Transforming Services for Children, Youth and Families through Systems Change: The Arizona Experienc

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Transforming Services for Children, Youth and
Families through Systems Change
The Arizona Experience

• Why We Needed to Change
• JK Settlement Arizonas Roadmap
• Pilots and Gurus Figuring Out How to Change
• Collaborative Voices and Structures
• Operationalizing Principles
• CQI Structure, Process, Outcomes
• Results to Date
• Lessons Learned

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Why WAS Transformation Necessary?

• Family Dissatisfaction
• Fragmented Care
• Inflexibility Few Alternatives
• Poor Outcomes

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Rapidly Expanding EnrollmentJune 2000 - June 2006
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Impetus for Change

• Community Initiatives
• Legislation Executive Order
• System of Care Grant Program
• Litigation

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J.K. Settlement Agreement

• Requires ADHS and AHCCCS to
• Improve frontline practice (CFT, best practices)
• Enhance capacity to deliver needed services
  
  
• Promote collaboration among public agencies and
  stakeholder participation
  
• Develop quality management/improvement system

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The Arizona Vision

• In collaboration with the child and family and
  others,
• Arizona will provide accessible behavioral health
  services
• designed to aid children to
• achieve success in school
• live with their families
• avoid delinquency
• become stable and productive adults
• Services will be tailored to the child and family
  and provided in the most appropriate setting, in
  a timely fashion, and in accordance with best
  practices, while respecting the childs and
  familys cultural heritage.
• J.K. vs. Eden et al. No. CIV 91-261 TUC JMR,
  Paragraph 18

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The 12 Arizona Principles

• Collaboration with the Child and Family
• Functional Outcomes
• Collaboration with Others
• Accessible Services
• Best Practices
• Most Appropriate Setting
• Timeliness
• Services Tailored to the Child and Family
• Stability
• Respect for the Child and Familys Unique
  Cultural Heritage
• Independence
• Connection to Natural Supports

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J.K. Settlement Agreement

• Requires ADHS and AHCCCS to
• Invite and heed Family Voice
• Improve frontline practice
• Enhance capacity to deliver needed services
  
  
• Promote collaboration among public agencies
  
  
• Develop a quality management and improvement
  system
• Six Year Term of Agreement

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Arizonas Early Innovators 300 Kids Project

• 49. Defendant ADHS/DBHS shall initiate a 300
  Kids Project.
• Will serve multi-agency children.
• Sites to engage intensively in system improvement
  activity.
• 50. The sites will serve two purposes
• test strategies for providing behavioral health
  services according to the 12 Principles.
• Serve as the first phase of a statewide effort to
  deliver services according to the Principles.

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Child and Family Team (CFT) Process

• Based on the Wraparound Approach
• Service planning is family-centered,
  strength-based, highly individualized, culturally
  competent and collaborative across systems,
  promoting reliance on informal and natural
  supports in combination with formal services.
• Congruent with
• Family-Group Decision-Making (Child Welfare)
• Team Decision-Making (Child Welfare)
• Person-Centered Planning (Development
  Disabilities)
• Individual Family Service Planning (IDEA - Part
  C)

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Child systems join an Understanding

• While ADHS and AHCCCS were named as defendants in
  the J.K. lawsuit, Arizonas remaining
  child-serving agencies (child welfare, children
  with special health care needs, early childhood,
  juvenile justice, and public school system)
  signed a Memorandum of Understanding, voluntarily
  and collectively embracing the Arizona Vision and
  the 12 Arizona Principles. The entities joined
  the Governors new Childrens Cabinet in 2003,
  and all have continuously reaffirmed their mutual
  commitments to this shared Vision and Principles
  since 2002.

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CHANGING Organizational Thinking

• Attitudes and Values
• Language as an Organizing Framework
• Leadership
• Parent/Professional Partnerships
• Early Innovators (Wraparound Maine, THRIVE System
  of Care)

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Changing Organizational Thinking

• Attitudes and Values The Relational Stance
• From Problem to Competence
• From Expert to Accountable Ally
• From Professional Turf to Family Turf
• From Teaching to Learning With
• William C Madsen, Collaborative Therapy with
  Multi-Stressed Families (1999)

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Structure, Process, Outcomes

• Structural Changes
• Covered Services
• Funding
• Structural Elements
• Process Changes
• Training and Coaching, Consultants
• Fidelity to Principles
• Clinical Guidance Documents
• Outcomes Improve
• Data-Driven Decision-Making

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Structural Changes Necessary

• Arizonas Covered BH Services
• Medicaid, Behavioral Health, Licensing
• Expanded Definition of professional
• Expanded Definition of family
• Expansion of Supportive Services
• Capacity and Competency, or
  Quantity v. Quality

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Structural Changes Necessary

• Funding
• Variations in State Capitation Rates
• Maximizing State Funding
• Provider Contracting Methodology
• Sustainability of Effort

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Structural Accomplishment in AZ

• On January 29, 2003, Gov. Janet Napolitano
  ordered the expansion of the 300 Kids Pilot to
  statewide implementation
• 01/31/2005 13.5 of 34,000 with CFTs
• 05/31/2006 32 with CFTs
• 12/31/2007 51.6 with CFTs
• Children involved with CPS Juvenile Justice,
  residing in or at risk of placement in
  out-of-home care settings (RTC, TGH) are priority
  populations.

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Process Changes Necessary

• Training and Coaching
• Coaching to Support Training
• Sequencing
• Who Needs to Transform?
• Costs/Investment
• Retention/Regeneration Strategies

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Process Changes Necessary

• Professional Roles
• Transforming Roles Relational Stance
• Movement to Strengths Based
• Values-Based Hiring Practices
• Training and Re-training
• Liability Myths
• Shared Expertise with Families

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Process Changes Necessary

• Clinical Guidance Documents
• Operationalizing and Memorializing
• Process for Development
• Contract Requirements
• Standardized Assessment (0-5, too)
• Example Child and Family Team PIP
• Prior Authorization

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Quality Management Structure

• Examples
• Enrollment/Penetration (Latino youth? 0-3 y.o.?)
• Number of functioning Child and Family Teams
• Number of counties with cross-system protocols,
  agreements in place
• Number of children placed outside of Arizona
• Number of children placed out of home
• Percentage of children in foster care with BH
  needs assessed beginning within 24 hours after
  removal

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Quality Management Structure

• JK Structural Elements (monthly -gt quarterly)
• CFT Capacity
• OOH Placements
• Urgent BH Responses
• Other Key Indicators (monthly) -
• CFT Capacity by Provider
• Rehab/Support Spending as of Total BH
• Latino Penetration by Provider
• Under 12 Initiative

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Quality Management Process

• CFT Process Measurement
• The Four Big Questions
• Has a trusting relationship been established with
  the family (engagement)?
• Does the Child and Family know the family and has
  it identified the strengths needs and culture of
  the family?
• Has an Individualized Service Plan been created
  that meets the needs of the child and family?
• Is the team implementing, monitoring and
  modifying the service plan toward a successful
  outcome for the child and family?

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Quality Management ProcessCFT Process
Measurement

• Fall 2005 Reviews
• Region A 67.8
• Region B 64.1
• Region C 74.1
• Region D 66.3
• Region E 73.3
• Region F 41.7
• Statewide 53.25 n 486

• Winter 2006 Reviews
• Region A 70
• Region B 64
• Region C 71
• Region D 61
• Region E 81
• Region F 53
• Statewide 60.45 n 418

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Figure One Group Comparisons. Figure One shows a
comparison of the average wraparound fidelity
index (WFI) scores for the two groups at 6 months
and the average baseline scores for five of the
outcome measures at intake. The second row shows
the difference in the overall average WFI scores
for the two groups. The WFI eight point scale
has been converted to a 100 point scale for ease
of comparison. Rows three through seven show the
intake data for four of the primary child and one
primary family outcomes. These data reflect the
six months prior to initiation of the wraparound
process.
From Rast, ODay Rider (2004)

• Improved Process Contributes to
  Improved Outcomes

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Figure Two CAFAS and CBCL Scores. The graph on
the left of figure two shows the average Child
and Adolescent Functional Assessment Scale
(CAFAS) Scores at intake and at six and twelve
month intervals following intake. The open
circles are the average scores for all 42
children, the black diamonds show the average for
the 21 children receiving low fidelity wraparound
and the grey squares show the data for the 21
children receiving high fidelity wraparound. The
graph on the right shows the same data for the
Child Behavior Checklist (CBCL) scores.
From Rast, ODay Rider (2004)
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Figure Three Residential Outcomes. Figure Three
shows a comparison of the impact of the fidelity
of the Child and Family Team process on the
restrictiveness of residential placement (left
graph) and on the stability of placement (right
graph). The figure on the left shows the average
level of residential placement on a six level
version of the ROLES. The open circles show the
average for all 42 of the children, the black
diamonds the 21 with low fidelity wraparound and
the grey squares the 21 with high fidelity
wraparound. The graph on the right shows the
average number of residential moves for each
group using the same symbols.
From
Rast, ODay Rider (2004)
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Figure Four Family Resource Scale. Figure Four
shows the scores for the Family Resource Scale
which measures a caregivers report on the
adequacy of a variety of resources needed to meet
the needs of the family as a whole, as well as
the needs of individual family members. Higher
ratings demonstrate more adequate resources. The
graph on the left shows the average rating for
the caregivers for all 42 children. The graph on
the right shows the average rating for each
group. The gray squares are for the caregivers
with the high fidelity wraparound and the open
circles are for the care givers with low fidelity
wraparound. From Rast, ODay Rider (2004)
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Comparing Outcomes for Arizona Children with and
without Child and Family Teams Ages 5-11From
ADHS (01/08) at http//www.azdhs.gov/bhs/measures/
charts_0108.pdffor all enrolled children in this
age range
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Comparing Outcomes for Arizona Children with
and without Child and Family Teams Ages
12-17From ADHS (01-08) at http//www.azdhs.gov/b
hs/measures/charts_0108.pdffor all enrolled
youth in this age range
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Wraparound Works

• Building on family strengths is essential if
  we are to prevent and control juvenile
  delinquency behavior. The Wraparound Process
  that embraces this concept can help prevent
  families from becoming abuse, neglect and
  delinquency statistics. It works well as an
  intervention model even for the most severe cases
  of abuse, neglect or delinquency.
• Hon. David C. Bonfiglio, Superior Court Judge,
  6/01
• Testimony before Indiana Select Legislative
  Committee on Education

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Second Generation Tasks in Arizona (July
2007)

• Adequacy and flexibility of case management (care
  coordination/wraparound facilitation) resources,
• Adequacy and availability of direct supports and
  rehabilitative services as a significant
  enhancement to traditional clinical services, and
• Continuing attention to maintain and improve
  observed, measured fidelity of wraparound
  (Child and Family Teams) process.

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For MORE INFORMATION

• Arizona/JK Initiative - www.azdhs.gov/bhs
• Frank Rider frider_at_ffcmh.org
• "The slowness of change is always respectable in
• the eyes of those who are in charge.
• It is a different story for the ones who are
  in pain.
• Jonathan Kozol (1967), Death at an Early Age.