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It Takes Teamwork — Systems of Care in Behavioral Healthcare
By Kelly Bauermeister, LCSW, and EAnn Ingram

Alex, a 17-year-old student, was diagnosed with a severe case of attention-deficit/hyperactivity disorder (ADHD) early in his high school career. He was struggling to concentrate in school and had been failing several classes. His impulse control was poor, and he was increasingly causing trouble both in the classroom and at home.

As his academic performance declined and his behavior worsened, Alex was reprimanded by his family and teachers and had his first run-in with the police. He was sent to counselors for treatment, but he never really took his treatment programs seriously. Goals and rules were dictated to him, and his treatment often seemed more like a punishment than a program designed to help him.

Alex got progressively worse and became isolated from his peers, teachers, and parents. He was headed down a path of self-destruction and was pulling his family down with him.

A second run-in with the law made it clear that Alex and his family needed a new way to deal with his problems. To help change Alex’s course, the court referred him to a federally funded system of care program that would change the type of care and support Alex received by creating a specialized wraparound process that involved both Alex and his family. Alex’s participation in the wraparound process was different; it involved everyone in his life—teachers, coaches, and community leaders—and let him play a significant role in creating a collaborative plan for his support and treatment.

With this support system, Alex learned more about his ADHD diagnosis, how to deal with his symptoms, and how to lead a productive life. Within months, his grades improved, trouble at home and school were practically eliminated, and his entire life turned around. Today, Alex speaks in public at county commission meetings and civic clubs as an advocate and living testament for systems of care.

What Are Systems of Care?
A system of care, a coordinated network of community services and supports, involves a youth’s entire care team. Instead of child agencies working in isolation and creating separate plans of care, these agencies—including schools, mental health providers, juvenile justice departments, and the Department of Children’s Services—work together with a child or an adolescent and his or her family to create and implement a collaborative and personalized approach to treatment. Systems of care are not a new approach to care, but their prevalence has increased significantly over the last decade in communities across the country.

All systems of care feature three core values: They are child centered and family driven, community based, and culturally competent. Systems of care programs also seek to reduce the stigma associated with the mental health needs of children and youth and focus on keeping youth in their communities. Too often, youths with severe behavioral health problems are sent out of the community to receive care, and they return without a local support system and the ability to function within their community. Systems of care help establish a local support system for each youth that helps teach them how to live a successful and productive life in tandem with their disorders.

In Alex’s case, his system of care made him a part of the decision-making process in his individualized support program. His mom, school counselor, probation officer, and high school basketball coach joined together with him in the decision and goal-making processes of his care. Together, they built a child and family team that assisted him in reaching his specific goals. Alex and his team were also assigned a community liaison and a family support provider that would help coordinate frequent team meetings to make sure his plan was on track and being consistently implemented.

Who Needs a System of Care?
The children who benefit most from a system of care program are those who have been in legal trouble or are at risk of being expelled or removed from their home, school, or community. In fact, according to the President’s New Freedom Commission on Mental Health report (2003), 5% to 9% of all U.S. youths have a reduced ability to function in the community, at school, and at home due to serious mental health needs.

It is common for families of children with behavioral problems to be blamed for the child’s problems. Communities assume there are issues within the family causing the disturbance. Systems of care are especially positive for these children and their families because, in a system of care, blame for the child’s behavioral problem is removed from the family, and the family is in turn made an expert in both the problem and its solution.

The Benefits
Systems of care have been proven to increase school performance and decrease behavioral issues for youth who have entered a system of care program. According to the 2008 Helping Youth Thrive in the Community report from the Substance Abuse and Mental Health Services Administration (SAMHSA), 73% of youth in a system of care received passing grades (a C or better) after 18 months of receiving services—a 31% increase from the time they entered a system of care program. The report also states that youths in systems of care have significantly fewer disciplinary problems. After 18 months of treatment in a system of care, the percentage of youth suspended or expelled from school was reduced 44%, from 52% to 29%.

Addressing a child’s mental health needs through a system of care has also been proven to help reduce overall strain in the household. In a 2004 national evaluation on grant communities funded from 1998 to 2000 by the Center for Mental Health Services (CMHS), it was reported that more than 93% of families and caregivers in a system of care reported decreased or stabilized strain associated with caring for a child or an adolescent with serious emotional needs. After 30 months in a system of care program, family functioning improved in more than one quarter of families in treatment and remained stable in more than one half of the families surveyed.

Additionally, systems of care have been proven to improve caregivers’ employment and income status. An update from the CMHS national evaluation stated that 18 months after beginning a system of care program, caregivers with an annual income of less than $15,000 reported improvements in job-related, vocational, and educational skills and increased earnings. In addition, 22.2% of families reported having more time and social support after 30 months in a system of care.

In addition to improved outcomes in a child’s care and within the family, systems of care can also help manage community resources. According to the 2008 SAMHSA report, children and youth involved in systems of care experience fewer arrests, saving juvenile justice systems nationwide an average cost of $808.32 per youth after six months in a system of care. Systems of care also ensure organizations aren’t duplicating resources on a child’s treatment. When community entities work together and form a collaborative treatment plan, systems of care can be an extremely cost-effective way to meet a child’s treatment needs.

The Future for Systems of Care
Though it may seem like a logical and simple way to provide care for at-risk youth, there are still hurdles that may have to be crossed to make a system of care possible in all communities. A system of care requires the cooperation of many parties—social service agencies, public officials, community leaders, legal authorities, and educators, to name a few.

Limited time and resources can make it difficult for these constituencies to collaborate effectively. In some communities, there may be resources or funding available to pool between agencies to establish a system of care program, or there may be state or federal funding available. However, No Child Left Behind law and state Medicaid regulations can impede the ease with which these programs can be implemented in schools and communities.

If systems of care are not currently available in your community, there are steps that can be taken to introduce them to your community leaders. The process typically begins with educators, mental health agencies, social workers, and juvenile justice representatives coming together to discuss collaboration and how a system of care might be established in their community.

There is no standard format for system of care. In some cases, systems of care have been established with a formal infrastructure that includes a steering committee, bylaws, and policies. In other cases, communities have established a more loosely affiliated network where social workers, medical professionals, and educators work together with an informal commitment to collaboration.

Regardless of exactly how systems of care programs are structured, there is evidence of their increasing success and positive impact within communities. There are multiple stories, such as Alex’s, that demonstrate how a system of care—and collaborative support from a child’s family, school, and community—is often the change a child needs to find successful treatment and management for their behavior healthcare needs.

— Kelly Bauermeister, LCSW, is director of child and adolescent services at Centerstone of Indiana.

— EAnn Ingram is the project director for the Mule Town Family Network, a partnership among the Tennessee Department of Mental Health and Developmental Disabilities, Centerstone, Tennessee Voices for Children, and other community partners.