National Technical Assistance and Evaluation Center for Systems of Care;;
Defining Systems of Care
The systems of care literature and the lessons learned by the nine federally funded States and tribes and the 18 participating communities of the Children's Bureau's Improving Child Welfare Outcomes Through Systems of Care demonstration initiative contribute to a foundational definition of systems of care in the child welfare context.
A review of the systems of care literature reveals that the definition of a system of care has evolved over the past two decades, based primarily on work in children's mental health. Hodges, Ferreira, Israel, and Mazza (2007) present a definition that reflects current systems of care components:
A system of care incorporates a broad, flexible array of services and supports for a defined population(s) that is organized into a coordinated network, integrates service planning and service coordination and management across multiple levels, is culturally and linguistically competent, builds meaningful partnerships with families and youth at service delivery, management, and policy levels, and has supportive management and policy infrastructure. (p. 9)
Similar to Hodges et al., other definitions that developed out of efforts to address failures to meet the mental health needs of children emphasize service planning and coordination. Overall, the definitions identify essential elements of a system of care: value-based, population-focused, strengths-based, family-driven, integrative and coordinated, individualized, culturally competent, community-oriented, and flexible with a broad array of appropriate services and natural supports.
Current definitions emphasize an ideal set of conditions for how a fully implemented system of care operates. In light of the challenges faced in child welfare, the developmental aspects of a system of care and its role in effecting change must be recognized. Given the current mandates for system change in child welfare, these elements are critical for administrators seeking to understand and develop systems of care.
Based on the experiences of the grant communities, systems of care in child welfare would be defined as a principle-guided approach to developing and sustaining systemic changes that result in improved outcomes for children and families.
Principle-guided - Child welfare driven systems of care are guided by six core principles, which are the essential elements of the framework for achieving a balanced and effective child and family service system. The six principles are interagency collaboration, individualized strengths-based care, cultural competence, child and family involvement, community-based services, and accountability. While definitions of these principles vary in the literature, they represent the foundation for creating a more effective child welfare system based on change and ongoing evolution. The goal of a principle-guided change process is to operationalize each principle throughout the child welfare system, with each principle embodied in, and guiding the work of, administration policies and practices (DeCarolis, Southern, & Blake, 2007).
Continuous Change Process - Guided by core principles, a system of care systematically promotes and manages system change efforts, including building a system of care and sustaining operation of the system. Similar to building or remodeling a house, constructing systems of care requires considerable advance work, such as planning, identifying and gathering essential resources and partners, and continuous quality improvement, to create a shared and compelling vision of desired outcomes. The building process requires diverse skills such as leadership, marketing, strategic planning, and collaboration. Once built, a system of care operates in a larger context of changing political, legislative, fiscal, and service issues. To maintain effectiveness, a system of care must continuously adapt to the environment. With the guiding principles and infrastructure as constants, the systems of care approach provides a framework for building and maintaining organizational and community capacity to successfully navigate the complexities of systems change.
Developmental Systems Change - In a stage-based developmental process, the systemic change necessary to achieve improved outcomes for children and their families takes considerable time to mature. Often supported by Federal, State, or private foundation funding, the initial stages of establishing a system of care may take 3—6 years. Building the infrastructure of a system of care requires time to craft a shared vision, develop a theory of change, develop strategic and action plans, establish governance structures, and foster the trust necessary to formalize and sustain long-term commitments. As the system develops, policy, practice, financing, and leadership will require adjustments, and a deepening commitment to the principles and goals will be necessary. In theory, a system of care moves from the infrastructure-building phase to sustainability with a gradual change in level of effort, as shown in figure 1. In reality (figure 2), phases often overlap and cycle between building/rebuilding and sustaining the system. Shifts in effort may be driven by a variety of forces such as changes in population, election cycles, funding, or leadership. This cyclical change process calls for revisiting earlier commitments and decisions at frequent intervals during the building stages and at regular intervals in sustaining operations. Because systems of care continuously monitor and adapt to changes in the environment, agencies adopting this approach operate as learning organizations characterized by purposeful and insightful agility (Senge, 1990).
Results Focused - Promoting systemic change in child welfare is meaningless unless the changes lead to better outcomes for children and families. Given the fiscal constraints and mandates that affect child welfare systems, decision-makers must be able to reliably determine if changes initiated through a systems of care approach are enabling better outcomes. In addition, they need to understand the impact of systemic change in relation to Federal and State mandates. Because systems of care often require collaboration with other departments, agencies, or organizations, their respective objectives for demonstrating results or impacts must also be addressed. Therefore, a well-designed quality assurance process through which timely data are collected, shared with stakeholders, and used to make adjustments is a vital element of any systemic change process.
Figure 1: Theory
Figure 2: Reality