Emerging from a strong need to reduce reliance on institutional care and to eliminate the fragmented care traditionally provided to youth who are at high risk, key child leaders and the federal Center for Mental Health Services (CMHS), among others, have been engaged in significant initiatives to better understand the best provision of care for this population. Wraparound, now being disseminated across the country, is seen as a promising approach focused at the child and family level to address mental health needs more appropriately and effectively in the community. While the major initiative to develop wraparound in many states has come from the mental health system, this is an intervention for all child service sectors, with education, juvenile justice, and child welfare also taking the lead role. This monograph was developed with the support of the Child, Adolescent, and Family Branch of the Center for Mental Health Services as part of an effort to increase understanding about the status of wraparound as a relatively new and innovative approach within a system of care. In this vein, a number of major questions were posed that have been addressed over the past year in a partnership with key developers and trainers, family members, wraparound program directors, state policy makers, and researchers. Briefly, these questions include:

• How is wraparound defined and operationalized; and is there consensus?
• How is wraparound organized, and to what extent has it been disseminated across the country?
• As wraparound is implemented, how is competence developed and quality monitored?
• How strong is the evidence that wraparound is effective in achieving its aims?
• What further steps in the arenas of policy, training, and research are recommended to facilitate broader dissemination?

The relevance of clearly defining an intervention is to ensure that it can be recognized and replicated. Clarification of the definition, values, elements, and practice requirements for the wraparound approach could help to determine whether what is being provided is truly wraparound, and to differentiate it from other interventions. Wraparound is consistent with system of care values and is a process for care delivery within a service system. At the same time, wraparound is closely tied to other key concepts of a system of care. It is individualized care, which is also true of other interventions often associated with the term "system of care."

Whether wraparound is equivalent to intensive case management has been deliberated. There are multiple approaches to case management, of which wraparound may be considered the strongest one, but this awaits research comparing approaches to case management. A survey of U.S. states and territories was conducted in order to examine in what ways and to what extent the wraparound process was being implemented across the country. Three promising programs were chosen from a number of strong candidates for site visits in order to further explore aspects of organization and implementation. This provided an opportunity for in-depth exploration of the process of implementing wraparound and identification of lessons learned from those sites that might be applicable to other communities as they engage in similar reform efforts.

The information gained over the course of this project is presented in the monograph. The origins and background of the wraparound approach are presented from the perspective of one of its founders.

The definition, values, elements, and requirements for practice are outlined, as agreed upon during the focus group meeting at Duke University. These delineations represent consensus among key stakeholders, in addition to the recognition that much more work needs to be done. Three model sites—Milwaukee, Wisconsin; La Grange, Illinois; and Santa Clara County, California—are discussed, with emphases on similarities and differences in their implementation of the wraparound approach. The results of the state wraparound survey are presented, followed by a description of some of the standards and fidelity measures received in response to the survey. The monograph also describes some approaches to training and quality monitoring, as well as some suggested steps to create and use tools that measure wraparound fidelity.

Definition and Description of Wraparound

Consensus among a range of partners was achieved during the Duke University meeting around the definition, values, essential elements, and requirements for implementation of wraparound. Each is presented in summary form below:

Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports individualized for that child and family to achieve a positive set of outcomes.

An ecological perspective guides wraparound. This means that development occurs in the context of interactions between the child and his/her environment. To increase healthy functioning, environmental forces, including the family, the community, and the service system, must support the strengths of the child and family. Values include voice and choice for the child and family, compassion, flexibility, and the core values of the system of care. (See Appendix B).

• Wraparound must be based in the community.
• Services and supports must be individualized, built on strengths, and meet the needs of children and families across life domains to promote success, safety, and permanence in home, school, and community.
• The process must be culturally competent, building on the unique values, preferences, and strengths of children and families, and their communities.
• Families must be full and active partners in every level of the wraparound process.
• The wraparound approach must be a team-driven process involving the family, child, natural supports, agencies, and community services working together to develop, implement, and evaluate the individualized service plan.
• Wraparound child and family teams must have adequate, flexible approaches, and flexible funding.
• Wraparound plans must include a balance of formal services and informal community and family resources.
• An unconditional commitment to serve children and families is essential.
• The plan should be developed and implemented based on an interagency, community-based collaborative process.
• Outcomes must be determined and measured for the system, for the program, and for the individual child and family.

Further operationalization of wraparound will benefit future training, quality monitoring, and research efforts. As wraparound is adapted for new child populations, organizations, or financing mechanisms, clear articulation of change will be important.

The Organization and Spread of Wraparound

Clear policy and strong training within wraparound programs are consistent with measurable positive outcomes and quality of care. Such programs are likely to be seen as models and tapped for policy and training leadership state-wide and nationally, potentially underscoring the importance of building increased capacity and support for leadership to take on as additional functions.

Training and Quality Monitoring

Some states have developed standards for wraparound. Existing ones tend to be quite general and could be enhanced with agreement within the field about the specification of wraparound. Few standards include benchmarks for monitoring purposes. Examples of well designed and tested standards should be made available to states that are in the process of developing their own specific standards. Early experience with developing and testing fidelity measures also has been reported. This requires further development to ensure that wraparound, as described, is actually being provided.

Research

Training in the wraparound approach and its role in systems of care should occur such that wraparound is understood as a legitimate, replicable service approach that includes a set of interventions by policy makers, administrators, mid-level managers, and supervisors, as well as front-line practitioners.

Training needs to involve state and local level agencies and all systems including mental health, substance abuse, social services, child welfare, education, early childhood, education, juvenile justice, and law enforcement. Attention to training for undergraduate and graduate students moving toward careers in human service sectors is also a high priority.