developing trauma-informed services and continuous quality...

Presented by:

Developing Trauma-Informed Services and Continuous

Quality Improvement Processes for Juvenile Justice

Arabella Perez, LCSW Executive Director THRIVE Initiative

Kristin Thorp CQI Coordinator THRIVE Initiative

Galan Williamson Regional Corrections Administrator Maine DOC

Sarah Goan, MPP Project Manager Hornby Zeller Associates, Inc.

28th Annual Research & Policy Conference on Child, Adolescent and Young Adult Behavioral Health

March 2015

working together for a brighter tomorrow

Goals for Today

• Review the history of SOC and trauma-informed in Maine

• Discuss the development of trauma-informed assessments for Community Services

• Share results from Maine’s pilot of trauma-informed assessments

• Discuss local and national implications

Background and Context


History of SOC, Planning and Expansion

• 2005, Trauma-informed System of Care “TRHIVE”

Maine Office of Child and Family Services was awarded a SOC grant to focus regionally on developing and assess with developing a trauma informed SOC

• 2011, Planning year

Awarded a SOC planning grant to expand our work statewide and bring on new partners such as DOC, Military families and expand the work with MH agencies

• 2012, “Expand ME”

Maine Department of Corrections, Juvenile Services awarded a expansion grant to focus on trauma informed care in Maine.


Why Does Trauma Matter?

• Trauma affects how children, youth and families approach, engage with and use services (Yoe, 2004).

• Children and youth react to trauma differently than adults (Ford et al., 2000; Husain, Allwood, Bell, 2008; Daud & Rydelius, 2009).

• A high number of traumatic experiences during childhood leads to higher risk of health and social problems (Felitti et al., 1998).


Trauma-Informed Approach: Key Points

• Asks “what has happened to you?” instead of “what is wrong with you?”

• Promotes general awareness and understanding of trauma among all staff/ stakeholders (broader than use of trauma-specific EBT models)

• Changes policy and practice to support a trauma sensitive approach

Using Trauma Theory to Design Services Systems

Roger Fallot and Maxine Harris


The Trauma-informed Principles

• Safety: physical and emotional

• Collaboration: sharing in responsibilities

• Choice: family and youth voice included in decisions made about care

• Empowerment: recognizing strength and building skills

• Trustworthiness: clarity and consistency

• Language Access and Cultural Competency: recognizing culture in the context of trauma

• Agency Support and Trauma Competence: trauma champions, monitoring, training and staff support


It’s a Journey

Creating a Trauma-informed Assessment for Juvenile Community Corrections


Why Be Trauma-informed: Juvenile Justice

• A large portion of youth involved with corrections have been exposed to trauma (est. 75 to 90%).

• Understanding trauma informs: Policies and practices Screening, assessment, case planning and the

selection of appropriate interventions Staff actions/reactions in specific interactions with

youth and families Management, supervision and response to staff

experiences

Maine Juvenile Community Corrections

• Three regional offices with 50 Juvenile Community Corrections Officers (JCCOs), 6 regional managers, 3 regional administrators

JCCOs = correctional case managers for youth under the supervision of the Division regardless of their status with the legal system.

Mission: To promote public safety by ensuring that juveniles under Department of Correction’s jurisdiction are provided with risk-focused intervention, quality treatment, and other services that teach skills and competencies; strengthen prosocial behaviors to reduce the likelihood of re-offending and require accountability to victims and communities.


Bringing Trauma-informed to Juvenile Justice

• Trauma-informed aligns with the mission for Juvenile Services

Clients under DOC supervision leave our system better than when they came into our system.

The three “Ds:” Detention, Diversion, Disposition

• Trauma-informed aligns with other on-going initiatives (JDAI, JJAG, RED, DMC)


Trauma-informed Juvenile Justice Services

• Ensure involved youth are screened, assessed and referred to effective services.

• Enhance the service array with Wraparound, Youth and Family Partners.

• Create an infrastructure within Juvenile Services for providing trauma-informed services.

Assess (and change) policies, practice and organizational culture

TI-CQI Process for Community Services

• Trauma-informed Continuous Quality Improvement (TI-CQI) is: Routine

Collaborative

Local and statewide

• Technical assistance and training available to help with TI-CQI.

Conduct TIAA

Assessment

Prioritize Areas of

Need

Create Regional CQI

Plans

Implement CQI Plans


The Role of Assessment

• Learn where trauma-informed services are being delivered well

• Pinpoint areas for improvement/change

• Identify training or technical assistance needs

• Establish standards and monitor improvements and/or maintenance over time


Engagement of Multiple Sectors

• Convened a representative workgroup to review documents and make important decisions

➢State leadership

➢Management and field staff

➢Mental health liaisons

➢Youth and family

➢Cultural brokers

Trauma Informed Principles

What to Assess? Trauma Informed Assessment Domain

Safety: physical and emotional

• Service delivery activities, settings and practices ensure the physical and emotional safety (e.g., sense of danger/being afraid) for families, youth and staff.

Physical and Emotional Safety

Collaboration: sharing in responsibilities

• Service delivery practices share responsibility with youth and families. Staff members maximize collaboration, choice and shared responsibility among providers, families and youth.

Youth and Family Empowerment

Choice: family and youth voice included in decisions made about care

• Service delivery practices include family and youth in decisions made about care. Staff members allow youth and family to experience

choice and control where possible.


Empowerment: recognizing strength and building skills

• Service delivery practices recognize strengths and build skills. Staff members prioritize activities and treatments that promote youth and family empowerment, strengths and skill building.


Trustworthiness: clarity, consistency

• Service delivery practices emphasize clarity and consistency. Staff

members ensure that expectations are clearly articulated for youth and families; rules and regulations are enforced consistently. Boundaries are maintained (especially interpersonal ones), as appropriate for the program.

Trustworthiness

Language Access and Cultural Competency: recognizing culture in the context of trauma

• Service delivery practices recognize trauma in the context of culture. Staff members take into consideration how culture, traditions and beliefs impact youth and family choices and wellbeing.

Cultural Competency

Agency Support: trauma champions, training and staff support

• The agency supports and promotes trauma-informed as part of its mission through identified “trauma champions,” practice review, changes, training and staff support. Staff members exhibit an understanding of the above principles in their work.

Trauma Competence & Commitment to Trauma-informed Practice


Developing Youth and Family Tools

• Supplemented existing youth client satisfaction survey (collected annually)

• Added a new family survey

• Reformatted survey to appear more streamlined, despite more questions

• Determined assessment cycle (annual, mirrors facilities)


Youth and Family Questions

• Emotional safety, trauma competency and trustworthiness. I feel safe with my JCCO.

I feel confident that private conversations with my JCCO cannot be overheard.

My JCCO asked me about any bad or upsetting events that may have happened to me.

My JCCO makes sure I understand the rules that must be followed when responding to my problems and situations.


Youth and Family Pilot

• April 2014: Distributed by staff through regular client satisfaction survey process ➢All clients on active status longer than 3 months ➢30 day time period

• Invited to complete in person ➢Survey mailed when in person was not possible

• Two ways to return surveys ➢Drop box in lobby ➢Stamped, addressed envelope to “Central” office


Developing the Staff Tool

• Key stakeholders reviewed policies and existing practices

• Developed standards for seven overarching domains Each rated on a 5-point scale of completeness and

consistency Feedback from stakeholders led to “new” domain

measuring staff empowerment

Staff Questions

• Physical safety and climate • Trustworthiness • Youth and family empowerment • Staff empowerment*

• Trauma competence • Organizational commitment to

trauma-informed • Cultural and linguistic

competence


Piloting the Staff Tool

• Collected via online survey platform Web link distributed by regional managers

• October 2014: Staff given one week to complete

survey after receiving web link Monitored responses by region Two week extension to improve response rate

• Hornby Zeller Associates analyzed data and

produced reports


Next Steps: CQI Support

• Reviewed results as a workgroup • Developed statewide CQI plan • Provided structured TA around CQI planning in

each region • Continue to provide ongoing support for

successful implementation of plans

Results: Trauma-informed Agency Assessment

Assessment Response Rates

Youth & Family

• April 2014: 15-item questionnaire (paper)

• 115 youth responses (~25%)

• 79 caregiver responses

Staff

Total Staff Received Rate

Region 1 20 16 80%

Region 2 19 18 95%

Region 3 17 16 94%

TOTAL 56 50 89%

• October 2014: 37-item questionnaire (on-line)


Youth and Family Results

• Youth and families: JCCOs were respectful, positive and made sure they understood the rules.

Privacy, safety, cultural competence and communication were not a concern.

Sometimes/Never Youth Family

Asked about bad or upsetting events 20% 11%

Reviewed their goals 25% 19%

Referred programs were helpful 25% 19%


Youth and Family Results

• Youth and families: JCCOs were respectful, positive and made sure they understood the rules.

Privacy, safety, cultural competence and communication were not a concern.

Sometimes/Never Youth Family

Est. Std. Dev. Conf. Int.

(95%) Est. Std. Dev.

Conf. Int. (95%)

Asked about bad or upsetting events 20.2% 0.403 +/-7% 11.5% 0.322 +/-7%

Reviewed their goals 25.0% 0.435 +/-8% 20.8% 0.409 +/-9%

Referred programs were helpful 26.1% 0.441 +/-8% 19.5% 0.399 +/-9%


Average Scores, by Domain

3.77

4.16

4.00

3.60

3.73

3.43

3.79

1.00 2.00 3.00 4.00 5.00

Safety and Well-being

Trustworthiness

Youth/Family Empowerment

Staff Empowerment

Trauma Competence

Commitment to Trauma-Informed

Cultural Competence

Commitment to Trauma-informed Approach

Lowest scores on trauma-informed development plan and policy

Staff promote TI with other providers/agencies

Area (AS = 3.43) Complete

Policy Consistent

Practice

Trauma-informed Policy 3.38 3.36 Routine Trauma Screening 3.44 3.44 Trauma-informed Development Plan 3.16 3.18 Promotes Trauma-informed Competence with Others 3.74 3.74

6% 11%

34% 35%

16%

0%

10%

20%

30%

40%

50%

One Two Three Four Five

Distribution of Responses

Staff Empowerment

Lowest responses related to communication, involvement and staff support agency-wide

Local communication was rated high


Policy Consistent

Practice

Local Communication 4.2 4.2 Strengths-based Supervision and Autonomy 3.9 4.0

Conflict Resolution 3.8 3.8 Staff Voice and Empowerment 3.5 3.5

Supports for Staff 3.3 3.3 Agency-wide Communication 3.2 3.1

Agency-wide Involvement 3.3 3.3

5%

13%

25%

34%

24%

0%

10%

20%

30%

40%

50%



Trauma Competence

Lowest score in trauma competency and personnel decisions.

High scores in EBTs and awareness of trauma


Policy Consistent

Practice Trauma Competencies in Personnel Decisions 3.14 3.12 Trauma Training for All Staff 3.76 3.66

Evidence-based Trauma Practices 4.14 4.16 Staff Awareness of Trauma 4.02 4.06

Agency Policy and Practices Aware of Trauma 3.58 3.62

4% 5%

27%

43%

21%

0%

10%

20%

30%

40%

50%



Lowest and Highest Scoring Items

Lowest Scoring Items Domain Question Average

Youth/Family Empowerment Agency-level Involvement 2.59

Trauma Competence Trauma Competencies in Personnel Decisions 3.13

Staff Empowerment Agency-wide Communication 3.15

Commitment to Trauma-informed Trauma-informed Development Plan 3.17

Staff Empowerment Agency-wide Involvement 3.28

Highest Scoring Items Domain Question Average

Youth/Family Empowerment Strengths-based 4.25

Youth/Family Empowerment Informed Participation 4.32 Youth/Family Empowerment Other Agency Involvement 4.38

Youth/Family Empowerment Service Preferences 4.42 Trustworthiness Agency Orientation 4.58


Differences Between Policy and Practice

Domain Question Policy Practice

Safety and Well-being

Space 3.76 3.62

Information Sharing Within Agency 3.86 3.96

Quality Improvement, Safety 3.54 3.48 Trustworthiness Youth and Family Informed of Staff Changes 3.78 3.88

Trauma Competence Trauma Training for All Staff 3.76 3.66 Cultural Competence Culture Considered in Accountability 3.68 3.76

Safety and well-being showed the most difference between policy and practice

Results from Validity Testing

Domain Cronbach

Alpha

Safety 0.899

Trustworthiness 0.850

Empowerment 0.846

Staff Empowerment 0.951

Trauma Comptence 0.909

Commitment 0.910

Culture 0.960

Factor Analysis

• Sample is small (lower end of acceptable range for factor analysis) Initial run suggests 15

factors…

• Initial correlations suggest some modifications

Planning for Change

What This Means Going Forward

• Improve and revise training curriculums

• Adds context at critical decision points (3Ds)

• Provides accountability and monitoring

What is Being Done?

• On-going policy review involving field staff

• Enhancements to physical environment

• Youth and family advisory groups

• Building support systems for youth and families

Conduct TIAA Assessment

Prioritize Areas of Need

Create Regional CQI Plans

Implement CQI Plans

Monitoring progress through youth, family and staff surveys


Lessons Learned

Increased awareness of trauma

Healthier relationships between staff, youth and families

Expanded community partnerships

Better outcomes for youth

The trauma-informed case management approach is healthier for clients and staff


Discussion and Questions

Arabella Perez, Executive Director THRIVE Initiative [email protected]

Kristin Thorp, CQI Coordinator THRIVE Initiative [email protected]

Galan Williamson, Regional Correctional Administrator Maine Department of Corrections [email protected]

Sarah Goan, MPP, Manager Hornby Zeller Associates, Inc. [email protected]

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