Pathways | Illinois’ Strategic Plan for Children's Mental Health

Pathways | Illinois' Strategic Plan for Children's Mental Health

Prepared by: Illinois United for Youth, A Systems of Care Initiative

Letter of Support

It is my pleasure to support the efforts of Illinois United for Youth, which has made critical strides in bringing together a group of key stakeholders to plan a more coordinated, integrated delivery system for children with behavioral health challenges and their families, using system of care principles as an organizing framework. With its emphasis on coordination and greater efficiency of care across systems and providers, partnerships with families and youth consumers, use of data and quality indicators to drive decision-making, and incorporation of evidence-informed practices, the system of care approach is aligned with the goals of state and national health reform.

The technologies associated with systems of care, such as care management entities and high quality wraparound, offer effective approaches to improve the quality and cost of care for children with serious behavioral health challenges who, typically, are involved with child welfare, juvenile justice and special education systems as well as Medicaid and behavioral health. Outcome data from states using these approaches indicate reduced use of restrictive, expensive out-of-home settings, per capita cost savings, and improved child-level outcomes such as improved school attendance and reduced recidivism. Children with behavioral health challenges are a relatively small but significantly high-need, high-cost subset of the Medicaid child population, and system of care technologies can be used to inform innovations for this population in Medicaid, such as health homes. It is my hope that Illinois United for Youth will continue to make progress in the design and development of a single, integrated delivery system for children with behavioral health challenges that brings together related reforms in Medicaid, child welfare and other children's systems by using a system of care frame.

Sheila A. Pires, Author

Building Systems of Care: A Primer

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Leadership

Message from Director: Julie Hamos, HFS

Today is a time of significant change in healthcare. Like Illinois, nationally states are looking to become more effective and efficient in their healthcare administration while preparing for the additions of new population and programming under the Affordable Care Act (ACA). Through these changes, HFS stands ready to join our sister agencies with Illinois' efforts in restructuring its children's behavioral healthcare service delivery model by emphasizing a coordinated continuum of service delivery at the community level. Tremendous synergy exists between Medicaid reform efforts, integration of care found in the ACA, and the core philosophies found within Systems of Care. I am encouraged that the Illinois United for Youth Project Team can establish a strategic plan to help push Illinois forward in the arena of children's mental health.

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Message from Senior Policy Advisor to the Governor: Lorrie Rickman-Jones, Ph.D

The Division of Mental Health envisions a well resourced and transformed mental health system that promotes equal access for children and adolescents who have been identified with or are at risk of serious emotional disturbances to a continuum of consistent, integrated, flexible, effective, family-driven, youth-guided, culturally inclusive array of services and programs including prevention, early intervention, and treatment. These evidence informed services are fully integrated with other health and human service systems to ensure seamless access to meet the unique social, emotional, behavioral, physical, and health needs of our children and adolescents through the promotion of healthy lifelong development that supports recovery and resilience. It is through the collaborative relationships developed as part of the Illinois United for Youth-Systems of Care Initiative that the State of Illinois will be able to realize this vision.

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Message from Senior Deputy Director and Chief of Clinical Operations: Debra Ferguson, Ph.D, DHS-DMH

Now is a time of tremendous change. The Affordable Care Act opens opportunities for early intervention, prevention, addressing health care disparities and the elimination of the artificial bifurcation between body and mind. Along with integrated care, our future direction holds a renewed investment in technology to support the delivery of health care and tying health care services to outcome. It is our responsibility to be vigilant, to be proactive and to be engaged while recognizing that advocacy grounded in data and outcomes will be extremely persuasive and play a larger role than ever before. We value our continued collaboration with the Illinois United for Youth Stakeholders who share our vision of whole health, wellness, recovery and resiliency. Every child deserves the broadest array of people around him/her to love, nurture, support and guide them. That's how we raise healthy children. It's been said that it takes a village to raise a child. It also takes partnerships to build and sustain strong villages.

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Introduction

Illinois United for Youth (IUY) is a System of Care (SOC) planning initiative resulting from an awarded Substance Abuse Mental Health Services Administration (SAMHSA) Statewide SOC Expansion Planning Grant. In response to receiving the SAMHSA award, IUY formed a collaborative partnership of public and private stakeholders with an investment serving children and adolescents with serious emotional disturbance. Once formed, IUY adopted the primary objective of developing a comprehensive strategic plan to improve and expand the service delivery system for Illinois youth, focusing on community-based interventions that are fully rooted in the Systems of Care Philosophy.

The Illinois United for Youth Strategic Planning Initiative leverages the commitment of youth, their families, the child-serving state Departments, a myriad of stakeholders, the collective experience of the three currently SAMHSA-funded Systems of Care in Illinois, and the work that has been done in Illinois focusing on behavioral health, since the implementation of the Children's Mental Health Act of 2003. By building upon Illinois' successes, and using the lessons learned as opportunities for change, the IUY Project Team seeks to establish a service delivery model capable of supporting children and adolescents: to remain safely at home with their families; to be successful in school and the community; and achieve success in life.

The IUY Planning Initiative is grounded in transforming Illinois' continuum of services towards a model that can deliver intensive, community-based services to children and adolescents that often have co-occurring behavioral, developmental, learning, and/or physical health disabilities requiring multi-system involvement. The service delivery model must also embrace the cultural, linguistic, trauma-informed, socio-economic, and other needs of youth and families requiring services. Finally, the service delivery model must provide for a broad array of services that can be flexible and individually customized in design, to reduce the reliance on out-of-home placements.

To achieve these ends, the IUY Project Team is committed to establishing a Systems of Care Philosophy across Illinois' behavioral healthcare delivery system; though it is understood that no single intervention or effort will result in the complete implementation of Systems of Care. In response, the IUY Project Team has identified multiple strategies that it believes will continue to push Illinois closer and closer to a full realization of a delivery system reflective of the SOC principles and values. It is with this desire to enact a statewide shift towards the adoption and integration of Systems of Care Principles across the service delivery systems for youth that the IUY Project Team has elected to identify multiple, purpose-driven strategies that constitute the conceptual foundation for the IUY "Pathways: Illinois Strategic Plan for Children's Mental Health.

Central to the success of the IUY Pathways approach is the establishment and availability of training, technical support, and infrastructure development - the IUY Project Team believes the more informed the stakeholders and leadership are about the benefits of the System of Care framework the more diligent and committed their efforts will be in financing, supporting, maintaining and sustaining statewide systems of care. The implementation success of Pathways will rely heavily on the ability to apply the strategic planning efforts to multiple locations within the state, each with varying degrees of need, resources, infrastructure, funding and other supports. The diverse makeup of Illinois serves to underscore the need for flexibility and modular development of any strategic plan that can be consumed in whole, or part, by any system partner, funder, or invested stakeholder.

In addition, while Illinois is currently experiencing a great deal of change in terms of regulatory environment and financial constraints, this is a time of opportunity to introduce Pathways as an alternative to the status quo. The federal implementation of the Affordable Care Act provides for a push towards integrated physical and behavioral healthcare, data-driven outcomes, and performance related financing options. At the state level, Medicaid Reform and the SMART Act set the tone for ensuring care coordination, performance-based contracting, and efficiency in state-funded healthcare spending. Pathways will naturally embrace the concepts central to both national and state healthcare reform efforts and provide Illinois with an opportunity to alter its service delivery model towards an efficient and effective community-based behavioral healthcare model, reducing the reliance upon costly out-of-home options such as residential or inpatient care.

Across the nation, states are using care management entities, managed care technologies, data-driven (performance metrics and outcomes) service delivery, and introducing family-driven and youth guided care as part of their Systems of Care initiatives - successfully meeting their states financial and service delivery challenges. The IUY Pathways approach provides Illinois with an opportunity to revise child and adolescent behavioral health service delivery across multiple systems in a purposeful and coordinated effort that has the opportunity to deliver the necessary behavioral health care needed to ensure Illinois' youth experience recovery.

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Forging a Union

In the wake of fiscal turmoil, the Illinois Department of Human Services - Division of Mental Health, Child and Adolescent Unit (DHS-DMH,C&A) utilized an opportunity set forth by the Substance Abuse Mental Health Services Administration (SAMHSA) to bring together the leadership, administrators, stakeholders, and families invested in Illinois Children's Mental Health System. DHS-DMH led Illinois through an assessment and application process, successfully bidding on a SAMHSA System of Care (SOC) Expansion Planning Grant that was awarded in September 2011. DHS-DMH titled the project: Illinois United for Youth (IUY), and with the support of the project team, set out to meet the responsibilities of the grant and an established set of state objectives for the project.

The Illinois United for Youth (IUY) System of Care Grant has allowed the Illinois Stakeholders to participate in numerous trainings and meetings to facilitate the final stages of a strategic plan, form consensus around a unity of purpose, and to plan and strategize the implementation of Systems of Care in Illinois.

Through the SAMHSA SOC Expansion Planning Grant, IUY was required to deliver the following responsibilities.

• Establish a system of care expansion planning team,
• Complete a self-assessment of readiness to implement systems of care,
• Create a blueprint/logic model for transformation,
• Develop a set of core SOC expansion approaches

• Develop a social marketing and strategic communications plan, and
• Develop a short and long-term strategic plan, with action steps, for expanding and enhancing the system of care framework.

In addition to the SAMHSA responsibilities, the IUY Project Team also developed and adopted the following objectives.

• Create a blueprint and model for services and supports that use a system of care approach in states, territories, or tribal entity2.
• Identify strategies to better invest public sector resources to improve behavioral health outcomes and to integrate a system of care approach into child and youth service delivery systems2.
• Incorporate a system of care approach consistent with Section 561 of the Public Health Service Act, as amended, within Block Grants, Medicaid, strategies to implement parity legislation and across other child serving system such as child welfare, education, juvenile justice, substance abuse and primary care2.
• Develop concrete action steps and priority strategies that will create and sustain a jurisdiction - wide system of care to serve children and youth with serious mental health conditions and their families2.

To meet these aims, DHS-DMH began to engage staff from the Governor's Office, multiple state Departments, local funders, trade associations, existing SOC efforts within Illinois, consumers, and other invested stakeholders. Though the group was not considered to be exhaustive, it was decidedly sufficient to begin the work, with additional stakeholders included as needed or identified. Page 4 highlights the members of the IUY Project Team.

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IUY Stakeholders

Agencies/Offices	Staff
Governor's Office	Michael Gelder, Senior Advisor on Health Policy Lorrie Rickman Jones PhD, Senior Policy Advisor on Mental Health
DHS - Office of the Secretary	Michelle R.B. Saddler, Secretary Caronina Grimble, Policy Advisor
DHS - Division of Mental Health	Theodora Binion, Th.D, M.Div, M.S., CADC, Director Renee Mehlinger, MD, Deputy Clinical Director, C&A Services Sharon Coleman, Associate Deputy Dir., Dept. Mental Health /Juvenile Justice Lisa Betz LCSW, LCPC Associate Deputy Clinical Director, C&A Services Constance Y. Williams, Ph D, Associate Deputy Clinical Director, C&A Services Art Zaitz, Child and Adolescent Administrator, Region 5 Jesus Tapia, Accountant Yolanda Linares, Information Systems Analyst Family Consumer Specialists (5): Carlendia Newton, Region 1; Susan Ling, Region 2; Penny Weedon, Region 3; Darlene McGary, Region 4; Judy Hutchinson, Region 5
DHS - Division of Alcoholism & Substance Abuse	Theodora Binion Taylor, Th.D, M.Div, M.S., CADC, Director Kellie Gage, Adolescent Treatment Services Manager
DHS - Family & Community Services	Linda Saterfield, Director
Healthcare and Family Services	Julie Hamos, Director Shawn Cole, MSW, HFS SASS Program Manager
Illinois Department of Children and Family Services	Richard Calica, Director Cynthia L. Tate, Ph.D., Deputy Director, Clinical Practice Kara Teeple, LCSW, Deputy Director, Placement and Permanency Kristine Herman, Medicaid
Illinois Department of Juvenile Justice	Arthur Bishop, Director Jennifer Jaworski, Psy.D., LCPC, Behavioral Health Service Administrator
Illinois State Board of Education	Dr. Christopher Koch, State Superintendent Elizabeth Hanselman, Assist. Superintendent of Spec. Ed. and Support Services Michele Carmichael, Principal Consultant
Illinois Department of Public Health	LaMar Hasbrouck, MD, MPH, Director Teresa Garate, Ph.D., Assistant Director
Illinois Chapter, American Academy of Pediatrics	Scott G. Allen, Executive Director
Illinois Children's Healthcare Foundation	Tammy Lemke, Executive Director Harvey Saver, Program Officer, Mental Health Initiatives
Community (Consumers & Family Members)	Guy Shinggoethe, Strengthening Families Regina Crider, ACCESS Initiative
ACMHAI	Phyllis Russell, Executive Director DeeAnn Ryan, Chair, Children's Committee of ACMHAI
Illinois Children's Mental Health Partnership	Barbara Shaw, Chair Colette Lueck, Managing Director Kim Miller and Chris Hendrix, Family Leadership Coordinator Janet Silas, Region 2 Family Leadership
Youth MOVE-IL
American Indian Center of Chicago	Kat Strangeman, MSW, Circles of Care Program Director
Illinois Systems of Care Initiatives	Todd P. Schroll, McHenry County Peter Tracy, co-PI, ACCESS Initiative/ Tracy Parsons, Project Director, Angie Hampton, co-PI, Project Connect/ Stacia McGuire, Project Director,
IUY Project Evaluator	Mark Aber, Ph.D. and Nicole Allen, Ph.D.
IUY Project Director	Todd P. Schroll, MSW, LCSW

Purpose

Throughout the developmental phase of the IUY Project, and in coordination with other Illinois planning efforts, the IUY Project Team was able to identify a consistent set of system needs that crossed all child serving systems. It was through the identification of these needs that the IUY Project began to solidify in its effort and purpose.

• A need for additional care coordination between levels of intensity and across service systems for children and their families.
• A need to enhance the current service delivery system to reduce psychiatric hospitalizations and residential placements.
• A need to reduce the segregation of funding for services which may result in fragmentation of care.
• A need for family-driven, youth-guided care.
• A need to establish a more flexible array of services.
• A need to establish an administrative framework that includes state, local and family voices.
• A need to promote services that are culturally competent and sufficient in scope and duration.
• A need to maximize service funding (e.g. blending, braiding, pooling, etc.) in support of the service array.
• A need to ensure transparency in utilization and cost data across systems.

In response to these needs, the IUY Project Team established a vision, mission, and value set that would drive team's efforts while seeking to establish cohesion amongst members and perspectives. On February 1, 2012, the IUY Project Team committed to the following guiding principles:

Vision: To ensure the development of a broad array of culturally relevant and evidence-informed services to improve overall health, safety and welfare of youth experiencing a serious emotional disturbance within the State of Illinois.

Mission: To develop a comprehensive strategic plan for integrating the system of care philosophy into Illinois' behavioral health service delivery model for youth with serious emotional disturbances.

Values: Family Driven, Youth Guided, Community-Based, Strength-Based, Evidence-Based and Informed, Trauma Informed, Culturally and Linguistically Competent, Continuous Quality Improvement.

By establishing a vision, mission and value set congruent to the Systems of Care Philosophy, the IUY Project Team established a framework capable of meeting the needs of state Medicaid reform; while lining up with Federal requirements found in the Affordable Care Act; with a focus on improving the continuity, quality, and outcomes of the experiences youth currently have when engaged with multiple Illinois' child-serving systems (e.g. funders).

SOC Strategies

The IUY Project Team looked to the core strategies, being utilized by other states using a Systems of Care Philosophy to impact positive outcomes in their children's mental health service delivery systems. This review led to the identification and adoption of 12 strategies, across all five of the SAMHSA Core Strategy Areas:

1. Implementing Policy, Administrative, and Regulatory Changes;
2. Developing or Expanding Services and Supports Based on the System of Care Philosophy and Approach;
3. Creating or Improving Financing Strategies;
4. Providing Training, Technical Assistance and Coaching; and,
5. Generating Support.
   

The specific strategies represent a distinct pathway that the IUY team believes can leverage systems change or enhancement, seeking to meet the Project's vision, mission, and values while addressing an identified need. By utilizing the Pathway's approach, Illinois hopes to establish a framework grounded in System of Care while allowing all funders and operating agencies to implement the change at manageable rates. By providing sufficient flexibility and space for change in increasingly challenging times, while clearly outlining positive directions forward for Children's Mental Health in Illinois. This approach is vital to the overall success of the IUY Project Plan.

IUY PATHWAYS 

1. Creating or assigning a viable, ongoing focal point of management and accountability at the state level (e.g., agency, office, staff) to support expansion of the SOC approach
2. Developing interagency structures (e.g., memoranda of understanding and interagency agreements) to set policy, guide, and support expansion of the SOC approach
3. Creating or expanding an individualized, wraparound approach to service delivery
4. Creating or expanding family-driven and youth-guided services and expanding family and youth involvement in the planning and delivery of their own services to improve outcomes to support expansion of the SOC approach
5. Developing and implementing strategies directed at reducing racial, ethnic, and geographic disparities in service delivery across child-serving systems to support expansion of the SOC approach, improving the cultural and linguistic competence of services
6. Increasing the Use of Medicaid to finance services by adding new services, changing existing service definitions, obtaining waivers, using EPSDT, using rehabilitation option, etc., to finance services and supports to support expansion of the SOC approach
7. Maximizing the use of federal system of care grants to finance infrastructure and/or services to support expansion of the SOC approach.
8. Redeploying funds from higher cost to lower cost services
9. Creating ongoing training and technical assistance capacity
10. Establishing a strong youth and family partnership/connection to support and be involved in expansion of the SOC approach (e.g., through funding, involvement at the system and policy levels, contracting for training and services)
11. Using data on the outcomes and cost avoidance across systems and services to promote expansion of the SOC approach
12. Cultivating partnerships with provider agency and organization leaders, managed care organizations, and other key leaders to support expansion of the SOC approach.
    

Operationalizing the Pathways 

The No-Cost Extension provided stakeholders the opportunity to participate in a robust schedule of meetings to operationalize the pathways through the development and expansion of the Goals and their short and long term objectives. These meetings and forums included:

1. "Array of Mental Health Services within a Three- Tier Public Health Approach." The meeting utilized a café-style approach to define a service delivery array across a continuum from promotion/prevention, early intervention, treatment/intensive intervention need and the interaction between these levels of service. The facilitated discussion then identified the infrastructure needed to support the development and implementation of this tiered approach to service.
2. "Expanding the Role of the Family in the Wraparound Process / Encouraging programs and systems to support the individual and the family" This meeting which occurred in April 2013 was facilitated by family leaders from throughout Illinois.
3. In May 2013, the focus of the meeting was "Team Building and Moving Forward Together". This meeting focused on expanding the Pathways through teamwork including the use of training, Social Marketing, and the changes being realized as part of the Affordable Care Act. The action plan developed during this meeting resulted in the following community level activities undertaken in the summer of 2013.
   

GEAR -Gaining Empowerment through Results (GEAR), a family run organization conducted a meeting for members of newly emerging Illinois family run organization Resources, Opportunities, Community Supports (ROCS). During this meeting members received training in the trauma informed family process, and strategies to strengthen the newly formed family run organization.

WRAPAROUND MILWAUKEE- Bruce Kamradt and his team provided a two day training to IUY Stakeholders. On the history, organizational model, components, structure, and financing that could inform the SOC process in Illinois.

URBAN YOUTH TRAUMA COALITION-Provided a two day train-the-trainer opportunity for family members and clinicians representing all five regions in Illinois. The focus of these trainings was to build the regional capacity of the State to provide training and implementation of evidence based/informed practices for violence prevention and trauma intervention.

COMMUNITY FORUMS- forums were scheduled in each of the five regions of Illinois to ensure that the Pathways: Illinois Strategic Plan for Children's Mental Health was presented at the community level where comments and feedback were received

TRAINING VIDEO- Child and Family Support Services of Arizona were engaged to develop webinars to be used in communities across the state on the role for Para-professionals and their integration in the mental health delivery system.

SOCIAL MARKETING- Our Social Marketing Campaign, "Say It Out Loud," which began as a Mental Health Public Awareness Campaign in Illinois 5 years ago, continued as "Say It Out Louder." IUY facilitated the expansion of this awareness campaign by providing the opportunity for families and youth to participate in community events focused on expressing stories of trauma and recovery through the arts. As part of the Community Forums, there were dramatic performances where actors reenact the stories of those who live with mental health challenges and suffer from trauma.

Additionally, we galvanized our words into action through colorful brochures, a power point presentation, calendars and posters to share the message of IUY and Systems of Care. By offering a vigorous array of culturally relevant and evidence informed learning opportunities community awareness of the debilitating effects of trauma on youth and families was realized. Illinois efforts to increase family driven and youth guided services infused with the knowledge and the training needed to ameliorate the impact of severe mental health problems was the focus of activities that occurred during the summer of 2013.

Pathways will naturally embrace the concepts central to both national and state healthcare reform efforts and provide Illinois with an opportunity to alter its service delivery model towards an efficient and effective community-based behavioral healthcare model, reducing the reliance upon costly out-of-home options such as residential or inpatient care. The diverse makeup of Illinois serves to underscore the need for flexibility and modular development of any strategic plan that can be consumed in whole, or part, by any system partner, funder, or invested stakeholder. The implementation success of Pathways will rely heavily on the ability to apply the strategic planning efforts to multiple locations within the state, each with varying degrees of need, resources, infrastructure, funding and other supports.

The members of the Illinois United for Youth Stakeholders group are confident that the time and energy invested in this planning, training, and collaborative process has resulted in a Blueprint for integrating a comprehensive array of community based services infused with Systems of Care values and principles that will improve the quality of mental health services in Illinois.

IUY PATHWAYS 

Pathway 1: Creating or assigning a viable, ongoing focal point of management and accountability at the state level (e.g., agency, office, staff) to support expansion of the SOC approach.
GOAL 1.1: Develop an administrative structure that will support implementation of the System of Care. Including the development of a cross-system governance body drives SOC planning, implementation, evaluation and CQI

	OBJECTIVES
SHORT TERM	Develop a Children's Cabinet at the Executive level bringing together all Child Serving Systems to make decisions and monitor care. Establish SOC Governance Council through the ICMHP structure Increase participation of local partners, families and youth within governance structure Institutionalize the parent and youth voice in governance
LONG TERM	Ensure that Managed Care and other contracts and regulatory documents are consistent with the Systems of Care Approach and EPSDT and other federal mandates.

Goal 1.2: Increased Governor Office, Legislative, and Executive level support for youth mental health challenges

	Objectives
SHORT TERM	Educate relevant leadership on SOC initiative through the use of national and state data. Secure leadership commitment to reinforcing participation in Governance Structure through Illinois children's Mental Health Act update.
LONG TERM	Coordinate a cross-system discussion reviewing strategic planning initiatives. Recruit legislative representatives to promote the goals and objectives of the IUY Pathways and Children's Mental Health.

Goal 1.3: Increased partnership in planning, development, evaluation and resource allocation among state and local partners

	OBJECTIVES
SHORT TERM	Establish governance representation and relationships with key trade organizations and local partners
LONG TERM	Align SOC strategic plan with regional and local strategic planning processes Coordinate continual dialogue with other state agencies to identify barriers and solutions to delivery of services.

Pathway 2: Developing interagency structures (e.g., memoranda of understanding and interagency agreements) to set policy, guide, and support expansion of the SOC approach.
Goal 2.1: A cross system SOC management structure guides SOC implementation, allowing for collaboration in cross system policy and budget development initiatives.

	OBJECTIVES
SHORT TERM	Develop a cross-system project management supervision team across DMH, DCFS, and HF Develop a cross-system facilitation team that includes representation from DMH, DCFS, HFS, ISBE, DASA, IDPH, ACHMAI, CBHA, parent leaders, YM-IL.
LONG TERM	Coordinate a cross-system discussion reviewing strategic planning initiatives

Goal 2.2: Increased use of state/local cross system workgroups to inform SOC planning, implementation, evaluation and CQI

	OBJECTIVES
SHORT TERM	Develop objective-driven, time limited, workgroups to promote SOC development Promote regional and local level participation in workgroup process
LONG TERM	Communication progress of SOC development through consistent information sharing and common language, which flows to and throughout organizations and governmental department, (state, regional, and local.)

Pathway 3: Creating or expanding an individualized, wraparound approach to service delivery.

GOAL 3.1: Develop and redesign the current mental health system allowing service delivery for all children, adolescents, and young adults regardless of individual needs, strengths, and level of acuity.

	OBJECTIVES
SHORT TERM	Adopt quality indicators and benchmarks which demonstrate sufficient home, school, and community based care options. Create an efficient and effective transition planning process to support children, adolescents, and young adults as they move across levels of care and child serving systems. Develop outcome measures to determine when children and adolescents are successfully support at home, in the community, obtaining a high school diploma, are out of trouble. Develop the use of Para Professional who can inform/operate as the care coordination and share information proving care navigation across systems. Create a uniform set of minimum requirements to support the treatment planning process that identifies clear and measurable outcomes to be shared across the WRAP service systems.
LONG TERM	Create a uniform set of minimum requirements that will be utilized across all child serving systems for assessment and treatment planning. Utilization of a Medical Home Model to provide coordination of care across systems. Development of individuals trained to provide guidance across systems, services, and interventions to ensure the stability of a systems that is proactive not reactive. Develop and utilize common use of tools for assessment and treatment, which will allow for at risk/potential IUY children and adolescents to be "red flagged" early in their development for linkage and referral to additional system supports.

 GOAL 3.2: Develop and implement a cross-system program to effectively transition young adults from child and adolescent services to the adult system, with emphasis on care coordination, education, benefits, housing, employment and other necessary supports and services to ensure successful transition to adulthood.

	OBJECTIVES
SHORT  TERM	Create a model of transition from child and adolescent systems to adult systems. Develop and implement a scripted hand off processes for transitional age youth across systems and developmental levels. Expand the roles of peer support in wraparound.

Goal 3.3: Develop and implement a cross system program to effectively monitor and engage children, adolescents and their families across the developmental continuum and across systems to ensure linkage to services as early as an identified concern as possible. 

	OBJECTIVES
SHORT TERM	Create a model to identify children and adolescents in need of WRAP services regardless of which system they are currently being referred from. Identify or establish local structures to support the implementation of wraparound. Implement a statewide training initiative focused on high fidelity wraparound infused with System of Care values and principles.
LONG TERM	Establish standards for a Wraparound Crisis Team as a core service that creates a safety plan, empowers parents, and mandates protocol among public and private agencies. Including investigation the development of a mobile wraparound crisis team.

Goal 3.4: Develop a Wraparound infrastructure to be state supported with consistent regional locus of control, who will be responsible for implementation. 

	OBJECTIVES
SHORT TERM	Establish a certification process for facilitators and Family Resource Developers to support the fidelity of the Wraparound process. Establish the tools to support the implementation of high fidelity wraparound.
LONG TERM	Establish a way to reinvest savings from high end care to be utilized as flex funds to support family needs identified as part of the wraparound process.

Pathway 4: Creating or expanding family-driven and youth-guided services and expanding family and youth involvement in the planning and delivery of their own services to improve outcomes to support expansion of the SOC approach.

Goal 4.1: Increase the presence and effectiveness of family leadership through a sustained statewide family run organization network

	OBJECTIVES
SHORT  TERM	Utilize ICMHP funds to secure contractual support in developing a statewide family run organization network 2. Explore funding strategies through state departments to fund the provision of specific recovery based supports within the context of the system of care
LONG TERM	Annually document progression of Parent Leadership in Illinois using the Target Parent Assistance Model to continually measure and access the need for additional training and support. Identify options on how to expand human capital in the context of the family run organization. Develop a 5-year strategic plan. Identify and establish programs to pilot technical assistance and support related to building, and enhancing family leadership.

Goal 4.2: Increase youth leadership through a sustained statewide youth run organization network (Youth MOVE Illinois)

	OBJECTIVES
SHORT  TERM	Strengthen the administrative infrastructure of YM-I Expand the development of local/regional YM-IL chapters

Goal 4.3:

Increase opportunities for parents and youth in recovery to serve in planning, service, support, evaluation and governance roles

	OBJECTIVES
SHORT TERM	Develop and provide the Targeted Parenting Assistance (TPA) model as the family support and leadership model in Illinois Expand the availability of Certified Family Partnership Professionals across the State within all child serving systems Expand credentialing efforts across the State within all child serving systems. Conduct SWOT (Strengths, Weaknesses, Opportunity, and Threats) with family/caregiver and youth from different areas across the state. Determine concrete measures to determine planned outcomes.
LONG TERM	Enhance parent, caregiver, and youth capacity by offering them workforce development opportunities. Develop the infrastructure to support a statewide family run organization initiative. Engage families in participating at local, regional, and statewide levels. Identify deliverables and services the family run organization community based entities will have the capacity to offer.

Pathway 5: Developing and implementing strategies directed at reducing racial, ethnic, and geographic disparities in service delivery across child-serving systems to support expansion of the SOC approach, improving the cultural and linguistic competence of services.

Goal 5.1: Increase cultural relevancy of services and supports though the implementation of a statewide and regional cultural and linguistic competency assessment and development plan

	OBJECTIVES
SHORT  TERM	Facilitate a cultural competency assessment and develop a corresponding CLC plan within key youth serving system partners 2. Facilitate a cultural competency assessment and develop a corresponding CLC plan within key youth serving SOC service providers

Goal 5.2: Increase diversity as evidenced by governance partners, service providers, and family/youth supports representing key cultural groups served

	OBJECTIVES
SHORT  TERM	The Governance Council ensures adequate representation from regional and local jurisdictions The Governance Council ensures representation from parents and youth and the African-American, Latino, LGBTQ, and other relevant threshold communities served

Goal 5.3: Increase cultural relevance of SOC services and supports as it relates to access, models of care, and evaluation

	OBJECTIVES
SHORT TERM	Implement CLC training focused on culturally relevant assessment, treatment, and discharge planning processes Implement models of care that are directly relevant, or modified to enhance relevancy, to threshold cultural populations served

Pathway 6: Increasing the Use of Medicaid to finance services by adding new services, changing existing service definitions, obtaining waivers, using EPSDT, using rehabilitation option, etc., to finance services and supports to support expansion of the SOC approach.

GOAL 6.1: Redesign the current Children's Mental Health Service delivery array ensuring that Early Periodic Screening Diagnosis and Treatment as well as intensive community based services are available to avert when possible the need for crisis services.

	OBJECTIVES
SHORT TERM	Identify the options for expanding the use of Tele-psychiatry, Tele-health, and Tele-conferencing to include Tele-medicine as a whole. 2. Identify the options for the expansion of the use of Illinois DocAssist (Psychiatric Consultation) to support Primary Care Physicians, Advance Practice Nurses, and Physician Assistants
LONG TERM	Develop and expand the concept of "No Wrong Door" approach to access children's mental health services. Identify the options for the expansion of the current SASS program to provide stronger EPSDT and long term supports. Identify the options for the expansion of services in schools through the use of Family Resource Developers, Peer Supports, Family Consumer Specialists, and Navigators.

Goal 6.2: Increase awareness of relevant funding through the implementation of a clear cross-system financial mapping of funding allocated to mental health services and supports

	OBJECTIVES
SHORT  TERM	Establish a Finance workgroup that can outline a feasible financial mapping plan and expectations Contract technical assistance to facilitate a financial mapping process

 
Pathway 7: Maximizing the use of federal system of care grants to finance infrastructure and/or services to support expansion of the SOC approach.
Goal 7.1: Increase efficient use of resources and expand the SOC by aligning the Mental Health Block Grant with SOC initiatives

	OBJECTIVES
SHORT TERM	Governance Council allocates resources to maximize MHBG initiatives focused on SOC expansion

GOAL7.2:  Develop a financial framework that leverages all sources of federal, state and private funding to support the Systems of Care.

	OBJECTIVES
SHORT  TERM	Amend current rule 132 or develop a specific Medicaid Rule for Children, Adolescents, and Young Adults that will allow for the delivery of a flexible broad array of community based behavioral health services. Ensure that experts in Children's Mental Health (example: DMH-C&A, DCFS, DASA, ISBE School Wide Systems of Support) are involved in all cross system planning and implementation of any care management approach that may involve health homes, care management entities, or other Medicaid/ACA reform activity utilized in Illinois for children.
LONG TERM	Develop policy and regulations to ensure that dollars saved from the use of effective diversion strategies from high end services are reinvested in the expansion of community based Systems of Care services. Investigate and implement incentives for providers who offer services in underserved areas.

Goal 7.3: Increase efficient use of resources and expand the SOC by aligning existing system of care initiatives with other statewide SOC development and implementation initiatives

	OBJECTIVES
SHORT TERM	Engage representatives of other statewide planning processes with the SOC governance council Project management develops a cross walk of statewide planning initiatives aligned with SOC efforts

Pathway 8: Redeploying funds from higher cost to lower cost services

Goal 8.1: Increase awareness of costs of services and supports across youth service systems

	OBJECTIVES
SHORT  TERM	Secure commitment from major systems to share specific financial data Facilitate financial mapping process

Goal 8.2: Increase the ability to systems to track and evaluate service utilization

	OBJECTIVES
SHORT  TERM	Establish a universal outcome reporting process Establish data sharing and confidentiality agreements

Goal 8.3: Increase cost savings and reallocate to expansion initiatives as guided by the governance body

	OBJECTIVES
SHORT  TERM	Establish a strategic plan for community and service infrastructure development Establish policies that memorialize cost shifting strategies

Pathway 9: Creating ongoing training and technical assistance capacity

Goal 9.1: Develop and implement a work force development strategy to ensure the expansion of core competencies within the Behavioral Health system that are grounded in the System of Care values and principles.

	OBJECTIVES
SHORT  TERM	Review current training, technical assistance, and coaching approaches to identify gaps or opportunities to improve in order to ensure that providers are prepared and skilled in the Systems of Care approach. Expand evidence-based/evidence-informed training collaborative/learning community Establish fidelity assessment process
LONG TERM	Develop new curriculum to fill any identified gaps or opportunities to improve work forces strategies. Create an ongoing training, technical assistance and coaching mechanism to ensure that providers are prepared and skilled to provide effective services and supports consistent with the Systems of Care approach. Conduct newly developed and improved training Implement PracticeWise, Educare and other e-learning technologies to increase access to training/TA

Goal 9.2:

Increase collaboration through the development and implementation of a short and long-term cross-system SOC training plan (i.e. state/local planning, professional/consumer partnerships)

	OBJECTIVES
SHORT TERM	Align training plans across state and local youth service systems Facilitate cross-system training events. Align training plans across state and local youth service systems to ensure common training.
LONG TERM	Develop and implement training and educational opportunities for all individuals who have the potential to be a member of the child and family team. This may include the Orthodontist, the ear nose and throat specialist, air ports, school bus, library, crossing guard, immediate and extended family members, non-biological parents raising children, faith-based, insurance companies across systems.

Goal 9.3: Increase sustainability of workforce development through a statewide SOC training network (i.e. in-person and on-line capacity

	OBJECTIVES
SHORT  TERM	Expand physical workforce through developing more para-professional and peer support roles across state systems and localities Establish a core set of SOC training opportunities and relevant competencies Develop an on-line/web-based training portal for community providers

Pathway 10: Establishing a strong youth and family partnership/connection to support and be involved in expansion of the SOC approach (e.g., through funding, involvement at the system and policy levels, contracting for training and services).

Goal 10.1: Increase SOC support through the establishment and sustainability of a statewide family run organization network

	OBJECTIVES
SHORT  TERM	Provide social marketing technical assistance to family run organizations Support family run organizations in developing evaluation plans
LONG TERM	Create a model of family leadership skills to market as a training tool to other states.

Goal 10.2: Increase youth leadership within the SOC through a sustained statewide youth run organization network (Youth MOVE Illinois

	OBJECTIVES
SHORT TERM	Provide social marketing technical assistance to youth organizations Support youth organizations in developing evaluation plans

Goal 10.3: Increase opportunities for parents and youth in recovery to serve in planning, service, support, evaluation and governance roles

	OBJECTIVES
SHORT  TERM	Train family members on how to use their voice to effect policy through governance Train youth on how to use their voice to effect policy through governance

Pathway 11: Using data on the outcomes and cost avoidance across systems and services to promote expansion of the SOC approach.

Goal 11.1: Data on the functional outcomes and cost avoidance across systems and services promotes expansion of the SOC approach

	OBJECTIVES
SHORT  TERM	Improve the quality of the SOC through a SOC CQI evaluation plan (i.e. universal outcomes, assessment tool) Establish an evaluation plan utilizing a universal outcome framework Provide training and technical assistance to SOC partners on outcome development, data collection, and reporting. Develop a data tool that demonstrates what practices result in successful outcomes to support the implementation of Evidence Based Practices.
LONG TERM	Support the utilization of Wraparound as an Evidence Informed Practice.

Goal 11.2: Increase collaboration through the implementation of a cross-system data sharing process 

	OBJECTIVES
SHORT TERM	Establish cross-system data sharing agreements Provide training and technical assistance to SOC partners on outcome development, data collection, and reporting Develop outcome measures to determine when children and adolescents are successfully support at home, in the community, obtaining a high school diploma, are out of trouble.
LONG TERM	Develop an infrastructure to support information sharing across systems beyond consents to the development of an informational IT system. Utilize the data available through the implementation of the IT system to share resources across systems and avoid duplication

Goal 11.3: Increase the use of data in community reporting and community planning processes

	OBJECTIVES
SHORT  TERM	Establish an evaluation committee through the Governance council Engage an evaluator for technical assistance in policy development initiatives
LONG TERM	Establish mechanisms to compare data across the state and with other states.

 

Pathway 12: Cultivating partnerships with provider agency and organization leaders, managed care organizations, and other key leaders to support expansion of the SOC approach.

GOAL 12.1: Develop a uniform Statewide approach across systems for assessment, treatment planning, and adopting quality indicators and benchmarks supporting System of Care values and principles and resulting in the development of a continuum of interventions from prevention, promotion, early interventions and treatment that covers the age spectrum from birth through transitioning young adults.

	OBJECTIVES
SHORT  TERM	Ensure that all aspects of the service array are family driven, youth guided, and cultural and linguistically competent. Develop assessment tools that are consistent with the System of Care Values and Principles Develop treatment planning tools consistent with the System of Care Values and Principles. Develop quality outcome measures consistent with the System of Care Values and Principles.

Goal 12.2: Increase effective collaboration through the implementation of a structural framework to promote and assess cross-system collaboration (i.e. Wilder Collaboration Factors Inventory)

	OBJECTIVES
SHORT  TERM	Facilitate a cross-system collaboration assessment/inventory Establish a cross-system commitment to the strategic plan and outline succinct collaboration strategies

Goal 12.3: Increase awareness of, and access to, the system of care through social marketing strategies celebrating SOC success, promoting access, and implementing CQI initiatives

	OBJECTIVES
SHORT TERM	Implement SOC social marketing plan (to be developed and attached) Disseminate quarterly SOC reports/updates to system partners

Goal 12.4: Increase collaboration through the development and implementation of a short and long-term cross-system SOC training plan (i.e. state/local planning, professional/consumer partnerships)

	OBJECTIVES
SHORT  TERM	Align training plans across state and local youth service systems
LONG  TERM	Facilitate cross-system training events Establish mandates which require training for managed care and insurance companies for full comprehension of needs and level of care required to mitigate a current crisis or elevated level of care when needed.

References 

1. Stroul, B. A., & Friedman, R. M. (2011). Issue brief: Strategies for expanding the system of care approach. Washington, DC: Technical Assistance Partnership for Child and Family Mental Health.
2. Planning Grants for Expansion of the Comprehensive Community Mental Health Services for Children and their Families, No. SM-11-008.
3. Illinois United for Youth (IUY) - System of Care Expansion Planning Initiative, Response to Application No. SM-11-008.
4. National Child Welfare Resource Center for Organizational Improvement, A service of the Children's Bureau, US Department of Health and Human Services, http://muskie.usm.maine.edu/helpkids/pubstext/Four%20Stages%20Strategic%20Planning.pdf
   

For additional information contact Yolonda.Linares@illinois.gov