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Researching Wraparound in Nevada

Overview of the “Youth and Family Supports Study”

Funded by the National Institute of Mental Health

State MH Consortium MeetingMay 22, 2008Reno, Nevada

Eric J. Bruns, University of WashingtonRamona Denby Brinson, University of Nevada, Las Vegas

Michelle Ramey, University of Nevada, Las Vegasebruns@u.washington.eduRamona.denby@unlv.edu Michelle.Ramey@unlv.edu

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Overview of this Presentation Background: What works in children’s 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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Getting Support

Self- Efficacy

Achieving Goals

Theory of change: Why wraparound may be critical to positive outcomes

Better plans

Teamwork & coordination

Better follow through

Facilitator, Team, Flex funds,

Service array

Natural supports

Positive

Outcomes!Fam

ily

Dri

ves

the

pro

cess

Optimism & Hope

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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 Nevada:Living in less restrictive, more community based settings

0

5

10

15

20

25

30

Traditional svcs Wraparound

Group

Nu

mb

er

of

Yo

uth

More Restrictive Less Restrictive

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Results from Nevada:Functioning better in the community

0

20

40

60

80

100

120

Intake 6 months 12 months 18 months

Av

era

ge

CA

FA

S S

co

res

TMH Services Wraparound

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Results from Oklahoma:Getting to permanency

0%

10%

20%

30%

40%

50%

60%

70%

6 Month Intervals

Per

cent

of Y

outh

in P

erm

anen

cy S

ettin

g

Comparison DHS Wraparound

Comparison 14.7% 20.60% 26.1%

DHS Wraparound 32.4% 43.20% 65.2%

6 mos 12 mos 18 mos

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Results from OklahomaSupporting re-integration of adult prisoners

Figure 1: Survival Analysis for Wrap Around Services versus Sample based on Race, Sex, Age, Crime Category and LSI Level for Medium to High Risk Offenders Only

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30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Month

Perc

ent S

urvi

ving

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OK, so the “theory of change” makes good sense. Families like

wraparound

The 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 >1 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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Team

Organization(lead and partner agencies)

System (Policy and Funding Context)

Effective

Supportive

Hospitable

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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

WFAS

WFI-4

TO

M

CSWI

Doc

Rev

iew

WFI-4 – Wraparound

Fidelity Index

CSWI – Community Supports for

Wraparound Index

DOC - Document Review Measure

TOM – Team Observation

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 N=75 assigned to Wraparound condition

as delivered by WIN and CCS N=75 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

YFSS - Recruitment summary

0 2 5 9

2939

45 4955

63

1018

2636

46

58

70

82

94

108

122

136

150

16

00

20

40

60

80

100

120

140

160

Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08

N E

nro

lle

d

Actual Goal #REF! #REF!

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Characteristics of YFSS Participants

N=48 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 (N=30) 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 (N=30)

1 Disorder, 172 Disorders, 8

3 Disorders, 3

4 Disorders, 2

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CAFAS Functioning Subscales:Percent of youth with “moderate to severe” needs

0 20 40 60 80 100

Home

Behavior to Others

Moods

School/Work

Community

Thinking

Self Harm

Substance Use

Percent "moderate" - "severe"

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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 N=90 youth drawn from

WIN and CCS in Clark Co Data collection completed for:

Wraparound Fidelity Index (WFI) N=59 youth 139 interviews completed across the 3 respondent

types Team Observation Measure (TOM)

N=27 team meetings observed by UNLV and DCFS staff Document Review Measure (DRM)

N=65 case files reviewed by UNLV and DCFS staff

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Results of Fidelity Assessment:Strengths 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 family’s plan

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Results of Fidelity Assessment:Needs 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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60

70

80

90

100

Per

cen

t o

f to

tal

fid

elit

y

State comparison 74.4 61.1 61.9

Clark County (59 youth) 78.3 70.4 68.8

"High fidelity" 83 80 77

Facilitator (N=53) Caregiver (N=49) Youth (N=27)

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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:

1. Community partnership2. Collaborative action3. Fiscal policies4. Service array5. Human resource development, and6. 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 Midway

Fully developed

Theme mean

0 0.5 1 1.5 2 2.5 3 3.5 4

Accountability

Human Resources

Access to Services

Fiscal Policies

Collaborative Action

Community Partnership

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Cross-Site Comparison:Nevada (site 2) versus 5 other Wrap initiatives

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Site 1 Site 2 Site 6 Site 3 Site 4 Site 5

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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

ItemMean 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 program’s 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