Why Systems Matter: State-Level Administrative Structure Predicts Caregiver Perceptions of Wraparound Implementation

Background and Purpose. Wraparound is an individualized, team-based care coordination process designed to support youth with complex behavioral health needs and their families. Previous research has demonstrated that Wraparound takes more time to implement with fidelity than other evidence-based interventions because it requires coordination across multiple organizations and systems. The current study examined caregiver perceptions of Wraparound implementation within two state-level administrative structures: Care Management Entities (CMEs) that are designed to support cross-system collaboration through dedicated care coordinators and flexible reimbursement rates; and Community Mental Health Centers (CMHCs) that offer traditional behavioral health services and use more rigid fee-for-service funding mechanisms.

Methods. We used mixed methods to examine factors that influence caregiver reports of Wraparound experiences. Data were gathered using the Wraparound Fidelity Index, Short Form (WFI-EZ), a validated self-report caregiver survey that includes closed- and open-ended items focused on implementation quality (N = 1946).

Quantitative data were drawn from the “key elements” section of the WFI-EZ, and qualitative responses were drawn from open-ended questions on caregiver experiences. Two qualitative coders coded for valence (Positive, Negative, Neutral, Mixed), with adequate inter-rater reliability (Kappa = .76, p < .001), and then identified common themes within each code. Basic data trends were analyzed with descriptive statistics, and predictors of caregiver perceptions were examined using logistic regression.

Results. Descriptive data suggest that a majority (70.4%) of caregivers reported positive experiences with Wraparound. Furthermore, caregiver reports suggest that Wraparound met basic fidelity thresholds, and these ratings did not vary across gender, race, or ethnicity. Results of the logistic regression reveal that the strongest predictor of caregiver perceptions was administrative structure (OR = 5.61, p < .001), with more positive comments among caregivers from CME states. We observed smaller but significant effects for Wraparound key elements including effective teamwork (OR = 1.05, p < .001), natural supports (OR = 1.03, p = .002), needs-based (OR = 1.04, p = .005), outcomes-based (OR = 1.02, p = .027), and family driven (OR = 1.03, p = .039). Follow-up qualitative coding suggests positive caregiver comments were most likely to focus on overall experiences, quality of Wraparound staff, communication, and youth progress. In contrast, negative comments focused on systems-level challenges, time delays, and poor connections to community resources.

Conclusions and Implications. Caregivers reported positive experiences with Wraparound, including favorable attitudes towards staff, communication, and youth progress towards goals. Implementation quality met basic benchmarks, and consistency in perceptions across demographic groups suggests that Wraparound was being delivered equitably across gender, race, and ethnicity.

Logistic regression results underscore the critical role of systems-level organizational supports in shaping caregiver experiences, with caregivers from CME states 5.6 times more likely to report positive perceptions than those from CMHC states. Such trends are validated by the finding that systems-level challenges, delays in service delivery, and lack of community resources were the most cited problems. Together, these findings suggest that efforts to improve Wraparound practice should begin by strengthening administrative infrastructures and addressing systems-level constraints with the goal of improving caregiver experiences with Wraparound.