Janet S Walker PhD Nancy Koroloff PhD Kathryn Schutte MSResearch and T - PDF document

1 Janet S. Walker, Ph.D., Nancy Koroloff,
Janet S. Walker, Ph.D., Nancy Koroloff, Ph.D., Kathryn Schutte, M.S.Research and Training Center on Family Janet S. Walker, Ph.D.Research and Training Centers Mental HealthPortland State University iv The recommended citation for this publication is:Walker, J. S., Koroloff, N., & Schutte, K. (2003). Implementing high-quality collaborativeIndividualized Service/Support Planning: Necessary conditions. Portland, OR: Portland StateUniversity, Research and Training Center on Family Support and Children’s Mental Health.The Research and Training Center makes its products accessible to diverse audiences. If you needa publication or product in an alternative format, please contact the Publications Coordinator:503.725.4175, rtcpubs@pdx.edu.This publication was developed with funding from the National Institute on Disability andRehabilitation Research, United States Department of Education, and the Center for Mental HealthServices, Substance Abuse and Mental Health Services Administration (NIDRR grantH133B990025). The content of this publication does not necessarily reflect the views or policiesof the funding agencies.Portland State University supports equal opportunity in admissions, education, employment, andthe use of facilities by prohibiting discrimination in those areas based on race, color, creed orreligion, sex, national origin, age, disability, sexual orientation, or veteran status. This policyimplements state and federal law (including Title IX). RFH National Institute on Disability and Rehabilitation Research, U.S. Department of Education Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services Federation of Families For Childrens Mental Health Research and Training Center ons MentalHealth, Portland State University v Table of ContentsTeam, organization, and system...........................................................4Configurations of support......................................................................5Overview of this report..........................................................................8Figure 1: Necessary conditions...........................................................10References...........................................................................................11Sources of information........................................................................17Expert review.......................................................................................20Practice model. Team level.................................................................25Figure 2: A model of ISP team effectiveness......................................26Practice model: Organizational level...................................................35Practice model: Policy and funding context (system level).................41References..................................................................................

2 ........43Necessary Conditions: Collabor
........43Necessary Conditions: Collaboration and PartnershipsCollaboration/partnerships: Team level...............................................53Collaboration/partnerships: Organizational level.................................55Collaboration/ partnerships:Policy and funding context (system level).......................................58References..........................................................................................61Necessary Conditions: Capacity Building and StaffingCapacity building/staffing: Team level.................................................65Capacity building/staffing: Organizational level...................................66Capacity building/staffing:Policy and funding context (system level).......................................67References..........................................................................................68 vi Necessary Conditions: Acquiring Services and SupportsAcquiring services/supports: Team level.............................................73Acquiring services/supports: Organizational level...............................76Acquiring services/supports:Policy and funding context (system level).......................................80References..........................................................................................82Necessary Conditions: AccountabilityAccountability: Team level...................................................................89Accountability: Organizational level.....................................................90Accountability: Policy and funding context (system level)...................91References..........................................................................................92Assessing Implementation and Prioritizing ActionsAssessment at the team level.............................................................97Assessment of organizational supports...............................................98Assessment of the policy and funding context....................................99Mutual accountability.........................................................................100Individualized Service/Support Planning Teams:Checklist for Indicators of Practice and Planning (ChIPP).............A-1Assessment of Organizational Supports forIndividualized Service/Support Planning........................................B-1Individualized Service/Support Planning........................................C-1 1Chapter 1: Team, organization, and system...............................................................................................................4...............................................................................................................5...............................................................................................................8.............................................................................................................10...............................

3 ........................................
...............................................................................11 2 3 In recent years, communities across the country have responded to the multifacetedneeds of children with serious emotional and behavioral disorders by using a variety ofcreative approaches for coordinating, designing, and delivering services. One popularapproach is the use of collaborative Individualized Service/Support Planning teams(ISP teams). The ISP team members—the identified child/youth, parents/caregiversand other family and community members, mental health professionals, educators, andchild and family. The planning process itself, as well as the services and supports provided,are intended to be individualized, family centered, culturally competent, and communityand strengths based. In different communities, ISP teams are known by a variety ofdifferent names, such as wraparound teams, family networking teams, child and familyteams, and so on. In 1999, it was estimated that as many as 200,000 ISP teams were atwork, and it appears that numbers have been increasing since.Among those who advocate and practice team-based ISP, there is a good deal ofagreement about the definition of the team. There is also a consensus about the value for ISP. Advocates and practitioners agree that the ISP process itself—as well asthe plans produced through the process—should be individualized, family driven,community and strengths based, and culturally competent. This approach has beencontrasted to traditional forms of service delivery, which have often been experiencedby families as professional driven, family blaming, deficit based, and lacking in respectfor the family’s beliefs and values.Achieving quality implementation of team based ISP has proven to be challenging.One set of challenges arises from the lack of a shared model of practice for ISP.Despite the consensus about the value base of ISP, there is little agreement regardingexactly how this value base should be translated into practice at the team level. As aresult, there has been no formal definition of the techniques, behaviors, or proceduresthat make up the ISP process. This has led to a wide variety of practice models, manyof which appear to be inconsistent with the original approach for ISP service delivery.Other challenges to high quality implementation arise from the larger context withinwhich ISP teams work. Practical experience has shown that achieving meaningful changeat the service delivery level requires extensive support from the organizational level, aswell as from the system level policy and funding context) This required support Throughout this document, we intend for the term “family” to refer to the adult(s) with primary,long-term caregiving responsibility for the identified child, together with other members of his/herhousehold. Such a family may or may not include, in the role of primary caregiver, biological parents,kin, foster parents a

4 nd/or other guardians. We consider a fam
nd/or other guardians. We consider a family-driven process to be one whichaccords significant weight not only to the perspectives of the caregivers, but also, to the greatestextent possible, to the perspective of the identified youth/child.We use these terms interchangeably in this report. 4 for the team ISP process can be hard to come by given that organizations and systemsare often locked in their traditional ways of doing business by organizational cultures;inter-agency barriers; funding exigencies; and skepticism regarding the effectivenessof family-centered, strengths-based practice. As the field has gained experience with the challenges associated with implementingISP, practitioners and advocates of the process have responded by developing a widevariety of supporting tools, procedures, policies, and structures at the team,organizational and system levels. Because each ISP program is embedded in its ownlocal context and subject to local policies, this set of supports tends to look somewhatdifferent in each community. Our research suggests, however, that these different tools,policies, procedures, and structures represent strategies that share a common goal: toproduce conditions that allow for quality implementation of the team ISP model. Whatwe propose here is to enumerate the conditions—at the team, organization, and systemlevel— which must be in place if an ISP program is to thrive.In the pages that follow, we propose a conceptual framework that specifies thesenecessary conditions. The proposed conceptual framework was developed through aprocess of “backward mapping.” Backward mapping begins with a description ofdesired behavior at the lowest level of intervention—in this case the team level—andthen proceeds to identify the resources and supports that are needed if the desiredbehaviors are to occur. In developing this framework, backward mapping began withbe recognized when teams conduct their work using practices that simultaneouslypromote both effective planning and the value base of ISP. Teams employing suchpractices maximize the likelihood that they will set and reach appropriately ambitiousgoals as they create and implement plans that are individualized, family driven,community and strengths based, and culturally competent. If this is to happen, whatare the conditions that must be in place at the team, organization, and system levels?Before beginning the discussion of the proposed necessary conditions, we would liketo clarify what we mean by organizationsystem (or policy and funding context). Aswe mentioned above, there is general agreement in the academic and training literature include the primary caregiver; the child or youth (if he or she iswilling and able to participate); other friends, family, or community members whomthe family finds supportive; and service providerswho figure importantly in the plan.In practice, the actual constitution of teams can vary widely not ju

5 st from team to teambut also from one me
st from team to teambut also from one meeting to the next. For the purposes of this discussion, we definea team as the caregiver and youth and at least two or three other consistently attendingcore members from the list above who are charged with creating and implementingplans to meet the needs of the family and child with an emotional disorder. This coreTeam, organization, and systemTeam, organization, and system Service providers include human service professionals (e.g. care coordinator, child therapist, schoolpsychologist, teacher, child welfare worker, probation officer) as well as professionals and volunteerswho provide services to the community (judo teacher, scout leader, pastor). team may be supplemented as necessary by others who attend when their role in theplan is under consideration or when their input is invited.At the organizational level, the picture becomes somewhat more complicated. We findit useful to distinguish between two roles that organizations or agencies can play relativeto ISP teams. In the first role, an agency takes the in the ISP implementation, andis responsible for hiring, training, and supervising team facilitators. This agency mayalso provide training for other team members with specialized roles, such as familyadvocates or resource developers. In the second role, an agency acts as a partnerteam-based ISP process by contributing services, flexible funds and/or staff who serveas team members. Communities have developed a variety of strategies for distributingthese roles across different agencies. In some systems, one agency may cover aspectsof both functions (for example, when a therapist is also the team facilitator), whereasin other communities, the ISP model specifies that these roles should not merge.Furthermore, elements of the lead and partner roles may be divided up between differentorganizations or agencies in different ways. Our conceptual framework stresses theimportance of the lead agency’s role because we see facilitation as a key to the team-based ISP process. We view the training and supervision of facilitators as requiring alevel of understanding of, and support for the team-based ISP process that is substantiallygreater than that required of agencies that act primarily in the partner roles.We use system levelpolicy and funding context to denote the larger service policy andeconomic context that surrounds the teams and team members’ agencies. The systemlevel is made up of multiple organizations that may focus on a specific set of services(e.g. mental health), a geographic area (e.g. county), population (e.g. children), or acombination of these. The policy and funding context may also include multiplegovernmental entities at the county, region, or state, as well as other organizations thatset policy, monitor or enforce policy, or interpret state or national policies to localservice providers. The system level also includes any body that has been constructed to

6 oversee the development of the service s
oversee the development of the service system or to manage funds that have beenpooled. The policy and funding context varies from community to community but atthe very least will include those individuals and bodies that make decisions regardingthe lead agency (or agencies) and by extension, the teams.The conceptual framework described here proposes that the necessary conditions forthe implementation of high quality ISP teams may be met even in the absence of adeveloping system of care. In fact, we have seen ISP teams function successfully incontexts offering very different levels organizational and system support. It appears,however, that different configurations of support have implications for the viability ofindividual teams, the stresses experienced by various stakeholders in the teams, and thesustainability of ISP programs over time. What is more, while some isolated mayfunction well in the absence of organizational and system support that meets theproposed necessary conditions, we do not believe that high-quality ISP programsable to do so. Below, we discuss several different configurations of organization andsystem support for ISP: the independent team (low organizational and system support), Configurations of support single agency program (high organizational support, low system support), newly developingsystem of care (high or low organizational support, low to moderate system support) andintegrated system of care (high organizational support, high system support).At the level of least support from either organizations or systems, we have observedsome teams that function for extended periods of time independently of any ISPprogram. These independent teams are unsupported by any formal arrangements at theorganizational or system level. Such teams seem to emerge from the interests and effortsof highly motivated families and service providers who have learned of the ISP modelbut cannot access such services locally. As a result, team members have chosen toimplement the model on their own, and in some cases have had a tremendous positiveimpact on the lives of the child and family for whom the team was formed. However,these independent teams tend to struggle, often unsuccessfully, to access and funddesired services and supports. Often they find they must either provide services/supportsthemselves or prevail upon sympathetic contacts in various agencies to make exceptionsand bend rules. Team members on independent teams are often highly stressed by theircontinual efforts to work around existing policies and providers, as well as the need tonegotiate multiple barriers to services and funds. Families also tend to be highly stresseddue to continual uncertainty. Over time, these teams are not likely to have a significantimpact on the agencies or systems with whom they interact, and so the stress experiencedby team members does not decrease. Without any organizational or system support,independent teams have difficulty

7 sustaining their work over time, and st
sustaining their work over time, and stimulating thecreation of multiple independent teams does not seem like a viable means ofsystematically meeting the goals of children and families with high levels of need. Wethus regard indifference on the part of organizations and systems—as is usuallyexperienced by the independent teams—as insufficient to support high-quality ISP.We did see evidence, however, of the potential for ISP programs to be successful indifferent to their existence. Usually, such programs areoperated using what we call a single agency program for ISP. In this model, the ISP programexists within an established, well-regarded human service agency which is able to providestrong support as the lead agency for ISP. Outside of this strong lead agency, thenecessary conditions for high quality ISP (i.e. the conditions fulfilled by partnerorganizations and the larger policy and funding context) are met in a minimal way, andoften through informal agreements or special arrangements. Directors and supervisorsat the lead agencies rely on relationships with various key allies both among their peersat partner agencies and at the county, regional, and/or state level. These key allies haveenough influence to ensure that the necessary conditions described here are met—butusually only for that specific agency and often on an ad hoc basis. Thus for example,allies at the system level might write special contracts that permit the agency flexibilityin managing funds or changing service categories and codes. Or county or regional-level allies might help the agency negotiate with other child serving agencies, such aschild welfare, on issues such as developing unified documentation of plans. Similarly,when teams need services or arrangements that are somewhat unusual, agencysupervisors or administrators often enlist the aid of peer allies in other agencies tonegotiate exceptions or to creatively work around barriers to services or funding. This is similar to the agency model described elsewhere. At the team level, there appears to be less stress on the families in the single-agencyprogram model than in the independent team model; however, relatively greater stressgenerally falls on the care coordinators who are constantly negotiating exceptions withcounterparts in other agencies and systems. The program may also experience setbacksand disruptions when key allies leave their jobs, and previous informal or specialarrangements must be re-negotiated. What is more, single agency programs, while capableof having a significant positive impact on a small number of families, may be quitelimited in terms of the number of teams they can support. For example, because theretends to be no restructuring of jobs in partner agencies to accommodate teamwork,team members from those agencies—or those in private practice—must donate theirservices to teams. As the number of teams in a community grows, it becomes increasing

8 lydifficult for the lead agency to find
lydifficult for the lead agency to find people who are willing to assume—on top ofexisting job responsibilities—the considerable efforts that can come with participationon ISP teams. A similar phenomenon exists with respect to community resources. Asmall number of creative teams may be very successful at linking to appropriatecommunity resources to support team plans. In the absence of a larger communityeffort to build capacity, increasing the number of teams at a given agency may quicklyexhaust community capacity to provide desired support.Most teams and programs appear to exist in a context of somewhat higher levels ofsystem support, particularly in the context of newly developing systems of carenascent systems of care have developed formal interagency agreements recognizingteams and providing pools of funds that can be used flexibly, as well as interagencycommittees which meet to problem solve or to create policies supportive of ISPteamwork. Ironically this situation can at times be even more stressful for team members,and particularly for care coordinators and families, than the single agency model describedabove. This appears to be especially likely when the lead agency is also newly createdand/or when the ISP program has been adopted as part of efforts at systems reformthat have shaken up multiple agencies. In these cases, the care coordinators are subjectto the same stresses as in the single-agency model, except that their power to elicitcooperation from partner agencies may be decreased (due to the agency’s lack of well-established reputation and relationships with peer and system-level allies) while resistanceto their efforts from partners may well increase (due to defensiveness on the part ofpeers in partner agencies which have also been swept up in the efforts to reform thesystem). Family members may experience high levels of stress due to uncertainties anddifficulty in accessing services, supports, and funds to meet unique needs. Lead agenciesin these circumstances may experience rapid turnover among care coordinators, andconsequently the capacity for high quality ISP may never develop. On the other hand,strong, well-established agencies with clear models of ISP practice appear to be able tosurvive, and even thrive in conditions such as these. In general, however, ISP programswith tenuous, newly developing and/or only nominal system support appear to bequite vulnerable to turnover among system-level allies and to changes in fundingarrangements. Such programs are often funded under pilot agreements or grant-basedinitiatives, and their support may wane quickly once the trial period ends.Recognizing these vulnerabilities, advocates of ISP in many communities seek to ensurethe longer-term viability and quality of ISP programs by institutionalizing supportingconditions and arrangements at the organization and system levels. In most cases, this is envisioned as coming about as part of the process

9 to develop a larger, fully integratedsy
to develop a larger, fully integratedsystem of care and/or through the formation of a locally managed system of carefocusing on subsets of children with high levels of need. With the move towards asystem of care, the stresses may decrease on the teams and care coordinators. Theymay find they have more legitimacy and leverage to work with partner agencies, moreresources and more flexibility with funding and documentation, and a greater pool oflike-minded peers who are willing and experienced participants on teams.As systems of care continue to develop, advocates of ISP programs may find that theway than under any other sorts of arrangements. However, making the transition to asystem of care is a long process, and there may be a tendency for resistance amongupper level managers and systems people to increase as they become more fully awareof the thoroughgoing changes required by a shift to the system of care approach.Whether these sorts of barriers can be overcome in many communities is a matter ofsome uncertainty at this point. What is more, research on systems integration sends astrong caution against relying on system reform, in and of itself, as a route to improvedoutcomes for children and families. These studies argue that without attention toimproving the quality of services and to increasing the capacity of organizations,there may be little reason to expect improved outcomes under systems of care.Even in the absence of obvious movement toward a system of care, it would appearthat the necessary conditions for stable system level support of high quality ISP can bemet through arrangements that are institutionalized in rules, policies, and structures.We propose that when the conditions are met in this manner, ISP programs can sustainhigh quality implementation even where the various child- and family-serving systemsare otherwise not well integrated. Sufficient institutionalized support will mean thatISP programs will not be excessively dependent on the good will and efforts of a fewkey allies and will not continually demand exceptional efforts from the team membersthemselves. Regardless of the level of system support, however, we do not believe thata high quality implementation of ISP can be achieved unless the lead agency is highlycapable, and can provide a strong model of practice, high quality supervision, and theother conditions described in this report. The remainder of this report focuses on work undertaken as part of Services project at the Research and Training Center on Family Support and Children’sMental Health. The goal of this work was to develop a conceptual framework describingthe conditions that are necessary to support high quality implementation of team-based ISP.Chapter 2 of this report provides a description of the types of information that wereused in building the conceptual framework. The chapter also describes the process bywhich the framework was further developed through several rounds

10 of expert review. See the descriptions
of expert review. See the descriptions of local managed systems of care in Pires. The next chapters describe the proposed necessary conditions for high qualityimplementation of ISP. We have grouped the conditions under five themes as outlined). Each theme is discussed in a separate chapter, as follows:Chapter 4: Collaboration/partnershipsChapter 6: Acquiring services/supportsConsistent with the idea of backward mapping, each chapter begins with a discussionof necessary conditions at the team level, and then goes on to discuss the organizationallevel and system level/policy and funding context (i.e. reading across the rows of Figure1). Thus Chapter 3 begins with support for a practice model at the team level, and continueswith the same theme at the organizational level and the policy and funding context(system level). Chapter 4 then returns to the team level to begin with the theme ofcollaboration and partnerships, and so on. The discussion of each condition includes evidenceand argument supporting its inclusion among those necessary to ISP implementation.Additionally, we offer examples of specific techniques, processes, procedures, structures,or other mechanisms that different communities or teams have used to satisfy theChapter 8 addresses the question of how this framework of necessary conditions canbe put to practical use to improve the quality of ISP implementation. The chapter isbuilt on the idea that quality can be improved when stakeholders 1) approachimplementation with an agreement about conditions that must be in place at the team,organization, and system levels; and 2) use relevant data to guide ongoing discussionsabout the extent to which these conditions are currently in place. The chapter introducesa series of assessments that were developed alongside the conceptual framework. Theassessments—for team practice and planning, organizational support, and policy andfunding (system) context—are designed to provide stakeholders with a structured wayof examining the extent to which the necessary conditions for ISP are present in theirlocal implementation. The assessments are not designed to provide a rating or rankingof the implementation; rather, they are intended for use in discussions of the strengthsof the implementation, as well as to help clarify and prioritize areas for furtherdevelopment.The assessments were also designed with an eye towards issues of mutual accountabilityacross the various levels of implementation of ISP. Traditionally, we think of people atthe service delivery level as accountable for the quality of the services that they provide.When programs fail to deliver desired outcomes, the blame flows downward: to frontlineservice providers, and even to the families served. However, as our research has madeabundantly clear, high quality work in ISP cannot succeed where support is lackingfrom organizations and from the policy and funding context. But how are people atthese levels to

11 be held accountable for providing an ac
be held accountable for providing an acceptable level of support? Webelieve that assessing the extent to which the necessary conditions are in place at theorganizational and system levels provides a means for pushing accountability upwardas well as downward. Used in the way that we envision, the assessment of organizational 10



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%\f\r&#'(&#$ 11 support and the assessment of policy and funding context are tools for this sort ofupward accountability. In contrast, the team level checklist can be seen as a more traditionalsort of tool, of the type that is used for supervision in a more familiar form of downward. The idea is that, rather than having two separate sorts of accountability, abalance of upward and downward accountability actually builds a culture of mutualaccountability that encourages focused problem solving over defensive blaming.1Bickman, L., Lambert, E.W., Andrade, A.R. and Penaloza, R.V. (2000) The FortBragg continuum of care for children and adolescents: Mental health outcomesover 5 years. Journal of Consulting and Clinical Psychology2Bickman, L., Noser, K. and Summerfelt, W.T. (1999) Long-term effects of asystem of care on children and adolescents. The Journal of Behavioral Health Servicesand Research3Burchard, J.D., Bruns, E.J. and Burchard, S.N. (2002) The wraparound approach.Community treatment for youth: Evidence-based interventions for severe emotional and (Burns, B.J. and Hoagwood, K., eds.), pp. 69-90, OxfordUniversity Press.4Burns, B.J., Schoenwald, S., K., Burchard, J.D., Faw, L. and Santos, A.B. (2000)Comprehensive community-based interventions for youth with severe emotionaldisorders: Multisystemic therapy and the wraparound process. Journal of Child andFamily Studies5Clark, H.B., Lee, B., Prange, M.E. and McDonald, B.A. (1996) Children lost withoutthe foster care system: Can wraparound service strategies improve placementJournal of Child and Family Studies 5, 39-54.6Duchnowski, A.J., Kutash, K. and Friedman, R.M. (2002) Community-basedinterventions in a system of care and outcome framework. In Community treatmentfor youth: Evidence-based interventions for severe emotional and behavioral disorders (Burns,B.J. and Hoagwood, K., eds.), pp. 16-37, Oxford University Press.7Elmore, R.F. (1979/80) Backward mapping: Implementation research and policydecisions. Political Science Quarterly8Farmer, E.M.Z. (2000) Issues confronting effective services in systems of care.Children and Youth Services Review 22, 627-650.9Faw, L. (1999) The state wraparound survey. In Systems of care: Promising practices inchildren’s mental health, 1998 series: Volume IV. Promising practices in wraparound forchildren with severe emotional disorders and their families (Burns, B.J. and Goldman, S.K.,eds.), pp. 79-83, Center for Effective Collaboration and Practice, AmericanInstitutes f

16 or Research.10Franz, J. (2002) Building
or Research.10Franz, J. (2002) Building the Caring Enterprise, http://www.paperboat.com/calliope/11Franz, J., Heinly, G. and Miles, P. (2000) Wraparound facilitator training, Prepared forClackamas County CMHS Project. References 12Friedman, R.M. (1999) A conceptual framework for developing and implementing effectivepolicy in children’s mental health. Research and Training Center for Children’s MentalHealth, Department of Child and Family Studies, The Louis de la Parte FloridaMental Health Institute, University of South Florida.13Glisson, C. and Hemmelgarn, A. (1998) The effects of organizational climateand interorganizational coordination on the quality and outcomes of children’sservice system. Child Abuse & Neglect 22, 401-421.14Goldman, S.K. (1999) The conceptual framework for wraparound. In care: Promising practices in children’s mental health, 1998 series: Volume IV. Promisingpractices in wraparound for children with severe emotional disorders and their families (Burns,B.J. and Goldman, S.K., eds.), pp. 27-34, Center for Effective Collaboration andPractice, American Institutes for Research.15Hodges, S., Nesman, T. and Hernandez, M., eds (1999) Systems of care: Promisingpractices in children’s mental health, 1998 series: Volume VI. Building collaboration in systemsof care, Center for Effective Collaboration and Practice, American Institutes forResearch.16Malekoff, A. (2000) Bureaucratic barriers to service delivery, administrativeadvocacy, and Mother Goose. Families in Society: The Journal of Contemporary HumanServices 81, 304-314.17Malysiak, R. (1998) Deciphering the tower of Babel: Examining the theory basefor wraparound fidelity. Journal of Child and Family Studies18McGinty, K., McCammon, S.L. and Koeppen, V.P. (2001) The complexities ofimplementing the wraparound approach to service provision: A view from theJournal of Family Social Work19O’Brien, M. (1997) Financing strategies to support comprehensive, community-based servicesfor children and families. National Child Welfare Resource Center for OrganizationalImprovement.20Olson, D.G., Lonner, T. and Whitbeck, J. (1993) Individualized tailored care: Cross-system community efforts in Washington State. In The 5th annual research conferenceproceedings: A system of care for children’s mental health: Expanding the research base. March (Kutash, K. et al., eds.), pp. 247-253, University of South Florida, TheLoius de la Parte Florida Mental Health Institute, Research and Training Centerfor Children’s Mental Health.21Pires, S.A. (2002) Health care reform tracking project (HCRTP): Promising approaches forbehavioral health services to children and adolescents and their families in managed care systems- 1: Managed care design & financing. Research and Training Center for Children’sMental Health, Department of Child and Family Studies, Division of State andLocal Support, Louis de la Parte Florida Mental Health Institute, Univers

17 ity of22Rosenblatt, A. (1996) Bows and r
ity of22Rosenblatt, A. (1996) Bows and ribbons, tape and twine: Wrapping the wraparoundprocess for children with multi-system needs. Journal of Child and Family Studies 23Shireman, J., Yatchmenoff, D., Wilson, B., Sussex, B., Gordon, L., Poirier, C.,Howard, W., Alworth, J., Eggman, S. and Hooper, R. (1998) Strengths/needs basedservices evaluation: Interim report. Portland State University, Graduate School of SocialWork.24Statewide Technical Assistance Team. (2001) Orientation to wraparound and system ofcare: Cycle one trainer’s manual, Oak Park, IL.25Walker, J.S. and Schutte, K. (2002) Team-based individualized services planning:How does observed practice compare to recommended practice? In conference: A system of care for children’s mental health: Expanding the research base, Tampa,FL (March).26Ware, L.P. (1994) Contextual barriers to collaboration. Journal of Educational andPsychological Consultation 14 15Chapter 2: ................................................................................17..............................................................................................18........................................................................................19.............................................................................................................20 16 17 information. First, project staff gathered relevant theory, research, and practice-oriented information available in published and unpublished literature. Second, weinterviewed a number of stakeholders in the team-based ISP process, including parents,facilitators and their supervisors; program and organization administrators; and countyand state administrators. Finally, we gathered information during observations of ISPteams as they planned, implemented, and monitored services for children and families.Each of these sources of information is described in greater detail below.in ISP to review our work and give us feedback. After each round of expert review,framework. Further information about the process of expert review is provided in thelast section of this chapter. organization, and systems levels. At the team level, one of our primary goals was tosimilar to ISP teams in important ways. For example, we were particularly interestedin locating information on teams that undertake a long-term planning process duringmonitor implementation and effectiveness of the strategies. We also soughtinformation on the effectiveness of teams that have demographic, power, and/orshown to impact effectiveness in multiple studies across a variety of planning contexts.Thus, we paid special attention to locating relevant research reviews and meta-analyses.and applied social psychology; however, we also consulted literature on groupISP.We also gathered and reviewed materials designed to guide the practice of ISP. Primarily,these materials were manuals for training team members in the ISP process. We gathered13 different training manuals

18 . Among these, 11 were developed for spe
. Among these, 11 were developed for specific sites (intraining activities. semi-structured interviews with a total of 55 people with high levels of experience inISP at the team, organization, and/or system levels. Included in this number wereinterviews conducted with 28 team members identified as experts who had workedwith multiple teams. Among these experts, eight were caregivers. The expert teammember interviews were part of a separate sub-study on supports and barriers for ISPteams. Since we will report some of the results of this study at various points in laterchapters, we provide here some information about the method used to obtain andtwo-thirds of the interviewees were identified by asking site directors to nominateby the Center for Mental Health Services as having implemented promising practicesrelated to ISP. The remaining interviewees were identified as experts by national leveltrainers with experience at numerous sites. The interviews with expert team memberslasted about an hour each, and focused on interviewee perceptions of factors thatinfluenced the success or failure of ISP teams. The factors identified by the intervieweesincluded both those that were mostly within the team’s control (e.g. team process andstructures), as well as those which were not (e.g. funding policies and supervisorTo analyze the data from the expert interviews, we developed a coding system thatwas designed to capture interviewees’ perceptions regarding the essential elementsfor overcoming these barriers. Records from six of the interviews were coded by twoover 62 ratings for each interview) on whether or not a given theme was or was notpresent. The remaining interview records were coded by one researcher.In addition to these experts, we also interviewed a further seven experienced teamISP programs; five system-level administrators from the county, regional, or statelevel; and two researchers with a national perspective on ISP teams. Our intervieweessystem level interviewees was a person of color. The interviews were tailored somewhatthe eliciting information about supports for and barriers to successful ISP teamwork. InterviewsSources of Information: Interviews from the Promising Practices Initiative of the Comprehensive Community Mental Health Services forand Practice, American Institutes for Research, in Washington, D.C. In preparing later drafts of this framework, we also had additional interview datateam meetings. For this study, we videotaped meetings of ISP teams whose memberswith key team members who watched a series of selected excerpts from the meeting.that segment. We also had an expert family member who worked with our projectreviewing the meeting using the same debriefing procedure. We completed this processfor a total of 11 teams and 52 debriefing participants. While we have not formallyanalyzed the data, the interview information has informed the preparation of thisobservations and follow-up of 72 meeting

19 s of 26 different collaborative family-p
s of 26 different collaborative family-provider ISP teams. Sixteen of the participating teams were observed during only onemeeting, and four teams were observed during five or more meetings. ObservationsThe teams that were observed were diverse in a variety of ways. In terms of geographicdiversity, participating teams represented 13 different communities in eight differentstates. Three of these communities were located in the core areas of large cities, twoareas where farmland and newer suburbs were intermixed. Teams were also diverse interms of the overall levels of organizational and system support they received. ForHealth Services as having implemented promising practices related to ISP. Ansubstantial federal grants to improve service coordination and to implement Systemsof Care. Members of some of the observed teams received extensive training andOne or two members of our research staff attended each observed meeting. Researchstaff collected any materials created by the team for use during the meeting (e.g.agendas, lists of goals), and took notes during the meeting about the structuralcharacteristics of the team and elements of team process and planning. Copies ofa post-meeting survey. Sources of Information: ObservationsObservations This family member had participated on, and then facilitated her son’s ISP team, and had participated meeting. Information collected included: sex, race, and role of each team member inlength of the meeting. Another section of the checklist was used to rate whether ornot various indicators of team process and planning were evident during the meeting.ISP. It was created as a means of assessing the extent to which there was evidence,during the observed meeting, that the team had the ability to promote both effectiveobservers over nine of the meetings that were attended by two staff members, amean agreement greater than 85% was achieved over the 28 items. A revised versionThe first draft of this report was written based on the information in the interviews,observations. Results from additional observations were incorporated into later draftsas the information became available.the Research and Training Center for Family Support and Children’s Mental Health.researchers with a high level of expertise in children’s mental health. From this group,three state-level administrators, and two consultants. Ten of the 11 reviewers provideddetailed feedback during interviews lasting about an hour in length. In most cases,interviews. Seven of the reviewers also provided written comments. One reviewerprovided only written comments. Once again, the feedback was incorporated into the Expert review** plan. We clarified this definition and were able to reach agreement. A second area of disagreementwhole had played no role in arranging the activity. Adjusting the definition of this item to reflect a teamrole in arranging the natural support led to acceptable agreement on this item. Finally,

20 disagreement aroseregarding the item cod
disagreement aroseregarding the item coding whether or not teams had looked into providing community service.Clarifying the definition of community service allowed agreement on the item. Revised definitions were feedback session. Feedback, which focused primarily on the assessments, wasincorporated into revisions of the assessments.consultants. Members of this group came from four different states. The second groupprogram administrators and consultants from seven different states. At the nationalthe participants discussed the appropriate assessment and provided feedback. Feedbackwell as on notes taken during the reaction sessions. A final draft of this report, includingthe assessments, was then prepared and sent out for final review. Final review includedinternal review, as well as review by a parent consultant to the research project. Thisadvocacy group taking a strong role in system reform. The current version of each of 22 23 Chapter 3: Practice model: Team leveli.Team adheres to a practice model that promotes teamwith the value base of ISP...............................................................25Figure 2: A model of ISP team effectiveness..................................261.Team adheres to meeting structures, techniques,and procedures that support high quality planning....................282.Team considers multiple alternatives beforemaking decisions.......................................................................293.Team adheres to procedures, techniques and/or structuresamong providers and families....................................................304.Team uses structures and techniques that lead allmembers to feel that their input is valued..................................325.Team builds agreement around plans despitediffering priorities and diverging mandates................................336.Team builds an appreciation of strengths..................................337.Team planning reflects cultural competence..............................34i.Lead agency provides training, supervision, and supportfor a clearly defined practice model................................................35ii.Lead agency demonstrates its commitment to the values of ISP...38iii.Partner agencies support the core values underlyingthe team ISP process......................................................................40i.Leaders in the policy and funding context actively support theISP practice model..........................................................................41........................................................................................................43 24 25 Practice model: Team levelThis chapter begins the discussion of the proposed necessary conditions for high qualityimplementation of collaborative team-based Individualized Service/Support Planning(ISP). The conditions covered in this chapter are those found in the top row offigure 1, and are related to support for a practice model for ISP

21 .This chapter begins with a discussion o
.This chapter begins with a discussion of the need for teams to adhere to an ISP practicemodel that promotes effectiveness in reaching desired outcomes. The chapter goes onto discuss the conditions that need to be in place at the organizational level to supportteams’ adherence to the practice model. Finally, the chapter discusses the conditionsthat must be in place in the policy and funding context (system level) in order to supportorganizations and teams in these efforts.Practice model: Team leveli. Team adheres to a practice model that promotes teamwith the value base of ISP.Individualized Service/Support Planning teams face a variety of challenges inaccomplishing their work. Like other teams involved in complex long-term planning,ISP teams need to overcome numerous challenges related to the “generic” tasks ofteamwork. If any team is to be successful, its members must be able to select appropriategoals, devise high quality solutions to problems, avoid destructive conflict, maintainconfidence in the team’s efforts, and so on. In addition to these generic challengesof teamwork, ISP teams face a series of additional challenges that are more specific tothe ISP process. These challenges arise because ISP specifies that team plans—as wellas the planning process itself—should be individualized, family centered, and culturallycompetent. ISP teams are further required to create plans which build on the strengthsand assets of the team, the family, and the community.In this section, we describe the types of knowledge and skills that team members mustpossess if they are to overcome these challenges and work together effectively. Thediscussion throughout this section is based on the model of ISP team effectivenessoutlined in figure 2 (). In developing the model, we incorporatedinformation from our interviews, as well as information from research and theory onteamwork and team effectiveness. (Much of this research and theory is cited in thechapter.) The resulting model is a variation on the type of model that is most commonlyused in research and theory on team effectiveness.The model shown in figure 2 isalso consistent with the way that expert ISP team members talk about teamwork. Inour study of expert team members, we asked our interviewees to describe challenges toeffective ISP teamwork and strategies for overcoming those challenges. In order toclassify the main themes that came up in their responses, we used a coding system thatwas derived from the same conceptual foundation as the model. The level of inter-rater reliability that we achieved in coding the interview material suggests that theconceptual foundation is a good fit for practical as well as theoretical understandingsof ISP effectiveness. 26



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Practice model: Team levelIn the model, the main route to effectiveness is from processes include team member skills, knowledge, and background, as wellas organizational and system support. ISP are specific techniques and proceduresthat team members intentionally employ as they work to develop the plan andoperationalize the ISP value base. Practices include specific techniques and proceduresfor defining and prioritizing goals, stimulating the exchange of information, makingdecisions, obtaining feedback, building an appreciation of strengths, ensuring family-centeredness, and so on. Practices take place within a short time frame, though thesame practice may occur on many occasions. ISP practices are translated into through their impact on two team-level pr

24 ocessesof building team cohesiveness. On
ocessesof building team cohesiveness. On cohesive teams, team members have developed theshared belief that they are willing and able to work together to achieve goals held incommon. Figure 2 describes the two processes in terms of a series of attributes thathave been linked to effectiveness in numerous team studies across a variety of contexts.These attributes are marked with asterisks in the figure. Other attributes of the twoprocesses reflect the special nature of ISP by incorporating elements of the value base.The two team-level processes are complex, and each is continually affected not only byteam practices but also by feedback loops that operate both within each process andbetween the two.The model of ISP effectiveness assumes that success in both processes is required ifteams are to be effective in achieving desired ISP (e.g. improved fit betweenservices/supports and needs, increased family empowerment, and improved quality oflife). In turn, effective practice is based on a clear understanding of how a given techniqueor procedure can be expected to impact team-level processes. In addition to beingknowledgeable about practices, team members must also have skills that will enablethem to implement practices at the appropriate times. These types of skills andknowledge are contained in a for ISP.The overall condition for high quality implementation of ISP at the team level is that ateam adheres to a practice model that promotes team cohesiveness and high qualityplanning in a manner consistent with the value base of ISP. This overall condition isquite complex, however, so we have organized the discussion around seven sub-conditions that provide more detail about the types of knowledge and skills that teammembers need to have in order to maximize the probability that their work will beeffective. These sub-conditions are:1.Team adheres to meeting structures, techniques, and procedures that support high2.Team considers multiple alternatives before making decisions,3.Team adheres to procedures, techniques and/or structures that work to counteractpower imbalances between and among providers and families,4.Team uses structures and techniques that lead all members to feel that their input isvalued,5.Team builds agreement around plans despite differing priorities and divergingmandates,6.Team builds an appreciation of strengths, and7.Team planning reflects cultural competence. 28 Practice model: Team levelBelow, we describe each of these sub-conditions more fully. We should be clear thatour intention is not to provide a full practice model. Instead, the sub-conditions of information that should be included in a practice model.Regarding the first sub-condition, for example, we argue that the practice model shouldprovide clear, detailed information about the structures, techniques, and proceduresthat teams should use to support their planning. And while in many cases we provideexamples of the types of techniques, structures,

25 or procedures that might meet a givensub
or procedures that might meet a givensub-condition, we do not attempt to offer a complete or exhaustive list.Extensive trainings in ISP already exist, and any given training or manual may providesufficient information to guide teams about how to meet most or all of the sub-conditions. However, in many communities, the local practice model is built from manydifferent sources, and training and/or the model itself may be extensively adapted tofit local needs. This list of sub-conditions can help communities judge whether or nottheir own practice model is sufficiently comprehensive and specific. The Checklist forIndicators of Practice and Planning (ChIPP, described in Chapter 8 and included asAppendix A) is an assessment that can also be used in efforts to assess the adequacy ofa practice model. Communities can then focus on filling in any gaps or weaknesses thatthey identify.Each of the following sections focuses on a single sub-condition, and includes a briefsummary of research results that support the idea that the condition is necessary foreffective ISP teamwork. The results cited are drawn both from our own work and fromother published studies. The cited research also provides evidence for the relationshipsbetween practices, processes, and outcomes depicted in the model.Ultimately, of course, it is up to the team to adhere to the practice model. As teamscarry out their work, different people, with different roles, will take primary responsibilityfor ensuring that various sub-conditions are met. For example, the person acting as thefacilitator often assumes much of the responsibility for seeing that the team implementsthe steps of an effective planning process. On different teams, facilitation may theresponsibility of a parent, a care-coordinator, or someone who has no other role on theteam. Similarly, on one team, a parent advocate may take on a good deal of responsibilityfor ensuring that teamwork is family centered and strengths based. Other teams willnot have a parent advocate, and so those teams will need other strategies to ensure thatthese values are guiding the team’s work. The practice model should provide sufficientguidance about how the various responsibilities are shared out among the various teammembers. Team members will, of course, require sufficient training to enable them tocarry out their roles on the team.1. Team adheres to meeting structures, techniques,At its heart, ISP is a planning process. Teams that are effective in complex, long-termplanning use a structured process for creating and monitoring their plans. The processmoves through successive cycles of setting goals, selecting and carrying out action The provision of training is considered the responsibility of the lead and partner agencies, and isdiscussed at the organizational level. 29 Practice model: Team levelsteps, assessing progress, and adjusting goals and strategies as needed. Such an approachA long-term goal or mission is agre

26 ed upon;Intermediate goals and observabl
ed upon;Intermediate goals and observable indicators of progress towards goals are clearlyTasks or action steps are linked to intermediate goals, and responsibility forperforming each task is assigned;Progress on each action, goal and/or sub-goal is monitored and/or revisited insubsequent meetings, and strategies for achieving the goals are altered as needed.Adherence to these structures of good planning helps ISP teams access other avenuesto increased effectiveness as well. Further along in this section, the discussion providesclarification of how adherence to these structures can lead to increased ISP teameffectiveness by: helping teams turn conflict to constructive ends, providing opportunitiesto promote the family’s perspective, and contributing to cultural competence and theindividualization of plans. It is worth emphasizing that these benefits accrue only when plan. Among the ISP teams we observed, less than onethird maintained a team plan with team goals. Thus, more than two thirds of the teamswere not making use of the structures of teamwork that have been most consistentlylinked to team effectiveness in virtually any setting. A practice model for ISP shouldprovide clear guidance to teams about how to maintain the essential elements of aneffective planning process.Training materials for ISP, as well as a formal consensus reached by ISP researchers,advocates, and trainers give the ISP team the additional responsibility for developingthe crisis plan for the child and family. While a crisis plan is different in some ways fromthe larger team plan, it nevertheless seems likely that imposing appropriate structure oncrisis planning can increase the potential for the plan’s effectiveness. For example, thecrisis plan can be developed to reflect a goal structure with action steps clearly defined.And even though the crisis plan may never be measured against indicators of success(because it may not be used), the strategies included in the crisis plan should be reviewedperiodically and revised where necessary. The practice model should provide guidelinesfor what should be contained in the crisis plan, as well as explicit expectations abouthow it should be reviewed and maintained. In general, the types of skills, procedures,and techniques that the ISP practice model provides for teamwork in developing theoverall plan would apply equally in the case of the crisis plan.2. Team considers multiple alternatives before making decisions.Teams are widely touted for their potential to reach creative solutions to complexproblems. However, this potential is often unrealized, and teams may well be less creativeand/or less productive than individuals working on the same task. This loss of creativepotential appears to come about because team members are often over-eager to committo the first goal, strategy, or solution that comes up, rather than generating multipleoptions and then choosing among them. Generating multiple optio

27 ns while problemthan those generated lat
ns while problemthan those generated later. Teams in general appear to be reluctant to adhere toprocedures—such as brainstorming—that have been shown to stimulate creative, open-ended thinking. 30 Practice model: Team levelThese barriers to creativity appear to be present in ISP teams as well. In our observations,fewer than one in five teams considered multiple options for ways to meet a goal orcarry out an action even one time during the meeting. Fewer teams still used a structuredactivity to stimulate creative thinking. This may be one of the reasons teams appear tohave relatively little success in developing highly individualized plans that incorporatecommunity and natural supports. Among the 72 meetings we observed, there wasonly evidence during 11 meetings that teams were providing access to a regularcommunity service or support (for example, by purchasing a membership in the YMCA).More strikingly, during only four meetings was there evidence that the teams wereactually tailoring a community service or activity to meet the specific needs or goals ofthe child or family.There are of course numerous barriers that limit ISP teams’ ability to respond creativelyto the challenges of planning. While many of these—particularly financial incentivesand funding issues—are primarily organization- and system-level issues, there are alsovarious barriers at the team level. Team members need to be keenly aware of a pitfallwe heard about frequently in our interviews—relying on traditional, categorical servicesin a non-individualized manner. Team members often complained that the results ofteam planning all too often came down to the provision of the same kinds of servicesthat had been happening before, albeit possibly in a more coordinated manner.A practice model for ISP should provide clear guidance on the procedures and techniquesthat teams can employ to increase creativity. Teams will need to develop a mindset thatwill keep them from committing too quickly to the first solution—often a servicesolution—that comes up. Discipline in generating multiple options also has greatpotential to increase the extent to which the plan will be family driven and culturallycompetent. When teams generate multiple options, family members have a greateropportunity to select the option that fits with their own preferences and their owncultural values.3. Team adheres to procedures, techniques and/or structures that work toThe value base of ISP specifies that the process is to be family centered,work of the team being driven by the family’s own sense of its strengths, needs, andpriorities. The family’s choice should also guide decision making regarding the servicesand supports that will be accessed or developed to serve the team’s goals. Plans devisedwith genuine family input are more likely to have realistic goals, to include creative andflexible strategies, and to engender a sense of family ow

28 nership. What is more, whenthe process i
nership. What is more, whenthe process is family centered, it is more likely that the plan will be truly individualized,and that it will reflect cultural competence.Available research indicates that it is likely very difficult to realize this vision of family-driven teamwork. Mental health professionals often demonstrate a reluctance or inabilityto hear the family’s perspective, or to respect the knowledge which families bring to This may also reflect a more general dynamic that appears inteamwork. On any team, people of higher social status tend to talk more and havemore influence over the decisions that are made. Thus, for example, team meetingsare likely to be dominated by men rather than women, by bosses rather than subordinates,or by people with more rather than less formal education. It is very difficult for teams Practice model: Team levelto overcome this sort of imbalance, even when team members are making consciousefforts to equalize participation and influence. On ISP teams, it is not uncommon forfamily members (particularly youth) to possess relatively few markers of high status.Even where family members have relatively high status outside of meetings, their statuswithin meetings is likely to be deflated because of team members’ tendency to see thefamily in terms of its needs and deficits. As noted above, professionals also tend tohave high opinions of their own expertise relative to those of families of children whoare experiencing emotional and behavioral difficulties.If the practice model does not provide teams with specific, concrete guidance abouthow to redress the imbalances of power between the family/youth and professionals,it is unlikely that the family’s perspective(s) will be adequately represented in the planningprocess. Simple process interventions to increase the number of contributions todiscussion and decision making may be effective, but it is likely that teams will need toemploy a variety of strategies for increasing family input and decision making at variousstages during the planning process. Strategies we have seen in use include providingopportunities for family members to speak first and last during discussions, checkingback in with families after any decision, or using a family advocate to reinforce thefamily perspective as elicited in interviews outside of full team meetings. It is particularlyimportant that the team goals reflect the family’s perspective. When the family’s strengths,needs, and priorities are codified in the goals, the team’s subsequent work by necessitybuilds from the family perspective. Obviously, this will not happen if the team has notselected goals, or if the goals are not clearly specified.A number of our interviewees and several of the training manuals stressed that, beyondalso provide room for a qualitatively different sort of input from the family by providingopportunities for family members to “tell their stories.”

29 Potentially, providing suchopportunities
Potentially, providing suchopportunities can be empowering for families by allowing them to provide a narrativeexplanation for how current situations have come to pass, and why. The family’s viewsof agency and causation thus become the frame for discussions of future steps. Inaddition to being inherently empowering, family storytelling can help the team accessinformation that might otherwise be lost in more formal or abstract processes that arepart of planning. A family’s story can contain important information about hopes,goals, strategies, and resources. In some communities, the family is encouraged to addto their story at each ISP meeting by reflecting on how things are going, while in othercommunities the bulk of the story is elicited outside of meetings during interviewswith a family advocate or care coordinator. Regardless of the specific techniques used,it appears that an ISP practice can be strengthened in important ways when opportunitiesare provided for family members to speak in an open-ended, narrative way about theirexperiences.Beyond merely providing opportunities for the family to assert its perspective, ourinterviewees stressed the importance of creating a team atmosphere such that familymembers feel safe to speak openly and honestly about difficult topics, feel comfortabletelling their stories, and feel engaged in the ISP process. Of course, it is desirable for team members to feel psychologically safe and engaged in the ISP process. The discussionbelow—particularly that contained under the sub-conditions having to do with valuinginput, building agreement, appreciating strengths, and reflecting cultural competence— 32 Practice model: Team levelprovides information about how the practice model should guide teams towards creatingthis sort of comfortable interpersonal environment. However, issues of psychologicalsafety and engagement are of particular importance to the family, and the team needsto practice extra care to maintain the meeting as a safe and comfortable place wherefamilies feel valued and supported. Thus, for example, where team members might usetechniques of active listening, such as reflecting and summarizing, to help demonstratevaluing of each team member’s input, this might be done with greater frequency anddeliberateness for input from the family.4. Team uses structures and techniques that lead allTeams are more effective when team members feel that discussion and decision makingprocesses are equitable or fair. It is important to note that equity and equality arenot the same. For example, teams may well feel that it is fair (equitable) for a mother tohave more (equal) opportunities than professional team members to speak and tomake decisions. Team members are likely to feel that teamwork is equitable when theybelieve that they are respected, and that their input is valued. When team members’participation is not perceived as equitable, the team’s effec

30 tiveness tends to suffer dueto decreases
tiveness tends to suffer dueto decreases in creativity and information sharing, and due to increases in destructiveconflict. When team members feel that decisions are reached through processes thatare not equitable, they are unlikely to feel committed to the decisions and to followthrough on tasks.As was noted previously, teams are often dominated by people with high status, andthis can easily lead team members to feel that team process is not equitable. For example,a team’s discussions may be dominated by a psychiatrist or clinical supervisor, andvaluable input from a behavioral skills specialist may be lost. Once again, it is likely thatthese tendencies will continue unless the practice model provides specific informationabout how to increase equity in participation, and how to make people feel that theirinput is respected and valued by the team. Teams need explicit guidance from thepractice model about techniques to increase team perceptions of equity, not just throughcounteracting status differences, but through other methods as well. Some examplesof team process or techniques that can increase perceptions of equity include: providingopportunities for each team member to give input into decisions; reflecting, summarizing,and/or recording team member ideas or suggestions; and having the team set its ownrules or guidelines for how to demonstrate interpersonal respect.The practice model should also provide specific guidance about how to help ensurethat youth team members will feel respected and valued. Existing research offers littleinformation about collaborative teamwork between adults and youth; however therewas a strong consensus among team members who participated in our studies thatincluding the youth could be quite difficult. On the other hand, we observed teams thatwere successful in engaging children as young as nine years old in the planning process.Teams that include the youth in the planning process may well also confront challengeswhen the youth and other family members disagree. 33 Practice model: Team level5. Team builds agreement around plans despite differingOn effective teams, members believe that their goals are cooperative. This meansthat team members believe that the actions of each team member serve to advance thegoals of all. This does not mean that team members will never be in conflict or havedisagreements; on the contrary, controversy is an essential source of creativity andlearning on successful teams. Disagreement and controversy are particularly likelyto occur on teams, like ISP teams, that have a high level of diversity in background andexperience. What is more, on ISP teams, different team members may be responsiblefor carrying out specific mandates that appear to be contradictory. Our intervieweesreported that this can be a source of great conflict on some teams.In teams and groups, conflicts are less likely to arise, and more likely to be resolvedwhen the team has a clear sense

31 of shared goals. On ISP teams, conflict
of shared goals. On ISP teams, conflict around thebest ways to achieve goals may be decreased when the action steps are clearly linked tothe goals. Furthermore, team members—especially those who may be skeptical abouta particular goal or action step—need to be able to trust that the team will be pragmaticin evaluating the success of strategies or action steps, and discarding those which arenot helping the team reach its goals.A practice model must provide teams, particularly facilitators, with a variety of specificstrategies for dealing productively with conflict and controversy. For example, facilitatorsshould be able to recognize and intervene quickly in “negative process,” cycles ofblaming and attacking behaviors which are detrimental to group functioning. Manystrategies for harnessing controversy depend on consistently reminding the team ofshared goals, and building from there. Where skills in conflict management are lacking,there is a high probability that the team’s effectiveness will suffer.6. Team builds an appreciation of strengths.The ISP value base stresses that the process should be strengths based. In particular,the strengths of the family and youth are to be built upon. Additionally, the assets ofother team members, and of the community, are to be drawn on in the plan. Researchhas little to say about whether a strengths orientation impacts team effectiveness;however, there is evidence that the affirmation of strengths can empower low statusteam members and increase their confidence and participation. Furthermore, sinceacting in a strengths-based way is one of the requirements for ISP teamwork, it isimportant for team members to be able to recognize when they are being successful inpracticing the value.In our observations, we saw teams using several strategies to focus on strengths, especiallythose of the family. During interviews, a number of team members pointed out thatchild and family strengths are affirmed when the family is trusted and empowered todrive the ISP process. This is concrete evidence of a team’s conviction that the familyhas a fundamental strength in knowing what to do to take care of itself. Research inother settings has shown that the participation of low status team members increasesduring teamwork when the team acknowledges specific contributions that the low statusmembers have made to achieving team goals. Despite the strengths activities we observed, 34 Practice model: Team leveland the comments we heard, team members in our studies consistently expressed concernbecause they were unsure about how to build a strengths perspective into the ISPprocess. Team members pointed out that it is not easy to design a plan that simultaneouslyaddresses needs and builds on strengths. They also expressed some confusion aboutthe differences between “real” and “fake” or superficial strengths, a distinction thatappears in many training materials. Cle

32 arly, a practice model for ISP should sp
arly, a practice model for ISP should specify theprocedures and techniques that teams can use to assist them in maintaining a strengthsperspective.7. Team planning reflects cultural competence.Each of the sub-conditions mentioned so far is potentially impacted by culturalvalues and norms. People from different cultural backgrounds may hold differentvalues and make different judgments about, for example:what sorts of team procedures and rules will be acceptable,what sorts of interactions communicate respect,how strengths are defined and how they are talked about,how needs are defined and how they are talked about,how conflict is expressed and managed, andthe most important types of goals for a child and family.Team members who hold different beliefs in these areas may have great difficulty workingcollaboratively together. What is more, cultural differences in values and norms canarise from many sources, and not just from differences in racial, ethnic, or religiousbackground. For example, individual families have their own norms and values; andmental health, juvenile justice, and child welfare workers are imbedded in organizationsand work-based interpersonal networks which reinforce their own norms and values.Indeed, the cultural gap between the perspective of professionals and the perspectiveof families is one that appears regularly in teams, regardless of the degree of the racial,ethnic or religious similarity among team members.The practice model should provide some specific information about how to increasethe cultural competence of teamwork. It is likely that this guidance will need to beformulated with the culture of specific communities in mind. Agencies will need toadjust and elaborate practice models to provide clearer support for cultural competenceon teams. Other agency efforts to support cultural competence are discussed in sectionson organizational supports for ISP.Beyond this, it is clear that teams are likely to be more culturally competent when theyadhere to the other elements of teamwork discussed above. For example, differencesin norms and values often exacerbate the difficulty that teams encounter in hearing thefamily and following the family’s lead in planning. This makes it even more importantthat the team adhere to structures, techniques, and procedures that support the family’svalues and the family’s voice. Similarly, cultural competence is likely to be greater whenthe practice model specifies how the planning process can be structured to offer choicesbetween options. This allows family members to review a variety of options, and selectthose that best reflect their values and priorities. A number of our interviewees believedthat cultural competence would be increased when teams included larger numbers ofcommunity and natural supports. This is another area where the practice model couldbe expected to provide concrete guidance, by specifying what teams can do to recruitand retain com

33 munity and natural supports (see Chapter
munity and natural supports (see Chapter 6). 35 This section discusses why it is necessary for the lead agency to clearly define a single,shared practice model that will guide ISP practice for all its teams. Successfullyimplementing the practice model at the team level requires considerable expertise fromteam members in key roles, and this section also focuses on the training and supportthat agencies will need to provide to key team members.The ISP practice model defined and supported by the lead agency may be one that hasbeen developed specifically within the agency, or it may be one that is agreed uponacross multiple sites. Regardless, it is critical that the practice model be shared amongthe facilitators, parent advocates, trainers, and supervisors who work together. Thismeans that they will understand ISP teamwork in terms of shared definitions for theessential elements of the practice model, including the required techniques, skills, andprocedures. Having shared definition will make it easy to recognize if a facilitator is,say, using procedure X for generating multiple alternatives to reach a goal, or using skillY for promoting team members’ sense of equity in decision making. Having shareddefinitions for essential elements of the practice model also makes it easier for trainers,supervisors, and team members to have a shared standard for evaluating the quality ofthe performance of key team roles.Various strands of research and theory support the idea that having this sort of sharedunderstanding of a clearly defined practice model is crucial for implementing andmaintaining high quality, complex interventions like ISP. For example, results fromresearch on training show that when a model for the practice of complex interpersonalinterventions is clearly defined, trainees and supervisees are more likely to learn theskills and techniques more quickly, apply them in their practice, and be more effectivethan practitioners using more eclectic or less fully specified approaches.meta-analyses examining psychotherapeutic interventions for children, the provisionof a structured model for practice is one of the factors that has been associated withthe apparent superiority of practice in research settings over practice in communitysettings. Shared understandings and shared vocabulary also facilitate discussion ofthe skills in a way that is effective in helping people develop metacognitive awarenessabout when to apply a particular skill or technique to a particular type of situation. Thedevelopment of metacognition appears to be an essential part of expert approaches to The various studies we cite have been selected focus either on training generally or on training infields in which the skills to be acquired are similar to those which are used in facilitation—i.e. skillsrequiring the trainee/supervisee to facilitate or guide interactions in a complex interpersonalenvironment. Little high quality research exists specif

34 ically addressing the effectiveness of t
ically addressing the effectiveness of trainingand/or supervision in the context of social service organizations.Our use of results from research in psychotherapy does not imply that we equate ISP with therapy.On the other hand, psychotherapy is like ISP in that practitioners need to learn and employ specifictechniques or skills for managing complex interpersonal interactions.Metacognition is, literally, thinking about thinking. Metacognition is a higher order thinking processthrough which people evaluate their reasoning, thereby learning to improve judgment on futureoccasions. a wide variety of complex cognitive tasks, including the types of relational tasks thatare central to teamwork. Having a clearly defined practice model is also essential formonitoring fidelity (the extent to which actual practice is “true” to recommendedpractice). If fidelity is not measured, or measurable, the chances of successfulimplementation of any intervention is greatly decreased, particularly if the interventionAt the team level, it is the facilitator who will have the primary overall responsibility forensuring that the team adheres to the practice model. For example, the facilitator mustensure that the family perspective is adequately represented in discussion and planning.The facilitator must also be able to help the team collaborate effectively despitedifferences of opinion and perspective. It is likely that it will take some time for facilitatorsto acquire the necessary expertise, and the lead agency must be prepared to offer supportas effectively as possible. Beyond providing training, the lead agency must providefacilitators with sufficient, high-quality, ongoing support to ensure that training istransferred into practice. High-quality support will include supervision and/orcoaching thatincorporates information from observations, audio- and/or videotapes of facilitatorperformance; andfocuses in a structured way on building knowledge about, and skills required for,Other team members with specialized roles, such as family advocates or resourcedevelopers, will also need training and support for their roles in the practice model,although this training may or may not be provided by the lead agency. Ongoing supportfor these team members should also encourage the transfer of training into practice byusing a structured approach to coaching and/or supervision. The rationale for theserecommendations is presented below.It takes time to develop expertise in a complex task, and research provides some clearguidance about the type of support that should be provided so that learning continuesbeyond the initial training episodes. Perhaps most important is the need for ongoingcoaching. It is estimated that only about 10% of training is actually transferred intopractice, even when the trained skills are simple. For more complex interpersonalskills, transfer may be even less; however, when there is a clear practice model, when ongoing coac

35 hing is provided, transfer can be dramat
hing is provided, transfer can be dramatically increased. Minimally,effective coaching for interpersonal skills involves observation of the trainee practicingthe skill, followed by a discussion of the observation session. While supervisors andtrainers can be used as coaches, peer coaching can also be very effective. The literatureon supervision suggests that ongoing support for skill acquisition will be more effective—as well as more satisfying to participants—when it is a structured processconceptual framework, and organized around the setting and monitoring of specificsupervisee goals. In meta-analyses examining psychotherapeutic interventionsfor children, supervisor monitoring of therapist practice (e.g. through review ofin research settings over practice in community settings.Our own research confirmed others’ assertions that many teams calling themselves ISPor wraparound teams do not appear to be working within the paradigm as it is defined, and that this is at least partly due to a lack of specification of a practice model.noted previously, we found many teams operating in an essentially unstructured way,without a team plan or team goals. Other markers of ISP, such as attention to strengthsor to the family perspective, were also absent in many meetings, including meetingsfrom sites held up as national models. The team members we interviewed, recognized as most expert, were almost unanimous in saying that they felt overwhelmed bythe complexity of the ISP process, and that they felt far from comfortable and competentin their roles. While many facilitators felt that the training they had received was usefulin helping them to learn about the philosophy underlying the ISP process, they alsosaid that they did not feel they had learned the specific procedures and skills that wouldmanaging meetings effectively. Even when a training had focused on procedures,techniques, and skills, some facilitators reported feeling overwhelmed by the volumeof information presented. Furthermore, while the extent of training varied from siteto site, a substantial number of facilitators from “average” teams reported receiving nospecial training at all prior to starting to facilitate team meetings.The supervision provided to team facilitators (as described by our interviewees) onlyrarely appeared to focus on the skills of team-based planning and facilitation Furthermore, it was rare to encounter agencies that had developed clarity about how torecognize indicators of good practice, collected data on the extent to which theseindicators appeared in teamwork, and then used the resulting data in supervision. Infact, there was no meeting, among the 72 that we observed, where there was a supervisorpresent to evaluate the performance of the facilitator or parent advocate (nor were anyof these meetings audio- or videotaped for this purpose). Most facilitators reportedreceiving regular “clinical supervision”; howev

36 er the supervisors were most frequentlyr
er the supervisors were most frequentlyreported to be clinical psychologists who were not experienced or trained in facilitationof the ISP process. Most facilitators also reported that they had group supervisionsessions with other facilitators.Facilitators reported that they felt supported by their supervision; however for themost part they also reported that both group and individual supervision sessions werequite unstructured, and that there tended to be no formal goal setting or data gatheringto assess facilitator skill or progress. Some sites have used, at least on occasion, reviewsof service plans or surveys of team members as a means of providing feedback tofacilitators and their supervisors, while other sites provided feedback based onobservations of team meetings. It is not surprising that ISP supervisors do not followrecommended practices for supervision. Generally in the human services it appearsthat supervisors are rarely trained in supervision, and that most have no clear model fortheir practice of supervision.Just like facilitators, people with other special roles on ISP teams are likely to be moreeffective when the ISP program supports a single, clearly defined practice model, andwhen the roles for carrying out the practice model are also clearly defined. The agencyproviding training and support for these team members may or may not be the leadagency. For example, parent advocates may be trained and supervised by family advocacyorganizations. Available research suggests that trained parent advocates can help increasefamily participation on collaborative planning teams, and theories of parentempowerment are becoming increasingly specific regarding what skills are most helpful 38 in helping to empower parents. Training curricula for parent advocates in the ISPprocess have been developed in several communities. On the teams that we observed,parent advocates rarely appeared to take an active role unless they were also facilitatingthe meeting. In and of itself, this is not direct evidence that the non-facilitator parentadvocates were ineffective; however, we were left with a sense that the parent advocatesin many instances were not confident about the role they were to play on the team.Finally, our interviewees suggested that all team members should receive orientation tothe basic ISP model, and that family members in particular would benefit from suchorientation. Many sites do, in fact, provide some form of orientation for teams. Often,portions of initial meetings are set aside for orientation and a discussion of proceduresand ground rules. In other instances, orientation takes place apart from the planningprocess and can range from very simple (e.g. providing team members with introductoryvideos, booklets or pamphlets describing the ISP process) to quite elaborate (havingteams come together to engage in structured team-building activities such as simulations,role plays or games). Some sites make a special

37 effort to orient families to the purpose
effort to orient families to the purpose,values, and process of ISP, and available research suggests that that this is indeed helpfulin increasing parent participation in collaborative planning.suggests that when all members of a group or team are aware of how the group isstructuring its work, they can all contribute to the facilitation of that process, therebyleading to more equitable participation.Many of our interviewees, as well as several of the trainers we spoke with, expressedagency demonstrated both:a conviction that ISP is an effective way to meet the needs of children and families,a belief that the values of ISP should structure not just team interactions but alsointeractions between and among staff.For example, there was agreement among the experienced facilitators, advocates, andadministrators with whom we spoke that truly family-centered ISP practice could onlytake place within organizations which intentionally cultivates a parent/youth/consumervoice in organizational decision making around team issues. Similarly, a number of ourinterviewees expressed the belief that strengths-based practice can only take place withinan organization that takes a strengths-based view of staff, and that culturally competentpractice can only be sustained within culturally competent organizations. Relevantresearch reviews and results, as well as a growing consensus among proponents ofsystems of care, provide a measure of support for the idea that there should beconsistency between the values advocated by an organization and the values the organization.In the literature on organizational effectiveness, there is large body of research whichgenerally supports the hypothesis that employees (and hence their organizations) performbetter when organizational values and culture are clear and consistent and aligned withexpectations for employee behavior. There is also a smaller body of research whichii. Lead agency demonstrates its commitment to the values of ISP. supports the idea that teams are more effective when there is alignment between teamand organizational goals (see the review and results reported by CohenSeveral of our research participants pointed out difficulties arising from a divergencebetween the values of ISP and the values practiced by managers and staff of the leadagency. A number of interviewees expressed the idea that lead agencies may be morewilling to “talk the talk” than “walk the walk” of ISP values. In these cases, managersand other staff in agencies were seen as being generally supportive of the idea of ISP,but unable, or unwilling, to change their own attitudes or behaviors in significant waysto reflect the values of the model. The most commonly suggested remedy for thissituation was increased ISP training for managers and other staff. Several intervieweesto ISP values as a prerequisite for hiring.Theory (and, to a lesser extent, research) on mental health services and systems of careals

38 o support our interviewees’ claim t
o support our interviewees’ claim that there should be consistency in values acrossdifferent levels of the service delivery system. At the organizational level, the need forconsistent values is seen primarily in discussions of the need for organizational levelattention to cultural competence and collaboration with families. In the system of careliterature, there is a general consensus in agreement with the proposition that culturalcompetence at the service level can only exist within organizations that are themselvesworking towards cultural competence. Further, organizations are called upon to domore than “talk the talk” of cultural competence by engaging in a structured processwhich includes substantial participation by diverse stakeholders. This process can bebased in organizational cultural competence self-assessment, or in other forms ofstructured discussion and planning. Another strand in the literature focuses on theneed to generate feedback about perceptions of cultural competence from consumers,using measures such as the Client Cultural Competence Inventory.Similarly, the theory and qualitative research on systems of care support our interviewees’contention that family-centered services will only be a reality when service-providingorganizations also collaborate effectively with families in determining organizationalpolicies and priorities. Our interviewees stressed that it difficult for agencies to fullyunderstand the importance of providing a means by which family perspectives canhave a real impact on the organization. Even where agencies might endorse this value,many barriers stand in the way of realizing it. Given this difficulty, it appears necessarythat agencies implement concrete strategies to ensure that the family voice has an impacton practices. Examples of such strategies are: hiring family members as staff, includingfamily members in setting practice/skill guidelines or in hiring or evaluating facilitators,providing seats for family and youth on boards of directors, including family membersin training for all staff, and involving families in service delivery. Similar strategies, aswell as others, have been designated as promising practices in children’s mental health,and are more fully described elsewhere.Finally, several interviewees were adamant that facilitators and other team memberscould only truly learn to be strengths based within agencies that treated strengths-based way, particularly with respect to supervision. Cohen makes a similarargument, supporting it with evidence from existing research. Various other theories,with limited research support, have focused on the more general idea that interactions 40 between clinicians and clients will parallel interactions between those same cliniciansand their supervisors. While our interviewees did not volunteer specific ideas abouthow to increase the strengths focus at the agency level, other sources provide examplesof stru

39 ctures and techniques for strengths-base
ctures and techniques for strengths-based supervision.During our observations and interviews, we were made aware of the importance ofpartner agency support for ISP values. A lack of support for such values was one ofthe barriers to effective team functioning that was most frequently cited by our expertteam members. Our interviewees did describe examples of teams that functioned welldespite the fact that some of their members came from organizations or agencies withvalues that were to some extent inconsistent with those underlying team-based ISP. Insome cases, the individuals from those partner agencies were asked to join the teamsprecisely because their personal values were more in line with the philosophy of ISP;however this could also mean that their values ran somewhat counter to those in their“home” (partner) agency. In other cases, individuals from partner agencies describedtheir values as changing as a result of their experiences with the team process.Interviewees reported that being at odds with the values of their home (partner) agencycould be quite stressful for team members, and could cause friction for them with theirsupervisors and/or co-workers. These team members might also have difficulty insecuring funds to help support team plans. Even when teams successfully “enculturated”individual members from organizations with different values, this could take a longtime and detract significantly from team effectiveness in the meantime. Furthermore,relying on particular individuals who had been enculturated in this manner left theteam vulnerable in the case of turnover. Finally, interviewees reported that some teammembers from partner agencies never became supportive of the ISP values, and thatlack of support could be very detrimental to the team’s ability to function.Each of these observations is supported to some extent by research in organizationand team effectiveness. Just as consistency in organizational values and culture hasbeen linked to positive outcomes for individual employees and for organizations(previous section), inconsistent demands from competing values is often associatedwith negative outcomes. For example, there are a number of studies suggesting that,when a person works under inconsistent or divergent values or expectations, she islikely to experience conflict and stresses that detract from work satisfaction andperformance (see reviews in Tubreand Nygaard). Studies of team effectiveness showthat unresolved value discrepancies among team members can have a variety of negativeimpacts on team functioning, including increased conflict, restrictions on informationsharing, and turf battles.Care coordinators and facilitators reported spending a great deal of time trying toeducate team members from partner agencies about the values of ISP and theeffectiveness of the ISP practice model. Unfortunately they also reported that theywere frequently unsuccessful in getting “buy

40 -in” from skeptical team members,pa
-in” from skeptical team members,particularly where their (partner) organizations’ cultures did not resonate with the ISPphilosophy. Similarly, they reported engaging in various efforts to educate supervisorsand managers at partner agencies about ISP and its values. Several interviewees reported 41 that training in ISP for partner agency staff was an effective way of remedying theirlack of support for ISP. Several other interviewees suggested that accessible materialssummarizing objective evidence of the effectiveness of ISP would be helpful in buildingpartner agency support. In cases where partner agency support was seen as high,interviewees reported that the agencies were willing to pay for their staff to attendtraining in the practice model and were willing to take agency time to orient administratorsand supervisors to the theory and skills underlying ISP.ISP teams faced with the daily reality of the needs of families and youth may view theknowledge and commitment of leaders from the funding and policy context as generallyirrelevant to team functioning and reflecting abstract political maneuvering.Furthermore, team members may see the policy and funding context as responsible forexcessive requirements for documentation and other bureaucratic demands.this rather pessimistic view, there are a number of well documented instances in whichstrong leadership from the policy and funding context have been instrumental in theimplementation of system changes and service delivery innovations. For example,Armstrong, Evans and Wood describe the important role played by the state of NewYork in the development of family involvement policies. Jordan and Hernandezthe existence of a statewide goal as one of the enabling factors in the development ofthe Ventura project in the state of California.During the era of Child and Adolescent Service System Programmany service innovations, including individualized planning, were identified andintroduced by mental health staff at the state level. In the current funding and policycontext, agency managers or line workers may champion innovations like ISP. Whateverthe origin of idea, in order for team-based ISP to be effectively implemented at thepractice and organization level, there must be at least some key leaders at the policy andfunding levels who have a commitment to ISP, understand the basic components ofthe practice model, and are willing to actively advocate for the needs of ISP teams. Anumber of our interviewees referred to these key leaders as of ISP. comments that a core of committed individuals who share a common visionare critical to the development of any effective service delivery effort. Hernandez and identify strong leadership as a prerequisite for shaping services within theperspective of outcome-oriented accountability. In their study of factors associatedwith successful and unsuccessful collaborations, Johnson and colleaguesthat strong leadership from key decision

41 makers was one of the three major varia
makers was one of the three major variablesWithout the benefit of active leadership from champions at the funding and policylevel, it seems unlikely that team-based ISP will be implemented in more than isolatedteams or within single agencies. Rosencheck reminds us of what he calls the “ironrule of hierarchy,” the tradeoff between innovation initiated by the upper levels of anorganization and innovations from the grass roots. If the innovation comes from higherin the hierarchy, more people will hear about it and it has the potential for a wider scope of dissemination. However, “If the impetus for implementation comes from lower inthe organization… it is more likely to succeed, because fewer stakeholders need toconcur, but the impact is likely to be limited and locally restricted” (p. 1610). In orderfor ISP to thrive, support for ISP and goals consistent with ISP need to be articulatedat upper levels of the system as well as within the organization and the team.It is not necessary that all ISP stakeholders at the system level be active champions ofISP; however, it is important that leaders of participating agencies (e.g. upper leveladministrators in child welfare or juvenile justice) have some basic knowledge aboutthe values and practice of ISP. This level of knowledge will help them understand howdecisions they make at their own agency may impact the ISP process, and can helpthem avoid initiating new policies that will adversely impact teams. It is also importantthat these individuals are at least willing to adopt a pragmatic attitude towards ISP(i.e. they agree that it’s a good idea for plans to be family driven and for children to betreated in the community if such services can be at least as effective and no moreexpensive than current practices). These leaders may well place philosophical concernsin second priority behind issues of efficiency and effectiveness, and they may predicatetheir long-term support on the extent to which ISP programs are able to produceevidence of their success. ISP champions at the system level also plan a critical regardin securing the ongoing good will (or pragmatic neutrality) of their less committedpeers. It is essential that the champions engage in ongoing efforts to educate their peersabout ISP values and practice, and that they also transmit evidence about the effectivenessof ISP wherever it is available.Successful implementation of supportive policies or funding processes that emanatefrom levels above the lead agencies is another important concern. In several of ourinterviews, we heard about policies or legislation supportive of ISP that had been codifiedin some manner but never implemented. Our interviewees stressed that an importantrole for leaders of the policy and funding context is to actively work for implementationof policies that support ISP, as well as making or supporting decisions that have adirect positive impact on ISP teams. They also st

42 ressed the importance of having aforum f
ressed the importance of having aforum for addressing difficulties that might arise due to differing interpretations ofsuch policies or a reluctance to implement them (see Chapter 4, system level,It is of course helpful if supportive leaders in the policy and funding context remain ininstitutionalized and thus able to survive turnover among systems champions. Amadoand McBride found that the degree of long-term commitment and support for long-term change were instrumental in the implementation of person-centered planning inthe five demonstration projects they studied. Systems champions must also maintain—and help their peers to develop—realistic expectations regarding both the time it willtake to achieve full implementation of ISP, and the outcomes that can be achieved. 43 1Allen, G.J., Szollos, S.J. and Williams, B.E. (1986) Doctoral students’ comparativeevaluations of best and worst psychotherapy supervision. Professional Psychology:Research and Practice2Amado, A.N. and McBride, M.W. (2002) Realizing individual, organizational, andsystems change: Lessons learned in 15 years of training about person-centeredplanning and principles. In Person-centered planning: Research, practice, and future directions(Holburn, S. and P.M.Vietze, eds.), pp. 361-377, Paul H. Brookes.3Anacona, D. and Caldwell, D. (1992) Demography and design: Predictors of newproduct team performance. Organization Science4Anderson, S.A., Schlossberg, M. and Rigazio-Digilio, S. (2000) Family therapytrainee’s evaluations of their best and worst supervision experiences. Journal ofMarital and Family Therapy5Armstrong, M.I., Evans, M.E. and Wood, V. (2000) The development of a statepolicy on families as allies. Journal of Emotional and Behavioral Disorders6Bart, C.K., Bontis, N. and Taggar, S. (2001) A model of the impact of missionstatements on firm performance. 7Berger, J., Rosenholtz, S.J. and Zelditch, M., Jr. (1980) Status organizing processes.Annual Review of Sociology8Beutler, L.E., Machado, P.P.P. and Neufeldt, S.A. (1994) Therapist variables. InHandbook of psychotherapy and behavior change (Bergin, A.E. and Garfield, S.L., eds.),pp. 229-269, John Wiley & Sons.9Binder, J.L. and Strupp, H.H. (1997) “Negative process”: A recurrently discoveredand underestimated facet of therapeutic process and outcome in the individualpsychotherapy of adults. Clinical Psychology: Science and Practice 4, 121-139.10Bottger, P.C. and Yetton, P.W. (1987) Improving group performance by trainingin individual problem solving. Journal of Applied Psychology11Brinckerhoff, J.L. and Vincent, L.J. (1986) Increasing parental decision-making atthe individualized educational program meeting. Journal of the Division for Early12Burchard, J.D., Bruns, E.J. and Burchard, S.N. (2002) The wraparound approach.Community treatment for youth: Evidence-based interventions for severe emotional and (Burns, B.J. and Hoagwood, K., eds.), pp. 69-91, OxfordUniversity Pre

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48 ’s mental health, 2001 series: Volu
’s mental health, 2001 series: Volume II. Learningfrom families: Identifying service strategies for success, Center for Effective Collaborationand Practice, American Institutes for Research. 50 51Chapter 4:Necessary Conditions: Collaboration and PartnershipsCollaboration/partnerships: Team leveli.Appropriate people, prepared to make decisions andcommitments, attend meetings and participate collaboratively.......53Collaboration/partnerships: Organizational leveli.Lead and partner agencies collaborate aroundthe plan and the team.....................................................................55ii.Lead agency supports team efforts to get necessarymembers to attend meetings and participate collaboratively..........56iii.Partner agencies support their workers as team membersand empower them to make decisions............................................57Collaboration/partnerships:i.Policy and funding context encourages interagency cooperationaround the team and the plan.........................................................58ii.Leaders in the policy and funding context play a problem-solvingrole across service boundaries........................................................60........................................................................................................61 52 53 The ISP process requires that team members representing a wide variety of perspectivesand mandates gather together and work in a spirit consistent with the values of ISP.the most basic level, interviewees reported that there is often difficulty getting thenecessary team members to come to meetings at all. Hectic schedules and/or a lack ofcommitment to the process may mean that team members find themselves “too busy”to attend meetings. Without the key team members in attendance, important decisionsmay have to be delayed or made provisionally, and team planning can easily becomeuncertain and ineffective. At a minimum, the team needs to have the key members inattendance on a consistent basis. Our interviewees also stressed that it is important forISP teams to maintain a stable membership over time. They provided numerous examplesof ways that a team’s work could be set back when there were changes in membership.There are a number of strategies that teams can use to increase team membercommitment and to encourage attendance. For example, team members are more highlycommitted to attending meetings and remaining as members of teams they perceive ascohesive and effective. Cohesiveness and effectiveness perceptions are likely to behigher on teams that incorporate elements of effective planning as laid out in Chapter3. For example, one of the most straightforward ways of building a sense of teamefficacy is through documenting successes, even if these represent only “small wins.” A closely related topic is discussed in Chapter 6, namely, how teams can encourage the inclusionand participation of natural support peo

49 ple on teams. This section focuses on at
ple on teams. This section focuses on attendance andcollaboration more generally.Collaboration and PartnershipsCollaboration/partnerships: Team leveli. Appropriate people, prepared to makedecisions and commitments, attendmeetings and participate collaboratively.Collaboration/partnerships: Team levelThis chapter continues the discussion of the proposed necessary conditions for highquality implementation of collaborative team-based Individualized Service/SupportPlanning (ISP). The conditions covered in this chapter are those found in the secondrow of figure 1, and are related the need for building the collaborative relationshipsthat are required to carry out the ISP practice model.The chapter begins with a discussion of the team-level need for collaboration. Thechapter goes on to discuss the conditions that must be in place at the organizationallevel to support team members as they work together collaboratively. Finally, the chapterdiscusses the conditions that must be in place in the policy and funding context (systemlevel) in order to support the collaboration of organizations and teams in the ISPprocess. Teams that have a clear sense of their goals, and of the steps they are taking to reachthese goals, will be able to document these small wins as they occur. What is more,increased perceptions of team efficacy lead to increased perceptions of teamcohesiveness. Perceptions of team cohesiveness can also be cultivated directly throughattention to issues of equity and cooperativeness as outlined in the team level conditionsTeams may find it more difficult to ensure stability of membership over time. Personalcommitment on the part of team members can go a long way towards decreasing teamturnover; however, turnover among human service workers and disruptions in fundingare frequent causes of discontinuity in team membership, and these are issues that aremore appropriately addressed at the organizational and system levels (next sections).When team member turnover does occur, having a clear and well-documented plancan be a major asset in preserving a team’s sense of purpose despite changes inmembership. A clear plan can also help in getting new team members “up to speed”and “on the page” more efficiently.It is of course not enough for team members to merely attend ISP meetings. Teammembers need to be able to participate flexibly and collaboratively as well. Often,collaboration will require making some degree of compromise regarding goals, priorities,and strategies. Our research participants tended to view team members from partnerorganizations as most likely to resist collaboration. Often the difficulty was attributedto a rigid interpretation of partner agency mandates, or to differences in levels of “buyin” to the values of ISP. For example, several interviewees reported difficulties in gettingparole officers to act collaboratively. Interviewees said that while some parole officerswere hig

50 hly collaborative, other parole officers
hly collaborative, other parole officers’ focus on community protection couldkeep them from considering certain types of goals and options in an open-mindedway. We also heard about teams on which it was the natural support people who weresometimes most resistant to collaboration. Typically, this came about when extendedfamily members had fixed ideas about what caregivers or youth “really” needed. Evenwhere differences of perspective among team members are not ongoing or clear cut,teams may experience periodic difficulties in reconciling divergent perspectives andpriorities.Among our interviewees, the most commonly reported strategy for increasing teammember commitment and collaborativeness was through facilitators’ or carecoordinators’ efforts to build individual relationships with team members who werenot collaborating well. Investing in these relationships helped to build interpersonaltrust, which could in turn be parlayed into support for ISP and the planning process.Facilitators and care coordinators reported spending a great deal of time in these efforts,however, they also pointed out these time-consuming efforts were often unsuccessful.Interviewees pointed to a great need for increased “buy in” among partner agencies, aswell as to a need for adequate support from the lead agency, as a remedy for this sort ofdifficulty (these issues are discussed in the organization and system level conditionslater on in this chapter). It should be noted that team members were not disagreeing with mandates per se; in fact, clearlydelineated mandates were seen as potentially quite helpful in helping the team decide on appropriategoals and strategies.Collaboration/partnerships: Team level 55 Interviewees also believed there was great value in providing training to team membersso that they would be more willing, and better able, to collaborate. Several sites offeredextensive training in the ISP process to partner agency staff, while other sites offeredworkshops, pamphlets, or other forms of orientation. One site had developed anambitious plan to provide collaborative problem solving training to interested individualsacross various levels of all participating agencies. The idea was to make the trainingattractive by highlighting the importance of collaborative group process within, as wellas between, agencies. At the same time, the training would have direct application tocollaborative efforts on ISP teams.Interviewees pointed out that it is also possible to increase collaborativeness throughthe planning process itself. One way this could be done, they said, was through skillfulteamwork in resolving conflicts. Many of the same team members, however, pointedout that they felt insufficiently trained in techniques for doing so. Experienced facilitatorsalso suggested that good plans—based on shared goals and documenting successes—can help overcome some degree of initial skepticism on the part

51 of uncommitted teammembers. By demonstra
of uncommitted teammembers. By demonstrating accountability (Chapter 7), teams encourage and supportmembers to find creative ways of working within their mandates.Research on effective teams provides a rationale for these recommendations. Thediscussion around necessary conditions for the practice model (Chapter 1) presentedevidence that team member collaborativeness tends to increase when:Teams structure discussions and decision making such that each team memberDecisions are made using processes perceived as fair,Teams have skills that enable them to engage in productive discussion of differencesof opinion while avoiding destructive conflict, andTeams are able to provide evidence of their effectiveness in reaching goals.As mentioned above, it is not always easy for natural support people to act collaborativelyon ISP teams. Teams must be prepared for the possibility that they will need to spendtime securing collaboration and commitment from natural support people as well asfrom professionals. Teams should keep in mind that natural support people do not getinstitutional support for attending meetings—it is not part of their job, and they arenot paid or given time off for attending meetings. Like other team members, naturalsupport people’s commitment to the team is likely to increase when they see that theircontributions are valued, that their time is being spent in a worthwhile effort, and thattheir voices are being heard.Collaboration/partnerships: Organizational leveli. Lead and partner agencies collaborate around the plan and the team.Because ISP teams work across the boundaries of many agencies and service systems,they face special challenges with regard to collaboration. Interviewees across stakeholdergroups stressed the importance of having the team’s work respected by staff in each ofthe participating agencies. When this does not happen, our interviewees told us, theteam’s work can easily be undermined or derailed. For example, in our observations, wefollowed a team whose different agency members maintained four separate plans ofcare for the family. Over the course of more than a year’s worth of meetings, we neverCollaboration/partnerships: Organizational level 56 observed team members sharing their separate plans with each other or with the family.Team meetings provided evidence of numerous occasions where the requirements ofdifferent plans were placing separate, and sometimes incompatible, sets of demandson the family. There was often also a good deal of confusion regarding exactly whohad agreed to do what, and there was little team level awareness of whether the actionsdefined in the separate plans had actually been accomplished. The overall effect wasone of extreme incoherence, and family members in particular expressed frustrationwith the lack of consistency across plans.If the team plan does not serve as the case plan for each participating agency, teammembers need assurance that p

52 artner agencies will respect the goals a
artner agencies will respect the goals and services/supports as decided by the team and will not develop separate goals and plans whichare inconsistent with or undermine that of the ISP team. A further step in collaborationinvolves the development of a common format for case plans so that each team memberis not required to translate the team plan into the language of their home agency—thusavoiding the temptation for goals and activities to drift away from the values and intentof the team. The development of a common format for plans also works to reduceinefficient and redundant paperwork thus giving team members more time to developresources and pursue other team activities. Even where a common plan format is notfully in place, agencies must work together to minimize redundant documentation andeffort.ii. Lead agency supports team efforts to get necessary members toattend meetings and participate collaboratively.As noted above, team level efforts to encourage key members to attend and collaborateduring meetings are not always successful, especially where support for ISP varies acrossparticipating partner agencies. Teams will sometimes need support from the lead agencyto supervisors and managers to encourage commitment and collaborativeness, especiallywhere buy-in to values and process of ISP is uneven across participating agencies.When the ISP facilitator has used all of the personal authority and persuasiveness shecan muster in her efforts to encourage collaborativeness, it is critical that she be able toappeal to management for backup and intercession. McGinty notes that the support ofagency administrators is vital to the successful implementation of wraparound programs.Although in our interviews it was viewed as a last line of defense by most, this level ofcommitment and support seemed critical to making teams effective. Lead agencysupervisors and managers also need to work in a peer-to-peer manner to help theirpartner counterparts understand—and then communicate to their staff—the need forflexibility with regard to fulfilling mandates and the need for open-mindedness aboutwhat goals the team should pursue.We were also told of occasions where attendance and/or collaborativeness wereproblematic even among certain team members from the lead agency. Under suchcircumstances, it may once again be necessary for supervisors or managers in the leadagency to support team efforts to help their coworkers develop a more supportiveattitude. Interviewees also reported that lead agency policies were sometimes to blamefor such problems, such as when two staff members from the agency were workingwith a family, but only one was allowed to attend team meetings, or only one wassupported in following up with team tasks. Lead agency policies around access to fundsCollaboration/partnerships: Organizational level 57 or services could also impede teamwork when staff were not empowered to makedecisions about access or expendi

53 ture during team meetings. (This difficu
ture during team meetings. (This difficulty is moreoften encountered among partner agencies, and is discussed in more detail in conditioniii, below.)Often, supervisor or manager peer-to-peer interactions with partner organizations takethe form of education about the team-based ISP process, its potential, and the need forsome degree of creativity in satisfying competing mandates. Our interviewees reportedthat these efforts can be enhanced when all involved have access to researchdemonstrating the efficacy of the team-based ISP process, and other materials thatdescribe the process. Sometimes, partner agencies are not receptive to this sort of“education,” and there may be a need to provide other incentives or to search out othermeans of encouraging collaboration. For example, we have seen situations in whichthe lead agency has funded training for administrators and potential team membersfrom partner agencies. In other cases, where the lead agency has the authority to selectand pay partners who most actively learn and practice the model, partner organizationshave an added incentive to become collaborative team members.This section focuses on the role of partner agencies in encouraging their workers toattend team meetings, to work collaboratively, and to make meaningful decisions duringthose meetings. Minimally, agencies whose professional workers participate on ISP teamsmust allow their workers to attend meetings on a regular and continuing basis. Thecontinual cycling of new members replacing veteran members on a team is cited bymany experienced team members as detrimental to team functioning. To more fullysupport team-based ISP, partner organizations permit workers to schedule their timeflexibly so as to allow for their participation on teams and for team-assigned activities.The supportive partner recognizes that, for staff who participate on ISP teams, fulfillingteam responsibilities takes time outside team meetings. Supportive partner organizationsadded on to an already existing set of job responsibilities.Another important aspect of the partner agency role is to support collaboration byallowing staff to make meaningful decisions during team meetings. One important wayfor partner agencies to support their workers in this area is to provide them with someflexibility around issues such as eligibility for services and how to meet agency mandates.Partner agencies further support collaboration by encouraging staff who participateon ISP teams to be open-minded in determining goals and seeking solutions. It is alsoimportant that partner agencies empower staff to make decisions about access to funds and services at the partner agency. Our interviewees pointed outthat when team members are not truly empowered to make decisions, they are oftenput in the position of having to go back to their home agency co-workers or supervisorsto try to “sell” the team plan. If the team member is then unsuccessful in gainin

54 gapproval from the home agency for the s
gapproval from the home agency for the services or funds laid out in the plan, theactivities of the whole team may be thrown into disarray. What is more, there may wellbe no efficient way to work out alternate solutions until the next team meeting. Wewere told of a number of instances in which a team member from a partner agencyCollaboration/partnerships: Organizational level 58 failed to get approval for an expenditure which had been written into the ISP planduring a team meeting, even though the expenditure seemed like a fairly routine andlegitimate use of agency resources. It is not hard to imagine the stresses that are placedon the team process if members of the team can only provisionally agree to theactivities and expenditures laid out in the plan.Our interviewees suggested that partner agencies are more likely to support their staffin collaboration on ISP teams when the partner agency supervisors and managersunderstand and support ISP as an effective way to deliver services. Intervieweesrecommended increasing buy-in at partner agencies by educating managers both aboutthe ISP process itself (see also Chapter 3) and about the mandates and work of otheragencies that were partners in the ISP process. This education could proceed in a varietyof ways. Minimally, managers and staff at partner agencies could be provided withorientation materials and information about partners. Several sites went further by havingrepresentatives from partner agencies (including management-level people) attend ISPworkshops or even full trainings together. One site trained upper level managers asteam facilitators or co-facilitators (at this site, facilitators did not have any other role ona given team). The idea was that the first-hand experience that these managers wouldhave with the ISP process would help them better understand the need for collaboration,and that this would encourage them to work to build a more collaborative attitude intheir home agencies. Other sites set up job shadowing opportunities during whichsupervisors or managers would spend some period of time observing the daily work ofa peer at a partner agency. Often the experience was accompanied by activities thatmight include discussion or journaling. At still other sites, partner agency representatives,including supervisors and/or managers, participated on standing interagency committeesthat worked to resolve difficulties around funding, mandates, and other aspects ofcollaboration. Participation on such committees was seen by our interviewees as aneffective way not only of resolving specific conflicts, but also of educating the committeemembers about what ISP teams do, and the need for improved coordination andcollaboration. Finally, there was one site that made an effort to train people across alllevels of partnering agencies in a generalized skill of collaborative problem solving.Collaboration/ partnerships:The development of interagency cooperation and coordination

55 around activities thatare mutually cond
around activities thatare mutually conducted is an ongoing challenge for the mental health community andhas suffered from a lack of research specific to children’s services organizations. Tuma,in his study of mental health services to children, found that many children with multipleagency involvement were not receiving comprehensive services. Whetten, work on interorganizational relations, identifies two groups of variables that arepreconditions to successful coordination. The first of these is perceptual conditions(such as a positive attitude toward coordination or a recognition of the need tocollaborate), and the second is resource and structural adequacies. In order to encourageCollaboration/partnerships: Policy and funding context partner organizations to cooperate with the team ISP process, perceptual conditionsmust be maximized so that the partner agencies understand the importance ofcollaboration to ISP, recognize the desirability of collaboration with the lead agency,and assess the costs of collaboration as being in their favor. Leaders in the funding andpolicy context can influence these perceptual conditions by education, active support,and/or pressure on organizations to work together. Administrators and supervisors inpartner organizations must be encouraged to allow their employees to participate inteam planning and to complete team tasks, even when these activities are differentfrom their usual work.Resource and structural adequacies must also be taken into consideration as a part ofthe strategy to encourage interagency cooperation. Decision makers in the policy andfunding context need to make rules that allow partner organizations to be flexible interms of how their mandates are met, and that allow for creative means of meeting themandates while also responding to the priorities as expressed by teams. Changes ininformation and reporting systems (particularly changes that enable the use of shareddocumentation and common formats across agencies) represent an important meansof streamlining work and enabling greater interagency collaboration.More generally, the policy and funding context should provide both pressures andincentives for the implementation of policies about interagency collaboration.unclear at this point, however, is whether or not such collaboration for the benefit of asmall number of children and families with multi-system involvement can be embeddedin a system in which agencies on the whole do not collaborate much, and in whichservices do not tend to be individualized and/or coordinated. Some of our intervieweesbelieved that collaboration in the team-based ISP process could not be sustained unlessentire systems were reformed, such that coming together around the specific andindividualized needs of particular children and families were the norm for all servicedelivery, not just the “200 kids with most needs.” This is an intriguing research question,and one that is difficult t

56 o address as there are few examples of t
o address as there are few examples of team-based ISP programswith long tenure or of systems in which collaborative activity and individualized servicesare the norm. However, as team-based ISP programs go on year by year within systemsthat are still largely organized into vertical “silos” (child welfare, mental health, juvenilejustice, education) there is increasing reason to believe the idea that team-based ISP canbe maintained within a policy and funding context that reflects the philosophy andvalues of ISP only to a limited extent.During the course of our interviews, we became increasingly aware of the importanceof a structure or mechanism that allows collaboration and coordination to occur. Threedistinct structures for managing interdependency among agencies are identified by mutual adjustment (little or no structure), corporate (single authoritystructure), or alliance (a medium amount of structure with a single lead agency). Althoughthe relationships between lead and partner agencies who collaborate around ISP teamsmight most effectively be supported by an alliance, most communities appear to workfrom a loosely structured form of mutual adjustment. Mutual adjustment approachesdepend on good working relationships among line level staff and rarely involve decisionmakers from upper levels of the organization.Collaboration/partnerships: Policy and funding context 60 In order to identify and solve mutual problems, there needs to be a recognized mechanismat the state, county, or regional level for bringing groups together to address policyissues that cut across agencies and affect the ability of teams to function. This nichecan be filled either by key individuals acting informally or by an individual or group thatis formally charged with this responsibility. The individual/group needs to be able tosolve problems or challenges in two areas: 1) resolving conflict over which stream ofresources will pay for what (unless most funds are blended), and 2) recognizing thechallenges to team functioning and bringing others together for the purpose ofaddressing those challenges. Further, it is important that individuals from teams andagencies understand that this is the mechanism for solving conflicts, and feel comfortablebringing their concerns to this individual or group.Johnson and colleagues note that involving upper management in planning and problemsolving was one of the frequently reported strategies used to address barriers tointeragency collaboration. We found examples of this kind of problem solving body inthe interagency or interdepartmental committees referred to in several of our interviews.In some instances, the interagency body is active in resolving conflict over which fundingstream should be used. Once the problem-solving group has taken action or made adecision, it is critical that it stays actively involved to make sure that the plan isimplemented. In some cases, the individual or group may make decis

57 ions supportiveof ISP but there is less
ions supportiveof ISP but there is less focus on serving as a strong advocate for the ISP philosophy.The interagency body will be most influential if it actively supports the philosophybehind team ISP and is able to assess potential decisions or policies with that philosophyin mind. Training opportunities, workload and caseload policies, personnel practicesand contract language are all examples of policies or decisions made at a county, regionalor state level that might effect the ability of teams to function. Additionally, in thecourse of ISP team planning, it is inevitable that specific difficulties, unique to thatteam, will arise.Collaboration/partnerships: Policy and funding contextOur interviewees pointed out that the primary mechanisms for achieving interagencycollaboration are meetings, and that there is often a direct trade-off between going tomeetings to learn about how things work in partner agencies and organizations, andusing that time to attend to other work. Administrators report a great deal of frustrationassociated with meeting-based efforts to increase interagency collaboration. Ourinterviewees suggested that in many cases the decision making capacity remains withinthe individual organizations and no real authority is vested in the interagency groups,typical of a mutual adjustment structure. As a result, the meetings become an additionalburden and serve no real coordinating or collaborative function. It was suggested thatwhen interagency groups are truly empowered to collaborate and make decisions, theinteragency body comes to replace decision making bodies within individualorganizations. Unless this happens, not only will the interagency groups be ineffective,but participants in such groups will continue to feel overburdened by attendance atmeetings with little impact on decisions. 61 1Cohen, S.G. (1994) Designing effective self-managing work teams. (Vol. 1)(Beyerlein, M.M. and Johnson, D.A., eds.), pp. 67-102, JAI Press.2Friedman, R.M. (1999) A conceptual framework for developing and implementing effectivepolicy in children’s mental health. Research and Training Center for Children’s MentalHealth, Department of Child and Family Studies, The Louis de la Parte FloridaMental Health Institute, University of South Florida.3Glisson, C. and James, L. (1992) The interoganizational coordination of servicesto children in state custody. Administration in Social Work4Goldman, S. and Faw, L. (1999) Three wraparound models as promisingapproaches. In Systems of care: Promising practices in children’s mental health,1998 series: Volume IV. Promising practices in wraparound for children withsevere emotional disorders and their families (Burns, B.J. and Goldman, S., eds.),pp. 35-78, Center for Effective Collaboration and Practice, American Institutesfor Research.5Jackson, S.E. (1992) Team composition in organizational settings: Issues inmanaging an increasingly diverse work force. In Group process and

58 productivity(Worchel, S. et al., eds.),
productivity(Worchel, S. et al., eds.), pp. 138-173, Sage.6Johnson, L.J., Zorn, D., Tam, B.K.Y., Lamontagne, M. and Johnson, S.A. (2003)Stakeholders’ views of factors that impact successful interagency collaboration.Exceptional Children7Latham, G.P. and Seijts, G.H. (1999) The effects of proximal and distal goals onperformance on a moderately complex task. Journal of Organizational Behavior8MacFarquhar, K.W., Dowrick, P.W. and Risley, T.R. (1993) Individualizing servicesfor seriously emotionally disturbed youth: A nationwide survey. and Policy in Mental Health9McGinty, K., McCammon, S.L. and Koeppen, V.P. (2001) The complexities ofimplementing the wraparound approach to service provision: A view from theJournal of Family Social Work10Miles, P. and Franz, J. (1994) Access, voice and ownership, http://www.paperboat.com/calliope.html.11Tuma, J.M. (1989) Mental health services for children. American Psychologist12West, M.A., Borrill, C.S. and Unsworth, K.L. (1998) Team effectiveness inorganizations. In International review of industrial and organizational psychology (Vol.13) (Cooper, C.L. and Robertson, I.T., eds.), pp. 1-48, John Wiley & Sons.13Whetten, D.A. (1981) Interorganizational relations: A review of the field. Journal 62 63 Chapter 5:Necessary Conditions: Capacity Building and StaffingCapacity building/staffing: Team leveli.Team members capably perform their roles on the team...................65Capacity building/staffing: Organizational leveli.Lead and partner agencies provide working conditions that.....................................66Capacity building/staffing:i.Policy and funding context supports development of the specialskills needed for key roles on ISP teams..........................................67........................................................................................................68 64 65 high quality implementation of collaborative team-based Individualized Service/and to retain them afterward. Finally, the chapter discusses the conditions that mustdevelopment of the special skills needed for key roles on ISP teams.Capacity Building and StaffingCapacity building/staffing: Team leveli. Team members capably perform their roles on the team.that will be required for ISP teams to function effectively. In particular, competentISP process. Teams will also require various other types of skills and knowledge tocarry out their work. For example, if teams are to create plans that are trulyindividualized resources, particularly those based in the community. While the necessaryknowledge (of what services and supports are available, how to access them, and soconnections and sources of information within the community. Beyond this, the teameffective providers.different ways on different teams. For example, on one team, a parent advocate mayfacilitate the team and also work with the family around defining strengths. On anothersupporting the family perspective during team meetings. On many

59 teams, the facilitatoron a facilitator w
teams, the facilitatoron a facilitator who specializes in that role, and fills no other role on teams. SomeCapacity building/staffing: Team level 66 assets are present on teams. The primary mechanism for this will be through supportthe various responsibilities of team members with specialized roles. Lead and partnerservice outcomes and service quality. In particular, much research has been conductedto keep workers who have attained the skills needed to perform effectively on ISPteams is directly related to the program’s ability to achieve good outcomes. In ourinterviews, we heard much concern about the rapid turn over among ISP facilitatorsand the number of crises the family experiences. Corrigan and colleagues reportare also likely to report a lack of cooperation and collaboration on their teams. Theand challenges that inevitably arise, as is supportive supervision. The lead agencythat hires, trains, and supervises team facilitators plays a strong role in demonstratingsupervision and support (Chapter 3) are important in increasing the skillfulness offacilitators and communicating this value. Rauktis suggests that supportivesupervision may be most effective when it is coupled with strategies at theconclusions. Some authors have reported a direct connection between caseload sizerecent work, Rautkis concludes that “work stress had a mediating or interveningthe relationship between work load and burnout” (p. 40). With regard to effective ISP,“teamloads” need to be kept to a level that does not overtax the facilitators. Thefacilitation—e.g. record keeping, case management, meeting and team support, etc.In many cases, facilitators do all of these tasks, and the consensus of our interviewees 67 “less than a living wage.” Furthermore, there is no clear career path for facilitators, soleaving work with public sector clients for private practice or other private systems.Not surprisingly, job tenure for facilitators in most sites was reported to be relativelyway that increases the intangible benefits associated with the job. In other instances,who serve regularly on multiple teams in the role of family advocate or parent partner.barrier to effective team functioning. Frequently, family members who occupy specialbenefits or experience promotional opportunities or a reasonable salary level. Treatingto training, supervision, compensation and promotion is a tangible way ofdemonstrating that the organization values their skills.meetings and for carrying out team-assigned tasks (Chapter 4). Additionally, supportivetraining needed for the development and delivery of services in a more traditionalservice system. State and local stakeholders have important roles to play with 68 regard to staff development and training concerns. In a study of human resourceissues in the southern region of the country, Pires found that 69% of those surveyedin children’s mental health. Leaders from the policy a

60 nd funding context have anstaff on ISP t
nd funding context have anstaff on ISP teams. This can include providing leadership to efforts to coordinateto encourage the development of ISP skills.developing skills needed for implementation of a system of care philosophy. Illbackstrategies for integrating and coordinating initiatives, and formulate a plan todemonstrate coordination and integration of training in pilot regions” (p. 148). In thebringing together administrators from various service components to educate eachother about their activities.responsibility to train and supervise people in these key roles; however, it is the policiesand rules set at the system level that makes it feasible for this to happen. Leadersadministrative rules that reflect an understanding of the need to retain and continuallyupgrade the skills of people in specialized team roles. Further, policies and contractscan set the standard for compensation, promotion and workload levels. Without somecompeting demands and financial pressures.1Cantrell, M.L., Cantrell, R.P. and Smith, D.A. (1998) Coordinating care throughConnections’ liaison staff: Services, costs, and outcomes. In Outcomes for children (Epstein, M.H. et al., eds.), pp. 205-229, Pro-ed.2Corrigan, P.W., Steiner, L., McCracken, S.G., Blaser, B. and Barr, M. (2001)with serious mental illness. Psychiatric Services3Garner, H.G. (1982) Teamwork in programs for children and youth: A handbook for, Charles C. Thomas.4Glisson, C. and Hemmelgarn, A. (1998) The effects of organizational climateand interorganizational coordination on the quality and outcomes of children’sservice system. Child Abuse & Neglect 22, 401-421. 5Hunt, M. (1979) Possibilities and problems in interdisciplinary teamwork. InTeamwork for and against: An appraisal of multidisciplinary practiceal., eds.), pp. 12-24, British Association of Social Workers.6Illback, R.J., Nelson, C.M. and Sanders, D. (1998) Community-based servicesin Kentucky: Description and 5-year evaluation of Kentucky IMPACT. In(Epstein, M.H. et al., eds.), pp. 141–172, Pro-ed.7Jackson, S.E., Schwab, R.I. and Schuler, R. (1986) Toward an understanding ofthe burnout phenomenon. Journal of Applied Psychology8Jerrell, J. (1983) Work satisfaction among rural mental health staff. Mental Health Journal 19, 187-200.9Koeske, G.F. and Koeske, R.D. (1989) Work load and burnout: Can social supportand perceived accomplishment help? Social Work10Maslach, C. and Jackson, S.A. (1981) The measurement of experienced burnout.Journal of Occupational Behavior11Maxwell, G. and Schmitt, D. (1975) Press.12Meyers, J., Kaufman, M. and Goldman, S., eds (1999) Systems of care: Promisingpractices in children’s mental health,1998 Series: Volume V. Training strategies for serving13Osher, T., deFur, E., Nava, C., Spencer, S. and Toth-Dennis, D., eds (1999)Systems of care: Promising practices in children’s mental health, 1998 series: Volume I.14Pires, S.A. (1996) Human resource development. In Childr

61 en’s mental health:Creating systems
en’s mental health:Creating systems of care in a changing society (Stroul, B.A., ed.), pp. 281-297, Paul H.Brookes.15Pires, S.A. (2002) Building systems of care: A primer, Human Service Collaborative.16Rauktis, M.E. and Koeske, G.F. (1994) Maintaining social worker morale: Whensupportive supervision is not enough. Administration in Social Work17Sundstrom, E., De Meuse, K.P. and Futrell, D. (1990) Work teams: Applicationsand effectiveness. American Psychologist 45, 120-133.18Tracy, E.M., Bean, N., Gwatkin, S. and Hill, B. (1992) Family preservationworkers: Sources of job satisfaction and job stress. Research on Social Work Practice 70 71 Chapter 6: Necessary Conditions: Acquiring Services and SupportsAcquiring services/supports: Team leveli.Team is aware of a wide array of services and supportsand their effectiveness......................................................................73ii.Team identifies and develops family-specific natural supports..........74iii.Team designs and tailors services based expressed needs...........................................................75Acquiring services/supports: Organizational leveli.Lead agency has clear policies and makes timely unique needs.........................................................76ii.Lead agency encourages teams to develop plansservice fads or financial pressures...................................................77....78iv.Lead agency demonstrates supports teams in effectively.........................................78v.Lead agency demonstrates its commitment to developingan array of effective providers..........................................................79Acquiring services/supports:i.Policy and funding context grants autonomy and incentiveswith the ISP practice model..............................................................80ii.Policy and funding context supports fiscal policiesthat allow the flexibility needed by ISP teams....................................80........................................81........................................................................................................82 72 73 quality implementation of collaborative team-based Individualized Service/Supportrow of figure 1, and are related the need for access to services and supports as calledfor in ISP plans.The chapter begins with a discussion of the team-level need to identify, access, and/or tailor services and supports as called for in the ISP plan. The chapter goes on toteam members’ efforts to acquire these services and supports. Finally, the chapterlevel) in order to support access to, and development of, effective services and supportsAcquiring services/supports: Team levelOne of the main functions of the ISP team is to match the family’s identified needs toavailable services and supports. In order to perform this sort of matching effectively,teams will need to know what services and supports are available and how to accessthem. Teams

62 will also need to know something about
will also need to know something about the effectiveness of varioustypes of services and supports, as well as the characteristics of providers who areOur interviewees often commented on how difficult it is to be aware of all possibleservices and supports, formal and community, that might be available to a team.Team members, of course, bring their own specific knowledge to bear on this issue,though a given team member’s knowledge is usually most detailed with regard to theservices or supports offered by his or her home organization or agency. Since teamshave greatest knowledge about professional, agency-based resources. Teams are oftennot knowledgeable about publicly funded services provided by agencies ororganizations not represented on the team, particularly school-based resources.Interviewees also pointed out that it can be very difficult to be up to date withinformation about community resources, and several said it could be of great benefitto teams to have a resource developer, or other expert in available services andsupports, as a member. Many team members cited the need for additionalHowever, even where services or supports are available, there is no guarantee thatthey will be of high quality. The team’s ability to achieve its goals is enhanced whenthe team can judge services or providers, using available information to decide whichis most likely to contribute effectively to positive outcomes. For example, a numberi. Team is aware of a wide array of services andAcquiring services/supports: Team level 74 of the teams we observed employed “mentors”; however a majority of thesethere was marked team dissatisfaction with the mentors’ behavior. Research onrelationships. One key element of a successful relationship is the length of time itendures, and in fact, short-term relationships may actually harm youth. Best practicesteams with information about the effectiveness of mentoring will be prepared tois most likely to meet an identified need. Alternatively, learning that no qualifiedalternate strategy.Virtually all the teams we observed purchased child psychotherapy services. Givenservices, rather than continuing in an uncritical way with whatever provider or whateverapproach is available. Teams that are aware of the evidence base for treatments forthose goals. A well-informed team might, for example, gather data on a youth’sperception of therapeutic alliance, and use this information in decisions regardingwhether or not to continue with the service and/or the provider. Another team mightii. Team identifies and develops family-specific natural supports.challenge. In trainings, and during interviews, we were often told that natural supportcase among the teams we observed. At the meetings we observed, there were nosupport at 32% of the meetings. A total of seven meetings out of 72 had more than Acquiring services/supports: Team level 75 community organization or institution (club, church,

63 sports). We have heardare higher, thoug
sports). We have heardare higher, though we have not been able to verify this formally. Additionally, severalpeople have suggested that participation of informal supports on teams is higher inrural areas.recruiting, and retaining natural supports on teams. Many of our interviewees pointedblame them for their children’s difficulties, and that this blaming attitude causes riftsthe high level of family needs and frequent crises. Another key barrier is familyfamily members to know details of their difficulties. Families also expressed reluctancecare and transportation. Finally, there were a number of family members whouse them effectively. Especially in teams that are dominated by professionals’began with a structured process to help the family think about people that could beinvited to join the team. Several sites have developed aids—interview prompts orcharts, for example—to help in this process. Other sites use trained parent advocatesfamily, educate them about the team process, and invite them to the team meeting.the beginning of the ISP process. Teams can also schedule meetings at times andthem to participate in team discussions and decision making. In many communities,is also crucial.iii. Team designs and tailors services based onA critical aspect of developing an ISP plan is listening carefully to the family’sservices traditional and/or community services that meet those needs. Ourobservational data suggest that teams are not very successful in individualizing plansto a significant extent. Teams did show a willingness to make small modifications—inAcquiring services/supports: Team level 76 scheduling or meeting place, for example—to services if the family requested this.We saw services being “tweaked” in this way in 88% of the meetings we observed. Inabout a third of meetings, services were added or dropped as requested in the teampercent of teams purchased community services for the family (e.g. membership atthe YMCA), but only 6% of teams tailored the community service or provided supportto the family to help ensure that the community experience would be successful. Forsuccessfully in activities at a community center. Or when a martial arts teacher isaware of a child’s particular behavior challenges, the teacher can help the child recognizeprocedures. At 14% of meetings we observed, there was evidence that the team wasusing flexible funds or other monies to purchase supplies or services to meet thefamily’s unique needs.Our observational data also showed that teams only very rarely spent time consideringtendency to rely on “off the shelf” services, this strongly suggests that teams have aneed for increased capacity for creativity in designing and tailoring services andsupports. Team process that stresses creativity-enhancing strategies during decisionmaking (Chapter 3) may be an essential ingredient in creating truly individualizedplans. The appare

64 nt lack of individualization of plans ma
nt lack of individualization of plans may also be caused by insufficientsupport for the family’s perspective during the planning process. This seems a reasonablestrategies for eliciting or reinforcing the family’s input into discussion and decisionmaking. A strong practice model may help to remedy some of these concernsIn order to function effectively, teams need to quickly get the funding they need topay for services or supports that are unique to the needs of an individual child orfamily. These unique costs may include special equipment, non-traditionalservices, services or supports from a new provider, or services that are specific tothe child’s cultural heritage. Most frequently, these funds come from a pool of moneydesignated as flexible funds. Given the increased emphasis placed on the availabilityorganizational polices and procedures regarding access to these funds.services/supports and those preferred by families rather than any one categoricalservice. 77 local team level. In our interviews, facilitators reported that they are best supportedwhen teams are trusted to make all but the most unusual purchases on their ownauthority. In one organization, facilitators were given an average amount of flexibleone family and less for another as long as the average was maintained. Team members“identifying the broad general uses for which money can be used” (p. 124). A numberof our interviewees pointed out that it is also helpful if there is a shared understandingabout the distinction between “enabling” and supporting families. Severaland is usually based more on experience and gut feeling than on a written policy.To add further complexity, the organization’s policies and procedures need to anticipatepotential community concerns about certain types of expenditures. For example, inrecreational expenses per family. This was in direct response to administrative concernsover how the community might view use of flexible funds. In this case, organizationalservices and has prepared the community in advance for these uses.The lead agency plays an important role in helping teams access services and supportscalled for in the ISP plan, and for helping to develop new services and supports whenimportance of monitoring how services and supports are developed so that “availabilityof specific services does not dictate wraparound planning” (p. 147). A support thatapproach. Another threat to optimal team functioning is the normal pressures towardsurvival that exist within agencies and within service systems. An example of such apressure is the subtle expectation to overpurchase certain formal services that are inplentiful supply. Sometimes team members have to face pressure from their ownemployer to make sure that certain programs are filled to capacity. Workers in thiscase may feel some need to refer children in order to make sure that the servicecontinues to exist. Similar pressures can

65 occur within the service system when a s
occur within the service system when a serviceprovided by another agency is threatened with cuts. Pressure also occurs when a newservice becomes available and workers and families see it as solution to a varietyof problems (e.g. mentoring). These pressures or incentives are often not recognizedTeam members need to be as free as possible from these pressures and incentives sothat recommendations for services are based on the child and family’s preferences 78 and needs, not organizational requirements. This buffer can be provided by a supervisorhave on team decisions.demands for types of services that ISP teams tend to favor. In the meetings weobserved, mentoring and respite were two services most often desired by families andof licensed respite homes. Lead agencies could also work with community and partneragencies to develop mentoring programs that mesh with the needs and goals of ISP.Given the diversity of the families served through ISP, it is important that the leadagency makes a commitment to cultural competence in the services and supportsfamilies from diverse backgrounds to participate in identifying services and supportsservices, and representatives from resources that serve diverse communities shouldand working in the community, having strong ties with community leaders, and speakingthe languages most often used by community members.iv. Lead agency demonstrates supports teams in effectivelyFor the most part, community resources that are supportive of families and childrenof informal support available. Team facilitators and the lead agency have to make aconscious effort to build capacity to develop needed community services and to makesure these services are connected to diverse cultural groups. Although still unusual,this task to an existing staff member. In one setting that we studied, the communityresources. In another, the position of family resource developer integrated the functionsof developing community resources with family support and advocacy. Examples of 79 such as church youth groups or Boy Scouts/Girl Scouts. Such positions are tangibleevidence of the organization’s commitment to developing community opportunitiesand tailoring them so that the opportunities are truly available to teams.In those service systems where community supports and natural networks are valuedinput from community members and the influence of community norms. The leadknowledge of diverse resources within the community, particularly those that supportchildren and families from diverse cultural backgrounds. Knowledge of resources inroles (e.g. family advocate, resource developer) because they often assume the role ofcultural specialist and can apply the knowledge to the ISP process.Supervisors should be knowledgeable about specific strategies for increasing the useof community resources and natural supports. Supervisors can help teams developfor including them in decision making. Our interviewees often noted a lack

66 of reallocal examples of the effective i
of reallocal examples of the effective inclusion of community and natural supports on teams.Supervisors can provide opportunities for team members with special roles—parentto share examples of novel ways to increase the availability of, or access to, supportsin the surrounding community.v. Lead agency demonstrates its commitment toEffective providers are those who adhere to evidence-based approaches, who conformother means. Effective providers can provide formal services such as therapy orsweat ceremonies, or community services such as mentoring or recreation. Althoughless research is available for non-traditional and community services, an evidencebase has been established for many services and supports, and best practiceshave been proposed for many others. While it is the responsibility of the teamfacilitators to know the array and quality of services available, it is the role of the ISPprogram manager and supervisor and other administrators of the lead agency topromote the development of high quality, evidence-based programs within thecommunity. The availability of services that are grounded in theory and havesame time, it is important to avoid limiting the team’s creativity in order to use onlyproven interventions. While most communities cannot afford a vast array of servicesand providers, some amount of choice is important to the family’s ability to feel thattheir needs are being considered. Teams that are limited to a few unproven approachesto treatment or one unsatisfactory provider will find it difficult to construct plans that 80 The ability to evolve a service system with a broad array of formal and informalservices seems to depend on both support from the top (policy and funding context)as well as creativity and energy from the bottom (provider and team level). apparent from our interviews that the leaders from the policy and funding context areservices that are consistent with the ISP practice model, especially services that arecommunity based rather than those that employ out-of-community strategies. At thesame time, many providers maintain that they could develop formal and informalservices consistent with family and community needs and ISP philosophy if systemlevel constraints were reduced and incentives increased. For example, in onecommunity, the lead agency developed a list of providers who showed the greatestwillingness to collaborate with team ISP. Some providers proved to be morecollaborative than others and because of this, more often received referrals. State andmanner.effective services and those that are include evidence-based practices. Fiscal incentivescan also be constructed so that programs and/or providers are rewarded for cooperatingto meet a family’s needs and for developing community and natural supports thatachieve good outcomes. In a number of communities, the money saved by keepingchildren out of institutions is kept in the community and redirected to local ser

67 vices.thus making tangible the commitmen
vices.thus making tangible the commitment to ISP. Similarly, contracts can be written totake into account the costs associated with training and supervising providers in theISP teams thrive in a funding context that supports flexible fiscal policies. Leaders invariety of strategies to increase flexibility. The two most commonly employed seemto be blended funding and flexible funding pools. Dollard proposes that the conceptmicro (individual team) levels. At the macro level, flexible fiscal policies suggestfunds across service areas often results in the removal of rigid eligibility criteria (e.g.income level), increases access to services and can be a major support to effectiveteam functioning wherever it occurs. This may be facilitated by leaders within the 81 and rewarding programs and policies that support non-categorical funding strategies.context can be instrumental in incorporating supports and services commonly usedby ISP teams into the existing fee structures. In some states, the work of parentadvocates and other family support services has been incorporated into the feestructure. In other communities, team facilitation is recognized as a “medicallynecessary” service. In general, many of our interviewees felt that the advent ofmanaged care had made the incorporation of these less traditional services into thefee system more difficult. The Health Care Reform Tracking Project partially confirmsthis perception, finding that managed care reforms resulted in more flexible,individualized services in those states with carve-out managed care designs anddecidedly less flexible service arrays in those states with integrated managed caredesigns.funds is that they are not tied to or ear-marked for any specific service or support.is no developed service or support available or when the available services are notacceptable to the family. Agencies working with ISP teams need the support of leadersinvolvement of family and youth on teams seems to occur most consistently.and funding issues requires dedication, effort and may pose significant challenges.centered and flexible services and supports. It appears to be particularly importantto ask for family member and youth input into the way that services are structuredand delivered and deliberate with them about these decisions. The inclusion of familiessupports efforts at the organizational and team levels and also serves to publicly 82 strategies for closing this divide are still in their infancy. Little research has beensuch as parents, on decision-making bodies.1Armstrong, M.I., Evans, M.E. and Wood, V. (2000) The development of a statepolicy on families as allies. Journal of Emotional and Behavioral Disorders 9, 240-2Beckstead, J.W., Evans, M.E. and Thompson, F. (1998) Alternative strategiesand provider designed service arrangements. In Research in community health (Vol.9) (Greenley, J.R. and Leaf, P.J., eds.), pp. 29-38, JAI Press.3Benjamin, M.P. and Isaacs-Shockl

68 ey, M. (1996) Culturally competent servi
ey, M. (1996) Culturally competent serviceapproaches. In Children’s mental health: Creating systems of care in a changing society(Stroul, B.A., ed.), pp. 475-491, Paul H. Brookes.4Burchard, J.D. and Clarke, R.T. (1990) The role of individualized care in a servicedelivery system for children and adolescents with severely maladjusted behavior.The Journal of Mental Health Administration5Burchard, S.N. and Burchard, J.D. (1993) One kid at a time: An independentevaluation of 11 cases in the Alaska Youth Initiative. In The 5th annual researchconference proceedings, a system of care for children’s mental health: Expanding the researchbase. March 2 to 4, 1992. (Kutash, K. et al., eds.), pp. 241-245, University ofand Training Center for Children’s Mental Health.6Burns, B., Hoagwood, K. and Mrzeck, P.J. (1999) Effective treatment for mentaldisorders in children and adolescents. Clinical Child and Family Psychology Review7Burns, B.J. (2002) Reasons for hope for children and families: A perspective andoverview. In Community treatment for youth: Evidence-based intervention for severeemotional and behavioral disorders (Burns, B.J. and Hoagwood, K., eds.), pp. 3-15,Oxford University Press.8Burns, B.J. and Goldman, S.K., eds (1999) Systems of care: Promising practices inchildren’s mental health, 1998 series: Volume IV. Promising practices in wraparound for9Cross, T., Bazeron, B., Dennis, K. and Isaacs, M. (1989) Towards a culturallycompetent system of care: A monograph on effective services for minority children who areNational Technical Assistance Center for Children’s Mental Health. 10Dollard, N., Evans, M.E., Lubrecht, J. and Schaeffer, D. (1994) The use offlexible service dollars in rural community-based programs for children withserious emotional disturbance and their families. Journal of Emotional and11Eber, L. (1996) Restructuring schools through the wraparound approach: TheLADSE experience. Special Services in the Schools12Friesen, B.J. and Huff, B. (1996) Family perspectives on systems of care. InChildren’s mental health: Creating systems of care in a changing society (Stroul, B.A.,ed.), pp. 41-67, Paul H. Brookes.13Friesen, B.J. and Wahlers, D. (1993) Respect and real help: Family support andchildren’s mental health. Journal of Emotional and Behavioral Problems14Grossman, J.B. (1999) The practice, quality and cost of mentoring. InContemporary issues in mentoring (Grossman, J.B., ed.), pp. 5-9, Public/PrivateVentures.15Grossman, J.B. and Johnson, A. (1999) Assessing the effectiveness of mentoringprograms. In Contemporary issues in mentoring (Grossman, J.B., ed.), pp. 24-47,Public/Private Ventures.16Hernandez, M., Gomez, A., Lipien, L., Greenbaum, P.E., Armstrong, K., H.and Gonzalez, P. (2001) Use of the system-of-care practice review in the nationalevaluation: Evaluating the fidelity of practice to system-of-care principles. Journal17Hoagwood, K., Jensen, P.S., Petti, T. and Burns, B.J. (1

69 996) Outcomes of mentalJournal of the Am
996) Outcomes of mentalJournal of the American Academy of Child and Adolescent Psychiatry18Hunter, R.W. (1994) Parents as policy-makers: A handbook for effective participation.Portland State University, Research and Training Center on Family Support andChildren’s Mental Health.19Isaacs-Shockley, M., Cross, T., Bazron, B.J., Dennis, K. and Benjamin, M.P.(1996) Children’s mental health: Framework for a culturally competent systemof care. In Children’s mental health: Creating systems of care in a changing society (Stroul,B.A., ed.), pp. 23–40, Paul H. Brookes.20Jensen, P.S., Hoagwood, K. and Petti, T. (1996) Outcomes of mental healthcomprehensive model. Journal of the American Academy of Child and AdolescentPsychiatry21Katz-Leavy, J., Lourie, I., Stroul, B. and Zeigler-Dendy, C. (1992) Individualizedservices in a system of care. Georgetown University Child Development Center,National Technical Assistance Center for Children’s Mental Health.22Koroloff, N., Hunter, R. and Gordon, L. (1995) Family involvement in policy making:A final report on the Families in Action project. Portland State University, Researchand Training Center on Family Support and Children’s Mental Health. 23Koyanagi, C. and Feres-Merechant, D., eds (2000) Systems of care: Promising practicesin children’s mental health, 2000 Series: Volume III. For the long haul: Maintaining24Kutash, K. and Rivera, V.R. (1996) What works in children’s mental health services:Uncovering answers to critical questions, Paul H. Brookes.25Lourie, I. (1994) 26Lourie, I.S., Katz-Leavy, J. and Stroul, B.A. (1996) Individualized services in asystem of care. In Children’s mental health: Creating systems of care in a changing (Stroul, B.A., ed.), pp. 429-452, Paul H. Brookes.27MacFarquhar, K.W., Dowrick, P.W. and Risley, T.R. (1993) Individualizingservices for seriously emotionally disturbed youth: A nationwide survey.28O’Brien, M. (1997) Financing strategies to support comprehensive, community-based servicesfor children and families. National Child Welfare Resource Center for Organizational29Ogles, B.M., Trout, S.C., Gillespie, D.K. and Penkert, K.S. (1998) Managedcare as a platform for cross-system integration. Journal of Behavioral Health Services30Olson, D.G., Whitbeck, J. and Robinson, R. (1992) The Washington experience:4th annual research conference proceedings: A system of care for children’s mental health:Expanding the research base. February 18-20, 1991. (Algarin, A. and Friedman,R.M., eds.), pp. 113-125, University of South Florida, The Louis de la ParteFlorida Mental Health Institute, Research and Training Center for Children’s31Pires, S.A. (2002) Building systems of care: A primer, Human Service Collaborative.32Pires, S.A., Stroul, B.A. and Armstrong, M.I. (2000) Health care reform trackingproject: 1999 Impact analysis. Research and Training Center for Children’s Mental33Stroul, B.A. (2002) Issue brief-sy

70 stem of care: A framework for system ref
stem of care: A framework for system reform in children’sTechnical Assistance Center for Children’s Mental Health.34Stroul, B.A. and Friedman, R.M. (1988) Caring for severely emotionally disturbedchildren and youth. Principles for a system of care. Child Today35Tannen, N. (1996) A family-designed system of care: Families first in Essexcounty, New York. In Children’s mental health: Creating systems of care in a changing (Stroul, B.A., ed.), pp. 375-388, Paul H. Brookes. 36U. S. Department of Health and Human Services. (1999) Mental health: A reportof the Surgeon General, U. S. Department of Health and Human Services, SubstanceAbuse and Mental Health Services Administration, Center for Mental HealthServices, National Institutes of Health, National Institute of Mental Health.37VanDenBerg, J.E. (1992) Individualized services for children. New Directions forMental Health Services38Weisz, J.B., Donenberg, G.B., Han, S.S. and Kauneckis, D. (1995) Child andJournal of Abnormal Child Psychology39Weisz, J.B., Donenberg, G.B., Han, S.S. and Weiss, B. (1995) Bridging the gapbetween laboratory and clinic in child and adolescent psychotherapy. Journal ofConsulting and Clinical Psychology 63, 688-701.40Weisz, J.R., Weiss, B. and Donenberg, G.R. (1992) The lab versus the clinic:Effects of child and adolescent psychotherapy. American Psychologist 47, 1578- 86 87 Chapter 7: Necessary Conditions: AccountabilityAccountability: Team leveli.Teams maintain documentation for continuous improvementand mutual accountability.................................................................89Accountability: Organizational leveli.Lead agency monitors adherence to the practice model,implementation of plans, and cost and effectiveness........................90Accountability:i.Documentation requirements meet the needs of policy makers,........................................................91........................................................................................................92 88 89 Accountability: Team leveli. Teams maintain documentation for continuousAccountability: Team levelquality implementation of collaborative team-based Individualized Service/Supportpractice model, implementation of plans, and cost and effectiveness.that supports mutual accountability and an effective planning process. The chaptermonitor the quality of teamwork and supervision. Finally, the chapter discusses theorder to ensure that ISP programs provide stakeholders with comprehensive informationabout cost and effectiveness.that teams: determine goals and indicators of progress towards goals, decide on actionof progress. We have observed teams that hold meetings and attempt to plan withoutclear reference to any documented goals or previously-used strategies. In fact, as notedearlier, among the ISP teams we observed, fewer than one third maintained a teamplan with team goals. In the absence of an overall plan, teams often appear to bedirectio

71 nless and without a sense of priorities.
nless and without a sense of priorities. It is our feeling that a lack of goalstructure and performance indicators contributes directly to the apparent lack ofcreativity and individualization in most ISP plans. When teams do not judge strategiesagainst performance indicators, there is little rationale or motivation to alter strategies.traditional services. In contrast, teams with clear documentation are able to adjuststrategies, and to gain support across the team for doing so.effectiveness. When team members know that they will be held accountable forcarrying out action steps, their motivation to follow through on assigned tasks increases. 90 Accountability: Organizational level Each of these points is presented in greater detail, with references to available research and theory, in theof being effective builds further effectiveness and helps keep team morale healthy.Conversely, it is clear that being ineffective and inefficient rapidly saps team morale.In addition to collecting information about how children are doing, it is important foragreed upon practice model and to feed this information back into the supervisionprocess. The lead agency should also collect information to help them monitor theextent to which supervisors are providing ongoing coaching that focuses in a structuredFew sites have developed ways of measuring adherence to ISP that is specific to thepractice model articulated in that agency. Some sites assess team-level adherence to ageneric ISP philosophy by the use of questionnaires or surveys such as the Wraparoundthat team process is consistent with the value base of ISP. This approach appears toprovide useful program level information. At the team level, feedback of this sortinto practice change and improvement. Other sites have used checklist observationforms such as the Wraparound Observation Form to monitor adherence to generalobservable behaviors which are identified and can be remedied. Similarly, the Checklistobservable indicators of team practice that promote both effective planning and theincorporated into supervision such that facilitators or teams could be coached toimprove their performance. Using a different accountability strategy, some sitescommunity-based services, informal supports, or other indications of adherence tothe ISP values.proceeding effectively, it will need documentation that each team is following a clearthe use of flexible funds). Although there is much information that could be collectedaccountable. Team members frequently mention the stress created by organizationalcase notes or treatment plans. They are clear that requirements to document are 91 defined by the team. For example, the team’s own planning documentation cansimultaneously serve as case notes or a treatment plan. In one state, the team plantemplate has been formulated in such a way that it meets the requirements of thecare coordinators. Developing this innovation required substantial leadership and

72 support at the system level as well as o
support at the system level as well as ongoing dialogue between managers in serviceprograms and accountants in the state and regional offices.Finally, the lead agency must gather information that can be used to assess whether or Furthermore, these outcomes should include not only those related to childlife. Program administrators and supervisors often emphasized the importance ofhaving recent and accurate information on the outcomes of ISP and its costs. Theyleadership also reported using information about effectiveness to educate communityand partner organizations and to proactively increase community trust so that suspiciondoesn’t develop about ISP. Less frequently mentioned was the practice ofdisseminating evaluation findings directly to the group of families currently served byISP. Although some sites employ a process of providing families with informationcollected from team members about their specific team’s functioning, few have foundan effective mechanism for informing families about the functioning of the ISPeffectiveness data may be difficult to accomplish with the basic information systemthat places an acceptable level of burden on team members. Efforts to reconcileclaim to be providing ISP are in fact doing so. Policy and funding arrangements shouldfor ISP. Beyond this, policy makers and funders primarily need aggregated cost andoutcome data so that they can determine whether team ISP is cost and outcomeneutral (at a minimum) as compared to alternate arrangements. In order to reflectthe goals of ISP, which may differ substantially from the goals of other service deliveryarrangements, evaluators may need to pursue different strategies and instruments formeasuring outcomes. For example, greater reliance on strengths-based instruments,measures of family satisfaction and empowerment, and assessment of caregiver strainare concepts important to team ISP. Ongoing dialogue is required between policy 92 program goals. The needs of the policy and funding context are an important ingredientin the process of creating documentation which simultaneously serves team,organization, and policy and funding purposes. Creation of unified case plan templatesrequirements with other service plans are areas where such collaborative planningcan have a great impact on the ability of teams to function efficiently.Another important concern at the policy and funding level is the family’s need forservices over time, the cost of those services, and the long-term outcomes that canhave no further need of formal services, other graduate families will experience newcrises, perhaps necessitating intensive services and supports once again. Still otherfamilies will continue to rely to some extent on formal supports due to the ongoingnature of their child’s needs. Leadership at the policy and funding level must buildterm cost projections; and they should communicate this understanding to all thestakeholders in ISP, so that f

73 amilies, teams, and agencies are working
amilies, teams, and agencies are working in an environmentthat does not hold them to unrealistic expectations.Most of the system level people we interviewed see the value of using evaluationmade before evaluating the program effectiveness. Although leaders at the policy andlegislature or a funding source may be less flexible. These leaders can be instrumentalagencies can focus on a single review or audit process.about the philosophy and goals of a variety of service options such as ISP andfrequently use cost and outcome data for this purpose. Several of our interviewees1Amado, A.N. and McBride, M.W. (2002) Realizing individual, organizational,centered planning and principles. In Person-centered planning: Research, practice, andfuture directions (P.M.Vietze, ed.), pp. 361-377, Paul H. Brookes.2Bruns, E.J., Suter, J.C. and Burchard, J.D. (2001) Pilot test of the Wraparoundfor children’s mental health: Expanding the research base (Friedman, R.M., ed.),Research and Training Center for Children’s Mental Health. 3Epstein, M.H., Jayanthi, M., McKelvey, J., Frankenberry, E., Hardy, R., Dennis,K. and Dennis, K. (1998) Reliability of the wraparound observation form: Aninstrument to measure the wraparound process. Journal of Child and Family Studies4Farmer, E.M.Z. (2000) Issues confronting effective services in systems of care.Children and Youth Services Review5Friedman, R.M. (1999) policy in children’s mental health. Research and Training Center for Children’s Mental6Friesen, B.J., Pullmann, M., Koroloff, N.M. and Rea, T. (2003) Multipleperspectives on family outcomes in children’s mental health. In roles in the system of care: Research and practice (Vol. 2) (Duchnowski, A., ed.), Pro-7Hernandez, M., Hodges, S. and Cascardi, M. (1998) The ecology of outcomes:System accountability in children’s mental health. Journal of Behavioral HealthServices & Research8Koyanagi, C. and Feres-Merechant, D., eds (2000) Systems of care: Promising practicesin children’s mental health, 2000 Series: Volume III. For the long haul: Maintaining9Lourie, I.S., Stroul, B.A. and Friedman, R.M. (1998) Community-based systemsof care: From advocacy to outcomes. In Outcomes for children and youth with emotionaland behavioral disorders and their families (Duchnowski, A., ed.), pp. 3-20, Pro-ed.10McGinty, K., McCammon, S.L. and Koeppen, V.P. (2001) The complexities ofimplementing the wraparound approach to service provision: A view from theJournal of Family Social Work 5, 95-110.11Moxley, D.P. and Manela, R.W. (2000) Agency-based evaluation andorganizational change in the human services. Families in Society: The Journal ofContemporary Human Services12Newman, F.L. and Tejeda, M.J. (1996) The need for research that is designed tosupport decisions in the delivery of mental health services. American Psychologist13Ogles, B.M., Trout, S.C., Gillespie, D.K. and Penkert, K.S. (1998) Managedcare as a platform for cross-system integra

74 tion. Journal of Behavioral Health Servi
tion. Journal of Behavioral Health Services14Tannen, N. (1996) Families at the center of the development of a system of care.Georgetown University Child Development Center, National TechnicalAssistance Center for Children’s Mental Health.15Usher, C.L. (1998) Managing care across systems to improve outcomes forfamilies and communities. Journal of Behavioral Health Services & Research 94 Assessing Implementation and Prioritizing Actions.............................................................................................................97Assessment of organizational supports.............................................................................................................98.............................................................................................................99Mutual accountability...........................................................................................................100Individualized Service/Support Planning Teams:............................................................................................................A-1Assessment of Organizational Supports for............................................................................................................B-1............................................................................................................C-1 96 97 and funding (system) context—are designed to provide stakeholders with a structuredin the concluding sections of this chapter.across the various levels of implementation of ISP. Traditionally, we think of peopleat the service delivery level as accountable for the quality of the services that theysupports are lacking. But how are people at these levels to be held accountable forproviding an acceptable level of support? We believe that assessing the extent toof policy and funding context are tools for this sort of upward accountabilityis used for supervision in a more familiar form of downward accountability The idea isthat, rather than being two separate sorts of accountability, a balance of upward andencourages focused problem solving over defensive blaming.Assessing Implementation andfor the implementation of high quality ISP. The indicators are scored as “yes” whenspecific sorts of team behaviors or products are present during team meetings. If the We also envision that the team level assessment could be put to good use to encourage horizontalaccountability, for example, when used as part of a process of peer coaching, or by teams as a form of 98 behaviors or products are not present, “no” is scored. Information on the reliabilitythe elements of good practice in Individualized Service/Support Planning are denselyinterconnected. For example, the earlier chapters provided information about how astrong goal structure contributes not only to effective planning but also allows forhigher levels of family voice, creativity, strengths orientation, and t

75 eamcollaborativeness.The ChIPP is intend
eamcollaborativeness.The ChIPP is intended to be used either as a self-assessment or as an observationaltool for supervision or peer coaching. It is not expected that all indicators would bepresent at every meeting. It is expected, however, that over a series of meetings ateam would demonstrate a repertoire of skills consistent with a spectrum of thelisted indicators. Similarly, across teams within a program, it would be expected thatthe full range of indicators would be seen. Consistent gaps would suggest that thepractice model does not provide sufficient guidance to teams in particular areas.As noted previously, the ChIPP, like the other assessments in this chapter, is notintended to provide an absolute rating or “grade” to teams or meetings. Instead, thedeveloping their metacognitive capacities as described in Chapter 4. Similarly, at theprogram level, the ChIPP provides a means for structuring discussions about theindicators in the ChIPP, or to substitute locally-derived indicators for indicators onthe checklist, these decisions are made intentionally, again encouraging well-groundedlocal context, and how they can be recognized in practice. Teams or programs wishingThe Assessment of Organizational Supports (AOS) for ISP uses a different assessmentstrategy than the ChIPP. The AOS assesses the necessary conditions at thesection of the AOS focuses on one of the conditions listed at the organizational levelin Chapters 3-7. These same conditions appear in Figure 1 in the central column. Foreach condition, the AOS lists a series of features that index the extent to which thecondition is in place. Individuals completing the AOS provide two ratings for eachThe AOS was designed to be completed by team members who participate on several 99 in place. It is likely, however, that a given team member may not be able to fill out thewill not be aware of the level of supervision and support at the lead agency. Programsintending to use the AOS will therefore need to provide some instruction toSimilarly, it will be necessary for local decision makers to provide respondents withother instructions that are specific to the local context and local needs. Decisionthey complete various sections of the assessment. For example, a facilitator in themembers. As the assessment is currently written, the facilitator would be asked toplace across partner agencies. After data is gathered and fed back to programs,however, ask facilitators to respond to the AOS by focusing on support availablefrom one specific partner agency. Decision makers could also ask facilitators to fillfor each key partner. In another example, team members from partner agencies mighttheir own agency, or with reference to their general sense of whether or not the featureis in place across partner agencies that collaborate on ISP teams.As is the case with the other assessments, the AOS is not intended to provide a ratingor grade to agencies. Instead, the purpose of t

76 he AOS is to provide data that can helpe
he AOS is to provide data that can helpeven that certain conditions are not truly necessary. Discussions of such possibilitiesLike the AOS, the Assessment of the Policy and Funding Context (APFC) for ISPuses an “upward” assessment strategy. Respondents to this system-level assessmentmight include managers, supervisors, and/or administrators in lead and partner agencies.appear in Figure 1 in the right hand column. For each condition, the APFC lists a 100 ISP program. Local decision makers will thus have to provide instructions tomanner similar to that described for the AOS, decision makers may also decide toTaken as a group, the assessments provide a framework for developing mutualaccountability within and across the various levels of implementation of ISP. Teamsare held accountable for demonstrating practice consistent with high quality ISP. At thepractice model, and for providing sufficient ongoing professional support for facilitators.Similarly, partner agencies are held accountable for supporting their staff in their roleson ISP teams. Finally, managers in the policy and funding context are held accountablefor providing a hospitable environment for ISP teams and programs. Ultimately, all ofare served through ISP programs.Mutual Accountability 2003 Research and Training Center on Family Support and Childrens Mental Health Portland State University, Portland ORFor permission to reproduce at no charge, please contact: $\n\f
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