Transforming Together-Building an Integrated System of Supp…

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Transforming Together Building an Integrated System of Supports

Transforming Together: Implementation Guide

Contents Building an Integrated System of

Closing.................................................. 44 What success looks like: A new Ecosystem of Care is emerging....................................44 Using Data and Community Engagement to Assess Needs and Gaps, Identify Priorities, and Measure Progress..........46 Introduction........................................... 46 The What..............................................46 The How...............................................46 Key Component: Co-Created Outcomes.....48 Stronger measurement of impact across systems................................................ 51 Tapping Parent and Youth Perspectives Creatively and Comprehensively...............53 Key Component: Well-Chosen Measures of Progress...........................................54 Key Component: Authentic Community and Family Participation.......................55 County Spotlight....................................58 The Case for Compensating Parents..........59 Recap: Strategies for Using a Community Needs Assessment to Inform Shared Outcomes and Measures.......................60 Using changes in systems, practices and data use to achieve better outcomes for families and youth................................62 What success looks like: Family and youth are co-designers of a new ecosystem of care. ..................................................... 64 Endnotes............................................... 67

Supports................................................. 1 Introduction. .......................................... 4 Why Integration Matters.........................4 About this Guide.....................................5 Why Change?...........................................7 The Case for Change.................................7 Moving from Siloed to Strategic..................8 California Policy Momentum.......................9 Fresno County: Building Access Through Trust and Integration......................................11 Resources for Implementation..............12 Supporting Systems Change—What this Guide Provides.......................................12 Four Chapters .......................................12 The Opportunity.....................................12 Neuroscience and Practice Inform a Whole- Child Definition . ..................................... 13 Research on Working Together for Whole- Child Success........................................15 Collective Impact....................................15 System of Care......................................16 Appendix: Outputs & Outcomes Framework. .......................................... 17 Establishing a Countywide Ecosystem of Care .....................................................20 Introduction........................................... 20 The What..............................................22 Key Components of an Ecosystem of Care Leadership Structure ..............................22 The How...............................................23 Engage in Existing Cross-Agency Efforts....23 From Host Agency to Shared Ownership....25 Create a Shared Vision and Clarify Roles....25 Moving Beyond Managing an Initiative to Leading Full Systems-Change...................28 Strategies for Building Cross-Agency Leadership and Collaboration ..................28 Building the Blueprint: How One County Mapped its Cross-Agency Meetings...........30

Chapter 2 Using Data and Community Engagement to Assess Needs and Gaps, Identify Priorities and Measure Progress

Transforming Together: Implementation Guide

Using Data and Community Engagement to Assess Needs and Gaps, Identify Priorities, and Measure Progress Introduction Chapter 1 describes how county leaders–when they set a new vision and commit to creating a new ecosystem of care–build structures to facilitate their cross-agency coordination and decision-making. Setting a shared vision for delivering child and family services differently is just the beginning. For a vision to lead to change, it must be coupled with a clear articulation of priorities and with concrete goals to measure progress. In addition, implementation is more successful when communities being served help co-create these priorities and goals–thus helping to ensure any new system reflects what is most needed. The What While most government leaders routinely consult with community members, set goals, measure impact, and use data and information to inform improvements and establish accountability within their own agencies, doing so as part of a cross-agency structure– and doing so in ways that ask community members to be co-designers and close partners–is inherently more challenging and complicated. Today, many government-sponsored child, youth, and family services in California use a variety of approaches to try and identify community and population needs, including even using nearly identical community assessments. The result: The efforts of

many agencies to identify community needs are often redundant and inefficient; indeed, families and youth often are asked to share and re-share the same information and background with each new agency from which they seek support. The How Shared Data Inventory Creating a new ecosystem of care, and working to better coordinate county services and collaborate across different county agencies and systems, is an opportunity to do better. One first step for county leaders is to take stock of the “macrodata” they can access from across all agency partners. Macrodata is information about service utilization, service or population gaps, trends, overall outcomes, etc. With macrodata from multiple agencies, leaders can ask: • What data do various state, county and education agencies already collect about our target populations? • Looking across all these data comprehensively, what do they suggest about needs and gaps? In particular, by looking at data from different agencies about the same populations or measuring similar outcomes at the same time, do any patterns or new insights emerge? • What do non-government partners–and the children, youth, and families they engage with and serve–identify as the biggest challenges in their communities? • How can all collaborating partners best measure, assess, monitor, and account for meeting these priorities? Integration of Both Qualitative and Quantitative Data In addition, consideration should be taken to incorporate both qualitative and quantitative

Transforming Together: Implementation Guide

Community Voice is Essential Another key first step to setting priorities and goals is committing to examine agency- collected data, discuss implications and possible priorities, and find solutions in collaboration with community members. In particular, county leaders should invite to the table those who have been harmed in the past by prior efforts or requirements, in order to minimize new harm going forward. Data can help guide this process—when reviewed collectively across systems, it can reveal patterns of inequity, surface systemic barriers, and illuminate where policies or practices may have caused or perpetuated harm. By leveraging shared data responsibly, counties can strengthen trust and ensure that future decisions are grounded in transparency and accountability (see here). County leaders can invite more authentic involvement in these ways 10 : 1. Invite and support historically underserved communities to identify actions necessary to create an ecosystem that earns trust (and recognizes any mistakes and harmful programs, policies, or practices). 2. Seek out accessible forums (traditional and non-traditional) and safe spaces that foster the conditions that allow for authentic community feedback to occur. 3. Commit to co-create shared goals that can become transparent metrics for success, tracked through a local dashboard that is accessible and understandable to all.

data in identifying community needs and shared outcomes. This can be in the form of interviews, focus groups, listening sessions, etc. Tool Spotlight: The Summary of Interviews (ESC Toolkit) captures insights from partner agencies and community members, offering counties a structured method to compare stakeholder perspectives with quantitative data. Tool Spotlight: The CYBHI County Case Studies provide detailed examples of how local leadership teams are advancing system-of-care integration through shared governance, data alignment, and cross- sector collaboration across nine California counties. From a data perspective, each case offers quantitative insights about a given county’s demographics, behavioral health outcomes, and resources compared to statewide averages. Each report also describes the working relationship of county agencies with one another through quantitative and qualitative means. With detailed references for each data source, these reports offer practical replicable models of shared dashboards and metrics for consideration. Making the most of system macrodata sometimes requires input from advisors with experience in system design, data strategy, and technology. These experts can help county leaders and agency staff navigate the inevitable challenges that come from aligning efforts and synthesizing data. Tool Spotlight: The Existing Needs Assessment Tools and Data Resources (ESC Toolkit) provides counties with a catalog of common data sources and assessments already in use, reducing duplication and helping leadership teams leverage what’s available before commissioning new studies.

Transforming Together: Implementation Guide

Key Component: Co-Created Outcomes Engaging those with lived experience and other community interest-holders is already an expectation for California agencies serving children, youth and families. However, in practice, these processes are often carried out inconsistently or without the structures needed to enable agency partners to authentically and comprehensively involve community members and seek input and advice on needs. Public agencies often struggle to build consistent, meaningful relationships with historically underserved communities—and also to involve these communities in any shared, authentic decision-making. 11 Reasons include: • Historical mistrust and harm: Many communities—particularly Black, Indigenous, and other communities of color—have experienced decades of systemic exclusion, surveillance, and harm at the hands of public institutions. This legacy of inequity and broken promises fosters deep mistrust, making it difficult for agencies to engage residents who have little reason to believe their voices will be heard or valued. • One-sided engagement practices : Agencies often rely on transactional or tokenistic outreach methods, such as town halls or surveys, that solicit input without redistributing decision-making power. These methods may check a box but don’t reflect the kind of relationship-building or shared governance that communities seek. Without clear roles, follow-through, or accountability, community members may feel their participation is performative or inconsequential.

Using “macrodata” to learn and set priorities: Essential… and legal Personally identifiable data are sometimes referred to as “microdata.” These include individual student assessment results, youth case plans, and other records tied to specific children, youth, or families. Aggregated and de-identified information—or “macrodata”—is often built from microdata but used at the system level. County leaders rely on this type of information to understand community needs, evaluate services, guide investments, and meet state and federal reporting requirements. One of the biggest barriers to local government agencies sharing data with each other has been a widespread perception that most data are too sensitive to share, even when it has been stripped of personal identifiers and is being used for big-picture planning. These concerns have led to delays, missed opportunities, and the repeated creation of new processes to solve the same problem: How can we use data to improve outcomes across systems? County and agency leaders should recognize that most de-identified data can be shared without issue. In fact, much of these data are already available through public reports and state-required submissions. Indeed, in many cases, formal data-sharing agreements between agencies may not even be necessary, and they should never become a barrier to moving forward with timely, coordinated improvements.

Transforming Together: Implementation Guide

• Structural and cultural barriers : Engagement efforts are frequently designed around agency convenience rather than community access. Meetings are scheduled during working hours, materials are only in English, and expectations for participation often ignore real constraints such as transportation, child care, or digital access. In addition, agencies may lack staff who reflect the communities they serve, limiting cultural competence and trust. • Limited internal capacity and skills : Public agencies are rarely structured or resourced to support deep, sustained community engagement. Staff may lack training in participatory practices or may not have the time, tools, or authority to meaningfully involve families and community leaders in planning and decision- making. Engagement is often siloed rather than integrated into the agency’s core functions. • Power imbalances remain unaddressed : Even when agencies invite communities to the table, they may fail to examine or shift the underlying power dynamics. Authentic shared decision-making requires not just inviting input, but actively sharing authority, ceding control, and valuing lived experience alongside professional expertise. Without intentional power-sharing, engagement efforts can reinforce rather than repair inequities.

Tool Spotlight: The Examples of Community Need, Mission Statements & Evidence (ESC Toolkit) shows how other communities have elevated lived experience into formal mission statements, offering models counties can adapt to codify power distribution meaningfully. When counties center community voices— especially from historically underserved groups—in their needs assessment and priority-setting processes, they gain clearer goals, more durable support, and stronger results. Outcomes that are shaped and informed by community input can lead to: 1 Stronger measurement of impact across systems Many agencies in California track similar outcomes—such as school readiness, family stability, and youth well-being—but they do so in isolation and with different approaches. When agencies come together to compare and align their data, they can better understand how their efforts overlap, reinforce one another, and contribute to shared efforts. For example, in one county data from different agencies illuminated the finding that children at risk of entering the foster care system were more successful when enrolled in alternative, community pathways, such as those funded under the Family First Prevention Services Act (fewer children entering foster care is the goal of FFPSA); county leaders hypothesized these pathways programs, which provide support services before families and children before kindergarten, are effective at helping children become ”school-ready” and more successful learners–and they chose to expand investments in similar community programs.

Transforming Together: Implementation Guide

Tool Spotlight: The Examples of Community Need, Goals, and Metrics (ESC Toolkit) provides concrete outcome frameworks counties can use to align measures across systems and reduce duplication. Similarly, in comparing and analyzing data from multiple systems and agencies, a different California county’s Interagency Leadership Team learned schools offering intensive mental health services had significantly fewer students who entered or re- entered the foster care system. Cross-agency data have also shown that young children whose families received help through a community school program were less likely to enter the child welfare system. These insights only became clear when partners took time to compare their data and outcomes across agencies. In some cases, state requirements already expect agencies to compare their outcome data with other agencies. These existing processes can be creatively expanded. Some opportunities include: • The Mental Health Plan’s External Quality Review (EQRO) process requires participation from multiple systems, including child welfare and juvenile justice. When done well, it includes youth and parent input and reveals how investments in one area (such as mental health) affect others (such as child welfare).

• Similarly, the Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP) processes encourage departments to align timelines, questions, and findings—giving a fuller picture of what communities need (see here). These processes now connect closely with the MCP Population Needs Assessment (PNA) and related state efforts to integrate CHA, CHIP, and PNA findings into a unified BHSA Integrated Plan framework, ensuring that local priorities and statewide planning are informed by consistent, population- level data (see DHCS Population Health Management Strategy). • California now has a unique opportunity, within its Behavioral Health Services Act (BHSA) Integrated Plan requirements, to establish an ecosystem wide reporting process that parallels local design objectives. While the reporting obligation for this data is the responsibility of the county BHS or MHP, the outcome measures included span a broad spectrum of partner objectives. The Behavioral Health Outcomes, Accountability, and Transparency Reports (BHOATR), could essentially serve as a universal outcomes frame for any county.

Transforming Together: Implementation Guide

Example

Stronger measurement of impact across systems Sacramento County: Building a Shared Data Dashboard

In parallel, Sacramento’s Public Health GIS Suicide Prevention Dashboard (see here) provides a powerful, complementary example of data integration. Developed with stakeholder input and grounded in public health, the GIS dashboard visualizes suicide trends and risk factors geographically, allowing agencies and community partners to align prevention efforts in real time. Together, these initiatives illustrate how shared data infrastructure can strengthen cross-system accountability and accelerate learning across the county’s ecosystem of care. Community-based organizations also can play a key role in contributing their insights— they often have trusted relationships, local data, and insights that public systems can learn from.

Sacramento County has made data the cornerstone of its system-of-care

transformation. Starting with its AB 2083 Interagency Leadership Team (ILT), county leaders committed to prevention and early intervention and to holding themselves collectively accountable. As of summer 2025, they are in the final stages of developing a cross-agency performance dashboard that links outcomes and program measures across child welfare, behavioral health, probation, Regional Centers, education, public health, and other system-of-care partners. Data experts and the county’s Child, Youth and Family System of Care Advisory Team have worked together to identify measures that not only reflect each agency’s work but also reveal how their efforts connect. Semi-annual reports to the ILT help leaders highlight trends, adjust practice, and allow partners to make decisions together. The dashboard intentionally informs both policy and frontline action.

Transforming Together: Implementation Guide

2 Increased political credibility and support When agencies work together and show how their programs contribute to shared outcomes–and can achieve a better “return on investment” than prior, siloed efforts–they gain credibility with boards, commissions, and elected officials. For example, a health services department leader who can say, “Our investment not only helped us meet our goals, but also improved school outcomes and reduced foster care entries,” sends a powerful message about impact and efficiency. Boards are more likely to support funding when they see coordination and shared success across agencies. 3 Stronger positioning for grants and external funding Funders—both public and private—want to invest in efforts that show collaboration, impact, and clear return on investment. When counties can tell a unified story, backed by shared data and outcomes, they become stronger candidates for funding. 4 Less duplication and administrative burden Some agencies have robust means and capacity for tracking outcomes and improving services; others have more limited staff and systems. By aligning outcomes and creating joint dashboards or data reports across all agencies, counties can reduce duplicated work (refer to Sacramento County vignette in Chapter 1), identify gaps, and better support agencies with fewer resources. This approach helps everyone spend more time improving services and less time on paperwork.

5 Clearer, more consistent communication with the community

When partners agree on key metrics they are tracking and why, their messages to the public become clearer and more trustworthy. Communities, elected officials, and local stakeholders are more likely to engage when they hear consistent, coherent, and transparent updates about outcomes. 6 More meaningful engagement with youth and families It is not easy for government agencies to involve youth, parents, and caregivers in government planning efforts. However, by looking for creative avenues and working hard to craft shared outcomes, the county’s ILT can cultivate deeper and more authentic engagement. When community members help shape how success is defined, the work becomes more relevant and accountable. Listening to lived experience—and incorporating that knowledge into decision- making—is a powerful way to correct past harms and create a new approach to service delivery that better meets families’ needs. Getting Started A county’s Interagency Leadership Team members should convene staff from across all children, youth and family-serving agencies and ask: • Which data does each agency collect about the populations it serves and the efficacy of services? • Do any of the data sources or collection efforts overlap? • How could the county use these data together to improve services and outcomes?

Transforming Together: Implementation Guide

Tapping Parent and Youth Perspectives Creatively and Comprehensively

One rural school district in California shows what is possible when leaders think creatively and comprehensively about learning from and getting advice from parents, youth and community members. With community partners, the district deliberately organized and aligned various surveys and feedback sessions to happen within the same springtime period, so results from these data sources could be readily compared side-by-side and inform decision- making. Feedback sources coordinated by the district included a special telephone survey of district families, school-based focus groups with students and with parents, and the California Healthy Kids Survey (administered to students aged 10 and older). One helpful finding from all these data: School leaders learned families deeply appreciated the district’s family connection center (the center was created to be a single, centralized hub where district families can easily find and access a range of supports, information, and services). According to the surveys and focus groups, parents praised the warm, respectful atmosphere at center, including simple gestures by staff at the center such as being greeted by name or feeling heard. At the same time, by being able to consider all these data side-by-side, leaders also saw clear themes where the district could do better or consider different approaches. These challenges included:

belonging. • Discipline practices perceived as unfair. Across all groups, there were strong concerns about inconsistent enforcement of rules, especially for students with staff or athletic ties–which they said undermined both trust and school climate. Students and parents called for clear, consistent, and equitable consequences. • Some engagements hampered by lack of relationships. Parents said they are more likely to engage—and students more likely to thrive—when they feel known and supported. Personalized outreach (e.g., positive calls home, teacher invitations to events) and teacher behaviors that show care were repeatedly cited as motivators for participation and academic effort. • Barriers to participation need structural solutions . Time, child care, and transportation remain major barriers to parent involvement. Suggestions included increasing advance notice for events, improving clarity about event content, and expanding access to family transportation or online engagement options. • Students concerned about safety and supervision. Many students reported bullying, fights, and widespread vaping— especially in unsupervised areas like bathrooms. They called for improved adult monitoring, better vape detection, and clearer consequences to reduce unsafe behaviors. • More emotional and academic support needed . Students expressed a clear desire for anger management tools, supportive adult spaces, and help catching up academically when they fall behind. They want support that is proactive, not punitive, and tailored to their emotional and learning needs.

• Inconsistent communication undermined trust. Both parents and students emphasized the need for more reliable, timely, and two- way communication. Parents want

regular check-ins and mandatory spring conferences, while students value everyday gestures—like being greeted or checked in on—which strengthen their sense of

Transforming Together: Implementation Guide

Collective impact: Examining data from multiple agencies contributes to better and more coordinated efforts

Key Component: Well- Chosen Measures of Progress When government, community, caregivers, and those who use health and education services work together to identify shared outcomes and metrics, actual needs can become better reflected in the priorities of the new ecosystem of care. In addition, community voices can point out when certain aspects or elements of what is measured have little actual meaning to those being served. For example, data such as utilization metrics or service penetration data don’t inform the actual effectiveness of a service and are of minimal use in discussions with most audiences. The starting point for identifying shared outcomes and measures should be a common vision that describes the change and impact desired in the community.³ In articulating a common vision, most counties can start with their Memorandum of Agreement established under AB 2083 for the foster

care system , which outlines cross-agency collaboration and shared accountability. Nearly all of these MOUs contain a high-level aspirational purpose amidst their provisions. Counties can also draw from emerging guidance under the Behavioral Health Services Act (BHSA), which provides a statewide framework of goals, quality metrics, and equity standards for behavioral health transformation ( see here ). Individual agency mission statements can also be sources from which to build a uniform statement of intent for the entire ecosystem of care. Broadly, AB2083 MOUs–and the overall goals of California’s System of Care approach–are to “keep children and youth at home, in school, and out of youth justice involvement.” Healthy development, opportunities to learn and thrive, and ultimately the well-being of young people, are the shared objective of every ecosystem partnership. Next, partners can use their shared vision to identify and recognize which goals and outcomes will support their desired reality for family and youth wellbeing. For example, a

Transforming Together: Implementation Guide

• Cultural and identity development: Increased offerings for and participation in culturally-specific programming and networks; increased number of programs that advance or address issues of racial equity and justice. • Crime prevention and juvenile justice reform: Reduced involvement in the juvenile justice system; increased participation in restorative justice programs; reduced juvenile justice referrals from education, foster care, and other systems. Finally, because health, human services, and education agencies in California already conduct various forms of needs determination, county leaders need to understand what efforts already take place and how communities respond–before setting out to design any added engagement efforts. Key Component: Authentic Community and Family Participation Engaging families and youth in decision- making is supported by decades of research; it is foundational to building strong, responsive systems of care. At the same time, agencies may fall short— and risk appearing disingenuous—when they “engage” community and family voices, particularly those who have been marginalized, without providing the support needed to participate meaningfully in these often complicated processes and without compensating them for time taken away from work or other commitments.

vision of “keeping children and youth at home” could be measured by permanency or entry into the child welfare system, or by students in school who are homeless or placed out of home due to special education needs. Partners can decide which of these measures–or both, or others–best reflect the change they hope to see (and the data they have ready access to). Remembering that local systems already assess many things, the what to measure could include: • Mental health and emotional wellbeing:

Reduced rates of youth mental health challenges, including suicidality and

externalizing behaviors; increased access to mental health resources; increased positive coping skills. • Education and academic success: Improved academic performance; increased graduation rates; increased enrollment in college and career programs; reduction in school absenteeism. • Physical health and safety: Reduced rates of substance use and abuse; increased physical activity and access to recreational programs; safe and clean environments. • Youth engagement: Increased youth involvement in community decision-making; volunteerism. • Social connectedness and support networks: Stronger peer relationships; stronger positive social interactions; increased mentorship; increased family engagement. • Economic opportunity and workforce opportunities: Increased access to and/or completion of financial literacy education;

increased access to and participation in internship opportunities; increased employment rates.

Transforming Together: Implementation Guide

Family Engagement Continuum Enhancements • How does this continuum accommodate collective, Indigenous, or other cultural approaches to decision-making? • How do communities hold systems accountable when they don’t progress along the continuum?

Then, once recruited to participate, community members become better positioned to actively and constructively contribute when agency staff work to communicate clearly, invite frequent questions, and avoid use of acronyms or other “insider” phrases, among other strategies. Conceptualized and refined by the federal Substance Abuse and Mental Health Services Administration (SAMSA), the International Association for Public Participation (IAP2) and many others, the Family Engagement Continuum offers a practical framework for government leaders to understand options for and strengthen involvement. The continuum outlines five progressive levels: Awareness, Consultation, Collaboration, Shared leadership, and Family-driven systems. Across these five levels, the role of the family in “engagement” activities evolves from receiving information (at one end of the continuum) to holding decision-making authority (at the other end of the continuum). This progression mirrors key ideas from Christine Ortiz Guzman’s work in equityXdesign, which emphasizes that process matters as much as outcomes, and that power should be intentionally shifted toward those most impacted by a system. In both the Family Engagement and in Ortiz Guzman’s conceptions, the goal is not simply to “engage” families, but to create conditions in which they are recognized as leaders, co-designers, and essential stewards of change. For government leaders and cross-agency teams like the Integrated Leadership Team, these frameworks offer a roadmap for building trust, sharing power, and designing systems that reflect the knowledge and priorities of the communities they serve.

• What happens when systems cause additional harm during engagement processes?

Realistic Engagement Expectations: Some community members want to be involved in systems-level decision making; however, most people simply want to live their lives, care for their children, and want to be able to rely on systems to operate in a user-friendly manner that allows them to have the most control possible over their life circumstances. Systems must work effectively for all community members regardless of their engagement preference. The five levels of the Family Engagement Continuum include: 1 Awareness & Information Sharing (Passive Engagement) • Concept: Families are informed about services, policies, and opportunities but are not actively involved in shaping them. • Goal: Ensure families are aware of their rights, resources, and system functions. • Examples: Websites, brochures, newsletters, automated calls, and social media updates.

Transforming Together: Implementation Guide

2 Consultation & Input (Advisory Role)

5 Family-Driven Systems (Transformational Engagement) • Concept: Families lead the design, implementation, and evaluation of services and policies, with systems accountable to them. • Goal: Shift power dynamics so that families drive decision-making at all levels. • Examples: Family-run organizations, parent-led training for providers, youth-led advocacy coalitions, or family-directed care models.

• Concept: Families are asked for feedback to improve services and policies, but do not have direct influence over decisions. • Goal: Gather lived experience to inform planning and enhance program relevance. • Examples: Surveys, town halls, listening sessions, focus groups, and parent/youth advisory councils. 3 Partnership & Collaboration (Active Engagement) • Concept: Families work alongside professionals in planning, implementation, and decision-making. • Goal: Ensure family perspectives shape how services are designed and delivered. • Examples: Family representatives on planning committees, participation in case planning meetings, co-design of programs or supports. 4 Shared Leadership & Decision- Making (Empowered Involvement) • Concept: Families take on formal leadership roles within governance, policy development, and system oversight. • Goal: Embed family voice within institutional decision-making structures. • Examples: Family members as voting board members, peer navigators, co-chairs of committees, or parent/youth co-facilitators.

Transforming Together: Implementation Guide

County Spotlight When the Santa Clara County Office of Education launched Student Wellness Advisory Groups (SWAG), the goal was clear: center youth voice in shaping wellness supports. Rather than designing services for students, county leaders created space for young people to lead. Starting with just six students, SWAG members were trained in civic engagement and supported by adult allies to form their own subcommittees. They advised on wellness center design—literally rearranging spaces into welcoming circles— and organized campaigns like “Hecka- Well Day,” which grew into a countywide wellness week. Over time, SWAG scaled from a small advisory to a movement, with over 100 wellness centers influenced by student input. Structures for continuity, such as including middle schoolers and creating “shadow” roles, helped sustain youth leadership as students graduated. Families were also engaged, building advocacy skills alongside their children. By treating youth as partners—equipping them with resources, leadership opportunities, and a seat at interagency tables—SWAG not only reshaped local services but also modeled how student voice can drive systemic change.

Tool Spotlight: The Examples of Integrated Systems Activities (ESC Toolkit) provides practical illustrations of how counties have operationalized family partnership at each level of the continuum, offering examples to adapt locally. California’s children and youth System of Care approach under AB 2083 adapts this Family Engagement Continuum to institutionalize family and youth participation across governance and planning structures. The California Health and Human Services Agency asks counties to ensure families, peer supporters, tribal representatives, and youth are engaged at all levels—shaping policies, coordinating services, and deciding on outcomes. Even in systems that have struggled to meaningfully include community perspectives in shared governance or ILT structures, other avenues for engagement remain available. These include inviting participation in partner-led or community- informed processes, such as local mental health, alcohol and drug boards; school boards; and other commissions. In addition, many counties have established youth commissions, and in some existing AB 2083 Systems of Care structures, youth participants serve as active members of Executive Advisory Committees or attend ILT meetings. These pathways offer additional opportunities to center the voices of those with lived experience and ensure that family and youth leadership becomes a core feature of an integrated system of care. Importantly, sustained engagement is only possible when all participants understand the purposes and process for how they can contribute.

Transforming Together: Implementation Guide

The Case for Compensating Parents

In recent years, there has been a growing shift toward compensating parents who participate in government-sponsored advisory committees—not just as a gesture of goodwill, but as a matter of equity and effectiveness. While many agencies have long acknowledged the importance of parent perspectives in shaping public systems, the practice of unpaid participation often has placed undue burden on families, especially those with limited income or inflexible work schedules. While local jurisdictions may have resource constraints, particularly in a challenging funding and budgetary landscape, compensation can help remove barriers that families face and support more consistent, representative, and meaningful engagement. At the same time, agencies operate within a constrained fiscal environment, often balancing rising service demands, workforce shortages, and competing program priorities. Acknowledging these realities underscores the need for sustainable, equity-driven funding strategies, those that make it possible to compensate families fairly while maintaining program viability and long-term impact. Paying parents acknowledges the real cost of participation—whether it’s taking time off work, arranging child care, or navigating transportation. Without compensation, these costs can exclude the very families whose perspectives are most critical to informing equitable policies and services. In contrast, offering payment levels the playing field, allowing families from a broader range of backgrounds to take part and stay involved over time.

Compensation also strengthens the quality and sustainability of parent participation— when parents are compensated for their time and expertise, they are better able to prepare, contribute actively, and remain engaged over time (see here). This in turn develops deeper relationships, more informed feedback loops, and ultimately more responsive decision-making by agencies. Moreover, valuing parent expertise alongside professional or technical expertise helps shift power dynamics in a way that builds trust and shared accountability (see here). This evolving practice reflects a broader movement toward more inclusive and equitable public systems—where families are not only heard, but supported as equal partners in shaping the policies that affect their lives. Some helpful resources county leaders can use to make the case for compensation of parent involvement and to determine when, how and how much to compensate include: • Engaging Community Members: A Guide to Equitable Compensation (prepared by the

Center for Health Care Strategies) • Parent Compensation Tools website

(prepared by the National Health Council) • Evaluating Incentive Strategies on Parental Engagement (prepared by the National Library of Medicine)

Transforming Together: Implementation Guide

Recap: Strategies for Using a Community Needs Assessment to Inform Shared Outcomes and Measures This section summarizes key strategies discussed throughout this chapter, offering a concise reference for how counties can translate community needs assessments into shared outcomes and measurable goals. Identifying needs authentically and transparently is not a “one and done” endeavor, but requires a “return and report” mindset for agency leaders committed to accountability and continuous improvement. Key actions for county leaders–as they work to establish a new ecosystem of care–include: 1 Establish a coordinated needs assessment process to inform cross-agency goals: • Identify existing agency-led needs assessments already being used across education, health, child welfare, juvenile justice, and social services. • Reduce redundancy by mapping overlapping efforts and integrating findings into a unified assessment process. i. Tool Spotlight: The Chart of Child & Family Serving Agencies (ESC Tool- kit) can help counties map which agen- cies already collect similar data, clarify- ing redundancies and enabling a more unified approach to needs assessments.

2 Commit to more authentic

community engagement and accountability in goal-setting:

• Ask and consult with historically underserved communities and individuals with lived experience to help determine county goals, service design, and delivery priorities, as well as which data should be prioritized. • Employ new approaches that authentically engage, listen to, and build trust with historically marginalized communities and that acknowledge and address any past systemic harms. • Systems aim to adapt engagement processes to honor community communication styles and decision-making approaches. Agency staff receive ongoing training on how to participate respectfully in community-led conversations and gatherings. 3 Identify specific goals and measurable outcomes to guide cross-agency priorities: • Adopt or build on visions and goals already established in the BHSA Integrated Plan framework, county’s AB 2083 MOU, or by the county’s Integrated Leadership Team. Note, many California county efforts have stated their goal for System of Care improvements is “keeping children and youth at home, in school, and out of youth justice involvement”; this aim might serve as an appropriate starting place for creating goals for a new ecosystem of care designed to serve all families and youth. • Leverage (as noted above) the findings from existing community-needs assessment processes to inform the development and refinement of new cross-agency goals.

Transforming Together: Implementation Guide

• Incorporate (as noted above) priorities identified by communities and populations served about what to prioritize, what gaps to fill and how government-sponsored programs can better interact with their client populations. • Ensure the Integrated Leadership Team (ILT) and Executive Advisory Committee (EAC) review and update shared goals annually. 4 Use shared data to improve services and advocacy: • Strengthen cross-agency data-sharing agreements (which can be done even while ensuring compliance with federal privacy laws such as HIPAA for healthcare operations and FERPA for student privacy) to ensure county leaders can access and use the full range of data collected by various agencies. • Integrate findings from mental health evaluations, child welfare assessments, and school performance metrics to create a holistic understanding of child and family needs and outcomes over time (see here for a state-level example). • Identify areas–across agencies–where redundant data collection and tracking can be eliminated or at least reduced. • Develop a shared dashboard to track progress across agencies (several California counties provide existing examples and ideas for establishing dashboards). • Establish protocols for using data to effectively monitor the system over time. • Use shared metrics to help demonstrate return on investment in interagency initiatives and to secure additional funding from local and state sources.

Transforming Together: Implementation Guide

Using changes in systems, practices and data use to achieve better outcomes for families and youth

In the above guide, ‘tiers’ refer to levels of support intensity within a coordinated system—typically organized as universal (Tier 1), targeted (Tier 2), and intensive (Tier 3) services—to ensure that children, youth, and families receive the right level of help at the right time. Even by following the suggested strategies in the previous chart, obstacles and setbacks will be inevitable. County leaders can confront these challenges by re-examining existing processes and asking whether other parts (or agencies) within the

ecosystem might suggest alternative solutions or approaches. For example, as part of the Comprehensive Prevention Plans required by the Child Welfare system’s Family First Prevention Services Plan, some counties have been able to incorporate focus groups research by collaborating with their First Five Commission, which also sponsors focus group research (targeting many of the same types of parents and community members) as part of its strategic planning process. Many forms of data, even when not perfect, are stable enough to serve as reliable proxies

Transforming Together: Implementation Guide

for decision-making and can be used to reasonably inform partner processes and collective decisions. For example, county- level school attendance and absenteeism data, while not capturing every nuance, can highlight meaningful trends that guide early interventions. Technology can further support this work by streamlining data sharing and creating common dashboards across agencies. For instance, integrated data platforms can allow behavioral health, education, and social services to input information into a shared system, reducing duplication and enabling real-time monitoring of student outcomes. Such tools not only improve alignment of efforts and input but also help agencies act more quickly and cohesively on shared priorities. Most counties find that the successful coordination of various agency assessment processes, audience and times requires some sort of ad hoc workgroup of quality improvement or system improvement analysts and other subject matter experts from different departments. When possible, youth and caregiver experience can be needed and powerful additions to this effort. The ILT can convene and charge this team. Once assembled, the group will need coaching and support to ensure their joint deliberations lead to a more cohesive and aligned needs determination–and to accomplish what the ILT intends.

Some principles and guidelines that can make this cross-agency team most successful include: • Use a functional inventory matrix or similar tool to crosswalk each agency’s existing processes. Note timelines, frequencies, and the content of each particular assessment. • Make time for the group to orient and educate one another to each department’s related processes. Do not expect that the similar use of terms always means the same thing to each agency. Common understanding and a shared vocabulary come from sharing in a detailed way what different indicators mean, how they are used, and where they fit in the larger determination of community need. • Review the team’s crosswalk to identify where processes or data collection can be streamlined or combined. Determine if any duplicate steps can be removed or if inquiries can be consolidated into a single, shared process. The goal is efficiency, not perfection; complete alignment may not always be possible given differing state and federal requirements • Engage state authorities to inform them that–driven by System of Care principles and in pursuit of better alignment and coordination–local departments will be conducting their needs determination in a broader and more concurrent manner. • Invite or require the ad hoc team to report regularly to the ILT, with status updates and requests for information, support, or clarity from the ILT or partners. • Document decisions and agreements into a shared policy, and reflect those agreements in the AB 2083 System of Care MOU.

Transforming Together: Implementation Guide

What success looks like: Family and youth are co-designers of a new ecosystem of care Momentum is growing in counties across California to center the voices, perspective and advice of youth and families in the design and delivery of new programs–and thus to create systems that are more effective and more responsive to community needs. In many counties, family members and young people now serve on collaborative leadership teams and offer their lived-experience insights to inform referral pathways, outreach strategies, and the kinds of supports being offered. For example, one county (see below) is using a community-driven partnership model to engage families, educators, and community partners in developing trauma-informed strategies and upstream interventions. The model convenes families as co-planners in setting goals, analyzing data, and shaping countywide priorities, ensuring that family voice guides both prevention and response efforts. Another county (see below) is creating family resource centers that serve as neighborhood hubs—co-designed with parents and community leaders to provide peer navigation, parenting supports, and trusted access points to public services in familiar, community-based settings.

Examples from the Field Counties across California are experimenting with locally grounded models of family and youth co-design. • Santa Clara County operates a countywide network of Family Resource Centers that serve as neighborhood hubs for parent leadership, peer navigation, and connection to public services. • Humboldt County established a Transition- Age Youth Collaboration within its Children’s System of Care, ensuring families and young people co-develop strategies for prevention and early intervention. • San Bernardino County has embedded family and youth voice directly into its Interagency Leadership Team (ILT) , pairing parents and young adults with agency leaders to inform policy, training, and cross- sector practice. Taking authentic engagement a further step, several California counties have been exploring ways of ensuring young people are part of the decision-making process shaping a new ecosystem of care. The counties are inviting youth to join ILT or EAC leadership teams, participate in advisory or specialty work groups, and contribute to planning and evaluation efforts with other system partners. For example, in one county, a school health steering committee recruited youth and family members from underserved communities to co-develop a behavioral health support system for schools. In another county, parents with lived experience are co-facilitating the System of Care’s Executive Advisory Committee’s monthly leadership meetings. Elsewhere, school-based mental health teams are engaging directly with students—using outreach, classroom education, and stigma- reduction strategies to incorporate youth voice into daily practice.

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