System of Care

System of Care is a best practice model for working with and for children and youth with complex needs in close partnership with their families and communities. Rather than implementing a one-size-fits-all program or service, System of Care focuses on each individual’s unique strengths and needs. It involves 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 children, youth, and families. Vaya’s Child and Youth Service Resource Guide also is supportive for implementing a successful System of Care.

What are the System of Care values?

• Child and family partnership: Each family decides what services and supports 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 reevaluated. 
• Individualized, strengths-based approach: All families have strengths. All families have areas in which they need support. Care plans meet families where they are, using their unique strengths and providing support where they feel they need it.
• Cultural and linguistic responsiveness: It is important to work with families in a manner that respects their cultural background and belief system. Communication is 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. 

Vaya’s System of Care Team

Family Partners have personal experience as the primary caregivers for 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.

System of Care coordinators support the development and maintenance of local child collaboratives, which are groups of community members who work together to accomplish shared goals. System of Care coordinators help create, roll out, and regularly evaluate each collaborative’s data-driven community projects. They are a pipeline of information among youth, families, child- and family-serving organizations, and community groups and provide links to training opportunities, resources, and current information about behavioral health best practices. When community needs and gaps are identified, System of Care coordinators bring this information to those best equipped to strategically address the issue.

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 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 System of Care 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