A system of care is a cross-system, coordinated network of services and supports organized for the purpose of addressing the complex and changing needs of children and families. The system of care includes structures (e.g., organizations and administrative arrangements), processes (e.g., streamlined access, transition mechanisms), and both formal and informal resources (e.g., flexible funds or parent-organized cooperatives). Thus, at the community level, it is possible to say that a "system of care" exists to a greater or lesser degree (i.e., the extent to which services are coordinated across systems, and the capacity to be flexible and responsive).

The true test of any system of care, however, is the experience of any given child and family with a specific need or set of needs. That is, the answer to the question, "Can the members of this family get what they need, when they need it, in a manner that is acceptable to them, and appropriate to the strengths and challenges they bring to the situation?"

Over the past several years, Stark County has received requests from several states, counties and localities to visit and see "the Stark County System of Care experience." That has been helpful for the county as well as challenging. Some visitors find they can readily understand and apply what they see, others find that they have little context for the discussion or may leave feeling that "this could never happen in our community."

To prepare for a visit to Stark County whether virtual or physical it is important to understand the vision which systems in Stark County have created. In Stark County, public systems are trying to create a reality in which all children and families get what they need. In order to do that well they are working change at all levels from the Executive to the mid-management to the direct service to the community level. This change effort aims to create a system which is based on a clearly held vision which makes operative a number of driving principles. The Stark County vision statement states:

The Stark County Family Council will endeavor to encourage and nurture the development of a unified service system that collaborates with families and pools resources to meet the individuals needs of children and their families. This collaboration will strengthen and empower all participants to meet the physical, emotional, intellectual and social needs of families and children, helping all to build on their strengths.

In addition to this vision statement, the following driving principles are in place.

The Stark County Family Council shall:

  • Empower families to identify their priorities, concerns and needs
  • Ensure family-centered, culturally sensitive, individualized services and supports
  • Develop programs that wrap services around the family's needs and work to provide whatever services are needed
  • Ensure availability of service coordination using a non-categorical approach
  • Affirm that the community is part of the solution
  • Reaffirm that everyone has the right to life, liberty and the pursuit of happiness
  • Affirm that all families are partners in the defining of the issues as well as the planning of the solutions
  • Meet the needs of families by utilizing the least restrictive community-based services and supports
  • Develop community awareness of the various systems that provide services and supports to families
  • Focus on prevention and the family's strengths, priorities and concerns
  • Accept every family with a "no eject, no reject" services and supports policy
This document was designed to give interested parties the opportunity to consider their own community's situation while gathering information about the experiences in Stark County. The first two sections provide a descriptive overview of the county and infrastructure which is currently operating in Stark County. The next sections are defined according to lessons which stakeholders have identified as critical in this community. Each lesson serves to illuminate a point which is transferable to another community. Readers are encouraged to move to lessons which they think can be useful in their own communities rather than trying to move through this document from beginning to end. Lesson One through Six are primarily about constructing an infrastructure designed to improve collaborative processes within a community. Lessons Seven through Fourteen focus on key ingredients to keep such an infrastructure responsive and functional after initial work has been done. Communities should assess where they are at with this process and identify lessons which they think are most relevant at this time for their own community development.

This preliminary workbook serves two purposes. The first is to help those visitors to Stark County prepare for their visit. For those who will not be visiting Stark County this document provides a grounded overview of the county and its efforts.

Describing Stark County

In order to understand the experience with System of Care Development, it is important to understand the community in which these efforts exist. Stark County is located in the Northeast quadrant of Ohio. The largest growth in population seems to be centered in working poor people. The total population is 367,585, 92% of whom are white. The minority population is located in the urban hub. The minority breakdown in Stark County is 7% African American, less than 1% Asian, less than 1% Hispanic, less than 1% Native American and less than 1% other. Stark County is the seventh largest county in Ohio. Its major cities include Canton, Massillon and Alliance. Canton serves as the urban hub for the county with approximately half of the county's population residing in the Canton/North Canton area. The other two population centers, Alliance and Massillon are located some distance from Canton. Due to a lack of transportation services between the three areas, social service agencies have traditionally provided some sort of service in all three areas. Except for the urban hub, most of the population is characterized as suburban or rural. Poverty is on the rise in this area which, since the early 1980s has been changing from a manufacturing based economy to a more service based economy.

Ohio is a home rule state with services being offered through county entities. Mental Health funds flow from the Ohio Department of Mental Health to local county Mental Health Boards, which function as the local mental health authority. As the Mental Health Authority, the Boards are responsible for funding, service development and monitoring local mental health services. Many Mental Health Boards including Stark County also generate funding through a local tax levy. Ohio law prohibits Mental Health Boards from providing direct services but allows for the provision of services through contracts with local providers organizations. In Stark County the provider organizations which serve children include the Child and Adolescent Service Center, Crisis Intervention Services Center, Family Services, Inc. Catholic Services , Pathways and the Northeast Ohio Psychological Services and other group and respite home providers.

Other children's services groups are also located in the local county structure. In Ohio, Child Welfare/Protective Services are located in either in a separate Children's Services Board or the county Departments of Human Services (DHS). In Stark County this function is housed in a DHS office. The local Mental Retardation/Developmental Disabilities (MR/DD) Board functions along similar lines to the Mental Health Board although it can function as both a provider as well as contractor of services. Alcohol and Drug Addiction Services are funded through the Alcohol and Drug Addiction Services Board which is responsible for contracting and arranging for service provision to the county.

System Development efforts in this county can be traced back to the seventies. In 1973, the first local Mental Health levy was passed which provided local dollars in addition to existing state funds. In 1976, the Child and Adolescent Service Center (CASC) was formed in order to create a separate mental health service center for children and adolescents. This step gave high community visibility to the mental health needs of children while solidifying the Mental Health Board's commitment to children. From the early eighties, the CASC and Mental Health Board maintained a very public commitment to building a range of community based services and supports for children.

In 1983 a local Family Court judge convened a meeting to brings systems executives together for the purpose of improving child serving systems relationships. In 1984, through a state mandate (Appendix A) this group was named the Stark County Interagency Cluster. The Cluster was convened to build a forum for cross-system discussions around children with multiple needs and multiple system involvement. The local Cluster functioned as the local interagency management structure throughout the eighties. The Ohio Cluster system was initiated as a direct result of the federal Child and Adolescent Social Service Program. (Appendix B)

What is noteworthy about this county is the participation of key players who participated in these early collaborative efforts. System Directors were the original participants on the Stark County Cluster, as contrasted with other counties where mid-management level representatives were often assigned to participation on the Cluster. During this period in the mid-eighties, the target population was seen as children with mental health and other complex needs who had multi-system involvement. System and agency directors met regularly to colloquially review these kids and attempt to come up with better solutions than out-of-county care. One of the remarkable things about Stark County is that, more than a decade later, many of the current system heads often speak about one of these first children whose situations they reviewed. This county is a collection of stories which start with individual children and families. System Directors carry those individual stories and communicate those lessons to new players as they join the system.

As the county progressed through the 1980s, the limitations of an Interagency Cluster process began to be considered. In particular, this county began to focus on how to target additional children, expand the target to include families as well as children and how to begin to build a system which would allow for cross system support to occur for all children. In effect the discussion moved from how to provide cross system support to individual children to how to assure that the community supports all families to assure that children can grow to their maximum potential. Recognizing that this community would need more than a few pilot projects or staffing functions in order to fundamentally change the response to children and families in need, the community began to develop an Infrastructure which would allow the county to formalize real response to human need. (Appendix C)

Each section of this document describes the lessons learned in building that infrastructure. Characterizing the infrastructure is a difficult task because System of Care efforts in this county are continually changing. Additionally, this county understands that System development is often a chaotic process. There is not a linear blueprint for this county's system development. It is a series of stories, rituals, and events.

Infrastructure

In Stark County, system and community representatives are serious about coming together to do business. There is a clear agenda and a clear procedure for accomplishing policy and administrative level tasks which have direct benefits for children and families. The Stark County Family Council serves as the coordinating hub for System of Care activities. (Appendix D) The Family Council is organized in the following ways:

The Family Council Board of Trustees: The Board of Trustees is responsible for system development, resource development, redirection of resources and policy impact. This role is very clear in the county and also serves as a point of accountability to the community. The Board models the business of doing business by maintaining a publicly held and viewed agenda and maintaining clear records of decisions made through publicly reviewed resolutions. This allows the Board of Trustees to be collectively accountable while building a base of accountability for individual system participants. Membership on the Board of Trustees includes System Executives, parents and at large community members (Appendix E) elected from the general membership. Each member of the Board of Trustees has a clearly spelled out term of office which is documented in the Family Council by-laws. (Appendix F) Additionally, the Board of Trustees base of authority is articulated in the Ohio Revised Code which requires that it operates as a public body.

ACCORD: Recognizing that systematizing support for children and families would take more than efforts by the top level executives in the county, Stark County has developed a clear forum for mid-level managers to come together across systems. This group's primary responsibility involves assisting direct service staff through reviewing individual situations of children and families, bending bureaucratic rules, identifying service gaps and developing new services when trends are recognized. In addition the ACCORD group manages all out of home care that includes a treatment focus. In managing this resource the ACCORD is responsible for authorizing length of stay as well as expenditures which come from a pooled fund.(Appendix G)This group consists of representatives from various systems and agencies as well as well parents of children who have received public and private service. (Appendix H) This group, the ACCORD, has a clearly delineated set of responsibilities and roles which include managing lengths of stay in out of home care, reviewing plans developed through a cross system planning process and managing the pooled funds. These responsibilities are articulated through the Board of Trustees who hold public meetings. The ACCORD is responsible for managing pooled funds and reporting to the Board of Trustees on a quarterly basis. (Appendix I)

Creative Community Options: This is a cross system service planning process with families which can be accessed and implemented by direct service staff. (Appendix J) Far too often, collaborative efforts look really good at the top but have little payoff for direct service staff.

The Stark County Family Council has taken care to assure they can build a process which can be implemented across systems under the auspices of the Council as well as outside of the parameters of the Council. The Creative Community Options process represents a forum in which direct service providers and families can come together around the needs of the single child and family. Membership changes based on who is most attached to the child or family and the preferences of the family. Meeting frequency is based on family needs. The CCO process is designed to move practice towards a better fit with the driving principles of Stark County efforts. (Appendix K) The Council keeps track of Creative Community Options meetings to assure that collaborative efforts are continuing to have an impact at the direct service level. (Appendix L) Since initiating CCOs across systems, Stark County has experienced a dramatic reduction in the number of children placed in out of home restrictive care. (Appendix M)

Working Councils: The Family Council also utilizes a series of working councils which assist with completing the business agenda. Those can be ad hoc committees designed to deal with specific tasks or issues, or longer term committees which address specific issues over time. Examples of specialized committees initiated in 1996 included committees on Community Violence, Communications, Cultural Competence, Managed Care, Operations, Young Children and Employment. (Appendix N)

Parent Advisory Council: The Board of Trustees of the Family Council originally established a permanent arm of the Board which was the Parent Advisory Council. The Parent Advisory Council was responsible for advising the Council on all family related issues and was responsible for forming the linkage between the council and families. The Parent Advisory Council also took on responsibility for communicating information about the Family Council to families within Stark County. Since its inception the Parent Advisory Council has changed. Through efforts of parent participants representing many parent organizations, family members have formed an organization with 501(c)3 status under the Internal Revenue Service Code. This group is called FACES (Family Advocacy + Community Education = Support) of Stark County. The Family Council also maintains a Parent Department staffed by 2 FTEs. (Appendix O)

Family Council General Membership: The Family Council, as the collaborative body for Stark County, is committed to inclusive opportunities for all members of the community. As a result, the Board of Trustees has created a membership structure associated with the Council. At this time, memberships totals over 200 people and includes any individual or organization within the community whose personal, professional or organizational interests are compatible with those of the Council. Individuals request membership status in writing and formally become members within 30 days of such a request. The Family Council has a formal membership meeting annually which requires a majority of members to be present. (Appendix P) At this annual meeting, members elect offices of the Board of Trustees as well as reviewing by-laws, approving the Council's service coordination plan as required by the state, approving the Family Council annual budget and other duties as required. This open community membership, which is rare in community councils, allows the Family Council to balance a business agenda with the need to be inclusive around guiding principles.

Family Council Staff: Most Board of Trustees members indicate that, at some point, collaborative efforts will require an investment on the part of participating systems through developing and supporting clear staff roles and responsibilities for the collaborative effort. Council staff includes an Executive Director who is directly responsible to the Board of Trustees. This position is not a Coordinator but an Executive level position which is directly accountable to the Board of Trustees. This position is influential both in terms of Family Council business as well as the business which occurs within existing systems. Other staff positions include an Early Childhood Program Development Specialist, a Fiscal Benefits/Entitlements Administrator, a Parent Coordinator, a Minority Outreach Parent Coordinator, and administrative support staff. Even though Family Council staff have different areas of expertise, they all have the same purpose in completing their tasks. Each staff person is involved in bring together groups from their areas of speciality to make collaborative decisions about funding, programming, access and other related issues. All Family Council staff are seen as representing the council and community.

A review of the Family Council's by-laws make it very clear that this community infrastructure has several things. These key ingredients or elements include:

  • A clear base of authority from which to operate: The Council was created through a resolution of the County Board of Commissioners in 1993. This clear base of authority allows the component parts of the Council to do business and hold public accountability. The Council is accountable to the community, which is operationalized through membership participation as well as reporting to the County Commissioners.

  • Clear lines of authority and responsibility: In building a collaborative infrastructure this community has paid attention to roles and responsibilities. Accountability for daily activities and policy implementation is very clear with the County Commissioners approving the budget and the County Auditor managing funds. Achieving this clarity is difficult to do with many collaborative structures since they often lack an "up front" plan, but rather grow and develop over time. Anyone in the community who wants to participate in Family Council activities is welcome. More importantly, they also have a clear role in which to participate. (Appendix Q)

  • A mechanism for participation: The presence of a membership allows the Council to function as an inclusive organization. This moves the responsibility for building a community wide support system from the hands of a few to the entire community. It allows for broad community input while also developing a basis for change. The inclusion of many and working councils allows the council to avoid stagnation through the new ideas, agendas and perspectives of Council members.

  • Administrative pathways: The creation and location of the Family Council allows administration to follow community decision making. The Council which is seen as owned by the community, has the administrative capacity to quickly follow up on infrastructure decisions which are made. For example, the decision to pool funds was made easier in this community by the presence of a commonly owned entity like the Family Council. The Council is the repository for those pooled funds. The Council is located within the county system which allows for public scrutiny of the use of these funds. Another example includes data management, with the Council serving as a place for other systems to share information across systems.

  • The centrality of parents & families: Families are central to the mission and daily operation of the Stark County Family Council. Family members are employed and engaged on all levels in the county including policy making, administrative, direct service and community. Six parents sit on the Board of Trustees as full voting members around policy and oversight. Parents are also represented on the ACCORD as full members of this quality review of individual child and family plans. Through a federal CMHS grant, Stark County has been able to hire parents as advocates and service plan facilitators. Finally, through the facilitation of FACES of Stark County, a vital volunteer component of parent involvement also exists.

    Clearly, this community has put a lot of thought into long term infrastructure in an effort to build a system wide response to children and families in need. In reading about this structure it would be tempting to see this as creating another layer of bureaucratic response to children and families. The Family Council has taken great pains to avoid this. The Council uses existing administrative procedures to get the job done. The Council does not have appointing or hiring authority; the Mental Health Board acts as the employer of record. Fiscal streams are combined into a Family Council line item through the County Auditor. The annual budget is approved by the County Commissioners.

    While the elements of the infrastructure are complex, the Stark County Family Council has moved to where it is today through a strong emphasis on relationship building. (Appendix R) Pre-dating the existence of the Council, this community has a history of system chiefs engaging in guided, creative thinking processes. Those creative planning retreats included concrete products and follow-up assignments but also allowed System Executives to get to know each other on a personal basis. These early relationships became the foundation for the structuring of a system designed to meet the needs of children and families. The next section of this document outlines lessons which have been learned in developing a sophisticated and personal infrastructure in Stark County.