Systems of care, featherless bipeds, and the measure of all things

Abstract

For more than 20 years, the system of care philosophy has comprised a central strategy of service reform in children's mental health at the federal, state, tribal, and local levels. System of care terminology has become widely used in many different service sectors but often without a shared understanding of what a system of care is. This manuscript, the feature article for this special issue of Evaluation and Program Planning, briefly traces the history of the system of care movement, discusses the more widely used definitions in the field of children's mental health, and offers an expanded version of the definition that takes into account the complex nature of systems of care. This manuscript was the product of a process used by the Case Studies of System Implementation research team to identify established system of care communities for inclusion in the research study. The purpose of this manuscript is to describe the process the research team engaged in while developing the revised definition and to open a public dialogue about how to characterize the essential properties of a system of care.

Introduction

Plato's definition of human as animal, biped and featherless was celebrated in ancient Greece. As the story goes, Diogenes of Sinope demonstrated his dissent by plucking a fowl and bringing it into the lecture room with the words, “Here is Plato's human being.” (Laertius, 1979). The dialogue of ancient Greek philosophers regarding the essential properties of human beings and other featherless bipeds provides useful, if humorous, impetus for exploring the definition of systems of care, our understanding of the essential properties of this concept, and its impact on the field of children's mental health.

The system of care concept was initially defined by Stroul and Friedman in 1986¹ in response to the crisis of inadequate and fragmented services for children with serious emotional disturbance. For more than 20 years, the system of care philosophy has comprised a central strategy of service reform in children's mental health at the federal, state, tribal, and local levels. The impact of the system of care concept is evidenced by the use of this term as a referent in the Surgeon General's report on children's mental health (U.S. Department of Health and Human Services, 1999) and the report of The President's New Freedom Commission on Mental Health (2003). It has been used to frame federal and state legislation (Comprehensive Services Act, 1992, Public Law 102-321, 1992, The California AB 377 Evaluation Project, 1988, Vermont Act 264, 1988) through funding and regulatory mechanisms that enable providers to work with families in a more collaborative, culturally sensitive manner. It is present in court rulings mandating services for children and youth with serious emotional disturbance (Felix v. Cayetano Consent Decree, 1993, Katie, 2002, Rosie, 2006).

Although it originated in the field of children's mental health, the term ‘system of care’ is now in use across the United States as a common referent for other public child-serving sectors such as education (No Child Left Behind Act of 2001), child welfare (U.S. Department of Health and Human Services, 2003a, U.S. Department of Health and Human Services, 2003b), and juvenile justice (Skowyra & Cocozza, 2006). Given the time and distance this concept has traveled since its inception, we should consider whether there exists a common and shared understanding of systems of care. We might also consider whether the definition for systems of care, like Plato's definition of human, should be expanded to provide a more comprehensive understanding of this concept in its current use and application.

The purpose of this paper is to describe the process that our research team used for defining systems of care and to open a public dialogue about how to characterize the essential properties of this concept. An expanded definition of systems of care was developed by the authors as part of a national investigation of system of care implementation funded through the Research and Training Center for Children's Mental Health (2004). This paper reviews the existing definitions for systems of care and presents an expanded definition that attempts to capture the complexity and dynamics of ongoing system development. The authors analyze the components of their definition for the purpose of articulating a logic regarding the essential properties of the system of care concept. The authors believe that clarity around the definition will increase fidelity of system of care implementation across diverse and evolving community contexts. Readers should note that the process and results described in this paper reflect the point in time at which this research study was initiated and aspects of the definition may have since evolved.

The immediate question raised by such an undertaking is, “What use is a definition, much less a redefinition?” Practically, defining a concept facilitates the efficient communication of a set of information. Definitions provide a basis for common understanding of phenomena. For systems of care, clarity about the concept of systems of care facilitates our understanding of the purpose and goals of such a system reform as well as our evaluation of its impact (Rosenblatt, 1998). As a scientific enterprise, defining a concept also opens it to logical, empirical, and experiential challenges. These challenges may serve as catalysts for re-examination and revision of the content and scope of a concept, as well as its lawful relations with other concepts. This has practical implications for service providers and families to the extent that new definitions of concepts are translated into structures, decision rules, and new concepts that are translated into novel action.

There are a number of reasons that this is an appropriate juncture to examine the definition of systems of care. The concept has been redefined since 1986, and multiple versions are currently in use. The initial concept of systems of care was redefined in an updated monograph by Stroul and Friedman (Stroul & Friedman, 1994). The Center for Mental Health Services (CMHS) has subsequently articulated a definition for systems of care that includes processes for family and youth involvement as well as cultural competence.² Second, the term “systems of care” is sometimes used without specific reference to its definition, such as in the report of The President's New Freedom Commission on Mental Health (2003) and the No Child Left Behind Act (2001), implying shared understanding of its meaning. System of care implementation has been funded in 144 communities nationwide through the federal Comprehensive Community Mental Health Services for Children and Their Families program (Substance Abuse and Mental Health Services Administration, 2008), making this term part of the lexicon of a broad range of public agencies and community-based organizations that may not know either its history or the issues surrounding the development of the concept. Although the concept has been further operationalized by Pires (2002) and Stroul and Blau (2008), such common usage across multiple settings assumes a shared meaning of this term that may or may not be widely held. Finally, recent advances in the scientific understanding of complexity and systems development (Holland, 1995, Plsek, 2003) as well as rapidly shifting demographic, political, and funding landscapes indicate that this is an opportune time to examine the definition of systems of care in the current context.