Community Characteristics and Implementation Factors Associated with Effective Systems of Care

  • Laurel M. Lunn
  • Craig Anne Heflinger
  • Wei Wang
  • Paul E. Greenbaum
  • Krista Kutash
  • Roger A. Boothroyd
  • Robert M. Friedman


How are characteristics of communities associated with the implementation of the principles of systems of care (SOC)? This study uses multilevel modeling with a stratified random sample (N = 225) of US counties to explore community-level predictors of the implementation factors of the System of Care Implementation Survey. A model composed of community-level social indicators fits well with 5 of 14 factors identified as relevant for effective SOCs. As hypothesized, community disadvantage was negatively and residential stability positively associated with the implementation of SOC principles. Designation as a mental health professional shortage area was positively related to some implementation scores, as was the percentage of minority residents, while rurality was not significantly associated with any of the factors. Given the limitations of the study, the results should be interpreted with caution, but suggest that further research is merited to clarify these relationships that could inform efforts directed at promoting SOCs.


Tucker Lewis Index Community Disadvantage Residential Stability Serious Emotional Disturbance Implementation Factor 



This research was partially supported by Grant H133B90004 from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, the National Institute for Disability and Rehabilitation Research, and the National Institute of Mental Health (NIMH, R01 MH70680-01A). The opinions contained in this manuscript are those of the authors and do not necessarily reflect those of the U.S. Department of Education, the Center for Mental Health Services, SAMHSA, or NIMH.


  1. 1.
    Stroul BA, Friedman R. A System of Care for Children and Youth with Severe Emotional Disturbances. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center, 1986.Google Scholar
  2. 2.
    Stroul BA, Friedman R. The System of Care concept and philosophy. In: Stroul BA, ed. Children's Mental Health: Creating Systems of Care in a Changing Society. Baltimore, MD: Paul H. Brookes Publishing Co, Inc., 1996, pp. 591–612.Google Scholar
  3. 3.
    American Academy of Child and Adolescent Psychiatry. Practice parameter on child and adolescent mental health care in community Systems of Care. Journal of the American Academy of Child and Adolescent Psychiatry. 2007; 46:284–299.CrossRefGoogle Scholar
  4. 4.
    American Academy of Child and Adolescent Psychiatry. Systems of Care Information and Resources. 2009. Available at Accessed February 9, 2009.
  5. 5.
    Substance Abuse and Mental Health Services Administration. Systems of Care. (n.d.). Available at Accessed February 9, 2009.
  6. 6.
    Pires S. Building Systems of Care: A Primer. Washington, DC: National Technical Assistance Center for Children's Mental Health, Georgetown University Child Development Center, 2002.Google Scholar
  7. 7.
    Walrath C, Garraza LG, Stephens R, et al. Trends in characteristics of children served by the Children's Mental Health Initiative: 1994–2007. Administration and Policy in Mental Health and Mental Health Services Research. 2009; 36:361–373.PubMedCrossRefGoogle Scholar
  8. 8.
    Hodges S, Ferreira K, Israel N, et al. Systems of care, featherless bipeds, and the measure of all things. Evaluation and Program Planning. 2010; 33:4–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Vinson NB, Brannan AM, Baughman LN, et al. The system-of-care model: Implementation in twenty-seven communities. Journal of Emotional and Behavioral Disorders. 2001; 9:30–42.CrossRefGoogle Scholar
  10. 10.
    Brannan AM, Baughman LN, Reed ED, et al. System of care assessment: Cross-site comparison of findings. Children Services: Social Policy, Research, and Practice. 2002; 5:37–56.Google Scholar
  11. 11.
    Center for Mental Health Services. Findings on the implementation of systems of care at 14 CMHS grant communities. EvalBrief: Systems of Care. 2004; 6:1–4.Google Scholar
  12. 12.
    Hodges S, Hernandez M, Nesman T. A developmental framework for collaboration in child-serving agencies. Journal of Child and Family Studies. 2003; 12:291–305.CrossRefGoogle Scholar
  13. 13.
    Hoge MA, Howenstine RA. Organizational development strategies for integrating mental health services. Community Mental Health Journal. 1997; 33:175.PubMedCrossRefGoogle Scholar
  14. 14.
    Boothroyd RA, Greenbaum PE, Wang W, et al. Development of a measure to assess the implementation of children’s systems of care: The System of Care Implementation Survey (SOCIS). Journal of Behavioral Health Services and Research, 2011; 38(3).Google Scholar
  15. 15.
    Greenbaum PE, Wang W, Boothroyd RA, et al. Multilevel confirmatory factor analysis of the system of care implementation survey (SOCIS). Journal of Behavioral Health Services and Research, 2011; 38(3).Google Scholar
  16. 16.
    Kutash K, Greenbaum PE, Wang W, et al. Levels of system of care implementation: A national benchmarking study. Journal of Behavioral Health Services and Research, 2011; 38(3).Google Scholar
  17. 17.
    Bronfenbrenner U. Toward an experimental ecology of human development. American Psychologist. 1977; 32:513–530.CrossRefGoogle Scholar
  18. 18.
    Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press, 1996.Google Scholar
  19. 19.
    Aday LA, Andersen RA. A framework for the study of access to medical care. Health Services Research. 1974; 9:208–220.PubMedGoogle Scholar
  20. 20.
    Andersen RM, Davidson PL. Measuring access and trends. In Andersen RM, Rice TH, Kominski GF (eds). Changing the U.S. Health Care System: Key Issues in Health Services, Policy, and Management. San Francisco: Jossey-Bass, 1996, pp.13-40.Google Scholar
  21. 21.
    Heflinger CA, Brannan AM. Rural Child/adolescent Mental Health Service Use (NIMH 1 R01 MH70680-01A2). Nashville, TN: Vanderbilt University, 2005.Google Scholar
  22. 22.
    Jones DL, Heflinger CA, Saunders RC. The ecology of adolescent substance abuse service utilization. American Journal of Community Psychology. 2007; 40:345–358.PubMedCrossRefGoogle Scholar
  23. 23.
    Haas JS, Phillips KA, Sonneborn D, et al. Variation in access to health care for different racial/ethnic groups by the racial/ethnic composition of an individual's county of residence. Medical Care. 2004; 42:707.PubMedCrossRefGoogle Scholar
  24. 24.
    Gresenz CR, Stockdale SE, Wells KB. Community effects on access to behavioral health care. Health Services Research. 2000; 35:293.PubMedGoogle Scholar
  25. 25.
    Kirby JB, Kaneda T. Neighborhood socioeconomic disadvantage and access to health care. Journal of Health and Social Behavior. 2005; 46:15–31.PubMedCrossRefGoogle Scholar
  26. 26.
    Litaker D, Koroukian SM, Love TE. Context and healthcare access: Looking beyond the individual. Medical Care. 2005; 43:531.PubMedCrossRefGoogle Scholar
  27. 27.
    Gilman SE, Kawachi I, Fitzmaurice GM, et al. Socio-economic status, family disruption and residential stability in childhood: Relation to onset, recurrence and remission of major depression. Psychological Medicine. 2003; 33:1341–1355.PubMedCrossRefGoogle Scholar
  28. 28.
    Bures RM. Childhood residential stability and health at midlife. American Journal of Public Health. 2003; 93:1144–1148.PubMedCrossRefGoogle Scholar
  29. 29.
    Ricketts TC. The changing nature of rural health care. Annual Review of Public Health. 2000; 21:639–657.PubMedCrossRefGoogle Scholar
  30. 30.
    Reschovsky JD, Staiti AB. Access and quality: Does rural American lag behind? Health Affairs. 2005; 24:1128–1139.PubMedCrossRefGoogle Scholar
  31. 31.
    US Bureau of the Census. Census 2000 Summary File 3: Technical Documentation. Washington, DC: US Bureau of the Census, 2002. Available at
  32. 32.
    Community Health Status Indicators Project Working Group. Data Sources, Definitions, and Notes: Community Health Status Indicators 2008. Washington, DC: Department of Health and Human Services; 2008. Available at
  33. 33.
    Inter-university Consortium for Political and Social Research. County Characteristics, 2000–2007 [United States]: Codebook. ICPSR20660-v2, Ann Arbor, MI: ICPSR, 2008.Google Scholar
  34. 34.
    Freedman VA, Grafove IB, Schoeni RF, et al. Neighborhoods and disability later in life. Social Science & Medicine. 2008; 66:2253–2267.CrossRefGoogle Scholar
  35. 35.
    Muthén LK, Muthén BO. Mplus User’s Guide Fifth Edition. Los Angeles, CA: Muthen & Muthen, 1998–2007.Google Scholar
  36. 36.
    Bentler PM. Comparative fit indexes in structural models. Psychological Bulletin. 1990; 107:238–246.PubMedCrossRefGoogle Scholar
  37. 37.
    Tucker LR, Lewis C. The reliability coefficient for maximum likelihood factor analysis. Psychometrika. 1973; 38:1–10.CrossRefGoogle Scholar
  38. 38.
    Steiger JH, Lind JC. Statistically-based tests for the number of common factors. Paper presented at: Annual Meeting of the Psychonomic Society; May 1980; Iowa City, IA.Google Scholar
  39. 39.
    McDonald RP, Ho M. Principles and practice in reporting structural equation analyses. Psychological Methods. 2002; 7:64–82.PubMedCrossRefGoogle Scholar

Copyright information

© National Council for Community Behavioral Healthcare 2011

Authors and Affiliations

  • Laurel M. Lunn
    • 1
  • Craig Anne Heflinger
    • 1
  • Wei Wang
    • 2
  • Paul E. Greenbaum
    • 3
  • Krista Kutash
    • 4
  • Roger A. Boothroyd
    • 5
  • Robert M. Friedman
    • 6
  1. 1.Department of Human and Organizational Development, Peabody CollegeVanderbilt UniversityNashvilleUSA
  2. 2.Department of Epidemiology and Biostatistics, College of Public HealthUniversity of South FloridaTampaUSA
  3. 3.Department of Child and Family Studies, MHC 2434, Louis de la Parte Florida Mental Health InstituteUniversity of South FloridaTampaUSA
  4. 4.Department of Child and Family Studies, MHC 2335, Louis de la Parte Florida Mental Health InstituteUniversity of South FloridaTampaUSA
  5. 5.Department of Mental Health Law and Policy, MHC 2719 Louis de la Parte Florida Mental Health InstituteUniversity of South FloridaTampaUSA
  6. 6.Department of Child and Family Studies, MCH 2312a, Louis de la Parte Florida Mental Health InstituteUniversity of South FloridaTampaUSA

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