SCAN METHODOLOGY
The scan was comprised of fourteen questions: 6 open-ended and 8 multiple choice. The study was distributed through the listserv of the National Association of State Mental Health Program Directors to the offices of all State Mental Health Program Directors. A brief letter was emailed to potential respondents introducing the study and explaining how to access the scan. The scan was conducted through the use of Survey Monkey, a web-based research tool that supports survey dissemination and response by E-mail, as well as producing databases of responses. Two follow up emails were also distributed as reminders to those who had not yet responded.

LIMITATIONS OF THIS SCAN
Issues ranging from survey construction, survey distribution, rate of participation by state mental health authorities, and information provided by respondents limit the findings of the survey.

SCAN CONSTRUCTION
A goal of Achieving the Promise (New Freedom Commission, 2003) is that, in partnership with health care providers, families will play a larger role in managing the funding for their services, treatment, and supports. Missing from this report is data related to the state administrative structures, policies and financial supports that are in place to prepare the mental health workforce for the employment of family members.

SCAN DISTRIBUTION
According to the Health Care Reform Tracking Project, only five states over the past decade have not implemented a publicly financed managed care system. Additionally, this same study found that families reportedly had significant involvement in one-third of managed care systems, although they reportedly had some involvement in another 56% of managed care systems. Managed care networks employment data regarding family members remains undocumented in this scan.

RATE OF PARTICIPATION BY STATE MENTAL HEALTH AUTHORITIES
Twenty-two state agencies responded to the scan with two responses from the same state. Thus, family member staffing positions that may exist in 29 states, plus the District of Columbia is unknown at this time.

INFORMATION PROVIDED BY RESPONDENTS
The individuals responsible for completing the scan were neither always knowledgeable about the family member staffing positions in their state mental health system or agency system nor aware of state dollars funding peer-to-peer/parent partner programs or family members working in family-run organizations.

FINDINGS
The scan on state family member employee positions and state supported family peer-to-peer programs had two content areas. The first content area included questions pertaining to the number of and the job titles assigned to state level family member employee positions. The second content area focused on questions about state supported programs in which family members provide information, support and advocacy to other families. Are they paid? Who supervises them? Where do they provide services? Are they trained? If so, is there a curriculum? And lastly, is there a state certification requirement for family peer-to-peer/parent programs? The findings section that follows is organized following this two-part pattern.

STATE FAMILY MEMBER EMPLOYEE POSITIONS
Of the twenty-two states that responded, one state having two respondents, thirteen states (59.1%) reported employee positions at the state level that either require they be filled by a family member or give hiring preference to family members. Nine states (40.9%) reported no state family member employee positions.

NUMBER OF EMPLOYEE POSITIONS
A total of ninety-eight (98) family member employee positions were reported by the thirteen states hiring family members. Seven (53.2%) of the thirteen states reported that they employ at least one family member. Only one state (7.6%) reported contract work with three family organizations and thirteen part time family members. The other six states employment data varied from three to forty employees. Appendix A lists the individual number of family member employees per state.

JOB TITLES OF EMPLOYEE POSITIONS
A total of eighteen different job titles were reported by the thirteen states respondents.
Three states (23.1%) reported titles as follows: Family Support Providers at facilities, Mystery Shoppers, and Family Coalition Member. Two states’(15.4%) job titles were: Community Service Agencies and Family Resource Facilitator. Appendix B includes these titles and the other eight (8) job titles.

STATE SUPPORTED PROGRAMS
Twenty states (90.9%) reported they operate state supported programs in which family members provide information, support and advocacy to other family members. These are sometimes called Peer-to-Peer or Parent Partners programs. Two states (9.1%) reported no state supported peer-to-peer programs.

Additional information specific to families working in state supported family-to-family programs is as follows.
• Is the parent staff paid? Fifteen state respondents (83.3%) indicated that they pay parent staff. Three state respondents (16.7%) do not pay parent staff. Four states did not respond to this question.
• Where do parent staff provide services? Thirteen states (68.4%) reported parent staff provide services at the practice/local level. In five states (26.3%), respondents reported parent staff providing services statewide. One state (5.3%) indicated parent staff work in “local family support programs and in selected residential programs as well as the state operated hospital system”.
• Do the parent staff receive training? Nineteen states responded they provide training to parent staff. Three states did not respond to this question.
• Is there a curriculum? Fourteen states (73.7%) indicated they have or are close to having a curriculum. Five states (26.3%) reported they do not have a curriculum. Three states did not respond to this question.
• What is the name of the curriculum? Each of the fourteen states having a curriculum submitted its name. Included in these responses are five family-run organizations contracted to provide training in an on-going basis.
• What is the name/title of the supervisor? Eighteen states reported various employees supervise parent staff depending on the location. One half of those eighteen states indicated supervisors are located in family run organizations.
• Is there a state certification requirement for parent staff? Two states (10%) reported certification requirements. Eighteen states (90%) reported no state certification requirements. Two states did not respond to this question.
• Please describe certification requirements. Two states (10%) responses showed that one is in the process of developing a certification program and the other is unable to answer as the FFCMH organization has the responsibility for this work.

GENERAL OBSERVATIONS AND ISSUES
This web-based scan provides a snapshot of family members as employees in state systems at a point time in May 2008. The information reported is descriptive, not evaluative, and provides baseline information from twenty-two states regarding family member employment data and state supported peer-to-peer/parent programs. As noted, the staff person responsible for completing the survey may not have been knowledgeable about the extent to which family members were employed in their mental health or agency system nor aware of state dollars funding peer-to-peer support and family member positions in FFCMH organizations.

FAMILY MEMBERS AS EMPLOYEES
The scan indicated family members are hired to do various jobs and the states use eighteen different job titles. Most of the titles would suggest that their jobs are to provide family support expertise, and, to share their in-depth experience with state policymakers. Also, it is likely that ongoing support and allegiance to their state employer would be expected. This raises the following questions:
• Is the reporting relationship clear?
• Are expectations clear and specific?
• Are there policies in place to support family members working in a state bureaucracy to ensure that they are respected partners?
• What roles and responsibilities do family member employees have with the state supported peer-to-peer parent programs?
• Are there administrative mechanisms and structures in the state mental health office that allows effective collaboration and coordination with all the family-to-family operations in the state including FFCMH chapters and statewide organizations?

STATE SUPPORTED PEER-TO-PEER/PARENT PROGRAMS
While most states reported operating peer-to-peer/parent programs (90%) with family members being paid in 83.3% of those states while in 16.7% of those states family members are working as volunteers. This reality is a major issue given efforts over the last decade by the family movement fighting to ensure family members will be paid for what they do in ways that are commensurate with those responsibilities. “There is no integrated family involvement unless some means is found to pay those involved in such a way that allows commitment to the task on the part of family representatives. This is a key element of a fully evolved system.” (Simpson, Koroloff, Friesen, & Gac, 1999)

The parent staff employees in the peer-to-peer programs work on multiple levels, with multiple supervisors, and with multiple service providers, and, attend a variety of specialized and targeted trainings. This raises a number of issues. Are any of the trainings closely linked to provider readiness to work with families as employees? Do the training programs teach how to meaningfully collaborate with one another? Are the major areas of attitude, knowledge and skill competencies for front-line workers, their supervisors, and their managers, that are necessary to move to a transformed family-driven system part of the trainings? To what extent are the parent partner programs activities congruent with the skill sets and competencies identified in the trainings? And, across all parent partners, how much of their time is spent on the curriculum’s skills and competencies versus other activities?

CONCLUSION AND RECOMMENDATIONS
The information collected in this scan highlights a variety of jobs and roles that have evolved as a result of the family movement. In 2003, the President’s New Freedom Commission on Mental Health called for mental health care to be “consumer and family-driven care” as part of the needed system transformation. Families working in the system are poised to expand the capacity of the workforce in children’s mental health but it will require a partnership between state, family members and local stakeholders to clarify and address the ways in which state policies and practices (e.g. regulations, funding, reporting requirements) can be strengthened or altered to support family member employment. This scan illustrated the lack of collaboration, communication and coordination between peer-to-peer support activities at the local level and parents hired at the state level. Further work is needed to determine characteristics of family-driven systems.

The National Federation, through an inclusive process, has developed a working definition of family-driven care that includes principles for everyday practice in service delivery. Strategies are needed to transform the management and structure of state programs, program operations and program impact to be family-driven. Workforce issues and public policy also need to be addressed to support this transformation.

Targeted attention to these areas should be directed at avoiding the difficulties the family movement experienced in defining and operationalizing the term family involvement. Transformative strategies such as attention to core competencies, infrastructure development, and new models for education and training that the National Federation and its membership should use to develop strategies for addressing the above issues.

And, finally, work should be done to develop recommendations for policy and practice related to family-driven workforce transformation strategies. A consensus meeting, for example, could address the following.

1. Identify key learnings across peer-to-peer/parent programs about how and why social support interventions work;
2. Identify key learnings of family members employed in state systems;
3. Identify the implications of such learnings for policy and practice;
4. Identify essential elements of the infrastructure needed to operate and maintain family driven systems over time; and
5. Develop recommendations for future policy, practice, and research.

Without an effective, system-wide training effort to ensure family members employed through the state system have the knowledge and skills regarding how and who establishes state policies and how policies influence funding and program decisions at the community level, the President’s New Freedom Commission on Mental Health (2003) stated goal of a family-driven system may stay out of reach.