Implementation and Mental Health Outcomes of a Service Cascade Linking Child Welfare and Children’s Mental Health Systems: A Case Study of the Gateway CALL Demonstration

Abstract

The mental health needs of children and youth involved in the child welfare system remain largely unmet. Service cascades are an emerging approach to systematizing mental health screening, assessment, and treatment referral processes. However, evidence is minimal and inconsistent regarding the effectiveness of such approaches for improving mental health service access and outcomes. In an effort to address this gap, this study presents a case-study of the implementation fidelity and treatment outcomes of the Gateway CALL service cascade. Study analyses involved longitudinal data collected as part of a larger evaluation of Gateway CALL. Specifically, descriptive and linear mixed model analyses were conducted to assess the implementation of service cascade components, and changes in mental health outcomes (behavior problems) among 175 children placed out-of-home during the study. Study analyses found that although fidelity was strong early in the service cascade, implementation began to break down once components involved more than one service system (child welfare, mental health). However, results also indicated that parent-reported child behavior problems decreased significantly over time, despite later cascade components being implemented with poor fidelity to the Gateway CALL service model. For children and youth involved in child welfare systems, service cascades like Gateway CALL have the potential to significantly improve both mental health service receipt and outcomes. To maximize the effectiveness of such approaches, later phases of implementation may require increased attention and support, particularly regarding processes and outcomes that cross child welfare and mental health service systems.

Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations

“…Cross-system interventions are challenging to implement because they involve multiple stakeholders and intervention components that must be aligned across different systems [ 3 , 4 ]. Differences in the values, priorities, regulations, funding, staffing, and capacity in two systems can undermine collaboration [ 5 ] and delay or threaten the implementation and sustainment of cross-system interventions [ 6 , 7 ].…”

“…Strong interorganizational collaboration is critical for implementing cross-system interventions [ 2 , 10 , 12 – 14 ]. For example, collaboration difficulties limited implementation in prior studies of cross-system interventions focused on screening, assessing, and referring children served by the child welfare system to community-based behavioral health services [ 7 , 15 – 19 ]. Collaboration problems included contract disruptions, poor communication, limited familiarity with external providers and their services, unclear referral protocols, and disagreements about data sharing [ 7 , 15 – 19 ].…”

“…For example, collaboration difficulties limited implementation in prior studies of cross-system interventions focused on screening, assessing, and referring children served by the child welfare system to community-based behavioral health services [ 7 , 15 – 19 ]. Collaboration problems included contract disruptions, poor communication, limited familiarity with external providers and their services, unclear referral protocols, and disagreements about data sharing [ 7 , 15 – 19 ]. Addressing these challenges is critical [ 20 ], but can be difficult and time-consuming [ 21 – 23 ] especially during early phases of preparation and implementation [ 24 ].…”