Special Issue Editor's Note Mental health service providers across the country are facing increasing pressure to demonstrate

the short- and long-term results of their work with children and families. Interest in accountability for outcomes in behavioral health systems has gained particular momentum, and identifying and tracking outcomes is an activity that is increasingly being used in service planning and delivery. Out- come activities range from efforts by state and local governments to develop performance-based contracts with providers to for-profit organizations using outcomes as a vehicle to increase effi- ciency and profitability. Although the excitement of this emphasis on outcomes brings many new possibilities to behavioral health organizations, it also brings many challenges. This special issue of The Journal of Behavioral Health Services & Research, titled System Accountability in Children's Mental Health, addresses various issues, approaches, and challenges inherent in building outcome accountability in child-serving systems.

This issue begins with a conceptual and practical framework for building and using outcome- oriented information that helps agencies respond flexibly to the needs of the children and families they serve. In "The Ecology of Outcomes: System Accountability in Children's Mental Health," Hernandez et al. 1 provide principles for establishing outcome accountability, discuss the prerequi- sites and building blocks for developing accountable systems, and offer recommendations for imple- menting an outcome information system and using its results.

Because outcomes are increasingly prominent in the expectations of funders of health services, the outcomes identified for measurement and tracking often reflect only the needs of policy makers and bureaucrats who oversee budgets. Input from other stakeholders such as parents, direct service workers, and other partners do not typically inform the process of outcome selection. An exception to this is Virginia's public sector effort, described in the article tiffed "A Multistakeholder-Driven Model for Developing an Outcome Management System" by Koch et al. 2 This article discusses a process for involving key stakeholders in developing assessment instruments and methodologies. Critical components of the process include the enlistment of stakeholders, the selection of outcome domains, the identification of assessment instruments to measure the domains, and implementation of a pilot project for evaluating the feasibility of the planned outcome initiative.

Another excellent example of engaging stakeholders in the design of an outcome-monitoring sys- tem is described in the article rifled "Multiagency Outcome Evaluation of Children's Services: A Case Study" by Beck et al. 3 This article presents the process as it developed in Pennsylvania through a private provider-initiated effort. Key lessons learned throughout the process included the initiation of the accountability approach, the primary design principles employed, the use of a social valida- tion process for selecting outcomes, and discussion of the methodological challenges encountered.

The next two articles provide case examples of the implementation of outcome accountability in children's mental health settings. In "Managing What You Measure: Creating Outcome-Driven Systems of Care for Youth With Serious Emotional Disturbances," Rosenblatt et al. 4 describe Cali- fornia's county-based approach to tracking outcomes. They illustrate how ongoing assessment of the costs and outcomes of service delivery can be an integral part of a service delivery model. Central to this approach is a five-step planning process that guides service system development and imple- mentation. The statewide continuous evaluation system implemented in Texas is described in "The Development of a Statewide Continuous Evaluation System for the Texas Children's Mental Health Plan: A Total Quality Management Approach" by Rouse et al : Implementation issues such as involving stakeholders, the evolution of the evaluation design, the modification of measurement methods, the integration of evaluation with other organizational processes, staff training, data qual- ity control, communicating results, and using results in decision making are discussed. Texas' evaluation approach demonstrates that the tools of quality management can provide a useful frame- work for building outcome accountability.

132 The Journal of Behavioral Health Services & Research 25:2 May 1998

An important element that contributes to the development of outcome accountability is being able to describe the services being delivered. Without an understanding of this, it later becomes impossi- ble to interpret the meaning of the outcomes that have been achieved. In "Program Specification: A Precursor to Program Monitoring and Quality Improvement. A Case Study From Boysville of Michigan," Savas et al. 6 describe an approach for helping evaluators and program staff define the services offered at the program level. This process, called p r o g r a m spec i f ica t ion , is designed to sup- port the integration of accountability with service delivery. It is the first step in Boysville's quality improvement system.

In "Managing Care Across Systems to Improve Outcomes for Families and Communities," Usher 7 emphasizes that accountability in comprehensive service systems is complicated because it involves outcomes that are not typically addressed by any single child-serving system. Implicit in this perspective on accountability is the assumption that it is difficult for highly specialized service systems to be fully responsive to the needs of families and the communities in which they live. This article outlines a framework within which community collaboratives can begin to address family- and community-level outcomes. This framework requires a commitment from mental health organi- zations that goes beyond traditional boundaries and roles.

The special issue closes with two commentaries regarding issues related to outcome accountabil- ity. In "Outcomes and Accountability From a Family Perspective," Osher 8 articulates a family per- spective about the quality and effectiveness of services to children with serious emotional distur- bances. This article highlights the need for families to see improvements in the lives of their children in functional terms. This includes having children live at home, attend and progress at school, enjoy friends and activities in the community, and become responsible adults. Osher also asks the question of how outcome data will be used once obtained. Families assert that the only appropriate use of the information is to improve services and support to children and families.

In the second commentary, titled "From Many Into One: Addressing the Crisis of Quality in Man- aged Behavioral Health Care at the Millennium," Manderscheid 9 emphasizes the need to include outcomes other than price into the arena of managed care contracts. The commentary argues that if price is the sole measure of quality in managing mental health care, critical resources for care will be rapidly eroded from mental health service delivery. Manderscheid believes that the often fragmented sectors of the mental health field, including consumers, family members, providers, managed care organizations, and payers, must mount a coordinated effort to develop practice guidelines, outcome measures, and report cards.

Acknowledgments This special issue is the result of the work of many individuals, including Editor Bruce Lubotsky

Levin and Editorial Associate Ann C. Taylor. This special issue was created during a time of rapid change in the way mental health services are funded and organized. Of particular note has been the rapid rise of issues related to accountability. Given this environment of change, I particularly want to thank the authors for their hard work and for their patience. I wish to also thank the reviewers for their timely and careful critiques. Finally, I wish to thank my colleague Sharon Hodges from the System Accountability Project for Children's Mental Health for the support and advice she has provided me in the creation and evolution of this special issue.

References 1. Hernandez M, Hodges S, Cascardi M: The ecology of outcomes: System accountability in children's mental health. The

Journal qf Behavioral Health Services & Research 1998; 25(2):136-150. 2. Koch JR, Lewis A, McCall D: A multistakeholder-driven model for developing an outcome management system. The

Journal of Behavioral Health Services & Research 1998; 25(2): 151-162.

Special Issue Editor's Note HERNANDEZ 133

3. Beck SA, Meadowcroft P, Mason M, et al.: Multiagency outcome evaluation of children's services: A case study. The Jour- nal t~f Behavioral Health Services & Research 1998; 25(2):163-176.

4. Rosenblatt A, Wyman N, Kingdon D, et al.: Managing what you measure: Creating outcome-driven systems of care for youth with serious emotional disturbances. The Journal of BehavioralHealth Services & Research 1998; 25(2): 177-192.

5. Rouse LW, Toprac MG, MacCabe NA: The development of a statewide continuous evaluation system for the Texas Chil- dren's Mental Health Plan: A total quality management approach. The Journal of Behavioral Health Services & Research 1998; 25(2): 193-206.

6. Savas SA, Fleming WM, Bolig EE: Program specification: A precursor to program monitoring and quality improvement. A case study from Boysville of Michigan. The Journal of BehavioralHealth Services & Research 1998; 25(2):207-215.

7. Usher CL: Managing care across systems to improve outcomes for families and communities. The Journal of Behavioral Health Services & Research 1998; 25(2):216-228.

8. Osher TW: Outcomes and accountability from a family perspective. The Journal of Behavioral Health Services & Re- search 1998; 25(2):229-231.

9. Manderscheid RW: From many into one: Addressing the crisis of quality in managed behavioral health care at the millen- nium. The Journal of Behavioral Health Services & Research 1998; 25(2):232-236.

M a r i o Hernandez , Ph.D.

Spec ia l Issue E d i t o r

Univers i ty o f South F lo r ida

134 The Journal o f Behavioral Health Services & Research 25:2 May 1998