Systems Navigation (Frederick County FY 18 and beyond-Annual)

Program Summary

FY20 - Systems and Family Navigators provide intensive supports to targeted linkages to overburdened families, guiding them through the myriad human services to ensure access to services that meet each family’s unique needs.

FY19 - Systems and Family Navigators provide intensive supports to targeted linkages to overburdened families, guiding them through the myriad human services to ensure access to services that meet each family’s unique needs. Provider: Mental Health Association of Frederick County.

Target Population

FY20  - Disconnected Youth (or Youth in Jeopardy of Disconnection), Families Impacted by Incarceration in Frederick County, and Families seen by the Local Care Team.

FY19 - The target population for Systems Navigation is disconnected youth and families impacted by incarceration.

Performance Measures
Current Actual Value
Current Target Value
% Change
Story Behind the Curve


Lower overall enrollments for FY19 resulted from:

  • A portion of the initial connections between navigator and potential participant conducted over the phone resulted in a referral that did not necessitate a face-to-face meeting
  • Some of the families experiencing a crisis who were referred for navigation saw a resolution of said crisis before following through with their navigation appointment, which resulted in no enrollment. 

Fewer disconnected youth were enrolled in FY19, in part to the situations above, and in addition:

  • There are many challenges with getting youth in particular to follow-through with initial in-person meetings after referral
  • A number of the youth who sought services did not meet the definition and age criteria; said youth were not attending school but were too young to legally drop out of school.

With regard to disconnected youth completing a plan, the number appears down compared to FY18 because enrollments were down, but every youth served in FY19 (100%) did complete a plan.


First year of GOC funded program focusing exclusively on disconnected youth and families impacted by incarceration.  Has required an adjustment in how connections and services provided based on needs and attributes of these populations.

  • Identifying youth is easier than keeping them engaged in services.
  • Began tracking number of connection attempts and number of successful connections
  • Families impacted by incarceration better at reaching out and reconnecting with navigators than youth
  • Most successful interactions occur with participants who are linked and connected to outside services providers for long term service
  • Villa Maria
  • Potomac Case Management System
  • Family Preservation Way Station
  • Workforce Services,
  • Frederick County Public Schools (FCPS)
  • Student Homelessness Initiative Partnership (SHIP)
  • Family Partnership  
What Works


  • Systems Navigation staff will incorporate the ACES questionnaire and resiliency education into assessments, using a strengths based approach.
  • Systems Navigation is part of  “Teen Roundtable”, a collaborative which consists many teen serving agencies. The “Teen Roundtable” includes Family Partnership, Excel Youth, Family Preservation, Workforce Services, Frederick County Public Schools, Villa Maria, Counseling Services and COIPP.  


The number one predictor of success for each participants is the relationship between the family and the navigator.  If there is a connection and trust, the outcomes and satisfaction ratings are higher.  This is the number one indicator from the SN post service surveys.  However, it is difficult to measure in an outcome.  As mentioned above, collaboration with community partners that increases everyone's ability to look for solutions outside the box is another indicator of success for participants.  Developing a service plan with obtainable objectives to reach an overall goal is also important.  The more concrete the objective, the better the outcome.  Families seem to do best when they can see progress and feel there is someone invested in the goal with them.   

Action Plan


  • The Systems Navigation program will work to increase the numbers served by a navigator by expanding outreach efforts to include participation at community events and highlight services they provide at partnership meetings.
  • A Systems Navigator will be present at all LCT meetings and families will be referred to a navigator at the meeting.
  • Program staff will meet with youth at the location of the referring agency to ensure more face-to-face connection and reduce the lack of follow-through by youth.


  • The program will improve internal data collection
  • Program staff will strengthen relationships with other programs. Community collaborations are essential and the program continues to work on strengthening these relationships.  As there is a lot of turnover in the agencies that navigator's work with, the program is constantly in a position of building relationships with front line workers.
  • The other area that requires additional focus is the on how progress is measured for families.  The program will incorporate shorter term goals (such as completion of identified objectives toward overall goals), in FY19 measures.  
Scorecard Result Program Indicator Performance Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy