System of Care

System of Care (SOC) is a best practice model of working with and for children and youth with complex needs, in close partnership with their families and communities. Rather than a one-size-fits-all program or service, SOC focuses on the unique strengths and needs of the individual. It pulls together multiple systems, such as child welfare, health care (physical and behavioral), schools, and juvenile justice, in a shared effort to help children succeed at home, in school, and in their community.

North Carolina Families United has a helpful handbook on System of Care for families.

What Are System of Care Values?

  • Child and family partnership: Each family decides what services and supports will best meet their needs and the needs of their children.
  • Interagency collaboration: Complex needs may require the inclusion of multiple agencies or “players” to meet children’s and families’ needs and goals. Service agencies and providers must work and communicate well together, always including the youth and family. 
  • Accountability to results: Progress toward goals is continually measured and evaluated. Successful services may be enhanced, and unsuccessful approaches will be re-evaluated. 
  • Individualized, strengths-based approach: All families have strengths. All families have areas in which they need support. Care plans are developed to meet families where they are, using their unique strengths and providing support where they feel they need it.
  • Cultural competence: It is important to work with families in a manner that respects their cultural background and belief system. Communication is made, when possible, in a family’s native or preferred language.  
  • Home- and community-based services and supports: Children thrive when they can remain in their own home, school, and community. Having professionals and natural supports close to home helps families stay together and connected. 

Child and Youth Services Resource Guide

Vaya Health’s SOC Team

Family Partners have personal experience as the primary caregivers of children with complex needs. They work directly with families, sharing their knowledge of how to navigate various child and family systems. They help families understand available services and supports, including potential barriers and how to overcome them. Family partners also offer guidance to families on how to advocate effectively for their needs. They support families in learning the skills needed to assume leadership roles on their Child and Family Teams and in community and statewide planning and problem-solving efforts.

SOC coordinators support the development and maintenance of local child collaboratives, which are groups of community members who work together to accomplish shared goals. SOC coordinators assist with the creation, rollout, and ongoing evaluation of each collaborative’s data-driven community projects. They are a pipeline of information between youth, families, child- and family-serving organizations, and community groups by providing links to training opportunities, resources, and current information about best practices in the behavioral health field. When community needs and gaps are identified, SOC coordinators ensure that the information is brought to those best equipped to strategically address the issue.

System of Care Grant

In 2020, Vaya was awarded a federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). The primary goal of the SAMHSA System of Care Expansion and Sustainability Grant is to improve behavioral health outcomes for youth 21 and younger while improving the wellbeing of their families. The grant project serves Alexander, Alleghany, Ashe, Caldwell, McDowell, Polk, and Wilkes counties.

For this project, Vaya partnered with Youth Villages to link youth and family support partners – people with personal experience navigating youth behavioral health services – with youth and families who are engaged with complex systems. Youth and family support partners connect with youth and families to:

  • Identify youth and family goals and needs
  • Connect with community resources to meet youth and family needs
  • Help youth and families understand and utilize the resources available to help them reach their goals

In its first three years, the SOC Grant has:

  • Increased access to training opportunities for families, providers, and community members
  • Supported the voices of youth and families in community collaboratives and policymaking
  • Helped community collaboratives and provider agencies identify and address youth and family needs

Vaya Health SAMHSA System of Care Grant: Year 1, Annual Evaluation Report

Vaya Health SAMHSA System of Care Grant: Year 2, Annual Evaluation Report

Vaya Health SAMHSA System of Care Grant: Year 3, Annual Evaluation Report

Grant Governance Board

The System of Care Grant Governance Board supports the start-up, implementation, and ongoing evaluation of the grant project. The board includes families, youth, and representatives from county Departments of Social Services and Juvenile Justice, schools, health care providers, community organizations, and local government.

Grant Governance Board members live in and represent the seven counties covered by the grant. They are available to provide information about the county they represent, offer insights, and help act as the voice of the communities in developing grant goals and services.

Grant Governance Board members are:

  • Angela Bollo, caregiver (Polk County)
  • Paula Cline, Executive Director, Alexander County Partnership for Children (Alexander County)
  • Diane Coffey, Parent to Parent Family Support Network, High Country (Alleghany and Ashe counties)
  • Aaron Greene, Superintendent, Polk County Schools (Polk County)
  • Allison Inman, Executive Director, Office of Communications, Vaya Health
  • Carlos Lopez, Centro Unido Latino-Americano (CULA) Youth Coordinator (McDowell County)
  • April Luttrell, MSW, Certified Peer Support Specialist, Youth Villages
  • Tressy McLean-Hickey, System of Care Project Director, Vaya Health
  • Lauren Oakes, MSW, LCSW, Early Childhood Therapist, Breathe Wellness Counseling (Caldwell County)
  • Rev. Rob Parsons, WithALL Congregation (Polk County)
  • Paige Stephens, Daymark Center Director (Alleghany and Ashe counties)
  • Kelby Trejo, Youth Representative (Polk County)
  • Vanessa Vargas, Lead Family Coordinator, Vaya Health
  • Dr. Gary Walby, Director, Complex Systems Innovations LLC
  • Brant Wilkins, Juvenile Court Counselor Supervisor (Wilkes)
  • Kim Wilson, DSS Program Manager (Polk County)
  • Kelly Wolf, System of Care Director, Vaya Health