Form SAIS

Attachment 3

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Self-assessment of Implementation Survey (SAIS)

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-03xx. Public reporting burden for this collection of information is estimated to average 30 minutes per respondent, per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Attachment 3a

CMHI SOC Evaluation: Self-Assessment of Implementation Survey

SAIS Purpose

The Self-Assessment of Implementation Survey (SAIS) is an online, self-administered tool, and its purpose is to assess system of care implementation and expansion at the jurisdiction level and describe implementation and expansion plans early in the system of care development process. This evaluation component focuses on jurisdiction-level activities. Of particular interest are the strategies employed to implement and expand system of care across the broad jurisdiction. Factors that impede and facilitate those efforts will also be explored.

Development of SAIS Questions Content

The SAIS was developed from a conceptual framework that is organized by service system components and system of care principles (listed below). Indicators were developed for this conceptual framework to capture how each system of care principle is enacted to achieve the goals within each service system component. Specific implementation and expansion strategies were generated that represent each of the different framework indicators. Survey questions were then developed that ask respondents to rate the level of implementation of specific strategies and their perceptions of how effective these strategies are in their jurisdictions.

The following service system components were used in the framework for developing the SAIS:

• Governance: The governing structure responsible for explicating the system’s goals, vision, and mission; strategic planning and policy development; and establishing formal arrangements among public agencies and family organizations. These structures may include boards of directors, oversight/steering committees, and interagency boards and structures.

• Management: Policies and procedures, developed at the jurisdiction-level, that impact service delivery across the jurisdiction.

• Support of Local Service Delivery: The extent to which jurisdiction-wide policies, procedures, and strategies impact local service delivery.

• Geographic Area Covered: The physical area encompassed by the jurisdiction.

The following system of care principles were included in the framework for the SAIS:

• Family-Driven: The recognition that (a) the ecological context of the family is central to the care of all children; (b) families are primary decision makers and equal partners in all efforts to serve children; and (c) all system and service processes should be planned to maximize family involvement and decision making. Also included is the importance of meeting the needs of families as they care for their children through formal and informal services and supports.

• Youth-Guided: The recognition that young people have a right to be empowered, educated, and given the opportunity to make decisions about their own care, and about the policies and procedures governing the care of all youth.

• Individualized: The provision of care that is expressly individualized and person-centered, that addresses the child or youth’s specific needs, and that recognizes and incorporates the child or youth’s strengths.

• Evidence-Supported: The provision of services that include evidence-informed and promising practices, as well as interventions supported by practice-based evidence, to ensure the effectiveness of services and improve outcomes for children and their families

• Culturally and Linguistically Competent: Sensitivity and responsiveness to, and acknowledgment of, the inherent value of differences related to race, ethnicity, religion, language, national origin, gender identification, sexual orientation, socio-economic background, and certain community-specific and family-specific characteristics. Recognition that providing culturally competent care requires the involvement of diverse perspectives in decision-making related to policies and procedures.

• Interagency/Collaborative: The involvement and partnership of core agencies from multiple child-serving sectors, including child welfare, health, juvenile justice, intellectual disabilities, substance abuse, education, and mental health.

• Coordination: Professionals working together in a complimentary manner to avoid duplication of services, eliminate gaps in care, and facilitate the child, youth and family’s movement through the service system. This includes non-governmental agencies such as private providers, community organizations, churches, advocacy groups, etc.

• Accessible: The minimizing of barriers to services in terms of physical location, convenience of scheduling, financial constraints, and perceptions (e.g., stigma).

• Community Based: The provision of services and supports within close geographical proximity to the intended population.

• Least Restrictive: The priority that services should be delivered in settings that maximize freedom of choice and movement, and interaction in normative environments such as school and family.

We also examined the following components more broadly:

• Quality Monitoring: Quality management throughout the system conducted through formal collection and analysis of process and outcome data, and the use of continuous feedback loops to improve jurisdiction-level system performance.

• Barriers and Facilitators: Factors that impede and facilitate implementing system of care principles and service components.

SAIS Respondents

Respondents for the SAIS will be top administrators involved in the expansion grant. The SAIS will be completed by:

• The CMHI Project Director

• The Jurisdiction Level Family Representative

• The Jurisdiction Level Youth Representative

• The Mental Health Agency Representative

• The Child Welfare Agency Representative

• The Juvenile Justice Agency Representative

• The Education Agency Representative

• Other Agency Representatives Identified by the Grantee as Relevant to the SOC effort

• The Individual Responsible for CMHI Quality Monitoring

Method of Data Collection

The self-administered survey will be completed online. Respondents will be sent a link to the survey and will complete and submit their responses online once annually.

Attachment 3b

INFORMED CONSENT

As the SAIS is an online, self-administered survey, an informed consent statement will be displayed on the screen when the respondent first accesses the survey online. After the informed consent statements are displayed, the respondent will be asked if they agree to participate in the survey. The respondent will be able to proceed only after checking “Yes” for agreement to participate.

Attachment 3c

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Self-assessment of Implementation Survey (SAIS)

INTRODUCTION

Thank you for your willingness to complete the Self-assessment of Implementation Survey (SAIS). The purpose of the SAIS is to assess system of care implementation and expansion at the jurisdiction level and describe implementation and expansion plans early in the system of care development process.

CONFIDENTIALITY/INFORMED CONSENT

This survey was developed by the National Evaluation Team.

For this survey, you will be asked to answer a series of questions about the implementation and expansion of your system of care.  

Your participation is completely voluntary.  You have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, your responses will be combined with other people’s responses, so your answers will never be attributed to your name.

By submitting this form you are indicating that you have read the description of the tool above and that you agree to participate.

[] Agree to Participate

If you have any questions, please contact the National Evaluation Team at cmhieval@westat.com

INSTRUCTIONS

This survey takes approximately 30 minutes to complete. Please try to answer each question on the basis of your impressions of implementation of activities in your system of care. If you feel that you do not have enough information to answer any particular question, please select the "don't know" option, rather than leaving the item blank.

For this survey, you will be asked to answer a series of questions about specific strategies to implement and expand system of care. When asked about system of care strategies, please respond based on the present state of system of care efforts in your system of care, and not only those activities that have resulted from the expansion grant.

Throughout the survey, the term “jurisdiction” is used throughout to mean the broad state, multi-county, territory, or tribal area that received federal grant funds within which smaller community areas are providing direct services to children, youth and families.

For your SOC, the term jurisdiction refers to [insert customized jurisdiction term for grantee respondent].

Also, the terms “children and youth” refer to the population of focus for your system of care and can include young people of any age between birth through young adulthood.

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

Subsection 1: Governance

The following questions are about system of care governance. By governance we mean, the jurisdiction-level governing body/structure responsible for 1) developing the system of care’s goals, vision, mission, 2) establishing strategic planning and policy development; and 3) establishing formal arrangements among public agencies, partner organizations, including youth and family organizations. These structures may include boards of directors, oversight/steering committees, and interagency boards and structures.

The term “governing body” refers to the body that makes the policy decisions for system of care expansion efforts.

G.1. Has (name of system of care) established a governing body that oversees system of care planning, implementation, and expansion efforts?

1. Yes (go to G.2.a.)

2. No (skip to M.1)

3. Don’t know (skip to M.1.)

Subsection 1: Governance (Continued)

G.2.a. SOC sites use several strategies to maximize full involvement of families in SOC governance at the jurisdiction-level. Please select the response that best describes how each is being used in [your system of care]. [A.1.a]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Governing body by-laws that specify involvement of family members	1	2	3	4	5	6	99
Formal agreements with a family organization(s)	1	2	3	4	5	6	99
Representation from family members not affiliated with a family organization	1	2	3	4	5	6	99
Family representatives have decision making votes	1	2	3	4	5	6	99
Training family member representatives on governance	1	2	3	4	5	6	99
Instrumental support to facilitate family members’ involvement in governance such as reimbursement for time, travel, childcare	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

G.2.b. Overall, how involved have family representatives been in SOC governance at the jurisdictional level in the past 6 months? [A.1.b.]

Not at all involved	A little involved	Moderately involved	Extensively involved	Don’t know
1	2	3	4	99

Subsection 1: Governance (Continued)

G.3.a. SOC sites use several strategies to maximize full involvement of youth representatives in SOC governance at the jurisdiction-level. Please select the response that best describes how each is being used in [your system of care]. [A.2.a.]

	Not planned	Planned by not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Governing body by-laws that specify involvement of youth members	1	2	3	4	5	6	99
Formal agreements with a youth organization(s)	1	2	3	4	5	6	99
Representation from youth not affiliated with a youth organization	1	2	3	4	5	6	99
Training youth member representatives on governance	1	2	3	4	5	6	99
Instrumental support to facilitate youth involvement in governance such as reimbursement for time, travel, childcare	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

G.3.b. Overall, how involved have youth representatives been in the SOC governance at the jurisdictional level in the past 6 months? [A.2.b.]

Not at all involved	A little involved	Moderately involved	Extensively involved	Don’t know
1	2	3	4	99

Subsection 1: Governance (Continued)

G.4.a. SOC sites use several strategies to promote cultural and linguistic competence in SOC governance at the jurisdictional level. Please select the response that best describes how each is being used in [your system of care]. [A.5.a.]

	Not Planned	Not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Efforts to ensure that the governance body membership reflects diversity in terms of race, ethnicity, language, and life style	1	2	3	4	5	6	99
Language translation services are offered at governance meetings	1	2	3	4	5	6	99
Other (specify)	1	2	3	4	5	6	99
Other (specify)	1	2	3	4	5	6	99

G.4.b. Overall, how effective have these strategies been for ensuring that SOC governance at the jurisdictional level is culturally and linguistically competent in the past 6 months? [A.5.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

G.5. Which child-serving agencies are involved in the system of care governance body? Select all that apply.

1 = Mental Health 4 = Juvenile Justice 7 = Intellectual Disabilities

2 = Education 5 = Public Health 8 = Other (describe)

3 = Child Welfare 6 = Substance Abuse

Subsection 1: Governance (Continued)

G.5.a. SOC sites use several strategies to maximize full involvement of child- and family-serving agencies in jurisdiction-level governance. Please select the response that best describes how each is being used in [your system of care]. [A.6.a.]

	Not Planned	Not started	Somewhat implemented	Moderately implemented	Substantially implemented	Extensively implemented	Don’t know
Formal agreements, such as MOUs	1	2	3	4	5	6	99
Governing body by-laws that specify involvement of child-serving agencies	1	2	3	4	5	6	99
Other (specify)	1	2	3	4	5	6	99
Other (specify)	1	2	3	4	5	6	99

G.5.b. Overall, how involved have child- and family-serving agencies been in the SOC governance at the jurisdictional level in the past 6 months? [A.6.b.]

Not at all involved	A little involved	Moderately involved	Extensively involved	Don’t know
1	2	3	4	99

Subsection 2: Management, Policies, Procedures

The following questions are about management, policies and procedures developed at the jurisdiction-level that impact operations and service delivery across the jurisdiction.

M.1.a. SOC sites use several strategies to involve family representatives/family organizations in SOC management at the jurisdiction-level. Please select the response that best describes how each is being used in [your system of care]. [B.1.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Family representation on the system-of-care management team(s)	1	2	3	4	5	6	99
Family representatives involved in developing policies and procedures	1	2	3	4	5	6	99
Family representatives employed as jurisdiction-level staff	1	2	3	4	5	6	99
Family representatives involved in training staff and system of care partners	1	2	3	4	5	6	99
Family representatives involved in the hiring process	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

M.1.b. Overall, how involved have families been in SOC management at the jurisdictional level in the past 6 months? [B.1.a.]

Not at all involved	A little involved	Moderately involved	Extensively involved	Don’t know
1	2	3	4	99

Subsection 2: Management, Policies, Procedures (Continued)

M.2.a. SOC sites use several strategies to involve youth representatives in SOC management at the jurisdiction-level. Please select the response that best describes how each is being used in [your system of care]. [B.2.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Youth representation on the system-of-care management team(s)	1	2	3	4	5	6	99
Youth involvement in developing policies and procedures	1	2	3	4	5	6	99
Youth employed as jurisdiction-level staff	1	2	3	4	5	6	99
Youth involved in training staff and system of care partners	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

M.2.b. Overall, how involved have youth representatives been in SOC management at the jurisdictional level in the past 6 months? [B.2.a.]

Not at all involved	A little involved	Moderately involved	Extensively involved	Don’t know
1	2	3	4	99

Subsection 2: Management, Policies, Procedures (Continued)

M.3.a. SOC sites use several strategies to ensure cultural and linguistic competence in SOC management at the jurisdictional level. Please select the response that best describes how each is being used in [your system of care]. [B.5.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Efforts to hire management staff who are diverse in terms of race, ethnicity, language, and life style	1	2	3	4	5	6	99
Documents and materials are offered in language(s) other than English	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

M.3.b. Overall, how effective have these strategies been for maximizing cultural and linguistic competence in SOC management at the jurisdictional level in the past 6 months? [B.5.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 2: Management, Policies, Procedures (Continued)

M.4.a. SOC sites use several strategies to maximize full involvement of child- and family-serving agencies in SOC management and operations at the jurisdiction-level. Please select the response that best describes how each is being used in [your system of care]. [B.6.a.]

	How fully implemented is each strategy?
	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Formal agreements, such as MOUs	1	2	3	4	5	6	99
Out-stationing (placing a staff member from one agency in the office of another agency, such as having a mental health care coordinator in a juvenile court offices)	1	2	3	4	5	6	99
Co-location (having two or more agencies housed in the same office, building, block or other near location)	1	2	3	4	5	6	99
Joint decision-making	1	2	3	4	5	6	99
Shared processes	1	2	3	4	5	6	99
Joint training	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

M.4.b. Overall, how involved have the key child- and family-serving agencies been in SOC management and operations at the jurisdictional level in the past 6 months? [B.6.b]

Not at all involved	A little involved	Moderately involved	Extensively involved	Don’t know
1	2	3	4	99

Subsection 2: Management, Policies, Procedures (Continued)

M.5.a. SOC sites use several strategies at the jurisdiction level to ensure access to services. Please select the response that best describes how each is being used in [your system of care]. [B.8.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Social marketing of system of care Specify: ______________	1	2	3	4	5	6	99
Training across the jurisdiction on eligibility criteria	1	2	3	4	5	6	99
Training across the jurisdiction on referral procedures	1	2	3	4	5	6	99
Expansion of the provider network (for example, contracting with new providers)	1	2	3	4	5	6	99
Jurisdiction-level policies to promote use of satellite offices	1	2	3	4	5	6	99
Jurisdiction-level policies to promote use of tele-health services	1	2	3	4	5	6	99
Jurisdiction level efforts to increase service capacity	1	2	3	4	5	6	99
Reduction in financial barriers Specify: ______________	1	2	3	4	5	6	99
Jurisdiction-level polices to expand hours of service	1	2	3	4	5	6	99
Jurisdiction-level policies that promote service provision in homes and schools	1	2	3	4	5	6	99
Compliance with all Americans with Disabilities Act (ADA) regulations	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

Subsection 2: Management, Policies, Procedures (Continued)

M.5.b. To what extent are efforts to expand access to services underway across the jurisdiction (as opposed to underway in just some areas of the jurisdiction)? [D.8.a.]

Underway in no areas	Underway in a small area	Underway in about half the jurisdiction	Underway in most of the jurisdiction	Underway in all of the jurisdiction	Don’t know
1	2	3	4	5	99

M.5.c. Overall, how effective have these strategies been for ensuring access to services in the past 6 months? [C.8.a.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

M.6.a. SOC sites use several strategies at the jurisdictional level to ensure that children, youth and families are served in their home communities. Please select the response that best describes how each is being used in [your system of care]. [C.9.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Expanding the service array across jurisdiction	1	2	3	4	5	6	99
Training on community-based care	1	2	3	4	5	6	99
Providing peer support	1	2	3	4	5	6	99
Providing respite services and other supports	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

Subsection 2: Management, Policies, Procedures (Continued)

M.6.b. Across the jurisdiction in your SOC, to what extent are children, youth and families served in their home communities (for example, are children, youth, and families in some areas of the jurisdiction more likely to receive services outside their community)? [D.9.a.]

In all of jurisdiction may receive services outside community	In most of jurisdiction may receive services outside community	In half the jurisdiction may receive services outside community	In a few areas the jurisdiction may receive services outside community	In no areas of the jurisdiction may receive services outside community	Don’t know
1	2	3	4	5	99

M.6.c. Overall, how effective have these strategies been for ensuring that children, youth and families are served in their home communities in the past 6 months? [C.9.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

M.7.a. SOC sites use several jurisdiction-level strategies to reduce the use of clinical residential services such as inpatient hospitalization and residential treatment centers. Please select the response that best describes how each is being used in [your system of care]. [C.10.a.]

	How fully implemented is each strategy?
	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Jurisdiction-level expansion of intensive non-residential clinical services options	1	2	3	4	5	6	99
Jurisdiction-supported training in least restrictive care	1	2	3	4	5	6	99
Jurisdiction-level expansion of family support services such as respite services	1	2	3	4	5	6	99
Jurisdiction-wide use of formal assessment of needs	1	2	3	4	5	6	99
Jurisdiction-level policies requiring discharge planning at the time of admission	1	2	3	4	5	6	99
Other (specify)	1	2	3	4	5	6	99

Subsection 2: Management, Policies, Procedures (Continued)

M.7.b. Across the jurisdiction, to what extent are children and youth served in least restrictive environments (for example, are children and/or youth in some areas of the jurisdiction more likely to receive overly restrictive care)? [D.10.a.]

In all of jurisdiction may receive overly restrictive care	In most of jurisdiction may receive overly restrictive care	In half the jurisdiction may receive overly restrictive care	In a few areas the jurisdiction may receive overly restrictive care	In no areas of the jurisdiction may receive overly restrictive care	Don’t know
1	2	3	4	5	99

M.7.c. Overall, how effective have these strategies been for reducing the use of clinical residential services in the past 6 months? [B.10.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 3: Support of Local Service Delivery

The following questions are about the extent to which jurisdiction-wide policies, procedures, and strategies impact service delivery at the local system level.

S.1.a. Different SOC sites provide a variety of services and supports to children, youth, and families served through the system of care. Please indicate to what extent are the following services available in [your system of care] [C.1.a., C.3.b., D.1.b, D.3.b.]

	Not available	Available in a small area of the jurisdiction	Available in about half of the jurisdiction	Available in most of the jurisdiction	Available throughout the jurisdiction	Don’t know
Diagnostic and evaluation services	1	2	3	4	5	99
Neurological and/or neuropsychological assessment	1	2	3	4	5	99
Outpatient individual counseling	1	2	3	4	5	99
Outpatient group counseling	1	2	3	4	5	99
Outpatient family counseling	1	2	3	4	5	99
Medication management	1	2	3	4	5	99
Case management/coordination services	1	2	3	4	5	99

Subsection 3: Support of Local Service Delivery (Continued)

Respite care	1	2	3	4	5	99
Professional consultation	1	2	3	4	5	99
24-hour, 7-day-a-week emergency services, including crisis outreach	1	2	3	4	5	99
Intensive day treatment services	1	2	3	4	5	99
Therapeutic foster care or therapeutic group home services	1	2	3	4	5	99
Intensive home-based services (for example, family preservation services)	1	2	3	4	5	99
Transition-to-adult services	1	2	3	4	5	99
Residential treatment	1	2	3	4	5	99
Inpatient hospitalization	1	2	3	4	5	99
Alcohol and Drug Prevention	1	2	3	4	5	99
Alcohol and Drug Treatment	1	2	3	4	5	99
Parent peer-to-peer support	1	2	3	4	5	99
Youth peer-to-peer support	1	2	3	4	5	99
Supported Employment	1	2	3	4	5	99
Supportive Housing	1	2	3	4	5	99
Other (specify): ____________________________________	1	2	3	4	5	99

S.1.b Overall, in the past 6 months, has the service array been sufficient to meet the needs of children, youth, and families served through the system of care across the jurisdiction? [C.1.a. & C.3.b.]

Not at all sufficient	A little	Moderately	Very sufficient	Don’t know
1	2	3	4	99

S.1.c. What service and support options are needed that are not currently available?

Subsection 3: Support of Local Service Delivery (Continued)

S.2.a. SOC sites use several jurisdiction-level strategies to support the delivery of evidence-supported services and supports for children and youth. Please select the response that best describes how each is being used in [your system of care]. [C.4.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Jurisdiction-mandated use of evidence-supported treatment model(s)	1	2	3	4	5	6	99
Jurisdiction-supported training in evidence-supported treatment models	1	2	3	4	5	6	99
Jurisdiction-mandated monitoring of treatment fidelity	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

S.2.b. Overall, how effective have these strategies been for providing evidence-supported services and supports to children, youth, and families in the past 6 months? [C.4.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 3: Support of Local Service Delivery (Continued)

S.3.a. SOC sites use several jurisdiction-level strategies to support local service systems in their efforts to effectively plan, deliver, and monitor individualized and/or person centered services and supports to children and youth. Please select the response that best describes how each is being used in [your system of care]. [C.7.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Mandated use of wraparound or other person-centered planning processes	1	2	3	4	5	6	99
Training in person-centered service delivery	1	2	3	4	5	6	99
Contracting with Care Management Entities (CMEs)	1	2	3	4	5	6	99
Other (specify)	1	2	3	4	5	6	99

S.3.b. Overall, how effective have these strategies been for ensuring services are effectively planned, delivered, and monitored in local service systems in the past 6 months? [C.7.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 3: Support of Local Service Delivery (Continued)

S.4.a. SOC sites use several jurisdiction-level strategies to support local service systems in their efforts to reach underserved populations. Please select the response that best describes how each is being used in [your system of care]. [C.5.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Support of local social marketing efforts Specify: ______________	1	2	3	4	5	6	99
Support of local needs assessment	1	2	3	4	5	6	99
Support of culturally and linguistically competent outreach efforts	1	2	3	4	5	6	99
Jurisdiction-supported training on culturally and linguistically competent outreach efforts	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

S.4.b. Overall, how effective have these strategies been for supporting local service systems in their efforts to reach underserved populations in the past 6 months? [C.5.a.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 3: Support of Local Service Delivery (Continued)

S.5.a. SOC sites use several jurisdiction-level strategies to support local service systems in their efforts to deliver services in a culturally and linguistically competent manner. Please select the response that best describes how each is being used in [your system of care]. [C.5.b.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Jurisdiction-supported training on the provision of culturally and linguistically competent services	1	2	3	4	5	6	99
Support of translation services	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

S.5.b. Overall, how effective have these strategies been for supporting the provision of culturally and linguistically competent services in local service systems in the past 6 months? [C.5.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 3: Support of Local Service Delivery (Continued)

S.6.a. SOC sites use several jurisdiction-level strategies to support effective service coordination in local service systems. Please select the response that best describes how each is being used in [your system of care]. [C.7.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Establish maximum caseload across the jurisdiction	1	2	3	4	5	6	99
Establish tiered and weighted caseloads (for example, case coordinators serving a more severe clientele have smaller caseload) across the jurisdiction)	1	2	3	4	5	6	99
Establish contracts with Care Management Entities	1	2	3	4	5	6	99
Jurisdiction-supported training in effective service planning and coordination	1	2	3	4	5	6	99
Implement shared client-level information/data systems	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

S.6.b. Overall, how effective have these strategies been for supporting effective service coordination in local service systems in the past 6 months? [C.7.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 4: Geographic Area Covered

The following questions are about the geographic area encompassed by the jurisdiction for your system of care expansion grant.

GA.1 To what extent do family organizations and/or representatives actively participate in planning, implementation, and expansion activities across the jurisdiction (for example, are there areas with little or no active family representation)? [D.1.a.]

Not active	Active in a small area of the jurisdiction	Active in about half of the jurisdiction	Active in many areas/most of the jurisdiction	Active throughout the jurisdiction	Don’t know
1	2	3	4	5	6

GA.2. To what extent do youth organizations and/or representatives actively participate in planning, implementation, and expansion activities across the jurisdiction (for example, are there areas with little or no active youth representation)? [D.2.a.]

Not active	Active in a small area of the jurisdiction	Active in about half of the jurisdiction	Active in many areas/most of the jurisdiction	Active throughout the jurisdiction	Don’t know
1	2	3	4	5	6

GA.3. To what extent are evidence-informed services available throughout the jurisdiction? [D.4.a.]

Not available	Available in a small area of the jurisdiction	Available in about half of the jurisdiction	Available in most of the jurisdiction	Available throughout the jurisdiction	Don’t know
1	2	3	4	5	6

GA.4. Over the past 6 months, to what extent is inter-agency collaboration active throughout the jurisdiction? [D.6.a.]

Not at all	Somewhat	Moderately	Extensively	Don’t know
1	2	3	5	99

Subsection 4: Geographic Area Covered (Continued)

GA.5.a. Which of the following strategies are used to share information on SOC implementation and expansion efforts with partner agencies and organizations across the jurisdiction? [D.7.a.]

	Not planned	Planned but not started	Little implementation	Somewhat implemented	Moderately implemented	Extensively implemented	Don’t know
Social marketing efforts Specify: ______________	1	2	3	4	5	6	99
Conferences and meetings	1	2	3	4	5	6	99
Webinars	1	2	3	4	5	6	99
Newsletters	1	2	3	4	5	6	99
Sharing meeting notes	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99
Other (specify) ____________________	1	2	3	4	5	6	99

GA.5.b. Over the past six months, to what extent have these strategies been effective to ensure that information regarding the system of care implementation and expansion efforts is shared with partner agencies and organizations across the jurisdiction? [D.7.b.]

Not at all effective	A little effective	Moderately effective	Very effective	Don’t know
1	2	3	4	99

Subsection 5: Continuous Quality Improvement

The following questions are about quality improvement activities, including the formal collection, analysis of process and outcome data, and the use of that information to improve jurisdiction-level system performance.

Q.1. Is there a process in place, across the jurisdiction, for quality monitoring (QM) purposes (i.e., to monitor and improve system performance and quality of service delivery across multiple areas)?

1. Yes (go to Q.2.)

2. No (skip to FB.1.)

3. Don’t know (skip to FB.1.)

Subsection 5: Continuous Quality Improvement (Continued)

Q.2. SOC sites monitor a variety of different areas for continuous quality improvement. Please select the response that best describes how each area is being monitored in [your system of care].

	Not planned	Planned but not started	Collected data in this area but not analyzed	Examined/analyzed data in this area but have not used findings for QM	Applied findings in QM process	Don’t know
Child/youth clinical and functional outcomes	1	2	3	4	5	99
Family well-being outcomes	1	2	3	4	5	99
Child, youth and family appraisals of service experience (for example, satisfaction with services)	1	2	3	4	5	99
Youth involvement in governance, management, and/or operations	1	2	3	4	5	99
Family involvement in governance, management, and/or operations	1	2	3	4	5	99
Monitoring of fidelity of evidence-supported services	1	2	3	4	5	99
Cultural and linguistic competence in SOC governance, management, and operations	1	2	3	4	5	99
Culturally competent service delivery	1	2	3	4	5	99
Interagency collaboration	1	2	3	4	5	99
Coordination of services	1	2	3	4	5	99
Accessibility of services	1	2	3	4	5	99
Community-based service delivery	1	2	3	4	5	99
Service delivery in least restrictive settings	1	2	3	4	5	99
Other (specify)	1	2	3	4	5	99

Subsection 6: Barriers/Facilitators

FB.1. What factors have facilitated system of care implementation and expansion efforts?

FB.2. What factors have impeded system of care implementation and expansion efforts?

End of Instrument:

Thank you for completing this tool. We appreciate your time and participation.

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Attachment #3 – Self-Assessment (SAIS)