Does mental health screening and assessment in child welfare improve mental health service receipt, child safety, and permanence for children in out-of-home care? An evaluation of the Gateway CALL demonstration

Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations

BACKGROUND

Cross-system interventions that integrate health, behavioral health, and social services can improve client outcomes and expand community impact. Successful implementation of these interventions depends on the extent to which service partners can align frontline services and organizational operations. However, collaboration strategies linking multiple implementation contexts have received limited empirical attention. This study identifies, describes, and specifies multi-level collaboration strategies used during the implementation of Ohio Sobriety Treatment and Reducing Trauma (Ohio START), a cross-system intervention that integrates services across two systems (child welfare and evidence-based behavioral health services) for families that are affected by co-occurring child maltreatment and parental substance use disorders.

METHODS

In phase 1, we used a multi-site qualitative design with 17 counties that implemented Ohio START. Qualitative data were gathered from 104 staff from child welfare agencies, behavioral health treatment organizations, and regional behavioral health boards involved in implementation via 48 small group interviews about collaborative approaches to implementation. To examine cross-system collaboration strategies, qualitative data were analyzed using an iterative template approach and content analysis. In phase 2, a 16-member expert panel met to validate and specify the cross-system collaboration strategies identified in the interviews. The panel was comprised of key child welfare and behavioral health partners and scholars.

RESULTS

In phase 1, we identified seven cross-system collaboration strategies used for implementation. Three strategies were used to staff the program: (1) contract for expertise, (2) provide joint supervision, and (3) co-locate staff. Two strategies were used to promote service access: (4) referral protocols and (5) expedited access agreements. Two strategies were used to align case plans: (6) shared decision-making meetings, and (7) sharing data. In phase 2, expert panelists specified operational details of the cross-system collaboration strategies, and explained the processes by which strategies were perceived to improve implementation and service system outcomes.

CONCLUSIONS

We identified a range of cross-system collaboration strategies that show promise for improving staffing, service access, and case planning. Leaders, supervisors, and frontline staff used these strategies during all phases of implementation. These findings lay the foundation for future experimental and quasi-experimental studies that test the effectiveness of cross-system collaboration strategies.

Integrating health systems for children and young people in out of home care: Challenging the nature of siloed service delivery in rural Australia

OBJECTIVE

The purpose of this paper is to report on enablers and barriers during the first 2 years of the health systems integration project that included the implementation of a health navigator role. The project aims to improve health outcomes for children and young people residing in out of home care in rural Australia with a health navigator co-located between child protection practitioners and community health services clinicians.

SETTING

Rural Northwest Victoria.

PARTICIPANTS

Sunraysia Community Health Services and the Department of Health and Human Services.

DESIGN

The qualitative design of the project evaluation involved semi-structured interviews and documentary evidence analysis. Analyses of interviews and documentary data demonstrate the challenging nature of siloed service delivery in rural Australia, particularly during a time that comprised multiple interruptions due to COVID-19.

RESULTS

A limited synergy between organisational priorities and reporting systems hindered project progress. The lack of a shared definition of 'health' challenged the effective collaboration between health clinicians and child protection practitioners and the role of the health navigator. The health navigator raising health awareness through project involvement, training and sector-wide stakeholder engagement resulted in a slow but steady process of increased prioritisation of health care, increased health literacy among the child protection workforce, and broadening participation of area-based stakeholders, but did not translate to increased access to health plans for children.

CONCLUSION

Integrating health systems across multiple sites with support of a health navigator revealed difficulties, particularly during COVID-19. The first phase of the project demonstrated the value of shared governance and partnerships as an imperative foundation for fundamental change. Relationships strengthened throughout the project, leading to a better understanding of area-based strengths, which in turn supports improved pathways to health care for children and young people in OOHC within rural communities and driving the subsequent phases of the 10-year project.

Implementation and Mental Health Outcomes of a Service Cascade Linking Child Welfare and Children's Mental Health Systems: A Case Study of the Gateway CALL Demonstration

The mental health needs of children and youth involved in the child welfare system remain largely unmet. Service cascades are an emerging approach to systematizing mental health screening, assessment, and treatment referral processes. However, evidence is minimal and inconsistent regarding the effectiveness of such approaches for improving mental health service access and outcomes. In an effort to address this gap, this study presents a case-study of the implementation fidelity and treatment outcomes of the Gateway CALL service cascade. Study analyses involved longitudinal data collected as part of a larger evaluation of Gateway CALL. Specifically, descriptive and linear mixed model analyses were conducted to assess the implementation of service cascade components, and changes in mental health outcomes (behavior problems) among 175 children placed out-of-home during the study. Study analyses found that although fidelity was strong early in the service cascade, implementation began to break down once components involved more than one service system (child welfare, mental health). However, results also indicated that parent-reported child behavior problems decreased significantly over time, despite later cascade components being implemented with poor fidelity to the Gateway CALL service model. For children and youth involved in child welfare systems, service cascades like Gateway CALL have the potential to significantly improve both mental health service receipt and outcomes. To maximize the effectiveness of such approaches, later phases of implementation may require increased attention and support, particularly regarding processes and outcomes that cross child welfare and mental health service systems.