During a breakout session at the National Council for Community Behavioral Healthcare's 2006 Annual Conference in Orlando, a psychiatrist described his disappointment and growing concern about the condition of his community's mental health system, which was in the throes of statewide managed care and privatization reform. Mental health professionals from a dozen or more states expressed similar concerns: What was happening to the community mental health movement and system? What would become of individuals and families who no longer met the service eligibility threshold? How could communities regain the autonomy to take care of their own citizens, and the authority to establish and monitor high-quality standards for that care?
In Durham, North Carolina, the human services system also had been grappling with these issues. The system had become fragmented, with children and families entering the system through many doors, and with agencies providing overlapping and uncoordinated services. And North Carolina was realigning public services into a private care model.
A More Comprehensive Approach
In 2002, families, providers, and community leaders in greater Durham decided to fundamentally restructure their local human services delivery system into a System of Care (SOC). Partners include:
Durham County commissioners
County manager's office
County Departments of Public Health and Social Services, and the county's Cooperative Extension Service
The Durham Center, the Local Management Entity responsible for managing behavioral health services through a network of private providers
District courts (including family and treatment)
Juvenile justice services
Durham Public Schools
Durham Police Department
Duke University Center for Child and Family Policy
Youths and family members
Approximately 60 private mental health, developmental disability, and substance abuse services providers
Initial system design focused on the basic concept that quality-of-care improvements would require a unified realignment to focus on improved outcomes. The first area tackled was services for children and their families. Since each agency had separate and sometimes conflicting mandates, a shift to a unified approach had to be voluntary, guided by a comprehensive model, and grounded in relationship building.
While everyone agreed that change was needed and that the vision of a SOC was compelling, the implementation challenges were daunting. There was no infusion of new dollars to develop a SOC. The time and resolve necessary to shift to a more comprehensive model had to be engendered with existing resources and within the context of the demands that daily business required of all the partners.
Five key elements successfully addressed these and other challenges:
Investment in dedicated staff resources. The Durham Center led the development of a cross-system infrastructure to establish the SOC by funding two part-time positions dedicated to SOC development. Simultaneously, Duke's Center for Child and Family Policy actively supported the effort by partially funding another position. This team of three people promoted, developed, and managed Durham's emerging SOC. By 2005, the school system and county Departments of Social Services and Public Health also reallocated internal resources to establish positions to support the SOC.
Relevancy and incentive. Staff identified the most pressing challenges facing each of the key public agencies and how the SOC might address them, helping each agency to better meet its mandates and priorities. A common theme emerged: Each agency was struggling to address the needs of children with serious emotional disturbances and their families.
A “case review” process exercise was conducted with the directors of key agencies and government officials, bringing home the reality that the complex needs of these children and their families could not be met through the best efforts of any one agency. The inherent motivation of these leaders to do the best job possible, coupled with concrete illustrations that the current way of doing business was not meeting their goals, provided the initial incentive to cooperatively implement a new comprehensive framework that held the promise for better results.
A set of common outcomes was developed to articulate what success would look like for these children in each of the agencies. The overarching goal of Durham's SOC thus emerged as “helping families help their children succeed at home, at school, and in the community,” unifying the work of each agency through the adoption of shared responsibility and accountability to improve results.
Engaging leaders. To realign policies and resources with the SOC, it was essential to galvanize the support of leaders in local government and agencies with responsibility for the care of children and their families. A peer-to-peer forum was developed for these leaders, which became known as the Durham Directors' Group. The group includes the chairperson of the county commissioners, school superintendent, assistant county manager, chief district court judge, juvenile court judge, chief court counselor, directors of the county Departments of Public Health and Social Services, and the director of The Durham Center.