Evaluation and Program Planning 33 (2010) 1–3

Introduction

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Evaluation and Program Planning

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It was never our intent to offer a be-all-end-all definition forsystems of care or to compete with existing definitions. Ourdefinition began in the spring of 2005 as an exercise intended tobuild methodological rigor for a newly funded 5-year nationalstudy at the Research and Training Center for Children’s MentalHealth (RTC) at the University of South Florida. The purpose of thisstudy was to identify fundamental mechanisms of system of careimplementation and understand how factors contributing tosystem implementation interact to produce well-functioningsystems of care. We realized that if we were to studyimplementation strategies used by established systems, we mustask ourselves how we would know that the systems identified forparticipation in this study were, in fact, established systems ofcare? Did our team share an understanding of what it means to be asystem of care? Could we agree on the core components of asystem of care? Would we know an established system when wesaw one? We decided that developing a shared understanding ofthe system of care concept among investigators would supportcareful and thoughtful adherence to our site selection criteria aswell as reliability in our data collection and analysis.

And so we began working together to develop a shared definitionfor systems of care that reflected our growing understanding ofsystems as dynamic, socially constructed, resulting from multipleperspectives, and embedded in multiple contexts. The exercise,which included linking each aspect of our definition to relevantliterature, served a valuable purpose for our research team. As far aswe were concerned, that was that. That is, until our friend andcolleague, Dr. Steven Banks, stopped us to chat after a meeting of RTCprincipal investigators in October 2006. Suddenly we were engagedin a conversation about the scientific importance of definitions anddefinitional processes. Steve, mathematician extraordinaire andnationally recognized expert in the field of mental health statistics,was a much loved research methodologist at the Louis de la ParteMental Health Institute at the University of South Florida whohelped us problem solve around issues of research design andepistemology. We had never thought of our definition or process asanything but an internal exercise, but Steve encouraged us to write apaper making both public. And after reading an early draft ofSystems of Care, Featherless Bipeds, and the Measure of All Things(this issue), he encouraged us to open a public dialogue on system ofcare definition by developing a special issue on this topic andoffering our ideas for commentary and critique.

It made sense to us that a public examination of the content andscope of the system of care concept might facilitate betterunderstanding of the concept’s purpose and goals, its implementa-

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tion, and the evaluation of its impact. Although the term ‘systemsof care’ was part of our common parlance, arriving at a shareddefinition had been more challenging than anticipated. Wethought this was important because the system of care conceptis at the heart of children’s mental health policy in the UnitedStates. The idea of opening our own work for public critique was(and remains) pretty intimidating. We also wondered whether wewould find a journal willing to accommodate the somewhatunorthodox format we were suggesting—our full-length definitionarticle followed by shorter critiques and commentaries from awide spectrum of voices that might not agree with us or each other.

We thank Jonathan Morell, Editor and Chief of Evaluation andProgram Planning, for taking us up on our idea. He found theconcept and content interesting and helped us structure a team-based peer review process that provided careful consideration ofthe submissions by people who understood the history andimportance of systems of care to children’s mental health in theUnited States. Together, the peer review team had more than alifetime of experience in systems of care that spanned conceptua-lization, research, evaluation, and system implementation.

As we initiated the call for papers, we were hopeful that a publicdiscussion of the reasoning behind system of care definition as wellas specific aspects of the definition would have practicalimplications for policy makers, administrators, service providers,evaluators, and family members. The concepts discussed as part ofa definition can be – and often are – translated into structures andprocesses that support service planning and delivery within andoutside systems of care. Of the many abstracts submitted for initialconsideration, we invited 35 full submissions for peer review. Fromthese, the peer review team selected the 14 papers to be part of thisissue in addition to summative comments. The result, we believe, isa rich and stimulating discussion. We hope it will challenge you, asit did us, to consider new ideas, to get a little less caught up in whatis ‘‘right’’ or ‘‘wrong,’’ to look for a kind of truth even when we donot fully agree with the premise or perspective being expressed.

So let us tell you about what you will find in this special issue. Ourfull-length paper on system of care definition opens the issue andprovides an accounting of how our research team arrived at a shareddefinition that we used to conduct our 5-year study of system of careimplementation. What is important to note about that paper is thatit reflects a point in time and in our thinking on a topic that is bynature dynamic. We resisted the temptation to alter our paper toreflect or incorporate the dialog engendered by the special issuebecause we felt it was important for readers to see what the othercontributing authors had been invited to respond to.

Introduction / Evaluation and Program Planning 33 (2010) 1–32

The papers that follow address a wide spectrum of topicsrelated to system of care definition including conceptualizingsystems, culture, partnerships, practice, and outcomes. These openwith an article by Foster-Fishman and Droege. The authors arguethat system building requires establishing system boundaries aswell as understanding key system characteristics and that thedefinition of systems of care should recognize the need to establishboundaries and provide descriptions of key system parts andinteractions. This paper, which advances a system-level focus insystem of care development, is followed by Rosenblatt’s paperwhich makes a case that the definition of systems of care exerts animportant influence on how this reform is evaluated. Rosenblattargues that it is important to use system-level evaluation andresearch designs on the system of care construct and proposes aresearch agenda that addresses systems of care as a system-levelconstruct. Also addressing the conceptualization of systems ofcare, Cook and Kilmer apply ecological theory to the definition as away to underscore the need for a broader system perspective.

Two papers give direct attention to the population served bysystems of care. Rotto and McIntyre argue that by restricting thepopulation served by system of care to those with seriousemotional challenges, the Hodges et al. definition unnecessarilyexcludes the vast majority of children and youth with mentalhealth needs. They believe that mental health services should beneeds driven and recommend a definition that allow system of careservices for all children and youth with mental health needs,regardless of severity. Pires takes a different approach to thequestion of population served by systems of care. She argues thatthe focus of systems of care should not be limited to those withmental health needs and recommends defining systems of care insuch a way that services are available to all children and families,regardless of whether they have mental health needs.

Two papers that follow address issues of mental healthdisparities. Cross, Bartgis, and Fox consider systems of care acultural phenomenon reflective of western models of thinking. Theyconsider the Hodges et al. definition against indigenous principlesand concepts and argue that cultural biases and assumptionsembedded in the system of care model restrict access for margin-alized populations whose worldview is shaped by other ways ofknowing. Callejas, Hernandez, Nesman, and Mowery also considerservice access and availability and argue that it is the responsibilityof the service system to better understand community context andto develop culturally embedded knowledge about service capacity.

Three papers consider the role of partnerships in systems of care.Brown argues that it is critical to define systems of care in a mannerthat includes primary care because this would better serve theintegration of primary and mental health care and would bettersupport the idea of prevention. Baxter articulates the necessity offamily involvement in system of care efforts in order to assureeffectiveness and sustainability. Fluke and Oppenheim write aboutcollaborations between mental health and child welfare andconsider two components of the Hodges et al. definition—populationserved and family-driven. Similar to Rotto and McIntyre, they arguethat defining systems of care in such a way that it includes familieswhose children are at risk of serious emotional disturbance mightprevent the onset of serious emotional disturbance, particularlyamong abused and neglected children. In addition, they argue thatparticularly in child welfare, family-driven should be a continuumthat encompasses degrees of family involvement depending on thecircumstances of each family.

Two papers relate to systems of care at the level of practice. Brunsand Walker reflect on methods that have been undertaken to definethe wraparound process and offer lessons that are useful in definingthe system of care concept. This is the only paper which commentson the process of defining as well as the content of the definition ofsystems of care. Walker, Koroloff, and Bruns consider the concept of

‘‘necessary’’ services and supports and argue that it is essential forsystems to be responsive to service-level processes in order toachieve their purpose. The discussion then shifts more directly to anoutcome focus for systems of care. Lyons, Epstein, and Jordan assertthat the system of care definition must be expanded to includemeasurement and outcomes monitoring so that communicationregarding performance crosses multiple levels of a system. Levison-Johnson and Wenz-Gross argue that if the ultimate outcome ofsystems of care is the development of an integrated service system,then the Hodges et al. definition does not adequately communicatethe developmental nature of systems of care. They describe theirexperiences using theories of change as a tool to manage thecomplexity inherent in the system of care developmental trajectory.

In closing the special issue, we are honored to includesummative comments from Beth Stroul and Robert Friedman,the authors of the original monograph operationalizing systems ofcare (1986, 1994). Stroul, joining with co-author Gary Blau, Chief ofthe Child, Adolescent, and Family Branch of the federal Center forMental Health Services, argues that systems of care cannot bedefined independently of the associated values and principles andsuggests modification of these based on the commentary in thisissue. Friedman challenges us to think of systems of care a complexand dynamic and encourages us to consider research andevaluation methods more adept at capturing this complexity.

The purpose of this special issue was to talk explicitly about ourreasoning and engage in a discussion with others who might offercritique and response to the ideas we discussed in our paper. As ithappened, the definition we offered was sometimes lauded, moreoften challenged, and sometimes flatly opposed. Even though wedisagreed with some of the positions taken in this issue, we wereinspired by the intellect and thoughtfulness that each authorbrought to the discussion. And that dialogue is what Steve Bankssuggested is an important part of the scientific enterprise—makingdebate public and inviting open, honest, and thoughtful commen-tary on a concept that has significant meaning to all of us involved.We have missed Steve’s gentle spirit since he passed away inAugust 2007. We hope he would have enjoyed the conversationsthat he inspired—those leading to as well as resulting from thepublication of this special issue. We surely would have enjoyed andbenefited from his counsel. We respectfully dedicate this specialissue to his memory.

Acknowledgements

The authors would like to thank Tracy-Ann Gilbert-Smith,Social and Behavioral Researcher in the Department of Child andFamily Studies at the University of South Florida, for herinnumerable valuable contributions to this special issue.

Introduction / Evaluation and Program Planning 33 (2010) 1–3 3

Sharon Hodges*Department of Child and Family Studies,

Louis de la Parte Florida Mental Health Institute,

College of Behavioral and Community Sciences,

University of South Florida, 13301 Bruce B. Downs Blvd.,

MHC 2439, Tampa, FL 33612, United States

Kathleen FerreiraDepartment of Child and Family Studies,

Louis de la Parte Florida Mental Health Institute,

College of Behavioral and Community Sciences,

University of South Florida, 13301 Bruce B. Downs Blvd.,

MHC 2433, Tampa, FL 33612, United States

*Corresponding author.Tel.: +1 813 974 6460; fax: +1 813 974 7563

E-mail address: hodges@fmhi.usf.edu (S. Hodges)kferreira@fmhi.usf.edu (K. Ferreira)

1 June 2009