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“Children’s System of Care” in Westchester County, New York

The System of Care concept for children and adolescents with mental health challenges and their families was first published in 1986 in an article by Beth Stroul and Robert Friedman. They articulated a definition for a System of Care along with a framework and philosophy to guide its implementation.

The original concept was offered to guide the field in reforming child serving systems, services, and supports to better meet the needs of children and youth with serious mental health challenges and their families. The concept has shaped the work of many communities across the country, and Westchester County has been a System of Care Community under the federal model, since 1999. The System of Care concept is a vision with continued potential to transform the systems which serve children with social, emotional and behavioral challenges. During the past two decades, the concept and philosophy have laid the foundation for such transformation.

As initially described by Stroul and Friedman, a System of Care is a spectrum of effective, community based services and supports for children and youth with or at risk for mental health or other challenges and their families, that is organized into a coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs, in order to help them to function better at home, in school, in the community and throughout life.

Westchester has long recognized the following core values as basic to the System of Care concept: (a) Being community based; (b) Family driven and youth guided; (c) Culturally and linguistically competent; (d) Cross system in approach; (e) Employing a “never give up” philosophy; and (f) Having a strength based foundation, with services individualized for each child.

Westchester’s investment in a “system of care” framework began long before we became a federally funded System of Care community in 1999. In the early 1990’s, Westchester County embarked on a mission to re-engineer its service delivery system for over 3,000 children with diagnoses of serious emotional disturbance. For the Westchester County Department of Community Mental Health (DCMH) this represented a fundamental change from a non-family focused, medical model approach to a family focused, strength-based value system. A system of care, we decided, was not a program, but a philosophy and a framework for a changed way of “doing business” for youngsters with high end service needs and their families. These ideas were recognized by New York State and resulted in the State’s early system of care effort known as the Coordinated Children’s Services Initiative.

Westchester used its successes as a pioneer in the New York State driven Coordinated Children’s Services Initiative and its county level successful Network model to apply for and win a Substance Abuse and Mental Health Services Administration (SAMHSA) CMHS system of care grant in 1999. Westchester’s System of Care effort has been known as The Westchester Community Network, and employs a multi-tiered approach in nine communities throughout Westchester. There are also Early Childhood and Aging Out/Transitional Networks. Network utilizes a “wraparound approach”, a dynamic, interactive process for children, youth and families identified in the community at the highest level of need, where no single system has been able to provide sufficient help. These families often feel “under siege,” rather than helped, by the multiple service systems involved in their lives. Children and families are invited to Network by someone who knows them and has worked with them in the community. The family is encouraged to invite people who have helped and supported them, including family, clergy, friends, former workers, therapists, etc. The first person a family meets at Network is another parent from a similar background and culture who can explain the process to them. An older adolescent will also meet with a peer. The strength-based assessment takes the form of a “public conversation” which is supportive and affirmative and establishes broad community support and recognition for the family.

The Networks themselves are complex and consist of a number of different relationships, associations, and regular meetings. On a monthly basis the Networks hold community organization meetings that bring together all of the agencies and support groups to share information, work on better coordination, and review service needs and resources. On a weekly basis, Network family-centered meetings (described above) are held. The family organization, Family Ties, plays a major part in orchestrating these meetings, supporting the participating families and guiding them through the process. From the family centered meetings, child and family teams for each family are organized which provide continuous support and services for the family. The plan of care for the child and family is developed here and is adjusted and revised over time as the needs of the child and family change. Finally, each Network is linked to a Community Planning Council that consists of local program administrators, religious and business leaders, and other community leaders who support the work of the Network and assist in resource development.

In successfully implementing a system of care approach in Westchester, leadership staff in the Department of Community Mental Health needed to win interagency and family stakeholder consensus. A long history in Westchester of working together across systems helped to accomplish this and to collectively articulate a shared vision and principles. The Department strongly supported the establishment and growth of the family movement, working with Family Ties as equal partners in the process. Achieving community ownership of the change process was integral to its success and the community basis of the Networks, representing the unique cultural and linguistic needs of each community helped to make this a reality. An oversight body was created using our standing Coordinated Children’s Services Committee as its base. This Committee continues to this day as the County’s longest standing cross system children’s planning entity and is co-chaired by DCMH and the Westchester County Department of Social Services.

Westchester County DCMH staff also understood that it was critical to identify strong leaders across systems and agencies in order to move vision from concept to reality. A leadership group was formed and met weekly to keep the approach on track and to develop and sustain new leadership. During Westchester’s five years as a federally funded System of Care grant-site we were identified as a model implementation of a system of care, and were asked to serve along with Wraparound Milwaukee and the Dawn Project, as one of three Host Learning Communities, and then as Team Learning Centers for the rest of the country. As such we were asked to demonstrate how to create an evolving oversight body to promote system level change, how to design, transform and sustain infrastructure development, how to organize at the community level within a county/state structure, how to provide direct access for families, and how to employ a “theory of change” model that addressed the needs of families and communities.

Westchester’s accomplishments as a System of Care have included first and foremost establishing true partnerships with families and the family movement, enabling them to serve as the driving force in policy development, program planning, service delivery, advocacy, research and training. Families/Youth were included as members of all standing planning and oversight committees, were paid for their time as such, became paid members of the research team, were involved in program planning and were members of a cross system hiring process for new workers in the System of Care. As the result of its growth and development in the federally funded System of Care effort, Family Ties became an independent 501c(3) with 35-50 employees. Resource Centers for families were developed in six communities.

Effective structures for Wraparound coordination were also built. Child and Family Networks were created in 9 Westchester communities serving over 300 families yearly. Networks worked to: create initial individualized wraparound plans derived from strength based assessments; utilize resources of the community making them uniquely culturally and linguistically driven; create ongoing support circles to maintain/adjust the plan over time; conduct community organizational meetings; and use the Family Group Conferencing Model to enhance cultural competency in situations where “bottom line” issues with serious consequences existed. Non-traditional clinical practices and wraparound designs flourished in the Westchester System of Care model. Mobile, family driven, community-based care coordination including respite and crisis components was instituted as was Safety Programming (Clinical and Case Management) for youth with sexually aggressive/sexually reactive behaviors. Risk Assessment and Strategic Community Safety Planning for youth with fire-setting behaviors was begun in a cross-system community based effort with fire departments and child welfare staff as well as mental health professionals.

A Network, clinical case management and peer support approach for young people aging-out of the Children’s Mental Health System was developed, as well as an Early Childhood System of Care model. The Westchester Community Network also embraced Positive Behavioral Interventions and Supports (PBIS) in schools across the county. True systemic change required ongoing expansion of the infrastructure. Single Point of Entry/Return Committees for Residential Care were created to examine the situations of each child referred for residential care in the County child serving systems, to ensure that wraparound plans had been examined to avert such placements, and that the least restrictive settings of home, school and community were applied. A Single Point of Access (SPOA) for Children’s Intensive Services in the mental health system was also adopted (1994) and eventually became required by the NYS Office of Mental Health across all counties in the state.

Cross system planning committees were instituted in the areas of: high risk adoption; bilingual/bicultural family support; co-occurring developmental disabilities and mental health needs; transitional/aging-out services; high risk mental health/child welfare situations; integrating evidence based practices into the System of Care; fire-setting behavior; sexually aggressive/sexually reactive behavior; as well as parents with mental health, substance abuse and developmental disabilities. Each committee, using the Westchester System of Care’s theory of change, examined the issues locally; gathered state and national data; looked at successful national and local programs and recommended clinical, case management, and training to be instituted as part of the System of Care. The latest additions have been the Subcommittees on Trauma and Community Partnership for Undoing Racism which have both profoundly affected the System of Care and has adjusted the framework in new ways.

Westchester’s System of Care has also created a social marketing and training plan which includes a System of Care orientation series for all new workers; cross system trainings; Strength based assessment training; specialized training for those working with youth with high risk issues including fire-setting, sexually aggressive/reactive behavior, victims of sexual abuse, and adoption issues; parent skills training (conducted solely by Parents); training for parents of youth aging-out of the children’s system (conducted solely by Parents); development of a System-of Care training manual and website.

The Westchester Community Network ended its period as a funded federal grant site in 2005. The System of Care has been sustained through cross system funding, creative use of newer, smaller grants, and through the efforts of those committed to the model across systems. The Westchester Community Network has a proven track record and long-term perspective that allows it to provide data, information on infrastructure development, community change, cross system collaboration, cultural competency, family/youth empowerment, and sustainability. We believe that the measure of success for a system of care is multi-dimensional, not just clinical. SOC represents an investment in long term change.

The System of Care approach has allowed us to incorporate a trauma informed narrative that goes hand in hand with System of Care values and principles and the CCSI Committee has a Trauma Subcommittee (along with many other subcommittees) exploring how to incorporate a trauma informed approach as we operate at the policy, program development, direct service, evaluation and training levels.

Westchester has truly sustained not only funding for its system of care, but more importantly the overarching belief system that allows for continued infrastructure development, reliance on a core set of values that drive programming, and a permanent “place at the table” for families and youth.

Our challenges include incorporating our new Managed Care requirements, implementing effective financing mechanisms for System of Care for those non-Medicaid participants in the process, developing a skilled workforce through education, training, technical assistance, coaching, information dissemination and expanding provider networks, and providing a public health approach to children’s mental health services.

For additional information on Westchester County Children’s System of Care contact Michael Orth at (914) 995-5225 or email mmo6@westchestergov.com.

Carol Hardesty, MSW, MPA, is Retired – Former Program Director, Westchester County Department of Community Mental Health and Executive Director, Family Ties of Westchester and Michael Orth, MSW, is Deputy Commissioner, Westchester County Department of Community Mental Health.

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