Sharon Hodges

Building Upon the Theory of Change for Systems of Care

The concept of systems of care for children with serious emotional disturbance and their families is described in this article as an explicit organizational philosophy that emphasizes services that are family focused, individualized, provided in the least restrictive environment, coordinated among multiple agencies, and culturally competent. This conceptualization is contrasted with the view of systems of care as discrete interventions causally related to improving child-level outcomes. Systems of care are presented as mutable strategies for improving organizational relationships that are best judged by outcomes focused at the organizational level. Rethinking and expanding the theory of change underlying systems of care are recommended in order to support development of the knowledge base for understanding what systems of care are, what they are not, and what they can be expected to accomplish.

Systems of care, featherless bipeds, and the measure of all things.

For more than 20 years, the system of care philosophy has comprised a central strategy of service reform in childrens mental health at the federal, state, tribal, and local levels. System of care terminology has become widely used in many different service sectors but often without a shared understanding of what a system of care is. This manuscript, the feature article for this special issue of Evaluation and Program Planning, briefly traces the history of the system of care movement, discusses the more widely used definitions in the field of childrens mental health, and offers an expanded version of the definition that takes into account the complex nature of systems of care. This manuscript was the product of a process used by the Case Studies of System Implementation research team to identify established system of care communities for inclusion in the research study. The purpose of this manuscript is to describe the process the research team engaged in while developing the revised definition and to open a public dialogue about how to characterize the essential properties of a system of care.

How organizational culture influences outcome information utilization

This article reports the results of a study of organizational culture and the local-level utilization of the client outcome information data that is generated as part of a continuous evaluation of the Texas Childrens Mental Health Plan. An in-depth study of utilization patterns was conducted at four local mental health authorities. Findings demonstrate that using outcome information in organizational decision making is grounded in the organizational culture of the information users. Developing a better understanding of the organizational culture in which a quality improvement process is implemented can provide insight into what strategies an organization might undertake to improve readiness for implementation.

A Developmental Framework for Collaboration in Child-Serving Agencies

Collaboration for the purpose of interdependent problem solving represents a fundamental reform of services for children with serious emotional disturbance and their families, which have typically been categorical, poorly coordinated, costly, overly restrictive, and frequently provided outside of the childrens home communities. This article presents a developmental framework for collaboration that is based on the experience of families, service providers, administrators, and community members who have been involved in local collaborative processes in their own communities. The framework provides those interested in building collaboration a clear identification of the stages of collaborative development, defining characteristics of each stage, collaborative activities typical of that stage, and identification of the catalyst for change to the next stage. The results of this project indicate that while well-developed professional collaboration is a necessary component of collaboration, it is not sufficient in and of itself. The sites participating in this project related their experiences in building collaborative processes to both the development of strong interagency collaborations and the development of family participation. Their experience indicates that these two processes must be fully developed and woven together to achieve the goal of true collaboration.

“If We're Going to Change Things, It Has to Be Systemic:” Systems Change in Children's Mental Health

Communities that undertake systems change in accordance with the system of care philosophy commit to creating new systems entities for children and adolescents with serious emotional disturbance. These new entities are values-based, voluntary, and cross-agency alliances that include formal child-serving entities, youth, and families. Describing the scope and intent of one such implementation of systems of care, a mental health administrator commented, “If we’re going to change things, it has to be systemic” (B. Baxter, personal communication, December 2, 2005). This paper explores the concept of “systemic” in the context of systems of care. Systems theory is used to understand strategies of purposeful systems change undertaken by stakeholders in established system of care communities. The paper presents a conceptual model of systems change for systems of care that is grounded in data from a national study of system of care implementation (Research and Training Center for Children’s Mental Health in Case Studies of system implementation: Holistic approaches to studying community-based systems of care: Study 2, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, Tampa, FL, 2004). The model is based on Soft Systems Methodology, an application of systems theory developed to facilitate practical action around systems change in human systems (Checkland in Systems thinking, systems practice, Wiley, Chichester, 1999). The implications of these findings to real world actions associated with systems change in systems of care are discussed.

The use of qualitative methods in systems of care research.

In an effort to understand the impact of qualitative methods on the field of children’s mental health, a review of the proceedings of the University of South Florida’s Research and Training Center for Children’s Mental Health (RTC) conferences from 1988 through 2003 was conducted. One hundred presentations published in the proceedings were identified as meeting criteria for inclusion as qualitative research. Data regarding title, topic, researchers, funders, methodology, and results were collected and reviewed across studies to identify patterns and themes. Results revealed that the number of qualitative studies presented at the conference and included in the proceedings since the inception of the conference in 1988 has increased. Understanding stakeholder perspectives and system and service delivery descriptions were among the most common topics of study. Most studies did not specify research design independently of describing methods used and did not specify the method used to analyze data. Recommendations are provided to improve future qualitative research to advance knowledge in children’s mental health.

Who's in Charge Here? Structures for Collaborative Governance in Children's Mental Health

Communities increasingly use community coalitions to promote collaborative action and community-based problem solving. This article presents research findings on governance structures and interagency collaboration in childrens mental health. Specific governance structures are discussed, as well as lessons in collaborative governance applicable to coalitions serving a variety of community needs.

Challenge and opportunity in children's mental health research.

Children’s mental health services research is both challenged and enriched by the complex environment of services and supports that exist for children and their families. It is a context in which the structures and processes that define children’s mental health are diffused across multiple sectors and the pathways to care are unclear, unavailable, and often inappropriate for the children and families most in need of services and support. This context presents a challenging research environment because it requires the development of knowledge and understanding within diffused service settings, across multiple and often multifaceted funding and service structures, and in collaboration with multiple stakeholders and an array of public and private agencies. The complexity of the research environment in which children’s mental health research is conducted creates methodological challenges that make it difficult for researchers to study phenomena objectively and independently of the natural service delivery settings. How do we understand the functioning of children’s service systems when they are composed of so many individual and dynamic parts? How do we understand the individual components of systems when we cannot isolate them from their multiple influences and interconnections? Either way, this makes for a research environment in which there are no clear starting points, it is difficult to isolate an intervention or create a control group, and researchers cannot assume that any variables are truly independent. Yet, these issues are faced daily in children’s mental health services research. This complex research environment also offers advantages. It is rich in opportunities to build knowledge that is based on experience and context, to build evidence of what works, and provide understanding of how successful service delivery models can be adapted to meet local needs. This special issue of the Journal of Behavioral Health Services & Research (JBHS&R) on qualitative methods explores that opportunity. The goal of this special issue is to examine the process of conducting research in the real-world settings of children’s mental health and to learn more about those settings from the people who are part of them. The use of qualitative methods to build the knowledge base in children’s mental health services research is growing. Qualitative research methods are valued in developing knowledge through experience and context, in understanding multiple perspectives on an issue or topic, and in understanding the complexity in which phenomena exist. Because child-serving environments

The Promise of Family Engagement: An Action Plan for System-Level Policy and Advocacy

In its blueprint for mental healthcare reform, the President’s New Freedom Commission outlined a plan for system transformation that prioritized consumer and family-driven care (2003). This federal policy position came on the heels of the Surgeon General’s Report on Children’s Mental Health (1999), advocating an integrated service system model that is inclusive of family engagement. Children’s mental health policy affects children, youth, and families at both the individual treatment level and the system level. The individual level refers to the ways in which direct care staff members interact with individual youth, families, and their support systems in the planning and delivery of services and supports (Rosenblatt, 1998). In contrast, the system level refers to the structural, administrative, and fiscal organization of a continuum of services and supports including linkages between child-serving agencies such as mental health, child welfare, juvenile justice, and education in a community-based setting (Rosenblatt, 1998). Although the past 20 years have marked significant expansion in the role of families in individual treatment-level decision making (Hoagwood, 2005), consistent and meaningful engagement of families in system-level policy action has been much more difficult to accomplish. Knitzer and Cooper (2006) note considerable variation across states related to family advocacy as well as value-driven conflict around family empowerment in system-level decision making.

A Multilevel Framework for Local Policy Development and Implementation

Children and families deserve to have confidence that the services and supports they receive are the most effective interventions available. The concept of evidence-based and promising practices has developed as a strategy for achieving improved mental health outcomes for children and families in recent years, and the implementation of evidence-based and promising practices has grown more influential in the United States (Raghavan, Bright, & Shadoin, 2008; Tanenbaum, 2003). The term evidence-based practices (sometimes called EBPs) refers to prevention or treatment approaches that are supported by documented scientific evidence (e.g., research results from randomized or quasi-experimental designs). Promising practices are those which, although lacking a rigorous base of research evidence, show promising field-based or theoretical support. These might include locally developed services and supports intended to meet the specific strengths and needs of local populations.