1 orientation to child and family team practice and the pennsylvania youth and family institute jim...
TRANSCRIPT
1
Orientation to Child and Family Team Practice
and the Pennsylvania Youth and Family
Institute
Jim Rast, Ph.D.John VanDenBerg, Ph.D.
December, 2007
2
This Pennsylvania Effort… Pennsylvania has a long history of successful
collaboration and programs to support children and their families.
Through the PYFI, VVDB is committed to developing capacity to provide, coach and train sites with a commitment to implementing Child and Family Teams processes (high fidelity wraparound) in PA
VVDB is partnering with the PYFI, participating Counties, and State Level partners to help this transformation succeed
3
Wraparound
Wraparound and wraparound are not the same thing.
PA uses the term wraparound differently than almost every other state.
Arizona had other uses for the term wraparound and chose to use the term “child and family teams” to describe the process of integration and individualization used at the practice level
4
Development of WraparoundGrassroots Development General Principles Applied in many different ways Creativity and advances 200,000 children in 1999
Initial Results Life changing success stories Strong support Mixed evaluation results Research shows results match fidelity
5
Defining Wraparound
Steps to Define Wraparound Duke meeting on principles National Wraparound Initiative
Who they are Process used Products produced
Wraparound Fidelity Assessment System
6
Wraparound Process
Is a Process for Supporting Youth and Families that
Is defined by 10 principles of how the process is implemented;
Is done in four phases and related activities that describe what is to be done; and
Fits the four components of the theory of change that explains why it works.
7
Principles for Wraparound
Family Voice and Choice
Team Based Natural Supports Collaboration (and
Integration) Community Based
Culturally Competent Individualized Strengths Based Persistence Outcome Based and
Cost Responsible
8
Phases and Activities, and Skill Sets NWI phases and activities Vroon VanDenBerg specific skill sets for
wraparound facilitators, coaches and family support partners
VVDB performance based training and coaching products
Credentialing and Quality Improvement Used and been in over 35 sites across North
America. Sites using these products report greatly improved
outcomes and more satisfied families and staff.
9
Impact on CAFAS Scores after 6 Months
-50
-40
-30
-20
-10
0
10
Trad MH Services High FidelityWraparound
Low Fidelity thenCoaching
Chn
age
In C
AFA
S S
core
s
6 months
10
2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
Intake 6 Months 12 Months
Ave
rag
e F
RS
Sco
re
Overall
2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
Intake 6 Months 12 Months
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Impact of Fidelity
11
Breakdown of Fidelity Scores
00.10.20.30.40.50.60.70.80.9
1
Principle
Ave
rag
e F
idel
ity
Sco
re
Low Fidelity High Fidelity
12
Impact on CAFAS Scores after 18 Months
-70-60-50-40-30-20-10
010
Trad MH Services High FidelityWraparound
Low Fidelity thenCoaching
Chn
age
In C
AFA
S S
core
s
6 months 18 months
13
The Theory of Change is
Is why we do wraparound Is what about wraparound that makes it
work Is what differentiates it from other service
coordination processes Defines expectations for what we hope to
accomplish through wraparound
14
Efficacy
Theory of Change for WraparoundWhy Does Wraparound Work?
Integrated Plan
NaturalSupportSystem
Self
Efficacy
NEEDS
15
Theory of Change for WraparoundWhy Does Wraparound Work?
Wraparound addresses the priority needs identified by
the youth and family
Efficacy
Integrated Plan
NaturalSupportSystem
Self
Efficacy
NEEDS
16
Families are not Fully EngagedFamilies are not Fully Engaged
Research finds that Up to 60% of families drop out of services before
they are finished Children from vulnerable populations are less
likely to stay in treatment
17
The Challenge of Full Family EngagementThe Challenge of Full Family Engagement
Why do families drop out?Treatment is stressfulTreatment seems irrelevantPoor relationship with therapistConcrete obstacles:
Time, transportation, child care, other priorities
18
Wraparound Supports Engagement
Addresses family prioritized needs Plans for needed support Family-centered and youth guided Culturally competent Strengths- and community based Creative and Individualized
Teams brainstorm how to mobilize professional, natural, and community supports to meet unique needs
19
Theory of Change for WraparoundWhy Does Wraparound Work?
Wraparound strengthens youth and families
confidence that they can create positive change
in their lives
Efficacy
Integrated Plan
NaturalSupportSystem
Self
Efficacy
NEEDS
20
Self-Efficacy is the belief in one’s capabilities to organize and execute
courses of action required to produce given attainments plays the central role in the cognitive regulation of
motivation
People with high self-efficacy are more likely to expend more effort, and persist longer
Low self-efficacy often results in poor task planning, as well as increased stress.
people with high self efficacy often take a wider picture of a task in order to take the best route of action
21
Theory of Change for WraparoundWhy Does Wraparound Work?
Wraparound strengthens the social support system that
helps the youth and family succeed
Efficacy
Integrated Plan
NaturalSupportSystem
Self
Efficacy
NEEDS
22
What or Who are Natural Supports
Natural supports are community resources available for use by youth and families within which are consistent with their cultural beliefs and practices.
Natural supports may involve individuals outside the immediate family and a variety of informal supports found in the neighborhood or larger community.
Natural resources are external to the child and family and, once accessed through active affiliation, become part of the child's and family's strengths.
23
Research on Impact of Natural Supports
positively impact chronic disease related health behaviors
increase compliance to routine medical care improved health for older people with chronic
conditions decrease postnatal depression for new mothers decrease depression in older women positive natural supports decrease drug use positive natural supports decrease HIV risk behaviors decrease punitive punishment from parents increase coping, resilience and sustainability for
caregivers
24
What Natural Supports Do for Caregivers
Natural Supports may support and influence improved and sustained care-giving by
Creating situations to observe and learn about effective parenting from people the family trusts
Providing a sense of attachment and someone to talk to during tough times
Someone to trust and provide respite from many types of demands of care giving
Providing access to resources and material goods
Providing coping resources
25
Theory of Change for WraparoundWhy Does Wraparound Work?
Wraparound creates an
integrated and simplified plan for the whole
family
Efficacy
Integrated Plan
NaturalSupportSystem
Self
Efficacy
NEEDS
26
Seriousness of the Problem
Prevalence of Serious Emotional Disturbance (SED)
Population Proportions (9 to 17 year-olds)
5-9% Youth with SED & extreme functional impairment
9-13% Youth with SED, with substantial functional impairment
20% Youth with any diagnosable disorder
27
Children with Behavioral Health Disorders Across Systems
0%
20%
40%
60%
80%
100%
Child
Welf
are
Juve
nile
Justi
ce
TANF
Educa
tion
Pe
rce
nt o
f Ch
ildre
n
None
BH Dx
SED
0%10%20%30%40%50%60%70%80%90%
100%
None Child Welfare Juvenile Justice
28
Fragmented System
Yet, for too many Americans with mental illnesses, the mental health services and supports they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery. Today’s mental health care system is a patchwork relic—the result of disjointed reforms and policies. Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities.
Michael F. Hogan, Ph.D. 2003 ChairmanPresident’s New Freedom Commission on Mental Health
29
Tyler Family
Marge, 38 Evan, 39 Billy, 14 Sam, 12 Sally, 12
Major Strengths, Family Culture: Parents married 17 years Marge’s parents alive and in the area, care
about the family Marge has entrepreneur skills in area of home
cleaning business Family has history of surviving adversity using
their wits Evan has over a year of sobriety after a decade
of untreated alcoholism Children provide active support to each other Family culture prioritizes educational goals Billy knows what “cool” is
30
Major Needs of Tyler Family
From the more detailed description of the Tyler family list concerns or risk factors
31
Major Needs of the Tyler FamilyBilly: Serious Juvenile Justice involvement Breaking and entering, shoplifting,
thefts of all types Two years behind in school but lots of
potential
Twins (Sam and Sally): Bi-polar, extreme mood swings. In child welfare custody in a
specialized foster home School is having problems controlling
behaviors and engaging them in lessons
All school behavior plans have failed, and school is suggesting home bound instruction
Evan: Verbally and physically
abusive to children unemployed, unable to
hold job due to self described “Stubborn attitude about authority”
Recovering from severe alcoholism
Marge: Family history of major
depression (untreated); Suicidal ideation which is
likely to result in death.
32
Pairs Activity
After the concerns and risk factors for the Tyler family are discussed brainstorm typical services and plan(s) for them in your county. We are going for typical – what the average youth and family in their situation would get.
33
Typical Plans for Tyler Family
34
How complex is the Tyler Family?
Based on initial information, rate this family from one to ten, with one being least complex needs and ten being most complex needs….
What don’t you see that would make this family rate a higher number?
35
26 Helpers and 12 Plans
School (5)Technical School (2)Child Welfare (1)Juvenile Justice (1)Children’s Mental Health (6)Adult Mental Health (3)Employment Services (2)AA (1)Housing Department (1)Bailey Center (2)Specialized Foster Care (2)
2 IEPs (Sally and Sam)Tech Center PlanPermanency PlanProbation Plan3 Children’s MH Tx Plans2 Adult MH Tx PlansBailey Center PlanEmployment Services
33 Treatment Goals or Objectives
36
Collaborative Efforts in Tyler’s Town1. Local Judge is chairing a restorative justice effort to address
truancy and violence in schools. Juvenile Justice and law enforcement has major presence in local High Schools.
2. School Superintendent and United Way are leading an interagency effort for substance abuse prevention.
3. Local Health Department has a grant and steering committee to decrease teenage Pregnancy.
4. Child Welfare has a mandated interagency coalition that is planning for multi-agency involved children and youth.
5. Children’s Mental Health has co-located staff at child welfare supporting family preservation and family group decision making.
6. Adult Mental Health and Adult Addictions Services are in same agency.
7. There is a grassroots effort to develop more church involvement in supporting children and families.
37
Your Collaboration
Is your communities more, the same, or less collaborative than the Tyler’s town?
38
Current Services to Tyler Family School has IEP for each of the
twins and extensive behavior support and planning.
Billy is in a tech center but is rarely in school, school has offered many adaptive plans but none have worked.
Both schools call parents frequently.
Child welfare has substantiated Dad’s abuse of twins, has removed them from the home, created a strict reunification plan that includes family therapy and supervised visits
Twins are in specialized foster care with care and a therapist who supports the foster parents.
Twins are in therapy, two different therapists and a psychiatrist
TSS to help out with Billie
Juvenile Justice has just released Billy from detention over breaking and entering, Billy has new charges of theft,
Court ordered therapy Restitution supervised by local
youth services agency with a counselor and mentor
Housing is trying to find safer housing
Marge sees a psychologist occasionally in crisis times and has been referred to a psychiatrist, went once but does not want to go back.
Evan goes to four AA meetings a week and sees his sponsor twice a week, calls daily
Evan goes to court ordered anger management
Evan is working with Vocational Services on employment skills
39
Monthly Appointments for the Tylers Child Welfare Worker 1Marge’s Psychologist 2Marge’s Psychiatrist ?Billy’s therapist 4Billy’s restitution services 4Appointments with Probation and School 2Family Based 4Therapeutic Support Staff 12Evan’s anger management 4Children’s Psychiatrist 1Other misc. meetings:, Housing, Medical 5AA Meetings 16
Also, consider daily schedule (School, tech center, and vocational training) and the dozen or more calls from the schools each month.
40
Comments from the Files:
Parents don’t respond to school’s calls Family is dysfunctional Parents are resistant to treatment Home is chaotic Billy does not respect authority Twins are at risk due to parental attitude Mother is non-compliant with her psychiatrist, does not
take her meds Father is unemployable due to attitude Numerous missed therapy sessions Attendance at family therapy not consistent, recommend
group therapy for parents
41
Mutual Perspective
How do the professionals involved with the Tyler family view this family, and their role in the family? Do they see their role as “Rescuer” “Stabilizer” “Enforcer” “Supervisor” “Teacher”?
How does the family view the professionals? Does the family feel that they are asking for help? Does the family want the same help as the help the professionals want to give?
42
Help isn’t help unless it is asked for!*
Sometimes people need help even though they don’t ask for it. How can we engage them in a way that
helps them trust us when we see a need that they do not see? Will any plan work if the Tylers are not on
board or don’t see the plan is theirs?
*Quote from Help: The Original Human Dilemma (pub. By Harper, 2004), author is Garret Keizer
43
Cost
Specialized Foster CarePsychiatristPsychologistTherapy (Individual and Family Based)Therapeutic SSTech CenterVocational TrainingSchoolRestitution
Per Month
Plus the cost of the salaries for the public staff and the time from AA. If there is a crisis, detention, or higher levels of care the cost goes up considerably
44
Going From Collaboration to Integration is a Needed Shift
Collaboration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, but retain single system decision making power and planning.
Integration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, sharing decision making in a team format that includes the family, producing a single plan that meets all system mandates and that is owned by the entire team.
45
Rate your town…
On collaboration, rate your town from one to ten, with ten being most collaborative?
On integration, rate your town from one to ten, with ten being most integrated?
If ratings were different, what are non-blaming or shaming reasons for the differential ratings? For example, staff may not be trained to integrate.
46
First: Crisis Stabilization
Before team building, stabilize immediate crises with safety plan for Billy’s criminal behavior, Marge’s suicidal behavior and maintenance of Evan’s sobriety
Crisis planning involves prediction of worst case scenario, functional assessment to target plan on function of crisis behaviors, implement individualized, strengths-based, culturally competent prevention efforts, and plan for what to do if crisis occurs
47
Initial Tyler Wraparound Team
All of the immediate family (5) Marge’s Parents (2) Twin’s behavioral staff from school Probation Officer Child Welfare Case Worker Marge’s business co-owner Evan’s AA Sponsor Care Coordinator Family Support Partner
14 total, team can change over time…
Later, teachers, therapists, vocational staff, others in consulting roles
48
Next, Prioritize Needs and Plan Notice that needs are addressed in sequence with integrated
approach to selection of need priority, with family in controlof final decisions with court approval
1. Billy’s thefts – highly individualized plan using the “cool” grandfather to help stop criminal behavior, do individualized restitution to victims, and build on Billy’s strengths
2. Support of twins and highly individualized plan to gradually move toward reunification, done at approximately same time as #3 so that school, foster home, and home are consistent
3. Plan to stabilize twin’s school behavior using Marge, grandparents and others as volunteer aides, including accelerated plan to get Billy up to grade level using volunteer aides who are “cool”
4. Support Marge’s business efforts to keep income rolling in5. Continued Vocational Services for Evan, with team support of job
finding
And so on, over a year (predicted)
49
Benefits of an Integrated Approach for the Tyler Family and the Town
Tyler family has real hope from their plan and process, have more energy each time a goal is met.
The professionals involved get to maximize the use of their own expertise. For example, which plan would you rather be the psychiatrist in? Or the teacher?
The professionals get to practice integration skills which will benefit 1000’s of other families, trading control and autonomy for outcomes at the family level, and more satisfying jobs. Also may decrease professional turnover.
Taxpayers get return for their investment Potential multi-generational positive effect Community building a family at a time.
50
Cost
Not why we are here, but the real five year cost of Tylers was in excess of $250,000 – real money paid by real taxpayers
Is the “typical plan” a good deal for taxpayers?
51
0%
10%
20%
30%
40%
50%
60%
70%
6 Month Intervals
Pe
rce
nt o
f Yo
uth
in P
erm
an
en
cy S
etti
ng
Comparison DHS Wrap
Comparison 23.5% 20.6% 14.7% 20.6% 26.1%
DHS Wrap 5.4% 13.5% 32.4% 43.2% 65.2%
B1 B2 1 2 3
Permanency
52
THE Placement The most important part of finding the placement is really getting to
know the strengths, culture and needs of the youth. Talk to the youth at length and also talk to people who know the youth
(caregivers, former caregivers, teachers, etc) Strengths include people who might provide some level of support Needs focus on what it will take in an environment to be successful for
the youth and what the youth wants out of life Needs include the challenges that make the youth hard to place
Once you know the youth use the information to match to THE placement Use the strengths to sell the youth to the placement Be very honest about the challenges and needs so placement knows
what to expect Plan with the youth and placement before the youth arrives so the initial
experience is better Frequent communication and support over time to youth and placement
once there In the meantime
Stall Use the same principles and keep working on the THE placement if a
temporary stop is required
53
Youth Story - THE Placement
Youth was 16 and in lock down for shoplifting and AWOL from TFC. History of sexual abuse and had become sexually reactive. Multiple failed placements because of sexual and aggressive to other kids. No supports or visits for several years.
Strengths – good with adults, motivated to succeed Challenges – around younger kids or kids in home, learning
disability requires very structured situation and instructions THE placement – a mature couple with no other children in the
home The Results – found grandmother and brother who want to support
him but could not provide placement. Developed long range vision of work with need for supported living. Completed school and went to Job Corp. Will return to live with grandparents supported by brother until he is ready to go out on his own.
54
Stability of School Placement
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2
Control WrapAv
era
ge
Nu
mb
er
of
Sc
ho
ols
pe
r S
ix M
on
ths
Baseline 6 Months
55
Summary of Results
Outcome (Data Source)Positive Direction
Comp DHS Wrap NC Wrap
Average Number of Days in Permanency Setting (KIDS) 7 92* 63*
Percent of Youth in Permanent Placement 12 to 18 months (KIDS) 4.1% 55.7%** 29.5%*
Change in Number of Residential Moves per Six Months (KIDS) + 0.7 - 0.6* 0
Number of Schools in Six Month Period (Caregiver Survey) 2.0 1.2* 1.4
Changes in Restrictiveness of Living Scale (KIDS) + 0.7 -1.26** -.32*
Change Level of Family and Caregiver Stress (Caregiver Survey) + 4.4 - 6.0** + 3.6
Change in Level of Youth Problems (Ohio Scales) + 1.3 - 5.8** +1.8
Change in Level of Youth Functioning (Ohio Scales) - 5.2 + 3.0** - 1.1
Change in Level of Impairment (CAFAS) - 11.4 - 25.0** -10.5
Reduction in Medicaid Spending (OHCA) $75,383 $400,906** $222,384*
56
Impact on Medicaid Spending
-500,000
-400,000
-300,000
-200,000
-100,000
0
100,000M
ed
ica
id B
HS
Co
stC
ha
ng
e f
rom
Ba
selin
e P
er
Pe
rio
d
Control DHS Wrap
Control 56,837 -10,604 -121,616 -75,383
DHS Wrap 35,711 -97,580 -339,037 -400,906
1 2 3 Total
57
Facilitator Credentialing using VVDB tools…
Novice -- has completed 24 hours of class room (or E-Learning) instruction, in-class behavioral rehearsals, pre and post tests, and 20 hours of shadowing
Practitioner -- has a professional development plan, is receiving appropriate supervision and coaching, and has demonstrated competency using VVDB documentation and observation review tools.
58
VVDB Observation and Review Tools
Either the Supervisor/Coach or Coach actively reviews document products and observes key activities based on NWI Phases and Activities
Documentation Reviews: SNCD; Wrap Plan; Functional Assessment; Crisis Plan; Progress Notes; Transition Plan
Observation Reviews (live): Initial Engagement meeting; Initial Team Meeting; Follow-up Meeting
59
Barriers to High Fidelity Wraparound in PA
1. In small groups, assign a recorder with good hand writing (the notes will be turned in)
2. Begin the discussion by introductions. Then, list out top barriers which may get in the way of implementing wraparound as defined by the National Wraparound Initiative (30 minutes)
3. Prioritize the list and choose the top barrier (5 minutes)
4. Then (most important) make a recommendation for removing the top barrier. (10 minutes)
60
Remember one thing…
High Fidelity Wraparound is a process of integration for children and families with co-occurring disorders. It is specifically designed to lead to positive clinical outcomes and is based on a theory of change
In general, the field has greatly underestimated the complexity of doing a good job with wraparound at the supervisor and staff levels.