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Completing the Equation:

Completing the Equation: . Building an Integrated Culturally Competent Systems of Care. Lessons Learned on Partnering with Tribes and the Development of a Rural Systems of Care in Oklahoma. Today’s Discussion. Identifying the need for Systems of Care Developing a structure

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Completing the Equation:

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  1. Completing the Equation: Building an Integrated Culturally Competent Systems of Care Lessons Learned on Partnering with Tribes and the Development of a Rural Systems of Care in Oklahoma.

  2. Today’s Discussion • Identifying the need for Systems of Care • Developing a structure • Systems of care efforts in Native Oklahoma • Challenges and opportunities in rural areas: Tribal and State perspective • Completing the equation Jami Bartgis, Ph.D., Keith Pirtle, MSW Director of Research and TA Senior State Project Director National Council of Urban Indian Health Oklahoma Systems of Care Washington D.C. Oklahoma City, Oklahoma

  3. What do we mean by a Systems of Care and what problems are you trying to solve?

  4. What are the issues? • Families were approaching the Oklahoma State Legislature asking them to make it easier to give up custody of their children so they could receive services

  5. What are the issues? • Services are not meeting the need (not enough and not high quality) • Kids are being placed out of their home to receive the services and supports they need • Kids are getting worse in the system not better • Services for the most complex families are not coordinated

  6. What are the issues and needs in Native Oklahoma? • Over-reliance on already over burdened and under funded Indian health systems (IHS, tribal, urban) by both native people and non-native agencies. • Native youth more likely to be in the juvenile justice system than to receive treatment or rehabilitation services. • Native people in the Oklahoma area IHS service population have higher disease burden connected to alcohol abuse, suicide, homicide, and injury/accidents than all US races combined. • Tribal and Indian health services add an additional “silo.” • Overall misperceptions about Indian people impact quality of life.

  7. Bottom Line • The child serving system is broken for families with the most complex needs • We want to change the system to be more responsive and easier to access • We want kids to stay at home and we want families and communities to function better

  8. A: What are the needs in New Mexico you are wanting to address? • Any similarities? • Access needs? • Coordination? • Unique presenting problems?

  9. Oklahoma Goals • Wraparound statewide for all families with complex mental health needs • Reduce or shorten out of home placements for reduced costs and healthier families • Systems of Care is a catalyst for needed Systems Reform

  10. A Systems of Care • Everyone agreeing on values and vision • Creating processes, relationships, policies and structures to get there

  11. Core Values • Child centered, family focused and needs driven • Community Based: Services, management and decision Making • Culturally competent for the community and the persons served

  12. What structure do we need? • To implement wraparound • To create systems reform in behavioral health

  13. Creating a Local Structure • Community Team -Could be any coalition. Roles include oversight for the initiative, approving budgets and setting overall direction of the project. • Tribal Community Team- Same purpose but the process may be different.

  14. The Broader role of the Community Team? • Agree on a mission and values • Learn about the Systems of Care and wraparound model • Engage the community in your mission • Bring elders, family and youth to the table as equal partners • Create a strategic plan for creating an integrated System • Look for unique ways to partner • Create a referral team and oversee the wraparound process • Continue to tie the knots that support the families

  15. Referral Team -approves referrals into the project and insures the project follows the principles of systems of care. Used as a place in the community to address the needs of families and link them to services and supports.

  16. Who is Wrap around for? • Children (at risk for or) with (temporary) serious emotional and behavioral problems (out of balance). • Between the ages of 0 and 21 • For the entire family (extended family and community) • Having problems at home, school and/or the community

  17. Local Staff • Project Director or lead staff person. This person is responsible for organizing the community team, conducting meetings, hiring staff and overall supervision and administrative lead for the initiative.

  18. Local Staff • Care Coordinator- Works directly with families to create a strengths assessment, assembles the family treatment team, facilitates family treatment team meetings, insures the completion of a treatment plan, and assists with emergency needs. • Family Support Provider -Someone who has a child experiencing a serious emotional imbalance and has experience being an advocate. This person works in a supportive and advocacy role with the family.

  19. What are the other services and structures? • Child Welfare • Case management • Individual and group therapy • Health services • Individualized Education Plans • Transportation

  20. State Systems of Care Advisory Team • Our mission is to create a unified and integrated behavioral health services system for all children, youth and their families. This accountable and efficient behavioral health system will provide individualized services based on the strengths, needs, and culture of the child and family.

  21. Where are we now? • 36 Systems of Care Sites covering 40 Counties • Served just over 2,000 families to date • Serving 650 at any given moment • Transforming the Child serving system

  22. Kay Grant Ottawa Nowata Harper Craig Texas Cimarron Beaver Woods Alfalfa Washington Osage Delaware Noble Mayes Woodward Garfield Rogers Major Started 2000 Started 2004 Pawnee Ellis Tulsa Payne WAGONER Dewey Kingfisher Creek Cherokee Started 2001 Started 2005 Blaine Logan Adair Lincoln Roger Mills Muskogee Custer Okmulgee Oklahoma Canadian Started 2002 Started 2006 Okfuskee Sequoyah McIntosh Washita Beckham Pottawatomie Haskell Started 2003 Started 2007 Caddo Cleveland Seminole Grady Hughes Greer Kiowa Pittsburg McClain Leflore Latimer Pontotoc Started 2008 Harmon Garvin Comanche Jackson Coal Stephens Murray June 2008 Pushmataha Tillman Atoka Carter Cotton Johnston Jefferson McCurtain Marshall Choctaw Bryan Love

  23. Systems of Care Efforts in Native Oklahoma • Choctaw Cares • Circles of Care

  24. What are the existing structures, supports and services in Native Oklahoma? • Written System: • State Systems: Child Welfare, Juvenile Justice, etc • Indian Health Services (IHS) • Tribal Services (if any) • 2 urban Indian clinics • Indian Child Welfare • Community Health Reps (CHR) • Unwritten System: • Elders and community members • Ceremonies/Practices/Teachings

  25. B: What are your existing services, supports and structures? • Juvenile Justice? • Child Welfare? • School based Services? • Mental health? • Med Clinic? • Individual therapy?

  26. What are the unique challenges and opportunities in rural areas?

  27. Workforce • Development of shared training • Creating levels of para-professionals (Behavioral Health Aid) • Cross training to share roles • Sharing leadership and administration • Culturally competent staff at all levels

  28. Transportation • Connecting families to each other • Using staff to help transport • Making travel a billable service

  29. What are the unique challenges and opportunities for Tribal communities? • Challenges • Historical/Current State-Tribal Relations • Divergent Business Methods • Individual and Collective Traumas • The “grapevine” and “crabs in a bucket” • Opportunities • The value of tribal governments • Medicaid match and rate • Leading the way in cultural competence • Enterprise and potential impact on health

  30. Ways to move forward in Tribal Communities • Oklahoma’s State/Tribal Work Group • Representation on State Level Committees • Partnering with the State on specific Projects • Looking at Medicaid Funding with Wraparound

  31. Not enough specialized staff • Therapy • Case management • Child welfare • School counselors • School based Social Workers

  32. Roles: Think of the family not the job description • What do families need? Support, transportation, food, clothing and shelter, crisis stabilization, friends Comply with treatment plan requirements like a clean house or parenting classes

  33. Who can address those needs? • Family members • Other friends and families receiving services • Therapist • Case manager • School counselor

  34. Paperwork and Rules • Use your tribal and state level leadership to change funding rules, combine paperwork, adjust funding from different areas • Working as a team reduces redundancy, such as multiple treatment plans

  35. C: Other Challenges from a Local Perspective in New Mexico? • Number of services • Specialization of services (psychiatrists) • Huge geographical areas to cover (no longer local voice) • Needs to be a bottom up- local needs to tell the state what needs are • Some local levels struggle to use power to have voice at state level • Region 6 is the Native American collaborative that covers the entire state- this is not a local voice • Time and Money to be involved in “Systems” transformation and coordination • Disconnect between time-oriented vs. process-oriented, diversity between cultures • Need sustainability- ongoing • Diversity within a culture

  36. Other Opportunities from a Local Perspective in New Mexico?

  37. Other Challenges from a State Perspective in New Mexico?

  38. Other Opportunities from a State Perspective in New Mexico

  39. Other Challenges from a Tribal Perspective in New Mexico

  40. Other Opportunities from a Tribal Perspective in New Mexico

  41. Completing the Systems of Care Equation • A: Need • B: Structures and Services • C: Unique Challenges • D: Unique Opportunities • E: Putting it all Together

  42. Funding and Data • Again: Look at your goals. In Oklahoma we want to keep kids out of the hospital and agency custody • How do you address the situation: Wraparound keeps kids at home. • Cost savings and better outcomes for kids • More money from the Legislature to serve more kids in wraparound and save more money

  43. A Word about Continuous Quality Improvement Monitor Systems of Care Fidelity Annual site visits Site visit checklist Creation of a site visit report

  44. A Word about Continuous Quality Improvement Monitor Wraparound fidelity at Systems of Care communities. Satisfaction surveys, wraparound event monitoring, Wraparound Fidelity Index, Ohio Scales individualized report Monitor Wraparound outcomes for disparate groups. Graduation rate, satisfaction surveys, Wraparound Fidelity Index, Built-in reports in Youth Information System

  45. What are the Outcomes of Wraparound? Change in SOC Clients after 6 months (n=784)* Reductions In: Total Out-of-home Placements 45% School Detentions 45% Self Harm Attempts 68% Arrests 49% *(Data collected in 2008)

  46. Questions?

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