A History of Systems of Care &Wraparound: National & RI Perspectives

A History of Systems of Care &Wraparound:National & RI Perspectives This section covers: The National System of Care Movement The Rhode Island System of Care Movement

Learning Objectives After learning this material, you should be able to: • List the benefits of Systems of Care (SOC) and Wraparound • Describe the origins of SOC and Wraparound • Explain Rhode Island’s SOC transformation Click to Continue

What are the benefits of this systemic change and practice method? Why Systems of Care and Wraparound?

Reflection Activity • What has worked well for children and families in Rhode Island’s current system? • What could be even better? Click here to see some of the systemic concerns that prompted the System of Care (SOC) movement… Take a few minutes to reflect on your experience as a human services professional.

What Prompted the SOC Movement? • The systems of care approach was originally created in response to concerns that: • Children in need of mental health treatment were not getting the services they needed • Services were often provided in restrictive out-of-home settings • Few community-based services were available • Service providers did not work together • Families were not adequately involved in their child's care • Cultural differences were rarely taken into account U.S. DHHS, Administration for Children and Families, Child Welfare Information Gateway

The Willie M. Story 1970s in North Carolina “By age 10, Willie had so many problems getting along with his family that a social worker had to be called in - enter the Division of Social Services within the state Department of Human Resources (DHR) and a county department of social services. Two years later, the troubled youngster started stealing from his elementary school and landed in juvenile court - enter the judicial system and the Administrative Office of the Courts. The local judge tried to find a placement for Willie, but various treatment programs wouldn‘t accept a child of his young age and with his mix of emotional and mental handicaps. Having no other option, the local judge sent Willie to a state training school hoping that the contained environment might set him straight-enter the Division of Youth Services, also within DHR.” Source: "Willie M." Treatment for Disturbed Young5ters Ambitious Community -Based Service System Lurches Forward by Kendall Guthrie and Bill Finger Continued…

The Willie M. Story “This training school, even after putting Willie in its special treatment ward, made no progress. Willie would either assault the staff or whimper in a corner, sucking his thumb. Perhaps special education and psychiatric help within a state mental institution could help Willie, the training school officials decided - enter the Division of Mental Health, Mental Retardation, and Substance Abuse Services, within DHR, and the Department of Public Instruction, which distributes state money for special education. But Willie couldn't cope with the specialized learning programs either.” Source: "Willie M." Treatment for Disturbed Young5ters Ambitious Community -Based Service System Lurches Forward by Kendall Guthrie and Bill Finger Continued…

The Willie M. Story “In frustration, the mental hospital discharged him to court officials back home. The court tried to find a suitable foster care placement, but Willie couldn't function in the school system. Too violent for adolescent wards, too young for adult treatment, too smart for mental retardation centers, but too volatile for special education classes in public schools - Willie didn't fit anywhere.” How many parts of the system was Willie M. exposed to at such an early age? And why couldn’t he get help? Source: "Willie M." Treatment for Disturbed Young5ters Ambitious Community -Based Service System Lurches Forward by Kendall Guthrie and Bill Finger Continued…

The Willie M. Story Answer: “Six different state agencies and various judicial offices had tried to deal with Willie. But in the vast state services delivery system, there seemed to be no niche that could help him. Apparently, no means existed among these agency officials to forge a new system to draw on available services and find a way to help Willie prepare for adulthood.” Willie and others like him had no options…so what would become of Willie? ENTER-THE WILLIE M. CLASS ACTION LAWSUIT Source: "Willie M." Treatment for Disturbed Young5ters Ambitious Community -Based Service System Lurches Forward by Kendall Guthrie and Bill Finger Continued…

The Willie M. Class Action Lawsuit • Since the mid-1970s, mental health officials, social workers, and juvenile court officials had recognized the lack of treatment facilities for violent and emotionally disturbed youth. • Judges found themselves sending the children to training schools, not because they had a record of serious criminal activity but because no one else would take them. • In September 1979, seven attorneys from five private firms and two public interest agencies filed a class-action lawsuit in Federal District Court in Charlotte, NC (Willie's home) on behalf of four named plaintiffs, the first of whom was Willie. Continued…

Results • In 1980, settlement of the lawsuit stipulated that the state of North Carolina create almost a whole new service delivery system for SED children, ranging from highly restrictive residential programs to daytime therapy in a child's home. • The lawsuit forced officials to spend $744 million over two decades to help these children. • The lawsuit fostered interagency collaboration, placement in least restrictive environments and the creation of new services and treatment centers in a timely fashion to meet a child’s needs. • The lawsuit helped many children once thought to be beyond help. It became a national model and one of the first Systems of Care in the country.

Results “Today, mental health officials hail the Willie M. program as a landmark experiment, a giant step forward in the way North Carolina - and the nation - cares for mentally ill children.” Source: www.newsobserver.com Willie M., then 10 or 11, shakes hands with former Governor Jim Hunt at the ribbon-cutting ceremony for the Whitaker School in Butner, one of many so-called 'Willie M.' schools opened after the lawsuit.

What is so special about a System of Care and Wraparound? • Think about the children and families you have worked with…are any of their stories similar to Willie M.’s? • What systemic and practice changes would have helped? Consider how SOC and Wraparound can help…

What is a System of Care (SOC)? • A System of Care incorporates a broad array of services and supports that is organized into a coordinated network, integrates care planning and management across multiple levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery and policy levels. System of Care Movement, www.soc-mo.dmh.mo.gov

SOC adheres to these values… • Family-driven and youth guided • Home and community-based • Strength-based and individualized • Culturally and linguistically competent • Integrated across systems • Connected to natural support networks • Data-driven and outcomes-oriented

…which come alive in the Wraparound Practice Method • A team-based planning process intended to provide individualized, coordinated, family-driven care to meet the complex needs of children and youth who are at risk of becoming involved or who are involved with one or more of DCYF’s divisions: • Child welfare • Children’s behavioral health • Juvenile corrections services • The Wraparound process requires that families, providers and key members of the family’s social support network collaborate to build a creative plan and engage in shared decision making to: • Respond to the particular needs of the child and family • Identify services that are flexibly adjusted as the family’s needs change What is Wraparound?

Family voice and choice Team based Culturally competent Collaboration Community-based Individualized Strength based Unconditional care Outcome based Natural supports Wraparound Practice is Guided by 10 Principles Stay tuned for more on this in the Fundamentals module…

WhyWraparound? • Wraparound puts System of Care values and principles into practice for service planning and provision • It is familiar to us since we already strive to be family centered • Research proved to us that the outcomes over many years are promising! • And even though we are in the beginning stages of our System of Care transformation in RI, we are already seeing positive outcomes.

Early Positive Signs in RI… Over the past five years DCYF has: • Reduced the number of children in residential care by over 30% • Reduced the number of youth placed out of state by over 50% from 2007 -2010 • Reduced the number of child maltreatment victims 18% from 4,400 in 2006 to 3,620 in 2010 • Lowered the number of children entering out of home care by 27% from 1,893 in 2006 to 1,380 in 2010 • Developed and implemented Phase I of the System of Care (FCCP) as a front end diversionary program that has successfully reduced the number of families becoming open to the Department and reduced the number of children in our care 19

The SOC and Wraparound helps Families, Community Partners and DCYF by… • Families • Validating natural supports • Improving permanency outcomes • Building capacity in neighborhoods • Community • Improving quality • of care • Experiencing greater satisfaction • Promoting shared responsibility & accountability • DCYF • Improving quality of care • Ensuring least restrictive placements • Reducing length of time in care

Now that we understand a bit about Systems of Care and Wraparound Practice… …and have learned why Rhode Island chose this route for our system and families… …let’s take a look at the origins of SOC and Wraparound.

When, where and how did SOC and Wraparound evolve? Origins of Systems of Care and Wraparound Practice

How did the SOC Movement Begin? • In the 1970s, intense advocacy from family, community, and professional groups resulted in national policy initiatives, commissions, and seminal reports addressing these problems. • Two early milestones were: • In 1978, President Jimmy Carter established the President’s Commission on Mental Health to “conduct such public hearings, inquiries, and studies as may be necessary to identify the mental health needs of the Nation.” The American Presidency Project • In 1982, Jane Knitzer’s publication, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services reported: • “(1) an overview of problems and policy issues regarding the delivery of mental health services to children and adolescents, (2) the results from a 50-state survey of state officials concerned with children's mental health and a discussion of the roles other state agencies play in delivering mental health services to children, and (3) a state-by-state analysis of statutes to voluntarily commit children to psychiatric institutions.” www.eric.ed.gov, ED223346 Excerpted from the Annual Report to Congress on the Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program, Center for Mental Health Services Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services SAMHSA Web Center for Mental Health Services (CMHS). 3/2001.

How did the SOC Movement Begin? • In response to the many calls for action, Congress appropriated funds for a new children’s mental health initiative in 1984, and the landscape of services for this population began to change. • “Under the Children’s Mental Health Initiative of 1984, the Substance Abuse and Mental Health Services Administration (SAMHSA) developed a federal program to promote and support a systems of care philosophy. This was the first federally organized effort to provide funding and help states design systems of care to deal with children’s mental health needs.” http://www.livestrong.com/article/166275-a-system-of-care-for-childrens-mental-health/#ixzz1VOCQPJeL

Some early SOC efforts & successes… • In the 1970s Karl Dennis , then the Executive Director of Kaleidoscope, Inc. in Chicago, IL, and his colleagues pioneered what later came to be known as “wraparound services” for children in foster care. • Kaleidoscope also was one of the first programs in the United States to provide intensive in-home services to foster care children and to offer therapeutic foster care. • Mr. Dennis and his colleagues found that “84% of those (SED) youth could be kept at home with their own families if we correctly provided services to those families.” (pg. 5, Dennis & Lourie, 2006).

Some early SOC efforts & successes continued… • In 1980 the Willie M. class action lawsuit settlement (profiled earlier in this presentation) led to the creation of therapeutic foster homes, interagency collaboration, and the start of Wraparound practices in North Carolina. • In 1984 the Alaska Youth Initiative was formed and resulted in returning almost all youth with complex needs who had been placed in out-of-state institutions to their communities; over 30 other states replicated this initiative. Click underlined words for more information

Large Scale SOC and Wraparound Practice is Born • In response to the Willie M. settlement, Dr. Lenore Behar, Wraparound pioneer and former director of North Carolina’s Mental Health Agency, piloted an integrated approach to services in North Carolina • This became the first large scale SOC in the U.S. • Dr. Behar coined the term “Wraparound” based on the concept of “no eject, no reject” (i.e., care and services for every child for as long as they need care and services). Click underlined words for more information

The National SOC Movement • The diagram that spans the next 3 slides depicts the progression of supportive legislation and funding that helped to shape the current Systems of Care across the country.

Support for the SOC Movement

Do you see evidence of how these values are supported by the legislation & funding? • Family-driven and youth guided • Home and community-based • Strength-based and individualized • Culturally and linguistically competent • Integrated across systems • Connected to natural support networks • Data-driven and outcomes-oriented

The National System of Care and Wraparound Movement has come to Rhode Island. Let’s take a look at our transformation. Logo courtesy of the National Wraparound Initiative web site: http://www.nwi.pdx.edu

What systemic preparations have we made in Rhode Island? Where are we currently in the change process? Rhode Island’s System of Care Transformation

DCYF is building capacity on so many levels to support SOC in Rhode Island… THE POLICY LEVEL (financing, rates, statutory, regulatory) THE MANAGEMENT LEVEL (data, quality improvement, human resources development, system organization) THE DIRECT PRACTICE LEVEL (assessment, care planning, care management, service/supports provision) THE COMMUNITY LEVEL (partnership with families, youth, natural helpers, community built-in) Pires, S. (2006). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

The transformation to SOC looks like this… FROM Fragmented service delivery Categorical programs/funding Limited services Reactive, crisis-oriented Focus on out-of-home placements Children out-of-home Centralized authority Creation of “dependency” TO Coordinated service delivery Blended resources Comprehensive services/supports array Focus on prevention/early intervention Individualized services & supports in least restrictive, normalized environments Children within families Community-based ownership Creation of “self-help” Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

Focus on Change • The Department has led an intensive multi-year effort to educate the staff, all branches of government, the community and the providers that a system transformation is needed. • System transformation reflects “best practices”, cost efficiencies and is aligned with our federal Program Improvement Plan goals. • The system is changing because we, along with our system partners, are committed to the change in philosophy….that we should provide services in the least restrictive, community-based setting appropriate for the child and their family. • As a result of the system changes, including implementation of Phase I of the System of Care, between 2007 and 2011, the average DCYF funded residential census has been reduced by 37% from 1012 to 641. (All residential placements have been reduced 38% from 1202 to 746 today.)

1989, CASSP– Child and Adolescent Service System Program (Infrastructure) Grant , SAMHSA 1991-Present, Statewide Family Network Grant 1992, Project REACH grant – Center for Mental Health Services (youth with serious emotional disorders and their families) 1997, Project HOPE grant – Center for Mental Health Services (youth adjudicated) SAMHSA 2003, Report of RI System of Care Task Force: Toward An Organized System of Care for RI’s Children, Youth and Families 2005, RI Positive Educational Partnership – Center for Mental Health Services (early childhood and positive behavior supports and interventions) SAMHSA 2009, Implemented RI Family Care Community Partnerships (FCCPs) 2011/2012, Established Networks of Care Rhode Island System of Care History

Rhode Island’s SOC Movement Phase I (2009) The Networks of Care and DCYF provide effective community based services and supports using a wraparound planning model to children, youth and families open to DCYF Referrals are made by DCYF to the Networks of Care Phase II (2011-2012) • The FCCPs provide effective community-based services and supports using a wraparound planning model to children and families not open to DCYF • Referrals are made by DCYF, other community agencies, or families themselves

What are the Family Care Community Partnerships (FCCP-Phase I)? • A formal collaborative structure for joint planning and decision-making through which community partners take collective responsibility for development and implementation of system of care and high fidelity Wraparound process. • Service delivery processes are organized through four regional “FCCP Lead” agencies who are the fiscal agents responsible for: • Building partnerships • Developing a comprehensive network of available formal and informal services and supports • FCCP providers, including all formal and informal community partners take collective responsibility for the development and implementation of system of care and high fidelity Wraparound process for eligible families. 40

Who are the Family Care Community Partnerships?

Who is Eligible for FCCP-Phase I? Children and families who are: • At risk for child abuse, neglect and/or dependency and DCYF involvement • Children birth to age 18 years old who meet criteria for having a serious emotional disturbance (SED) • Youth with SED 18 to 21 years old in accordance with DCYF Policy 700.0240, Services to Youth Ages 18-21 • Youth concluding sentence to the Rhode Island Training School (RITS) who agree to participate, including youth leaving the RITS and youth leaving temporary community placement (TCP)

What is a Network of Care (NOC-Phase II)? • Similar to the FCCPs, Networks of Care are “comprised of a Network Lead and collaborative, interdependent agencies and stakeholders united by written contracts or agreements and possessing the capacity to” meet the needs of referred children, youth and families while adhering to System of Care and Wraparound values, principles and practices. • The Network Lead and its partners must have the capacity to provide comprehensive, quality, timely services to referred children, youth and families. Rhode Island Partnership for Family and Community System of Care – Phase II – Networks of Care DCYF, Request for Proposals, June 2011

How are referrals made to the Networks of Care? • “The Department will assign children, youth and families to a Network of Care in a manner that ensures equitable distribution as to type of placement, locality and level of intensity.” • “The Department will screen each child, youth and family utilizing a standardized process and make recommendations regarding need to the Network.” • “Networks of Care must accept all referrals and may not refuse or reject any Department referrals.” Rhode Island Partnership for Family and Community System of Care – Phase II – Networks of Care – DCYF, Request for Proposals, June 2011

Networks of Care - Phase II • There will be two Lead Agencies with RI’s Networks of Care. • Contract negotiations are underway and are expected to be finalized before the end of the year. • In order to insure the best transition, Phase II will be implemented incrementally beginning with: • Children & youth in congregant care – paid residential and treatment foster care • Any family whose child or youth’s placement changes to congregant care • Decisions regarding the transition of additional children, youth & families into the Network of Care are underway for the following groups: • Children and youth in DCYF (generic) foster care • Children and youth in kinship care • Children and youth being maintained in the home

Eligibility Requirements for the Networks of Care-Phase II? • Children and youth from birth to age 18 with the exceptions specified by state law, and their families. Also youth to age 19 referred because of juvenile justice involvement and children and youth to age 21 who are diagnosed with a serious emotional disturbance (SED). • These children, youth and/or their families will be open to the Department and will have service needs not covered by other funding sources. • These children, youth and families will include but not be limited to those under legal supervision or commitment, in temporary custody, under legal guardianship, in voluntary placement or adjudicated wayward/delinquent. • The service population does not include children, youth and families served by or eligible for services from the Family Care Community Partnerships.

As we transform our system in Rhode Island, we are building opportunities to work as a team to improve outcomes for children and families. ~~~~~ To support you in this transformation, the modules that follow will provide an overview of the Language, Roles, Phases and Practices of SOC and Wraparound Team Meeting Methods.

Phases Engagement and Preparation Planning Service Implementation Transition “New” Practices/Terms Strengths, Needs & Culture Discovery Functional Assessments Crisis Plans Wrap Plans Transition Plans RI is Building Opportunities Family Natural Supports Professionals Supports - community schools, child welfare, etc… Rhode Island’s System of Care Roles Family (Voice & Choice) DCYF Network Care Coordinators Family Support Resources Natural Supports Team Meeting Joining together across roles and systems to support the family on their journey to achieving their goals (safety, permanency, well-being, etc.) W R A P A R O U N D W R A P A R O U N D Rhode Island’s System of Care

Quiz To receive credit for Module I, you will need to complete an online quiz. To take the quiz, you will need to provide the following indentifying information: • Last name • First name • Month you were born in • Name of the agency you work for The Child Welfare Institute will maintain the confidentiality of all data and information associated with your participation on the quiz. • Click on the link below to take the Module 1 Quiz: https://docs.google.com/spreadsheet/viewform?formkey=dDl4MDNudndZQWZtMDVRMmtJTEJQLXc6MQ

References and Resources • A System of Care for Children's Mental Health by Sandi Busch , July 5, 2010 http://www.livestrong.com/article/166275-a-system-of-care-for-childrens-mental-health • Dennis, Karl and Lourie, Ira (2006) Everything is NORMAL Until Proven Otherwise, A Book About Wraparound Services. CWLA Press, Washington D.C. • Excerpts from presentation by Janet Anderson, Ed.D, Assistant Director of DCYF for Community Services and Behavioral Health at the Child Abuse Prevention and Children’s Mental Health Summit, June 6, 2011, Newport, RI entitled, Understanding National Trends and Best Practices: Rhode Island's Family Care Community Partnerships • Excerpts from the Annual Report to Congress on the Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program, Center for Mental Health Services Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services SAMHSA Web Center for Mental Health Services (CMHS) 3/2001. • National Wraparound Initiative, www.nwi.pdx.edu • RI Department of Children, Youth and Families (2011). Request for Proposals, Rhode Island Partnership for Family and Community System of Care – Phase II Networks of Care.

A History of Systems of Care &Wraparound: National & RI Perspectives