Blueprint for 2016 – 2020
In FY 2015, Board of Supervisors' funding created a new program unit to implement a System of Care (named Healthy Minds Fairfax in 2017) model by connecting the continuum of supports and services across county agencies, Fairfax County Public Schools and community partners. The new unit was charged with developing new policies and procedures on providing care coordination and service delivery, as well as oversight, to the various entities delivering services along the continuum.
Additionally, the new unit was to be responsible for implanting contractual services for individuals with emerging mental health and substance use issues. In November and December 2015, under the capable facilitation of a senior policy associate from the Georgetown University National Technical Assistance Center for Children’s Mental Health, a 30 member planning team comprised of county human service staff, school staff, non-profit representatives, family organizations, family representatives, and George Mason University faculty was convened. This planning team was charged with developing a vision and mission for the initiative and establishing goals, strategies, and action steps and a timetable for their accomplishment.
The following comprises the work of the planning team in the development of the fifteen goals that make up the blueprint of Healthy Minds Fairfax, the Fairfax-Falls Church System of Care for children, youth and families.
Goal 1: Deepen Community System of Care Approach
Deepen the system of care approach to inform the entire continuum of behavioral health services for children, youth and families through:
- A governance structure that guides the entire continuum,
- Financing strategies that support sustainability and improve capacity and,
- Continuous improvement to service quality and access.
The strategies set forth in this goal address establishing a Children’s Behavioral Health System of Care (BHSOC) oversight committee; creating cross-system behavioral health practice standards, policies and procedures; generating support for these efforts from the general public, policy makers and local administrators at the state and local levels; and furthering the development of partnerships with community organizations and agencies in different sectors for coordination, financing and support of the system of care approach. It further calls for a system mapping process to maximize, braid or combine funds. Additional strategies include striving for more inclusion of providers and families in the development of system of care training policy and annual planning; collecting and reporting on community outcomes and assessing gaps; and finally, reviewing intake, assessment, triage and referral protocols with the goal of supporting families in accessing both public and community provided resources.
Goal 2: Data Systems
Increase collaboration through the implementation of a cross-system data sharing.
Efforts here are in the direction of increasing data sharing and using the cross-system data to improve decision-making and resource use. This cross-system data sharing can lead to the improvement of process and outcome evaluations, reduce duplication and improve efficiency and increase the use of data in community reporting and planning processes.
Goal 3: Family and Youth Involvement
Increase the presence and effectiveness of family leadership through a sustained family-run network.
The strategies focus on strengthening and expanding family leadership; increasing the presence of family and youth involvement in system planning, implementation, evaluation of services and system improvement; and expanding evidenced based peer to peer groups and family/community networks.
Goal 4: Increase Awareness and Reduce Stigma
Use social messaging to promote awareness and help seeking behaviors and reduce the stigma surrounding mental illness and behavioral health care.
In an effort to accomplish the above, strategies revolve around educating and informing the public to increase their understanding of mental illness, its signs and symptoms and how to support others to get help. It also addresses involving youth to combat stigma and creating a speaker’s bureau of approved presenters for the school and community to access.
Goal 5: Youth and Parent/Family Peer Support
Develop and expand youth and parent/family peer support services.
The creation of a Family Navigator program to assist families in “navigating the system” and expansion of evidence-based peer to peer groups round out the strategies of this goal.
Goal 6: System Navigation
Educate/inform/assist families on how to access services and navigate the system to include developing an accurate and accessible database of behavioral health care providers that includes information on if they are accepting new clients, if they accept insurance and their areas of expertise.
This goal is a most needed and ambitious one as it addresses developing an accurate, accessible, real time data base of behavioral health care providers and creating a clearinghouse for information on children’s behavioral health issues and resources that is accessible in person, by telephone and on line.
Goal 7: Care Coordination and Integration
Improve care coordination and promote integration among schools, primary care providers and mental health providers, including the integration of primary and behavioral health care.
More and more research points to the efficacy of integrating primary and behavioral health care. In that vein, strategies here relate to providing behavioral health consultation to primary care providers, implementing tiered levels of integration and increasing the use of behavioral health screenings and referrals in primary care settings.
Goal 8: Equity/Disparities
Implement targeted strategies to address disparities in outcomes and access based on race, ethnicity, sexual orientation, socio-economic status, geography and other factors.
Strategies involve increasing access and availability to behavioral health services for underserved populations, using Culturally and Linguistically Appropriate Services standards, training in cultural competence for County, Fairfax County Public Schools and County-contracted providers along with additional support structures for LGBTQ youth.
Goal 9: Reducing Incidents of Youth Suicide in our Community
Reduce the incidence of youth suicide in our community.
As we continually work to provide a safe and supportive community for our children and youth, the focus in this goal addresses developing universal suicide and/or depression screening protocols for community organizations; having guidelines for service providers on the availability and effective use of crisis services, developing a common and coordinated approach to youth suicide postvention; continuing and promoting the suicide prevention hotline and text line; and training behavioral health providers in evidence-based practices for suicidal youth.
Goal 10: Evidence-Based and Informed Practices
Increase the availability of and capacity for evidence-based practices/interventions along the continuum of prevention through treatment.
Trauma is ever present in many of the children and youth seeking our services. These strategies target the development of core competencies in trauma treatment needed by the treating clinicians and creating definitions and criteria for evidence-based and evidence-informed practice, along with training County/FCPS staff and contracted providers in evidence based practices.
Goal 11: Trauma-Informed Care Community
Enhance the community’s ability to effectively identify and respond to children and families who have been exposed to trauma.
While many of our children and youth present with symptoms of trauma, our provider network of trauma informed practitioners needs to increase along with the community’s understanding of what trauma informed care means. Strategies to target these concerns include educating non-clinical staff and the community at large on the impact of trauma and trauma informed practices; ensuring there is sufficient clinical capacity to provide the trauma specific interventions for our children and youth; having a shared cross-system screening and referral process for individuals impacted by trauma; and integrating the concepts of trauma-informed care into our organizational structure.
Goal 12: Behavioral Health Intervention
Address the needs of children and youth with emerging behavioral health issues who have not been able to access appropriate, timely and matching treatment services in the community.
Intervening early when children and youth present with emerging behavioral health issues can reduce the intensity of the symptoms and duration of treatment. These strategies attend to creating capacity to address the behavioral health needs of children from 0-7; developing/identifying a validated cross-system screening process to determine the needs, resources and desirable outcomes; creating a training consortium in partnership with a university and private provider partners; and expanding a current pilot initiative of providing timely and available behavioral health services to school age children and youth with emerging behavioral health issues who have not been able to access services. In addition, there is a need to expand the Diversion First initiative to include youth who come in contact with the criminal justice system and reduce youth substance use and abuse.
Goal 13: Service Network for High Risk Children
Develop an improved service network for high risk children to include appropriate evidence-based practices, care coordination, and crisis intervention/stabilization, in order to improve the outcomes for those served.
This goal includes a myriad of strategies the highlights of which are implementing an evidence-based parenting program for adolescents and specifically for children under 12; increasing the capacity for youth to receive appropriate case management services; developing a communication plan to share information about services and care coordination offered through the system of care process; providing IT infrastructure to support data collection for fidelity monitoring and outcome evaluation along with electronic records management; and exploring opportunities to serve youth on diversion/probation who need intensive behavioral health services.
Goal 14: Developmental Disabilities/Autism Services
Develop expanded continuum of care of services for youth with Developmental Disabilities/Autism.
These strategies identify that a needs assessment and service inventory of existing services and supports is necessary to identify critical service gaps for this population leading to a plan that will be developed to address the critical service gaps; that an outreach campaign and social messaging will help to promote earlier identification of children with DD/Autism; and that this population needs additional transition planning, access to crisis stabilization, case management, care coordination along with a community awareness campaign educating the community about the special needs of these children and youth.
Goal 15: Transition Age Youth
Provide coordinated services and supports for youth and young adults of transition age, both those still in school and those who have left school. Reduce the number of youth of transition age who are living with unidentified and untreated serious mental illness who have signs and/or symptoms of a serious mental health condition that emerged before they transition out of youth-serving systems/programs.
This goal addresses a long known need to improve transition planning for youth in need of adult behavioral health services. This goal’s strategies address adapting a primary care transition model of resources and tools for use in behavioral health care; ensuring that “navigators” have knowledge and understanding of unique transition issues and requirements; reflecting these unique needs in navigation tools; improving transition planning for transition age youth in need of adult behavioral health services.
Scope of the Blueprint
This multi-year plan is for calendar years 2016 through 2019, and fiscal years 2017, 2018 and 2019. The plan will be reviewed and revised at least annually. It represents goals and strategies to be implemented by and with the support of Fairfax County human services departments and Fairfax County Public Schools. It is important to acknowledge that much work related to system of care is, and will continue to be, supported and led by family, consumer and other non-profit organizations, and provider agencies in the community.
Wherever possible and appropriate, the public entities responsible for implementation of particular strategies noted in the plan will work in conjunction with these agencies and organizations. Moreover, consistent with the system of care principles, it is envisioned that families and consumers will be intricately involved in planning, implementation and evaluation of activities related to all levels of behavioral health care from prevention through intensive intervention for children, youth and families in the Fairfax-Falls Church community.