Researching%20Wraparound%20in%20Nevada%20Overview%20of%20the%20

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Researching Wraparound in NevadaOverview of the
Youth and Family Supports StudyFunded by the
National Institute of Mental Health

• State MH Consortium Meeting
• May 22, 2008
• Reno, Nevada
• Eric J. Bruns, University of Washington
• Ramona Denby Brinson, University of Nevada, Las
  Vegas
• Michelle Ramey, University of Nevada, Las Vegas
• ebruns_at_u.washington.edu
• Ramona.denby_at_unlv.edu
• Michelle.Ramey_at_unlv.edu

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Overview of this Presentation

• Background What works in childrens mental
  health?
• The role of Wraparound in achieving positive
  outcomes for youth and families
• What does it take to implement wraparound?
• Research on wraparound fidelity
• The Nevada Youth and Family Supports Study
• Study goals
• Data still to come
• Opportunities for Nevada
• Data from the Study so far Implementation of
  Wraparound in Nevada
• What next?

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What is an Evidence Based Practice?

• A process of applying scientific knowledge about
  service practices to the situation of an
  individual child and family
• Treatment procedures that have been shown to be
  effective through scientific evidence of some
  level of robustness

From Bruns, Hoagwood et al. (in press). State
implementation of evidence based practice, Part
2 Recommendations for research and policy.
Journal of the American Academy of Child and
Adolesc. Psychiatry.
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We have treatments with evidence for
effectiveness for

• Anxious or Avoidant Behaviors
• Attention and Hyperactive Disorders
• Autistic Spectrum Disorders
• Disruptive and Oppositional Behaviors
• Self-harming Behaviors

• Assaultive and Aggressive Behaviors
• Sexually Aggressive Behaviors
• Traumatic Stress
• Interpersonal problems
• Substance use
• Delinquent behavior
• History of abuse and neglect

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Unfortunately, major barriers to using EBPs in
real world practice

• Complexity of child and family needs
• Multiple and overlapping child problem areas
• Unmet basic family needs
• Many providers, many requirements, little
  coordination
• Lack of full engagement and partnership with
  families
• Families are overwhelmed, do not feel their
  priority needs are being addressed
• Leads to treatment dropouts, missed opportunities
  for positive change, bad outcomes

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Theory of change Why wraparound may be critical
to positive outcomes
Facilitator, Team, Flex funds, Service array
Getting Support
Positive
Achieving Goals
Teamwork coordination
Family Drives the process
Optimism Hope
Better plans
Better follow through
Self- Efficacy
Outcomes!
Natural supports
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Promising Outcomes for Communities using the
Wraparound Process
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Outcomes Wraparound Milwaukee

• Average daily Residential Treatment population
  reduced from 375 placements to 70 placements
• Psychiatric Inpatient Utilization reduced from
  5000 days per year to under 200 days (average LOS
  of 2.1 days)
• Reduction in Juvenile Correctional Commitments
  from 325 per year to 150 (over last 3 years)

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Results from NevadaLiving in less restrictive,
more community based settings
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Results from NevadaFunctioning better in the
community
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Results from OklahomaGetting to permanency
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Results from OklahomaSupporting re-integration
of adult prisoners
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OK, so the theory of change makes good sense.
Families like wraparoundThe model is being
better understood. The research base continues to
grow So, what is the challenge?
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A National Reviewof Wraparound Teams
Showed(Walker, Koroloff, Schutte, 2003)

• Less than 1/3 of teams maintained a plan with
  team goals
• Less than 20 of teams considered gt1 way to meet
  a need
• Only 12 of interventions were individualized or
  created just for that family

• All plans (out of more than 100) had
  psychotherapy
• Natural supports were represented minimally
• 0 natural supports 60
• 1 natural support 32
• 2 or more natural support 8
• Effective team processes were rarely observed

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Hospitable
System (Policy and Funding Context)
Supportive
Organization (lead and partner agencies)
Effective
Team
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System and organizational supports for wraparound

• Community Partnership. Community ownership of
  wraparound is built through collaborations among
  key stakeholder groups.
• Collaborative Action. Stakeholders involved in
  the wraparound effort take concrete steps to
  develop concrete policies, practices and
  achievements.
• Fiscal Policies and Sustainability. The community
  has developed fiscal strategies to meet the needs
  of children participating in wraparound and
  methods to collect and use data on expenditures.

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System and organizational supports for wraparound

• Access to Needed Supports Services. There are
  mechanisms for ensuring access to the services
  and supports that teams need to fully implement
  their plans
• Human Resource Development Support. The system
  supports wraparound staff and partner agency
  staff to fully implement the wraparound model.
• Low caseloads
• The right job descriptions
• Training and coaching
• Good supervision, etc
• Accountability. The community has mechanisms to
  monitor wraparound quality and outcomes.

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Monitoring quality of implementation of child and
family teams

• Have facilitators and team members fill out
  activity checklists
• Look at plans of care and meeting notes
• Sit in on and observe team meetings
• Ask the people who know parents, care givers,
  youth, facilitators, program heads

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Wraparound Fidelity Assessment System
WFI-4 Wraparound Fidelity Index
TOM Team Observation Measure
WFAS
WFI-4
TOM
Doc Review
CSWI
CSWI Community Supports for Wraparound Index
DOC - Document Review Measure
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Summary What Leads To Outcomes?
Program and System Supports
Sticking to the wrap principles in service
delivery
Improved Child and Family Outcomes
Training, Coaching, and Quality Assurance
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A summary of research on wraparound
implementation

• There are connections between system support for
  wraparound implementation and fidelity
• There are connections between wrap fidelity and
  child and family outcomes
• We are beginning to get a sense of what high
  fidelity is in terms of scores on tools like the
  WFI
• BUT The research is still preliminary, and the
  field is looking for additional evidence

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• Studying Wraparound Implementation in Nevada

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The Outcomes of Wraparound in Nevada Study

• The first NIMH-sponsored controlled research
  study of wraparound
• Examines the differences in outcomes, treatment
  processes, and costs of wraparound vs. case
  management
• Tests psychometrics of the Wraparound Fidelity
  Index and other fidelity tools
• A chance to use data on treatment processes,
  costs, and outcomes to inform implementation of
  services for youth with SED in Nevada

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Major Research Questions

• Does implementing wraparound for a youth with SED
  result in a different service process than
  implementing intensive CM?
• Does the wraparound process lead to better
  outcomes?
• What are the costs of the two models?
• How important is wraparound fidelity to
  achieving outcomes?

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Study population

• 150 children and youth (age 6-17) with SED that
  requires intensive intervention
• Fee for service Medicaid eligible
• N75 assigned to Wraparound condition as
  delivered by WIN and CCS
• N75 assigned to CM delivered by Mojave

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What data is the Youth and Family Supports Study
providing?

• Child Behavior and Functioning
• Strengths and Difficulties Questionnaire (SDQ)
• Child and Adolescent Functional Assessment Scale
  (CAFAS)
• Child Status Report Residential Setting Child
  Welfare, School, and Juvenile Justice Outcomes
• Services received
• Services Assessment for Children and Adolescents
• Case Management Function Form
• Service processes and satisfaction
• Parent and Youth Satisfaction Questionnaires
• Working Alliance Inventory
• Family Empowerment Scale
• Glisson Organizational Social Context Scale
• Also being collected via admin. data from DCFS,
  DJJS, CCPSS

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Additional data from the Youth and Family
Supports Study

• Fidelity to the wraparound model
• From interviews of the WFI
• From team observations from the TOM
• System support for wraparound
• Community Supports for Wraparound Inventory
  (CSWI)
• Connections to resources who is on their team?
  What is in their plan?
• Whether services are making a difference in areas
  that matter to families (e.g., optimism level of
  empowerment lost days at work)

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• Progress report

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Study Enrollment to date
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Characteristics of YFSS Participants

• N48 total (41 active) cases with baseline data
  collection completed as of April 2008

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Demographics

• Male 22 (46)
• Female 26 (54)
• Age
• Mean 11.42 (SD 3.35)
• Range 6-17
• Race
• African American 16 (36)
• White 12 (27)
• Hispanic 7 (16)
• Mixed Race 7 (16)
• AA White 3 AA Hispanic 4
• Native American 1 (5)
• Biological parents w/parental rights 15 (31)

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Referral and study information

• Referral source (to services)
• Child welfare 37 (79)
• Self 7 (15)
• School 2 (4)
• Mental health agency/provider 1 (2)
• Language spoken at home (other than English)
• Spanish 2 (4)
• Assignment to services
• ICM 20
• WIN 20
• CCS 8

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Placement and Placement History

• Current placement
• Foster Care 18 (44)
• Biological or Adoptive Parents 11 (27)
• Group Home or Shelter 5 (12)
• Relative 5 (10)
• Residential job corps/vocational 2 (5)
• Previous 6 mos
• Group Home or Shelter Care 8 (20)
• Residential Treatment 4 (10)
• Psychiatric Hospital 3 (7)

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DSM Diagnoses assigned (N30)

• Adjustment Disorders 10 (33)
• ADHD 8 (26)
• Mood Disorders (incl. Depression/Bipolar) 7
  (22)
• Disruptive disorders (incl. ODD/CD) 7 (22)
• Post Traumatic Stress 4 (13)
• Attachment Disorders 2 (7)
• Developmental Disorders 2 (7)
• Substance Abuse Disorder 1 (3)
• Learning Disorder 1 (3)
• Psychotic Disorder 1 (3)

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Number of Diagnoses Assigned (N30)
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CAFAS Functioning SubscalesPercent of youth
with moderate to severe needs
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• Findings on Wraparound Implementation in Nevada
  from the YFSS

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Baseline Fidelity data assessment (2006-07)

• Vision for the project
• Inform high quality practice,
• Create a culture in which data is used to inform
  decision making,
• Ensure a better understanding of wraparound on
  the part of families and providers, and
• Help make the case for better support for
  wraparound implementation in Nevada.

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Baseline Fidelity data assessment (2006-07)

• Methods
• Random sample of N90 youth drawn from WIN and
  CCS in Clark Co
• Data collection completed for
• Wraparound Fidelity Index (WFI)
• N59 youth
• 139 interviews completed across the 3 respondent
  types
• Team Observation Measure (TOM)
• N27 team meetings observed by UNLV and DCFS
  staff
• Document Review Measure (DRM)
• N65 case files reviewed by UNLV and DCFS staff

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Results of Fidelity AssessmentStrengths of
wraparound implementation

• Cultural Linguistic Competence.
• WIN and CCS teams have shown respect for the
  values, preferences, beliefs, culture, and
  identity of the child and family, and their
  community. Items for this indicator were
  extremely high across all instruments used.
• Collaborative Efforts.
• Those serving on WIN and CCS wraparound teams
  demonstrate cooperation and shared responsibility
  for developing, implementing, monitoring, and
  evaluating wraparound plans.
• In particular, effective team brainstorming of
  strategies was noted in the WFI.
• Persistence.
• Data indicate WIN and CCS wrap teams persist in
  working towards goals included in the wraparound
  plan, despite challenges presented by enrolled
  families.
• Teams successfully maintain youth in the
  community, and ensure some members of the team
  will be available after formal wraparound is
  finished.
• Other strengths
• Working to keep the youth in the least
  restrictive environment, encouraging youth and
  family voice, maintaining a positive team culture
  and having team members who share responsibility
  for designing and implementing the child and
  familys plan

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Results of Fidelity AssessmentNeeds for
improvement

• Natural Supports.
• Seeking out and encouraging full participation of
  individuals from family members networks of
  interpersonal and community relationships.
• Team Based.
• The family and youth are not typically picking
  who will be on their child and family team, and
  there are unclear roles for natural community
  supports on teams.
• Outcome Based Process.
• WIN and CCS wrap teams are not consistently tying
  the goals and strategies of the wraparound plan
  to measurable indicators, measuring progress,
  using assessment of progress to guide
  follow-through.
• Crisis Planning.
• Many records did not include crisis plans that
  based on functional assessments for the children
  and youth and did not have strategies for
  preventing the crisis or detailed steps to be
  taken.
• Other needs for improvement
• Strategizing ways to involve the youth and family
  in community activities
• Transition planning
• Clarity of roles between DCFS and child welfare
  staff

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Summary scores Wraparound Fidelity
IndexCompared to another state high fidelity
benchmarks
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• More Results on Wrap Implementation
• From the Community Supports for Wraparound
  Inventory

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The Community Supports for Wraparound Inventory

• The 40 items are grouped within 6 themes
• Community partnership
• Collaborative action
• Fiscal policies
• Service array
• Human resource development, and
• Accountability
• Respondents complete the 40 items by rating the
  development of supports in their community or
  program on a 5 point scale
• 0 least developed and 4 fully developed

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Method

• 31 stakeholders in the Nevada system of care were
  identified and invited to complete the CSWI
• These stakeholders were sent a link to a web
  survey version of the CSWI
• 22 nominated respondents completed the CSWI
  (71), 4 declined to complete the CSWI (13), and
  5 did not respond (16)

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Respondents
Mean total experience with wraparound 6.6
years Mean years in current wrap program 3.6
years
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Respondents Experience by Role in Wraparound
Implementation
Role Number Mean Experience in Role
Family/youth on team 4 5.8 years
Natural support on team 8 6.0 years
Parent partner/advocate 7 5.3 years
Facilitator/Care co-ord. 9 4.1 years
Professional on team 12 6.5 years
Wrap supervisor/coach 8 3.3 years
Trainer/Consultant 9 2.2 years
Manager/administrator 10 5.2 years
Higher admin/Policy 4 5.8 years
Researcher 4 1.5 years
This column total sums to more than total
respondents due to people having filled multiple
roles over time.
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CSWI Results Averages by Theme for NV
Least developed
Fully developed
Midway
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Cross-Site ComparisonNevada (site 2) versus 5
other Wrap initiatives
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Results

• Greatest relative strength

Item Mean Rating
2.1 Community Principles and Values 2.4
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Other areas of relative strength Moderate
development
Item Mean Rating
5.4 Professional development 2.11
5.5 Supervision 2.11
1.1 Community team 2.09
1.2 Empowered community team 2.09
2.3 Proactive Planning 2.06
2.8 State interface 2.06
2.5 Partner agency staff preparation 2.06
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Other areas of relative strength Moderate
development
Item Mean Rating
2.2 High-level leadership 1.89
2.7 Single plan 1.89
5.3 Caseload sizes 1.89
1.5 Agency support 1.86
3.6 Sustained funding 1.82
5.2 Agency job expectations 1.76
5.1 Wraparound job expectations 1.76
2.6 Information sharing 1.74
1.3 Family voice 1.73
4.1 Program access 1.72
6.2 Range of outcomes 1.65
6.1 Outcomes monitoring 1.63
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Areas of modest development
Item Mean Rating
6.1 Outcomes monitoring 1.63
6.3 Wraparound quality 1.59
2.4 Joint action steps 1.59
1.7 Community representativeness 1.55
6.4 Plan fulfillment 1.53
4.5 Service/support quality 1.53
4.2 Service/support availability 1.50
4.4 Choice 1.50
3.5 Fiscal flexibility 1.47
5.6 Compensation for wraparound staff 1.41
6.6 Satisfaction monitoring 1.40
4.3 Building natural and community supports 1.39
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Least development
Item Mean Rating
6.5 Grievance procedure 1.29
1.6 Community stakeholders 1.23
4.6 Crisis response 1.22
6.7 Addressing barriers 1.20
3.1 Fiscal understanding 1.13
3.2 Removing fiscal barriers 1.07
3.3 Collective fiscal responsibility 0.88
3.4 Fiscal monitoring 0.87
1.4 Youth voice 0.86

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Results Big Picture summary

• WIN programs strengths are in the first two
  themes Community Partnership (except youth
  voice) and Collaborative Activity
• Least developed area fiscal policies and
  sustainability

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Results Positive Comments from Respondents

• Foundations of collaboration
• All agencies are at the table talking.
• When the systems work together, family and
  children benefit. In addition, when the agencies
  are committed to the wraparound process, work
  satisfaction increases, positive collaborative
  efforts increase and again, the family and
  children benefit
• The wraparound model
• Using a team approach--Family driven, strength
  based, family voice and choice
• The strength-based approach, family voice and
  choice has empowered the families I've provided
  services. Along with The Child and Family Team
  Approach.

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Results Positive Comments (continued)

• Building capacity for wraparound practice
• Even without good system supports, wraparound
  appears to show good outcomes - if there is good
  supervision of staff that ensures the highest
  fidelity
• Building system capacity
• There is a stable infrastructure for the
  wraparound program. There are beginning efforts
  to implement continuous quality improvement
  strategies for wraparound.
• I have seen through the past four years more
  support to really do the model with our families.
  More people know about wraparound.

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Results Comments about Challenges

• Fiscal issues, particularly lack of funding for
  support services
• Lack of funding for Family Support services.
• Funding for non-governmental organizations
  continues to be a problem.
• Fiscal policies and practices present barriers to
  effective implementation of wraparound. There is
  a grossly inadequate capacity to provide the
  supportive services necessary for wraparound
  (therapies, psychiatric services, mentoring,
  behavioral support services, etc.)
• Collaboration between agencies
• Cross-Agency collaboration and full understanding
  of the wraparound process..
• Conflicting philosophies among public agencies.
  Lack of understanding of what the wraparound
  process is both in public and private system
  partner agencies and therefore, inadequate buy-in
  and support for the process.
• Getting everyone's buy in and to agree on one
  process in implementation.

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So What are next steps?

• The Youth and Family Supports Study will continue
  to provide information on
• Wraparound Implementation and Fidelity
• Satisfaction and services being received
• Outcomes for 150 youth in the system in the areas
  of home, community, and school
• Progress being made by youth and families toward
  their wraparound goals, permanency, and other
  outcomes
• Costs of serving youth and cost-savings
• Question What additional information will the
  Consortium benefit from?
• By when? Formatted how?

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Next steps for the Consortium?

• When considering how best to support
  implementation or expansion of wraparound,
  consider
• Leadership
• Infrastructure and oversight
• Fiscal and other Policies
• Collaboration across stakeholders and agencies
• Social Marketing
• Professional development Support for high
  quality supervision, training, and coaching of
  staff