Adopting the systems of care approach promoted in federal law requires a sea change in policy, clinical practice and administration. States and localities are expected to re-orient, re-design and re-finance child mental health services into true "systems" of care. It is in sites that effected the hoped-for sea change—where major and systemic re-thinking and re-orienting have occurred—are judged by stakeholders to be most likely to sustain themselves in a vibrant manner.

Federal law assumes that states and localities will commit to providing additional new funds to match the federal grant. Sites that have accepted that federal money is flexible, but time-limited, and have used their grant to build a partnerships with multiple agencies, families and sponsors find it easier to sustain the program.

This monograph is based on a review of non-federal funds secured by sites, and on conversations with site directors, policymakers and others concerning the most successful strategies to ensure long-range stability for the sites.

Sites have been quite successful in securing funds from various state and local sources, with a heavy emphasis on government funds. Most sites rely primarily on the mental health system, although child welfare agencies also contribute significant amounts. Education and juvenile justice agencies contribute at lower levels. Private funds are small, but often very precious to the site because of their flexibility. Sites obtain third party payments for direct services and have garnered support from local and national foundations, local businesses, charities and community organizations, often in the form of in-kind assistance.

Long-term financial stability requires that sites plan in a thorough and businesslike fashion for future funding and sponsors. Sites need to be entrepreneurial and directors report that sustainability planning is a long-term, iterative process that needs to begin with a long-range sustainability plan written early during the grant. Repeated reviews and revisions will then be necessary, as the plan must be adapted continually to meet new challenges.

All successful sites have good leadership. In several, a single charismatic individual has been instrumental in conceiving and organizing the site. But leaders will come and go and, for some sites, turnovers have caused difficulties. Even the most brilliant idea requires staying power. Leaders themselves must recognize the need to foster a program that is not dependent on one person.

Site directors are not running profit-making businesses, but they can learn from research and experience in the business world. Many business leaders emphasize a facilitation style, based on team work, not a top-down approach. This recognizes and respects the capability of all staff. The leader’s role is to keep the organization moving and responding to changing circumstances.

One of the most fundamental aspects found in successful sites is strong, and real, interagency collaboration. The development of true collaborative partnerships creates a means to ensure fiscal accountability for all partner agencies. Successful sites recommend that others build true partnerships, from the beginning, because this is where sustainability begins.

Assisting in the creation of a local parent support organization or strengthening an existing one, is another important step. In certain states, family organizations have played key roles in ensuring sustainability with the legislature and other policymakers.

A strong potential strategy for sustainability is to seek redirection of resources. Initiatives in various states have redirected institutional funds to community-based services. Several sites have benefited from state initiatives to blend resources for meeting the needs of children served by more than one system. Blended funding pools can be created out of existing resources or they can involve allocation of new resources, secured through the federal grant or other sources and channeled into the pool. However, although blended funding is effective, it is difficult to accomplish.

Without pooling funds, other agencies may provide significant resources to a site through direct contributions, in-kind (staffing) contributions or specific "purchases" of service. Sites have found that purchase of service arrangements can accomplish the same goal as blended funding.

A reinvestment strategy can convince those who control the budget for human services to reinvest other resources in the site. Under reinvestment, the value of specific savings resulting from the improved organization and delivery of services through the site is calculated, in concrete financial terms, and funds that can be "saved" are reinvested in the site.

Managed care can be a pro-active strategy for sustainability or a reactive strategy. Managed care represents an approach for ensuring accountability in service delivery and the issue for sites, is how managed care is implemented and their role in delivering services through the managed care system. Several sites demonstrate that managed care can redirect resources. Sites that have dealt most successfully with Medicaid managed care are those where the public system has organized the managed care approach. Sites that must interact with private managed care companies—either behavioral health care carve-out firms or health care managed care entities, such as health maintenance organizations—have had the most significant problems.

The importance of presenting good data to policymakers cannot be overemphasized. Policymakers need reliable data that points to a clear conclusion of effectiveness of services and cost-effectiveness of the system. Data should be relevant to current political concerns, such as child welfare placement rates, school drop-outs, rising juvenile justice facility populations and easily understood and supported by concrete examples of child and family experiences.

Sophisticated communications and media work are essential for any organization seeking to become an effective agent for social change. It allows a site to inform and mobilize the public, shape the policy agenda and strengthen the site’s support in its local community. A media campaign should not run in a vacuum; it should be tied to the organization’s priorities, such as securing resources.

Several sites have secured funds for their staff to provide training. This permits the site to garner additional resources to underwrite salaries and overhead costs. The training can have a significant impact on service providers who then are more supportive of the site and its goals.

Some examples of the many sites that have effective strategies to ensure sustainability are:

• Kansas, Rhode Island and Vermont had successful campaigns to secure state appropriations.
• Maine and Rhode Island built a system of care approach into their state mental health laws. In California, systems of care are supported through a child welfare waiver reform.
• Kansas, North Dakota, Philadelphia and Baltimore have influenced improvements in Medicaid to fund community services.
• Three sites have had good experiences using managed care—Wraparound Milwaukee is a managed care entity, Lane County funds child services under managed care and the Philadelphia site has a contract with the city’s managed care arrangement.
• Blended funding is effective in Rhode Island, Vermont, Stark County, Ohio and purchase of service agreements work well in Santa Barbara and Milwaukee.
• Private, flexible resources are used in San Diego and Baltimore.
• Marketing has been emphasized in Santa Barbara.
• Several sites are skilled at using media: Kansas, Rhode Island, Milwaukee Wraparound and North Dakota’s Partnership.

Sites can be successful in achieving financial sustainability, but it takes work and much planning. To achieve sustainability, sites must maintain their commitment to the philosophy of a system of care, adapt to broader state policy initiatives, especially managed care, and tap into major entitlement funding and state government resource streams. Reallocating resources is an important part of the solution, and generating broad community support through community organizing, social marketing and media work is essential.