System Of Care Philosophy Research Articles

A Comprehensive Review of Wraparound Care Coordination Research, 1986–2014

Wraparound is a team-based care coordination strategy for children and youth with complex behavioral health needs and their families. Despite widespread adoption, a review of the literature pertaining to Wraparound has not previously been conducted. To address this gap, we conducted a comprehensive review, ultimately identifying 206 unique Wraparound-related publications in peer-reviewed outlets. We then coded and analyzed the publications’ methods, main foci, measures, and findings. Eighty-three publications (40%) were non-empirical, most of which focused on defining Wraparound and advocating for its use, largely based on its alignment with the System of Care philosophy. Among empirical studies (n = 123; 60%), 22 controlled studies were found, most finding positive or mixed evidence for Wraparound’s effectiveness. Other empirical studies examined implementation issues such as necessary system conditions and measurement and influence of fidelity. Major gaps include rigorous tests of Wraparound’s change mechanisms, workforce development models, peer support, and the use of specific treatments. We conclude that literature produced to date has provided useful information about Wraparound’s core components, program-level and system-level implementation supports, and applicability across systems and populations, as well as preliminary information about effectiveness and cost-effectiveness. The Wraparound research base would, however, benefit from additional studies of the model’s intervention and implementation components, as well as more rigorous effectiveness studies.

Educational outcomes in a system of care for children with emotional disturbance.

In North Carolina, only 69% of high school students graduate in 4 years; however, recent data suggest that only 42% of students with mental and emotional disabilities graduate. MeckCARES, a system of care (SOC) in Mecklenburg County, North Carolina, is designed to serve youth with severe emotional disturbances and their families. The SOC philosophy is a prominent family-focused approach intended to provide comprehensive, coordinated networks of services, tailored to the needs of the child and family, while emphasizing the strengthening of natural community supports. In addition to other mental health objectives, a particular goal of MeckCARES is to address specific school-based needs of system-identified youth to improve educational outcomes and reduce the risk of dropping out. This study sought to assess empirically the impact that enrollment in MeckCARES has on graduation precursors; namely, grades, suspensions, and absences. This study found that, on average, enrollment in MeckCARES is not associated with positive changes in educational variables. Implications of these findings are discussed, as are future directions. For example, additional research is needed with more sensitive measurement and data collection procedures (i.e., access to graduation rates and Medicaid information) to adequately assess the impact of enrollment in MeckCARES on educational outcomes.

Systems of Care: The Story Behind the Numbers

This article presents a brief description of a longitudinal study of system-level change, offers observations about what has been learned about the evolution of systems of care from the unique and qualified perspectives of the group of site visitors who gathered the data for the study, and identifies a set of issues that needs to be addressed to advance the system of care model in community based care of children and youth with behavioral health needs and their families. The article describes the system of care assessment portion of the national evaluation of the Federal Children's Mental Health Initiative and presents a brief summary of accumulated findings from the assessments conducted in communities funded in six successive waves of awards to provide context for the site visitors' observations and the authors' recommendations. The authors draw upon the expert observations of the site visitors, who represent many different disciplines and backgrounds, which suggest that, as a set of guiding principles, the system of care philosophy and approach seem to have become accepted standards of program practice and system operation in the funded sites, although implementation is uneven across principles and sites. The article concludes with the authors' identification of high-level system issues that must be addressed more effectively if systems of care are to come to scale.

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 children's 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 children's 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.

Wraparound

ABSTRACT Wraparound has grown in stature as a way to provide services to some of the neediest children and families in the foster care system. With this growth there is a need for clarification of Wraparound's definition, a description of its development, and an understanding of where it fits within the field of child welfare. The purpose of this paper is to clarify the definition of Wraparound, as well as its relationship with the closely linked system of care philosophy, before discussing its emergence from the field of mental health and use in child welfare. This clarity is necessary for successful research, evaluation, policy-making, and practice.

The U.S. Child Welfare System: A De Facto Public Behavioral Health Care System

At a recent child protection hearing, a presiding judge was heard to query “What is a child with emotional problems doing in foster care?” The implication of this question was the judge's underlying belief that if a child who was a ward of the state had an emotional or behavioral disorder, then surely he or she should be in specialized foster care, residential treatment, or a psychiatric hospital. Although for many who have worked in child welfare setting, this question reveals a startling level of naiveté on the part of the judge, this quote eloquently illustrates the importance of the work published by Barbara Burns and her colleagues in this issue of the Journal. If, in fact, half of the children in the child welfare system have clinically significant emotional or behavioral problems, then the child welfare system is a de facto behavioral health care system. Recognition of this reality by all child welfare system partners is the first step to addressing the complex needs of involved youths. Considering current system funding levels, there is absolutely no way any state could afford to address these needs by placing half of their children in specialty treatment settings. Unfortunately, as Burns et al. demonstrate and the judge's comments might suggest, most child welfare systems do not have sufficient community-based services in place. The result is that many children's behavioral health needs do not get addressed until they are serious enough to warrant residential or hospital treatment. We know the solution. The system of care philosophy with child-serving systems is the consensus approach ( Stroul and Friedman, 1996 Stroul B Friedman R The System of Care Concept and Philosophy in Children's Mental Health: Creating Systems of Care in a Changing Society. Brookes, Baltimore1996 Google Scholar ). Only by carefully building an integrated system in which behavioral health needs are identified and addressed throughout the child welfare system can these frequent and complex needs be met with any consistency ( Lyons, 2004 Lyons JS Redressing the Emperor: Improving the Children's Public Mental Health System of Care. Praeger., Westport, CT2004 Google Scholar ).

Practice and Process in Wraparound Teamwork

Collaborative family—provider teams have become an increasingly popular mechanism for creating and implementing individualized service and support plans for children and families with complex needs. In the context of children's mental health,this type of individualized service planning is most often known as wraparound, and it has become one of the primary strategies for implementing the system of care philosophy. A consensus has been reached about the values that underlie wraparound; however, less agreement exists regarding the specific techniques or procedures that translate the value base into practices at the team level. Difficulties in reaching agreement about guidelines or standards for wraparound practice are exacerbated by the lack of a theory describing how the wraparound process produces positive outcomes. This article brings together theory and research from a variety of sources in proposing a model of effectiveness for wraparound. The model specifies relationships between team practices, processes, and outcomes. The model is then used as a basis for recommending specific practices for wraparound teamwork.

Promoting Family Empowerment Through Multiple Roles

SUMMARY A guiding principle in the system of care philosophy for meeting the needs of children with serious emotional problems and their families is that the families “should be full participants in all aspects of the planning and delivery of services” (Stroul & Friedman, 1996, p. 9). Family members, both individually and as representatives of family organizations, are participating in systems of care in a number of vital roles. Friesen and Stephens (1998) delineated six of these roles, and summarized related practice and research. In this paper we expand and continue their discussion of multiple roles, adding a seventh with elaboration of the role of family members as educators and trainers, separating that from the role of service provider. The following roles are reviewed: family members as context; targets for change and recipients of service; partners in the treatment process; service providers; educators and trainers of professionals, students, and other family members; advocates and policymakers; and evaluators and researchers. Recognition of these expanded family roles may help service providers be better prepared to work collaboratively with families and family organizations, and to become aware of the accomplishments that may be achieved through such collaboration.

Families and therapists achieve clinical outcomes, systems of care mediate the process

The values articulated in the system of care philosophy (Stroul & Friedman, 1994) have been necessary elements of local, state, and national efforts to reform mental health care for children. The importance of the values of family collaboration, cultural competence, interagency coordination, individualized care, and use of the least restrictive treatment setting articulated by the system of care philosophy has been affirmed by practitioners, policy makers, and mental health services researchers. Such values, however, are likely not sufficient to achieve clinical outcome. Clinical outcomes are more likely to be achieved by family members and therapists when clinical practices are changed to reflect the demanding and comprehensive work of changing child and family social ecologies.