and determine decisions, actions, and 

other matters.18

Policies can be Federal, State, tribal, local, or 

agency-specific legislation, mandates, rules, or 

regulatory requirements. Policies formalize practice 

and can be interagency agreements or MOUs/

MOAs, or agency-specific for personnel, fiscal 

issues, administration, or programs. In systems 

of care, policy supports and sustains the efforts of 

interagency partners and community stakeholders 

responsible for the safety, permanency, and wellbeing of children, youth, and families.

Goals

Your community might establish systems of care 

policy goals such as:

z Policies of child- and family-serving agencies 

are aligned with systems of care principles. 

z Policies promote interagency approaches to 

address the safety, permanency, and wellbeing of children, youth, and families.

z Policies promote family-based practice 

strategies to improve outcomes for children, 

youth, and families.

z Policies support service coordination 

approaches designed to ensure the safety, 

permanency, and well-being of children, youth, 

and families.

z Policies reflect systems of care principles as 

a framework for conducting business and 

funding and providing services.

z Policies support the application of interagency 

and intra-agency processes for measuring, 

analyzing, and monitoring outcomes.

z Policies support the application of data- and 

results-driven, decision-making and fact-based 

management processes within agencies 

involved in systems of care. 

z Policies support interagency community-based 

systems of care.

Resources

State statutes supporting systems of care 

in California, Connecticut, Minnesota, and 

Guam. http://www.childwelfare.gov/systemwide/laws_policies/search/index.cfm

Memorandum of agreement used in 

systems of care work in North Carolina. 

http://www.dhhs.state.nc.us/mhddsas/

announce/moa_state3-31-03_child02-03.pdf 

The Finance Project (policy and practice 

issues relating to children and families). 

http://www.financeproject.org

The Urban Institute (social policy research 

organization). http://www.urban.org

The Juvenile Law Center. http://www.jlc.org

Major Federal legislation concerned with 

child protection, child welfare, and adoption. 

http://childwelfare.gov/pubs/otherpubs/

majorfedlegis.cfm

Center for Law and Social Policy. http://

www.clasp.org

Center on Budget and Policy Priorities. 

http://www.cbpp.org

National Center for Children in Poverty. 

http://www.nccp.org

State Line (State-by-State politics and policy 

news). http://www.stateline.org

The National Conference of State 

Legislatures. http://www.ncsl.org

National Governor’s Association Center for 

Best Practices. http://www.nga.org/center/

The Nelson A. Rockefeller Institute of 

Government, gateway to State and local 

government information. http://rfs.rockinst.org

Nevada AB94 for youth transitioning out of 

foster care. http://www.leg.state.nv.us/71st/

Minutes/Senate/GA/Final/1357.html;

http://www.leg.state.nv.us/71st/bills/AB/

AB94_EN.pdf (Section 14.5, page 14)

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 45

z Examine intra-organizational policies, 

procedures, and practice (tools, samples, 

lessons learned).

z Identify policies that impede implementation 

(confidentiality, data sharing, Health 

Insurance Portability and Accountability Act, 

out-of-community placement costs borne by 

the State).

z Examine PIPs and other agency plans to make 

sure they do not conflict. 

z Determine methods for utilizing data and 

outcomes, including CFSR data, to inform 

policy development.

Implementation Phase

z Develop executive orders, legislation, statutes, 

and governor mandates.

z Modify interagency regulations and policies.

z Create/promote policies that reallocate 

revenue from out-of-home placement to 

community-based services.

z Establish contracts with consultants and 

service providers that reflect systems of care 

principles.

z Continuously assess the impact of new 

legislation and funding on systems of 

care development, implementation, and 

sustainability.

Personnel

The people who perform policy duties in your 

community might include:

z Interagency and family-involved committee to 

recommend ongoing policy needs

z Administrative support position

z System analyst

z Government relations staff

z Legislative staff

z Advocacy organization staff

z Legal counsel, as needed

Systems of Care Principles 

and Values

The following are just a few ways systems of care 

principles and values might be evident in policy in 

your community:

z Policy development is guided by desired 

results and outcomes.

z Policy maximizes family involvement.

z Policy requires involvement of all child-serving 

agencies including child welfare, education, 

juvenile justice, behavioral health, mental 

health, primary health, and substance abuse 

treatment, as well as representatives of the 

systems of care target population. 

z Policies address the cultural, ethnic, and 

linguistic needs of the target population.

z Policies support community-based services.

z Policies are aligned across child-serving 

agencies to support children and families.

Activities and Tasks

Policy activities and tasks in your community might 

include:

Pre-Planning Phase

z Be aware of other agencies’ policies and how 

they affect systems of care work, and how 

systems of care work will affect policies of 

other agencies.

z Identify individuals and organizations key to 

identification, review, and analysis of existing 

policy and to development of new or revised 

policies and procedures.

Planning Phase

z Establish MOUs/MOAs.

z Conduct cross-agency policy analysis.

z Identify licensure (credentials) required of 

service providers and determine if they need to 

be revised.
46

Questions to Consider

As systems of care policy evolves in your community, keep in mind questions such as:

z Have all relevant policies affecting the system 

of care been assessed? What are current 

policy barriers to building, implementing, or 

sustaining systems of care? How can those 

barriers be eliminated?

z Is there emphasis on offering communitybased services and reducing out-of-home 

placements?

z Is there thorough understanding of the various 

kinds of polices that can support systems of 

care? If not, how will this understanding be 

developed?

z Are there current policy gaps? What is the 

strategy to fill them?

Example from the Field

Site 

Contra Costa County, California

Goal

The goal of the agency is to integrate family participation at all levels of the organization and its 

service delivery in pursuit of a growing culture of strengths-based practice. It is recognized that 

involving family members as staff has helped outreach to families entering the system, yet it is still 

difficult to engage consistently families who are court ordered into the system. Nonetheless, the 

culture of the organization is slowly changing, as is its perception in the community.

Strategy/Approach

What Was Done 

At the governance level, the site included two family members and several youth representatives 

as participating members on its interagency policy council. At the service delivery level, two family 

members were hired in full-time positions and several part-time positions were added to help families 

involved with child welfare navigate the system, understand and maximize their roles and responsibilities in the Team Decision Meetings, and find the resources necessary for their success. At the 

procedural level, family members participate in co-training of all new staff in order to integrate family 

involvement and a strengths orientation at all levels of the organization. Parent partners advocate for 

the needs and interests of families and help the agency ensure that its redesign is as family-centered 

and strengths-oriented as possible. 

z Do policies of one participating agency conflict 

with those of another participating agency? 

What strategy can address the conflict?

z Has a stakeholder group been established, 

including families and elected officials, to 

address policy issues?

z Does the governance structure or another 

interagency committee have case plan 

review authority when a case plan cannot 

be implemented because of a policy issue, 

service gap, or funding problems?

z Is there a mechanism within the governance 

structure to highlight and recommend policy 

issues and changes based on unresolved 

case plans?

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 47

Who Was Involved?

Family involvement is integrated into all levels of the child welfare redesign effort, including policy 

and governance, procedure and supervision of staff, and practice or service delivery. Every effort is 

made to integrate the value of family involvement at all levels of the organization by having active 

participation of family members at all levels. Agency leadership initiated the action and supervisors 

and line staff, as well as partners from other agencies, supported it. There is a significant impact 

on other public agency partners as they experience parent partners in joint meetings, from policy 

to service delivery. Child welfare’s efforts have encouraged a cultural change across the county. 

The county’s high visibility in the State makes this shift in values, policy, and practices a potential 

sea change. Finding parent partners willing to work inside the agency was no small feat and took 

courage on the part of the parents to initiate a new role in a system that had previously exerted 

considerable control over their lives.

Time Frame

Family members began their work toward the end of the second year of the grant. Child Welfare built 

upon the work of parent partners in the mental health system to further demonstrate the value and 

impact of family involvement across all publicly funded agencies. For example, caseworkers have 

begun to see the value of parent partners in resource development, problem solving, and program 

success through Team Decision Meetings participation. The work will continue to require ongoing 

training of all hired staff, as well as constant consideration of roles and responsibilities, as the agency 

continues its redesign and adjusts to social, cultural, fiscal, and political needs across time.

Why This Approach Was Selected

A role for family members pre-existed this grant due to previous systems of care implementation 

and was supported as the county’s systems of care development effort shifted its leadership from 

the mental health system to child welfare with the receipt of this grant. The impetus for this action 

was the grant itself and its requirements, but the values and belief in family involvement were already 

present in the county and thus are being expanded. 

Systems of Care Principles

Family involvement as a foundation of a system of care provided the motivation to move from a 

theoretical belief in family involvement to a practical implementation through employment of family 

members and their integration into all levels of the system. The idea of providing co-professional/

family member training for all staff helped bring the concept of family involvement into reality for staff 

at all levels. Building on previous systems of care work among publicly funded agencies through its 

existing policy council, the child welfare system has opened the door to broader consideration of 

relevant stakeholders for the policy council, such as faith community and service providers. This will 

further expand the community’s understanding of the pivotal role and importance of family involvement to achievement of their collective goals for community improvement.

Lessons Learned 

Parent Partners add an exciting new dimension to the work of child welfare in a number of ways. As 

parent leaders, parents offer a unique insight and perspective relative to the work. They can tell us, 

from the parents’ point of view, what is working well and what is not. They can point out areas that 

need attention, and alert us to barriers to family engagement. As parent advocates, they have an 

unsurpassed credibility to the families with whom they work. Their very presence offers hope. They 

can say to a family in crisis, “I know what you are going through, but you can do it. I did and you 

can too. Let me show you how.” One of the lessons that we have learned is just how powerful those 

words can be to the recipient. 
48

Parent Partners also challenge us to “think outside the box.” Sometimes we get so accustomed 

to doing things in a certain way that we forget there may be alternatives. They remind us of the 

real life issues of the families that we work with, and can bring their reality to our attention if we 

forget. Parent Partners are extremely helpful to casework staff in a number of ways: they are well 

connected with the community and its resources. We envision that Parent Partners can be useful 

in a number of significant ways: they can take the time to help families with everything from getting 

on a waiting list for services to learning how to manage their time through the use of a calendar. 

They can attend AA and domestic violence meetings with parents who are reluctant to go alone 

and need some moral support. They can show parents how to use public transportation. They also 

remind us to be culturally sensitive to the families with whom we work.

The Parent Partners are also ambassadors for other parents, dispelling the “them and us attitude” 

we sometimes find. When staff get to know the Parent Partners, they begin to see parents are 

people, not unlike themselves. They begin to realize the parents that they are working with (and 

perhaps frustrated by) may have the same potential as the Parent Partners. In this way, the Parent 

Partners give staff hope as well.

Involving parents was not without challenges. Having parents at a meeting in the office made 

some staff uncomfortable. They felt that they would not be able to speak as freely, or that the 

Parent Partners would side with the parents at meetings and “gang up on them.” The issues of 

workplace bias were addressed swiftly and directly. We found that the most effective way of dealing 

with workplace bias was a clear message from administration that we will be inviting parents to 

be full participants in the process, and administration invited staff and community partners to 

welcome parents to the work. We developed a comprehensive Professional Development Plan 

for the Parent Partners to familiarize them with looking at child welfare through a different lens, 

and preparing them for meeting professional expectations in the workplace: meetings, speaking 

engagements, court, Team Decision Meetings, and television and newspaper interviews. These 

experiences presented the parent partners with unique opportunities to affect families, the child 

welfare system, the courts, and the community.

Change is always difficult, and we found resistance to change to be problematic. Although, the 

agency was looking for different outcomes through the use of Parent Partners, staff sometimes 

found it difficult to accept that we would have to do things differently in order to get the desired 

results. Parent Partners disturbed the status quo. They made us rethink our approaches to case 

planning and problem solving. Partnering with parents challenged us in unexpected ways, and as 

we grappled with these issues the culture of the agency began to change.

Our model has both full-time and part-time Parent Partners. We have been able to get suitable 

nominees for part-time Parent Partners and train them, but once their training is complete, we seem 

to lose a large percentage of them. We evaluated the reasons for this, and decided to expand the 

mentoring model to include the new Parent Partners. We give them enhanced shadowing experiences and greater responsibility earlier on in the process. Each of the experienced Parent Partners 

takes responsibility for one or more of the trainees and gives them additional one-on-one support. 

We also invited the Parent Partner trainees to participate in our child welfare orientation sessions 

and invited some of them to travel to Kansas to participate in the Family Involvement Summit.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 49

FINANCE

Definition

Finance refers to receiving and allocating funds 

and conducting resource development activities 

designed to build capacity and sustain systems of 

care.

Financing systems of care is an intricate process 

since each participating agency has unique funding 

sources and mandates, which often specify goods 

or services to be purchased for a targeted group 

of individuals. Identifying and coordinating funding 

sources is crucial to:

z Operate an organized system of care. 

z Gain efficiencies in using public funds.

z Decrease duplication of effort. 

z Maximize funds that can be used as match to 

Federal revenue. 

Resources

See Appendix I for an example of how a 

system of care community has structured 

management of revenue from multiple 

sources.

See Appendix J for information from 

Michigan about steps to take when implementing a refinance initiative.

See Appendix K for lessons learned from 

Michigan’s Integrated Funding Initiative.

The Finance Project. http://www.financeproject.org

Connected by 25: A Plan for Investing in 

Successful Futures for Foster Youth. http://

www.financeprojectinfo.org/publications/

foster%20care%20final1.pdf

The Cost of Protecting Vulnerable Children 

IV: How Child Welfare Funding Fared During 

the Recession. http://www.urban.org/

UploadedPDF/411115_VulnerableChildrenIV.pdf

State Legislation Allowing Community 

Collaboratives to Pool Funding and Maximize 

Federal Funds. http://www.ncsl.org/

programs/cyf/fund_maximization.htm

Goals

Your community might establish systems of care 

finance goals such as:

z Increase flexible funding through utilization of 

a consolidated, independent resource pool 

with contributions from public child-serving 

agencies.

z Apply financing strategies to develop optimum 

service and financial accountability.

z Expand services.

z Develop a flexible fund.

z Reallocate resources for purchasing out-ofhome placements to developing services that 

keep children and youth in their home and 

local school community.

z The system of care is organized and managed 

efficiently and effectively.

z Maximize Federal resources.

z Maximize revenue spent on the target 

population within the State, county, city, tribal 

community, or neighborhood.

z Monitor expenditures and assess the 

effectiveness of services funded to support 

systems of care.

Systems of Care Principles 

and Values

The following are just a few ways systems of care 

principles and values might be evident in the financing elements of your system of care infrastructure:

z Children with multiple needs are able to 

receive a range of services funded by 

numerous agencies as part of a global, 

individualized case plan designed to increase 

safety, permanency, and well-being.

z Funds pay for services that meet the unique 

needs of the child, youth, and/or family.

z Child welfare staff has access to a broad set of 

service options for children and youth in their 

care. These services are part of the communitybased system of care and are accessible, 

regardless of who funds them, to families and 

children in the child welfare system.
50

z Children, youth, and families have access to a 

full array of services and supports, including 

a family-based, team process for coordinating 

services.

z Financial strategies are monitored and 

analyzed to determine their ability to improve 

efficiency and meet desired outcomes.

z Agencies that fund or provide services are 

committed to systems of care principles and 

values.

Activities and Tasks

Finance activities and tasks in your community 

might include:

Pre-Planning Phase

z Establish work groups.

z Assess interagency resources available to 

support the fiscal structure.

z Focus on efficiency and effectiveness in 

system reform.

z Identify duplication of effort (each participating 

agency providing similar training to its own 

staff rather than providing joint training).

Planning Phase

z Develop a sustainability plan based on the 

community’s definition of sustainability.

z Analyze and assess:

{ Funding sources

{ How money is spent

{ How much money is available

{ If there are mandates associated with the 

money

{ Who controls the money

{ Spending flexibility 

{ Funding needs.

z Establish connections with State finance 

officials (TANF, Medicaid).

z Identify State and local general fund revenue 

that is not being used to match Federal money.

z Identify and develop creative refinancing 

strategies (redeployment of existing revenue, 

submission of Federal waivers).

z Identify and develop methods for efficiently 

reimbursing service providers.

z Assess existing mechanisms for tracking 

revenue, reporting expenditures, and 

implementing sound fiscal utilization.

z Identify non-service expenditures and 

determine how to sustain what is being 

purchased (staff development, training, 

operating and administrative costs)

z Identify and eliminate funding constraints, 

when possible.

Implementation Phase

z Determine cost effectiveness of services being 

purchased so revenue allocation is linked to 

outcomes.

z Identify and eliminate spending constraints 

and fiscal barriers, when possible.

z Plan for and respond to gaps or changes in 

services or funding.

z Conduct resource development activities to 

obtain funding to support and sustain systems 

of care.

z Determine the effectiveness of submitting 

waivers (Medicaid, Title IV-E).

z Identify and eliminate duplication in spending.

z Develop and manage the systems of care 

budget.

z Develop a process for efficiently and effectively 

managing resources.

z Track and monitor spending and outcomes.

z Implement processes for sharing fiscal 

information with all relevant constituents.

z Implement activities associated with the 

sustainability plan.

Personnel

The people who perform finance duties in your 

community might include:

z Interagency finance committee 

z Administrative support

z Agency budget office staff

z Chief financial officer

z Governance body

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 51

Questions to Consider 

As systems of care financing evolves in your 

community, keep in mind questions such as:

z Does an interagency and family-involved 

committee meet to address fiscal issues?

z Are there unmatched general fund dollars that 

could be used to draw down Federal revenue?

Example from the Field

Site

Oglala Lakota Tribe, South Dakota

Goal

To establish a child welfare system of care composed of private, Federal, State, and tribal agencies 

that collaborate and blend funding to develop and implement an integrated system of services that 

includes child protection, child welfare, Temporary Assistance for Needy Families, community development services, adult protection, and other social, education, and community services as needed 

for children and families. The name of the organization is the Lakota Oyate Wakanyeja Owicakiya Pi 

Okolakiciye (Lakota People Helping Children).

Strategy/Approach

What Was Done

Taking advantage of multiple funding streams resulted in development of an integrated financing 

implementation plan that included establishing a State-Tribal Title IV-E Agreement that would outline 

reimbursement guidelines, contracting child welfare services that are provided by the Bureau of 

Indian Affairs, contracting with Casey Family Programs for recruitment and licensure of family foster 

homes, providing training that can be reimbursed by the State of South Dakota under the 45 CFR 

1356.60 (b), and accessing Title XIX Social Services Block Grant funding and Bureau of Indian Affairs 

Public Law 93-638 funding. 

Other financing strategies include establishing partnerships and/or contracts with Indian Health 

Services, Education and Special Education, Mental Health, and Juvenile Justice to expand the availability of core services. Additionally, Casey Family Programs provided funding for a transition team 

(staff and activities) to ensure there would be a smooth process of transferring services from public, 

private, tribal, and Federal child welfare agencies into one integrated center. These financing strategies contribute to capacity building as well as sustainability of the system of care.

Who Was Involved

The entities represented in the strategic planning process included parents, community members, 

traditional healers, tribal child welfare, State child welfare, Bureau of Indian Affairs child welfare, and 

a private child welfare agency, Casey Family Programs. These entities entered into a partnership to 

work on the Transformation Project funded by Casey Family Programs. 

z Do contracts incorporate language that 

reinforces systems of care principles? 

z Is there duplication of effort among 

participating agencies?

z Has an analysis been conducted of funds 

spent in out-of-State facilities? 

z Has a financial plan been developed to seek 

funds from a number of sources (Federal, 

foundations, State, and local) to expand 

community-based services?
52

Time Frame 

The work to establish a system of care that was funded by multiple sources began approximately three 

years prior to the formal establishment of the organization. To transition child welfare services provided by 

Casey Family Programs, the State, Bureau of Indian Affairs, and tribal child welfare to a tribally chartered 

integrated child welfare model, the Casey Family committed funding to ensure there was a smooth 

transition process, which included paying current Casey Family staff to serve as the transition team.

Why This Approach Was Selected 

The Federal, State, tribal, and private child welfare agencies concluded they were all doing the same 

work and helping the same individuals and that there was little communication or interagency collaboration among them. This led to development of an integrated child welfare model that was chartered 

by the Oglala Sioux tribal government the same year the Lakota Oyate Wakanyeja Owicakiya Pi 

Okolakiciye was founded. The Pine Ridge Child Welfare Needs Assessment Report conducted two 

years prior identified barriers related to service delivery, such as lack of coordination and collaboration 

among agencies across the reservation, lack of culturally competent models, and minimal information 

sharing and exchange. Resources available to families were not shared readily.

Systems of Care Principles

Systems of care principles and values were the basis for the strategic planning process and for the 

development of the official guidance documents, including the charter and bylaws. The principles 

are clearly outlined as the guiding tenets in the charter document, which includes development 

of services that are comprehensive, community-based, individualized, culturally appropriate, and 

provided in the least restrictive environment. The governance structure has broad representation 

from child-serving agencies, elders, parents, and community people.

Lessons Learned 

z Understand that integration of financial resources is a critical element of infrastructure development.

z Ensure that the implementation plan clearly defines and describes the governance process, staffing 

requirements, and legal entity structure, and includes an integrated financial resources pool. 

z Partner with tribal government and community leadership from the beginning. Obtain a tribal 

resolution to sanction the change work with a well documented needs report.

z Identify resources for planning as an essential beginning point and obtain resource commitments 

from involved agencies and programs to fund specific aspects of planning and development. 

z Fund a full-time coordinator to maintain and support group commitment to the process. 

z Have a designated community liaison as the facilitator, which is critical. The importance of this 

person’s role in being the point person for the work, managing the project, being a community 

organizer, leading focus groups, navigating the politics, knowing the protocol, and accessing 

resources cannot be underestimated, particularly for developing partnerships to blend and/or 

braid funds. In this case, the community liaison/coordinator’s understanding of the vision and 

commitment to the work was powerful.

z Engage the facilitators and leaders from the natural support system of the culture and 

community; e.g., establish a Lakota traditional/spiritual leader as a content expert/leader.

Barriers and Facilitators

z Beginning everything with a prayer and the wisdom of the ancestors was powerful in 

overcoming barriers.

z Effective collaborations were a challenge to establish. Overcoming turf issues in a tribal/rural 

setting is daunting; however, a skilled community organizer can overcome this.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 53

CONTINUOUS QUALITY 

IMPROVEMENT 

Definition

Continuous quality improvement is the complete 

process of identifying, describing, and analyzing 

strengths and problems and then testing, implementing, learning from, and revising solutions. It 

relies on an organizational culture that is proactive and supports continuous learning. 

Continuous quality improvement is 

firmly grounded in the overall mission, 

vision, and values of the agency. 

Perhaps most importantly, it is dependent upon the active inclusion and 

participation of staff at all levels of 

the agency, children, youth, families, 

and stakeholders throughout the 

process.19 

To implement continuous quality 

improvement, organizations should 

form a team that has knowledge of 

the system needing improvement, 

define a clear aim, understand the 

needs of those served by the system, 

and identify and define measures 

of success. In addition, organizations can advance toward continuous 

quality improvement by brainstorming 

potential change strategies; planning, 

collecting, and using data for effective decision-making; and applying 

the scientific method to test and refine 

changes.20 

Involving stakeholders, creating a 

theory of change, and applying a 

Resources

Quality Assurance Mission Statement, Quality Assurance Flow Chart, Quality Improvement Plan, 

Quality Assurance Plan, and overview of a Quality Assurance Program for Wraparound Milwaukee, 

a systems of care effort in Milwaukee, Wisconsin. http://www.county.milwaukee.gov/display/router.

asp?docid=10151

Performance 

Measurement 

System

Provider

Accountability

 Provider

Network

 Financing

 Structures

and Strategies

Range of

 Effective Services

 and Support

Pathways

 to Care Implementation

Plan

Family Choice

Collaboration and 

 Family Voice

Transformational

Leadership

Governance

Theory of Change

Stakeholders

Values and

Principles

Population

Description

continuous quality improvement framework to 

infrastructure components and systems of care 

principles are represented in the following illustration, developed by Robert Freidman at the 

University of South Florida.21
54

Goals

Your community might establish systems of care 

continuous quality improvement goals such as:

z Create a continuous learning environment.

z Use data consistently to guide fiscal and 

programmatic decision-making.

z Utilize a management information system 

that can track data across agencies, when 

possible, and can produce data to inform 

decisions. 

z Develop a process for monitoring crossagency data, if a common interagency 

management information system is not an 

option.

z Develop evaluations that incorporate systems 

of care principles.

z Develop processes for using data and 

outcomes to improve agency processes, 

procedures, and functions.

Systems of Care Principles 

and Values

The following are just a few ways systems of care 

principles and values might be evident in your 

community’s continuous quality improvement:

z All key stakeholder groups determine 

measures to be used. 

z Processes and instruments gather information 

on short-term, intermediate, and long-term 

outcomes.

z Results are used continually to improve systems 

of care for clients and families, practitioners, 

administration or governance, and policy.

z Continuous quality improvement activities are 

integrated into all aspects of systems of care.

z Client outcomes, program performance, and 

system measures are part of the continuous 

quality improvement process being assessed.

z Personnel within systems of care have 

maximum access to data. 

Activities and Tasks

Continuous quality improvement tasks and activities in your community might include:

Pre-Planning Phase

z Assess existing agency continuous quality 

improvement processes that can be enhanced.

z Identify staff and consultants with expertise in 

continuous quality improvement to assist in 

developing continuous quality improvement 

processes within systems of care.

z Identify members who are interested in 

serving on a continuous quality improvement 

committee.

Planning Phase

z Establish protocols for sharing information. 

z Determine what data are collected, how they 

are used, who has access to them, where they 

are housed, and who owns them. 

z Establish information system support and 

management.

z Establish feedback loops for the quality 

assurance process and monitoring function 

and include families.

z Diagnose, process, and develop a remediation 

plan (continuous improvement, management 

benchmarks, and goals).

z Identify domains to be measured.

z Establish processes for identifying problems 

and managing the quality improvement 

process.

z Conduct geomapping. 

z Identify resources and gaps in resources. 

z Identify other research and evaluation 

resources.

Implementation Phase

z Identify emerging trends in the environment 

(population, fiscal).

z Connect to universities and other programs 

and determine key success factors (what is 

adoptable versus adaptable, evidence-based 

practices).

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 55

z Monitor service utilization.

z Create an interagency management 

information system, if possible.

z Conduct training.

z Make sure continuous quality improvement is 

integrated with the rest of the initiative.

z Integrate national and local evaluations.

z Identify trends.

z Provide support.

z Embrace mistakes as important steps to 

success.

Personnel

The people who perform continuous quality 

improvement duties in your community might 

include:

z Interagency data team 

z Data collectors and data analyzers

z Administrative support

z Service delivery staff

z Continuous quality improvement personnel 

and consultants

Questions to Consider

As systems of care continuous quality improvement evolves in your community, keep in mind 

questions such as:

z Has a committee responsible for evaluation, 

data, and continuous quality improvement 

been established?

z Has a set of measures been developed to 

determine that current and future investments 

yield expected results?

z Is the information from evaluation activities 

used to inform and improve the delivery of 

services and supports to the target population? 

Are direct service workers able to view 

progress? 

z Are qualitative and quantitative methods used? 

z Has an interagency team been created 

to determine the ability to purchase and 

administer an interagency management 

information system, or discuss other methods 

to streamline and integrate information about 

the target population? 

Example from the Field

Site 

Contra Costa County, California

Goal

The goal of the Systems of Care/Evaluation Team is to track and monitor continuously the activities 

that were set forth in the strategic plan. Additionally, the team makes adjustments in practice, data 

collection strategies, and/or reports, and revises implementation strategies based on the continuous 

feedback from both the program staff and the evaluators. This is the essence of continuous quality 

improvement, joining evaluation, program, and management personnel to use real time information 

to review and revise implementation strategies across the areas addressed in the strategic plan. This 

makes the plan a working document, reviewed and revised at each meeting of the team, continuously updating information, reviewing successes and challenges, and developing strategies to address 

them. It also creates a shared vision across the team and ultimately across the system of care. 
56

Strategy/Approach

Continuous quality improvement has been a major focus for the Contra Costa County systems of 

care team since the very beginning of the initiative. Contra Costa County created an evaluation team 

composed of data managers and analysts working within the county’s child welfare system, as 

well as external evaluators from the University of California-Berkeley. This structure allows firsthand 

knowledge of the child welfare system’s data capabilities, limitations, and reporting structures, while 

including evaluation expertise from a respected university in the community. The evaluation team 

provides the information to agency managers, supervisors, and case workers about the progress 

toward goals identified within the systems of care initiative, as well as to agency partners who sit 

on the systems of care interagency council, and the community and families we serve and support. 

These data and their analysis give us the ability to track progress, consider successes, and identify 

and address barriers more quickly.

Additionally, the county created an evaluation subcommittee called the Systems of Care Evaluation/

Policy Team that includes the local evaluation team, external evaluator, and the program staff. This 

subcommittee meets monthly, and more if needed, to develop, review, and execute activities to 

ensure the quality of services provided. Initially, the subcommittee analyzed child welfare data to 

identify four target populations with the most need within the county child welfare system: multi-jurisdictional youth, transition-aged youth, youth at risk of multiple placements, and youth with three or 

more placements in a 6-month period. 

Not only has the evaluation team identified target populations and shaped other planning activities, it 

also uses performance measures to track progress toward our goals. Assessments (e.g., to identify 

children at risk of multiple placements) are constantly being reviewed and revised based on data 

from the target population. The evaluation team also collects and reports immediate outputs of grant 

activities. For example, the evaluation team will track several measures that may lead to modifications in the team decision-making process, such as whether the meetings have active participation 

from all relevant parties, participant satisfaction with the meetings, and whether the meeting assists 

in linking youth with resources to support the transition out of foster care. The evaluation team will 

also track outcomes that are relevant to each target population and systems of care activities, such 

as a reduction in the number of youth who are in three or more placements over a 6-month period, 

more integrated case planning processes for multi-jurisdictional youth, and more youth linked to 

needed resources upon emancipation. 

Systems of Care Principles

The systems of care principle that guides this approach is that of accountability. In order to ensure 

that this project stays on track and will be measurable and trackable, the team approach is utilized.

Lessons Learned

Contra Costa County has learned that there is an immense need for a committed evaluation team, 

and that the team is most effective if it includes both external and internal evaluators. Contra Costa 

has discovered that establishing continuous quality improvement is a difficult and time-consuming 

process, but the result of sustaining true change in the child welfare system is worth it. 

Facilitators 

Contra Costa County used systems of care committed funds to help develop and improve the internal 

evaluation team, as well as bring in external evaluators. While evaluators helped guide the process, 

the development of an evaluation subcommittee was also integral to the success of continuous 

quality improvement.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 57

It is important to have family partners involved in continuous quality improvement from the outset. 

Their input and participation give the other professionals strategies for how best to report data so 

that they are meaningful to families and it keeps the language and the process realistic. 

It is important to spend time and train all the members of an evaluation team, and/or those addressing continuous quality improvements, in the language of evaluation. The data provided and reported 

are only as valuable as their ability to truly inform all of those who read it so they can be used to 

improve performance and assist managers with resource decisions. Additionally, these data are our 

best marketing tools for telling the story of the success of systems of care. Our partners need this information, our current and potential funders need this information, and the community and families we 

serve need it too. Joined with the stories of the families we have helped succeed, these data help us tell 

the story of our success, improve the quality of our services at all levels, and engage agency partners 

and our community in accomplishing our mission and creating a sustainable system of care.

HUMAN RESOURCES AND 

STAFF DEVELOPMENT

Definition

Staff development refers to the practice of providing training, workshops, mentoring, or other tasks 

to employees to inspire, challenge, and motivate 

them to perform the functions of their position to 

the best of their ability. Staff development activities provide employees with the tools they need to 

develop professionally, increase their knowledge, 

and build their capacity to perform the tasks associated with their position within an organization. 

Since systems of care operate within existing 

human service agencies, it is expected that most 

human resources and staff development issues 

such as hiring, benefits, staff recognition, and 

performance issues would be handled within existing agency human resources departments. 

Goals

Your community might establish systems of care 

human resources and staff development goals 

such as:

z Create a continuous learning environment 

throughout systems of care.

z Make training opportunities available 

across agencies and departments, to other 

stakeholder groups, and to families, youth, and 

other community partners. 

z Develop performance appraisal systems that 

support systems of care principles.

z Hire, promote, and retain culturally, 

linguistically, and ethnically diverse individuals 

consistent with the cultural and ethnic makeup 

of the involved community.

z Hire as employees or consultants, where 

possible and appropriate, qualified youth and 

families who have been service recipients.

z Develop consistent personnel practices across 

agencies involved in systems of care.

z Consistently and adequately fill administrative 

and program positions responsible for 

performing activities within the system of care.

z Hire systems of care staff in a timely fashion. 

z Incorporate systems of care principles into job 

descriptions and consultant contracts. 

Resources

System of Care Promising Practice 

Monograph, Training Strategies for 

Serving Children with Serious Emotional 

Disturbance and Their Families in a 

System of Care. http://media.shs.net/ken/

pdf/1998monographs/vol5.pdf
58

z Develop a performance system that is 

quantifiable and accounts for continuous 

professional development.

z Team processes are utilized to complete tasks 

associated with systems of care.

z A reward structure is developed for employees 

or contractors who demonstrate an adherence 

to systems of care principles.

z A strength-based, positive performance 

approach is used to affect recruitment, hiring, 

retention, supervision, and professional 

development.

Systems of Care Principles 

and Values

The following are just a few ways systems of 

care principles and values might be evident in 

human resources and staff development in your 

community:

z Staff of systems of care agencies and 

organizations regard children, youth, and 

families as community responsibilities.

z For certain positions within systems of care, life 

experience is considered equal to, or in some 

cases more important than, a degree or other 

credentials. 

z Outcomes are developed that measure and 

identify changes generated from systems of 

care principles into human resources and staff 

development functions. 

z A culturally, linguistically, and ethnically diverse 

and competent staff is evident in human 

resources and staff development activities. 

z Family and youth involvement is evident in 

positions (employees or contractors) within the 

system of care.

z An interagency training committee creates a 

cross-agency training agenda to address staff 

needs. 

z Ongoing staff development occurs across 

all systems of care partners to enhance 

performance of interagency teams. 

Activities and Tasks

Human resources and staff development activities 

and tasks in your community might include. 

Pre-Planning Phase

z Invite and encourage human resources and 

staff development professionals to be involved 

in planning and implementation. 

Planning Phase 

z Develop job descriptions and performance 

evaluations that incorporate systems of care 

principles, values, and expectations.

z Develop an annual training and staff 

development calendar, accessible to the 

community and all interested parties. 

z Survey service providers and direct 

services staff to determine their training and 

development needs.

z Develop mechanisms for interagency training.

z Collaborate with universities and training 

centers.

z Establish a staff development plan.

z Develop systems of care training centers.

z Establish an interagency training committee.

Implementation Phase

z Conduct training and workforce development 

activities.

z Conduct leadership development activities.

z Conduct cultural competence training 

activities.

z Have human resources professionals offer 

periodic seminars to systems of care staff.

z Teach systems of care in institutions of higher 

education in social work, psychology, and 

education programs. 

z Coordinate training for multiple agencies.

z Reward and recognize staff for work 

performance that is consistent with systems of 

care principles.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 59

z Coordinate training resources (revenue and 

staff) among systems of care partners.

Personnel

The people who perform human resources and 

staff development duties in your community might 

include:

z System of care director

z Cross-agency training coordinator

z Support staff

z Family member recruitment for interagency 

teams and other activities

z Consultant pool

z Existing human resources staff in partner 

agencies and departments

z Existing child welfare training center staff

z Agency staff development personnel

Questions to Consider 

As human resources and staff development evolve in 

your community, keep in mind questions such as:

z Is there a training committee that features 

interagency and family involvement? 

z Has systems of care staff been trained in 

cultural competence?

z Has a yearly training calendar been developed 

based on needs of staff providing services and 

support to the target population?

z Are new members of child and family teams 

routinely trained in systems of care policies 

and procedures? 

z Are staff development opportunities open to all 

interagency partners, youth, and families?

z Is there a process for providing continuous 

feedback among administrators, supervisors, 

and staff? 

Example from the Field

Site

Clark County, Nevada

Goal

The goal was to enhance staff skills for facilitating Child and Family Teams (CFTs) and strengthsbased case planning, and to develop supervisors’ skills as coaches to their staff. 

Strategy/Approach

What Was Done

A unit-based approach to training for CFTs and strengths-based case planning was developed and 

implemented. The five-part plan included: overview of CFT/strength-based case planning; consultant facilitates an actual CFT with supervisor observing; supervisor facilitates a CFT, with consultant 

coaching; employee facilitates a CFT, with supervisor coaching employee and consultant coaching 

supervisor; consult based on individual needs of each unit.

Who Was Involved

All child protective services and permanency staff and supervisors received the training. Trainings 

were individualized to each unit and their supervisor, utilizing the strengths and addressing challenges 
60

of each team. As at least three of the consults involved actual CFTs, families, informal and formal 

supports, and community providers were also involved in the process. 

Time Frame 

The initial five-part plan was completed over a 5-month period, with one consult per month for each 

unit. Ongoing consults are being continued for additional support.

Why This Approach Was Selected 

The unit-based approach was developed to enhance staff skills, ensure consistency, and maximize 

use of staff time. CFTs were being done on some cases and larger group trainings on CFTs had 

occurred. With new case planning policy calling for CFTs for all case plans, it was essential that a 

consistent and thorough process be developed. By bringing training to each child protective services and permanency unit, the strengths of each team could be built upon and the challenges of each 

unit could be better addressed. Not only were skills gained, but team building was also reinforced. 

As staff has multiple time demands, bringing the consultant to each of the sites and engaging in 

actual CFTs helped minimize their time away from working directly with families. 

Systems of Care Principles 

Nevada’s PIP adopted systems of care principles to guide PIP activities. To ensure individualized, 

strengths-based approaches with child and family involvement in case planning, CFTs were written 

into new policy and procedures. This training approach and ongoing practice of CFTs also helped 

ensure cultural competence and enhance collaboration among child- and family-serving agencies. 

Lessons Learned

Barriers/Facilitators

One of the challenges was the constraints and competing demands on staff and supervisors’ time. 

By taking the training to the units in their neighborhood-based sites, travel time has been reduced 

and staff is better able to recognize the priority the agency is placing on this approach. Coaching 

staff with real case planning with actual families has also allowed them to get hands-on experience. 

Another challenge was that staff and other providers were sometimes engaging in team meetings 

that did not always stay true to systems of care principles. By providing consistent training to all staff 

(and community providers), expectations of the core elements of CFTs and strengths-based case 

planning are better understood. 

What Might Have Been Done Differently

While community providers have participated in CFTs for families they are involved with, some 

have expressed a desire to have more inclusion in trainings. Plans are in place for future trainings 

specifically geared toward the involvement of community providers and partner agencies in the 

CFT process.

CHAPTER 5 Infrastructure Components
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 61

CONCLUSION

infrastructure building to a more permanent and 

secure working environment that children, families, 

and agency partners need. Policy development, 

like strategic planning, is an ongoing activity and 

should start soon after the systems of care infrastructure design is determined. 

More than 18 States now have legislation that 

codifies various aspects of their systems of care, 

including defining the target population, the structure of State and local interagency teams, various 

entitlements for children and families, requirements 

for individualized plans of care, oversight boards, 

and the role of family involvement in all aspects of 

systems of care. For example, both California and 

Nevada have legislation particularly designed for 

systems of care that serve populations of children 

in the child welfare system.

While informed leadership and comprehensive 

policy development are vital to long-lasting and 

effectively functioning systems of care, all systems 

of care infrastructure components discussed in 

this guide must be recognized as equally important and addressed thoroughly in communities 

throughout the nation. Communities will enter 

this work at different points in the development of 

each infrastructure component. Some will have 

strong planning mechanisms while others may 

have a solid governance structure. Communities 

will approach systems of care development from 

different perspectives and, ultimately, how systems 

of care infrastructure is configured will reflect the 

particular needs of a community’s children, youth, 

and families. 

The infrastructure of an organized system 

of care must be comprehensive, complex, 

and ultimately unique to every community 

that undertakes addressing the needs of children 

and families in this strategic way. For implementation to be successful, the individuals who will guide 

the design and development of the infrastructure 

must be aware of the dynamic and complex nature 

of leading change. Systems of care leaders also 

must be patient, innovative, and diligent in pacing 

change. Change that takes place too quickly 

will meet potentially enormous resistance while 

change at too slow a pace risks losing stakeholders who do not appreciate subtle advances. 

Scores of communities throughout the United 

States and around the world have designed, built, 

and are sustaining successful systems of care. We 

have the opportunity to learn from them, just as 

communities in the future will benefit from learning 

about the challenges encountered and successes 

marked by today’s systems of care initiatives. 

Special attention also must be paid to sustainability and policy development. Ensuring that political, 

personnel, and other shifts do not threaten established systems of care requires incorporating 

support into policies and procedures as well as 

revising existing policies to make them compatible with an organized community-based systems 

of care approach. State statutes, interagency 

agreements, or MOUs are used by many States, 

counties, and communities to legitimize, stabilize, 

and sustain systems of care infrastructure and they 

reflect a transition from the initial ad hoc nature of 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 63

ENDNOTES

1

 Organizations identified reflect affiliations at the 

time of this document’s development.

2

 Stroul, B. A. (2001). Issue brief: Systems of care: 

A framework for system reform in children’s behavioral health. National Technical Assistance Center 

for Children’s Behavioral Health, Georgetown 

University Child Development Center. Washington, 

DC: U.S. Department of Health and Human 

Services, p. 5. 

3

 Kotter, J. P. (1996). Leading change. Boston, MA: 

Harvard Business School Press, p. 57. 

4

 Kotter, J. P. (1996), pp. 59-60. 

5 Kotter, J. P. (1996), p. 66.

6

 Pires, S. A. (2002). Building systems of care: A 

primer. Human Services Collaborative. National 

Technical Assistance Center for Children’s 

Behavioral Health, Georgetown University. 

Washington, DC: U.S. Department of Health and 

Human Services. 

7 Hernandez, M., & Hodges, S. (2003). Crafting 

logic models for systems of care: Ideas into action. 

Department of Child & Family Studies, Louis de la 

Parte Florida Mental Health Institute. Washington, DC: 

U.S. Department of Health and Human Services.

8

 Center for Behavioral Health in Schools at UCLA. 

(2004). An introductory packet on working together: From school-based collaborative teams to 

school-community-higher education connections. 

Retrieved January 11, 2006, from http://smhp.

psych.ucla.edu/pdfdocs/worktogether/worktogether.pdf

9

 Merriam Webster On-Line Dictionary. (2005). 

Infrastructure. Retrieved January 11, 2006, from 

http://reference.aol.com/dictionary.

10 U.S. Department of Health and Human Services, 

Administration for Children, Youth and Families. 

(2001). National survey of child and adolescent 

well-being: Local child welfare agency survey: 

Report. Washington, DC.

11 U.S. Department of Health and Human Services, 

Administration for Children, Youth and Families. 

(2003). National study of child protective services 

systems and reform efforts: Review of state CPS 

policy. Washington, DC, Chapter 2. 

12 U.S. Department of Health and Human Services, 

Administration for Children, Youth and Families, 

(2003), Figure 2-1.

13 Stroul, B. A. (2001), p. 9. 

14 Iron Cloud Two Dogs, E. (2005). Discussion on 

assessing progress in systems of care. Fairfax, VA: 

Caliber Associates. 

15 Pires, S. A. (2002). 

16 Bruns, E. J., Koroloff, N., Schutte, K., & Walker, 

J. S. (2004). Organizational and system support 

for wraparound: An introduction. Portland, OR: 

National Wraparound Initiative, Research and 

Training Center on Family Support and Children’s 

Behavioral Health, Portland State University.

17 Pires, S. A. (2002). 

18 Pickett, J., et al. (Eds.). (2000). American heritage 

dictionary of the English language (4th ed.). Boston: 

Houghton Mifflin. 

19 National Child Welfare Resource Center for 

Organizational Improvement and Casey Family 

Programs. (2005). Using continuous quality improvement to improve child welfare practice. Retrieved 

December 13, 2006, from http://muskie.usm.maine.

edu/helpkids/rcpdfs/CQIFramework.pdf

20 Iowa State University. (2006). Continuous quality 

improvement (CQI). Retrieved November 20, 2006, 

from www.fpm.iastate.edu/worldclass/cqi.asp

21 Friedman, R. (2005, February). Effectively serving 

children with special needs and their families: 

What does it take? Paper presented at the 2005 

Systems of Care Communities Meeting, Dallas, TX. 

Retrieved November 15, 2006, from http://rtckids.

fmhi.usf.edu/presentations.cfm

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 65

APPENDICES

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 67

 Youth

 Subcommittee

 SOC Grant

 Policy Council*

June 2005: Self 

Assessment Team disbands 

and interested members 

join Work Groups

District Redesign Committee

(continue to be chaired by op. DMs)

Finance

Bureau Director

Self-Assess Team

Division Manager

Partnerships 

Division Manager

Intake 

Division Manager

Permanency & Youth 

Transition 

Division Manager 

SOC Grant Activities 

Workforce 

Preparation

Division Manager

Comm. Strategy

Division Manager

Accountability 

Division Manager 

County Team

Bureau Director and Division Managers

F2F Committees to be integrated 

into Work Groups

District Implementation Teams: Partnerships

RTS: Permanency & Youth Trans. Partnership

TDM: Permanency & Youth Transition Intake 

Structure, Partnership

Comm. Partners: Partnership

Evaluation: Accountability

* Council includes: youth, families, children’s mental health, substance abuse services, juvenile justice, child welfare, education, 

primary health, independent living services, and other community-based organizations and agencies.

APPENDIX A: Governance Structure for Contra

Costa County, CA Systems of Care Effort

Child Welfare Redesign 

Steering Committee

Bureau Director

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 69

General Description

Under the supervision of the Project Director of the 

systems of care project, the Interagency Liaison/

Administrative Coordinator is responsible for the 

coordination and execution of administrative activities, outreach, clerical and technical support to the 

interagency governance entity providing leadership 

to the systems of care project. This position provides 

the assistance and support required for members 

of the governance entity to operate efficiently and 

effectively. 

Duties and Responsibilities

1. Establishes and maintains contact with 

representatives of community groups, 

organizations, agencies, and other 

stakeholders serving on the governance body, 

its committees and subcommittees.

2. Provides clerical and technical support and 

assistance to members of the governance 

body, committees and subcommittees.

3. Attends meetings of the governance entity and 

associated committees and subcommittees, 

keeping minutes and documenting 

proceedings.

4. Maintains and disseminates minutes and other 

documentation associated with meetings of the 

governance body and all related committee 

and subcommittee structures.

5. Works closely with the Project Director 

and Governance body Chair person(s) 

to coordinate meetings, develop meeting 

agendas, make logistical arrangements and 

provide administrative support.

6. Documents contacts with governance body 

members and systems of care staff.

7. Coordinates meetings, conferences, trainings 

and other events that are sponsored by the 

systems of care project.

8. Coordinates and arranges for out of town 

travel for members of the governance entity, 

committees and subcommittees.

APPENDIX B: Interagency Liaison/Administrative

Coordinator

9. Follows Robert’s Rules of Order for meetings.

10. Posts meeting agendas as required for public 

view (on the internet, local county or State 

television).

11. Submits invoices from family and youth 

members of the governance entity, it’s 

committees and subcommittees, for 

out of town travel reimbursement, food, 

transportation, child care and other supports 

necessary to support their involvement.

12. Performs other duties as assigned.

Education and Training

High school diploma or GED equivalent. Training in 

Robert’s Rules of Order, short hand, and proficiency 

in Microsoft Office is preferred. 

Knowledge, Skills and Abilities

Ability to communicate effectively orally and in 

writing. Ability to work autonomously. Proficiency in 

Spanish preferred. Ability to work effectively within a 

team environment, and demonstrated skills in office 

management and clerical duties. Demonstrated 

ability to multi-task, organize and manage time, and 

work in a fast-paced environment. 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 71

APPENDIX C: Example of who to involve in a

Local Systems of Care Governance Structure

(including committees and subcommittees)

z Families of children who have, at one time, met 

the target population criteria for the project 

(resource families, adoptive parents, biological 

parents, kin care givers, etc.);

z Youth who have, at one time, met the target 

population criteria for the project (former foster 

youth, youth who have been reunified with 

their family, youth who have been adopted, 

etc.);

z Representatives from the law enforcement 

community (county sheriff, city police, etc.);

z Representatives from the judicial/court 

community (county judges, family court 

judges, juvenile probation officers, Chief 

county probation officer, etc.);

z Representatives from the Alcohol and Other 

Drug Treatment community;

z Representatives from the legal community 

(District Attorney’s office, Guardian Ad Litem, 

etc.);

z Court Appointed Special Advocates (and other 

advocacy organizations);

z Foster Parent Association representatives;

z Representatives from organizations addressing 

domestic violence;

z Representatives from faith-based community;

z Representatives from the primary health 

care community (pediatricians, public health 

nurses, children’s hospital representatives, 

medical social workers, emergency room 

intake workers, administrators, etc.);

z Representatives from the behavioral health 

community (psychiatrists, psychologists, social 

workers, therapists, administrators, etc.);

z Representatives from the prevention and early 

intervention community;

z Representatives from the education 

community (including Head Start and other 

early childhood initiatives, and individuals 

representing local school districts);

z Representatives from the business community, 

and/or the local Chamber of Commerce;

z Representatives from the public assistance 

community (Medicaid, TANF, Welfare to Work 

Coalition, etc.);

z Representatives from the child care community 

(day care centers, after school programs, etc.);

z Representatives from the Children’s Trust 

Fund, or Children’s Advocacy Center;

z Representatives from Adoption agencies;

z Representatives from the independent living 

and transitional services community; 

z Representatives from the service provider 

community (family preservation services, foster 

care services, intake and referral services, etc.);

z Representatives from the child welfare agency 

(Case workers, Supervisors, Administrators, 

etc.); and 

z Representatives from the County Child Welfare 

Board.

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 73

Interagency Liaison/

Administrative Coordinator

SOC Training and Technical 

Assistance Coordinator

APPENDIX D: Example of the Management

Structure of a Systems of Care (SOC) Effort

SOC Evaluator*

Social Marketing Coordinator

Parent & Youth Involvement 

Coordinator

Community Outreach 

Specialist

SOC Project Director*

Interagency Governance Body

SOC Principle Director*

Options: Contracted out, new staff position(s) within the child 

welfare agency, or functions added to existing positions

*Positions required by the Improving Child Welfare Outcomes through Systems of Care grant program

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 75

APPENDIX E: Service Coordination Processes

Used in Systems of Care Communities

Communities that have adopted systems of care 

often develop methods for incorporating existing 

strength-based, family-centered service coordination approaches as part of the array of services and 

supports available to children, youth and families 

with multiple needs. The core values inherent in 

these approaches are analogous to systems of 

care principles. For example, core values of family 

meetings include: 1) all families have strengths; 

2) families are experts; 3) families are equals on a 

team; 4) families can make well-informed decisions 

about keeping their children safe when supported; 

5) when families are involved in decision-making, 

outcomes can improve; and 6) A team is often 

more capable of creative decision-making than one 

individual alone.

The following chart, adopted from a similar table 

created by the Annie E Casey Foundation, provides 

information about the key characteristic of family 

meetings conducted on behalf of families, youth 

and children involved in the child welfare system. 

Each of these approaches provides a process for 

coordinating multiple services, and involving the 

child, family and community in creating a plan for 

meeting needs and building on strengths.

Characteristics shared 

by all

Team DecisionMaking (TDM)

Family Group 

Decision-Making 

(FGDM)

Family Team 

Conference (FTC)

Wraparound

(child & family team, 

care coordination)

Purpose To provide support to families 

at risk of or already involved 

in child welfare, in a strengthbased team setting which 

ensures child safety, permanency and well-being.

To make immediate 

decisions regarding a 

child’s placement.

To develop a plan that 

ensures the protection of 

a child.

To develop a plan that 

ensures the protection 

of a child.

To develop a plan that links 

strengths and needs to 

services and supports that 

ensure child safety, permanency and well-being.

Goal To develop a case plan using a 

solution-focused, family-driven 

team approach. 

Team, including the 

family, seeks consensus decision regarding 

the placement of a 

child in order to protect 

the child and preserve 

or reunify the family.

The family, with the 

support of others, makes a 

plan for the child to ensure 

safety and stabilize the 

current crisis.

The family, using the 

expertise and support 

of team members, 

develops a plan to 

address family needs, 

and build on their 

strengths, at a variety 

of critical points.

The team develops a plan 

that links services and 

supports to strengths and 

needs. Team includes 

family members/caregivers, community members, 

service providers and 

agency staff. Family voice is 

central to the process.

Distinctive 

Element(s) 

Distinctive 

Element(s)

Needs and strengths-focused, 

culturally appropriate and 

individualized case plans are 

developed inclusive of relevant 

interagency partners and family 

members. Linkages to continuing supports both natural and 

traditional.

Held for EVERY placement-related decision 

faced by EVERY 

family receiving child 

welfare services.

Emphasis is on being the 

fact that the meeting is for 

the family—rather than the 

agency. May have 20-30 

or more family members in 

attendance. Private family 

time is a core element of 

the process.

Family tells their 

story. Can be used for 

prevention purposes 

with families not yet 

involved with the child 

welfare system.

Begins with a family meeting 

with a facilitator. Family tells 

their story and identification 

of needs and strengths 

begins. Family determines 

who is on their team. Team 

members are expected to 

participate in implementation of the case plan.
76 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Characteristics 

shared by all

Team DecisionMaking (TDM)

Family Group 

Decision-Making

(FGDM)

Family Team 

Conference (FTC)

Wraparound

(child & family team, 

care coordination)

Decision 

Responsibility

Goal is to place the family 

at the center of decisionmaking. Ultimately, the 

Social Worker must 

approve of the plans 

made.

The agency maintains 

responsibility if consensus 

regarding placement 

cannot be achieved.

The family develops a 

plan for the child. The 

agency must be able 

to support the family’s 

ideas and incorporate 

them into the FGDM 

plan.

The family determines 

the outcome, except for 

identified non-negotiable 

issues.

Decisions are decided by 

the team but are centered 

on the strengths and needs 

of the child(ren) and family. 

Outcomes are decided by 

the team but are family and 

child-centered. Plans are 

coordinated by the lead 

agency.

Scheduling Varies. Mandatory—meeting is 

held before any placement 

or re-placement occurs, 

or before any initial 

court hearing in cases 

of imminent risk of 

removal from the home 

environment.

Voluntary—the family 

plays a major role in 

when and where the 

meeting takes place.

Voluntary—the meeting 

is held only with the 

family’s approval and if 

scheduled by the family’s 

assigned worker.

Voluntary—the meeting is 

held only with the family 

present and with the team 

members that have been 

invited. Meetings take 

place at a time and location 

designated by the family. 

Meetings are scheduled 

whenever changes to the 

plan need to be made—can 

be a crisis, change in 

behaviors or a change in 

living situation.

Referral Varies. Assigned Social Worker 

is required to schedule 

when placement-related 

decisions must be made.

Any professional 

involved with the family 

may offer FGDM to 

the family for their 

consideration.

Assigned social worker, 

family or other team 

member may refer at 

any time.

Referral is determined 

by agency policy and 

procedures.

Preparation Preparing the family for the 

meeting is both respectful 

and important to achieve 

positive outcomes.

Often limited preparation 

due to the crisis nature of 

many placement decisions. 

Assigned Social Worker 

invites the family and 

prepares them for the 

meeting.

The emphasis is on 

advance planning, 

often 20-30 hours, over 

a 3-4 week period. 

Coordinator invites and 

prepares the family and 

others for the meeting.

The assigned Social 

Worker has a premeeting with the family 

to determine their goals/

desired outcomes and to 

prepare the family and 

identify team members.

The lead agency staff 

person meets with the 

family to determine their 

vision, goals, and outcomes, 

identify strengths and 

needs and develop a crisis 

plan. Team members are 

identified, invited and given 

an overview of the purpose 

of the team and their role.

Team Members Birth parent(s), extended 

family, non-relative 

supports chosen by 

the family, the child (as 

appropriate), service 

providers, assigned Social 

Worker and involved 

agency staff.

Neighborhood or other 

community partners, child’s 

caregiver (if already placed 

outside of the family), 

and a facilitator identified 

as a team member. All 

who attend have either 

the family’s permission or 

participate as “treatment 

team” members.

Family decides, with 

input from the facilitator.

All family members are 

encouraged to attend, 

even if the birth parents 

object.

Family, relatives, and other 

support people who are 

identified by the family. Also 

includes interagency service 

providers. 

Facilitator Trained facilitator with 

strong strengths-based 

orientation and excellent 

group process skills.

Immediately accessible, full 

time agency staff member 

who, as a team member, 

shares the responsibility for 

decision-making. Ideally, 

the same facilitator works 

with the family throughout 

their involvement with child 

welfare.

An impartial facilitator, 

often a coordinator, who 

is responsible for all 

aspects of the meeting 

process.

Trained agency staff, 

often the assigned 

Social Worker or service 

provider.

Trained agency staffshares responsibility for 

coordinating the plan, and 

facilitating the meeting. 

Can be provided by a lead 

agency, or contract provider.

APPENDIX E Service Coordination Processes Used in Systems of Care Communities
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 77

Characteristics 

shared by all

Team DecisionMaking (TDM)

Family Group 

Decision-Making 

(FGDM)

Family Team 

Conference (FTC)

Wraparound

(child & family team, care 

coordination)

Length of 

Meeting

Varies. One to two hours. Three to five hours. Varies. Varies.

Confidentiality Privacy and respect are 

core values and set the 

tone for the meeting. 

New allegations of 

abuse or neglect must 

be reported.

There is a focus on 

privacy—the family is told 

that information may be 

used for case planning, or 

in court if necessary. 

A signed confidentiality 

agreement is often 

used.

A signed confidentiality 

agreement is used.

A signed confidentiality 

agreement is used.

Post-meeting 

Responsibility

Attention to postmeeting safety and 

emotional issues is 

part of the discussion. 

Follow up meetings are 

typical.

Assigned Social Worker 

is primarily responsible to 

implement the decision 

agreed upon at the 

meeting. Other participants 

play supporting roles. 

Outcome data is collected 

and used for selfevaluation and planning.

Assigned Social 

Worker is responsible 

for monitoring and 

ensuring the plan is 

implemented.

The primary Social 

Worker monitors the 

Individualized Course 

of Action plan and 

makes the necessary 

adjustments.

The primary worker monitors 

the plan, responds in crisis 

situations and makes 

adjustments to the plan as 

necessary (with the team). The 

worker meets with the child 

and family on a regular basis 

to ensure the plan is being 

implemented as expected.

Usage Growing-and 

complementary—a 

continuum of family 

meeting types provides 

the opportunity for best 

practice and positive 

outcomes for children, 

youth and families.

TDM is a core strategy 

used in over 30 Annie E 

Casey Foundation Family 

to Family sites, including 

Denver, CO, Cleveland, 

OH, Louisville, KY, Detroit, 

MI, and San Francisco, CA.

Variations of FGDM 

are in place in several 

hundred sites across 

the United States, 

Canada and Europe.

Used in Community 

Partnership for 

Protecting Children 

sites in St. Louis, MO, 

Jacksonville, MS, and 

Cedar Rapids, IA.

Used throughout the United 

States. Examples include: 

the State of New Jersey, 

Wraparound Milwaukee, 

Milwaukee, WI, The Dawn 

Project, Indianapolis, IN, and The 

Medicine Moon Initiative, ND.

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 79

Family Centered Systems of Care is a state 

movement that will employ a combination of 

proven marketing techniques - research, product 

positioning, brand identification, advertising, direct 

mail, and public relation - blended with critical 

grassroots organizing and outreach strategies 

which will begin in 3 pilot communities (Cherokee, 

Riley, Reno). The designed purpose is to increase 

awareness about the need to decrease the number 

of contacts that children of the state of Kansas 

have with Child Welfare and to increase community systems capacity to assist and partner with 

families to strengthen and protect children. To 

create massive and unprecedented community 

support and involvement on their behalf. The state 

of Kansas can be a leader if we promote the 6 

principles of SOC when partnering in meeting child 

welfare outcomes. 

When should you run a social marketing 

campaign?

z When trying to change the behavior of a large 

number of people.

z When trying to change behavior over a long 

period of time.

z When resources exist to manage a 

comprehensive effort. 

How do you manage a social marketing 

campaign?

z Define and understand 

z Choose appropriate strategies 

z Implement

z Ongoing evaluation 

Define and understand 

z Define the problem. 

z Define the goals of FCSOC.

z Define your audience. All Kansas families and 

children. 

z Understand your audience. (Community 

Assessments) 

APPENDIX F: Kansas Family Centered Systems

of Care Marketing Strategy

Choose appropriate strategies 

z Brainstorm strategies 

z Decide the amount of time and resources for 

each subgroup 

z Determine if different strategies are needed for 

each segment, or just different messages and 

mediums 

z Choose specific strategies based on identified 

needs of your target audience.

z Design messages 

z Select channels of communication 

z Pretest ideas and messages 

Implement and evaluate

z Establish a tracking system

z Continuously modify your work based on 

results 

z Celebrate your accomplishments

1. Deciding to conduct a social marketing 

campaign

FCSOC seeks to make long term changes in the 

culture of Child Welfare in Kansas. We seek to 

infuse this philosophy along with its 6 principles 

into the everyday policies and practice process that 

is utilized in partnering with families and children. 

2. Identifying targets and agents of change 

and desired behaviors

Identifying what the people who live in the 3 pilot 

communities see as their priority is critical. The 

focus groups (community assessment) conducted 

involved stakeholders from diverse areas of child 

welfare. The top issues coming from that community assessment rural poverty, lack of resources to 

name a few.

For this initiative to be successful, the community 

must determine the demographic group that they 

wish to target. It is, however, strategic to involve 

those who are identified as the usual and unusual 

suspects who have a lot at stake in child welfare 

but have different levels of power and influence 

over the system. The benefits of this initiative will 
80

strive to influence positive change in the culture of 

the various areas/entities within child welfare. 

Who benefits from this marketing strategy/

campaign? A better life for Cherokee county 

children would be observed as well as Kansas 

children. Stakeholders would increase their collaboration with one another resulting in tremendous 

qualitative gains throughout the community and 

state. The Courts and law enforcement benefits 

because there are less negative encounters/

contacts, SRS because of the reduction in number 

of out of home placements and increase in family 

preservation efforts.

3. Stating the goals and behavioral objectives

The goals of the marketing campaign are four 

broad goals as identified by the leadership of the 

initiative. They included: 1) the increased interagency collaboration; 2) the increased involvement 

and interest of stakeholders in the outcomes of all 

children within their community; 3) increased family 

involvement in the development and influence of 

policy making decisions that affect children and 

families; and 4) the development of a sustainable 

infrastructure that supports families and children 

on the community level and less on the state level. 

We must incorporate the brand/logo/title/slogan 

(through marketing efforts) into the conscious of 

everyone who is involved in the decisions being 

made in child welfare at both an individual and 

business/institutional level. This would happen in any 

place decisions were made. The price would vary 

largely depending on the decision to be made. The 

initiatives logo/slogan should be promoted through 

multiple media domains (brochures, giveaways at 

conferences, grant team appearances at conferences, workshops, radio, television, and newsprint 

ads), faith communities, social agencies, school 

organizations, and businesses. Stakeholders from 

area business, civic, and faith communities, school 

boards and directors of agencies need to be identified, personally contacted by staff, and challenged 

to promote the vision/mission/ and guiding principles in both their personal and professional lives. 

They should be encouraged to discuss policy and 

the merits of change in light of Family Centered 

Systems of Care.

No one group can be singled out as most likely to 

make the most difference in affecting the well-being 

of children. Those in business might influence the 

establishment of child friendly business practices, 

those in local government would make decisions 

affecting public recreational facilities and safety 

practices, those who were parents, teachers, or 

after school care providers could directly engage 

and mentor children. The strength of this marketing strategy is in its recognition that all people and 

their decisions are interconnected and potentially 

could affect children’s lives. 

The benefit in implementing this marketing strategy would be to increase the well-being of Kansas 

families and children. Increased physical, mental, 

and social health; increased opportunities for 

education, growth, and security; and increased 

success and support in transition to adulthood.

In general, utilizing Family Centered Systems of 

Care would create an environment in which not 

only the child but the family’s concerns would be 

a priority.

Potential behavioral objectives

1) increase community capacity 2) increase 

community collaboration 3) increase community 

resources 4)increase positive law enforcement 

contacts 5) increase community awareness 6) 

increase involvement in after school programs 

designed for children and families. 

4. Engaging potential partners

Potential partners are often the same people targeted for change. We must tap into various spheres 

of influence, including the faith community, neighborhoods, and business and commerce sectors. A 

broad spectrum of leadership must be represented, 

tapping into multiple networks of people through 

out the target communities. Influential partners 

were seen as individuals who would spread the 

message through their networks, provide accurate 

knowledge and insight into the message of family 

centered child welfare practice and motivate others 

to increase their collaboration to assist families and 

children. 

Additional funding to support this campaign could 

be sought from stakeholders/community partners 

like the Robert Wood Johnson, Ewing Marion 

Kauffman, and Kansas Health Foundations. 

Once we have agreed upon the marketing strategy and our efforts were more clearly focused, 

experts in marketing and media awareness could 

APPENDIX F Kansas Family Centered Systems of Care Marketing Strategy
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 81

be consulted to create TV and radio spots targeted at various stakeholders (school, parents, civic 

leaders, and business)

5. Defining the audience

In order to increase the readiness and receptivity 

of people in pilot community to the grant’s goals, 

the initiative needed to increase knowledge about 

family and children’s issues and surface the importance of children’s and family’s well-being to the 

community and the future. Their behavior would be 

key to creating an environment in which children’s 

issues and their welfare would be put first by the 

community.

The marketing strategy could be implemented 

in 3 phases: first, increase awareness of family 

centered systems of care (and how it might affect 

one’s community) through advertising; second, 

challenge stakeholders (business and civic leaders, 

governing councils, schools and social agencies, 

and individuals) to commit to applying the 6 principles of FCSOC in making decisions; and finally, 

model, encourage and reinforce behavior changes 

that occur or will occur as a result of this strategy.

6. Analyzing key behaviors and environments 

related to the goal 

This initiative wants to increase stakeholder 

involvement in the lives of Kansas families and 

children. To increase the number of people influencing policies that affect children and families, 

and develop community capacity for community 

partners who want to support families and children 

but were limited by time and circumstances.

What would be the benefits if such goals were 

attained? Potential results might include (but are 

not limited to) improved educational outcomes 

for children, improved adult-youth communications, decreased youth negative law enforcement 

contacts, elevation in rates of school success 

(e.g., high school graduation rates, school 

activity involvement), increased availability of afterschool programs or mentoring programs which 

link community partners with local families and 

children, increased usage of outdoor and indoor 

public recreation facilities, and a decrease in the 

incidence of child neglect and abuse.

7. Identify core components of the campaign

In order for this marketing campaign to succeed, we 

must incorporate three tried and true components 

from marketing research to “sell” the campaign’s 

message: 1) to have a good product; 2) to conduct 

good market research about issues important to 

the community; and 3) to have committed financial 

resources. Advertising would be futile if the product 

(FCSOC) wasn’t connected to and imbedded in 

the community, so grassroots organizations and 

faith communities must be engaged, in addition to 

the efforts made by staff with community leaders, 

to spread the word.

Family Centered Systems of Care is easy to 

remember and simple to understand. It can be 

integrated into every day decisions without setting 

aside additional time or resources. Moreover, 

if it were used consistently, it could dramatically increase the awareness of how stakeholder 

decisions affect the quality of life for children and 

families within their communities. Advertising in 

the media will need to include real people from the 

pilot communities instead of actors, both children 

and families. Advertisement has to be thoughtful 

and have a warm tone, with the scripts relaying 

how each person benefits by the implementation of 

this new approach in the daily lives of children and 

families. The people in the ads need to represent 

multiple racial/ethnic identities and different potential groups of change agents, including business 

people, leaders of faith communities, school and 

community action council members, and parents. 

Prior to any delivery or airing to the media any 

aspect of the campaign, the images, print ads, 

commercials must be piloted with community 

members (steering committee) for the clarity and 

accuracy of the message.

Incorporating FCSOC into decision making was 

made easier to do by emphasizing its simplicity and presenting it as not yet another “thing to 

do”, but instead as the next right answer in what 

we all strive to do in child welfare every day. In 

addition media spots can encourage listeners and 

viewers to envision the difference partnering with 

families would make in the life of the community. 

The initiative must also educate/inform governing 

councils to act on and commit to the use of FCSOC 

principles by publicizing their commitments to their 

constituents and encouraging their constituents to 

hold them accountable for their decisions.

We must consistently thank publicly stakeholders who have contributed to the proliferation and 

emphasis on the use of FCSOC at organizational 
82

functions, like dinners sponsored by community 

partners (example, the United Way), and through 

opinion-editorials in local newspapers.

8. Tailoring campaign components

In order to increase the impact of the message the 

initiative is trying to convey, media spots must be 

shown at strategic times in order to reach specific target audiences. [For example, air time was 

bought on the Lifetime channel in order to reach 

women ages 24-45 years because market research 

indicated that particular audience was more likely 

to watch that channel.] In order to reach business 

and civic leaders, media spots were shown during 

morning news shows. Although the campaign 

was aimed at all Kansans, media messages were 

somewhat created to increase the likelihood of 

various audiences identifying with certain characters. Audiences would see themselves in the 

actors and identify with their message. Messages 

could include representatives from the business 

community, various faith communities, school 

and education leaders, and parents in general. 

The message would be presented simply and 

succinctly. 

9. Pretesting and revising campaign components

Because of the extensive preplanning, we could 

anticipate little need for revision. Conducting the 

focus groups within our pilot communities may 

make it unnecessary to pretest the media spots 

with the public prior to airing.

10. Implementing the social marketing campaign

The social marketing campaign would begin in the 

fall of 2005 with the Governor and Secretary taking 

part in a kickoff. Legislatures and/or community 

leaders would follow up and take part in local 

level kickoffs. Television and print ads would run 

for six weeks, and again the following March and 

September. Radio spots would continue intermittently through December 2006, encouraging the 

community to continue to collaborate with one 

another to keep families and children a priority 

in their decision making. We would contact all 

identified stakeholders in Kansas and continue to 

challenge them to adopt a FCSOC to their private 

and professional lives. 

11. Evaluating the effects

The University of Kansas Work Group on Health 

Promotion and Community Development could be 

employed to evaluate the campaign’s success at 

raising awareness and creating behavior change in 

the 3 pilot communities around issues of children 

and family well-being. Phone surveys could be 

conducted in the pilot communities and comparison counties on an annual basis to inquire about 

people’s familiarity with the campaign, their levels 

of investment in the initiative and if their actions to 

support community caring for children and families 

(e.g., volunteering for work teams, policy teams, 

school board task force teams, writing elected 

or appointed officials regarding their concerns). 

A tracking system could be created to assess 

how awareness and behavior changed in the 

pilot communities, documenting the community 

changes and response to the campaign from fall 

2005 throughout the final 3 years of the grant.

The community would gain from healthy children 

growing up surrounded by a caring community 

with resources available to support and strengthen 

families.

12. Celebrating and sustaining the effort

A large celebration set for the fall 2005 could be 

set to kick off the social marketing campaign. 

Articles could be published in opinion editorials 

promoting this initiative as the next right answer 

to advance issues for children and families in their 

communities. 

Long-term sustainability can be elusive, however, 

because of lack of long-term funding sources and 

changing leadership. Nevertheless, a grass root 

effort with maximum community level organizational involvement can increase the likelihood of 

sustaining the FCSOC approach to child welfare 

practice in Kansas.

Adapted from the community toolbox at www.ctb.

ku.edu

APPENDIX F Kansas Family Centered Systems of Care Marketing Strategy
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 83

APPENDIX G: State of Kansas Family Centered

Systems of Care Social Marketing Campaign

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 85

Family Centered 

Systems of Care 
86 APPENDIX G State of Kansas Family Centered Systems of Care Social Marketing Campaign
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 87
88 APPENDIX G State of Kansas Family Centered Systems of Care Social Marketing Campaign
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 89

Principle of the Month “Youth and Family 

Involvement”

z Youth and Family Involvement is the first of the six Guiding Principles of 

Family Centered Systems of Care to be featured because it is the most 

important of all. Interagency collaboration, individualized strengthsbased care, cultural competence, community-based services and 

accountability are not as effective if the process is not family-driven or 

family-centered. 

z Our agency’s vision of “Partnering to connect Kansans with supports 

and services to improve lives” begins with this principle. The 

“Partnering” of our vision statement begins with the very family and 

youth we are here to serve. And our agency’s mission “To protect 

children and promote adult self-sufficiency” cannot be truly fulfilled 

without this principle. We must develop a “nothing about them, without 

them” attitude. 

z Full youth and family partnership is an investment, and essential to 

the development and provision of any service, program, or policy for 

the individuals, families and children we serve. This principle requires 

mutual respect, and the intentional establishment and support of 

meaningful partnerships between youth, families and staff. It requires 

us to not only “make room at the tables” where they were not previously 

invited, but to also consistently challenge ourselves to view the work we 

do in light of their perspective. 

z Points to ponder: How can you further involve the individuals, youth 

and families in the process of developing the services provided for 

them? How family-centered and family-driven are the services you are 

providing? 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 91

Appendix H: Planning a Systems of Care

Conference: Lessons Learned in North Carolina

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 93

The birth of an idea

 State Collaborative’s newly formed committee 

to connect with local collaborative groups

 Division of Social Services desire to 

coordinate a SOC conference

 Division of Mental Health Developmental 

Disabilities Substance Abuse desire to 

coordinate a SOC conference
94 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Contributing factors

 Unexpended year one funds that would not 

be carried over to year 3

 Mecklenburg County’s annual conference in 

initial planning stages and infrastructure was 

already in place

 Division of MHDDSA survey of local MH 

Collaboratives
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 95

First steps – establish purpose & goal

1. To provide basic and intermediate 

knowledge about SOC to various 

collaborative groups across the state

2. Increase communication between the State 

Collaborative for Children and local 

collaborative groups

3. Provide an opportunity for local collaborative 

groups to share successes and challenges 

with each other
96 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Initial Decisions

 Registration would be handled by Charlotte 

Area Health Education Center (AHEC)

 Based on AHEC’s fee a small registration 

fee would be required for the conference

 Conference would take place over 2 days

 National and local speakers would be invited 

to present on SOC

 Departmental Secretaries would be invited 

to talk about agency specifics and 

expectations
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 97

Initial Decision Continued

 Multiple collaborative groups that focus on 

children were invited

 Comprehensive Treatment Services Program 

Collaboratives

 Community Child Protection Teams

 Juvenile Crime Prevention Councils

 Smart Starts

 United Way

 Parent Organizations & Family Resource Centers
98 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Budget

 Majority of the funding from SOC grant

 MH covered the expenses of national 

speakers and made other in-kind staff 

contributions

 Other agencies offered in-kind support in 

planning and presenting

 AHEC registration fee covered some of the 

lodging and food expense
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 99

Planning

 Several sub-groups were developed with 

Mecklenburg staff and sub-committee 

members

 Logistics

 Agenda & Activities

 Communications
100 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Logistics

 Location – changed to accommodate 400 

participants

 Hotels – through grant funds overnight 

stipends were offered. Multiple hotels offered 

a discounted rate

 Volunteers were solicited to help with the on 

site logistics of the conference
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 101

Agenda

 Went through multiple versions – initially 

there were multiple tracks related to various 

SOC principles and values

 After discussion with agency partners it was 

decided that large group presentations were 

the best avenue to convey SOC and state 

information, including legislative activities.

 Successful and promising collaboratives from 

across the state were invited to speak
102 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Agenda Continued

 The final agenda included 5 concurrent break 

out sessions based on the core SOC 

principles

 Regional discussions were included to gather 

information about local strengths and needs. 

These regions were chosen based on the 9 

different AHEC regions.
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 103

Media/Communications Plan

 Save the date card was developed by the 

planning group and sent to all the local 

collaborative groups identified (approx 800)

 Letters of invitation were sent to 

Departmental Secretaries and Legislators

 All communications were from the State 

Collaborative to ensure that no one agency 

was given credit for organizing the event
104 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Evaluation

 AHEC had developed a satisfaction survey 

for the conference

 Regional discussions were to provide 

qualitative information back to the state 

collaborative
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 105

Lessons Learned

 Don’t plan during Hurricane Season

 Have a clear purpose and audience before planning 

begins

 Have each agency actively involved in planning and 

funding the event

 Have the folks who can make contacts and influence 

attendance on board early

 Have multiple communication plans, save the date and 

a letter were not enough to encourage participation

 Have the local communities help plan

 Be clear about roles, expectation and function at the 

beginning of the process 
106 APPENDIX H Planning a Systems of Care Conference: Lessons Learned in North Carolina

Planning a SOC conference

Questions & Answer
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 107

Appendix I: Milwaukee Wraparound

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 109 APPENDIX I Milwaukee Wraparound Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 111

Scope Out The Environment & Do Your 

Homework

1. Make certain you have the administrative and 

management support to engage in the work 

you will be doing to proceed with your idea.

2. Determine a policy agenda and identify key 

constituents needed to support your work. 

3. Assess if the political will is there to proceed. 

Develop a plan for how to address this issue, 

according to the political environment in which 

you will be working.

4. Identify the target goal to address. 

(Redeployment of out of home placement 

funds to create more community based 

services, decrease the cost of out of 

home care, decrease numbers of custody 

relinquishment cases, etc.).

5. Identify the population of children you want to 

target.

6. Cite other initiatives or research that builds the 

case for what you are trying to do.

7. Develop a key message to market what 

you seek to do. (Increased fiscal efficiency, 

decreased duplication of services, increased 

community based services, etc.)

8. Identify an interagency group with whom you 

can present your ideas and gain support.

Interagency Group Characteristics

1. Membership is composed of families and 

agency individuals with the authority to 

make policy, finance and programmatic 

recommendations to their agency’s Director 

and/or public policy recommendations to their 

State or local legislative bodies.

2. A Memorandum of Agreement, legislative 

mandate or other document authorizes the 

work of the interagency group.

3. A plan detailing the mission, vision, goals, 

objectives and strategies of the interagency 

group has been created and is in sync with the 

proposed initiative.

APPENDIX J: Steps for Implementing a

Refinancing Initiative

4. A set of bylaws or other rules that explain the 

roles, responsibilities, and decision-making 

procedure of members of the interagency 

group and subcommittees has been 

developed.

5. Relationships between members are built 

on mutual trust that enables cross-member 

information sharing regarding budgets and 

fiscal information.

6. Subcommittees of the interagency group are 

composed of members that represent varied 

constituents that focus on specific issue areas.

7. A clear direction has been provided to 

subcommittees to clarify their charge from 

the larger interagency group. (Such as a logic 

model.)

Work of the Subcommittee (or 

Interagency Group if there is no 

Subcommittee)

1. Identify desired outcomes.

2. Involve agency fiscal staff.

3. Develop work plan.

4. Assign members to specific roles and tasks. 

(Chair, co-chair, etc.)

5. Identify target population service utilization in 

the agencies that purchase their care through 

contracts with providers. (Child welfare, 

juvenile justice, mental health, health, social 

services, education). (EX: children in certain 

types of out of home care). Can use last 4 

digits of SSN to keep information confidential. 

6. Identify public and private revenue types used 

to purchase services for the target population. 

(State and local General Revenue, SCHIP, 

Medicaid, United Way, Federal, State and local 

juvenile justice, mental health, education, child 

welfare and social service funds).

7. Identify which General Revenue dollars are 

matching federal revenue and which are not. 

(For those that are not, build the case to use 

them to match federal dollars).
112

8. Determine how much revenue is used to 

purchase services for how many children over 

a given period of time. Use this information 

as part of the development of a message to 

market what you are doing to key constituents. 

(Can do point in time analysis or other process 

such as a sample of children).

9. Conduct care-mapping analysis to determine 

the pathways in which the target population 

accesses the services being purchased by 

the partner agencies. (What is the process for 

accessing care, what services are currently 

being used by the target population, what 

is the average length of stay in the services 

purchased, how much are the services used 

costing each of the funders and which revenue 

streams are being used to purchase what 

services). (This can help determine the need 

for increased care coordination, identify where 

there may be duplication of effort, or provide 

incentives to change the policies for accessing 

services across agencies).

10. Determine how to initiate the integrated finance 

initiative. (Demonstration sites, county based, 

zip code based, statewide, etc.)

11. Complete a finance matrix.

12. Complete a matrix of providers and services.

13. Develop document (concept paper) 

detailing the information gained through the 

subcommittee’s work.

Solicit Top Level Support

1. If you are not a Director, strategize about how 

to involve them. Talk to them individually.

2. Identify interagency group members who will 

present information to certain key constituents 

(judges, County Commissioners, City Council 

members, State legislators, etc.).

3. Present information [concept paper, finance 

matrix, service matrix, research and other State 

examples, etc.] with key messages to the 

Director and elected officials.

4. Educate the community about what you are 

doing.

5. Include State level budget development, 

accounting and audit staff. At the county 

level include finance people from each of the 

agencies.

6. Involve federal agencies and seek federal 

approval.

7. Identify advocates and other individuals 

who can lobby on behalf of the initiative for 

legislative support and potential State policy.

Other Essential Functions

1. Provide training and technical assistance.

2. Identify who is responsible for making sure 

things get done.

3. Identify quality improvement processes.

4. Determine method of payment by fund source. 

(Cost reimbursement, case rate, fee for service, 

capitation).

5. Stipulate funds to be used.

6. Establish rates for services that will be 

purchased.

7. Identify how funds will be managed, monitored 

and allocated.

8. Develop provider network and method for 

enrollment.

9. Develop contracts with service providers.

10. Develop process for monitoring progress.

11. Develop process for reporting to funders and 

to all key constituents. 

APPENDIX J Steps for Implementing a Refinancing Initiative
Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 113

The following is a list of lessons learned by the 

individuals involved in Michigan’s integrated 

funding effort:

1. Be clear about your vision and values.

2. Decide early on whether it is to be a multisystem effort or a single system effort.

3. Decide early on whether its purpose is to 

maximize Federal revenue.

4. Define the target population, even if it is broad 

to start with.

5. Define your outcomes.

6. Be prepared for a “fear of takeover” and for 

values conflicts.

7. Understand the differences between agency 

mandates (child welfare—to protect children, 

the courts--to protect the community, 

education—to teach, mental health--to improve 

functioning).

8. Secure support from the State Department 

Directors and the Governor’s Office when 

needed. (You must have support from the 

highest levels and there must be strong 

leadership at the top.)

APPENDIX K: Lessons Learned: Michigan’s

Integrated Funding Effort

9. Involve finance staff from the beginning (don’t 

hire a finance person).

10. Use consultants as experts.

11. Copy the best ideas from other States.

12. Know the systems are always changing (like 

changing the tires on a moving bus).

13. Separate State departments do not 

document financial information in similar 

ways. (This includes how cases are counted, 

how funding sources are tracked, how 

services are funded, etc.).

14. Learn everything you can about Federal 

regulations on Federal funds.

15. Understand the Code of Federal Regulations.

16. Involve the State Medicaid Director.

17. Involve other people who know and 

understand funding rules and regulations. 

(Access Federal web sites).

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities 115

WORKSHEETS

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

PLANNING WORKSHEET

1. Goals of systems of care planning in my community are: 

2. Systems of care values and principles are evident in my community’s planning in the following ways:

3. Systems of care planning activities and tasks in my community are:

4. People who perform systems of care planning duties in my community are:

5. Questions my community should consider for systems of care planning are: 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

GOVERNANCE WORKSHEET

1. Goals for the systems of care governance structure in my community are:

2. Systems of care values and principles are evident in my community’s governance structure in the 

following ways:

3. Systems of care governance activities and tasks in my community are:

4. People who perform systems of care governance duties in my community are:

5. Questions my community should consider for systems of care governance are: 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

SYSTEM MANAGEMENT WORKSHEET

1. Systems of care management goals in my community are:

2. Systems of care values and principles are evident in my community’s system management structure 

in the following ways:

3. Systems of care management activities and tasks in my community are:

4. People who perform systems of care management duties in my community are:

5. Questions my community should consider for systems of care management are: 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

COORDINATION OF SERVICES AND SERVICE ARRAY 

WORKSHEET

1. Goals for systems of care coordination of services and service array in my community are:

2. Systems of care values and principles are evident in my community’s coordination of services and 

service array in the following ways:

3. Systems of care coordination of services and service array activities and tasks in my community are:

4. People who perform coordination of services and service array duties in my community are:

5. Questions my community should consider for systems of care coordination of services and service 

array are: 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

COMMUNICATION WORKSHEET

1. Goals for systems of care communication in my community are:

2. Systems of care values and principles are evident in communication in my community in the following 

ways:

3. Systems of care communication activities and tasks in my community are:

4. People who perform systems of care communication in my community are:

5. Questions my community should consider for systems of care communication are: 

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

POLICY WORKSHEET

1. Policy goals for my community’s system of care are:

2. Systems of care values and principles are evident in policy in my community in the following ways:

3. Systems of care policy activities and tasks in my community are:

4. People who perform systems of care policy activities and tasks in my community are:

5. Questions my community should consider for systems of care policy are:

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

FINANCE WORKSHEET

1. Goals for systems of care finance in my community are:

2. Systems of care values and principles are evident in finance in my community in the following ways:

3. Systems of care finance activities and tasks in my community are:

4. People who perform systems of care finance duties in my community are:

5. Questions my community should consider for systems of care finance are:

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

CONTINUOUS QUALITY IMPROVEMENT WORKSHEET

1. Goals for systems of care continuous quality improvement in my community are:

2. Systems of care values and principles are evident in continuous quality improvement processes in my 

community in the following ways:

3. Systems of care continuous quality improvement activities and tasks in my community are:

4. People who perform systems of care continuous quality improvement duties in my community are:

5. Questions my community should consider for systems of care continuous quality improvement are:

Improving Child Welfare Outcomes through Systems of Care: Building the Infrastructure	 	 A Guide for Communities

HUMAN RESOURCES AND STAFF DEVELOPMENT 

WORKSHEET

1. Goals for systems of care human resources and staff development in my community are:

2. Systems of care values and principles are evident in human resources and staff development activities 

in my community in the following ways:

3. Systems of care human resources and staff development activities and tasks in my community are:

4. People who perform systems of care human resources and staff development duties in my community 

are:

5. Questions my community should consider for systems of care human resources and staff development are: