CANS and System of Care Design.

'System of Care' is an organizing philosophy. The goal of a System of Care is to provide culturally competent, family-driven and youth-guided care in the least restrictive, most normalizing setting so that children and youth achieve success in school, the community, and in relationships at home (Stroul, Blau and Friedman, 2010).

The CANS is one way to translate the System of Care organizing philosophy into concrete actions which help children and youth to reach their goals. When correctly implemented, the CANS is exceptionally useful for:

-- Empowering families and youth to be active partners in defining their needs and strengths

through a culturally-appropriate dialogue

-- Defining youth and family treatment goals in their own words

-- Helping multiple system stakeholders create a shared understanding of family needs, strengths, and appropriate services

-- Helping multiple system stakeholders create a shared set of family-driven, yoth-guided goals

-- Identifying the intensity of supports most likely to be effective in meeting child, youth, and

family needs

-- Creating an expectation that services will be effective in meeting client treatment goals

-- Regularly reviewing progress towards goals, and creating clear lines of accountability for

reaching child, youth, and family goals over time

-- Aligning each level of the system of care to be responsive to the specific needs and

strengths of children, youth, and families

Tools can help us achieve youth and family goals in value-driven, empowering ways. The CANS is a tool which, when implemented properly, can help stakeholders work collaboratively from the moment of first contact with a family or youth to the moment a child or youth achieves their behavioral health and wellness goals. For more about using the CANS to its full potential at the child / youth, program, and system levels see the description of Total Clinical Outcomes Management (below). Throughout this page we will walk through examples of how we have used the CANS to align the multiple systems to the needs and strengths of children and youth in San Francisco. For each example we briefly describe the effort, and then provide an attachemnt or link with a more thorough description and supporting data regarding each effort in place.

CANS and Family-Driven Care.
Families teach Clinicians. Families define what practices lead to engaged, collaborative care. In San Francisco, we engage in a collaborative, ongoing process with diverse families to better understand how we can provide effective family-driven care. From this process, families have described actions which helping professionals can take to better build trust, engage in collaborative assessment, arrive at family-defined goals, and insure progress towards those goals over time. This process is described in this brochure:
One outcome of these discussions has been the development of a training for clinicians which is co-taught by family members. In this training clinicians learn six key skills for engaging families, collaboratively assessing the child or youth's needs and strengths, defining treatment goals in families' terms, and reviewing progress towards achieving treatment goals. A description of this process and the training are provided in detail here:
CANS Parent and Caregiver Resources

Families teach Families. Families have also made clear that family-to-family communication can help families empower each other to reach their goals. Family-to-family communication tools are being built based on family input and family priorities.
These tools are designed to set an expectation for high-quality collaborative care from the moment families step in the door. The tools include:
a) A collaborative scheduling tool which sets the expectation that families will review the Assessment and drive the selection of Treatment Plan goals

b) Pre-formatted letters requesting key actions for families, including getting copies of an Assessment or Treatment Plan, asking for an updated Assessment or Treatment Plan, and requesting a therapist who is a better match for the family.
c) Responses from individual agencies regarding how service providers at that agency can work in a collaborative family-driven manner (example below)

These tools are designed to provide families and youth with additional concrete supports to help make the goal of collaborative, family-driven a reality.
CANS and Multi-Sector Stakeholders
Children and youth involved in multiple systems are often very high risk in terms of their danger to self or others, and have needs requiring extensive, often ongoing, supports. These very vulnerable children and youth often return through various parts of the system multiple times across their development. Despite repeated contacts across systems, they are rarely enabled to be successful in school, in the community, or at home. In order to better understand how to change this situation, in San Francisco we asked families about their experiences with these systems and how we could provide more useful care.
Families reported that people from various systems often viewed them with suspicion, treated them as if they were the problem and not the solution, provided limited and frequently unhelpful supports, and worked towards goals which were at odds with both personnel from other systems and the family. These experiences made it difficult for families to trust providers. Even when providers did genuinely connect with families, the specific interventions which they used to meet common goals were often too lengthy, inappropriate for their situation, or simply ineffective.
Families made clear that they need and deserve coordinated, strengths-based, family-directed and youth-guided effective care. The federal Center for Mental Health Services has made it their policy that behavioral health providers work from this perspective. Yet the experience of families is that such care is quite rare. Achieving families' goals requires that each step in treatment is coordinated across providers from each systems, transparent, evidence-based, and the result of a collaborative decision which builds on families' and clinicians' expertise.
When we looked carefully at our services for multi-system involved families, we realized that we could provide much more effective care for children and youth. We have embarked on a multi-year effort to transform these services from being fragmented and ineffective to being rational, coordinated, and effective. Key examples of these efforts are described below.
Foster Care
In the fall of 2007, administrators from the San Francisco Human Service Agency (the agency in charge of foster care placements) met with the director of the San Francisco's public children's mental health system. The message of the meeting was clear: children in youth in foster care were waiting too long for behavioral health assessment and treatment. When assessments were completed they were full of technical jargon, and did not clearly justify the types of behavioral health services recommended for the child or youth. Furthermore, the treatment services children and youth received did not appear to be effective. These conditions had to change. In late 2007, two staff were reassigned to work exclusively on improving the timeliness of assessment and access to care for this population. These staff were co-located within the foster care agency, and began a pilot of the Child and Adolescent Needs and Strengths tool. This system intervention has resulted in more children and youth in foster care receiving treatment for behavioral health needs
The use of a CANS-based level of care algorithm has resulted in clearer inter-departmental communication regarding treatment placements. The desire to insure that children receiving intensive supports are being treated effectively has also led to the development and use of a decision-support tool. This tool helps cross-system partners have a structured discussion of the types of supports in place and needed for a particular child or youth to be successful
Juvenile Justice
In the Juvenile Justice system, the CANS has been implemented as part of a two-stage needs identification process. First, youth are screened using a short version of the CANS. Next, youth whose screen indicates a need for more intensive services are given a comprehensive assessment. Based on that assessment, treatment recommendations are made. These recommendations are written up in a brief, concise report which is provided to the Probation Officer and used by the presiding judge to determine case disposition and appropriate supports. The program has been successful in identifying high-need youth and linking them to appropriate and effective services, including Multi-Systemic Therapy (MST).
Child Crisis
The use of a short version of the CANS (the Crisis Assessment Tool, or CAT) at the mobile Crisis service grew out of a need for transparency and consistency in hospitalization decision-making. In 2008 Crisis staff were trained on the use of the CAT. Over the course of the next year Crisis decision-making was tracked to understand whether appropriate decisions were being made regarding hospitalization. The findings highlight that the staff are using the CAT to make clinically appropriate hospitalization decisions. Areas of additional clinical inquiry and opportunities for better understanding the rationale behind hspitalization decision-making are also discussed. A summary of the results can be found here.


In San Francisco, school truancy was recently spotlighted as an area of concern. Because the CANS includes a School Attendance item in the Life Domain Functioning section, we could easily and rapidly create a fact sheet to describe the scope of School Truancy concerns among public behavioral-health involved children and youth, and frame policy discussions about what to do to address this concern. Further analysis of the data indicated that we have an especially high concentration of youth with School Attendance problems who are served by one of our intensive case management programs. Reducing School Attendance problems among these youth has been identified as a core Quality Improvement project for this program.

CANS and Primary Care
San Francisco's Department of Public Health is committed to providing a medical home to all residents meeting program income requirements. The medical home model is being implemented in an effort to coordinate physical and behavioral health care, and improve access to timely and appropriate care. One example of the medical home model's approach to addressing specialized need is the use of the behaviorist. The behaviorist is a trained psychiatric professional dedicated to working in the medical office to provide brief assessment ad treatment of child and adult mental health concerns. The behaviorist treatment model is based on immediate, brief care (usually beginning with a hand-off from the physician, and lasting less than 5 sessions). There are several aspects of this model which require building appropriate local procedures and making sure those procedures are being followed via sustained training efforts. One aspect of the effort requiring clarification was the criteria for referral. The behaviorist may need to refer child and youth with more intensive needs for longer-term treatment in the community. Additionally, community practitioners need to triage clients and refer clients with less severe needs to the behaviorist. A brief version of the CANS has been developed for this task. Criteria for referral were developed to facilitate transparency in decision-making.

Summary: CANS and System of Care Development

Throughout numerous efforts with diverse clients and system stakeholders, the CANS has been implemented as a tool to improve communication across stakeholders, increase access to appropriate services, and improve care. These efforts have taken time and attention, and each has experienced its own implementation challenges. Despite these challenges, the investment in these efforts has consistently reaped dividends in increasing system transparency and helping achieve the behavioral health and wellness goals desired by families. We look forward to ongoing efforts to continue system improvement empower families and youth to direct the system of care to be increasingly efficient and effective in helping children and youth experience full, healthy lives in the community.