Creating A Front Porch For Services: Strategies for Transforming Communities

1. Creating A Front Porch For Services:Strategies for Transforming Communities 2008 Behavioral Health Collaborative Conference A Place in the Community…and Beyond Albuquerque, NM – December 2-5, 2008 Mario Hernandez, Ph.D. Professor/Chair Department of Child and Family Studies Louis de la Parte Florida Mental Health Studies School of Mental Health Studies

2. The Challenge Of Complexity • Human service systems are often asked to respond to multiple and changing needs • Service delivery environments are complex and frequently changing • Size (Rural, Urban, Tribal, Colonias, Barrios) • Effective systems must find ways to respond and manage complexity

3. Local Conditions Resulting from Fragmentation • Inadequate range of services and supports • Failure to individualize services • Service fragmentation for children and families with multiple service needs • Lack of clear values/principles for system • Lack of clarity about population of concern • Lack of adequate responsiveness to cultural and linguistic differences • Inadequate accountability

4. Barriers Associated With Seeking And Receiving Mental Health Services • Income, Geographic Location, Language • Managed Care, Medicare/Medicaid • Stigma • Lack of trust • Insurance and related policies • System bias Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health. Online at:http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/CultCompServices.pdf

5. Main Assumption Culture and social context influence mental health, mental illness, and mental health services in America U.S. Department of Health and Human Services [USDHHS] (1999). Mental health: A report of the Surgeon General. Rockville, MD: USDHHS, SAMHSA, CMHS, NIH, NIMH.

6. “From an early age, we are taught to break apart problems, to fragment the world. This apparently makes complex tasks and subjects more manageable, but we pay a hidden, enormous price. We can no longer see the consequences of our actions; we lose our intrinsic sense of connection to a larger whole” (p.3). Peter Senge (1990).The fifth discipline: The art and practice of the learning organization. New York: Doubleday.

7. System Reform • Since the mid 1980s reform has been through the development and implementation of community-based services and supports called systems of care. • Based on a set of principles and values and the best available evidence for systems and services.

8. Defacto System • Diffused Child Mental Health Services • Unclear Pathways to Care • Other Sectors • Growing

9. Improved implementation of effective practices across organization levels Improved availability of services Improved pathways to care Improved Outcomes ƒ + + Values and Principles of a System of Care Transformation To A System Of Care

10. Systems of Care • When addressing children’s mental health needs, a System of Care (SOC) includes all of the formal providers and agencies that can help to meet a child’s needs, as well as family members and the informal supports that a family relies on in their daily lives. • In a SOC, these providers must work together and respect each others’ mandates and roles to address the child’s/family’s needs within the community in which they live.

11. Systems of Care • Simply put, a SOC reflects how a community takes care of its own members.

12. Expectations For Communities The system of care approach expects local planners to improve: • Local services/supports and service delivery processes • Supporting service delivery infrastructure

13. This Expectation Requires… • Clear understanding of the local mission, plan and expectations • Clear understanding of ideas inherent in Systems of Care as they relate to the local strategy

14. How Communities Can Implement A System Of Care: Theories of Change

15. Implementation of Services Conceptualization and Operationalization Linking Ideas To Action Assumption: the degree of overlap between the two functions contributes to improved planning and service delivery

16. What Is A Theory Of Change? • The underlying assumptions and strategies that guide local system of care development and are believed by local planners/builders to be critical to producing changes in available service/supports that are expected to lead to improvements for children and their families.

17. Theory Of Change • Beliefs that system, planners, builders, and implementers have about: • What children with serious emotional/behavioral challenges and their families need from services/supports in order to thrive in their communities and… • What local strategies will enable these services/supports to become available and meet those needs

18. Theory Of ChangeComponent 1 Three core elements of a Theory of Change: • A clear description of the local population of concern • A clear articulation of goals and outcomes • A clear description of local strategies that includes services/supports and the associated infrastructure

19. Population Context Outcomes Theory of Change Strategies Theory Of ChangeComponent 2 • A clearly expressed relationship between the three core elements

20. Reasons For Population Focus • Ensures that planning is driven by the needs and strengths of children and families • Suggests what system and practice issues should be addressed

21. Population Of Concern • A greater number of children and youth in the child welfare and juvenile justice systems have mental health problems than those in the general population. • 50% of children and youth in the child welfare system have mental health problems. • 67% to 70% of youth in the juvenile justice system have a diagnosable mental health disorder. Facts Compiled by the National Center for Children in Poverty http://nccp.org/pub_ucr06b.html

22. Population Of Concern • Children with mental health problems have lower educational achievement, greater involvement with the criminal justice system, and fewer stable and longer-term placements in the child welfare system than children with other disabilities. Children’s Mental Health Facts for Policymakers. By: Rachel Masi and Janice Cooper. Publication Date: November 2006. Online at: http://nccp.org/publications/pub_687.html#10.

23. Population of Concern:Current Level of Meeting Mental Health Needs Across Populations Unmet Need for Racially/Ethnically Diverse Populations: • 76% of White children have unmet mental health needs. • 87% of Black children have unmet mental health needs. • 88% of Latino children have unmet mental health needs. • 90% of Other children have unmet mental health needs Service Use for Racially/Ethnically Diverse Populations: • 31% of white children and youth receive mental health services, and 13% of children from diverse racial and ethnic backgrounds receive mental health services. (Hernandez, 2007)

24. Population Characteristics • Parents from various backgrounds have been found to differ in the degree to which they identify child behavior and emotional problems as serious. • Differences have also been found across cultural groups in their beliefs about whether these child problems are likely to improve in the absence of professional support. (Wiesz & Weiss, 1991)

25. Population Characteristics • It is generally recognized that an individual’s help-seeking behavior for mental health problems is linked to cultural factors • The process of seeking help by various people, and the interactions that result with both formal and informal sources of help, serves as a filter that often discourages contact with mental health professionals (Leong, et al. 1995)

26. Conceptual Model for Accessibility of Mental Health Community Context Characteristics of a community’s population Degree of compatibility defines level of access for a community’s population Compatibility Outcomes An organization’s/system’s combined policies, structures and processes Hernandez, M., & Nesman, T. (2006).

27. Characteristics of theCommunity Population Characteristics of a community’s population Compatibility An organization’s/system’s combined policies, structures and processes Assessing compatibility is dependent upon having information about the community’s populations, context, and the organization’s policies, structures, and processes

28. Characteristics of theCommunity Population Characteristics of a community’s population Compatibility An organization’s/system’s combined policies, structures and processes View of Mental Health History Language Characteristics Resource Characteristics Strength Characteristics Needs Characteristics

29. Conceptual Model for Accessibility of Mental Health Community Context Characteristics of a community’s population Degree of compatibility defines level of access for a community’s population Compatibility Outcomes Organization’s/System’s Direct Service Domain/ Functions Infrastructure Domain/ Functions Hernandez, M., & Nesman, T. (2006).

30. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed • Organizational Values • Policies/Procedures/ Governance • Planning/Monitoring/ Evaluation • Communication • Human Resources Development • Community & Consumer Participation • Facilitation of a Broad Service Array • Organizational Infrastructure/ Supports Compatibility between the infrastructure and direct service functions of an organization Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

31. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed • Organizational Values • Policies/Procedures/ Governance • Planning/Monitoring/ Evaluation • Communication • Human Resources Development • Community & Consumer Participation • Facilitation of a Broad Service Array • Organizational Infrastructure/ Supports Compatibility between the infrastructure and direct service functions of an organization Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve • The left triangle highlights the infrastructure component, which includes organizational functions that are based on the domains identified in through an analysis of cultural competence protocols

32. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services • The Infrastructure domain is made up of multiple functions that are typical of organizations. • Organizational values, policies, procedures and governancecontribute to access when they promote compatibility with the community served and provide support for staff to provide services. • Likewise, planning and evaluationprocesses contribute access when they include representatives from key populations in their communities as fully contributing partners with shared responsibilities, and when they collect data that reflects the diversity of the community Infrastructure Domain/Function • Organizational Values • Policies/Procedures/ Governance • Planning/Monitoring/ Evaluation • Communication • Human Resources Development • Community & Consumer Participation • Facilitation of a Broad Service Array • Organizational Infrastructure/ Supports

33. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services • Communicationthat supports access includes two-way communication and learning within the organization and between the organization and the community • Human resourcesand service arraydomains include strategies to increase bilingual/bicultural capacity, recruitment, and retention, and availability of services that are appropriate and of high quality for the target population • Methods of outreach to communities and opportunities for community/consumer participationare important mechanisms that can lead to greater compatibility • Organizational infrastructurecan promote access by bringing in financial, technological and other needed resources Infrastructure Domain/Function • Organizational Values • Policies/Procedures/ Governance • Planning/Monitoring/ Evaluation • Communication • Human Resources Development • Community & Consumer Participation • Facilitation of a Broad Service Array • Organizational Infrastructure/ Supports

34. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed • Organizational Values • Policies/Procedures/ Governance • Planning/Monitoring/ Evaluation • Communication • Human Resources Development • Community & Consumer Participation • Facilitation of a Broad Service Array • Organizational Infrastructure/ Supports Compatibility between the infrastructure and direct service functions of an organization Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve • The right triangle highlights the direct service domain, which includes aspects of access, availability, and use of services. Findings are based an analysis of literature related to services for racially/ethnically diverse children and families.

35. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services • Access is defined as mechanisms that facilitate entering, navigating, and exiting appropriate services and supports as needed. • Availability is defined as having services and supports in sufficient range and capacity to meet the needs of the populations they serve. This may include availability of bilingual personnel and/or trained translators. • Utilization is defined as the rate of use of services or their usability for populations served. Utilization may include issues such as length of time in service, retention, or dropout rates. Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

36. Organizational/System Implementation Domains For Improving Access And Use Of Mental Health Services Direct Service Domain/Function • This model shows that there is a need for compatibility between the organizational infrastructure and direct service. It also highlights the need for compatibility between each of the direct service domains. Access The ability to enter, navigate, and exit appropriate services and supports as needed Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

37. Common SOC Outcomes • A full array of community-based services • Reduced reliance on restrictive treatment environments and out-of-home placements • Increased interagency coordination and collaboration • Flexible services • Cost containment and effectiveness (Stroul, 1993)

38. Common SOC Outcomes • Increased satisfaction with services • Improved access to care (Schoenwald, 2001)

39. Mental Health/Health Focused Approach To Eliminating Disparities: Everyone has a mental health disparity • Leads to focus on mental health/Health • Access • Quality • Problem is that social inequities exist and that there is a relationship between social inequities and mental health/health Eliminating Disparities by Transforming Mental Health

40. Aligned Approach • Leads to collaborative planning • Leads to a population based approach • Leads to community ownership Juvenile Justice Eliminating Disparities by Transforming Mental Health • Goals must be linked Child Welfare Education

41. Aligned Approach • Community Context: Urban, Rural, Tribal, Colonias, Barrios Reducing Over-Representation in Juvenile Justice Eliminating Disparities by Transforming Mental Health Reducing Over-Representation in Child Welfare • Related • Goals Reducing Over- and Under-Representation in Education

42. Aligned Approach Community-Based Approach to Eliminating Disparities and Over-Representation Linked Goals • Population Focused • Larger than TreatmentOutcomes • This leads to planning and “solution making” that: • Focuses on a community as a whole • Focuses on the linkages across sectors

43. Where Should Alignment Occur… • Aligned approach is critical to transformation that is consistent with SOC values and principles • This alignment has to occur… • Across state agencies • Between the state and local communities • Across agencies, providers, and families at the local level

44. Transforming Systems and Services for Children with Mental Health Challenges and Their Families Three Basic Questions • How can we improve access to care for those in need? • How can we improve quality and effectiveness of care? • How can we improve the mental health status and well-being of all children? (Friedman, 2008)

45. “Uno es el arquitecto de su propio destino” “One is the architect of their own destiny” New Mexico Latino Behavioral Health Policy Summit Report, Sept 2007